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Employed White Southerners Most Likely to Lose Coverage in Supreme Court Case


Gov. Pat McCrory has said he is reluctant to talk about expanding Medicaid until the Supreme Court issues a decision on the King v. Burwell case in June. What is the case all about? And who stands to lose?

By Michael Ollove


If the U.S. Supreme Court strikes down tax credits for people buying health insurance on the federal exchange, about 8.2 million Americans in 34 states could lose their coverage under the Affordable Care Act. Most of the people likely to be affected are white, employed and low- to middle-class. They also are concentrated in a single region of the country: the South.

North Carolina joined in a legal brief filed by Virginia (another state without its own exchange) opposing the plaintiffs in the lawsuit. Health insurance rates in those states are expected to rise by as much as 35 percent, which may make coverage unaffordable even for those who don’t qualify for tax credits. Some believe that if the tax credits are disallowed by the Supreme Court, the underpinnings of President Barack Obama’s signature health care law would collapse.

“It will be a horror movie if [the credits are struck down],” said Georges Benjamin, executive director of the American Public Health Association, which supported passage of the ACA.

Supreme Court Building, Image by dbking, Flickr Creative Commons

Supreme Court Building, Image by dbking, Flickr Creative Commons

At issue in King v. Burwell, scheduled for oral arguments next month, is whether people in states that use the federal government’s exchange ( to buy insurance are eligible for federal subsidies in the form of tax credits to help them pay their premiums.

The case hinges on the fact that the ACA provision governing tax credits refers to people enrolled “through an Exchange established by the State,” without mentioning the federal exchange. The ACA anticipated that all states would create their own state exchanges, but it allowed states that did not want to set up their own exchanges to use the federal one instead.

The lawsuit originated at a 2010 meeting of conservative lawyers convened by the American Enterprise Institute to explore “legal vulnerabilities” in the ACA. After the lawyers identified the tax credit as a promising point of attack, a related right-leaning group, the Competitive Enterprise Institute, found four Virginia plaintiffs to launch the lawsuits (King v. Burwell consolidated them). According to its website, CEI is coordinating and financing the legal effort.

Opponents – including the drafters of the original law, 21 states and the District of Columbia – say that whatever the exact language of the statute, Congress did not intend to make any distinction between federal and state exchanges when it came to tax credits. When questions were raised about the language, the IRS announced in 2011 it would issue the credits in states with federal exchanges too.

King v. Burwell is scheduled to be argued in the Supreme Court March 4, but a ruling is not expected until June.In the 34 states where people use the federal exchange, an estimated 9.3 million people are expected to receive $36.1 billion in tax subsidies in 2016. A recent analysis by the Robert Wood Johnson Foundation and the Urban Institute estimated that if the Supreme Court blocked these subsidies, 8.2 million of these residents would not be able to find affordable health insurance in 2016.

“[A King win] disenfranchises millions of Americans from affordable health coverage, most of them working people,” said Trish Riley, executive director of the National Academy for State Health Policy.

Not the poor

Of those 8.2 million, the study found, 61 percent are non-Hispanic whites, 62 percent live in the South, 71 percent work at least part time and 82 percent are considered, by federal measures, to be low- or middle-income rather than poor. The tax credits are available for people with incomes between 100 percent and 400 percent of the federal poverty level. For a family of four, the eligible income range is between $23,850 and $95,400.

Gov. Pat McCrory and Department of Health and Human Services Sec.  Aldona Wos have both said they cannot push for Medicaid expansion until the results of the case are announced in June.In 2014, the first year the exchanges were open, the Obama administration reported that 87 percent of the 5.4 million Americans who chose a health plan through the federal health exchange were eligible for some financial help. Those who qualified for tax credits on the federal exchange paid an average of $82 a month in premiums for their coverage, which was about one-fourth of what they would have paid without the federal assistance.

But even people who don’t qualify for the tax credits would be affected by their disappearance. Because many of the people who receive the credits are relatively healthy, their departure from the insurance pool would lead to a 35 percent increase in premiums, according to the report.  That increase would make coverage unaffordable for about a quarter of the 4.9 million Americans who bought insurance on the federal exchange without a tax credit.

The Supreme Court’s ruling in King v. Burwell will not affect tax credits in the 13 states and the District of Columbia which operate their own exchanges. Nor would it affect the three states – Nevada, New Mexico and Oregon – which have federally supported, state-based exchanges, that perform all of the functions of a state exchange while relying on the federal government for technology support.

Many of the states that declined to create their own insurance exchanges were expressing their opposition to the Affordable Care Act. However some of them, such as Delaware, decided they didn’t have the technical capacity to create one.

A congressional fix?

Congress could provide a fix, but no one believes that Republicans and Democrats could agree on a solution. That leaves the states to step in, but they may not have the time, resources, technical ability or political will to prevent large-scale disruption.

Originally, North Carolina planned to create its own exchange, but SB 4, passed in 2013, forbade the state from pursuing a separate health insurance exchange.States now using the federal exchange could try to convert to state exchanges. But some states, such as Missouri, Montana and North Carolina, have passed legislation prohibiting the creation of a state exchange, and the Republican governors and legislatures in many of those states may still object to taking any steps to support the ACA.

There are nonpolitical problems as well. The ACA provided nearly $5 billion in federal financial assistance for states that built their own exchanges prior to 2014. That money is no longer available. States would have to spend tens of millions of dollars of their own money to develop their own exchanges.

Timing is also a factor. Presuming the Supreme Court’s ruling comes in June as anticipated, states would have only five months to build sophisticated insurance operations and websites. By the time the first state exchanges opened in 2013, a number of states – Maryland, Vermont and Oregon, among others – had already devoted years to fashioning their systems, and those still failed spectacularly in the first year of operation.

The seven states that operate exchanges in partnership with the federal government – Arkansas, Delaware, Illinois, Iowa, Michigan, New Hampshire and West Virginia – may have an easier time. Those states already handle some exchange responsibilities, such as consumer assistance, and may be able to assume the rest. Arkansas already has plans to launch its own exchange in 2017, although that would be a year late for the 95,000 Arkansans who would lose their federal tax credit for next year.

Theoretically, it’s possible that states could switch to a state exchange. But Sara Rosenbaum, a professor of health law and policy at the Milken Institute School of Public Health at the George Washington University, said it wouldn’t be easy.

“There is no assurance of that because it takes money, it takes technology, said Rosenbaum, who worked on an amicus brief siding with the Obama administration on behalf of the deans of university schools of public health.

What would happen to the 8.2 million who could lose their health insurance is unclear. They could turn to the charity of hospitals for health care, although hospitals receive far less federal money for such care than they did before implementation of the ACA. The sharp reduction in patients with insurance also would cost doctors, perhaps forcing some of them to close their practices, according to Benjamin of the American Public Health Association.

Some worry the ACA, which is designed to provide affordable health care coverage to the vast majority of Americans, would collapse if the federal tax subsidies are not available everywhere. Without the tax credits, said Rosenbaum, the entire package of reforms that constitutes the ACA “would be unthinkable.”

Stateline is a nonpartisan, nonprofit news service of the Pew Charitable Trusts that provides daily reporting and analysis on trends in state policy.


Government To Grade Nursing Homes on Tougher Scale


Kaiser Health News

Starting immediately, the federal government is making it harder for nursing homes to get top grades on a public report card, in part by increasing scrutiny of their use of anti-psychotic drugs and raising the bar on an array of quality measures.

Sweet Nursing Home Resident

Image courtesy of robinsan, Flickr Creative Commons

Those grades – in the form of one- to five-star ratings – are part of Nursing Home Compare, a government website to help consumers evaluate nursing homes. While the star ratings, which debuted in December 2008, are lauded as an important tool, critics say they rely too heavily on self-reported data and allow a majority of homes to score high ratings.

The website rates more than 15,000 nursing homes in three broad categories: government inspections, quality measures and staffing levels. An overall score is a fourth category.

The system has come under recent criticism, with complaints that some highly rated nursing homes have numerous problems and face fines and other enforcement actions. On Thursday, the federal government said it would require nursing homes to do more to get higher-quality scores.

Among the better-known measures that go into quality scores are the percentages of residents who develop bed sores or are injured in falls. The scores will now count the percentage of residents given anti-psychotic drugs, reflecting concern that too many are unnecessarily drugged to make them easier to manage. All of those measures will continue to be reported by the homes themselves, however.

The changes mean many homes could drop a star or more from their January levels, even though nothing may have changed, said officials from the Center for Medicare & Medicaid Services. They declined to say how many might see a ratings drop.

The Medicare Inspector General found nursing home patients who died had problems such as preventable blood clots, fluid imbalances, excessive bleeding from blood-thinning medications and kidney failure.

In a previous report, the Medicare inspector general found nursing home patients who died had problems such as preventable blood clots, fluid imbalances, excessive bleeding from blood-thinning medications and kidney failure. Image courtesy Thomas Nemcsek, flickr creative commons

Consumer advocates welcomed the adjustments, but industry officials said the new rules may confuse patients and their families if scores change suddenly.

“If centers across the country start losing star ratings overnight, it sends a signal to families and residents that quality is on the decline, ” said Mark Parkinson, president and CEO of the American Health Care Association, the industry lobby.

But Brian Lee with Families for Better Care, a Florida-based advocacy group for nursing home residents and their families, said the shift was necessary.  More information is always better, he said. He and other advocates had raised concerns that high rates were too easy to achieve.

Lee said about 55 percent of the nation’s nursing homes had overall scores of either four or five stars on Nursing  Home Compare in January. Drilling down, Lee said only about one-third of them got four or five stars on the website for inspections, which he calls the most objective measure because it is based on government rather than self-reported data.

“But when you look at the quality-scores portion, 80 percent of homes are four- or five-star rated,” Lee said. “Something is not coming out in the wash.”

The new ratings will  be reflected on the website as of Feb. 20.  Nursing home administrators will be able to see their scores under the new system starting Friday.

The changes follow others announced in October that require additional verification of self-reported staffing levels and other efforts to confirm quality data submitted by the homes.

This story originally appeared in Kaiser Health News, an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

KHN’s coverage of aging and long term care issues is supported in part by a grant from The SCAN Foundation.

Study: Physicians Report Few Requests By Patients for ‘Unnecessary’ Treatments



Kaiser Health News

Though medically unnecessary tests and procedures are often blamed for the nation’s high health care costs, patients’ requests for such superfluous treatments may not be what triggers them, suggests a study published today in the JAMA Oncology.

Photo courtesy Seattle Municipal Archives

Photo courtesy Seattle Municipal Archives

Conventional wisdom suggests that doctors often give unnecessary treatments because patients demand them. Some estimate this care accounts for a third of the $2.8 trillion spent annually.

But the survey, which tracked 60 Philadelphia-based clinicians’ interactions with about 3,600 cancer patients, found that patients asked for a particular treatment in only 8.7 percent of those exchanges. Of those requests, doctors considered only 11.4 percent to be for inappropriate or unnecessary care.

Those findings, the paper’s authors write, indicate that patient demands are likely not the impetus for unnecessary procedures. That might suggest doctors provide extraneous treatments for other reasons, though the authors didn’t speculate on what those could be.

“There just aren’t many patients’ demands or requests for unnecessary tests and treatments, and when there are doctors comply with very few of them,” said Ezekiel Emanuel, one of the authors and chair of the University of Pennsylvania’s Department of Medical Ethics and Health Policy.

It’s not entirely clear whether the findings from this study, which focused on oncologists and cancer patients, can be generalized to medicine at large. Though cancer seems like a fitting condition to study due to its “extremely high stakes and very expensive treatments,” it is possible other specialties, such as primary care, actually elicit a lot more patient-requested procedures, said Emanuel, who also is a former White House health policy adviser.

He recommended other researchers conduct similar studies investigating specialties in cities other than Philadelphia to see whether those results echo this study’s conclusions. When it comes to patient requests, “if you don’t see them in oncology, it’s kind of unlikely you’re going to see them a lot of other places, like cardiology or rheumatology or surgery,” he added.

The authors may be correct that patients in general don’t seek unnecessary treatment, said Jason Doctor, an associate professor at the University of Southern California’s School of Pharmacy, who was not involved in the study. “But they need to test it in a broader, more general clinical setting,” such as outpatient facilities, he said.

It would make sense to expect similar results in other specialties, said Katherine Kahn, a professor of medicine at the University of California, Los Angeles and a senior scientist at the RAND Corp., which researches health costs, among other subjects. Still, Kahn, who is not affiliated with the study, cautioned against using the results to make a definitive statement about what drives health costs.

The study indicates that patient requests can be a valuable part of practicing medicine, she said, highlighting needs doctors otherwise might not notice. “Patients often have information about their symptoms or their values or their priorities that clinicians might not know,” Kahn said.

But it takes a bit of a jump, she added, to go from establishing that idea to answering questions around “overuse and costs associated with overuse in the United States.”

That’s especially true in this study, she said, because doctors were the ones who determined and reported what wasn’t an appropriate request, and that potential bias or perspective makes it hard to know how often wasteful or unnecessary procedures actually took place.

Even so, Emanuel said, it highlights a larger point.

Anecdotally, “It’s doctors who say, ‘We had a lot of patients ask for inappropriate tests and treatments.” By quantifying how often doctors actually think this happens – and by noting that, in practice, doctors rarely indicate this is the case – the findings suggests patient demands aren’t the source of wasteful procedures, he said.

“There’s always this question about provision of inappropriate treatment: Is it driven by patient demand or provider supply, and what’s the best way to address the problem?”

Doctor said. “People should study this through, then we can understand whether we should do supply-side intervention or demand-side interventions to reduce inappropriate treatment.”

This story originally appeared in Kaiser Health News, an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

In States with Looser Immunization Laws, Lower Rates


North Carolina’s immunization rate is one of the highest in the nation. The only way parents can ask for exemption is with a letter signed by a physician.

By Christine Vestal


The U.S. Centers for Disease Control and Prevention issued a health advisory this month about an ongoing measles outbreak, with more than 102 cases in 14 states so far. The highly contagious disease can cause severe health complications, including pneumonia, encephalitis and death.

More than 1500 pharmacists in North Carolina have gone through the approval proces to give immunizations.

Photo courtesy U.S. Army Corps of Engineers Europe District, flickr creative commons

By 2000, measles had been nearly wiped out in the U.S., with fewer than 60 cases per year, most connected with foreign travel. Public health officials declared victory, the result of effective state-based immunization campaigns requiring kids to be vaccinated before they enter public schools.

Since then, however, the number of cases has risen along with the number of parents who have received religious or philosophical exceptions to state rules. In 2014, there were at least 23 outbreaks and more than 600 cases.

The federal government’s goal is to immunize at least 90 percent of all children before they enter school to keep measles and other childhood diseases at bay.  Although the national average immunization rate (91.1 percent) exceeds that number, several states fall below it.

“To have pockets where community immunity is below 90 percent is worrisome, as they will be the ones most vulnerable to a case of measles exploding into an outbreak,” said Litjen (L.J) Tan, chief strategy officer of the Immunization Action Coalition, which advocates for higher levels of immunization.

State immunization rates vary widely, with generally lower rates of inoculation occurring in states that make it relatively easy to get an exception. Lawmakers in California, Oregon and Washington state are trying to tighten their laws to allow fewer nonmedical exemptions. Laws allowing religious exemptions have been around longer than those allowing philosophical or “personal belief” exemptions, said Joy Wilson of the National Conference of State Legislatures.

In many but not all states, philosophical exemptions are easier to get than religious exemptions, which typically require parents to cite and explain the religious doctrine in question. Overall, states with philosophical exemptions have 2.5 times the rate of opt-outs than states with only religious exemptions.


Stateline is a nonpartisan, nonprofit news service of the Pew Charitable Trusts that provides daily reporting and analysis on trends in state policy.

Advocates Gear Up for Final Push on Health Insurance Enrollment

By Rose Hoban

With only days to go before the end of this year’s health insurance exchange open-enrollment period, organizers took to the road to get stragglers signed up for coverage.

Close to a half-million North Carolinians have either been re-enrolled or newly enrolled for health insurance that’s available as a result of the Affordable Care Act. Proponents believe they’ll easily top the half-million mark by the time open enrollment ends on Feb. 15.

Advocates Gear Up for Final Push on Health Insurance Enrollment

Advocates, ministers, organizers and patient enrollment “assisters” gathered in front of their tour bus in Raleigh Wednesday morning to plan to get more people enrolled for health insurance before the Feb. 15 deadline. Photo credit: Sorien Schmidt, Enroll America

“We were at 450,000, so we should get to half a million,” said Sorien Schmidt, state head of Enroll America, a not-for-profit organization that’s coordinating sign-ups for the exchanges in 11 states. “How much over that, I don’t know.”

Schmidt said her organization didn’t set any goals this year because it’s only the second year for enrollment and the first year was marked by website and other glitches.

“We really didn’t know what to expect,” she said.

During her telephone interview with N.C. Health News, Schmidt was riding on a bus that’s wrapped with messages in English and Spanish urging people to “Get Covered,” or “Aseguráte.” The bus stopped Tuesday in Asheville, Winston-Salem and Greensboro and on Wednesday in Raleigh. Schmidt was headed to Charlotte for another enrollment rally.

“We had partners, volunteers, assisters and community members there,” Schmidt said. “It was a great turnout.”

Young, new, Medicaid-eligible

Officials from the Centers for Medicare and Medicaid Services said that as of Jan. 30, North Carolina had 479,748 enrollees for coverage. In the Charlotte metropolitan area, 122,837 people have signed up for coverage, while in Raleigh a little more than 60,000 people have enrolled.

People who want help signing up for insurance can call 1-855-733-3711 to find out who in their county can help them.More than a quarter of this year’s enrollees are the so-called “young invincibles.” Younger adults, who as a group are generally healthy, balance out insurance companies’ financial risks of covering older people, who are more likely to become ill. At least 36,000 enrollees are children under 18, who also tend to cost less to insure.

Another 35,000 enrollees are people who in signing up were found to be eligible for coverage under North Carolina’s Medicaid program, according to an update from CMS issued last week.

About 92 percent of enrollees qualified for financial assistance in the form of tax subsidies, higher than the national rate of 87 percent.

In North Carolina, 40 percent of enrollees (more than 187,000 people) are new. The rest (more than 280,000), reenrolled in plans from last year. Not all of the 357,584 people who enrolled during the first year are coming back to the marketplace: Some people got jobs that provide insurance coverage, others simply haven’t reenrolled. And some people earned too little to qualify for financial help this year; for a family of four, that would be annual earnings of about $31,500.

Enroll America national president Anne Filipic said that after last year’s enrollment period her organization did a national survey of people who didn’t enroll. She said they learned that many people didn’t realize they would be eligible for financial help.

“They assumed they could not find affordable options,“ Filipic said. “They’d heard of the Affordable Care Act, but they thought they couldn’t afford it. Most didn’t know about tax subsidies.”

After a slowdown in enrollment during the holidays, the pace has picked back up. Filipic said North Carolina’s enrollment rate is one of the highest in the country, coming in just behind Florida’s.

“I’d point to collaboration among organizations and local leaders throughout the state,” Filipic said.

Do I Have To Repay Premium Tax Credits If The Marketplace Miscalculated Them?


By Michelle Andrews

Kaiser Health News

This week brings answers to questions from readers who are running into difficulties with premiums and tax credits on their marketplace plans.

My 63-year-old husband has Alzheimer’s disease. Our annual income is $41,000, from a combination of his Social Security disability insurance (SSDI) and a disability policy he had from a previous job. Last year I bought a single policy on the health insurance exchange. My husband gets coverage through the Veterans Administration. The monthly premium was reduced by a $278 tax credit based on our estimated annual income. Now I’m reviewing IRS form 8962 that’s used to reconcile what we received in premium tax credits against what we should have received based on our actual income. It looks like we’ll have to repay $2,500! We can’t afford that. If the marketplace made a mistake in figuring our tax credit, do we still have to pay the money back?

image of money and tax forms

Image courtesy

If you received too much in premium tax credits, you’ll generally have to pay some or all of it back. Health policy experts say they know of no provision in the health law or rules that would excuse someone from repayment if an error that resulted in a tax credit overpayment was made by the online marketplace. An administration official didn’t respond to a request to clarify whether those situations would be handled differently than if someone underestimates their own income and receives too much.

The amount you’ll have to repay is capped based on your income. A couple with an income between 200 and 300 percent of the federal poverty level ($31,460 to $47,190 for a family of two in 2014) would have to repay up to $1,500. (People with incomes above 400 percent of poverty –$62,920 for a couple — would have to repay the entire amount.)

It’s hard to know if or where an error occurred. It’s possible that you or the marketplace calculated your income incorrectly. SSDI counts as income when figuring your eligibility for premium tax credits, but disability insurance payments received from an employer policy may or may not count as income depending on who paid the premium, says Karen Pollitz, a senior fellow at the Kaiser Family Foundation (KHN is an editorially independent program of the foundation.)

Perhaps you or the marketplace entered information incorrectly, transposed figures or made some other manual or computer entry error.

By early February you should receive Form 1095-A from the marketplace detailing how much you received in tax credits for reconciliation purposes. It will be important to use that to make sure your calculations on Form 8962 are correct.

If you discover there was an error in your premium tax credit last year, you’ll still have time to sit down with a navigator to go over your 2015 coverage choices before open enrollment ends Feb. 15.

“If she made a mistake, she doesn’t want to compound it by making it again,” says Pollitz.

I had coverage through a health insurance marketplace plan last year, and this year I’m told my costs will increase significantly. The actual premium the insurance company will charge won’t change and my income hasn’t changed. But the amount of premium tax credit I receive will go down. What can I do?

Before you renew your coverage with the same plan you had last year, go back to the marketplace and check out what else is available. It sounds as if the benchmark plan in your area may have changed, and that could mean a higher bill for you unless you switch plans.

Here’s how it works: Premium tax credits are based on the second-lowest-cost silver plan in your area, called the benchmark plan. If the cost of the benchmark plan this year is lower than it was last year, your tax credit may be lower as well. That’s not a problem if you switch to the new, cheaper benchmark plan. But if you renew your old plan, you’ll have to pay the difference in cost between its higher premium and that of the new benchmark plan.

“Even though your premium didn’t change and your income didn’t change, you could see a significant difference in what your contribution is because the premium for the second lowest cost silver plan is different,” says Judith Solomon, vice president for health policy at the Center on Budget and Policy Priorities.

I am being told that I must furnish automatic debit card information before an insurance company will provide me with coverage through the exchange. Can they do that?

Health insurers that sell coverage on the marketplaces are required to accept various forms of payment, says Sandy Ahn, a research fellow at Georgetown University’s Center on Health Insurance Reforms. That includes paper and cashier’s checks, money orders, electronic funds transfers and pre-paid debit cards.

An insurance industry representative said this sounded like a misunderstanding. “Plans accept various forms of payment and wouldn’t limit a consumer only to a debit card,” says a spokeswoman for America’s Health Insurance Plans, an insurance industry trade group. “Health plans regularly work with their members to establish the payment plan that works best for them.”

This story originally appeared in Kaiser Health News, an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

Hatch Vows To Dismantle Health Law But Predicts Bipartisan Success On Other Issues


By Mary Agnes Carey

Kaiser Health News

While Republicans cannot expect a full repeal of the health law while President Barack Obama remains in office, the GOP intends to “strike away at it, piece by piece,” Senate Finance Committee Chairman Orrin Hatch (R-Utah) said Tuesday.

But in a speech at the U.S. Chamber of Commerce, Hatch also said he expected that Republican and Democratic lawmakers would work together on several other key pieces of health legislation.

Sen. Orrin Hatch (R-Utah)

Sen. Orrin Hatch (R-Utah)

Hatch said there may be more bipartisanship in some “must-pass items,” including continued funding for the Children’s Health Insurance Program and overhauling the way Medicare pays physicians, known as the “sustainable growth rate.”

On CHIP, Hatch said the Finance Committee has “heard from a number of governors from red states and blue states alike that they want to see this program extended. It has been a marvelous program. It has worked very, very well. I’m optimistic that we can work on a bipartisan, bicameral basis to extend CHIP in a responsible way.”

Hatch also said he wants the Finance Committee “to address the SGR challenge once and for all.” Last year he co-sponsored legislation that would move physicians from the traditional system in which they are paid for volume and instead use financial incentives to encourage them to move to alternative payment models emphasizing quality care.

Finance must also act “sooner rather than later” to strengthen Medicare, Medicaid and Social Security, he said, noting that in the last Congress he supported several significant changes to Medicare, including raising the eligibility age and simplifying cost-sharing in the program.

In his remarks, Hatch said his committee would work on several measures to repeal elements of the health law – including its medical device tax and employer mandate – even though Obama would be likely to veto the measures.

“We can send them all to the president’s desk and have him try to explain to the American people why he’s right and they’re wrong,” Hatch said.

While House Republicans have passed dozens of measures to repeal or weaken the health law, the Senate has not voted on many of those bills because until this month Democrats controlled the chamber. With Republicans now in charge with 54 seats, odds are better that some of the repeal measures will see floor consideration. But the GOP will still need some Democratic support to reach 60 votes to avoid a filibuster, and they are unlikely to garner enough Democratic support for the 67 votes needed to override a presidential veto.

In a wide-ranging speech that also touched on tax reform, trade and pensions, Hatch said the first health-related bill the Finance Committee will consider is legislation the House passed earlier this month. It allows employers to exempt workers who received health coverage through the Defense or Veterans Affairs departments from the tally used to determine whether the employer is meeting the health law’s requirements for providing coverage.

Hatch said Republicans need to be ready with an alternative to the health law if the Supreme Court later this year strikes down the provision that provides premium subsidies for low- and middle-income people buying coverage on the federal exchanges. If that happens, “we’ll need to act to mitigate the additional damage Obamacare will inflict on the health care system,” he said, but he offered no specific remedies.

Along with Sen. Richard Burr (R-N.C.) and former Sen. Tom Coburn (R-Okla.), Hatch last year co-sponsored a health law alternative that, among its provisions, would repeal the health law’s individual and employer mandates.

Hatch said while he prefers to find bipartisan solutions on health care and other topics, he did not rule out a procedure known as budget reconciliation that allows legislation to pass with 51 votes in the Senate rather than the 60 needed to stop a filibuster. A number of Republicans have suggested that reconciliation could be used to repeal major portions of the health law.

“Should we decide to go that route, I’ll work with my colleagues on the Budget Committee to make sure whatever we do under the Finance Committee’s jurisdiction is effective,” he said.

Kaiser Health News (KHN) is a nonprofit national health policy news service.

With Millions of Sign-ups So Far, Obamacare Enrollment Is Brisk


Enrollment in the Affordable Care Act’s insurance exchanges is on track for meeting Obama administration projections.

Kaiser Health News

A month into this year’s enrollment period, health care experts say sign-ups are on course to hit or exceed the Obama administration’s projection of about 9 million enrollees in 2015.

Several weeks into the second year of the Affordable Care Act’s insurance exchanges, at least 2.5 million people have enrolled in coverage, according to data from state and federal exchanges. 2015 portal 2015 portal

As of Dec. 12, almost 2.5 million had enrolled through the federal insurance exchange, which serves 37 states, the Centers for Medicare & Medicaid Services reported this week. Hundreds of thousands of others chose plans through state exchanges, according to a Kaiser Health News analysis of state exchange data.

Many more are expected to have signed up ahead of a Dec. 15 deadline to get coverage that begins Jan. 1, 2015. Those enrollment figures will be available later this month.

“Exchange enrollment is far ahead of 2014’s pace due to improved technology performance,” said Caroline Pearson, vice president of Avalere Health, a consulting firm.

She said sign-ups are on track to “far exceed” the Obama administration’s 9 million projection, made just before open enrollment began in November. If enrollment continues at this pace, she said, the federal and state exchanges should enroll between 4 and 5 million new participants, she said. That’s in addition to 6.7 million who got coverage for 2014, many of whom are expected to re-enroll for 2015.

Enrollment in 2014 plans reached nearly 7 million despite the disastrous rollout of the federal and several state exchanges, which made it difficult if not impossible to sign up in the early months.

Sign-ups for 2015 began Nov. 15 and continue through Feb. 15. However, those who wanted coverage in January needed to enroll by this past Monday.

Some Republicans have argued that enrollment would suffer in the law’s second year because people would be unhappy with their coverage and prices would skyrocket. So far, that does not appear to be happening.

Several state insurance exchanges reporting data appear to be ahead of where they were several weeks into open enrollment last year, including Massachusetts, Maryland and Vermont.

It is not known how many of the enrollees in some state exchanges are new to the market. But on the federal exchange, about 48 percent of the people selecting plans are new, while 52 percent had coverage in the marketplace this year, according to the CMS.

California officials said it was too early to tell how many of the 1.1 million current enrollees have returned for 2015. In most states, consumers will be automatically re-enrolled in the same plan or one like it if they had not selected a plan by Dec. 15. They can switch before Feb. 15.

“The pace of enrollment is very strong,” Peter Lee, executive director of Covered California, told reporters Wednesday. The state is already on its way to meeting its goal of 750,000 new enrollees this year, Lee said.

He said he expected the momentum to continue, with more than 40 enrollment events planned through Dec. 15.

On the federal exchange, tens of thousands of people have started accounts but not yet selected a plan.

Charles Gaba, a blogger based in Bloomfield Hills, Mich. who accurately forecast 2014 enrollment, predicts that about 12 million Americans will enroll in exchange coverage in 2015.

The Congressional Budget Office had predicted about 13 million sign-ups for 2015, but in November, administration officials estimated about 9 million, in part because fewer employers than expected were dropping coverage and sending their workers to the exchanges. That includes those who re-enroll in coverage as well as new sign-ups.

Similar to last year, the biggest surges in enrollment were expected immediately before the Dec. 15 deadline to have coverage by Jan. 1 and then again right before Feb. 15, which is the final deadline to have coverage in 2015, Gaba said.

Dan Schuyler, senior director of exchange technology at consulting firm Leavitt Partners, said state exchanges are performing much better than they did last year, though there have been minor glitches.

Two state exchanges, Nevada and Oregon, switched to the federal portal after abandoning their own failed software. Maryland, meanwhile, took software from the Connecticut exchange.

“It seems like state exchanges have turned the corner this year,” Schuyler said.

Jon Kingsdale, who oversaw the Massachusetts health insurance exchange from 2006 to 2010 and is a managing director of the Wakely Consulting Group, said customer call centers are also working better with better-trained staff.

One big challenge facing the exchanges, he said, is how well they “hand off” enrollments to health plans, which was a problem in some states last year.

The exchanges also have to make sure automatic re-enrollment works later this month, Schuyler said. Many consumers who are automatically re-enrolled may be shocked to learn their plans have raised rates or changed their benefits, he said.

State and federal officials also have to keep reaching out to consumers. California’s insurance exchange has partnered with hospitals and medical groups to get the word out about the availability of coverage. The agency also stepped up advertisements, including a bilingual campaign featuring people who enrolled last year.

Anna Gorman and Lisa Gillespie contributed to this story.

This story originally appeared in Kaiser Health News, an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

Fracking Regulators Deny Legal Request for Air Pollution Rules

Commissioners at the N.C. Mining and Energy Commission said they don’t have the legal power to institute new air rules, but agreed to study the issues surrounding drilling’s air pollution.

By Gabe Rivin

State drilling regulators on Friday rejected a legal petition from environmentalists who sought new rules to minimize the air pollution released by natural gas wells, which may soon dot North Carolina’s map.

Members of the N.C. Mining and Energy Commission concluded that they don’t have legal authority to develop air pollution rules. The Blue Ridge Environmental Defense League filed a legal petition in August requesting that the commission develop these rules.

Amy Pickle, the vice chairwoman of the MEC, found that the commission doesn't have the legal authority to develop air rules. Photo courtesy Duke University

Amy Pickle, vice chairwoman of the MEC, found that the commission doesn’t have the legal authority to develop air rules. Photo courtesy Duke University

“We have to have statutory authority to promulgate any rule that we write, including rules that we are petitioned to write,” said Amy Pickle, vice chairwoman of the MEC and the director of the state policy program at Duke University’s Nicholas Institute for Environmental Policy Solutions. “[The air rules] are not rules that we have the authority to change.”

Pickle had previously chaired a committee that reviewed BREDL’s request. At a hearing on the petition in October, the committee discussed the potential shortcomings of the state’s current rules.

But despite the concerns raised by Pickle and others, the committee ultimately recommended that the MEC reject the petition. Their reasoning was steeped in a close reading of state law. SB 820, a 2012 law, established the MEC and set the state on course to issue drilling permits. Before issuing permits though the MEC must finish writing a large bundle of rules, a task it is required by a newer law to complete by January.

Despite the breadth of their work, the MEC is not tasked by SB 820 to develop air rules. Instead, the N.C. Environmental Management Commission bears both the authority and responsibility to develop those rules.

This means the MEC does not have the power to carry out BREDL’s request, Pickle’s committee found.

The MEC voted unanimously at Friday’s meeting to agree with this legal interpretation.

New regulations

BREDL’s petition requested that the MEC amend the state’s rules to list gas drilling as a source of air pollution.

This, they said, would require future drillers to secure air permits. And these permits would limit drillers’ abilities to pollute the air.

Their cause for concern is significant, if recent academic studies are any indication. Researchers have found that drilling can release harmful pollutants into air near drilling sites. Those pollutants include benzene, a volatile organic compound that’s known to cause leukemia. Gas drilling elsewhere has caused spikes in ground-level ozone, which can cause respiratory problems even at low levels, according to the U.S. Environmental Protection Agency.

But the Environmental Management Commission chose to not develop any new rules for drilling’s air pollution.

A natural gas well. Drilling can release numerous harmful pollutants, including benzene, a known carcinogen. Photo courtesy U.S. Bureau of Labor Statistics

A natural gas well. Drilling can release numerous harmful pollutants, including benzene, a known carcinogen. Photo courtesy U.S. Bureau of Labor Statistics

The EMC opted instead to rely solely on federal rules. But environmentalists say those rules are limited at best, and could offer large loopholes for future drillers.

According to Lou Zeller, BREDL’s executive director, BREDL initially tried to spur the EMC to action. In a letter last September, the group laid out its request for new air rules.

Zeller said the EMC failed to respond, which is why the group petitioned the Mining and Energy Commission instead.

Environmentalists aren’t the only constituency that expressed frustration over the state’s inaction. Residents in Lee County, a potential hotspot for drilling, have grown frustrated too, according to Matt Matthews, a commissioner with the MEC.

“What we see is the feds seem to be dragging their feet; the state seems to be dragging its feet,” Matthews said.

A study committee

Pickle on Friday reiterated her concerns about potential loopholes in state and federal rules. She also acknowledged that the MEC has not yet issued recommendations to the EMC about air rules, a requirement under SB 820.

Pickle recommended that the MEC establish a permanent committee to study air rules. The committee would look at potential loopholes in federal rules and technologies used to capture air pollution, in addition to related issues.

The MEC adopted this recommendation as well, and agreed to begin this work quickly.

Federal Officials Urge Marketplace Consumers To Look For Better Deals In 2015


By Mary Agnes Carey

Kaiser Health News

More than 70 percent of people who currently have insurance through the health law’s federal online marketplace could pay less for comparable coverage if they are willing to switch plans, officials said Thursday.

With a Dec. 15 deadline looming for coverage that would begin Jan. 1, current policyholders should come back to to see if they can get a better deal, the officials said. They’ll find more plans available and nearly eight in 10 current enrollees can find coverage for $100 or less a month, with subsidies covering the rest of the cost. 2015 portal 2015 portal

A Department of Health and Human Services analysis of 2015 individual market premium data for 35 of the states participating in the federal marketplace, or exchange, found that premiums for the lowest-cost silver plans will increase on average by 5 percent, while prices will increase on average by 2 percent for the second-lowest-cost silver plans, which is called the benchmark plan because subsidy levels are pegged to its cost.

“The plans offering the lowest prices have sometimes changed from 2014 to 2015, so consumers should shop around to find the plan that best meets their needs and budget,” the report advises.

If they stay in their current plan, consumers may discover that their subsidy may not go as far if the price of the benchmark plan declined for 2015.

“We strongly, strongly encourage people to come back to the website and shop,” marketplace CEO Kevin Counihan told reporters during a press call. Federal marketplace enrollees who do not switch plans by Dec. 15 will be automatically re-enrolled in their current coverage.

The number of companies offering policies for next year has increased by 25 percent. Consumers can choose from an average of 40 plans for 2015, up from 30 in 2014, based on the HHS analysis, which examined plan rates at the county level.

Consumers have until Feb. 15 to enroll for coverage in 2015, the marketplace’s second year.

The HHS analysis, mirroring other reviews of 2015 premiums, shows that what consumers pay for coverage depends on where they live. In Juneau, Alaska, for example, a 27-year-old enrolled in the second-lowest-cost silver plan would pay $449 per month for coverage in 2015 before tax credits, a 34 percent increase from 2014. In Jackson, Miss., that same level of coverage would cost $253, or 24 percent less than $332 charged in 2014.

Kaiser Health News (KHN) is a nonprofit national health policy news service. 

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