Health Care Reform Implementation Update – November 14, 2013

Earlier today, President Obama announced that health insurers will be able to extend existing plans for individuals through 2014 that would have been otherwise canceled due to changes under the Affordable Care Act. This proposed fix does not guarantee that extensions will be available, but rather allows insurers to offer the extension and for state regulators to approve it.

The administration has now released enrollment numbers for the Affordable Care Act (ACA) health insurance exchanges. Coming in far below the administration’s predictions, 106,185 people have signed up for health insurance plans through the ACA. A quarter of these individuals enrolled through, while the rest signed up in state-run exchanges. Congress continues to grill those responsible for the exchanges and ACA implementation more generally at hearings and through subpoenas for documents, with Republicans, Democrats and individuals throughout the country requesting or insisting that they be permitted to keep their health insurance plans. Notably, former President Bill Clinton spoke out this week saying that President Obama should let Americans keep their health insurance plans. Meanwhile, interest and momentum are growing for a bill introduced by Senator Mary Landreiu (D-La.) and five others to allow individuals to keep their individual market plans that have been canceled as a result of ACA requirements. It is not clear what, if any, position the White House will take on this legislation.

In the past week, Centers for Medicare and Medicaid Services (CMS) Administrator Marilyn Tavenner testified before the Senate Health, Education Labor & Pensions (HELP) Committee, Department of Health and Human Services (HHS) Secretary Kathleen Sebelius testified before the Senate Finance Committee, and top operational officials for the ACA exchanges, including Chief Technology Officer Todd Park, testified before the House Oversight and Government Reform Committee. Comments on the Senate Finance and House Ways and Means draft Sustainable Growth Rate (SGR) formula repeal were due on November 12, and MedPAC discussed its intent to avoid interfering with discussions on the topic in order to enable Congress to move more swiftly in light of the reduced Congressional Budget Office (CBO) cost of eliminating the formula this year.


On November 5, CMS Administrator Marilyn Tavenner testified before the Senate HELP Committee. Chairman Sen. Tom Harkin (D-Iowa) defended the ACA and criticized Republicans for making implementation difficult. Ranking Member Sen. Lamar Alexander (R-Tenn.) brought up the cancelations in light of President Obama’s promises. Administrator Tavenner highlighted improvements that had been made to the website including faster response times, greater ease in browsing options and ensured security. Administrator Tavenner said the administration was shooting for enrollment in October and November around 800,000. Her communications director later clarified that this number includes total enrollment in federal and state exchanges, as well as Medicaid and Children’s Health Insurance Programs (CHIP) programs.

On November 6, HHS Secretary Sebelius testified before the Senate Finance Committee. Ranking Member Orrin Hatch (R-Utah) said he wants monthly hearings with Sec. Sebelius. Sen. Roberts (R-Kan.) again called for Sec. Sebelius to resign; however, Chairman Max Baucus (D-Mont.) said she needed to remain at HHS. Additionally, Sec. Sebelius warned that she expected enrollment numbers to be low.

The House is planning a vote for November 15 on a bill sponsored by Energy & Commerce Chairman Fred Upton (R-Mich.), the Keep Your Health Plan Act. The bill has 88 co-sponsors in the House and would allow plans that existed on the individual market on January 1, 2013 to stay in effect through 2014.

On November 13, the Committee on Oversight and Government Reform held a hearing to investigate the operational challenges in the development of Committee Chairman Darrel Issa (D-Calif.) called the website “an insult” to the online shopping sites that the online health insurance exchanges had been compared. White House Chief Technology Officer told the Committee that the technology teams were working aggressively to fix the website so it could work for the vast majority of Americans by the November 30 deadline the administration set. Committee Ranking Member Congressman Elijah Cummings (D-Md.) said that though CMS had failed to deliver what it said it would deliver, Republicans are refusing to be helpful in making the reforms work.

House Oversight and Government Reform Committee staff interviewed Henry Chao, who supervised the construction of and participated in signing off on the launch of the website, in a nine-hour closed session on November 8.

The House Committee on Oversight and Government Reform sent letters to health insurance exchanges in states running their own exchanges requesting documents related to the in-person assisters who are assisting with enrollment.

On November 5, Ways and Means Committee Chairman Dave Camp (R-Mich.) issued a subpoena to CMS requesting that it provide all data on enrollment in the exchanges. Congressman Camp first requested this information during a hearing with Administrator Tavenner and then again in a letter on November 1. Additionally, Chairman Camp sent a letter requesting that IRS Acting Commissioner Daniel Werfel disclose all information the agency has about eligibility determinations for premium tax credits under the ACA.

On November 14, the House Committee on Education and the Workforce held a hearing on how the ACA is affecting the country’s education system. The Committee highlighted news that schools at all levels are struggling under the weight of the ACA.

On November 7, HHS announced $150 million in awards under the ACA to support 236 health center sites across the country, which will help care for approximately 1.25 million additional patients.

Sens. Joe Manchin (D- W.Va.) and Mark Kirk (R-Ill.) introduced legislation that would delay the ACA’s individual mandate until January 2015. The proposal would waive the $95 penalty for 2014 entirely.

The Medicare Payment Advisory Commission, MedPAC, the independent body that advises Congress on issues affecting the Medicare program, met on November 7 and 8. The meeting was broken into the following sessions: synchronizing Medicare policy across delivery systems, measuring quality across Medicare’s delivery systems, Medicare accountable care organizations (ACOs), rationalizing Medicare’s payment for post-acute care, improving Medicare payment for chronically critically ill patients in hospital settings, Medicare managed care topics, initial approach to the payment update and other policy options for physicians and other health professionals, and Medicare beneficiaries’ access to hospital care and near-term changes in Medicare’s payment policies. Notably, during the ACO panel, there seemed to be support for a phase in over a two-sided risk model; on the topic of Medicare managed care and the issue that employer-group Medicare Advantage plans bid differently than non-employer plans, the general consensus of the commissioners was in favor of setting the employer bid to benchmark ratio equal to the nationwide non-employer ratio; and in the panel on the topic of a payment update for doctors, Chairman Hackbarth expressed that MedPAC is very supportive of Congress’s work on the SGR repeal formula and will not vote on a strategy for offsets to pay for SGR repeal in order to allow Congress to move swiftly on its proposal.

The Medicaid and CHIP Payment and Access Commission, MACPAC, a non-partisan federal agency charged with providing policy and data analysis to the Congress on Medicaid and CHIP, will meet on November 14 and 15. The meeting is divided into sessions on the future of CHIP, long-term care, short and long-term issues for CHIP, Medicaid Interactions with the ACA, and Medicaid Non-DSH Supplemental payments.


On November 8, long-awaited mental health parity final rules, which arise from the 2008 Mental Health Party and Addiction Equity Act, were released. The regulations implement requirements that treatment for mental illness and substance abuse be treated equally to physical care.

The Obama administration has decided that neither the federal insurance exchange nor the federal subsidies paid to insurance companies on behalf of low-income individuals qualify as “federal health care programs.” The significance of this categorization is that it results in the exchanges and exchange subsidies being exempt from a federal law banning rebates, kickbacks, bribes and some other financial arrangements in federal health care programs.

CMS Chief Information Officer Tony Trenkle announced his resignation on November 6, effective November 15.


A group of 15 Senate Democrats up for re-election in a year met with President Obama and other administration officials on November 6 about the ACA exchanges and the website. The group meeting at the White House included Sens. Mark Begich (D-Alaska), Cory Booker (D-N.J.), Chris Coons (D-Del.), Dick Durbin (D-Ill.), Al Franken (D-Minn.), Kay Hagan (D-N.C.), Mary Landreiu (D-La.), Jeff Merkley (D-Or.), Mark Pryor (D-Ark.), Jack Reed (D-R.I.), Jeanne Shaheen (D-N.H.), Brian Schatz (D-Hawaii), Mark Udall (D-Colo.), Tom Udall (D-N.M.), Mark Warner (D-Va.), and Michael Bennet (D-Colo.).


Terry McAuliffe was elected Governor of Virginia last week. Among the potential implications of McAuliffe’s election is a renewed possibility of Medicaid expansion in the state. Notwithstanding McAuliffe’s support for Medicaid expansion, the state legislature must vote to expand Medicaid before any such legislation gets to the Governor’s desk. Last year, the Virginia legislature gave control of Medicaid reform and expansion to a legislative commission made up of 10 members and controlled by Republicans. The commission has said it is open to expansion if coupled with other major reforms. In his concession speech, gubernatorial candidate Ken Cuccinelli attributed the closeness of the race to the country’s dislike of the Affordable Care Act and the faulty rollout of the exchanges.

Gov. Chris Christie was reelected as Governor in New JerseyGov. Christie had already signed off on his state’s expansion of Medicaid.


New analysis by the Kaiser Family Foundation shows nearly six in 10 people eligible for the insurance exchanges next year will qualify for subsidies to help buy coverage.

Under pressure from the state of California, Blue Shield of California agreed to hold off on canceling plans for 115,000 subscribers until March 31, which marks the end of the ACA’s open enrollment period

On November 12, former President Bill Clinton said that President Obama should make changes to the ACA to allow people to keep their existing health insurance plans.

Over the past few weeks, insurers have reported that enrollees in the ACA exchanges are older than expected. To function as intended, the exchange will need a significant proportion of young enrollees as well. Some are very concerned, and others are certain that the young beneficiaries will sign up close to the deadline.

On November 5, The American Academy of Actuaries warned Congress that delaying the ACA’s individual mandate would hike premium rates. The academy has been circulating a letter around Congress warning about the potential danger of a delay in the individual mandate.


On November 7, President Obama offered an apology to those losing their health insurance plans and said in an interview, “I am sorry that they are finding themselves in this situation based on assurances they got from me.” Sen. Ron Johnson (R-Wis.) pushed back saying that the president’s apology was not genuine.


To view our compilation of recent health care reform implementation news, click here.

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Posted in ACA, ACOs, Affordable Care Act, Articles, Children's Health Insurance Programs, CHIP, CMS, doc fix, Health Care Reform Implementation Updates, health insurance marketplaces,, MACPAC, Medicaid, Medicaid expansion, SGR, Washington, D.C.

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