KHN’s ‘What’s Health?’: Finally Fixing ‘Family Trouble’

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The Biden administration this week issued regulations aimed at fixing the “family problem” of the Affordable Care Act, which has prevented families who cannot afford their employer’s insurance from getting subsidized coverage from the insurance marketplace. The Obama administration decided that only Congress could fix the problem.

Meanwhile, open enrollment for Medicare begins Oct. 15, when beneficiaries can join or switch to individual Medicare Advantage plans or stand-alone prescription drug plans. For the first time, Medicare Advantage plans are poised to enroll more than half of the Medicare population despite complaints that many large insurers are receiving billions of dollars in overpayments from the federal government.

This week’s panelists are Julie Rovner of KHN, Margot Sanger-Katz of The New York Times, Joan Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico and Rachel Kohrs of The State.

Among the takeaways from this week’s episode:

  • The “family problem” has arisen because under ACA rules, people with insurance through their workplace are generally not eligible for subsidies if they instead purchase a policy on the marketplace — unless their work is deemed unaffordable. That determination was based on the cost of insurance for the individual worker, not the cost of a family policy. Because family policies are considerably more expensive than individual policies, they are often unaffordable for workers. New federal regulations will consider the cost of family coverage.
  • Democrats were aware of this problem even after the passage of the ACA. But it’s an expensive change, and they were desperate to keep the cost of the bill under $1 trillion. They promised to fix the “family problem” but didn’t.
  • Many health policy experts believed that reform was needed by Congress, but the Biden administration chose to do it through regulation. It’s unclear whether the regulation will face legal challenges from critics, but opponents may have a hard time proving they are harmed by the new rules and have standing to bring a lawsuit.
  • Many seniors are happy with their Medicare Advantage plans, which often offer more benefits than traditional Medicare at a lower cost. Enrollees, however, generally must be within a plan’s network of health care providers.
  • Questions have been raised about federal payments to the plans. They were initially conceived as a way to save money because lawmakers thought they would be more efficient than government-run plans. But the plan’s benchmark formula now pays them more than 100% of what the government would pay for an average person in traditional Medicare, and the government pays the plan bonuses for taking on sicker patients.
  • These bonuses have been the subject of numerous government investigations, whistleblower complaints and some fraud lawsuits alleging that the plans misidentified enrollees’ medical conditions in order to receive higher reimbursements from the government. But despite some watchdog groups raising concerns, the Centers for Medicare and Medicaid Services has not made major changes to reimbursement formulas, in part because Medicare Advantage has high patient satisfaction and bipartisan support on Capitol Hill.
  • As lawmakers approach Election Day next month, Democrats have touted their support for abortion rights and hit back at Republicans who supported the Supreme Court’s overturning decision. Roe v. Wade, which ensured access across the country. However, Democrats have not been as active in their case for passage of the Inflation Reduction Act, which proposed several popular changes, including a cap on out-of-pocket drug costs for Medicare beneficiaries, including a provision that would have allowed Medicare to open negotiations. Some drug prices, and an extension of improved subsidies for those who purchase insurance in the ACA marketplaces.
  • Democrat John Fetterman’s campaign for the U.S. Senate seat from Pennsylvania has slowed somewhat as he recovers from a stroke earlier this year. He’s back on the trail and performing live, but he uses a computer device to help translate conversations into written language because he says his hearing process hasn’t healed. Critics say he should be more transparent with his medical records. Disability advocates hit back at Fetterman’s criticism.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week that they think you should read:

Julie Rovner: KHN’s “If you care about the environment, consider composting when you die,” Bernard J. by Wolfson

Margot Sanger-Katz: KHN’s “Baby, That Bill Is High: Private Equity ‘Gambit’ Pushes Excessive ER Charges from Routine Births,” by Rae Ellen Bichel

From Joan: Food & Environmental Reporting Network’s “For a historically black California town, a century of water access denied,” by Teresa Cotsirilos

Rachel Kohrs: STATUS “A Tiny New HHS Office Has a Big Goal: Tackling Environmental Justice,” by Sarah Woermohle

Also mentioned in this week’s episode:

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