Welcome to Health Reform Watch, Sarah Kliff’s regular look at how the Affordable Care Act is changing the American health-care system — and being changed by it. You can reach Sarah with questions, comments and suggestions here. Check back every Monday, Wednesday and Friday afternoon for the latest edition or sign up here to receive it straight from your inbox. Read previous columns here.
Health Reform Watch's Fix Tracker!
President Obama has asked states to allow insurance companies to renew non-Obamacare compliant plans through 2014. We'll be using this tracker to keep a running list of how states are deciding. For a more thorough version of this tracker, check here. And let us know if your state is missing!
Allowing late renewals: Hawaii, Ohio, N.C., Fla., Ky., Tex.
Not allowing late renewals: Mass., Md., Minn., R.I., Vt., Wash.
Still deciding: Calif., Colo., D.C., Ind., Miss., Ore., S.D.
The White House invited a handful of insurance commissioners to talk with the president Wednesday about his proposal to reverse health insurance cancellation notices. This is not the first time that President Obama has invited insurance regulators to Washington; the group's work has been key to other health law provisions, such as a rule that all insurers must spend at least 80 percent of subscriber premiums on medical bills.
Still, Wednesday's meeting could prove a bit more tense than the other summits. A half-dozen insurance commissioners have already announced that they do not plan to implement the president's proposal. Here are a few questions that we'd expect to come up at the meeting.
So...where is everybody?
Some of the insurance commissioners invited to the White House have declined, saying that they had "serious reservations" about the meeting.
"While we greatly appreciate the opportunity to meet with President Obama, briefing the membership and working to build consensus on a meeting of this importance needs to occur prior to sitting down with him," one letter signed by six insurance commissioners, said.
Insurance regulators have expressed frustration at not getting much of a heads-up on a policy change they are now supposed to implement. "It only dropped in our laps yesterday morning," National Association of Insurance Commissioners president Jim Donelon told me in an interview Friday.
Are the risk pools going to get messed up?
One big concern of insurance regulators is that allowing consumers to extend these insurance plans could mess up the configuration of the group of people buying coverage through the new exchange. The people in the pre-Obamacare plans are kept in a separate "risk pool," with their own health care costs used to calculate premiums for that specific group of people.
People who already have individual market coverage tend to be a bit healthier than those who will likely gain coverage under Obamacare. So the worry is, if you segregate the non-Obamacare people into a separate risk pool, premiums will go up in 2015.
A more immediate concern though, is what happens in 2014. Insurers set their prices for the exchanges months and months ago, expecting that the people with cancellation notices would hop into the new risk pool. If they don't, that could mean that the premiums charged in the marketplace would be insufficient to cover subscriber costs.
What about your risk corridors?
The risk corridors are not front page news but they're also a key part of the health care law, a program that reimburses insurers' for some of the costs of super-expensive patients. Here's how they work: If insurers' actual costs -- the claims they pay out -- are more than 3 percent higher than "target" costs, the government will foot 50 percent of the difference. Get 8 percent higher, and the government chips in 80 percent.
The federal government has hinted that it might change change the risk corridor program to better accommodate insurers that wind up with even sicker subscribers than they had expected. But in a meeting with insurance executives last week, Politico reported, the president made clear there would be a limit to those changes.
Why do this by executive order?
This is an issue that Donelon, the NAIC president, raised in my interview with him Friday. He says that a lot of states aren't quite sure whether they can treat an executive order with the force of law.
"The various state general counsels are looking at that," he says. "I have seen one state attorney general opine that the state regulator [there] does not have the authority to act based upon an executive order from the president or anyone else. That state regulator is limited to legislative action."
There were a few proposals to reverse cancellation notices floating around Capitol Hill, but all of them tended to go a good deal further in allowing plans that don't comply with Obamacare to stick around. One would allow new people to enroll in these products; another would give family members the option to join up. That made these plans, from the White House's view, less preferable than the president's own fix. But working by executive order could be difficult for states.
Could we do this again some time?
Adam Hamm is North Dakota's insurance commissioner and one of the six who turned down the White House invitation. In a separate statement, Hamm said that much of the reason for declining to attend has to do with timing.
"It's an honor to have been invited to meet with the President and I would enjoy the opportunity to do so in the future," he said in his statement. "However, because the topic for the meeting (Affordable Care Act) is so delicate and potentially divisive among the nation's insurance commissioners, a meaningful discussion between all the commissioners needs to take place before a meeting with the President."
Donelon expected that the NAIC would put out some of its own research on how the president's policy would be implemented likely by the end of this week. That could lay the groundwork for a meeting at a future date.
KLIFF NOTES: Top health policy reads from around the Web.
Congressional staff are getting hands-on help using the exchange. "While millions of Americans have been left to fend for themselves and go through the frustrating experience of trying to navigate the federal exchange, members of Congress and their aides have all sorts of assistance to help them sort through their options and enroll. Lawmakers and the employees who work in their “official offices” will receive coverage next year through the small-business marketplace of the local insurance exchange, known as D.C. Health Link, which has staff members close at hand for guidance." Robert Pear in the New York Times.
Connecticut's health exchange enrollees skew older. "Data released Tuesday by Connecticut officials show that more people over the age of 55 enrolled in private insurance (40%) than people under the age of 35 (26%). The figures represented enrollment in private health plans as of Nov. 15. Those figures track pretty closely with information released earlier by Kentucky. In the Bluegrass State, 39% of enrollees in private insurance were 55 or older, compared with 24% of people ages 34 and younger." Amy Schatz in the Wall Street Journal.
Maryland still having trouble getting its exchange off the ground. "Maryland is wrestling with stubborn technological problems with its online insurance exchange, posting weak enrollment even as other states have signed up thousands of consumers for plans under President Obama’s new health-care law. In October, the exchange’s first full month of operation, 1,278 people signed up for the private plans, and 465 signed up in the first week of November. Those low numbers raise questions about whether Maryland will achieve its enrollment target of 150,000 by the end of March. The state has about 800,000 uninsured residents." Lena H. Sun in The Washington Post.