Pre-X Redux

With the focus now mainly on exchanges, Medicaid expansions, and enrolling the uninsured in newly available coverage arrangements, there is less attention lately to the ACA insurance reforms which have always been the most popular parts of the law – changes which could affect every American’s insurance in some way…

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Covering The ACA May Be Almost As Hard As Implementing It

This Pulling It Together was adapted from a column I published earlier this week in Politico, with a new introduction added. You can read the original Politico column here. The implementation of the ACA is news and the public will demand information about it. Journalists and news organizations have an obligation…

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Poor People Have the Same Needs as Others

Drew Altman, President and CEO of the Foundation, was asked to contribute to the New York Times’ Room for Debate discussion on More Medicaid, More Health? In his piece, Dr. Altman concludes “Insurance — public or private — provides financial protection and access to medical care which low-income people need just as everybody else does. But it cannot by itself change behavior, alleviate poverty, or guarantee that the medical system is doing all it can to improve health.”

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Can We Learn From ACA Implementation and Improve the Law?

Senator Baucus made headlines recently when he predicted a “train wreck” for Obamacare. David Brooks predicted “chaos” in a recent column. In a news conference, the President offered a different perspective.  “There’ll still be, you know, glitches and bumps…. That’s pretty much true of every government program that’s ever been…

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We Still Have a Health-Care Spending Problem

Drew Altman, President and CEO of the Foundation, and Larry Levitt, Senior Vice President, co-authored a Washington Post op-ed that examined how the economy affects the nation’s health spending.  It concludes that the record slow growth rate of recent years stems largely from economic factors beyond the health system, with the…

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Questions for 2014

Today’s discussion of the Affordable Care Act (ACA) is focused on immediate implementation milestones leading up to 2014 when the law’s major provisions are set to kick in.  This is a critical period when the foundation for the ACA is being established and key building blocks such as the state…

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                    [post_content] => With the focus now mainly on exchanges, Medicaid expansions, and enrolling the uninsured in newly available coverage arrangements, there is less attention lately to the ACA insurance reforms which have always been the most popular parts of the law – changes which could affect every American’s insurance in some way and which go into effect regardless of the implementation decisions states make.  In this column, I draw on our recent tracking polls to review where the public stands on the most prominent of these insurance reforms – guaranteed issue. This is another area where information could matter because many people with pre-existing medical conditions who stand to benefit from the law don’t seem to know about it.

Forty-nine percent of the American people under the age of 65 report that they or a family member have a pre-existing medical condition such as heart disease, diabetes, asthma, and cancer. Among this group, a quarter (25%) say that they or someone in their household has been denied coverage or had their premium raised because of a pre-existing condition.

Thirty-five percent say they worry that they will have to pass up a job opportunity or forego retirement plans to maintain coverage and nearly one in ten (9%) say they or someone in their household has passed up a job opportunity or decided not to retire in the past year because of “job lock”.

The “guaranteed issue” requirement in the ACA fixes this problem, which is called medical underwriting. It requires insurers to issue health plans to anyone in the individual or group markets, regardless of their health status, and prohibits rate surcharges based on health status in the individual and small group markets.  Like most of the ACA’s major revisions, it kicks in January 1 of next year, with open enrollment beginning this October.

The provision is popular; 66% of the American people support it. It is also one of those ACA provisions Republicans like, with 56% of Republicans supporting it. The President has talked about it often, journalists have publicized it, and experts have debated the impact of eliminating medical underwriting on the costs of insurance since passage of the law.  But like many elements of Obamacare, many people who will benefit from it don’t seem to know about it. Among those who report that someone in their household has a pre-existing condition, four in ten are not aware of the guaranteed issue provision. Just like the other group who will benefit most from the ACA, the uninsured, a large number – in this case half of all people who have someone in their household with a pre-existing condition – say they don’t have enough information about the ACA to know how it will impact them or their family.

Not everyone with a pre-existing condition has had a problem getting health insurance. People with employer-based coverage are protected under the previous law unless they lose their job and experience a coverage gap. Nor does liking the idea of guaranteed issue necessarily mean someone will support the ACA; people like or dislike the ACA for various reasons. And, there are tradeoffs in eliminating underwriting against people with pre-existing conditions. Premiums may rise somewhat to accommodate coverage for people who are sick (the idea is to balance this to some extent by insuring people who are young and healthy as well).

But there is a large constituency of people with major illnesses who will benefit from the law who do not seem to know it, and virtually everyone benefits from the peace of mind of knowing that if they get sick they no longer can be denied coverage or priced out by surcharges, even if they have large group coverage and lose it. Right now, working people who get sick and need to leave their jobs have only expensive COBRA coverage as a temporary solution.

The ACA awareness and outreach effort now getting underway is aimed more at the goal of connecting the uninsured to new coverage opportunities than helping people to understand the security of knowing that they can’t be denied coverage if they get sick. There is obvious logic in that, since the law cannot succeed without getting people enrolled. But, many people with pre-existing conditions such as cancer, heart disease, or diabetes are represented by organized and usually very effective disease groups. They have a role to play in informing their constituents about this issue as do health professionals whose patients may benefit from the guaranteed issue provision. Fifteen percent of those with a pre-existing condition say they have talked with their doctor or a medical professional about the ACA.

One reason this is important now: as the economy improves, people will be looking for better job opportunities, and there is a significant group of people still afraid to change jobs because they are sick and who seem not to know that they soon will not have to worry about that anymore.

________________

(Note: In this column, I report data on pre-existing conditions from our March, April and June 2013 Kaiser Tracking Polls and our September 2011 Tracking Poll. I focus on the non-elderly because seniors are protected from medical underwriting by the Medicare program.)
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                    [post_content] => This Pulling It Together was adapted from a column I published earlier this week in Politico, with a new introduction added. You can read the original Politico column here.

The implementation of the ACA is news and the public will demand information about it. Journalists and news organizations have an obligation to cover this story.  As Kaiser CEO I serve as the publisher of our non-profit news service, Kaiser Health News, and also as the head of our large health policy information and analysis enterprise, so I see ACA implementation from a variety of perspectives. The ability of journalists to cover the ACA accurately and in depth will be related to our ability in the health policy community to provide facts, data, and evidence on ACA implementation in near real time, and to provide expert analysis journalists can rely on. Ultimately it will also depend on our ability to evaluate the impact of the law on coverage, access, people’s financial burdens, and overall health care spending, and to do it in a time frame that is not so slow that public and political judgment on the ACA has already been rendered. This column addresses the challenges journalists face covering the ACA, but ACA implementation confronts the health policy community with challenges that are at least as formidable as those faced by journalists. They will be the subject of another column.
Covering The ACA May Be Almost As Hard As Implementing It
President Barack Obama recently predicted “glitches and bumps” when major provisions of the Affordable Care Act are implemented next year. It is always this way. Today we think of Medicare as a popular program that is part of the fabric of American life. But my friend Joseph Califano, who helped create Medicare while working for Lyndon B. Johnson, recalls real problems during the early days of the program, including resistance to desegregating hospitals and physician reluctance to participate. But there is at least one big difference today: Our almost instant and nonstop news cycle, the Internet and the impact of the news echo chamber on the public. As several news organizations learned during last summer’s coverage of the ACA ruling in the Supreme Court, it’s better to be right than to be first. Getting the ACA story “right” will be nearly as difficult as implementation itself. Here are four major challenges all news organizations will face. These are challenges we face too at Kaiser Health News. 1. The biggest challenge is that ACA is no longer a Washington story. As the story moves to the states, national news organizations will need to cover the law’s implementation beyond the Beltway and explain what it means for the American people. Few national news organizations have the “eyes and ears” across the country to do this well, and regional and local news organizations do not have the on-staff health policy expertise, even if they have the local ties. This is a challenge for us at Kaiser Health News, with a staff of reporters and editors based mostly in Washington. We are establishing partnerships with regional newspapers, NPR affiliates and others, so that together we can spot the most relevant state and local stories to report them locally and nationally through our distribution partners. Other news organizations will find their own answers. 2. Another challenge will be judgment by anecdote. Critics will feed reporters ACA horror stories and supporters will sell them success stories. Every journalist will be able to find a bad ACA story or a good one. When does “one” person’s experience represent “many,” or “most”? The gold standard is to take examples from a statistically representative group using a scientifically valid survey, but that’s just not going to happen very often with reporters working under deadlines. Journalists will need to do interviews, check with experts, scrape together what early data exist and make judgment calls about whether the anecdote they have is an outlier or representative of broader experience. Let’s say Bill Smith in Arkansas chains himself to the IRS building and refuses to pay his fine in protest of the law’s requirement that Americans buy health insurance, but that overall, the mandate works smoothly, as it has in Massachusetts. No doubt, Smith will be “breaking news” on your favorite cable channel. With complex stories like ACA, there is a temptation to cover only breaking news and not the broader story. These news judgments matter because powerful anecdotes stick in the public mind in ways statistics never will. 3. A third challenge is deciding what to cover. When the “death panel” story broke, many news organizations sprang into action to fact check and debunk the claim. Cable news covered the story day after day. No doubt the repeated coverage of nonexistent death panels contributed to public anxiety about the law. Today, 40 percent of the American people still believe there are death panels in ACA. News organizations need to make their own judgments about what is important to cover and be on guard against being manipulated by the political process. The decision about what stories to cover can be even more important than how to cover them. 4. Finally, there is the “balance trap” — the pressure to present the views of the organized right and left rather than the facts. This is a general problem for journalism today but one that is particularly relevant to ACA because views on it are so sharply divided along partisan lines. I recently moderated a panel with three top journalists from The New York Times, NPR and The Wall Street Journal. All three said that the pressure to do just this was their biggest challenge covering health reform in a hyperpartisan Washington. It is not always easy to find the facts, and sometimes issues are maddeningly gray in health policy. But often the facts are clear in statute or regulations. They are in a government report or a study from a respected organization. Our polls show that the public remains only dimly familiar with the details of ACA, and those who stand to gain the most (the uninsured or people with pre-existing medical conditions) often know the least. As the main elements of the law are implemented, efforts are being mounted by the federal government, states and nonprofit organizations to inform people. As important as these targeted awareness and outreach efforts will be, the news media have always been the public’s main source of health information. And while local TV news has traditionally been the public’s top source of health news, newspapers, radio, online news and cable news are closely bunched as their top sources of information about ACA. How well news organizations step up to these and other ACA coverage challenges will have a big impact on implementation of the law and public judgment about it. [post_title] => Covering The ACA May Be Almost As Hard As Implementing It [post_excerpt] => [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => covering-the-aca-may-be-almost-as-hard-as-implementing-it [to_ping] => [pinged] => [post_modified] => 2014-03-04 11:14:33 [post_modified_gmt] => 2014-03-04 16:14:33 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.kff.org/?post_type=perspective&p=74512 [menu_order] => 0 [post_type] => perspective [post_mime_type] => [comment_count] => 0 [filter] => raw ) [2] => WP_Post Object ( [ID] => 71636 [post_author] => 36621681 [post_date] => 2013-05-07 17:31:38 [post_date_gmt] => 2013-05-07 21:31:38 [post_content] => Drew Altman, President and CEO of the Foundation, was asked to contribute to the New York Times' Room for Debate discussion on More Medicaid, More Health?  In his piece, Dr. Altman concludes "Insurance -- public or private -- provides financial protection and access to medical care which low-income people need just as everybody else does. But it cannot by itself change behavior, alleviate poverty, or guarantee that the medical system is doing all it can to improve health." New York Times: "Poor People Have the Same Needs as Others" [post_title] => Poor People Have the Same Needs as Others [post_excerpt] => Drew Altman, President and CEO of the Foundation, was asked to contribute to the New York Times' Room for Debate discussion on More Medicaid, More Health? In his piece, Dr. Altman concludes "Insurance -- public or private -- provides financial protection and access to medical care which low-income people need just as everybody else does. But it cannot by itself change behavior, alleviate poverty, or guarantee that the medical system is doing all it can to improve health." [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => poor-people-have-the-same-needs-as-others [to_ping] => [pinged] => [post_modified] => 2013-05-08 20:25:41 [post_modified_gmt] => 2013-05-09 00:25:41 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.kff.org/?post_type=perspective&p=71636 [menu_order] => 0 [post_type] => perspective [post_mime_type] => [comment_count] => 0 [filter] => raw ) [3] => WP_Post Object ( [ID] => 70869 [post_author] => 48572675 [post_date] => 2013-05-07 09:00:20 [post_date_gmt] => 2013-05-07 13:00:20 [post_content] => Senator Baucus made headlines recently when he predicted a “train wreck” for Obamacare. David Brooks predicted “chaos” in a recent column. In a news conference, the President offered a different perspective.  “There’ll still be, you know, glitches and bumps…. That’s pretty much true of every government program that’s ever been set up,” Obama said. “But if we stay with it, and we understand what our long-term objective is, which is making sure that in a country as wealthy as ours, nobody should go bankrupt if they get sick, and that we would rather have people getting regular checkups than going to the emergency room because they don’t have healthcare, if we keep that in mind, then we’re going to be able to drive down costs.” There are always problems in big government programs and unintended consequences that could not be predicted in advance of implementation. The longer term question is not whether there will be problems – there will be glitches and there will be even more successes as people gain coverage and insurance is reformed – but whether the political system today has the capacity to learn from implementation, adapt and make improvements. In the history of domestic programs there are few if any examples of “train wrecks” or “chaos”. Yes, Medicare Catastrophic was, well catastrophic, but it was never implemented.  Social Security, Medicare, and Medicaid were all implemented reasonably smoothly. In the ACA, like Medicaid or welfare, states bear a lot of responsibility for implementation and administration and there will be substantial variation in performance across the states. Some view that as a problem and some see it as a strength. One under-appreciated aspect of the ACA is how fundamentally the Supreme Court changed the law when it made the Medicaid expansion a state option. Many governors also waited for the outcome of the election to decide what they would do. The result is that the program being implemented is, in important respects, not the same as the one originally envisioned in the statute. There is no doubt states will make adjustments as implementation proceeds and they learn what is working and what is not in their exchanges and Medicaid expansions. Right now only seven states are planning “active purchaser” exchanges that, among other things, more aggressively try to control premium increases among plans offering business in their exchanges. One prediction I will make (it could be wrong) is that over time more states running their own exchanges will move away from the passive Expedia.com model exchange towards a more active purchaser model. HHS will also have the ability to make changes through administrative authority, waivers, and new regulations. The question is the Congress. Typically the process of learning from experience culminates in Congress with new legislation. Welfare reform legislation, for example, began in the Reagan years but was revisited comprehensively in the Clinton years. And both Medicare and Medicaid have been substantially modified through successive waves of legislation over the years. Laws are changed as we learn what works, as needs and circumstances change, and as political support for needed changes coalesces. Can today’s hyperpartisan, largely paralyzed Congress agree on legislation to improve ACA as we learn from implementation? Would Republicans agree to anything Democrats want? Would Democrats open up the ACA for legislative tinkering? It is not easy to envision agreement on ACA-related legislation any time soon. One thing that could change the picture somewhat is the current negotiations occurring between several states and the administration over the Medicaid expansion. If HHS and these states can successfully negotiate arrangements that give the states the flexibility they want and at the same time provide adequate protections for beneficiaries, it will bring more red states and their governors into the fold and create a much more bipartisan base for the ACA in the states than it has had in Washington, as well as a broader constituency for changes to improve the law over time. This will not happen overnight. Another factor that will affect the ability to learn and adapt as implementation proceeds is media coverage. If journalists focus on both what is working well as well as what is not, they can make a real contribution not only to public judgment about the ACA but future efforts to improve it. If they focus only on gotcha outlier horror stories that do not reflect general experience with the ACA, their reporting will do more to fuel political partisan debate than inform future policy. Of course the Congress itself could change in coming years, but with only thirty to forty seats up for grabs in the House of Representatives and the others mostly safe districts that lean right or left, redistricting has baked a certain degree of polarization into Congress for the immediate future. As implementation unfolds there are as many questions about the ability of our political system to learn from implementation and respond intelligently to the ACA as there are about the ACA itself. [post_title] => Can We Learn From ACA Implementation and Improve the Law? [post_excerpt] => [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => can-we-learn-from-aca-implementation-and-improve-the-law [to_ping] => [pinged] => [post_modified] => 2014-03-04 11:14:34 [post_modified_gmt] => 2014-03-04 16:14:34 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.kff.org/?post_type=perspective&p=70869 [menu_order] => 0 [post_type] => perspective [post_mime_type] => [comment_count] => 0 [filter] => raw ) [4] => WP_Post Object ( [ID] => 68482 [post_author] => 36622400 [post_date] => 2013-04-22 19:00:49 [post_date_gmt] => 2013-04-22 23:00:49 [post_content] => Drew Altman, President and CEO of the Foundation, and Larry Levitt, Senior Vice President, co-authored a Washington Post op-ed that examined how the economy affects the nation’s health spending.  It concludes that the record slow growth rate of recent years stems largely from economic factors beyond the health system, with the economy explaining 77 percent of the slowdown, and more rapid growth expected in coming years if the economy strengthens as expected.  The op-ed was based on a related Foundation Issue Brief.

Washington Post Op-Ed

 washingtonpost_logo [post_title] => We Still Have a Health-Care Spending Problem [post_excerpt] => [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => we-still-have-a-health-care-spending-problem [to_ping] => [pinged] => [post_modified] => 2013-05-09 18:55:04 [post_modified_gmt] => 2013-05-09 22:55:04 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.kff.org/?post_type=perspective&p=68482 [menu_order] => 0 [post_type] => perspective [post_mime_type] => [comment_count] => 0 [filter] => raw ) [5] => WP_Post Object ( [ID] => 68402 [post_author] => 5093470 [post_date] => 2013-03-22 09:52:28 [post_date_gmt] => 2013-03-22 13:52:28 [post_content] => Today’s discussion of the Affordable Care Act (ACA) is focused on immediate implementation milestones leading up to 2014 when the law’s major provisions are set to kick in.  This is a critical period when the foundation for the ACA is being established and key building blocks such as the state Medicaid expansions, exchanges, and a host of regulations about other elements of the ACA being produced by HHS are getting our attention. But there is also an ACA horse race mentality threatening to take over: Is this or that regulation on time or late?  How many states have committed to the Medicaid expansion so far or to one kind of exchange or another?  Will every element of the ACA be ready to go in 2014 as envisioned in the legislation? Is the ACA succeeding or failing?  Everybody is keeping score.  In a partisan Washington with a gotcha media, it’s easy to get lost in the weeds.  Here are five big picture questions to keep in mind about the ACA.
1. As Republican governors slowly come on board, can the ACA make the transition from an ideological and partisan war zone to a more bipartisan effort to benefit people, with more traditional tensions between Washington and the states over money, flexibility and control?
Governors, historically more pragmatic than ideological, may be reverting to form and could give the ACA the bipartisan support on the ground it has not had in Washington.  It is still too early to say if the Republican governors will actually change the politics of the ACA. Conservative legislatures in some states, including Florida, are putting up resistance to their governors' decisions.  Some governors are also putting their own twist on how their Medicaid expansions will operate, to distance themselves from Obamacare at the same time as they embrace the Medicaid expansion and substantial federal funding for it (though not necessarily the exchanges and the rest of the law).  More of this two-step - embracing while distancing - may be necessary to bring conservative state legislatures along.  It is possible that the governors, pushed by providers in their states and local government and their own sense of pragmatism, will slowly transform the ACA from a partisan conflict to a more typical federal-state program with more traditional state-federal tensions over money and control. To be clear, it is the federal money and the potential to provide coverage for their citizens which is moving the Republican governors, not some overnight conversion to Obamacare, but the longer term result could be a much more bipartisan complexion for the law.
2. Will there be a rush to judgment in 2014 when there are inevitable early implementation stumbles and enrollment builds more slowly than expected?
It may be time to recalibrate expectations about timetables set originally to pass legislation to reflect new realities.  Since the ACA passed, the Supreme Court effectively made the Medicaid expansion a state option.  Many governors and legislators also waited for the outcome of the election to decide whether or not to move forward on ACA implementation.  As a result, the ACA being implemented now is no longer exactly the same health reform law that passed the Congress, and the circumstances affecting implementation have changed.  Already the Congressional Budget Office (CBO) has adjusted their enrollment projections. It will take time for enrollment to build up as new systems and outreach efforts gear up. Our newest tracking poll shows that the public remains confused about what the ACA does, including groups like the uninsured who will benefit most. This is not surprising, since mostly what the public has heard for three years is partisan bickering about the ACA. Only now as we head for implementation of its key provisions in 2014, is the ACA beginning to be introduced to the public for real.  This transition point from political talking point to reality is both a challenge and a critical opportunity for the law. To be clear, implementation deadlines should not be changed.  People have waited long enough for the coverage and other benefits the ACA will provide; and if they are changed, the implementation effort will slow accordingly.  Quite the contrary, now is the time for an all-out implementation effort.  But expectations may now need to be adjusted to reflect post Supreme Court realities and the uncertainties of current federal budget debates.
3. Will there be a backlash to the individual mandate and the law in general if some people find the policies they are now required to buy unaffordable, especially those who will not be receiving premium subsidies in the exchanges?
Policies available in the exchanges will provide far better value than those offered today in the largely broken non-group market.  Even so, the affordability of bronze and silver plans as perceived by people who buy them, not by experts calculating their actuarial value in advance of implementation, will be a critical moment for the ACA.  And people will be required to buy these policies.  The mandate worked smoothly in Massachusetts, the only place where it has been tried.  The citizens of the state like the program and by all accounts no one ran from Massachusetts for Rhode Island or New Hampshire because of the mandate.  Does that mean the ACA’s mandate will work smoothly in the rest of the country?  The vast majority of people buying policies in exchanges will like the deal they are getting but some may not.  How will the press handle a relatively small number of people experiencing rate jitters?  How will policymakers respond?
4. If, as I suspect, costs begin to rise again when the economy strengthens, will that be blamed on the ACA?
It should not be.  The ACA supports important Medicare payment and delivery experiments.  It also has provisions (medical loss ratio thresholds and rate review) that put downward pressure on premium increases in some parts of the market.  And it is entirely plausible (to me) that the ACA has precipitated a market response beyond its own Medicare pilot projects resulting in changes in payment and delivery and at least temporary cost moderation, just as the mere threat of health reform legislation has done in the past.  But the ACA is neither the cause of nor the ultimate solution to the larger problem of rising health care costs.  The causes of the recent slowdown in health costs are a much bigger topic that we will be addressing in a forthcoming analysis.  We have seen slowdowns in health costs before and they have always been followed by upticks. It is  important to understand when the slowdown started, how much of it is due to the effects of the weak economy on utilization or, potentially, to changes in health delivery and financing, and what the future outlook might be.
5. In the hyper-partisan political system we have with today’s media, is there the capacity to learn from implementation so health reform can continue to be reformed and improved?
The idea that you pass a law, write regulations, implement it, and then judge its success or failure bears little relationship to how programs do or should work.  Not everything can be anticipated when legislation is written, and much that goes into legislation is designed to win enough votes for it to pass rather than for it to work optimally in the real world. This legislation too was passed without the normal reconciliation between House and Senate plans, which offers opportunities to fix problems in the law and choose the best of both approaches. Circumstances also change as programs are implemented.  Reflecting this, Medicare and Medicaid have changed substantially over time.  Can adjustments to the ACA be made in this Congress?  In the states?  By our current largely frozen political system? The kinds of changes often made to improve legislation do not seem possible in the current Congress. In 2014 there will be an ample supply of both early ACA success stories and stumbles.  It will take years for scientific evaluations to measure the impact on access and financial burdens and other outcomes.  The year 2014 is merely the date when major ACA provisions begin, and it will take years beyond 2014 before it is clear how many states undertake Medicaid expansions or what the ultimate mix of state versus federal exchanges is and how many people ultimately benefit from the ACA’s coverage expansions.  While no doubt some will try, 2014 is not the right time to declare success or failure for the ACA any more than 1966 was the right time to do the same for Medicare or Medicaid. [post_title] => Questions for 2014 [post_excerpt] => [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => questions-for-2014 [to_ping] => [pinged] => [post_modified] => 2014-03-04 11:14:34 [post_modified_gmt] => 2014-03-04 16:14:34 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.kff.org/?post_type=perspective&p=68402 [menu_order] => 0 [post_type] => perspective [post_mime_type] => [comment_count] => 0 [filter] => raw ) ) [post_count] => 6 [current_post] => -1 [in_the_loop] => [post] => WP_Post Object ( [ID] => 76279 [post_author] => 36621681 [post_date] => 2013-06-20 09:00:41 [post_date_gmt] => 2013-06-20 13:00:41 [post_content] => With the focus now mainly on exchanges, Medicaid expansions, and enrolling the uninsured in newly available coverage arrangements, there is less attention lately to the ACA insurance reforms which have always been the most popular parts of the law – changes which could affect every American’s insurance in some way and which go into effect regardless of the implementation decisions states make.  In this column, I draw on our recent tracking polls to review where the public stands on the most prominent of these insurance reforms – guaranteed issue. This is another area where information could matter because many people with pre-existing medical conditions who stand to benefit from the law don’t seem to know about it. Forty-nine percent of the American people under the age of 65 report that they or a family member have a pre-existing medical condition such as heart disease, diabetes, asthma, and cancer. Among this group, a quarter (25%) say that they or someone in their household has been denied coverage or had their premium raised because of a pre-existing condition. Thirty-five percent say they worry that they will have to pass up a job opportunity or forego retirement plans to maintain coverage and nearly one in ten (9%) say they or someone in their household has passed up a job opportunity or decided not to retire in the past year because of “job lock”. The “guaranteed issue” requirement in the ACA fixes this problem, which is called medical underwriting. It requires insurers to issue health plans to anyone in the individual or group markets, regardless of their health status, and prohibits rate surcharges based on health status in the individual and small group markets.  Like most of the ACA’s major revisions, it kicks in January 1 of next year, with open enrollment beginning this October. The provision is popular; 66% of the American people support it. It is also one of those ACA provisions Republicans like, with 56% of Republicans supporting it. The President has talked about it often, journalists have publicized it, and experts have debated the impact of eliminating medical underwriting on the costs of insurance since passage of the law.  But like many elements of Obamacare, many people who will benefit from it don’t seem to know about it. Among those who report that someone in their household has a pre-existing condition, four in ten are not aware of the guaranteed issue provision. Just like the other group who will benefit most from the ACA, the uninsured, a large number – in this case half of all people who have someone in their household with a pre-existing condition – say they don’t have enough information about the ACA to know how it will impact them or their family. Not everyone with a pre-existing condition has had a problem getting health insurance. People with employer-based coverage are protected under the previous law unless they lose their job and experience a coverage gap. Nor does liking the idea of guaranteed issue necessarily mean someone will support the ACA; people like or dislike the ACA for various reasons. And, there are tradeoffs in eliminating underwriting against people with pre-existing conditions. Premiums may rise somewhat to accommodate coverage for people who are sick (the idea is to balance this to some extent by insuring people who are young and healthy as well). But there is a large constituency of people with major illnesses who will benefit from the law who do not seem to know it, and virtually everyone benefits from the peace of mind of knowing that if they get sick they no longer can be denied coverage or priced out by surcharges, even if they have large group coverage and lose it. Right now, working people who get sick and need to leave their jobs have only expensive COBRA coverage as a temporary solution. The ACA awareness and outreach effort now getting underway is aimed more at the goal of connecting the uninsured to new coverage opportunities than helping people to understand the security of knowing that they can’t be denied coverage if they get sick. There is obvious logic in that, since the law cannot succeed without getting people enrolled. But, many people with pre-existing conditions such as cancer, heart disease, or diabetes are represented by organized and usually very effective disease groups. They have a role to play in informing their constituents about this issue as do health professionals whose patients may benefit from the guaranteed issue provision. Fifteen percent of those with a pre-existing condition say they have talked with their doctor or a medical professional about the ACA. One reason this is important now: as the economy improves, people will be looking for better job opportunities, and there is a significant group of people still afraid to change jobs because they are sick and who seem not to know that they soon will not have to worry about that anymore. ________________ (Note: In this column, I report data on pre-existing conditions from our March, April and June 2013 Kaiser Tracking Polls and our September 2011 Tracking Poll. I focus on the non-elderly because seniors are protected from medical underwriting by the Medicare program.) 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