KHN’s ‘What is Health?’: Finally Fixing the ‘Family Problem’


[This podcast was produced by Kaiser Health News]

October 13, 2022

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The Biden administration this week released rules to fix the Affordable Care Act’s “family gap,” which prevents families who can’t afford employer insurance from getting subsidized coverage from the insurance marketplaces. The Obama administration has decided that only Congress can fix the deficit.

Meanwhile, open enrollment for Medicare begins Oct. 15, where consumers can join or switch private Medicare Advantage plans or stand-alone prescription drug plans. For the first time, Medicare Advantage plans are set to enroll more than half of the Medicare population, even as many of the largest insurers are receiving billions of dollars in overpayments from the federal government.

This week’s panelists are KHN’s Julie Rovner, The New York Times’ Margot Sanger-Katz, Johns Hopkins Bloomberg School of Public Health and Policy’s Joanne Cannon, and Rachel Kohrs of Stat.

Among the events covered in this week’s class:

  • The “family problem” arose because under the ACA law, people who provide insurance at their workplace are generally ineligible for subsidies if they buy a policy on the marketplace — unless the workplace insurance is deemed unaffordable. This decision is made based on the cost of insurance for the individual worker, not what a family policy would cost. Because family policies are more expensive than individual policies, they are usually not available to employees. The new federal regulation takes into account the cost of family coverage.
  • Democrats were aware of this problem when they passed the ACA. But this is a very expensive change, and they really wanted to keep the cost of the bill below $1 trillion. They promised to fix the “family problem” but never did.
  • Many health policy experts believed the fix should be done by Congress, but the Biden administration chose to do it by directive. It is unclear whether the rule will face legal challenges from critics, but opponents will have to prove they are being harmed by the new law and have standing to file a lawsuit.
  • Many seniors enjoy their Medicare Advantage plan, which is often offered at a lower cost than traditional Medicare. However, enrollees generally must remain in the plan’s network of health care providers.
  • Questions have been raised about federal payments for the plans. It was originally envisioned as an option to save money because lawmakers thought it would be more efficient than a government-run plan. But the plans’ benchmark formula now gives them more than 100% of what the government pays the average person under traditional Medicare, and the government pays the plans bonuses for taking on sicker patients.
  • Those bonuses have been the subject of numerous government investigations, driver’s license lawsuits and some fraud allegations that the plans failed to accurately identify enrollees’ medical conditions in order to get higher payouts from the government. But while some watchdog groups have raised concerns, the Centers for Medicare and Medicaid Services has not made major changes to payment formulas, in part because of Medicare Advantage’s high patient satisfaction and bipartisan support on Capitol Hill.
  • As lawmakers approach election day next month, Democrats have hit back at Republicans who have backed abortion rights and overturned the Supreme Court decision. Roe v. Wade, which was guaranteed access to the entire country. However, Democrats have not been active in making a case for their passage of the inflation-reduction legislation, which offers a number of notable changes, including lower out-of-pocket drug costs for Medicare beneficiaries. The cost of certain drugs, and the extension of improved subsidies for people who buy insurance through the ACA marketplaces.
  • Democrat John Fetterman’s campaign to win a US Senate seat from Pennsylvania has slowed slightly as he recovers from a stroke earlier this year. He’s back on track and performing live, but says his hearing hasn’t recovered, so he uses a computer device to help translate conversations into written language. Critics say there should be more transparency in the medical records. Disability advocates hit back at Fetterman’s criticism.

Plus, for extra credit, the panelists recommend the week’s favorite health policy stories they think you should read:

Julie Rovner: KN”If you are concerned about the environment, consider polluting it when you die” by Bernard J. Wolfson

Margot Sanger-Katz: KN”Baby, that bill is high: Private equity ‘Gambit’ squeezes more ER bills than normal births”, by Ellen Bischel

Joan from: Food and Environment Reporting NetworkFor one historically black California town, access to water has been denied for a century.” by Teresa Cotsirilos

Rachel Kors: Statistics”Small new HHS The office has a mammoth goal: fighting for environmental justice”, by Sarah Owermohle

Also mentioned in this week’s episode:

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