Finally solving the “family problem”

The Biden administration this week released regulations aimed at addressing the “family problem” of the Affordable Care Act, which has prevented families who can’t afford insurance from their employers from getting subsidized coverage on insurance markets. The Obama administration had decided that only Congress could solve the problem.

Meanwhile, open Medicare enrollment begins Oct. 15, when beneficiaries can join or change private Medicare Advantage plans or standalone prescription drug plans. For the first time, Medicare Advantage plans are poised to enroll more than half of the Medicare population despite claims that many of the largest 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, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico, and Rachel Cohrs of Stat.

Among the takeaways from this week’s episode:

  • The “family problem” arose because under ACA rules, people offering insurance through their workplace are generally not eligible for subsidies if they buy a policy on the market instead – at unless their work insurance is deemed unaffordable. This decision was made based on the cost of insurance for the individual worker, not the cost of a family policy. Since family policies are considerably more expensive than individual policies, they are often unaffordable for workers. The new federal regulations will take into account the cost of family coverage.
  • Democrats were aware of this problem even as they passed the ACA. But it’s a costly change, and they were desperate to keep the cost of the bill below $1 trillion. They had promised to settle the “family problem” but had not done so.
  • Many health policy experts believed the solution should be delivered by Congress, but the Biden administration chose to do so through regulation. It’s unclear whether the settlement will face legal challenges from critics, but opponents may struggle to prove they’re harmed by the new rule and have standing to sue.
  • Many seniors are happy with their Medicare Advantage plans, which often offer more benefits than traditional health insurance at a reduced cost. Enrollees, however, generally must remain within a plan’s network of healthcare providers.
  • Questions have been raised about federal payments to plans. They were originally envisioned as a way to save money because lawmakers thought they would be more efficient than the government-run plan. But the benchmark formula for the schemes now gives them more than 100% of what the government would pay for an average person under traditional health insurance, and the government pays the schemes premiums for taking care of sicker patients.
  • These bonuses have been the subject of numerous government investigations, whistleblower allegations and some fraud lawsuits alleging that the plans misidentify enrollees’ medical conditions to obtain higher reimbursements from the government. But while some watchdog groups have raised concerns, the Centers for Medicare & Medicaid Services hasn’t made major changes to reimbursement formulas, in part because Medicare Advantage has high patient satisfaction and bipartisan support on Capitol Hill. Hill.
  • As lawmakers edge closer to Election Day next month, Democrats have trumpeted their support for abortion rights and hit hard at Republicans who backed the Supreme Court’s decision to overturn Roe vs. Wade, access to which was guaranteed throughout the country. Democrats, however, weren’t as active in advocating for their passage of the Cut Inflation Act, which proposed several popular changes, including caps on out-of-pocket drug costs for recipients of Medicare, a provision allowing Medicare to begin negotiating the price of certain drugs, and an extension of enhanced subsidies for people who buy insurance in ACA markets.
  • Democrat John Fetterman’s campaign for a US Senate seat from Pennsylvania has been hampered a bit by his recovery from a stroke he suffered earlier this year. He’s back on the track and making live appearances, but he uses a computing device to help him translate conversations into written language as he says his hearing processing hasn’t healed. Critics said he should be more transparent with his medical records. Disability advocates have 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”If you’re concerned about the environment, consider being composted when you die“, by Bernard J. Wolfson

Margot Sanger-Katz: KHN”Baby, that bill is high: ‘Gambit’ private equity cuts excessive emergency costs for routine births,” by Rae Ellen Bichell

Joanne Kenen: The Food and Environment Reporting Network”For a historically black Californian city, a century of denied water access,” by Teresa Cotsirilos

Rachel Cohrs: Statistics “A tiny new HHS office has a colossal purpose: to fight environmental justice,” by Sarah Owermohle

Also mentioned in this week’s episode:

This article was taken from courtesy of the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health policy research organization not affiliated with Kaiser Permanente.