Although some Democrats recognized problems with the Health Bill over the years, they hesitated to highlight its shortcomings while it was under heavy attack from the GOP. But with the Supreme Court decision last week likely to signal the end of Obamacare’s long-running war, lawyers and experts hope the Biden administration will focus on strengthening its foundation – even as the Democrats like their pursuit of other health reforms intensify drug pricing and expand Medicare.
“The ACA has made a difference for the people we represent, but if we allow the decay behind the scenes, these stories are the ones that will steal the narrative,” said Katie Berge, a former Obama administration health official. the now . is the director of federal relations for the Leukemia & Lymphoma Society.
Biden campaigned to build Obamacare rather than an expensive “Medicare for All” model favored by the progressive wing of his party. He urges Congress to make a permanent temporary expansion of the statutory health insurance subsidies that were included in this year’s Covid relief package.
The Department of Health and Human Services is “always looking for ways to improve oversight and efficiently allocate resources to oversee compliance by regulated companies,” a spokesman said in a statement sent via email. “We do not take this responsibility lightly and have implemented high standards and regulations that ensure that millions of people who have health insurance through a marketplace plan receive the highest possible quality at the lowest possible cost.”
However, experts and advocates say Biden officials need to step up scrutiny of issues that have existed since the law went into effect or have worsened under the Trump administration’s apathy for the law.
“We are at a moment when insurers are no longer running away from the exchanges and there is relative stability in the individual market – and this is a moment when insurance regulators and policymakers should be asking how their market plans are for consumers work better? ”said Kevin Lucia, a former Obama administration health officer who worked on enforcing the law.
Some experts referred to a Report from the Kaiser Family Foundation Earlier this year, it emerged that insurers on HealthCare.gov, the federal insurance marketplace that serves about two-thirds of the states, turned down 17 percent of medical claims submitted in 2019. Only 0.1 percent of customers objected to these rejections. Depending on the service, a denial of claims can incur unexpected healthcare costs of thousands of dollars on patients.
The rejection rates varied considerably depending on the state and did not necessarily correspond to its political leanings. They ranged from under 8 percent in Oregon to nearly 20 percent in New Mexico and over 38 percent in Tennessee, KFF found.
“There is no excuse for this data and we should all be wondering what it means for patient care and outcomes,” said Katie Keith, a professor at Georgetown University who specializes in the ACA.
Health insurers argue that the report does not give an accurate picture because the data is patchy and there is a lack of reporting standards. Obamacare relies on insurers to report rejection rates themselves, but does not require federal officials to review company filings. The law also doesn’t allow the government to cancel an insurer’s contract to sell Obamacare plans because too many claims have been denied. The HHS spokesman noted that state insurance regulators have the primary authority for denying claims.
Numerous consumer advocacy groups have already reached out to the Biden government with recommendations to strengthen ACA coverage, said Cheryl Fish-Parcham, director of access initiatives at Families USA. The groups have urged HHS to review the health plans’ rejection of claims outside the network, which may be a sign that the provider networks are not strong enough, and set standards to ensure that patients can see a doctor without having to To travel far or to wait too long.
There’s also a lack of data on whether ACA insurers’ provider networks have become more robust since the law was first introduced, experts say. Tight networks have allowed insurers to keep costs down, but inadequate networks can undermine the law’s cover commitments, especially for those with higher health needs. A 2015 study, a year after the insurance marketplaces opened, found that nearly 15 percent of ACA plans Contract with at least one specialty not concluded Provider, likely a violation of the law.
Experts fear that provider networks may have narrowed further as healthcare costs continued to rise. Additionally, the Trump administration has eliminated federal reviews of whether ACA health plans complied with the law’s network standards, leaving that oversight to the states that have typically directed the regulation of individual and small-group insurance markets.
Kristine Grow, a spokeswoman for America’s Health Insurance Plans lobby group, said state regulators were effectively overseeing the ACA provider networks. While she found that many insurers relaxed network restrictions – such as telemedicine – during the pandemic to make patient care easier, she attributed some network problems to the consolidation of groups of providers that are raising prices in some markets.
Conservative critics say these problems stem from errors in the ACA itself.
“The incentives at the ACA are not about providing the best care to those in greatest medical need,” said Doug Badger, health research fellow for the Conservative Heritage Foundation. “You cover your premiums, but the quality of the care you receive and your access to the providers of that care is severely limited.”
Proponents of the law instead argue that it is about putting the insurance markets under scrutiny that is long overdue.
“The process is solid, but do you have the resources, the manpower, and the political will to take on and roll back some of these things?” Said Keith, the Georgetown professor.
The Biden administration has signaled that it will step up standards enforcement on provider networks after a federal judge sided with the cities in March in a lawsuit alleging the Trump administration failed to properly enforce the law . However, the Biden administration said it will not do so until 2023 as the annual update of the rules for the insurance marketplace for 2022 is already in full swing.
The Department of Health “intends to reconsider this policy and the Biden government is committed to advocating for consumers in the health insurance market,” the HHS spokesman said.
Experts across the political spectrum have also said that there is growing evidence that insurers are overpricing their plans, despite the fact that the Court of Auditors is essentially capping their profits by asking them to offer discounts above a certain threshold. Health plans are expected to deliver record levels of rebate payments for the third year in a row, Keith said.
Insurers and the Biden government said the discounts, which amounted to around $ 2.5 billion last year, are an indication that marketplaces are still adjusting after the law’s chaotic early years. But Keith and others say it’s a trend to watch out for.
“It suggests the products are overpriced,” said Karen Pollitz, health professional at KFF. “Yay for the discounts, but the premiums should be lower – that might help with the uninsured.”