The Progress Report: ThinkProgress.org

Yesterday, President Obama sought to sell the health overhaul law to skeptical seniors, “launching a defense of his presidency’s biggest accomplishment” as the government prepared to release “the first batch of $250 checks to seniors who fall into Medicare’s prescription drug coverage gap, known as the ‘doughnut hole.'” “Each month, as more seniors hit the doughnut hole, more and more checks will hit the mail, helping more than 4 million seniors by the end of this year,” Obama explained. “Now, beginning next year, if you fall into the coverage gap, you’ll get a 50 percent discount on the brand-name medicine that you need — 50 percent. And by 2020 — it’s being phased in, but by 2020 this law will close the doughnut hole completely.” The White House’s pitch comes in the midst of a renewed Republican effort to discredit reform as a costly and unnecessary government takeover of the system. Yesterday, right-wing pundit Bill Kristol launched a new website, ObamaCareWatch.org, and “28 Republican Representatives, including top GOP House leadership,” signed onto an amicus brief “filed in support of Virginia’s constitutional challenge to the law.” As Rep. Mike Pence (R-IN) said in April, “House Republicans will not rest until we repeal Obama care lock, stock and barrel and replace it with health care reform that will lower the cost of health insurance without growing the size of government.” But as Obama explained yesterday, he will not allow the country to move backwards on reform. Republicans “would roll back the rebate to help you pay for your medicine, if you fall in the doughnut hole. They’d roll back the free preventive care for Medicare recipients,” Obama said. “They would roll back all of the insurance provisions that make sure that insurance companies are not cheating folks who are paying their premiums. … They’d put insurance companies back in charge.” “I refuse to let that happen. We’re not going back. We are going to move forward. That’s why I was elected.”

IMPLEMENTING INSURANCE REFORMS: On Monday, the Department of Health and Human Services (HHS) announced that it will be freeing up $51 million in grant dollars through the health care law to help states strengthen their premium review programs and prevent insurers from dramatically increasing insurance premiums. While the federal government does not have authority to overturn so-called “unreasonable” premium increases, the law does allow the HHS Secretary to assist states in developing a plan for denying rate hikes or preventing insurers with “unreasonable” hikes from participating in the exchanges. Insurers will be required to submit “a justification for an unreasonable premium increase” to the state insurance commission authority, who then makes the appropriate recommendations “to the State Exchange about whether particular health insurance issuers should be excluded from participation in the Exchange.” Significantly, states will also be required to report their medical loss ratios — “the fraction of premium dollars collected that are actually spent on health services instead of on administrative underwriting, marketing, and capital costs including profits or surpluses or both.” Insurers will have to report their MLR ratios “in the 2010 plan year,” and by 2011, “all commercial insurers will have to meet minimum loss ratio requirements in all markets.” The regulations are designed to prevent insurers from rounding up huge profits before most of the reforms are implemented in 2014. The new law also requires individuals who “have been uninsured for at least six months and who have a serious preexisting condition be eligible to buy an insurance product” in a state-based high-risk insurance pool by the end of the month and the Department has been moving quickly to implement the measure. In April, the Secretary sent a letter to all governors “clarifying her intent to build on existing state programs and make this a joint effort with the states,” 35 of which already have high risk pools in operation. States have the choice of operating their own pools or ceding control of the operation to the federal government, as approximately 19 states have chosen to do.

ESTABLISHING THE EXCHANGES: The high-risk pools are a temporary measure that will serve as a dress rehearsal for the new health insurance exchanges. Although states can opt out of the process, “the new law gives states the clear responsibility of creating their own exchanges and offers them many choices about how to do so.” Jon Kingsdale, who until recently ran the successful Commonwealth Health Insurance Connector Authority in Massachusetts, suggests that exchanges should function as shops for insurance and help customers choose a compatible insurance plan. A purchaser of insurance should be able to “generate rate comparisons for any level of benefits simply by providing his or her date of birth, household size, and ZIP code. These rating rules make it possible to automate insurance pricing and facilitate comparison shopping in an exchange.” But “how many choices to offer, and of what kind, are matters of judgment and consumer preference,” Kingsdale suggests. “Too much choice may confuse consumers and lead to adverse selection. On the other hand, too little choice may conflict with consumers’ preferences and stifle innovation in the design of insurance policies and benefits.” Kingsdale writes that exchanges have to create administrative efficiencies and add transparency to the health care system. “Today, in the absence of exchanges, the  non group and small-group markets offer a bewildering array of benefit choices and crate hurdles to purchasing coverage.” “Many of the functions associated with sales, enrollment, premium billing, and collections could be streamlined through a combination of manual rating and economies of scale,” he predicts.

EXPANDING MEDICAID: About half of the increase in health insurance coverage is expected to come from expanding Medicaid in 2014 “to a new nationwide eligibility threshold of 133 percent of the poverty level — $14,400 for a single adult or $29,300 for a family of four.” Throughout the health reform debate, state governors complained that this requirement amounted to an unfunded mandate, but as Leighton Ku explains in Health Affairs, the federal government will be picking up most of the cost of the expansion. For instance, the Congressional Budget Office estimates that the federal government expenditures “will rise above the baseline by $434 billion during the next decade, while states will incur just $20 billion in higher expenditures.” Similarly, a recent study by the Kaiser Family Foundation found that “the federal government will bear virtually the entire cost of expanding Medicaid under the new health-care law” and states will be able “reduce payments they make to support uncompensated care costs.” As Ku notes, “some states’ projections of new costs appear to be overstated,” as governors have “not accounted for factors such as the reduced costs of serving the newly eligible.” Moreover, “most economists expect the economy and employment to brighten by 2014, so there should be fewer income-eligible people and higher state revenues than today.” The expansion and increase volume of patient needs will require plans to expand networks and states will have to take steps “to design simple application forms and procedures, including online.