Fix Deadline Crossed

The November 30 deadline for significant improvements in the site passed late last week. The site is now capable of handling and processing a significantly larger flow of traffic than at its launch. According to the Department of Health and Human Services, 950,000 people visited the site on Wednesday alone. The enhanced “window-shopping” features of, allows hundreds of thousands of consumers to get additional information about plans and costs without officially registering on the site. Some news sources have reported that roughly 100,000 persons enrolled in private health insurance using in November, but CMS has not confirmed those reports. HHS will release its November enrollment report sometime in mid-December. 

However, amidst these improvements, errors persist in the enrollment files being transmitted from to insurers with whom individuals have enrolled. Anecdotal reports that much of the information being shared is either wrong or incomplete have raised concerns that even those who have technically completed the process of enrollment may find themselves without coverage on January 1. On Friday afternoon, CMS spokeswoman Julie Bataille said that up to 25 percent of the enrollment files generated by in October had errors, were duplicates or were never transmitted to carriers. CMS now estimates that only 10 percent of the 834 enrollment files now contain errors. 

Who exactly is signing up for coverage remains an important question. In a nod to the importance of getting young and/or healthy people to use the marketplace and purchase insurance, President Obama addressed a summit of youth leaders, urging them to help spread the word to their fellow Millennials about the December 23 deadline for selecting a health plan. On this note, a new survey from Harvard’s Institute of Politics found that 57% of young voters opposed the Affordable Care Act. In the same poll, just 29 percent of uninsured 18-to-29-year olds said they would “definitely” (13 percent) or “likely” (16 percent) enroll in the marketplace. 

Another concern arose from HHS' announcement that the online enrollment portal for the Federally-facilitated SHOP marketplace for small businesses (50 or fewer employees) will be delayed until November 2014. The delay is the second for the SHOP, whose launch was previously postponed from October 1 to November of this year. 

Budget Conference Committee Appears Close to Deal for FY14

House Budget Committee Chairman Paul Ryan (R-WI) and his Senate counterpart, Patty Murray (D-WA), look to be on track to reach a deal that would establish a consensus spending level for the current fiscal year. The conference committee created as part of the agreement that reopened the federal government in October has a December 13 target for putting a plan forward. Republican leadership in the House is tentatively planning to brief their caucus on Tuesday ahead of a possible floor vote on Wednesday. Democratic leader Nancy Pelosi (D-CA) wants to see an extension of long-term unemployment benefits included in the package. It appears the deal will relieve and offset approximately $34 billion of the sequester for this year and next. Still to be settled are the final cost savings figures and the sources of the offsets.

The only health care component reportedly still being considered as part of the deal is an extension of the reduction in Medicaid disproportionate share hospital (DSH) payments. However, this would likely not occur until 2023. The ACA included a permanent reduction in Medicare DSH, but only a ten-year reduction in Medicaid DSH. The offset being considered as part of the FY14 plan would extend the Medicaid cut an additional year and yield approximately $4 billion in savings, as was done last year to pay for a patch on the Sustainable Growth Rate formula (see below for more on this topic). 

Supreme Court Accepts, Rejects Cases Challenging ACA Provisions

After last year’s sweeping ruling that the Affordable Care Act was fundamentally constitutional, the Supreme Court is now faced with several new challenges to specific provisions in the law. Thus far, they have been selective in deciding which they will consider.

The Court denied Liberty University’s challenge to the employer mandate included in the ACA on Monday, a decision that mirrored an earlier refusal by the court to take up the mandate. But just days before, the Court accepted two cases, one from Hobby Lobby Stores and another from the Conestoga Wood Specialties Corp., to review the law’s requirement that the employers offer insurance that includes coverage for contraceptives. Hobby Lobby and Conestoga Wood Specialties stated that they have religious objections to providing contraceptive access and that the mandate to provide contraceptives should be overturned on the grounds that it violates their religious freedom. Another suit, brought by attorneys general in several states, claims that language in the ACA prohibits the federal government from providing premium subsidies to those purchasing insurance through the federal exchange. The case is working its way through lower courts and could also be in front of the Supreme Court in 2014.

Doc Fix Remains on Table as End of Year Nears

A bipartisan, bicameral sprint is on to meld several proposals that would avert a steep reduction in reimbursement for doctors participating in the Medicare program starting January 1. Versions of the so-called “doc fix”, an annual ritual on Capitol Hill, have been percolating among the House Energy and Commerce, House Ways and Means, and Senate Finance Committees for several months. The latter two reached a framework agreement on the plan in October, while the former passed its own legislation earlier this year. On Wednesday, Ways and Means and Finance aides shared details on a revised version of the bill with provider groups.

The latest bill would replace the Sustainable Growth Rate formula at the heart of the yearly drop-offs in doctor fees and allow doctors to continue participating in the current fee-for-service system (in which rates would be frozen for the coming ten years) or move to an alternative payment system. In either case, providers would be allowed to participate in a new Value Based Performance structure that would reward or penalize doctors for positive outcomes and efficient treatments. 

In November, a group of nearly 200 House members from both parties sent a letter to Speaker John Boehner and Minority Leader Nancy Pelosi supporting the permanent repeal, citing a reduced CBO estimate of $139 billion to do so. The Senate Finance and House Ways and Means Committees are each expected to mark-up a doc fix bill next week, although lawmakers are struggling to identify offsets that would cover the cost of ending the SGR. Given the tight timeframe, and despite the display of bipartisan cooperation, a temporary patch is likely to be put in place to prevent the currently-scheduled cuts from going into effect before a final bill can be signed into law.

From the States

A complete roundup of this week’s exchange action in the states is available through our State of the States: Health Insurance Exchanges publication here. 

California. The state-run exchange officially launched its small business portal on December 1. Covered California’s SHOP exchange will offer products from Blue Shield of California, Chinese Community Health Plan, Health Net, Kaiser Permanente, Sharp Health Plan and Western Health Advantage. 

Illinois. Blue Cross Blue Shield of Illinois announced on Monday that they would extend all current health policies for an additional year, regardless of whether they meet full compliance with ACA requirements. Several other Blue Cross affiliates have done the same in their states.

Maryland. State officials continued to struggle with its Maryland Health Connection exchange. In an appearance before the state legislature’s Senate Finance Committee, Maryland Health Secretary Joshua Sharfstein declined to give a date as to when the balky marketplace might be fully operational.

Wyoming. Governor Matt Mead (R) announced that the state will not participate in the Medicaid expansion option offered under the ACA. The state legislature’s Labor, Health and Social Services Committee spent the fall discussing three possible expansion schemes, after a commission appointed by Mead had previously developed its preferred “Medicaid Fit” model, would have offered more limited benefits while making recipients share in the cost of their care.

Calendar: Looking Ahead

The House and Senate are in session this week, in advance of their Christmas break

Tuesday December 10

  • The Heritage Foundation holds a panel discussion on the legal case on the Affordable Care Act 

Wednesday December 11

  • The House Energy and Commerce — Subcommittee on Health holds a hearing on the Affordable Care Act, its implementation and the rollout of with testimony from Kathleen Sebelius - Secretary of Health and Human Services
  • The House Small Business Committee holds a full committee hearing entitled "The Small Business Health Options Program: Is It Working for Small Businesses?", with testimony from Gary Cohen, Deputy Administrator and Director, Centers for Medicare and Medicaid Services 
  • The National Academy of Sciences holds an event entitled, “Back to the Future of Nursing: A Look Ahead Based on a Landmark IOM Report,” featuring former HHS Secretary Donna Shalala

Thursday December 12

  • The Senate Finance Committee holds a full committee markup of legislation to repeal the sustainable growth rate system and to consider health care extenders.