KHN’s “What the Health?”: Finally Fixing the “Family Bug”

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This week, the Biden administration issued regulations aimed at fixing the “Family Dysfunction” in the Affordable Care Act, which has prevented families who cannot afford employer insurance from obtaining coverage subsidized by insurance markets. The Obama administration decided that only Congress could fix the problem.

Meanwhile, Medicare open enrollment begins October 15, when beneficiaries can join or change private Medicare Advantage or standalone prescription drug plans. For the first time, Medicare Advantage plans are preparing to enroll more than half of Medicare’s residents despite allegations that many of the largest insurers are taking 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, Joan Kenin from the Johns Hopkins Bloomberg School of Public Health and Politics, and Rachel Kors from Stat.

Among the points learned from this week’s episode:

  • The “family glitch” arose because under the rules of the ACA, people who provide insurance through their workplaces generally do not qualify for benefits if they instead purchase an insurance policy in the marketplace – unless their employment insurance is unaffordable. This decision was made based on the individual worker’s insurance cost, not the cost of the family policy. Since family policies are much more expensive than individual policies, workers often cannot afford them. New federal regulation will take into account the cost of family coverage.
  • Democrats were aware of this problem even when they passed the ACA. But this is a costly change, and they were desperate to keep the bill cost under a trillion dollars. They promised to fix the “family bug” but they didn’t.
  • Many health policy experts believe that reform should be done by Congress, but the Biden administration has chosen to do so through regulation. It is not clear if the regulation will face legal challenges from critics, but opponents may have difficulty proving they have been harmed by the new rule and have the ability to file a lawsuit.
  • Many seniors are happy with their Medicare Advantage plans, which often offer more benefits than traditional Medicare at a lower cost. However, enrollees generally must stay within the plan’s network of health care providers.
  • Questions have been raised about the federal payments to the plans. It was initially conceived as a way to save money because lawmakers thought it would be more efficient than the government-run plan. But the standard wording of the plans now gives them more than 100% of what the government would pay the average person in traditional Medicare, and the government pays bonuses for plans to take in the sickest patients.
  • These bonuses have been the subject of numerous government investigations, whistleblower allegations, and some fraud lawsuits alleging that plans misidentify medical conditions for registrants for higher government payouts. But while some control groups have raised concerns, the Centers for Medicare and Medicaid Services has not made significant changes to reimbursement formulas, in part because Medicare Advantage has a high degree of patient satisfaction and bipartisan support on Capitol Hill.
  • As lawmakers approach Election Day next month, Democrats voiced support for abortion rights and hit hard on Republicans who supported the Supreme Court’s repeal. Raw vs. Wade, which guarantees access to all parts of the country. However, Democrats were not active in making a case for passing the Inflation Control Act, which introduced several popular changes, including capping out-of-pocket drug expenses for Medicare recipients, a clause that would allow Medicare to begin negotiating. The price of some medications, extending boosted benefits to people who buy insurance in ACA Markets.
  • Democrat John Fetterman’s campaign for a US Senate seat from Pennsylvania has slowed somewhat due to his recovery from a stroke earlier this year. He’s back on track and back live, but uses a computer to help him translate conversations into written language because he says his auditory processing hasn’t healed. Critics said he should be more transparent about his medical records. Disability advocates responded to Fettermann’s criticism.

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

Julie Rovner: KHN’sIf you are concerned about the environment, consider composting when you dieWritten by Bernard C. Wolfson

Margot Sanger Katz: KHN’sHoney, the bill is high: private property’s ‘maneuvering’ squeezes excessive emergency fees from routine deliveriesWritten by Ray Ellen Bischel

Joan Kenin: Food and Environment Reporting Network”For a historic black city in California, a century of access to water has been deniedWritten by Teresa Cotsirillos

Rachel Kors: stat”HHS’s new small office has a huge goal: tackling environmental justiceWritten by Sarah Oermuehle

As stated in this week’s episode:

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