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unidentified
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| A look at the future of the Affordable Care Act with Julie Rovner of KFF Health News. | ||
| She's a chief Washington correspondent. | ||
| Thanks for giving us your time. | ||
| Of course. | ||
| Before we look at the future, let's look at the present. | ||
| What's the trend as far as those signing up for the Affordable Care Act, and how does this year compare to previous? | ||
| Well, during the pandemic, the subsidies were expanded for people to buy private insurance on the marketplaces. | ||
| And we saw really enrollment basically double. | ||
| So we have about 24 million people now with Affordable Care Act coverage. | ||
| That's just the private coverage through the marketplaces. | ||
| We also have about 20 million additional people who joined because of the Medicaid expansion. | ||
| Those were the two biggest pieces of the Affordable Care Act. | ||
| So right now, it's fair to say that enrollment under the law is at its all-time high. | ||
| When you take the subsidies in, the question, how long do the subsidies last for? | ||
| And are there concerns that the subsidies might go away? | ||
| Yes, there are a lot of concerns. | ||
| The subsidies will go away unless Congress renews them. | ||
| They go away at the end of this year, at the end of 2025. | ||
| So Congress has a decision to make whether it wants to continue the subsidies or let them expire. | ||
| But if there's no action, then they go away at the end of this year. | ||
| Our guest already mentioned that these enhanced subsidies took place with the onset of the American Rescue Plan. | ||
| More than 2020 enrollment has doubled. | ||
| When it comes to the subsidies, and you said Congress ultimately will decide, I guess it's, I don't know, for every member of Congress, but generally, where is Congress on this idea of continuing the subsidies? | ||
| Well, there's a general thought, you know, when President Trump was re-elected and Republicans took control of Congress, the thought was that the subsidies would go away, that they would need that money to extend their tax cuts. | ||
| And that indeed may still be the case. | ||
| But we're seeing a lot of Republicans, a lot of this expanded coverage, particularly people buying their own coverage, happened in Republican states, particularly in Republican states that didn't expand Medicaid. | ||
| So we've seen huge increases in places like Florida and Texas and Georgia. | ||
| And some of the senators from those states are a little bit having some second thoughts about whether or not they want to, you know, basically raise people's premiums. | ||
| In some cases, premiums could double. | ||
| So there's some back and forth about whether or not they're going to let these subsidies expire. | ||
| What degree then do these senators that might want to keep these things in place are talking to the White House about keeping these things in place? | ||
| And what's the White House's mind on this? | ||
| You know, I haven't heard what the White House has said about this because remember, this really is a congressional decision. | ||
| They will automatically expire unless Congress extends them. | ||
| And of course, then the president would have to sign it. | ||
| This is supposed to be part of the one big beautiful bill that the president keeps saying that he wants that would have the tax cuts and more money for immigration enforcement and more money for energy. | ||
| This is part of this whole reconciliation process that Congress is about to launch into. | ||
| Just for a reminder, what does the ACA cover generally? | ||
| Well, the ACA is an enormous bill that does a lot of things, but the main part of it is to expand coverage, both by giving people who don't have access to workplace coverage through either through Medicaid or through buying it themselves. | ||
| There are new rules for insurance companies. | ||
| There are a lot of programs that help train future health care workers, health care professionals. | ||
| There's everything from, you know, there was a permanent reauthorization of the Indian Health Service in the Affordable Care Act. | ||
| There was enabling generic biologic drugs for the first time in the Affordable Care Act. | ||
| So it was an enormous law. | ||
| But the main part of it that we think about is this expanded coverage and the rules of the road for what has to be covered. | ||
| Specifically, what does the law, or what do those who get the ACA, how much does it cover preventative care? | ||
| Well, that was one of the big and popular issues in the Affordable Care Act is a requirement that certain types of preventive care be covered with no additional out-of-pocket costs. | ||
| So no co-pays or deductibles for certain types of preventive care. | ||
| And there are a number of them, but many of them come from something called the U.S. Preventive Services Task Force, which is a quasi-independent agency under the Department of Health and Human Services of experts that basically evaluate preventive services and decide whether or not they're essentially worth the money that they cost. | ||
| So they give them grades and anything that the U.S. PSTF grades A or B is required to be covered with no additional out-of-pocket costs by the Affordable Care Act. | ||
| The topic of that preventative care was centerpiece at the Supreme Court this week, a specific case brought against that, looking at that. | ||
| Can you tell our viewers about that case? | ||
| Yes, this case says that the U.S. Preventive Services Task Force was not properly established under the Constitution because it's too independent and that they cannot legally, because the members were not appointed by the President and confirmed by the Senate, they are not allowed to make these types of decisions about what should be covered. | ||
| Interestingly, well, the Biden administration first started defending this case. | ||
| Interestingly, when the Trump administration came in, they continued to defend this case. | ||
| So they were at the Supreme Court saying, no, we think that this task force is fine and okay. | ||
| And by the way, we exercise enough control over their decisions, or at least whether their decisions are finally implemented, that we think everything is A-OK. | ||
| And you don't need to decide that this needs to be completely taken apart and reestablished. | ||
| The case, if I understand it correctly, brought by a set of employers out of Texas, those who, I guess, classify themselves as Christian employers. | ||
| How does that factor into that? | ||
| That's right. | ||
| They were objecting to one of the USPSTF recommendations for something called PREP, which is preventive care for AIDS and HIV. | ||
| And they were saying that requiring them to cover PrEP with no additional out-of-pocket cost encourages homosexual activity and intravenous drug use. | ||
| That's kind of a stretch of a claim, but that is their claim. | ||
| They also charge that it violated their religious freedom, but that is not a piece of the case that the Supreme Court was looking at. | ||
| Was there a sense of how the justices, when they heard the case, how they responded to it? | ||
| There was. | ||
| I mean, there isn't always, and you never know for sure, but certainly some of the conservatives that the plaintiffs would need to rule with them, particularly Justice Kavanaugh and Justice Barrett, seemed kind of dubious about these arguments. | ||
| And most people who watched the arguments, including me, seemed to feel like it was more likely that the court is going to rule for, in this case, the Trump administration, which was previously the Biden administration, which is against the plaintiffs in this case. | ||
| And what does that mean then? | ||
| Does that mean preventative services go away, or to what degree do they go away? | ||
| Right, well, it would mean that nothing would change. | ||
| If they do what we assume they do, which is say that, no, the U.S. Preventive Services Task Force is okay as it is, then everything would be okay. | ||
| If they were to rule the other way, it gets complicated because, of course, the U.S. Preventive Services Task Force predates the Affordable Care Act. | ||
| They just sort of wrote in the requirements for an existing body of experts that were already making these recommendations. | ||
| So, basically, what could go away are all of the recommendations that they've changed since 2010, since the Affordable Care Act was signed into law. | ||
| So, a lot of those are sort of changes in things like cancer screenings. | ||
| They've changed ages, they've changed populations who would be covered. | ||
| There aren't that many changes, it would get very complicated very quickly. | ||
| Julie Robner, for this discussion with KFF Health News, if you have questions about the future of the Affordable Care Act, different lines today. | ||
| For those of you who received insurance under the Act 202748-8000, it's 202-748-8001. | ||
| If you have private insurance, if you're not insured, 202-748-8002 and all others, 202748-8003. | ||
| Let's hear from Clyde. | ||
| Clyde is in Oklahoma, a receiver of ACA insurance. | ||
| Clyde, thanks for calling. | ||
| You're first up. | ||
| Go ahead. | ||
|
unidentified
|
Well, I've been trying to figure out something. | |
| I mean, it talks about the deadly wound in the Bible. | ||
| Are we running head on into it? | ||
| It looks like it. | ||
| Thank you very much. | ||
| Okay, let's hear from Pat. | ||
| Pat in North Dakota on our line for those who are not insured. | ||
| Pat, hello. | ||
|
unidentified
|
Hi. | |
| I'm calling for my daughter. | ||
| She's a realtor, and they had group insurance through the Realtor Association, and the government took it away from them. | ||
| And now she's stuck with Obamacare. | ||
| And she said it's terrible. | ||
| They give you a list of doctors you can call, and then when you call, half of them say they no longer take Obamacare. | ||
| And then when you go to the doctor, there's a deductible, and she says it's cheaper to pay cash. | ||
| So she gets nothing from Obamacare. | ||
| And I think the government has no business taking people's group insurance away. | ||
| If you can get a group insurance to sign up for, you should be able to get it. | ||
| That's all I have to say. | ||
| Thanks. | ||
| Julie Robner, a couple of calls there. | ||
| One specifically about her daughter's situation. | ||
| What's the takeaway? | ||
| Yeah, well, you know, a lot of people were affected in a lot of different ways. | ||
| It may have just been that the group insurance didn't meet the requirements of the law, or it may have just been that the group decided that the insured didn't want to cover them anymore. | ||
| And, you know, in many cases, there are a lot of plans that don't meet the needs of people, but that's why there's also a lot of choice. | ||
| You know, one of the big complaints, particularly early on, again, was that they had these very narrow networks in some of these plants, and the premiums and the out-of-pocket costs were pretty high. | ||
| One of the things that these additional subsidies did was at least make that cheaper, didn't always make the networks broader, but you can usually find a broader network plan. | ||
| It's always a trade-off in sort of how much you're going to pay versus, and this is true in group insurance too. | ||
| You know, the broader the network, the more you're likely to have to pay for the insurance. | ||
| It's always a trade-off with pretty much all kinds of insurance. | ||
| What's been the impact of the ACA on health insurance companies overall? | ||
| It's been different. | ||
| I mean, a lot of insurance companies are doing very well. | ||
| A lot of insurance companies are doing very well in the ACA market. | ||
| Some of them came in, maybe bid off more than they could chew, and then left. | ||
| But the market's been relatively stable for the last couple of years. | ||
| And as I said, we've doubled the number of people in these ACA plans. | ||
| And as the costs have gone down, the satisfaction has gone up. | ||
| There are still a number of issues. | ||
| Some the Biden administration was addressing. | ||
| There was sort of an unfortunate incentive for rogue brokers to shift people around between plans, even if they didn't want to change plans because the brokers got paid additional money. | ||
| That's something that they were trying to address. | ||
| Now we're seeing the Trump administration cutting back on some of the staff who helps people who run into problems with their ACA plans, which could be another issue. | ||
| So it's not, you know, it isn't perfect. | ||
| Nobody ever suggested it was, but it is, you know, now, excuse me, 15 years sort of into this, it is a relatively stable way that a lot of people get their health insurance. | ||
| I suppose that in the lead up to the passage of the ACA, you heard from critics and supporters alike that it would change the way that doctors practice. | ||
| It would change the way that hospitals do their business. | ||
| What's the evidence of that so many years in? | ||
| Well, we've seen a lot of other changes in the health care system. | ||
| I mean, one of the things we're seeing a lot of is private equity coming in because we spend so much money on health care, and that's had, I would say, a bigger impact on how the provision of health care has changed than the Affordable Care Act, which remember, yes, yes, it's between the Medicaid expansion and the people on the marketplace coverage, it's 40 million people, but we have, you know, 330 million Americans now, because of the law, most of whom have some kind of health insurance. | ||
| So it's not necessarily from the law that has changed the health care system. | ||
| The health care system has, I mean, the healthcare system has changed and the law along with it. | ||
| Let's hear from Debbie. | ||
| Debbie has ACA. | ||
| She's in Missouri. | ||
| Hi, Debbie. | ||
| You're on with our guests. | ||
| Good morning. | ||
|
unidentified
|
Hey, good morning. | |
| I just want to say I've had ACA care for a few years now, and it helps me when I go to get my testing done, you know, my cholesterol, colonoscopies, all kinds of stuff. | ||
| I don't find the deductible absorbent. | ||
| And if it wasn't for that, you know, I wouldn't have good care. | ||
| It's not much good for, you know, if you're sick and need to go in for that. | ||
| I mean, all insurance, you have to meet your deductible. | ||
| If I may ask, Debbie, what's your deductible like? | ||
|
unidentified
|
I want to say it's a little over $500. | |
| So, I mean, you know, that's completely reasonable. | ||
| Okay. | ||
| Debbie there in Missouri giving her thought on the ACA and the deductible. | ||
| Julie Robner, the deductible portion of it is, I guess there's no way to know for sure, but it's $500 general or people pay more or less. | ||
| How does that work usually? | ||
| No, that's pretty typical. | ||
| And that's pretty typical of employer plans these days, too, is $500 or even $1,000. | ||
| I mean, there are a lot of ACA plans. | ||
| And again, there's a choice of plans. | ||
| If you want to pay lower premiums, you're going to have higher deductible. | ||
| It's just like car insurance. | ||
| So there are people with multi-thousand dollar deductibles who are basically crossing their fingers and hoping that they don't get sick and need expensive care. | ||
| But as Coller said, and as we were talking about this, preventive care comes without any additional out-of-pocket costs because they want to incentivize people to get preventive care so they don't get sick. | ||
| So they don't need to go into the hospital or have some kind of procedure where they would have to pay their deductible, but also the insurance would have to kick in a lot more money. | ||
| Mick is in Illinois. | ||
| Mick, receiver of private insurance. | ||
| Hello, Mick. | ||
|
unidentified
|
Hello. | |
| Hello. | ||
| I'm a federal retiree, and so I opt to, although I qualify for Medicare, I keep my federal insurance at a cost of about $250 a month, just fearing a Republican administration, what they might do. | ||
| If I don't renew it, I lose it for the rest of my life. | ||
| So that's my plan. | ||
| And also, I would like to say that it's preventive, not preventative. | ||
| It's three syllables. | ||
| So thank you. | ||
| Okay. | ||
| Anything from that, Julie Robner? | ||
| Nope. | ||
| But a lot of federal retirees do keep their federal insurance is very good, and many of them do keep it in addition to Medicare. | ||
| From Michigan, Ron is next, receiver of private insurance. | ||
|
unidentified
|
Hi. | |
| Hi, I got private insurance. | ||
| I don't seem to have any problems with my insurance except the proscene from the medical field. | ||
| Seems like they overcharge the insurance companies. | ||
| They probably give them a kickback, too. | ||
| It's like a big scam between the hospitals and the insurance companies and the government and stuff, mostly just the insurance companies in the hospitals. | ||
| And to that guy that was talking about the deadly wound, that's talking about baptism that was changed in 325 AD by the church. | ||
| That was a deadly wound when they changed baptism from Jesus' name to Father Son. | ||
| Okay, okay. | ||
| Okay, we got it, Ron. | ||
| To the point of how hospitals practice their care, Julie Robner, what are the discussions going into the ACA is monitoring how much it costs for a hospital to provide services and what could be done about those costs? | ||
| Where are we today on those? | ||
| More recently, there have been efforts, both Republican and Democratic efforts, to increase transparency in pricing, both from the insurance side and from the provider side, from the hospital side. | ||
| They've been met with different levels of success. | ||
| It's still a work in progress. | ||
| But, you know, there's the hope that if people have a better idea of what things actually cost, that they might be able to do better job comparison shopping. | ||
| Perhaps prices could be a little bit better controlled. | ||
| As I say, that is something that the Affordable Care Act kind of sidestepped and that other legislation has addressed since then. | ||
| And we're still working on it. | ||
| And so, could somebody go to their provider today and say, hey, provide me a list if I'm going to receive these types of services? | ||
| To what degree can they say, here's the exact cost? | ||
| Yes. | ||
| Well, you're supposed to be able to. | ||
| You're supposed to be able to get an estimate from your provider, and you're supposed to be able to get an estimate from your insurer about how much they will pay. | ||
| And sometimes you can, and sometimes you can't. | ||
| Jeffrey is in North Carolina. | ||
| Jeffrey, a receiver of private insurance. | ||
| Hi there. | ||
| You're next. | ||
|
unidentified
|
Yes. | |
| Thank you for taking the call. | ||
| Good morning. | ||
| And I just feel that the private sector insurance is just way too much. | ||
| I had tried that, and the copay was just staggering. | ||
| And I had to sign up for the Affordable Care Act for the services that I needed, my back surgery, my knee surgery. | ||
| The copay was staggering. | ||
| The Affordable Care Act put me in a position to be able to have these necessary surges that I needed. | ||
| I just feel the government is in such a strong financial position. | ||
| It's confusing that we proclaim a title of the wealthiest and the rich, but you have other nations or countries, and correct me if I'm wrong, that provides that for the citizens in their country. | ||
| Why we don't have something being able to on both sides balance this out? | ||
| This is a concern every day for the average American citizen that need medical care, that cannot walk into a facility to be able to medically get treated because they are definitely feeling the responsibility of a massive debt that they cannot get out of under the provision of what insurance carries that you have or if it's private. | ||
| But I just feel it has to be a better way. | ||
| It should be a better way because I should not have to have shoes off of private insurance and then it was better with affordable care. | ||
| So if it's working, why tear that down? | ||
| Got you, Jeffrey. | ||
| Thank you. | ||
| And Julie Robner. | ||
| Well, this is a hundred years debate now about how the U.S. should provide health services and health insurance to the population. | ||
| We've never been able to agree on, you know, the Affordable Care Act was a very hard, hard-fought battle over not just the sort of the two years that it took Congress to do it, but the preceding six or seven. | ||
| And, you know, we saw another, we saw fights in the 1940s. | ||
| We saw fights in the 1960s that gave us Medicare and Medicaid. | ||
| We saw fights in the 1970s and the 1980s. | ||
| You know, we were going to, we're going to continue. | ||
| It's a work in progress. | ||
| Nobody, I think it's fair to say, is very satisfied with the way our health system is working. | ||
| But at least I think the consensus is it's better than it was. | ||
| There's still a lot of work to do. | ||
| Julie Robner, we've heard about cuts throughout the federal government. | ||
| Could those cuts or proposed cuts affect those who receive insurance under the Affordable Care Act? | ||
| Yes, as I said, already the Trump administration has vowed to cut the outreach and to, again, shorten the sign-up period for the Affordable Care Act. | ||
| That was something that the first Trump administration did. | ||
| We're seeing these offices laid off these caseworkers who help people who run into problems with their plans. | ||
| As we know, it's not a completely smooth running system. | ||
| So, and of course, depending on what Congress does, if they cut back on the Medicaid expansion that was in the law, that could affect as many as 20 million people. | ||
| And whether or not they extend these additional subsidies or let them expire, that's another 20 million people. | ||
| So there could be big changes coming. | ||
| Robert joins us next. | ||
| Robert is in Ohio, a receiver of ACA insurance. | ||
| Hi, Robert. | ||
|
unidentified
|
How are you? | |
| Thanks for having me on. | ||
| I have a Medicaid and Medicare. | ||
| I went through, I have a disability, got into an accident. | ||
| And, you know, it surprises me when I got this insurance that I could just walk in and get my insurance, you know, get whatever I needed taken care of, whatever ailment, walk out, spend very little on, you know, my prescriptions and the bill and everything. | ||
| And I think with all that we've paid into our system and with having friends benefits in the past way before my time, the insurance would be a priority because it is known that we're all going to get sick at some point. | ||
| That's a fact. | ||
| Everyone in this country is going to get sick at one point. | ||
| And with all that we've put into it and all the progress that we've made, I would hate to see anything like this go away. | ||
| I think we need more. | ||
| I think we need to go towards more of a, even more universal health care because this relieves the stress of a lot of Americans, you know, and that in itself makes life a lot easier. | ||
| And I would like to push to see it go even further and even more affordable. | ||
| That's just me, but I enjoy. | ||
| I enjoy being taken care of and paying what little bit of taxes I have into it, and I'm okay with it. | ||
| Okay. | ||
| That's Robert there in Ohio. | ||
| Yeah, and I think it's important. | ||
| You know, there are several million, what are called dual eligibles, people who are eligible for both Medicare and Medicaid. | ||
| And they do have virtually all of their needs taken care of because they have low incomes. | ||
| That's what makes them dueligible. | ||
| But that's a fairly small subset of the rest of the population. | ||
| From Robert in Maryland, a receiver of private insurance. | ||
| Hello. | ||
|
unidentified
|
Hey, good morning. | |
| How you doing? | ||
| Hi, thank you. | ||
|
unidentified
|
Go ahead. | |
| Yes, sir. | ||
| I have insurance through the government. | ||
| And the problem, like other government programs, the insurance industry needs to get a halt of the excessive amount of cost. | ||
| A caller hit on it a few hours back. | ||
| You know, my wife had a back surgery, and we were sent band-aids, you know, to cover her incision on her back. | ||
| And the insurance charge, or the doctor charged insurance like $3,000 for 10 of these band-aids. | ||
| And when it all come down, the insurance negotiations come down to us. | ||
| We still had to pay $400 out of pocket for these band-aids that you could get off of eBay for less than $50. | ||
| I don't understand the ballooning of these prices. | ||
| Well, I do understand it because it's all corporate greed, but that needs to get a hold of. | ||
| And insurance will be a lot more affordable in this country. | ||
| Yeah, there's no doubt that there is vast overcharging. | ||
| There are a lot of people who are in the, a lot of people in the healthcare industry who are making a lot of money. | ||
| And basically, it's an arms race between insurers and payers and providers. | ||
| And hospitals need to keep their doors open 24-7 and have staff available 24-7. | ||
| Insurers want to pay, don't want to overpay because they want to be able to charge as low premiums as they can. | ||
| So it is just sort of the constant back and forth. | ||
| But there are, as I said, there's a lot of now, there's a lot of private equity coming in that wants to basically take as much profit as they can out of what's a very profitable sector. | ||
| So it is a continuing fight. | ||
| The private equity aspect, are they buying hospitals wholesale? | ||
| Are they buying practices wholesale? | ||
| Describe the nature of that. | ||
| Yes, that is correct. | ||
| I mean, one of the things that we're seeing is that private equity is buying up hospital chains, basically selling out, you know, taking it apart for parts, selling the real estate and having the hospitals then pay rent because they don't own their land anymore. | ||
| And then some of the hospitals have ended up in bankruptcy and ended up closing. | ||
| It's been a real problem, sort of the things that private equity has come in and done to basically make profits for the private equity shareholders. | ||
| It's not a really sort of, it's not the best model for how private equity should work, which is not to say that private equity isn't useful often. | ||
| You know, it comes in and provides capital for things that are absolutely necessary. | ||
| It's just when private equity comes in and takes apart something that's already existent. | ||
| How are doctors responding to that trend happening? | ||
| Well, doctors' practices are also getting bought up by private equity. | ||
| And a lot of them, you know, end up with not exactly what they thought they were going to get. | ||
| That they're having to see more patients in less time, not being able to practice the way they would like to. |