The Supreme Court, the ACA, Healthcare.gov, and an Alternative Plan

The US Supreme Court will be hearing a case – known as King v. Burwell – this coming week on whether or not the federal healthcare exchange program, known as Healthcare.gov, is legal. The question before the Court is whether or not the Affordable Care Act (ACA) allows for subsidies for healthcare premiums in any of the 34 states that refused to set up their own healthcare exchanges under the ACA.

The plaintiffs – four people from Virginia – argue that the federal government misinterpreted the ACA in regards to the subsidies. They argue that the law only allows for subsidies in states that set up a state-based exchange. Virginia in one of the 34 state who opted out of a state-based exchange. These four individuals, who don’t want to purchase insurance, say that without the subsidies, they would not have to either buy insurance or pay a penalty since they do not make enough to afford healthcare without the subsidy*. The Obama administration argues that this is a politically motivated argument to narrowly interpret a couple of words found in the ACA in order to gut it.

If the US Supreme Court invalidates the Healthcare.gov websites in all of the states that refused to set up their own healthcare exchanges, everyone who gets a subsidy to purchase their health care through the exchange will lose that subsidy. According to the Washington Post, this type of ruling would affect about eight million people across the country. That’s about 87% of all Healthcare.gov users nationwide in the 34 states that did not set up a state-based exchange receive. In Pennsylvania, somewhere between 70-84% of all users of healthcare.gov receive these subsidies.

The subsidies in Healthcare.gov currently reduces healthcare premiums by up to 72% of the full premium, depending on the size of one’s family and family income. So if the Court holds that subsidies within the Federal Healthcare exchange are illegal, premiums for individuals needing these subsidies will dramatically increase; out-of-pocket premium increase could amount to an average increase of 256%. This increase could begin in as little as 25 days after the ruling is made in June 2015. OR the Court could set a date further in the future to allow some time for transition.

What would the end of these subsidies mean?

Healthcare in the 34 states in the federal exchange program would destabilize. The predictions include lots of people – mostly the young and the healthy – ending their insurance, insurance companies pulling out of the exchanges in these states, lots of layoffs, and a return to uncovered people attempting to get care in hospitals without any coverage. Those left in the exchanges after the young and healthiest leave are the older and the sickest individuals. Insurance companies will begin to feel the pain and start to pull out of the exchanges as participation in the exchanges would no longer be financially viable. With fewer people seeking care on the federal exchange, thousands of people hired by the insurance companies and by the federal exchange system will likely face layoff. In addition, hospitals will once again see a surge in the uninsured arriving on their doorstep for care.

Here’s how the Kaiser Family Foundation summarizes this issue:

People Leaving the Market Followed by Premium Increases for Those Who Remain. As a result, the elimination of the subsidies would destabilize the individual insurance markets in states not running their own marketplaces. Under the ACA, insurers would still be required to guarantee access to coverage irrespective of health status and prohibited from charging sick people more than healthy people. Even without the subsidies, many people who are sick would likely find a way to maintain their insurance in the face of substantial premium increases. However, people who are healthy would likely drop their insurance.

Insurers in the affected states would immediately find themselves in a situation where premiums revenues were insufficient to cover the health care expenses of the remaining enrollees, who would be far sicker on average than what insurers assumed when they set their premiums for 2015. This would trigger a classic adverse selection “death spiral,” where insurers would seek very large premium increases, which in turn would cause the healthier of the remaining enrollees to drop coverage….

Insurance Companies Leave the Market and Layoff Employees…Under ACA regulations, premiums for insurance sold inside the marketplaces are locked in for a full calendar year. So, the earliest those premiums could change would be January 1, 2016, though even that would be tricky since insurers will have already submitted proposed 2016 premiums to state insurance departments by the time the Court issues a decision. Depending on state laws, premiums for products sold outside of the marketplaces could potentially be increased more quickly. And even if insurers could adjust rates, establishing stable and sustainable premium levels in this type of environment is extremely difficult, because as rates move higher, more of the relatively healthy enrollees drop their coverage.

Because this may all happen very quickly, it is possible that many or all insurers would choose to exit the individual markets in these states rather than facing significant losses in a quickly shrinking market. Insurers that remain in the market risk being one of the only carriers continuing to guarantee access to coverage to people in poor health (since people who lose coverage from exiting insurers have special enrollment periods to choose new coverage).

Since it is unlikely that Congressional opponents to the ACA would be willing to craft a law allowing for subsidies within Healthcare.gov should the Court overturn this portion of the ACA regulations, the burden of the fix falls upon each of the 34 states. Some of these 34 states will allow the healthcare exchange to die with the dire predictions quickly coming to fruition. Others, in advance of the Court’s hearing and decision of this case, are starting to talk about alternatives should the Court outlaw the subsidies in their states.

One of these states attempting to deal with this possibility is Pennsylvania, where I live. The insurance companies and hospitals throughout the state, fearing for their livelihood, are lobbying the PA General Assembly to set up a state-based exchange system. Tom Wolf (D), our new Governor, has said he is interested in setting up a state-based exchange.

The question then becomes, where would the money for the set-up of a state exchange come from in a state that has a large budget deficit since federal dollars for such a set-up are no longer available.

Might this be a great time to lobby for a universal health care plan for Pennsylvania? As well as in the other 21 states currently working towards such a solution as well?

Healthcare for All PA, in conjunction with some of our state legislators, are working on re-introducing the Pennsylvania Health Care Plan. This bill, if it becomes law, would

…create one insurance plan that has one single payer, to cover all Pennsylvania taxpayers.  The premiums for The Pennsylvania Health Care Plan would be a flat rate of 3% of income for individuals and 10% of payroll for businesses.  The Pennsylvania Health Care Plan would place you and your healthcare provider in charge of you and your family’s healthcare. The plan will be a public/private hybrid with the insurance function provided by the state government and the medical care would be privately delivered.

It’s cost effective. It covers everyone. It’s comprehensive in that it covers all medical treatment, dental care, eye care, physical therapy, mental health treatment,  hospice care, treatments for addiction, long-term care, access to wellness programs, prescription drugs and emergency transport. And you won’t need an army of navigators in either a state- or a federal-based healthcare exchange to help you interpret your plan.

Check out Healthcare for All PA for more information on this bill and become a citizen lobbyist for comprehensive health care that allows you access to the healthcare you need and want without bankrupting you, your family or your neighbors.

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*NOTE: The four plaintiffs in this case before the Supreme Court–David King, Douglas Hurst, Brenda Levy and Rose Luck—appear to be either ideologues and/or guinea pigs for the libertarian Competitive Enterprise Institute (CEI). CEI is an organization committed to overturning the Affordable Care Act. If the subsidies are overturned, all four of these individuals may not even be affected by the Court’s ruling according to a February 9 article in Mother Jones. Three of the four – Levy, King and Hurst – are now or soon will be fully eligible for Medicare. Two of them – King and Luck – already qualify for a hardship exemption from purchasing healthcare and/or paying a penalty due to their relatively low-income levels. However, the issue of “standing” (the legal argument that they would actually be harmed if the law were to continue), for some reason, has not been raised in this case by the Obama administration and will not be considered when the Court hears the case next week.

Throwing Gun Safety Away in PA

Stop Violence Against Women NOW diamond

Stop Violence Against Women NOW

I received an email late last night from CeaseFirePA  regarding pending legislation in the Pennsylvania General Assembly.  Here’s the main part of that email regarding two bills designed to reduce gun safety within the state:

There has been a MAJOR development in our state House that is designed to seriously undermine our safety as Pennsylvanians. IT IS UP TO YOU TO ACT TODAY.

Our state House Judiciary Committee just released a surprise agenda for… March 18 and it’s a doozy. The legislators controlled by the gun lobby are trying to railroad five firearms related bills-at least two of which are extremely dangerous for Pennsylvania-through the legislature without giving the public time to weigh in on them. These dangerous Bills are:

-HB 921, which would eliminate Pennsylvania’s background check system (PICS)–a system that our state police swear by and that contains thousands of records, particularly mental health records and records of PFAs [Protection from Abuse orders]/domestic abuse, that are not included in the National Instant Check System (NICS);

-HB 2011, which would-for the first time EVER in Pennsylvania history-allow a special interest group (in this case, the gun lobby and groups like the NRA) and the interest group’s entire membership base special, automatic standing to sue towns and cities because the group does not like the ordinances that these towns have passed to increase the safety of their citizens, even when the ordinance has not been enforced against any member of that group.

—Rob Conroy, CeaseFirePA, Western PA Regional Director

Based on the Gun Safety resolution that both Pennsylvania NOW and National NOW passed, respectively, in January and February 2013, Pennsylvania NOW decided to oppose both of these bills.  [FYI for disclosure purposes, I serve on both of these organizations’ boards — as a member of the Executive Committee for Pennsylvania NOW and as a member representing the Mid-Atlantic Region on the National NOW Board of Directors]. For more information on this NOW policy, go to the end of this blog to see the text of the resolution passed on February 25, 2013 by the National NOW Board of Directors calling for Sensible Gun Safety Legislation; this policy passed following the many concerns raised by the shootings at Sandy Hook Elementary School on December 14, 2012.  My very first blog on this site was written the day of these shootings.)

Why Pennsylvania NOW Opposes these Bills

Pennsylvania NOW opposes HB 921 that eliminates PA’s background check for gun sales and increases the threat of gun violence to victims of domestic violence who have or want to seek out a Protection From Abuse (PFA) order.

Pennsylvania NOW also opposes HB 2011 since it allows special interest groups without legal standing to sue to overturn any local ordinance they don’t like.  This second bill could overturn not only local gun-related ordinances, but also other ordinances such as local anti-discrimination ordinances that have added marital status, familial status, family responsibilities, gender identity, and/or sexual orientation to the list of protected classes in preventing discrimination in housing, employment, and public accommodations.

Status of these Bills

The members of the Pennsylvania House Judiciary Committee met at 10 am this morning.  I talked to Rep. Thomas Caltagirone’s (D-PA 127) office (he’s the Minority Chair of the House Judiciary Committee).  The woman I talked to said that his entire staff (except herself) was in the Committee meeting and she had no idea as to whether or not these bills had been voted on.  At 2 pm today, I checked the General Assembly’s website.  As of that time, nothing had been posted regarding a committee vote on these bills.

Based on the make-up of the Judiciary Committee, we suspect that both bills will be voted out if they haven’t already been.  So all members of the legislature need to be contacted to tell them to vote no on both bills when they come to the floor.

Be/Become an Activist for Gun Safety

We don’t need to throw away our gun safety laws.  We need, instead, to make sure gun safety rules are in place to protect our loved ones.

So, please take time to contact your legislator.  Here’s where to find your legislator’s contact info. Tell him/her to vote NO on HB 921 and HB 2011 to protect the lives of our loved ones from unsafe gun sales and preemption of local ordinances that improve our local communities.

Addendum

CALL FOR SENSIBLE GUN SAFETY LEGISLATION

WHEREAS, the National Organization for Women (NOW) “[E]nvision[s] a world where non‑violence is the established order”; and

WHEREAS, we, along with the rest of the nation, have witnessed in horror and, with deep sadness, the most recent massacre on December 14, 2012, by an individual with assault weapons, of his mother first, then innocent children and teachers at the Sandy Hook Elementary School in Newtown, Connecticut; and

WHEREAS, this horrific incident is the latest in a string of recent, shocking gun attacks, all of which have been perpetrated by individuals with assault weapons and which have mostly targeted women and children around the country, including at:

  • a shopping mall in Portland, Oregon in December 2012;
  • the movie theater in Aurora, Colorado in July 2012;
  • a shopping mall in Tucson, Arizona in January 2011, where Congresswoman Gabrielle Giffords was grievously injured, and where other casualties included the death of 9-year old Christina Taylor-Green; and
  • an Amish school in Nickel Mines, Pennsylvania in October 2006 where 5 young girls were slaughtered and 5 more girls were seriously injured after the shooter released the boys and the adults; and

WHEREAS, according to the Congressional Research Services, there were more than 310 million firearms in private ownership in the United States in 2009, and another 5.2 million are manufactured annually and another 3.2 million imported annually, and according to the National Center for Health Statistics, more than 30,000 people in the US are killed each year by firearms, and the vast majority of female homicide victims in the U.S. are killed with handguns by intimate partners rather than by strangers; and

WHEREAS, we respect the rights conferred under the Second Amendment but believe that the right to bear arms does not mean that assault weapons—which are designed solely to kill people—should be sold to members of the public; and

WHEREAS, as President Obama said in Newtown, “These tragedies must end;”

THEREFORE BE IT RESOLVED, that NOW calls upon our federal- and state-level elected representatives to protect and defend our children, our communities and our nation from further gun violence by immediately implementing sensible gun safety  legislation, including:

  • Reinstituting the ban on assault weapons that was in effect prior to 2004; and
  • Banning the sale, transfer, transportation and possession of large clips of ammunition containing more than 10 bullets; and
  • Closing the “Gun Show Loophole” which allows individuals to purchase guns without a background check; and
  • Appointing a permanent position as Director of Tobacco & Fire Arms Department; and
  • Retaining the results of all Federal background checks for five years; and
  • Requiring universal background checks, including checks  for domestic violence for the purchase of any legal weapon; and
  • Creating a national gun registry that will allow law enforcement to track weapons; and
  • Requiring devices be added to weapons which would limit the use of any privately-owned gun to the registered owner; and

BE IT FURTHER RESOLVED, that NOW encourages our chapters and members to:

  • Lobby their elected officials for effective legislation to end gun violence, with the NOW Action Center providing educational information to assist in such efforts; and
  • Contact entertainment providers and their sponsors to ask that they do not manufacture or sponsor video games, movies, television shows or music that glorify gratuitous violence; and
  • Lobby and/or protest professional organizations in the entertainment industry that honor exceptionally violent content; and
  • Advocate for programs and their funding in schools to teach tolerance and conflict resolution; and

BE IT FINALLY RESOLVED, that NOW endorses actions advocating for solutions to end gun violence when it can be done in accordance with NOW’s Coalition Guidelines.

—Passed by the National NOW Board of Directors, February 25, 2013

Pennsylvania General Assembly Again Attacking Women’s Reproductive Health

Keep Abortion Legal NOW Round

Keep Abortion Legal Safe, Legal and Accessible (http://www.now.org/issues/abortion/)

It’s 2013 and the Pennsylvania General Assembly continues to attack women’s access to reproductive health. According to WeveHadEnoughPA.org, the Pennsylvania legislature has launched and maintained a 2+ year attack on women’s health. There have been numerous bills introduced and in some cases passed that restrict women’s vital access to reproductive health.  Since January 2011, there have been at least 55 votes in the Pennsylvania General Assembly to restrict access from birth control to safe, legal abortions.

The most recent attack is happening this month.  On April 10, the Pennsylvania Senate Insurance and Banking Committee heard and passed out SB 3 by an 8-5 vote; a floor vote could occur any time this month.  This coming Monday, April 15th, the Pennsylvania House Health Committee will be hearing and voting on HB 818, the companion bill to SB 3.

The Additional Burdens on Women Seeking Abortion Care in These Bills

Both of these bills would prohibit insurance companies who provide health care coverage from including abortion coverage within the new healthcare Exchange crafted by the Affordable Care Act (aka Obamacare). The only exceptions to this proposed ban are for women who become pregnant because of rape or incest if they personally report the sexual assault to law enforcement officials and for women who will die without immediate access to abortion services. If a woman doesn’t meet one of these two exceptions, she must completely pay for the abortion totally out of her own pocket, unlike any other medical care she would receive under her health insurance plan.

Currently, about 80% of private insurance companies provide coverage for abortion services. This is important because these very same plans will be offered to people purchasing insurance through the Exchange. As part of the federal law, however, all plans that offer abortion coverage in the Exchange must have a separate payment for that portion of the coverage. This bill would deny women the right to make this separate payment and deny them what is currently available to most people covered by the current private health insurance system. While women would still be able to have abortions in this circumstance, they would be forced to fully pay out-of-pocket all cost for these procedures; their insurance company would be prohibited from paying any portion of this treatment.

This proposed ban places an undue burden on victims of rape and incest and on those women whose lives are in danger health-wise by adding unnecessary barriers to receiving the critical medical attention they need. The two exceptions allowed are extremely limited. These bills require woman who are victims of rape or incest to notify the police and identify the perpetrator prior to seeking abortion treatment.  It also limits women with health issues that complicate their medical treatment to those that are in immediate danger of dying and requires additional medical certification by second, non-attending physician.

This bill places these restrictions on access to health insurance not by mentioning rape or incest or the death aversion clause, but by referring to and expanding Pennsylvania’s version of the Hyde Amendment.  This language is embedded in 18 Pa.C.S. § 3215(c) and would expand restrictions on public funds to all privately paid insurance plans purchased within the Exchange. The law (18 Pa.C.S. § 3215(c))as currently written is a prohibition of the state spending of public funds but not personal funds provided by the person herself for her own health insurance coverage.

The Rape and Incest Exception

Women and minors who are raped would be denied access to abortion services unless they formally report and identify their rapist to the police or child protective services.  Most sexual assaults are not reported to the police. This is even truer when the perpetrator is a family member or acquaintance. According to the Pennsylvania Coalition Against Rape, sexual assault occurs at a much higher rate than is actually reported.

Reasons for not reporting include an initial denial that they have been raped; fear that you won’t be believed or are ashamed for having been raped; or having an ongoing relationship (such as a spouse or parent) with the perpetrator. In order to be safe from further violence by the perpetrator, women and girls may decide not to report the attack to the authorities.  And if you are in denial you are also unlikely to report your rape or the incest of your child to authorities as required in this proposed legislation.

So that means if this bill becomes law and you become pregnant from rape or incest, you are further burdened with the additional costs of fully paying for the abortion. If this bill were not to go into effect, then following the restrictions placed on abortion care under federal law, you would have the abortion services covered based on the insurance rider you purchased in the exchange and you wouldn’t be forced to file a complaint with the police.  This is just one reason why this bill should be voted down.

The “Avert” Death Exception and Need for Expanded Health Exception

In addition, under this proposed law, women who are near death could receive an abortion.  However, say a woman develops cancer or an infection during her pregnancy that will not immediately kill her but would complicate her medical treatment should she continue with the pregnancy.

This health threat/complication is not included in the current bill’s health exception as that exception allows abortions only to “avert” the woman’s death. Any woman with a medical condition that is complicated by the pregnancy but doesn’t immediately place her in danger of death would be forced to bear the additional burden of the full cost of an abortion in addition to the increased threats to her health as well as the additional medical bills for the remaining part of her care.  The medical community, advocates and some legislators are very concerned about this limited exception and have proposed an amendment to both the House and Senate bill to expand this exception from “averting” her death to coverage of the abortion for any pregnancy that poses a substantial risk to the woman’s physical health.

But even if the health exception is expanded to include threats to women’s physical health and care, this bill continues to attack women’s health and lives and should be voted down.

Why this Bill Should be Voted Down

The question of whether abortion will be covered in federally subsidized insurance exchanges has already been settled.  In response to concerns raised by US Senator Ben Nelson, a staunch opponent of abortion, women who want to use their own money to purchase a health insurance plan that covers abortion services must send a separate payment so the funding for abortion coverage is completely separate and paid entirely by the individual. This bill denies women their right to make this separate payment.  And with an estimated 80% of private insurance plans currently covering abortion care, banning abortion coverage in the state exchange would leave women worse off than they were before health care reform began.

Abortion care is a legally authorized and fundamental component of women’s basic health care.  Women should not be denied access to safe, legal, and critical care as part of health care reform implementation.

If abortion coverage is available to some, it should be available to all.  Politicians should not discriminate against women participating in the health insurance exchange.  All women deserve the same peace of mind that they can obtain the health care they need, regardless of where their insurance comes from.

The decision to have an abortion is a private decision between a patient and her physician. It should not be denied by politicians interfering with an insurance company and the policies they offer to the consumer for this procedure.

Banning abortion coverage in transactions between a private company and an individual is governmental activism of the worst kind.  With all of the heated rhetoric over healthcare reform, one would assume that lawmakers would be sensitive about taking any action that suggests government intervention in private healthcare decisions.

Finally, instead of denying Pennsylvania women access to fundamental reproductive health care services, politicians should be working to protect and advance women’s health.

Action Needed

Contact your Pennsylvania Senator and Representative today (find their contact information here).  Tell her/him to support the expanded health exception amendment to both SB 3 and HB 818 and to oppose the entire bill regardless of the inclusion of the amendment.