Happy Family Health History Day!

    Thanksgiving is coming, and the Department of Health and Human Services wants citizens to mark the day by discussing history.  No, not Pilgrims, Native Americans, and how they came together as the Pilgrims thanked God for His blessings -- rather, your family health history:

Acting Surgeon General Boris Lushniak Declares Thanksgiving “Family Health History Day" 

As we celebrate the Nation’s 10th annual Family Health History Day this Thanksgiving, I encourage everyone to spend time talking with their family members about their health.  National Family Health History Day is a great opportunity to draw attention to the importance of sharing family health history. 

Both rare diseases and common ones, like heart disease, cancer, and diabetes, can run in families. Understanding your family health history can help you and your health care provider predict your risk for health problems and keep you and your family healthy. 

    As mentioned above, this is the 10th annual observance, so it cannot be chalked up to an Obamacare plot to hijack a religious holiday, as tempting as that is.  George Bush was president in 2004 when Obamacare was just a gleam in Senator Max Baucus's eye. (Think of it more like changing the smoke alarm batteries on your birthday.)  That being said, it didn't stop Acting Surgeon General Lushniak from sneaking in an Obamacare reference:

If someone in your immediate family—mother, father, sister or brother—has heart disease, you have twice the risk of developing heart disease as someone without that family history. Thanks to the Affordable Care Act, many preventive screenings are now covered under health insurance with no cost share for Americans.

    On second thought, perhaps the mention of Obamacare is entirely appropriate.  After all, what  Thanksgiving is complete without the turkey?

Obamacare Deadlines Shortened By Lack of Payment Options

    When the Obama administration launched the Healthcare.gov website on October 1, the president and his officials focused on the coverage that would now be available to the uninsured as of January 1, 2014.  However, with the recent flood of cancellations of those who were told they could "keep their plan," millions more will need new insurance in place by the beginning of the new year.  The well publicized "glitches" have slowed enrollment considerably, and now there is new evidence that consumers will find themselves with even less time to secure coverage than originally thought.

    An editorial in Wednesday's USA Today repeats the common belief about the deadline: "The deadline for signing up for insurance that begins Jan. 1 is Dec. 15."  However, "signing up" for insurance is not enough.  As the Healthcare.gov website states [emphasis added]:

If you enroll in a private health insurance plan any time between October 1, 2013 and December 15, 2013 and make your first premium payment, your new health coverage starts January 1, 2014.

    Kathleen Sebelius echoed this requirement in a Wednesday conference call:

 Payment is not due until Dec. 15 for January coverage, Sebelius said. 

"By the 15th of December, we'll be able to tell you how many people have actually paid for the first month of coverage," she said.  

    However, paying the premium is not necessarily a simple matter.  An online chat with a Healthcare.gov representative revealed that the site is not recommending using the exchange to make the initial premium payment. The representative was not even completely sure the option was being offered.  Here is an excerpt from the chat [emphasis added]:

Healthcare.gov Representative:  To have coverage effective January 1, 2014, you must make your first premium payment by December 15, 2013. Your health insurance company can tell you how to make your premium payment. If you do not make a payment on December 21, 2013, you may have to fill our another application.  

The Weekly Standard:  I can't make a payment through healthcare.gov?  

Rep:  It may give you that option when you complete your enrollment.  

TWS:  If I don't pick a plan until 12/15, won't it be too late for my info to go to the insurance company, them to bill me, and me to make a payment by 12/21?  Seems pretty tight.  

Rep:  You must make your first premium payment by 12/15/13 for your coverage to begin January 1, 2014. If you make your payment by the 21st, your coverage will begin in February 1, 2014.  

TWS:  You said above "It may give you that option" to pay on healthcare.gov.  Does that mean it's not available yet?  

Rep:  We are still experiencing some technical difficulties with the website, which is why it would be best to possibly go through the insurance company to make your first premium payment.

    The federal government run exchange is not the only one to experience problems with premium payments.  The Maryland Health Connection, that state's version of the Obamacare exchange, announced a week ago Friday that it was suspending the bill-pay feature indefinitely:

Accepting payment is not required of a state-based marketplace, and the Board approved deferring this option until after the core items are addressed. The ACA requires insurance carriers to be ready to accept the first payment from consumers, and our carriers are prepared to bill and receive the first payment from our enrollees.

    In addition, just last Friday, Maryland announced that individuals should enroll early to allow time for billing and payment:

For coverage effective by January 1, 2014, individuals are encouraged to enroll before December 10 to allow time for premium invoicing and payment processing with their insurance carrier. 

    Since information regarding plans, premiums, and possibly subsidies must pass from the exchanges to the insurance companies before the consumer can be billed, someone who waits until December 15 to enroll seems unlikely to secure coverage by January 1.  The mid-December deadline therefore would appear to be optimistic, and in reality probably falls earlier in the month, very close to the November 30 target date for the Healthcare.gov website to be fixed.  The window of opportunity for consumers needing coverage for 2014 for all practical purposes may be about a week.


Note: A version of this article first appeared at The Weekly Standard.

Contractor Supporting Insurgents in Afghanistan Granted Access to Coalition Facilities

    In a November 8 letter to Secretary of Defense Chuck Hagel, the Special Inspector General for Afghanistan Reconstruction (SIGAR) warned that a contractor that had been identified with the insurgency had been granted access to a Coalition facility last November, and that the threat of further access by such contractors remains.  SIGAR uncovered the information while conducting an investigation of the structural defects at the Parwan Justice Center, a new courthouse being jointly constructed by the State and Defense Departments.  The letter reads in part:

Evidence obtained by SIGAR indicates that a contractor identified by the CENTCOM Commander as supporting the insurgency in Afghanistan gained access to a Coalition-controlled facility. This security lapse seems to have been caused by gaps in how contractor information is shared by U.S. government agencies supporting the reconstruction effort. Unless immediate action is taken to correct this matter, this contractor and other supporters of the insurgency could continue to gain access to U.S.- and Coalition-controlled facilities in Afghanistan...

Evidence obtained by SIGAR indicates that for two days in November 2012, employees of ZMTL were given access to the Parwan Justice Center complex.2 However, these individuals should not have had access to a Coalition-controlled facility, because the U.S. government determined as early as April 2012, that the Zurmat Group poses a threat to U.S. and Coalition forces.  

Specifically, on April 27, 2012, the Department of Commerce added the Zurmat Group and ZMTL to its Entity List3 because of their involvement in “networks that provide components used to make improvised explosive devices (IEDs) used against U.S. and coalition troops in Afghanistan.”

     To date, the U.S. Army has rejected all 43 of SIGAR's requests that insurgent-supporting contractors, including Zurmat, be subjected to debarment from future work on coalition projects.  The Army has rejected these requests on concerns that debarment would "violate their due process rights under the U.S. Constitution."  SIGAR believes this is a "flawed approach", and that "until action is taken on all 43 insurgency-related cases SIGAR has referred to the Army for debarment, the safety of our troops could still be at risk and U.S. government funds could be diverted to supporters of the insurgency."


Note: A version of this article appeared first at The Weekly Standard.

After One Month, 1,284 Individuals Enrolled in Private Health Plans Through Maryland Obamacare Site

    The latest weekly report for the Maryland Health Connection reveals that the Obamacare marketplace for the state is continuing to under-perform versus expectations.  Two weeks ago, the state reported that through November 1, enrollment had reached 4,651 for the first month of open enrollment, and an additional 84,273 Marylanders would be automatically signed up for Medicaid as of January 1, 2014.  The following week, as I reported, the state withheld enrollment figures because the "Maryland Health Connection is revising its approach to providing numbers of enrolled Marylanders."  The current report reflects the revised approach and the result is rather stunning.  Only 1,274 individuals were enrolled in plans they had chosen during the first month of enrollment.
    A footnote in the weekly report explains the reason for the revised numbers:

In previous reports, we included Marylanders who chose managed care plans among “enrollments.” Because Medicaid coverage does not require plan selection (unlike coverage through qualified health plans), the eligibility determination is a better representation of insurance status than plan selection for this population. 

    Here is the official breakdown:

On Wednesday, the U.S. Department of Health and Human Services reported that from October 1 through November 2:  

• 10,917 applications were submitted in Maryland for coverage;
• Among Marylanders included on submitted applications, 5,923 were determined eligible for Medicaid and 3,498 were determined eligible to purchase private health insurance; and 
• 1,284 Marylanders had selected a health plan for enrollment.

    A chart accompanies the breakdown that shows enrollment by age bracket.  Included in the breakdown of the 1,284 Marylanders that have selected a plan are 108 listed as "< 18." This signifies that minors are included in the 1,284, meaning that the 1,284 literally represents totals persons covered by selected plans; the number of households coverage then would be somewhat less.
    Also revealed in the numbers in that in addition to the 84,273 automatically being added to Medicaid rolls, another 5,923 were determined eligible for the program as well, bringing the Medicaid total to over 90,000.  So for every one person enrolled in an individually selected private health plan, 70 have been added to Medicaid.
    Another worrisome aspect of the report is the rate of creation of verified accounts, the first step toward obtaining coverage through the exchanges.  Before the first two weeks were finished, 30,000 verified accounts were created.  But by November 9, that total had only grown to 53,000, an increase of 23,000 in twice the time.  After an average of 15,000 a week for the first two weeks, the increase slipped to about 6,000 a week since then.
    In spite of the problems, the report remained optimistic:

Through November 9, 1,743 Marylanders have chosen to enroll in private health plans through Maryland Health Connection. This is a 36% increase over the total through November 2.

     While 36% sounds substantial, it represents only 459 individuals.  Even if the exchange added 1,000 individuals per week for the remaining 20 weeks of open enrollment, the total as of March 31 would be about 22,000, far short of the 150,000 Maryland hoped to sign up during the first year of Obamacare.

Maryland Obamacare Exchange Suspends Bill Pay Option

    The insurance marketplaces established by the Affordable Care Act, or Obamacare, have been billed as a one-stop shopping experience.  However, in Maryland, two stops will be needed, at least for the time being.  Originally, individuals had been told that they would be able to make their first payment through the Maryland Health Connection, but this option has been suspended indefinitely, per a press release last Friday:

Bill payment. Accepting payment is not required of a state-based marketplace, and the Board approved deferring this option until after the core items are addressed. The ACA requires insurance carriers to be ready to accept the first payment from consumers, and our carriers are prepared to bill and receive the first payment from our enrollees.

    Although bill payment is optional for individuals per the Affordable Care Act, we reported back in September that, according to Betsy Charlow (communications manager for the Maryland Health Connection,) "employer bills get handled by Maryland Health Connection (federal requirement)," and not just the initial paymen, either.  Ms. Charlow went on to say that "the employer would not get multiple bills. The SHOP would aggregate all carrier bills so the employer can make one payment. The Maryland Health Benefit Exchange would then distribute payment to the appropriate carriers on behalf of the employer."
    If the exchange has delayed even the relatively simple feature of accepting initial payments from individuals to be remitted to insurance carriers, the more complex aggregation of premium billings from multiple carriers and the collection and distribution of those dollars on an ongoing basis will certainly require far more resources and planning.  As I reported at The Weekly Standard, the launch of SHOP in Maryland has been postponed until April 1, 2014.  The Maryland board is counting on the additional three months to make sure that the opening of the SHOP Marketplace does not mirror the debacle that accompanied the debut of the individual insurance exchange.

Maryland Delays Obamacare Small Business Exchange, Jeopardizes Tax Credits

    In mid-October, the Maryland Health Benefit Exchange quietly postponed all of the forums it had scheduled to inform small businesses about the Small Business Health Options Program (SHOP), as reported by THE WEEKLY STANDARD.  Now, in a Friday press release, the Maryland board overseeing the state's Obamacare website announced it had postponed the opening of the SHOP exchange itself from January 1 until April 1, 2014, which could impact businesses who are counting on the tax credits heavily promoted by the Obama administration to help small businesses provide coverage to their employees:

Maryland has a well- functioning small group market which offers the same prices as those that will be offered through the small group exchange, known as the SHOP. The Board approved a plan to open the SHOP on April 1, 2014, which will allow more time for testing and coordination over the next several months.

     Although the press release says that Maryland's small group market offers the same prices as SHOP plans, it does not mention that beginning in 2014, the health insurance tax credits available to businesses are only available to plans purchased via the SHOP exchanges, as noted at Healthcare.gov, and as we reported back in July.  Coverage for small businesses through Maryland's SHOP was previously able to start as early as March 1, 2014, but now that the opening of the marketplace has been delayed until April 1, the earliest date coverage can begin is unclear.  A business that desires to take advantage of the tax credits would either have to delay coverage until SHOP plans are available, or buy a plan through the conventional insurance system, and then reapply through SHOP once the exchange opens.  In either case, the tax credit would only be available for the portion of the year that SHOP coverage is in effect.
    The Maryland Health Connection website itself is also still promoting the tax credits.   It does not indicate what effect the delay will have on the ability of businesses to qualify, though it also notes that "[t]he health care tax credits and deductions are available only if you get coverage through the SHOP."
Since only premiums paid on coverage obtained through SHOP qualify for the tax credit, the calculator provided on the site to come up with a business's estimated annual tax credit is not accurate for coverage obtained during 2014 because it does not take the partial year into account.
    Although the Maryland Health Connection website does not address the effects of the delay, a presentation prepared for a Maryland Health Benefit Exchange Board Meeting on Friday, November 8, asserts that "Tax credits will not be lost – available for 2 years from first receipt."  This is an apparent reference to the fact that the tax credit is limited to two consecutive years, beginning the year coverage starts.  However, according to proposed rules by the IRS published in the federal register, the two-year limit is being interpreted as two tax years, not a 24-month period that may overlap into three different years [emphasis added]:

[T]his credit is available to any eligible small employer only twice (because the credit can be claimed by a small employer only for two consecutive taxable years beginning after December 31, 2013, beginning with the taxable year for which the small employer first claims the credit). Accordingly, no small employer will calculate the credit amount or complete the process for claiming the credit under this regulation more than two times.

    This means that an employer who obtains SHOP coverage sometime in 2014 after the exchange opens could either file for a partial-year credit for 2014 and a full-year credit in 2015, or skip filing for any credit in 2014 and then file for full-year credits in 2015 and 2016.  Since the only apparent advantage of purchasing coverage via SHOP versus the conventional insurance market is the availability of the credits, the delay in the opening of SHOP seems to amount to a de facto delay to January 1, 2015, at least for businesses intent on obtaining the maximum benefit from the tax credits.
    Unless the Maryland Health Connection can reconcile the SHOP delay with the proposed IRS rules, small businesses will be getting something less than is being promised.  An email to the Maryland Health Benefit Exchange requesting clarification on the effect of the delay on tax credits has not yet been returned.


Note: A version of this article first appeared at The Weekly Standard.

White House Goes on the Offensive on Obamacare

    Evan as millions of taxpayers are receiving cancellation notices for their health insurance that President Obama assured them they could keep, the White House has gone on a Twitter campaign to excoriate Republicans for not expanding Medicaid to another 4.5 million people.  In a series of tweets on Wednesday, the GOP in Texas, Florida and North Carolina were characterized as putting politics over people by refusing to expand Medicaid roles under the Affordable Care Act:

    Given the news recently, it does not take much imagination to tweak the White House graphic to tell the real story: