By Rebecca Adams, CQ HealthBeat Associate Editor

December 10, 2014 -- With an important deadline looming, nearly 1.4 million people have signed up for or renewed coverage through the insurance marketplaces established by the health care law.

But the numbers indicate that a large portion of people who already have a marketplace plan will stay with their current arrangement, even though Obama administration officials warn that most people could save money if they switch plans.

Millions of people enrolled in a marketplace plan may be unaware that their costs could go up in January.

About 52 percent of the sign-ups so far during the enrollment period that started Nov. 15 are people renewing coverage, and 48 percent are new customers. The people who renewed since November represent less than 11 percent of the 6.7 million people were enrolled in a marketplace plan in October.

If people do not change plans and update their information by Dec. 15, they will be renewed in their current plan or a similar plan at the same tax subsidy level. One risk is that people may face increases in their costs unnecessarily. Another is that their tax subsidy level could be wrong.

If the number of people choosing a plan this week continues to grow by about the same amount as last week, by Friday more than 5.6 million people who are currently enrolled will still need to come back to the website by the end of Monday to choose a plan or face auto-enrollment.

Charles Gaba, a supporter of the law whose projections for enrollment have been followed closely, predicted in a phone interview that enrollment will tick up as it did for deadlines last year. He projected that about 3.5 million to 4 million people will be auto-renewed because they will not take action by Monday.

The auto-renewal deadline affects everyone covered by a marketplace plan, regardless of whether their benefits kicked in during January, May, or any other month this year. Previously, plans in the individual market typically lasted for a year.

Administration officials also are urging new consumers to pick a plan so that their benefits can start in January. If people wait until later in December to sign up, their benefits won’t start until Feb. 1.

Health and Human Services (HHS) officials noted that the number of people choosing plans last week was 33 percent higher than the first week of the open enrollment season that started Nov. 15.

“Open enrollment’s momentum is building, and I’ve seen that firsthand as I traveled the country and talked to people from Florida to New Jersey to Pennsylvania to Texas,” HHS Secretary Sylvia Burwell said in a blog post. “With less than a week left to sign up for coverage that starts January 1, we’re encouraging new and returning consumers to visit healthcare.gov.”

More than 2.5 million people had filled out applications since November but have not gone on to pick a plan. After people choose a plan, they need to pay their first month’s premium in order to be enrolled.

State-run marketplaces are not included in the HHS count. Neither are Oregon and Nevada, which switched from a state-run website to the federal website this year.

A handful of states have deadlines that are later than Dec. 15 for auto-renewal and benefits that start in January.

Separately, California officials in a call with reporters earlier in the day said they are pleased with the progress in their state-run exchange. The interest this year “far exceeds” the number of sign-ups during this point of the sign-up period last year, said Peter Lee, the executive director of the state marketplace, which is known as Covered California.

Almost 50,000 Californians selected a plan in the two-and-a-half weeks between Nov. 15 and Dec. 3, said Lee. Last year, only about 31,000 people chose a plan during the entire first month of the sign-up period, he said.

The California data only includes new customers. Lee said that he will release more statistics, including those for renewals, in January.

With the Dec. 15 deadline approaching for people who want coverage on Jan. 1, Lee predicted “continued and even growing interest in enrollment.”

By Rebecca Adams, CQ HealthBeat Associate Editor

December 8, 2014 -- The public has until Feb. 6 to comment on a health IT strategy released by 35 federal agencies Monday.

The plan will feed into a broader roadmap that will be released early next year.

The strategy is one of a series of efforts put forward by federal officials. The first federal health IT strategic plan was published in June 2008.

“With this updated plan, the federal government signals that, while we will continue to work towards more widespread adoption of health IT, efforts will begin to include new sources of information and ways to disseminate knowledge quickly, securely, and efficiently,” said Karen DeSalvo, national coordinator for health IT and acting assistant secretary for health, in a letter included in the plan.

The plan’s goals include ways to boost the collection and sharing of electronic health information.

The strategy affects the more than 400,000 hospitals and physicians participating in the Medicare and Medicaid Electronic Health Record Incentive Programs, as well as professionals that work with medical records for military personnel or veterans, among other programs.

“As a large provider and purchaser of care, we continually look for ways to expand the sharing of critical healthcare information with our healthcare partners,” said Karen S. Guice, principal deputy assistant secretary of defense for health affairs at the Pentagon.

The plan “represents specific goals and strategies for how interoperability will be leveraged to foster the technological advancement of health information exchange to improve quality of care for veterans,” said Gail Graham, deputy secretary for health informatics and analytics at the Department of Veterans Affairs.

By Melanie Zanona, CQ Roll Call

December 9, 2014 -- Failure to replace Medicare's oft-criticized physician payment formula has shifted federal attention away from other necessary health reforms, witnesses told a House hearing on Tuesday, further stoking the debate over advancing permanent "doc fix" legislation in Congress.

"The sustainable growth rate was designed to control Medicare physician reimbursements, but has instead continued to stifle other federal entitlement reforms because it must constantly be addressed," said Christopher W. Holt, director of health care policy for the American Action Forum.

Witnesses at a House Energy and Commerce Health Subcommittee hearing urged lawmakers to find a permanent solution for avoiding the scheduled cuts facing Medicare physicians on March 31. Some of their recommendations for offsetting the cost include identifying overpriced services, instituting payment updates that are higher for primary care than specialty care and establishing a primary care bonus that is funded by non-primary care services.

Finding a way to pay for a doc fix marred efforts to pass legislation this year, with Republican Michael C. Burgess of Texas acknowledging that "it seems unlikely that the Senate will act" on the issue in the lame-duck, even though "the failure to replace the SGR has cost money."

Witnesses at Tuesday's hearing warned lawmakers that despite a recent slowdown in federal health spending growth, Congress will soon have to grapple with the aging baby boomer population and rising federal debt levels, suggesting a variety of entitlement reforms.

"Health care spending and its growth over time puts pressure on employer, government, and family budgets," said Mark Miller, executive director of the Medicare Payment Advisory Commission. "For the Medicare program, this pressure is particularly acute given the outlook for the federal debt and the projected increases in Medicare enrollment."

MedPAC, which is a nonpartisan commission that advises Congress on issues affecting Medicare, suggested short-term ways for reducing federal health costs and improving the program could include updating the fee-for-service payment rates, creating site-neutral payments, bundling payments, and incentivizing reductions in readmission rates in an effort to encourage cheaper and better quality of care.

However, some lawmakers took issue with the penalties imposed on hospitals when a patient is readmitted. They were concerned the penalties could unfairly punish facilities when a patient is readmitted for reasons unrelated to their first visit, but Miller emphasized that the penalties are not assessed on a case-by-case basis and instead examine a hospital’s overall rates of readmission.

"We don't want the penalty, we want them to avoid readmission, which is a much better event for everyone," Miller said.

Long-term improvements suggested by MedPAC include offering regulatory relief for providers who take on risk and streamlining quality measurements.

Lawmakers also raised concerns about how they can carefully balance entitlement reforms without harming beneficiaries. Democrats largely lauded Medicaid expansion in states, while Republicans criticized cuts to the popular Medicare Advantage program.

"There are no easy choices in health reform, and few if any changes that produce all winners and no losers," said Marc Goldwein, senior policy director at the Committee for a Responsible Federal Budget. "However, it is certainly possible to identify reforms that create more or bigger winners than losers by improving the way we deliver and consume health care and reforms that allocate resources to where they are needed most."

Some of the reforms suggested by Goldwein include encouraging the use of generic drugs, expanding bundled payments, reducing payment updates for post-acute care providers and scaling back certain exchange subsidies under the 2010 health care law (PL 111-148, PL 111-152).

By Melissa Attias, CQ Roll Call

December 11, 2014 -- Some doctors who treat Medicaid patients will see significant cuts for primary care services next year if Congress adjourns without extending a provision of the health care law, as is widely expected.

The overhaul (PL 111-148, PL 111-152) provided a two-year boost in payments for Medicaid primary care physicians, which was designed to put fees for the federal–state health program for the poor on a par with Medicare. That policy expires at the end of the month and—with the House headed out as soon as Thursday—it seems highly unlikely Congress will come to the rescue.

Advocates had also been pushing lawmakers to address three other provisions in the health law that provided mandatory funding through next September, whose expiration is known collectively as the primary care cliff. They say the funding uncertainty is already affecting the programs, which provide support for community health centers and loan repayment and training for health professionals.

A spokeswoman for Patty Murray, who is widely expected to become the ranking member of the Senate Health, Education, Labor, and Pensions Committee next year, said the four programs continue to be priorities for the Washington Democrat. Barring any last-minute progress, she added, Murray will keep pushing for them next Congress.

But getting them enacted may become an even greater challenge in the 114th, when Republicans control both the House and the Senate. GOP lawmakers will likely be reluctant to extend policies and funding linked to the health law, and all four would cost the federal government money to continue.

Sen. Bernard Sanders said proponents of extending funding for the trio of primary care cliff provisions have not gotten the necessary financial support. He pledged to look at every approach possible to ensure continued support for the three programs.

“At a time when we have a major, major crisis in primary health care in America, if we do not address . . . this cliff problem, millions and millions and millions of people will lose access to doctors and dentists and mental health counseling and low-cost prescription drugs,” said the Vermont independent. “It is an absolute imperative that we address this.”

In a December brief, the Urban Institute estimated that the expiration of the Medicaid primary care payment adjustment would reduce fees for eligible providers by an average of 42.8 percent in 2015. The drop would be steeper in states that are not planning to extend the fee increase using their own money, at 47.4 percent on average. The Kaiser Family Foundation reported in October that 15 states were planning to fully or partially continue the boost using state money, 24 had indicated they were not planning to and 12 were undecided.

David A. Fleming, president of the American College of Physicians, released a statement Thursday criticizing Congress for looking like it will adjourn without repealing Medicare’s physician formula or moving the Medicaid payment extension.

“ACP will continue its efforts to inform the new 114th Congress of the devastating impact such cuts will have on Medicaid patients’ access to primary care, and to seek to get the Medicaid pay parity program renewed early in the new Congress,” he said.

Ray Quintero, vice president of government relations for the American Osteopathic Association, also said his group remains strongly committed to getting the payment bump extended “to ensure physicians remain available to treat our most vulnerable population.”

Although funding for fiscal 2016 wasn’t addressed, the year-end spending deal (HR 83) released this week would provide $1.5 billion in discretionary money for community health centers in fiscal 2015. Combined with $3.6 billion in mandatory funding included in the health law—the funding stream slated to expire at the end of September—that would provide nearly a $1.5 billion overall increase for the centers over fiscal 2014.

The other two primary care cliff provisions—the National Health Service Corps and Teaching Health Centers—are currently funded entirely by the mandatory funding from the overhaul and would as a result lose all money if Congress doesn’t act before Oct. 1. Supporters say addressing the teaching centers is particularly urgent because they have to decide on the number of residents they can take in January. Funding uncertainty could preclude them from taking any.

By Rebecca Adams, CQ HealthBeat Associate Editor

December 9, 2014 -- Getting enrolled in Medicaid is hard enough, with many people encountering enrollment delays this year. But once consumers get their cards for the health program, they face a new challenge: finding a doctor to treat them, according to a federal audit.

More than half of the 1,800 primary care doctors or specialists that the Department of Health and Human Services inspector general contacted either were not at the location that their health plan listed for them, or refused to treat program enrollees.

The biggest problem—affecting 35 percent of the providers that auditors contacted—was that private managed care plans administering Medicaid benefits were not providing accurate information about providers. In some cases, a doctor had retired. Other times, a physician group didn’t know the doctor listed in a plan’s provider directory as a member.

Another 8 percent did not participate in the Medicaid managed care plan, and another 8 percent would not accept new patients.

The findings raise questions about whether plans’ networks are broad enough to serve the influx of patients entering the Medicaid system. About 9.1 million additional people have joined the Medicaid and Children’s Health Insurance Program since last year, according to federal officials.

Among the providers who would set up an appointment, the median wait time was two weeks. But some waits were much longer. More than one-fourth of those willing to treat new Medicaid patients required a one-month wait, and 10 percent required a wait of two months or more.

Primary care doctors were less available for appointments. But the wait time for specialists was longer on average than primary care providers, said the report.

The Centers for Medicare and Medicaid Services Administrator Marilyn Tavenner said she would implement the report’s three suggestions. The agency agreed to work with states, which help run Medicaid, to check on the number of providers offering appointments and require insurers to offer more accurate information about providers. Federal officials also said they would do more to ensure that plans’ networks are adequate to care for patients and that the plans are complying with state standards.

Many patient advocates have complained that insurers are not doing enough to give patients accurate information about which doctors are in plans’ networks. Health plans’ inaccurate information about providers may prevent a patient from getting care they need quickly.

The complaints about providers’ networks affect not only Medicaid but other types of insurers as well, such as those participating in the new marketplaces under the health care law. The National Association of Insurance Commissioners is exploring ways to update its recommendations for states, and CMS has proposed in a recent rule that insurers that offer marketplace plans update their online provider directories regularly.

The report may increase pressure on states and the federal government to require Medicaid managed care plans to offer broader networks and ensure that information about which providers are covered is correct. Federal officials are working to create a new proposed rule that will govern Medicaid managed care plans.

The Medicaid Health Plans of America, an industry trade group, said that the report looks at one of the ways that consumers get information about providers in a plan’s network, but not all of the tools available.

“Our plans have programs in place that help connect people to care,” said Amy Ingham, director of federal policy at the managed care trade group. “Plans do have robust care coordination where we connect individuals with available providers and services, helping them navigate the system.”

Ingham also noted that the report does not assess whether patients who are in fee-for-service Medicaid, in which they can use any doctor that accepts Medicaid benefits, are able to easily find a doctor.

“In order to paint a complete picture it would need to do that,” she said.

The Office of the Inspector General report is the second one on Medicaid managed care to be released this fall. The other report found that states had widely varying standards to measure whether patients were able to get access to care. It also said that states and the federal government did not do enough to oversee the standards and monitor patients’ access.

By Melanie Zanona, CQ Roll Call

December 12, 2014 -- Legislation to exempt expatriate health care plans from the health law's coverage requirements is hitching a ride on the omnibus, the first in what could become a long string of provisions in the next Congress aimed at undermining President Barack Obama’s signature achievement.

Although the bill on its own enjoys bipartisan support, the idea has been caught in the deep divide over the health care law. The expatriate measure fell short in a suspension vote in the House before passing earlier this year, but it then was blocked from a unanimous consent request in the Senate. It now faces a potentially difficult Senate vote after the "cromnibus" was delayed and narrowly advanced by the House on Thursday.

“This was a long, tough battle,” bill sponsor John Carney, D-Del., said in a statement on Thursday. “Getting this bill passed required reaching across the aisle, persistence, the cooperation of many and a lot of hard work.”

Appropriators folded language into the fiscal 2015 spending measure (HR 83), or cromnibus, that is similar to a bill (HR 4414) passed by the House in April. The measure would not require health insurance plans for expatriates to comply with the individual and employer mandates under the health care law.

Expatriate health care plans are offered to workers outside their home country – such as corporate executives, nongovernmental organization employees, foreign aid workers, pilots, cruise ship workers and overseas contractors – and typically provide high-end, comprehensive coverage.

Lawmakers rebuffed a motion in April to advance the legislation under a suspension of the rules, an expedited process that requires a two-thirds majority for passage. The chamber later passed the measure with the support of 60 Democrats, after tightening the definition of an expatriate to someone who has been abroad for at least six months as opposed to three, echoing concerns raised during the legislation’s first floor debate.

“This is our second go around at this legislation,” Carney said on the House floor. “We’ve worked painstakingly to improve our bill, and we have.”

Bill authors again negotiated changes to make the measure more palatable in the Senate, but were unable to fast track the bill, facing opposition from conservative firebrand Ted Cruz. Hoping to avert a unanimous consent request and the potential that the legislation would die because of the narrowing window for legislative action in the waning days of the 113th Congress, lawmakers tacked the measure onto the critical spending legislation.

However, the Senate may now try to pass the cromnibus by unanimous consent Friday, where Cruz could be a likely dissenter because of Obama’s executive actions on immigration. The Texas Republican helped force a government shutdown last year over his objection to the health care law.

Supporters say the exemption is necessary to make American health insurance plans more competitive with foreign companies abroad, who do not have to comply with the health law’s requirements. “Cigna implemented a hiring freeze at its Delaware facility and has warned of potential layoffs should this legislation not be signed into law,” Carney said.

Critics worry the legislation would create loopholes that would allow people who are out of the country for only a few weeks or foreign workers in the U.S. to be sold substandard policies. “It allows big insurance companies to sell second-class insurance policies to American families and workers in the United States,” a group of senior House Democrats wrote in a “Dear Colleague” letter in April.

The language in the spending bill includes changes meant for the bill as it was teed up for Senate passage, such as requiring expatriate insurers to be licensed to provide health insurance in more than two countries and clarifying that expatriates in the U.S. must be on a work-related, specific and temporary purpose or assignment.

A Senate Democratic aide said the language is not considered a blanket exemption or rollback of the health law because expatriate plans would still be required to comply with reporting and affordability standards and provide benefits that are actuarially similar to or better than those offered by domestic health plans. The aide said expatriate plans were never meant to be covered by the health law and the bill would provide a legislative fix that the administration was open to.

The White House said in a Statement of Administration Policy prior to the measure’s passage in the House that it does not support the bill because it would “reduce consumer protections and create even more loopholes in the tax code.” But the administration on Thursday said it supports the fiscal 2015 spending bill.

Supporters of the expatriate bill called the opposition hypocritical since the administration has already granted the plans temporary relief from the law and said they had worked on the issue with the administration for several years.

Although the "expat bill" is a small and technical fix, the spending bill sets the stage for a larger battle with Obama over the health care law in the 114th Congress. The cromnibus also includes provisions that would rescind $10 million from the law’s Independent Payment Advisory Board and block the Centers for Medicare and Medicaid Services program management account from being used to make payments under the law’s “risk corridor” program.