“The Default Setting”: Why Your Employer Can’t Cut Off Your Contraception Coverage
On the Fourth of July, while you were stuffing your face with patriotic burgers and watching patriotic fireworks, the Supreme Court handed down an emergency injunction in a case involving Wheaton College’s objection to the Affordable Care Act’s contraception benefit, a decision that acted as an addendum to the Hobby Lobby decision. As I ranted over here, this is the decision that could really open the floodgates to thousands of claims from all kinds of organizations and companies that don’t want to let their employees get contraception. But after thinking and reading about it for a while, there’s something I think everyone seems to be missing, and it could mean that no one is actually going to lose their coverage, even temporarily.
I should say that it’s entirely possible that I’m completely wrong about this, and there’s some bureaucratic detail deep within the ACA that I’ve overlooked. But the first thing to remember is that the ACA requires that insurance plans cover a variety of kinds of preventive care, including contraception; this issue is about what exactly a company or organization has to do when they have an objection to contraception coverage. The Obama administration constructed an alternative arrangement, which until now was supposed to be used only for religiously affiliated non-profits but, after the Hobby Lobby decision, may have to be used for basically anyone, including for-profit companies. The way it works is that if your group doesn’t want to be tainted by the sin of contraception, there’s a form you file with the government stating your objection. You send a copy to your insurer or third-party administrator (TPA), and the insurer/TPA (I’m just going to say insurer from this point on) arranges for the coverage with the government, by getting reimbursed out of other funds.
The problem is that Wheaton College, along with dozens of other organizations that have filed suit, believes that just filling out this form and sending it to their insurer makes them complicit in sin, because doing so triggers the arrangement under which their employees will get coverage. Let’s leave aside the merit of this belief, but by granting the emergency injunction the Court’s majority essentially accepted that filling out the form and sending a copy to their insurer was indeed a burden on Wheaton’s religious freedom. This made Sonia Sotomayor absolutely livid, since just four days before the Court had used the existence of that very form as proof that there was a less restrictive alternative than the contraception mandate available.
So what Wheaton would prefer is that they not fill out the form and send it to the insurer. Instead, they want to send a letter to the government just stating their objection—a letter which wouldn’t have to inform the government of who their insurer is. In her dissent, Sotomayor warned that this could become a bureaucratic nightmare, because now the government has to figure out who the insurer is for every company that sends a letter, so they can get in touch with the insurer and arrange the alternate payment procedure for contraceptive coverage.
And this is where I’m puzzled. Because under the ACA, ordinary insurance coverage has to provide prescription contraception with no cost-sharing (meaning without copayment or deductable). That’s the default setting. So let’s say I’ve started a new non-profit aimed at educating America’s youth about the important cultural contributions of 1980s hair metal bands. I get health insurance for my employees, and because of the requirement in the ACA, it includes coverage for contraception. Then after spending an extended period listening to Stryper, I realize that contraception is sinful and try to deprive my employees of it.
Depending on the outcome of these cases, I may have a couple of options. I can file the original form with the government and send a copy to my insurer, in which case those two will arrange for my employees’ contraception coverage to continue. If I object to the form, as Wheaton College does, I’ll just send a letter to the government saying “I’ll have none of this!”
But since I don’t want to inform my insurer and thus trigger the alternate arrangement, my insurer has no idea that I object to contraception coverage. That means they’ll continue to provide it to my employees, as the law requires. If because of ordinary bureaucratic slowness it takes the government a while to find my insurer and inform them of my objection, my employees will still have contraception coverage in the meantime. Whether I’m active or passive the coverage continues, either because the alternate arrangement has been triggered, or because the insurer keeps doing what they’ve been doing because they don’t know of my objection.
To repeat, there may be something I’m missing here. But it seems that even if the Hobby Lobby and Wheaton cases impose more bureaucracy and make things more cumbersome for the government and insurers, as long as contraception coverage without cost-sharing is the default setting for insurance plans, people won’t actually have their coverage interrupted, no matter what the preferences of their employer.
By: Paul Waldman, Contributing Editor, The American Prospect, July 7, 2014
“Rand Paul’s Crazy Word Salad On Obamacare”: A Symbol Of GOP’s Larger Mess
Sen. Rand Paul made national news this weekend when he refused to say precisely whether he wanted to repeal Kentucky’s version of the Affordable Care Act, Kynect, along with the federal act itself. He bobbed and weaved like his boy Mitch McConnell, and most people have left it at that: another scared Republican afraid to tell the voters what he really thinks about a program that’s helped many of them. Reporters are used to that. Nobody except liberals even criticize it anymore, sadly.
But I want to look at Paul’s entire ludicrous soliloquy on Obamacare, Kynect and healthcare generally, because it shows how fundamentally unserious he is about domestic policy. Or if he is serious, he’s seriously delusional. It was every bit the nonsensical word salad we are used to being served by Sarah Palin, but maybe it’s sexism: Paul is never called out on it or mocked the way the former Alaska governor was. He ought to be.
I’ve written before that “Paul is what you get when traditional and corrosive American nepotism meets the 21st century GOP echo chamber: a pampered princeling whose dumb ideas have never been challenged by reality.” Ron Paul’s son has a tendency to look proud of himself whenever he shows a passing familiarity with facts and figures and ideas, even if he’s conflating or distorting them beyond any resemblance to reality. It’s on display in this interview with Kentucky reporters.
The junior senator from Kentucky starts out by acknowledging that Kynect gets a lot of praise, locally and nationally.
I think the real question that we have in Kentucky is people seem to be very much complimenting our exchange because of the functionality of it, but there are still the unknown questions or what’s going to happen with so many new people.
OK. Let’s take a look at “what’s going to happen with so many new people.” Here Paul rolls out some brand-new GOP anti-ACA scare tactics. First: The rapid expansion of Medicaid, he claims, is costing jobs.
I mean it’s basically about a 50 percent increase in Medicaid in one year. That’s a dramatic shot to a system. And my question is what will happen to local hospitals. If you look at [Glasgow, Kentucky, hospital] TJ Samson laid off 50 people and they’re saying they can’t afford the huge burden of Medicaid.
Oops, stop right there. While the hospital’s CEO did in fact link the layoff of 49 staffers to Obamacare in April, days later the Kentucky Cabinet for Health and Family Services disputed that account. It said the hospital would take in hundreds of thousands of dollars more in Medicaid funding annually, because it’s now being reimbursed for uninsured patients it used to treat without payment. Asked about the discrepancy, Paul just pointed to earlier reporting about the Samson CEO’s remarks and said: “All I know is what I read in the papers.”
So for President Rand Paul, the buck would presumably stop with the papers.
Then Paul raised the specter of folks getting their private health insurance subsidized under the Affordable Care Act, but with such high deductibles that they ultimately won’t be able to pay.
That’s gonna mean … you’re still just a non-payer, probably. And hospitals are going to have to figure out, we won’t know this for six months to a year, how many people who show up with subsidized insurance will actually be able to pay [their] deductible.
This could conceivably be a problem – actually, it was a big problem before the ACA – but Paul has no evidence the ACA made the problem worse. More likely it has helped some, because even with a high deductible plan, many preventive services are now provided without a co-pay. The point is, there’s no evidence of such a problem yet; Paul is just throwing trash at Obamacare to see what will stick. And there’s more:
How many of the new people on Medicaid, how many of those people may have actually had insurance before? Did they go from being a non-payer to being a government payer? Or did they maybe have insurance, but now they’re on Medicaid because it’s easier than having insurance?
Paul could probably find out the answers to these questions, with staff work and a little consultation with the Kentucky Cabinet for Health and Family Services, but he would never bother. After hearing all of this bad news, much of it invented, a local reporter asked the senator the obvious question:
With all those unknowns, do you think Kynect should be dismantled?
And here Paul joins McConnell and punts. Or lies, since it’s pretty sure from his answer he thinks Kynect should be dismantled.
You know I’m not sure — there’s going to be … how we unravel or how we change things. I would rather —I always tell people there’s a fork in the road.
Oh, that fork in the road. Paul turns to boilerplate conservative rhetoric:
We could have gone one of two directions. One was towards more competition and more marketplace and one was toward more government control. The people who think that the government can efficiently distribute medicine need to explain why the VA’s been struggling for decade after decade in a much smaller system.
Points for working in the VA, the Obama scandal du jour. Let’s leave that alone, it’s a story in itself. Continue, Sen. Paul:
And they also need to explain, even though I think we all want Medicare to work better, why Medicare is $35 trillion short.
Huh? First of all, Paul doesn’t “want Medicare to work better,” he wants to repeal it. That’s something you don’t hear much about, but he sponsored a bill with Utah Tea Party Sen. Mike Lee to replace Medicare with the Congressional Health Care Plan members of Congress buy in to, essentially privatizing it. The bill would also raise the age of eligibility from 65 to 70. That ought to go over well with the GOP’s rapidly aging white base. That’s why Paul is forced to lie about his own Medicare position.
And the allegation that Medicare is “$35 trillion short”? I could find no documentation for it besides a Heritage Foundation blog post, and a ton of YouTube videos where Rand Paul makes the claim on Fox News. It seems to refer to a 2011 estimate by Medicare trustees that the Part A Trust Fund would face a shortfall by 2026 unless payroll taxes were raised or program costs were trimmed – and the Affordable Care Act has been trimming them. It’s bunk.
Then Paul turns briefly to the question of Kynect:
There’s a lot of questions that are big questions that are beyond the exchange and the Kynect and things like that. It’s whether or not how we’re going to fund these things.
But then he detours again, to take us back to the already debunked example of TJ Samson hospital’s Medicaid-induced “layoffs.”
If they lose 50 good paying jobs in the hospital, is that good? Then we’ve got more people in the wagon, and less people pulling the wagon.
With that profound Kentucky take on Paul Ryan’s “makers vs. takers” narrative, he walks away. And we’re back to Mitt Romney’s deriding the “47 percent.” In Paul’s more colorful telling, the problem is that some of us pull the wagon, while freeloaders and layabouts just lounge in it. For 50 years, Republicans have tried to tell voters the folks “in the wagon” are minorities. But in Kentucky, which is 88 percent white, they’re mainly white. So Rand Paul, the great 2016 hope, is really a prisoner of the elitist 2012 narrative that cost the GOP the White House.
Even though there’s so much to explore in Paul’s Kynect two-step – delusion, ideology, outright lies – the media mostly ignored it. Those who’ve paid attention simply covered the admittedly newsworthy Obamacare evasion. But I think Paul’s entire stand-up act, his performance art — Being a Very Serious Senator, or at least playing one on TV — deserves more attention. It’s only the soft bigotry of the media’s low expectations for Republicans, and maybe a little of society’s sexism, that makes Rand Paul someone to contend with in 2016, when Sarah Palin is widely just a punch line.
By: Joan Walsh, Editor at Large, Salon, June 2, 2014
“Deciduous Tree Rot”: McConnell Should Be Removed “Root And Branch”
In Kentucky, the federal health care exchange created by the Affordable Care Act is called Kynect. Kynect is very popular, but ObamaCare is very unpopular. So it goes.
Senate Minority Leader Mitch McConnell wants to rip up ObamaCare “root and branch” and toss it in the mulch pile, but he doesn’t want to do a thing to Kynect because it has already given more than 400,000 Kentuckians health insurance, many for the first time. Of course, since Kynect and ObamaCare are actually two words for the same thing, it isn’t possible to kill one without killing the other.
The Lexington Herald-Leader explains:
Repeal the federal law, which McConnell calls “Obamacare,” and the state exchange would collapse.
Kynect could not survive without the ACA’s insurance reforms, including no longer allowing insurance companies to cancel policies when people get sick or deny them coverage because of pre-existing conditions, as well as the provision ending lifetime limits on benefit payments. (Kentucky tried to enact such reforms in the 1990s and found out we were too small a market to do it alone.)
Kentucky’s exchange also could not survive without the federal funding and tax credits that are helping 300,000 previously uninsured Kentuckians gain access to regular preventive medicine, including colonoscopies, mammograms and birth control without co-pays.
As a result of a law that McConnell wants to repeal, one in 10 of his constituents no longer have to worry that an illness or injury will drive them into personal bankruptcy or a premature grave.
Repealing the federal law would also end the Medicaid expansion that is enabling Kentucky to expand desperately needed drug treatment and mental health services.
Kynect is the Affordable Care Act is Obamacare — even if Kentuckians are confused about which is which.
The Herald-Leader goes on to wonder how average Kentuckians are supposed to understand the Affordable Care Act if Mitch McConnell doesn’t understand (or pretends not to understand) it himself.
The answer to that is pretty easy. If Kentuckians start with the presumption that nothing that Mitch McConnell says about Kynect or ObamaCare or the Affordable Care Act is true, they will be much less confused. If they like Kynect, then they like ObamaCare and the Affordable Care Act. If they like it, they should vote out Mitch McConnell and prevent him from removing their benefits “root and branch.”
By: Martin Longman, Washington Monthly Political Animal, May 28, 2014
“The Human Consequences”: Cost Of The Medicaid Expansion Rejection In Lives As Well As Dollars
The more research that is done on the human toll of denying people health insurance, the easier it is to place a price in lives as well as dollars of decisions like that made by nearly half the states to reject the Medicaid expansion provided for in the Affordable Care Act. At Politico Magazine (in a piece given the wonderful, Celine-esque title, “Death on the Installment Plan”) Harold Pollack of the University of Chicago utilizes the findings of last week’s study on the lives saved by RomneyCare in Massachusetts to make some suggestions for those that might be saved by making Medicaid available to more non-elderly adults:
As a matter of fiscal policy, [rejecting the Medicaid expansion] makes little sense. The federal government would initially cover 100 percent of the costs. Its share will gradually drop to 90 percent over the coming years. Over the next decade, the federal government will cover more than 95 percent of the Medicaid expansion’s total cost. Edwin Park of the Center on Budget and Policy Priorities notes that the ACA raises state expenditures on Medicaid and the Children’s Health Insurance Program (CHIP) by only 1.6 percent, when compared with what expenditures would have been in the absence of health reform.
Even the above figures overstate states’ true fiscal burden, since these federal dollars would cover many services such as mental health care, public hospital services and services to the correctional population that would otherwise be supported by states and localities. Medicaid expansion is a significant economic stimulus to the states that have adopted it. Even in deeply conservative states such as Texas, the expansion is strongly supported by the medical community, hospitals, cities and localities and other key constituencies.
Texas and other huge states like Florida are leaving tens of billions of dollars on the table. When asked to give an accounting of themselves, officials offer flimsy justifications to evade two obvious realities: First, Republican politicians do not want to embrace the centerpiece domestic policy achievement of the Obama presidency. Second, many of these same politicians display conspicuously tepid concern for the wellbeing of the expansion’s most obvious beneficiaries: poor, nonwhite, politically marginal residents of their own states….
Nearly 5 million low-income Americans are income-eligible for Medicaid under the ACA, yet live in states that now reject the Medicaid expansion. Within this rather small but critical low-income population, that same one-per-830 estimate [made in the Massachusetts study] implies that almost 5,800 people will die every year as a result of being left uninsured. That’s only an estimate. It may overestimate—or underestimate—the true human consequences. In my view, there’s no escaping the fact that partisan opposition to the ACA is costing thousands of actual human lives every year.
That’s a hell of a toll for scoring an ideological point.
By: Ed Kilgore, Contributing Writer, Washington Monthly Political Animal, May 12, 2014
“More People Have Health Insurance”: Another Day, Another Sign That Obamacare Is Working
It’s impossible to say how big an impact the Affordable Care Act is having on the uninsured. But it’s getting impossible to deny that it’s having an impact at all.
The latest evidence comes from the Gallup organization, which surveys respondents about insurance status. According to Gallup, the percentage of adults without health insurance has been falling since the middle of last year. Now, Gallup says, it’s down to 15.6 percent. That’s the lowest rate that Gallup has recorded since late 2008.
These tracking surveys on the uninsured are far from precise. Among other things, people answering these surveys aren’t always sure of their own insurance status. Nobody should treat them as gospel.
But Gallup also found the most dramatic change in insurance status among low-income and minority populations, which would be consistent with implementation of a law that has its most dramatic impact on people with the least money. It’s also consistent with three other pieces of information
- Health Reform Monitoring Survey. In this survey, conducted by the Urban Institute and supported by the Robert Wood Johnson Foundation, the rate of uninsurance among non-elderly adults fell from 17.6 percent in the first quarter of 2013 to 15.2 percent in the first quarter of 2014.
- The Rand Corporation. According to reporting by Noam Levey of the Los Angeles Times, unpublished research from Rand suggests that the percentage of uninsured Americans fell from 20.9 in late 2013 to 16.6 percent in early 2014.
- Department of Health and Human Services. Late last week, HHS announced that enrollment in Medicaid and CHIP was 3 million higher than it had been in late 2013.
The Congressional Budget Office has projected that 13 million Americans will get health insurance because of Obamacare. Gallup’s numbers would correspond to a significantly smaller decline, although the numbers depend on what you choose as a starting point. Then again, Gallup’s numbers don’t account for the end of open enrollment—when, by all accounts, large numbers of people rushed to sign up for coverage. They also don’t account for a full year of enrollment in Medicaid and the Children’s Health Insurance Program, since people can sign up for those programs all year long.
In short, it seems pretty clear that, because of Obamacare, more people have health insurance. And, yes, that accounts for people who lost existing coverage because insurers cancelled old policies. The question is how big a difference the law is making. And it’s going to be a while before anybody knows.
By: Jonathan Cohn, The New Republic, April, 7, 2014
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