Questions About HealthCare.gov And The Affordable Care Act

MS. DIANE REHM

10:06:53
Thanks for joining us. I'm Diane Rehm. HHS Secretary Kathleen Sebelius answers questions on Capitol Hill today related to the poor performance of the federally run website, HealthCare.gov. It's the site individuals in many states are supposed to be using to shop for health insurance. A significant percentage of early enrollees in some state-run exchanges qualify for Medicaid.

MS. DIANE REHM

10:07:24
Joining me to talk about Affordable Care implementation challenges: Ron Pollack of Families USA, Gail Wilensky of Project HOPE, former administrator of Medicare and Medicaid in the George H.W. Bush administration, and, joining us from a studio at NPR in New York City, Shannon Pettypiece, a reporter with Bloomberg News. I do invite you to be part of the program with your questions, comments. Join us, 800-433-8850. Send us your email to drshow@wamu.org. Follow us on Facebook or Twitter. And welcome to all of you. Thank you for being here.

MR. RON POLLACK

10:08:13
Good morning, Diane.

DR. GAIL WILENSKY

10:08:15
Very nice to be here with you.

REHM

10:08:16
Good to have you. And, Ron Pollack, I know you saw Secretary Sebelius yesterday. Tell us about your conversation.

POLLACK

10:08:28
Well, we sat around her large conference table with a number of others. And she's well prepared for these hearings. You know, if I had to give one or two words about characterizing the secretary, she's resilient, and she's determined. She's determined because she really wants to get this problem fixed, and she's working really hard at it. She described some of the things that she and her colleagues are doing to get this fixed. She does have confidence that she's got the A-team working on this.

POLLACK

10:09:08
She called literally each of the contractors who have been working on this website and said, you know, you've got to get your best people here. And she said, in fact, they are doing that. So she's got confidence that this will be fixed. We now know that the timeline is that it is expected that it will be fixed by the end of November, which is later than she wanted.

POLLACK

10:09:36
But I think it's very important to understand -- and she emphasized this -- you know, there are 182 days in this first enrollment period. It's a six-month enrollment period that runs through March 31. And so there's a lot of time to get this fixed and to get people enrolled. But that still does not take away her disappointment and others that this healthcare.gov website has not been working well.

REHM

10:10:03
Ron Pollack, executive director of Families USA. Gail Wilensky, I gather what you'd really like is more transparency.

WILENSKY

10:10:17
Correct. That this has been a rocky, bumpy start -- rockier and bumpier than most people anticipated -- is obvious. People understand that. The states that have their own exchanges -- Maryland, District of Columbia also has its own exchange -- has been remarkably transparent about exactly where they are.

WILENSKY

10:10:41
You can go on their websites, see how many people have gone to the website, how many people have checked plans out, how many people have set up an enrollment account, and how many people have actually enrolled in private insurance. In Maryland, it's very easy to see right underneath that how many people are in their expanded Medicaid program as well.

WILENSKY

10:11:04
Everything someone like me might want to know about how the state is doing. My advice to the federal government is stop this business about we're not going to tell you anything except what sound like big numbers until mid-November. They're not fooling anyone. People would like to know how the enrollment in private insurance is going.

WILENSKY

10:11:25
As Ron said, this is the beginning of the period. There's a lot of reason why people may want to wait, check out their options, see exactly what it would cost them, and what they get for their money with the different options, and then make a decision end of November, early December. They really have got to stop the stonewalling of information.

REHM

10:11:43
Gail Wilensky, she's an economist and senior fellow at Project HOPE, former administrator of Medicare and Medicaid, and Health Policy Advisor in the George H.W. Bush administration. Shannon Pettypiece, when do you think we actually might be getting figures about the federally-run exchanges and how many people have shopped and how many people have decided to buy?

MS. SHANNON PETTYPIECE

10:12:20
The official line they are telling us is mid-November. We should hear something by mid-November. Of course, the website's not expected to be really fully functioning and running until the end of November. So giving numbers by mid-November is still going to capture some people who have tried to sign up but actually haven't been able to.

REHM

10:12:42
Ron Pollack, what about Gail Wilensky's comments that Maryland, the District of Columbia, have been totally transparent about who's up, who's going for it, who's in this category and that category? Why is it that the federal exchange has been so opaque?

POLLACK

10:13:07
Well, I think we're seeing different things in different states. You know, many of the…

REHM

10:13:14
Is it states that have cooperated versus states that have not?

POLLACK

10:13:18
Correct. Correct.

REHM

10:13:20
Is that what you're seeing?

POLLACK

10:13:22
Correct. Of the states that are cooperating, meaning they are actually running their own marketplaces, they each have their own time schedule as to when they're releasing information. Most of them actually have not provided information yet about how many people got enrolled.

REHM

10:13:42
But they're easier to maneuver?

POLLACK

10:13:45
Yes. And I think that, you know, if you look at past experiences with other programs, typically the information about how many people got enrolled typically occurs on a monthly basis. That's what occurred with respect to Medicare Part D. That's what occurred in Massachusetts. So, soon enough, within about 2 1/2 weeks, we're going to have good information about what is happening with respect to enrollment. And I presume we're going to know this not just for the federally-facilitated exchanges, which is about two-thirds of the states, but we're going to know it for the other states as well.

POLLACK

10:14:29
And I know -- I've been talking to the leader of the marketplace in California -- they expect to be releasing data in the middle of November about how many people got enrolled. Meanwhile, we're getting information about how many people have contacted the particular website, but I think we're going to have the best information mid-November, not just for the federally facilitated marketplaces but also for the other states as well.

REHM

10:14:58
Gail?

WILENSKY

10:14:59
I understand that. First, that's what they said. I hope they deliver. I just think it's not in the federal government's interest. People understand there have been more hiccups.

REHM

10:15:10
Excuse me. What is not in the federal government's interest?

WILENSKY

10:15:14
Not releasing the information they could release now. State of Maryland had a troubled start. They were actually my candidate, my personal candidate for best in class, easiest off the ground. Their first couple of weeks were very rocky and bumpy. There was a point at which Prince George's County, one of our neighboring counties to the District, was enrolling people using paper enrollment forms.

WILENSKY

10:15:40
So it's not just that the states that have had an easy lift-off, so to speak, are making that information available. Maryland has had its challenges. The governor has indicated dissatisfaction with some of the early experiences. They're working hard, like the federal government, to remedy it. I just think you don't help your cause, as the federal government, to not provide information. It frankly makes people wondering what you're trying to hide.

REHM

10:16:06
Shannon Pettypiece…

PETTYPIECE

10:16:07
Yeah.

REHM

10:16:07
…is there a difference, though, between states like Maryland, states like California running their own state-run applications versus the federal government?

PETTYPIECE

10:16:24
Well, there has been a big difference between these state-run insurance websites and the federal insurance website. And the big difference is, by the first week, most states were pretty much up and running smoothly. There were a few, you know, error messages you would get here and there, but, for the most part, the states were churning along.

PETTYPIECE

10:16:42
And when I talked to people in these states that are running their own exchanges, like New York and California and Kentucky, they were signing up people very productively, getting people enrolled. When I talked to people in the states where the federal government is running the exchanges, like Texas, they weren't able to enroll anyone.

PETTYPIECE

10:17:00
You know, I talked to an organization that had 90 volunteers that were out there trying to enroll people in these exchanges in Texas, and they hadn't been able to get a single person enrolled. So, yeah, the states actually are putting out enrollment numbers, and they have had people enroll, you know, with more success than the federal website, that there are people who have been able to get on in the federal website and enroll. But it certainly has been a much smoother process in the states.

REHM

10:17:26
Shannon?

PETTYPIECE

10:17:27
And I -- yeah?

REHM

10:17:28
I'm wondering if you can explain the differences between the computer processes that the states are using versus those that the federal government's using.

PETTYPIECE

10:17:43
Well, the states got to pick their own contractor. And first of all, a lot of them have fewer contractors. They only have to worry about one state, one database, one population to manage.

REHM

10:17:54
I see.

PETTYPIECE

10:17:56
They've had more money. Some states have had a lot more money than the federal government did to roll out their own exchanges. And they haven't had the same political pressures that the federal government has in dealing with this. And the federal government, they're running this website for 36 states because a lot of states, like Texas and Florida, that have Republican governors, said, I don't want anything to do with Obamacare.

PETTYPIECE

10:18:20
The federal government's going to take this. And the Feds had to step in late in the game and pick up these states and try and help manage that for them. So the federal website's just been much more complicated than at the state level.

REHM

10:18:32
Shannon Pettypiece, reporter for Bloomberg News. When we come back, we're going to talk about Medicaid and how many people are trying to get insurance there as well.

REHM

10:20:02
And welcome back as we talk about the troubles that have faced the Affordable Care Act. As we tried to roll it out, the federal government seems to have been having many, many more problems enrolling people than those states which have agreed to participate in the process. Here with me, Ron Pollack and Gail Wilensky. Shannon Pettypiece of Bloomberg news is on the line with us. Let's talk about Medicaid, Ron Pollack, and how much enrolling new Medicaid folks is going to cost the federal government.

POLLACK

10:20:56
Well, the Medicaid program has grown significantly.

REHM

10:21:00
And it's growing with this process, is it not?

POLLACK

10:21:03
It will grow significantly. Frankly, I hope that happens because we're talking about the poorest of the poor. You know, and it's really important to emphasize how low the income eligibility standards are in states.

REHM

10:21:18
Tell us.

POLLACK

10:21:19
So let's pick a few states. So you might expect in the Deep South, Alabama, if you're a parent in a three-person family, you're ineligible if your annual income is more than $3,221.

REHM

10:21:38
I don't understand that, Ron.

POLLACK

10:21:40
I know. And I presume your listeners are shaking their head, you know, in bewilderment. In Florida, it's $6,800.

REHM

10:21:48
And are these two states that have decided not to participate?

POLLACK

10:21:54
That's correct. And, you know, in Texas, if your income is above $3,700 in a family of three, annual income, you're ineligible for Medicaid.

REHM

10:22:05
Gail Wilensky, how do you explain this?

WILENSKY

10:22:08
Medicaid has, in the past, been a program that is in general up to the state in terms of setting cutoffs. There are certain populations however that need to be covered. Children up to the poverty line need to be covered until they're 18 years old. Pregnant women up to 200 percent of the poverty line have needed to be covered. But families particularly have not had that same coverage requirement.

WILENSKY

10:22:40
And many states have been able to limit populations by how they determine asset limits. So if you own a car, even a not-very-well-functioning or very-highly-valued car, in some states that could make you ineligible. States have the option, under the Affordable Care Act, to expand up to 138 percent of the poverty line. The federal government, for the first three years, will pick up 100 percent of the cost. Then they pick up...

REHM

10:23:09
In the states participating.

WILENSKY

10:23:11
If the states participate.

REHM

10:23:12
Right.

WILENSKY

10:23:12
And then after that time, the federal government will pay 90 percent of the cost for the new populations, much more than is traditional under Medicaid.

POLLACK

10:23:22
And, you know, one thing I really want to emphasize, not only are these eligibility standards -- income eligibility standards low for parents, but if you're an adult and you don't have children -- in 43 states it makes no different what your income is -- you are ineligible for Medicaid. You can literally, not rhetorically, literally be penniless, and you're ineligible for Medicaid. So what the Affordable Care Act is designed to do is to create a floor under which nobody would fall.

POLLACK

10:23:54
And that was a design of the Affordable Care Act. However, the Supreme Court and part of its ruling on the Affordable Care Act converted what was a requirement of the states to create this floor and converted it to a state option. And half the states so far have opted into it. Half the states have not opted into it.

REHM

10:24:15
And, Shannon Pettypiece, you've surely talked to many people who are going to participate and those who are unable to participate. What are their reactions? What do you hear from lawmakers in the states who are not participating, who have large populations who are in need of assistance?

PETTYPIECE

10:24:43
Well, in the states that aren't expanding -- so Texas is a good example. They have more uninsured than anywhere else in the country, a big population of the eligible for Medicaid. It's obviously very frustrating for the people. For lawmakers, they say you're leaving money on the table because under the law the federal government would pick up the tab for this expansion. For a limited number of years -- no one knows what would happen after that -- but for a limited number of years, the Feds would come in and help pay to cover these extra people. So they say, you're leaving money on the table.

PETTYPIECE

10:25:17
On another level, too, of concern is the hospitals. So hospitals under this law, they gave up a lot of things. They made a lot of concessions to the government in order to get everyone insured. That was their understanding, so they wouldn't have all these uninsured people flooding into the emergency room that they have to provide charity care to.

PETTYPIECE

10:25:37
So if you're a hospital in Texas, let's say, you've given up concessions under this law in the belief that you were going to get fewer uninsured people. And now you're told by the government that they're not going to expand Medicaid, so you've still got a flood of uninsured people coming into your emergency room, people you have to provide charity care to without any sort of benefits or safety net to them anymore.

POLLACK

10:26:00
And, you know, mind you, not only is Shannon right about all that, you know, in the states that expand the Medicaid program, they not only get for the first three years 100 percent funding from the federal government...

REHM

10:26:11
Right, right.

POLLACK

10:26:12
...and it never goes below 90 percent thereafter, but the states save in two ways that are very significant. First, today states pay some significant amount of money. When somebody goes to an emergency room in a public hospital, the state is going to pick up a part of that cost. Now, when these people get health coverage through the Medicaid Program, the state will save a lot of that money.

POLLACK

10:26:37
Secondly, the states that expand the Medicaid Program are going to see significant new jobs in the state, which will bring revenue and improve the economy of the states. So this is shortsighted from the governors who refused this.

REHM

10:26:52
All right. And, Shannon, Ohio's Gov. John Kasich, whose state legislators had refused to expand Medicaid, he managed to do it anyway. What did he do?

PETTYPIECE

10:27:08
Well, you know, I'm actually not an expert on what's going on in Ohio. There's been so much back and forth there. Maybe Ron or Gail are more familiar with what happened in Ohio.

REHM

10:27:14
Sure, sure. Thank you.

PETTYPIECE

10:27:16
It's been a lot of back and forth, yeah.

REHM

10:27:18
Of course.

POLLACK

10:27:18
So Gov. Kasich actually pushed very hard for the Medicaid expansion. By the way, he was one of 10 Republican governors who did not like the Affordable Care Act...

REHM

10:27:30
Right.

POLLACK

10:27:30
...who said, we should do the Medicaid expansion. It's good for our state. It's good for the people who are low income. So the governor pushed hard, and last week a group called the controlling board, which is a board composed of seven people who are state legislators. They make decisions about whether the state is going to accept federal money.

POLLACK

10:27:55
And the controlling board voted 5-to-2 to expand the Medicaid Program as the governor had requested. And that means in Ohio there are 275,000 low-income people who are currently uninsured who will now be eligible for coverage. And over the course of the next two years, the state is going to get from the federal government $3 billion in order to provide that expansion.

REHM

10:28:26
All right. There's another question outstanding, and that goes back to President Obama, Gail Wilensky, saying from the start, if you have insurance you like, you can keep it. It turns out not quite.

WILENSKY

10:28:44
Not quite. Not quite.

REHM

10:28:46
Explain what happened and why.

WILENSKY

10:28:49
Well, you're seeing the conflict between a politician trying to sell his most prominent idea in the realities of everyday life coming to bear. The issue is mostly for people who buy their own insurance in the private insurance market. There are about...

REHM

10:29:08
Those who are not covered by employers.

WILENSKY

10:29:11
Exactly. There are 15 to 17 million people who have been buying their own insurance. Most of us, about 160 million, receive insurance through our employers, or our spouse receives it. And through the spouse, the rest of the family receives their insurance. Generally, their insurance is not going to be affected if for no other reason than the employer mandate and the employer provisions were put off a year. So that clearly buys them time. The problem that some individuals are finding themselves in -- later, they can decide how big a problem it is...

REHM

10:29:47
Right.

WILENSKY

10:29:48
...is that the insurance they had been buying does not meet the qualifications in the current law. So let me give you an example of what might now.

REHM

10:29:55
Good, good.

WILENSKY

10:29:58
The law requires no charge for preventative services. So if there is a charge for your preventative services in your plan...

REHM

10:30:07
Within your plan.

WILENSKY

10:30:09
...your plan would no longer be eligible. One of the other benefit categories is mental health coverage. Mental health coverage tends to be quite expensive, and some people have chosen plans that do not provide that, or prescription drug coverage, although most plans now provide prescription drug...

REHM

10:30:26
So for the most part, what you're saying is that the Affordable Care Act is actually broader in coverage than some of these private plans. But on the other hand...

WILENSKY

10:30:43
They may cost more.

REHM

10:30:43
...some individuals don't want to pay for mental health care because they don't think they're going to need it or some other service.

WILENSKY

10:30:53
And it really will depend then what their income will be. First, it will depend on what plans are available in the area and how much they cost. It varies all over the map depending on what type of plan you choose but also which state you live in. And the net cost to you depends on your income. So for some people who lose the plan they had been buying, if their income is around twice the poverty line, they may still get a substantial subsidy.

WILENSKY

10:31:26
If it's around three times the poverty line, which for a family of two is about $46,000 right now, they're going to get a very small subsidy. And we've been reading in the paper these last few days about people who are saying, well, maybe it's a better plan, but it's not an affordable better plan. And I liked what I had. And beside the president said, if you like your plan, you can keep it.

WILENSKY

10:31:49
If you want to stay with your doctor, you can stay with your doctor. Because the other thing some of the people are going to find is that, in order to meet the cost requirements that the exchanges agreed that the insurance plan could charge, they have pretty narrow networks of physicians. And so people may find it's not just what the plan costs them, but they have to look to see what they actually get.

REHM

10:32:17
So this is clearly a political setback for President Obama having said that way back then and now having the reality unfold, Ron.

POLLACK

10:32:34
So clearly the president was referring mainly to...

REHM

10:32:38
People.

POLLACK

10:32:38
...employer-sponsored insurance. And...

REHM

10:32:39
Right. OK. But he should have said that. He should've said, if you are insured under your employer, you won't have a problem. You stay with it. However would have been a good addendum to that sentence. And you're listening to "The Diane Rehm Show." Go ahead, Ron.

POLLACK

10:33:05
So, as Gail was saying, this coverage is not -- is broader, but it does some things that really provides real insurance. For example, one of the things that the Affordable Care Act does is it prohibits annual caps or lifetime caps in how much is paid out. So if you have a major accident or a major illness and you've been in a hospital for quite a while, you're going to find out your insurance does not insure you. And so what consumers are mainly concerned about is not simply one part of the equation, namely the premiums, but they're concerned about the entire equation.

REHM

10:33:42
Sure.

POLLACK

10:33:43
What do they pay in deductibles? What do they pay in copayments? What do they pay for services that are uncovered?

REHM

10:33:47
Of course.

POLLACK

10:33:48
And so, yes, when you make a policy a better policy, insurance that truly insures, the premiums will go up somewhat. That'll be changed for those people who qualify for the subsidies. But for everyone, it means they're going to have true insurance that will help you at the back end when you need care.

REHM

10:34:08
Gail.

WILENSKY

10:34:09
Well, it depends on what people want and what people expected. I am all for having good catastrophic coverage. Whether or not you have to have free preventative services is really a subject of some debate.

REHM

10:34:22
But aren't we all encouraged to go in for physical exams to insure that we're not getting sick?

WILENSKY

10:34:33
There's some debate about the effectiveness of annual physical exams, the example you happen to have chosen.

REHM

10:34:36
Efficacy, yeah. Right. Sure.

WILENSKY

10:34:42
And people who believe that this would be of benefit to them should go use those services. People should use preventive services, at least those that are targeted (unintelligible).

REHM

10:34:53
What about the no cap, no lifetime cap?

WILENSKY

10:34:57
Well, the no -- no lifetime cap was a good provision, but you didn't have to include all of the other features. It's mainly because these make the plans more expensive.

REHM

10:35:08
But how can you ever know if you will need mental health care? How can you ever know whether you will need catastrophic health insurance?

WILENSKY

10:35:19
You -- the answer is...

REHM

10:35:20
You don't.

WILENSKY

10:35:20
...you don't know. Typically in this country, we have allowed people to make the decision about what they buy depending on what they believe they need...

REHM

10:35:31
Right.

WILENSKY

10:35:32
...and how much they want to spend.

REHM

10:35:33
Right.

WILENSKY

10:35:33
People were told that would continue. It's the shock of saying, you told me, but it's not true.

REHM

10:35:38
OK. And how many people fall into this category, Ron Pollack? Do we know who will lose because their insurance does not meet the requirements of the ACA? How many people are we talking about?

POLLACK

10:35:56
So there are really two questions in your one question. One is, how many people currently have substandard policies who can't stay on those policies? The other question is, how many of them will now get different coverage that will provide them with better coverage?

REHM

10:36:12
Better coverage.

POLLACK

10:36:14
And how many of these people are going to get subsidies that are going to make the premiums considerably less expensive? These subsidies reach deeply into the middle class.

REHM

10:36:25
You're not answering my question.

POLLACK

10:36:26
Well, I don't know...

WILENSKY

10:36:27
It's 50 to 70 percent, is the estimate that's been made of people who will have their insurance plans affected. The number I read this morning in Maryland is 150,000 individuals will lose their coverage.

REHM

10:36:40
All right. But let's be clear. We're talking about 70 percent of the population...

WILENSKY

10:36:48
The 50 to 70 million with individual insurance.

POLLACK

10:36:50
You know, but it's really important to put that into perspective. I think the Department of Health and Human Services will come out with numbers fairly soon that shows in this individual market, which is what we're talking about, what kind of changes occur from year to year in terms of coverage. And about two-thirds of the policies, there are significant changes in terms of the coverage people get. And so this is not usually different from what's occurring in the current market.

REHM

10:37:20
Ron Pollack, Gail Wilensky and Shannon Pettypiece, they'll all answer your questions after a short break. Stay with us.

REHM

10:40:01
And welcome back as we talk about the hitches that have come up in the rollout of the Affordable Care Act. And, Shannon Pettypiece, I've got a tweet here that says, "Small employers are also getting plans cancelled. So it's not just the individual market. Our small company got a cancellation Saturday." I know you're talked to people about this.

PETTYPIECE

10:40:35
Yes. Yeah, and I actually -- I did talk to a small business owner who said the same thing. It's basically anyone who was buying a plan that didn't meet these sort of essential benefits, that didn't have the things like the prenatal care and the drug coverage or the hospitalization that didn't meet these requirements under the new law. Anyone who had one of those plans is getting it cancelled.

PETTYPIECE

10:40:56
So, yes, if you work for a small business and your employer was providing you a plan that didn't qualify, well, the insurers technically can't sell that to you anymore under this law that doesn't qualify under this law. So, yeah, your employer could be telling you the same thing, that now your plan is cancelled, even though you thought you had coverage through your work.

REHM

10:41:16
So how are these employees reacting?

PETTYPIECE

10:41:22
Well, we've talked to a number of them. Frustration, confusion, dismay are some of the words that I've heard people say. And it's particularly difficult for people who are in these states, the 36 states that have to use this federal website that we've been talking about that's had all of these errors. So they're getting a cancellation notice in the mail and told that they're going to have to go out and find a new plan. And they're going to have to do that by Dec. 15 if they want their coverage to be effective Jan. 1, so there's no gap in coverage.

PETTYPIECE

10:41:56
So they go on to healthcare.gov. OK, let me find a new plan and see what's happening, and then they can't get through. So it's even more frustration that sort of builds and builds and builds. And it's causing a lot of stress for people who are trying to plan, you know, am I going to have to pay another $300 a month for health insurance come December or January than I'm paying now? And for some people, it could be, you know, double what they're paying, even, you know, three or four times what they're paying. So it's extremely stressful.

REHM

10:42:24
How likely is that, Ron Pollack, that these who have lost employer insurance because it doesn't meet the standard, how likely is it they're going to have to pay a heck of a lot more money?

POLLACK

10:42:41
Well, first thing is that for those people who are in a company that is told that their current insurance that they're providing to their workers is substandard and they can't continue that, that doesn't mean that that business is going to stop providing health insurance.

REHM

10:42:57
Right.

POLLACK

10:42:58
And so we don't know yet -- when you asked for numbers, we don't know yet how many of these employers are now going to upgrade their coverage and find a way to continue coverage.

REHM

10:43:13
All right. Let me read this email from Tom in Pittsburgh, where I happen to be going next week. He says, "The criticism of President Obama's statement, you can keep your current coverage, misses the real point. Before the ACA, many individual policies were substandard with just bare bones coverage. Some like AFLAC offer only limited cash benefits.

REHM

10:43:48
"If ACA did not set a coverage standard, the purpose of the law to make sure that Americans have adequate coverage would be frustrated. The ACA requirement is no different than the requirements the Medicare supplement policies meet certain coverage requirements. And nobody complains about that. Same is true for auto policies." Gail Wilensky.

WILENSKY

10:44:21
Well, he doesn't say -- he's correct what he says. He's misleading what he doesn't say. No one requires people to have Medigap policies, the policies that supplement Medicare. Most people do because they recognize that there are holes in the current Medicare package. So it's not really appropriate to say, well, we set standards here, so it's hardly surprising we would set standards for the policies that would be deemed appropriate.

WILENSKY

10:44:56
The notion of setting policies is appropriate. Whether or not you agree with all of the standards that were set is a different thing. They will increase the cost. And whether or not people want to pay more for that increased coverage in part will depend on whether they get a subsidy. Some will. Some will get a big subsidy.

WILENSKY

10:45:16
Some will get a very small subsidy. Some won't get any subsidy. It's that people are being told, you must have this, and you must have a policy that is different from the policy you've been having, whether or not you are happy with it, because we say -- the government -- that it's not adequate. People tend to not like that kind of a strategy.

REHM

10:45:35
All right. Let's take a call from Jerry in San Diego, Calif. Jerry, you're on the air.

JERRY

10:45:44
Yes. I have a basic question about the ACA.

REHM

10:45:47
Sure.

JERRY

10:45:47
I've heard a lot of discussion about premium and deductible. But I haven't heard any comment about what I call negotiated rate. That is, I'm in the individual market in California. And Blue Cross -- let me say it this way. Providers and doctors, hospitals all have contracts with Blue Cross. It doesn't matter which I go to -- which doctor I go to.

JERRY

10:46:16
If they have a contract with Blue Cross, there's a negotiated rate for a procedure. Now, so before I hit my deductible, let's say I -- and when I had Blue Cross, I had a $6,000 a year premium with a $9,000 deductible. So before I hit the deductible, if I went to a doctor, I was going to pay the negotiated rate with the -- that that doctor had with Blue Cross of California.

JERRY

10:46:48
Now when I go to compare plans, how do I know what the -- and when I went to Blue Cross, just as another fact, when I changed policies at one time from Blue Cross to Blue Shield, Blue Shield had a different set of negotiated rates with the same doctor. So if I went to that doctor and I was under Blue Cross, before I exceeded my deductible, I was paying a different amount.

REHM

10:47:18
Interesting.

JERRY

10:47:18
And I haven't heard any discussion whatever about whether every doctor or hospital is going to have to have contracts with -- you understand the

REHM

10:47:28
OK, Jerry. You're about to hear it. You're about to hear it. Go ahead, Ron Pollack.

POLLACK

10:47:34
Well, Jerry's absolutely right. We generally don't know what an insurance company pays a hospital or a doctor.

REHM

10:47:41
Right.

POLLACK

10:47:42
In fact, you ask an insurance company, they will tell you that's proprietary information because they work out different deals for different hospitals and different physicians. You know, one of the things I do hope -- this does not quite -- I think Jerry's situation where he doesn't know how much is being paid to a doctor, I think that may continue for a while.

REHM

10:48:04
Is the Affordable Care Act going to standardize those rates?

WILENSKY

10:48:10
No.

POLLACK

10:48:10
Not -- no.

WILENSKY

10:48:12
No.

REHM

10:48:12
No. Shannon, you're laughing. Tell us why you're laughing.

PETTYPIECE

10:48:18
Well, yeah, because this is one of the most confusing and infuriating things from the healthcare system is that no one knows how much anything costs actually. And, you know, the Affordable Care Act is really about getting people coverage, getting people insurance, and it does a few things to try and address costs. But it's not really tackling this huge cost issue. That's something that I think the Obama Administration was hoping would come next, if we could ever get past this issue of addressing coverage.

PETTYPIECE

10:48:45
But, yeah, I mean, a procedure at one hospital can cost you two or three times the amount at another hospital. And for most of us with insurance, you know, we don't care. I pay my $20 co-pay or my 20 percent, you know, deductible, and I don't even really notice. But more and more people are going to be getting these plans where they're going to be bearing a bigger burden of the cost. They're going to now have a $10,000 out-of-pocket deductible or $5,000 out-of-pocket deductible.

PETTYPIECE

10:49:14
So that is really going to matter how much it costs. And there's this huge variation from one hospital to another. And there's just not really any good way to shop around and even compare prices. There's some companies -- tech companies that are trying to come up with a way, so you can shop around and compare hospital prices. But it's so confusing. I hear that very same thing that your caller -- that question your caller had all the time.

WILENSKY

10:49:38
It's a fixable problem.

REHM

10:49:39
It's a fixable problem?

WILENSKY

10:49:41
It's a fixable problem.

POLLACK

10:49:43
And, you know, there are...

REHM

10:49:44
Well, wait a minute. I want to hear how it's fixable.

WILENSKY

10:49:46
Well, it's a fixable problem because you can have listings of what, either given your particular insurance or if you don't have insurance, what the prices would be charged for various...

REHM

10:49:59
Transparency.

WILENSKY

10:50:00
And there's no reason you can't do it.

REHM

10:50:01
All right.

WILENSKY

10:50:02
I just heard of somebody who went to a dentist, was in the dental chair, had flipped up on the top, given her insurance, here were the charges that she would face for a whole list of items that -- services that would be provided. There's no reason it can't be. Traditionally, users haven't required or asked for it. Employers who are the sponsors of insurance haven't insisted their employees see it. And the rest of us haven't cared because somebody else was paying the bill.

REHM

10:50:32
All right.

WILENSKY

10:50:32
It is fixable.

REHM

10:50:33
Let's go to Portsmouth, N.H. Chad, you're on the air.

CHAD

10:50:38
Hi. I wanted to call and give you some real life experience. I'm an individual that is trying to buy insurance on this marketplace.

REHM

10:50:45
OK.

CHAD

10:50:45
I'm a financial planner. I've been buying my own policy for years. Next year I am going to be forced to buy a new policy, so my insurance will be cancelled. So I actually got the pricing and all the parameters. And let me just say one thing. I deal with this every day in my practice. I have an insurance license. I have a masters in finance. I do this day in and day out. Next year I'm going to pay 50 percent more for my policy. And I cannot use the local hospital in Portsmouth, nor can I use hospitals in Boston. They're out of network. To get those hospitals included in my policy, it'll be 80 percent more.

CHAD

10:51:17
Now, I know someone up there will say, well, you're getting better coverage. Let's talk about that. I'm a 52-year-old man. Now I have prenatal and maternity coverage. That's not very helpful for me. I also have gastric bypass coverage. Well, I do triathlons and marathons. I doubt that's going to be handy for me. I mean, the list of things that are covered that I don't need is tremendous. And I am perfectly capable of evaluating my personal life and knowing what I need and don't need.

REHM

10:51:43
Chad, I want to ask you a question. Are you not covered -- tell me about New Hampshire. What did New Hampshire decide to do...

CHAD

10:51:54
New Hampshire decided to let the federal government run its marketplace.

REHM

10:51:59
OK. And...

CHAD

10:51:59
I am covered by an individual policy, and I have been for 10 years now.

REHM

10:52:03
Right. So, Ron Pollack, why is his policy going to go up by 50 percent?

POLLACK

10:52:12
I don't know the answer to his specific situation.

REHM

10:52:17
He was getting a bare bones policy, I'm sure, and feeling healthy. At 52, decided he didn't need any frills.

POLLACK

10:52:26
So we are -- one of the things the Affordable Care Act does is it tries to make sure that insurance really does insure people.

REHM

10:52:36
Everybody.

POLLACK

10:52:36
And, by the way, not only does this protect you in the back end when you start needing care in terms of you've got better coverage, you're going to have -- you're going to be paying less out of pocket. There are limits, by the way, in out-of-pocket costs under the Affordable Care Act. But one of the things this does, once you start creating a more standardized system...

REHM

10:53:00
For the entire population.

POLLACK

10:53:03
That's right. It makes it easier for consumers to choose among various plans because no longer are you comparing apples with some other species. Now it's apples to apples, and it's easier to make a good selection.

REHM

10:53:16
And you're listening to "The Diane Rehm Show." Shannon, from what you've seen, do you believe that we'll have numbers and the websites will be sorted out by the end of November?

PETTYPIECE

10:53:37
Well, there's a lot at stake and a lot on the line now if it isn't. It does seem, by actually coming out and giving a deadline, that they have made some assessments and been able to say that there are problems that are fixable, that by the end of November, I think, by coming out so publicly and saying -- they must've done some thinking and planning to be able to make that sort of deadline.

PETTYPIECE

10:53:59
However, they do always keep saying that it -- they're not necessarily saying it'll be 100 percent by the end of November. I think the words they've used are the vast majority of users will be able to get through and won't be getting any error messages. So it is possible that, you know, Dec. 15 or something, people could still be running into occasional errors. I think the end of November for the website is really when it's supposed to be, you know, much more functional, but it might not be 100 percent.

REHM

10:54:26
All right. Let's go to Tripp (sp?) in Dundalk, Md. Hi there, you're on the air.

TRIPP

10:54:33
Hi, Diane. Hi, panel.

REHM

10:54:33
Hi.

TRIPP

10:54:34
Hi. I'd like to draw on an analog to counter a little bit of the -- what fear-based doom and gloom crowd. And they've been here for a long time. And I remember car seats were a real controversy. They were going to do no more than trap you in your car when you had a fiery crash, and you'd burn to death. And airbags, they were going to self-deploy and cause you to crash. And who worries now about that now that they're just standard? And how many deaths and injuries have been prevented? I mean, it's just part of our social evolution.

REHM

10:55:07
What do you think, Ron Pollack?

POLLACK

10:55:09
I think Tripp's got it exactly right. This is going to help the vast majority of people in the country. First of all, we've got, right now, 48 million people in the country who have no insurance whatsoever. That's going to change significantly. People are underinsured. They've got insurance technically. But it's Swiss cheese coverage.

POLLACK

10:55:29
And that's going to be improved. A lot of people are going to get subsidies that are going to make coverage more affordable. People who need health coverage the most, people with preexisting conditions or chronic health problems, they no longer can be shut out of the system.

REHM

10:55:44
All right. Gail, here's a final email from Chip in Cincinnati, Ohio who says, "My understanding of health insurance is the more people in your group, the better your premium will be. If I wait to sign up for health insurance, do I have a better chance of getting a lower premium?"

WILENSKY

10:56:10
No. You would have to wait some extended period of time that is not this year that we're talking about to know whether the premium would go up or would go down. And in that case you would make yourself subject to the penalty of not having insurance as of March 31. These premiums have been set. They've been set before anybody enrolled. What we don't know is whether or not the guess of the insurers negotiated by the exchange people was the right number. We'll know that next year.

REHM

10:56:44
And, Shannon, final yes or no to you. Do you believe there's going to be a 45th vote in the House to overturn the ACA?

PETTYPIECE

10:56:59
Probably, yeah. I'm sure we're -- this is not over with. Yeah, it's not the end.

REHM

10:57:03
All right. Shannon Pettypiece of Bloomberg News, Gail Wilensky, an economist senior fellow at Project Hope, Ron Pollack, executive director of Families USA, you've all been so helpful. Thank you.

POLLACK

10:57:23
Thanks for inviting us.

WILENSKY

10:57:25
Nice to be here, Diane.

PETTYPIECE

10:57:26
Thank you.

REHM

10:57:27
And thanks for listening. I'm Diane Rehm.
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