Cooley’s Anemia Advocacy Forum Update: November 18

November 18, 2014The Cooley’s Anemia Advocacy Forum (CAAF) is a Cooley’s Anemia Foundation project aimed at helping thalassemia patients and families learn how to make their voices heard on federal issues of importance to the thalassemia community. (A brochure about CAAF can be downloaded by clicking here.) Following is a report from Lyle Dennis and Katie Schubert.

Election Results

By the numbers, here’s what happened in the November 4 congressional midterm elections:

  • Republicans caught a wave and captured control of the US Senate, assuring themselves of at least 53 seats, with the Louisiana race still to be decided in a December runoff.
  • With a handful of races still outstanding, Republicans widened their margin of control in the House, giving the GOP its largest majority since the Truman administration.
  • The Republican wave swept across the nation’s state governments as well, holding at least 33 governorships and 67 state legislative chambers–more than at any point in history.

In addition to the shift in control in the Senate, next year will see some major changes in key committees that control programs of interest to CAF. Senator Harkin (D-IA) who heads the HELP committee that oversees the Public Health Service and chairs the Labor-HHS appropriations subcommittee that funds medical research and the CDC is retiring. His House counterpart on the Appropriations committee, Rep. Jack Kingston (R-GA), lost his bid for a Senate seat. Final decisions on their replacements and other key committee assignments will not be made for several weeks.

Next Steps

But even before a new Congress is sworn in next year, the current Congress has about a month to work through a pretty daunting to-do list.

Lawmakers returned to work November 12 for what is called a “lame-duck” session. One of the issues they hope to resolve involves the Medicare formula for calculating physician reimbursements. Congress has until April 2015 to fix the current formula, otherwise physicians face a 24 percent cut in Medicare payments for medical services they perform-a cut many physicians say would force them to stop treating seniors.

But certainly one of the most critical decisions facing House and Senate leaders is whether to complete work on 12 appropriations bills to fund federal programs in the fiscal year that began October 1. Since none of the spending bills have been enacted, lawmakers in September passed a stop-gap funding bill, called the continuing resolution (CR), that would allow programs to continue operating at their current rate until December 11.

For the past several weeks, House and Senate appropriations staff have been negotiating what they hope will constitute an omnibus appropriations bill that would fund federal programs through September 2015. If a deal cannot be struck by December 11, lawmakers will either pass another short-term continuation lasting until the new Congress can be sworn in or a full-year CR. The latter would mean programs would be flat-funded.

At the center of the debate is the Labor-HHS appropriations bill, which provides funding for the National Institutes of Health and the CDC. Unless lawmakers can reconcile their differences over funding, funding for both agencies will remain flat or possibly be cut.

ACA Open Enrollment Begins

The second open enrollment for the Affordable Care Act began Saturday, November 15. Individuals may also qualify for special enrollment outside of the open enrollment. (See below.)

Who can enroll? You can sign up if you are uninsured, buy your coverage outside the ACA marketplaces or are enrolled in a marketplace plan. People earning between 138 percent and 400 percent of the federal poverty level ($16,105 and $46,680, respectively, for an individual and family) can qualify for financial assistance to buy coverage. In the 23 states that have not expanded Medicaid to cover nearly all low-income adults, people with incomes above the federal poverty line ($11,670 for an individual) can also receive subsidies to buy insurance on ACA marketplaces.

How long do I have to enroll? The enrollment period is three months, from November 15 to February 15, 2015. But there is another deadline that consumers should be aware of: You must sign up by December 15 if you want to switch into a new plan by January 1 or want coverage that starts then.

How do I enroll? You can find in-person enrollment help by searching

What if I miss open enrollment? You can qualify for a special enrollment period during the year if you experience certain life events, such as moving, losing your job, a change in family status, e.g. marriage or birth of a child or loss of other health coverage.

Is there a penalty for not enrolling? Yes. The penalty for not having coverage increases next year, to $325 or up to 2 percent of household income, whichever is higher.

However, the penalty does not apply to people who earn too little or qualify for an exemption because of certain hardships, such as a recent bankruptcy or an eviction.

Determining Exchange Plans’ Provider Networks May Be a Challenge

Most insurers offering exchange plans include high-ranked hospitals in their provider networks, but consumers may find it difficult to determine exactly which hospitals are covered because they must leave the exchange website in order to see that information, according to a new study.

The report, compiled by Urban Institute researchers with funding from the Robert Wood Johnson Foundation, examined the hospitals offered in exchange plans available in Denver, New York City (Manhattan), Portland, Providence, Baltimore and Richmond. The report found that every hospital in each city is included in at least one exchange plan. The study also looked at how the size of the plan impacted premiums, and found that while generally those with narrower networks had lower rates, that was not always the case. “For example, Oscar in New York and CareFirst in Baltimore have very broad hospital networks but relatively low premiums. United in New York and Baltimore have broad networks and high premiums,” the study found.

“Every hospital in these cities participates in at least one marketplace plan, and that’s an important takeaway,” said Kathy Hempstead, who directs coverage issues at the Robert Wood Johnson Foundation. “Some consumers may want to choose the cheapest plan, while others may want to choose a plan based on access to a particular provider. We need a marketplace where all of those choices are possible,” she added.

The authors worried that it generally would be “cumbersome” for a consumer to discern the size of the hospital network. For all of the study cities, with the exception of Denver, a consumer must leave the exchange website and go to an insurer’s site to research provider networks. This can be difficult for less-computer savvy people and can also create distractions that may ultimately prevent people from purchasing a plan, the authors say.

Such conditions mean that many consumers are likely unaware of exactly what they are purchasing via the exchanges and whether his or her desired facility, or provider, is included in the network, they add.

“Future improvements to state-based and federally facilitated Marketplace websites should better enable consumers to view the size and quality of each plan’s network,” the study says. “In the meantime, this research indicates that in six major cities, most consumers can find a plan on the Marketplace that includes his or her desired hospital, and that even relatively narrow networks are likely to include at least one high-quality hospital.”

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