# Health Insurance Reform

Coventry to keep selling policies on Iowa's health insurance exchange (updated)

Best news I've heard in a while: Coventry has told the Des Moines Register's Tony Leys that it will continue to sell health insurance through Iowa's exchange during 2016. Since the collapse of Co-Oportunity Health, Coventry has been the only provider selling individual and family policies on Iowa's exchange. If the company had opted out for 2016, roughly 40,000 Iowans who qualify for federal subsidies would have had no way to obtain that assistance, likely pricing them out of health insurance for next year.

The 800-pound gorilla of Iowa's insurance market, Wellmark Blue Cross/Blue Shield, will yet again opt out of our state's exchange in 2016, Leys reported. Iowa's Insurance Commissioner Nick Gerhart lacks the power to force Wellmark to sell through the exchange, because Governor Terry Branstad insisted on forming a "partnership" exchange with the federal government, rather than a fully state-based exchange.

More competition in Iowa's health insurance market would be preferable; currently West Virginia is the only other state with just one company selling policies on the exchange. Still, Coventry's decision to stay for next year removes a huge threat to the well-being of thousands of Iowa families. I was worried that Coventry would cut their losses here after taking on most of the relatively expensive former Co-Oportunity customers.

The U.S. Supreme Court's pending ruling in King v Burwell remains another potential threat to the 40,000 Iowans who rely on federal subsidies to make health insurance affordable. It's not clear whether the Republican-controlled Congress could pass a fix if the high court rules that those subsidies are not allowed for Americans who purchase health insurance through the federal website. Some Republicans would be willing to address the problem to preserve access to health care for millions, but others would insist on a full repeal of "Obamacare," the 2010 Affordable Care Act.

UPDATE: At least one other company will also offer health insurance for 2016 through Iowa's exchange. Excerpts from Leys' updated report for the Des Moines Register are after the jump.

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Iowa reaction to ruling striking down health insurance reform

U.S. District Court Judge Roger Vinson struck down last year's health insurance reform law yesterday, backing the lawsuit filed by Florida's attorney general and joined by 25 other states. Vinson's 78-page opinion can be read in full here. David Kopel summarized the key points at the Volokh Conspiracy blog:

1. The 26 states lose on the argument that the mandate for drastically increased state spending under Medicaid is unconstitutional. State participation in Medicaid always has been voluntary, and remains so. [...]

2. The plaintiffs win on the individual mandate. The individuals plaintiffs, and the National Federation of Independent Businesses have standing to challenge the mandate. So do Utah and Idaho, at the least, because of state statutes forbidding health insurance mandates. According to original meaning, "commerce" was trade. Citation to Randy Barnett. Even the modern precedents require "activity" as a predicate for commerce clause regulation.[...]

3. Necessary & proper does not save the mandate. [...]

4. The mandate is not severable from the health control act. Defendants themselves have argued forcefully that the mandate is absolutely essential to the entire regulatory scheme. There is no severability clause. The mandate is tightly integrated into the entire act. [...]

6. The entire act is declared void. [...] Of course the 11th Circuit might grant a stay, and Judge Vinson might also do so, but as of right now, there is no stay.

The White House immediately made clear that the federal government will continue to implement the Affordable Care Act. I would be shocked if the U.S. Court of Appeals doesn't grant a stay of Vinson's ruling, especially since two other U.S. district court judges ruled last year that the individual mandate is constitutional. Vinson's ruling went further than U.S. District Court Judge Henry Hudson's decision in December, which struck down the federal requirement that individuals purchase health insurance but let the rest of the law stand. Click here for links to numerous reactions to Vinson's ruling. Legal analyst Ilya Somin finds the judge's reasoning persuasive, while Orin Kerr argues that Vinson erred by going against precedent (Supreme court case law). Dave Weigel explains how Congressional Democrats failed to include a standard severability clause in this legislation. Brian Beutler notes that U.S. Supreme Court Chief Justice John Roberts (one of the most conservative members of the high court) recently struck down a single provision of a law that lacked a severability clause.

Representative Steve King (IA-05), a champion of efforts to repeal health insurance reform, was jubilant about yesterday's news: "Many of us opposed ObamaCare in part because of our oath to the Constitution. Any member who had reservations should now be empowered to vote with those of us who will cut off all funding to ObamaCare starting with the continuing resolution." The full text of King's press release is after the jump.

Iowa State Senator Jack Hatch blasted Vinson's "blatant judicial overreach" and expressed confidence that courts will ultimately uphold the federal law. Hatch chairs the Working Group of State Legislators for Health Reform and joined more than 70 state lawmakers who filed a "friend of the court" brief in the Florida case supporting the constitutionality of the law. The full press release from Progressive States Network and the Working Group of State Legislators for Health Reform is after the jump.

Senators Tom Harkin and Chuck Grassley didn't release any statement on Vinson's ruling, which surprised me, since both quickly reacted to Hudson's ruling against the individual mandate in December. Yesterday Harkin publicized the first in a series of Senate HELP Committee hearings about "the tangible, positive impact that [health insurance] reform is having on Americans' lives."

Governor Terry Branstad joined the plaintiffs in the Florida lawsuit two weeks ago (disregarding Iowa Attorney General Tom Miller's opinion). I was surprised not to see any statement from the Branstad administration on Judge Vinson's ruling yesterday. I will update this post with further Iowa reaction as it becomes available.

UPDATE: Through the governor's Twitter account, Branstad's communications director Tim Albrecht said released this statement:

"This health care law is clearly not sustainable nor is it affordable for the long-term. I believe it would be appropriate for both parties to start over and advance a plan that is more workable."

When I asked how questions about whether the law is sustainable or affordable related to the constitutional matters at hand (judge rejecting argument against Medicaid expansion but accepting case against individual mandate), Albrecht added, "The governor continues to believe the individual mandate is unconstitutional." To my knowledge, Branstad has not publicly acknowledged that a few years ago he supported a state mandate to purchase health insurance.

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House votes to repeal health reform, Branstad completes flip-flop

The House of Representatives passed a bill today on "Repealing the Job-Killing Health Care Law Act" by a vote of 245 to 189. Iowa's delegation split along the usual party lines: Democrats Bruce Braley (IA-01), Dave Loebsack (IA-02), and Leonard Boswell (IA-03), who voted for the Affordable Care and Patient Protection Act last year, voted against repeal. Republicans Tom Latham (IA-04) and Steve King (IA-05) voted against health insurance reform last year and for repealing it. King was delighted: "100% of my language to repeal 100% of ObamaCare just passed the House with 100% Republican support = 100% great day 4 the USA!" Press releases from Braley, Loebsack, Boswell, Latham and King are after the jump. Latham's statement mentions the main points of the "replacement health care legislation" House Republicans are drafting.

Various groups and politicians have issued statements warning that many Americans will be hurt by repealing the health insurance reform. I've posted a few of those after the jump too, but I wouldn't lose any sleep worrying about that just now. Repeal is a dead letter at least through 2012 and could advance in 2013 only if Republicans capture the U.S. Senate and defeat President Barack Obama.

I found it interesting that only three House Democrats voted for today's repeal bill, even though 13 current members of the Democratic caucus voted against health insurance reform in the last Congress. Good whipping by Nancy Pelosi and Steny Hoyer, or recognition that popular support for repeal may be declining?

Here in Iowa, Governor Terry Branstad announced on January 18 that he joined the state of Florida's lawsuit challenging the constitutionality of health insurance reform:

"I am signing on to this suit as the governor on behalf of the people of Iowa, because I believe Iowa taxpayers deserve to be heard on this critical matter," Branstad said in a statement. "As we begin constructing our five-year budget, there is no doubt that the current federal health care law will shackle Iowa taxpayers for billions in unfunded mandates."

The suit challenges the individual mandate of the health care reform law, as well as the expansion of Medicaid, the state-federal health insurance program for low-income people, said Branstad spokesman Tim Albrecht.

Branstad's action is purely symbolic. The case will be litigated no matter how many states sign on as plaintiffs, and if the law is ruled unconstitutional, all states will be affected, not just those that joined the suit. Though I'm not an attorney, it seems that a whole lot of federal laws would have been struck down over the years if unfunded mandates really were unconstitutional.

Legal experts disagree over whether the Commerce clause gives Congress the power to require individuals to purchase health insurance reform.

Politically, Branstad's opposition to health insurance mandates will boost his standing with the Republican base. They don't really mind "activist judges," and they won't remember that Branstad advocated for a mandate to purchase health insurance as recently as 2007. (He explained why here.) The governor's legal counsel, Brenna Findley, made the case against the individual mandate a central argument in her campaign against Attorney General Tom Miller last year. Miller supports the federal health insurance reform and has said the law is "heavily on the side of constitutionality."

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Zaun swings at Boswell, hits Latham and King

Republican Congressional candidate Brad Zaun has promised to give voters 14 reasons not to re-elect 14-year incumbent Leonard Boswell in Iowa's third district. Last week Zaun unveiled reason number 1: Boswell "has been listed as a 'follower' according to the non-partisan website www.GovTrack.us. [...] Boswell has sponsored only 66 bills since January 7, 1997, and 63 never made it out of committee. Only three of Boswell's bills were successfully enacted...and of those three, two were for renaming federal buildings."

Bleeding Heartland readers who are familiar with the workings of the Iowa Senate may be amused by backbencher Zaun calling someone else a "follower." Technically, Zaun is one of four assistant Iowa Senate Republican leaders; that's a four-way tie for the number 3 spot in an 18-member caucus. He isn't exactly a commanding presence at the capitol. Boswell was much more influential as Iowa Senate president in the 1990s before his first election to Congress. But I digress.

Zaun misleads by implying members of Congress can only be judged by the bills they sponsor, and I'll have more to say on that after the jump. First, let's see how Iowa's two Republicans in the House of Representatives look through GovTrack's prism.  

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Most Iowans with pre-existing conditions won't get help until 2014

Last week the federal departments of Health and Human Services, Labor, and Treasury “released interim final regulations implementing five of the insurance enrollee protections of the Patient Protection and Affordable Care Act” (the official name for the health insurance reform law adopted in March). Timothy Jost analyzed the regulations for the Health Affairs blog, and his whole post is worth reading. While a lot of uncertainty surrounds the new rules, the cost of compliance is expected to be low. Jost finds that “[r]elatively few people will directly benefit” from the health insurance reform, but there will be “[l]arge benefits for those who are affected.”

During the last presidential campaign and more than a year of health care debates on Capitol Hill, countless politicians swore they were committed to ending discrimination against Americans who have pre-existing medical conditions. After reviewing the interim regulations, Jost has good news and bad news for adults who lack health insurance because of a medical problem.

The ban on preexisting conditions exclusion found in the Affordable Care Act is much broader than the preexisting condition exclusion imposed by the Health Insurance Portability and Accountability Act [of 1996].  It prohibits any limitation or exclusion of benefits in a group or individual plan based on the prior existence of a medical condition.  The provision not only prohibits the exclusion of coverage of specific benefits based on a preexisting condition, but also the complete exclusion from the plan of a particular person if the exclusion is based on a preexisting condition.   The regulation does not, however, prohibit coverage exclusions that apply regardless of whether a condition is a preexisting condition or not.   The provision applies to enrollees under the age of 19 effective the first plan year beginning after September 23, 2010, but to adults only beginning in 2014.

In the summer of 2009, many progressives were disturbed to learn that the draft House health care bill delayed implementation of the pre-existing condition provision until 2013 (the date was pushed back to 2014 later in the legislative process). Why should Americans with previous or chronic medical problems continue to be denied health insurance for four more years? Don’t worry, we were told: new high-risk pools will be created to bridge the gap for people with pre-existing conditions.

We are now learning more about how the new Pre-Existing Condition Insurance Plan will operate. Eligible Iowans will be able to start applying for our state’s plan on July 15. But uh oh:

The new program, expected to start in a few weeks, will be financed with $35 million in federal money from the new health care reform law. That money will be enough to help only 975 Iowans, state administrators have concluded.

“$35 million doesn’t cover as many people as you’d hope,” said Susan Voss, Iowa’s insurance commissioner.

Another twist is that Iowans who participate in the state’s current high-risk insurance pool won’t be able to switch into the new pool, which will be significantly less expensive.

Federal experts have estimated that 34,500 Iowans could be eligible for the new pool.

The money is supposed to last until 2014, when private insurers will be banned from discriminating against people with pre-existing health conditions. At that point, such people should be able to buy their own insurance just like anyone else, health reform proponents say.

You see immediately what Jost was getting at: few Iowans with pre-existing conditions will benefit from the new high-risk pool (perhaps 3 percent of the eligible population). For those who get in, though, the benefits are immense: insurance for about the same price a healthy person would pay.

While helping 950 uninsurable Iowans obtain coverage is significant, it would have been better to implement the health insurance reform on a faster timetable. Because Congress lacked the political will to impose significant costs on insurance companies, 97 percent of Iowa adults with pre-existing conditions will have to wait until 2014 to reap the full benefit of the health reform.

That sounds like over-promising and under-delivering to me. But I can’t say I wasn’t warned a long time ago.

UPDATE: Democrats will talk up the health reform changes that take effect sooner, such as new Medicare reimbursement rates. Those are expected to increase payments to Iowa doctors and hospitals. But the public case for health care reform wasn’t built on wonky issues like Medicare reimbursement rates. It was a simple moral argument, and not letting insurers discriminate against people with a pre-existing condition was at its core.  

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Boswell's opponents are not ready for prime time

Iowa Republicans are deluding themselves if they think Representative Leonard Boswell is highly vulnerable this year. The more I see of the Republican primary campaigns, the less worried I am about holding Iowa's third Congressional district in the Democratic column.

Four of the seven Republicans running against Boswell have no chance of winning the nomination. Jason Welch hasn't attended any candidate forums, and I wonder why he went to the trouble of qualifying for the ballot. Pat Bertroche and Scott Batcher are ill-informed sideshows who will be lucky to win 5 percent of the vote. Mark Rees seems to have the firmest grasp of the issues, but there aren't enough moderate Republicans anymore for someone like Rees to win a primary. Rees could affect the election, because a strong showing for him (10 to 20 percent of the vote) would increase the chance that no candidate receives at least 35 percent in the primary. But whether Republicans pick a winner on June 8 or at a district convention later, Rees will not be Boswell's general election opponent.

That leaves the Washington establishment candidate Jim Gibbons, State Senator Brad Zaun and tea party favorite Dave Funk. After watching yesterday's forum featuring six of Boswell's opponents, Graham Gillette argued that Funk, Gibbons and Zaun "are all capable of putting together a strong general election effort." After the jump I explain why I disagree.

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