History of journalism and fake news. Tonight at 8 00 p. M. Eastern ere on cspan. Host we want to welcome back julie rovner to talk about the Affordable Care act. Let me read from the fifth Circuit Court of appeals, the recent ruling. The individual mandate is unconstitutional because it can no longer be read as attacks. There is another constitutional provision that justifies this exercise of congressional power. We remand to the District Court to provide additional analysis of the provisions of the aca as they currently exist. It may still be that none of the aca is severable from the ndividual mandate. It may be that all the aca is severable from the original individual mandate. It may also be that some of it is severable and some is not. What did they rule . Guest it helps to go back to 2017 when the republicans have the white house, the house, and the senate and they wanted to replace and repeal the Affordable Care act. They cannot agree. You can remember john mccain turning thumbs down on the last try. At the end of 2017, the republicans passed a tax bill and they reduced the penalty for not having insurance to zero. They couldnt eliminate it. There were all kinds of rules. They were trying to pass it with 50 votes. You either have Health Insurance r you pay penalty. After 2017, the rule was, you either by Health Insurance or you pay penalty of zero dollars. In february of 2018, republican attorneys general said, if there is no tax anymore, the mandate is no longer constitutional because in 2012, when the Supreme Court upheld the entire law, chihihihihice roberts wrote that this would be unconstitutional except it is a tax and therefore appropriate use of congresses taxing power nd it is all ok. Lawyers on both sides think this is a very dubious argument. They are reading the individual mandate to say you shall have Health Insurance rather than a choice. Without the tax, there is some freestanding requirement for people to have Health Insurance, hich there really isnt. They went to court and they found the judge in texas who agreed with them. The ruling came down a year ago this week. That judge said that not only is the individual mandate as it currently exists unconstitutional but because it is so intertwined with the rest of the law, the entire law has to fall. The democratic attorneys general defending the law went to the appeals court, which had its hearing in july and ruled this week and said, we agree with the lower courts that the individual mandate is unconstitutional. We are not going to say which parts of the law can stay or go and we do not the analysis of the lower court judge. Were sending it back to the lower court judge and telling him to do it over again. Thats kind of where we are. Host a good explanation. Where does it go from there . Does this make it all the way to the Supreme Court . Guest eventually, it makes it all the way the Supreme Court. Either it can go back to the lower court judge, and everybody assumes he will do a more granular analysis and end up at the same place, saying the entire law has to be jettisoned. It goes back to the court of appeals and then to the Supreme Court. Or the democratic attorneys general are talking about going straight to the Supreme Court now. To appeal the ruling that says the mandate is unconstitutional. See if they can get the court to pick it up. They say they would like for the court to pick it up this session which means they are really running out of time. The decision would come down to the middle of the president ial campaign and the politics of this are almost as complicated as the actual structure. That is the decision being made in the next few days, whether they will try to go to the Supreme Court or they will let it go back to the lower court. He can take as long as he wants, judge oconnor. He wrote the original opinion. Host the judge in texas . Guest the judge in texas. Who knows how long that would take. There is still so much uncertainty. Since the penalties went away as of january 1, 2019, even though it was in the 2017 tax bill. The Affordable Care act has been operating just fine without it. The legal argument is, the rest of the law has to fall because if you dont have that tax, it cannot function. Obviously, it can function because it is functioning. Host are people signing up . Guest they are. That was a surprise to a lot of people. The subsidies is worth a lot more to people than the potential. It wasnt that big a penalty. It was several hundred dollars. Health insurance is expensive and if you get a big subsidy, there is every reason to sign up and people are doing that. We have not seen final numbers, open enrollment just ended on wednesday. There are a few states for you can sign up. It looks like it has been going down a little bit at the bottom has not fallen out. There are still 10, 11, 12 Million People still buying coverage without the mandate. Host julie rovner is here to take your questions and omments. This is how we divided the lines. Aca enrollees as well as employer insurance, the number on your screen. Uninsured and all others. That is how we have divided the lines for you to call this morning. We want to get your thoughts on the Affordable Care act, especially if you are participating in it. What are your questions and oncerns . He talked about what happens next. What are some of the other movements in the Affordable Care act that you have been writing about lately . Guest i did a piece earlier this week about what would happen if the law went away in its entirety. Here is so much to it. People think of it as people who sign up and get expanded medicaid. There were huge amounts of things that were not related to that at all. It was a moving congressional vehicle at it carried a lot of things, like a permanent authorization of the Indian Health service and a way to create an approved generic copies of expensive biologic drugs and calorie counts on menus and limits on profits that Health Insurers can make. Things that do not have anything to do with the individual mandate. There were 10 titles of the Affordable Care act. It is an enormous sprawling law. One of the things that congress did this week is repeal several of the taxes that were paying for the Affordable Care act. It took them a while. Theyre really popular. The medical Device Industry and the Health Insurance industry and employers who have generous plans and workers who have those generous plans, they did not like the taxes out there. Part of the big spending bill, those taxes are going away. Host how much money were they providing . Guest interestingly, particularly the cadillac tax, the 40 excise tax on very Generous Health plans. It was supposed to go into effect 2018 they kept pushing it ack. When congress did this in 2010, the theory was all of these industries would benefit by more people having insurance. They would be able to afford more medical care. The idea of taking back a little bit of the windfall the Health Industry was getting but the Health Industry thought a public battle thought a public battle to make these taxes go away. The two largest moneymakers of the taxes paying for the Affordable Care act are a couple f tax on wealthy people. There was an increase in the payroll tax and other taxes aimed at wealthy people, like 1 million in income people. Those were collecting the bulk of the money. I dont remember the exact numbers but it adds to the deficit because this is money that the federal government wont be taking in. Host what does it do to the a. C. A. To not have that money . Guest theoretically it doesnt do anything at all but it takes away the democrats talking points. When the republicans passed the medicare drug bill in 2003 it wasnt paid for. There were a number of conservative republicans who didnt vote for it because it wasnt paid for. It was a big deal to pay for the Affordable Care act which was twice as big in terms of dollars as the medicare drug bill was. There were enormous fights over how to pay for it and which taxes to raise and lots but they were bound and determined that it would not add to the deficit. I havent seen the its hard to update the numbers on it because the Affordable Care act is so embedded into the rest of the Health Care System so c. B. O. Has stopped doing separate estimates. But its still certainly it is unlikely it is being paid for. The fewer people took advantage of the benefits. The c. B. O. Thought many people would be smaller employers who werent required to provide coverage would send people to the marketplaces. The marketplaces for a variety of reasons havent been that popular so that didnt happen. So in that is sense, its less expensive, but i dont think its less expensive enough to make up for the taxes that are being repealed. Host we go to kyle, washington state. Uninsured. Why are you uninsured . Caller i am 26, on my parents Health Insurance plan right now. I talked to my parents because theyre going through Health Insurance issues as well. I should probably go to the dentist before it expires because i am unsure about what i do next if i dont have insurance . Shes like well, you will still have to pay because we havent covered the deductible yet for the year. I was still going to be paying out of pocket regardless. So thats what the a. C. A. Was still protecting me for. I thought i was good. I could go to the dentist and good from there. So you guys were already talking about what the alternatives are now that the individual mandate will be unconstitutional. Where does the funding come from . You guys are discussing that. Thats really difficult because i dont know how we will combat the private Insurance Companies in this country. Good luck with that. Host lets take the first part of kyles comments. He is still on his parents insurance until 26. But he has to his parents havent covered the deductible. Guest this is one of the reasons why the marketplaces havent been that popular because in order to have expansive benefits and loan premiums to attract people they created these huge deductibles. This is happening in employer insurance too. As medical care gets more expensive, the only way to keep the premium down is to raise the deductible. You see this when you buy car insurance. You can have a 5000 deductible, premium will be this high. If you want to go to a 1,000 deductible, your premium will be lower. Thats what happens in Health Insurance. The problem is the deductibles have gotten so high that a lot of people expect have insurance and cant afford to use it. This happens frequently in the Affordable Care act although there are different tiers where you can get smaller deductibles. I remember for most of my life i had an annual deductible that was a couple hundred dollars. Now i think the average deductible is over 1,000. Host even in private insurance . Guest yes. The deductibles in the Affordable Care act, particularly the lower tier plans, can be 7,000 or 8,000. People say, well, i am buying insurance, but it doesnt cover what i need. It is a big problem. Congress is thinking about what to do, but the bottom line is what they need to do is lower the cost of health care and that means taking money away from people who advertise and lobby and congress has proved its inability to do that at least so far this year. Host tell us who those people are. Guest those people are there is a fight over Surprise Medical Bills which happens often when people havent met their deductible. But sometimes when they have because theyre out of network and congress and republicans, democrats, President Trump vowed to fix this and they havent been able to because of ferocious fighting between hospitals, doctors and Insurance Companies, and emergency room doctor practices that are owned by wall street firms, that founded as a place to make money because you can basically charge whatever you want. Health news has been doing a series of stories about people who are being sued by hospitals because they cant pay either their deductible or their outofnetwork bill. Its a huge, huge problem. Host oscar in california, enrolled in the a. C. A. What has your experience been like . Caller its been fantastic thanks to cspan and kaiser. I have the a. C. A. Plan. I am a tweener so at 63 years old i wasnt working anymore, but i couldnt accept couldnt sign up for medicare until 65. There is a twoyear bridge there where the a. C. A. Kicked in. I make about 25,000 a year. Premium through kaiser is a i pay 140. My deductible is 650. My max out of pocket per year is 2,300. I have never ever paid a bill more than 100 and that was for outside radiology, where kizer kaiser didnt have the facility. That was a 700 bill. My payment was 100. So that launch of the a. C. A. With the computer glitch and the whole way it started out got this whole a. C. A. Off to a bad start and it didnt have the political backing. It also wasnt promoted well. Many states poohpoohed it. Now the reality is i am one of the a. C. A. Members. I have a 650 deductible, 2,300 max out of pocket per year. I pay 140 a year. I go to a fantastic doctor, great care. Just like the old days. I even have a designated personal physician, and all of these things go ahong with it. Those who are in between like me or maybe that young person at 26 who is now bridging to a job that might offer health care, he will have nothing until he is hired, there is a 90day waiting period. So this a. C. A. Plan insurance you in times of need. Its not the cure for everything, but the foundation of it is fantastic for those who dont have employer insurance. Thats 160 million americans. There is still another currently 20 million signed up, between 10 million and 20 million. Theres probably another 50 Million People who could have signed up if it was marketed properly and accepted and understood by people. Host ok, oscar. Kaiser health news is part of the Kaiser Family foundation. We are not affiliated with kaiser permanente, the health insurer. Yes, this gentleman is exactly what the Affordable Care act was designed to address. People who have retired but are too young for medicare no longer have employer insurance. As the caller mentioned younger people who are coming off their parents plans but may not have a job with Health Insurance yet. California is one of the states that really took on this law aggressively itself, which is why it tends to be working a little more smoothly in california than in some other states. California just last year extended subsidies further up the income scale, which no other state has done yet. So if you instead of topping out at 400 of poverty, its 600 of poverty. There are a big chunk of people not eligible for subsidies which is one of the problems of the Affordable Care act, which is if you are getting help to buy insurance on the exchange, you are probably doing pretty well. But as soon as you tip over that point where there is no help anymore, the individual market policies are really expensive and there are a lot of people priced out, another big issue. I think the caller is sort of spoton about the marketing of this. Obviously the Trump Administration is trying very hard to sort of not market it. They cut the outreach money and money for navigators who help people find out. But even the Obama Administration didnt put a whole lot of emphasis into the marketing and i think that really has sort of hindered the signups. There are i cant remember the number but several Million People who are eligible for a free bronze plan because the subsidies are big enough that they could literally get it for zero dollars. It would have a big deductible but if they got run over by a truck theyd be in good shape and they dont know they should sign up. Host i want to show viewers this map from your organization, which shows insurer participation in the a. C. A. Marketplace from 2014 to 2020. Can you explain a little bit, the blue is three or more, light blue is two and orange is one. Where are we seeing participation across the country and lack thereof . Guest its not just states but regions and sometimes counties. There was a concern after the first year or two that insurers were going to drop out, and insurers were dropping out, but the market has stabilized. What we have seen this year is insurers coming back. We have seen more insurers than we have last year and we are also seeing more stability in premiums. Hey started out sort of companies were competing. They wanted to get people signing up for the first time. Then they spiked because there were a lot of sick people who couldnt get insurance before who signed up and started using a lot of care because they had had needs that had been growing for a while. So premiums really spiked the second and third year. But of course the Affordable Care act has provisions that say you cant make more than you can only keep a certain percentage of each dollar for administration and profit. So there were a lot of big refunds that went out. What we have seen the last two years are much more stability in the premiums because this was a new market. The insurers didnt know how they were going to price things. The market itself is stabilizing. Its smaller than expected. There was a concern about that, but it seems to be bumping along ok. Host take a look at this map from kaiser. It shows the light blue, blue is lower premiums, and the orange to red is where the higher premiums reaching almost 200. The lowest around 119. Guest yeah. It varies. One of the reasons the premiums vary so much is health care varies so much. There are parts of the country where health care is just traditionally much more expensive and parts of the country where it is traditionally much less expensive. Everybody sort of beats up on the Insurance Industry, but really there are things you can beat up on them for but the basic prices are what the providers charge. Its what insurance has to pay in order for people to be able to get care. Thats sort of the issue that nobody has been able to grapple with yet. Host chief washington correspondent, rooney in wisconsin. You get your insurance through your employer. Caller yes, i do. First, Kaiser Health news, is that a nonprofit . Guest yes. Kaiser health news is editorially independent program of the Kaiser Family foundation, which is not affiliated with kaiser permanente. Caller ok. Second question is you have been discussing insurance all morning long. What about health care . The United States pays twice as much as any other western country. We have an abysmal Health Care System because the insurance people do nothing. The amount of money we spend on the administration of health care is crazy. Why dont you talk about the health care and how much insurance actually costs us as part of our Health Care Dollars . Host lets talk about it. Guest if you have a managed care plan, then the insurer is doing more than just sitting there. Insurers will say they have a lot of programs for wellness and prevention, but the bottom line is we spend more than other countries. We dont consume that much more health care than other countries do. We just pay more. Our prices are too high. The Insurance Industry, which would arguably have a say in bringing those prices down, has not done a very effective job at doing that. So we have basically a price problem. We also have a health problem. Its beyond medical care. There are housing issues and Food Insecurity issues and what they call social determinants of health that are huge, that if we could take care of some of the social issues the nations medical bill would likely go down. Host you are talking about the nutrition side. Guest everything. Its nutrition, housing, transportation, its the things that surround that determine Peoples Health thats not traditional medical care. Host this was a headline today in the newspaper, new Research Finds that by 2030 nearly half of american adults, 49. 2 , to be exact, they write, will be obese. In every single state, no fewer than 30 of owe dults will have a body index of 30. Talk about the impact on health care. Guest its huge. Policymakers have been talking about it for 30 years, the rise in type two diabetes, heart disease, stroke. There is a lot. It goes back to then you are not taking on the medical industry. You are taking on the food industry. They were working on the Affordable Care act, one of the proposed taxes was on sugared soft drinks. It didnt get anywhere because the people who grow sugar dont want to have to pay tax, dont want people to pay a tax on their products. We have seen this in relatively few places, but its been unbelievably controversial, and thats on soda, something that arguably has no nutritional value. So it is host who is behind the sugar lobby . Guest its mostly farmers. We get corn syrup, corn growers and sugar growers. Host rick in pennsylvania enrolled in the a. C. A. Good morning to you. Caller good morning, ladies. I have been on the a. C. A. Plan for the last seven years or so. I am selfemployed. It has been a godsend as far as allowing me to make regular doctor visits for routine checkups and things of that sort, which would not have been possible for me otherwise. The problem this year is because the Trump Administration reduced the subsidies Going Forward. My premium costs will go up more than 400 for 2020. That will make things more challenging. I have a silver plan which covers some doctor visits. If i were to switch to a bronze plan, i would not be covered for routine doctor visits until the deductible is used up. So that is a concern Going Forward because the subsidies have been cut that i will not have as much access to medical care as i might have otherwise. Also this plan goes away, if the courts decide that the entire act should go away, what will be there to replace it . I am 62, three years away from medicare. So i may be in a situation that i was in, say a decade ago, where i went several years without insurance because i couldnt afford it. Host ok. Guest if the law goes away, it will be a mess. There is no replacement at the moment. It is hard when you get to be in your late 50s, early 60s to buy insurance. One of the most popular the most popular provision in the Affordable Care act is protection for people with preexisting conditions because prior to the Affordable Care act, basically if youve ever gotten any health care, you might not be able to get Health Insurance on the individual market. Only sick people would sign up. Thats why subsidies were so important. The subsidies didnt get cut but they did get reconfigured. President trump in 2018 it was 2017, unilaterally eliminated federal payments. There was a court case over they said there had been no appropriation for them, but it meant that the subsidies got reconfigured. If you were outside the exchange, dependsing on your state, on a silver plan you might end up paying more. I mention people who dont get subsidies are in a world of hurt right now. But its for many people, the subsidies the change in the way they calculated the subsidies made it easier for them to buy more generous plans. But there were people when this all got shaken up and put back down who did come out worse. Host keith from florida gets his insurance from his employer. Welcome to the conversation. Caller yes, i have a question about what did the Cadillac Health tax entail . Guest it was an excise tax of 40 on very Generous Health plans. I forget the exact threshold but it wasnt that high. It was like 10,000 for an individual, something close to that. Health insurance is expensive, particularly Union Members who negotiated away bigger raises for Better Health benefits which was good for employers because they dont pay payroll taxes. It was a winwin but a lot of Union Members ended up with really generous plans and a lot of those plans would have been hit. I think one of the biggest issues with the cadillac tax from the beginning was it was a fairly broad tax. 40 excise tax and based on a dollar amount of how much the plan costs and as i mentioned earlier, Health Care Costs different amounts in different parts of the country and its not necessarily urban, rural. Its just sort of odd and quirky. Its the way the system has grown up. Therefore people in expensive places are more likely to get hit with the cadillac tax simply by virtue of the fact their insurance is more expensive there. I think that was never really got to that issue because it never really took effect. Everybody agreed that the cadillac tax as originally written was probably not very workable. Host from alabama, johnny is uninsured. How come you are uninsured . Caller i am insured through tricare, i am 64 years old, and one year or nine months from now my tricare ends and i must join medicare. After 34 years of military service and eight combat tours and a bronze star, i have to go on medicare . Guest i believe i know it varies and i am not an expert on this, but that your tricare yes, you do go on medicare becomes your primary, but i think there is a tricare sort of gap but you can ask somebody who handles your tricare about that. The military Health System is different from the rest of it. There is actual military medicine and there is tricare mostly for family members and people on active duty. Funny things happen when you hit that 65 point. You should check that out. But i do think there is a tricare supplement that you can get. Host baltimore, good morning to you. Caller good morning. Thank you to cspan, thank you for the Kaiser Family. I use the website often to do research. Its a really good website. This is one of my soapbox issues, the Affordable Care act. The way it was originally set up, everyone should have been covered. Health insurance works because everyone pays in. When you pull out the money is there. Its set up so that up to 133 would be the expngs medicaid. 133 to uld pay from 140 , they would get premium or get assistance and over 400 you can afford health care. I have seen it being picked apart since its inception. The individual mandate, the states that need it the most, mainly the red states, did not do the expansion. So people who make less than 133 , which would have been eligible for that, did not get it, and i am just watching this and theyre putting profits before people and they dont care. I see people yelling, well, what happened to obamacare . It was set up to work and immediately it was torn apart and its still being torn apart. You have people who dont have Health Insurance, and then theyre doing which should have been done away with. The states that are getting the uncompensated care payments, theyre the red states that say we hate this program but are getting funding from the government. Host julie is shaking her head. Guest yeah. I think that was right there. From the very beginning there were people who were opposed to the law who went around to a bunch of state capitals. Its the red states, people who would have benefited and said we will take this law down. The expansion was unprecedented in medicaid history, basically states pay roughly half of edicaid costs. Government kicks in more. Its up to 8020. After that, we will start paying it down. At the end we will stay pay 90 . It was a huge file of money from the federal government. Rural hospitals wanted it very, very much. Texas has not expanded. Florida has not expanded. Georgia has not expanded. There are pretty big states with t of eligible people who we are showing it. Texas, oklahoma, mississippi, alabama. Georgia, north carolina. South carolina. Tennessee. Florida. Wisconsin. Guest wisconsin is an odd case. They had expandsed up to 100 of poverty. Tommy thompson when he was governor, they expanded to 100 . They dont have a gap. Over 100 you can buy into the exchanges with the subsidy. One thing the caller said, she was right, the thought was that if you earn more than four times the poverty line you could afford Health Insurance. Thats turning out not to be the case. There are a lot of people, if you are a single person, its like 60,000 which is a good income, but if insurance is 2,500 a month, thats a problem. Host joel in idaho, good morning to you. Caller good morning. Julie, you made a comment regarding not being able to grapple with the cost. There is a surgeon at john hopkins who wrote a book called the price we pay and cspan has had him on. Its a very easy read, but he has three points. The first approach is there is a lack of transparency in the Hospital System and that is largely due to the fact that there is poor communication between administrative and clinical side. I would like you to comment on that. The next point he makes is that there is a program called pharmacy benefit manager and what these guys do is they go out and they act as stewards for he phrma and negotiate these high prices and there is very little competition there. The third point is that the suppliers of medical care medical supplies put out these providers arehey limit who cans forced to pay the price. I would like you to address that but i encourage everyone to read this book. The author is going to be on washington journal on the 25th from 8 00 to 9 00 a. M. Eastern time. I have read the book. This is it isth so hard because the Health Care System is so complicated. System, it is getting to be close to 1 5 of the economy. There are so made players. Our podcast panelist went out and it ended up being a discussion of all of the ways we could not navigate the Health Care System and we are supporters. How much find out anything cost. Its almost impossible until after the fact which is kind of crazy. We have new Electronic Health records which is supposed to be researcherso make track your progress but the billing side and the clinical side sometimes have trouble communicating with each other. There are basically a lot of likee who, capitalism is lets go make money and health care. Make can people listen to your podcast . Lth. Called what the hea good morning. Right now, my husband and i are on the obamacare. Premium is 415. I am the only one working. Because my income went up a little bit this year, we are going our premium is going from 413, to over 1800 a month. And the difference was a mere, between 400 and 500 above the limit. How can that much go up, from 413 to over 1800 a month . We wont have insurance as of january 1. I am an rn. I am starting a new job this next week. We will have Health Insurance hopefully through them. It will be something that will be affordable. But this is just totally ridiculous, that a few hundred dollars of extra monthly premium by that much. This is the basically a meanstested program. There is a cliff, and if you fall over the cliff, youre on your own. I have done a lot of work on this. That is why california increased their subsidies, because this was happening to a lot of people in california. The curve in california has been extended further up because there were a lot of people who were just right over the threshold who could not afford how much insurance costs without the help. Jen in wyoming. Hi. I am in wyoming. Id. To my insurance back in 2006 i dumped my insurance back in 2006 because i run the numbers. For 85 of people, your insurance premiums go to pay for other Peoples Health care. Actuarially, if youre reasonably healthy and you have 2 dimes to scrape together, youre better off not dying insurance. Doctors love cash not buying insurance. Doctors love cash. The Insurance Industry uses scare tactics like, god forbid you get hit by a bus, the reality is, only 5 of people get hit by buses. 90 of the time you are flashing your premiums down the toilet. You are better off putting that money in a savings account, an investment account, keeping it so you have got it, than handing it over to somebody else. When you do have to see a doctor and you are paying cash, you try to negotiate . Are they willing to negotiate . Absolutely. I usually can get a 50 discount off the prices. Julie rovner. A lot of people do. And there are Health Savings account where, particularly if you are not insured, you can put money away it is taxfree going in and taxfree comingout. When you turn 65, it is taxfree coming out for whatever you want. It is a very generous benefit if you want to go in that direction. Only 5 of people and the really needing significantly expensive care. You just dont know when you are going to be one of those 5 . I have people who say, i never signed up for the medicare benefit when i was eligible, because i was not taking any drugs. Now it is 10 years later and they are taking drugs, and if you sign up for it later, you have to pay a penalty. It is sort of how you feel about insurance in general. Julie rovner, chief correspondent with Kaiser Health news. Again, the website is kaiser kaiserhealthnews. Org. Thank you for the conversation. Washington journal live every day with news and policy issues that impact you. Coming up thursday morning, as part of author wake of a former senator will join us to talk about challenges facing native americans today from his new book the girl in the photograph. Correspondent will be odd to talk about impeachment in campaign 20 to eight. Be sure to watch washington journal live at 7 00 eastern thursday morning. Join the discussion. Be sure to watch this week starting at 8 00 a. M. Next, a discussion about humans side of judging. With former and current state judges. Wrotederator