Government Executive - Authors - Margot Sanger-Katz

Administration Delays Obamacare Employer Mandate

Margot Sanger-Katz, National Journal — Wed, 03 Jul 2013 09:23:25 -0400

The delay of a major health reform provision means that employers won't be required to offer their workers health insurance next year. The complex and unpopular Obamacare requirement will not be implemented in 2015, after next year's election, the Treasury Department announced on Tuesday.

The decision is a relief to employers, which have been struggling to prepare for a series of new requirements next year. Under the health reform law, any business with 50 or more full-time workers would need to provide affordable health insurance to its workers or pay a fine. But the rules were complicated, and even businesses that currently insure their workers were complaining it would be tough to comply.

"We have listened to your feedback," Mark Mazur, the assistant secretary for tax policy wrote on the Treasury website. "And we are taking action."

Politically, the decision cuts both ways. The employer mandate was never very popular among business owners, especially in the retail and restaurant sector. This decision placates them for now and undercuts criticism that the law hobbles business.

But the delay, originally reported by Bloomberg, also allows Obama's critics to allege that the administration is falling down on the job of administering its health reform law. Christopher Jacobs, a senior policy analyst at the conservative Heritage Foundation, quickly posted on the organization's blog that the administration now "admits Obamacare's a job-killer."

It also does little to appease the Affordable Care Act's most determined political critics. House Majority Leader Eric Cantor, R-Va., didn't hesitate to use the news to renew calls for repeal. "This further confirms that even the proponents of ObamaCare know it will hurt jobs, decrease economic growth and make it harder for families to have access to quality and affordable health care. Rather than continuing to delay the predictable pain until another election day has passed, we should scrap this entire law and instead implement patient-centered reforms before any more damage is done to our economy or the health care families depend on," he said in a statement. House Speaker John Boehner's statement said the move was "a clear acknowledgement that the law is unworkable."

But despite the rhetoric, the practical effects of the delay may not be large. A 2010 RAND analysis of the employer mandate found that the provision would influence the behavior of very few employers. Most large employers already offer their workers insurance. And many who expanded coverage would do so in response to employee demand, not the fear of penalties, the study found.

"The employer mandate didn't end up having much "bite," says Christine Eibner, a RAND economist who worked on the analysis.

The law's biggest features will still roll out on time. Administration offiicals continue to say that new insurance marketplaces will be ready for people to sign up as scheduled on Oct. 1. And just last week, the administration issued its final rule on the requirement that individuals obtain health insurance, which means the law's most unpopular provision will kick in next year.

(Image via lenetstan/Shutterstock.com)

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No, Oncologists Are Not Going Broke

Margot Sanger-Katz, National Journal — Tue, 23 Apr 2013 15:01:00 -0400

When the automatic spending cuts kicked in for Medicare this month, every doctor saw a 2 percent reduction in reimbursement from the government insurance program. But cancer doctors have made the most noise. A front-page Washington Post story reported that thousands of cancer patients were being turned away by doctors who could no longer afford to treat them. Members of Congress responded quickly, introducing legislation to reverse the cancer reimbursement cuts and asking the Health and Human Services Department to reinterpret the sequester law to exempt oncologists. “This particular cut itself is so devastating to cancer patients that this is one that we just have to see our way to improving and fixing,” said Rep. Renee Ellmers, R-N.C., who sponsored the bill to reverse the cancer cuts. (The doctors are unlikely to find an ally in President Obama, whose budget last week recommended even deeper cuts to their reimbursement.)

Partly, this is political theater. While some oncologists warn that patients will lose access to lifesaving care, others admit they’ll simply absorb the cuts and keep treating their ailing charges. Their median compensation was $430,695 in 2011, according to the Medical Group Management Association. But the situation also highlights how problematic the business of oncology has become. Federal-payment policies have distorted the market and perverted incentives for providers.

Like other physicians, medical oncologists are paid to diagnose disease and devise treatment plans for patients. But for years, they have also had a thriving side business buying and reselling the expensive chemotherapy drugs they administer. Instead of paying for compounds directly, or sending patients to buy them from a retail pharmacy, Medicare reimburses cancer doctors for buying the drugs, then pays them a 6 percent markup above an “average sales price” for the medication.

That markup is designed to reimburse practices for the cost of acquiring, storing, and managing the drugs (doctors often buy the medications before they get paid to administer them). But even accounting for those costs, the margin on cancer drugs still represents 21 percent of the average practice’s revenue, according to asurvey by the firm Oncology Metrics published in the Journal of Oncology Practice. Cancer tends to strike people later in life, so Medicare beneficiaries make up the majority of patients, but many practices also obtain higher drug markups from younger patients with private insurance.

Why the Senate Democrats' Budget Will Be Vague

Margot Sanger-Katz and Nancy Cook, National Journal — Mon, 11 Mar 2013 08:19:57 -0400

The GOP has long hoped that by prodding the Senate majority to produce a budget, it could force Democrats to commit to paper some unpopular political choices on spending cuts and health care programs. But if Republicans want specifics this spring, they’ll have to wait. The Senate Democrats’ budget, scheduled for release this week, is expected to offer only broad outlines of many of the party’s usual talking points, leaving the Republicans with little new political ammunition in the ongoing fiscal war.

The new Senate Budget Committee chairwoman, Patty Murray, will propose additional revenue beyond the fiscal-cliff deal, as well as more spending on education, transportation infrastructure, and job training, according to aides and Democratic members familiar with the discussions. Her budget will seek to undo nine years of sequestration, starting next fiscal year, through policy ideas that Democrats have already proposed: closing tax loopholes, for example, and saving money from the troop drawdown in Afghanistan. And it will offer targets for revenue and spending that the federal government should hit over the next 10 years—along with possible instructions for tax reform.

What the proposal is unlikely to do is lay out a detailed blueprint for cutting the federal health entitlement programs that drive the country’s long-term deficit. “Our budget is going to reflect the need to deal with our long-term health care costs without impacting our beneficiaries in a way that puts us in a place where people can’t sustain their own budgets at home,” Murray tells NationalJournal. Two recent budget memos, circulated to Senate Democrats, emphasized the need for revenue and barely mentioned the health programs.

Budget discussions among Senate Democrats are ongoing, and it’s unclear if they’ll go as far as the president did in proposing entitlement savings. As part of a deficit-reduction deal, the White House has said it would be willing to wring $400 billion from Medicare and Medicaid, primarily through cuts in Medicare payments to doctors and hospitals. President Obama is also willing to change the way the federal government calculates certain government benefits, an adjustment to the cost-of-living calculation known as chained CPI, a change that that could also bring in more revenue. In the past, Murray and Majority Leader Harry Reid have considered that verboten.

Even behind closed doors on the deficit-reduction super committee, on which Murray was a cochairman, she was not known as a vocal supporter of significant entitlement changes. Murray and the other Democrats talked about cuts at the margins or the need for greater efficiency within the medical system, says former Sen. Jon Kyl, a GOP member of the 12-person committee. “As a general proposition, the Republicans were disappointed that the Democrats did not put real reforms on the table,” he says.

The vagueness likely to characterize the Senate Democrats’ proposal partly stems from the nature of congressional budget documents, which tend to be more political statements than policy prescriptions. That’s true for both parties. Politicians can propose to cut spending by a certain percentage in a budget without wading too much into the programs, personnel, or agencies that would have to be cut to meet that target. “Primarily, the job of the Budget Committee is to establish a framework and leave it to the committees of jurisdiction to fill in the gaps. We’re supposed to provide a skeleton, and they’re supposed to put the meat on the bones,” says Rep. Chris Van Hollen of Maryland, the ranking member of the House Budget Committee and a close ally of the White House in fiscal matters.

But the nature of budget resolutions isn’t the only thing shaping this particular proposal. It’s also the nature of the politics and the opposition. The Republican chairman of the House Budget Committee, Rep. Paul Ryan, holds a reputation as a policy wonk, whereas Murray is known more as a political animal. “She’s a pretty good arbiter and proxy for the caucus as a whole,” says Rich Tarplin, a lobbyist close to Senate Democrats. “Her own personal views pretty well represent the balance between the progressives and the moderates.”

Ryan’s draft budget proposal is already freaking out moderates in the GOP caucus, whereas Murray’s goal is to craft something that can attract broad support within the Senate Democratic Conference—from liberal members on her own committee, such as Sen. Bernie Sanders, I-Vt., to the handful of centrist members facing tough reelection battles in 2014. So, by political necessity, her budget is designed to be vague.

It’s the only way Murray can rally her Senate colleagues and prove her worth as a good soldier for the leadership. A budget that alienates Democrats on her committee and fails to get a floor vote would be a political disaster. “This is the next best step at replacing the sequester and getting revenue, despite the gridlock,” a Senate Democratic leadership aide says. “We’re not going to negotiate everything away in the first round.”

It’s also a chance for Senate Democrats to show they can produce and pass a budget—a feat not accomplished since 2009 and a favorite jab of House Republicans. In this round of the fiscal wars on Capitol Hill, the bar is pretty low.

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Budget office predicts rocky start for health care law

Margot Sanger-Katz, National Journal — Wed, 06 Feb 2013 09:53:34 -0500

The Obama administration has been publicly upbeat about the coming rollout of its health care law. But a new report from the nonpartisan Congressional Budget Office suggests that at least one set of influential observers anticipates some turbulence in the law’s first years.

On several important measures of the law’s success, CBO’s numbers are pessimistic compared with earlier estimates: Fewer uninsured people will get coverage, insurance options will be more limited, and more employers will stop covering their workers. Perhaps most noteworthy, the report suggests that the new health insurance marketplaces set to launch later this year are unlikely to be completely ready in time.

That negativity came cloaked in the careful language of the budget office—what former Bush health official Tevi Troy called “heavy bureaucratese”—but the report signaled CBO officials are worried that key provisions of the law are not going to work as intended.

“They view the odds of success as diminishing sharply,” said Douglas Holtz-Eakin, the president of the conservative American Action Forum and a former CBO director.

The health insurance marketplaces, or exchanges, will be the place where individuals, families, and small businesses can shop for insurance using tax credits. They are a key element of the law, because they will be the place where uninsured Americans can purchase health plans.

Publicly, administration officials have promised that the new exchanges will be ready on time. In a characteristic statement, Gary Cohen, who runs the agency overseeing the exchanges, told the House Energy and Commerce Committee in December that they would open their doors for enrollment in October, as scheduled. But the CBO report expresses skepticism. The “change reflects the agencies’ judgment about a combination of factors, including the readiness of exchanges to provide a broad array of new insurance options, the ability of state Medicaid programs to absorb new beneficiaries, and people’s responses to the availability of new coverage.”

In plain language, that means CBO thinks the marketplaces won’t have many insurance choices, the Medicaid enrollment systems will not be ready for new people to enroll, and people will be less enthusiastic about signing up for new insurance options.

Critics have long been cautioning that the administration’s optimism was unwarranted. “A whole bunch of people have been saying for quite a while that these things are not going to be ready, and when they are ready they’re not going to be the be all and end all that people say they’re going to be,” said Troy, a senior fellow at the Hudson Institute.

The revised estimates only apply to the first two years of the law’s implementation—2014 and 2015. Over the long run, the CBO does expect the new marketplaces to work as they had previously predicted. But in 2014, it now anticipates only 7 million people will be insured through the marketplaces. That’s down 2 million from its last estimate, in July.

Dan Mendelson, the CEO of the consultancy Avalere Health, and a former White House budget official, said that the new estimates do not predict calamity, but they do reflect a growing awareness that implementation of the health law will not be easy.

“They are starting to adjust to reality, and reality is you have to work really hard to get people to sign up,” he said. “While I don’t think they are predicting a failure of the systems, they are acknowledging the realities that people do not sign up instantaneously.”

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Senate Aide Wants to be a Millionaire

Margot Sanger-Katz, National Journal — Fri, 16 Nov 2012 14:50:00 -0500

Chris Jacobs wants to be a millionaire.

He might well be one already, but he won’t tell. The Republican Senate Joint Economic Committee staffer and prolific health care blogger is also a self-described “trivia hustler.”

On election day, he was travelling to New York City, where he taped an episode of Who Wants to Be a Millionaire? the next day.

The Millionaire appearance won’t be Jacobs’s first game show. As a teenager, he appeared onJeopardy, where he walked away with $5,000.

If he won big, he won’t say. His episode likely won’t air until the spring, and the show bars him from saying a peep about his possible winnings under threat of losing them. But Jacobs’s officemates have been grilling him, even scrutinizing his wardrobe for signs of newfound wealth. If it’s any indication, since his return, he has continued blogging up a storm. “People are trying to get all sorts of hints about what I won, how much, what did I do, all that sort of thing,” Jacobs said. “I haven’t told them anything.”

Nor would he tell us.

UPDATE: Jacobs writes us, "I view a discussion of whatever money I did (or didn't) win on the show as slightly academic - Obamacare's taxes will likely take most of it anyway, so what's the difference...?"

(Image via Michaelstockfoto/Shutterstock.com)

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Jobs and deficit likely to dominate debate

Margot Sanger-Katz and Catherine Hollander, National Journal — Wed, 03 Oct 2012 09:52:39 -0400

Wednesday evening’s presidential debate is a chance for voters to see where President Obama and his GOP challenger Mitt Romney stand on key domestic issues such as job creation, the budget, and health care policy. The 90-minute event, moderated by PBS’s Jim Lehrer, will be divided into six 15-minute sessions—half on the economy and the rest on health care, the role of government, and governing style.

Here are some of the issues likely to come up:

Job creation. Both candidates are likely to be grilled on how they would bring down the nation’s 8.1 percent unemployment rate, including their strategy to push measures through a gridlocked Congress. Expect Romney to be asked how he’ll create a promised 12 million jobs, and how that number was calculated. Obama offered a series of job-creation proposals in his State of the Union address at the beginning of this year. He might be asked what he's learned from his struggles to pass those proposals and his difficulty in bringing down stubbornly high unemployment.

Deficit reduction. The Congressional Budget Office has forecast that debt held by the public will surge to 90 percent of gross domestic product in the next 10 years. Plans put forth by Romney and his running mate Paul Ryan would rein in entitlement spending and overhaul the tax code while bringing down income-tax rates. But Romney has provided few specifics on the tax plan, and independent analysts have questioned whether it could achieve all of its goals without adding to the deficit. Expect him to be grilled on the details. Obama has offered a plan to reduce the deficit by $4 trillion over the next 10 years. But the number counts savings from the winding down of the wars in Iraq and Afghanistan. The president will likely be asked how he can achieve such a high number without significant changes to the three main debt drivers: Medicare, Medicaid, and Social Security.

Financial regulation. Romney has said he would repeal the 2010 Dodd-Frank financial-reform law. But he has not said what he would put it its place, and a natural question would be whether Romney’s plans would enable banks and businesses to grow without risking another financial crisis. The Dodd-Frank law is a key achievement of Obama’s first term, but critics contend that the regulations are too complicated and have the potential to hamper economic growth. Obama may have to respond to this charge.

The Federal Reserve Board. The central bank has been in the political crosshairs ever since it embarked on a series of extraordinary measures to boost economic growth in the aftermath of the Great Recession. Romney denounced the Fed’s most recent action—a new round of bond-buying intended to drive down long-term interest rates—as a “sugar high” and cautioned that it risks causing a rise in inflation. He has said he wouldn’t reappoint Fed Chairman Ben Bernanke, whose term expires in 2014. Romney could be asked to discuss potential successors. Obama’s White House rarely comments on the politically independent Fed. But in 2010, Obama reappointed Bernanke, who was initially tapped for the Fed by Republican President George W. Bush. A fair question, then, is whether he endorses Bernanke’s methods, and whether he would appoint the Fed chief again or seek a fresh leader of the central bank.

Immigration. Citing the economic benefits, Romney and Obama have both said they want to lift quotas on visas for high-skilled immigrants and to grant permanent residency to foreign students in science, technology, engineering, and math fields. Due to the similarity of their positions, the candidates may be more likely to be pressed on specifics on illegal immigration, where they differ. Romney offered few details on his plan to reform immigration, particularly what would happen to the 12 million undocumented people currently living in the United States, although he told The Denver Post earlier this week that he would not repeal temporary visas for children brought to the U.S. illegally by their parents. Obama, on the other hand, has focused on so-called pathways to citizenship for illegal immigrants, but has failed to get Congress to pass any legislation to that effect. Obama vowed this spring in an interview with Univision to pursue comprehensive immigration reform in the first year of a second term, but he could be pressed to detail how he would overcome Republican congressional opposition.

Energy jobs. Both candidates have been singing the praises of the energy sector as a potential source of jobs. Romney has touted jobs tied to oil, gas, and coal, also known as “brown” jobs, while Obama has emphasized "green" jobs tied to renewable-energy development. Romney could face questions on the environmental consequences of expanded development of fossil fuel industries. Obama could face questions over government loan guarantees provided to failed solar-panel-maker Solyndra.

Health care reform. On health care, Romney has alternately praised and criticized the approach to expanding health coverage at the heart of his Massachusetts plan and Obama’s health reform law. He will need to answer which provisions, exactly, he thinks are right for the country and what policies should replace "Obamacare" if he persuades a new Congress to repeal it. Key among the questions he must answer: Does he want to expand health insurance coverage to Americans who don’t have it? Obama will need to defend the costs of the unpopular health reform law. While it saves money on paper, Republicans have been hammering the law as a new entitlement program and a budget-buster, and the Obama administration’s chief Medicare actuary argues that the law’s Medicare savings are unrealistic.

Medicare. With Paul Ryan’s addition to the Republican ticket, Medicare has become a hot topic in the election. Romney and Ryan support a plan to convert Medicare from a government insurer to a program in which the government subsidizes a variety of private plans. When he talks about Medicare, Romney typically criticizes Medicare cost savings that are part of the Obama health reform law instead of discussing his own plan. A tough moderator will ask him to explain how his proposed system would work and why it would not harm seniors. Obama should, similarly, be pressed to explain how his law can rein in Medicare spending without reducing patients’ access to care. Both Obama and Romney may also be asked to address whether their plans would actually resolve Medicare’s long-term budgetary problems. (Hint: they don’t.)

Role of government. The moderators have set aside a 15-minute block to ask about the candidates’ views on the role of government, a fitting topic in an election in which visions differ so significantly. Romney will need to explain his “47 percent” comments, presumably defending his ticket’s critique of growing government entitlements while explaining when and how government programs should intervene to help Americans in trouble. Obama drew criticism this summer with his "you didn't build that" remark referring to businesses, which aides said was a reference to how public structures enable commerce. The incumbent must also counter concerns that in areas across the domestic policy spectrum—in health care, environmental protection, fiscal policy, financial regulation, and student loans—he has sought to expand the role of government. Each will need to explain where they believe government helps and hampers individual success and economic growth. Expect sharp contrasts.

Relations with Congress. The fiscal cliff, a combination of tax hikes and automatic spending cuts that will kick in at the end of the year without action by Congress, will provide a test of presidential leadership for Obama when lawmakers return to Washington for the postelection lame-duck session. Obama has taken heat for his failed attempts at a deficit deal last year, a failure that led to a credit downgrade for U.S. debt. More broadly, both candidates are likely to face divided government, if current polls are any indication, and both should be able to spell out a strategy for working with their opponents in Congress’s increasingly polarized environment.

Executive authority. Frustrated by a paralyzed Congress, the Obama administration has been making the most of its executive authority to enact domestic policy, including deciding to allow young undocumented immigrants to avoid deportation, requiring the Environmental Protection Agency to regulate carbon dioxide emissions, and allowing states flexibility in interpreting welfare-to-work rules. Romney has promised to use the presidency to issue waivers to undo Obama’s health reform law “on day one.” The candidates are likely to be asked about their visions of the proper roles for the president and Congress, and their views on the limits on executive power in the domestic sphere.

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Will health rebate checks help Obama?

Margot Sanger-Katz, National Journal — Wed, 26 Sep 2012 09:09:04 -0400

Some commentators this summer predicted the mailing of the checks could be a turning point for the controversial health law and perhaps give a political boost to Obama in his reelection bid.

“There are a variety of incremental ways that people are learning that the Affordable Care Act will be helpful to them,” said Ron Pollack, the president of Families USA, a liberal health care advocacy group. “The rebate checks will be a part of that.”

Still, despite that enthusiasm, the arrival of the rebates is unlikely to shift public perceptions in a major way. The policy has affected only a small percentage of Americans, not everyone is getting a direct payment, and the average size of the rebates is modest.

The health reform law limits how much of their customers’ premiums they can pocket for overhead and profits. Under the law, insurers must pay either 80 or 85 cents of every dollar on medical care. The insurers who fail to meet this target—called a medical loss ratio—are required to give their customers a refund for the difference and send them a letter specifying that the rebate is thanks to the health reform law.

Nationwide, the total rebates sound large. The Health and Human Services Department says that insurers owe Americans a total of $1.1 billion. But that number gets smaller once it’s spread out. Just under 13 million policy holders got rebates, about 5 percent of the U.S. population, or 10 percent of all households. The average refund was $151, but many Americans who get insurance through their employer received only a fraction of the total refund amount. (Washington, D.C., residents were more likely than most to get a rebate. Seventy-eight percent of employees working for large businesses were eligible.)

Many individual beneficiaries were delighted to get a refund. “It was like, finally, I’m not asked to shell out more money for health insurance,” said Morgan Theriot, 43, a self-employed human resources consultant from Silver Spring, Md., who got a $260 rebate check last month. “Finally, something is due back to me.”

But not everyone who got a check is now singing the praises of the health care law. Theriot said she had a client who was opposed to the law and got a $300 check. That woman said she’d be making a $300 donation to the Republican Party.

Not everyone is getting a check, either. People who buy their own policies, a small fraction of the market, will get a rebate directly from their insurer. But insurers will send rebates to employers who provide coverage for their workers. By law, employers are required to use the money to benefit their employees, but they have used a variety of strategies to do so, according to Tracy Watts, a partner at the employee benefits consultancy Mercer.

“In terms of employers’ actions, it is a mixed bag,” Watts said. “Some have actually cut checks and sent them to employees. Some have given a premium credit. And some have given employees extra money in their paycheck. I’m aware of one employer who put the money into a wellness fund that benefits employees.”

Watts said that many employers passing rebates along to their workers are not handing over the full amount. Since employees, on average, pay about a quarter of their insurance premiums, employers are tending to refund a prorated amount, a fraction of the average $151 amount.

Polling from the Kaiser Family Foundation suggests that some combination of news reports and letters in the mail has raised awareness of the law’s provision. In its August Health Tracking Poll, 42 percent of those asked knew about the refund provision, up from 35 percent in March. Sixty-two percent had a favorable view of the rebate provision.

Cynthia Cox, a policy analyst at Kaiser who has studied the issue, said this evidence suggests that the word is getting out about a popular provision. “More people may be aware of it than actually got the rebate,” she said.

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FDA inspectors could be moving to China

Margot Sanger-Katz, National Journal — Mon, 13 Feb 2012 17:37:00 -0500

If it gets the funding it wants, the Food and Drug Administration will be spending $10 million next year to expand its inspection operations in China.

Nearly all of the increases to the agency's $4.5 billion budget come from user fees paid by drug and device makers who want their products approved. But the president has also requested $10 million in new approriations so that FDA can move 19 full-time employees abroad. Sixteen of them would be inspectors.

According to Patrick McGarey, the agency's assistant commissioner for budget, that total will include $4.4 million for food inspection and $5.6 million for inspection of drug plants.

The budget request reflects a recognition of the growing number of drugs, foods and ingredients coming from abroad. FDA has had an office in China since 2009, but McGarey said the new funds would allow the agency to expand its footprint.

"Their full responsibility is not just in inspection," McGarey said in a conference call with reporters. "There is a saying -- I didn't invent it, but it makes good sense to me -- it's much more efficient to educate people into compliance than to inspect them into compliance."

There's reason to think that the idea could garner Republican support. In a House Energy and Commerce health subcommittee meeting on drug safety last week, both Republicans and Democrats expressed concern about lax oversight of plants in foreign countries.

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What kind of health insurance do the GOP candidates get?

Margot Sanger-Katz and Meghan McCarthy, National Journal — Thu, 12 Jan 2012 00:00:00 -0500

Charles Krupa/AP

Mitt Romney's rivals may enjoy repeating his line that he likes "being able to fire people who provide services to me," but when it comes to health insurance, he has the luxury of choosing among several coverage options, thanks to the health care reform law he signed in his home state.

Romney, like all his rivals for the Republican nomination, says he would like to repeal the 2010 health care reform law, privatize parts of Medicare, and create a system in which more people shop for health insurance on the individual market. But that's not the option most of the candidates have taken for their personal health care-which is not surprising, considering that the individual market is generally the most restrictive and most expensive place to buy health insurance.

The Romney campaign refused to say where he gets his health care coverage. But because of the health care reform law he signed as governor of Massachusetts, he is lucky to live in one of the few states with good insurance options for a 64-year-old unemployed man with a wife who has a preexisting health condition: multiple sclerosis. Massachusetts law, like a provision of the national health care law set to go into effect in 2014, requires insurers to offer coverage to all comers and limits the amount they can raise premiums because of a customer's age or health history. The Romneys have a choice of 41 private health plans, with premiums ranging from $997 to $1,026 a month.

"His experience in Massachusetts would be profoundly different from any other state," said Sara Iselin, president of the Blue Cross Blue Shield of Massachusetts Foundation and the former commissioner of the Massachusetts Health Care Finance and Policy Division.

Only one other candidate buys his insurance on the individual market. Rick Santorum, the 53-year-old former senator from Pennsylvania, is enrolled in insurance that "is totally private, and not related to his time in Congress," his spokesman, John Brabender, said in a phone interview. And if Republicans succeed in their stated goal of repealing "Obamacare," Santorum likely won't be firing his insurer any time soon. One of the first pieces of the health reform law to go into effect was a ban on denying coverage to children with preexisting conditions. His youngest daughter, Isabella, suffers from a rare genetic disorder that requires ongoing and costly treatment, just the sort of preexisting condition that makes her look like a poor insurance risk. All insurance plans issued after March 23, 2010, must cover children up to age 19, regardless of prior illnesses.

Many of the Republican presidential nominee hopefuls enroll in public-employee benefit programs that give them the advantages of large-group pricing-and heavy taxpayer subsidy of their premiums. Newt Gingrich, 68, is enrolled in Medicare and buys his own supplemental insurance from Blue Cross Blue Shield, according to his campaign. Paul, 76, as a member of Congress, gets his insurance coverage from the federal-employee benefit program, his campaign says. Rick Perry, 61, gets his insurance from the state of Texas, a benefit he can continue to receive for the rest of his life. (According to the Texas Tribune, Perry is already collecting a state pension, even while he earns his salary as governor.)

Huntsman's campaign also declined to say what type of plan the former governor has. At 51, he is the youngest in the field, making his options for individual coverage better than the others. Utah has its own insurance exchange, but the choices are slim for individual customers, especially when compared with the Massachusetts Connector health exchange. The Utah Health Exchange website merely offers individual insurance shoppers links to five insurance company websites that provide individual coverage in the state. The exchange also lacks many of the consumer protections that Massachusetts offers.

Several of the candidates qualify for multiple government plans. Perry and Paul could apply for benefits through the Veterans Affairs Department because of their military service. Santorum will eventually qualify for the federal-employee benefit plan. Paul is eligible for Medicare. (It is a strange twist that Paul, the candidate most committed to dismantling public benefit programs, finds himself eligible for health benefits from three of them; for his part, he has said publicly that he doesn't use the insurance he has.)

The candidates are lucky to have large personal fortunes and access to public insurance plans. Unlike Massachusetts, most states have no requirement that insurers take customers with health problems, and many allow them to vary pricing tremendously based on age. (And let's be honest: These guys are not spring chickens.)

"It is difficult for the average person to get coverage in the individual market, but we're not talking about average people, in a number of ways," said Paul Fronstin, the director of health research at the Employee Benefit Research Institute, a think tank funded by the business community.

Fronstin said that until the health care reform law kicks in in 2014, insurance companies in most states can deny anyone based on potential preexisting conditions. The cost of coverage in the individual market, which can run as high as $15,000 for a year of family coverage, can also be prohibitive. But the biggest difference between the candidates and the general public is a history of holding public office.

"You're talking about people who have had public service, and public service tends to have the most-generous retiree health benefits at this point," Fronstin said.

One goal of the health care reform law is to set up state insurance exchanges so that individuals in every state will have access to an array of choices like those currently available to the Romneys. If any of the candidates succeeds in repealing that law, shopping around for insurance and firing companies that don't perform are likely to get harder, not easier.

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Supreme court to take health care case

Margot Sanger-Katz — Mon, 14 Nov 2011 00:00:00 -0500

This story has been updated and corrected.

The Supreme Court said on Monday that it would consider several challenges to last year's health care reform law, setting up a major ruling on the Obama administration's signature legislative achievement just months before the 2012 election.

The case will probably be heard in March, making a final decision likely by the end of the Court's term in June. Opponents and supporters of the health care law were equally delighted that the matter may be settled.

In apparent recognition of the complex issues presented by the cases, the Court allotted an unusual five and a half hours for arguments. Usually, cases get an hour of oral arguments.

The justices asked lawyers to answer four legal questions about the law in their briefs, signaling that they will rule on each.

They are:

The individual mandate. The law's requirement that virtually every individual buy health insurance is at the heart of the many challenges to the law. The challengers contend that such a requirement is unconstitutional because the commerce clause should not used to compel individuals to purchase a product they do not want.

So far, two Appellate courts have rejected this argument, ruling that the mandate is acceptable. One court has sided with the challengers, saying the mandate should be overturned.

Severability. When the law was passed, members of Congress said that the mandate was essential to make other insurance reforms in the law work. If the justices strike down the mandate, they will have to decide whether that means the law can stand without it, or the whole law must fall.

The one court to overturn the mandate, the 11th Circuit Court of Appeals in Atlanta, found that it can be separated from the rest of the law, and it ruled the rest of the law should be preserved.

Medicaid expansion. The health care law expands eligibility for Medicaid programs by threatening to withhold all federal Medicaid funds if states don't cover anyone earning up to 133 percent of the federal poverty limit. Critics say that placing such significant financial conditions on a state's behavior is "coercive" and exceeds Congress's spending power. The issue has only come up so far in the 11th Circuit cases, but neither the trial court nor the Appellate Court agreed with this argument.

Jurisdiction. Judges in two Appellate courts have argued that the time is not right for the courts to even consider whether the law is constitutional. They cite an 18th-century law that prevents individuals from challenging their taxes until after they've been assessed and paid.

The justices will have to decide whether the law's penalty for not buying insurance functions enough like a tax that these rules should apply. If they agree with the argument, lawsuits will be barred until after the mandate goes into effect.

The Court had its choice of a combined five cases from three federal Appellate courts for its consideration. The cases it has agreed to hear all come from the 11th Circuit, which ruled in August against the law. It has not decided to hear cases from the 6th Circuit or 4th Circuit and probably will not, since they raise similar legal issues. A fourth case, from the D.C. Circuit Court of Appeals, was decided recently but has not yet reached the high court.

"The Florida case presents every single question that they would want to decide, so once you decide that you would grant in those cases, there's no real reason to grant in the others," said Bradley Joondeph, a constitutional-law professor at Santa Clara University, who has been maintaining a blog on the challenges to the health care law.

The cases it took are NFIB v. Sebelius and Florida v. HHS on severability; HHS v. Florida on the mandate and jurisdiction; and Florida v. HHS on the Medicaid expansion.

HHS v. Florida, Florida v. HHS, and NFIB v. Sebelius were originally the same case. They involved a challenge to the law from 26 states, led by Florida, the National Federation of Independent Business, and two individuals. Because the challengers won on some issues and lost on others in the circuit court, both sides have appealed.

HHS v. Florida is the government's appeal of the 11^th Circuit's decision to strike down the individual mandate as unconstitutional. The appeals court did not agree with the challengers on their objection to the Medicaid expansion or their contention that various aspects of the law could not be considered separately. The NFIB also separately appealed the 11^th Circuit's decision on severability.

Parties on both sides welcomed the Supreme Court's embrace of the controversial case. The White House issued a statement expressing confidence about the outcome. "We know the Affordable Care Act is constitutional and are confident the Supreme Court will agree," said spokesman Dan Pfeiffer.

The Obama administration surprised many observers by asking the Supreme Court to weigh in on the law.

Health and Human Services Secretary Kathleen Sebelius said she was pleased. "We're very pleased that they have indeed decided to take the case," Sebelius told reporters. "We're confident that the law is constitutional, will be upheld as constitutional."

Republicans who have been howling for repeal of the law were equally pleased with the High Court's decision. "In both public surveys and at the ballot box, Americans have rejected the law's mandate that they must buy government-approved health insurance, and I hope the Supreme Court will do the same," Senate Minority Leader Mitch McConnell, R-Ky., said in a statement.

Sen. Orrin Hatch, R-Utah, ranking member of the Senate Finance Committee agreed. "The Supreme Court's decision to consider the unconstitutional health law is a big step towards restoring liberty and limits on government under the U.S. constitution," Hatch said.

Republican presidential candidate Rep. Michele Bachmann, R-Minn, called on the administration to give up. "Furthermore, I call on President Obama and Congress to cease enforcement of the remaining provisions of Obamacare immediately until the Supreme Court rules on its constitutionality," she said.

Karen Harned, executive director of the small-business legal center for the NFIB, sounded an equally optimistic note. "Our nation's job-creators depend on a decision being reached before the harmful effects of this new law become irreversible," she said in a statement.

Health insurers, doctors, and the U.S. Chamber of Commerce have been among the many other groups asking the Court not just for a particular ruling but simply to take a case and clear up uncertainties about whether health care reform will proceed.

Correction: The original version of this report inaccurately described the ruling of the 11th Circuit on the question of whether an individual mandate could be separated from the rest of the health care reform law. The court found that it could be severed. The story also misstated the origin of the three cases that the Supreme Court has agreed to consider. All three originated in the 11th Circuit.

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