UPDATED MARCH 3, 2015
If you’re uninsured, you may have questions about possible penalties for not having coverage. The fine may be bigger than you expect. Here are the details:
Is everyone required to have health insurance or pay a fine?
Most people who can afford to buy health insurance but don’t do so will face a penalty, sometimes called a “shared responsibility payment.” The requirement to have health insurance, which began in 2014, applies to adults and children alike, but there are exceptions for certain groups of people and those who are experiencing financial hardship.
What kind of insurance satisfies the requirement to have coverage?
Most plans that provide comprehensive coverage count as “minimum essential coverage.” That includes job-based insurance and plans purchased on the individual market, either on or off the exchange. Most Medicaid plans and Medicare Part A, which covers hospital benefits, count as well, as do most types of Tricare military coverage and some Veterans Affairs coverage.
Insurance that provides limited benefits generally does not qualify, including standalone vision and dental plans or plans that only pay in the event someone has an accident or gets cancer or another specified illness.
If I don’t have health insurance, how much will I owe?
For 2014, the penalty is the greater of a flat $95 per adult and $47.50 per child under age 18, up to a maximum of $285 per family, or 1 percent of the portion of your family’s modified adjusted gross income that is more than the threshold for filing a tax return. That threshold is $10,150 for an individual, $13,050 for a head of household and $20,300 for a married couple filing jointly.
For 2015, the penalty increases to $325 per adult or 2 percent of income, and in 2016 it will be the greater of $695 or 2.5 percent of income.
The $95 penalty has gotten a lot of press, but many people will be paying substantially more than that. A single person earning more than $19,650 would not qualify for the $95 penalty ($19,650 – $10,150 = $9,500 x 1percent = $95). So the 1 percent penalty is the standard that will apply in most cases, say experts. For example, for a single person whose modified adjusted gross income is $35,000, the penalty would be $249 ($35,000 – $10,150 = $24,850 x 1percent = $249).
The penalty is capped at the national average price for a bronze plan, or about $9,800, according to Brian Haile, the former senior vice president for health policy at Jackson Hewitt Tax Service. The vast majority of taxpayers’ incomes aren’t high enough to be affected by the penalty cap, he says.
Many more people will be able to avoid the penalty altogether because their income is below the filing threshold.
If I owe a penalty for not having insurance in 2014, how do I pay it?
If you had health insurance for only part of 2014 or didn’t have coverage at all, you’ll have to file Form 8965, which allows you to claim an exemption from the requirement to have insurance or calculate your penalty for the months that you weren’t covered.
What if I just realized I face a penalty for 2014. Can I do anything to avoid a penalty next year?
Open enrollment for 2015 coverage ended Feb. 15 but there is a special enrollment period from March 15 to April 30 for uninsured consumers who are just learning of the penalty. That provision applies only to people in the 37 states that use the federal exchange, healthcare.gov, but many of the states running their own health marketplaces have made similar offers.
Are there other circumstances that allow me to get insurance outside the annual open enrollment period?
Yes. If you have a change in your life circumstances such as getting married, adopting a child or losing your job and your health insurance, it may trigger a special enrollment period during which you can sign up for or change coverage and avoid paying a fine. In addition, if your income is low and meets guidelines in the law, you can generally sign up for your state’s CHIP or Medicaid program at any time.
I was uninsured last spring and signed up on the exchange in March 2014 for a plan that started May 1. Will I owe a penalty for the first four months of the year?
No. In October 2013, the Department of Health and Human Services released guidance saying that anyone who signed up for coverage by the end of the open enrollment period on March 31 would not owe a fine for the months prior to the start of coverage.
What if I have a gap in coverage after open enrollment ends? Will I have to pay a fine?
It depends. If the gap in coverage is less than three consecutive months, you can avoid owing a penalty. Subsequent coverage gaps during the year, however, could trigger a fine.
If you have coverage for even one day during a month, it counts as coverage for that month. The penalty, if there is one, would be calculated in monthly increments.
Are parents responsible for paying the penalty if their kids don’t have coverage?
They may be. If you claim a child as a dependent on your tax return, you’ll be on the hook for the penalty if the child doesn’t have insurance. In cases where parents are divorced, the parent who claims the child as a tax dependent would be responsible for the penalty.
Who’s exempt from the requirement to have insurance?
The list of possible exemptions is a long one. You may be eligible for an exemption if:
- –Your income is below the federal income tax filing threshold (see above).
- –The lowest priced available plan costs more than 8 percent of your income.
- –Your income is less than 138 percent of the federal poverty level (about $16,105 for 2015 coverage for an individual) and your state did not expand Medicaid coverage to adults at this income level as permitted under the health law.
- –You experienced one of several hardships, including eviction, bankruptcy or domestic violence.
- –Your individual insurance plan was cancelled and you consider plans on the marketplace are unaffordable.
- –You are a member of an Indian tribe, health care sharing ministry or a religious group that objects to insurance.
- –You are in jail.
- –You are an immigrant who is not in the country legally.
When should I claim or file for an exemption?
There’s no one-size-fits-all answer. You can claim some of the exemptions when you file your tax return in 2015, but for others, you will have to complete an exemption application available at healthcare.gov.
Are U.S. citizens living overseas subject to the penalty for not having insurance?
If you live abroad for at least 330 days during a 12-month period, you aren’t required to have coverage in the States.
What happens if I don’t pay the penalty?
The IRS may offset your income tax refund to collect the penalty, but that’s about it. Unlike other situations where the tax agency can garnish wages or file liens to collect unpaid taxes, the health law prohibits these activities in cases where people don’t pay the penalty for not having insurance.
This story was originally published March 24, 2014.
Jeff Clarke, 58 and daughter Stormy Clarke, 23, talk about the lack of access to mental health care in Hayfork – a tiny rural town in northern California.
Leading Texas Republicans on Monday asked the Obama administration for greater flexibility to administer Medicaid — a move that has gotten little traction in the past — while reiterating that they would not participate in an expansion of the program under the Affordable Care Act.
“Any expansion of Medicaid in Texas is simply not worth discussing,” state Sen.Charles Schwertner, R-Georgetown, chairman of the Senate Committee on Health and Human Services, said at a press conference.
Schwertner and Lt. Gov. Dan Patrick both told reporters that the federal-state health insurance program for the poor and disabled was on an “unsustainable trajectory” of growing costs. In a letter, they asked the federal government for more wiggle room to administer the program, requesting cost-cutting changes to its benefits packages and seeking to require that Medicaid beneficiaries have or seek employment to get health coverage.
Similar requests by former Gov. Rick Perry for flexibility in spending Medicaid dollars failed under both Democratic and Republican presidents. About 4.1 million Texans are on Medicaid, which constitutes about 29 percent of the total state budget.
In 2008, Perry asked health officials under President George W. Bush for a waiver allowing the state to limit its number of Medicaid beneficiaries and create a less generous benefits plan. That request was rejected.This copyrighted story comes from The Texas Tribune, produced in partnership with KHN. (Learn more about republishing Texas Tribune content)
And in 2011, Perry signed legislation asking the feds for a Medicaid block grant, a capped amount of money that would have come with more flexibility for the state to toy around with spending. That proposal also hit a dead end.
Asked about previous attempts to get federal permission to change the state’s Medicaid program had failed, Schwertner acknowledged that those requests went unapproved.
“The federal government has been very unwilling to work with increased flexibility,” he said. “That’s why we are calling for increased flexibility to preserve the Medicaid program.”
State Rep. Garnet Coleman, D-Houston, said Monday that the proposals were “a nonstarter and everyone knows it.”
“We should be following the example of other Republican states who are finding fiscally responsible solutions to closing the coverage gap rather than increasing it,” Coleman said in a statement.
Twenty-eight states and the District of Columbia have expanded Medicaid under the federal law.
In celebration of Women’s History Month and International Women’s Day (March 8) we thought we’d try something a bit different for the blog. We asked the foreign law specialists, analysts, and interns at the Law Library of Congress to provide responses to a series of questions related to the history of women’s rights in various countries. Margaret also contributed information on the U.S. We particularly wanted to highlight some of the important milestones and people around the world in three areas: women’s suffrage, political participation, and involvement in the legal profession.
Today, in the first of three posts to be published over the next week, we look at women’s voting rights. In our next post we will examine the participation of women in national legislatures. Finally, our third post will cover women in the law, including the first women lawyers and judges in different countries.
QUESTION: When did women gain the right to vote?
BRAZIL (by Eduardo Soares): Regionally, in 1927 an Electoral Law issued by the state of Rio Grande do Norte determined that all eligible persons could vote and stand for election, without distinction of sex. As established in the law, in 1928 women from the cities of Natal, Mossoró, Açari e Apodi registered to vote. Women were granted the right to vote in national elections in 1932, when an Electoral Code was enacted through Decree No. 21,076 of February 24, 1932.
CHINA (by Laney Zhang): The first Electoral Law of the People’s Republic of China (PRC or China), promulgated in 1953, expressly stipulated that women enjoy the same rights to vote and stand for election as men. More than 90% of women cast their vote in the subsequent elections conducted at the grassroots level nationwide in December that year.
EGYPT (by George Sadek): Article 61 of the 1956 Egyptian Constitution and article 1 of Law No. 73 of 1956 on the Exercise of Political Rights granted women the right to vote in Egypt. Women participated in the national elections for the first time in 1957.
FRANCE (by Nicolas Boring): While there appears to be evidence that French women had voting rights in medieval assemblies such as the General Estates, the regimes that came out of the French Revolution only allowed male citizens to vote. In 1944, after the liberation of France, women were allowed to participate in the national elections under an ordinance of the French provisional government. Two and a half years later, the Preamble to the Constitution of 1946 proclaimed that women would have the same rights as men in all matters, including the right to vote. The Preamble was incorporated by reference into the Constitution of October 4, 1958, which is France’s current constitution.
GERMANY (by Wendy Zeldin): Women in Germany were granted the right to vote and to stand for election in 1918. The first government of the new German Republic, formed in 1918, introduced the principle of women’s active (right to vote) and passive (right to stand for election) suffrage which was reflected in article 109 of the Constitution of 1919, “Weimarer Reichsverfassung” (Die Verfassung des Deutschen Reichs).
GREECE (by Theresa Papademetriou): Women were granted the right to vote and to be elected in parliamentary elections in 1952 by Law No. 2159/1952. However, women could not vote in the November 1952 elections because they were not registered in time to be included in the voter registration lists, as required by law.
INDONESIA (by Constance Johnson): The 1945 Constitution, which was promulgated after Indonesia became independent in August 1945, granted Indonesian women the right to vote in national elections for the first time.
ISRAEL (by Ruth Levush): Israeli women had the right to vote from the day the state of Israel was established in 1948. Israel’s Declaration of Independence provides that the State of Israel “will ensure complete equality of social and political rights to all its inhabitants irrespective of religion, race or sex.”
JAPAN (by Sayuri Umeda): A December 1945 revision of the Election Law granted women the right to vote in Japan. Women then participated in the April 1946 election, the first general election to be held after the war.
MEXICO (by Gustavo Guerra): On October 17, 1953, the Mexican federal government published the law, amending articles 34 and 115 of the 1917 Constitution, that granted women the right to vote in national elections.
NEW ZEALAND (by Kelly Buchanan): On September 19, 1893, New Zealand became the first self-governing country in the world to grant women the right to vote in parliamentary elections when a new Electoral Act was signed into law. Women were then able to vote in the November 1893 election, with about 80% of women in the country registering to vote and 85% of those registered actually voting on election day – a higher percentage turnout than that of men, at 70%.
NICARAGUA (by Norma Gutiérrez): On April 20, 1955, amendments to Nicaragua’s 1950 Constitution gave women the right to vote by removing all the previous legal restrictions. Women exercised their right to vote for the first time in the February 3, 1957, election.
PAKISTAN (by Tariq Ahmad): Pakistan adopted universal adult suffrage for provisional assembly elections soon after it became independent in 1947. Pakistan’s first and second Constituent Assemblies were formed through indirect elections of provincial assemblies. In 1956, women were granted the right to vote in national elections under Pakistan’s first Constitution. However, due to political instability and cycles of military rule it was not until 1970 that Pakistan had its first direct general elections for the National Assembly. Pakistan’s current 1973 Constitution preserves the right of women to vote and includes provisions for reserved seats for both houses of parliament.
RUSSIA (by Peter Roudik): The rights of women to vote and be elected to the national legislature were granted in August 1917 by the Statute on Election of the Constituent Assembly. In July 1918, this right was constitutionally protected by the first Russian Constitution, and women were represented in all Soviet legislative bodies.
SOUTH AFRICA (by Hanibal Goitom): South Africa accorded women who were “wholly of European parentage, extraction or descent” the right to vote in 1930 through the Women’s Enfranchisement Act of 1930. “Coloured” women and Indian women (along with men in the same categories) were accorded the right to vote in 1984 under the Electoral Act Amendment Act of 1984. Black women and black men were granted franchise after the end of the apartheid era under the 1993 Interim Constitution.
THAILAND (by Ployparn Ekraksasilpchai): Thailand was formerly governed under an absolute monarchy and changed to a constitutional monarchy on June 24, 1932 (B.E. 2475). As a result, the first Constitution was signed by the king in December of that year and this document permitted women to vote and stand for elections.
UNITED KINGDOM (by Clare Feikert): A bill allowing women to vote was first presented before parliament in 1870, but it took almost fifty years until the Representation of the People Act was passed in 1918 for women to get a very limited right to vote. The 1918 Act only served to enfranchise women over the age of 30 that met certain property qualifications. In 1928, the Representation of the People (Equal Franchise) Act gave all women aged 21 and over the right to vote.
UNITED STATES (by Margaret Wood): The first state to grant women the right to vote was Wyoming when it was admitted to the Union in 1890 with a constitution that specifically included women’s suffrage. As a territory, it had granted suffrage through a bill signed on December 10, 1869, the first legislative body in the world to do so. Fourteen other states granted women the right to vote in state and national elections before the passage of the Nineteenth Amendment to the U.S. Constitution in 1920.
Health Care Transparency Will Help Address Overincarceration and Violence at Rikers, According to NYCLU Testimony
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CONTACT: 212-549-2666, email@example.com
Regular reporting on the physical and mental health of people incarcerated on Rikers Island and the provision of care prisoners there receive will take New York City a step closer toward addressing the violence that plagues the jail, according to testimony to be delivered today before the New York City Council.
“The systemic failure to address the health care needs of those incarcerated on Rikers Island – a population challenged by mental health and medical issues so severe that they shouldn’t be incarcerated in the first place – exacerbates the culture of brutality that plagues Rikers Island,” said New York Civil Liberties Union Executive Director Donna Lieberman. “That culture itself is inexcusable and has to be met head on, but at the same time it must be acknowledged that corrections officers are simply not prepared or trained to deal with the level of suffering they are forced to confront at Rikers. Defining the magnitude of the problem will be a crucial first step toward ending it.”
In its testimony, the NYCLU called for the swift passage of Intro. 440, legislation that will permit the city to better assess the number of individuals detained at Rikers who suffer from mental health or medical conditions so serious that they should never be incarcerated and should instead be diverted to a more appropriate therapeutic setting. The data will also permit a long overdue comprehensive assessment of medical and mental health care at Rikers that can be used to inform sweeping improvements in the quality and delivery of that care, a critical component for addressing the excessive and punitive use of force by correction officers against individuals who are suffering from a lack of adequate mental health treatment.
The NYCLU’s testimony also offers recommendations to clarify and expand the reporting requirements, including amending the bill to clarify that any agency involved in the delivery of health care must be required to collect and report relevant data; adding the reporting of key demographic data, including race, age and gender; and reporting on training of correctional staff on health care matters.
To read the NYCLU’s complete testimony and recommendations, visit:
By Steven Schlozman, M.D.
I remember the exact moment I realized that I could be Mr. Spock.
I was 9 years old, trapped in the “Husky” jeans section of the local Macy’s department store. Looking around at the selection of very big pants, I understood viscerally what I had known intellectually for years.
“Husky” meant “fat.” It meant that I was fat.
Not super fat, but fat enough to be in the Husky section.
I was awkward, developing in that tortured way that evolution see’s fit to make us endure. Staring at the mirror while my Mom gathered trousers for me try on, I was pissed off that because of this shopping trip, I was missing the rerun of “Star Trek” that aired on weekday afternoons.
“What would Spock think about the ‘Husky’ designation?” That’s what I was pondering. I was wondering how the master of logic would justify and make sense of the clearly derogatory way I was feeling about myself.
“Fascinating,” I imagined him saying, and he would raise that patented eyebrow.
Then I looked in the mirror, furrowed my brow, took note of the barely present peach fuzz growing under my nose, and with all the power of a Vulcan mind meld, I imagined that my right eyebrow was being pulled by a thread towards the stars. That one eyebrow was to boldly go where no eyebrow of mine had ever gone before.
And I did it. I raised that eyebrow.
“Fascinating,” I muttered. And then I did it again, and again. It was like a teeny Bar Mitzvah moment. “Today, I am a Vulcan.”
Spock meant that much to me. Spock could be friends with a tough guy like Kirk. Spock was unfazed by McCoy’s insults. Spock tolerated with admirable self-control the romantic advances of Nurse Chapel. Spock would, I was certain, be emotionally impervious to the Husky section of Macy’s.
“Fascinating,” I said, and again I raised my right eye brow.
I share the world’s sadness for Leonard Nimoy’s passing. I am grateful that he stuck around so long after he began his “five year mission.” I feel like a kid every time I hear his voice in the Imax theater at Boston’s Museum of Science. Every time I hear his voice, I am wearing Husky jeans but feeling OK about it.
These days I’m still raising one eyebrow on an almost daily basis. I even had a patient’s parent give me Vulcan ears for Christmas a few years ago.
“They’re not because you’re emotionally cold,” she explained.
No, I thought, Spock wasn’t cold.
“They’re because you’re not freaked out by our child. They’re because you’re interested.”
There could be no higher compliment.
Spock’s final frontier wasn’t just a place you could go at Warp 7. Mr. Nimoy’s portrayal of Spock showed us all that “Star Trek’s” Prime Directive, the principle that you should never irrevocably interfere with an established culture, applied as much to ourselves as to the planets that the Enterprise visited. He might as well have been quoting Polonius.
To your own Vulcan self, be true.
When “Star Trek” first aired, being biracial was just barely something anyone talked about. Spock was the ultimate half-breed. Half human, half Vulcan, Spock was forced by his own people to reject assimilation and instead to choose whether he would be human or Vulcan. He couldn’t be both. Tell me Spock’s struggles didn’t resonate with every kid in the ’70s who played football and “Dungeons and Dragons.” Tell me Spock’s struggles don’t resonate today as we continue to define ourselves.
Like all good fictional characters, Spock’s challenges pose profound and fundamental questions for humanity.What is normal? Do we have to choose how to behave or can we just be who we are? And who ARE we in the first place?
Spock was all about identity and balance.
Spock would not have road rage.
Spock would keep his cool when his flight was delayed.
Another 10 inches of snow?
He’d raise that eyebrow and ponder the climate.
“Fascinating,” he’d say, and then he’d grab a shovel and clear himself a path.
Steven Schlozman, M.D. is an assistant professor of psychiatry at Harvard Medical School and a staff child psychiatrist at Massachusetts General Hospital. He is also associate director of The Clay Center for Young Healthy Minds. Tweet Dr. Schlozman at @zombieautopsies.
In Dr. Abraham Morgentaler’s 26 years as a urologist who treats issues of male sexuality, he has seen thousands of patients, and “probably there hasn’t been a single one who hasn’t paid attention to his penis size on some level,” he says.
“Most men tend to believe they’re smaller than average, and there’s some distortion about what reality is,” says Morgentaler, director of Men’s Health Boston and author, most recently, of “The Truth About Men and Sex: Intimate Secrets From the Doctor’s Office.”
A new study could help combat some of that reality distortion.
Combining 17 previous published studies for a total of 15,521 men, it amounts to the biggest review to date of medically measured penis size, says its lead author, Dr. David Veale of King’s College London. It processed the data into “nomograms,” or graphical diagrams, like the one above, familiar to parents as the typical form for the growth charts that pediatricians use.
From the press release on the paper (metric conversions mine), which is titled “Am I normal? A systematic review and construction of nomograms for flaccid and erect penis length and circumference in up to 15,521 men”:
The nomograms revealed that the average length of a flaccid penis was 9.16 cm [3.6 inches], the average length of a flaccid stretched penis was 13.24 cm [5.21 inches], and the average length of an erect penis was 13.12 cm [5.165 inches]. The average flaccid circumference was 9.31 cm [3.66 inches], and the average erect circumference was 11.66 cm [4.59 inches]. There was a small correlation between erect length and height.
So those are the averages, but the great beauty of a nomogram is that it can also give you a sense of the distribution of the variation, and you may have already noticed that the curve above looks strikingly flat. That is, there’s just not much difference, except at the extreme edges.
If your erect penis is 11 centimeters, that puts you down in the 10th percentile; if your erect penis is 15 centimeters, that puts you way up in the 85th percentile. Quite a jump, for a little over an inch.
“What’s interesting is, when you look at the curves, you see that most penises actually are fairly similar in size,” Dr. Morgentaler says. “You really have to go to the extremes — the top or bottom 5 or 10 percent — to really see some big differences. And truthfully, in my practice, I would say that’s exactly right. Most men have penises roughly the same size.”
But somehow, many men who are average think they’re below average. The study notes:
“Men may present to urologists or sexual medicine clinics with a concern with their penis size, despite their size falling within a normal range. This type of concern is commonly known as ‘small penis anxiety’ or ‘small penis syndrome.’ Some men who are preoccupied and severely distressed with the size of their penis may also be diagnosed with body dysmorphic disorder (BDD), where the preoccupation, excessive self-consciousness and distress is focussed on their penis size or shape. The diagnosis of BDD or small penis anxiety excludes 2.28% of the male population who are abnormally small as less than 2 standard deviations below the mean.
A recent New York Times piece on what our Google searches reveal about our sex lives documents the depth and breadth of (mostly sub-clinical) penis anxiety.
“Men Google more questions about their sexual organ than any other body part: more than about their lungs, liver, feet, ears, nose, throat and brain combined,” Seth Stephens-Davidowitz writes. “Men make more searches asking how to make their penises bigger than how to tune a guitar, make an omelet or change a tire.”
Size means more than just centimeters, Dr. Morgentaler emphasizes. “The whole issue is how much men actually look at their penis size as a stand-in or surrogate for their degree of masculinity. And we can argue that it shouldn’t — that we should be more highly evolved than that — but whatever we may think, we’re left with what guys actually do, and they are concerned about it.”
Manliness is a key issue for boys growing up, and later in life as well, he says; many men are vulnerable to concerns that they don’t “stack up well.” Not in a stereotypical way of being “if I can use the term, cocksure, arrogant, thoughtless, unfeeling sexual robots.” Rather, Morgentaler says, after 26 years of talking to men behind closed doors, he understands that they want to be good sexual providers for their partners — and often see size as part of that.
So could this study indeed help dispel the common distortion about what’s normal?
Says lead author David Veale, in the press release:
“We believe these graphs will help doctors reassure the large majority of men that the size of their penis is in the normal range. We will also use the graphs to examine the discrepancy between what a man believes to be their position on the graph and their actual position or what they think they should be.”
For men who are not consulting doctors armed with nomograms, however, the odds seem stacked against them gaining confidence that they stack up, especially in this era of Internet porn.
Dr. Emily Nagoski, author of the new book “Come As You Are: The Surprising New Science That Will Transform Your Sex Life,” says it’s hard to know whether the new nomograms will foster more feelings of normalcy.
“Seeing a graph of the distribution of shapes written in centimeters is nowhere near as compelling and as persuasive as the penises you see in porn,” she says. “So until I see an array of average, normal-size penises right there in front of me, how am I going to know what it actually means that the average penis is however many centimeters it is?”
Personally, she adds, she is persuaded by numbers, “but a lot of people, they believe what they see.”
Still, she concludes, the more good information, the better.
“The more we can increase the visibility of a science-based approach to understanding sex and sexuality, the more of a counter-weight that is against the moral/cultural messages that generally have a hidden agenda,” she says. “Whereas science, at its best, is only concerned with the truth, and the more we can have, the better.”
Dr. Morgentaler holds out some hope: “I think information is powerful,” he says, and reality checks can help. For example, the study debunks urban lore linking the size of a man’s penis with his finger length and shoe size, and shows that even the link with height is weak, he notes.
“I think there’s value in the data here,” he says. “It’s worthwhile for men to know that the amount of variation for about 85 or 90 percent of the male population for penis size is all centered around pretty much the same number.”
Readers, reactions to the chart? Experiences with penis anxiety?
In their latest attack on the Affordable Care Act, House Republicans question why the Obama administration transferred money last year from the National Institutes of Health and the Centers for Disease Control and Prevention to pay for the operation of the federal health insurance marketplace.
“Now it appears that we are robbing Peter to pay Paul in order to finance the disaster that is healthcare.gov,” said Rep. Jody Hice, a Republican congressman from suburban Atlanta.
Hice complained at a hearing last week that the Department of Health and Human Services shifted millions of dollars last year from those agencies to help pay the $1.4 billion cost of running the insurance marketplaces in 37 states, according to an HHS spending document.
But HHS officials say they have authority to move money between agencies that are under their jurisdiction. And they note that only about 0.25 percent of each department’s funding – about 50 in all, including global health and AIDS and substance abuse treatment programs — was used to finance the exchange.This KHN story can be republished for free (details).
Congressional Democrats did not appropriate sufficient funding to support the startup and operation of the federally run exchange, partly because they expected most states to run their own marketplaces. More than three dozen states decided to rely on the federal government, leaving HHS scrambling to find money to do the job. In 2013, HHS took $454 million from the $15 billion Prevention and Public Health Fund, created by the health law, and $158 million from the health law’s Health Insurance Reform Implementation Fund, according to the Congressional Research Service.
In 2014, the single largest dollar amount that was transferred within HHS — $34.2 million — came from the Low Income Home Energy Assistance program, which helps poor people heat their homes in winter. Another $12 million came from the National Cancer Institute and nearly $11 million came from the National Institute of Allergy and Infectious Diseases. In contrast, the state-run exchanges received an “indefinite appropriation” from Congress to support their operations until this year when they were supposed to become self-sufficient. However, the federal exchange could not tap that money. Both the state and federal exchanges are also supported by premium taxes paid by those buying health plans in the marketplaces.
HHS officials say they have used their authority to transfer funds from one budget category to another when faced with pressing needs before, including paying for cybersecurity protection, caring for unaccompanied children caught crossing the U.S.-Mexico border and helping states provide medicines to individuals living with AIDS.
Sabrina Corlette, senior research fellow at Georgetown University, said the Obama administration is doing the best it can with funding limitations from the law and a resistant Republican controlled Congress. “A successful launch of the exchanges and health reform in general is a huge priority for the administration and in their first year of operation the user fees (from the exchange) are not completely covering their costs,” she said.
“They are having to run exchanges in more states than anyone anticipated …and they did the best they could with the cards they were dealt,” Corlette said.
Joe Antos, a health economist at the conservative American Enterprise Institute, agrees that officials can shift money between departments within their jurisdiction.
“There is no issue on whether they have the authority to do this,” he said, “but the question is whether this is the best way to fund the federal exchange.”
Antos questioned whether the federal exchange is costing the federal government more money not just because more states are using it than originally envisioned, but because of the technological problems that caused sign-up delays during the first open enrollment period in the fall of 2013.
President Barack Obama’s 2015 fiscal year budget proposed about $1.8 billion to operate the federal exchange, of which nearly $1.2 billion would come from the premium tax and $629 million would come from Centers for Medicare & Medicaid Services, according to a Congressional Research Service report last October.
MARY AGNES CAREY: Welcome to Health on the Hill, I’m Mary Agnes Carey. The Affordable Care Act is headed back to the Supreme Court. At stake are millions of subsidies that help people in more than three-dozen states afford health care coverage. Julie Rovner, a senior correspondent for Kaiser Health News, joins me now to discuss the case. Hi Julie.
JULIE ROVNER: Hi, Mary Agnes.
MARY AGNES CAREY: What’s this all about? Lay out the case for us.
JULIE ROVNER: Well, it’s certainly not about the constitutionality of the Affordable Care Act. A lot of people are saying that. This is what’s known as a statutory interpretation case, something else that the Supreme Court tends to do when there’s an argument over what Congress meant. Basically, the Supreme Court acts as a referee. And that’s basically what they’re doing here.The ACA Goes Back To The Supreme Court
MARY AGNES CAREY: And what are the legal arguments on both sides?
JULIE ROVNER: Well, the challengers in this case say the phrase “established by a state” means that only tax credits that are given out in state exchanges are allowed. And that means, as you mentioned, more than three-dozen states that are using the federal exchange, healthcare.gov, can’t provide tax credits to people. Now they say Congress intended to do this in an effort to pressure states to create their own exchanges. Those on the other side, including the government and the people who wrote the law say that’s not the case at all. It was just sort of an odd way that sentence was written and Congress always intended for tax credits to be available to everyone regardless of whether the exchange was established by a state or the federal government. And that’s basically what’s at stake here. We’re looking at a regulation by the Internal Revenue Service that implements that portion of the law that tax credits and the IRS said that everyone should be able to get those tax credits.
MARY AGNES CAREY: Everyone to receive them whether in the state or the federal exchange.
JULIE ROVNER: That’s right. Everybody who’s eligible regardless of who’s running the exchange.
MARY AGNES CAREY: So what happens if the court rules that people in the federal exchanges can’t get these subsidies any longer?This KHN story can be republished for free (details).
JULIE ROVNER: Well both sides agree on this; and the answer is basically chaos. It would be kind of a mess. Several states actually tried to reform what’s called the non-group market, the individual insurance market, by making insurance available to people with pre-existing conditions but without help for other people to buy insurance or to require them to buy insurance. And it did not work very well. In Kentucky, basically every insurer left the state when they tried it in the 1990s. There are various estimates. Somewhere around 7.5 million people would likely lose their subsidies. Because of the way the law is written, if insurance costs more than 8 percent of your income, you’re not required to buy it. So most of those people would not buy insurance. They wouldn’t have to. The people who would buy insurance are probably the people who need it the most. That would result in a risk pool that is sicker and therefore premiums would have to go up. Estimates are that premiums would go up somewhere in the neighborhood of 35 to 45 percent. Obviously for people who were getting subsidies, their costs would go up enormously. The average subsidy is about $268 and that covers somewhere in the neighborhood of three-quarters of their premium. So they would basically be priced out of these markets. Insurance companies are very worried about this. Hospitals and other health care providers are also worried about this. They’ve all written amicus briefs to the court saying this would be a real disaster if the subsidies were not available in these states where the federal health exchange is being used.
MARY AGNES CAREY: So on Wednesday we’ll have the oral arguments and then the judges begin their deliberations. Take us through some of the issues that guide those deliberations.
JULIE ROVNER: Well as I mentioned this is what’s called a statutory interpretation case. They have to decide whether Congress intended for the subsidies to be available in the state and federal exchanges or just in state exchanges. And mostly when they get these cases, they use what’s called Chevron Deference, that’s a reference to a 1984 case. The way it works is that first it’s a two part test. They look at the language of the law and they say, “Is it straightforward or is it ambiguous?” If they find it ambiguous, then they are suppose to defer to the agency, in this case the IRS, as long as the IRS’ interpretation isn’t unreasonable. That’s why the challengers in this case are trying to make the case that Congress intended for the tax credits to be denied to people using the federal health exchange because that would make the IRS’ interpretation unreasonable, because only if the interpretation is unreasonable, would the Supreme Court then overrule it.
MARY AGNES CAREY: There’s also some issue involved where if the federal government is going to change something with the states, they have to tell the states they’re doing that. That’s one of the issues here.
JULIE ROVNER: That’s right, a number of states in their court filings are saying that when they were deciding whether or not to have a state exchange, they didn’t know, no one ever told them there was a possibility that their residents wouldn’t get these tax credits if they didn’t create an exchange and that’s a violation of other sort of previous court rulings that said you can’t limit things, that you can’t limit what they states get if you don’t tell them what their options are. And frankly as someone who covered this law from its inception, I certainly never heard anybody talk about the idea that only states exchanges would have access to the tax credits. It simply was never discussed.
MARY AGNES CAREY: Thank you so much Julie Rovner, Kaiser Health News.