Provisions of health care reform spark lawsuits, divide state leaders, and encourage release of federal guidelines to curb ED visits by newly insured patients

A Mixed Bag for Ongoing ACA Legal Battles

If you thought the legal wrangling over the Affordable Care Act (ACA) might finally slow down in 2014, think again. In January alone, several major court cases yielded victories for supporters and opponents alike. In one closely watched case, a federal judge blocked a Missouri law that would have required navigators or others providing information about the ACA’s health care plans to be licensed by the state.

Meanwhile, a District of Columbia federal judge dismissed a lawsuit brought by a group of business owners and individuals in six Southern states who had sued to prevent IRS tax credits to low- and moderate-income people buying insurance through the federal exchange. The Obama administration successfully argued that a bit of sloppy language left in the law that seemingly applied subsidies only to plans in state exchanges was meant to apply to both state and federal exchanges. The case, Halbig v. Sebelius, had been viewed as a significant threat to the ACA, though it’s not quite over: The plaintiffs are appealing the decision, and similar lawsuits are pending.

The administration received a setback of its own when the Supreme Court extended an injunction for a Denver-based Catholic charity, Little Sisters of the Poor Home for the Aged. The court decision temporarily exempts the nonprofit organization from several requirements of the ACA, including birth-control coverage, while the case is heard in the 10th Circuit Court of Appeals. The Catholic Church and other groups have vigorously opposed the birth-control coverage mandate on religious grounds.

More States Considering Medicaid Expansion

Few provisions of the ACA have divided states more than the question of whether to expand Medicaid. By the end of 2013, the states were equally split: 25 (plus the District of Columbia) had agreed to expand coverage, while the other half were either undecided or actively opposed.

That dynamic is changing, according to the nonpartisan Pew Charitable Trusts.

An additional nine states are now considering expansions of their own, including Utah, where Republican Gov. Gary Herbert announced his support in January. Officials in several other nonexpansion states have fretted over recent reports suggesting that they may lose out on billions of dollars in matching federal funds.

Another driving factor in the recent warming trend toward some form of expansion may be the growing use of waivers to craft state-specific versions of the federal program. Arkansas and Iowa have already used an alternative called the “private option” to enroll beneficiaries in private insurance plans. The Obama administration has given the Department of Health & Human Services leeway to grant these waivers to states wanting to experiment with health-care delivery methods as long as their Medicare modifications meet minimum standards and remain cost neutral.

With the private option now on the table, Kaiser Health News reported that Medicaid expansion is gaining more traction in Utah and other Republican-led states such as New Hampshire, Florida, and Pennsylvania. Arkansas, however, may be poised to go in the opposite direction: The state legislature is locked in a fight over whether to defund its own recent expansion.

The Supreme Court extended an injunction for a Denver-based Catholic charity, Little Sisters of the Poor Home for the Aged. The court decision temporarily exempts the nonprofit from several requirements of the ACA.

Website Blunders Abating?

After the healthcare.gov website’s botched rollout last November, the federal government received dismal approval ratings on its performance in several public polls. But after a much-publicized scramble to fix the main health insurance portal, media reports suggested that its performance has improved markedly. Polling numbers are trending upward, and a security scare over potential hacking turned out to be a false alarm.

Will it be enough to make up for lost ground? Despite a recent surge, most analysts doubt whether the government can meet its initial goal of 7 million new enrollees by the end of March. On Feb. 25, President Obama announced that more than 4 million people have signed up for health care through ACA marketplaces. A recent “Avalere Health 2014 Industry Outlook” report, however, suggests that despite rapidly accelerating enrollment, the final tally may reach only about 5 million. Nor have the missteps ended entirely: The website was down for maintenance on National Youth Enrollment Day.

And after so much attention on the federal site, however, the spotlight is being trained more harshly on some of the 14 highly uneven state-run exchanges. States like California and Washington are posting encouraging enrollment numbers. Others have been far less fortunate. The state-run exchanges in Oregon and Maryland are so troubled that officials there are considering switching to the federal health care exchange next year.

Political Duel Continues over Health Care Reform

Both Democrats and Republicans are honing their health care reform talking points and tactics in the run-up to midterm elections later this year. In his defense of the ACA during January’s State of the Union address, President Barack Obama signaled his intent to more aggressively paint Republicans as obstructionists by challenging them to specify a viable alternative instead of repeatedly calling for a full repeal. “I know that the American people are not interested in refighting old battles,” he said.

Republicans have adapted, too. In January, three Republican senators unveiled a “repeal and replace” alternative called the Patient Choice, Affordability, Responsibility and Empowerment (CARE) Act. The overhaul eliminates or reduces most government mandates while offering tax credits to help lower-income people buy insurance. The proposal limits the tax exclusion for insurance offered by employers and permits insurers to charge more for preexisting conditions if beneficiaries do not maintain continuous coverage.

In February, the Obama administration responded to sustained pressure from the business community by delaying the ACA’s insurance mandate for employers with 50 to 99 workers until 2016. The news revived a Republican talking point that the law unfairly postpones rules for businesses but not individuals.

Push to Curb ED Visits by New Medicaid Beneficiaries

Backers of the ACA have argued that improved access to health care might decrease emergency department visits by new Medicaid beneficiaries. Experts, however, have warned of an increase in ED visits—at least initially—and the Centers for Medicaid & Medicare Services recently released guidelines designed to mitigate any uptick in unnecessary visits.

Among the agency’s three main strategies: focusing on “super-utilizers” through services like health homes and on-site ambulatory clinics, increasing access to primary care, and using more targeted interventions for patients with behavioral health issues.

Several experts told Modern Healthcare they were unimpressed with the guidelines, citing a lack of new ideas and insufficient attention to mental health. Meanwhile, a study in the journal Science added fuel to the fire by finding that new Medicaid beneficiaries in Oregon significantly increased their visits to the ED and to other care providers during their first 18 months of coverage.

Why? Economists told The New York Times that patients may be accessing ED services more often as Medicaid reduces their upfront costs. Experts have hotly debated whether this higher usage will persist and whether it also reflects a lack of primary care access. The heightened demand could put more strain on the nation’s emergency physicians, though the overall financial impact may be more limited. In 2010, a government report found, total ED visits represented only 4 percent of total U.S. health care spending.

Bryn Nelson is a freelance medical journalist based in Seattle.