Reporters offer state, local story ideas for covering ACA #ahcj15

The first day of Health Journalism 2015 featured a session “The ACA: Will it survive? And how to cover it now” with Kaiser Health News’s Julie Appleby and Vox’s Sarah Kliff. Their major themes included:

Julie Appleby & Sarah Kliff

Julie Appleby & Sarah Kliff

  • The King v. Burwell Supreme Court case over federal subsidies
  • What’s next in Congress?
  • Exchanges
  • Medicaid
  • And – the topic that got by far the most attention from the crowd – narrow networks.

Here are some of their highlights and story suggestions, with an emphasis on stories that state and local reporters can tackle. (Here are Kliff’s slides.)

The Supreme Court

Appleby noted that it’s highly unusual to have a law face so much controversy, and so much uncertainty, five years after passage.

The next big test will be the King v. Burwell case that will decide whether subsidies can still flow through the 34 states using the federal health exchange, rather than running their own.

If the subsidies do get cut off, it could happen fast.

Congress could extend them, but Congress hasn’t been doing much on health (except fighting about it) these days.

States using the federal exchange might try to switch to a state one – but that’s an expensive, complicated, and time-consuming process. Not all states will want to make that shift, and there are questions about whether those that do want to try will be able to achieve it.

Appleby asked reporters, “What is happening in your state? Is your state going to be one of the six or seven or so that say ‘We do want to have a contingency plan available.’”

She also cautioned that we can guess and speculate as much as we want, but we really don’t know what the Supreme Court will do in the ruling, expected in late June.  She reminded us that “many people didn’t predict accurately” with the last ruling, in 2012. “But it will certainly make all of our lives interesting at the end of June.” Kliff also urged reporters to start asking what the end of subsidies could mean for ordinary people in their state.


Kliff said it’s hard to know what Congress will do about the health law but, “Generally, if you are going to be betting on something [about Congress] the safe bet is that they are not going to do anything.”

With more than 11 million people covered under the ACA exchanges, it’s harder and harder to envision repeal, but if a Republican wins the White House in 2016, and Republicans retain control of the House and Senate, “it’s possible we’d see some changes to Obamacare.”

In the meantime, Congress did – uncharacteristically – recently pass a big, significant health law, repealing the Sustainable Growth Rate (the flawed formula that had been used for Medicare physician pay). After a transition period, providers will get paid in part based on quality not volume. And they have to start thinking about this now. Reporters should start asking providers, including hospital administrators, about what they need to do now to prepare for these changes.

The next big issue for legislators – and action is not imminent – will probably be addressing costs, Kliff said. That’s what Massachusetts did – first address coverage, and then come back and look at costs.


The big question mark is the Supreme Court case, but there are lots of other questions about exchanges and enrollment. Did your state do better or worse in year two? Why? What do they have to do differently next year? What are they spending? The state exchanges are supposed to be financially sustainable now. Is yours?

Appleby noted for instance that California has spent $1 billion – but signed up only about 7,000 new people this year, and that only 65 percent of the 2014 enrollees had re-enrolled. “Why are they having trouble getting people signing up,” she said. Part of the reason people don’t get covered is still affordability.

“Affordability is always the issue in health care,” she said. “That was true before the ACA and it’s still true now for many people.”

“Follow the money,” she advised when tracking state exchanges.


The country is still split between Medicaid expansion and non-expansion states, but very recently the administration signaled it’s getting a lot more aggressive with the states that are still balking. It’s threatening to reduce money for hospitals that serve low income people in Texas and Florida, which have resisted expansion.

Narrow networks and access to care

This was the biggest topic of discussion at the session, one that drew the most questions, discussion and comments.

As Appleby (who has reported extensively on this topic) said, the narrow networks are supposed to keep premiums down. It’s a tradeoff – lower costs, but less choice.

But in some states, the narrowness of the networks (and lack of transparency on the part of the health plans about which providers are in network) are fueling some backlash. Some states are looking at what to do about the networks, or about consumer protection for out of network charges. The National Association of Insurance Commissioners is working on a model law, which could be out in August. (States aren’t bound to follow it –and it may not have a lot of teeth).


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