A stethoscope is displayed for a photograph in New York, U.S., on Tuesday,… (Daniel Acker/Bloomberg )
With the national health law’s political future now entrenched, a deluge of new rules is expected in the coming days and weeks as the Obama administration fleshes out the law’s complex components.
Most of the anticipation has been focused on rules that determine how the new state-based insurance marketplaces called exchanges will operate. But also closely awaited are decisions about how the government will tax medical devices, allot the shrinking pool of money for hospitals that treat the uninsured, and determine how birth control insurance coverage can be guaranteed for employees of religious schools, universities and charities.
“We knew right after the election, this is all coming out,” said Blair Childs, an executive at the Premier health alliance, which advises hospitals.
Some of these rules have been under development for nearly a year.
Other key decisions will be determined outside the rulemaking process, as the Obama administration selects participants in several experimental programs, including a new payment method for doctors, hospitals and other providers.
Here are summaries of some of the significant decisions on the health law that the administration is expected to announce shortly:
Medical Device Excise Tax. Last February, the Internal Revenue Service proposed a rule on how to apply this 2.3 percent tax, which kicks in at the start of January. The major unresolved issues concern which devices will be included and how the tax is applied and collected.
Among the questions: Should the tax apply to devices commonly used by veterinarians if the device is also used in human medicine? What about items sold in retail settings but also used in medical procedures such as dental instruments and latex gloves? Does the tax apply to kits — two or more medical tools packaged and sold together — even if the manufacturer of each component had already collected the tax when it was sold to the kit maker?
Brendan Benner, a spokesman for the Medical Device Manufacturers Association, said companies are making marketing and sales decisions based on what they expect will happen, but that presents problems. “When you don’t know what the answer to the question is, it’s hard to make a decision,” he said.
Hospital Payments. Between 2014 and 2019, the government will cut $36 billion out of the money that goes to hospitals that treat large numbers of poor patients. The cuts were included in the health law under the rationale that many currently uninsured patients would be covered either through the expansion of Medicaid or through subsidized insurance.
The administration has to figure out how it will allocate those cuts among hospitals — a task made more complicated by last summer’s Supreme Court ruling that allows states to opt out of expanding Medicaid. On the one hand, hospitals in states that don’t expand Medicaid will continue to serve a crush of uninsured patients, so they will want more federal support. On the other hand, experts note, the government doesn’t want its policy to reward those states for their parsimony by ponying up more money to soften the blow.
“It’s a paradoxical situation,” said Chip Kahn, president and chief executive of the Federation of American Hospitals. “In states that choose not to do the Medicaid expansion, they’re going to still have the uncompensated care, and those people are still going to go to hospitals.”
Insurance plans. For the administration, some of the trickiest decisions concern how insurance policies must be designed, priced and sold starting next October, when open enrollment begins for the new online marketplaces, called exchanges, that will offer plans to individuals and small businesses. For instance, the law allowed insurers to alter their prices for people based on age, family size, where they live and tobacco use. The Department of Health and Human Services has to determine how insurers can go about setting those prices.
“The big one that everyone’s watching is more definition around the exchanges,” said Chas Roades, chief research officer at the Advisory Board, a Washington consultancy.
The government also has to specify how cost-sharing rules for consumers will work and what types of medical services must be covered in health plans sold in the exchanges. Twenty-six states have already chosen an existing health plan as a benchmark identifying what “essential benefits” their state’s insurers must provide. In those states that don’t establish a benchmark, the administration is empowered to choose one. Until the government does, insurers say they are hampered in devising what kind of insurance policies to offer.