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No Way To Prevent Disaster If The Supreme Court Guts Obamacare, Top Official Says

Jeffrey Young   |   February 24, 2015    4:38 PM ET

The federal government is powerless to prevent millions from losing health insurance if the Supreme Court rules against President Barack Obama in a lawsuit to be argued next week, Health and Human Services Secretary Sylvia Mathews Burwell wrote in a letter to lawmakers Tuesday.

The case, King v. Burwell, alleges the Obama administration unlawfully provided subsidies to millions of residents of states that did not create health insurance exchanges under the Affordable Care Act. The federal government operates at least part of the the exchange marketplaces in 37 states. The Supreme Court will hear oral arguments next Wednesday and is expected to issue a ruling in June.

The lawsuit has enormous stakes for the estimated 10 million people who would lose their health coverage if the court decides against Obama. The exit of that many people from the insurance markets in their states also would destabilize the markets, leading to big price increases that would drive more individuals away from health coverage. People living in 14 mainly Democratic states that established health insurance exchanges would be unaffected.

Republicans, who have refused to consider legislation to amend the single clause in the law that is the subject of the challenge, have demanded the Obama administration explain how it would fix the disruption caused in states with federal exchanges, most of which are governed by the GOP.

Before Tuesday, Burwell and other officials would go no further than stating they expected to win the case. Burwell reiterated that point in her letter, but also declared she can do nothing on her own authority.

"While we are confident in our position, a decision against the administration in the King case would cause massive damage," Burwell wrote. "We know of no administrative action that could, and therefore we have no plans that would, undo the massive damage to our health care system that would be caused by an adverse decision."

With the federal government adopting the position that it can't repair that damage on its own, the likelihood of chaos reigning in two-thirds of the states' health insurance markets appears high.

Congressional Republicans repeatedly have promised plans that would "replace" Obamacare, either after a legislative repeal or a Supreme Court ruling against the law, since before Obama signed the Affordable Care Act in March 2010. But they have failed to coalesce around a policy, and have very little time to do so before a June ruling by the high court. The GOP has rejected a targeted fix to the law that would preserve the subsidies if the court decides they aren't legal.

Governors and state legislators looking to protect their residents from this disruption could do so by establishing health insurance exchanges, but none appear poised to act. At the National Governors Association meeting in Washington last weekend, Wisconsin Gov. Scott Walker (R) and others said they had no plans to take action, referring to the health insurance subsidies for millions of their constituents as a federal matter.

About 11 million people are enrolled in private coverage chosen via Obamacare's health insurance exchanges after two years of sign-ups, according to the Department of Health and Human Services. Because of those enrollments and the Affordable Care Act's expansion of Medicaid -- adopted mainly by Democratic-run states -- the rate of uninsured Americans is the lowest in at least seven years, according to Gallup.

Read Health and Human Service Secretary Sylvia Mathews Burwell's letter to Congress:

HHS Secretary Burwell Letter to Congress

Obamacare Enrollment Reopened For Taxpayers Hit By Mandate Fine

Jeffrey Young   |   February 20, 2015   10:01 AM ET

Taxpayers facing fines for not having health insurance in 2014 will get another chance to sign up for benefits on the Obamacare exchanges this year, federal officials announced Friday.

From March 15 through April 30, individuals who learn when they file tax returns that they must pay a penalty under the Affordable Care Act's individual mandate can return to HealthCare.gov to choose a plan for the current year, Andy Slavitt, the principal deputy administrator of the Centers for Medicare and Medicaid Services, told reporters on a conference call.

The three-month Obamacare sign-up campaign officially ended Sunday. But President Barack Obama's administration and some state authorities are reopening enrollment around tax time as a means of covering more uninsured people and mitigating the backlash from taxpayers who weren't covered last year and discover they owe fines starting at $95 per person when they file their 2014 returns.

This tax season is the first time Americans must account for their health insurance status when they file tax returns, and the first time anyone will have to pay a penalty for not being covered. Awareness of that penalty remains low among the uninsured, according to survey results published Thursday by the Urban Institute. As many as 6 million people will have to pay the mandate fine this year, the Treasury Department estimates.

That makes this a unique circumstance, not a signal that future enrollment deadlines will be so flexible, Slavitt said.

"Our intention is that this is one year only for people who have not been in the communication loop around the tax penalty and whose first time learning of it will be filling out their taxes this year. So this is really a one-year-only special enrollment period," Slavitt said.

The "special enrollment period" announced Friday applies to residents of the 37 states where the federal government operates the health insurance exchanges. The state-run exchanges in Minnesota, Vermont and Washington previously established a second sign-up period for people who owe the Obamacare mandate fine. California also announced a special enrollment period Friday, as did New York, which will accept new enrollees from March 1 to April 30. Other states may do the same, including Connecticut, Idaho and Kentucky.

Not everyone who failed to sign up by the Feb. 15 deadline is eligible for the new enrollment opportunity. Those who qualify must not have health insurance, must already have filed their taxes and paid the mandate penalty for 2014 and must attest they only learned about the fine after Sunday's insurance sign-up deadline, Slavitt said. Individuals who enroll during the upcoming period will still owe the penalty for last year unless they qualify for an exemption. These individuals also may still have to pay a partial penalty when they file their 2015 taxes because the Affordable Care Act requires people to have health coverage for at least nine months a year.

The Centers for Medicare and Medicaid Services also announced Friday the availability of a tool on HealthCare.gov designed to simplify the process of determining whether an individual is exempt from the individual mandate.

Health and Human Services Secretary Sylvia Mathews Burwell revealed less than a week ago that she was considering restarting enrollment for people subject to the mandate penalty. A group of congressional Democrats and organizations like Families USA that support Obamacare had urged her to make these allowances for taxpayers in that situation.

"There remain millions of people who are unaware of the premium subsidies that make insurance affordable and who didn’t know about the tax penalty for failing to buy insurance. This special enrollment period will therefore be a helpful, teachable moment and will enable many people to obtain health coverage and avoid future penalties,” Families USA Executive Director Ron Pollack said in a press release.

Federal officials also disclosed Friday that many of the tax forms sent to Obamacare enrollees contain errors. People enrolled in health insurance plans began receiving so-called 1095-A forms last month, which are needed when filing taxes to ensure households received the correct subsidy amount for their insurance. When a taxpayer's income is higher than reported to the health insurance exchange, he or she may have to repay at least a portion of the tax credits received for a health plan, while those whose income was lower than reported may receive a larger tax refund.

The federal government sent incorrect forms to about 20 percent of individuals who bought health insurance through the federally run health insurance exchanges, or 800,000 people, Slavitt said. Starting today, those households will be notified of the mistake and provided with corrected tax forms. About 50,000 of those people already have filed their taxes and will contacted by the Treasury Department about rectifying the issue. States including California and Nevada also provided inaccurate 1095-A forms to residents. And problems with these tax documents in Connecticut delayed delivery to health insurance customers.

This story has been updated to note that California and New York will also reopen enrollment.

Obamacare Enrollment Ended Sunday. Except It Didn't.

Jeffrey Young   |   February 19, 2015    2:44 PM ET

The second year of Obamacare enrollment just ended. Or did it?

The Department of Health and Human Services has hinted it might reopen enrollment on the Affordable Care Act’s health insurance exchanges in 37 states around the tax filing deadline April 15, with the aim of enrolling people who learn for the first time they owe a fine under the law’s individual mandate to have health coverage. Already, Minnesota, Vermont and Washington have done so, and states including California may do the same.

Since Obamacare’s exchange marketplaces first opened in October 2013, federal and state authorities have simultaneously emphasized the importance of the deadlines to sign up for coverage and then fudged them to accommodate their own errors and a public that remains uninformed about the 5-year-old health care law’s requirements and benefits.

“We’ve got millions of people who are still qualified who have a chance to sign up, but you’ve got to do it by Feb. 15,” Obama said at the White House earlier this month.

Maybe not, it turns out just a few days after that supposed deadline.

Health and Human Services Secretary Sylvia Mathews Burwell will announce plans for the federal health insurance exchanges using HealthCare.gov within two weeks, she said at a press conference Wednesday. “What we try and do -- as we have throughout this open enrollment -- is focus deeply on the issue of the consumer,” she said. A group of congressional Democrats has urged the administration to permit more people to sign up, as have tax-preparation companies and groups that support Obamacare.

Allowing more people to enroll in health insurance has obvious benefits for the Obama administration and states like Vermont that operate their own exchanges. It would also help at least some of the consumers who might sign up. More uninsured people would gain coverage, fewer people would owe tax penalties next year and the backlash about the fine would be mitigated.

“It would be awful for a Vermont family to have to pay a fee of several hundred dollars or more, and then have to pay 100 percent of their medical care on top of that, just because they didn’t know the penalty existed,” Lawrence Miller, chief of health care reform for Gov. Peter Shumlin (D), said in a press release Thursday.

But the approach also carries risks.

Reopening enrollment after hyping the previous deadlines could contribute to confusion about when people are supposed to act in future years. It could also lead consumers to conclude upcoming deadlines aren’t real, especially considering the many other parts of the Affordable Care Act that have been delayed or even canceled since the law passed in 2010. And there’s a small chance it could encourage people to postpone getting coverage until they have medical needs, which would increase costs.

If a special enrollment period is going to succeed without causing problems for consumers and insurers this year, authorities will have to communicate that it’s a unique event for a specific population, said Clare Krusing, a spokeswoman for the trade group America’s Health Insurance Plans.

“Special enrollment periods need to be clearly defined in terms of who qualifies and the start and end date to make sure that consumers understand and health plans can help those folks navigate that process,” Krusing said.

One reason a special enrollment period may be deemed necessary is that outreach campaigns have downplayed the mandate and the penalty. The individual mandate is the least popular part of an unpopular law, and enrollment efforts instead have focused on positive messages, like the availability of subsidies and access to coverage for people with pre-existing conditions.

"There's been such a reluctance to talk about the mandate, and so, shockingly, people don't realize that they have to buy coverage," said Caroline Pearson, who leads the health reform practice at Avalere Health, a consulting firm.

The Treasury Department estimates as many as 6 million people will owe the penalty for not having health coverage last year, despite a slew of exemptions from the mandate. Signing up for coverage during one of these special enrollment periods wouldn’t eliminate the penalty for last year, and taxpayers who sign up for insurance would still owe a partial penalty for this year because the law allows only a three-month grace period.

This tax season is the first time Americans have to factor health insurance into their returns. The Obamacare mandate fine starts at $95 per person, but will be based on a percentage of income -- and thus be higher -- for most households subject to it for the 2014 tax year. And it gets a lot bigger for 2015: at least $325 or a percentage of income. The minimum fine goes up to $695 for 2016.

“There still remain millions upon millions of people who are unaware about these penalties,” said Ron Pollack, executive director of Families USA, a consumer advocacy organization supportive of the Affordable Care Act. “And there are still millions of people who are not even aware of the subsidies they may be eligible for,” he said during a conference call with reporters Wednesday.

Obamacare uses fixed time periods for enrollment to dissuade consumers from putting off getting coverage until they get sick and need costly medical care. That’s the same way most employers handle job-based health benefits, and how Medicare handles sign-ups for prescription drug and Medicare Advantage insurance plans.

“It really goes to the core reason that the Affordable Care Act has an open enrollment period instead of enrollment periods throughout the year,” Peter Lee, executive director of Covered California, that state’s exchange, said on the Families USA call. “The right question is, does having a special period for one time cause injury to that and affect the risk pool?”

So far, the dates for regular enrollment have varied every year: Oct. 1, 2013, to March 31, 2014, for last year; Nov. 15, 2014, to Feb. 15 for this year; and tentatively Oct. 1, 2015, to Dec. 15, 2015, for next year. And that doesn’t count prior deadline extensions, or the practice of allowing people who didn’t complete their applications on time to finish them after deadlines passed, which has been happening since Sunday.

Since all of this is so new, now may be a good time to be flexible, but the exchanges must have deadlines that matter at some point, said Sydney Smith Zvara, executive director of the Association of Washington Healthcare Plans in the Evergreen State. “Down the line, some people could end up after it’s tightened up being disappointed that they are held to a deadline, because it looked like they were so elastic,” she said.

Overall, the health insurance industry doesn’t appear concerned so far.

Blue Cross and Blue Shield of Vermont and MVP Health Care each endorsed Vermont’s decision, according a press release from the exchange. Insurers in Minnesota also aren’t worried about the special enrollment period disrupting their operations, Jim Schowalter, president and CEO of the Minnesota Council of Health Plans, wrote in an email. Washington state insurers support getting more people covered, but some companies are wary of creating incentives for people to postpone buying insurance, Zvara said.

Minnesota's MNSure is permitting new enrollments only for people who owe a fine from March 1 to April 30, Vermont Health Connect is available starting Thursday until May 31 for those subject to the penalty, and Washington Healthplanfinder reopened sign-ups for this group this Tuesday through April 17. “This is just a one-time opportunity. It’s not going to be throughout the year. It’s very defined,” Richard Onizuka, the CEO of Washington state’s exchange, said on the Families USA call.

California will reveal its decision early next week, and the exchanges in Connecticut, Hawaii, Idaho, Kentucky and New York are weighing more enrollment this year, officials from those states said. By contrast, states including Colorado and Maryland currently are not eying reopening their exchanges, representatives told The Huffington Post. Early moves by Minnesota, Vermont and Washington states could put pressure on authorities elsewhere to follow suit.

Allowing uninsured people who owe the mandate fine to sign up late actually could benefit insurers, Pearson of Avalere Health said. Individuals who remain without health coverage may be healthier than those already enrolled, because sick people are more driven to get insurance, she said.

“It’s mostly upside. I think you have the potential to actually get a reasonable enrollment bump, and I don’t think there’s really significant risk,” Pearson said. “As long as it stays limited.”

Obamacare Signups Top 11 Million In Second Year, White House Says

Jeffrey Young   |   February 17, 2015    7:53 PM ET

WASHINGTON -- The Obama administration has beaten its own projections for Obamacare enrollments, which exceeded 11 million through Sunday's deadline for most U.S. residents to choose a health insurance plan, the White House announced Tuesday.

In a video posted to Facebook, Health and Human Services Secretary Sylvia Mathews Burwell informs President Barack Obama of preliminary estimates of this year's signups. The three-month enrollment period all but ended Sunday, but federal and state officials are allowing consumers who began applications prior to the deadline to complete them.

"We just got great news today, which is that during this open enrollment period for the Affordable Care Act, a.k.a. Obamacare, 11.4 million people have either re-enrolled or enrolled for first the first time," Obama says on the video. "It gives you some sense of how hungry people were out there for affordable, accessible health insurance."

Prior to the Nov. 15 kickoff of this year's enrollment campaign, the Department of Health and Human Services set a target of 10.3 million to 11.2 million people enrolled in private policies obtained via the Affordable Care Act's health insurance exchanges by the close of the signup period. Tuesday's announcement shows the exchange marketplaces have bested that goal before the final accounting is made. The department projects a smaller number, 9 million to 9.9 million, will have this coverage at the end of the year.

Sunday was the biggest day for Obamacare enrollment to date during the signup periods for 2014 and 2015, Burwell says on the video. The new enrollment data includes signups from federally run health insurance exchanges on HealthCare.gov in 37 states, as well as from those operated by 13 states and the District of Columbia.

More than 1 million people signed up for a health plan during the last nine days of enrollment, according to a senior administration official. Of the 11.4 million enrollees, 8.6 million came from federally managed exchanges and 2.8 million from state-run marketplaces, the official said.

The White House didn't reveal how many of the 11.4 million enrollees are renewing coverage from last year and how many are new to the marketplaces.

Burwell is considering re-opening enrollment around tax-filing season in April, when as many as 6 million people may learn they owe a fine for not having health coverage under Obamacare's individual mandate. Some congressional Democrats and consumer advocates have pleaded with the Department of Health and Human Services to allow people who owe the individual mandate penalty to instead buy insurance. Burwell will announce her intentions within weeks, Bloomberg News reported last week. Washington state already has extended its enrollment period until April, The Wall Street Journal reported Tuesday.

The enrollment tally is bound to come down in the coming months. The figures disclosed Tuesday don't factor in whether customers have paid their first premium, which is necessary to secure coverage. In 2014, enrollment surpassed 8 million in April after a six-month signup period, but fell below 7 million by October as consumers switched to other forms of health coverage or simply allowed their policies to lapse. Federal authorities also canceled coverage for hundreds of thousands of people who could not verify their citizenship or legal residency status.

Although Sunday technically was the deadline for applying for subsidies and enrolling into health coverage for this year, federal and state health insurance exchange authorities are giving would-be customers extra time to complete applications and select a policy if they began the process before the deadline, or encountered problems accessing the systems. People using a federal exchange have until Feb. 22; the final date varies among the other states.

Last-minute technical problems and long waits for assistance on telephone hotlines prompted the extensions, which are similar to those instituted when the first enrollment period ended last March. In addition, 28 states are allowing people to sign up for health insurance beyond the Feb. 15 deadline, if they aren't also applying for subsidies, according to eHealth, an online insurance broker.

People who experience a change in life circumstances, such as marrying or having a child, can access the health insurance exchanges year-round. The enrollment numbers announced Tuesday don't include people who signed up for Medicaid or the Children's Health Insurance Program this year. There is no deadline to enroll in those programs for low-income households.

Watch the White House video on Obamacare enrollment:

Rush Of Obamacare Enrollees Expected Before Sunday Deadline

Jeffrey Young   |   February 12, 2015    7:32 AM ET

With only a few days remaining in the second-ever Obamacare sign-up season, the White House, insurance companies and enrollment workers expect a big rush as Americans hurry to get health coverage.

“Consumers should consider Feb. 15 as their last opportunity to get coverage,” said Andrew Slavitt, principal deputy administrator of the Centers for Medicare and Medicaid Services, during a conference call with reporters Wednesday. “Interest in signing up for coverage in the final week of open enrollment is beginning to increase,” he noted.

The Centers for Medicare and Medicaid Services is the federal agency that oversees enrollment under Obamacare.

In the weeks leading up to the deadline, federal and state officials, the insurance industry and enrollment workers around the country have stepped up their outreach, marketing and assistance activities. They expect a wave of new sign-ups in the final days, as happened when the first Obamacare enrollment period wound down last April. Traffic to HealthCare.gov was 58 percent higher Wednesday than a week before, and calls to the hotline have increased 37 percent, Slavitt said.

“People are going to perk up and people are going to start paying attention close to those deadlines,” said John Gilbert, national field director for Enroll America, a Washington-based nonprofit that organizes sign-up campaigns.

After this Sunday's deadline, the next open enrollment period for private health insurance sold on the Affordable Care Act’s exchanges won’t begin until October. Anyone who starts an application prior to the Feb. 15 deadline will have time to complete it, Slavitt said. In addition, people can access the insurance exchanges during the year if their life circumstances change -- if they get married, for instance, or have a baby. Plus, there is no deadline for enrolling in Medicaid and the Children’s Health Insurance Program.

The second Obamacare sign-up period has gone considerably more smoothly than the first, which launched with a thud in October 2013 amid confusion and near-catastrophic technological failures of HealthCare.gov and the websites of several state-run exchanges. The websites have been running much better this year, and the numbers of enrollees reflects that and the greater public awareness of the Affordable Care Act.

“In every respect, this is working not just as intended but better than intended,” President Barack Obama said at the White House last week. “I want everybody to get on HealthCare.gov. Find out what options are available to you in your state and in your community.”

The president may be overstating the case for his signature program, but round two of Obamacare is going much better from the perspective of those seeking to enroll people. “Certainly, it is much improved from last year,” said Kurt Kossen, vice president for retail markets at Chicago-based Health Care Service Corp., which operates Blue Cross and Blue Shield health insurance plans in Illinois, Montana, New Mexico, Oklahoma and Texas.

Since this year’s sign-up period began on Nov. 15, almost 10 million people have enrolled in private health insurance plans selected via the exchanges. Those include the 37 sites run by the federal government via HealthCare.gov and the 14 operated by states and the District of Columbia, like Covered California and Your Health Idaho. About 3 million of those customers were new to the online marketplaces, and the remainder were individuals with exchange policies last year who had renewed, the Department of Health and Human Services reported last month.

If the last sign-up period is any guide, those numbers could jump after Feb. 15. Forty-seven percent of the 8 million people who enrolled for 2014 coverage did so during the final month of the campaign. Enrollments for 2015 already surged shortly before Dec. 15, which was the final day to choose a plan that would be in place at the beginning of this year.

More than 1,400 enrollment events are scheduled for the final two weeks of the sign-up period, according to HHS. Officials, workers and volunteers are stressing the availability of both health coverage and financial assistance for low- and moderate-income families.

obamacare enrollment deadline

People wait at the Baltimore Convention Center to enroll in health coverage this past Saturday. (Photo: Jeffrey Young/The Huffington Post)

Enroll America and its partner organizations arranged 1,110 events in 109 cities across 11 states in the three weeks leading up to Feb. 15, Gilbert said. The group’s “Countdown to Get Covered” bus tour will hit Alabama, Florida, Georgia and North Carolina in the final days, he said.

Health insurance companies also are gearing up for the deadline. Health Care Service Corp. ramped up its TV advertising in the middle of January, said Kossen. The company’s on-the-ground outreach includes mobile assistance centers across its home territory, like the “Destination Blue” recreational vehicle visiting numerous towns in Texas.

“We’re just starting to see indications of increased activity starting to come in, especially at our community events over the weekend,” Kossen said. “We anticipate seeing increased activity throughout the remainder of the week.”

An enrollment event in Baltimore on Saturday attracted more than 300 people looking for help. Some waited hours at the city’s convention center for an opportunity to sit down with one of 40-some enrollment counselors from HealthCare Access Maryland, which ran the six-hour event.

“It’s been very quiet and it’s been steadily busy,” Kathleen Westcoat, president and CEO of HealthCare Access Maryland, said of this year’s sign-up campaign. “We are seeing more people towards the end of enrollment period trying to enroll.”

The turnaround in Maryland since the last time may be even more striking than the improvements to HealthCare.gov. The Maryland Health Connection website was worse than HealthCare.gov, leading the state to scrap its system and use technology from Access Health CT, Connecticut’s exchange. As of Feb. 4, almost 101,000 people had signed up for private insurance for 2015 on Maryland’s exchange, 20,000 more than the number who enrolled for 2014 coverage.

Baltimore resident Harold Waters, 56, joined those ranks Saturday, when he spent more than two hours at the convention center getting help in choosing a subsidized insurance policy from Kaiser Permanente. The policy will cost Waters $74 a month because of tax credits that reduced its price from $434.

obamacare enrollment deadline

Melinda Jones and Harold Waters attended a health insurance enrollment event at the Baltimore Convention Center on Saturday. (Photo: Jeffrey Young/The Huffington Post)

Waters has been unemployed and uninsured since he was laid off as a grocery store manager in July. He suffered a minor stroke after that and was fortunate that Kaiser Permanente offered him a deep discount on his medical treatments, charging him only $962 of the more than $3,000 he owed. “I’ll be able to go see a doctor now,” he said.

Without insurance, Waters was afraid to run up medical bills, said his partner, Melinda Jones, 59.

“I have to scream at him to get him to go to the doctor, because he won’t go. ‘I don’t have any insurance. I don’t have any insurance.’ I don’t want to hear it!” Jones said. “If he dies on me, I’m digging him up and killing him again.”

An Obamacare 'Replacement?' Don't Believe The Hype

Jeffrey Young   |   February 5, 2015    5:17 PM ET

It’s Obamacare replacement season! Or at least, that’s what congressional Republicans want people to believe.

Nearly five years after the Affordable Care Act became law and two years into its expansion of health coverage to an estimated 10 million uninsured people, GOP lawmakers are renewing their so-far fruitless efforts to develop a health reform plan they can position as a “replacement” for President Barack Obama’s health care law.

It’s no coincidence that this is taking place in the run-up to a June Supreme Court ruling that could blow a giant hole in the Affordable Care Act. A decision against Obamacare would kick millions of people, mainly living in red states, off their health plans -- and leave them looking to the Republican Congress for a solution.

Congressional Republicans want Americans -- especially the nine on the Supreme Court -- to think the GOP can do in less than five months what it took Democrats decades to achieve: enact comprehensive health care reform legislation. But given that Republicans have been unable to reach consensus on much beyond repealing Obamacare in the last five years, that’s an ambitious timeline.

This pattern has been repeating itself since 2009. Just this week, House Republicans approved yet another bill to repeal the Affordable Care Act, and this one included language charging three House committee chairmen with devising a replacement plan.

Meanwhile, Senate Finance Committee Chair Orrin Hatch (Utah), Sen. Richard Burr (N.C.) and House Energy and Commerce Committee Chairman Fred Upton (Mich.) unveiled the GOP's latest attempt to construct an Obamacare alternative on Wednesday.

Even though the proposal is virtually identical to the one that Hatch and Burr issued a year ago with then-Sen. Tom Coburn (R-Okla.), the duo -- along with Upton -- scored headlines describing their framework as the Obamacare replacement plan. But remarks from House Speaker John Boehner (R-Ohio) on Thursday underscore how far congressional Republicans are from having an actual alternative in place.

“Clearly, our three chairmen have an awful lot of work to do to come up with our replacement. But I would expect all of this to be part of the discussion -- all of it. Listen, there’s a lot of ideas out there," Boehner said. "The key is going to be to boil those concepts down to what a real replacement would look like."

That won’t be easy.

The Hatch-Burr-Upton proposal is a case study in the difficult trade-offs Republicans would eventually have to negotiate among their members and supporters -- and then defend to the broader public. Relative to Obamacare, the Republican proposal would provide financial assistance to fewer people and cut off aid at a lower income level. It would also roll back Obamacare’s Medicaid expansion, replacing it with a tax credit for buying private insurance; eliminate regulations that guarantee all policies include comprehensive benefits; and, among other things, give insurers more leeway to vary premiums by age.

Republicans promote these changes as increasing “choice” and “flexibility” in insurance, claiming that they will result in less federal spending and that younger adults will pay lower prices.

But each of these proposed changes would carry other consequences as well. Policies without full benefits, including “junk” plans and mini-med policies, would return to the market. The same pricing practices that reduced premiums for 25-year-olds would jack them up for 60-year-olds, putting insurance out of reach for many older Americans.

The proposal’s precise effect on the uninsured is hard to tell, but under the prevailing assumptions of most forecasting models -- including those used by the Congressional Budget Office -- the likely impact would be more people without insurance and/or much weaker financial protection, as an analysis of last year’s plan by the Center on Budget and Policy Priorities suggested.

Republicans might have a hard time defending those changes -- particularly when so many of their constituents now benefit from the Affordable Care Act’s more generous assistance and protections. Yet for more conservative Republicans who are bent on full repeal and resistant to increased federal authority over the health care system, the proposal might actually not go far enough. (Last year’s plan drew fire from the right for precisely that reason.)

Indeed, the GOP is far from agreement on the question of whether Congress should replace Obamacare with anything at all, in the event the law is repealed legislatively or gutted by the Supreme Court. As a general rule, expanding access to health care reform requires enacting redistributive tax and social welfare policies -- the kind many conservatives oppose on principle.

To date, none of the GOP health care reform proposals have so much as made it out of committee. And no Republican in Congress has laid out a plan for advancing any health care bills through the legislative process this year. In 2013, then-House Majority Leader Eric Cantor (R-Va.) couldn’t even get a comparatively modest bill funding high-risk pool insurance programs for sick people passed, thanks to a conservative revolt.

This week, Sen. Lamar Alexander (R-Tenn.), who chairs the Health, Education, Labor and Pensions Committee, acknowledged to Politico that Republicans might choose not to come together on a plan at all.

Perhaps Alexander realizes that putting together a real Obamacare alternative will take more time -- and more genuine interest -- than Republicans have, or than the Supreme Court's schedule demands.

Sabrina Siddiqui contributed reporting.

Obamacare Nears Major Goal With One Month To Go

Jeffrey Young   |   January 27, 2015    3:27 PM ET

More than 9.5 million people have signed up for private health insurance coverage this year using the Obamacare exchanges, the Department of Health and Human Services disclosed Tuesday, putting the program within striking distance of meeting its enrollment targets.

The deadline to choose a health insurance plan on the Affordable Care Act's exchange marketplaces like HealthCare.gov and Covered California is Feb. 15. Federal officials projected at least 10.3 million would be enrolled by that date, and that at least 9 million would have this form of health coverage by the end of the year. The new figures do not reflect how many enrollees have paid for their insurance, which is the final step to securing coverage.

With the technical failings of HealthCare.gov and several state-run health insurance exchange websites behind them, the marketplaces mostly are managing this year's sign-up period smoothly. The Department of Health and Human Services estimates that 42 percent of enrollees through mid-January -- 3 million people -- are new to the exchanges, while most others are renewing coverage. Enrollment for 2015 insurance plans began Nov. 15.

"We still have a lot of work to do before Feb. 15, but are encouraged by the strong interest we've seen so far," Health and Human Services Secretary Sylvia Mathews Burwell said in a press release.

The federal government is handling enrollment in 37 states, while 13 states and the District of Columbia operate their own health insurance exchanges. More than 7.1 million of the sign-ups came from those federal exchanges, while more than 2.3 million were via state-run marketplaces. The vast majority of those signing up are eligible for financial assistance: 87 percent on the federal exchanges and 70 percent in the nine state exchanges that provided this information to the Department of Health and Human Services.

The enrollment figures from state-based health insurance exchanges undercount the total number of sign-ups. Hawaii, Maryland and Massachusetts did not report how many customers automatically re-enrolled into the policies they had in 2014. Idaho launched its own exchange for 2015, and also is not reporting what share of its residents who used a federally run exchange last time are signing up again.

The Congressional Budget Office projects greater enrollment in health insurance from the exchanges this year than the Department of Health and Human Services. According to a report issued Monday, the CBO expects an average of 12 million people to have this form of coverage over the course of 2015. The same report also estimates the Affordable Care Act will cost taxpayers about 20 percent less than projected in 2010, partly because of enrollment totals and health insurance premiums that are lower than expected.

GOP Governor Expands Medicaid Under Obamacare

Jeffrey Young   |   January 27, 2015   12:14 PM ET

Indiana Gov. Mike Pence on Tuesday became the latest Republican governor to accept an expansion of Medicaid to cover more poor residents under the Affordable Care Act.

Like the expansions in other Republican-led states, Pence's plan doesn't merely broaden Medicaid, but rather uses the federal funding available to remake the program. Enrollment starts immediately, and coverage begins Feb. 1. The expansion eventually will reach 350,000 people, Pence said when announcing federal approval for the proposal at a news conference in Indianapolis.

Republican resistance to the Medicaid expansion at the state level has worn down since a Supreme Court ruling in 2012 made this part of Obamacare optional for states.

GOP governors and legislators in states like Arkansas, Ohio and Pennsylvania have extracted concessions, including increasing the role of private health insurance plans in Medicaid, from President Barack Obama's administration, which is eager to provide Medicaid coverage to as many poor Americans as possible. Including Indiana, 28 states and the District of Columbia have expanded Medicaid under the Affordable Care Act.

Pence's plan is the biggest departure from traditional, government-run Medicaid yet. The so-called Healthy Indiana Plan 2.0, as Pence dubbed it, ties benefits to monthly payments by beneficiaries below the poverty line, a first for Medicaid, and includes other features Pence billed as conservative and market-based.

"We have worked hard to ensure that low-income Hoosiers have access to a health care plan that empowers them to take charge of their health and prepares them to move to private insurance as they improve their lives," Pence said in a press release.

The Healthy Indiana Plan 2.0, or HIP 2.0, differs greatly from traditional Medicaid, under which people with low incomes and people with disabilities are covered by a government program that pays for their medical care.

Pence's program builds on the state's 7-year-old Healthy Indiana Plan, which currently covers 60,000 people with high-deductible health insurance and health savings accounts. Adults without disabilities who are currently enrolled in traditional Medicaid will be moved to the Healthy Indiana Plan, also known as HIP.

The most novel aspect of the so-called HIP 2.0 is that enrollees will have to make contributions into "POWER accounts," modeled after private-sector health savings accounts. People with incomes above poverty, which is about $11,500 for a single person, must deposit between $3 and $25 into these accounts per month. People who fail to make these payments can get their benefits taken away for six months. These contributions are optional for people making below poverty wages, but if these beneficiaries don't contribute, they receive less generous health coverage. Individuals who use these POWER accounts and receive required preventive health services will pay less for their benefits.

In addition, Healthy Indiana Plan 2.0 will provide financial assistance to qualified workers to buy into their employers' health insurance programs. The plan will also link Healthy Indiana Plan enrollees to voluntary job-training and referral services.

The Affordable Care Act provides full federal funding of Medicaid expansions through next year. States will be required to cover a portion of the cost in future years, but never more than 10 percent. State cigarette taxes will fund a share of Indiana's future expenses, and members of the Indiana Hospital Association agreed to finance another share starting in 2017. The hospital financing also will cover the cost of increasing payments to doctors and other medical providers. Hospital associations in most states support expanding Medicaid because they currently lose money when they treat uninsured patients who can't afford the care they receive.

Republicans in states including Alaska, Tennessee and Utah also are debating expanding Medicaid in some form this year.

“I continue to be encouraged by interest from governors from all across the country who want to bring health care coverage to low-income people in their states by expanding Medicaid," U.S. Health and Human Services Secretary Sylvia Mathews Burwell said in a press release. "The administration will continue to work with governors interested in expanding Medicaid to devise approaches that work for their states while keeping faith with the law’s goals and consumer protections."

CORRECTION: A previous version of this story incorrectly stated Indiana is the first state to require Medicaid enrollees above the poverty level to make monthly payments for their coverage. It also incorrectly described how much states are required to pay for the Affordable Care Act's expansion of Medicaid.

Here's How Obamacare Is Going To Affect Your Taxes

Jeffrey Young   |   January 26, 2015    9:33 AM ET

Taxes are a pain. Health insurance is a pain. This year, Americans will suffer both when they file their income taxes. Ouch.

The Affordable Care Act, aka Obamacare, inserted health insurance into tax season in two ways, affecting nearly all of us. The first is the law's mandate that almost all U.S. residents get health coverage or pay a penalty. The second is the tax-credit subsidy millions of Americans received via Obamacare's exchanges to lower their health insurance premiums.

Oh, and there are new IRS forms, too.

"The ACA has made health care a tax issue and, in that sense, everyone will see an impact on their tax return this year," said Kathy Pickering, the executive director of The Tax Institute at H&R Block. "It may potentially impact their refund."

Before you freak out, rest assured that little has changed for about 80 percent of Americans. Still, some people will have to jump through new hoops -- and might see big effects on their tax refunds or bills.

It's easy enough to figure out which camp you fall into. Here's what each group of Americans will have to do:

I Get Health Coverage From An Employer Or A Government Program Such As Medicare Or Medicaid

When you file your return, you hardly have to do anything different. There's a new line on the 1040 -- line 61, to be precise -- where you attest that you do, in fact, have health coverage. If that's the case, then mark it down here, and you're done.

"All that they will need to do is, in effect, check a box on the front of the return," Pickering said.

Make sure it's true that everyone in your household was covered, though, including those who may have had different insurance from you, she said.

For the more than 8 in 10 Americans who have one of these forms of coverage, tax filing is pretty much business as usual this year. So it's horrible, but not more horrible.

I Bought My Health Insurance From An Obamacare Exchange And Got Tax Credits

The good news is, tax credits made your health insurance more affordable. The bad news is, you now have to prove you still have insurance, and that you didn't get too much or too little of a subsidy. If your tax credit was too large, you'll have to pay back at least some of it.

But first, you'll need one of those new forms, a 1095-A. The health insurance exchanges for each state -- whether federal or state-run -- will send these to households that bought private insurance policies from them (as opposed to Medicaid or the Children's Health Insurance Program). This is your proof of insurance.

Those 1095-A forms are supposed to arrive in your mailbox by Feb. 2, so be on the lookout. You also can download them from the exchange website or call the exchange and ask it to send you one. You may get more than one form, depending on how each member of the family is covered. If you see any inaccuracies on these documents, contact your insurance exchange.

The 1095-A shows how much your total insurance premium was and how large a tax credit you got each month you were covered. You'll need that information to fill out another form, called the 8962. (Yes, a form to fill out a form.)

There's a lot of gobbledygook behind it, but basically the IRS needs to make sure you got the right amount of financial assistance for your health coverage.

When you applied for a credit, you told the exchange what you expected to earn in 2014, and that number was used to calculate your subsidy. Now, when you file the 8962 with your taxes, you're running the numbers again based on what you really made. If those amounts are different, your tax credits have to be adjusted. Those who owe the IRS can set up payment plans.

How many people will see their refunds cut (or face a tax bill), and how many will get money back? No one can say for sure. But H&R Block projects that about half of all exchange customers didn't estimate their incomes correctly, and should expect some kind of adjustment, either higher or lower, Pickering said.

It makes sense: People's incomes and lives change all the time. Maybe you got a raise. Maybe you got married. Obamacare customers are supposed to report such changes to the exchanges so their subsidies can be adjusted during the year.

Oh, here's another annoying thing: If you got Obamacare subsidies, you can't file your income taxes with the 1040-EZ. Instead, you have to use the longer 1040.

I Have Health Insurance That Isn't From A Job Or The Government And I Didn't Get Any Tax Credits

About 15 percent of people who bought their policies through an exchange didn't get subsidies, and a few million more bought policies directly from an insurance company, bypassing the exchanges. These folks have to do more than people with job-based insurance or Medicare, but less than their subsidized neighbors.

Basically, if you bought an unsubsidized plan from an Obamacare exchange, take the information from your 1095-A and put it on your 8962, and check off line 61 of your 1040. If you didn't use an exchange, you just need to care about line 61. When it comes to taxes, that counts as easy.

One more thing for unsubsidized people who used an exchange: You might still be able to get tax credits. If you earned less than four times the federal poverty level -- $46,680 for a single person and $95,400 for a family of four -- you can apply for a subsidy via the exchange. If you skipped the exchange, then this isn't possible, no matter what your income was.

I Don't Have Health Coverage At All

Obamacare's individual mandate requires most legal U.S. residents to get covered, so you might be subject to a tax penalty if you were uncovered for more than three months. The formula is complicated, but the penalty starts at $95 and goes all the way up to about $11,000. (Read this for more information.) If you didn't earn enough money to pay taxes, meaning you made less than $10,150 as a single person under 65 or more for other types of households, then there's no health insurance mandate for you, and you don't have to file a return.

There are tons of exemptions to the Obamacare mandate, but you must apply for most of them. The majority of exemptions are granted by the IRS, but some have to come from the exchange. You'll need form 8965 to include a mandate exemption on your tax return.

The idea behind the mandate was that everyone who can "afford" insurance should buy it, to avoid saddling the rest of us with the cost of their medical care. The Affordable Care Act says insurance is "affordable" if it costs 8 percent of your income. If insurance was available to you below that price and you didn't get coverage, you'll have to pay a penalty.

If you really couldn't find "affordable" coverage, then you're exempt. But you do have to document that to the IRS. Other exemptions you can claim on your tax return include living abroad or being in prison.

For some exemptions, though, you'll have to apply to your insurance exchange. Those include belonging to a religion that objects to insurance, or living in a state that didn't expand Medicaid under Obamacare and left you ineligible for low-cost or free coverage, or getting your pre-Obamacare insurance policy canceled. And the exchanges will provide "hardship" exemptions for a slew of reasons, like being evicted or filing for bankruptcy.

You can file your taxes and claim those exemptions while waiting for your exchange to tell you whether you're exempt. If it says no, then you can sort that out with the IRS later.

I Need Help!

About that. The IRS telephone hotline will probably be a nightmare this year, in large part because of budget cuts. And the exchanges' help lines will be pretty tied up through Feb. 15, when Obamacare enrollment for this year ends. There are other options, thankfully, but hurry to seek assistance so you're not last in line as April 15 approaches.

Companies such as H&R Block and accountants in your area will do your taxes with you, for a price. There are online applications such as Intuit TurboTax that also charge money. Some of these companies offer some free assistance as promotions for their paid services.

If you make less than $60,000 a year, you can use the IRS' Free File option, but you'll still have to do a lot of math yourself. If you make less than $53,000 a year, you can take advantage of tax preparers participating in the IRS' free Volunteer Income Tax Assistance program. The IRS' Tax Counseling for the Elderly program is available at no charge to people 60 and older. And Enroll America will offer no-cost local help using Intuit TurboTax.

Key Obamacare Official Stepping Down

Jonathan Cohn   |   January 16, 2015    9:14 AM ET

A senior government official with almost unparalleled authority over the U.S. health care system is stepping down, ending a tenure that included one highly publicized, highly consequential failure on Obamacare as well as significant, if less heralded, successes.

Marilyn Tavenner will resign as administrator of the Centers for Medicare and Medicaid Services, effective at the end of February, officials in President Barack Obama’s administration told The Huffington Post. Andrew Slavitt, the agency’s second-ranking official, will take over in an acting capacity. An announcement is planned for Friday.

Tavenner is the latest high-profile resignation after the botched early implementation of the Affordable Care Act. The biggest change came at the top of the chain, when Health and Human Services Secretary Kathleen Sebelius ended the second-longest tenure in the 62-year history of that cabinet position in June. Sylvia Mathews Burwell succeeded Sebelius, bringing her reputation as a seasoned manager to the position.

Like Burwell, Slavitt boasts a background in corporate management, which may aid his prospects for Senate confirmation should the president ultimately decide to nominate him for the top post. But any nominee would face a confirmation battle in a Senate newly controlled by Republicans more interested in derailing Obamacare than assuring a smooth transition of its leadership.

Tavenner isn’t a household name, but she heads an agency that spends more money than the Pentagon every year -- and, through Medicare and Medicaid, provides health insurance to nearly one in three Americans. Modern Healthcare magazine, in its most recent ranking of the 100 most influential people in health care, ranked Tavenner fifth.

Tavenner’s responsibilities have included one task that her predecessors never faced: implementation of the Affordable Care Act. Many will remember her for her management of that episode -- and, in particular, the development of HealthCare.gov, the Obamacare insurance-shopping website that launched and promptly crashed on Oct. 1, 2013. The website essentially was nonfunctional for nearly two months, creating a severe political crisis for the Obama administration and nearly unraveling Obamacare itself.

Exactly who in the administration was chiefly responsible for the debacle, and how they failed, remains the subject of great debate -- even among those who were on the inside. Steven Brill’s new book, America’s Bitter Pill, gives one deeply reported account and pins a large share of the blame on poor management by Tavenner’s agency. Tavenner herself apologized for the HealthCare.gov disaster at a House hearing in October, during which she underwent withering question by committee members. The Centers for Medicare and Medicaid Services also was later responsible for reporting inflated enrollment figures.

Less publicly, but no less importantly, Tavenner’s agency has received criticism from consumer advocates, who say that, in crafting the new rules for the Obamacare marketplaces, it went too easy on insurers, drugmakers and other key players in the health care industry.

But Tavenner’s many defenders, inside and outside the administration, point to the obstacles she faced -- including a bureaucracy not up to the task of developing such a website and enormous political pressure, sometimes from Republicans in Congress and sometimes from higher-ups in the administration. "When bad information from the bottom meets unrealistic expectations from the top," one health care lobbyist sympathetic to Tavenner told HuffPost, "bad things happen to the person in the middle."

Others cite the law’s successes, which haven’t always received the same level of publicity.

After some heroic repair work, HealthCare.gov, along with the health insurance exchange systems operated by 13 states and the District of Columbia, proved capable enough to process more than 8 million enrollments as of April. And among the more than half of the states that adopted Obamacare’s Medicaid expansion, millions more signed up for that program. On one key metric of the Affordable Care Act, its success is clear: The uninsured rate dramatically dropped after the first enrollment period, and the progress of this year’s sign-up campaign suggests more will gain coverage.

Tavenner, a nurse by training who rose to become an executive at the for-profit hospital chain HCA and the top health official in Virginia, also has a longstanding interest in finding better ways for Medicare and Medicaid to encourage medicine that is better, cheaper, or both. Here, too, there are real, if tentative, signs of progress: Health care spending is rising at historically slow rates, and research suggests hazardous medical errors inside hospitals are on the decline, although most experts think it’s too soon to know how significant or permanent these changes are.

"If I could rewind the clock, we would have had a smoother implementation last October," Tavenner acknowledged in an interview with HuffPost. But she said she was proud of what the law has accomplished. "Our quality work was huge. We were able to make progress. We're now seeing data out there, showing reduction of patient harm and increasing quality. And we've been able to do a lot on costs. Whether you look at our own actuary data or reports from outside the government, we're doing better on costs than we have in a long time."

Tavenner first joined the agency in 2010, became Obama’s nominee to lead it and won Senate confirmation in 2013 with just seven dissenting votes.

"Marilyn Tavenner has devoted five years and countless hours to the cause of improving health care quality, holding down costs, protecting the Medicare Trust Fund and expanding access to affordable health care coverage to millions of Americans," HHS Secretary Burwell said in a statement to be released Friday. "In so doing, she delivered historic results that have impacted countless lives -- both today and for decades to come -- all for the better."

At the health agency, Tavenner maintained good relationships across the aisle, according to insiders, despite the toxic political environment around Obamacare. "She’s not been viewed in town as a particularly political figure. She’s viewed as a manager, which says something about her leadership," said Karen Ignagni, president of America’s Health Insurance Plans, an industry lobbying organization.

Maintaining that reputation will be no less a challenge for Slavitt, who assumes command of the agency just months before the Supreme Court hears a new, existential challenge to Obamacare -- one that threatens to take back the subsidies millions of consumers receive to cut their health insurance costs. Slavitt, a Harvard Business School graduate, was deeply involved in HealthCare.gov development as an executive at one of the contractors that built it, Optum, a unit of the health insurance giant UnitedHealth Group. He has been the principal deputy administrator at the health agency since June.

Whatever Slavitt’s qualifications, filling the position of Centers for Medicare and Medicaid Services administrator has been a major challenge for Obama and his predecessor, President George W. Bush, in contrast to the relative ease previous presidents had with their nominees to the agency.

Before Tavenner, the last Senate-confirmed administrator was Mark McClellan, who stepped down in 2006 -- a gap of more than six years. Senate Democrats quietly obstructed Bush’s nominee, career civil servant Kerry Weems. They were outdone by their Republican counterparts when Obama took office and nominated pediatrician and health care quality expert Donald Berwick. Berwick served under a recess appointment for more than a year.

This story has been updated to include comment from Marilyn Tavenner.

Why We're Picking Walmart And CVS Over Doctors' Offices

Jeffrey Young   |   January 12, 2015    2:31 PM ET

The American health care system may finally be catching up to the rest of the 21st-century economy, in which convenience is not only expected, but demanded -- and massive retailers are driving the change.

Patients suffering everyday complaints like chest colds or ankle sprains have long faced the lamentable choice between waiting days to see their family doctors or enduring time-sucking, unpleasant and expensive visits to hospital emergency rooms, especially at night and on weekends when physicians typically aren't open for business. It's one of the most annoying aspects of the way medical care is provided in the United States.

Big chains like CVS, Walgreens and Walmart are stepping in to try to correct this market failure. These and other retailers are opening hundreds of new walk-in clinics, staffed by medical professionals such as nurse practitioners and physician assistants. They're betting that Americans craving speed, convenience and easy-to-understand prices will be willing to break their habit of expecting a doctor to handle all of their medical issues.

"People are demanding health care to react similarly to other service industries, where people have a need and they want it relatively easy," said Nancy Gagliano, a primary care physician and chief medical officer for CVS Health's MinuteClinic. "The traditional health care system really is not adequate to support the need."

Although still vastly outnumbered by doctors' offices and hospitals, retail clinics are spreading rapidly: There currently are almost 1,900 across the U.S., up more than sevenfold since 2007, according to data compiled by Merchant Medicine, a consulting firm that tracks the sector.

The time seems right for the health care landscape to include places such as CVS MinuteClinic, Walgreens Healthcare Clinic and Walmart Care Clinic, along with similar locations housed inside retailers such as Kroger, Target and Rite Aid.

For starters, patients appear eager for the clinics. When the Advisory Board Co., a Washington-based consulting firm, surveyed consumers last year, it found respondents valued being treated by a physician less than the convenience of night and weekend hours, getting seen without an appointment, and being able to fill prescriptions on-site.

"People are also more sophisticated than, I think, in the past, health care has given them credit for," Gagliano said. "They have a really good sense of when the MinuteClinic-type visit is appropriate for their needs and when it's worth waiting for their doctor for a more complex issue or more chronic and preventative-care follow-up."

CVS Health's MinuteClinic, the market leader with close to 1,000 locations in 31 states and the District of Columbia, had more than 18 million patient visits in 2013, up from 5 million just two years prior, according to the company. It plans to have 1,500 clinics by 2017.

Eric Knudtson of New York might be the prototypical retail clinic patient. Knudtson, a 23-year-old student, visited a clinic inside a New York City Duane Reade -- owned by Walgreens -- last week for a check-up. He opted for the clinic because it was convenient and because he doesn't have a regular doctor in the city, he told HuffPost.

"I just came here because it was on my way home from school," said Knudtson. The two times he used the Duane Reade clinic weren't as time-consuming as visiting a physician's office, he said. His visit last week took less than an hour, including wait time. "It seems like it's gone pretty quickly."

Locations like these offer basic check-ups plus vaccinations and treatment for minor ailments, and their medical professionals can write prescriptions. Unlike the pharmacy and grocery chains, Walmart is positioning itself as a true primary care provider, while both Walmart and Walgreens tout their services for patients with chronic diseases. Walmart sets a flat price of $40 per visit (or $4 for company employees), while CVS Health and Walgreens charge less than $100 for most treatments. Lab work, drugs, vaccines and other things carry additional fees.

Retail clinics can't replace the physician's office or the emergency room, retail executives emphasized. Doctors are better-trained than nurse practitioners and physician assistants and are more knowledgeable about their patients' medical histories. ERs are equipped to handle life-threatening medical problems that retailers cannot, and can admit the sickest patients directly to the hospitals. Retail clinics also typically offer a less-comprehensive set of services than urgent-care centers, and don't have as much high-tech equipment.

Medical societies like the American Academy of Family Physicians and the American Academy of Pediatrics have expressed other concerns about these clinics.

Records of what services a patient gets at a retail clinic may not be shared with their doctors, even though retailers can transmit them electronically or on paper. That could lead to problems such as unsafe mixing of medicines, physicians being unaware of changes to their patients' health, or tests and treatments being needlessly duplicated.

But there's also a well-documented shortage of primary care physicians in the U.S., making it harder for people to get timely appointments or even to find a family doctor. And medical schools can't churn them out quickly enough to meet the demand. This problem could become even more acute as millions of Americans get health care coverage because of the Affordable Care Act. Inadequate access to doctors also has prompted some states to loosen restrictions on what non-physician practitioners are allowed to do.

Between 40 percent and 50 percent of the patients who have visited the clinics at CVS, Walgreens and Walmart reported they have no regular primary care provider, according to executives at those companies.

At the same time, health insurance -- from employers and from the Obamacare exchanges -- increasingly requires patients to pay more when they get medical care. Retail clinics offer services at clearly marked prices that often are lower than at physician's offices and hospitals.

"We have what I term as a new age of consumerism," said Patrick Carroll, the chief medical officer for Walgreens Healthcare Clinics and a primary care physician. "They're making choices based on convenience and economics."

Another draw is that Americans are working longer -- and less flexible -- hours. Employers and employees alike welcome retail clinics that can treat workers' minor ailments quickly and get them back to work sooner, said Jennifer LaPerre, senior director of health and wellness at Walmart U.S.

"It's hard to leave work during the day hours when you need to get care. But if they need to, they certainly don't want to be gone long," LaPerre said.

For the struggling retail industry, medical clinics offer both a new source of revenue linked to the massive and growing U.S. health care market, as well as a means of driving foot traffic into their stores, where customers may buy other products.

"We really want to be able to serve that audience who probably is shopping in our stores, but who may not have access to affordable health care," LaPerre said.

Jillian Berman contributed reporting.

Supreme Court Could Kick 10 Million People Off Health Insurance

Jeffrey Young   |   January 8, 2015    3:19 PM ET

The Supreme Court might be about to blow a hole in Obamacare large enough to fit nearly 10 million people, a new analysis shows.

The high court is scheduled to hear arguments this March in a lawsuit claiming President Barack Obama's administration does not have the legal authority to give tax credit subsidies to millions of people who have insurance under the Affordable Care Act. The argument is over a small bit of wording in the law, which says subsidies can go to people buying insurance on state-run marketplaces, but not to people buying on federally run ones.

Since the federal government operates the exchanges in two-thirds of the states, a ruling for the plaintiffs would gut the Affordable Care Act.

The result: 9.6 million people living in 34 states would be forced to give up their health insurance policies, according to a report issued Thursday by the Rand Corp., a nonprofit consulting firm and think tank. That's 70 percent of the 13.7 million people Rand projects will have health insurance through the exchanges this year. The administration projects 9.1 million enrollees this year; 70 percent of that total would be 6.4 million people.

This latest legal challenge to the Affordable Care Act, called King v. Burwell, alleges that seven words in the statute -- "through an exchange established by the state" -- signify that only state-run health insurance marketplaces are permitted to dole out federal subsidies. The Obama administration, along with the congressional Democrats who wrote the law, reject this argument, and contend a full reading of the statutory language makes plain the ACA's intent is to provide subsidized health coverage to low- and middle-income households in every state.

The Supreme Court agreed to hear this case, one of several similar ones, in November, even though no federal appeals court had ruled in the plaintiffs' favor. Previously, the administration asked the justices to postpone any consideration of the suits until appeals courts issued different decisions. The Supreme Court upheld the Affordable Care Act in another major case against it in 2012, when conservative Chief Justice John Roberts joined four liberal justices in a 5-4 ruling.

The dire effects of a ruling against Obamacare subsidies in states with federal exchanges wouldn't be limited to the people who get tax credits, Rand economists Evan Saltzman and Christine Eibner conclude. At least 85 percent of enrollees get financial assistance via the federal health insurance marketplaces.

In addition to low- and middle-income subsidy recipients finding their health insurance policies unaffordable, unsubsidized customers also would be affected. The sudden withdrawal of 70 percent of enrollees, including large numbers of young and healthy policyholders, would trigger a chain reaction known in industry jargon as a "death spiral."

Health insurance companies would respond to the exit of so many customers, especially the more price-sensitive healthy ones vital to keeping overall costs down, by raising prices. Those high prices would then drive out more consumers, and those who are most expensive to insure because of poor health would be likeliest to remain. That, in turn, would lead to higher costs for insurers, causing them to further increase prices, or to leave exchanges entirely. For a 40-year-old nonsmoker, the premium for a mid-level "Silver" insurance plan initially would jump from $3,450 to $5,060 a year, the study says.

The Robert Wood Johnson Foundation and the Urban Institute issued findings similar to Rand's in a separate report published Thursday. Invalidating tax credits in federal exchange states would increase the number Americans without health coverage by 8.2 million, take away $28.8 billion in subsidies and shrink the exchange markets in those states from 14.2 million customers to 3.4 million.

State governments could forestall these consequences by establishing their own exchanges, but none have made efforts to do so since the Supreme Court announced it would hear the King case. Now, little time remains before justices issue a ruling, which will likely come in June. Similarly, Congress could rectify any ambiguity in the law's language to prevent major disruption in the majority of states, but it has not.

The threat to the Affordable Care Act comes at a time when enrollment on the exchanges is climbing and the share of Americans without health insurance is falling.

From the beginning of the 2015 enrollment period on Nov. 15 through Jan. 2, almost 6.6 million people signed up for private health plans for 2015 on the federal exchanges, along with an estimated 1.5 million or more who enrolled on state-run exchanges. And Gallup survey results issued Wednesday show the national uninsured rate dropped to 12.9 percent during the fourth quarter of last year, the lowest since the polling firm began tracking the statistic in 2008.

The Uninsured Rate Just Keeps Falling, New Survey Shows

Jeffrey Young   |   January 7, 2015   11:07 AM ET

The share of Americans without health insurance fell below 13 percent by the end of 2014, a rapid drop from just a year before and a clear sign that one of Obamacare's primary missions is succeeding, according to new data from the polling firm Gallup.

In the fourth quarter of last year, 12.9 percent of Americans were uninsured, a steep drop from 17.1 percent a year before. The change was driven mainly by increased coverage through the Affordable Care Act's health insurance exchanges and by the expansion of Medicaid access in more than half the country, the Gallup-Healthways Well-Being Index shows, based on more than 43,000 interviews conducted between Oct. 1 and Dec. 30.

President Barack Obama and the congressional Democrats who enacted the Affordable Care Act had broader aims for the law than just covering the uninsured, including providing stronger consumer protections for health insurance customers and curtailing unsustainable increases in national health care spending. But extending coverage to uninsured people, especially those with low and moderate incomes eligible for financial assistance, is the most tangible effect of the law, and survey after survey shows it's working. These gains are threatened, however, by the newly empowered Republican Congress and the Supreme Court.

"The Affordable Care Act has accomplished one of its goals: increasing the percentage of Americans who have health insurance coverage," the Gallup report says. "The uninsured rate as measured by Gallup has dropped 4.2 points since the requirement to have health insurance or pay a fine went into effect. It will likely drop further as plans purchased during the current open enrollment period take effect."

obamacare uninsured
Source: Gallup-Healthways Well-Being Index

The second Obamacare sign-up period began Nov. 15 and ends Feb. 15. As of late December, 6.4 million people had enrolled into private health insurance policies for 2015, about 2 million of whom were new to the Obamacare exchanges.

The Department of Health and Human Services estimates that more than 9 million people will be covered by private Obamacare exchange plans by the end of the year. In addition, nearly 10 million more people are covered by Medicaid or the Children's Health Insurance Program, two joint federal-state benefits for low-income households, than were covered before Obamacare enrollment kicked off in October 2013.

The new Gallup survey shows declines in the uninsured rate for all segments of the working-age population, and the share of people ages 18-64 without coverage stood at 15.5 percent in the fourth quarter of 2014. The largest decrease was among people ages 18-25, a population that experienced a 6.1 percentage point drop in uninsurance since 2013 to 17.4 percent. Almost all people 65 and older have coverage through Medicare. Low-income Americans and blacks also saw disproportionate declines in their uninsured rates, Gallup found.

Other surveys have shown the improvements in the uninsured rate to be geographically uneven. Southern states with higher-than-average uninsured populations, for instance, rejected the Medicaid expansion, which the Supreme Court made optional for states in 2012, leaving millions of low-income residents uninsured.

And Obamacare's coverage expansion is in grave jeopardy this year.

Republicans newly in control of Congress after the November midterm elections aim to dismantle the law, starting with a House vote this week on a bill that would weaken the Affordable Care Act's requirement that large employers provide health benefits or pay penalties. Obama has vowed to resist these efforts.

But the more serious danger for Obamacare, and for the millions who have gained coverage under the law, is King v. Burwell, a case now pending before the Supreme Court. The plaintiffs claim the federal government lacks the legal authority to provide health insurance subsidies to people living in states that didn't establish health insurance exchanges and allowed the Department of Health and Human Services to do so instead. A ruling against the Obama administration would invalidate the tax credits 85 percent of exchange enrollees receive, making their insurance policies unaffordable and likely causing most to drop their coverage.

Obamacare Sign-Ups Reach 6.4 Million

Jeffrey Young   |   December 23, 2014   10:32 AM ET

Enrollments via the federally run Obamacare health insurance exchanges on HealthCare.gov surged leading up to a big deadline last week and reached almost 6.4 million after the first month of sign-ups, the Department of Health and Human Services announced Tuesday.

That tally, including about 1.9 million new customers and the re-enrollments of millions more already covered by Obamacare plans, combined with more than 1 million sign-ups so far through the exchanges operated by 13 states and the District of Columbia, appears to put the program on target to surpass Burwell’s self-imposed target of 9.1 million total enrollments by the end of next year. The open enrollment period for health insurance policies purchased on these exchanges for 2015 started Nov. 15 and ends Feb. 15, 2015.

“We still have a ways to go and a lot of work before Feb. 15, but we do have an encouraging start,” Health and Human Services Secretary Sylvia Mathews Burwell said at a press conference Tuesday. “This law is working, and families and businesses and taxpayers are better off as a result.”

Compared to the chaotic rollout of the Affordable Care Act’s exchanges in October 2013 that resulted in sluggish sign-ups for the first months of enrollment into 2014 health coverage, the second enrollment period is running remarkably smoothly at the federal and state level. That’s in spite of lingering technical issues and major public outreach and educational challenges facing exchange authorities and insurance companies seeking to usher existing customers through a potentially confusing renewal process while searching for millions of uninsured to sign up.

“A month ago, people were raising questions about whether or not consumers would actually come to the marketplace,” Burwell said. But the HealthCare.gov website is working, more insurance companies are offering policies compared to last year, and premium increases are modest on average, she said.

These private health insurance plan enrollments as of Dec. 19 are in addition to the almost 10 million people who have signed up for Medicaid or the Children’s Health Insurance Program since last October. The Affordable Care Act broadens Medicaid access in states that elect to participate, but 22 states have not done so, leaving millions of low-income Americans uninsured.

Just 106,000 people managed to sign up during the first month of the inaugural enrollment period, while more than half a million chose policies during the first week of this year’s campaign.

The improvements at the federal level are mirrored in the states with their own insurance marketplaces. States with troubled exchanges last time around, including Maryland and Massachusetts, have rebounded, and other states still having technical problems, such as Minnesota, nevertheless are signing up consumers. The exchanges in the populous states of California and New York performed well during the first enrollment period and continue to enroll large numbers of residents.

“It definitely looks like it’s going to work," Caroline Pearson, vice president of the health care reform practice at the consulting firm Avalere Health, said before the HHS announcement. "All signs are that the markets are working really effectively. You’ve got an increased insurer participation and very stable premiums,” she said. The average nationwide price increase for next year is 5.4 percent, but there's a lot of variation and some premiums even went down, according to PricewaterhouseCoopers.

In addition to the 1.9 million new customers who signed up, about 4.5 million current customers have re-enrolled for next year. Most of them automatically were rolled over into their current plans -- or the next closest thing if their policies have been discontinued -- for 2015.

Significantly, however, more than one-third of existing customers took active steps to re-enroll, rather than opting to be automatically re-enrolled, Burwell said. According to the department’s preliminary analysis, a share of current enrollees in the mid-to-high 30 percent range did so; this was more than expected based on how people with other types of coverage, including job-based health benefits, tend to keep the same plans every year rather than comparison shop, she said.

“In looking at what happens with people in employer-based plans and other things, I think probably wouldn’t have expected a number that high in terms of people’s behavior,” Burwell said. This could mean fewer of consumers than feared will suffer sticker shock next month.

Shopping around is crucial to consumers looking to avoid big rate hikes, especially for the more than 8 in 10 enrollees who receive Obamacare tax credits. Volatility in health insurance premiums, especially among those plans used to set the value of the Obamacare subsidies, means more than 70 percent of people who signed up for these plans could save money by changing to new policies, according to HHS.

Consumers who are automatically re-enrolled can switch to a cheaper policy for February if they make a change by Jan. 15, and all enrollees can choose a different plan for the rest of the year by Feb. 15. But anyone who didn’t choose a new plan by Dec. 15 will have to keep what they have in January, unless they opt to go uninsured for the month instead.

Avalere Health expects 4.5 million to 6 million new customers will sign up for health insurance via the exchanges by Feb. 15 and that total enrollments will reach 9.5 million to 11 million, including renewed coverage for current customers. The Congressional Budget Office projected enrollments would reach 13 million by the end of 2015.

Despite the positive trends for 2015 enrollment, projections from Avalere, the Congressional Budget Office and the Department of Health and Human Services are lower than before the beginning of the first-sign up period, and evaluations of the exchanges’ performance during the 2015 sign-up phase should consider that, Pearson said.

“It looks good relative to the expectations or the goals that HHS set for themselves, but it looks a bit disappointing relative to where we thought we would be a year ago,” Pearson said. “It has proven harder to do the outreach and get people to sign up than we expected and it’s been harder to keep people enrolled.”

Exchange enrollments for 2014 peaked at more than 8 million, but dipped to 6.7 million as of October as a share of customers gave up their plans, for reasons including not being able to afford the premiums, not valuing the coverage, gaining employment at companies that offer health benefits or enrolling into Medicaid because their incomes fell. HHS expects 83 percent of the total number of enrollees as of Feb. 15 to still be covered by exchange plans at the close of 2015.

Pearson expects enrollments to spike again by Jan. 15, as current customers who didn’t shop around scramble for lower-cost policies for the rest of the year, and then again when the final deadline arrives on Feb. 15.

This article has been updated with additional information from a news conference with Health and Human Services Secretary Sylvia Mathews Burwell and from a federal report.

To see an estimate of how much your health insurance might cost, use this calculator from the Henry J. Kaiser Family Foundation: