What a difference a year makes.

With its technical troubles largely behind it, healthcare.gov enrolled 1.9 million new customers for health insurance between Nov. 15 and Dec. 18. At the same time, another 4.5 million existing policyholders either re-enrolled or were automatically renewed into their existing policy or a similar one beginning Jan. 1.

“We still have a ways to go and a lot of work before Feb. 15,” the deadline for open enrollment, Health and Human Services Secretary Sylvia Burwell told reporters Tuesday. “But we do have an encouraging start.”

Burwell said of those who were re-enrolled, percentages “somewhere in the mid- to high-30s” logged into the system and either renewed their old plans or changed to a different one. The rest were automatically re-upped. About 2 percent of policy holders, she said, could not be auto-renewed because their plan has been discontinued and there is not another one similar enough. Those people, as well as anyone who was auto-renewed, can still change plans until Feb. 15.

Many people will find it financially advantageous to switch plans for a variety of reasons, including increased competition among plans, variations in premiums or benefits, or changes in their financial circumstances that affect the amount of subsidy they may receive.

Meanwhile, Burwell steadfastly refused to answer questions about whether her department is making contingency plans in the event the Supreme Court rules that subsidies are not available in the 37 states where healthcare.gov is operating the exchange. The court announced earlier this week it would hear oral arguments in the case, King v Burwell, on March 4.

“The law of the land is that where we are right now is those subsidies are available and people are shopping, they are coming in, they are getting affordable care,” Burwell said. “We are focused on open enrollment and we are focused on a position where we believe we have a position that will prevail.”

The plaintiffs in that case argue that Congress intended to make subsidies to purchase insurance available only in exchanges “established by a state,” which does not include the federally-run exchange. Backers of the law, including most of the Democrats who wrote it, say the wording was awkward, but the law always intended to make the subsidies available to all, regardless of whether an exchange was state- or federally-run. If the Supreme Court rules that subsidies are not available in the federal exchange, it could cause millions of people to shed coverage.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Andy Pasternak, a family doctor in Reno, Nev., has seen more than 100 new Medicaid patients this year after the state expanded the insurance program under the Affordable Care Act.

But he won’t be taking any new ones after Dec. 31.  That’s when the law’s two-year pay raise for primary care doctors like him who see Medicaid patients expires, resulting in fee reductions of 43 percent on average across the country, according to the nonpartisan Urban Institute.

“I don’t want to do this,” Pasternak said about his refusal to see more Medicaid patients next year. But when the temporary pay raise goes away, he and other Nevada doctors will see their fees drop from $75 on average to less than $50 for routine office visits.

“We will lose money when they come to the office,” he said.

Experts fear other doctors will respond the same way as Pasternak, making it harder for millions of poor Americans to find doctors. The pay raise was intended to entice more physicians to treat patients as the program expanded in many states. In the last year, Medicaid enrollment grew by almost 10 million and now covers more than 68 million people nationwide.

The challenge is to convince physicians not just to continue accepting such patients but to take on more without getting paid what they’re used to, said Dr. J. Mario Molina, CEO of Molina Healthcare, one of the nation’s largest Medicaid insurers.

Charles Duarte, CEO of a large community health center in Reno where some patients already wait two months or more for appointments, foresees increased demand for services at his Community Health Alliance clinics, which are paid more generously by Medicaid and were not eligible for the enhanced pay.

“We will see more patients and longer wait times,” he predicted.

State Impact Differs

Despite the concerns, most states say they’ve seen no evidence the increase has resulted in greater doctor participation — mostly because it was temporary. The bonus boosted pay rates for primary care doctors who saw Medicaid patients to the same level as they are paid by Medicare.

Because Medicaid reimbursement rates for doctors vary by state, however, the pay bump varied from no change in Alaska, Montana and North Dakota, to a 50 percent raise or more in California, New York, New Jersey, Michigan, Florida and Rhode Island, according to the Urban Institute.

Only a handful of states have acted to continue the Medicaid pay boost using their own funds, including Maryland, Alabama, Colorado, Iowa and Mississippi. Connecticut will continue the raise, but not for primary care services done in hospitals.

Nevada and several other states are still considering extending it.

The American Academy of Family Physicians has lobbied Congress to extend the higher pay rate, but has been hampered by lack of data showing the higher fees spurred more doctors to join, said Robert Wergin, president of the academy and a physician in Milford, Neb.

Wergin said he participated in Medicaid before the health law and won’t be deterred from accepting new patients in the rural town in which he practices after the pay raise expires.

Nonetheless, “I believe access as a result of the cuts will be an issue,” he said.

Low reimbursement rates are not the only reason doctors’ avoid Medicaid. High patient no-show rates also make private physicians reluctant about participating, Duarte said.

Kaveh Safavi, global managing director of Accenture Health, said physicians have always gone in and out of the Medicaid program as a business decision. Others participate because they feel a social obligation, especially if they practice in an area where patients don’t have other health care options.

“There are a lot of dynamics at play … though historically, things have not changed [doctors’ participation] as much as when states make payment changes,” he said.

Rhode Island Faces Biggest Cuts

The Urban Institute study found that Rhode Island doctors will face the biggest pay drop next year — 67 percent. Even so, the Rhode Island Medical Society expressed doubt that the change will cause disruption. It notes that some large insurers require doctors in the state who want to treat privately insured patients to see their Medicaid members, too.

“Every little bit helps, but I don’t see this as a deal breaker,” said Steven DeToy, director of governmental public affairs for the society.

Officials with Neighborhood Health Plan of Rhode Island, one of two Medicaid health plans in the state, said they’re not worried about the end of the pay raise.

“We had wide availability of doctors before the pay raise and don’t expect much change when it ends,” said spokesman Tom Boucher.

The pay raise went to doctors working for private managed care plans, as well as those in private practice.

Stephen Zuckerman, senior fellow at the Urban Institute, said the states that will use their own funds to continue the fee increase were typically paying higher-than-average Medicaid rates already. But the most populous states — among them, New York, California and Illinois — are not doing that.

“It’s an open question of whether more doctors will quit Medicaid or stop seeing new Medicaid patients,” Zuckerman said. “But these cuts cannot help.”

Impact Debated

Measuring Medicaid enrollees’ access to care is not simple.

While fewer primary care practices are willing to accept new Medicaid patients, those that do accept them typically offer appointments within a week, according to a separate Urban Institute study. 

But a December report by the Health and Human Services’ Office of Inspector General found that about half of Medicaid doctors listed as participating in managed-care plans don’t have availability or don’t contract with the health plan at all.

Jeff Myers, president of Medicaid Health Plans of America, the trade group, said the plan’s provider directories should be updated but the findings don’t mean patients can’t get care. He pointed to federal documentation showing increasing patient satisfaction.

Other experts note that the pay raise was just one way the health law tried to ensure that newly covered Americans would have a place to get care. Funding to community health centers was also boosted by $11 billion from 2011 to 2015 to help them expand.

“The Medicaid pay boost was never meant to be a silver bullet,” said Leonardo Cuello, director of health policy at the National Health Law Program, an advocacy group for low-income Americans.

Still, the provider fee cuts have him worried. “It won’t sink the ship but … I’m concerned it will contribute to access problems.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Readers have raised many questions about enrolling in Medicare. I answer two recent ones here.

Q. My wife has been automatically re-enrolled in a silver policy on the Oklahoma health insurance marketplace. She will turn 65 and be enrolled in Medicare on May 1, 2015. Can she keep her silver policy when she is enrolled in Medicare? And, if she does, will she automatically lose her premium subsidy? Do we have to cancel the policy or will the insurer do it automatically?

A. Your wife doesn’t have to give up her marketplace policy when she turns 65, but financially it probably doesn’t make sense to keep it, says Tricia Neuman, director of the program on Medicare policy at the Kaiser Family Foundation (KHN is an editorially independent program of the foundation.)

Once she’s eligible for Medicare, your wife will no longer qualify for premium tax credits on the marketplace, making that coverage more expensive.

The federal office responsible for appeals for Medicare coverage has cut in half the waiting time for beneficiaries who are requesting a hearing before a judge.

The progress follows an announcement last January that officials were going to work through a crushing backlog by moving beneficiaries to the front of the line and suspending hearings on cases from hospitals, doctors and other providers for at least two years.

The Office of Medicare Hearings and Appeals (OMHA) has decided most of the 5,162 cases filed by beneficiaries in the fiscal year ending Sept. 30, plus 1,535 older cases, according to statistics provided to Kaiser Health News.

That’s a dramatic change from the year before, when a third of beneficiary cases (1,493) were not decided and nearly half (1,705) of the 2012 cases also were unresolved.

Still, about 900,000 appeals are awaiting decisions, with most filed by hospitals, nursing homes, medical device suppliers and other health care providers, said Jason Green, OMHA’s program and policy director. The wait times for health providers’ cases have doubled since last year, and are nearly four times longer than the processing time for beneficiary appeals.

Hospitals file more appeals than any other provider. The single largest reason is the increasing number of Medicare payment denials for patients who have been admitted to the hospital but whom auditors later say should have been kept instead for observation care, a status that reduces payments.

Seniors also have long complained about observation care because Medicare doesn’t cover follow-up nursing home care for observation patients.

The rise in beneficiary appeal decisions is a direct result of the “beneficiary-first” policy Chief Judge Nancy Griswold announced last January, said Green. The temporary measure will remain in place as long as there is a backlog, he added.

Since then, beneficiaries have waited 113 days on average for a hearing, compared to 235 days the year before, said Green. This includes appeals from beneficiaries in traditional Medicare and private Medicare Advantage insurance plans. It’s a big improvement but still not in compliance with the federal requirement that an appeal be decided within 90 days after a request for a hearing.

“We are striving toward that 90-day mark,” said Green, who expects the beneficiary appeals backlog will continue to shrink next year.

Reaching the Office of Medicare Hearings and Appeals (OMHA) is the third of four stages in the appeals process and the first opportunity for Medicare beneficiaries or health care providers to present their case before a judge. The odds of winning an appeal at the third stage are far better than at the previous levels, which involve only a review of the case files, the Health and Human Services inspector general has found.

But seniors seeking top priority treatment, must identify themselves by addressing their appeal to an OMHA office in Cleveland and writing “Attn: Beneficiary Mail Stop” on the envelope. Griswold announced the new mail address last February, and it is part of the instructions beneficiaries receive when their appeal is denied at the second level.

Beneficiary appeals filed before the new policy was established may be languishing in the backlog pile until officials find them.

“Beneficiaries can help us to help them get to the front of the line,” Griswold said at a meeting in October. She urged those beneficiaries to write to her office using the special mailing address or to call her office at 855-556-8475.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.