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Obama Delays Implementing Another Part Of Affordable Care Act


Patients with chronic illnesses often face high medical bills. And even with good insurance, some people still pay thousands of dollars a month. ObamaCare offers relief by limiting out-of-pocket expenses, but that provision won't kick in for another year.

As reporter Sarah Varney explains, employers have been given more time before they have to comply.

SARAH VARNEY, BYLINE: If you work for a large employer, it's a good bet that you have one insurance company for your medical benefits - like hospital and doctor's visits - and another company - like Express Scripts or CVS Caremark - which handles your prescription drugs. Employers like this setup because the insurers focus on controlling medical costs and Pharmacy Benefit Managers - or PBMs, as they're called - keep a lid on drugs.

The problem is, often, the two companies don't talk to each other. Ed Kaplan, a senior vice president at Segal Consulting, advises large employers on HR and health benefits. He says with the federal health law's fast-approaching deadline to cap out-of-pocket expenses, even his company, experts in the field, were having a tough time figuring out how to comply.

ED KAPLAN: Before the delay, we were starting to work on, OK, who's going to integrate it? Who are we going to use? How quickly will they be able to transfer data? The issue was the PBM was like, we're gonna have to charge you for that. And PBMs weren't really ready to, I don't think, handle all the demand to make the integration.

VARNEY: Kaplan says the administration's decision to delay enforcing the out-of-pocket cap - at about $6,300 a year for an individual and about 12,700 for a family - was mostly about giving employers more time to sort out the messy logistics and integrate their different vendors.

A spokesperson for the Department of Health and Human Services said earlier today that the one-year delay applies only to employees insured through their jobs. It does not apply to individuals, families and small businesses purchasing health coverage through the state-based marketplaces expect to open for business this fall. That is little comfort to Marc Boutin, executive vice president of the National Health Council, an association of patient advocacy organizations.

MARC BOUTIN: There's been more than three years to plan and prepare for this. And for them to come back and say we need more time to figure this out is really just a red herring. It's clearly an opportunity to use these high out-of-pocket costs to deny access to care and to keep their costs down.

VARNEY: Boutin says the cap on out-of-pocket costs - including deductibles, co-pays and co-insurance - was a key reason patient groups supported the Affordable Care Act. Although the delay will continue the hardship for some patients, the total number is small. Steve Wojcik is with the National Business Group on Health, a coalition of employers. He says many employers already limit how much workers have to pay.

STEVE WOJCIK: Our data show that the average out-of-pocket cost in total for 2013 is about a little over $2,500. So it's not anywhere near the maximum that would be permitted by the law.

VARNEY: Wojcik calls the one-year grace period a practical and reasonable recognition, that much work remains to be done upgrading their computer systems.

WOJCIK: I think the law has added an impetus that we, frankly from the employer side, would have liked to have seen a long time ago, you know, much more cooperation and sharing of data, because in the end, when they share data, it helps not only the employer but the employees.

VARNEY: The grace period comes after federal officials delayed a mandate for one year that large employers offer health insurance to most full-time workers. The two delays are unrelated, but together, Republican critics of the health law have seized on them. Health benefit experts, though, say the delays are much more a reflection of the stupefying fragmentation of the U.S. health care system that will take many years to patch together. For NPR News, I'm Sarah Varney.

SIEGEL: And our two health stories today come to us through partnerships of NPR, Capital Public Radio and Kaiser Health News.

(SOUNDBITE OF MUSIC) Transcript provided by NPR, Copyright NPR.

Sarah Varney
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