During tonight’s Delaware Senate debate, Christine O’Donnell was full of contradictions. She said she supported the new consumer protections in the Affordable Care Act but then promised to “fight to fully repeal that so that we can begin to enact real reform.” She argued against the individual mandate, before insisting that “nobody should be forced to pay for anyone else’s health care.” And finally, asked how she would treat an individual who chose not to purchase coverage but then became sick and needed medical care, O’Donnell was left without much of an answer:

ODONNELL: They could afford to buy a catastrophic only policy from across state lines.

BLITZER: But what if that person doesn’t want to buy it?

ODONNELL: Well, then we have to address that. We have to address that.

BLITZER: Would all of us taxpayers have to pay for that?

ODONNELL: No, anything that they do when they have another bill they can’t pay, make them pay that, hold them accountable for that.

KARIBJANIAN: Before or after they get care?

ODONNELL: Well, that’s up to the hospital. But right now, we’re forcing them to, we’re forcing them that they have to give care to illegal aliens.

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Desperate for any solution for how to encourage an individual to pay for his own medical bills without a mandate, O’Donnell concluded by accusing the moderators of trying to scare the public into supporting health care reform. “You’re also talking about a very small hypothetical using scare tactics to make people support this health care bill,” she said. “Nobody should be forced to pay for anybody else’s health care and that’s what Obamacare is doing.”

HHS Secretary Kathleen Sebelius has written a letter to the National Association of Insurance Commissioners reiterating what states to prevent insurers from dropping child-only policies, but HHS officials also reiterated that if states fail to act, the agency may issue a nationwide regulations to address the issue. The letter comes after several insurers announced they would stop offering child-only plans in response to new regulations that required companies to guarantee coverage to all children.

“While we recognize industry concerns about adverse selection, we believe that there are options other than abandoning families who seek this coverage, as evidenced in States with similar laws already in place,” the letter states. “In response to questions we have received, we have clarified that a range of practices related to “child-only” policies are not prohibited by the Affordable Care Act, such as allowing:

- Issuers in the individual market to determine the number and length of open enrollment periods for children under 19 (as well as those for families and adults), consistent with state law;

- Rates to be adjusted for health status as permitted by state law (note: the Affordable Care Act prohibits health status rating for all new insurance plans starting in 2014);

- The imposition of a surcharge for dropping coverage and subsequently reapplying for it if permitted by state law;

- The implementation of rules, consistent with state law, to help prevent employers from encouraging workers to enroll children in child-only policies instead of employer-sponsored insurance; and

The letter notes that some states already “have in place existing laws to prevent discrimination against children and others with pre-existing conditions” and uniform open enrollment periods, while others allow middle-income parents to buy child-only policies through the CHIP program or enroll in existing high-risk insurance pools.

“We want to make clear that kids to have options and so what we’re doing here is setting out several of the options kids have both in the private market and in various state programs and the established high risk pools and the new Pre-existing Condition Insurance Plans [PCIP],” Jay Angoff, HHS’s Director of the Office of Consumer Information and Insurance Oversight said on a conference call with reporters. Angoff said that while some states will have to rely on the legislature to pass the new changes, others can implement the rules by bulletin.

Asked why HHS doesn’t establish a federal open enrollment period, Angoff replied, “we need to do it by regulation and the regulation would take some time.” “I mean, that’s something that we’re very seriously considering and talking to the industry about and if that would result in companies who stop writing child-only business, starting again to write child-only business, I think that’s something that makes a lot of sense.”

Insurers had first challenged the law’s pre-existing requirements in March, insisting that the provision would increase premiums and was not required by the law. Pressed by HHS Secretary Kathleen Sebelius, however, AHIP, the industry’s lobby, eventually relented. Karen Ignagni issued a letter promising to “fully comply with [the] regulations.”

Center for Medicare and Medicaid Services (CMS) Chief actuary Rick Foster has sent a letter to Sen. Chuck Grassley (R-IA) arguing that the health law’s reduction in subsidies to private Medicare Advantage plans will eliminate some benefits in the Medicare Advantage program and increase co-payments:

The new provisions are expected to reduce MA rebates to plans and thereby result in less generous benefit packages….Prior to this legislation, the average annual MA rebate was estimated to grow from $1,093 in 2010 to $1,580 in 2019. Under the new provisions, the average MA rebate is expected to decline from its current level to $43 in 2019.

As indicated in the table, the reduction in MA rebates will cause a large increase in the out- of-pocket costs incurred by MA enrollees. This impact will be partially offset, however, by the effect on such costs from the Medicare fee-for-service provisions in the Affordable Care Act, which include reduced cost sharing for Medicare Parts A and B, lower Part B premiums, and the filling in of the Part D coverage gap…. The overall results are a decrease in beneficiary out-of-pocket spending of $30 for 2010 and then significant increases in such costs beginning in 2011 and reaching an estimated $873 in 2019.

To be clear, the government is lowering rebates to Medicare Advantage plans (which receive payments that are on average 19% higher than traditional Medicare) because the extra dollars don’t always lead to improved care. In fact, over the years, a number of government reports and independent estimates have found that some plans use the extra dollars to, pad their bottom lines and expose beneficiaries to serious financial risks. For instance, a recent report from the Government Accountability Office (GAO) concluded that some MA plans used lower premiums to attract healthier enrollees, but then hit them “with high and unexpected out-of-pocket costs.”

The expectation is that by phasing out the subsidy, reform will force inefficient MA plans to become more efficient. Those that do, will receive a 5 percent bonus on top of their competitive bid to pay for the extra benefits.

Regulators will certainly monitor the changes to the system to ensure minimum disruption, but as HHS Secretary Kathleen Sebelius writes in her own letter to Grassley, some of the fears surrounding MA are already unfounded. In fact, despite Foster’s predictions, the actual MA premium bids for 2011 show that “99.7 percent of Medicare beneficiaries who have access to a Medicare Advantage plan today will have access to a a Medicare Advantage plan in 2011.” Premiums will decline by 1 percent in 2011 compared to 2010 and “Medicare Advantage enrollment is projected to rise in 2011 by 5 percent,” Sebelius wrote, noting that “these are not my projections or those of the CMS Chief Actuary; the come from the health plans themselves, which predict that Medicare Advantage plans will offer numerous affordable options with improved benefits often at a lower premium.” (H/T: Politico Pulse)

Sen. Tom Coburn (R-OK) — a vocal opponent of health care reform — made several apocalyptic predictions about the U.S. health care system during an appearance at the Republican Women’s Club of Tulsa County on Tuesday:

“There will be no insurance industry left in three years,” Coburn told the Republican Women’s Club of Tulsa County.

“That is by design. You’re going to make insurance unaffordable for everyone — which is what they want. Because if there’s no private insurance left, what’s left? Government-centered, government-run, single-payer health care.”

Coburn apparently based his prediction on reported hikes in private insurance premiums, increases he attributed to the new law. [...]

Coburn, facing re-election on Nov. 2, said it will be “the beginning of the end of America” if the reform bill’s so-called individual mandate is not revoked or thrown out by the courts.

Coburn is no stranger to bizarre comments about reform. During a town hall in September, Coburn said that Democrats were hoping that the law would fail. “I believe,” he told his audience, “the plan is for this plan to fail. In fact, I know this plan will fail.” Coburn also indirectly suggested that he wished that ailing Sen. Robert Byrd couldn’t cast his vote (“What the American people ought to pray is that somebody can’t make the vote tonight”), warned seniors that if health care reform is implemented they would “die sooner” and said he would go to jail to protect the conscience clause.