Category Archives: Health Insurance Coverage Adequacy

The Affordable Care Act is Back on Stage: What to Expect

Posted on by • Posted in 2024 Election Issues, ACA, Affordability, American Recovery and Reconstruction Act (ARRA), District Court, District Court of Appeals, Health Insurance Coverage Adequacy, Healthcare Reform, Medical Loss Ratio (MLR), Misinformation, Mislead, Misleading, Preexisting Conditions, Public Opinion, Public Perception, Supreme Court, Triple Aim • Leave a comment
The Affordable Care Act is Back on Stage: What to Expect

In the last 2 weeks, the Affordable Care Act (ACA) has been inserted itself in Campaign 2024 by Republican aspirants for the White House:

  • On Truth Social November 28, former President Trump promised to replace it with something better: “Getting much better Healthcare than Obamacare for the American people will be a priority of the Trump Administration. It is not a matter of cost; it is a matter of HEALTH. America will have one of the best Healthcare Plans anywhere in the world. Right now, it has one of the WORST! I don’t want to terminate Obamacare, I want to REPLACE IT with MUCH BETTER HEALTHCARE. Obamacare Sucks!!!!” 
  • Then, on NBC’s Meet the Press December 3, Florida Governor Ron DeSantis offered “We need to have a healthcare plan that works,” Obamacare hasn’t worked. We are going to replace and supersede with a better plan….a totally different healthcare plan… big institutions that are causing prices to be high: big pharma, big insurance and big government.”

It’s no surprise. Health costs and affordability rank behind the economy as top issues for Republican voters per the latest Kaiser Tracking Poll. And distaste with the status quo is widespread and bipartisan: per the Keckley Poll (October 2023), 70% of Americans including majorities in both parties and age-cohorts under 65 think “the system is fundamentally flawed and needs major change.” To GOP voters, the ACA is to blame.

Background:

The Affordable Care Act (aka Obamacare aka the Patient Protection and Affordable Care Act) was passed into law March 23, 2013. It is the most sweeping and controversial health industry legislation passed by Congress since Lyndon Johnson’s Medicare and Medicaid Act (1965). Opinions about the law haven’t changed much in almost 14 years: when passed in 2010, 46% were favorable toward the law vs. 40% who were opposed. Today, those favorable has increased to 59% while opposition has stayed at 40% (Kaiser Tracking Poll).

Few elected officials and even fewer voters have actually read the law. It’s understandable: 955 pages, 10 major sections (Titles) and a plethora of administrative actions, executive orders, amendments and legal challenges that have followed. It continues to be under-reported in media and misrepresented in campaign rhetoric by both sides. Campaign 2024 seems likely to be more of the same.

In 2009, I facilitated discussions about health reform between the White House Office of Health Reform and the leading private sector players in the system (the American Medical Association, the American Hospital Association, America’s Health Insurance Plans, AdvaMed, PhRMA, and BIO). The impetus for these deliberations was the Obama administration’s directive that systemic reform was necessary with three-aims:  reduce cost, increase access via insurance coverage and improve the quality of care provided by a private system. In parallel, key Committees in the House and Senate held hearings ultimately resulting in passage of separate House and Senate versions with the Senate’s becoming the substance of the final legislation. Think tanks on the left (I.e. the Center for American Progress et al.) and on the right (i.e. the Heritage Foundation) weighed in with members of Congress and DC influencers as the legislation morphed. And new ‘coalitions, centers and institutes’ formed to advocate for and against certain ACA provisions on behalf of their members while maintaining a degree of anonymity.

So, as the ACA resurfaces in political discourse in coming months, it’s important it be framed objectively. To that end, 3 major considerations are necessary to have a ‘fair and balanced’ view of the ACA:

1-The ACA was intended as a comprehensive health reform legislative platform. It was designed to be implemented between 2010 and 2019 in a private system prompted by new federal and state policies to address cost, access and quality. It allowed states latitude in implementing certain elements (like Medicaid expansion, healthcare marketplaces) but few exceptions in other areas (i.e.individual and employer mandates to purchase insurance, minimum requirements for qualified health plans, et al). The CBO estimated it would add $1.1 trillion to overall healthcare spending over the decade but pay for itself by reducing demand, administrative red-tape and leveraging better data for decision-making. The law included provisions to…

  • To improve quality by modernizing of the workforce, creating an Annual Quality Report obligation by HHS, creating the Patient Centered Outcome Research Institute and expanding the the National Quality Forum, adding requirements that approved preventive care be accessible at no cost, expanding community health centers, increasing residency programs in primary care and general surgery, implementing comparative effectiveness assessments to enable clinical transparency and more.
  • To increase access to health insurance by subsidizing coverage for small businesses and low income individuals (up to 400% of the Federal poverty level), funding 90% of the added costs in states choosing to expand their Medicaid enrollments for households earning up to 138% of the poverty level, extending household coverage so ‘young invincibles’ under 26 years of age could stay on their parent’s insurance plan, requiring insurers to provide “essential benefits” in their offerings, imposing medical loss ratio (MLR) mandates (80% individual, 85% group) and more.
  • To lower costs by creating the CMS Center for Medicare and Medicaid Innovation to construct 5-year demonstration pilots and value-based purchasing programs that shift provider incentives from volume to value, imposing price and quality reporting and transparency requirements and more.

The ACA was ambitious: it was modeled after Romneycare in MA and premised on the presumption that meaningful results could be achieved in a decade. But Romneycare (2006) was about near-universal insurance coverage for all in the Commonwealth, not the triple aim, and the resistance calcified quickly among special interests threatened by its potential.

2-The ACA passed at a time of economic insecurity and hyper-partisan rancor and before many of the industry’s most significant innovations had taken hold. The ACA was the second major legislation passed in the first term of the Obama administration (2009-2012); the first was the $831 billion American Recovery and Reconstruction Act (ARRA) stimulus package that targeted “shovel ready jobs” as a means of economic recovery from the 2008-2010 Great Recession. But notably, it included $138 billion for healthcare including requirements for hospitals and physicians to computerize their medical records, extension of medical insurance to laid off workers and additional funding for states to offset their Medicaid program expenses. The Obama-Biden team came to power with populist momentum behind their promises to lower health costs while keeping the doctors and insurance plans they had. Its rollout was plagued by miscues and the administration’s most popular assurances (‘keep your doctor and hospitals’) were not kept. The Republican Majority in the 111th Congress’ (247-193)) seized on the administration’s miss fueling anti-ACA rhetoric among critics and misinformation.

3-Support for the ACA has grown but its results are mixed. It has survived 7 Supreme Court challenges and more than 70 failed repeal votes in Congress.  It enjoys vigorous support in the Biden administration and among the industry’s major trade groups but remains problematic to outsiders who believe it harmful to their interests. For example, under the framework of the ACA, the administration is pushing for larger provider networks in the 18 states and DC that run their own marketplaces, expanded dental and mental health coverage, extended open enrollment for Marketplace coverage and restoration of restrictions on “junk insurance’ but its results to date are mixed: access to insurance coverage has increased. Improvements in quality have been significant as a result of innovations in care coordination and technology-enabled diagnostic accuracy. But costs have soared: between 2010 and 2021, total health spending increased 64% while the U.S. population increased only 7%.

So, as the ACA takes center stage in Campaign 2024, here are 4 things to watch:

1-Media attention to elements of the ACA other than health insurance coverage. My bet: attention from critics will be its unanticipated costs in addition to its federal abortion protections now in the hands of states. The ACA’s embrace of price and quality transparency is of particular interest to media and speculation that industry consolidation was an unintended negative result of the law will energize calls for its replacement. Thus, the law will get more attention. Misinformation and disinformation by special interests about its original intent as a “government takeover of the health system” will be low hanging fruit for antagonists.

2- Changes to the law necessary intended to correct/mitigate its unintended consequences, modernize it to industry best practice standards and responses to court challenges will lend to the law’s complex compliance challenges for each player in the system. New ways of prompting Medicaid expansion, integration of mental health and social determinants with traditional care, the impact of tools like ChatGPT, quantum computing, generative AI not imagined as the law was built, the consequences of private equity investments on prices and spending, and much more.

3-Public confusion. The ACA is a massive law in a massive industry. Cliff’s Notes are accessible but opinions about it are rarely based on a studied view of its intent and structure. It lends itself to soundbites intended to obscure, generalize or misdirect the public’s attention.  

4-The ACA price tag. In 2010, the CBO estimated its added cost to health spending at $1.1 trillion (2010-2019) but its latest estimate is at least $3 trillion for its added insurance subsidies alone. The fact is no one knows for sure what its costs are nor the value of the changes it has induced into the health system. The ranks of those with insurance coverage has been cut in half. Hospitals, physicians, post-acute providers, drug manufacturers and insurers are implementing value-based care strategies and price transparency (though reluctantly) but annual health cost increases have consistently exceeded 4% annually as the cumulative impact of medical inflation, utilization, consolidation and price increases are felt.

Final thought:

I have studied the ACA, and the enabling laws, executive orders, administrative and regulatory actions, court rulings and state referenda that have followed its passage. Despite promises to ‘repeal and replace’ by some, it is more likely foundational to bipartisan “fix and repair’ regulatory reforms that focus more attention to systemness, technology-enabled self-care, health and wellbeing and more.

It will be interesting to see how the ACA plays in Campaign 2024 and how moderators for the CNN-hosted debates January 10 in Des Moines and January 21 in New Hampshire address it. In the 2-hour Tuscaloosa debate last Wednesday, it was referenced in response to a question directed to Gov. DeSantis about ‘reforming the system’ 101 minutes into the News Nation broadcast. It’s certain to get more attention going forward and it’s certain to play a more prominent role in the future of the system.

The ACA is back on the radar in U.S. healthcare. Stay tuned.

PS The resignations under pressure of Penn President Elizabeth Magill and Board Chair Scott Bok over inappropriate characterization of Hamas’ genocidal actions toward Jews are not surprising. Her response to Congressional questioning was unfortunate. The eventuality turned in 4 days, sparked by student outrage and adverse media attention that tarnished the reputations of otherwise venerable institutions like Penn, MIT and Harvard.

The lessons for every organization, including the big names in healthcare, are not to be dismissed: Beyond the issues of genocide, our industry is home to a widening number of incendiary issues like Hamas.

They’re increasingly exposed to public smell tests that often lead to more: Workforce strikes. CEO compensation. Fraud and abuse. Tax exemptions and community benefits. Prior authorization and coverage denial. Corporate profit. Patient collection and benevolent use policies. Board independence and competence and many more are ripe for detractors and activist seeking attention. 

Public opinion matters. Reputations matter. Boards of Directors are directly accountable for both.  

Higher-risk patients paying more for colonoscopies

Posted on by • Posted in Colonoscopy, Colonoscopy Diagnostic, Colonoscopy Screening, Health Insurance Coverage Adequacy, Health Insurance Industry, High Deductible Health Plans, High Prices, High Risk Patients, Out of Pocket Expenses, Surprise Bills • Leave a comment

https://mailchi.mp/9b1afd2b4afb/the-weekly-gist-december-1-2023?e=d1e747d2d8

Published this week in Stat, this article explores the confusing payment landscape patients must navigate when receiving colonoscopies. While the Affordable Care Act requires that preventative care services be covered without cost-sharing, this only applies to the “screening” colonoscopies that low-risk patients are recommended to get every ten years.

But when procedures are performed at more frequent intervals for higher-risk patients, they are called “surveillance” or “diagnostic” colonoscopies, for which patients have no guarantees of cost-sharing protections, despite being essentially the same procedure, done for the same purpose.

If a gastroenterologist finds and excises one or more precancerous polyps during a screening colonoscopy, the procedure can leave the patient—especially one with a high deductible health plan—with a large, unexpected bill. 

The Gist: Against the backdrop of a sharp rise in colorectal cancer rates among US adults under 65, articles like this are a frustrating demonstration of how insurance incentive structures can work against optimal care delivery. 

Incentives should be carefully designed such that proven, preventative screenings—at the discretion of their doctor—are widely available to patients with minimal financial barriers. Surely, no one is “choosing” to have an “unnecessary” colonoscopy—as the procedure is notoriously disliked by patients. 

Health Care Sharing Ministries Leave Consumers with Unpaid Medical Claims

Posted on by • Posted in Denial, Health Care Sharing Ministries (HCSMs), Health Insurance Coverage Adequacy, Health Policy, Marketing Deceptive, Out of Pocket Expenses, Public Good, Public Perception, Underinsured, Uninsured • Leave a comment

https://www.commonwealthfund.org/blog/2023/health-care-sharing-ministries-leave-consumers-unpaid-medical-claims

Health care sharing ministries (HCSMs) claim to offer health coverage: members follow a common set of religious or ethical beliefs and make monthly payments to help pay the qualifying medical expenses of other members.

These products often appear comparable to insurance, but they lack the consumer protections and benefit standards that apply to comprehensive coverage. HCSMs are under no obligation to pay members’ claims and often require members to negotiate discounts or seek charity care from health care providers.

Because of how HCSMs are marketed, consumers may have difficulty identifying the significant limitations of these arrangements and risk getting stuck with unpaid bills. Until recently, states did not have access to data on HCSMs’ enrollment, operations, and finances.

Massachusetts and Colorado have begun to fill these gaps, and the data they have obtained are revealing. The Massachusetts marketplace began requiring HCSMs to report key data in 2020; and last year, Colorado became the first state to require comprehensive data from all HCSMs enrolling Colorado residents. The state’s first report provides a detailed look at HCSMs selling memberships in Colorado.

What’s in Colorado’s First Report?

The data show HCSMs have grown to include far more members than previously understood and shed light on risks for consumers who pay monthly fees with an expectation that their membership will cover health care claims.

Greater than expected enrollment. National enrollment for the HCSMs included in the Colorado report is larger than previously recognized: 1.7 million people. In Colorado alone, HCSM enrollment (at least 68,000) is equivalent to 30 percent of marketplace enrollment. Because HCSMs often exclude essential health services and are therefore more attractive to people who are relatively healthy, enrollment of this size, relative to marketplace enrollment, may increase premiums for marketplace plans.

It also means a significant number of people have forgone comprehensive coverage and federal subsidies to buy this alternative arrangement that does not guarantee health care costs will be paid.

One HCSM recently surveyed its members and found 42 percent had incomes under 200 percent of the federal poverty level (about $50,000 annually for a family of three). Individuals and families at this income level would likely be eligible for low- or no-cost coverage in the marketplace or Medicaid.

Broker-driven marketing. Seven HCSMs reported using brokers to market their plans; some said they rely heavily or exclusively on brokers to grow membership. About one-third of all enrollment in these seven HCSMs was attributed to brokers.

Because HCSMs pay substantially higher commissions (15% to 20%) than marketplace insurers (2.6%) typically do, brokers have an incentive to place consumers in these arrangements.

Unpaid claims. Though their members submitted about $362 million in claims during the reporting period, the HCSMs asserted that only one-third of this amount — about $132 million — was eligible for payment. During the same time period, HCSMs brought in about $97 million, resulting in an apparent shortfall of $35 million. The low share of eligible claims is attributable in part to the HCSMs’ strict rules that disallow reimbursement for various types of care.

In addition, HCSMs have broad flexibility to refuse sharing of a claim even if it otherwise meets the rules. For example, HCSMs often require their members to negotiate their own discounts or seek charity care from health care providers before their claims will be eligible for sharing.

Essential care ineligible for sharing. HCSMs reported they exclude from sharing any expenses for certain essential health care, including costs related to preventive care, mental health care, and substance use disorders, and exclude coverage for many preexisting conditions, including asthma, autism, cancer, diabetes, and hypertension. Alternatively, comprehensive insurance must cover essential health benefits and all preexisting conditions.

Getting Uniform Data Is Challenging but Essential

The first-year report shows the challenges of obtaining data from HCSMs that are not subject to any of the standards or oversight that apply to comprehensive health insurance. Regulators determined that several HCSMs marketing memberships in Colorado had failed to report data and getting complete and accurate data from those that did was difficult. A second report, recently released, indicates those challenges continue, making it impossible to draw comparisons between the two years. Still, by requiring HCSMs to use templates and state-defined terms to submit data in a uniform way, Colorado regulators seem to be on the path to a clearer understanding of how HCSMs are working, their financial solvency, and their effect on state residents and the health insurance market. Indeed, data in the second report show the risks to consumers described above persist.

Looking Ahead

Colorado’s annual requirement to share data will help regulators better understand HCSM operations and finances and, with improved compliance to data submission requirements, should allow for comparisons across HCSMs and from year to year. Data can help point regulators to HCSMs that warrant closer scrutiny and identify for policymakers ways to better protect consumers who may lack a clear understanding of the financial risks of HCSM membership.

How America skimps on healthcare

Posted on by • Posted in ACA, Cost Management, Cost Reduction, Cost Shifting, Delayed Care, Denial, Denial Rates, Employee Benefits, Health Insurance Coverage Adequacy, Health Insurance Denial, High Deductible Health Plans, Labor Spend Management, Medicaid, Medical Loss Ratio (MLR), Medicare, Prior Authorization, Shrinkflation, Utilization Trends • Leave a comment

https://www.linkedin.com/pulse/how-america-skimps-healthcare-robert-pearl-m-d–p1qnc/

Not long ago, I opened a new box of cereal and found a lot fewer flakes than usual. The plastic bag inside was barely three-quarters full.

This wasn’t a manufacturing error. It was an example of shrinkflation.

Following years of escalating prices (to offset higher supply-chain and labor costs), packaged-goods producers began facing customer resistance. So, rather than keep raising prices, big brands started giving Americans fewer ounces of just about everything—from cereal to ice cream to flame-grilled hamburgers—hoping no one would notice.

This kind of covert skimping doesn’t just happen at the grocery store or the drive-thru lane. It’s been present in American healthcare for more than a decade.

What Happened To Healthcare Prices?  

With the passage of the Medicare and Medicaid Act in 1965, healthcare costs began consuming ever-higher percentages of the nation’s gross domestic product.

In 1970, medical spending took up just 6.9% of the U.S. GDP. That number jumped to 8.9% in 1980, 12.1% in 1990, 13.3% in 2000 and 17.2% in 2010.  

This trajectory is normal for industrialized nations. Most countries follow a similar pattern: (1) productivity rises, (2) the total value of goods and services increases, (3) citizens demand better care, newer drugs, and more access to doctors and hospitals, (4) people pay more and more for healthcare.  

But does more expensive care equate to better care and longer life expectancy? It did in the United States from 1970 to 2010. Longevity leapt nearly a decade as healthcare costs rose (as a percentage of GDP).

Then American Healthcare Hit A Ceiling

Beginning in 2010, something unexpected happened. Both of these upward trendlines—healthcare inflation and longevity—flattened.

Spending on medical care still consumes roughly 17% of the U.S. GPD—the same as 2010. Meanwhile, U.S. life expectancy in 2020 (using pre-pandemic data) was 77.3 years—about the same as in 2010 when the number was 78.7 years.

How did these plateaus occur?

Skimping On U.S. Healthcare

With the passage of the Affordable Care Act of 2010, healthcare policy experts hoped expansions in health insurance coverage would lead to better clinical outcomes, resulting in fewer heart attacks, strokes and cancers. Their assumption was that fewer life-threatening medical problems would bring down medical costs.

That’s not what happened. Although the rate of healthcare inflation did, indeed, slow to match GDP growth, the cost decreases weren’t from higher-quality medical care, drug breakthroughs or a healthier citizenry. Instead, it was driven by skimping.

And as a result of skimping, the United States fell far behind its global peers in measures of life expectancy, maternal mortality, infant morality, and deaths from avoidable or treatable conditions.

To illustrate this, here are three ways that skimping reduces medical costs but worsens public health:

1. High-Deductible Health Insurance

In the 20th century, traditional health insurance included two out-of-pocket expenses. Patients paid a modest upfront fee at the point of care (in a doctor’s office or hospital) and then a portion of the medical bill afterward, usually totaling a few hundred dollars.

Both those numbers began skyrocketing around 2010 when employers adopted high-deductible insurance plans to offset the rising cost of insurance premiums (the amount an insurance company charges for coverage). With this new model, workers pay a sizable sum from their own pockets—up to $7,050 for single coverage and $14,100 for families—before any health benefits kick in.

Insurers and businesses argue that high-deductible plans force employees to have more “skin in the game,” incentivizing them to make wiser healthcare choices.

But instead of promoting smarter decisions, these plans have made care so expensive that many patients avoid getting the medical assistance they need. Nearly half of Americans have taken on debt due to medical bills. And 15% of people with employer-sponsored health coverage (23 million people) have seen their health get worse because they’ve delayed or skipped needed care due to costs.

And when it comes to Medicaid, the government-run health program for individuals living in poverty, doctors and hospitals are paid dramatically lower rates than with private insurance.

As a result, even though the nation’s 90 million Medicaid enrollees have health insurance, they find it difficult to access care because an increasing number of physicians won’t accept them as patients.

2. Cost Shifting

Unlike with private insurers, the U.S. government unilaterally sets prices when paying for healthcare. And in doing so, it transfers the financial burden to employers and uninsured patients, which leads to skimping.

To understand how this happens, remember that hospitals pay the same amount for doctors, nurses and medicines, regardless of how much they are paid (by insurers) to care for a patient. If the dollars reimbursed for some patients don’t cover the costs, then other patients are charged more to make up the difference.

Two decades ago, Congress enacted legislation to curb federal spending on healthcare. This led Medicare to drastically reduce how much it pays for inpatient services. Consequently, private insurers and uninsured patients now pay double and sometimes triple Medicare rates for hospital services, according to a Kaiser Family Foundation report.

These higher prices generate heftier out-of-pocket expenses for privately insured individuals and massive bills for the uninsured, forcing millions of Americans to forgo necessary tests and treatments.

3. Delaying, Denying Care

Insurers act as the bridge between those who pay for healthcare (businesses and the government) and those who provide it (doctors and hospitals). To sell coverage, they must design a plan that (a) payers can afford and (b) providers of care will accept.

When healthcare costs surge, insurers must either increase premiums proportionately, which payers find unacceptable, or find ways to lower medical costs. Increasingly, insurers are choosing the latter. And their most common approach to cost reduction is skimping through prior authorization.

Originally promoted as a tool to prevent misuse (or overuse) of medical services and drugs, prior authorization has become an obstacle to delivering excellent medical care. Insurers know that busy doctors will hesitate to recommend costly tests or treatments likely to be challenged. And even when they do, patients weary of the wait will abandon treatment nearly one-third of the time.

This dynamic creates a vicious cycle: costs go down one year, but medical problems worsen the next year, requiring even more skimping the third year.

The Real Cost Of Healthcare Skimping

Federal actuaries project that healthcare expenses will rise another $3 trillion over the next eight years, consuming nearly 20% of the U.S. GDP by 2031.

But given the challenges of ongoing inflation and rapidly rising national debt, it’s more plausible that healthcare’s share of the GDP will remain at around 17%.

This outcome won’t be due to medical advancements or innovative technologies, but rather the result of greater skimping.

For example, consider that Medicare decreased payments to doctors 2% this year with another 3.3% cut proposed for 2024. And this year, more than 10 million low-income Americans have lost Medicaid coverage as states continue rolling back eligibility following the pandemic. And insurers are increasingly using AI to automate denials for payment. 

Currently, the competitive job market has business leaders leery of cutting employee health benefits. But as the economy shifts, employees should anticipate paying even more for their healthcare.

The truth is that our healthcare system is grossly inefficient and financially unsustainable. Until someone or something disrupts that system, replacing it with a more effective alternative, we will see more and more skimping as our nation struggles to restrain medical costs.

And that will be dangerous for America’s health.

California takes a step toward establishing universal health coverage for residents

Posted on by • Posted in Center for Medicare and Medicaid Services (CMS), Health Insurance Coverage Adequacy, Health Policy, Healthcare Reform, Universal Coverage, Universal Healthcare System • Leave a comment

https://mailchi.mp/de5aeb581214/the-weekly-gist-october-13-2023?e=d1e747d2d8

California Governor Gavin Newsom signed a bill directing the state’s Health and Human Services Agency to work with the federal government to create a waiver allowing Medicare and Medicaid funding to be reallocated toward a universal health insurance system for its residents. 

The established timeline sets California on track to submit its final waiver for federal approval in 2026. The law does not specify whether universal coverage would be via a single-payer system, which is what Newsom favored in 2018. The California Nurses Association opposed the bill on the grounds that it does not commit to a single-payer outcome, while the California Association of Health Plans protested against its threat to end private coverage in the state.

The Gist: This is California’s 10th attempt at universal care, with all previous attempts having ended in failure because, despite both popular and political support in the state, there has not been consensus on how to pay for it. 

This most recent bill only passed because it was separated from a funding bill, since shelved, addressing the over $300B in tax revenue needed to pay for it. This process-first approach may be seen as a calculated appeasement of the Democratic Party’s left wing, as Governor Newsom clearly holds aspirations for higher office—but so far, 

healthcare has not ranked among the top issues for the current roster of candidates targeting the White House in 2024.

How US is failing to keep its citizens alive into old age

Posted on by • Posted in Access & Quality of Healthcare, Accessible Care, Affordability, Chronic Care Management, Chronic Conditions, Chronic Diseases, Health Equity, Health Inequity, Health Insurance Coverage Adequacy, Health Policy, Health Predictors, Mortality, Poverty, Social Determinants of Health, Systemic Issues • Leave a comment

https://mailchi.mp/9fd97f114e7a/the-weekly-gist-october-6-2023?e=d1e747d2d8

Published this week in the Washington Post, this unsparing article packages a year of investigative reporting into a thorough accounting of why US life expectancy is undergoing a rapid decline. 

After peaking in 2014, US life expectancy has declined each subsequent year, trending far worse than peer countries. In a quarter of US counties, working-age Americans are dying at the highest rates in 40 years, reversing decades of progress. While deaths from firearms and opioids play a role, chronic diseases remain our nation’s greatest killer, erasing more than double the years of life as all overdoses, homicides, suicides, and car accidents combined.

The drivers of this trend are too numerous to list, but experts suggest targeting “the causes of the causes”, namely social factors, as the death rate gap between the rich and poor has grown almost 15x faster than the income gap since 1980. 

The Gist: This reporting is a sobering reminder of the responsibilities—and failures—borne by our nation’s healthcare system. 

The massive death toll of chronic disease in this country is not an indictment of the care Americans receive, but of the care and other resources they cannot access or afford. 

While it’s not the mandate of health systems to reduce systemic issues like poverty, there is no solution to the problem without health systems playing a key role in increasing access to care, while convening community resources in service of these larger goals.

Tightening the Rules Around Short-Term Health Insurance Plans Won’t Lead to More People Going Without Insurance

Posted on by • Posted in ACA, Health Insurance Coverage Adequacy, Health Policy, Out of Pocket Expenses, Preexisting Conditions, Short Term Health Insurance, Skinny Health Plans, Underinsured, Uninsured • Leave a comment
https://www.commonwealthfund.org/blog/2023/tightening-rules-around-short-term-health-insurance-plans-wont-lead-more-people-going?utm_campaign=Achieving%20Universal%20Coverage&utm_medium=email&_hsmi=277181558&_hsenc=p2ANqtz–ufaBTL0WjY2jmyaMR5rMHK2CXJeRoV0TJdWU7NpyNnRfxoN9jXrKrarEMBbia0VnU80H3epvGGw9ZlaL12EzzgnMkjA&utm_source=alert

Short-term, limited-duration insurance (STLDI) plans are exempt from the Affordable Care Act’s (ACA) essential benefit coverage requirements and from prohibitions on medical underwriting.

This means that consumers with preexisting conditions can be denied coverage and anyone who purchases such a plan may lack coverage for key services.

In August 2018, under the Trump administration, the U.S. Department of Health and Human Services revised the definition of short-term plans to include coverage with an initial term of less than 12 months that could be renewed for up to 36 months. While the purported goal of this change was to increase coverage and reduce uninsured rates, our analysis indicates that it did not accomplish this: coverage did not increase and the uninsured rate did not drop.

In July 2023, the Biden administration issued a notice to limit the initial duration of short-term plans to three months, with an option to renew for one additional month. This change was intended to ensure that people purchasing insurance coverage have meaningful protection and to preserve the preexisting condition protections in the ACA. 

Critics feared and some cost estimates suggested that tightening the STLDI rules could leave many without any coverage at all.

In 2019, the Congressional Budget Office (CBO), using its forecast model (data were not yet available), estimated that 1.5 million people would purchase short-term plans and that 500,000 would gain coverage (relative to being uninsured). Our analysis suggests that these forecasts substantially overstated the effects of the rule change; far fewer people enrolled in STLDI plans and the enrollment that did occur was from people moving off marketplace coverage.

There is no evidence that the number of uninsured people declined because these plans became available.

Using data from the American Community Survey and marketplace enrollment from the Centers for Medicare and Medicaid Services (CMS), we assessed whether the loosening of STLDI regulations (under the Trump administration) led to increased enrollment in off-marketplace nongroup coverage in states that permitted sales compared to those that did not. Plans sold off the marketplace include STLDI as well as ACA-compliant plans, grandfathered coverage, health care sharing ministries, and fixed indemnity plans. Next, we looked to see whether the Trump-era regulations increased nongroup insurance coverage altogether (including marketplace coverage) in these states. Finally, we looked to see whether the broader availability of STLDI was associated with lower uninsured rates. We examined coverage patterns for adults ages 26 to 64 and then focused on young men ages 26 to 35, who may be most sensitive to the presence of regulations similar to those in the ACA because they are less likely to have preexisting conditions or to seek comprehensive coverage.

In 2017, 2.6 million adults ages 26 to 64, about 1.6 percent of that population, purchased private nongroup insurance outside the marketplace. By 2020, about 270,000 more people were enrolled in off-marketplace nongroup plans, across all states, than had been in 2017. There was a larger increase in off-marketplace nongroup enrollment among all adults and among young adults (we cannot separate young men in the CMS data) in states that permitted the sale of STLDI coverage, compared to those that prohibited it. This is consistent with the evidence of growth in sales of these plans. Across all states, about 160,000 more young adults, ages 26 to 34, held off-marketplace nongroup coverage in 2020 than in 2017.

The ACS data show that off-marketplace plans largely substituted for marketplace plans in states that permitted the sale of STLDI. Patterns of enrollment in nongroup plans overall were very similar in states with and without STLDI plans available for purchase over this period. While nongroup coverage was consistently more popular in states with no restrictions, between 2017 and 2020 enrollment in nongroup plans declined slightly more in states where STLDI plans were available for purchase than in those where they were not. The same pattern of marginally greater declines held for young men (and young adults) in states where STLDI plans were available.

Nongroup coverage was slightly higher in states where STLDI plans were available for sale, but the overall uninsured rate is much higher in these states, primarily because many did not expand Medicaid eligibility.

The gap in uninsured rates between states with STLDI plans available and those in which they were not available widened through 2018, narrowed slightly in 2019, and rose again in 2020. Patterns among young men were similar.

The lack of reliable information on STLDI plans and the small size of the market make it difficult to draw strong inferences about how changes in regulations affected participation. Nonetheless, by comparing states where the 2018 regulatory changes took effect and those where they did not, we are able to rule out any notable effects. A modest number of people — no more than one-fifth of the 1.5 million the CBO projected — are likely to have enrolled in STLDI plans that became available after the Trump administration’s regulatory change. This enrollment mainly appears to have displaced marketplace coverage.

There is no evidence that the broader availability of STLDI plans had any meaningful effect on nongroup coverage in general or on uninsurance, either in the full population or among young men.

This suggests that the Biden administration’s proposed tightening of STLDI is unlikely to have substantial negative effects on nongroup coverage or uninsurance. Instead, limiting STLDI will likely strengthen the health insurance marketplaces that offer reliable, comprehensive nongroup coverage.