Tag Archives: ACA Repeal

Pre-ACA Market Practices Provide Lessons for ACA Replacement Approaches

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Pre-ACA Market Practices Provide Lessons for ACA Replacement Approaches

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Significant changes to the Affordable Care Act (ACA) are being considered by lawmakers who have been critical of its general approach to providing coverage and to some of its key provisions. An important area where changes will be considered has to do with how people with health problems would be able to gain and keep access to coverage and how much they may have to pay for it.  People’s health is dynamic. At any given time, an estimated 27% of non-elderly adults have health conditions that would make them ineligible for coverage under traditional non-group underwriting standards that existed prior to the ACA. Over their lifetimes, everyone is at risk of having these periods, some short and some that last for the rest of their lives.

One of the biggest changes that the ACA made to the non-group insurance market was to eliminate consideration by insurers of a person’s health or health history in enrollment and rating decisions.  This assured that people who had or who developed health problems would have the same plan choices and pay the same premiums as others, essentially pooling their expected costs together to determine the premiums that all would pay.

Proposals for replacing the ACA such as Rep. Tom Price’s Empowering Patients First Act and Speaker Paul Ryan’s “A Better Way” policy paper would repeal these insurance market rules, moving back towards pre-ACA standards where insurers generally had more leeway to use individual health in enrollment and rating for non-group coverage.1  Under these proposals, people without pre-existing conditions would generally be able to purchase coverage anytime from private insurers.  For people with health problems, several approaches have been proposed: (1) requiring insurers to accept people transitioning from previous coverage without a gap (“continuously covered”); (2) allowing insurers to charge higher premiums (within limits) to people with pre-existing conditions who have had a gap in coverage; and (3) establishing high-risk pools, which are public programs that provide coverage to people declined by private insurers.

The idea of assuring access to coverage for people with health problems is a popular one, but doing so is a challenge within a market framework where insurers have considerable flexibility over enrollment, rating and benefits.  People with health conditions have much higher expected health costs than people without them (Table 1 illustrates average costs of individuals with and without “deniable” health conditions). Insurers naturally will decline applicants with health issues and will adjust rates for new and existing enrollees to reflect their health when they can.  Assuring access for people with pre-existing conditions with limits on their premiums means that someone has to pay the difference between their premiums and their costs.  For people enrolling in high-risk pools, some ACA replacement proposals provide for federal grants to states, though the amounts may not be sufficient.  For people gaining access through continuous coverage provisions, these costs would likely be paid by pooling their costs with (i.e., charging more to) other enrollees.  Maintaining this pooling is difficult, however, when insurers have significant flexibility over rates and benefits.  Experience from the pre-ACA market shows how insurers were able to use a variety of strategies to charge higher premiums to people with health problems, even when those problems began after the person enrolled in their plan.  These practices can make getting or keeping coverage unaffordable.

The discussion below focuses on some of the issues faced by people with health issues in the pre-ACA non-group insurance market.  These pre-ACA insurance practices highlight some of the challenges in providing access and stable coverage for people and some of the issues that any ACA replacement plan will need to address. Many ACA replacement proposals have not yet been developed in sufficient detail to fully deal with these questions, or in some cases may defer them to the states.

We start by briefly summarizing key differences between the ACA and pre-ACA insurance market rules for non-group coverage that affect access and continuity of coverage.  We then focus on pre-ACA access and continuity issues for three different groups: (1) people transitioning from employer coverage or Medicaid to the non-group market; (2) people with non-group coverage who develop a health problem; and (3) people who are uninsured (are not considered to have continuous coverage) who want to buy non-group coverage.  After that, we discuss how medical underwriting and rating practices can segment a risk pool, initially and over time, and challenges that this poses for assuring continuous coverage.  We end by reviewing some of the policy choices for addressing the challenges that have been raised.

Ten Ways That the House American Health Care Act Could Affect Women

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Ten Ways That the House American Health Care Act Could Affect Women

Women have much at stake as the nation debates the future of coverage in the United States. Because the Affordable Care Act (ACA) made fundamental changes to women’s health coverage and benefits, changes to the law and the regulations that stem from it would have a direct impact on millions of women with private insurance and Medicaid. On May 4, 2017, the House of Representatives passed the American Health Care Act (AHCA), to repeal and replace elements of the ACA (Appendix Table 1). It would eliminate individual and employer insurance mandates, effectively end the ACA Medicaid expansion, cap federal funds for the Medicaid program, make major changes to the federal tax subsidies available to assist individuals who purchase private insurance, and ban federal Medicaid funds from going to Planned Parenthood. It would also allow states to waive the ACA’s Essential Health Benefits requirements and permit health status as a factor in insurance rating for individuals who do not maintain continuous coverage with the goal of reducing insurance costs.1 The Senate will now take up legislation to repeal and replace the ACA and may consider several elements that the House has approved in the AHCA. This brief reviews the implications of the AHCA for women’s access to care and coverage.

No, Medicaid isn’t broken

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https://www.axios.com/no-medicaid-isnt-broken-2404950733.html

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One reason the architects of the American Health Care Act want to cut Medicaid spending and give more responsibility to the states is that they believe that the current program is “broken,” with inadequate access to physicians and out-of-control costs. This is one of those canards that is repeated so often that many people just accept it as true. Mostly, it is not true.

Like any big messy public program, Medicaid is very far from perfect, as I learned when I oversaw a Medicaid program for a Republican governor in New Jersey. But on basic measures of access and satisfaction with care, Medicaid beneficiaries look very much like people with private employer coverage despite the fact that they are sicker and poorer. And they’re doing better than the uninsured.

The bottom line: Medicaid isn’t broken — at least, not any more than private insurance is.

Finding doctors: The biggest problem that’s usually cited with Medicaid is that people have trouble finding doctors who will take them. And there are troubles with low Medicaid provider reimbursement rates and physician access, but they vary around the country. It’s not hard to find a state, or more typically a region within a state, where physician access is a real problem.

But overall:

  • 74% of Medicaid beneficiaries see a doctor each year
  • 69% for people with employer based private coverage see a doctor each year.
  • People on Medicaid are also nearly just as satisfied with their health care as people with employer coverage.

Costs aren’t out of control: Medicaid spending did jump to 10.5% in 2015 with the Affordable Care Act coverage expansion, but it dropped to 5.9% in 2016 and is projected to grow by 4.5% this year.

And per capita Medicaid costs are not rising faster than costs for private insurance. In fact, they’re projected to grow more slowly.

Some would say that’s because Medicaid underpays providers, and it does pay substantially less than Medicare in many states. Others would say, good for Medicaid; it drives a tougher bargain with providers while getting results comparable to other payers.

The AHCA would take more than 800 billion dollars out of Medicaid over the next decade by reducing funding for the Medicaid expansion and capping federal Medicaid spending. The architects of the AHCA may believe Medicaid dollars are better spent elsewhere or not spent at all, or that somehow states can make Medicaid work better with far less money.

There are many principled conservative arguments for smaller government. But the argument that Medicaid is “broken” is not one of them; it is more urban legend than fact.

States Seek to Join Appeal of House Obamacare Lawsuit

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https://morningconsult.com/2017/05/18/states-seek-join-appeal-house-obamacare-lawsuit/

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More than a dozen states and the District of Columbia filed a motion on Thursday to intervene in the appeal of a lawsuit targeting the Affordable Care Act’s cost-sharing reduction payments, which have become a focal point for how President Donald Trump plans to treat the 2010 health care law.

The 15 states argue that the executive branch is not adequately defending its authority to make the CSR payments and does not represent their interests. They also said that if the appeals court agrees with the previous ruling that the Obama administration unconstitutionally paid the subsidies, states and their residents would be harmed and there would be significantly higher costs for health care.

The subsidies are at the center of a lawsuit brought by the U.S. House of Representatives against the Obama administration, which the Trump administration must now deal with.

“Because of an intervening presidential election, the current parties appear ready to agree to allow the injunction to stand, without giving this Court the opportunity to determine whether the district court had either jurisdiction to enter it or a legal basis to enjoin the permanent appropriation that Congress intended to provide,” the motion reads.

House Republicans argued the Obama administration paid the subsidies — which help lower-income people afford out-of-pocket costs under the ACA — without an appropriation from Congress. A district court judge ruled in favor of the House last year, and the Obama administration appealed the ruling.

The payments have been made while the lawsuit is pending, but the Trump administration has wavered on whether it will continue to make them in the future, worrying insurers as they prepare to set their premium rates for 2018. Insurers say they need to know the payments’ status before filing their requests by the June 21 deadline.

The states in the lawsuit say their “concerns are concrete and immediate,” due to the urgency insurers face. If the payments are not made, insurance premiums would likely rise and insurers could abandon the individual market, which could trigger a “death spiral” and cause people to lose health coverage, the states warned.

Trump is using the payments as “political bargaining chips,” meaning states and their residents can’t rely on the administration to represent their position, they said.

“The public record makes clear that the current Administration does not represent the States’ interests,” according to the motion jointly filed by California, Connecticut, Delaware, Hawaii, Illinois, Iowa, Kentucky, Maryland, Massachusetts, Minnesota, New Mexico, New York, Pennsylvania, Vermont, Washington state and the District of Columbia.

The Kaiser Family Foundation has estimated that the average premiums for silver plans sold on the ACA exchanges would increase by about 19 percent to compensate for insurers’ lack of funding without the CSR payments.

The Trump administration and the House are set to update the court on Monday on how they plan to proceed with the case. In February, an appeals court agreed to keep the case on hold while both sides continued to work toward a resolution.

House GOP may have to vote again on healthcare bill

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http://www.fiercehealthcare.com/aca/house-gop-may-have-to-vote-again-healthcare-bill?utm_medium=nl&utm_source=internal&mrkid=959610&mkt_tok=eyJpIjoiWlRsbE5tRmhNVGsxWVRnMSIsInQiOiIrSG9qdHJ5aEdETGxnaVl4QWYybXJqdnhZN0JqREZCVWF4NWFPRXZ0TnhqdFRZOVZtbFBrbjVhS0doQXhvNCtLOEVkditHSUpCOHkyQXVlVDVyQUV6Wmlpa3NleHhETzNQMm9QbnU1NkxKZjhlWFl4cGxsWiszQkI2SHpobnpGcSJ9

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House Republicans, who voted on the American Health Care Act before the Congressional Budget Office scored the bill, might have to take another vote on the measure if the CBO finds it doesn’t reduce spending by at least $2 billion.

The bill has yet to be sent to the Senate as the House awaits the CBO’s report to see if it meets budget reconciliation rules. If it doesn’t, it will need 60 Senate votes to pass instead of 51—a threshold that would be be impossible without support from at least some Democrats.

Rising Insulin Prices Have Diabetics Crying Foul

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http://www.cbsnews.com/news/insulin-prices-rise-yet-again-causing-diabetics-to-cry-foul/

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Insulin prices are only getting more painful.

Drugmakers Eli Lilly (LLY) and Novo Nordisk recently boosted their insulin list prices by almost 8 percent each, adding to concerns that treating diabetes is unaffordable for some patients. The average price of insulin almost tripled between 2002 and 2013, according to the American Diabetes Association (ADA). Even before the most recent price hike, some diabetics were cutting back or even going without the drug because of its expense.

The price hikes come at a sensitive time for the drugmakers as Eli Lilly, Novo Nordisk and rival Sanofi-Aventis are facing a class-action lawsuit alleging they conspired to raise their prices in lockstep. Almost one in 10 Americans has diabetes, a group of conditions where the body fails to properly regulate blood sugar. People with Type 1 diabetes, often referred to as juvenile diabetes, need to take insulin daily to stay alive.

“We were really disappointed in this announcement,” said Dr. William Cefalu, the chief scientific, medical and mission officer for the ADA, who noted that his organization has partnerships for research with the drugmakers. “This is really going in the wrong direction.”

 

Lobby groups to watch in Senate healthcare fight

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Lobby groups to watch in Senate healthcare fight

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Lobbying groups opposed to the House’s healthcare reform bill are pinning their hopes on the Senate for big changes.

Industry groups felt largely cut out of the House’s drafting and passage of the American Health Care Act and now are clamoring for action to fix what they view as serious defects in the legislation.

Major hospital and doctor associations, for example, want people with health insurance to stay covered and are pushing to ensure adequate funding for the Medicaid program.

Characterizing this wish list, one healthcare lobbyist put it simply: “Coverage, coverage, coverage.”

AARP, meanwhile, is urging the Senate to start from scratch on a new healthcare bill. The powerful lobbying group for senior citizens believes the legislation, in its current form, creates  “an unaffordable age tax” for older Americans.

Here are the industries and groups to watch as senators write their healthcare reform bill.

Hospitals

Just a day after the House released its bill, the American Hospital Association (AHA) sent a letter to lawmakers in opposition — and that position hasn’t changed.

In a statement after the bill’s passage through the House, AHA President and CEO Rick Pollack said he was “disappointed” because the bill “jeopardize[s] coverage for millions of Americans” and “makes deep cuts to Medicaid.”

The association’s voice carries weight, as it represents nearly 5,000 member hospitals and healthcare systems and is the sixth-highest spender on lobbying this year, according to OpenSecrets.

About 24 million people would become uninsured under the House bill, according to the nonpartisan Congressional Budget Office (CBO). An updated score from the CBO is expected next week.

Other hospital organizations have also panned the House’s healthcare bill, including the Federation of American Hospitals and America’s Essential Hospitals.

Hospital associations want a bill that won’t result in millions more without health coverage and are looking to prevent the CBO-estimated $880 billion in Medicaid cuts. They say the proposed reductions will make it more difficult for hospitals to deliver care.

One hospital advocate said its group is having serious conversations on the policy recommendations it can make to the Senate to help protect patients and hospitals from the costs that could fall on their shoulders.

Healthcare providers

The fourth-largest lobbying spender this year, the American Medical Association (AMA), is also a vocal critic of the House bill.

On Monday, the group representing physicians and medical students sent a letter to Senate Majority Leader Mitch McConnell (R-Ky.) and Senate Minority Leader Charles Schumer (D-N.Y.) to “reaffirm the principles” that they say should guide any bill that changes ObamaCare.

Health coverage is a top priority for the group.

“Throughout the current debate we have consistently recommended that any proposals to replace portions of the current law should pay special attention to ensure that individuals currently covered do not lose access to affordable, quality health insurance coverage,” AMA CEO James Madara wrote in the letter.

The group is pushing to retain protections for pre-existing conditions and ensure states that expanded Medicaid under ObamaCare isn’t put at risk.

The AMA also says the new tax credits in the Republican bill for purchasing insurance should factor in income, geography and age. The House-passed bill only factored in age for determining a credit, increasing the size of the subsidy as a person gets older.

The American College of Surgeons, consisting of more than 80,000 members, didn’t formally oppose the House bill. Yet it had concerns about the bill’s access to surgical care and ability to let states opt out of requiring insurers to cover a list of 10 categories of services.

“Making sure that patients have insurance that is needed to making sure that they have timely access to surgical care was important, and I know will continue to be important to the American College of Surgeons as we review a Senate bill,” Christian Shalgian, the director of the group’s division of advocacy and health policy, said.

He added: “I think we’re definitely getting a receptive ear from the Senate. They’re interested in where we’re at with what they’re going to be doing in the coming weeks and months.”

Insurers

The leading lobbying group for health insurers, America’s Health Insurance Plans (AHIP), didn’t oppose the House bill.

But it did see room for improvement — and was quick to provide recommendations to the Senate.

Just two hours after the House passed its bill, Marilyn Tavenner, AHIP president and CEO, detailed a few proposed changes in a statement. They included bolstering tax credits for lower-income Americans, older adults and those living in areas with high healthcare costs and providing enough time for people to adjust to Medicaid changes, among others.

Insurers also have an immediate request, though: getting certainty from the administration and Congress that crucial ObamaCare payments to insurers, to the tune of about $7 billion, will continue to be made.

The Association for Community Affiliated Plans (ACAP) did come out against the bill. ACAP represents 60 nonprofit safety net plans serving those enrolled in public health programs, such as Medicaid and the children’s health insurance program.

ACAP CEO Margaret Murray said the House’s bill, if enacted, “would cause considerable damage to our health care system.” Areas of concern included Medicaid cuts and phasing out the enhanced federal funding to states that expanded the health program for the poor and disabled.

“[The bill] will severely limit access to services for the more than 70 million people who rely on Medicaid for effective health coverage — and locks states’ funding to what they spent on Medicaid in 2016,” Murray said in a statement an hour before the bill passed.

AARP

AARP says the bill has an “age tax.”

The group, which represents nearly 38 million people, opposes a provision in the House bill that would let insurance companies charge older adults five times more than younger people.

This is a change from ObamaCare, which operates under a 3-to-1 ratio — a ratio that AARP would like to keep, said David Certner, AARP’s legislative counsel. “Already at 3-to-1, it’s quite expensive,” he said.

AARP is concerned that the change to the age ratio, coupled with reduced financial assistance, will result in premiums older adults can’t afford. The CBO estimated a 64-year-old making $26,500 a year would have to pay more than half of their income in premiums under the American Health Care Act.

“AARP urges you to ‘start from scratch’ and craft health care legislation that ensures robust insurance market protections, controls costs, improves quality, and provides affordable coverage to all Americans,” AARP Executive Vice President Nancy LeaMond wrote in a letter sent to senators Monday.

House Bill Targets Pre-Existing Conditions in Multiple Ways

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http://www.realclearhealth.com/articles/2017/05/18/house_bill_targets_pre-existing_conditions_in_multiple_ways_110599.html?utm_source=RC+Health+Morning+Scan&utm_campaign=38995c8cb7-EMAIL_CAMPAIGN_2017_05_19&utm_medium=email&utm_term=0_b4baf6b587-38995c8cb7-84752421

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For those with pre-existing medical conditions, the House-passed health bill became notorious for a last-minute addition that would let insurers once again charge them higher premiums in the individual market based on their health status. But the focus on this single provision distracts from a troubling fact: even without it, the bill would threaten health care for those with pre-existing conditions in four broader ways.

#1: The bill would cap and cut federal funding for virtually all of Medicaid by imposing a per capita cap or letting states convert Medicaid into a block grant.

A per capita cap would set annual limits on federal funding per beneficiary that would grow more slowly than actual health care costs. A block grant would cap the amount of overall federal Medicaid funding the state could receive. Either way, states would receive significantly less federal funding compared to current law, under which the federal government pays a fixed share of state Medicaid costs, and the funding cuts would grow deeper each year.

Faced with large cuts in federal funding, states would have no choice but to sharply cut their programs. Consequently, tens of millions of people with pre-existing conditions – including millions of children with disabilities and special health care needs – would face the threat of Medicaid cuts.  They could lose coverage entirely or go without needed care as states scaled back covered benefits and payments to medical providers.

Home- and community-based services, an optional Medicaid benefit that most states already limit based on available funds, would be at particular risk. These services, which include nursing and home health care and help with chores, meals, transportation, and other services, let seniors and other low-income people with serious health problems remain in their homes instead of having to go to a nursing home.

#2: The federal government wouldn’t provide any more enhanced funding after 2019 for Medicaid enrollees who were enrolled because their states took the option, under the Affordable Care Act (ACA), to expand their Medicaid programs.

That would force states to pay three to five times more for the ACA’s Medicaid expansion.  Most or all of the 31 states and Washington, D.C. that have adopted it would have no choice but to drop it because they could no longer afford it.

The Medicaid expansion now covers 11 million people, including many who have pre-existing conditions. For example, almost 30 percent of those benefitting from the Medicaid expansion have a mental illness or substance use disorder. By effectively ending the Medicaid expansion starting in 2020, the House bill would leave millions of low-income people with pre-existing conditions without coverage.

#3: The bill would let insurers charge older people — many of whom have pre-existing conditions —at least five times more to buy coverage compared to younger consumers, while also slashing the subsidies that help them afford insurance. 

For example, a 60-year-old woman with $22,000 of annual income who faced the national average benchmark premium would pay $8,200 more in premiums after accounting for federal tax credits than she does now. The Congressional Budget Office projects that uninsured rates for people age 50-64 would double due to the House bill.  Some 84 percent of people age 55-64 have pre-existing health conditions.

#4: The bill would eliminate a broad range of consumer protections that the ACA established in the individual market, threatening access to health care and coverage for those with pre-existing conditions.

Plans would no longer need to offer a comprehensive set of benefits and could exclude even core benefits such as maternity services and mental health care. Nor would they have to limit the amount that people with expensive health care must pay out-of-pocket for deductibles and other cost-sharing each year.  Insurers could again place annual and lifetime limits not only on individual and small-group plans but also on coverage that people get from large employers, leaving millions with costly pre-existing conditions to once again worry about exhausting their benefits.

All told, then, the House bill would bring back the highly-flawed, pre-ACA individual insurance market that made it impossible for millions with pre-existing conditions to get adequate, affordable health coverage.  Additionally, it would threaten the coverage of millions of Medicaid recipients with pre-existing conditions.

That’s not a health care system that should make us proud.

AHCA Would Affect Medicare, Too

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http://www.commonwealthfund.org/publications/blog/2017/may/ahca-would-affect-medicare?omnicid=EALERT1211869&mid=henrykotula@yahoo.com

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“Don’t touch my Medicare” has been a rallying cry in recent years, first as Congress considered health reform and now as it debates the fate of the Affordable Care Act (ACA). While the bill that would repeal and replace the ACA—the American Health Care Act (AHCA)—does not include explicit changes to Medicare, the legislation could have a profound impact on the 11 million Medicare beneficiaries who also rely on Medicaid for key components of their care. Here’s a look at how the ACHA’s major changes in federal funding for Medicaid would affect low-income older adults and the Medicare program.

One-Third of All Medicaid Spending Is for People Covered by Medicare

Low-income Medicare beneficiaries who also are enrolled in Medicaid—often referred to as “dual eligibles”—could be disproportionately affected by congressional efforts to cut and cap federal Medicaid financing. Not only do these older adults account for one-third of all Medicaid spending, much of the Medicaid spending for low-income Medicare beneficiaries is “optional” for states.1

The nearly three-quarters (72%) of dual eligibles who receive full Medicaid benefits are most at risk under the AHCA’s funding caps.2  They tend to be in poorer health than other Medicare (and Medicaid) beneficiaries, and rely on Medicaid for high-cost services.3  While Medicare covers physician, hospital, and most other acute care, Medicaid covers some of dual eligibles’ behavioral health services as well as most of their long-term services and supports, such as nursing home and home and community-based services. Under federal law, many of these services are optional. Similarly, many low-income Medicare beneficiaries who qualify for Medicaid are “optional” beneficiaries who qualify only when they incur health and long-term care costs that are well in excess of their incomes. States can drop optional services and optional enrollees even without any new federal flexibility.

58% of Physicians ‘Strongly Negative’ on AHCA

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http://www.healthleadersmedia.com/physician-leaders/58-physicians-strongly-negative-ahca?spMailingID=11059722&spUserID=MTY3ODg4NTg1MzQ4S0&spJobID=1161579213&spReportId=MTE2MTU3OTIxMwS2

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Survey data suggests that physicians dislike the GOP’s American Health Care Act even more than they disliked the Affordable Care Act.

Two-thirds of physicians do not like the American Health Care Act, the Republican House bill to unwind Obamacare, while only about a quarter support it, a new survey indicates.

The survey of 1,112 physicians by the Dallas-based physician search firm Merritt Hawkins found that 66% of doctors have a negative impression of the AHCA, 26% have a positive impression, and 7% are neutral.

“Physicians have consistently expressed dissatisfaction with government-sponsored healthcare legislation in the past, and the AHCA does not reverse this trend,” Mark Smith, president of Merritt Hawkins, said in a media release. “So far, the bill rates a strongly negative diagnosis from physicians.”

In a 2016 survey of 17,236 physicians that Merritt Hawkins conducted for The Physicians Foundation, 23% of physicians gave the Affordable Care Act a grade of A or B, 28% gave it an average grade of C, while 48% gave it a D or F.

The AHCA, now being considered by the Senate, gets an even higher negative rating in the new Merritt Hawkins survey. Fifty-eight percent of those surveyed have a strongly negative impression of the bill, 8% have a somewhat negative impression, while 7% are neutral.

At the other end, 27% of physicians favor full repeal and replacement, while only 7% of respondents say keep it as it is, indicating the extent of dissatisfaction with the ACA, the HealthLeaders Media survey showed.

The Merritt Hawkins survey findings are in line with a HealthLeaders Media survey published in January, which showed that healthcare industry leaders support changes to the ACA rather than replacing it. Two-thirds of respondents (66%) said the best option for the healthcare industry regarding the ACA would be to make some changes but otherwise retain it.

Physicians Groups Denounce AHCA

Opposition to the AHCA among practicing physicians is reflected by the nation’s major physicians associations, all of which have come out against the repeal and replace proposal.

The American Medical Association, the nation’s largest physicians’ association, made clear its strong opposition to the ACHA in a March 7 letter to Congress, and again on April 27. Of course, the AMA has a long history of railing against government-sponsored healthcare.

The Merritt Hawkins survey was sent by email to about 80,000 physicians randomly selected from Merritt Hawkins’ database and has an error rate of +/- 2.87% as determined by experts in statistical response at the University of Tennessee.