Pre-existing conditions: Does any GOP proposal match the ACA?

https://www.politifact.com/truth-o-meter/article/2018/oct/17/pre-existing-conditions-does-any-gop-proposal-matc/?fbclid=IwAR2QXSwiwRryxaHWJVgO3evTUtJPk6QcV1HkxkaI2qq3iPWqsrXqGA0qPeY

From a routine visit to a critical exam, the stethoscope remains one of the most common physician tools. (Alex Proimos, via Flickr Creative Commons)

In race after race, Democrats have been pummeling Republicans on the most popular piece of Obamacare, protections for pre-existing conditions. No matter how sick someone might be, today’s law says insurance companies must cover them.

Republican efforts to repeal and replace Obamacare have all aimed to retain the guarantee that past health would be no bar to new coverage.

Democrats aren’t buying it.

In campaign ads in NevadaIndianaFloridaNorth Dakota, and more, Democrats charged their opponents with either nixing guaranteed coverage outright or putting those with pre-existing conditions at risk. The claims might exaggerate, but they all have had a dose of truth.

Republican proposals are not as air tight as Obamacare.

We’ll walk you through why.

The current guarantee

In the old days, insurance companies had ways to avoid selling policies to people who were likely to cost more than insurers wanted to spend. They might deny them coverage outright, or exclude coverage for a known condition, or charge so much that insurance became unaffordable.

The Affordable Care Act boxes out the old insurance practices with a package of legal moves. First, it says point-blank that carriers “may not impose any preexisting condition exclusion.” It backs that up with another section that says they “may not establish rules for eligibility” based on health status, medical condition, claims experience or medical history.

Those two provisions apply to all plans. The third –– community rating –– targets insurance sold to individuals and small groups (about 7 percent of the total) and limits the factors that go into setting prices. In particular, while insurers can charge older people more, they can’t charge them more than three times what they charge a 21-year-old policy holder.

Wrapped around all that is a fourth measure that lists the essential health benefits that every plan, except grandfathered ones, must offer. A trip to the emergency room, surgery, maternity care and more all fall under this provision. This prevents insurers from discouraging people who might need expensive services by crafting plans that don’t offer them.

At rally after rally for Republicans, President Donald Trump has been telling voters “pre-existing conditions will always be taken care of by us.” At an event in Mississippi, he faulted Democrats, saying, they have no plan,” which ignores that Democrats already voted for the Obamacare guarantees.

At different times last year, Trump voiced support for Republican bills to replace Obamacare. The White House said the House’s American Health Care Act “protects the most vulnerable Americans, including those with pre-existing conditions.” A fact sheet cited $120 billion for states to keep plans affordable, along with other facets in the bill.

But the protections in the GOP plans are not as strong as Obamacare. One independent analysis found that the bill left over 6 million people exposed to much higher premiums for at least one year. We’ll get to the congressional action next, but as things stand, the latest official move by the administration has been to agree that the guarantees in the Affordable Care Act should go. It said that in a Texas lawsuit tied to the individual mandate.

The individual mandate is the evil twin of guaranteed coverage. If companies were forced to cover everyone, the government would force everyone (with some exceptions) to have insurance, in order to balance out the sick with the healthy. In the 2017 tax cut law, Congress zeroed out the penalty for not having coverage. A few months later, a group of 20 states looked at that change and sued to overturn the entire law.

In particular, they argued that with a toothless mandate, the judge should terminate protections for pre-existing conditions.

The U.S. Justice Department agreed, writing in its filing “the individual mandate is not severable from the ACA’s guaranteed-issue and community-rating requirements.”

So, if the mandate goes, so does guaranteed-issue.

The judge has yet to rule.

Latest Republican plan has holes

In August, a group of 10 Republican senators introduced a bill with a title designed to neutralize criticism that Republicans don’t care about this issue. It’s called Ensuring Coverage for Patients with Pre-Existing Conditions. (A House Republican later introduced a similar bill.)

The legislation borrows words directly from the Affordable Care Act, saying insurers “may not establish rules for eligibility” based on health status, medical condition, claims experience or medical history.

But there’s an out.

The bill adds an option for companies to deny certain coverage if “it will not have the capacity to deliver services adequately.”

To Allison Hoffman, a law professor at the University of Pennsylvania, that’s a big loophole.

“Insurers could exclude someone’s preexisting conditions from coverage, even if they offered her a policy,” Hoffman said. “That fact alone sinks any claims that this law offers pre-existing condition protection.”

The limit here is that insurers must apply such a rule across the board to every employer and individual plan. They couldn’t cherry pick.

But the bill also gives companies broad leeway in setting premiums. While they can’t set rates based on health status, there’s no limit on how much premiums could vary based on other factors.

The Affordable Care Act had an outside limit of 3 to 1 based on age. That’s not in this bill. And Hoffman told us the flexibility doesn’t stop there.

“They could charge people in less healthy communities or occupations way more than others,” Hoffman said. “Just guaranteeing that everyone can get a policy has no meaning if the premiums are unaffordable for people more likely to need medical care.”

Rodney Whitlock, a health policy expert who worked for Republicans in Congress, told us those criticisms are valid.

“Insurers will use the rules available to them to take in more in premiums than they pay out in claims,” Whitlock said. “If you see a loophole and think insurers will use it, that’s probably true.”

Past Republican plans also had holes

Whitlock said more broadly that Republicans have struggled at every point to say they are providing the same level of protection as in the Affordable Care Act.

“And they are not,” Whitlock said. “It is 100 percent true that Republicans are not meeting the Affordable Care Act standard. And they are not trying to.”

The House American Health Care Act and the Senate Better Care Reconciliation Act allowed premiums to vary five fold, compared to the three fold limit in the Affordable Care Act. Both bills, and then later the Graham-Cassidy bill, included waivers or block grants that offered states wide latitude over rates.

Graham-Cassidy also gave states leeway to redefine the core benefits that every plan had to provide. Health law professor Wendy Netter Epstein at DePaul University said that could play out badly.

“It means that insurers could sell very bare-bones plans with low premiums that will be attractive to healthy people, and then the plans that provide the coverage that sicker people need will become very expensive,” Epstein said.

Insurance is always about sharing risk. Whether through premiums or taxes, healthy people cover the costs of taking care of sick people. Right now, Whitlock said, the political process is doing a poor job of resolving how that applies to the people most likely to need care.

“The Affordable Care Act set up a system where people without pre-existing conditions pay more to protect people who have them,” Whitlock said. “Somewhere between the Affordable Care Act standard and no protections at all is a legitimate debate about the right tradeoff. We are not engaged in that debate.”

 

 

IN SEARCH OF INSURANCE SAVINGS, CONSUMERS CAN GET UNWITTINGLY WEDGED INTO NARROW-NETWORK PLANS

https://www.healthleadersmedia.com/search-insurance-savings-consumers-can-get-unwittingly-wedged-narrow-network-plans?utm_source=silverpop&utm_medium=email&utm_campaign=ENL_181101_LDR_BRIEFING%20(1)&spMailingID=14541829&spUserID=MTY3ODg4NTg1MzQ4S0&spJobID=1520057837&spReportId=MTUyMDA1NzgzNwS2

Wedged Into Narrow-Network Plans

Despite federal rules requiring plans to keep up-to-date directories, consumers may lack access to clear information about which health plans have ‘narrow networks’ of providers or which hospitals and doctors are in or out of an insurer’s network.

As a breast cancer survivor, Donna Catanuchi said she knows she can’t go without health insurance. But her monthly premium of $855 was too high to afford.

“It was my biggest expense and killing me,” said Catanuchi, 58, of Mullica Hill, N.J.

A “navigator” who helps people find coverage through the Affordable Care Act found a solution. But it required Catanuchi, who works part time cleaning offices, to switch to a less comprehensive plan, change doctors, drive farther to her appointments and pay $110 a visit out-of-pocket — or about three times what she was paying for her follow-up cancer care.

She now pays $40 a month for coverage, after she qualified for a substantial government subsidy.

Catanuchi’s switch to a more affordable but restrictive plan reflects a broad trend in insurance plan design over the past few years. The cheaper plans offer far narrower networks of doctors and hospitals and less coverage of out-of-network care. But many consumers are overwhelmed or unaware of the trade-offs they entail, insurance commissioners and policy experts say.

With enrollment for ACA health plans beginning Nov. 1, they worry that consumers too often lack access to clear information about which health plans have “narrow networks” of medical providers or which hospitals and doctors are in or out of an insurer’s network, despite federal rules requiring plans to keep up-to-date directories.

“It’s very frustrating for consumers,” said Betsy Imholz, who represents the advocacy group Consumers Union at the National Association of Insurance Commissioners. “Health plan provider directories are often inaccurate, and doctors are dropping in and out all the time.”

These more restrictive plans expose people to larger out-of-pocket costs, less access to out-of-network specialists and hospitals, and “surprise” medical bills from unforeseen out-of-network care.

More than 14 million people buy health insurance on the individual market — largely through the ACA exchanges, and they will be shopping anew this coming month.

TREND APPEARS TO BE SLOWING

For 2018, 73 percent of plans offered through the exchanges were either health maintenance organizations (HMOs) or exclusive provider organizations (EPOs), up from 54 percent in 2015.

Both have more restrictive networks and offer less out-of-network coverage compared with preferred provider organizations (PPOs), which represented 21 percent of health plans offered through the ACA exchanges in 2018, according to Avalere, a health research firm in Washington, D.C.

PPOs typically provide easier access to out-of-network specialists and facilities, and partial — sometimes even generous — payment for such services.

Measured another way, the number of ACA plans offering any out-of-network coverage declined to 29 percent in 2018 from 58 percent in 2015, according to a recent analysis by the Robert Wood Johnson Foundation.

For example, in California, HMO and EPO enrollment through Covered California, the state’s exchange, grew from 46 percent in 2016 to 70 percent in 2018, officials there said. Over the same period, PPO enrollment declined from 54 percent to 30 percent.

In contrast, PPOs have long been and remain the dominant type of health plan offered by employers nationwide. Forty-nine percent of the 152 million people and their dependents who were covered through work in 2018 were enrolled in a PPO-type plan. Only 16 percent were in HMOs, according to the Kaiser Family Foundation’s annual survey of employment-based health insurance.

The good news for people buying health insurance on their own is that the trend toward narrow networks appears to be slowing.

“When premiums shot up over the past few years, insurers shifted to more restrictive plans with smaller provider networks to try and lower costs and premiums,” said Chris Sloan, a director at Avalere. “With premium increases slowing, at least for now, that could stabilize.”

Some research supports this prediction. Daniel Polsky, a health economist at the University of Pennsylvania, found that the number of ACA plans nationwide with narrow physician networks declined from 25 percent in 2016 to 21 percent in 2017.

Polsky is completing an analysis of 2018 plans and expects the percent of narrow network plans to remain “relatively constant” for this year and into 2019.

“Fewer insurers are exiting the marketplace, and there’s less churn in the plans being offered,” said Polsky. “That’s good news for consumers.”

Insurers may still be contracting with fewer hospitals, however, to constrain costs in that expensive arena of care, according to a report by the consulting firm McKinsey & Co. It found that 53 percent of plans had narrow hospital networks in 2017, up from 48 percent in 2014.

“Narrow networks are a trade-off,” said Paul Ginsburg, a health care economist at the Brookings Institution. “They can be successful when done well. At a time when we need to find ways to control rising health care costs, narrow networks are one legitimate strategy.”

Ginsburg also notes that there’s no evidence to date that the quality of care is any less in narrow versus broader networks, or that people are being denied access to needed care.

Mike Kreidler, Washington state’s insurance commissioner, said ACA insurers in that state “are figuring out they can’t get away with provider networks that are inadequate to meet people’s needs.”

“People have voted with their feet, moving to more affordable choices like HMOs but they won’t tolerate draconian restrictions,” Kreidler said.

The state is stepping in, too. In December 2017, Kreidler fined one insurer — Coordinated Care — $1.5 million for failing to maintain an adequate network of doctors. The state suspended $1 million of the fine if the insurer had no further violations. In March 2018, the plan was docked another $100,000 for similar gaps, especially a paucity of specialists in immunology, dermatology and rheumatology. The $900,000 in potential fines continues to hang over the company’s head.

Centene Corp, which owns Coordinated Care, has pledged to improve its network.

Pennsylvania Insurance Commissioner Jessica Altman said she expects residents buying insurance in the individual marketplace for 2019 to have a wider choice of providers in their networks.

“We think and hope insurers are gradually building more stable networks of providers,” said Altman.

NEW STATE LAWS

Bad publicity and recent state laws are pushing insurers to modify their practices and shore up their networks.

About 20 states now have laws restricting surprise bills or balance billing, or which mandate mediation over disputed medical bills, especially those stemming from emergency care.

Even more have rules on maintaining accurate, up-to-date provider directories.

The problem is the laws vary widely in the degree to which they “truly protect consumers,” said Claire McAndrew, a health policy analyst at Families USA, a consumer advocacy group in Washington, D.C. “It’s a patchwork system with some strong consumer protections and a lot of weaker ones.”

“Some states don’t have the resources to enforce rules in this area,” said Justin Giovannelli, a researcher at the Center on Health Insurance Reforms at Georgetown University. “That takes us backward in assuring consumers get coverage that meets their needs.”

 

 

What’s at Stake for Health Care in Your District This Midterm Election?

https://www.chcf.org/publication/whats-at-stake-health-care-midterm/

Image result for What’s at Stake for Health Care in Mid Term Elections

 

On November 6, 2018, Californians will head to the polls to vote for who will represent them in Congress. The outcome of races could have significant implications for health care in California and nationwide. Major policies at stake include the Affordable Care Act (ACA), the Medicaid program (called Medi-Cal in California), and protections for those with preexisting conditions.

What’s at stake for California?

  • 1.4 million Californians purchase coverage through Covered California, the health insurance marketplace established under the ACA. Close to 90% receive federal subsidies to help them afford their premiums.
  • 13.5 million Californians are covered by Medi-Cal.
  • 6.7 million Californians would have lost coverage by 2027 if the last attempt by Congress to repeal the ACA and cut Medicaid (through a proposal called Graham-Cassidy) had passed. It is widely anticipated that a future attempt to repeal the ACA would be modeled after Graham-Cassidy.
  • 550,000 fewer jobs would have been created in California by 2027 if Graham-Cassidy had passed.
  • 16.7 million nonelderly Californians are estimated to live with a preexisting condition.

What’s at stake in your district?

 

High-Deductible Health Plans Fall From Grace In Employer-Based Coverage

https://www.thefiscaltimes.com/2018/10/03/High-Deductible-Health-Plans-Fall-Grace-Employer-Based-Coverage

With workers harder to find and Obamacare’s tax on generous coverage postponed, employers are hitting pause on a feature of job-based medical insurance much hated by employees: the high-deductible health plan.

Companies have slowed enrollment in such coverage and, in some cases, reinstated more traditional plans as a strong job market gives workers bargaining power over pay and benefits, according to research from three organizations.

This year, 39 percent of large, corporate employers surveyed by the National Business Group on Health (NBGH) offer high-deductible plans, also called “consumer-directed” coverage, as workers’ only choice. For next year, that figure is set to drop to 30 percent.

“That was a surprise, that we saw that big of a retraction,” said Brian Marcotte, the group’s CEO. “We had a lot of companies add choice back in.”

Few if any employers will return to the much more generous coverage of a decade or more ago, benefits experts said. But they’re reassessing how much pain workers can take and whether high-deductible plans control costs as advertised.

“It got to the point where employers were worried about the affordability of health care for their employees, especially their lower-paid people,” said Beth Umland, director of research for health and benefits at Mercer, a benefits consultancy that also conducted a survey.

The portion of workers in high-deductible, job-based plans peaked at 29 percent two years ago and was unchanged this year, according to new data from the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

Deductibleswhat consumers pay for health care before insurance kicks in — have increased far faster than wages, even as paycheck deductions for premiums have also soared.

One in 4 covered employees now have a single-person deductible of $2,000 or more, KFF found.

Employers and consultants once claimed patients would become smarter medical consumers if they bore greater expense at the point of care. Those arguments aren’t heard much anymore.

Because lots of medical treatment is unplanned, hospitals and doctors proved to be much less “shoppable” than experts predicted. Workers found price-comparison tools hard to use.

High-deductible plans “didn’t really do what employers hoped they would do, which is create more sophisticated consumers of health care,” Marcotte said. “The health care system is just way too complex.”

At the same time, companies have less incentive to pare coverage as Congress has repeatedly postponed the Affordable Care Act’s “Cadillac tax” on higher-value plans.

Although deductibles are treading water, total spending on job-based health plans continues to rise much faster than the overall cost of living. That eats into workers’ pay in other ways by boosting what they contribute in premiums.

Employer-sponsored group health plans, which insure 150 million Americans — nearly half the country — tend to get less attention than politically charged coverage created by the ACA.

For these employer plans, the cost of family coverage went up 5 percent this year and is expected to rise by a similar amount next year, the research shows.

Insuring one family in a job-based plan now costs on average $19,616 in total premiums, the KFF data show. The American worker pays $5,547 of that in a country where the median household income is more than $61,000.

The KFF survey was published Tuesday; the NBGH data, in August. Mercer has released preliminary results showing similar trends.

The recent cost upticks, driven by specialty drug costs and expensive treatment for diseases such as cancer and kidney failure, are an improvement over the early 2000s, when family-coverage costs were rising by an average 7 percent a year. But they’re still nearly double recent rates of inflation and increases in worker pay.

Such growth “is unsustainable for the companies I have been working with,” said Brian Ford, a benefits consultant with Lockton Companies, echoing comments made over the decades by experts as health spending has vacuumed up more and more economic resources.

For now at least, many large employers can well afford rising health costs. Earnings for corporations in the S&P 500 have increased by double-digit percentages, driven by federal tax cuts and economic growth. Profit margins are near all-time highs.

But for workers and many smaller businesses, health costs are a heavier burden.

Premiums for family plans have gone up 55 percent in the past decade, twice as fast as worker pay, according to KFF.

Employers’ latest cost-control efforts include managing expenses for the most expensive diseases; getting workers to use nurse video-chat services and other types of “telemedicine”; and paying for primary care clinics at work or nearby.

At the “top of the list” for many companies are attempts to manage the most expensive medical claims — cases of hemophilia, terrible accidents, prematurely born infants and other diseases — that increasingly cost as much as $1 million each, Umland said.

Employers point such patients to the highest-quality doctors and hospitals and furnish guides to steer them through the system. Such steps promise to improve results, reduce complications and save money, she said.

On-site clinics cut absenteeism by eliminating the need for employees to drive across town and sit in a waiting room for two hours to get a rash or a sniffle checked or get a vaccine, consultants say.

Almost all large employers offer telemedicine, but hardly any workers use it. Thirty-nine percent of the larger companies covering telemedicine now make it comparatively less expensive for workers to consult doctors and nurses virtually, the KFF survey shows.

 

 

 

Cost of Family Health Insurance Now Nearly $20,000 a Year

https://www.thefiscaltimes.com/2018/10/03/Cost-Family-Health-Insurance-Now-Nearly-20000-Year

 

Annual premiums for employer-provided health insurance hit an average of $19,616 for a family this year, a rise of 5 percent over 2017, according to a new survey by the Kaiser Family Foundation. Employees paid an average of $5,547 for their coverage, with employers covering the rest.

The average premium for family coverage has risen 55 percent since 2008 — about twice as fast as wages, which are up 26 percent, and three times as fast as inflation, up 17 percent over a decade.

Faced with relentlessly rising health care costs, many companies have required employees to pay for more of their care before insurance kicks in, and the Kaiser survey found that deductibles are rising even faster than premiums. Among workers who have a deductible — about 85 percent of insured workers — the average deductible amount has risen to $1,573, a 212 percent increase since 2008. Deductibles have risen eight times faster than wages over the last 10 years, the survey said (see the chart below).

Kaiser President and CEO Drew Altman said that he expects health care costs to be an important political issue for the foreseeable future. “As long as out-of-pocket costs for deductibles, drugs, surprise bills and more continue to outpace wage growth, people will be frustrated by their medical bills and see health costs as huge pocketbook and political issues,” Altman said.

Read a summary of the Kaiser Family Foundation’s 2018 Employer Health Benefits Survey here, and the .

 

1 big thing: Out-of-network coverage is disappearing

https://www.axios.com/newsletters/axios-vitals-df4bea3c-3e1a-4efb-84f7-6e3247205ba7.html?utm_source=newsletter&utm_medium=email&utm_campaign=newsletter_axiosvitals&stream=top

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One reason surprise medical bills are going up: Coverage for out-of-network care is going down, according to the Robert Wood Johnson Foundation.

Per RWJF:

  • Just 29% of insurance plans in the individual market provide any benefits for out-of-network providers. That’s down from 58% a mere three years ago.
  • Coverage is also declining in the market for small businesses, but not nearly as dramatically — 64% of small-group plans offer some out-of-network coverage, down from 71% in 2015.
  • Those small-group numbers are probably roughly in line with where things stand among large employers’ plans.

Why it matters: The burgeoning controversy over surprise hospital bills stems partly (though not exclusively) from the bills patients receive when they’re treated by an out-of-network provider — even without their knowledge, often within an in-network facility.

  • Out-of-network coverage has obviously never been as generous as in-network coverage (that’s the whole point of creating a network), but as insurers pull back even further, more patients will likely find themselves on the hook for even bigger bills.

 

How hospitals protect high prices

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Large hospital systems don’t command high prices just because patients like them, or just because they have strong market share. There’s also another big reason: their contracts with insurance companies actively prohibit the sort of competitive pressures a free market is supposed to support.

“The free market has been distorted in an unhealthy way,” health care consultant Stuart Piltch told the Wall Street Journal’s Anna Wilde Mathews for this deep dive into hospitals’ pricing practices.

How it works: Hospital systems are consolidating rapidly and buying up physicians’ practices (which charge higher prices once they’re part of a hospital).

On top of that, per WSJ: Hospitals’ deals with insurance companies “use an array of secret contract terms to protect their turf and block efforts to curb health-care costs.”

  • Some hospitals do not allow their prices to be posted on the comparison-shopping sites insurers provide to their customers.
  • They often require insurers to cover every facility or doctor the hospital owns, and prohibit insurers from offering incentives — like lower copays — for patients to use less expensive competitors.
  • When Walmart, the country’s biggest private employer, wanted to exclude the lowest-quality 5% of providers from its network, its insurers couldn’t do so because of their hospital contracts.

The other side: Hospital executives told the Journal that mergers don’t drive higher prices, and reiterated their position that hospitals have to collect higher payments from private insurance to make up for the lower rates they get from Medicare and Medicaid.

My thought bubble: High-deductible health plans are increasingly popular, in part, because of the idea that patients will use their purchasing power to drive a more efficient system overall.

  • But if Walmart doesn’t have enough market power to actually penalize low-quality providers, you and I definitely don’t, either — especially if we can’t find out what the prices are, and especially if we only have one hospital to choose from in the first place.

Go deeper: Think drug costs are bad? Try hospital prices