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Saturday, October 15, 2016

Health Care Reform Articles - October 15, 2016

History (of Health Insurance Greed) Repeats Itself

by Wendell Potter - Common Dreams

It doesn't take a psychic to predict that health insurance carriers will return to the Obamacare fold in 2017 with dollar signs in their eyes.
by Wendell Potter - Common Dreams

On a Friday afternoon 16 years and four months ago, after the close of trading at the New York Stock Exchange, my staff and I at Cigna disseminated a press release we knew would lead to a lot of angst in Washington, on Wall Street and around the country.
Sure enough, the next Monday morning, June 5, 2000, The Wall Street Journal ran a big story under this daunting headline:
Cigna to Curb Medicare-HMO Risk; Move May Signal Industrywide Trend
These words followed:
In what is likely to be the first of many similar announcements from large managed-care companies, Cigna Corp. said it is pulling out of most of its major-market Medicare businesses. The company cited reduced government fees and competitive pressures for its decision.
This was the headline in the company’s hometown newspaper, The Philadelphia Inquirer:
The newspapers went on to report that 104,000 of Cigna’s senior-citizen subscribers were being dumped because the company wasn’t happy with how much the government was paying it to provide access to medical care for those folks.
Insurers had been unhappy with their pay from Uncle Sam since the passage of the Balanced Budget Act of 1997, when Republicans were in charge of both the House and Senate. The GOP wanted to rein in spending on “entitlement” programs, and the Balanced Budget Act did indeed do that — at least for a while. It reduced Medicare spending by more than $100 billion between 1998 and 2002.
One of the ways it did that was to cap annual reimbursement increases to Medicare HMOs (which, at the time, were called Medicare + Choice plans) at 2 percent on average. That was a big problem for Cigna and other companies because, as The Inquirer noted, medical inflation was averaging eight percent annually. The companies clearly were not managing medical costs nearly as much as they had told lawmakers and their customers they would be able to do. So Cigna, at least, had decided to cut bait.
The Wall Street Journal was right: several other insurers did indeed follow Cigna’s lead. Hundreds of thousands of other senior citizens received notices over subsequent months and years that their insurers were cutting them loose.

Déjà vu all over again
Fast forward to Aug. 15, 2016 and the era of Obamacare. That was the day Bloomberg ran a story under this angst-producing headline:
Aetna to Quit Most Obamacare Markets, Joining Major Insurers
These words followed:
Health insurer Aetna Inc. will stop selling individual Obamacare plans next year in 11 of the 15 states where it had been participating in the program, joining other major insurers that have pulled out of the government-run markets in the face of mounting losses.
In this instance, Aetna was not leading the way to the exits. UnitedHealthcare told investors earlier this year that it was bailing out of most of its Obamacare markets. Humana said it, too, would scaling back big time.
Why? Because, once again, the big insurers were not only not making the profit margins they felt they should be making, they were losing money on this particular book of business. Like the old Medicare + Choice plans, they were in many cases paying out more to cover medical claims than they were taking in from the government and Obamacare health plan enrollees. So, just like they did a decade and a half ago, they decided to cut those enrollees loose.
Was there collusion among the departing insurers, then and now? No, because that would be illegal. But you can be certain of this: the insurers’ trade associations, both then and now, began behind-the-scenes lobbying campaigns to get lawmakers and regulators to change the rules so they could turn the ink on their financial statements from red to black.
And they were spectacularly successful back in the early 2000s. In short order, there was a reversal in fortune — in the insurers’ favor. So if the past is prologue, we can expect the insurance industry’s lobbyists to be hard at work to make sure history repeats itself.
Keep in mind that the insurers’ Medicare + Choice losses were an unintended consequence of the Balanced Budget Act of 1997. Republicans in particular were alarmed when the insurers began abandoning the Medicare HMO market because it has long been a tenet of faith among many of them that private insurers could operate more efficiently than the traditional Medicare (TM) program, and consequently reduce overall spending on Medicare.

Congress showed health carriers the money
It certainly didn’t turn out that way, but many lawmakers kept the free-market faith. So halfway into the George W. Bush administration, with Republicans still in charge of both the House and Senate, the Medicare Prescription Drug, Improvement and Modernization Act of 2003 became law. The insurance industry’s lobbyists scored two big victories under that act:
First, the prescription drug benefit (known as Part D) was structured in a way that makes it necessary for Medicare beneficiaries to buy their drug coverage through private insurers. And second, the Medicare + Choice program was overhauled to the industry’s liking (and renamed Medicare Advantage).
As part of the overhaul, the government began paying private insurers more to cover the cost of sicker Medicare enrollees, so the companies that had bailed came rushing back in. There were also other provisions of the 2003 law that boosted the government’s pay to insurers. As a consequence, by the time Obamacare became law in 2010, according to the Medicare Payment Advisory Commission, the government was actually paying Medicare Advantage plans 14 percent more per beneficiary ($1,100 on average) than it would cost to cover those beneficiaries in traditional Medicare. Between 2004 and 2008, the overpayments totaled almost $44 billion.
One of the aims of Obamacare was to reduce those overpayments, and they have been reduced, but most insurers are still finding their Medicare Advantage business to be very profitable. You certainly don’t hear about insurers threatening to jump ship now.

Retreating carriers will scurry back
Speaking of Obamacare, you can be certain the companies that are dropping out of several Obamacare markets next year will return if they can get Congress and the next president to sweeten the pot for them like the Medicare pot was sweetened back in 2003.
How successful they will be will depend to a large extent on which party winds up in control of Congress and the White House. If the Democrats prevail, they undoubtedly will want to find ways to entice the insurers back into the Obamacare marketplace. (If Donald Trump wins and the GOP keeps control of Congress, all bets are off, but I guarantee the insurers will find ways to thrive.)
So what would make the insurance industry’s lobbyists happy in a Clinton administration? I’m sure they’d like to see some changes to the law that would enable them to get more federal dollars for covering older and sicker folks, like the Medicare Advantage program since 2004.
I’m sure they’d also like to be able to charge older people much more than they can today. During the health care reform debate in 2009 and 2010, they lobbied hard to be able to charge older folks five times as much as younger folks for the exact same policy. They only got a 3-1 ratio.
They’d also like to make it much more expensive to remain uninsured. The industry was correct when it argued that young and health people in particular would continue to go “bare” if the penalty for doing so was not substantial. Democrats in Congress and the White House were not willing to make the penalty nearly as substantial as industry lobbyists wanted. You can bet that the lobbyists will try again to make it much more painful financially for not buying their products.
You can also expect the insurers to lobby for more “flexibility” in designing their policies. They’d love to be able to go back to the days when they could sell junk insurance policies with such meager benefits they rarely had to pay out much in claims.
What actually happens will depend on the outcome of the election next month. But regardless of who wins, don’t bet against health insurance companies. Chances are, they’ll win either way, and one way or another, most of us will be paying even more for health care than we do today. Profits come first in our health care system.
© 2016 HealthInsurance.org
Wendell Potter is former Vice President of corporate communications at CIGNA, one of the United States' largest health insurance companies. In June 2009, he testified against the HMO industry in the U.S. Senate as a whistleblower. He is now the Senior Fellow on Health Care for the Center for Media and Democracy in Madison, Wisconsin.

Health Care Law’s Beneficiaries Reflect Its Strengths, and Its Faults

by Abby Goodnough and Reed Abelson - NYT

WASHINGTON — Cara Suzannah Latil is living proof that the Affordable Care Act works — but also of why a central piece of the law is in turmoil.

Ms. Latil, 49, who works at a homeless shelter in Santa Fe, N.M., is one of millions of Americans who once found it difficult or impossible to get health insurance because they already had serious illnesses. Hepatitis C was ravaging her liver when she learned in 2014 that she also had breast cancer. Through the health care law, she was able to buy subsidized insurance that paid for all but $800 of her cancer surgery and radiation, she said, as well as tens of thousands of dollars’ worth of medications that cured her hepatitis.
But stories like Ms. Latil’s help explain a critical challenge for the health law: The subsidies it provides to help people pay for coverage, and the penalties for those who remain uninsured, have not coaxed enough young, healthy people into the insurance marketplaces it created. So the pool of customers in some parts of the country is too sick and too small.
Most Americans get their health insurance through their employers, or via Medicareor Medicaid. But millions use the insurance markets But millions who lack those options use the insurance markets set up under the law.
It has turned out that so many marketplace customers need expensive medical care that some insurers are spending more on claims than they earn in premiums. And the federal government’s strategies for protecting insurance companies from large losses have not been as effective as hoped.
Insurers, including a few big ones like Aetna and Humana, are withdrawing from the marketplaces in many states, saying they are losing too much money.
Others are sharply raising prices for next year, and the turbulence is fueling Republican criticism — including from Donald J. Trump during Sunday’s presidential debate, in which he called the rate increases “astronomical.”

A few customers can generate big costs.

Even a small number of customers with serious conditions can greatly increase costs. Roy Vaughn, a senior vice president at BlueCross BlueShield of Tennessee, said that just 5 percent of the company’s marketplace customers had accounted for nearly 75 percent of its claims costs.
The company recently announced that it would stop selling marketplace plans in Knoxville, Memphis and Nashville.
There are other reasons insurers are raising their rates or leaving the marketplaces. A big one is that the Obama administration, thwarted by Republican opponents in Congress, has paid out only a fraction of the $2.5 billion it owes insurers under a provision of the health law that was supposed to protect them against unexpectedly large losses during their first few years in the marketplaces.
But these payments would not be so important if more of the roughly 10 million marketplace customers were in good health. The Blue Cross Blue Shield Association reported in March that new customers who bought marketplace plans from its member insurers in 2014 and 2015 had higher rates of hypertensiondiabetes, coronary artery disease, depression, H.I.V. and hepatitis C.

Chronically ill patients are worried about next year.

Many of these customers are in better shape after a few years with health insurance. But they are scared about the Affordable Care Act’s future.
Marque Dailey of Dallas, who has multiple sclerosis, said his marketplace plan from BlueCross BlueShield of Texas had paid for visits to a neurologist, physical therapyand a drug called Lemtrada that is administered through two series of infusions a year apart. The list price for the treatment is $158,000, although insurers usually negotiate lower rates.
When Mr. Dailey, now 32, was uninsured, he could not treat his symptoms and had to rely more and more on a wheelchair. The stiffness in his legs got so bad, he said, that he had to quit his part-time job as a merchandiser at Coca-Cola, which did not offer insurance. Now he is working again, as a field organizer for a Democratic state legislative candidate. But Blue Cross narrowed the network of doctors and hospitals he could use this year, and he is worried that 2017 will bring even fewer choices.
“I understand I’m an insurance loss,” Mr. Dailey said. “I do feel bad about it. But without this, I’m just kind of left out of everything.”

Costs are burdensome to customers, too.

Other marketplace customers with expensive medical needs pointed out that the costs had been a burden to them as well as their insurers, most of which remain profitable even as they lose money in the Affordable Care Act markets.
Vickie Wilkerson, 46, of Shreveport, La., has a plan from Blue Cross and Blue Shield of Louisiana that she said had paid about $21,000 so far this year for injections of Stelara, a drug that has helped her severe psoriasis. She pays just $5 per shot, but only because by the time her doctor prescribed it this year, she had already met the $6,000 deductible on her plan. Two emergency room visits, for bronchitis and a bad fall, had left her with thousands of dollars in bills.
She chose a high-deductible plan, she said, because the subsidy she received covered the monthly premiums in full. She had not anticipated needing emergency care or being put on such an expensive drug. Nor had she realized that by choosing a different type of plan with higher premiums, she could have qualified for extra federal aid that would have helped pay her deductible.
Ms. Wilkerson, who never had insurance through her longtime job as a housekeeper, relied on sporadic charity care until getting marketplace coverage in 2014.
Her worst fear, she said, is that insurance companies “will find some kind of loophole” to deny coverage to people with existing conditions, as they did before the health law was passed.
“I don’t know what I’d do,” she said.
Her insurer is raising rates an average of 24 percent next year. But Ms. Wilkerson is looking into whether she qualifies for Medicaid now that Louisiana has expanded it under the Affordable Care Act.
“I’m finally on a medication that is working,” she said. “I don’t want to have to stop that now and go back to the drawing board.”

Insurers are limiting choices.

Cathy Richardson of Elizabethtown, Pa., who works at her husband’s small financial planning business, was a healthy, low-cost customer for the first two years she had coverage through the Affordable Care Act. But early this year, Ms. Richardson, 54, received a diagnosis of Stage 3 rectal cancer and quickly became expensive to her insurer, Capital BlueCross. She has had two operations, chemotherapy, radiation and two additional hospitalizations.
There are signs that Ms. Richardson’s insurer is working to contain the costs of sick customers like her: It will not pay for treatment at the larger, more prestigious hospital in her area, requiring her to go to a smaller hospital instead. And a case manager from the insurance company calls her weekly to make sure she is getting the care she needs, which could prevent expensive complications.
The smaller hospital does not have a cancer center, so her oncologist, radiologist and surgeon do not work as a team. “You have to navigate between the three of them,” she said, “and you never know who to go to.”
Still, her costs have been limited to about $5,200. She is bracing for a letter from her insurer, due this month, that will notify her of any price increase and changes to her coverage for 2017.
“Our choices are probably going to be pretty limited,” she said.

Insurers are frustrated by customers dropping coverage.


The Obama administration is planning greater outreach, through advertising, social media, mailings and email, to new ways to persuade young, healthy Americans to buy marketplace coverage during the next enrollment period, which starts on Nov. 1. It is also taking other steps to address problems with the risk pool, which it says shows signs of improvement.
But insurers say they also wish the government could make it harder for people to drop their coverage after their health problem is treated. Health Care Service Corporation, which operates Blue Cross plans in five states, said less than half of its marketplace customers paid for coverage for the full year.
Ms. Latil dropped her coverage recently; she had finished her hepatitis treatment, a nearly six-month regimen of the drugs Sovaldi, Daklinza and ribavirin. It was not a willful swipe at the system, she said; she was struggling to make her premium payments of $179 a month.
“I got my stuff taken care of,” said Ms. Latil, who will soon have insurance through her job. “I am so extremely grateful.”

In North Carolina, ACA insurer defections leave little choice for many consumers
by Amy Goldstein - Washington Post
North Carolina has welcomed the insurance of the Affordable Care Act as have few other states, with more than 600,000 people from the Blue Ridge to the Outer Banks enrolled in health plans created under the law.
Yet this achievement is now yielding to a darker distinction for the Tar Heel state. As major insurers jilt their ACA customers, nowhere in the country will more people be left with only a single insurer when the marketplaces open for a fourth year of business.
These defections are causing turbulence for a quarter-million North Carolinians whose insurance companies are leaving the state — and for the main insurer that will remain. Such turbulence is especially palpable in the rolling Piedmont in and around Greensboro. Of more than 30,000 people here who have gained ACA insurance, 80 percent have been relying on United Healthcare or Aetna Health, the companies pulling out at the end of December.
“Wow, it is going to be huge,” said Natalie Cunningham, a 30-year-old hairdresser who had been uninsured for years before she got her first ACA coverage in 2014. Her health plan enabled her to see a chiropractor who diagnosed her neck and back pains as arthritis that probably was a remnant of a decade-old car accident.
As of a week ago, Cunningham had not yet received the letter required of her current insurer, an Aetna subsidiary called Coventry, informing her that she needs to find different coverage. But she is like many residents in worrying how much insurance will cost in the coming year. Or whether they will be able to continue to see the same doctors. Or how their narrowing choice will affect the hopscotch they’ve been playing year to year in pursuit of a health plan they can afford.
At the Legal Aid office downtown, one of North Carolina’s many foot soldiers in helping people use the marketplace has started to get anxious calls from clients losing their health plans. “My job is to reassure people they are going to be fine,” Emily Rhyne said. But without yet knowing exactly what will be available, she is careful not to overpraise.
What is happening in the Piedmont epitomizes the nation’s growing checkerboard of ACA haves and have-nots.
In its waning months, the Obama administration insists the exchanges are still viable. When the insurance sign-up season begins on Nov. 1, three-fifths of Americans in the marketplaces nationally will have a choices of three or more insurers — each selling multiple health plans — according to an analysis by the Kaiser Family Foundation.
That is an erosion from a year ago, however, when more than 85 percent had such wide choices. And the whittling has been concentrated in certain regions, particularly in parts of the Southwest and Southeast.
Alabama and South Carolina are among five states in which just one insurer will be selling ACA plans this time. Nearly three-fourths of Florida’s counties and more than four-fifths of Missisippi’s will be down to one insurer. In North Carolina, five counties around Raleigh will have two insurers if Cigna arrives as expected. The other 95 counties, including Guilford, where Greensboro is the county seat, will have only one.
Administration officials maintain that the geography of the departures essentially returns to a pattern predating the 2010 health-care law, when insurance options tended to be scarce in rural America. But in several states, the have-not parts of the checkerboard include urban centers. In North Carolina, marketplace shoppers in Charlotte, Winston-Salem and Fayetteville will find a single insurer.
Companies have attributed their withdrawal to financial losses, saying their ACA customers have been sicker and more expensive than they expected.
In Durham, at the sparkling-glass headquarters of Blue Cross Blue Shield of North Carolina, the economics of those customers are a real concern. For 2014 and 2015, Blue Cross lost $405 million on its marketplace business. Suddenly becoming the health-care law’s sole insurer in all but a few counties is an unwelcome prospect.
After United and then Aetna announced they were leaving, Blue Cross said it might not stick around either. It had a quarter of a million unexpected customers heading its way, with no clue as to how much medical care they use and too little time to hire and train enough customer service workers. 
The timing for its decision to stay or go was especially inopportune. Last month, the North Carolina Department of Insurance fined Blue Cross $3.6 million — a state record — over computer problems last winter that left some customers without insurance cards and some doctors without payments.
Only a few weeks ago did Blue Cross announce that it would remain statewide for 2017. “The easy thing to have done would have been to quit,” chief executive Brad Wilson acknowledged in an interview. He said that staying involves “some reputational risk” and that he hopes customers will be patient with an “extraordinary environment here in our state, where all our competitors decided to flee and we decided to...stand in the gap.” 
Blue Cross is trying to calibrate the expectations of consumers and government regulators alike, warning that customers may encounter long holds on call lines and urging them to sign up early.
Rates will soar. Blue Cross raised 2016 premiums for its marketplace plans by one-third, on average, making its coverage in Greensboro and some other communities more expensive than its competitors’. It sought another 19 percent hike for 2017, then asked for more after Aetna’s decision.
While the state will not disclose final rates until late this month, Wilson confirmed that regulators have agreed to the higher amount, averaging about 24 percent — a main reason the insurer is staying. 
The ripple effect on consumers will vary. Blue Cross is emphasizing that the higher the insurance premiums, the larger the government subsidies for the vast majority of ACA customers who qualify.
In Greensboro, Keith and Erin Rosen have no such buffer. They chose a Blue Cross plan on the marketplace after the scrap-metal company for which he was chief financial officer was sold and he left. The Rosens, who are both 54, appreciate that the health-care law lets them keep their three young-adult children on their policy. But with his consulting income too high for ACA subsidies, their 2016 premiums spiked by nearly $7,000 — to almost $27,000 total.
Expensive though it is, they can’t imagine being without coverage, particularly this year. He needed repairs of a hernia and a detached retina. She learned on April Fool’s Day that the lump under her left arm was a form of chronic leukemia.
Lately, Keith Rosen has begun talking with a few business friends about forming a small company — just to get out of the marketplace and buy insurance collectively. The idea of paying more than $30,000 in insurance premiums is “tremendously annoying,” he said. “Where does it stop?” 
Cunningham has no idea what she will be paying, but she already knows the complications of insurance-hopping. A single mother, she works full-time at a Great Clips franchise that doesn’t offer health benefits. Her income — $29,000 last year — allows her elementary school-aged daughter and son to be on Medicaid. But not her, which is why in the past she’d waited in lines at the county health department or avoided doctors. When she cut the chiropractor’s hair, she used to make up excuses for why she didn’t see him for her back and neck pain. 
In spring 2014, she asked another customer what he did for a living and learned he was signing up people for the new marketplace coverage. The first two years, she paid $56 a month for a Blue Cross plan. This year, even with her subsidy, that shot up to $139.
Cunningham switched to her Coventry plan, which costs her $9 a month, even if all the doctors are in High Point, where she doesn’t know her way around. So she recently ended up back at the county health department for an infection and keeps putting off an ultrasound she should have had months ago. 
If she goes back to Blue Cross, her monthly payments might go down. If they go up, she might work extra shifts at other hair salons.
Or, she figures, she might go back to being uninsured.

Medicare unveils far-reaching overhaul of doctors’ pay

by Ricardo Alonso Zalvidar - Associated Press

WASHINGTON — Changing the way it does business, Medicare on Friday unveiled a far-reaching overhaul of how it pays doctors and other clinicians.
The goal is to reward quality, penalize poor performance, and avoid paying piecemeal for services. Whether it succeeds or fails, it’s one of the biggest changes in Medicare’s 50-year history.

The complex regulation is nearly 2,400 pages long and will take years to fully implement. It’s meant to carry out bipartisan legislation passed by Congress and signed by President Obama last year.
The concept of paying for quality has broad support, but the details have been a concern for some clinicians, who worry that the new system will force small practices and old-fashioned solo doctors to join big groups. Patients may soon start hearing about the changes from their physicians, but it’s still too early to discern the impacts.
The Obama administration sought to calm concerns Friday. ‘‘Transforming something of this size is something we have focused on with great care,’’ said Andy Slavitt, head of the federal Centers for Medicare and Medicaid Services.
Officials said they considered more than 4,000 formal comments and held meetings around the country attended by more than 100,000 people before issuing the final rule. It eases some timelines the administration initially proposed, and gives doctors more pathways for complying.
The American Medical Association said its first look suggests that the administration ‘‘has been responsive’’ to many concerns that doctors raised.

In Congress, staffers were poring over the details. Representative Tom Price, a Georgia Republican, who worries that Medicare’s new direction could damage the doctor-patient relationship, said he’s going to give the regulation ‘‘careful scrutiny.’’ Senator Orrin Hatch, a Utah Republican, chairman of a panel that oversees Medicare, called it an ‘‘important step forward,’’ but said the administration needs to keep listening to concerns.
MACRA, the Medicare Access and CHIP Reauthorization Act, creates two new payment systems, or tracks, for clinicians. It affects more than 600,000 doctors, nurse practitioners, physician assistants, and therapists, a majority of clinicians billing Medicare. Medical practices must decide next year what track they will take.
Starting in 2019, clinicians can earn higher reimbursements if they learn new ways of doing business, joining a leading-edge track that’s called Alternative Payment Models. That involves being willing to accept financial risk and reward for performance, reporting quality measures to the government, and using electronic medical records.
Medicare said some 70,000 to 120,000 clinicians are initially expected to take that more challenging path. Officials are hoping the number will quickly grow.
Most clinical practitioners — an estimated 590,000 to 640,000 — will be in a second track called the Merit-Based Incentive Payment System. It features more modest financial risks and rewards, and accountability for quality, efficiency, use of electronic medical records, and self-improvement.
Finally, about 380,000 clinicians are expected to be exempt from the new systems because they don’t see enough Medicare patients, or their billings do not reach a given threshold.
‘‘Half of the physician practices under 10 [doctors] will not be reporting at all,’’ said Slavitt.
Advocates say the new system will improve quality and help check costs. But critics say complicated requirements could prove overwhelming. The administration says some doctors will be pleasantly surprised to find out that reporting requirements have been streamlined to make them easier to meet.
With 57 million elderly and disabled beneficiaries, Medicare is the government’s premier health insurance program. The Obama administration has also been working to overhaul payment for hospitals and private insurance plans that serve Medicare beneficiaries. The unifying theme is rewarding quality over volume.
Although some quality improvements have already been noted, it will probably take years to see if the new approaches can lead to major savings that help keep Medicare sustainable.
John Feore of the consulting firm Avalare Health said it appears many doctors are still unaware of the magnitude of the changes ahead. ‘‘MACRA is a huge change in how physicians are paid, and there is a wide spectrum on whether they are ready,’’ said Feore. ‘‘By providing some options and a transition over a year or two, the [administration’s] intent is to allow them to get comfortable.’’

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