Federal government failed in Puerto Rico following Hurricane Maria
by Larry Kaplan - Portland Press Herald - October 28, 2017
We owe the U.S. citizens there the same commitment and vigor that we offered to Houston and Miami.
CAPE ELIZABETH — As a 35-year veteran of multiple international humanitarian medical relief missions (in Cambodia in 1979, in Honduras in 1998 and in Haiti in 2010), I am accustomed to landing on the ground a few days after a catastrophe and daily treating 90 to 100 acute care patients. I’ve seen endless cases of physical trauma, pneumonia, diarrhea, skin infections, conjunctivitis and a host of tropical infections. So when I signed up with Project Hope to join its medical team in Puerto Rico a week after the devastation of Hurricane Maria, I expected a similar experience.
What I soon learned was that U.S. government agencies and American nongovernmental organizations completely misunderstood or failed to evaluate the medical conditions in Puerto Rico immediately after the hurricane.
Before the hurricane, Puerto Rico, a U.S. commonwealth of 3.4 million people, received relatively good medical services through private insurance and U.S. government-sponsored health care programs. Unfortunately, Puerto Ricans appear to be plagued, perhaps because of their diet, with chronic diseases such as diabetes, hypertension and heart disease, but they were being treated for such disorders.
So when my Project Hope team ventured out of San Juan into towns that suffered massive infrastructure destruction and personal property losses, the team of experienced medical personnel with decades of international experience treating acute diseases ended up distributing a limited number of medications for treatment of chronic diseases, medications not available because pharmacies and hospitals were closed. No wonder that the USNS Comfort, a naval vessel with roughly 800 medical and support personnel and 250 beds that docked in San Juan on Oct. 3 and sailed around the island, treated on average 12 patients a day. Or why 200 medical personnel, employees of the U.S. Public Health Service, spent the majority of their 10-day tour idle in the San Juan Convention Center, waiting for assignments.
Had Federal Emergency Management Agency experts better understood medical conditions in Puerto Rico, these resources could and should have been diverted to backing up the island’s 70 hospitals with generators, medicines and potable water and clearing roads so residents would have access to hospitals and clinics in the immediate aftermath. What Puerto Rico experienced after Hurricane Maria was not an acute medical crisis, but a public health catastrophe and the gross failure of U.S. government agencies to deliver to the victims of the hurricane life-saving essentials of food, clean water and shelter.
Twelve days after the hurricane, my Project Hope team traveled by car on passable roads to Toa Baja, a coastal town 45 minutes west of San Juan. Toa Baja, where entire neighborhoods were submerged by overflowing rivers and now littered with decaying garbage, human waste, animal carcasses and discarded household furniture covered with mildew, had not received any material aid from the central Puerto Rican government or FEMA in the first 10 days after the hurricane.
It wasn’t until the municipal government and Toa Baja residents organized their resources to provide food, clothing and shelter – and local medical personnel set up a temporary emergency room with medications later transported by Project Hope – that services started to reach the community.
How ironic that the acute diseases that I had expected to encounter when I first entered Puerto Rico are now appearing with serious health consequences: bacterial infections from tainted water, bronchitis and asthma from air pollution, polluted groundwater, numerous animal-borne diseases and skin diseases from lack of ability to bathe or wash clothes with uncontaminated water.
And Puerto Ricans continue to die from chronic diseases such as diabetes, kidney failure and hypertension because they still cannot readily access medications and medical care.
The U.S. government did not conduct itself admirably in Puerto Rico in the first month after Hurricane Maria. For a country that rebuilt Europe after World War II and is magnanimous in victory to our enemies in defeat, we now owe it to the U.S. citizens of Puerto Rico to rebuild their island with the same vigor and commitment that we offered to the citizens of Houston and Miami.
Opposing Medicaid expansion is not a conservative position
by Lance Dutson - Bangor Daily News - October 30, 2017
Gov. Paul LePage’s opposition to Medicaid expansion is one of the most destructive acts of his tenure in office — denying healthcare to 70,000 low-income Mainers purely out of spite. And it’s predicated on a series of logical fallacies that should make his allegedly conservative followers cringe with embarrassment.
Here’s the most obvious one: If you spend $54 million in order to get $500 million, it’s not “costing” you anything. It’s a $446 million net gain. Those are roughly the terms of Medicaid expansion: The federal government will give Maine more than $500 million a year in funding for healthcare for low-income Mainers if we contribute $54 million to the same cause.
This nearly 10-to-one return is the deal our alleged businessman governor is opposing.
It is not fiscally conservative to deny hundreds of millions of dollars in federal funding because we will need a 10 percent match. It’s fiscally ludicrous.
Anyone able to do basic elementary school math should be able to understand this. It’s why Republican governors in other states — including Vice President Mike Pence when he was governor of Indiana — have already accepted expansion. In total, 31 other states and the District of Columbia have expanded Medicaid.
Maine accepts federal matches on all kinds of things — roads, bridges, first responder funding, to name a few — much of it with far less favorable terms than what the Affordable Care Act (ACA) provides for Medicaid expansion. Additionally, many of our biggest employers rely almost entirely on federal funding — companies like Bath Iron Works, for example.
Can you imagine BIW turning down a shipbuilding contract for the US Navy that would profit them a billion dollars because they’d have to spend $140 million in infrastructure upgrades to be able to build it?
Speaking of BIW, there’s another massive logical flaw coming from LePage’s camp. They claim $500 million a year in federal health care funding won’t have a positive impact on Maine’s economy. (Seriously, they are saying this.)
If you are one of the people who thinks $500 million a year in new economic activity won’t have a positive impact on our state, consider this: BIW’s entire annual payroll is $400 million.
In fact, expanding Medicaid would be a lot like opening another BIW in Maine — a federally funded job machine supporting 6,000 skilled workers and swirling hundreds of millions of new dollars into Maine’s economy.
But LePage and company say $500 million won’t help our economy.
Another major logical flaw in Medicaid expansion opposition hits at the heart of the GOP’s anti-ACA sentiment. Republicans dislike Obamacare for one simple reason: it makes insurance more expensive. So how then can you oppose a program that makes it less expensive for people to get insurance?
The proposed expansion of Medicaid would give health insurance to people making up to 138 percent of the poverty level. This means a couple things. First, it means the recipients are working — otherwise they’d have no income. It also means these people are the ones at ground zero of America’s healthcare crisis. They’re working, they aren’t making much, and they can’t afford health insurance.
Aren’t these the exact people Republicans claim to care about when they decry the impacts of Obamacare?
If lowering the cost of health insurance is not the primary goal of the anti-Obamacare crowd, what is?
The bottom line is Team LePage doesn’t care about the fiscal impact of Medicaid expansion. They simply care that it’s a Democratic program, and it helps poor people. LePage Republicans have such a blind tribal rage that it doesn’t matter if it’s a good deal for Maine’s economy or not, or that it helps mitigate the core problem with Obamacare — prohibitively expensive health insurance.
They simply want to wreck another social service program because that’s what they do.
LePage has put Maine in the absurd position of shouldering all the negative market impacts of Obamacare without receiving any of the positive benefits meant to offset them. It’s clear by now that he is not a fiscal conservative, and that his sycophant followers aren’t either. They are angry populists whose causes border at times on anarchy. They will oppose things simply for the destructive impact of their opposition.
And standing in the way of federal money meant to provide health insurance for tens of thousands of working low-income Mainers simply out of spite is pretty darn destructive.
Fortunately, LePage and his lackeys don’t get to make the decision this time.
Lance Dutson, a principal of Red Hill Strategies, is a Republican communications consultant. He has served on the campaign teams of U.S. Sens. Susan Collins and Kelly Ayotte, as well as the Maine Republican Party.
Maine Voices: Medicaid expansion in Maine would come at steep cost, loss of medical-care price control
by Martin Jones - Portland Press Herald - November 1, 2017
FREEPORT — When Medicare and Medicaid were passed as amendments to the Social Security Act in 1965, Medicare for the elderly was the main event. Medicaid was an add-on designed to provide aid to poor parents and to the blind and disabled. In 1966, there were 4 million Medicaid beneficiaries.
Today, Medicaid has 73 million enrollees, about 23 percent of the population. Around 12 million of these individuals have been added as a result of the program’s expansion under Obamacare. Most of them are working-age adults, with and without children, with incomes up to 138 percent of the poverty level. Most have access to employer insurance or to generous Obamacare subsidies. Even before the Obamacare expansion, the history of Medicaid had become the best example we have of how a welfare program can grow far beyond the intended scope and cost estimates of its designers.
Public policy based on good intentions usually has a cost, and in the case of Medicaid, the cost has been very high. Expansion advocates paint a very rosy picture of the economic benefits that would result from an inflow of federal dollars. But the picture completely ignores the cost of the federal funding and simply treats it as free money.
Medicaid is already the third- largest domestic item in the federal budget. The Congressional Budget Office estimated in June that program outlays will rise at an annual rate of 5.4 percent over the next 10 years, considerably faster than growth in the economy or federal revenues, and will be $655 billion in 2027. It is feckless to pretend that providing federal funds to the states for Medicaid has no cost and only provides benefits.
Although the states pay only about 40 percent of Medicaid’s cost on average, it is now the second-largest item in their budgets, and many of them have been struggling with their portion of the program’s expense for years. Yet 31 of them couldn’t resist the temptation to expand their programs when the federal government offered to pay 100 percent of the cost initially, declining to 90 percent in 2020 and beyond. The expansion states began paying their part of the expansion cost this year, and over the next several years many of them will find that even 10 percent of increased program expenses will put additional stress on their budgets.
In Maine, the Office of Fiscal and Program Review estimates that expansion would cost the state $31 million in 2019 and nearly $55 million by 2021 – and the cost would continue to rise after that. Even if some of the cost is offset by increased economic activity, the additional burden on the state’s budget would be substantial. Maine, like other expansion states, would have to pay the additional cost by raising taxes, making cuts elsewhere in the budget, reducing eligibility for other beneficiaries, reducing provider reimbursements or some combination of these. The necessary adjustments would be difficult and painful.
There is an even larger and more important issue relating to Medicaid. The greatest flaw of Obamacare is that it widened and deepened the role of the third-party payment system, which is the primary driver of higher health care and insurance costs.
When someone else pays the bills, consumers don’t care about expense. It will be impossible to control the rising cost of care and escalating insurance premiums unless consumers have more control over their health care dollars, have an incentive to seek value and providers have an incentive to create it. Medicaid removes any incentive to restrain demand or to seek value. This is a cold reality that Medicaid and universal care advocates don’t want to hear.
There will always be individuals and families with special and expensive needs that are not accommodated easily in the existing private-public policy framework. Advocates think that Medicaid is the simple solution to these needs because the care is free and there are no limits on claims. But a general policy covering a large segment of the population to meet the needs of a relatively small number of individuals is likely to be extremely expensive, as Medicaid has proven to be. It would be far more efficient and cost effective to provide targeted, means-tested assistance to those with special needs than to expand free care to a large number of mostly healthy individuals who have other options for insurance.
When Silver Costs More Than Gold: How Trump’s Actions Have Scrambled Insurance Prices
by Margot Sanger-Katz and Kevin Quealy - NYT - October 27, 2017
The rates for next year’s Obamacare plans are out, and they show how President Trump’s actions have scrambled the insurance marketplace.
Usually, plans known as gold have higher monthly premiums but lower out-of-pocket costs than “silver” plans, which have tended to cost less each month and have been the most popular plans.
But this month, Mr. Trump carried out a longstanding threat and ended certain subsidies for insurers. To compensate for the lost funding, insurers increased the prices of their plans — heavily in the silver category and less so in others.
Now the silver plans will be more expensive in many markets than gold plans that have much lower deductibles. For people who qualify for government subsidies, that’s good news: Their subsidies will rise with the rising cost of silver plans, and they’ll be able to afford a plan that requires much less out-of-pocket spending for their health care. For those who don’t, it highlights just how expensive many silver plans have gotten as a result of the president’s action, and how hard people may need to work to find an affordable option.
The least expensive gold option for next year is cheaper than the least expensive silver option in about a sixth of counties using Healthcare.Gov to market plans, as you can see on our map. Gold is a better option in much of New Mexico, Wyoming, Kansas, and parts of Wisconsin, Pennsylvania and Georgia. There are also a substantial number of counties in Texas, Florida, Oklahoma, South Carolina and Michigan where the price difference between a gold plan and a silver plan with a much higher deductible is smaller than $25 a month.
That is confusing, and consumers are likely to be surprised when the enrollment period opens on Wednesday.
The Trump administration created this pricing chaos by eliminating cost-sharing subsidies, a payment to insurance companies that was tied up in a legal dispute. But it has also taken steps to limit the damage. It permitted states and insurers to change their prices at the last minute to compensate for the change. It made price information for next year publicly available a week early, so customers could have more time to window-shop and explore their options.
It also organized plans on its site in order of their premium price, so that customers who live in a place where a gold plan costs less than the cheapest silver plan would have an easier time figuring that out.
If you live in one of the places where the gold plan is cheaper than the silver plan, and you earn more than about $24,000, you should not buy the more expensive silver option. The gold plan will cost less, and have a lower deductible. There are also high-deductible bronze plans that will have substantially lower premiums that you may also want to consider. If you qualify for a government subsidy, those will be your best options.
If you earn too much to qualify for federal help buying insurance, you should also steer clear of the more expensive silver plans on HealthCare.gov. But there may be cheaper options in the silver category if you buy directly from an insurance company. A broker may be able to help you examine all of those options.
If you earn less than $24,000, a silver plan will still be your best choice. That’s because you qualify for additional discounts that will lower your deductible and co-payment, making a silver plan even more generous than a gold plan. Premium subsidies, which are unaffected by the president’s actions, will protect you from premium price increases.
The loading of cost increases onto silver plans also makes it hard to easily describe how much more expensive insurance will be next year, compared with this year. The consulting group Avalere Health published a report Wednesday saying that the average silver plan on HealthCare.gov would increase in price by 34 percent — by far the largest annual price increase since the Obamacare markets began.
Normally, that silver price increase is a good barometer for what’s happening with the entire health insurance market. But the Avalere report highlighted that the prices of other plan types aren’t rising as fast. Gold plans are going up, on average, by 16 percent. Bronze plans are rising, on average, by 18 percent.
Some of those increases are probably because of Trump administration actions as well. The government has cut back on advertising and outreach to help enroll healthy customers, and has signaled that it may not enforce the government mandate to obtain insurance as vigorously as the Obama administration did. In their filings with regulators, insurance companies said they were increasing premiums to address that broader policy uncertainty.
Our map draws on prices that were published online Wednesday for 2018 plans on HealthCare.gov. The website serves 39 states, and the precise prices we examined were for single customers who don’t smoke, age 40, though the trends should be the same for customers with different family sizes and ages. Information from the remaining states, which run their own marketplaces, will become available next week.
How a Republican Idea for Reducing Medicare Costs Could Affect You
by Austin Frakt - NYT - October 30, 2017
Last month, as Republican leaders were preoccupied with another unsuccessful attempt to replace Obamacare, a senior Trump administration official issued a warning about a different major medical program, Medicare.
The official, Seema Verma, administrator of the Centers for Medicare and Medicaid Services, wrote in The Wall Street Journal that Medicare was facing a fiscal crisis. She announced that she was asking the agency’s innovation center for ideas to address it, and that part of the answer was to give consumers “incentives to be cost-conscious.” This has some Democrats worried that she’s trying to move Medicare toward something called premium support, which would be a huge change for consumers.
Before we get into the pros and cons, what’s the fiscal crisis? According to projections from this year’s Medicare Trustees’ report, the fund that pays for Medicare-financed hospital care will be depleted in 12 years, and care for other services will consume an ever-larger share of the economy and federal revenue. Citing trends like those, Republicans included the outlines of a Medicare premium support plan in the House of Representatives’ fiscal year 2018 budget resolution, as they did in several prior ones.
In broad terms, “premium support” means the government pays a contribution toward premiums, and beneficiaries pay the rest. In a sense, today’s Medicare program already has such a structure. For either the traditional program or a private Medicare Advantage plan, the government pays a preset premium stipend (alternatively called a subsidy, credit or voucher) that varies across these two parts of the program. In all cases, stipends grow at the rate of health care costs.
If Medicare already has a form of a premium support model, what’s all the fuss about?
The important difference is in how stipend levels are set. Today’s stipends are not driven by the market, but are set according to legislatively established formulas. But the type of premium support Medicare reformers usually advocate — what people generally mean when they use this term — would use market signals to set stipend levels.
“Premium support could result in increased efficiency in the Medicare program,” said Bryan Dowd, a health economist at the University of Minnesota, and co-author of a book that analyzed various premium support options. That efficiency could push the hospital trust fund depletion date further into the future and reduce “the financial burden on future generations.”
Premium support models take many forms, but there are two crucial variables. One is how stipend levels are set, which determines how much of beneficiaries’ own money they need to contribute. The other key feature of premium support is how much the stipend grows over time. Both aspects are hotly debated.
In some versions of premium support, the stipend level would grow more slowly than health care costs, forcing people to pay more out of pocket over time to purchase coverage. In other versions, the stipend level would grow at the same rate as health care costs, so beneficiaries would continue to pay about the same share of their own money for health insurance.
Most premium support approaches would retain traditional Medicare, though its fate would be uncertain, a source of controversy. “A lot rides on how the government’s support level differentially impacts the cost to beneficiaries of private plans versus traditional Medicare,” said Timothy McBride, a health economist with Washington University in St. Louis. Geography also plays a role. “If traditional Medicare is disadvantaged, that would hit rural beneficiaries harder, because a larger share of rural America relies on the traditional program than do urban Americans.”
As a report this month from the Congressional Budget Office reveals, how much premium support could save the government varies considerably depending on how stipend levels are established. Across the variations the C.B.O. examined, Medicare spending could fall by as much as 9 percent or as little as about 0.5 percent. But premiums could rise, including the premium for traditional Medicare. Under one projection, the C.B.O. estimates, traditional Medicare’s premium could double.
In all the scenarios the C.B.O. analyzed, stipend levels would be based on bids from Medicare Advantage plans and traditional Medicare that reflect the cost to cover a person for standard Medicare services. Stipend levels would keep pace with overall health care costs, but they could still be lower than what many Medicare beneficiaries receive today.
For example, tying the stipend to the second-lowest bid and requiring all Medicare beneficiaries to be subject to that new, lower level would save $419 billion over 2022-2026, the C.B.O. estimated.
Tying it to the average bid or requiring only new beneficiaries to be subject to the new stipend would save less. In either case, people would have access to plans that don’t cost more than today’s. But those who opted for more expensive plans because they offer more benefits, or the traditional program because it covers any doctor willing to accept Medicare patients, would pay more out of pocket. Consequently, more people would opt for cheaper, private plans — and fewer would choose traditional Medicare.
This worries some health policy experts. “Traditional Medicare has been the leader in reforming the health care payment and delivery system to improve efficiency,” said Paul Van de Water, senior fellow with the Center on Budget and Policy Priorities. “It has outperformed private insurance in holding down the growth of health costs, but its ability to continue to do that would shrink significantly if premium support caused its enrollment to dwindle.”
Exactly how much more people would pay depends not only on the plans they select, but also on where they live. In some markets, many plans, including the traditional program, might charge premiums close to the second-lowest bid. In others, plans that many beneficiaries may want might cost a lot more.
In the premium support debate, there’s a fundamental lesson: It’s conceptually simple to reduce federal spending on health care, but it’s very hard to do so in a way that doesn’t increase costs for at least some consumers. To actually reduce total (not just federal) health care spending for everyone, one has to overhaul how care is delivered, not just how it is paid for. That’s much harder.
How to Be a Smart Obamacare Shopper
by Margaret Sanger-Katz and Haeyoun Park - NYT - November 1, 2017
The Trump administration’s actions to scale back Obamacare have made it harder and more complicated to find the best health plan. But the pricing chaos has also created great deals for some consumers, who can sign up during open enrollment beginning today. Here’s our advice on how to shop — the best strategy depends on how much you earn.
If you qualify for big discounts on deductibles and co-payments, it’s probably best to stick to the cheapest silver plan.
If you earn below 200 percent of the federal poverty level, or about $24,000 for a single person, you can get lower out-of-pocket medical costs because the government pays insurers to give you discounts.
The Trump administration ended these subsidies, but the law requires that insurers still give the discounts to consumers. That means a silver plan is still going to be the best deal, since you will be able to get a rich set of benefits for a fraction of your income.
While premiums have risen over all, there are still many places where the cost of the least expensive silver plan will cost less for people like you, according to data from the Kaiser Family Foundation.
Change in price of lowest-cost silver plan after subsidies for a 40-year-old earning $20,000, 2017 to 2018
Less expensive
than 2017
Source: Kaiser Family Foundation | Note: Map looks at states that sell health plans through the federal HealthCare.gov website. Information about the remaining states will be made public in November.
It’s worth looking at the different silver options to see which ones cover the doctors and hospitals you care about.
If you get premium subsidies but not big discounts, you may be better off with a gold or bronze plan.
If you earn between 200 percent and 400 percent of the poverty level, about $24,000 to $48,000 for a single person, you qualify for help paying your premiums from the federal government.
Because most states are increasing prices on silver plans, which are used to calculate your subsidy, you are likely to have more buying power this year if you want to buy a gold plan, with a lower deductible. In the past, the cheapest gold plans have always cost more than the cheapest silvers.
Where gold is cheaper than silver for a 40-year-old earning $30,000, after premium subsidies
Source: Kaiser Family Foundation | Note: Map looks at states that sell health plans through the federal HealthCare.gov website. Information about the remaining states will be made public in November.
You may also be able to use your enhanced subsidy to buy a free high-deductible bronze plan. (If you do, you may want to sock away some of your savings, so you can pay that deductible if you have a big medical emergency.)
Where a bronze plan is free for a 40-year-old earning $30,000, after premium subsidies
Source: Kaiser Family Foundation | Note: Map looks at states that sell health plans through the federal HealthCare.gov website. Information about the remaining states will be made public in November.
If you are older than 40 or earn less than $30,000, there may be even more places where you can find a free bronze plan.
Even if you are not in a place where you can benefit from a cheaper gold or free bronze plan, the law’s subsidy structure still protects you from price increases. Indeed, many people who buy the least expensive silver plans for 2018 will pay less out of pocket than they did this year.
If you don’t get any government subsidies, you are probably better off looking outside the Obamacare marketplace.
If you make over 400 percent of the federal poverty level, or about $48,000 for a single person, you can’t collect a subsidy, and you’re on the hook for the whole price of your coverage.
But in many states, though not all, there will be silver plans you can buy directly from an insurer that will cost less than the plans that are sold on the Obamacare marketplace. A human or online broker can help you explore all those options.
Look at the example below, to get a sense of the better deals you may be able to find outside the state exchange.
Average monthly premium for a 40-year-old in Scranton, Pa., without subsidies
On and off exchange
Source: Pennsylvania Insurance Department
If you have Obamacare coverage this year, don’t just renew your coverage without exploring all your options.
This is such an odd year for price increases that switching may get you better coverage for less money. Even if you like your plan, you should make sure it remains the best choice for you.
The last day to enroll for coverage is Dec. 15 in most states.
Choosing a Health Insurance Plan Is Not ‘Shopping’
by Helaine Olden - NYT - November 2, 2017
It’s time to select a health insurance plan for 2018! Whether we get covered through an employer or the Affordable Care Act exchanges, we’ll be told to carefully review our options to find a plan that will give us the best coverage for the least amount of money.
We will be told we need to shop.
“I encourage you to shop around,” Senator Jeanne Shaheen, Democrat of New Hampshire, told her Facebook followers who are choosing plans from the A.C.A. marketplaces. The human resources giant Mercer wrote last year, “This open enrollment, think of employees as shoppers.” The American Diabetes Association, the American Institute of Architects, the Robert Wood Johnson Foundation and Aetna all use the terms in their literature or on their websites.
Make it stop!
This is not shopping. Shopping is a fun activity, like choosing a pie from the bakery or picking out cereal at the supermarket. The farthest thing from “shopping” is the arduous annual ritual of reviewing the complex and all but impossible to decipher health insurance options.
That’s partly because insurers do their best to make the experience as miserable as possible. Many of them offer up less-than-accurate lists of providers and participating institutions. They reserve the right to deny you coverage of a service, and you won’t know if they have until the day you need it — and maybe after the fact. Prospectuses are complex, and few of us fully understand them. Only 9 percent of Americans can properly define all four of these rather vital phrases: health plan premium, health plan deductible, out-of-pocket maximum and coinsurance, according a survey recently released by United Healthcare.
No surprise, reviewing our health insurance options doesn’t score high on the fun-o-meter. A 2016 Harris Poll discovered almost half of the employees they questioned always found choosing an insurance plan stressful. A similar number told Aflac they would rather talk to an ex or walk across hot coals than enroll in a health insurance plan. And yet another United Healthcare survey found more than a quarter of respondents would rather lose their credit card, smartphone or luggage, not to mention suffer a flat tire, than review their health insurance options during open-enrollment periods.
Plus, we have choices when we do the real kind of shopping. If we don’t like the luggage in one store, we can always head to another. But if we don’t like the health insurance options our employer selects, or the options on the local exchange — well, short of changing jobs or moving, we’re stuck. That’s hardly the definition of consumer empowerment.
Yet the term “shopping” puts the onus on the patient, not the overpriced American system of medical care. This is no exaggeration. At an election town hall last year, a woman confronted Hillary Clinton, explaining that her health insurance costs doubled to over $1,000 a month after the Affordable Care Act went into effect. Mrs. Clinton responded that she would work to keep costs down but told the woman to “keep shopping, because what you’re telling me is much higher than what I hear from other families.”
Isn’t it absurd to describe us as shoppers? When I go shopping at the mall, I get perfume samples and free chocolates. When I consider health insurance plans, I am offered no such things.
Moreover, 326 million Americans cannot combat our high-cost medical system with one savvy purchase. The term prioritizes the values of the marketplace and financial world. It also signals that instead of contemplating how to make the medical-industrial complex work for us, our energy is channeled into getting the best deal we can from a system that’s designed not for our benefit, but to extract the greatest amount of profit from every patient.
Health care is much more than a mere consumer item, even if we do spend money to get it. It’s fundamental to our lives. So hear me out. Whether you are a reporter on deadline, an insurance official discussing plans or someone reviewing your options, just say people should “choose” or “pick” a plan. But whatever you do, don’t conflate the pleasurable experience of real shopping with the dreary task of finding a health insurance plan.
As Open Enrollment for Obamacare Begins, Confusion Reigns
by Abby Goodnough and Robert Pear - NYT - October 31, 2017
MACON, Ga. — David Branch knew that his job, helping people sign up for Obamacare, would be harder this year. But Mr. Branch didn’t fully realize the scope of his challenge until a group that he approached with his fliers insisted that the Affordable Care Act had been repealed.
“They said: ‘Why are you guys here? Obamacare is done,’ ” Mr. Branch recalled Friday as he finished a training session here.
In fact, the Affordable Care Act has survived blow after blow since President Trump took office in January, including repeated attempts by Congress to repeal it. But as the fifth open enrollment period starts Wednesday, the law is reeling from continued attacks by Mr. Trump that have sown confusion and anxiety among the roughly 10 million Americans with coverage through its insurance marketplaces and millions more who remain uninsured.
Most recently, Mr. Trump announced plans to cut off subsidies that reimburse insurance companies for assistance they are required to provide to low-income customers who struggle with co-payments and deductibles. The cuts resulted in a crazy quilt of premiums for 2018 that differs radically from the pattern of the last four years, which will upend expectations of consumers in many states.
And the administration’s sharp cuts to advertising for the law’s open enrollment period and to groups that employ enrollment “navigators” like Mr. Branch have almost certainly limited public awareness that now is the time to enroll. Those who have heard Mr. Trump’s message that insurance premiums are way up may not realize that the subsidies that help low- and middle-income Americans pay those premiums will rise as well.
The enrollment period for the federal marketplace has been cut in half, to 45 days, with hardly any publicity by federal officials. No one is sure how well government call centers and computer systems will handle the expected surge of applications leading up to the Dec. 15 deadline for people to enroll through HealthCare.gov.
In Washington and across the nation, supporters of the law are doing what they can to combat misperceptions.
“Consumers are unclear whether the marketplaces still exist, whether they still have an obligation to get coverage, whether the mandate exists, whether they can get financial assistance,” said Kelley Turek, a policy analyst at America’s Health Insurance Plans, a trade group. “Our message is: Come back. The marketplaces are still here.”
Here in Georgia, what had been the largest navigator group, Insure Georgia, lost 86 percent of its $2.3 million federal grant and had to lay off half its staff, leaving Mr. Branch and 10 other counselors to provide enrollment assistance for all 159 counties in the state. Humana is leaving the insurance marketplace here, and while three other insurers will remain, all but 10 counties will have a single company selling coverage for next year. Rates for popular silver-level “benchmark” plans are rising by 47 percent on average here, according to the Department of Health and Human Services, although most customers will qualify for subsidies that will grow by a similar amount. The department found that premiums for benchmark plans are increasing by 37 percent nationwide, compared with 24 percent last year.
Other types of plans may be less expensive, because to compensate for the funds they will lose now that Mr. Trump has ended the cost-sharing payments, insurers have generally raised the price of silver plans more than those in the bronze, gold and platinum categories. As a result, some gold plans will now be less expensive than some silver plans, even though gold plans cover more of the costs of a typical consumer.
Sorting through these complications will be difficult for many consumers.
At a Halloween “safety expo” at Coliseum Medical Centers here on Saturday, several hundred parents and children filed past an Insure Georgia table by the front door, where Amber Higgins, another navigator, asked over and over, “Do y’all have health insurance? You know anyone who’s doing without it?”
“My niece who just moved here from Ohio,” said one woman, taking a flier.
“My sister in Texas,” said another.
“Me,” said yet another woman, scanning the income requirements for receiving subsidies, which Ms. Higgins had placed in a frame.
The response was not surprising. Georgia has the nation’s fourth-highest number of uninsured residents, after Texas, California and Florida. In some of the state’s rural counties, enrollment under the Affordable Care Act dropped by as much as 36 percent this year, according to a new report, which pointed to the diminishing choice of insurers in rural areas as a likely reason.
Briana Zoellick, 26, told Ms. Higgins she had checked the HealthCare.gov website when it started allowing people to preview their options last week and was astonished to learn that her family’s subsidy would be a lot bigger next year even though their income has risen. Ms. Zoellick, a medical assistant and mother of two, said she and her husband, a graphic designer, canceled their coverage earlier this year because they could not afford their portion of the premium, about $140 a month.
Next year, she has learned, their subsidy will rise to more than $800, from $650 — “incredible,” she said — and their share will be less than before.
Yet Ms. Zoellick said her husband remained wary of signing up because of everything he had heard about Mr. Trump ending the payments to insurers. Many customers are mistakenly assuming that what he is blocking is premium subsidies, which are separate and not affected by Mr. Trump’s action.
“He was like, ‘I don’t know if that’s going to actually happen because of what Trump’s doing,’ ” Ms. Zoellick said, referring to their higher subsidy.
The California marketplace, run by an independent state agency, is spending $111 million on advertising, more than 10 times as much as the federal government intends to spend for the entire country. The New York marketplace, run by the state Health Department, is spending $15 million.
“Despite attempts at the federal level to take health care from New Yorkers, our marketplace is ready to open Nov. 1 as strong as ever,” said Donna Frescatore, the executive director of the New York insurance marketplace. “For many consumers, prices in 2018 will be the same as this year, or lower for the same level plan.”
In some states that run their own insurance exchanges, consumers will have more time to sign up. The deadline is Jan. 14 in Minnesota, Jan. 15 in Washington State and Jan. 31 in California and New York.
While many consumers will have fewer choices and will face higher premiums next year, the situation varies greatly from state to state.
In Tulsa, Okla., seven health plans will be available, all from one company. For the most popular plans, the average premium for a 35-year-old will be about $560 a month, according to HealthCare.gov. In Phoenix, consumers will have a choice of five plans, all from one company. For the two popular silver plans, premiums for a 35-year-old average $470 a month.
Mike Kreidler, the insurance commissioner in Washington State, approved rate increases averaging 36 percent last week, and he attributed 10 percentage points of the increase to Mr. Trump’s decision to cut off the subsidies known as cost-sharing reduction payments.
“I fear that many will go uninsured,” Mr. Kreidler said, while noting that some plans would not be affected by the president’s action.
In Macon next year, 13 plans will be available, all from Blue Cross Blue Shield of Georgia. A 50-year-old woman with income of $30,000 will be eligible for a subsidy of $597 a month. That subsidy would lower her premium to an average of $236 a month for silver plans and $77 a month for bronze plans, according to HealthCare.gov.
But for a 50-year-old woman in Macon with annual income of $50,000, costs would be much higher. She would not be eligible for financial assistance and would have to pay $768 a month — more than 18 percent of her income — for the cheapest silver plan. Prices in rural southwest Georgia and a few other parts of the state will be even higher, although in Atlanta they will be lower.
For Pat and John Curry of Augusta, who are both 57 and own a small coffee-roasting business, options will range next year from a bronze plan for $1,526 a month with a $13,500 family deductible to a gold plan for $3,142 a month and a $3,900 family deductible. Blue Cross is the only insurer selling in their county. The couple, who each have chronic conditions and take multiple daily medications, said they would research whether buying a plan directly from Blue Cross would be cheaper.
Ms. Curry will also consider buying coverage only for her husband, who is getting follow-up care for cancer.
“I don’t know what we’ll be doing for insurance,” Ms. Curry said, looking at rates under the Affordable Care Act, “but it won’t be this.”
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