Why it matters: Despite enormous spending on health care, quality is uneven
If the presidential candidates do not engage the nation in debating the future of health care, it still matters.
by Ricardo Alonso - Zaldivar - Associated Press
THE ISSUE
About 9 in 10 Americans now have health insurance, more than at any time in history. But progress is incomplete, and the future far from certain. Millions remain uninsured. Quality is still uneven. Costs are high and trending up again. Medicare’s insolvency is two years closer, now projected in 2028. Every family has a stake.
WHERE THEY STAND
Hillary Clinton would stay the course, making adjustments as needed to major government health insurance programs. She’d build on President Barack Obama’s health care law, with one exception — a tax on generous coverage that she’d repeal. Medicare, the health care program for older Americans and the disabled, would get new legal powers to negotiate prescription drug prices with pharma companies. Clinton would also offer some relief from rising out-of-pocket costs, like deductibles and copayments. Donald Trump would repeal “Obamacare.” But a recent study found his plan would make 18 million people uninsured. Stay tuned, because Trump has also said he doesn’t want people “dying on the street.” Similar to Clinton, he has promised not to cut Medicare. He agrees Medicare should be able to negotiate drug prices, unusual for a Republican. Trump’s campaign has said he may revisit major health care programs once in the White House.
WHY IT MATTERS
Patients from all over the world come to America for treatment. U.S. research keeps expanding humanity’s ability to confront disease. But the U.S. still spends far more than any advanced country, and its people are not much healthier.
Obama’s progress reducing the number of uninsured may be reaching its limits. Premiums are expected to rise sharply in many communities for people covered by his namesake law, raising concerns about the future.
The health care overhaul did not solve the nation’s longstanding problem with costs. Total health spending is picking up again, underscoring that the system is financially unsustainable over the long run. Employers keep shifting costs to workers and their families.
No one can be denied coverage anymore because of a pre-existing condition, but high costs are still a barrier to access for many, including insured people facing high deductibles and copayments. Prescription drug prices — even for some generics — are another major worry.
The election offers a choice between a candidate of continuity — Clinton — and a Republican who seems to have some core beliefs about health care, but lacks a coherent plan.
If the presidential candidates do not engage the nation in debating the future of health care, it still matters.
Even if you’re healthy, deeper national debt affects the economy and in some way everyone’s standard of living, especially the next generation. If the government has to spend more on health care, it comes at the expense of more debt, cuts in something else or higher taxes.
America’s problem with health care spending can’t be ignored or wished away. Political leaders can postpone hard choices, but that will mean consequences even more wrenching when the bill comes due.
Cost, Not Choice, Is Top Concern of Health Insurance Customers
by Reed Abelson - NYT
It is all about the price.
Millions of people buying insurance in the marketplaces created by the federal health care law have one feature in mind. It is not finding a favorite doctor, or even a trusted company. It is how much — or, more precisely, how little — they can pay in premiums each month.
And for many of them, especially those who are healthy, all the prices are too high.
The unexpected laser focus on price has contributed to hundreds of millions of dollars in losses among the country’s top insurers, as fewer healthy people than expected have signed up. And that has created two vexing questions: Will the major insurance companies stay in the marketplaces? And if they do, will the public have a wide array of plans to choose from — a central tenet of the 2010 Affordable Care Act?
“The marketplace has been and continues to be unsustainable,” said Joseph R. Swedish, chief executive of Anthem, one of the nation’s largest insurers.
Most Americans with health insurance get it through their employers or from government programs like Medicare and Medicaid. The marketplaces were created under the health care law to give the millions of people not covered in those ways a way to buy health plans.
While major insurers continue to make profits over all, they say that the economics of the marketplaces do not work for them. Insurers can offer marketplace plans at four different coverage tiers, and the government subsidizes the premiums for millions of people. The thinking was that enough healthy people would buy insurance to balance out the costs for the not-so-healthy.
But things are not going exactly as envisioned.
People shopping in the marketplaces are overwhelmingly choosing the cheapest plans they can find, according to a federal analysis. In 2014, two-thirds of people went for the lowest- or second-lowest-priced plans in each of the tiers. In 2015, about half chose the cheapest plans.
The pricing pressure is playing out on multiple fronts. People with expensive medical conditions, knowing that they need reliable coverage, seem willing to pay a little more for plans offered by the large companies. Those plans tend to have a wider choice of doctors and a stronger brand name, and the insurers say the people signing up are sicker than they expected.
Healthy and young people — who are essential to insurers to offset the costs of care for unhealthy people — are regularly turning to whatever plan is cheapest, including those from little-known insurers or with the smallest networks of hospitals and doctors.
Many other young and healthy people, particularly those not eligible for generous subsidies, are shunning plans altogether, finding all of the prices too high. That decision puts them at risk of tax penalties. By some estimates, about 10 million people are signed up, fewer than half of the 21 million expected by now.
All of this has the major insurance companies, as they finish their third year of selling individual policies under the law, reevaluating their role in the marketplace.
The top insurers have essentially stopped talking about expanding their marketplace ambitions. Two companies, UnitedHealth Group and Humana, have said they plan to largely exit the marketplaces. Aetna has halted plans to enter more states.
Even insurers that insist they are committed, like Anthem, which offers for-profit Blue Cross plans in more than a dozen states, are struggling to find their way. Mr. Swedish describes the market as “not predictable and not reliable.”
If the major insurers keep cutting back, it could lead to a cascade of effects for the people who depend on the marketplaces for coverage. People could potentially face higher premiums because there are fewer insurers competing, and they could have more limited choices of plans and doctors.
The apprehension is not lost on regulators and lawmakers. On Thursday, the Obama administration said it was exploring ways to protect insurers from very expensive medical claims. And recently in The Journal of the American Medical Association, President Obama wrote that more financial assistance for people may be needed.
So the mainstream insurers are struggling to find a business model for the marketplaces that works. If an insurer is successful at being the cheapest in a market, it has often found that it priced its plans too low to cover its medical costs. Some smaller insurers have already gone out of business. But if an insurer prices a plan too high, it might not attract enough healthy people to break even.
Companies both large and small now plan to raise prices sharply for 2017, which could prevent even more people from buying policies.
“The price competition has turned out to be much more cutthroat than anyone expected,” said Larry Levitt, an executive with the Kaiser Family Foundation, which closely tracks the law.
Still, most experts say there is no immediate danger that the market will collapse. Marjorie Connolly, a spokeswoman for the Department of Health and Human Services, said in a statement that the Obama administration was confident that the marketplaces would “continue to thrive for years ahead.”
The department said on Thursday that the people entering the marketplaces are becoming more mixed over time, and the marketplaces are attracting more young and healthy people over all. The major insurers, though, say the healthy people are going to other plans, often the least expensive ones offered by their smaller competitors.
Some defenders of the law say it is working as intended, harnessing competition to keep premiums as low as possible.
“We have to be realistic,” said Linda J. Blumberg, a health care expert at the Urban Institute, noting that some large companies may not be nimble enough to succeed. “You can’t lower costs without breaking some eggs.”
Not every insurance company is struggling. The exceptions seem to be those that offer the most limited choice of doctors and hospitals and may pay them the least, including plans offered by companies like Molina and Centene, which previously specialized in covering low-income Medicaid patients.
The insurers faring the worst sell plans that resemble those traditionally offered through employers. The plans give customers much greater latitude over where to get care and cover some of the high-priced doctors and best-known hospitals. The trouble is that people signing up for those plans are less healthy — and more expensive to treat — than anticipated.
The companies also say that the provisions of the law aimed at stabilizing the market and protecting them from heavy losses are not working. Several say that consolidation is the answer. Anthem, for example, says the only way it can expand in the marketplaces is by merging with Cigna, a deal the Justice Department is trying to block.
Another remedy is to attract a broader range of customers. “We have to get a healthier pool of people in the market,” said Kurt Kossen, an executive at Health Care Service Corporation, which operates nonprofit Blue Cross plans in several states but lost $1.5 billion last year.
The result could be a market essentially left to insurers that offer the same narrow networks found in Medicaid plans and some remaining Blue Cross plans, said Mr. Levitt, of the Kaiser Family Foundation.
“The market is sustainable but with a different mix of plans,” he said.
ACA may not be ‘terrific,’ but it’s making a difference
Editorial - Boston Globe
From the day the Affordable Care Act was signed into law more than six years ago, Republicans have vowed to repeal the sweeping legislation that so far has extended medical coverage to more than 20 million previously uninsured Americans. Following in that dubious tradition, Donald Trump has made overturning the law a marquee issue of his presidential campaign, vowing to replace it with “something terrific.” Their criticisms are many, but most revolve around the insurance program being too expensive and cumbersome for businesses and individuals. And, they dislike that it was built on what they consider an objectionable “individual mandate.” Yes, there have been many bumps along the way — and a few gaping holes that still need to be filled — but various studies and analyses indicate that the ACA is working to cut medical debt, and greatly reduce the number of people who are without insurance. It’s far from perfect, but even further from failure.
Now, a new study finds that the law may be helping to improve the lives of low-income people who previously received most of their health care in hospital emergency rooms. It looked at several states where some low-income residents did not qualify for Medicaid, the federal government insurance program for disabled people and the poor. Under a momentous 2012 US Supreme Court ruling, states are not obligated to expand Medicaid coverage to these residents under the ACA. In Arkansas and Kentucky, two states that opted to do so, the study found people were taking better care of themselves, compared with those in Texas, which chose against Medicaid expansion. The comparison is more nuanced than that, of course, but in general, low-income residents who had health insurance for the first time were more likely to turn to a primary care doctor instead of the ER, fill prescriptions for medications, and to seek routine preventive care, like glucose tests, cholesterol screenings, and blood-pressure monitoring
The study was published last week in the journal JAMA Internal Medicine. Its author, Benjamin Sommers, is quick to point out that none of this is immediately saving money — people with insurance go to a doctor more often than those who have to foot the entire bill. But Sommers, an assistant professor of health policy and economics at Harvard’s T. H. Chan School of Public Health, also notes that the federal dollars from expanded Medicaid coverage can help boost a state’s health care industry, particularly in low-income areas. That raises a point that ACA critics often ignore: Ultimately, the goal of the legislation is to make Americans healthier. As that happens, over time there likely will be cost savings.
“There’s a social contract part of this,” says Sommers. “Is it fair for the richest country in the world to have people not to be able to afford their medical care?”
It’s something for Trump to think about before launching into his next rant against “Obamacare.” He might even want to discuss it with his vice presidential running mate, Mike Pence. Last year, the Indiana governor decided to start accepting additional Medicaid funding for his state. He’s investing it in an innovative program called Healthy Indiana Plan 2.0, which provides insurance to adults earning up to 138 percent of the federal poverty level, if they agree to put a modest amount of money in a health savings account. As of January, nearly 350,000 were participating. Not quite the Affordable Care Act “disaster” of Trump’s rhetorical theatrics.
Health Insurers Use Process Intended to Curb Rate Increases to Justify Them
by Robert Pear - NYT
WASHINGTON — After the Affordable Care Act took effect in 2010, it created a review mechanism intended to prevent exorbitant increases in health insurance rates by shaming companies that sought them.
But this summer, insurers are turning that process on its head, using it to highlight the reasons they are losing money under the health care law and their case for raising premiums in 2017.
That has ignited an election-year fight between insurers and consumers, who are complaining bitterly about the double-digit increases being sought across the country.
The conflicts have been on vivid display at hearings in states like Pennsylvania, where Highmark, one of the state’s largest insurers, has proposed rate increases averaging 41 percent.
“The health of the citizens of Pennsylvania is worth more than the profits desired by health insurance companies,” Rose Lynd, 35, of Pittsburgh, testified at a hearing in Harrisburg held late last month by the Pennsylvania insurance commissioner, Teresa D. Miller, a former Obama administration official.
Ms. Lynd, a cancer survivor, said her costs were onerous.
“My premiums are more than $600 a month, which is more than our mortgage payment,” Ms. Lynd said. “I am grateful that the Affordable Care Act is here for my family, but I am disappointed by its limitations. All I want is a plan that makes our health care affordable, but it doesn’t exist.”
Highmark defended its request by saying it was paying out more in claims than it was receiving in premiums. Jeff Scheib, the vice president in charge of actuarial services at Highmark, offered a statistic to illustrate the problem.
“There were close to 250 individual A.C.A. policyholders in Pennsylvania who incurred over $100,000 each in claims and then canceled coverage before the end of the year,” Mr. Scheib testified. “This behavior drives up the cost to insure the entire pool, because people use insurance benefits and then discontinue paying for coverage once their individual health care needs have been temporarily met.”
While state insurance commissioners, who review rates, are trying to balance the needs of consumers and insurers in a turbulent market, insurers have extra leverage this year. At least a dozen nonprofit health insurance cooperatives have collapsed, and several big commercial insurers have decided to cut their losses by limiting their participation in the insurance exchanges, the new marketplaces created under the health law.
The problems threaten to shadow Democrats through Election Day. While Hillary Clinton has vowed to “defend and expand” the Affordable Care Act, her Republican opponent in the presidential race, Donald J. Trump, has seized on the issue. At a rally in Fairfield, Conn., on Saturday, he repeated his vow to repeal the health law, saying consumers were facing rate increases greater than they had ever seen.
Ms. Miller, the Pennsylvania commissioner, said that protecting consumers was a top priority. But she said, “The large requests before me this year are not unique to Pennsylvania, unfortunately.” Arthur M. Lucker, a consultant to the Pennsylvania Insurance Department, said insurers had requested rate increases of more than 25 percent in at least 20 states, including Arizona, Florida, Ohio and Texas.
Aviva Aron-Dine, an economist at the federal Department of Health and Human Services, said predictable factors were behind the upward pressure on rates. For example, the federal government is ending a program that helped pay some of the largest claims incurred by insurers.
In addition, Ms. Aron-Dine said, some insurers may be trying to make up for having initially set premiums too low. In any event, she said, most people buying insurance on the exchanges receive subsidies.
Connecticut has a state-run insurance exchange considered one of the most successful in the nation. But that has not provided a guarantee of stable rates.
Continue reading the main story
Anthem, for example, is seeking an average increase of 27 percent in Connecticut.
That is “just off the charts and unacceptable,” one Anthem customer, Douglas H. Wade Jr. of Bridgeport, said at a hearing in Hartford on Aug. 3.
Matthew McDermott, the leader of an interfaith advocacy group, Congregations Organized for a New Connecticut, said: “We’re concerned that the proposed rate increases will drive many employers and many individuals to drop coverage altogether. And we worry that that heads us toward a market failure here in Connecticut.”
Two of the four insurers on the Connecticut exchange have indicated that they will not be offering plans in that marketplace next year. “Higher-than-expected health care costs have jeopardized the financial solvency of some insurers and have caused other insurers to leave the exchange altogether,” said James Augur, a regional vice president of Anthem in Connecticut.
At a hearing in Helena, Mont., Monica J. Lindeen, the state insurance commissioner, asked Blue Cross and Blue Shield why it was seeking an average rate increase of 62 percent for 2017, after receiving an increase of 22 percent this year.
“Cost is what’s really driving our rate increases,” said Michael E. Frank, the president of Blue Cross and Blue Shield of Montana.
“For every dollar we brought in last year, we paid out $1.26 for medical care,” Mr. Frank said. “In the first six months of this year, we have already paid $4.17 million in medical costs for the top 10 individuals. That’s $70,000 a month for those individuals.”
Insurers invariably cite drug costs as a factor driving up premiums. James Spencer, the chief actuary of Blue Cross and Blue Shield of Montana, said 1 percent of prescriptions accounted for 30 percent of pharmacy costs.
Ms. Lindeen wanted to know why Montana Blue Cross and its parent company, Health Care Service Corporation, had not constrained the pay of top executives. The parent company reported total compensation of more than $11 million for its chief executive in 2014. A Blue Cross executive told Ms. Lindeen that executive payreflected “the size and complexity of our business” and was a tiny share of total expenses.
While the Obama administration has said the federal insurance marketplace is gaining healthier, lower-cost consumers, several insurers said at the hearings that they had not seen a significant improvement.
“Studies concluded that the market would stabilize after absorbing the pent-up demand from the previously uninsured population,” testified Eric Galvin, the chief financial officer of ConnectiCare Insurance Company. But, he said, “rather than stabilize, that cost has continued to skyrocket, and we see no end to that higher level of spending.”
Christopher F. Koller, a former health insurance commissioner in Rhode Island, said he was always concerned that insurers were seeking higher rates than necessary, with the expectation that their requests would be cut back by state regulators.
But even if officials trim proposed rates, consumers can still face substantial increases.
This month New York officials approved rate increases averaging 16.6 percent for individual health insurance plans in 2017, more than twice the average in the state for 2016.
The insurance commissioner in Mississippi approved an average rate increase of 43 percent for Humana, fearing that the company might otherwise leave the state’s insurance exchange, as UnitedHealth intends to do.
And the Kentucky insurance commissioner has approved increases averaging 5.6 percent for Aetna, 22.9 percent for Anthem and 31 percent for Humana.
Aetna to Pull Back From Public Health Care Exchanges
by Robert Pear - NYT
WASHINGTON — In a blow to President Obama’s health care law, Aetna, one of the nation’s major insurers, said Monday that it would sharply reduce its participation in the law’s public marketplaces next year.
Aetna said it would no longer offer individual insurance products on the exchanges in about two-thirds of the 778 counties where it now provides such coverage. The company will maintain a presence on exchanges in Delaware, Iowa, Nebraska and Virginia, it said.
In recent months, the large insurers UnitedHealth and Humana also said that they intended to pull back from the online exchanges, and other insurers are struggling to break even in marketplaces where low prices appear to be the top priority for low-income consumers.
The exchanges are a centerpiece of the Affordable Care Act: the only place where consumers can obtain subsidies to buy health insurance, which most Americans are required to have under the 2010 law. About 11 million consumers have coverage through the marketplaces, and about 85 percent of them receive subsidies in the form of tax credits.
Mark T. Bertolini, the chairman and chief executive of Aetna, said the company was responding to financial losses: “a second-quarter pretax loss of $200 million and total pretax losses of more than $430 million since January 2014 in our individual products.”
“As a strong supporter of public exchanges as a means to meet the needs of the uninsured, we regret having to make this decision,” Mr. Bertolini said. But, he added, the company cannot provide affordable, high-quality plans through the exchanges without a larger number of healthy people to help offset the costs of coverage for less healthy consumers.
“Individuals in need of high-cost care” account for a disproportionate share of the enrollment in Aetna’s marketplace plans, and the federal government does not adequately adjust its payments to account for these costs, he said.
Obama administration officials reacted angrily to Aetna’s announcement. They suggested that Aetna was retaliating against the administration because the Justice Department filed suit last month to block Aetna’s proposed acquisition of Humana. Attorney General Loretta E. Lynch said that transaction would reduce competition in violation of federal antitrust law.
Kevin J. Counihan, the chief executive of the federal insurance exchange, said the marketplace would remain strong and vibrant despite Aetna’s decision.
“It’s no surprise that companies are adapting at different rates to a market where they compete for business on cost and quality, rather than by denying coverage to people with pre-existing conditions,” Mr. Counihan said Monday.
In a conference call with securities analysts in April, Mr. Bertolini said that Aetna had 911,000 members with individual coverage through the exchanges and added, “We see this as a good investment.”
Senator Elizabeth Warren, Democrat of Massachusetts, said she saw a possible connection between the antitrust case against Aetna and its decision to reconsider participating in the exchanges.
“Aetna may not like the Justice Department’s decision to challenge its merger, and it has every right to fight that decision in court,” Ms. Warren said in a Facebook post last week. But, she said, “the health of the American people should not be used as bargaining chips to force the government to bend to one giant company’s will.”
Aetna backs out of plan to enter Maine health insurance marketplace
The company's move reflects the difficulty of accurately predicting costs in a program that is just entering its fourth year.
by Joe Lawlor - Portland Press Herald
Aetna is canceling its plans to join the Affordable Care Act’s health insurance marketplace in Maine after spending months preparing to compete against three other insurers in offering subsidized benefits.
In May, Aetna had filed paperwork with the state to join Anthem, Community Health Options and Harvard Pilgrim in the ACA marketplace, but on Aug. 5 the company filed a notice with the Maine Bureau of Insurance canceling its plans. Aetna will still offer individual plans outside the marketplace.
About 84,000 Mainers have individual marketplace coverage, according to insurance filings.
The decision is part of Aetna’s national strategy to pull back from the ACA marketplace for financial reasons, according to Mark Bertolini, the company’s chairman and CEO, in a transcript of an Aug. 2 conference call with analysts that was provided to the Portland Press Herald.
“We are committed to being good stewards of our balance sheet and managing the financial risk and level of investment associated with this opportunity,” Bertolini said. “In light of the disappointing year to date performance … we believe it is only prudent to reassess our level of participation on the public (marketplace).”
The decision comes on the heels of UnitedHealth Group’s move in April to abandon the ACA marketplace in most of the 34 states in which the insurer was operating. UnitedHealth does not offer marketplace plans in Maine.
Sandy Ahn, an associate professor at Georgetown University’s Center on Health Insurance Reforms, said she doesn’t see the decisions to scale back as a sign that insurers will stampede away from offering ACA marketplace coverage.
“This is just part of the growing pains of establishing the program. We’re only in year four,” said Ahn, pointing out that most consumers still have several choices among insurance companies. Ahn said other government programs that proved to be successful had similar problems at the outset, such as the Medicare prescription program from the early 2000s.
Aetna had planned on expanding in Maine, New Jersey, Oklahoma, Indiana and Kansas, according to The Wall Street Journal. The company will also re-evaluate whether to continue offering marketplace plans in the 15 states where it already operates, Bertolini said.
Patients in the ACA marketplace can on average choose among 5.8 insurance companies, down from 6.9 in 2015 and 6.5 in 2016, according to a study of marketplace offerings in 17 states by the Kaiser Family Foundation.
Emily Brostek, executive director of Consumers for Affordable Health Care, an Augusta-based health advocacy group, said she doesn’t see the decisions by Aetna and UnitedHealth as a severe problem for the ACA, but it’s a reflection of how difficult it was to predict how much it would cost to cover people, many of whom never had health insurance.
“It’s a trickier needle to thread than some companies expected,” Brostek said.
She said that while insurance companies had decades of knowledge about the patient pool in existing employer-based networks, predicting the patient pool in the ACA, often from self-employed or part-time workers who never had health insurance, proved to be far more difficult.
As a result, insurance companies suffered losses in 2015 and have requested double-digit premium increases for 2017 in filings with the Maine Bureau of Insurance. The requests include a 25.5 percent increase by Community Health Options, 21.1 percent by Harvard Pilgrim and 19.4 percent by Anthem.
Those requested increases are under state review and may be reduced.
For about 90 percent of patients who qualify for subsidies, the premium increases will be absorbed by the subsidies and not borne by the patients. However, people who don’t qualify for subsidies will have to pay the full increase.
Incorrect projections regarding the health of the patient population was a major factor in the financial woes reported by Community Health Options, the co-op established in Maine and other states with a federal loan as part of the ACA.
CHO is currently being monitored by the Maine Bureau of Insurance, although its financial performance is on track with expectations, according to bureau filings.
CHO is also suing the federal government for $22.9 million under a program designed under the ACA to protect insurers from losses caused by faulty estimates. CHO lost $31 million in 2015 and has set aside $43 million in reserves for 2016 to absorb losses.
Anthem, in a filing with the state on Aug. 5, said that the 19.4 percent rate increase it requested should not be reduced, due to the ripple effect of Aetna’s pulling out of the marketplace.
Aetna’s withdrawal “materially increases” Anthem’s financial risk for a number of reasons, including that Anthem is “likely to receive significantly greater enrollment than contemplated in its rates,” according to Anthem attorney Christopher Roach.
The insurance bureau will likely finalize rates this week, although they must also be approved by the federal government. Patients can sign up for 2017 marketplace insurance plans starting on Nov. 1.
Insurers' Fine Print May Exclude Health Care Important To Women
By MICHELLE ANDREWS
Buried in the fine print of many marketplace health plan documents is language that allows them to refuse to cover a range of services that are used more often by women, a study finds.
It's unclear if these exclusions have prevented patients from getting needed treatments. An insurance industry representative says patients are generally able to get care if it's appropriate for them. Yet some women with a family history of hereditary breast and ovarian cancer, for instance, may have gaps in care because of the exclusions.
More broadly, advocates say, the report suggests coverage issues that may still need to be addressed, despite significant improvements in coverage of women's health needs following passage of the Affordable Care Act.
The study by researchers at the National Women's Law Center, an advocacy group based in Washington, D.C., examined exclusions in marketplace plans offered by 109 insurers in 16 states in 2014 and 2015.
The health law requires insurers to explain whether they cover 13 services, including acupuncture, bariatric surgery and infertility treatment, in a plan's easy-to-read general summary of benefits. But other services that aren't required to be listed there may also be excluded. And those exclusions may be hard for to find in the more detailed plan coverage materials, which can be quite technical and run dozens of pages.
The researchers reviewed plans' detailed documents and identified six types of excluded services that could have a disproportionate impact on women's health care, although many of them also are used by men. The excluded services included:
- Treatment for conditions that result from non-covered services, such as an infection following cosmetic surgery. They were excluded by 42 percent of plans.
- Maintenance therapy for a chronic disease or other care that prevents regression of a stable condition (27 percent of plans).
- Genetic testing, except as required by law (15 percent).
- Fetal reduction surgery, which is sometimes recommended when a woman is carrying multiple fetuses in order to protect the woman's health or improve the odds of a successful pregnancy (14 percent).
- Treatment for self-inflicted conditions, such as a suicide attempt, (11 percent).
- Preventive services not required by law (10 percent).
"We wanted to highlight issues that would have a particular impact on women as well as show how broad some of the exclusions are," says Dania Palanker, who co-authored the study and is now an assistant research professor at Georgetown University's Center on Health Insurance Reforms.
It's not uncommon for women who have a family history of breast or ovarian cancer to run into this type of roadblock when they need genetic testing or preventive services, says Lisa Schlager, vice president of community affairs and public policy at Force, an advocacy group for people affected by hereditary breast, ovarian and related cancers.
The Affordable Care Act requires insurers to cover services that are recommended by the U.S. Preventive Services Task Force, an independent panel of medical experts, without requiring consumers to pay anything out of pocket. The task force recommends that women with a family history of breast or ovarian cancers receive genetic counseling and, if necessary, testing for a mutation in the BRCA1 or BRCA2 genes that are known to increase the risk of developing those cancers.
However, insurers aren't required to cover testing for the 40 or so other genetic mutations that are also recognized as increasing women's risk of breast or ovarian cancer, Schlager says, and many don't do so.
If a woman does test positive for a BRCA mutation, insurers may not cover earlier or more frequent screening or other preventive care she may need, Schlager says.
"We are in this strange scenario where insurers are paying for the testing and then not paying for the breast MRIs or prophylactic mastectomies," she adds.
Clare Krusing, a spokeswoman for America's Health Insurance Plans, a trade group, calls the report "overblown." She says it fails to address whether treatments are safe and effective for all patients; whether other effective treatments are covered; and whether there are processes to help patients get access to excluded treatments.
"If a patient has a medically necessary reason for this care, it will likely be covered," Krusing says.
Kirsten Sloan, senior policy director at the American Cancer Society Cancer Action Network, says people who use the society's call center aren't generally complaining about plan coverage exclusions. Still, coverage distinctions may be confusing for patients, Sloan says, and highlight the need for better transparency in communicating coverage information.
A doctor bikes across the country to ask Americans about Obamacare. This is how he ended up feeling hopeful
by Noam N. Levey - LA Times
Jim Vetsch shifted uncomfortably as Dr. Paul Gordon leaned in and asked him about Obamacare.
The two men — one a retired power plant operator, the other a medical school professor — were standing in Vetsch’s kitchen at the Horse Creek Bed and Breakfast in eastern Montana where Gordon had stopped for the night.
Vetsch wasn’t happy about the country’s direction, he told Gordon at last. And he definitely didn’t like the Affordable Care Act — it was too expensive, and the government shouldn’t be providing health insurance.
“It’s a crutch,” Vetsch declared.
Gordon tried to press Vetsch, asking what should happen to people who couldn’t afford health coverage. Vetsch didn’t answer directly. “I’ve worked all my life,” he stated, noting he’d always had jobs with benefits.
Gordon had heard a lot of that in recent months. On sabbatical from the University of Arizona, he had set off in the spring on a cross-country bicycling trip and “listening tour” from Washington, D.C., to Seattle, talking along the way to Americans about the controversial health law that President Obama signed six years ago.
Much of what Gordon uncovered was as unsettling as the current presidential campaign. Americans raged at the government, at the healthcare system, at fellow citizens who’d gained coverage through Obamacare.
The outpouring of resentment and apparent lack of empathy disturbed Gordon at first. “Not a lot of generosity of spirit,” he noted glumly over the phone early in his trip.
But as he made his way west, Gordon’s feelings evolved. His depression gave way to a new sense of resolve. As a doctor, he could and should do something about the anger he was hearing.
“I saw this could make me a better teacher, a better clinician, a better human being,” he said.
Gordon, 61, a compact man with sharp features, black half-rim glasses and a gray beard that gave him a distinctly academic look, conceived his ride as a scholarly exercise that would generate academic papers about perceptions of the health law while fulfilling his 40-year dream of biking across the country.
Eager to learn what his unusual project might reveal about a bitter national healthcare debate I’d been covering for nearly eight years, I met up with him in eastern Montana to bike along and listen for a day.
We started in Forsyth, an aging railroad town in the wide Yellowstone Valley where long coal trains rumble past at all hours. Gordon was moving into the arduous final third of his 3,255-mile journey, which would go up through the Rockies and the Cascades before ending on the West Coast.
We planned to ride west along the Yellowstone River paralleling the route Lewis and Clark had taken, then south into the foothills of the Big Horn Mountains where Custer was famously ambushed.
All around us, mammoth ranches stretched across valleys dotted with sage brush and lazy cattle sheltering under stands of cottonwood trees.
On either side, pine-studded ridge lines offered shelter to elk, mountain lions and wolves.
Gordon and his team — which at times had included his wife, his adult children, a couple he’d befriended in Arizona and a medical student, Laurel Gray, who made the trip a research project — had endured far harder rides: long slogs across the Dakotas where towns were separated by 60 miles or more, and cold days of freezing rain in the Midwest.
But what had proved most challenging for Gordon were the conversations.
In Pennsylvania, a restaurant owner complained about her rising insurance bills and told Gordon she was sick of her insurance payments covering other people’s medical care.
In a small cafe in western Minnesota, a 64-year-old woman accused the law of spawning widespread abuse. “Obamacare encourages people to take advantage of the system,” she told Gordon.
Outside a convenience store in eastern South Dakota, another woman said — somewhat ashamedly — that everyone in town thought Obamacare and Obama were terrible. “He just gives all the taxpayers’ money away to poor people,” she said.
“I thought, ‘Oh, my God, how did we get here?’” a dispirited Gordon told me as he struggled to decipher the anger.
“I am having these beautiful days riding through the country, and then at the end of the day, I sit down to talk to people and hear this terrible stuff.… It’s overwhelming how little care people seem to have for others.”
Equally jarring, Gordon found that few of the people he met seemed mean-spirited.
“These were people who would help you on the side of the road,” Gordon said. “They are good people. But what was coming out of their mouths was so ugly.”
Gordon, who has spent 30 years as a family physician caring for patients, had been prepared to hear frustrations. He expected complaints about rising premiums and deductibles that were making growing numbers of Americans skip medical care.
He also knew many people he met wouldn’t share his liberal political views.
Gordon had resolved he wouldn’t argue or try to sway opinions. He wanted to record what Americans were thinking.
But as his conversations uncovered basic misunderstandings about healthcare and health insurance, Gordon tried to push people to think about how they would fix the system.
Rarely did he get much of an answer.
“There just weren’t solutions,” Gordon told me at one point, venting his frustration with the misinformation and the cable news sound bites he was hearing. “All we had were complaints.”
Over time, however, Gordon began to see that those complaints represented an opportunity.
Doctors, he concluded, could step in and begin to correct some of the misinformation and help Americans better understand their healthcare system.
“I actually feel inspired,” he said at one point.
As we rode up out of the Yellowstone Valley, climbing gently but steadily along a meandering stream called Sarpy Creek, Gordon expanded on what he had come to appreciate.
The U.S. healthcare system is numbingly complex. It’s difficult for patients to understand why it costs so much, even how health insurance works.
At the same time, Americans’ anger about how much they are paying is justified. “These are legitimate concerns, the kind of concerns my patients could have when they come into the office,” Gordon said.
If these patients worried about a medical issue – a sore throat, an aching leg – he would consider it a professional duty to investigate and to seek a remedy.
Physicians have been reluctant to talk to patients about the healthcare system, however, perhaps leery of being drawn into the partisan political debate.
That is a mistake, Gordon concluded.
“I’m not saying, ‘Be political.’ … I’m not going to tell someone to vote for this candidate or that.”
But, he reasoned, physicians could do far more to guide their patients through the system and explain how it works. Armed with better information, perhaps Americans would base their opinions about health policy on more than the kind of emotional responses he heard across the country.
“We, as doctors, need to help people understand,” he said.
As we neared the end of our 50-mile ride that day, the hills got steeper and the temperature soared to more than 100 degrees. Conversations quieted.
By midafternoon, we made it to a turnoff about halfway up the valley. There, Vetsch picked us up, saving five miles of pedaling down a dirt road to his inn.
He greeted us warmly, helping put the bikes on a trailer before driving us to his ranch house on a slight rise overlooking the valley.
Vetsch offered tall glasses of iced tea as we gathered in his kitchen, surrounded by photos of his family. After the awkward conversation about Obamacare, we all helped chop vegetables as Vetsch cooked chicken breasts.
I caught a ride back to Forsyth after dinner with a local hunting guide Vestch knew.
Later, as Gordon reflected on the conversation, he said it would have once frustrated him. By Montana, it was another reminder of how much explaining Gordon and other doctors needed to do.
A few weeks later, after he arrived in Seattle, Gordon told me he was feeling good about the journey and the more than 100 conversations he’d had across the country.
“I’m tired,” he admitted. But he was thinking about another potential project – a ride across Canada to talk with Canadians about their healthcare system.
When you wish away state government, there are bound to be consequences
Editorial Board - Bangor Daily News
When Gov. Paul LePage indicates his goal is to cut the size of the state government workforce in order to pay for state income tax cuts, in part by leaving vacant positions unfilled, he’s referring to jobs like those of public health nurses.
When Maine faced an outbreak of a novel strain of influenza in 2009, H1N1, it had 50 public health nurses at the ready to set up and staff more than 200 vaccination clinics, to go into schools and immunize students, and to train others on vaccination protocols, including safe storage and distribution of limited vaccine supplies.
With public health nurses’ help, Maine was able to vaccinate children and seniors against the H1N1 influenza strain at some of the highest rates in the nation.
Today, Maine’s corps of public health nurses — one of the first positions in the state’s Division of Public Health, which today is the Maine Center for Disease Control and Prevention — is half as large. The diminished ranks throw into question Maine’s ability to respond effectively to a disease outbreak similar to H1N1, which infected thousands and caused outbreaks at 40 summer camps and 200 schools.
Aside from being prepared to respond to a public health crisis, Maine’s 25 remaining public health nurses who are regularly out in the field maintain a long list of responsibilities aimed at improving the public’s health in communities across the state — including visiting new moms and babies in their homes, particularly drug-affected babies and those with other special medical needs — and controlling the spread of communicable diseases, especially tuberculosis.
The state’s public health nursing program didn’t shrink as the result of a mass layoff or a single budget cut. It became smaller gradually as nurses left their positions and the Maine CDC never attempted to replace the departing nurses despite the pleas of the program’s directors and lawmakers who purposefully kept funding in the state budget to fill the positions.
“Basically, I was just told, ‘no,’ and I would request every week or every other week for those positions to be filled,” said Ted Hensley, the former public health nursing director.
In addition to leaving positions unfilled, Maine Department of Health and Human Services leadership implemented policies that simply made it more difficult for the public health nursing program to function. DHHS closed many of the program’s regional offices and cut clerical support for nurses, leaving nurses filling out paperwork in their cars. Hensley, as the program’s director, was barred from emailing the staff members under his supervision without approval from staffers in DHHS Commissioner Mary Mayhew’s office. DHHS leadership ordered public health nursing to remove its program brochures from circulation, limiting the program’s ability to get the word out to health care providers.
It all contributed to a demoralizing and secretive work environment, in which nurses didn’t know what was happening to the program they worked for as it shrank around them. Between April and July, five nurses departed.
“Everything was secrecy, not transparency,” said Ronnie Paradis, who worked for 10 years as a public health nurse in Lewiston before retiring in June 2015. “We didn’t know if we were going to be fired or let go or what. Everything was a secret. Nobody would tell us what they were doing.”
With so few nurses left on the job, the remaining nurses are spread thin. The Bangor area is down to one full-time nurse and one part-time nurse out in the field, covering a territory that spans rural Penobscot and Piscataquis counties and, nowadays, because of unfilled positions, parts of Kennebec County. When a nurse’s services are required in Lewiston, often to monitor a patient undergoing treatment for latent tuberculosis, a nurse may be called in from the Augusta area since Lewiston staffing is so limited.
In undermining the ability of public health nurses to effectively do their jobs, the LePage administration has undermined a core part of Maine’s public health infrastructure and the state’s ability to respond effectively to the next public health threat.
It’s one example that shows that when the LePage administration wishes away a fifth of the state workforce in order to pay for income tax cuts, there are bound to be consequences.
Maine got millions to help moms and babies, but has little to show for it
by Matthew Stone - BDN
With a single nurse dispatched to Maine’s rural outposts in 1923, the state launched what would become a key effort to stop infants from dying: public health nursing.
Almost 100 years later, Maine faces similar health challenges. Rural areas still have limited health services, and the state has seen a rise in infant mortality.
Unlike in 1923, public health nursing is no longer the only available service in Maine that sends a trained professional into a new or expectant mother’s home to offer parent coaching and, sometimes, basic health services. Three such programs operate in Maine today, each with different specialties and target populations. Butthe latest available data show they reach only 28 percent of new Maine parents.
Research has shown home visits reduce the likelihood of pregnancy complications, infant deaths, family violence and child maltreatment. They also contribute to improved parenting practices and school readiness.
That’s why Congress and the Obama administration made a $400 million-per-year federal investment in home visiting servicesthrough the Affordable Care Act. And it’s why, in 2011, the Maine Department of Health and Human Services applied for a special federal award to expand home visiting services statewide. Maine won a four-year, $5.7 million grant as a result; it was one of just nine states to receive an expansion award.
With $5.7 million, the state’s plan was to reach 72 percent more parents and babies through Maine Families, which has evolved over the past two decades to become Maine’s largest home visiting program. Maine’s plan also relied on improved collaboration among existing home visiting services and closer connections with a variety of other early childhood services in order to ensure high-need families received the services they needed.
“The thoughtful combination of direct service delivery, community collaboration, evaluation, and sustainability strategies on top of an already proven structure and network offer a compelling model for successful home visiting in all states,” read the grant application, led by Sheryl Peavey, then the director of Maine DHHS’ Early Childhood Initiative and now the chief operating officer of the Maine Center for Disease Control and Prevention, a part of DHHS.
But in the five years since Maine received $5.7 million to expand home visiting, the expansion hasn’t happened and the collaborative spirit hasn’t materialized.
— The latest available data show Maine’s home visitors aren’t reaching more families.
— Key efforts highlighted in the grant application to simplify how families are referred to home visiting have largely stalled.
— Plus, home visiting and early childhood programs in some parts of the state report that competition for referrals has intensified with time and that cooperation has fallen by the wayside.
“The whole point is to expand the services that are going to serve this state well going forward,” said Karen Heck, senior program officer with the Bingham Program in Augusta, a charitable endowment that funds efforts aimed at improving Maine’s health. “We continue to be disappointed that collaboration doesn’t occur and that the families who need services are the losers in the short term, and the state is the loser in the long term.”
Maine Families served 2,368 families in 2011 and just 25 more — 2,393 — in 2014, according to the KIDS Count database.
By the end of the third year of the grant, Maine DHHS had estimated that home visitors would have served an additional 1,300 families.
A spokesman for the Maine CDC didn’t respond to requests for comment from the BDN regarding the state’s home visiting programs and collaboration among them.
Short on coordination
Part of the state’s plan for the $5.7 million home visiting expansion grant was to ensure that families received referrals to the correct home visiting service based on their particular needs, that the referral process became simpler, and that longstanding confusion surrounding referrals ended.
As public health nursing has become limited to families with special medical needs and as the LePage administration has allowed the program to shrink by half, Maine Families has taken nursing’s place as the state’s universally available home visiting program. The program sends about 125 certified parent educatorsinto families’ homes across the state. Those home visitors can offer parent education but not medical services.
Early Head Start — which is funded by the federal government without state management — offers home visits and other services to low-income families living at or below the federal poverty level. Early Head Start home visits are typically more frequent and occur over a longer timespan than visits through Maine Families, but they’re not available across the state.
“There’s a need for both kinds of services at different times,” Ted Hensley, who resigned in March as director of Maine’s public health nursing program, said of nursing and home visiting. “We were working on making sure that there was optimal coordination between the groups.”
The mechanism to bring about that coordination among home visiting services with a limited history of working together was CradleME, a referral system developed by public health nursing and Maine Families staff that used algorithms to determine the right referral based on a family’s needs.
“If there’s only a single program, you’ve missed the richness and resources that other programs can offer,” said Nell Tharpe, who led the effort for public health nursing during her time as the program’s maternal and child health consultant, from 2012 until January 2015. “That’s what’s great about collaboration. You maximize every resource for the benefit of those you serve.”
CradleME started as a pilot project in 2013 involving Eastern Maine Medical Center, Maine Families, public health nursing and the city of Bangor’s public health department, which holds a Maine CDC contract to provide maternal and child health nursing visits within city limits.
No longer would a hospital or doctor’s office have to decide on the right program; a health-care provider would make a single referral, and the destination would be decided in Augusta based on predetermined clinical factors.
“I felt it was a project that all other states would want to follow up with,” Hensley said, “that they would want to do the same thing that we were doing in order to be able to coordinate and effectively and efficiently get people served by the best partners.”
CradleME’s designers set up the system to refer parents to Maine Families home visiting when they needed only support for settling into parenting. Those with medical needs were to receive a referral to public health nursing. Some parents with health and social needs would receive referrals to both programs. Early Head Start didn’t participate in the pilot project.
The program got off to a promising start in its pilot phase in the fall of 2013. Referrals were about evenly split between public health nursing and Maine Families. Previously, the overwhelming majority of referrals went to public health nursing. What’s more, a greater percentage of families offered home visiting services accepted them, according to a state report on CradleME’s first phase. The partnering programs and EMMC all offered positive reviews.
The next steps included developing an electronic — instead of paper-based — referral system, refining the scoring system, incorporating prenatal referrals and preparing for statewide implementation.
‘Dead in the water’
According to Hensley and other former public health nursing employees, the model is now “dead in the water” even if CradleME still exists in name. It has strayed far from the timeline its designers set out for it in 2013 and 2014, and it’s strayed far from the criteria it initially used to refer parents to the appropriate home visiting service.
The original timeline was to figure out expansion plans at the end of 2014. Five months later, in May 2015, state CDC leaders said their plan was to “accelerate” the initiative, rolling out CradleME statewide within three months, according to a presentation Maine CDC leadership and Peavey, then the strategic reform coordinator in Health and Human Services Commissioner Mary Mayhew’s office, made to public health nursing managers on May 5, 2015.
But CradleME still hasn’t moved beyond the pilot phase and Eastern Maine Medical Center.
Plus, Hensley said, staff in Mayhew’s office continued to insist on adjustments to the criteria CradleME used to refer new parents to public health nurses. Originally, clinically trained nursing staff had developed the criteria for nursing referrals, he said. The new adjustments — which Maine CDC officials have issued on multiple occasions since November 2015 — narrowed the criteria by which parents are referred to public health nursing services, limiting the number of mothers and babies who receive visits from a nurse.
“It’s like a bus driver telling a doctor how to practice,” Hensley said. “These are non-clinicians. They essentially held up the whole process based on their desire for us not to be providing services that we deemed were appropriate.”
CradleME is behind schedule on a number of measures. EMMC continues to fax in paper referral forms. A fall rollout of electronic referrals is possible, said Pam LaHaye, the statewide coordinator for Maine Families. (The Maine Children’s Trust, which took over Maine Families oversight from the state earlier this yearthrough a no-bid contract, will receive $105,000 over the next two-and-a-half-years to pay for CradleME maintenance.)
Meanwhile, under CradleME, EMMC doesn’t know what happens to patients once the hospital faxes in referrals, said Mark Moran, a licensed social worker who leads EMMC’s family service and support team. Ensuring that such information would be communicated was one of the project’s initial goals.
“They’re still getting serviced by someone, but I’m not sure the high-risk families are really getting the service that they need if the workforce isn’t adequate to provide that,” Moran said, referring to low numbers of public health nurses.
Beyond CradleME
The effects of increasingly narrow criteria for public health nursing referrals haven’t been limited to the CradleME pilot project and its participants.
Bangor Public Health is one of a handful of agencies around the state that hold Maine CDC contracts to provide maternal and child health nursing services in specific geographic areas. The contracts are funded through the federal Maternal and Child Health Block Grant, which brings about $3 million to Maine each year.
The city of Portland holds a contract similar to Bangor’s to deliver nursing services within city limits. Outside of Portland, the agency MaineHealth Care at Home provides maternal and child health nursing home visits in York and Cumberland counties. Androscoggin Home Care and Hospice holds the nursing contract for Lewiston and Auburn.
Those agencies all saw the number of families and children referred to them plummet at the start of the year when the Maine CDC started handling all referrals itself, instead of allowing the agencies to continue receiving referrals and handling them directly.
“The lack of adequate communication, planning and coordination with contracted providers and referral sources have resulted in a steady decline in referrals for all participating agencies and has left many patients without a safety net,” the agencies wrote in a letter to Mayhew on June 29.
The state’s 2011 federal grant application spoke of “creating improved referral systems” among Maine Families, health-care providers, public health nursing and the agencies around the state that hold maternal and child health nursing contracts.
But as the state took over nursing referrals, the new process resulted in delays, said Mia Millefoglie, grant manager for the maternal and child health program at MaineHealth Care at Home.
Meanwhile, hospitals and doctors’ offices continued to send referrals directly to the nursing agencies, which the agencies then had to fax to the Maine CDC in Augusta. The reason behind all of the changes, Millefoglie said, is that the state has chosen to use the money it receives through the federal Maternal and Child Health Block Grant for moms and babies with acute health needs. The grant traditionally paid for nursing services for all moms and babies who requested them.
“With all the confusion, we have all faced a tremendous decline in referrals, which is alarming, and now we’re faced with rebuilding,” Millefoglie said. “The state has refocused its efforts in terms of this grant on those with higher-acuity needs. That’s a shift, and that’s a shift we need to work through.”
In the interim, the Maine CDC has returned to allowing the local nursing agencies to handle their own referrals.
“We had been very concerned that if we went through the state process that we might have very sick mothers and children fall through the cracks,” Millefoglie said.
Competition continues
While the 2011 home visiting expansion grant emphasized collaboration among home visiting and early childhood services, program operators report an atmosphere of competition that has generally intensified in recent years.
Around the time the state received its federal award, Heck, of the Bingham Program, offered her organization’s services to improve collaboration among Maine Families and Early Head Start. She facilitated a meeting that brought together staff from the state and both programs.
Since then, however, “it’s only gotten worse,” Heck said.
The state’s public health nursing program has shrunk by half, and the state no longer has a Head Start State Collaboration Office. The office’s role was to ensure that the federally funded Head Start was integrated into the state’s full range of early childhood services.
The collaboration office closed last September after the LePage administration didn’t apply for the federal funds that paid for it. Maine is the only state in the nation that lacks such an office.
“We continue to be disappointed [by] this kind of focus on one program,” Heck said, referring to an emphasis from state officials on Maine Families.
A July 2015 report from Maine’s Head Start collaboration office highlighted this frustration shared by Head Start directors across the state.
Families can sometimes start with Maine Families and receive an Early Head Start referral. If an Early Head Start classroom program has available spots, Maine Families can alert eligible families so they can enroll their children. But 36.4 percent of Maine Head Start directors said it was “extremely difficult” to “establish linkages” with their local Maine Families program. Some 54.5 percent said it was “somewhat difficult” to do the same with public health nursing. (The report highlighted the most common response from Head Start directors.)
“[Early Head Start] home visiting and Maine Families have wonderful services to offer families,” wrote one Head Start director. “It is too bad that a competition approach exists for the two programs.”
“Our work with Maine Families has changed dramatically over the last two years,” wrote another director. “We have gone from a program that worked in complete partnership to having no relationship at all. Information leads us to believe that direction from the State level has influenced this change and the result has been that local Maine Families programs are not working cooperatively with Head Start and [Early Head Start] programs.”
LaHaye, the statewide Maine Families coordinator, didn’t return a follow-up phone call from the BDN regarding collaboration with other early childhood services.
Hensley reported a similar sentiment from public health nursing.
“Some of them worked very closely with our nurses and got along very well professionally, and many Maine Families workers were absolutely quick to recognize and refer to nursing when nursing was needed,” he said. “In other parts of the state, there was more of a competition for clients.”
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