Maine Medical Center will drop Anthem as in-network insurer
Maine Medical Center will leave Anthem insurance network, citing overdue payments
MaineHealth announced its Portland hospital will no longer be an in-network provider starting in January 2023.
by Joe Lawlor - Portland Press Herald - April 7, 2022
Maine Medical Center plans to leave the Anthem insurance network in January 2023 because of the insurer’s payment practices, including what hospital officials say is $13 million in underpayments to the hospital and more than $70 million in unpaid claims to the MaineHealth network.
The dispute pitting the state’s largest hospital against Maine’s largest health insurer could affect more than 150,000 patients, forcing them to pay higher out-of-pocket costs at Maine Med.
Maine Medical Center in Portland is the flagship hospital of the MaineHealth network, which announced the change Wednesday. MaineHealth has seven other hospitals in Maine and one in New Hampshire that will continue to be part of the Anthem network.
An Anthem spokeswoman blamed Maine Medical Center for charging unacceptable fees and indicated that there’s a chance the dispute could be resolved.
“There is a long way to go before the end of the year, and we would think they will work with us on resolving these issues,” Anthem spokeswoman Stephanie DuBois said in a written statement.
Gov. Janet Mills issued a statement saying she is “deeply concerned” and urged the two sides to resolve their differences.
“Maine Medical Center is the largest tertiary care hospital in Maine and Anthem is the state’s largest insurer, serving more than 300,000 people, including state employees. Termination of the contract would significantly harm the cost of and access to care for Maine people who are Anthem customers, particularly in southern Maine, and seriously impact the operation of the health care market across the state,” Mills said. “Termination should be avoided at all costs. As both private parties negotiate the contract, I strongly urge them to put the interests of Maine people first, to resolve this issue in a timely way, and to reach an agreement that averts the need for such a drastic, damaging move.”
OUT-OF-POCKET COSTS WILL INCREASE
The move would mean Maine Medical Center becomes an out-of-network health care provider for people who are insured by Anthem, either through their jobs, the Affordable Care Act marketplace or as individuals. The change would increase out-of-pocket costs for Anthem patients who receive non-emergency care at the hospital. It would apply to non-emergency care only because Anthem would be required by law to fully cover emergency care, MaineHealth said.
While insurance plans vary widely, out-of-network care generally costs patients far more than in-network. For instance, the price of an in-network procedure might be 80 to 90 percent covered by insurance or even fully covered, while insurance may only pay 50 to 60 percent of an out-of-network procedure. Other patient costs such as co-pays and out-of-pocket maximums also are higher when getting out-of-network care. In one analysis of a $22,000 hospital bill by the California Department of Managed Care Health, an in-network cost to the patient was $2,800, while the same care provided out-of-network would cost the patient $13,600.
Mitchell Stein, a Maine-based independent health policy analyst, said that insurers and health care networks have payment disputes all the time.
“What is unusual is that these disputes don’t usually end up being aired in public,” said Stein, a volunteer board member for Community Health Options, the Lewiston-based health insurance cooperative.
He said insurers and health care systems have different motives for their bottom line. The insurers are attempting to limit the costs that they pay to hospitals to keep premiums down for their members, while hospitals are trying to maintain revenue streams to pay for the services they provide.
‘COMPETING INTERESTS’
“There aren’t good guys and bad guys in this. There are competing interests,” Stein said.
MaineHealth estimates the decision would affect more than 150,000 Anthem patients based on the number of patients who made a claim at Maine Med during the past three years.
“Even though Anthem subscribers will have nine months to prepare, we know that this will affect many of our patients, and we deeply regret having to take this step,” said Dr. Andrew Mueller, CEO of MaineHealth. “We will do everything in our power to reduce the impact of this change on our patients. However, our relationship with Anthem has reached a point where it is hurting our ability to sustain the level of care our communities have come to expect from MaineHealth and its flagship hospital, Maine Medical Center.”
Anthem owes MaineHealth more than $70 million for health care services dating back over three years, MaineHealth said. Anthem also has been reducing negotiated payments to the Portland hospital that should not be in dispute, Mueller said.
DuBois, the Anthem spokeswoman, said that “we’ve had a strong working relationship with MaineHealth for many years, but for the last few years we’ve been in discussions with them regarding unilateral increases in charges for health services provided at Maine Medical Center. This has resulted in direct higher costs to our members and all consumers that use Maine Medical Center, which is unacceptable.
“It’s disappointing MaineHealth would choose to alarm consumers by announcing an intention to leave our care provider network when our current contract doesn’t expire for another two years. We have a responsibility to those we serve, and we remain committed to resolving these years-long issues with MaineHealth. We hope they will join us and get back to working on how we can restore affordability at Maine Medical Center.”
ANTHEM ALLEGES OVERBILLING
DuBois said MaineHealth has been “overcharging our members” for at least four years and “this is unacceptable.”
“During a routine review in 2018, Anthem discovered overbilling by Maine Medical Center for anesthesia and operating room services. We worked with MaineHealth to identify the Anthem members impacted by this, and as a result of our investigation, MaineHealth eventually relented and issued refunds to our members for the amount they were overcharged. These overcharges amounted to nearly $20 million to our members. If it were not for our audits, these overcharges may never have been discovered.”
John Porter, MaineHealth spokesman, said the health care network would have no comment in response to Anthem’s statement about increased charges.
While MaineHealth said its entire network is owed money by Anthem, the issue is most critical at Maine Medical Center.
Mueller, in a news conference on Wednesday, said Anthem is withholding $1 million per month in payments to Maine Med. He said the reduction is about equivalent to payments the hospital receives from the 340B federal medication discount program, which lowers the cost of prescription drugs to hospitals that have a high number of Medicaid patients.
Mueller said Anthem has not admitted that program is the cause of the reduction, but he believes it is not a coincidence. He said if MaineHealth doesn’t stand its ground on the issue, it could set a precedent and result in reductions by Anthem across all nine of the system’s hospitals. The dispute is an “existential” threat to MaineHealth services, Mueller said.
DuBois said the dispute is not about 340B but “goes back to the fact that MaineHealth unilaterally raised charges, which is costing our members and all of Maine Medical Center consumers more money. We can’t allow that to happen. We’ve been trying to resolve this and now they appear to be walking away.”
NEGOTIATIONS ‘DIFFICULT’ FOR LONG TIME
Mueller said negotiations with Anthem have been “difficult” for a long time, and reached an impasse in January.
“We seemed to be moving farther and farther apart,” Mueller said.
Mueller said the drastic move comes as a last resort, because if the reduced payments continue, financial pressures could lead to services being threatened, especially in rural areas. “We have a lot of other issues we would rather tackle,” Mueller said.
Timothy Schott, acting superintendent of the Maine Bureau of Insurance, encouraged the two sides to reach an agreement.
“The Bureau of Insurance has been in contact with both MaineHealth and Anthem about the concerns in their relationship,” Schott said in a statement. “While the bureau cannot get involved in contractual matters, it has encouraged both parties to work in good faith to resolve their differences well before January 1. The Bureau is currently considering how best to work with Anthem to ensure that it maintains an adequate network of providers so its members can get the benefits to which they are entitled.”
The move will not affect subscribers to Anthem-MaineHealth Medicare Advantage plans. MaineHealth said the Portland hospital will remain in-network for those patients. Also, MaineHealth said it has no plans to remove its physicians and other providers in its systemwide medical group from the Anthem network, and no other hospitals are affected.
MaineHealth also is dropping Anthem as the insurance carrier for its 22,000 employees, starting in January 2023. A new carrier has not yet been chosen, Mueller said.
COMPLAINTS ABOUT TIMELY PAYMENTS
The decision comes on the heels of months of complaints by hospitals about Anthem’s issues with paying health care providers in a timely manner.
“We’ve been getting a lot of complaints from hospitals. Providers are saying their claims aren’t getting processed,” said Steven Michaud, president of the Maine Hospital Association. “There’s been a big problem.”
Northern Light Health, which operates Northern Light Mercy Hospital in Portland, continues to experience “some delays” with Anthem payments but is working with the insurer and meeting monthly to discuss outstanding issues, Senior Vice President Suzanne Spruce said in a written statement.
Judith Watters, spokeswoman for the Maine Bureau of Insurance, said in an email response to questions that the “Bureau of Insurance is aware of the payment issues providers have experienced with Anthem.”
“The bureau is conducting a market conduct examination of Anthem, which will include a review of provider payment issues. The exam is expected to continue for several months. At this time, Anthem has worked through most of its backlog of claims,” Watters said.
Indianapolis-based Anthem is one of the nation’s largest health insurance companies. A member of the Blue Cross Blue Shield Association, it provides coverage to people in Maine and 13 other states. Its share (ANTM) price rose $12.09, or 2.44 percent, on Wednesday, to close at $506.87.
A staffing crisis is causing a months long wait for Medicaid, and it could get worse
by Bram Sable Smith - Kaiser Health News - April 4, 2022
Korra Elliott has tried to avoid seeing a doctor while waiting to get on Medicaid. She worries she can't afford more bills without any insurance coverage. But in early March — five months, she said, after applying and with still no decision about her application — a suspected case of the flu sent her blood pressure soaring and landed her in the emergency room.
The 28-year-old mother of four from Salem, Mo., is among the tens of thousands of uninsured Missourians stuck waiting as the state slogs through a flood of applications for the state-federal health insurance program. Missouri expanded the program last year after a lengthy legal and political battle, and it now covers adults who earn up to 138% of the federal poverty level — about $18,800 annually for an individual.
Missouri had nearly 72,000 pending Medicaid applications at the end of February and was averaging 119 days to process one, more than twice the maximum turnaround time of 45 days allowed by federal rules. Adding people to Medicaid is labor intensive, and the jobs require training and expertise. The program covers many populations — children, people with disabilities, seniors, adults who are pregnant or have children, and some without children. Different rules dictate who qualifies.
Missouri simply doesn't have the workers to keep up. Last fiscal year, 20% of its employees who handled Medicaid applications left their jobs, said Heather Dolce, a spokesperson for the Missouri Department of Social Services. And the average number of job applications received for each opening in the department's Family Support Division — which oversees enrollment — dropped from 47 in March of 2021 to 10 in February of 2022.
Just about every industry is struggling to find workers now, but staffing shortages in state Medicaid agencies around the country come at a challenging time. States will soon need to review the eligibility of tens of millions of people enrolled in the program nationwide — a Herculean effort that will kick off once President Joe Biden's administration lets the covid-19 public health emergency declaration expire. If Missouri's lengthy application backlogs are any indication, the nation is on course for a mass-scale disruption in people's benefits — even for those who still qualify for the insurance.
"If you don't have people actually processing the cases and answering the phone, it doesn't matter what policies you have in place," said Jennifer Wagner, director of Medicaid eligibility and enrollment for the Center on Budget and Policy Priorities, a left-leaning think tank in Washington, D.C.
Federal officials have said they will give states 60 days notice before ending the public health emergency, so it's unlikely to expire before summer. Once it does, enrollees won't be kicked off immediately: States can take up to 14 months to complete renewals, although budget pressures may push many to move faster. A bump in federal Medicaid funds to states, provided by Congress through covid relief legislation in 2020, will end shortly after the emergency's expiration.
Ultimately, workers are needed to answer questions, process information confirming that someone's Medicaid enrollment should be renewed, or see whether the person qualifies for a different health coverage program — all before the benefits lapse and they become uninsured.
State Medicaid officials have said staffing is one of the top challenges they face. In a January meeting of the Medicaid and CHIP Payment and Access Commission, an outside panel of experts that advises Congress, Jeff Nelson said 15% to 20% of the Utah Department of Health's eligibility workers were new. "We've got a fifth of the workforce that potentially doesn't know what they're doing," said Nelson, who oversees eligibility for Utah's Medicaid program.
Eligibility worker vacancies at the Texas Health and Human Services Commission have quadrupled over roughly two years — 1,031 vacant positions as of late February compared with 260 as of March 31, 2020, according to spokesperson Kelli Weldon.
Medicaid renewals are less labor-intensive than initial applications, but it takes time before an eligibility worker knows the ins and outs of the program, Wagner said.
"It's months before you are fully functional," said Wagner, who previously oversaw the Illinois Department of Human Services offices that determine applicants' eligibility for Medicaid, the Supplemental Nutrition Assistance Program that provides food stamps, and other assistance programs.
Other social services may be gummed up in the process because many workers also handle applications for other programs. In addition to Medicaid, workers for Kentucky's Department for Community Based Services handle SNAP and child care assistance applications.
Consumer advocates who connect people to safety-net programs worry that an overwhelmed workforce won't be able to keep up.
"It's going to be a lot of work for everyone," said Miranda Brown, who helps people apply for benefits as outreach coordinator for the Kentucky Equal Justice Center, a legal aid group.
Brown said she recently called a state office on behalf of a client toward the end of the day. She waited on hold for an hour only to be told by a caseworker that the agency couldn't process any more cases that day.
"I even have a [phone] line that I get through faster than a consumer calling for themselves," she said. "If it's hard for me, it's very hard for consumers who are trying to call on their lunch break at work."
South Carolina planned to hire "a couple hundred workers" beginning this spring to help manage renewals at the end of the public health emergency, said Nicole Mitchell Threatt, deputy director of eligibility, enrollment and member services at the Department of Health and Human Services. The turnover rate among eligibility workers was about 25% from July 2020 to June 2021, jumping from a 15% rate in the previous 12 months.
In Missouri, Dolce said her department hopes a recently approved pay increase will help recruit more workers and improve staff morale and retention. The department is being sued over delays in enrollments for SNAP benefits, which it also oversees.
Kim Evans, director of the Missouri Department of Social Services' Family Support Division, told the state Medicaid oversight committee in February that her division was offering overtime and even pizza to speed up the processing of applications. But the department is enrolling fewer than 3,000 people per week, leaving tens of thousands waiting and delaying their care.
In the suburbs of Kansas City, M0., Stacey Whitford, 41, applied in December for Medicaid for herself and her 13-year-old son. Her son needs hearing aids that she said cost $2,500 apiece without insurance. She also lined up a support worker for the boy, who has autism, through the Department of Mental Health, but said she was told the worker can begin only once her son is enrolled in Medicaid.
"It's just like hanging a golden ticket right in front of your face and saying, 'Here it is, but you can't touch it,'" she said in early March.
Whitford spent hours on the phone trying to sort out the status of their applications, then on March 31, just shy of four months after applying, they were finally approved.
"I am so excited! We can run with scissors now," she joked.
But Elliott, the mother of four in Salem, is still waiting. She gave up calling the state's Medicaid helpline after growing frustrated from spending hours on hold and being disconnected because of high call volumes. Instead, she checks on her application through the enrollment specialists at the clinic where she applied.
She was sent home from the ER with ibuprofen and Tamiflu and has yet to see a bill. If her Medicaid application is approved, her coverage will be backdated to the month she applied, likely covering her ER trip. But if her application is rejected, that cost will be added to her medical debt, which Elliott estimates is already tens of thousands of dollars.
"It makes me feel like it's a joke," Elliott said of Missouri's expansion of Medicaid. "Like they're just throwing it out there to get all these people to apply for it, but they're not going to really help anybody
Covid and Diabetes, Colliding in a Public Health Train Wreck
by Andrew Jacobs - NYT - April 3, 2022
After an insect bite on his back became infected, David Donner, a retired truck driver in rural Alabama, waited six hours in a packed emergency room with his wife, before coronavirus vaccines were widely available. A few days later, they both began experiencing the telltale symptoms of Covid-19.
Debra Donner quickly recovered, but Mr. Donner, 66, landed in the I.C.U. “The virus barely slowed her down, but I ended up surrounded by nurses in hazmat suits,” he said. His halting recovery has left him dependent on a wheelchair. “I walk 20 feet and I’m huffing and puffing like I ran 20 miles.”
The Donners see little mystery in why they fared so differently: Mr. Donner has diabetes, a chronic disease that hobbles the body’s ability to regulate blood sugar and inexorably wreaks havoc on circulation, kidney function and other vital organs.
After older people and nursing home residents, perhaps no group has been harder hit by the pandemic than people with diabetes. Recent studies suggest that 30 to 40 percent of all coronavirus deaths in the United States have occurred among people with diabetes, a sobering figure that has been subsumed by other grim data from a public health disaster that is on track to claim a million American lives sometime this month.
People with diabetes are especially vulnerable to severe illness from Covid, partly because diabetes impairs the immune system but also because those with the disease often struggle with high blood pressure, obesity and other underlying medical conditions that can seriously worsen a coronavirus infection.
“It’s hard to overstate just how devastating the pandemic has been for Americans with diabetes,” said Dr. Giuseppina Imperatore, who oversees diabetes prevention and treatment at the Centers for Disease Control and Prevention.
Diabetes patients hospitalized with Covid spend more time in the I.C.U., are more likely to be intubated and are less likely to survive, according to several studies, one of which found that 20 percent of hospitalized coronavirus patients with diabetes died within a month of admission. Though researchers are still trying to understand the dynamics between the two diseases, most agree on one thing: Uncontrolled diabetes impairs the immune system and decreases a patient’s ability to withstand a coronavirus infection.
Diabetes is a pernicious disease that is at once ubiquitous and invisible, partly because most people with the condition do not appear outwardly ill. It affects 34 million Americans, or 13 percent of all adults, but draws less funding and public attention than other major killers like cancer, Alzheimer’s and heart disease.
Even as the pandemic’s hold on political leaders and the public begins to fade, researchers, clinicians and other experts in the field are hoping the disproportionate suffering and death among people with diabetes will bring renewed attention to the disease, which annually claims 100,000 lives and soaks up one in four health care dollars spent.
“Millions of Americans were already struggling with diabetes, and then Covid came along and cut a huge swath of suffering and misery that has been largely overlooked by the public and policymakers,” said Dr. David Kerr, the director of research and innovation at Sansum Diabetes Research Institute in California. “Diabetes is a wicked problem and Covid has just shone a bright light on this crisis.”
Like the pandemic, which has had an outsize toll on communities of color, the burden of diabetes falls more heavily on Latino and Black Americans, highlighting systemic failures in health care delivery that have also made the coronavirus far deadlier for the poor, said Nadia Islam, a medical sociologist at NYU Langone Health. “It’s not that diabetes itself makes Covid inherently worse but rather uncontrolled diabetes, which is really a proxy for other markers of disadvantage,” she said. Compounding the concerns, some studies suggest that a coronavirus infection can heighten the risk of developing type 2 diabetes, a disease that is largely preventable through a healthy diet and exercise. Type 1, by contrast, is a genetic disorder that tends to emerge early in life and is sometimes referred to as juvenile diabetes. More than 90 percent of all diabetes cases in the United States are type 2.
One study published last month found that patients who recovered from Covid were 40 percent more likely to be diagnosed with type 2 diabetes within 12 months compared with the uninfected, though researchers have yet to determine a connection between the two conditions.
Over the past two years, doctors have also reported a sharp rise in young people being diagnosed with type 2 diabetes, an increase that many believe is tied to the drastic spike in childhood obesity during the pandemic. “We’ve seen kids coming in so sick and dehydrated that they sometimes require I.C.U. care,” said Dr. Daniel Hsia, a diabetes specialist at the Pennington Medical Research Center at Louisiana State University.
About 1.5 million Americans are diagnosed with diabetes each year, according to the C.D.C., and roughly 96 million, about one in three adults, are at high risk for developing the disease.
Although the number of new diagnoses has begun to decline, the overall number of Americans with diabetes has doubled in the past two decades, an increase that mirrors the alarming rise of obesity, which affects more than 42 percent of adults.
Diabetes is an insidious disease that significantly increases the risks of premature blindness, stroke, and circulatory and neurological problems that can lead to infections requiring amputation of gangrenous toes and feet. As with many chronic conditions, the poor and people of color are diagnosed with diabetes at disproportionately higher rates. Black and Latino Americans are more than twice as likely to receive a diabetes diagnosis as whites, and inadequate access to medical care can make it harder for them to juggle the complex dietary, monitoring and treatment regimens that can stave off its devastating complications. Although there is much researchers don’t understand, many believe that uncontrolled diabetes greatly amplifies the perils of a Covid diagnosis. That’s because a sedentary lifestyle, putting on extra weight or failing to keep close tabs on blood sugar levels fuel chronic inflammation inside the body, which can increase insulin resistance and weaken the immune system.
Inflammation triggers the release of cytokines, tiny proteins that regulate the body’s immune response to infection or injury. Cytokines are a critical component of the normal healing process, but for people with diabetes and underlying chronic inflammation, all those cytokines can damage healthy tissue. Covid, it turns out, can provoke an uncontrolled release of cytokines, and the resulting “cytokine storm” can wreak havoc on vital organs like the lungs, leading to dire outcomes and death.
People with type 2 diabetes tend to fare more poorly than those with type 1, in part because those with type 1 tend to be younger.
In some respects, the pandemic has already had some positive effects on diabetes care by elevating the adoption of technology that enables remote management of the disease. The ramped up embrace of telemedicine, for example, has made it possible for health care providers to spot a worrisome foot wound on a homebound patient.
Early in the pandemic, the Food and Drug Administration gave hospitals and long-term care facilities permission to distribute continuous glucose monitoring devices to coronavirus patients as a way of reducing the risks to health care workers. Clinicians have also learned the nuances of caring for hospitalized diabetics with Covid through more intensive monitoring and management of blood sugar levels.
But many advancements have been unevenly distributed. The uninsured cannot afford the latest glucose monitoring or insulin delivery devices, and in economically disadvantaged communities with low digital literacy, experts say that doctors are less likely to offer new technologies and treatments to Black and Hispanic patients, even when they are covered by insurance.
“The advances of recent years have been stunning but not everyone has access to them and that’s just tragic,” said Dr. Ruth S. Weinstock, a board member of the American Diabetes Association.
The soaring cost of insulin, an essential medicine for diabetes management, has also had a greater impact on the poor. A 2019 study found that one in four people with diabetes had rationed their insulin use, which can have dire health consequences. On Thursday, the House voted to cap the price of insulin at $35 a month. President Biden supports the measure, which the Senate has yet to consider.
Betty Angeles, 59, sees up close the challenges of managing diabetes for the farmhands, busboys and other low-wage laborers in and around Santa Barbara, Calif. Ms. Angeles, a native of Peru, herself juggles three jobs: as a house cleaner, a pastry chef and a community health worker at Sansum Diabetes Research Institute, where she helps Spanish-speaking clients navigate the complexities of diabetes treatment.
“When you are uninsured and working two or three jobs it’s difficult to regularly see a doctor like you should,” said Ms. Angeles, who has managed her own diabetes for nearly three decades.
Sansum runs programs to make it easier for patients to stay healthy. That means regularly testing their blood sugar levels; encouraging clients to exercise, even if that means jogging in place for 15 minutes between jobs; and teaching them to prepare meals that favor fresh produce over bread, rice and tortillas — starchy carbohydrates that can complicate the body’s ability to regulate glucose.
Arianna Larez, who oversees the institute’s type 2 diabetes program, says Ms. Angeles and other outreach workers with community roots are the key to its success. She strongly believes the especialistas, as they are known in Spanish, deserve some credit for one encouraging data point: though many have been infected by the coronavirus, so far none of Sansum’s 400 clients have died of Covid.
“Building trusted relationships and creating easy-to-understand, culturally relevant information has real-world implications,” Ms. Larez said.
Experts say addressing the nation’s diabetes crisis will require more than expanding the number of community health workers: Well-funded public education campaigns are needed to drive home the importance of exercise and healthy eating, as are seismic changes to a food system geared to cheap, processed food — a heavy lift given the political might of the food and beverage industry.
But researchers say state and local governments can make a difference through programs that subsidize fresh produce for low-wage earners and zoning measures to lure supermarkets to so-called food deserts.
“Instead of telling poor people they’re lazy for not being physically active, why not make their neighborhoods safer so they aren’t afraid to go outside and exercise?” asked Dr. Sudip Bajpeyi, a researcher at the University of Texas at El Paso whose study on hospitalized Covid patients last June was among the first to highlight the outsize death toll among people with diabetes. “The only way to move the needle is to reform a system that prioritizes cures and new drugs over prevention.”
https://www.nytimes.com/2022/04/03/health/diabetes-covid-deaths.html
With Obama looking on, White House to open ACA plans to more families
by Amy Goldstein - Washington Post - April 4, 2022
President Biden plans to announce Tuesday that his administration is making a tweak to federal rules long sought by advocates that would allow millions of additional families to buy health plans through the insurance marketplaces created under the Affordable Care Act.
The announcement will represent Biden’s latest effort to use the ACA as the main fulcrum for his goal of making health insurance more available and affordable to American consumers.
In a piece of political theater to symbolize that point, the current president will be accompanied during an afternoon Rose Garden announcement by former president Barack Obama, who was in office when the sweeping health-care law passed a dozen years ago. Obama on Tuesday will make his first return visit to the White House since he moved out in 2017 after two terms with Biden as his second-in-command.
The tweak involves what is known in health-policy circles as the ACA’s “family glitch.” It involves who is eligible to buy health plans with federal subsidies through HealthCare.gov, the federal ACA insurance marketplace that opened in 2014, or similar marketplaces in states that operate their own.
For the most part, those marketplaces are open to U.S. residents who do not have access to health benefits through a job. However, the law also contains a provision that lets people buy ACA health plans even if they have a job that offers health benefits. They can do that if monthly premiums would require them to spend roughly 10 percent or more of their household income on that coverage.
The wrinkle has been that, in calculating how big a bite an employers’ health plan would take out of a worker’s income, the amount has taken into account only the premiums for an individual insurance policy — not a policy that covers a workers’ spouse or children, too.
Under the Obama administration, regulatory officials said those dependents were not eligible for a federal subsidy to help pay for an ACA health plan, even when family coverage through an employers’ health benefit costs far more than the law says is affordable.
During a briefing for reporters Monday evening to preview Biden’s announcement, senior administration officials said the Treasury Department, which handles ACA subsidies because they are in the form of a tax credit, is proposing a rewrite of the ACA’s rules so that the cost of job-based coverage for an entire family is taken into account.
Assuming the proposed tweak completes the federal regulatory process, the change would begin Jan. 1 next year, according to the officials, who spoke on the condition of anonymity about a change that is not yet public.
Slightly more than 5 million people nationwide are affected by the family glitch, according to estimates last year by the Kaiser Family Foundation, a health-policy research group. Most are children and women, Kaiser found.
The White House estimates that perhaps 1 million people would switch to ACA health plans if the rules change, while many others would keep their job-based health benefits, even if they cost more. And an estimated 200,000 uninsured people would gain coverage, the administration officials said.
Larry Levitt, Kaiser’s executive vice president for health policy, said, “Fixing the family glitch is the single most significant step the Biden administration can take to improve affordability under the ACA without Congress. And Congress has not exactly been moving with lightning speed lately.”
Levitt noted that other parts of Biden’s health-care agenda have stalled on Capitol Hill. Congressional Democrats, who hold slender majorities in the House and Senate, have not amassed enough votes even within their own party to pass broad social policy legislation known by Biden and other proponents as the Build Back Better Act.
Part of that legislation would make marketplace health plans available at little or no cost for low-income people in a dozen states that have not expanded Medicaid under the ACA. The stalled legislation would also try to ease the nation’s expenses for prescription drugs by allowing Medicare, the federal insurance system for older Americans, to negotiate prices directly with drug manufacturers.
In the absence of such legislative accomplishments, Biden is striving to draw attention to changes he can make through his own powers. He also plans Tuesday to issue an executive order that will be a sequel to one he signed when he came into office that directed federal agencies to do what they could to strengthen Medicaid and the ACA.
Under the new order, administration officials said, Biden will direct agencies to “continue doing everything in their power to expand affordable quality, affordable health coverage.” The order does not spell out specific steps. But it says in broad strokes that the government should help people get and keep coverage, understand their insurance choices and connect with health services when they need them.
https://www.washingtonpost.com/health/2022/04/04/aca-insurance-for-families/
No comments:
Post a Comment