Letter to the editor: Poll of Mainers confirms what we know about health care
Portland Press Herald - May 27, 2023
The vast majority who believe affordable, comprehensive insurance must be a top legislative priority should press their lawmakers to pass two bills that would further that objective.
There is broad agreement that our health care system is not serving us well. Too many of us are uninsured or underinsured and forgo or seriously compromise the medical care that we should all be getting. Compared with our peers in other wealthy countries, we spend more, are less healthy and die earlier.
With a recently published survey of Maine voters, we can now quantify the level of our discontent. The survey was conducted by Digital Research and was commissioned by Consumers for Affordable Health Care.
The survey showed that most Mainers believe just one major medical event or illness could cause financial disaster for them. Nearly all surveyed (89%) believe it is highly important that everyone in the state have access to comprehensive health insurance. The question was asked, “How much of a priority should it be for lawmakers in Augusta to work to ensure that every Mainer has access to some form of affordable comprehensive health insurance?” Eighty-six percent of respondents answered that it should be the top or a high priority.
The Legislature is already working hard on An Act to Ensure Health Care for All Maine Residents (L.D. 329) and a proposed amendment to the state constitution guaranteeing a right to health care (L.D. 590). Now is the time for all of us, in the 86% majority, to contact our state representatives and senators to express our appreciation of their work and our support for the proposed legislation. By doing this, we can all make a difference.
Michael Bacon
Westbrook
Hundreds of Thousands Have Lost Medicaid Coverage Since Pandemic Protections Expired
As states begin to drop people from their Medicaid programs, early data shows that many recipients are losing their coverage for procedural reasons.
by Noah Weiland - NYT - May 26, 2023
Hundreds of thousands of low-income Americans have lost Medicaid coverage in recent weeks as part of a sprawling unwinding of a pandemic-era policy that prohibited states from removing people from the program.
Early data shows that many people lost coverage for procedural reasons, such as when Medicaid recipients did not return paperwork to verify their eligibility or could not be located. The large number of terminations on procedural grounds suggests that many people may be losing their coverage even though they are still qualified for it. Many of those who have been dropped have been children.
From the outset of the pandemic until this spring, states were barred from kicking people off Medicaid under a provision in a coronavirus relief package passed by Congress in 2020. The guarantee of continuous coverage spared people from regular eligibility checks during the public health crisis and caused enrollment in Medicaid to soar to record levels.
But the policy expired at the end of March, setting in motion a vast bureaucratic undertaking across the country to verify who remains eligible for coverage. In recent weeks, states have begun releasing data on who has lost coverage and why, offering a first glimpse of the punishing toll that the so-called unwinding is taking on some of the poorest and most vulnerable Americans.
So far, at least 19 states have started to remove people from the rolls. A precise total of how many people have lost coverage is not yet known.
In Arkansas, more than 1.1 million people — over a third of the state’s residents — were on Medicaid at the end of March. In April, the first month that states could begin removing people from the program, about 73,000 people lost coverage, including about 27,000 children 17 and under.
Among those who were dropped was Melissa Buford, a diabetic with high blood pressure who makes about $35,000 a year at a health clinic in eastern Arkansas helping families find affordable health insurance. Her two adult sons also lost their coverage.
Like more than 5,000 others in the state, Ms. Buford, 51, was no longer eligible for Medicaid because her income had gone up. A notice she received informing her that she did not qualify made her so upset that she threw it in a trash can.
But a majority of those who lost coverage in Arkansas were dropped for procedural reasons.
Daniel Tsai, a senior official at the Centers for Medicare and Medicaid Services who is helping to oversee the unwinding process for the Biden administration, said that more outreach was needed to help those who lost coverage that way. He said federal officials were in regular contact with state officials around the country to review early data on the unwinding and check whether people who lost coverage had a fair shot to prove their eligibility.
Gov. Sarah Huckabee Sanders of Arkansas, a Republican, has framed the unwinding as a necessary process that will save money and allow Medicaid to function within its intended scope.
“We’re simply removing ineligible participants from the program to reserve resources for those who need them and follow the law,” Ms. Sanders wrote in an opinion essay in The Wall Street Journal this month. She added that “some Democrats and activist reporters oppose Arkansas’s actions because they want to keep people dependent on the government.”
Medicaid, which is financed jointly by the federal government and the states, has become an increasingly far-reaching component of the American safety net. Early this year, 93 million people — more than one in four Americans — were enrolled in Medicaid or the Children’s Health Insurance Program, up from 71 million before the pandemic.
What has played out in Arkansas so far offers evidence of the widespread disruption that the unwinding process is likely to cause in households across the country in the coming months, forcing Americans to find new insurance or figure out how to regain Medicaid coverage that they lost for procedural reasons. The federal government has projected that about 15 million people will lose coverage, including nearly seven million people who are expected to be dropped despite still being eligible.
Among the biggest looming questions is how the process will affect children. In Florida, for instance, a boy in remission from leukemia and in need of a biopsy recently lost his coverage.
Researchers at the Georgetown University Center for Children and Families estimated before the unwinding that more than half of children in the United States were covered by Medicaid or CHIP. Many children who lose coverage will be dropped for procedural reasons even though they are still eligible, said Joan Alker, the center’s executive director.
“Those kids have nowhere else to turn for coverage,” she said. “Medicaid is the single largest insurer for children. This is hugely consequential for them.”
In Arkansas, many of the children who lost Medicaid were “the poorest of the poor,” said Loretta Alexander, the health policy director for Arkansas Advocates for Children and Families. She added that losing coverage would be especially harmful for young children who need regular developmental checkups early in life.
Most states are taking around a year to complete the unwinding, with each one using its own approach to removing people from Medicaid. But in Arkansas, legislation passed in 2021 required state officials to complete the process in just six months. State officials checked the eligibility of children with Medicaid coverage early in the process because they make up a substantial share of those who are enrolled, according to Gavin Lesnick, a spokesman for the state’s Department of Human Services.
In her opinion essay, Ms. Sanders pointed to the campaign that the state has waged to alert residents to the unwinding, called Renew Arkansas.
“We hired extra staff and enlisted volunteers to help,” she wrote. “We texted, emailed and called tens of thousands of Arkansans who likely are now ineligible for Medicaid, and we have made a special effort to reach out to those with disabilities, those who have moved, those with afflictions like cancer, those receiving dialysis and women who are pregnant.”
Local health workers like Ms. Buford are trying to help people regain coverage if they still qualify for it. She said that she had worked with 50 to 75 Medicaid recipients who had lost coverage in April, helping them fill out forms or answering their questions about how to verify their eligibility.
Other states have also removed a large number of Medicaid recipients for procedural reasons. In Indiana, nearly 90 percent of the roughly 53,000 people who lost Medicaid in the first month of the state’s unwinding were booted on those grounds. In Florida, where nearly 250,000 people lost Medicaid coverage, procedural reasons were to blame for a vast majority.
In addition to taking different approaches to removing people from Medicaid, states are also releasing data about their progress in different ways, making it difficult to compare their strategies in the early stages of the unwinding. “We’re comparing apples to oranges to tangerines,” Ms. Alker said.
Some people who lose Medicaid coverage are expected to get health insurance through their employer. Others are likely to turn to the Affordable Care Act’s marketplaces to sign up for private insurance, and many of them will be eligible for plans with no premiums.
Debra Miller, 54, of Bullhead City, Ariz., lost Medicaid coverage in April after her roughly $25,000 annual salary as a Burger King cook left her ineligible. Ms. Miller, a single mother with diabetes and hypothyroidism, worked with an insurance counselor at North Country HealthCare, a network of federally funded health clinics, to enroll in a marketplace plan with a roughly $70 monthly premium.
“It’s a struggle because it’s a new bill that I haven’t had before,” she said. Her new plan, she added, does not include vision insurance, leaving her worried about paying for eye appointments she needs as a diabetic.
Ms. Buford said that for some people in Arkansas, marketplace coverage would be too expensive.
“You have a car, mortgage, kids, food,” she said. “You really don’t have that much left to pay that much for health insurance.”
Ms. Buford said that her job helping others find health insurance in underserved areas was a calling inspired by watching her grandmother struggle to afford her medications and rely on food pantries. Ms. Buford went to a community college near her hometown so she could take care of her sick father, who passed away in his 40s. “I love my job because I’m able to help people,” she said.
Now that she has lost her Medicaid coverage, Ms. Buford said she hoped to find an affordable marketplace plan in the near future. The family plan offered by the clinic where she works is too costly, she said.
“I’m grateful for what I have because someone else doesn’t have what I have,” Ms. Buford said. “I just wish I could have kept my Medicaid.”
https://www.nytimes.com/2023/05/26/us/politics/medicaid-coverage-pandemic-loss.html
Opinion Denials of health-insurance claims are rising — and getting weirder
by Elizabeth Rosenthal - Wasington Post - May 17, 2023
Millions of Americans in the past few years have run into this experience: filing a health-care insurance claim that once might have been paid immediately but instead is just as quickly denied. If the experience and the insurer’s explanation often seem arbitrary and absurd, that might be because companies appear increasingly likely to employ computer algorithms or people with little relevant experience to issue rapid-fire denials of claims — sometimes bundles at a time — without even reviewing the patient’s medical chart; a job title at one company was “denial nurse.”
It’s a handy way for insurers to keep revenue high — and just the sort of thing that provisions of the Affordable Care Act were meant to prevent. Because the law prohibited insurers from deploying a number of previously profit-protecting measures such as refusing to cover patients with preexisting conditions, the authors worried that insurers would compensate by increasing the number of denials.
And so, the law tasked the Department of Health and Human Services with monitoring denials in both plans on the Obamacare marketplace as well as those offered by employers and insurers. It hasn’t fulfilled that assignment. Thus, denials have become yet another predictable, miserable part of the patient experience, with countless Americans unjustly being forced to pay out of pocket or, faced with that prospect, forgoing needed medical help.
A recent study by the Kaiser Family Foundation (KFF) of plans on the Affordable Care Act marketplace found that even when patients received care from in-network physicians — doctors and hospitals approved by these same insurers — the companies in 2021 nonetheless denied, on average, 17 percent of claims. One insurer denied 49 percent of claims in 2021; another’s turndowns hit an astonishing 80 percent in 2020. Despite the potentially dire impact that denials have on patients’ health or finances, data shows that people appeal only once in every 500 cases.
Sometimes, the insurers’ denials defy not just medical standards of care but also plain old human logic. Here is a sampling collected for the “Bill of the Month” joint project of KFF Health News, where I work, and NPR.
- Dean Peterson of Los Angeles said he was “shocked” when payment was denied for a heart procedure to treat an arrhythmia, which had caused him to faint with a heart rate of 300 beats per minute. After all, he had the insurer’s preapproval for the expensive ($143,206) intervention. More confusing still, the denial letter said the claim had been rejected because he had “asked for coverage for injections into nerves in your spine” (he hadn’t) that were “not medically needed.” Months later, after dozens of calls and a patient advocate’s assistance, the situation is still not resolved.
- An insurer’s letter was sent directly to a newborn child denying coverage for his fourth day in a neonatal intensive-care unit. “You are drinking from a bottle,” the denial notification said, and “you are breathing on your own.” If only the baby could read.
- Deirdre O’Reilly’s college-age son, suffering a life-threatening anaphylactic allergic reaction, was saved by epinephrine shots and steroids administered intravenously in a hospital emergency room. His mother, utterly relieved by that news, was less pleased to be informed by the family’s insurer that the treatment was “not medically necessary.”
As it happens, O’Reilly is an intensive-care physician at the University of Vermont. “The worst part was not the money we owed,” she said of the $4,792 bill. “The worst part was that the denial letters made no sense — mostly pages of gobbledygook.” She has filed two appeals, so far without success.
Some denials are, of course, well-considered, and some insurers deny only 2 percent of claims, the recent KFF study found. But the increase in denials, and the often strange rationales offered, might be explained, in part, by a ProPublica investigation of Cigna — an insurance giant with 170 million customers worldwide.
ProPublica’s investigation, published in March, found that an automated system, called PXDX, allowed Cigna medical reviewers to sign off on 50 charts in 10 seconds presumably without even examining the patients’ records.
Decades ago, insurers’ reviews were reserved for a tiny fraction of expensive treatments to make sure providers were not ordering with an eye on profit instead of patient needs.
These reviews — and the denials — have now trickled down to the most mundane medical interventions and needs, including things such as asthma inhalers or the heart medicine that a patient has been on for months or years. Automation makes the reviewing cheap and easy. A 2020 study estimated that automated claims-processing saves U.S. insurers more than $11 billion annually.
Worse still, what’s approved and what’s denied can be based on an insurer’s shifting contracts with drug and device manufacturers rather than optimal patient treatment.
Challenging a denial can take hours of patients’ and doctors’ time — the process for larger claims is often fabulously complicated. Many people don’t have the knowledge or stamina to take on the task, unless the bill is especially large or the treatment obviously lifesaving.
The Affordable Care Act clearly stated that HHS “shall” collect the data on denials from private health insurers and group health plans and is supposed to make that information publicly available. (Who would choose a plan that denied half of claims?) The data is also supposed to be available to state insurance commissioners, who share with HHS the duties of oversight and trying to curb abuse.
To date, such information-gathering has been haphazard and limited to a small subset of plans, and the data isn’t audited to ensure it is complete, according to Karen Pollitz, one of the authors of the KFF study. Federal oversight and enforcement based on the data are therefore more or less nonexistent. HHS did not respond to requests for comment.
The government has the power and duty to end the fire hose of reckless denials that are harming patients financially and medically. Thirteen years after passage of the ACA, perhaps it is time for the mandated investigation and enforcement to begin.
https://www.washingtonpost.com/opinions/2023/05/17/health-insurance-denial-claims-reasons/
Resident Doctors Go on Strike at Elmhurst Hospital in Queens
The strike, the first by doctors in New York City since 1990, shows how the pandemic may be leading to rising activism among young doctors
More than 150 trainee doctors went on strike Monday morning at Elmhurst Hospital Center in Queens, the first physician strike at a hospital in New York City in more than 30 years.
Chief among their grievances is the fact that they are generally paid less working at a public hospital in Queens, where they care for poor patients, than their counterparts are paid at wealthier Manhattan institutions.
Though the strike is relatively small and not expected to result in major disruptions to care, it is heavy on symbolism. Some three years ago, Elmhurst was among the first hospitals in the United States to be overwhelmed by Covid-19.
Descriptions of panicked, gasping patients, chest compressions and refrigerated morgue trucks — scenes one Elmhurst doctor described as “apocalyptic” — served as a warning for the rest of the country.
Now the striking young doctors, many of whom were still in medical school in 2020, say the pandemic has encouraged activism and organizing — and a growing willingness to challenge the low pay young trainee doctors receive for working long and grueling hours.
Trainee doctors who work at the city’s public hospitals have often been reluctant to rock the boat in the past. Many were born and educated abroad and are in the United States on a visa.
“As international residents, we’re always so thankful — we feel very lucky to be here,” said Dr. Sarah Hafuth, a leader among the resident physicians, who comes from Canada. She added: “The pandemic was an eye-opener. Physicians really started to question our worth and asking, ‘Are we getting the support we need, given the situation we’re in?’”
At Elmhurst, residents had more difficulty obtaining hazard pay during the pandemic than residents at some Manhattan hospitals. That angered many resident physicians and hazard pay remains one of the issues driving the strike, one union delegate, a psychiatry resident, Dr. Tanathun Kajornsakchai, said on Friday.
Physician strikes are a rarity in the United States. The last one in New York City, according to the Committee of Interns and Residents, the union organizing this week’s strike, was in 1990 when young doctors at a Bronx hospital went on strike for nine days. They ultimately won a pay raise and stricter enforcement of rules against working more than 12 hours in a row.
Though the striking doctors work at Elmhurst, they are employed by the Icahn School of Medicine at Mount Sinai, which has its headquarters in Manhattan.
Doctors at many of New York’s 11 public hospitals are employed by major Manhattan hospitals and medical schools — the result of longstanding “affiliation” agreements between the public hospital system and the city’s leading medical institutions.
That means that the city’s public hospital system, NYC Health + Hospitals, is largely a bystander in the negotiations.
“Our medical residents play a critical role in patient care, and we are hopeful they will reach a labor agreement soon to avoid a strike,” the public hospital system said in a statement. “In the meantime, we are making all the necessary preparations to ensure uninterrupted access to patient care services if there is a strike.”
Chief among the residents’ complaints is that their counterparts working at Mount Sinai’s main hospital, opposite Central Park on East 98th Street, make considerably more.
Dr. Hafuth said that first-year residents assigned to Elmhurst made about $68,000 a year, while the residents working at Mount Sinai’s main campus made $75,000. The Manhattan resident physicians also have several perks, Dr. Hafuth said, including that they can take a car service home at night.
“Our patient load is all the same,” she said. “We see the same medical pathologies, the same complexity. So we’re at a point where we’re quite frustrated about why Mount Sinai is willing to pay the residents on the Upper East Side more than us.”
A spokeswoman for Mount Sinai, Lucia Lee, said in a statement that the health system was “committed to working toward an equitable and reasonable resolution that is in the best interest for both our residents at Elmhurst as well as for the Mount Sinai Health System.”
The strike comes after more than 10 months of contract negotiations between Mount Sinai and the Committee of Interns and Residents, the union that represents the resident doctors. Mount Sinai said that the union rejected its “last, best and final offer” — which, according to Mount Sinai, would have provided for raises of between 5 and 7 percent a year, for the next three years.
As many as 172 doctors went on strike at 7 a.m. Monday, drawn from the departments of internal medicine, pediatrics and psychiatry.
“Our dedicated staff are ready to take on extra shifts, and we will be able to mobilize clinicians from other health system hospitals if necessary,” the statement from the public hospital system said.
https://www.nytimes.com/2023/05/22/nyregion/resident-doctors-strike-elmhurst-hospital-nyc.html
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