William P. White was among the first insurance commissioners in the nation to push back on the President’s plan to allow some people to keep their current plans. DC Wonks #predictablyoutraged.
More at The Washingon Post.
Above the Fold
What I Expect From the Medicare Program
After half a lifetime of following the Medicare program, on October 1, 2013, I became a Medicare beneficiary. I turned 65 on October 31. I’m part of the leading edge of baby boomers joining the program, ten thousand a day. We’re going to change this program, both by how we use it and what we expect its keepers in Washington to do to improve it.
Here are some reflections upon joining Medicare.
1-Don’t Refer to Me as “Retired”, Please. I’m still working (hard) and paying Medicare as well as income taxes taxes every month. Like most of my fellow boomers, I lack the financial cushion I want in order to stop working. Additionally, for what it’s worth, like all too many boomers, I don’t know how not to work. So my main goal, which is closely aligned with the country’s, is to stay healthy enough to keep working long enough to be able to retire comfortably when I wish to do so.
I plan on staying a long way away from the expensive parts of our healthcare system, if only to avoid being inadvertently harmed. Rest assured that if I know I’m dying, you won’t find me in a hospital if I have any say in the matter.
I don’t consider myself “entitled” to Medicare, or to subsidies from younger people. I’m paying more than $400 a month in Part B fees and the special assessment on Part D that got tacked on in the Affordable Care Act. After what I’ve already paid in, that’s not exactly a flaming bargain. I’ve paid Medicare enough over my working lifetime to buy a house, and will pay more Medicare taxes for years to come for each month that I work. Nothing makes me angrier than the suggestion that I’m somehow sponging off my kids by participating in Medicare.
2- The Regular Medicare Program is a Relic. There is a lot of political fog enshrouding Medicare. Personally, I could care less about the politics of this program. The big choice was fairly cut and dried: either regular Medicare plus a supplemental plan or Medicare Advantage. After logging onto Medicare.gov, I found the regular Medicare benefit completely incomprehensible- chopped up into Parts that may have made legislative sense in the 1960’s. If you included the supplemental coverage, there were just too many moving parts that didn’t seem to fit together into a unified benefit.
So I chose Medicare Advantage. It’s simple to understand and user-friendly, and looks a lot like my previous coverage. My doctor is a participating physician as is my beloved community hospital, Martha Jefferson. And the price is right: zero dollars after my Part B premium. More than 40% of boomers are picking Medicare Advantage, largely because it’s easy to use and remains a bargain. It will eventually be half the program.
Five Questions Journalists Should Be Asking About the Affordable Care Act
I’m hearing a lot of the lazy “but what are the political implication” perpetual horse race questions from the media about recent developments surrounding the Affordable Care Act. That’s fun Inside-the-Beltway stuff, but in the mean time there are real people who are likely to be helped and hurt with matters as essential as their health. So, what I am not hearing enough of yet, however, are tough, substantive questions that get to the heart of whether the Affordable Care Act is going to be stillborn.
Here are some questions that I think intelligent journalists and blogger ought to be asking in light of recent developments with the Affordable Care Act. Getting answers in many cases may take persistent questioning and closer scrutiny of existing documents. In others, FOIA requests may be needed.
1. Actual v. Anticipated Age Distributions in the Exchanges
What is the age distribution by state and in the aggregate of persons who it is claimed have enrolled in Exchange-based plans under the Affordable Care Act? Once we have this data, we can compare it to (a) census data on the age distributions in the various states and (b) any prior estimates on what the age distribution of Exchange enrollees would be such as those described in this government document.
If there is a significant difference between the age distribution encountered thus far and the anticipated age distribution, that increases the probability of the ACA succumbing to an adverse selection death spiral.
What Could Have Been and What Still Has To Happen
Covered California, the state-run Obamacare health insurance exchange, announced on Wednesday that 59,000 people have so far signed up for health insurance.
Given that California amounts to about 10% of the nation’s population, this would suggest a smooth running federal exchange might well have enabled the Obama administration to have met its national first month goal of 500,000 sign-ups.
But the California enrollment also points to the real challenge Obamacare faces.
In the first month, 84% of the enrollees did not qualify for a subsidy. It has been widely estimated that about half of all potential enrollees will eventually qualify for a subsidy. As Covered California’s chief executive said, “Those are individuals who have been waiting a lifetime for health coverage.”
Covered California is not scheduled to release any age data until next week, but the health plans already know what they are getting. The President of the California health insurance trade association also said yesterday, “It is important for the exchange to achieve a balance in enrollment between the old and the young and the sick and the healthy to allow costs to be spread among all people.”
These Healthcare.gov problems have been a sideshow for Obamacare. The main event will be about whether more than just those who have been “waiting all of their lives” to get guarantee issue health insurance they are sure to make money on will eventually sign-up in adequate numbers.
Continue reading…
What the “Doc Fix” Should Tell You About the “Grandfather Fix”
With his announcement on Nov. 14 of a plan to offer a temporary reprieve to people facing cancellation of their health-care policies, President Barack Obama may have created his own version of the much-maligned, often yearly, Medicare “doc fix”.
The doc fix, a recurring effort by Congress to override statutory formulas that limit the growth in Medicare payments to doctors, often sparks political theatrics as lawmakers work to assuage the concerns of physician groups and Medicare recipients. Many members of Congress want to repeal and replace the underlying program — the sustainable growth rate formula for reimbursing physicians — but agreement has proved elusive, in part because of deficit concerns and the high cost of repealing the formula.
The president may have set himself up for another situation similar to the doc fix with his proposal to administratively tweak the health law. Obama said he will temporarily allow health insurance companies and state insurance commissioners to continue offering insurance plans “that would otherwise be terminated or canceled” for failing to meet the requirements of the Affordable Care Act (ACA).
Has President Obama created his own version of the annual “doc fix” by continuing insurance plans that would have otherwise been canceled?
While this change will help some health-insurance consumers, it is a serious complication for health insurers who in a few weeks will have to readjust their plans. In the 24 hours since the announcement, the initial reaction from insurers and state health insurance commissioners has been mixed. Some insurers have already voiced concerns that any short-term fix will deprive their ACA-compliant exchange plans of the healthier customers needed to keep rates down for everyone, including older, sicker customers.
Fast-forward 11 months to late October, 2014, with the midterm elections imminent and the president’s “transitional policy” about to expire. Will Democrats want the issue of whether people can “keep their health plan if they like it” raising its ugly head again, just as voters are about to cast their ballots?
The Statinization of America
On November 12, 2013, the American Heart Association (AHA) and the American College of Cardiology (ACC) disrupted the cardiovascular disease (CVD) universe by issuing four new guidelines. The guidelines depart from past efforts because the relevant federal agency, the National Heart, Lung, and Blood Institute (NHBLI), did not lead development. NHBLI now ‘sponsors’ guideline development, but has deferred actual writing and publication to private groups.
No word on when long-awaited companion blood pressure guidelines will emerge. If the blood pressure guidelines look anything like these cholesterol guidelines, then all rational arguments about cost containment will effectively come unhinged.
The guideline release was well orchestrated, not unexpected in organizations so well-funded by the pharmaceutical companies. They are the population that stands to benefit the most from what Alan Cassels, author of Selling Sickness and Seeking Sickness, which both seemed to anticipate moves like this, calls “statinization.” Fortunately, not everyone was drinking the “treatment today, treatment tomorrow, treatment forever” Kool-Aid; contrarian physicians believe that the guidelines simply lowered the therapeutic bar without clear evidence that doing so will improve outcomes, an ironic observation given that this is supposed to be about primary prevention.
The contrivance of simply altering a definition and having the subsequent area under the curve of healthy people who require treatment expand to include, oh, say 30 million more Americans is a merger-and-acquisition coup for pharma that would make Gordon Gekko blush.
Lowering the therapeutic bar will increase health care spending as physicians write more prescriptions and see more patients more often, certainly to monitor liver health, and probably for the side effects that cause double digit percentages of patients to stop and are routinely underreported in studies sponsored by the industry.
It also gives patients false security by promoting the belief that the heartily recommended drugs – statins – will provide a “cure,” a clinical get-out-of-jail-free card, which will surely diminish enthusiasm for lifestyle-based approaches to prevention that are free but unfortunately not reimbursable. And, as Abramson and Redberg note in their New York Times essay, the enunciated strategy will require perpetual treatment of 140 people to forestall 1 heart attack. Many of these people will now live long enough to experience “disease substitution,” allowing them to die of cancer or dementia.
The most important element of the new guidelines, however, is the shift away from pursuit of hard targets (get total cholesterol below 240 and LDL below 180) to a risk-based approach (for people without clinically evident disease), in which the therapeutic goal is to medicate non-diseased adults aged 40 to 75 who have an estimated 10 year risk of developing heart disease greater than 7.5% (down from 10% risk over 10 years). Overall, this necessary and overdue shift properly emphasizes CVD risk as a constellation and exposes our cultural tendency to seek or initiate treatment because of a single adverse attribute, which has led us to waste a fortune chasing clinical ghosts.
You Can Keep Your Plan. Maybe.*
Facing a revolt by Democratic lawmakers unhappy with the rollout of the health law, the Obama administration announced this morning that it will allow insurers to renew cancelled health plans that fail to meet the standards set by the Affordable Care Act.
Insurers will be required to notify customers with cancelled plans that they have the option of upgrading to an ACA-compliant plan. Plans can be extended through the end of 2014.
The decision does not impact new customers who will still be required to buy coverage that meets the stricter standards set by the new health law – either on the exchanges or directly from an insurer.
The move is likely to add additional confusion and uncertainty to an already chaotic marketplace shaken by the widely publicized problems at HealthCare.gov.
It is unclear, for example, how the customers of specific health plans who have already had their coverage cancelled will be impacted. The decision of whether or not to reinstate individual plans is being left up to individual insurers.
Exactly why they’d want to reinstate the cancelled plans isn’t obvious. Five million people have received cancellation letters according to one recent estimate.
Health plan insiders have argued for months that reversing course will be difficult, if not impossible, for plans that have built their actuarial models on the assumption that certain numbers of healthy people will enroll by certain dates. Industry representatives immediately warned that the impact would likely be higher premiums.
In a letter sent to state health insurance commissioners this morning, Center for Consumer Information and Insurance Oversight (CCIIO) director Gary Cohn spelled out the details of the fix. A plan must have been in effect on October 1st, 2013. Health plans must notify consumers in writing of their eligibility for an ACA-compliant plan. And they must explain what they’re not getting. A request that, in effect, asks insurers to advertise the Obamacare plans, something they haven’t exactly been enthusiastic about doing in the past. That may or may not turn out to be a smart move.
Health plan consultant Robert Laszewski – a frequent THCB contributor – warned:
This means that the insurance companies have 32 days to reprogram their computer systems for policies, rates, and eligibility, send notices to the policyholders via US Mail, send a very complex letter that describes just what the differences are between specific policies and Obamacare compliant plans, ask the consumer for their decision — and give them a reasonable time to make that decision — and then enter those decisions back into their systems without creating massive billing, claim payment, and provider eligibility list mistakes. This puts the insurance companies, who have successfully complied with the law, in a hell of a mess.
My Wife Has Cancer. I Need to Know: Will She Have Insurance On January 1st?
On February 16 of last year, I was in a New Orleans hotel room preparing for a meeting when my wife Becky called and said simply, “I have cancer.”
We knew it was possible, but that didn’t in any way lessen the impact of those three words.
I have cancer.
Everything that was right and comfortable was in that instant washed away by a million questions with no answers. At a time when we needed nothing more than certainty and clarity, there was only confusion and doubt.
Upon landing in Philadelphia hours later, I called to see how she was doing with her newly diagnosed breast cancer. Feeling numb, I managed to make one other call soon after landing. Not to friends. Not to family. Instead, it was to our insurance company.
That’s right: Other than my wife, the one person I most wanted to speak to in the world was a Cigna call center operator.
We hadn’t even had a chance to meet with her oncologist to discuss potential courses of treatment, but we had questions because we had recently changed our plan to carry higher out-of-pocket costs and lower deductibles. We needed answers to those questions so we could go about worrying about more important things.
What procedures are covered? Are the doctors at the cancer center in plan? What is the maximum out of pocket? What other limits should we know about?
A 15-minute conversation later, we were comfortable that insurance wouldn’t be an issue and had a decent understanding of what our share of the costs would be. At a time of absolute fear and confusion, our insurer provided a moment of comfort and clarity.
That is the kind of financial and emotional stress that millions of people face every day in the United States. That is also the kind of financial and emotional security the Affordable Care Act was supposed to provide — especially to those who currently lack health insurance. Continue reading…
Could Med Students Help Win the Enrollment War?
State health exchanges are facing many challenges in the recent scramble to enroll their residents in the healthcare marketplace. Among the numerous obstacles, including online systemic glitches (Washington state botched the tax-credit calculation while Maryland’s appears to be having just general technical incompetence) and complete lack of knowledge (according to a recent Gallup poll, 71% of uninsured Americans have no clue what the exchanges are), a critical challenge is the quick generation of a new healthcare workforce, namely enrollment counselors and navigators.
According to the Center for Medicare and Medicaid Services, enrollment navigators are supposed to help people enroll, whether through online or paper applications, determine individual eligibility for various subsidies and assistance programs, and generally educate the public regarding the new health exchanges. Certified application counselors differ slightly from navigators, taking a less involved role in the process, but still serving as assistants to people who need help completing their application.
However, in many states, including Florida (1 navigator per 100,000 uninsured citizens as of October 1st), Georgia (only 4 people were certified to be counselors when the exchanges went live) and California (official numbers will be released on November 14th, but current estimates suggest less than 20% of future counselors are fully certified yet), there is a huge workforce shortage which is both reducing the rate of enrollment and contributing to people’s doubts about the Affordable Care Act in general.
Part of the problem is that many states, for several months now, have purposely made it more difficult for people to become certified enrollment employees; Ohio and Missouri are widely cited as two of those. They have also instituted regulations on what information counselors can and cannot give patients and have tried to implement large fines, such as in Tennessee, which luckily ruled to temporarily restrain these penalties, for those who may unknowingly breach part of the contract.
As a medical student hoping to be more involved in influencing patient care, but unable to do so at a clinical level just yet, the opportunity to serve as an enrollment counselor or navigator is more than timely.
In my home state of California, training and certification to become a Certified Enrollment Counselor is not easy, but it’s doable. The process involves 20 hours of in-person courses, a number of online modules, and a background check. However, the cost of training is compensated—$58 per completed application, to be exact.
Wait. So How Do I Find out if a Specialist Is Covered by My Plan?
A THCB reader in Connecticut writes:
“I’m a pretty level headed person. I’ve been following the Healthcare.gov story in the news and figured it was more of the usual partisan stupidity out of Washington. I decided to do my homework before getting too worked up.
I went on to my state exchange and compared the available plans. Gold. Silver. Bronze. All very logical. I spent some time comparing options and found a plan I liked. So far so straightforward. No complaints. No plan shortage in my state.
The problems started when I picked up the phone and attempted to communicate with a living breathing human being. I figured it would be a good idea to confirm that my OBGYN’s practice is covered. To make a long story short, I have a pretty serious pre-existing condition that could hypothetically kill me. My OBGYN is one of the best in the state. Moving to another practice is NOT AN OPTION.
Knowing how the system works, I called my OBGYN’s office and asked them to confirm that my doctor’s plan was covered. Should be a five minute call. No luck. Sorry. They don’t have the information yet. Probably yes. They helpfully suggest I give the health plan a call. Well, that’s logical, I think to myself. It takes time for new plans to about the plans to make it through the system. So I take their advice.
I call the health plan involved and politely tell them why I’m calling and what I need to know. Guess what? They don’t know either.
