11.9% Is the New Normal

The Gallup organization has become the go-to sources for monthly tracking of progress in reducing the numbers of uninsured Americans.  Yesterday, they came out with their latest estimate that the percentage of American adults without health insurance has now dropped to Gallup201511.9%, down from 18%in mid-2013, and down from 12.9% in late 2014.  Because rates of coverage are higher among children, the overall uninsurance rate among all Americans is lower, though no precise estimate is include.

If you look at the chart, it’s unmistakeable that the drop in coverage began with the implementation of the major Affordable Care Act insurance coverage expansions that took full effect on January 1 2014.  Of course, if all 50 states — instead of the current 28 — joined the Medicaid expansion for poor adults, then the rate would be substantially lower, especially with the addition of states with very high rates of uninsured adults such as Texas, Florida, North Carolina, Georgia, Louisiana, and others.

We can hope that 11.9% will not be the new normal for long and that the next new normal will be even lower.  This achievement is a victory for Americans everywhere working so hard to make sure that everyone benefits from the ACA.  Below are some more details — you can see that the expansions are working precisely as intended, and that the groups benefiting the most are those with the highest rates of uninsured: the young, those with lower incomes, and racial/ethnic minorities. Gallup2

 

Reality and Unreality in the New Congressional Medicare (SGR) Deal

This week, you can be confident that the US Senate will approve bipartisan legislation approved on March 26 in the House of Representatives by an overwhelming (392-37) bipartisan majority to repeal a long-standing feature of Medicare physician payment policy called the Sustainable Growth Rate or SGR.

If you’ve never heard of SGR, you are among the 99%. Still, the SGR story has been fascinating and frustrating since it began as part of the 1997 Balanced Budget Act (BBA) agreed to by President Bill Clinton, House Speaker Newt Gingrich, and Senate Majority Leader Trent Lott.  And as SGR begins its final exit, a host of good and not-so-good elements in the repeal legislation come into play. Nancy+Pelosi+Congressional+Leaders+Honor+Fresco+DnF8pOwGvVhl

What’s good and what’s not so good about this deal?  Well, everything, depending on your point of view.  Here are the leading candidates (and my grade):

  • Repealing SGR – very good
  • Refinancing the Children’s Health Insurance Program (CHIP) for two years – very good (excellent if it were for four years)
  • Authorizing $7.2 billion for community health centers and the National Health Service Corps – wonderful!
  • Replacing SGR with a more sensible set of physician payment quality incentives (that follow the logic of the ACA, believe it or not) – very good
  • Not paying for the $141 billion 10-year cost of SGR repeal to the federal Treasury – not so good though worthy of forgiveness this time

So, wow.  Does this augur a new era of bipartisan Congressional cooperation on health policy?  Nope.  Let’s look at each of these in turn. Continue reading “Reality and Unreality in the New Congressional Medicare (SGR) Deal”

Oh Brother! Those Awful Out-of-Network Charges!

One of the reasons I like this new site is because I can easily bring in other voices.  And why not start close to home.  May I present … my big brother.  Joseph P McDonagh — yes, he changed the spelling of his last name to the traditional Irish version figuring the rest of us would follow.  Guess again!

Joe is a life and health insurance agent (aka: broker) in the state of Connecticut.  He also 1 joe mcdhappens to be a progressive Democrat (former chair of the Hamden Democratic Town Committee).  Because there are so few liberal Democrat insurance brokers, it’s actually a pretty good marketing asset in a state with lots and lots of liberal Democrats.  Even more rare in the broker community, Joe is a supporter of the Affordable Care Act and a friend of the Universal Health Care Foundation of Connecticut.  Today he published a blog post on the Foundation’s website and I think you might appreciate reading it because it’s about a growing problem all over the U.S. that seems to be getting worse.  Let me know what you think:

Surprise Out-of-Network Charges Cost Us All

I see many types of bills as a health insurance agent, but I received one from a client last week that highlights a disturbing trend.  Unfortunately, it was the third bill of its type that I’ve seen in 2015.

The bill was from a physician assistant for $6,200.  The physician assistant didn’t perform the surgery – obviously, a surgeon did that.  The physician assistant wasn’t known to my client; he had no idea who this person was until the bill arrived.  To top it off, the $6,200 bill was more than what the surgeon was paid.

The bill was so high because the physician assistant was billing separate from the facility, the surgeon, and the anesthesiologist. This is because the physician assistant was “out of network,” meaning they are not a participating provider with my client’s insurance company. This entitled them to bill my client for the full amount.

 

I am a veteran in the health insurance field. I work mainly with small employers with fewer than 50 employees. And especially for them, part of what I do includes helping to explain why they’re being billed for something. A major part of my job is calling the insurance company when a claim is denied and negotiating my client’s way through the confusion of 21st century health insurance.

This task keeps getting tougher.

A month ago, another client sent me an “explanation of benefits” (EOB) – the notoriously obtuse and unintelligible statement that an insurance company sends when a claim has been processed by an insurance company.  He, too, had been in the hospital for surgery.

The EOB showed a $2,400 bill for the anesthesiologist, of which the insurance company paid nothing because the anesthesiologist, a person my client hadn’t chosen and only met for the first time on the morning of the surgery, was also out of network.

A third client contacted me in January.  She had been to see her regular doctor for a routine annual exam, including blood tests.  She received a bill from the laboratory that performed the blood tests for over $2,800. That lab, like the physician assistant, like the anesthesiologist, is out of network. Do you see a trend?

When a bill is presented for out of network services to an insurance company, it is either denied outright if the insurance plan doesn’t cover out of network services, or it is paid at a significant discount.  However, unlike an in-network provider, the out of network provider can send a bill to the patient for the part of the bill that the insurance company won’t pay and demand full payment.

If you deliberately chose that out of network provider – maybe it was a highly recommended orthopedic surgeon, a chiropractor who was known to work magic, or a psychiatrist who doesn’t accept insurance – the full cost is rightfully on your shoulders.

But when the facility, the doctor, or the physician assistant wasn’t selected by you and is out of your control, why should you be held responsible for that cost?  You shouldn’t. And if you aren’t, it is a long and arduous process to get the bill settled.

Your insurance company’s denial must be appealed, a process that will typically take about a month.  It is your responsibility to file the appeal, not the out of network provider’s (who might, in the meantime, be sending your bill to a collection agency).  And when the bill is finally settled, the end result often is that the provider is reimbursed by your insurance company for the full amount billed.

Why?  Why should a physician assistant receive more in payment than the surgeon?  Why should an anesthesiologist receive four times what would have been paid if he was in network?  Why should an out of network laboratory receive ten times what would have been paid to an in-network lab?

They shouldn’t, but they often are.  And ultimately, although you won’t be paying that provider directly, we are all paying the costs for these unwarranted out of network expenses in higher premiums.

These three cases aren’t unusual.  What is unusual is that I am confronted with these sorts of problems more frequently these days.  Just as we are trying to gain control over health care costs with viable new ideas – patient-centered care, capitation payments replacing fee-for-service, etc. – these out of network provider costs threaten to undermine our efforts.

When an insured patient enters the hospital for an emergency, no one is required to ask if the physicians attending are in network.  Emergency services are rightly covered as though in-network, even if the providers are not.

But in the case of scheduled surgery, unless the patient has specifically requested the services of an out of network provider, no one in the operating room should be outside the network and certainly no one should be paid other than what is appropriate for the in-network care.

It’s not enough that my clients won’t have to pay these outrageous bills; their insurance company shouldn’t be paying them either.

The state legislature is partially addressing this issue via S.B. 808.

Economic Facts and the ACA

We see a daily drumbeat of negative news about the impact of the Affordable Care Act on individuals and the economy — see this report on Friday from Fox News.  Rising premiums, loss of full time jobs, bigger deficits, and so much more all tied to ObamaCare.

That’s why I was pleased to see Jason Furman, Chair of the White House Council of Economic Advisors, come out with a presentation and report on Friday at the Center for American Progress detailing “The Economic Benefits of the Affordable Care Act.” Like it or not, we have to keep driving home these facts as often as possible because ACA’s opponents still have the advantage with public opinion.

What are these facts?

For example, many charges that the ACA would cause economic havoc have been disproven.  First, the ACA is not a “job killer” — since the major ACA expansion took effect on January 1 2014, we’ve had the strongest year of private sector job growth, 3.1 million, since 1998.  Second, the 1 netChangeACA has not created a “part-time job” economy, with employers pushing workers into part-time work to avoid health insurance responsibilities — see this chart from the CEA.  Part time employment has gone slightly down while full-time employment is increasing at the best rate since President Bill Clinton’s tenure.

Meanwhile, we can see indications Continue reading “Economic Facts and the ACA”

Explaining ObamaCare to Foreigners

I wrote this column for Commonwealth Magazine on the 5th anniversary of the ACA’s signing on March 23.  In case you did not see it, there are messages in here helpful to Americans in understanding this massive policy change.  Let me know what you think.  One correction: the decline in some hospital acquired conditions referenced near the end of the column can be traced to the early 2000s and has accelerated significantly in the past five years.

Here goes:

On the fifth anniversary of the signing of the Affordable Care Act, I ponder how 1 ACAOCnon-Americans view our momentous and controversial health reform law. Like many US health policy analysts, I get requests from groups outside the US to explain the ACA, or “Obamacare.” I have traveled to Brazil, Australia, and South Africa, and also addressed foreign audiences here in the US, to explain what they should they know about the law and why they might care. I offer them two conclusions, and believe Americans might benefit by knowing them. They are: we remain laggards in providing access to health care coverage, and we are now real leaders in global efforts to improve health care’s quality, efficiency, and effectiveness.

First, when it comes to providing universal coverage and financial protection from the costs of illness and injury, non-Americans have almost nothing of value to learn from us. Even after the ACA’s health insurance expansions are fully implemented by 2016-2017, the US will still have the most inefficient, expensive, wasteful, and unfair coverage system of any advanced nation on the planet.

Long before President Obama signed the ACA in 2010, every other developed nation had established a system to provide universal coverage for all their citizens. Each found its own idiosyncratic path, using differing measures of market and government intervention to align with their distinct economic and political cultures. They all did it better than the ACA ever will. Continue reading “Explaining ObamaCare to Foreigners”

Reheating Health Stew

Health Stew John 300x300_editedAbout 12 months ago, I suspended writing this blog, Health Stew, which I had produced since late 2011. The original site for the Stew, boston.com, ended their Community Voices series, and I had some big work commitments that convinced me to take a hiatus.  I also, naively, believed that in 2014, after implementation of the big access expansions of the Affordable Care Act were done, that health policy would, finally, get boring again.  Boy, was I wrong!

So after a year off, I’m back with the Stew as an independent blogging site for me, and I hope for others looking for a nontraditional and nonaligned site for commentary and analysis on health policy and politics in Boston, Massachusetts, the US, and around the globe.

Why do this?  I do this because I feel a need to add my voice to those who seek to advance a fairer, more just, more equitable, smarter, and better health care system for all Americans.  I don’t — and can’t — pretend to be neutral when it comes to the Affordable Care Act — or ObamaCare.  I was one of an army of Congressional staff who worked on the writing and passage of the law between 2008 and 2010. I wrote a book about the ACA called Inside National Health Reform to help people understand both the process to passage and the substance of this most important federal law.  I believe in health reform as a continuous process that never ends and, we can hope, gets better.

I chose the name Health Stew because I like stew and I like the image of a lot of ingredients coming together to produce a nutritious and tasty dish with an attractive aroma.  My interests in health policy are wide ranging and include access, quality, costs, public health, health inequities and disparities, health politics, history, economics, psychology, sociology, law, finance, and much more.

If you want to catch up, you can check out all my earlier Health Stew posts by clicking here.  They are reverse chronological, and my advisers and I are trying to figure out how to make them all more easily searchable and categorized.  Stay tuned.

My special thanks to Jennifer Powell from the Excellent Writers Group for her great consultation and support, as well as to Tania Helhoski for her graphic design.

So much to talk about !  Let’s get started…