MONEY health insurance

Why You May Have to Spend More on Health Care Next Year

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Larry Washburn—Getty Images/fStop

When open enrollment kicks off at your workplace this fall, you should see only modest premium hikes. But you'll also come across more plans with higher out-of-pocket costs and surcharges to cover your spouse.

Fall is enrollment season for many people who get insurance through their workplace. Premium increases for 2015 plans are expected to be modest on average, but the shift toward higher out-of-pocket costs overall for consumers will continue as employers try to keep a lid on their costs and incorporate health law changes.

Experts anticipate that premiums will rise a modest 4% in 2015, on average, slightly higher than last year but lower than typical recent increases.

“That’s really low,” says Tracy Watts, a senior partner at benefits consultant Mercer.

Even so, more employers say they’re making changes to their health plans in 2015 to rein in cost growth; 68% said they plan to do so in 2015, compared with 55% just two years earlier, according to preliminary data from Mercer’s annual employer benefits survey.

They are motivated in part by upcoming changes mandated by the health law. Starting in January, companies that employ 100 workers or more generally have to offer those who work at least 30 hours a week health insurance or face penalties.

“The more people you cover, the more it’s going to cost,” says Watts.

In addition, experts say, employers are ramping up efforts to avoid a 40% excise tax on expensive health plans—those with premiums that exceed $10,200 for individuals or $27,500 for families—that will take effect in 2018.

More employees can expect to be offered high-deductible health plans linked to health savings accounts or health reimbursement arrangements in 2015. Nearly three-quarters of companies with more than 1,000 workers offer such plans, according to the 2014 Towers Watson/National Business Group on Health employer health care survey. Nine percent said they planned to add them in 2015.

For a growing number of employees, those plans may be the only ones available through work. For 2015, 30% of large employers said they expected to offer only an account-based plan to workers, nearly double the percentage that did so in 2014, the Towers Watson/NBGH survey found.

For some consumers, however, those plans raise concerns about the cost of care. A new survey by The Associated Press and the NORC Center For Public Affairs Research found that people with high deductible plans were twice as likely as those with traditional health insurance to report that they did not go to a doctor when sick or injured because of concerns about the costs.

When employers shift toward plans with higher deductibles, they often try to sweeten the deal for employees by offering to put money into the financial accounts to help defray the workers’ increased cost, says Brian Marcotte, president and CEO of the National Business Group on Health. The extra cash—an average $600 per employee—is often tied to wellness activities such as agreeing to get health screenings, says Marcotte. As employees evaluate their health plan offerings this fall, it’s worth checking to see if such incentives are offered.

Also this year, workers may find it increasingly expensive to cover their spouses, especially if they have coverage available through their own jobs.

Employers have been increasing workers’ costs to cover dependents, including spouses, in recent years. Nearly half of employers say they’ve hiked employee contributions for dependent coverage, and another 19% plan to do so in 2015, according to the Towers Watson/NBGH survey. Upcoming increases are particularly aimed at spouses, including $50 to $100 monthly surcharges for spousal coverage, says Sandy Ageloff, a senior consultant at benefits consultant Towers Watson.

“Legally under the Affordable Care Act, plans can’t exclude coverage for kids,” says Ageloff. “But they’re really trying to shift the onus back on to spouses.”

This fall, employees who work for small businesses may see fewer changes in their coverage than those who work for large companies. In March, the Obama administration announced that individuals and small businesses with plans that didn’t comply with health law coverage and cost requirements could be extended until 2017.

As many as 80% of companies with up to 50 employees opted to renew their non-compliant plans for 2014, says David Chase, national health care policy director at the Small Business Majority, an advocacy group. A similar percentage will likely try to do so this year as well, he says.

“That’s going to be a popular option for folks, if their states allow it,” Chase says. It’s up to states to determine whether insurers can continue to sell small group plans that don’t meet the requirements of the health law.

There could be a downside, however. “Sticking with the same plan doesn’t mean sticking with the same premium,” Chase says. “Those premiums could go up more than ACA-compliant plans.”

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

TIME 2014 Election

Democrats See Obamacare Silver Lining in 2014 Playbook

From fierce opposition to a "fading issue"

A year ago, the health care reform law was an albatross around the Democrats’ collective neck. Its disastrous roll out dominated headlines. Republicans gleefully predicted they would build on their House majority and take back the Senate in the midterm elections thanks to the unpopularity of President Barack Obama’s signature domestic achievement.

Republicans may well still pick up House seats and win the Senate—but if they do, it won’t be because of Obamacare. The “incredibly fading issue,” as U.S. News and World Report recently called it, it has become “background noise” in an election dominated by parochial interests, as Politico put it. Indeed, some Democrats are going so far as to predict that Obamacare could end up a silver lining come Election Day.

The Affordable Care Act is now the second-most important issue for unmarried women, according to a new poll by Democracy Corps for the Women’s Voices Women Vote Action Fund, a key demographic Democrats are hoping to turn out this November. Unmarried women vote reliably Democratic, but tend not to turn out in midterm elections. If Democrats can turn out that one group at the same levels they voted in 2012, forecasts indicate Democrats would keep the Senate and take back the House.

That kind of turnout is highly unlikely. But every little bit counts as Democrats try to fend off the kind of wave election that drowned them in 2010. That year, a genuine backlash against Obamacare helped Democrats lose the women’s vote for the first time since Ronald Reagan, and the House with it. In most battleground Senate races, Democratic candidates are winning by double-digits with women, particularly unmarried women

The law is also popular with minorities, another demographic with which Republicans have struggled. Some 74% of minorities support the Affordable Care Act, according to the Democracy Corps poll. “The health care law has become much more important as a reason why people are voting for Democrats,” says Stan Greenberg, a co-founder of Democracy Corps. “The threat of repeal appears to be giving unmarried women and minority voters a reason to vote.”

Republicans seem to have felt the tide receding. In April, Obamacare was the subject of 54% all political TV ads; by July that number had fallen to 27%, according to a July report from nonpartisan analysts Kantar Media CMAG. “Obamacare will not be the most important issue,” GOP pollster Whit Ayres, co-wrote in an August memo outlining 57 alternate lines of attack for outside spending groups such as Crossroads GPS and the American Action Network.

Still, opponents still use the issue far more than supporters; overall this election cycle, anti-Obamacare groups have spent 15 times as much on ads than groups supporting the law, the Kantar Media CMAG found. “Did Obamacare dominate the midterms as some Republicans had predicted? Definitely not,” says Larry Sabato, head of the University of Virginia’s Center for Politics. “But has it been used widely by GOP candidates for House and Senate in their TV ads and on the stump? A resounding yes. And that makes sense. Midterm elections are low-turnout battles between the two party bases. Any hot button issue that gets partisan voters to cast a ballot is used extensively. Obamacare still causes Republicans’ blood pressure to rise.”

The Affordable Care Act almost surely remains a net negative for Democrats. “It helped bake voters’ opinions into the general election cake,” says Jennifer Duffy, who follows Senate races for the nonpartisan Cook Political Report. “The early advertising effort also kept vulnerable Democratic incumbents on the defensive. This was particularly helpful in states in which Republicans had primaries.”

Support for Obamacare remains in the red, with 51.1% opposing the measure and only 38.7% supporting it, according to a Real Clear Politics average of national polls. Which is why the handful of positive ads Democratic candidates have attempted to run on behalf of the law—most notably in Arkansas and West Virginia—have been resoundingly mocked by Republicans.

But all the negative attention paid to Obamacare also had another side effect for Democrats. The four states that have seen the highest per capita anti-Obamacare ad spending—Kentucky, Arkansas, Louisiana and North Carolina—have conversely seen higher rates of enrollment, according to a July study by the Brookings Institution. “In the states where more anti-ACA ads are aired, residents were on average more likely to believe that Congress will repeal the ACA in the near future,” wrote the study’s author, Niam Yaraghi. “People who believe that subsidized health insurance may soon disappear could have a greater willingness to take advantage of this one time opportunity.”

MONEY Ask the Expert

What Happens If You Get Your Obamacare Subsidy Wrong

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Robert A. Di Ieso, Jr.

Q. What happens to someone who has overestimated his income and received the wrong subsidy amount for a marketplace plan? Does he get a tax refund when he files? What if he underestimated his income and was paid too much? Does the system catch it when he reapplies for coverage in 2015? Will he be prevented from renewing automatically?

A. If you received too small a subsidy because you overestimated your income, that amount will be added to your tax refund—if you’re receiving one—or it will reduce the amount of tax that you owe, says Timothy Jost, a law professor at Washington and Lee University and an expert on the health law.

Similarly, if your subsidy was too large because you underestimated your income, you may have to pay some or all of it back. If your income is more than 400% of the federal poverty level ($94,200 for a family of four that enrolled for 2014), you’ll owe the full amount of any subsidy overpayment. At lower incomes, the amount that must be repaid is capped.

How your 2015 subsidy will be handled when you renew your coverage this fall will vary. If you live in one of the states where the federal government runs the health insurance marketplace, you may be automatically enrolled in a 2015 plan and, unless you contact the marketplace to update your income and other details, your subsidy amount will remain the same next year. That’s probably not in your best interest, since changing marketplace policy details and changes in your own financial situation could mean you either may not receive the total amount you’re due or you’ll be on the hook to repay a too-generous subsidy. The system, however, won’t prevent someone from renewing next year, automatically or otherwise, because his subsidy amount was incorrect.

“The best thing to do is to get in touch with the exchange to make sure they have the most up-to-date information,” says Jost.

States that operate their own marketplaces may handle enrollment differently. Those states may, for example, require everyone pick a new plan and update their subsidy eligibility information instead of simply auto-enrolling them, says Judith Solomon, a vice president for tax policy at the Center on Budget and Policy Priorities.

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

MONEY Health Care

Why Your New Health Plan Might Not Cover Hospital Stays

Person in hospital bed
Companies that haven't offered health coverage before are the most likely candidates to roll out hospital-free plans now. Blend Images—Alamy

A debate is growing over whether an Obamacare calculator really lets some employers offer health insurance without hospital coverage. Is this a software glitch, or a giant loophole in the law?

Lance Shnider is confident Obamacare regulators knew exactly what they were doing when they created an online calculator that gives a green light to new employer coverage without hospital benefits.

“There’s not a glitch in this system,” said Shnider, president of Voluntary Benefits Agency, an Ohio firm working with some 100 employers to implement such plans. “This is the way the calculator was designed.”

Timothy Jost is pretty sure the whole thing was a mistake.

“There’s got to be a problem with the calculator,” said Jost, a law professor at Washington and Lee University and health-benefits authority. Letting employers avoid health-law penalties by offering plans without hospital benefits “is certainly not what Congress intended,” he said.

As companies prepare to offer medical coverage for 2015, debate has grown over government software that critics say can trap workers in inadequate plans while barring them from subsidies to buy fuller coverage on their own.

At the center of contention is the calculator — an online spreadsheet to certify whether plans meet the Affordable Care Act’s toughest standard for large employers, the “minimum value” test for adequate benefits.

The software is used by large, self-insured employers that pay their own medical claims but often outsource the plan design and administration. Offering a calculator-certified plan shields employers from penalties of up to $3,120 per worker next year.

Many insurance professionals were surprised to learn from a recent Kaiser Health News story that the calculator approves plans lacking hospital benefits and that numerous large, low-wage employers are considering them.

Although insurance sold to individuals and small businesses through the health law’s marketplaces is required to include expensive hospital benefits, plans from large, self-insured employers are not.

Many policy experts, however, believed it would be impossible for coverage without hospitalization to pass the minimum-value standard, which requires insurance to pay for at least 60% of the expected costs of a typical plan.

And because calculator-approved coverage at work bars people from buying subsidized policies in the marketplaces that do offer hospital benefits, consumer advocates see such plans as doubly flawed.

Kaiser Health News asked the Obama administration multiple times to respond to criticism that the calculator is inaccurate, but no one would comment.

Calculator-tested plans lacking hospital benefits can cost half the price of similar coverage that includes them.

While they don’t include inpatient care, the plans offer rich coverage of doctor visits, drugs and even emergency-room treatment with low out-of-pocket costs.

Who will offer such insurance? Large, well-paying employers that have traditionally covered hospitalization are likely to keep doing so, said industry representatives.

“My members all had high-quality plans before the ACA came into existence, and they have these plans for a reason, which is recruitment and retention,” said Gretchen Young, a senior vice president at the ERISA Industry Committee, which represents very large employers such as those in the Fortune 200. “And you’re not going to get very far with employees if you don’t cover hospitalization.”

But companies that haven’t offered substantial medical coverage in the past — and that will be penalized next year for the first time if they don’t meet health-law standards — are very interested, benefits advisors say.

They include retailers, hoteliers, restaurants and other businesses with high worker turnover and lower pay. Temporary staffing agencies are especially keen on calculator-tested plans with no hospital coverage.

“We’ve got many dozens of staffing-firm clients,” said Alden Bianchi, a benefits lawyer with Mintz Levin in Boston. “All of them are using these things.”

Advisors and brokers declined to identify employers sponsoring the plans, citing client confidentiality.

Benefits administrators offering the insurance say it makes sense not only for employers trying to comply with the law at low cost but for workers who typically have had little if any job-based health insurance.

“This is a stepping-stone to bring in employers who have never [offered] coverage and now they’re willing to come forward and do something,” said Bruce Flunker, president of Wisconsin-based EBSO, a benefits firm.

The plans are an upgrade for many workers at retailers, staffing agencies and similar companies, he said.

“OK, if I go to the hospital I don’t have coverage,” he said. “But I don’t have [hospital] coverage now. And what I get is a doctor. I can go to a specialist. I get a script filled at the pharmacy. I get real-life coverage.”

Companies considering such plans include a restaurant chain with 1,000 workers, a trucking firm with 500 employees and dependents, a delicatessen, a fur farm and firms working the oil boom in upper Midwest, Flunker said.

Employer interest in the plans “is definitely picking up pretty quickly,” said Kevin Schlotman, director of benefits at Benovation, an Ohio firm that designs and administers health coverage. “These are organizations that are facing a significant increase in expenses. They’re trying to do their best.”

Because hospital admissions are rare, plans paying for routine care are more valuable to low-wage workers than coverage of expensive surgery and other inpatient costs, say consultants offering them.

Such plans come with deductibles as low as zero for doctor visits and prescriptions and co-pays of only a few dollars, they say. Emergency-room visits cost members in the $250 or $400 range, depending on the plan.

By contrast, health-law-approved insurance with inpatient benefits often includes deductibles — what members pay for all kinds of care before the insurance kicks in — of $6,000 or more.

Generous coverage of routine care is “what these people want,” said Shnider. “They want to be able to go to the doctor. Take care of their kids, go to the emergency room.”

In some cases, employers sponsoring calculator-approved plans without hospital coverage also offer “fixed indemnity” coverage that does pay some hospital reimbursement, advisors say. But the benefits are typically a small fraction of hospital costs, leaving members with the likelihood of large bills if they are admitted.

Concerned for their reputations, larger administrators are wary of managing benefits without hospitalization, even if they do pass the calculator.

“Our self-funded customers hand out insurance cards to their employees with Blue Cross all over it,” said Michael Bertaut, health care economist at BlueCross BlueShield of Louisiana, which has no plans to handle such coverage. “Do we really want someone to present that card at a hospital and get turned away?”

There are two health-law coverage standards that large employers must meet to avoid paying a penalty.

One, for “minimum essential coverage,” merely requires some kind of employer medical plan, no matter how thin, with a potential penalty next year of up to $2,080 per worker. Many low-wage employers are meeting that target with “skinny” plans that cover preventive care and not much else, say brokers and consultants.

The calculator tests the health law’s second, more exacting standard — to offer a “minimum value” plan at affordable cost to workers. Failure to do so triggers the second penalty, of up to $3,120 per worker.

The argument over the calculator is whether plans carving out such a large chunk of benefits — hospitalization — can mathematically cover 60% of expected costs of a standard plan.

They probably can’t, Jost said. The fact that the calculator gives similar, passing scores to plans with hospital benefits and plans costing half as much without hospital benefits suggests that it’s flawed, he said. Plans with similar scores should have similar costs, he said.

On the other hand, others ask, why did the administration make a calculator that allows designers to leave out inpatient coverage? Why didn’t the law and regulations require hospital coverage for self-insured employers — as they do for commercial plans sold through online marketplaces?

“The law and calculator were purposely designed as they are!” Fred Hunt, past president of the Society of Professional Benefit Administrators, said in an email widely circulated among insurance pros. “No ‘glitch’ or unintended loophole.”

“That’s baloney,” said Robert Laszewski, a consultant to large insurers and a critic of the health law. “Nobody said we’re going to have health plans out there that don’t cover hospitalization. That was never the intention… I think they just screwed up.”

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

TIME Healthcare

Obamacare Hasn’t Saved Our Rural Clinic

Rural Uninsured Receive Medical Care In Southern Colorado Clinics
Medical assistant Elissa Ortivez draws an MMR vaccination at the Spanish Peaks Outreach Clinic on August 5, 2009 in Walsenburg, Colorado. The Spanish Peaks Regional Health Center treats rural Coloradans who come for medical care from throughout southern Colorado, where hospitals and clinics are scarce. John Moore—Getty Images

Frank Lang is a family nurse practitioner.

Cost-per-patient shouldn't be the only factor determining where we send help

Thirty-eight years ago, a young nurse practitioner moved his family from Denver to Downieville, California, the Sierra County seat, to volunteer for the National Health Service Corps.

On my first night in town, I was hooking up the television for my children and by sheer coincidence received a fragmented radio signal through the TV receiver from the sheriff’s office: There was an emergency, and they needed medical help. I found the sheriff’s office and was whisked to the crisis—a car resting precariously on an embankment 150 feet below the road, with an unconscious person inside. I was lowered down by a tow truck cable, then secured the vehicle and started the patient on an IV. He was lifted back up on a Stokes rescue litter and taken by ambulance to the nearest hospital—in Grass Valley, 50 miles away.

What had I gotten myself into?

When I arrived in Downieville—population 500—in 1976, there was virtually no consistent primary medical care or integrated emergency medical services response to trauma and medical emergencies. An emergency like the one I’d attended depended on well-intentioned citizens getting into cars and trying to help out. No one knew what a nurse practitioner was; I lacked any credibility except what I could demonstrate or do for the ill or injured.

Luckily, I loved what I was doing from the start, and my work became our family’s story.

The National Health Service Corps (NHSC), which places health professionals in rural communities, had sent me to Downieville to open a health clinic. NHSC would pay my salary and clinical expenses for a couple years, then the operation would be taken over by the community.

I started by building the clinic’s infrastructure: buying equipment, hiring staff, developing integrated referral processes to make it easy for patients to see specialists, and creating an emergency response system. Because of Downieville’s geographic isolation, the clinic staff needed to be able to treat a wide variety of illnesses and injuries. We took classes at the UC Davis School of Medicine to fill in gaps, and I got licensed through the state to do things like dispense medication in the absence of a local pharmacy.

After the NHSC placement and funding ended, I decided to stay on in Downieville. The California State Rural Health Association funded my salary, and I wrote grants to foundations and nonprofits to build up the facility, though we still operated on a month-to-month basis.

In 2007, our peak year, the clinic offered access to a nutritionist, physical therapy, and home care, and had substantial savings in the bank. But then the recession hit, our grants started to dry up, and state funding levels dropped.

Over the past few years, Downieville has been caught up in changes for funding health clinics. Federal and state priorities have shifted from rural and frontier areas to underserved, urban population areas. When you do the math, the cost-per-patient equation will always come out in favor of a clinic in an urban area. As a result, a rural clinic must rely on the support of a larger, population-focused clinic.

In 2010, the number of patients we were seeing yearly decreased from 4-4,500 to 3-3,500, and we joined forces with a clinic in Grass Valley that sees 17,000 patients per year. Originally, the Downieville clinic was guaranteed continuing support for our 24 hour, 7 days per week medical care. But nutrition, physical therapy, and dental services were all cut. Behavioral health services are now accessed via telemedicine.

On October 1, Downieville’s medical care is scheduled to be reduced to three days per week. The integrated frontier healthcare delivery system I built over decades is being systematically dismantled; I worry that a patient will come into the clinic one day and be greeted by nothing more than an iPad.

The clinic is going to join forces with other community partners to develop an integrated 24 hour a day, seven days a week paramedic and clinic system. It won’t be ideal, but it is sustainable. And it will probably be paid for by the people it serves—with support from a western Sierra County health services fee for all landowners, increased user fees for community events, and higher ambulance fees.

Now, under the Affordable Care Act, everybody has insurance. Theoretically, this means people should have more access to healthcare. But that’s not true in Downieville. More insurance won’t help people if healthcare treatments are inconsistent or unavailable.

One of the changes expected to take place in this new healthcare landscape is more reimbursement for clinics. But such reimbursement is based on the number of people served. There are not enough patient encounters in frontier areas like ours to be sustainable without grant or government funding.

Frank Lang is a family nurse practitioner. He has a master’s degree from the University of Colorado School of Nursing and is a graduate of the University of California Davis School of Medicine Family Nurse Practitioner Program. He wrote this for Zocalo Public Square.

TIME Ideas hosts the world's leading voices, providing commentary and expertise on the most compelling events in news, society, and culture. We welcome outside contributions. To submit a piece, email ideas@time.com.

MONEY Health Care

Early Analysis Finds a Drop in Obamacare Premiums Next Year

A first look at policies sold on the online exchanges shows a small decline in the average cost of coverage for 2015. But consumers should still shop for health insurance with care.

In preliminary but encouraging news for consumers and taxpayers, insurance filings show that average premiums will decline slightly next year in 16 major cities for a benchmark Obamacare plan.

Prices for a benchmark “silver” or mid-priced plan sold through the health law’s online marketplaces aren’t all moving in the same direction, however, a report from the Kaiser Family Foundation (KFF) shows. (Kaiser Health News is an editorially independent program of the foundation.) In Nashville, the premium will rise 8.7%, the largest increase in the study, while in Denver it will fall 15.6%, the largest decrease.

But overall the results, based on available filings, don’t show the double-digit percentage increases that some have anticipated for the second year of marketplace operation. On average, rates will drop 0.8% in the areas studied.

“If you’re the government, this is great news,” said Larry Levitt, KFF senior vice president. “Competition in the marketplaces is helping drive down the cost of the tax credit” that subsidizes coverage for lower-income consumers.

That’s because the credits are based on the cost of the second least-expensive silver plan, known as the benchmark plan. That’s the one KFF studied. The lower the benchmark-plan rates, the lower the cost to taxpayers.

For consumers, the picture is also promising—but more complicated.

The main message: shop around, says Levitt.

The fact that average premiums in selected cities are declining doesn’t mean your rates will fall. Premiums may vary significantly within states. Premiums for plans with different benefit levels—higher platinum and gold and lower bronze—may behave differently than prices for silver plans. And just because your policy was the least expensive in your area for 2014 doesn’t mean it will stay that way for 2015.

Bottom line: There is increased competition as more insurers enter the marketplaces and tune prices to attract customers. But you may need to switch plans to take advantage of that.

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

MONEY Health Care

Why Health Care Spending Is Going Up—But Not Skyrocketing

A stronger economy and more insured Americans should help push up health care spending in the coming years, according to a new government report. But don't expect a return to the high pre-recession growth rates soon.

National health spending will increase modestly over the next decade, propelled in part by the gradual rebound of the U.S. economy and the growing ranks of Americans who became insured under the health law, government actuaries projected Wednesday.

But those growth rates are not as high as what the country saw for the two decades before the Great Recession crippled the U.S. economy at the end of 2007, according to the report from the Centers for Medicare & Medicaid Services Office of the Actuary and published in the journal Health Affairs.

The actuaries estimate that health spending grew just 3.6% in 2013, the fifth year of historically low rates of spending growth. But it will accelerate to 5.6% in 2014. They also forecast that the average growth rate for 2015-2023 would be 6%. That is up just slightly from last year.

The findings also suggest that health care will outpace growth in the gross domestic product over the next decade. Health care’s share of GDP, which has remained fairly stable since 2009, will rise from 17% in 2012 to more than 19% in 2023.

While some health care analysts and Obama administration officials have said the Affordable Care Act is reducing costs, CMS actuaries are no longer measuring the effects of the law on health care spending.

“We are no longer quantifying the impacts of the Affordable Care Act on national health spending,” Andrea M. Sisko, the lead author on the study, told reporters at a briefing on the findings. “Now that the Affordable Care Act has been in place for well over four years, it is becoming increasingly difficult to accurately estimate … what the world would look like in the absence” of the law.

Sisko also said it is too soon to estimate the impact of the health law’s delivery system changes on the nation’s health care system.

Paul Ginsburg, a public policy professor at the Schaeffer Center for Health Policy and Economics at the University of Southern California, said the report illustrates that “the recession and the very slow recovery from the recession are important determinants of health spending trends …. There’s a been a lot of debate over the past year or two about how much of the slowdown we’ve experienced has been from the business or the economic cycle and how much is due to real changes in health care. My sense is it’s both. This very steep recession and this very slow recovery from it, especially when you look at the very low growth in wages, is something that has definitely depressed health care spending. The implication of higher deductibles, of greater cost sharing, that’s important as well.”

Better economic conditions, the aging of the baby boomer generation into Medicare and increased number of people with insurance are expected to result in greater demand for health care goods and services, increases in health coverage and faster rates of spending growth, in particular for private health insurance, the researchers said.

Those trends, the researchers said, will be countered by somewhat slower growth in Medicare payment rates mandated by the health law, cuts made to hospitals and doctors in the congressional budget-cutting efforts and the increasing use of higher deductibles in private insurance plans that have cut down on consumer health spending.

The number of uninsured people is projected to fall from about 45 million in 2012 to 23 million by 2023, according to CMS actuaries.

Other key takeaways from the CMS report include:

– Medicare spending growth slowed from 4.8% in 2012 to 3.3% in 2013. That was caused by the automatic 2% payment cuts known as sequestration and other payment adjustments, especially reductions in federal payments to the private Medicare Advantage plans that offer an alternative to traditional Medicare. Late last month, the Congressional Budget Office estimated that lower costs for medical services and labor will help reduce both Medicare and Medicaid spending over the next decade.

Continued movement of baby boomers into the program and more spending on older beneficiaries will cause Medicare expenditures to rise 7.9% in 2020, according to the CMS report.

– Medicaid’s growth rate is expected to rise from 3.3% in 2012 to 6.7% in 2013, reflecting the health law’s Medicaid expansion—which is optional for states—and the effect of the law’s temporary payment increase for primary care physicians, among other factors. The researchers forecast that Medicaid spending will spike nearly 13% in 2014 but the growth rate will fall back to 6.7% the following year.

– In 2014, private health insurance premiums are projected to grow 6.8%, largely a result of higher per-enrollee spending and increased insurance coverage through the health law’s online marketplaces, or exchanges, and individually purchased insurance. For 2016-23, average premium growth for private health insurance is projected to be 5.4% per year.

– For 2016-2023, faster increases in disposable personal income and greater enrollment in private health insurance will contribute to the projected 6.1% spending growth per year for health care services, faster than the 4.7% average growth expected for 2013-15. But those conditions are likely to change, researchers warned.

“Consistent with the historical relationship between health spending and economic cycles, these projected changes in the economy are expected to influence health expenditure growth with a lag,” resulting in a projected peak growth in health spending of 6.6% in 2020, CMS said.

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

MONEY Health Care

Why a Trip to the ER Could Cost You More Than You Expect

If a holiday weekend mishap sends you to the emergency room, watch your wallet. You shouldn't owe more if the hospital is outside your insurance network. But that could change if you're admitted.

When you need emergency care, chances are you aren’t going to pause to figure out whether the nearest hospital is in your health insurer’s network. Nor should you. That’s why the health law prohibits insurers from charging higher copayments or coinsurance for out-of-network emergency care. The law also prohibits plans from requiring pre-approval to visit an emergency department that is out of your provider network. (Plans that are grandfathered under the law don’t have to abide by these provisions.)

That’s all well and good. But there are some potential trouble spots that could leave you on the hook for substantially higher charges than you might expect.

Although the law protects patients from higher out-of-network cost sharing in the emergency room, if they’re admitted to the hospital, patients may owe out-of-network rates for the hospital stay, says Angela Gardner, an associate professor of emergency medicine at the University of Texas Southwestern in Dallas who is the former president of the American College of Emergency Physicians.

“Even if the admission is warranted, you are subject to those charges,” she says.

If you live in a state that permits balance billing by out-of-network providers, your financial exposure could be even greater. In a balance-billing situation, a hospital may try to collect from the patient the difference between what the hospital billed and what the health plan paid for care. Such practices aren’t generally allowed if a consumer visits an in-network provider.

Consumers shouldn’t expect that the hospital will inform them of potential out-of-network coverage issues, so they need to inquire, says Gardner.

“At least being informed and knowing what you’re getting into can set you up to handle it with your insurer,” she says.

And while you’re at it check into being transferred to an in-network facility if it’s feasible.

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

MONEY Health Care

How Some Insurers Still Avoid Covering Contraception

Locked up birth control pills
Nicholas Eveleigh—Getty Images

Under health reform, your birth control should be fully paid for by insurance. But even before the Supreme Court gave more employers an out, some insurers have been pushing back.

How much leeway do employers and insurers have in deciding whether they’ll cover contraceptives without charge and in determining which methods make the cut?

Not much, as it turns out, but that hasn’t stopped some from trying.

Kaiser Health News readers still write in regularly describing battles they’re waging to get the birth control coverage they’re entitled to.

In one of those messages recently, a woman said her insurer denied free coverage for the NuvaRing. This small plastic device, which is inserted into the vagina, works for three weeks at a time by releasing hormones similar to those used by birth control pills. She said her insurer told her she would be responsible for her contraceptive expenses unless she chooses an oral generic birth control pill. The NuvaRing costs between $15 and $80 a month, according to Planned Parenthood.

Under the health law, health plans have to cover the full range of FDA-approved birth control methods without any cost sharing by women, unless the plan falls into a limited number of categories that are excluded, either because it’s grandfathered under the law or it’s for is a religious employer or house of worship. Following the recent Supreme Court decision in the Hobby Lobby case, some private employers that have religious objections to providing birth control coverage as a free preventive benefit will also be excused from the requirement.

In addition, the federal government has given plans some flexibility by allowing them to use “reasonable medical management techniques” to keep their costs under control. So if there is both a generic and a brand-name version of a birth-control pill available, for example, a plan could decide to cover only the generic version without cost to the patient.

As for the NuvaRing, even though they may use the same hormones, the pill and the ring are different methods of birth control. As an official from the federal Department of Health and Human Services said in an email, “The pill, the ring and the patch are different types of hormonal methods … It is not permissible to cover only the pill, but not the ring or the patch.”

Guidance from the federal government clearly states that the full range of FDA-approved methods of birth control must be covered as a preventive benefit without cost sharing. That includes birth control pills, the ring or patch, intrauterine devices and sterilization, among others.

But despite federal guidance, “we’ve seen this happen, plenty,” says Adam Sonfield, a senior public policy associate at the Guttmacher Institute, a reproductive health research and education organization. “Clearly insurance companies think things are ambiguous enough that they can get away with it.”

If you are denied coverage, your defense is to appeal the decision, and get your state insurance department involved.

“The state has the right and responsibility to enforce this law,” says Sonfield.

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

More on the Affordable Care Act and contraception coverage:

 

 

 

 

 

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