TIME 2014 Election

Voters Say Events in U.S. ‘Out of Control’

Poll finds anxiety on a range of issues, from Ebola to health care costs

Call it the Freakout Election.

Two-thirds of likely voters in the most competitive states and congressional districts in the midterm election fight think events in the U.S. are “out of control,” according to a new poll. The survey by Politico found widespread anxiety about the Ebola outbreak, terrorism, health care costs and President Barack Obama’s leadership. Only 36% think the U.S. is “in a good position to meet its economic and national security” challenges.

The poll underscores how both Obama’s low approval ratings and a general sense of disarray are weighing down Democrats just weeks before voters go to the polls to decide which party will control the Senate. A majority of voters, 54%, either strongly disapprove or somewhat disapprove of Obama’s job performance.

Read more at Politico

MONEY Medicare

Some Medicare Advantage Plans Have Hidden Risks—Here’s How to Avoid Them

hands using measuring tape
Nils Kahle

Although they promise quality care at lower cost, some Medicare Advantage plans fall short. Before you enroll, here are key questions to ask.

Seniors have flocked to Medicare Advantage in recent years, attracted by savings on premiums and the convenience of one-stop shopping. But as the annual Medicare enrollment season began this week, a memorandum from federal officials to plan providers surfaced that serves as a big red warning flag.

The upshot: Assess the quality of any Advantage plan before you sign up.

The memorandum, first reported by the New York Times, described ongoing compliance problems uncovered in federal audits of Advantage and prescription drug plans. These include inadequate rationales for denial of coverage, failure to consider clinical information from doctors and failure to notify patients of their rights to appeal decisions. The audits also uncovered problems with inappropriate rejection of prescription drug claims.

Advantage is a managed care alternative to traditional fee-for-service Medicare. It rolls together coverage for hospitalization, outpatient services and, usually, prescription drugs. Advantage plans also cap your out-of-pocket expenses, making Medigap supplemental plans unnecessary.

The savings can be substantial. Medigap plan premiums can cost $200 monthly or more, and stand-alone drug plans will average $39 a month next year. Enrollees have been voting with their wallets: 30% are in Advantage plans this year, up from 13% in 2005, according to the Henry J. Kaiser Family Foundation.

Advantage plans are subject to strict rules and regulations, and must cover all services offered in original Medicare, with the exception of hospice services. Some offer extra coverage, such as vision, hearing, dental and wellness programs.

And there is evidence that the quality of these plans is rising. Medicare uses a five-star rating system to grade plan quality, and plans can earn bonus payments based on their ratings. Average enrollment-weighted star ratings increased to 3.92 for 2015, from 3.86 in 2013 and 3.71 in 2013, according to Avalere Health, an industry research and consulting firm. Avalere projects that 60% of Advantage enrollment will be in four- or five-star plans next year, up from 52% this year.

But the Medicare memorandum focuses on problems outside the rating system. “It’s about basic blocking and tackling and whether a plan adheres to the program’s technical specs,” says Dan Mendelson, Avalere’s chief executive officer. “These are the basic functions that every plan should be able to handle.”

Nevertheless, consumer advocates say they deal with these compliance problems regularly, and more often with enrollees in Advantage than in traditional Medicare.

“The most typical problems have to do with plans that are making it difficult or impossible for people to get their medications,” says Jocelyn Watrous, an advocate for patients at the Center for Medicare Advocacy. “They impose prior authorizations or other utilization management rules that they make up out of whole cloth.”

Consumer advocates urge Medicare enrollees to restrict their shopping this fall to four- and five-rated plans, of which plenty are available in most parts of the country. “If a plan consistently gets four or five stars, all other things being equal it will be a high performer,” says Joe Baker, president of the Medicare Rights Center.

Few Medicare enrollees roll up their sleeves to shop, however. A study by Kaiser found that, on average, just 13% of enrollees voluntarily switched their Advantage or drug plans over four recent enrollment periods. And focus groups with seniors conducted by the foundation last May found that few pay attention to the star ratings.

“Seniors said they don’t use the ratings because they don’t feel they reflect their experiences with plans,” said Gretchen Jacobson, associate director of the foundation’s Medicare program. “Even when we told them that their plan only has two stars, many just wanted to stay in that plan.”

Advocates say the star ratings are just a starting point for smart shoppers.

They say you should check to make sure health providers you want to see are in a plan’s network. You should also consider how you would react if any of those providers disappeared during the 12 months that you are locked into the plan. Advantage plans can—and do—drop providers. UnitedHealth Group, the industry’s largest player, made headlines last year when it dropped thousands of doctors in 10 states. Advantage plans in Florida, Pennsylvania, California and Delaware also terminated provider relationships.

Also be sure to examine the prescription drug “formularies” in your plan—the rules under which your medications are covered. And talk with your doctors about any plan you are considering, especially if you see specialists for a chronic condition.

The Medicare memorandum to plans also underscores the importance of appealing denied claims, Baker says. “Appeal, appeal, appeal—it’s like ‘location, location, location’ in real estate.”

TIME Health Care

The Price of Staying Alive For the Next 3 Hours

Stayin' alive—and cheap at the price
Stayin' alive—and cheap at the price ZU_09; Getty Images

A new study suggests a little spending now can buy you a lot of time later

How much do you reckon you’d pay not to be dead three hours from now? That probably depends. If you’re 25 and healthy, a whole lot. If you’re 95 and sickly, maybe not so much. But for people in one part of the world—the former East Germany—the cost has been figured out, and it’s surprisingly cheap: three hours of life will set you back (or your government, really) just one euro, or a little below a buck-thirty at current exchange rates.

That’s the conclusion of a new study out of Germany’s Max Planck Institute, and it says a lot about the power of a little bit of money now to save a lot of suffering later—with implications for all manner of public health challenges, including the current Ebola crisis.

The new findings are a result of one of the greatest, real-time longitudinal studies ever conducted, one that began the moment the Berlin Wall fell, on Nov. 9 1989. Before that year, there were two Germanys not just politically, but epidemiologically. Life expectancy in the western half of the country was 76 years; in the poorer, sicker east, it was 73.5. But after unification began, social spending in the East began rising, from the equivalent of €2,100 per person per year to €5,100 by the year 2000. In that same period, the difference in lifespan across the old divide went in the opposite direction, shrinking from 2.5 years to just one year as the east Germans gained more time. Crunch those numbers and you get the three extra hours of extra life per person per euro per year.

“Without the pension payments of citizens in east and west converging to equivalent levels,” said Max Planck demographer Tobias Vogt in a statement, “the gap in life expectancy could not have been closed.” Increased public spending, Vogt adds, is often framed as an unfortunate knock-on effect of longer life. “But in contrast,” he says, “our analysis shows that public spending can also be seen as an investment in longer life.”

The idea that generous, tactical spending now can be both a money-saver and lifesaver is one that health policy experts tirelessly make—and that people in charge of approving the budgets too often ignore. Bill Gates often makes the point that $1 billion spent to eradicate polio over the next few years will save $50 billion over the next 20 years, not just because there will no longer be any cases of the disease to treat, but because the global vaccination programs which are necessary just to contain the virus can be stopped altogether when that virus is no more.

As TIME reported in September, British inventor Marc Koska made a splash at the TEDMed conference in Washington DC when he unveiled his K1 syringe—an auto-destruct needle that locks after it’s used just once and breaks if too much force is used to pull the plunger back out. That prevents needle re-use—and that in turn not only reduces blood-borne pathogens from being spread, it does so at a saving. According to the World Health Organization (WHO), $1 spent on K1 syringes saves $14.57 in health care costs down the line—or $280 for a $20 order of the shots.

All across the health care spectrum, such leveraging is possible. Critics of the Affordable Care Act have slammed the law for the cost of the preventative services it provides, and while it’s way too early to determine exactly how successful the law will be, the encouraging stabilization in the growth of health costs suggests that something, at least, is working.

Global health officials are making a similar, though more urgent, preventative argument concerning the Ebola epidemic in West Africa. Americans are rightly jumpy over the few cases that have landed on our shores, but the 1,000 new infections per week that are occurring in the hot-spot nations of Liberia, Guinea and Sierra Leone make our concerns look small. Frighteningly, according to the WHO’s newest projections, that figure will explode to 10,000 cases per week by December if the resources are not deployed to contain the epidemic fast.

“We either stop Ebola now,” WHO’s Anthony Banbury said in a stark presentation to the U.N. Security Council on Sept. 14, “or we face an entirely unprecedented situation for which we do not have a plan.”

Suiting up and wading into the Ebola infection zone is a decidedly bigger and scarier deal than spending an extra euro on public health or an extra dollar for a new syringe. But the larger idea of intervention today preventing far larger suffering tomorrow remains one of medicine’s enduring truths. We lose sight of it at our peril.

TIME health

How Lessons From the AIDS Crisis Can Help Us Beat Ebola

Health officials counsel guests on the p
Health officials counsel guests on the prevention of HIV/AIDS transmission at the Argungu fishing festival in Kebbi State, northwestern Nigeria on March 13, 2008. Hundreds of fishermen from different parts of Nigeria and neighbouring West African countries have started arriving in Argungu fishing Town to participate in the fishing festival. AFP PHOTO / PIUS UTOMI EKPEI (Photo credit should read PIUS UTOMI EKPEI/AFP/Getty Images) PIUS UTOMI EKPEI—AFP/Getty Images

Ruth Katz is the director of the Health, Medicine and Society program at the Aspen Institute, a nonpartisan educational and policy studies institute based in Washington, D.C.

For too long, the history of infectious diseases has been that of ignoring a threat until it nears disaster

Without urgent action, Ebola could become “the world’s next AIDS,” said Thomas Frieden, director of the U.S. Centers for Disease Control and Prevention (CDC). HIV/AIDS has killed some 36 million people since the epidemic began, and another 35 million are living with the virus. Is history really about to repeat itself?

It doesn’t have to, if we have the wisdom to learn from past experiences. The tools we need immediately are swift international action, strong leadership, respect for science and broad-based compassion. But once we contain Ebola – and we will – we need new resource commitments and global health strategies to bring the next deadly epidemic under control much more quickly.

We’ve already done some things right. President Obama traveled to CDC headquarters in Atlanta, a rare presidential action, to detail an aggressive offensive against Ebola that includes sending troops and supplies to build health care facilities in Africa. Contrast that with the response to AIDS under President Reagan, who did not mention the epidemic publicly until 1987, six years after people started dying from it. This time around, we’re seeing leadership at the top.

Health officials have also put out a unified message about how Ebola can be transmitted – only through direct contact with bodily fluids. That, too, stands in welcome contrast with HIV, where irresponsible rumors quickly took hold and people worried about sharing toilets seats and touching doorknobs. The importance of educating health care workers and keeping them safe represents a commonality between Ebola and HIV, and must be among our highest priorities. Following the science is the only way we’re going to stop this thing.

Another lesson from HIV is that adequate resources can transform disease outcomes. The President’s Emergency Plan for AIDS Relief (PEPFAR), a $15 billion, five-year commitment under President George W. Bush saved millions of lives around the world. But by contrast, even though the CDC is attacking Ebola with the largest global response in its history, the effort doesn’t come close to having the budget necessary to do all the field work needed to really beat back Ebola. Bipartisan funding support is crucial to enable public health officials to act aggressively.

One lesson that has not been well learned is that we stigmatize people at our own peril. During the AIDS epidemic, we saw an American teenager, Ryan White, expelled from school after he contracted HIV through a blood transfusion. In Dallas, where the first known Ebola victim in the U.S. has died, we hear reports that people of African origin have been turned away from restaurants and parents are pulling their children out of school. Cries to ban flights from Ebola-affected countries — an ineffective strategy reminiscent of the 22-year ban on the entry of HIV-positive people into the U.S. — are growing louder.

Experience tells us that when we are driven by fear, we tend to push infected people underground, further from the reach of the health-care system and perhaps closer to harming others. There was a time when many people assumed every gay man could spread AIDS; now some are suspicious that anyone from West Africa could harbor a deadly virus. Acting on ignorance is the best way to disrupt an optimal public health response.

We should look to other infectious diseases for lessons as well. After severe acute respiratory syndrome (SARS) surfaced in China in 2002 and spread to more than 30 countries in just a few months, an aggressive, well-coordinated global response averted a potential catastrophe. We saw how much could be done when political and cultural differences were set aside in favor of cooperation. SARS also spurred the World Health Organization (WHO) to update its International Health Regulations for the first time in 35 years, and prompted many countries to strengthen their surveillance and response infrastructure, including establishing new national public health agencies.

But glaring gaps remain in the health care and public health systems of many nations, despite years of warnings from almost anyone who has taken a careful look at them. With a population of 4 million, Liberia has only 250 doctors left in the country. That’s more than just Liberia’s problem, because if we can’t contain the Ebola epidemic there, we’re at much higher risk here. And within our own borders, we have a public health system that the Institute of Medicine termed “neglected” back in 2002. That assessment was largely unchanged a decade later when the IOM said that “public health is not funded commensurate with its mission” in the U.S.

The international community dragged its feet far too long on Ebola, and as a result, the virus still has the upper hand, outpacing the steps finally being taken to defeat it. Sierra Leone has just 304 beds for Ebola patients and needs almost 1,500 right now; by next week, it will need more. When it comes to control and prevention, speed is paramount. With the epidemic doubling every three weeks, the actions we take today will have a much greater impact than if we take those actions a month from now.

When we finally subdue this epidemic, we also need to shed our complacency towards the infectious diseases that plague us still, and the new ones likely to arrive with little warning. In a globalized world, they remain an immense threat. Almost 50,000 new HIV infections occur in the United States every year, as do 2 million worldwide. Influenza kills thousands of people annually, and more virulent strains can be much more dire. Yet we shrug most of this off, rarely paying attention until blaring headlines announce an impending cataclysm.

To get ahead of the curve, we need a renewed commitment to research and action, and enough resources to put more public health boots on the ground, both at home and abroad. Greater support for the Global Health Security Agenda, designed to close gaps in the world’s ability to quell infectious disease, should be a priority. The agenda, launched earlier this year, is a partnership involving the U.S. government, WHO, other international agencies and some 30 partner countries.

For too long, the history of infectious diseases has been that of ignoring a threat until it nears disaster, and then stepping in to prevent it from getting even worse. We can’t afford to keep repeating that pattern, and squandering blood and treasure in the process.

Ebola is a humanitarian crisis, but it does not belong to West Africa alone. We are all in this together.

 

aspen journal logo

Ruth Katz is the director of the Health, Medicine and Society program at the Aspen Institute, a nonpartisan educational and policy studies institute based in Washington, DC. She served from 2009 to 2013 as Chief Public Health Counsel with the Committee on Energy and Commerce in the U.S. House of Representatives. Ms. Katz was the lead Democratic committee staff on the public health components of the health reform initiative passed by the House of Representatives in November 2009. Prior to her work with the Committee, Ms. Katz was the Walter G. Ross Professor of Health Policy of the School of Public Health and Health Services at The George Washington University. She served as the dean of the school from 2003 to 2008. This article also appears in the Aspen Journal of ideas.

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.

TIME ebola

CDC to Send Dallas Healthcare Worker Infected with Ebola to Special Hospital

CDC Atlanta Ebola
Exterior of the Center for Disease Control (CDC) headquarters in Atlanta on Oct. 13, 2014. Jessica McGowan—Getty Images

Officials are weighing the possibility in the wake of failures in Dallas, but there is only room for 19 patients

Thomas Eric Duncan, the first Ebola case diagnosed in the U.S., was a warning to hospitals that a patient infected with the deadly virus could walk into their emergency room at any time. Hospitals from New York City to Seattle are now running Ebola drills, testing their staffs to ensure they are prepared to diagnose the disease without putting healthcare workers at risk of contracting it.

“Every hospital in the country needs to be ready to diagnose Ebola,” Dr. Thomas Frieden, the director of the Centers for Disease Control and Prevention (CDC), said at a news conference on Tuesday.

The question is whether every hospital is equipped to care for a patient who tests positive for the disease, which has killed nearly 4,500 people in West Africa. During this outbreak, the most deadly since the disease was first discovered in 1976, the mortality rate is about 70%, according to statistics compiled by the World Health Organization. Health care workers are at particular risk for infection, which is transmitted through contact with a symptomatic patient’s bodily fluids, like blood or vomit.

Those risks have been born out in Texas Health Presbyterian Hospital in Dallas, where Duncan was admitted on Sept. 28 and died on Oct. 8. Early Wednesday, the hospital said a second healthcare worker who administered care to Duncan had tested positive for the disease. The hospital’s stumbles have prompted critics to question whether the additional infections were avoidable—and whether future patients should be cared for at specialized hospitals with the expertise and facilities to treat Ebola cases.

Frieden said Tuesday that the second healthcare worker would be transported to Emory University Hospital in Atlanta, which has a specialized isolation unit for treating diseases like Ebola and has successfully cared for patients with the virus in the past.

Some doctors say moving future Ebola patients to specialized hospitals makes sense. “Given some of the complexities, patients who have this disease are probably best cared for by those who have experience caring for it, and whose healthcare workers are highly trained and drilled in self-protection,” says Dr. Gabe Kelen, the director of the Johns Hopkins Office of Critical Event Preparedness and Response. “It’s not appropriate to think that each and every hospital in the country could bring the resources, the intense training for the healthcare workers that is required.”

There are four hospitals in the U.S. with special isolation units designed to contain biohazards like Ebola. In addition to Emory, they are the National Institutes of Health Clinical Center, in Bethesda, Md., a hospital at the University of Nebraska in Omaha and St. Patrick Hospital in Missoula, Mt. The facilities in Atlanta and Omaha have successfully treated Americans infected with Ebola overseas without any healthcare workers contracting the virus.

Though transporting future cases to these facilities may be prudent, they have limited beds: only 19 between them, according to CNN. Exclusively using specialized hospitals to treat Ebola is only an option so long as the number of cases in the U.S. remains extremely low.

A CDC spokesman said the agency may announce further measures for Ebola on Wednesday.

-Additional reporting by Zeke J. Miller

TIME justice

Supreme Court Halts Some Texas Abortion Restrictions

A group from Texas display their flags during a rally on the Mall for the March for Life anti-abortion demonstration on Jan. 22, 2014.
A group from Texas display their flags during a rally on the Mall for the March for Life anti-abortion demonstration on Jan. 22, 2014. Tom Williams—Roll Call/Getty Images

Justices suspended key parts of a law that has closed all but eight facilities providing abortions in the Lone Star state

The Supreme Court on Tuesday blocked key parts of a 2013 law in Texas that had closed all but eight facilities providing abortions in America’s second most-populous state.

In an unsigned order, the justices sided with abortion rights advocates and health care providers in suspending an Oct. 2 ruling by a panel of the New Orleans-based U.S. 5th Circuit Court of Appeals that Texas could immediately apply a rule making abortion clinics statewide spend millions of dollars on hospital-level upgrades.

The court also put on hold a separate provision of the law only as it applies to clinics in McAllen and El Paso that requires doctors at the facilities to have admitting privileges at nearby hospitals. The admitting privileges remains in effect elsewhere in Texas.

Justices Samuel Alito, Antonin Scalia and Clarence Thomas said they would have ruled against the clinics in all respects.

The 5th Circuit is still considering the overall constitutionality of the sweeping measure overwhelmingly passed by the GOP-controlled Texas Legislature and signed into law by Gov. Rick Perry last year.

But even as it weighs the merits of the law, the appeals court said that it can be enforced in the meantime — opening the door for the emergency appeal to the Supreme Court.

The 5th Circuit decision had blocked an August ruling by Austin-based U.S. District Judge Lee Yeakel, who had found that requiring hospital-style upgrades was less about safety than making access to abortion difficult. Yeakel’s ruling temporarily suspended the upgrade rules before they could go into effect Sept. 1 — and the order from the Supreme Court means they are on hold again.

Allowing the rules on hospital-level upgrades to be enforced — including mandatory operating rooms and air filtration systems — shuttered more than a dozen clinics across Texas.

Until the nation’s highest court intervened, only abortion facilities in the Houston, Austin, San Antonio and the Dallas-Fort Worth areas remained open. And none was left along the Texas-Mexico border or outside any of the state’s largest urban areas.

Some other clinics, meanwhile, had closed even earlier amid enforcement of the rule on admitting privileges at nearby hospitals. That portion has already been upheld twice by the appeals court.

The fight over the Texas law is the latest over tough new abortion restrictions that have been enacted across the country. The office of Texas Attorney General Greg Abbott, a Republican who is the favorite in next month’s governor’s race, is leading the defense of the law.

Critics call the measure a backdoor effort to outlaw abortions.

Attorneys for the state have denied that Texas women would be burdened by fewer abortion facilities, saying nearly 9 in 10 would still live within 150 miles of a provider. The law’s opponents, however, note that still leaves nearly a million Texas women embarking on drives longer than three hours to get an abortion.

Democrat Wendy Davis launched her campaign for governor behind the celebrity she achieved through a nearly 13-hour filibuster last summer that temporarily blocked the law in the state Senate.Justices stop parts of Texas abortion law

MONEY health insurance

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

141014_FF_OPENENROLLMENT
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 Health Care

Terminally Ill Woman Explains Her Decision to Die

"I don't want to die"

A 29-year-old terminally-ill woman in Oregon defended in a new interview Tuesday her decision to forgo aggressive cancer treatment in favor of physician-assisted suicide.

“I don’t want to die,” Brittany Maynard said on CBS.”If anyone wants to hand me, like, a magical cure and save my life so that I can have children with my husband, you know, I will take them up on it.”

In the interview, Maynard’s husband and mother explain how they came to terms with Brittany’s decision.

“The idea of wanting my wife at my side forever—that was the original plan, right?” said Dan Diaz, Maynard’s husband “But the reality that I guess that feeds into the argument of quality of life versus just quantity.”

Maynard said her goal is to make it to Nov. 1 before allowing herself to die. She moved to Oregon because it allows certain types of physician assisted-suicide.

[CBS]

MONEY Health Care

The Price of Health Care Is Finally Public (in One State)

Massachusetts General Hospital, Boston, Massachusetts
Massachusetts General Hospital in Boston Michael Dwyer—Alamy

This month Massachusetts rolled out total medical price transparency. What can you learn from these new shopping tools?

Without much fanfare, Massachusetts launched a new era of health care shopping last week.

Anyone with private health insurance in the state can now go to his or her health insurer’s website and find the price of everything from an office visit to an MRI to a Cesarean section. For the first time, health care prices are public.

It’s a seismic event. Ten years ago, I filed Freedom of Information Act requests to get cost information in Massachusetts—nothing. Occasionally over the years, I’d receive manila envelopes with no return address, or secure .zip files with pricing spreadsheets from one hospital or another.

Then two years ago, Massachusetts passed a law that pushed health insurers and hospitals to start making this once-vigorously guarded information more public. Now as of Oct. 1, Massachusetts is the first state to require that insurers offer real-time prices by provider in consumer-friendly formats.

“This is a very big deal,” said Undersecretary for Consumer Affairs and Business Regulation Barbara Anthony. “Let the light shine in on health care prices.”

There are caveats.

1. Prices are not standard, they vary from one insurer and provider to the next. I shopped for a bone density test. The low price was $16 at Tufts Health Plan, $87 on the Harvard-Pilgrim Health Care site and $190 at Blue Cross Blue Shield of Massachusetts. Why? Insurers negotiate their own rates with physicians and hospitals, and these vary too. Some of the prices include all charges related to your test, others don’t (see No. 2).

2. Posted prices may or may not include all charges, for example the cost of reading a test or a facility fee. Each insurer is defining “price” as it sees fit. Read the fine print.

3. Prices seem to change frequently. The first time I shopped for a bone density test at Blue Cross, the low price was $120. Five days later it had gone up to $190.

4. There is no standard list of priced tests and procedures. I found the price of an MRI for the upper back through Harvard Pilgrim’s Now iKnow tool. That test is “not found” through the Blue Cross “Find a Doc” tool.

5. Information about the quality of care is weak. Most of what you’ll see are patient satisfaction scores. There is little hard data about where you’ll get better care. This is not necessarily the insurer’s fault, because the data simply doesn’t exist for many tests.

6. There are very few prices for inpatient care, such as a surgery or an illness that would keep you in the hospital overnight. Most of the prices you’ll find are for outpatient care.

These tools are not perfect, but they are unlike anything else in the country. While a few states are moving toward more health care price transparency, none have gone as far as Massachusetts to make the information accessible to consumers. Tufts Health Plan Director of Commercial Product Strategy Athelstan Bellerand said the new tools “are a major step in the right direction.” Bellerand added: “They will help patients become more informed consumers of health care.”

Patients can finally have a sense of how much a test or procedure will cost in advance. They can see that some doctors and hospitals are a lot more expensive than others. For me, a bone density test would cost $190 at Harvard Vanguard and $445 at Brigham and Women’s Hospital.

The most frequent early users of the newly disclosed data are probably providers. Anthony says some of the more expensive physicians and hospitals react with, “I don’t want to be the highest priced provider on your website. I thought I was lower than my competitors.”

Anthony is hoping that will generate more competition and drive down prices.

“I’m just talking about sensible rational pricing, which health prices are anything but,” she added.

Take, for example, the cost of an upper back MRI.

“The range here is $614 to $1,800, so three times,” said Sue Amsel, searching “Now I Know,” the tool she manages at Harvard Pilgrim. “That to me is a very big range.”

In this case, the most expensive MRI is at Boston Children’s Hospital and the lowest cost option is at New England Baptist, with no apparent difference in quality.

“It’s not just for choosing. It’s primarily for getting you the information, about whatever you’re having done, so you can plan for it,” she said.

Most of us don’t have to plan for anything except our co-pay. But about 15% of commercial insurance plans have high deductible plans, in which patients pay the full cost of an office visit or test up to the amount of their deductible, and that number is growing.

“As more and more members are faced with greater and greater cost share, this sort of information is really important,” said Bill Gerlach, director of member decision support at Blue Cross.

To use these tools, you’ll log in on to your insurer’s website. If you have a high deductible, the online calculator shows how much you’ve spent so far this year toward your deductible. If your coverage does not include a deductible, the tool will calculate the balance towards your out-of-pocket maximum.

All these numbers are confusing. Most of us haven’t thought about shopping for health care or paid attention to how much we spend. The state and most of the insurers are rolling out education campaigns to help us wrestle with the previously hidden world of health care prices.

One last tip: Each insurer uses a different title for its calculator. Look for the Blue Cross cost calculator under “Find a Doctor.” It’s not as easy to find as Tufts’ “Empower Me” page or Harvard Pilgrim’s “Now iKnow.”

Both Tufts and Harvard Pilgrim used Castlight Health to build and now run their shopping tools while Blue Cross contracted with Vitals.

Aetna was the first insurer in Massachusetts to offer cost and quality comparisons through its Member Payment Estimator. It’s not clear if all insurers doing business in the Bay State met the Oct. 1 deadline, but all of the major players did. There is no penalty for those who failed to do so.

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.

Read more on how to research and manage your health care costs:

MONEY Health Care

The Biggest Healthcare Benefits Decision You’ll Have to Make This Year

Teddy bears with bandages
Zachary Zavislak—Prop Styling by Linda Keil

This year, your company may push you to a high-deductible health plan that looks cheaper, but it may not be.

This benefits open-enrollment period, your employer may ask you—even force you—to enroll in a high-deductible health insurance plan with a health savings account. Nearly three-quarters of companies expect to offer this type of plan as an option for 2015, up from 63% in 2014. And 23% say it will be the only option, Towers Watson found.​

While premiums on high-deductible health plans are typically 10% less than those of more tradi­tional PPO plans, according to data from the Kaiser Family Foundation, co-insurance doesn’t kick in until you’ve paid much more out of pocket.

On average, you’ll foot the first $2,200 in costs as an individual, or $4,500 as a family. (Employers like the plans because they motivate you to be more discerning about your spending.) To pay the bills, you can save pretax dollars—up to $6,650 for a family—in a health savings account (HSA). Most companies throw in cash to sweeten the pot.

According to conventional wisdom, high-deductible plans save money for the young and healthy, who rarely see doctors. But with deductibles and premiums rising across all plans and more companies offering only this coverage, everybody needs to know how to best use high-deductible plans. “Whether we like it or not, higher levels of cost ­sharing is the way of the future,” says University of Michigan Medical School professor Dr. Jeffrey Kullgren. Here’s how to assess your options if you have options—and how to hedge your risk if you don’t:

If you have a choice of plans

Compare costs for a typical year. Your employer, hopefully, will make this easy for you: This fall, 76% of companies plan to offer tools to help employees assess plan options, says Towers Watson. Often these build in your current year’s usage of health services.

No such luck? Estimating your total costs under each plan isn’t easy, but it’s necessary to make the right choice. Start by reviewing your 2014 explanation of benefits statements—probably available on your insurer’s website—to see the insurer-negotiated prices for your usual services, says Paul Fronstin of the Employee Benefit Research Institute. Add the premiums to your expected out-of-pocket costs in each plan—up to and after deductibles—and subtract any employer HSA contribution for the high-deductible option.

Assess a worst-case scenario. In more than 58% of high-deductible plans, families could rack up bills exceeding their yearly HSA contribution limit, according to Kaiser data. In such cases, if you suffer a health crisis, “you’re at risk of using a lot of post-tax dollars,” says Katy Votava, founder of health insurance consulting firm Goodcare. “I like to see an out-of-pocket max that isn’t much more than the HSA limit.”

Gauge your cost tolerance. An American Medical Association study found that 43% of higher-income families in high-deductible plans had delayed or forgone care because of the cost. Almost a third of them reported greater stress, and 15% suffered a disability as a result of putting off care. If you’re likely to skip treatment to save a buck, this plan isn’t your best choice, particularly if you have a chronic condition.

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If you go high-deductible

Budget for your costs. Set aside at least enough in the HSA—­including employer contributions— to cover your expected care, and ideally more, says Kullgren. That way, “when you need care, you’re not faced with the decision to get the service or go without.” Rather than worrying about saving too much, think of this as a backup account for retirement: Leftover funds carry over year to year, growing tax-free, and can be withdrawn penalty-free for any purpose once you’re 65. (You will owe income taxes if the funds are used for anything but health costs.)

Be a savvy consumer. High- deductible plans put the onus on you to be price-conscious. Learn the costs of procedures in advance, and ask questions like “How will this test result affect what you do for me?” says Jacksonville financial planner and MD Carolyn McClanahan. Prices vary wildly, so comparison shop for services like blood tests and MRIs. It’s in your interest to get the best deal you can.

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