MONEY Health Care

Why You Could Get Stuck Paying for More of Your Health Care

Red traffic light
Your insurer may put a stop to how much it will spend on your surgery. iStock

A growing number of companies are capping what your insurance will pay for certain medical procedures. Get more expensive care, and you could be on the hook for the extra.

Aiming to contain health care costs, a growing number of employers and insurers are adopting a strategy that limits how much they’ll pay for certain medical services such as knee replacements, lab tests and complex imaging. A recent study found that savings from such moves may be modest, however, and some experts question whether “reference pricing,” as it’s called, is good for consumers.

The California Public Employees’ Retirement System (CalPERS), which administers the health insurance benefits for 1.4 million state workers, retirees, and their families, has one of the more established reference pricing systems. More than three years ago, the agency began using reference pricing for elective knee and hip replacements, two common procedures for which hospital prices varied widely without discernible differences in quality, says Ann Boynton, CalPERS’ deputy executive officer for Benefit Programs Policy and Planning.

Working with Anthem Blue Cross, the agency set $30,000 as the reference price for those two surgeries in its preferred provider organization plan. Members who get surgery at one of the 52 hospitals that charge $30,000 or less pay only their plan’s regular cost-sharing. If a member chooses to use an in-network hospital that charges more than the reference price, however, they’re on the hook for the entire amount over $30,000, and the extra spending doesn’t count toward their annual maximum out-of-pocket limit, Boynton says.

“We’re not worried about people not getting the care they need,” says Boynton. “They have access to good hospitals, they’re just getting it at a reasonable price.”

In two years, CalPERS saved nearly $6 million on those two procedures, and members saved $600,000 in lower cost sharing, according to research published last year by James C. Robinson, a professor of health economics at the University of California, Berkeley, and director of the Berkeley Center for Health Technology. Most of the savings came from price reductions at expensive hospitals.

The agency recently set caps on how much it would spend for cataract surgery, colonoscopies, and arthroscopic surgery, Boynton says.

Experts say that reference pricing is most appropriate for common, non-emergency procedures or tests that vary widely in price but are generally comparable in quality. Research has generally shown that higher prices for medical services don’t equate with higher quality. Setting a reference price steers consumers to high-quality doctors, hospitals, labs and imaging centers that perform well for the price, proponents say.

Others point out that reference pricing doesn’t necessarily save employers a lot of money, however. A study released earlier this month by the National Institute for Health Care Reform examined the 2011 claims data for 528,000 autoworkers and their dependents, both active and retired. It analyzed roughly 350 high-volume and/or high-priced inpatient and ambulatory medical services that reference pricing might reasonably be applied to.

The overall potential savings was 5%, the study found.

“It was surprising that even with all that pricing variation, reference pricing doesn’t have a more dramatic impact on spending,” says Chapin White, a senior policy researcher at RAND and lead author of the study.

Even though the results may be modest, a growing number of very large companies are incorporating reference pricing, according to benefits consultant Mercer’s annual employer health insurance survey. The percentage of employers with 10,000 or more employees that used reference pricing grew from 10% in 2012 to 15% in 2013, the survey found. Thirty percent said they were considering adding reference pricing, the survey found. Among employers with 500 or fewer workers, adoption was flat at 10% in 2013, compared with 11% in 2012.

The approach is consistent with employers’ general interest in encouraging employees to make cost-effective choices on the job, whether for health care or business supplies, says Sander Domaszewicz, a principal in Mercer’s health and benefits practice.

This spring, the Obama administration said that large group and self-insured health plans could use reference pricing.

The health law sets limits on how much consumers have to pay out of pocket annually for in-network care before insurance picks up the whole tab—in 2015, it’s $6,600 for an individual and $13,200 for a family plan. But if consumers choose providers whose prices are higher than a plan’s reference price, those amounts don’t count toward the out-of-pocket maximum, the administration guidance said.

Leaving consumers on the hook for amounts over the reference price needlessly drags them into the battle between providers and health plans over prices, says White.

“You expect the health plan to do a few things: negotiate reasonable prices with providers, and not to enter into network contracts with providers who provide bad quality care,” White says. “Reference pricing is kind of an admission that health plans have failed on one or both of those fronts.”

Some experts, however, say the strategy can work for consumers.

“What I think is that reference pricing is a choice-preserving strategy, when you look at the alternative, which is a narrow network,” says Robinson.

That may be a question of semantics, if relatively few providers meet the reference price.

Recent guidance from the administration spells out some of the requirements that health plans must meet in order to ensure that there are adequate numbers of high-quality providers if reference-based pricing is used. Among other things, it suggests that plans consider geographic distance from providers or patient wait times.

Like so much about reference pricing, it remains a work in progress. The administration says it will continue to monitor the practice, and may provide additional guidance in the future.

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 to Save Lots of Money on the Health Tests You Need

Legs on scale at doctor's office
Scott M. Lacey

Catching medical problems early is good for your health—and your wallet. But don't go overboard. Learn to weigh the pros and cons of what the doctor orders.

The latest big push in health care is keeping you from getting sick in the first place. Insurers are sending you reminders to schedule regular exams. Employers are rewarding workers who quit smoking or lose weight. And a key provision in the Affordable Care Act, a.k.a. Obamacare, is full coverage for certain preventive care—with no out-of-pocket costs for you.

Getting a handful of basic tests ­every year can reap rich rewards. “So many diseases, such as hypertension and diabetes, are symptomless in the early stages, when they can be easily caught and controlled,” says Dr. Nieca Goldberg, director of the NYU Women’s Heart Center. So see your primary-care doctor annually once you reach your forties (until then, every two or three years is usually sufficient).

Even though fully covered tests are getting more common, for many ­others you will face co-pays or co-­insurance—and shoulder the full cost until you reach your deductible. To keep those costs to a minimum, we recommend two strategies.

First, look for ways to save on every test you take. Prices can vary widely for the same service, even when you stick with in-network doctors and facilities.

Start by checking your health insurer’s website—many list doctors that insurers believe offer quality care at fair prices. Keep in mind that MRIs, CT scans, and other imaging tests often cost much less at free­standing radiology centers. ­(Just be sure the facility is accredited by the American College of Radiology and that your doc will accept the results.) And when your doctor orders a blood test, ask about all your options, including outside the office. “Labs are so standardized, a $10 lipid panel will get the same results and same quality as a $200 lipid panel,” says Scott Matthews of Castlight Health, which helps big businesses manage their health care costs.

Second, learn which screenings are worth your health care dollars and which you can skip. Here’s what you need to know:

6 Essential Tests for Everyone

1) Skin exam

With skin cancer on the rise, it’s smart to have a dermatologist examine the skin over your entire body, looking for suspicious growths, moles, and lesions.

When to get it: At least once a year. “If you have risk factors, such as being fair, having a lot of moles, or having a family history of skin cancer, you may need to be seen as often as every three to six months,” says Dr. David Leffell, chief of dermatologic surgery at the Yale School of Medicine. You could go to your ­primary-care doctor, but dermatologists are better at diagnosing potentially cancerous lesions, studies show.

Cost: $50 to $150. Insurance covers the visit after you meet your deductible; your usual co-pay or co-insurance will apply.

2) Cholesterol check

This blood test, a.k.a. a lipid panel or profile, reports your total cholesterol, your LDL (“bad”) cholesterol, your HDL (“good”) cholesterol, and a type of fat in the blood called triglycerides. High levels of all but the good stuff raise your risk of heart disease and stroke.

When to get it: Men over 45 and women over 50 should be checked every one to three years, says Goldberg. (Until menopause, women have the protective benefits of estrogen.) At younger ages, test every four to six years. Among the reasons for more frequent screenings: Your results aren’t normal, there’s a family history of heart disease, or you have risk factors like being overweight, you smoke, or you have high blood pressure.

Cost: $110 to $305 for test alone. Cholesterol testing is often included in an annual physical, which insurance covers in full.

3) Blood-pressure check

High blood pressure raises your risk of heart disease, stroke, kidney failure, and other serious conditions.

When to get it: Every two years as part of a routine physical; once a year or more if your pressure is above 120/80.

Cost: $70 to $200 for a doctor’s visit, but insurance pays the full tab for your annual preventive checkups

4) Eye exam

Even if you think your vision is 20/20, have your eyes examined regularly—­especially after 40. As you age, you’re at risk for conditions such as glaucoma, which is symptomless. “An exam can also find signs of another disease that may be affecting your eyes, such as diabetes or high blood pressure,” says Dr. Rebecca Taylor, an ophthalmologist in Nashville and a spokesperson for the American Academy of Ophthalmology.

When to get it: Before age 40, Taylor suggests getting a full exam with an optometrist or ophthalmologist every five to 10 years (yearly if you wear glasses or contacts). After that, make it every two years. Reasons to get more frequent exams include a family history of eye disease, previous eye injuries or surgery, diabetes or high blood pressure, or you are over 65.

Cost: $75 to $200 with an ophthalmologist; $50 to $150 with an optometrist. Insurance coverage varies.

5) A1C blood test

This has become the screening test of choice for diabetes, as it measures your average blood glucose over roughly three months; the fasting blood glucose test tells doctors just what your level is at that moment.

When to get it: The standard recommendation is every three years starting at 45. The American Diabetes Association advises beginning earlier if you’re overweight and have certain risk factors, including high blood pressure.

Cost: $40 to $260 for test. If you have high blood pressure, insurance covers in full.

6) Colonoscopy

This exam is your best defense against colon cancer. While there are other screening tools, a colonoscopy is considered the gold standard: “It doesn’t just diagnose; if the doctor sees adenomas [potentially precancerous polyps], he can remove them then and there,” says Dr. Seth Gross, director of endoscopy at Tisch Hospital at NYU Langone Medical Center.

When to get it: Start at age 50, earlier if you’ve got other risk factors, such as a family history or if you have suspicious symptoms. If the test is negative, get one every 10 years.

Cost: $1,100 to $2,800. Insurance pays every 10 years for adults ages 50 to 75.

4 Essential Tests for Women

Insurance will cover the basic pelvic and breast exams that are part of your annual visit to a gynecologist. Other tests aren’t needed as often—and your insurance coverage will probably reflect that.

1) Pap smear

A Pap smear, also called a Pap test, is when your gynecologist collects cells from your cervix to screen for precancerous changes. Thanks to this test, the cervical cancer death rate declined by almost 70% between 1955 and 1992, according to the American Cancer Society (ACS).

When to get it: Every three years, provided your last test was normal; most women can stop at age 65.

Cost: $75 to $350. Insurance pays in full every three years from ages 21 to 65.

2) Mammogram

There’s been controversy in recent years about when to begin breast cancer screening and how often to do it, but the American Cancer Society and American College of Obstetricians and Gynecologists still recommend getting your first mammogram, an X-ray of your breasts, at 40— earlier if you have risk factors like a family history. Ask your doctor about 3-D mammography, now available at some major medical centers: It reduces false positives and slightly bumps up detection rates, according to a recent JAMA study.

When to get it: Once a year starting at age 40.

Cost: $150 to $375. Screening is covered every one to two years at age 40-plus. Most plans don’t cover more precise 3-D mammograms, so you may owe $40 to $60.

3) DEXA scan for bone density

An X-ray test to measure bone density, this screening is recommended for all women at age 65. But you may want to get one around menopause, when declining estrogen levels increase your risk of osteoporosis.

When to get it: Start at age 65, then consult doctor. With risk factors like smoking and osteoporosis in family, begin at menopause.

Cost: $60 to $385. Insurance pays in full when 65-plus; with preapproval, it often pays for younger postmenopausal women too.

4) HPV (Human – papilloma- virus) test

Typically done at the same time as a Pap, this checks for strains of HPV that are most likely to cause cervical cancer. Before age 30, nearly all sexually active people contract HPV at some point, according to the Centers for Disease Control. Most of the time, HPV is harmless and clears up on its own. But since HPV infection is less common in women over 30, a positive test result is more apt to signal a potential problem.

When to get it: Women ages 30 to 65 should get an HPV test paired with a Pap smear every five years.

Cost: $30 to $125. Insurance pays in full every five years from 30 to 65.

6 Tests You May Need

1) Vitamin D test

Vitamin D helps you absorb calcium and maintain strong bones. Since up to 75% of Americans have low levels (a 2009 study suggests), ask your doctor about adding this to your physical, advises Dr. Marianne Legato, professor emeritus of clinical medicine at Columbia University Medical Center.

Cost: $25 to $150; some, but not all, insurers cover

2) Thyroid-stimulating hormone test

Experts disagree about whether routine thyroid screening is necessary, but make sure to get your blood level of TSH checked if you have fatigue and unexplained weight gain.

Cost: $15 to $115; often covered. Deductible and co-pay or co-insurance apply.

3) Cholesterol particle tests

People whose particles of LDL cholesterol are mostly small and dense have a threefold greater risk of coronary heart disease. Ask your doctor about this test if your cholesterol is borderline, especially if you’re debating whether to go on cholesterol-lowering medications, Goldberg says.

Cost: $15 to $265; not usually covered for routine screening but may be covered in part if you have risk factors.

4) Coronary calcium scan

A CT scan of your heart is used to look for specks of calcium in your arteries that may indicate early signs of coronary artery disease. While this scan is not recommended for everyone, it can be useful if you’ve got a family history or other risk factors. “A score greater than 300 tells us that you’re at increased risk of cardiovascular events in the next five to 10 years,” Goldberg says.

Another heart exam—an exercise stress test—isn’t a useful screening tool if you’re low risk, she adds, due to a high rate of false positives. As a rule, it’s best reserved for people who have risk factors or symptoms such as chest pain or an irregular heartbeat.

Cost: $10 to $300; not usually covered for routine screening, but may be covered in part if you have risk factors.

5) CRP (C-reactive protein) test

This measures blood levels of CRP, an inflammatory protein associated with heart disease. It’s most predictive in men over 50 and women over 60, Goldberg says. In a 2010 study, people in these age groups who were at intermediate risk of heart disease and who had normal cholesterol but high CRP levels benefited from going on cholesterol-lowering medications.

Cost: $10 to $115; not usually covered for healthy patients but often covered in part if you have risk factors.

6) Prostate exam

Screening for prostate cancer used to be a must. Now it’s a maybe. “Intuitively, it makes sense to treat prostate cancers early,” says Dr. Richard Wender, chief cancer control officer at the American Cancer Society. “But some grow so slowly that they’d probably never be life-threatening, and the treatment would be worse for quality of life than the disease itself.” That said, a study published in The New England Journal of Medicine this past March found that men under age 65 who underwent surgery for early-stage prostate cancer (instead of watchful waiting) had better survival rates.

Bottom line: At 50, talk to your doctor about your risks (like a family history). If you decide to undergo a PSA (prostate-specific antigen) blood test and it’s under 2.5 ng/mL, you can wait at least another two years to retest. If it’s over that, test annually.

Cost: $25 to $125 and may be covered by insurance for men older than 50, or starting at age 40 if you face certain risk factors.

 

 

 

TIME Innovation

Five Best Ideas of the Day: October 15

The Aspen Institute is an educational and policy studies organization based in Washington, D.C.

1. Americans are often oblivious to the role of farming in their lives. To get the smart policies needed to feed our nation and the world, we must reconnect people to agriculture.

By Ian Pigott in the Des Moines Register

2. Even employer-paid health insurance can worsen poverty and increase inequality.

By David Blumenthal in Commonwealth Fund

3. Is “feminist marketing” an oxymoron?

By Chandra Johnson in the Deseret News

4. Helsinki has a plan cities everywhere could try: Combine the sharing economy, transit and mobile technology to eliminate cars.

By Randy Rieland in Smithsonian

5. America’s best bet in Africa is a strong relationship with Nigeria.

By Daniel Donovan in Foreign Policy Blogs

The Aspen Institute is an educational and policy studies organization based in Washington, D.C.

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

The Chicken Littles Were Wrong. But Americans Still Think the Sky Is Falling.

The list of false prophesies of doom by Obama's critics is long.

The U.S. economy has added jobs for 55 consecutive months, bringing unemployment below 6 percent. The budget deficit has fallen from $1.2 trillion when President Obama took office to less than $500 billion today, from an unsustainable 10 percent of GDP to a relatively stable 3 percent. More than 10 million Americans have gained health insurance through Obamacare, while medical costs are growing at their lowest rate in decades. Gasoline prices are gradually dropping. Medicare’s finances are dramatically improving.

The sky, in other words, is not falling. On the contrary, things keep getting better. Which means a lot of people have a lot of explaining to do.

To recognize that America is doing better is not to suggest that America is doing great. Wages are too low. Washington is dysfunctional. There’s too much depressing news about Ebola, gridlock and our perpetual conflicts abroad. But the Cassandras of the Obama era ought to admit their predictions of doom were wrong. There has been no hyperinflation, no double-dip recession, no Greece-style debt crisis, no $5-a-gallon-gas, no rolling blackouts, no “insurance death spiral.” Despite “job-killing tax hikes” and “job-killing regulations” and “job-killing uncertainty” created by the “job-killing health care law,” private employers are consistently creating more than 200,000 jobs a month. Our gradual recovery from the 2008 financial crisis continues apace.

Some of the wrong predictions of the last six years merely reflected the paranoia of the Tea Party right—or the cynical exploitation of that paranoia. In 2008, Newt Gingrich got some attention by warning that President Obama would muzzle Rush Limbaugh and Sean Hannity; it worked so well that in 2012, he predicted that Obama would declare war on the Catholic Church the day after his reelection. The National Rifle Association’s fever-screams that Obama would cancel the Second Amendment and seize America’s guns have not come to pass, either, although they helped boost gun sales. Sarah Palin’s “death panels” also have yet to materialize.

It’s doubtful that those opportunists ever believed their own Chicken Little rhetoric; when their doomsday warnings were proven wrong, they simply issued new doomsday warnings. But other prophecies of doom reflected a sincere view of the economy and other public policy issues that simply happened to be incorrect.

The government response to the financial crisis probably inspired the most wrongheaded commentary. Critics complained that the Wall Street bailouts begun by President Bush and continued by Obama would cost taxpayers trillions of dollars. “If we spent a million dollars ever day since the birth of Christ, we wouldn’t get to $1 trillion,” fumed Darrell Issa, the top Republican on the House government oversight committee. Ultimately, the bank bailouts cost taxpayers less than nothing; the government has cleared more than $100 billion in profits on its investments. Obama’s bailout of General Motors and Chrysler also inspired some overheated commentary; Mitt Romney wrote that if it happened, “you can kiss the American automotive industry goodbye.” But it did happen, and the American automotive industry is now thriving, saving an estimated 1.5 million jobs.

It’s fun looking back at misguided crisis predictions. Liberal critics like Paul Krugman warned that the banking system would collapse unless it was temporarily nationalized; Krugman scoffed that Treasury Secretary Tim Geithner’s “stress test” would never end the crisis. “He was right,” Krugman later admitted, “I was wrong.” Conservatives like Dick Morris warned that the president’s $800 billion fiscal stimulus package and other activist policies would create an “Obama Bear Market”; in fact, the Dow has soared more than 250 percent since bottoming out in March 2009. Conservatives like Paul Ryan have also consistently warned that the Federal Reserve’s aggressive monetary stimulus would weaken the dollar—their preferred phrase is “debase the currency”—and create crippling inflation. They have been consistently wrong, as inflation has remained stubbornly low.

After the Great Recession ended in the summer of 2009—sooner than anyone (especially historians of financial crises) predicted—Republicans quickly turned their attention to the budget deficit, which had ballooned to $1.4 trillion. They complained that America was becoming Greece, that we were spending our way into a sovereign debt crisis, that brutal increases in interest rates were on the way. But America did not become Greece. There has been no debt crisis. Interest rates have remained historically low. In fact, despite the howling on the right, non-military spending (excluding mandatory expenses like Medicare) has dropped to its lowest level since the Eisenhower administration. Oh, and speaking of Medicare, its financial position has gotten so much better—thanks to a general slowdown in health care costs—that its trust fund, which was expected to go bust in 2017 when Obama took office, is now expected to remain solvent through 2030.

That slowdown in medical costs is another example of a phenomenon that critics confidently predicted would never happen in the era of Obamacare. Also, the administration would never meet its goal of 7 million signups by April 2014. (The actual figure topped 8 million.) Yes, but they would never pay their premiums. (The vast majority did.) OK, but those premiums would surely soar. (They haven’t.) Still, the entire program will be doomed to a “death spiral” unless healthy young people sign up in large numbers. (They have.)

Nevertheless, most Americans seem to think that Obamacare is a failure, that the economy stinks, that the deficit is getting worse. There are many explanations for those beliefs, but one is surely that initial predictions of doom are uncritically reported at the time and conveniently forgotten once they’re disproven. There is no penalty in American politics for being wrong. Republicans paid no price for their confident predictions that President Clinton’s tax hikes would destroy the economy, that the Bush tax cuts would pay for themselves, that the Obama tax hikes would create a double-dip recession. Even after the BP spill, petroleum interests proclaimed that tighter regulations on offshore drilling would ravage the oil industry and punish Americans at the pump; domestic production is at an all-time high while gas prices are steadily dropping, but they haven’t changed their tune at all. Similarly, even after the financial meltdown, Wall Street moneymen said financial reforms would shred our free enterprise system; they’re still whining despite their record profits.

Obama is often guilty of rhetorical overkill, too. He’s always warning that Armageddon is just around the corner—when Republicans blocked his American Jobs Act and other infrastructure bills, when they insisted on the deep spending cuts in the “sequester,” and when they threatened to force the Treasury to default on its obligations. (Actually, that last one almost did create Armageddon.) But because he’s president, the media correctly holds his feet to the fire, pointing out that he didn’t keep his promises to fix Washington or let you keep your insurance if you like it. There’s less accountability for his critics on the left and the right.

There’s no need for sympathy; Obama volunteered for the job. He gets a cool plane and a nice house regardless of public perceptions about the state of the country. But if you want to know why voters think the false prophets were right, maybe it’s because nobody ever corrected them.

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 Walmart

Why Walmart Workers Losing Healthcare Might Not Be Bad

Getty Images

Ironies abound

Talk about irony. In the same week that Walmart announced employees who work less than 30 hours will be losing their health care coverage, the company also announced that it’d be getting deeper into the business of selling insurance, making it easier for customers to price shop for insurance in stores. In some ways, this mirrors Walmart’s overall business model—keep prices down for consumers, but keep wages and benefits for employees low too.

Ironically, under the rules of Obamacare, it’s possible that those part time employees will get a better deal on health care exchanges, thanks to subsidies that help lower income workers buy insurance. It’s all part of the new landscape created by the Affordable Care Act. As Obamacare turns one year old, Joe Nocera and I discussed how it’s changed healthcare, business, and the economy, on WNYC’s Money Talking.

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

140603_FF_QA_Obamacare_illo_1
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.

TIME Supreme Court

Meet the Lawyers Fighting for Religious Freedom Today Before the Supreme Court

The Becket Fund for Religious Liberty
Counsel for The Becket Fund for Religious Liberty outside of the Supreme Court in Washington. Courtesy Becket Fund

Arguing for a Muslim prisoner's right to grow a beard is just the latest effort for the firm that won the Hobby Lobby case

Gregory Houston Holt wants to grow a half-inch beard but he can’t, and that’s a problem. Holt is Muslim and he believes that wearing a beard is a requirement of his Salafi faith. But he’s serving a life sentence for attempted murder in Arkansas, where the Department of Corrections has banned beards as a potential security threat. On Tuesday, the U.S. Supreme Court will hear Holt’s case, and just as interesting as the outcome of his claim is who will argue it for him. Holt, who now goes by the name Abdul Maalik Muhammad, has put his faith not in a big name first amendment litigator nor in the secularist American Civil Liberties Union, but in the lawyers of the Becket Fund for Religious Liberty.

Holt’s faith in the Becket Fund is well founded. A small, non-profit public interest law firm, with just eleven litigating attorneys and a $5 million annual budget, the Fund is a rising star in Washington. Everyone from unknowns like Holt to corporate giants like Hobby Lobby, which this year won expanded religious exemptions from Obamacare, turns to Becket for high profile cases at the high court. Its lawyers are most famous for arguing the often politically incorrect view that the constitution’s protection of the free exercise of religion has been eclipsed in recent years by government deference to other parts of the constitution. That’s no easy task, since arguments over religious liberty can be some of the thorniest, and most heated, in America.

But the Becket lawyers are shaking up Washington for a simple reason: they win. Over 20 years, Becket has won 85% of its cases–from 1920-2000, the ACLU averaged a little over 65% in religion cases at the Supreme Court, according to the website procon.org. The Supreme Court repeatedly cites the Fund’s briefs in decisions, and Becket’s first case at the Court in 2012 was a 9-0 slam dunk, ruling that the government cannot interfere with a religious group’s choice of whom to hire, even when the employees claim they were discriminated against because of their physical disabilities. Becket is mastering a pattern, supporters say: identify religious litigants with strong claims, present compelling constitutional arguments, and recruit top free exercise litigators. The result is a resurgent ascendancy of religious freedom relative to other rights. “They have outsized success in these cases coming to the court and winning them at the court,” says Viet Dinh, former U.S. Assistant Attorney General and professor at Georgetown University Law Center. “In many ways I think of them as God’s ACLU.”

Every generation has its own fight over religious freedom—it’s a debate that has driven the American story from the day the pilgrims set sail on the Mayflower. The influx of Catholic immigrants after the Civil War prompted the rise of the Blaine amendments to stop public funding of religious education. Jehovah’s Witnesses who refused to salute the flag sparked national debates during World War II. Public school prayer, nativity displays, and the pledge of allegiance prompted the fights of the later 20th century.

It was in the midst of those debates, in 1994, that Kevin “Seamus” Hasson founded the Becket Fund. Hasson, a Catholic lawyer specializing in religious liberty law at Williams and Connolly, felt that the conversation about religion in America was becoming one great non sequitur—one side was arguing that religion was not a societal good while the other insisted that America was a Christian country. Hasson believed that religious liberty comes not from the government or from faith itself, but rather from human dignity. “What we require freedom for is to seek the true, the good, and the beautiful, embrace whatever it is we believe we have found, and express it according the full measure of humanity,” Hasson, who retired in 2011 due to Parkinson’s, says.

Though many of its recent and more prominent clients have been Christian, the Becket Fund has made a point of not pegging itself just to Christian interests, taking on Muslim and Jewish clients, and even more obscure religious causes, like those of a Santeria priest in Texas. Unlike commercial for-profit firms, Becket relies on donors to underwrite its free representation of clients. Some 70% of its donations come from individuals, usually in $25,000 to $100,000 chunks, says Becket Fund president Bill Mumma. The firm’s lawyers are first amendment religious liberty specialists, but the Fund requires they also all be faithful—employees include Mormons, Catholics, evangelicals, Muslims and others.

Becket broke onto the national scene thanks to the Affordable Care Act’s contraception mandate. Its clients Wheaton College, an evangelical liberal arts school, and Catholic organizations like the Little Sisters of the Poor and Eternal Word Television Network, are among the 319 plaintiffs claiming the law’s requirement to provide female employees with insurance plans that include payment for various contraceptives violates religious freedom. But Becket also focuses on low-profile, high-impact cases. The Fund defended Amish men in upstate New York who said local building regulations infringed on their traditional construction methods. It backed a Sikh woman who wanted to wear a kirpan, a small, religiously-symbolic knife, at her job in a government building. Becket has also mastered plain English press releases and media-savvy optics. When the Supreme Court ruled with Becket that Hobby Lobby should have a religious exemption from the contraception mandate, Becket’s female lawyers, not its male ones, were front and center on TV.

Ultimately, though, Becket’s success comes from higher courts’ openness to new interpretations of the First Amendment’s religious protections. For the last half of the 20th century, the Supreme Court read the amendment’s ban on state-established religion and its guarantee of free religious exercise largely as protecting minorities including smaller sects, women and others. Under recent, more conservative courts, Becket has found sympathy for the idea that majority Christian religions get those protections, too, especially when they face off against local, state and federal governments. That casts religious freedom in a similarly broad jurisprudential light as the First Amendment’s subsequent guarantee protecting free speech. “The overall trend is the court coming to a good place for the proper accommodation of religious views,” says Georgetown’s Viet Dinh, and “that is largely due to the work of the Becket Fund.”

The next big question for Becket is how broad that approach can go—and which other government-protected rights the Supreme Court believes should rank below religious freedom. America’s rapidly shifting views on sexuality, and the government’s willingness to protect same-sex relationships, will soon conflict with groups that believe their religious freedom includes the right to discriminate on the basis of sexual orientation. Mumma suggests his firm will remain on the front line of that fight. “Anytime the government moves strongly closer to or farther away from those big issues that religion occupies, you are going to get religious liberty cases,” he says. “I think we are not yet done with that sort of big round of religious liberty cases.”

For now, Becket’s small team of lawyers is already working on some 40 cases. Firm leaders say it has no plans to expand, instead maintaining its focus on finding and litigating high-impact cases. “When the music stops and we go into court, it really matters whether our lawyers have written a good brief, made a good argument, are able to present a case that’s compelling to judges of all political flavors,” says Mumma. “If we can’t do that it doesn’t matter how much public attention we get.” So far, that strategy is working.

MONEY health insurance

You Can Now Buy Health Insurance at Walmart. Should You?

America's largest retailer is expanding more aggressively into the insurance market, hoping to become the go-to place for all your health care needs. But the store is far from the only place to get your coverage questions answered.

UPDATED: 5PM ET

Want help choosing a health insurance plan? Superstore Walmart is betting that many consumers do—and that they will visit a big-box store for guidance.

The company announced this morning that it is teaming up with the health comparison website DirectHealth.com to house insurance agents in 2,700 of its 4,300 U.S. stores. The agents will help shoppers understand and compare individual insurance plans as well as private Medicare plans, including drug, supplemental, and Advantage policies.

The agents will be in stores from this Friday, October 10, through December 7, a time frame that captures the kick-off of the annual enrollment periods for both individual health plans and private Medicare policies. Medicare open enrollment starts October 15; you can begin shopping for an individual policy for 2015 on November 15.

“For years, our customers have told us that there is too much complexity when it comes to understanding their health insurance options,” said Labeed Diab, president of Walmart’s U.S. health and wellness group, in a press release announcing the program. Since 2005, Walmart has hosted insurance agents from individual insurers in some stores to answer questions and enroll customers in health plans. This new program expands on that.

A bid for more health care business

This move isn’t the first time Walmart has dabbled in health care. The company has been slowly adding retail clinics to many of its locations, letting shoppers get primary care such as strep tests and treatment for ear infections at the store. Walmart’s total number of clinics, though, falls far short of what pharmacy chains CVS or Walgreens offer.

By adding insurance agents to its stores, the retailer appears to be aiming to get consumers to think of Walmart as a one-stop resource for health care. Walmart will not receive commissions on the sale of health plans, the Associated Press reports, but hopes the agents will attract consumers who will then rely on the stores for other health care needs, such as prescriptions. The agents will receive a commission from the insurers whenever a patient enrolls in a plan in the store, The Washington Post reports.

Where else to get help

In announcing the program, Walmart noted that many consumers have difficulty understanding their health plans. While that’s true, Walmart will be just one of many places where you can find guidance. Other comparison websites, such as ehealthinsurance.com and gohealthinsurance.com, already offer online and call-in assistance, though neither have retail locations around the country.

So should you head to Walmart face-to-face help with an individual or Medicare plan? The store will offer individual plans from 300 carriers, and Medicare plans from 13 firms. So you should be able to find options in your area. But keep in mind what other help is out there.

•For individual health insurance plans: Unless you qualify for a special enrollment period because you, say, lost your employer-based coverage or got divorced, you are generally locked out from buying a new individual health insurance plan or switching policies until the annual open enrollment period, which this year begins November 15 and runs through February 15. You’ll be able to buy a policy either through your state insurance exchange (find yours at healthcare.gov), an insurer, a comparison website, or an insurance agent.

Once open enrollment begins, many community centers and non-profits around the country will be staffed with counselors, navigators, or other assisters who can offer explain a plan’s details (though many aren’t supposed to tell you which plan is best for you). Find a group offering assistance in your area at localhelp.healthcare.gov. For questions about a plan sold on the public exchange, Healthcare.gov lists the 1-800 number for your state.

Unless you qualify for a subsidized policy under Obamacare (in which case you may be required to buy through an exchange), you should compare policies on the exchanges with those sold directly by insurers. You can find a local insurance agent who can sell you an on- or off-exchange individual policy at nahu.org. Comparison websites also list details for both types of plans, though there’s no guarantee every off-exchange plan available from an insurer will be listed on each site.

One caveat: the in-store agents will be able to explain plan details and help with comparison shopping, but they won’t be able to actually enroll you in an individual plan in the store, according to a Walmart spokesperson. To sign up you’ll need to call Direct Health, Walmart’s partner, or go to the website. (The agents will be able to enroll you in a Medicare plan while you’re in the store.)

Keep in mind that while DirectHealth.com is required by law to list every plan available through the exchange, it won’t necessarily include the full details for each plan. Instead, the site attempts to determine which plans may best suit you, says Michael Mahoney, senior vice president of marketing at GoHealth, which powers the DirectHealth.com comparison site. “We want to make sure people have the right amount of choice without overwhelming them,” he says. You decide if you’d rather see all your options, or only a limited choice.

•For private Medicare plans: You can make changes to your Medicare drug or Medicare Advantage plan starting on October 15. It is a good idea to analyze your current plan and new options every year instead of sticking with what you’ve got, since plans and premiums change and new options appear.

The Medicare Rights Center offers a national help line (800-333-4114) to help seniors understand the program and determine if their income qualifies them for other resources, such as a prescription drug subsidy. Your local State Health Insurance Assistance Program offers one-on-one assistance to Medicare beneficiaries and their families. Find your state’s at shiptalk.org.

The medicare.gov tool run by the Centers for Medicare and Medicaid Services lets you compare plans in your local area. This tool also lists every possible plan available to you, which is not the case with Walmart’s program. For example, a 67-year-old woman who lives in one Northern California zip code and takes no drugs has 11 Part D prescription drug plans options listed on DirectHealth.com. On medicare.gov, that same woman would find more than 30 choices.

 

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