MONEY Health Care

Why Your New Health Plan Might Not Cover Hospital Stays

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

TIME Healthcare

Obamacare Hasn’t Saved Our Rural Clinic

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

Frank Lang is a family nurse practitioner.

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

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

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

What had I gotten myself into?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

TIME Health Care

Survey: Number of Americans Without Health Insurance Falls

Health Insurance Doctor Patient
Getty Images

Federal survey found an 8% decline in uninsured Americans over the year to April 2014

The number of uninsured Americans dropped in the wake of the Affordable Care Act, according to the first government survey conducted since the law’s major insurance expansion programs went into effect.

In the National Health Interview Survey, a widely respected measure of the rate of insurance nationwide, researchers from the Centers for Disease Control and Prevention interviewed 27,000 people in the first quarter of 2014, and found that the number of Americans without health coverage had fallen by 8% since the same period in 2013. That was a decline of 3.8 million, resulting in a new total of 41 million uninsured.

Before the health law was implemented, many predicted it would bring new health coverage to millions more than that, but the CDC survey did not capture the surge of insurance sign ups in the final days of the first ACA open enrollment period, experts said.

Larry Levitt, a director at the Program for the Study of Health Reform and Private Insurance at the Kaiser Family Foundation, told the New York Times, “Regardless of what you think of the [Affordable Care Act], there should be no doubt at this point that the law is increasing the number of people insured.” He added that this survey’s findings “dramatically understate the effect” of the law.

 

TIME 2014 elections

Losing Among Women, Republican Scott Brown Offers Them Awards

Scott Brown Campaign Rally
Former Sen. Scott Brown, candidate for U.S. Senate in New Hampshire, holds a campaign town hall rally at the Pinkerton Academy in Derry, N.H., on Aug. 18, 2014. Bill Clark—CQ Roll Call/Getty Images

The recipient is puzzled and embarrassed by the honor

Janice Leahy, a small businesswoman in New Hampshire, still doesn’t understand why Republican senate candidate Scott Brown gave her a “hero” award when they met in May. “I’m an ordinary person,” Leahy tells TIME. “I’m no hero. I don’t look at myself as person of stature or significance or anything else.”

Armed with spreadsheets, Leahy had met with Brown at a diner in Windham to talk about the burden of Obamacare on her small software and professional services businesses. That’s when he presented her with a polished black plaque, emblazoned with the words, “Women for Scott Brown.” A press release followed. “I’m pleased to award Janice with a Hero Award to celebrate her determination to maintain a business despite government red tape and burdensome regulations that make for a very tough environment not only for women-oriented businesses, but for everyone,” Brown said in the statement. “That’s why I support full repeal of Obamacare.”

Leahy, a Republican, says she was left confused and embarrassed by the whole episode. She also says she is not sure she will vote for Brown in November, given his 2012 vote against an equal pay bill, an issue close to her heart given that she works in a male-dominated industry. “I’m not happy about his vote against it and I would need to know more about it before I vote for him,” Leahy says. “I haven’t decided yet which way I’ll vote in November.”

The episode is emblematic for Brown, who has been struggling to connect with women in his bid to unseat Democrat Jeanne Shaheen. Although Brown and Shaheen are neck-and-neck in polls overall—with Brown garnering 44% of likely voters to Shaheen’s 46%—Brown is losing women to Shaheen by 39% to 53%, according to an Aug. 21 WMUR Granite State poll.

He has tried to chip away at this deficit on the campaign trail. Brown’s campaign defines “The Women for Brown ‘Hero’ Awards” as commendations “meant to recognize individuals who are contributing to the economic life of New Hampshire, helping our community thrive and building strong families, sometimes despite adverse circumstances.” Emails to the campaign asking about how the honorees are selected went unanswered.

The awards have been timed to underscore policy talking points the campaign has sought to spread. The second plaque was given to Naswa Resorts owner Cynthia Markis and her mother, Hope, for operating their business despite high energy and Obamacare costs. And Brown gave a third award to Commandant Peggy LaBrecque, who runs the state’s only longterm care facility for veterans, on Veterans Day, using the event to highlight a package of veterans policy initiatives he unveiled that day. Repeated calls for comment to Markis and LaBrecque went unanswered.

Shaheen is the first woman in U.S. history to be elected both governor and senator. If Brown loses, he’ll also make history: He’d be the first man to lose two Senate races to two women. In 2012, he lost his Senate seat in neighboring Massachusetts to Elizabeth Warren. Shaheen’s campaign says Brown’s awards are patronizing towards women. “New Hampshire women aren’t looking for plaques, they are looking for a Senator who stands up equal pay for equal work and protecting access to basic health services like mammograms —and Scott Brown has proven he can’t be trusted to do that,” says Harrell Kirstein, a Shaheen campaign spokesman.

Brown’s challenge is shared by Republicans across the country. Unlike 2010, the GOP wave year when Republicans won the female vote for the first time since Ronald Reagan, women have helped Democrats stay competitive so far in several races across the country this year, including New Hampshire, North Carolina and Louisiana. Democrats have made a concerted effort to appeal to female voters, hoping to avoid another wave of losses like in 2010. They’ve introduced a women’s economic agenda and have repeatedly hit Republicans for waging a ‘War on Women,’ over access to abortion and contraceptives.

Leahy says she now sees the award as a thing meant to mean more for Brown than her. “I think it’s his push to show women in the area he understands inherently their issues, what’s near and dear in their hearts,” Leahy says.

But she noted that Brown has a tough task ahead of him, given the pride the state now has in having an entirely female Congressional delegation, which includes Brown’s rival Shaheen. “I do think it’s the coolest historical thing that we have full female congressional delegation,” Leahy said. “Being a woman, I like that that’s brought to the forefront all the time.”

MONEY Health Care

Early Analysis Finds a Drop in Obamacare Premiums Next Year

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

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

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

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

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

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

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

The main message: shop around, says Levitt.

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

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

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

TIME Health Care

Obamacare Website Was Hacked in July

Obamacare's 6-Million Target Hit As Exchange Sees Visits Surge
Marketplace guide Stephanie Cantres works on the Healthcare.gov federal enrollment website as she helps a resident sign up for a health insurance plan under the Affordable Care Act at a Westside Family Healthcare center enrollment event in Bear, Delaware, on March 27, 2014. Andrew Harrer—Bloomberg/Getty Images

No personal information was stolen in the breach

A hacker managed to breach cybersecurity at HealthCare.gov and implant malicious code on the federal Obamacare website, officials revealed Thursday.

Healthcare.gov hosts the federal insurance exchange on which millions of Americans have purchased health insurance since the Affordable Care Act mandate that most people be insured began rolling out last year. Officials said they learned of the hack, which took place in July, last week.

The attack is apparently the first instance of a hacker successfully breaking through the site’s defenses, an anonymous employee of the Department of Health and Human Services told The Wall Street Journal.

Officials said the attacker does not appear to have stolen any personal data and only broke in to a server used to test run software for the site. HHS said the Healthcare.gov site doesn’t seem to have been a specific target of the attack.

“Our review indicates that the server did not contain consumer personal information; data was not transmitted outside the agency, and the website was not specifically targeted,” HHS said in a statement to the WSJ. “We have taken measures to further strengthen security.”

Investigators found that hackers had not coordinated an assault to get valuable personal information, but had intended to install malware to allow other computers to control the Healthcare.gov system for later mass attacks, like a DDOS attack, designed to send so many visitors to a website it overwhelms the site’s ability to function. Investigators said they believe the hack is not the work of another government or government sponsored group.

Such security breaches are not uncommon but the attack raises concerns about the security of the website, which contains confidential personal details of millions of Americans. Republicans, who are united in opposition to the law and its implementation, have long warned the site was at risk of attack by hackers.

“If this happened anywhere other than HealthCare.gov, it wouldn’t be news,” a senior DHS official told the WSJ.

[WSJ]

MONEY Health Care

Why Health Care Spending Is Going Up—But Not Skyrocketing

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

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

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

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

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

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

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

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

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

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

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

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

Other key takeaways from the CMS report include:

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

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

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

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

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

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

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

MONEY Health Care

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

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

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

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

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

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

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

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

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

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

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

MONEY Health Care

How Some Insurers Still Avoid Covering Contraception

Locked up birth control pills
Nicholas Eveleigh—Getty Images

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

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

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

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

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

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

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

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

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

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

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

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

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

More on the Affordable Care Act and contraception coverage:

 

 

 

 

 

TIME 2014 Election

This Democratic Senator Is Running on Obamacare in a Surprising New Ad

Hell freezes over

Senator Mark Pryor (D-Ark.) is running in one of the tightest reelection races in the country, facing freshman Rep. Tom Cotton (R-Ark.), a U.S. Army veteran. So it may come as some surprise that in Pryor’s new ad released Wednesday, he chose to hone in on his support of President Barack Obama’s unpopular healthcare law.

In the personal new ad, Pryor’s father, David, a former senator himself, talks about his son’s battle with sarcoma, a rare form of cancer, in 1996. “When Mark was diagnosed with cancer, we thought we might lose him,” David Pryor says in a voiceover. “But you know what? Mark’s insurance company didn’t want to pay for the treatment that ultimately saved his life.”

By opening up about the struggle for his own life, Pryor aims to connect with his constituents. “No one should be fighting an insurance company when you’re fighting for your life,” he says in the ad. “That’s why I helped pass a law that prevents insurance companies from canceling your policy if you’re sick or deny coverage from preexisting conditions.”

Pryor’s ad does at least three things right. First, he hones in on the most popular aspect of the Affordable Care Act: coverage for those with preexisting conditions, which has support across the aisle. “We all agree that nobody should be denied coverage due to a pre-existing condition,” David Ray, a Cotton campaign spokesman, told TIME in an emailed statement.

Second, Pryor’s ad doesn’t use the term “Obamacare,” the Affordable Care Act’s nickname first coined by its critics. A Kaiser Health Tracking poll released August 1 found that a little over half of the public—53%—have an unfavorable view of Obamacare. But when referred to by a different name, the law’s negative ratings can decrease, polls show. One Kentucky poll in May found that while 57% of registered voters disliked “Obamacare,” only 22 percent had unfavorable views of Kynect, the state exchange created as a result of the Affordable Care Act’s passage in 2010.

Third, the ad includes his father, a former Congressman, Senator and Governor who is still a popular advocate despite being out of office for the better part of two decades.

And as Pryor runs on Obamacare, Senate Republican candidates and their supporters across the country have backed off on their attacks against the law. In April, anti-Obamacare advertising accounted for 54 percent of the issue ads in North Carolina, and almost all ads in Louisiana were focused on the health care law, according to Kantar Media’s Campaign Media Analysis Group, as reported by Bloomberg. But by July, that number dropped to 27% in North Carolina and 41% in Louisiana.

This shift could be for a variety of reasons, including a renewed focus on the economy and jobs in this election cycle. But Republicans might also be reacting to a law that beat expectations, with higher enrollment figures and fewer than expected cancelled plans (1.9 million versus the purported 4.8 million, according to Health Affairs.) In Arkansas, the law reduced the percentage of uninsured from 22.5% to 12.4% over last year, according to Gallup. That 10.1% decline is the largest of any state in the nation.

Of course, Republicans stated goal on Obamacare remains “repeal and replace,” and ads could reemerge this fall even if premiums don’t increase. David Ray, a campaign spokesman for Pyror’s opponent, Cotton, told TIME in an emailed statement that the aforementioned pre-existing condition provision makes sense, but overall the law should be overturned as it raises health care costs and taxes and lowers wages.

“We thank God that Senator Pryor survived cancer, and we admire his courage in that fight,” wrote Ray. “However, we didn’t need Obamacare to change insurance regulations. We all agree that nobody should be denied coverage due to a pre-existing condition. Obamacare raises taxes on the middle class, has caused millions of Americans to lose insurance plans they were promised they could keep, has doubled or even tripled premiums on families who can’t afford it, has caused lost wages and hours at work, and is preventing many small businesses from growing and hiring more people. Further, Senator Pryor has supported a taxpayer-funded bailout of big insurance companies that lose money as a result of Obamacare. We need to start over with reform that makes healthcare more affordable and keeps healthcare decisions between patients and doctors.”

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