JustCare

Tag: Affordable Care Act

  • Don’t trust your health plan’s provider directory

    Don’t trust your health plan’s provider directory

    Traditional Medicare’s “one size fits all” approach offers a wide choice of doctors and hospitals at a predictable cost, for which you can budget. With commercial insurance, be it through a Medicare Advantage plan, a state health care exchange, or your employer, your choice of doctors and hospitals can be quite limited; and you may not be able to see the doctors you want to see. Beyond that, you can’t trust your health plan’s provider directory to reflect accurately the doctors you can use or the locations at which you can get care.

    If you’re looking to see certain doctors, a plan’s provider directory may list them as part of their network, but the doctors may not be in your health plan. And, if the doctors are in your health plan, they may not be taking new patients from your health plan. Or, the doctors may only be seeing patients from your health plan at a location that is inconvenient for you, which is different from the location listed in the directory. (Here are two tips to help you choose a health plan.)

    To address problems with health plan provider directories and help people make better decisions about their health plans, CMS imposed rules on health plans that became effective in 2016. Both Medicare Advantage plans and plans in the state health exchanges must publish up-to-date provider directories, including which doctors are seeing new patients, their locations, contact information, specialties and hospital affiliations. And, in addition to making them easily accessible, they must keep them updated each month. Three years later, the rules are not working.

    CMS may impose penalties on Medicare Advantage plans up to $25,000 per person enrolled if they violate the rules and up to $100 per enrollee on health plans in the state exchanges. These penalties should deter plans from listing doctors in their directories who have left their plans as much as ten years back, as some have been doing, but they have not. (In November 2014, California levied penalties of $250,000 each on Blue Cross of California and Anthem Blue Cross because 25 percent of the doctors they listed said they did not accept these plans or did not offer services at the listed locations.)

    The Washington Post reports that for the third year in a row a CMS audit found that more than half of the Medicare Advantage plans have at least one deficiency in their provider directories–mistakenly telling people that doctors are in-network when they are not or that they are taking new patients when they are not or that they are seeing patients at particular locations when they are not. Yet, the Trump Administration has chosen not to fine Medicare Advantage plans that violate these rules.

    If CMS were to use its power to impose fines on Medicare Advantage plans, Medicare revenues could be way up. One recent CMS investigation found that the online directories of 54 Medicare Advantage plans had incorrect information on more than 2,500 of the 5,832 doctors listed. 

    Since you can’t trust the provider directory, how can you help ensure you see in-network doctors?

    1. Talk to the staff of the doctors you use to see what plans they are in and whether you will be able to see them in-network.
    2. Keep in mind that three out of ten doctors change their hospital affiliations or practice group each year.
    3. Insurance contracts can be so complex that sometimes staff don’t know what plans the doctors are in. Always call your health plan to double check.
    4. Finally, make sure that whatever plan you join has a stable of good specialists. Even if you’re healthy, you want to know that there are doctors in the plan who will meet your needs if you develop a costly or complex condition. (Indeed not knowing your future health care needs makes it challenging to choose a health plan that’s right for you.)

    Unfortunately, it’s still hard to avoid medical bills from providers who are not in your plan’s network if you are hospitalized. Often the in-network hospital has teams of out-of-network doctors.

    Congress is now looking to address the problem of these “surprise medical bills.” Twenty-five states have already passed laws offering people some protection against these surprise bills.  The best way to protect yourself is to let the hospital know in advance of being admitted that you only want to be treated by in-network doctors.

    To learn more about Medicare Advantage plan networks and provider directories, there’s a September 2015 report by the Government Accountability Office (GAO) critiquing CMS oversight of Medicare Advantage plans to ensure adequate access to care in the wake of United Health terminating contracts with well over 1,000 Medicare Advantage providers in 24 states. Medicare Advantage plans can end contracts with doctors and other providers at any time for any reason. The GAO recommended heightened CMS oversight of Medicare Advantage plans and rules to help patients accurately understand health plan provider networks.

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  • Guaranteeing coverage to people with pre-existing conditions critical to most voters

    Guaranteeing coverage to people with pre-existing conditions critical to most voters

    According to a new Kaiser survey, a majority of voters say that a federal candidate’s position on pre-existing conditions is an important factor in their 2018 vote. Voters care more about this than they care about repealing the Affordable Care Act or passing legislation to bring down drug prices and a range of other issues. Another recent study showed that candidates’ position on health care costs is also important to voters.

    It’s not clear that there is a single Republican running for Congress who supports the provision in the Affordable Care Act that requires health insurance companies to enroll people with pre-existing conditions and to charge them the same premium as everyone else. Indeed, the vast majority of Republicans want to repeal the ACA, including this provision. (N.B. A majority of voters also believe that President Trump is trying to make the ACA fail; it protects people with pre-existing conditions.)

    Before the ACA was enacted, health insurers had the power under federal law to deny coverage to anyone with a pre-existing condition. Or, they could offer coverage but refuse to cover services related to the pre-existing condition. And, if they enrolled people with pre-existing conditions, they could raise their premiums.

    In this survey, Kaiser did not ask about the importance to voters of federal candidates’ positions on reining in health care costs, which has been a top priority, along with reining in drug costs, for several years now.

    If you agree that health insurers should be required to enroll anyone who applies to enroll regardless of their health status, make sure you vote for candidates who support protecting people with pre-existing conditions. And, if you want Congress to improve and expand Medicare, so that everyone in America is guaranteed health coverage throughout their lives, without the burden of premiums, deductibles and copays, let your members of Congress know. Sign this petition. Today, 63 percent of the public supports improved Medicare for All. 

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  • 2018 Trustees’ reports show GOP tax cuts hurt Medicare and Social Security

    2018 Trustees’ reports show GOP tax cuts hurt Medicare and Social Security

    The Medicare and Social Security Trustees just released their reports on these two vital social insurance programs. More than anything, they show that the GOP tax cuts are hurting Medicare and Social Security.

    The Medicare report reveals that the Part A trust fund, which is funded with workers’ payroll contributions, is now projected to face a shortfall eight years from now, 2026. The Social Security report reveals that its trust fund, which is also funded through workers’ payroll contributions, will not face a shortfall until 16 years from now, 2034, the same projection as in 2017. It should be noted, however, that over the course of the last several decades shortfall projections have never been accurate and have changed from one year to the next.

    Indeed, projections this year for the Social Security disability program are that it will not face a shortfall until 2032, four years longer than projected last year.

    For the record, neither Medicare nor Social Security has ever actually faced a shortfall. Sometimes, the economy improves and more workers contribute to these programs. Or, workers make higher wages, increasing contributions to these programs. And, Congress can always step in to ensure these programs are adequately funded. With Social Security, Congress would need only to lift the $128,400 cap on Social Security contributions. 

    Even if none of these things were to happen and the Medicare Trust Fund were to face this shortfall in 2026, it would still be able to pay out more than 90 percent of its estimated benefits. Similarly, if the Social Security Trust Fund were to face a shortfall in 2034, it would still be able to pay out 77 percent of its estimated benefits. Neither program would be insolvent.

    Moreover, as Nancy Altman explains, the US can easily afford both Social Security and Medicare. The only reason we are seeing these projections from the Trustees, according to Altman, is that the Republicans have sabotaged Medicare. If Congress wanted to, it could easily expand both of these programs.

    Trump and GOP initiatives are reducing the number of workers paying into Medicare and Social Security. And, their tax cuts reduce income for Medicare and Social Security. They also lower taxes on Social Security benefits. “As a whole, the law has a significant net negative effect on the financial status of the OASDI program [both retirement and disability] over the short-range projection period and a negligible net positive effect over the long-range projection period,” according to the Trustees.

    As of 2019, the GOP tax cut ends the penalty on people who do not have health insurance under the Affordable Care Act, which will increase Medicare costs. More people will go without insurance pre-Medicare, now that they do not have to pay a penalty for so doing. And, that will mean that more uninsured will need hospital care, driving up hospital costs and, as a result, increasing the amount Medicare pays hospitals.

    The GOP also ended the Independent Payment Advisory Board, which was designed to help ensure Medicare remained strong, keep its rate of growth down and improving quality. Without IPAB, there is no mechanism to realize these goals.

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  • There may soon be a female Democratic doctor in the House

    There may soon be a female Democratic doctor in the House

    Erin Mershon of StatNews reports that, over the last almost 60 years, there have been 49 physicians who have become members of Congress. Of that group, only a few have been Democrats and only two have been women. None has been a Democrat and a woman. A grassroots organization is working to change history and put some female Democratic doctors in the House and Senate.

    A group of 8,000 Democratic doctors who are women, led by Dr. Ramsey Ellis, is supporting eight female Democratic physician candidates for Congress this year. Dr. Ellis was a grassroots organizer for Hillary Clinton. Now, she is heading Physician Women for Democratic Principles in order to help ensure there are more women and more physicians governing our country and leading the public debate on health issues.

    Imagine how Democratic physician women policymakers might have shaped and improved on Medicare, Medicaid and the Affordable Care Act had they been our representatives in Congress when these major pieces of legislation were being debated. Only two Republican female physicians have ever served in Congress, Reps. Nan Hayworth of New York and Shelley Sekula-Gibbs of Texas. Today, there are 15 physicians in Congress, all are men and 13 of them Republicans.

    With one third of the physicians in the US female, it seems reasonable that five physicians in Congress would be female. Similarly, about half of physicians are Democrats. If the physicians in Congress reflected the national pool of physicians, seven or eight of them would be Democrats, not just two of them.

    Stat interviewed several Congressional candidates who are physicians to understand why they were running for office. Their primary reason: To solve the health care problems presented by the Affordable Care Act. Candidates who are members of Physician Women for Democratic Principles want to strengthen the ACA and Medicaid. Not surprisingly, Republican physician candidates want to repeal the ACA and slash Medicaid funding.

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  • What will Democrats do on health care in budget negotiations?

    What will Democrats do on health care in budget negotiations?

    What will the Democrats do on health care and other social justice fronts to start the 2nd Session of the 115th Congress? Democrats have major leverage in negotiations over keeping the government open, as the budget requires 60 votes to pass. But, how the Democrats’ leverage translates into policy still remains unclear.  Will Republicans be able to take advantage of their majority as they look to confirm new cabinet members and move forward with the Trump Administration agenda? The Republican caucus is fractured, and 2018 might be enough to break them apart for good.    ​

    As much as the Republicans would like to repeal and replace the Affordable Care Act, they now hold only 51 Senate seats, which undermines their likelihood of success. Their repeal attempts were unsuccessful in 2017, when they held 52 seats. So, Republicans are considering other moves that could undermine consumer protections in the insurance market. The Administration is proposing association health plans, which would allow businesses in a geographic area or in an industry to come together to provide their members health insurance that does not have to cover the essential benefits required by the ACA. Other consumer protections would also fall by the wayside, including the rule requiring insurers to spend at least 80 percent of premium dollars on health care. This proposal would likely drive up health care costs for older adults and people with pre-existing conditions in the health insurance exchanges.

    Republicans also want to confirm former prescription drug executive Alex Azar as head of HHS. Democrats could use their leverage to block Azar’s confirmation.

    According to Politico, the Democrats’ number one priority in budget negotiations is a deal to help Dreamers. In addition, Senator Schumer tweeted that the Senate Democrats are focused on “fighting the opioid crisis, supporting America’s veterans and protecting the pensions American workers have earned.” On the health care front, House Minority Leader Nancy Pelosi has said the Democrats are fighting for renewed funding of the Children’s Health Insurance Program and community health clinics.

    In related news, the Trump Administration is reported to want to slash social welfare programs, including food stamps and housing subsidies. Speaker Paul Ryan has confirmed his desire to support these cuts, along with cuts to Medicare.

    And, Senate Republicans are proposing a $492 million cut to the Social Security Administration (SSA). These cuts, which come on top of millions in SSA cuts Republicans have already made since 2010, would restrict Social Security services as well as erode confidence in Social Security.

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  • One in four insured Americans go without care, struggle to pay high deductibles

    One in four insured Americans go without care, struggle to pay high deductibles

    A new Kaiser Family Foundation report finds that fewer than half of single people have the money to pay $2,000 in deductibles and other cost-sharing requirements in most commercial health plans. In sharp contrast to wealthy Americans who can afford high deductibles and copays, high cost-sharing too often keeps working people from getting needed care. With health plan deductibles and copays rising more quickly than people’s income, more Americans are unable to afford their care.

    Commercial health plans for people under 65 typically have out-of-pocket limits of $6,850 for an individual and $13,700 for a family, far more than most Americans can afford. Only about half of people living alone have $2,500 in cash or other liquid assets. And, only about half of larger households have $5,000 in liquid assets. Slightly more than one in three households could pay $6,000 in cost sharing.

    More than forty percent of people with incomes between 150% and 400% of the federal poverty level are at risk of going without care if they get sick, without the money to pay even a $1,500 deductible ($3,000 for families), the average deductible for people with employer coverage. About sixty percent of people in this income range could not afford a $3,000 deductible ($6,000 for families), which are typical in the state exchanges.

    Access to care for working families in the US has declined in the last couple of years as health plans increasingly ration care based on people’s ability to pay. In 2015, Families USA reported that one in four Americans with non-group coverage—insured either through the health insurance exchanges or outside the health insurance exchanges—could not afford their medical care. They were unable to pay the high deductibles (which, according to the Kaiser report, averaged over $3,000 in 2016 and 2017) or out-of-pocket costs their policies require. As a result, they went without care they need.

    In 2013 and 2014, 25.2 percent of people in non-group plans went without care because they were not able to pay for it. Not surprisingly, people with incomes between 139 and 249 percent of the federal poverty level had more trouble affording care (32.3%) than people with incomes between 250 and 399 percent of poverty (22.2%).

    And almost three in ten people with deductibles of $1,500 or more (29.8%) went without medical care as compared with about two in ten people with deductibles under $1500 (19.6%). A somewhat smaller percentage of people who got their coverage through the state exchanges had deductibles of $1500 or more (42.8%) than people who got their coverage outside the exchanges (58.3%).

    According to a September 2016 CDC report, in the first quarter of 2016, 40 percent of Americans were enrolled in high-deductible health plans, up from 36.7 percent in 2015 and from 25.3 percent in 2010.

    The Families USA report found that the most common procedures people skipped were medical tests, treatments and follow-up visits (15.3%) and filling prescriptions (14.2%). Many prescription drugs have become prohibitively expensive even with insurance. Not only have prices on brand-name drugs gone up, but copays on brand-name drugs have risen signficantly, to as much as 30 percent of the cost. It’s no wonder that government drug price negotiation is a top policy issue for democrats and republicans alike.

    If you support improved Medicare for all, please sign this petition.

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  • What you should know about Graham-Cassidy bill

    What you should know about Graham-Cassidy bill

    Senator Mitch McConnell has just conceded defeat for now in his effort to repeal the Affordable Care Act through the Graham-Cassidy bill. The bill, sponsored by Senators Lindsay Graham (SC) and Bill Cassidy (LA), would gut Medicaid, tax credits to help people buy health insurance, and consumer health insurance protections. Three Republican senators–John McCain, Susan Collins and Rand Paul–said they would oppose the bill, depriving McConnell of the votes needed to pass it.  What should you know about Graham Cassidy?

    Graham-Cassidy eliminated the ACA mandate that everyone have health insurance. It would have dramatically slashed Medicaid spending, ended subsidies for people with low incomes, and eliminated insurance protections for people with pre-existing conditions. According to the Congressional Budget Office, millions of people would have lost insurance coverage had the bill passed.

    Insurers would have been able to charge people with pre-existing conditions higher premiums and would not have to sell them policies that covered essential benefits. It would have block granted some federal Affordable Care Act funds to the states beginning in 2020 through 2026. By 2027, it would end those funds completely.

    Today, about 11 million older adults and people with disabilities rely on Medicaid to supplement Medicare. Medicaid may cover Medicare premiums and copays and the cost of nursing home care. In fact, Medicaid currently picks up the cost of nursing care for about 75 percent of older people. And, in many states, Medicaid covers other long-term services and supports. Depending upon the state you live in, it may also pay for hearing, vision and dental care.

    The Center on Budget and Policy Priorities projected that Graham-Cassidy would have meant federal spending cuts on Medicaid alone of $243 billion between 2020 and 2026. Alaska, California, Connecticut, Delaware, the District of Columbia, Hawaii, Kentucky, Louisiana, Maryland, Massachusetts, Minnesota, Montana, New Hampshire, New Jersey, New York, North Dakota, Oregon, Rhode Island, Vermont, and Washington, would have seen 35 to almost 60 percent cuts in federal funding for their Medicaid programs and ACA premium assistance.

    By 2036, according to Avalere, had Graham-Cassidy passed, federal funding cuts to states could top $4 trillion. States would have been hard-pressed to fill these funding gaps. States that have passed Medicaid expansion and/0r that have more residents receiving insurance premium assistance would have seen the largest federal funding cuts.

    Graham-Cassidy also would have set a federal per-person spending cap for almost all Medicaid enrollees. States would be forced to either cut Medicaid benefits and/or restrict Medicaid eligibility further and/or cut other programs and/or raise taxes.  

    The AARP, American Hospital Association, American Medical Association among many other organizations, opposed the bill.

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  • Sanders and 15 other Senators introduce Medicare for All bill

    Sanders and 15 other Senators introduce Medicare for All bill

    As Congressional Republicans continue to seek a vote to repeal the Affordable Care Act, Senator Bernie Sanders and 15 other Senators introduced a Medicare for All bill, providing universal health care.

    Even with the Affordable Care Act, more than 28 million Americans remain uninsured, and the cost of health care is prohibitively high for many. Sanders’ bill would both allow people to use virtually any doctor or hospital in the country and lower their costs. It recognizes that Medicare is the most cost-effective health insurance system in the U.S. (The V.A. system is arguably more cost-effective but is socialized medicine and not an insurance system.) And, it projects huge savings from ending the profits and administrative waste of private health insurance, which would no longer be available as primary coverage.

    Sanders’ bill is designed to end the financial and bureaucratic obstacles that keep people from going to the doctors they know and trust, getting needed in-hospital care or taking life-saving medications. The bill is aimed at extending lives, cutting our health care costs significantly from the $10,000 per person average today. Sanders’ bill also fills critical gaps in Medicare, offering hearing, vision and dental services and a catastrophic coverage cap. And, people with Medicare would see these additional benefits right away.

    The Sanders bill phases in improved Medicare for all for people who do not yet have Medicare over four years. People 55 and older, along with children under 18, would enjoy Medicare coverage in year one. In year two, people 45 and older would be eligible. In year three, people 35 and older. And, in year four everyone. No question that if it were to become law, Medicare for All would give everyone better coverage than they have today—access to the doctors and hospitals they know and trust and all others that they may want to use anywhere in the U.S.—at lower cost. And, The April 2-4, 2017 Economist/YouGov poll shows that the majority of the public–60 percent–supports it.

    With a groundswell of support, Congress eventually may do right by the American people and enact Medicare for all. If you support Medicare for all, please let Congress know. Sign this petition.

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  • If Trump undermines ACA, CBO says health insurance premiums will soar

    If Trump undermines ACA, CBO says health insurance premiums will soar

    President Trump has not succeeded on his promise to repeal the Affordable Care Act. Now, the Congressional Budget Office (CBO) says health insurance premiums will soar if Trump follows through on his vow to undermine the ACA. In fact, Trump’s plan to destroy the ACA would cost the U.S. almost $200 billion over the next ten years.

    According to the CBO, 2018 premiums would rise by 20 percent if Trump refuses to pay the ACA’s copay and deductible subsidies, called “cost-sharing reductions,” guaranteed to people with incomes under 250 percent of the federal poverty level. By 2025, premiums would rise by 25 percent. Insurers would need to raise premiums to make up for their lost copay and deductible revenue.

    Because the federal government helps pay the premiums of people with incomes under 400 percent of the federal poverty level who enroll in health plans through the state health insurance exchanges, a 20 percent premium increase would mean the government would have to pay an additional $194 billion in premium costs.

    The CBO further projects that some health plans would leave the ACA marketplace, reducing choice and competition. And, 5 percent of health care markets would not have a health plan in 2018. As of now, in 2018, one county in Wisconsin and one in Colorado will have no ACA plan options.

    Higher insurance premiums would mean that the federal deficit would increase $53 billion by 2026.

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  • Senate health care bill will leave millions without needed care

    Senate health care bill will leave millions without needed care

    If passed, the Republican Senate’s misnamed “Better Care Reconciliation Act” (BCRA) would deny health care coverage to 22 million low and middle income Americans, according to the Congressional Budget Office. It would end Medicaid coverage for millions of Americans and would not guarantee people even basic coverage of essential health benefits, likely leaving millions without needed care. It also permits states to allow insurers to hike up premiums and out-of-pocket costs significantly.

    Under pressure from doctors, activists and the public at large and without adequate support in the Senate, Senator Mitch McConnell is delaying a vote on the bill until after the July 4th recess. Right now, Republican Senators Rand Paul and Ron Johnson believe the Senate bill to be too generous and have said they will not support it. And, Republican Senators Dean Heller of Nevada and Susan Collins say it is not generous enough. After McConnell said he would delay the vote, Senators Jerry Moran of Kansas, Shelley Moore Capito of West Virginia and Rob Portman of Ohio also came out publicly against the bill, according to the New York Times.

    It’s not at all clear that all of the elements in the Better Care bill can be included as part of the budget reconciliation because they bear on matters beyond the budget. Only if they can, could they be enacted by a simple majority in Congress.

    For now, here are key provisions of the BCRA:

    • Wealthy people and the health care industry would pay lower taxes, while middle and lower income people, older people and less healthy people, will pay more for their health care coverage. The tax cut for the wealthy and the health care industry will mean $700 billion less to support health care for people with lower incomes and in poorer health over the next ten years. The 400 highest-income earning families in America–people who earn more than $300 million a year–would each see $7 million more a year. The $33 billion more they will see over the decade beginning in 2019 would fund Medicaid expansion for 726,000 people in Arkansas, Alaska, West Virginia and Nevada, according to the Center on Budget and Policy Priorities. The bill would repeal the 3.8 percent Medicare tax on unearned income as well as the tax on high earners. The ACA’s tax on health insurers, medical device companies and drug companies also would be eliminated.
    • Insurer premiums would no longer be restricted to the cost of providing care plus a 15-20 percent charge for administrative costs and profits. If the state permits it, premiums could be set to deliver less value to consumers and give insurers far higher profits.
    • States would have the authority to determine whether their health insurance marketplace continues and whether insurers must cover essential health benefits, such as maternity care, mental health care and prescription drugs. States could also decide that insurers do not need to impose annual out-of-pocket caps and may impose annual and lifetime coverage limits. The only constraint on states is that their plan not increase the federal deficit.
    • Individuals would not be required to have health insurance. Without an insurance mandate, people with coverage will pay higher premiums. They will end up subsidizing the cost of care for people who do not buy insurance, and the pool of people with coverage will include fewer healthy people who will be more inclined to go without coverage.
    • Medicaid would be cut significantly. Not only does it end Medicaid expansion in 2021, it slashes the Medicaid budget by $772 billion. It also limits coverage to a fixed amount per person or a fixed amount per state. Under the ACA, 31 states expanded Medicaid to cover people up to 138 percent of the FPL, about $15,000; and, currently, Medicaid covers as much care as people need, without limit.
    • Subsidies for people with low incomes would be cut significantly and their deductibles and copays would rise. People with incomes under 350 percent of the federal poverty level would still get some help. But, unlike the ACA, which helped people up to 400 percent of the FPL with the cost of a good health insurance policy, the Senate Republican plan helps only a little with the cost of a limited insurance policy. The ACA provided help to people who needed to spend 9.7 percent or more of their income on a plan that covered 70 percent of their health care costs. The Senate bill expects people to spend as much as 16.2 percent of their income on a plan that covers only 58 percent of health care costs before it provides a subsidy.
    • Insurers would still be required to cover everyone who sought coverage, including people with pre-existing conditions who waited to get sick before applying for coverage. But, there would be a six-month waiting period before coverage kicked in.

    If you support improved Medicare for all to ensure health care for everyone in America, please sign this petition.

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