New data show health exchanges expand competition

By Kelly Kennedy, USA TODAY 5:10 p.m. EDT May 30, 2013


Story Highlights

  • About 90% of Americans will be able to pick from five or more insurers
  • Early results show premiums lower than expected

WASHINGTON — New data collected by the Department of Health and Human Services show that about 90% of Americans buying individual insurance from state health insurance exchanges will have at least five companies to choose from when the exchanges start operations Oct. 1, according to a memorandum released by the White House Thursday.

In many states, the memorandum said, only one or two insurers have controlled the market for individual insurance policies, the type that people without employer-supplied health insurance have to buy.

The data are not surprising, said Robert Zirkelbach, spokesman for America’s Health Insurance Plans, because insurers are doing all they can to provide a variety of plans at lower costs. In the states that have released plans and prices, such as Oregon and California, he said there are plenty of choices.

“I think that’s what we’re going to see across the country,” he said. “Competition is a good thing.”

According to the HHS statistics, which could change as states review the plans for approval, about 120 insurers have applied to operate plans through the exchanges. HHS found that 65% of new insurance entrants will be in states where one company dominates the market now.

The HHS examined data from 19 states with a federally run exchange and from other state marketplaces that have publicly released insurer information, the memo said. “Together, these states represent an estimated 80% of the 7 million people” the Congressional Budget Office said will buy insurance through the exchanges next year.

In the past, the insurance market has been essentially static as new customers tended to move into the market through their employers, rather than the individual market. Those with pre-existing conditions were often excluded from buying new plans.

As part of the 2010 health care law, the 7 million new customers give insurers an incentive to compete for that market, the memo said. Customers will easily be able to do a side-by-side comparison of costs and benefits in the online health exchanges.

Seventeen states and the District of Columbia have received HHS approval to create their own exchanges, and 15 states will work with HHS to run a marketplace, while the 19 remaining states will operate exchanges created for them by the federal government. Many states, particularly those with Republican legislatures and governors opposed to President Obama’s health care law, did not create exchanges.

States operating federally created exchanges will work with HHS to to ensure that insurers follow state and federal laws. Those states’ insurance commissioners will operate as they have in the past, Gary Cohen, director of the Center for Consumer Information and Insurance Oversight, told USA TODAY in March.

Before the entry of new insurers into state markets this year, HHS statistics show, most states’ insurance markets were dominated by either one or two companies. In 2012, HHS found the following:

• In 11 states, the largest two insurers covered 85% or more of the individual market.

• In 29 states, one insurer covered more than 50% of enrollees in the individual market.

• In 45 states and the District of Columbia, two insurers covered more than half of enrollees.

Beginning in October, individuals will be able to do a side-by-side comparison of plans either through online state or federal exchanges. Insurers will not be able to charge more for or exclude those who have pre-existing conditions.

Insurers have submitted proposed pricing and plans, and, in the states that have released that data, there is a large variety of pricing. California’s premiums came in 50% lower than what had been projected, and in Washington and Oregon, people will pay less for premiums on the individual market than they did before the law, also called the Affordable Care Act.

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CDC: 1 in 5 Adults Used Emergency Department in 2011

John Commins, for HealthLeaders Media , May 31, 2013

The federal agency’s findings, other data, and practical experience suggest that hospitals should brace for a pronounced increase in ED use in 2014 when the ranks of the insured are expected to expand, says a board member of the American College of Emergency Physicians.



One in five adults visited the emergency room at least once in 2011 and 7% reported two or more visits for the year, the Centers for Disease Control and Prevention reports.

The CDC’s 36th annual Health, United States, 2012 report also found that in the decade from 2001 to 2011 both children and adults on Medicaid were more likely than the uninsured and people with private insurance to have at least one emergency room visit in the past year.

Andrew I. Bern, MD, an emergency physician in Florida and a board member with the American College of Emergency Physicians, says much of the CDC report “absolutely validates” what his organization has long been saying.

 “The data is debunking the myth that only the uninsured go to the ED,” Bern says. “We’ve been saying that for a while but it has not been carried well by the media.”

Bern says the CDC data, other reports, and practical experience suggest that hospitals should brace for a pronounced increase in ED use in 2014 when the ranks of the insured are expected to expand by about 30 million people under the Patient Protection and Affordable Care Act.

“If you look at the Massachusetts, which is the basis for the Affordable Care Act, they found their volume of ED visits increased about 9% a year. When Canada instituted similar sorts of coverage their visits went up as well,” Bern says. “Wherever this has been attempted to provide universal coverage or near-universal coverage utilization increases unless you provide an infrastructure alternative, such as increasing the primary care physician access.”

Bern says it’s becoming apparent that sufficient ED alternatives will not be in place in many parts of the U.S. in 2014 when the ranks of the insured expand.

“You have alternative sites of care being developed but there is not good information on what impact that will have,” he says. “Those alternative sites of care include the retail clinics run by nurse practitioners, urgent care centers, and free-standing emergency departments that are popping up in different states. These may ultimately provide different sites of care when people are looking for care urgently but there is no consistent basis. If a patient wants to be sure that they are not going to be turned away the only sure bet they have is the emergency physicians who are under federal law to treat everybody regardless of their ability to pay.”

The CDC report also noted that:

  • In 2009–2010, cold symptoms were the most common reason for emergency room visits by children (27%) and injuries were the most common reason for visits by adults (14%.)
  • Between 2000 and 2010, 35% of emergency room visits included an x-ray, and the use of CT or MRI scans increased from 5% to 17% of visits.
  • In 2009–2010, 81% of ED visits were discharged for follow-up care, 16% ended with the patient being admitted to the hospital, 2% ended with the patient leaving without completing the visit, and less than 1% ended in the patient’s death.
  • In 2009–2010, 59% of ED visits (excluding hospital admissions) included at least one drug prescribed at discharge.
  • During 2001-2011, the percentage of persons with at least one ED visit in the past year was stable at 20-22%, and the percentage of persons reporting two or more visits was stable at 7-8%.

Bern says the CDC findings are consistent with a RAND Corporation study commissioned by the Emergency Physician Action Fund which shows that emergency physicians are key decision makers for nearly half of all hospital admissions.

RAND found that hospital admissions from the ED increased 17% over seven years, accounting for nearly all the growth in hospital admissions between 2003 and 2009, offset by a 10% drop in admissions from primary care physicians and clinical referrals. Nearly all of the increase was from “non-elective” admissions from the ED—a rate 3.8 times the rate of population growth.

Hospital inpatient care is a key driver of healthcare costs, accounting for 31% of the nation’s healthcare expenses. Because of that, the role emergency physicians play in deciding who to admit to the hospital is critical to hospital cost savings, since the average cost of an inpatient stay ($9,200) is roughly 10 times the average cost of a comprehensive emergency visit ($922), RAND said.

“When you look at the overall $2.7 trillion healthcare system and that 31% of that expense is in the hospital and we are integrally involved in 50% of those admissions decisions it points to the value of the emergency physicians in the entire system,” he says.

“The things we are proposing in terms of costs savings and integration are important points and our role in the entire healthcare context is one that is very very important to the bulk of that.”

John Commins is a senior editor with HealthLeaders Media.

Young adults protected from emergency room costs under Affordable Care Act: Study

By Ryan Jaslow /

CBS News / May 29, 2013, 6:13 PM

The Affordable Care Act has provided financial protections for young adults facing medical emergencies, according to a new study.

President Barack Obama signed the law in March 2010, and one of its provisions that kicked in that September allowed young adults between the ages of 19 and 25 to stay on their parents’ private health insurance plans. The extra coverage stops when they turn 26 years old.

Researchers from the nonprofit research organization, the RAND Corporation in Washington D.C., examined more than 480,000 emergency room visits that took place between 2009 and 2011 at nearly 400 U.S. hospitals, to find out whether the ACA had any impact on their coverage.

They were only looking at serious injuries and illnesses that would likely cause a person to seek care in the emergency room whether or not they had insurance. Uninsured patients sometimes visit the ER as their primary care provider for even minor ailments.

The researchers compared the coverage rates in young adults to a comparison group of adults ages 26 to 31 who were not affected by the new law. They found in 2011, more than 22,000 emergency visits involved young adults who were newly insured because of the provision. That represented at 3 percent increase in health insurance coverage rates among young adults in need of emergency care.

The study was published May 29 in the New England Journal of Medicine.

“The change allowing young people to remain on their parents’ medical insurance is protecting young adults and their families from the significant financial risk posed by emergency medical care. Hospitals are benefiting, too, because they are treating fewer uninsured young people for emergency ailments,”” lead author Andrew Mulcahy, a health policy researcher at RAND, said in a press release. “Because we looked at only the most-serious emergency cases to rule out the influence of insurance on the decision to seek health care, we probably underestimate the full financial benefits that the new rules have provided to young adults who need urgent medical care.”

Research in September 2011, one year after the young adult provision had been implemented, found the number of uninsured adults between 19-25 dropped from 10 million from 2010 to 9.1 million in the first three months of 2011, a sharp drop for a short time period.

A more recent study RAND cites estimated the provision led to an added 3.1 million insured young adults.

The ACA’s mandate to cover all uninsured Americans begins in 2014. has more information on the Affordable Care Act for young adults.

© 2013 CBS Interactive Inc. All Rights Reserved.
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For Many, Affordable Care Act Won’t Cover Bariatric Surgery

by Sarah Varney

May 27, 2013 3:31 AM |


JACKSON, Miss. — Uninsured Americans who are hoping the new health insurance law will give them access to weight loss treatments are likely to be disappointed.

That’s especially the case in the Deep South, where obesity rates are among the highest in the nation, and states will not require health plans sold on the new online insurance marketplaces to cover medical weight loss treatments like prescription drugs and bariatric surgery.

Dr. Erin Cummins directs the bariatric surgery department at in the state capital of Jackson. She grew up in the Delta, her husband is a cotton farmer, and although she’s petite and fit, she understands well enough how Mississippians end up on her operating table.

“You have to realize in the South, everything revolves around food. Reunions, funerals, parties — everything revolves around food,” Cummins says.

That long-standing food culture, as well as other factors like inactivity and poverty, have saddled Mississippi with the highest obesity rate in the nation.

Roughly 1 in 3 adult Americans is now obese. And ground zero for the nation’s obesity battle is Mississippi — where 7 of 10 adults in the state are either overweight or obese. The problem is most pronounced in Holmes County — the poorest and heaviest in the state.

Doctors here are no longer surprised to see 20-somethings with diabetes, hypertension, sleep apnea, heart disease and severe joint pain. And the prevalence of severe and super-obesity is growing rapidly. For those patients, bariatric surgery is considered the most effective treatment to induce significant weight loss.

Cummins describes the procedure: “We’re restricting the stomach size to where a patient isn’t going to eat as much. Then we reroute the intestines a little bit and realign it to delay digestion, so to speak, to bypass it. So everything a patient eats in a gastric bypass is not going to be absorbed.”

After surgery, many of the complications of obesity, like sleep apnea and high blood pressure, are reversed. Multiple that about 80 percent of diabetics can stop medication in the first year.

Medicare and about two-thirds of large employers cover bariatric surgery in the U.S. But the procedure is pricey — an average of $42,000 — and many small employers, including those in Mississippi, don’t cover it.

When the Affordable Care Act became law in 2010, one goal was to erase those sorts of regional variations in access.

“Our hope was that there would be a single benefit for the entire country, and as part of that benefit there would be coverage for obesity treatment,” says . He is director of bariatric surgery at Stanford University Morton, and has led national and state lobbying efforts to get insurance coverage for teh surgery.

But amid worries that a uniform set of benefits would be too expensive in some states, and sensitive to the optics of the federal government laying down one rule for all states, the U.S. Department of Health and Human Services changed course. It decided instead to match benefits to the most popular small group plan sold in each state, in essence reflecting local competitive forces.

That’s led to an odd twist: In more than two dozen states, obesity treatments – including intensive weight loss counseling, drugs and surgery – won’t be covered in plans sold on the exchanges.

Bariatric surgery won’t be covered on the exchanges in Alabama, Louisiana, Arkansas, Texas and Mississippi. That’s where, according to the Centers for Disease Control, .

Morton applauds the growing awareness around obesity prevention in the U.S., but, he says, some 15 million Americans who are already severely obese still need medical treatment.


“If they don’t have insurance, they’re not going to get the therapy,” Morton says. “We see cancer therapy covered routinely. We see heart disease covered routinely. Why is it that we don’t see obesity coverage routinely?”

Therese Hanna, Executive Director of the , isn’t surprised that obesity treatments are excluded on the insurance exchange in her state. She says it all has to do with keeping cost down for many people who will be buying insurance for the first time.

“With the discussions around what should be covered under the exchange within the state, a lot of it had to do with balancing cost versus the coverage,” says Hanna.

Hannah says Mississippians who buy insurance on the exchange will likely be the cashiers, cooks, cleaners and construction workers that make up much of the state’s uninsured. And even though many of them will qualify for federal subsidies, the price of monthly premiums must be kept low.

“If you try to include everything, the cost would be so high that people wouldn’t be able to afford the coverage, so you defeat the purpose,” Hanna says. The discussion in Mississippi, she says has focused on providing care for things like high blood pressure, diabetes and heart disease. “So we have a lot of needs to be covered other than obesity itself.”

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.

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Virginia to Launch 4-Year Managed Care Program for Dual Eligibles

Written by Jim McLaughlin

May 22, 2013

Becker’s Hospital Review

Virginia has received federal approval for a four-year managed care program for 78,000 dual eligibles that could save the state tens of millions of dollars by 2015, according to a report by the Washington Post.

Gov. Bob McDonnell (R) backed the Commonwealth Coordinated Care program as a condition for his support for expanding Medicaid. When the program goes live Jan. 1, it is expected to save the state $11 million in its first six months through improved management of agencies that administer Medicare and Medicaid for dual eligibles.

Officials estimate the program will save an additional $22.6 million in fiscal year 2015, which begins July 1, 2014.

 © Copyright ASC COMMUNICATIONS 2012. 

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Labor union concern over fallout on Obamacare is growing, report says

Wall Street Journal’s Streaming Coverage

President Obama is beginning to find an unlikely rival to his signature health-care overhaul initiative — labor unions.

By Russ Britt

The Hill reports that President Obama is beginning to find an unlikely rival to his signature health-care overhaul initiative — labor unions.

Several labor groups are concerned that implementation of the measure formally known as the Affordable Care Act will let their members fall through the cracks in the law and they’re calling for those to be patched up before the major portions of the bill go into effect next year, The Hill said in a report on Tuesday.

The publication that covers Washington politics said the 1.3 million-member United Food and Commercial Workers Union is worried that restaurant employees covered under multi-employer coverage known as Taft-Hartley plans. It seems that those plans, which cover 20 million people, are not be eligible for tax subsidies.

Therefore, employers may release their workers from those plans and let them pursue their own insurance on state-run exchanges. Democratic leaders, including outgoing Montana Sen. Max Baucus, are worried that troubles like these could result in a “train wreck” once the administration tries to pass the measure.

Further, other unions are concerned about the issue, including the United Union of Roofers, Waterproofers and Allied Workers, as well as the hotel workers’ union Unite Here and the International Brotherhood of Teamsters. And passing legislation to repair any fixes may be impossible with the current divisive climate in Congress.

UFCW President Joseph Hansen, in an accompanying op-ed piece for the publication, nevertheless said it is up to Obama to try and find a solution.

“We’d be open to a legislative fix, but ultimately this is the administration’s responsibility. They are leading the regulatory process. It’s their signature law,” Hansen wrote. “We don’t want a handout. Our members want to keep the healthcare they currently have. We just want them to be treated fairly.”

Follow Russ Britt on Twitter @russbrittmktw


Follow Health Exchange on Twitter @MWHealthBlog


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Uncompensated Care Faces a Double Hit in Some States

Philip Betbeze, for HealthLeaders Media , May 22, 2013

Hospitals in states that opt not to expand Medicaid are at a severe disadvantage to their counterparts in other states, not only because they will miss out on additional Medicaid-based reimbursement, but also because they will face the same cuts in disproportionate share funding as everyone else.

This article appears in the May issue of HealthLeaders magazine.

Medicaid is widely regarded as a poor payer related to costs, but hospitals, especially the nation’s safety-nets, are eager to get more of their state’s residents on the plan nevertheless. That’s because Medicaid’s reimbursement rate, which varies by state, is much better than nothing at all, which is what many hospitals claim they get, in reimbursement terms, from treating the uninsured.

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But getting more of their patient mix from Medicaid patients rather than the uninsured will be difficult for those in states that have so far refused to expand their Medicaid rolls. Refusing expansion, of course, is their right, according to the Supreme Court’s 2012 decision on the constitutionality of the Patient Protection and Affordable Care Act, in which the Medicaid expansion is enfolded.

But doing so might not only transfer funding to states that do expand, but it also might leave safety-net hospitals with the same costs to treat the uninsured, while other sources of funding, such as disproportionate share dollars, are reduced over time.

As HealthLeaders went to press, 14 states still have refused to participate in the Medicaid expansion, which would take effect in 2014 and make adults with incomes up to 138% of the federal poverty level eligible to enroll.

The problem, say state governors who are resisting, is that although the federal government has agreed to pick up all of the tab for the first three years of expansion and 90% thereafter, there is no way to ensure that future Congresses will keep those promises, meaning states could be on the hook for more than they bargain for under current rules.

The problem for hospital leaders, however, is that if a state does not choose to expand, hospitals in those states will be forthwith at a severe disadvantage to their counterparts in other states not only because they will miss out on additional Medicaid-based reimbursement, but also because they will face the same cuts in disproportionate share funding that their counterparts in other states will see.

“The most vulnerable hospitals will be major safety-nets in urban areas that are currently treating patients who don’t have health insurance and that are dependent on local funding and disproportionate share funding,” says Bruce Siegel, MD, MPH, president and CEO of the National Association of Public Hospitals and Health Systems, a Washington, D.C.–based organization that lobbies on behalf of its members. “We’ll see this funding drop, and will also see continued pressure on the local funding side because of the economy.”

Those dollars lost will be significant, he adds. An NAPH study released late last year found that hospitals could face an increase in uncompensated care costs of $53.3 billion by 2019 if a substantial number of states do forego expansion, coupled with an estimated loss of $14.1 billion in disproportionate share funding.

For most safety-net hospitals, many of which already get by on local tax subsidies, such a drop in revenue could be devastating not only for them but for other hospitals in their states, which would presumably see increased bad debt and funding shortfalls where treating the uninsured is concerned.

Revenue issues apply statewide
Safety-net hospitals will initially bear the brunt of their states’ decisions not to expand, says Siegel.
“If you’re a hospital today that has mostly paying patients and very little charity care, you should be okay, at least in the short term,” says Siegel, who previously served as president and CEO of Tampa General Healthcare and also of New York City Health and Hospitals Corporation. “You’re not counting on coverage expansion and you don’t need disproportionate share and you’re probably not getting much of it right now anyway. But if you’re a safety-net hospital, you have potentially the worst of all
possible worlds.”

For John Haupert, CEO of Atlanta’s 650-staffed-bed Grady Health System, that could mean an annual loss of tens of millions in reimbursement for an already fiscally challenged public hospital system.

By 2016, when disproportionate share funding scales back to 50% of its current levels, “we lose $45 million a year,” he says.

But on a longer-term basis, other hospitals will also be negatively affected.

“All hospitals have skin in this game,” says Siegel. “A lot of hospitals maintain their margin because of the safety-net taking the uninsured, and if that goes away, they will bear the brunt. That’s not a secret to them, but still a threat.”

The haves and have-nots
Though the states that have so far refused still can accept Medicaid expansion, safety-nets in states that refuse expansion are likely to be most at risk.

And though Grady’s Haupert expects much to change in coming years surrounding the Medicaid expansion, he and his board are having to make long-term plans to deal with lots of potential challenges. And it’s frustrating to them that hospitals are in a political fight they didn’t ask for.

“Already we get a disproportionate unfunded mandate. That’s our mission and we have some local tax support, but the bigger issue for us is that the way the law is written, you’re going to give back 50% of your disproportionate share funding even if they don’t expand,” Haupert says.

“The diabolical thing is we have an uncertain insurance expansion and a certain cut in disproportionate share,” echoes Siegel.

If nothing changes, that would mean huge disparities in how much reimbursement similar safety-net hospitals in other states would get versus hospitals in states like Georgia.

“Many say this is too good of a deal to pass up because if the feds don’t deliver on paying for the expansion, you can unwind it,” says Haupert. “Our reality, though, is that I don’t see us expanding immediately.”

For Haupert and his board, that means serious consideration of cuts in services, and with a $45 million annual hole to fill, and it’s not idle talk to discuss eliminating money-losing services, like behavioral health, he says.

“We’ll eliminate or reduce clinical services, period,” Haupert says. “One example I gave to the governor [Republican Nathan Deal] personally is that Grady is the state’s second-largest provider of mental health [care]. If this happens, can we continue to provide it? We could save $25 million to $30 million a year by not doing it, but what does that do to the state? In this case the law of unintended consequences is significant.”

Other hospitals in less populated areas of the state, he predicts, will simply close.

“We have 15 hospitals that will close if the state does not expand its Medicaid program or we don’t get the disproportionate share funding issue resolved, and I don’t see too many governors who want that on their hands,” he says.

Many of the states that are so far rejecting the Medicaid expansion are the same ones that are not planning on setting up insurance exchanges on their own. Though both pieces of the legislation have serious implications for hospital revenue, the delays that are expected to surround states that aren’t setting up exchanges could have a knock-on effect on revenues for hospitals in those states.

Hard lobbying
Like Haupert, Siegel says hospital leaders need to take their issues straight to their governors and paint the picture. He says it can be effective to partner with businesses to push for the expansion.
“Not expanding is an act of fiscal insanity. This is a core economic issue,” he says. “States that do not expand are literally taking their federal tax money and giving it to other states. It’s hurting patients and small businesses in your state.”

But some governors seem steadfast, at least for now. That’s why, in parallel, NAPH and hospitals that will be affected by the disproportionate share funding drop are working on possible modifications to that piece of the law. But as Haupert says, hospitals are caught in the middle of two government entities engaging in high-stakes brinksmanship.

“Someone’s going to have to blink,” he says. “HHS is going to use the disproportionate share issue to the final minute to get the s and years, especially surrounding adjustment of the disproportionate share cuts.

“All of us should be working really hard to educate our governors and congresspeople about the reality of the DSH cuts,” Siegel says. “That will take some time. Right now, the reductions are still a few years out—they don’t start getting big until after 2016, but in an atmosphere of gridlock, it’s hard to get action until a disaster is about to occur.”

Of course, if modifications are made to disproportionate share funding to help alleviate the burden on hospitals in states that won’t expand, some might see it as a reward for political intransigence.

“If they let the number of uninsured drive the calculation, they’ll have to take disproportionate share money away from states like New York and California and give it to states like Texas,” Siegel says, “which would be ironic. There are lots of carrots and sticks in play here.”

Reprint HLR0513-5

This article appears in the May issue of HealthLeaders magazine.

House Lawmakers Grill CMS Over Health Exchange Navigators

Margaret Dick Tocknell, for HealthLeaders Media , May 22, 2013

The role of navigators, expected to help millions of uninsured make their way through the health insurance market, came under fire Tuesday by members of Congress who raised questions about oversight and the role of the IRS in the implementation of healthcare reform.

A meeting of the House Committee on Government Oversight and Reform called ostensibly to discuss the role that navigators and assistors will play in the enrollment process for new health insurance marketplaces included statements and questions about role the IRS is expected to play in the implementation of healthcare reform.

See Also: What About the Insurance Exchanges?

The meeting veered further off topic into concerns over the fundraising efforts of Kathleen Sebelius, the secretary of the Department of Health and Human Services.

Rep. Jim Jordan (R-OH), chair of the Subcommittee on Economic Growth, Job Creation, and Regulatory Affairs, set the Republican tone in his opening comments. “In light of the revelations of the IRS targeting conservative groups… it is crucial for the American people to understand that Obamacare tasks the IRS with enforcing nearly 20 new tax laws. That’s amazing to me. The very organization charged with enforcing Obamacare was systematically targeting conservative groups that came into existence because they oppose Obamacare.”

Jordan stated that the IRS role in enforcing Obamacare is tied to the navigator and assistor program through the premium subsidies that will be available to qualified individuals. “If [they] incorrectly fill out a person’s health insurance application, and that person receives subsidies to which they are not entitled, then the IRS will go after the individual.”

He went on to note that as part of “Obamacare, the IRS is building the largest personal information data hub that the federal government has ever attempted.”

On the Democratic side reaction was swift and pointed. “Until recently I thought that the difference between us and a Banana Republic was that in this country once a law is passed or the Supreme Court has spoken, the law was the law even when our side lost,” said Rep. Eleanor Holmes Norton (D-DC).

“Republicans are still fighting the Affordable Care Act as if it is not the law of the land… Today’s hearing is merely an effort to continue to obstruct the law and the right of citizens to health insurance.”

Amid the posturing on both sides of the aisle, the sole witness, Gary Cohen, deputy administrator and director for the Center of Consumer Information and Insurance Oversight for the Centers for Medicare & Medicaid, soldiered on. His five-minute statement focused entirely on how navigators are expected to help millions of uninsured make their way through the complicated health insurance market.

While the marketplaces hold the promise of being places where consumers will be able to easily compare costs, benefits, and cost-sharing to select a plan that is right for them, Cohen stated that “ensuring that consumers and businesses participate in the marketplaces requires that they learn about the benefits that these marketplaces have to offer and that they get the help they need to take advantage of those benefits. This is a significant undertaking. We know quite a bit about the uninsured American we need to reach: many have never had health insurance, so the transaction of selecting, applying, and enrolling in healthcare coverage will be unfamiliar…20% have not completed high school. To effectively reach these populations…information must be provided by people connected to the community in an appropriate manner.”

He noted that navigators and assistors will operate much like insurance brokers and agents and agents already do today—educating consumers about the marketplaces and insurance affordability programs, comparing plans, helping consumers receive eligibility determinations, and enrolling in coverage.

Felons as navigators?
Rep. James Lankford (R-OK), chair of the Subcommittee on Energy Policy, Healthcare, and Entitlements, asked about basic requirements to become a navigator. “Has HHS mandated criteria for individuals who would be navigators? Could felons, individuals convicted of identity theft, or high school dropouts become navigators and handle sensitive and personal information? Is there an expectation that a navigator will have any prior knowledge of the health insurance market? Is there an oversight plan?”

In his statement, Cohen noted that HHS has extensive experience providing outreach and enrollment assistance in Medicaid, the Children’s Health Insurance Program (CHIP), and Medicare. “CMS designed navigator and in-person assistance grant programs that will allow qualified and well-trained individuals and organizations help consumers find and enroll in healthcare coverage, while adhering to standards and requirements designed to ensure that taxpayer money is used appropriately.”

HHS has earmarked about $54 million to fund navigator in federal or state marketplaces. Cohen said the opportunity is open to the self-employed as well as community and consumer-focused non-profits. Trade, industry, and professional associations, commercial fishing industry organizations, ranching and farming organizations, chambers of commerce, unions, and licensed insurance agents and brokers may also apply.

The CMS Office of Acquisitions and Grants Management will oversee the review and evaluation of the grant applications. Grantees must also complete a 20-30 hour training program and pass an exam.

“I’m a dentist and I don’t see how 20 hours of training will get this done. That’s inadequate. What are the checks and balances on the education component?” asked Rep. Paul Gosar (R-AZ). “Is someone visiting with that navigator or is [the training] all online? What stops a convicted felon from becoming a navigator?”

“It’s online just as it is in many states for insurance agents and brokers,” responded Cohen. “If you look at the type of organizations that will apply for these grants I don’t think felons will be a problem.”

In his final comment Rep. Jim Jordan again turned his attention to the IRS. “The American people want to know what role the IRS will play in their healthcare and the implementation of the Affordable Care Act. As an American, does the IRS role in this scandal trouble you?

“The IRS has a significant role in enforcing tax provisions of the Affordable Care Act, but there’s more to the ACA than just tax questions” noted Cohen. He added that he didn’t see a connection between the navigator programs and the IRS monitoring conservative groups.

Concerns about Sebelius’s fundraising
Rep. Lankford (R-OK) then turned to media reports that Secretary Sebelius is soliciting funding for the assistor program from health plans, hospitals and pharmaceutical companies to donate to nonprofits responsible for outreach efforts. “These actions unduly pressure private companies to financially support implementation and promotion efforts. Fearing HHS retribution if they don’t contribute. The secretary must stop using unethical methods to fund the law’s implementation.”

“I have no knowledge of her calls,” responded Cohen. He added that public-private partnerships are often used to help fund projects.

Margaret Dick Tocknell is a reporter/editor with HealthLeaders Media.

Doctor shortages may undercut Kentucky Medicaid expansion

Flood of patients is a concern

May 21, 2013   |
Written by
Laura Ungar
The Courier-Journal

Dr. Ron Waldridge II sees up to 24 patients a day at a busy family practice in Shelbyville, and says he can’t take on any new ones unless they are family members of people he already treats.

So he wonders how he and other Kentucky doctors will be able to handle the tens of thousands of Kentuckians expected to get Medicaid coverage through health reform.

“On the one hand, you’d love to see universal coverage,” the second-generation family physician said. “But I don’t think there’s a lot of open space for people getting insurance to find a new doctor.”

Gov. Steve Beshear’s recent decision to expand Medicaid opens the program to 308,000 residents earning 138 percent of the federal poverty level or less, and officials estimate that 332,000 more uninsured residents can gain coverage using new insurance marketplaces called exchanges.

But Kentucky’s longstanding physician shortages, combined with refusals by some doctors to take new Medicaid patients because of low reimbursements, threaten to undercut those efforts — particularly in rural areas.

The result might affect not only the newly insured but other patients who potentially face longer waits to see a doctor or specialist.

Data analyzed by The Courier-Journal shows that Kentucky counties that will see the largest portion of nonelderly residents become eligible for Medicaid often have fewer primary care doctors per capita. Casey County, for example, has the highest portion of newly eligible residents at 13.5 percent, but it ranks in the bottom third for doctors per capita.

Experts say expanding community health centers serving low-income patients, and creating more teams of health care workers may help but won’t solve the problem.

Similar issues plague rural states across the nation, said Peter Cunningham, senior fellow at the Center for Studying Health System Change, based in Washington, D.C.

“Rural areas simply don’t attract enough physicians,” he said. “In a lot of places, there’s already strained capacity, and this is going to strain it even more.”

Demand and supply


The federal government lists 192 areas in Kentucky — including 47 counties — with shortages of health professionals. Kentucky Health Facts listed about 10,000 physicians in the state in 2009, including 4,200 in primary care.

“We can’t grow physicians fast enough to meet the need, in the rural areas especially,” said Susan Zepeda, president and chief executive officer of the Foundation for a Healthy Kentucky.

The state Cabinet for Health and Family Services plans a briefing on the health care work force today, during which officials will discuss results of a study by Deloitte Consulting intended to address the issues.

Officials would not release the study early, but the cabinet and Beshear’s office said in a joint statement that “issues around access to health care and workforce capacity have been a concern for a number of years in Kentucky.”

Shelby County, where Waldridge practices, ranks in the bottom half of counties for primary-care doctors per residents. Waldridge said he and the partners in his practice, which is part of KentuckyOne Health, have about 10,000 patients, about 15 percent of whom are on Medicaid. Waldridge said he personally sees about 1,700 patients.

As a state, he said, “the physician manpower issues we deal with should have been addressed before this.”

Other doctors and nurses shared similar concerns, with some saying patients may turn to emergency rooms because they can’t find primary care doctors.

“I’m not sure who’s going to pick up all those (new) patients into their practices,” said Julianne Ewen, a nurse practitioner in Lexington and president of the Kentucky Coalition of Nurse Practitioners and Nurse Midwives.

The problem is less acute in Louisville, which has one of the state’s highest rates of primary care doctors compared with population, and where hospital systems, such as Norton Healthcare, Baptist Health and KentuckyOne Health have been expanding their primary care networks.

“We think we can absorb a significant number” of new patients, Norton Chief Executive Officer Stephen Williams said.

Waits and crowding are “certainly a potential problem,” Williams said. “But 300,000 (new Medicaid patients) are going to be spread across the entire state. I doubt this will turn into a huge problem — although there may be pockets.”

Patients, payments

Doctors and nurses said another complicating factor is that newly insured patients tend to be sicker because they’ve delayed getting needed care.

Angela Estes, 43, of Columbia, an assistant at a nurse-practioner-only primary care office in her hometown, is uninsured but eligible for Medicaid under the expansion. She gets primary care at her workplace but has been putting off getting a mammogram, updated MRI scans for headaches associated with a neck injury, and recommended sinus treatment that would cost about $7,000.

With Medicaid, she said, “I’ll be able to hopefully get the care for things I need.”

But how quickly will they get it?

Doctors said patients who have put off care may need longer appointments, referrals for specialized care or hospitalizations — pushing up patient loads across the board.

Complicating matters, not all doctors take new Medicaid patients.

According to a 2012 study in the journal Health Affairs, 79 percent of office-based physicians in Kentucky, and 69 percent nationally, accepted new Medicaid patients in 2011.

State statistics show that the portion of Medicaid-registered primary-care providers currently accepting new Medicaid patients ranges from 81 percent to 99 percent, depending on the managed-care company.

Medicaid traditionally has reimbursed providers at lower rates than other types of insurance. Ewen, who said about a third of patients are on Medicaid, said the reimbursement is only $23 for a lower-level visit by an established patient.

The health reform law includes an incentive for more health providers to take Medicaid — an enhanced reimbursement rate for 2013 and 2014 at least equal to Medicare reimbursements. But health care workers said that is only temporary.

Addressing problem

A possible long-term solution includes greater reliance on community health centers, some say.

Family Health Centers in Louisville plans to renovate portions of the Phoenix Health Care for the Homeless site and relocate the East Broadway site to an adjacent building, making room to eventually see 10,000 new patients. Officials there said last May that they received $5.4 million in federal health reform grants for these projects.

At Park DuValle Community Health Center, meanwhile, Chief Executive Officer Anthony Omojasola said “none of our four sites are operating at full capacity right now, so we plan to absorb some of that surge in demand.”

Another solution is to attract more nonphysician health care providers, such as nurse practitioners, to areas lacking doctors. But not everyone agrees on how to do that.

Ewen and Beth Partin, who co-owns the practice where Estes works, said the state’s 2,800 nurse practitioners shouldn’t need “collaborative agreements” with doctors that are now required to prescribe nonscheduled drugs such as blood pressure medications. Partin said such agreements put practices in jeopardy if a doctor dies, moves or charges a large signing fee.

Physicians, however, have long argued that those agreements are essential. Cory Meadows, director of advocacy and legal affairs with the Kentucky Medical Association, talks about expanding care with nonphysicians in a “physician-led, team-based approach.”

“If we team up together to take care of people, we may not be as short of manpower,” Waldridge said.

Some health care leaders said the growing array of walk-in clinics, such as Baptist Express Care in Walmart stores, provide another avenue for care, at least for minor illnesses.

And hospital officials said they plan to continue expanding primary care and employ telemedicine. Ruth Brinkley, president and chief executive officer of KentuckyOne Health, for example, said her system is looking to open new primary care offices and hire more staff.

Meanwhile, Dr. David Dunn, vice president for health affairs at the University of Louisville, said the university is increasing physician training in such areas as family medicine and geriatrics and using funds from partner KentuckyOne to expand the nursing work force with professionals, such as advanced nurse practitioners.

Health providers and advocates agreed that getting more people insured should produce a healthier population in the end. But they said much remains unknown, including how many of those eligible for coverage under health reform will sign up for it.

“The more people we can get into the health care system, the more people get care. It not only saves and improves lives, but it also reduces costs,” said Norton’s Williams. “It’s going to be a positive over the long term. But I think there will be a learning curve and an experience curve.”

Reporter Laura Ungar can be reached at (502)582-7190 or on Twitter @lauraungarcj.


Latest Health Hurdle: Buying Insurance Without A Bank Account

by Sarah Varney

May 20, 2013 4:27 PM

Partner content from: Kaiser Health News

Millions of people who rely on check-cashing stores, like this one in New York City, could run into trouble buying health insurance.

Mary Altaffer/AP

When movie stars become unbankable, they’re no longer a slam dunk at the box office. When investments become unbankable, they’re relegated to the Wall Street’s junk pile. For ordinary Americans deemed unbankablethose who don’t have a traditional checking or savings account — it can be hard to simply pay bills.

And that absence of a bank account is about to become a big problem for those who also lack health coverage — and for the health insurance companies trying to sell them coverage. After all, how do you sell a product to a customer who has no easy way to pay you?

One in five households in the U.S. have only a tenuous relationship with a traditional bank. Many of 51 million adults in these households rely on check-cashing stores and money lenders, the Federal Deposit Insurance Corporation.

The federal health law requires most Americans to carry health insurance starting next January. The presents a particular problem for those households. Most health plans accept a credit card for the first month’s premium payment and then require customers to pay monthly with a check or an electronic funds transfer from a checking account.

Those options won’t work for the so-called unbankables looking to purchase health coverage with federal subsidies through online insurance marketplaces, says , a director at Leavitt Partners, a firm that is advising private insurers and states on how to comply with the law. “You don’t want to take these millions of unbankable people through the entire enrollment process and then at the end of line say, ‘OK, the only way you can pay for your share of the premium is with a bank account number,’ ” he says.

The consequences could be severe. When your cable gets turned off, you miss The Walking Dead or Pawn Stars. But starting next year, if your insurance is canceled, you’ll be breaking federal law and liable for any medical bills.

Researchers consumer financial behavior say people have their reasons for spurning banks. New immigrants, for example, may have distrusted the banks in their home country and brought that skepticism with them to the U.S. And for many people of modest means, overdrafts and fees charged by traditional banks can upend the financial balance in their household.

“The bank account is extremely stressful when you don’t have a job that’s reliable,” says Tran, a 25 year-old community organizer and Ivy League graduate who lives south of San Francisco.

Her current employer doesn’t offer her health benefits, and she was turned down, she says, when she applied for health coverage on her own. Tran hopes to get hired to a full-time position and asked that we use just her last name so it didn’t give her bosses a bad impression.

Tran says when she took her new job and no longer had direct deposit, Bank of America began charging her, up to $12 a month. “I was not happy with the charges,” she says.

Consumers who will be required to purchase health coverage will need payment options that are simple, easy and affordable, say consumer advocates and health care experts.

“I think there is a dawning awareness that this is a large problem,” says , senior vice president for health policy at Jackson Hewitt Tax Service. Until last year, Haile was wrestling with this problem on behalf of the state of Tennessee, where he served as director of the Insurance Exchange Planning Initiative. “We raised these issues with the federal government well over a year ago and in a series of about four or five letters.” Haile said he didn’t get much of a response then.

Indeed, neither the Affordable Care Act, nor any other federal health laws, require health insurers to accept all forms of payment, such as credit cards or the cash-loaded, prepaid debit cards that many people without bank accounts often rely on.

Federal officials are wary of doing anything to discourage insurance companies from selling plans on the exchanges, say current and former state health officers who have pressed the federal Department of Health and Human Services for a ruling.

One of the largest players on the new exchanges is likely to be WellPoint, a Blue Cross and Blue Shield licensee. In an email, a WellPoint spokesperson says the company is “evaluating expanded payment options to members.” Other insurers, including Cigna and UnitedHealthcare, are urging state officials in planning documents to allow companies to set their own payment policies.

Federal health officials issued a letter in April stating that all health plans selling coverage in the federally run insurance marketplaces in 28 states will have to accept payments in ways that don’t discriminate against their customers, but didn’t prescribe what those payments should be.

Varney is a reporter with our partner , a nonprofit news service.