Affordable Care Act has been good for temporary staffing agency

June 26, 2013, 11:09am EDT | Business First of Louisville

Malone Solutions clients are reluctant to hire permanent workers because they don’t know how strong the economic recovery will be and because of the uncertainties involved in which employees will need health insurance coverage under the Patient Protection and Affordable Care Act.

Although the Patient Protection and Affordable Care Act is not fully implemented yet, it already is benefitting at least one local business — staffing agency Malone Solutions.

Companies’ reluctance to hire permanent workers because of the unknowns involved in the implementation of the act has prompted a boom in revenue at Louisville-based Malone Solutions, said the company’s financial consultant, Brad Knight.

Last year, the company grew from $48 million to $78 million in revenue, he said in an interview, and this year he expects it to top $100 million. “We’re getting a lot of inquiries and talking to a lot of people,” he said.

The company employs more than 3,000 temporary workers in 20 states, Knight said. Most of the temps work in the auto industry.

The employers for which Malone provides temps are reluctant to hire permanent workers because they don’t know how strong the economic recovery will be, he said, but also because of the uncertainties involved in which employees will need health insurance coverage under the terms of the act.

“In the fact of the unknowns, they are increasing their contingent work force,” he said. “It’s a lot easier for our customers to put the burden of those unknowns on us than to make a long-term commitment to employees.”

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HHS Launches Health Insurance Exchange Campaign: Educational Efforts Aim to Help Enroll

Revamped website, call center and other educational efforts aim to help enroll 7 million people in state HIEs within six months.

Ken Terry
| June 25, 2013 12:15 PM


In an effort to get the word out to individuals and small businesses that will be eligible to buy health insurance through the new state health insurance exchanges starting in October, the Department of Health and Human Services (HHS) has launched a health reform outreach campaign that includes a 24-hour call center with a toll-free number and a revamped website.

Between October and March, HHS hopes to enroll 7 million people in the health plans that will compete for business in the state insurance exchanges. By 2022, the number of enrollees is expected to swell to 24 million, according to the Congressional Budget Office.

If the insurance exchanges meet the projection for this year, noted Kaiser Health News, it would be the biggest open enrollment season in the history of health insurance. But to get there, HHS and its partners will have to overcome widespread ignorance among the uninsured about the state insurance exchanges.

To help address these challenges, HHS has transformed into an educational site that provides general information about the insurance exchanges and the Affordable Care Act. Starting October 1, eligible individuals and firms with up to 100 employees will be able to purchase insurance, in whatever state they live or do business, through

According to a news release, “Key features of the website, based on consumer research and online commercial best practices, include integration of social media, sharable content and engagement destinations for consumers to get more information. The site will also launch with Web chat functionality to support additional consumer inquiries.”

The website is designed so that consumers can access it from mobile devices as well as desktops and laptops. In addition, HHS is providing an application programming interface (API) so that developers can insert some of the site’s contents in their own applications.

Meanwhile, an equally big health IT story is playing out behind the scenes. The Centers for Medicare and Medicaid Services (CMS) — a unit of HHS — and some states are scrambling to assemble the health IT infrastructure that will be needed when the exchanges open for business on October 1. In 34 states, the feds are building the exchanges because the states either declined to participate or agreed to help CMS carry out only some of the exchange operations. Among these functions, a new GAO report says, are eligibility and enrollment, plan management, and consumer assistance.

At the center of this huge enterprise will be a CMS data hub. “To support consumer-eligibility determinations, for example, CMS is developing a data hub that will provide electronic, near real-time access to federal data, as well as provide access to state and third-party data sources needed to verify consumer-eligibility information,” GAO noted. “While CMS has met project schedules, several critical tasks, such as final testing with federal and state partners, remain to be completed.”

The report further describes the work that has been done on this data hub, including external testing of the link between CMS and the Internal Revenue Service. Information from the IRS and other sources will determine whether people buying insurance on the state exchanges are eligible for federal subsidies.

Explaining how this will work, GAO says, “CMS has also begun to test capabilities to establish connection and exchange data with other federal agencies and the state agencies that provide information needed to determine applicants’ eligibility to enroll in a QHP [qualified health plan] or for income-based financial subsidies, such as advance premium tax credits and cost-sharing assistance, Medicaid or CHIP.”

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Where each state stands on ACA’s Medicaid expansion

A roundup of what each state’s leadership has said about their Medicaid plans

June 14, 2013 | Posted on The Advisory Board Company,


The Supreme Court’s ruling on the Affordable Care Act (ACA) allowed states to opt out of the law’s Medicaid expansion, leaving each state’s decision to participate in the hands of the nation’s governors and state leaders.

Based on lawmakers’ statements, press releases, and media coverage, the Daily Briefing and American Health Line editorial teams have rounded up where each state currently stands on the expansion.

We will continue to update this map and list as more information becomes available. Send us news, tips, and feedback by commenting below or emailing

Click to expand a quick-to-scan graphic or an interactive graphic. (Note: The interactive graphic may not be optimized for all mobile devices.)

A state-by-state look at governors’ stances

Text last updated on June 14, 2013. States are categorized based on statements from governors or enacted state laws.

* indicates a state’s participation in the multistate lawsuit against ACA


  • Alabama*: Gov. Robert Bentley (R) on Nov. 13 announced that Alabama will not participate in the Medicaid expansion because the state “simply cannot afford it” (Gadsden Times, 11/13).
  • Georgia*: Gov. Nathan Deal (R) in an Atlanta Journal-Constitution/Politico/11 Alive interview on Aug. 28 said, “No, I do not have any intentions of expanding Medicaid,” adding, “I think that is something our state cannot afford.” When asked about the insurance exchanges, Deal said “we do have a time frame for making the decision on that I think, especially on the exchanges,” adding that “we have just a few days after the election in order to make a final determination on that” (Wingfield, “Kyle Wingfield,” Atlanta Journal-Constitution, 8/28/12).
  • Idaho*: Gov. C.L. Otter (R) in his 2013 State of the State address delivered on Jan. 7 said that while “there is broad agreement that the existing Medicaid program is broken,” the state “face[s] no immediate federal deadline” to address the situation. He added, “We have time to do this right … [s]o I’m seeking no expansion of” the program. Otter said he’s instructed the state Health and Welfare director to “flesh out a plan” that focuses on potential costs, savings and economic impact, which he plans to introduce in 2014 (Ritter Saunders, Boise State Public Radio, 1/7/13; Young, Huffington Post, 1/7; Petcash, KTVB, 1/7/13).
  • Louisiana*: Gov. Bobby Jindal (R) in an NBC “Meet the Press” interview on July 1 said, “Every governor’s got two critical decisions to make. One is do we set up these exchanges? And, secondly, do we expand Medicaid? And, no, in Louisiana, we’re not doing either one of those things” (Barrow, New Orleans Times-Picayune, 7/2/12).
  • Maine*: Gov. Paul LePage (R) on Nov. 16 said that Maine will not participate in the Medicaid expansion. He called the expansion and the state-based insurance exchanges a “degradation of our nation’s premier health care system” (Mistler, Kennebec Journal, 11/16/12).
  • Mississippi*: Gov. Phil Bryant (R) on Nov. 7 said Mississippi will not participate in the Medicaid expansion, reiterating previous statements that he had made about the ACA provision (Pender/Hall, Jackson Clarion-Ledger, 11/7/12).
  • North Carolina: Gov. Pat McCrory (R) on Feb. 12 announced that his state will not expand Medicaid or establish its own health insurance marketplace under the Affordable Care Act. McCrory said state officials conducted a comprehensive analysis to determine the advantages and disadvantages of expanding Medicaid and the right type of exchange option in the state, and concluded that it is “abundantly clear that North Carolina is not ready to expand the Medicaid system and that we should utilize a federal exchange.” He said the review included discussions with other governors, White House officials, health care providers, and leaders in the state Legislature (Binker/Burns, “@NCCapitol,” WRAL, 2/12/13; Cornatzer, Raleigh News & Observer, 2/12/13).
  • Oklahoma: Gov. Mary Fallin (R) on Nov. 19 said Oklahoma will not participate in the Medicaid expansion. “Oklahoma will not be participating in the Obama Administration’s proposed expansion of Medicaid,” she said in a statement. She noted that the program would cost the state as much as $475 million over the next eight years (Greene, Tulsa World, 11/19/12).
  • Pennsylvania*: Gov. Tom Corbett (R) on Feb. 5 sent a letter to HHS saying he “cannot recommend a dramatic Medicaid expansion” in Pennsylvania because “it would be financially unsustainable for Pennsylvania taxpayers.” He noted that the expansion would necessitate “a large tax increase on Pennsylvania families” (Tolland, Pittsburgh Post-Gazette, 2/5/13).
  • South Carolina*: Gov. Nikki Haley (R) on July 1 announced via Facebook that South Carolina “will NOT expand Medicaid, or participate in any health exchanges.” The state Legislature is expected to make a decision on the Medicaid expansion during the 2013 session (Gov. Haley Facebook page, 7/1/12; Holleman, Columbia State, 11/9/12).
  • South Dakota: Gov. Dennis Daugaard (R) in his annual budget address on Dec. 4 said he does not plan to participate in the Medicaid expansion. “I really think it would be premature to expand this year,” he said, adding that he hoped for more flexibility for the state program (Montgomery, Sioux Falls Argus Leader, 12/4/12).
  • Texas*: Gov. Rick Perry (R) in a statement on July 9 said, “If anyone was in doubt, we in Texas have no intention to implement so-called state exchanges or to expand Medicaid under ObamaCare.” Perry also sent a letter to HHS Secretary Kathleen Sebelius on July 9 asserting this position. The Dallas Morning News reported that on Nov. 8, Perry reiterated his opposition to the expansion, saying, “Nothing changes from our perspective” (Office of Gov. Perry release, 7/9/12; Gov. Perry letter, 7/9/12; Garrett, Dallas Morning News, 11/11/12).
  • Wisconsin*: Gov. Scott Walker (R) on Feb. 13 announced his rejection of the Medicaid expansion. He proposed an alternative plan that would expand coverage to low-income state residents through private health care exchanges (Spicuzza, Wisconsin State Journal, 2/13/13).


  • Alaska*: Gov. Sean Parnell (R) on Feb. 28 expressed opposition to the Medicaid expansion. He said he will not ask the state Legislature to consider expansion this session, but he will continue to examine the issue (Bohrer, AP/Alaska Journal of Commerce, 3/1/13).
  • Kansas*: Gov. Sam Brownback (R) has punted the decision on Medicaid expansion to Kansas’ Republican-controlled legislature. Lawmakers have not reached consensus on the issue, and a state budget amendment that is expected to pass would prohibit Brownback from expanding the program without the support of the legislature (Celock, Huffington Post, 5/6/13).
  • Nebraska*: Gov. Dave Heineman (R) in a statement on his website on June 28 said, “As I have said repeatedly, if this unfunded Medicaid expansion is implemented, state aid to education and funding for the University of Nebraska will be cut or taxes will be increased. If some state senators want to increase taxes or cut education funding, I will oppose them.” Heineman on July 11 sent a letter to state lawmakers saying the state could not afford the expansion, but he stopped short of saying that the state will not participate in the expansion, according to Reuters (Office of Gov. Heineman release, 6/28/12; Wisniewski, Reuters, 7/11/12).
  • Utah*: Gov. Gary Herbert (R) has not yet announced a decision on Medicaid expansion. He has asked the state health department to convene a workgroup to examine cost-effective alternatives that would expand coverage for low-income residents (Dobner, Salt Lake Tribune, 4/23/13).
  • Virginia*: Although Gov. Bob McDonnell (R) has not made an official announced on the Medicaid expansion, he has expressed opposition to the ACA provision, according to the Virginian-Pilot. However, the Pilot notes, the future of the state’s Medicaid expansion will likely depend on the outcome of the November gubernatorial election: Democrat Terry McAuliffe support expansion, but Republican Ken Cuccinelli opposes it (Walker, Virginian-Pilot, 4/11/13).
  • Wyoming*: Gov. Matt Mead (R) on Nov. 30 recommended that Wyoming not participate in the Medicaid expansion, but added that his position could change in the future and urged “everyone to keep an open mind on this.” The state legislature will make the final decision on whether to expand the program, the AP/Jackson Hole Daily reports (Brown, Wyoming Tribune Eagle, 12/1/12; Graham, AP/Jackson Hole Daily, 12/1/12).


  • New York: Gov. Andrew Cuomo (D) in a statement on his website on June 28 said he was “pleased the Supreme Court upheld the [ACA]” and looks forward “to continuing to work together with the Obama administration to ensure accessible, quality care for all New Yorkers.” On July 26, Danielle Holahan—project director for New York’s health insurance exchange planning—said the state “largely meet[s] the federal required Medicaid levels already.” Although Cuomo’s office has not officially announced a decision, the Associated Press reported on Nov. 13 that New York will expand Medicaid (Office Gov. Cuomo release, 6/28/12; Grant, North Country Public Radio, 7/27/12).

PARTICIPATING (26 states and the District of Columbia)

  • Arizona*: The Arizona Legislature on June 13 approved a fiscal year 2013-2014 budget blueprint that includes a plan to expand the state’s Medicaid program under the Affordable Care Act. Gov. Jan Brewer (R)—who in January announced her support for the expansion, which would extend Medicaid coverage to about 300,000 additional state residents—is expected to the sign the budget measure (Viebeck, “Healthwatch,” The Hill, 6/13; Schwartz, Reuters, 6/13/13; Christie/Silva, AP/Yahoo! News, 6/14/13).
  • California: Gov. Jerry Brown (D) in a statement on June 28 said the Supreme Court’s ruling “removes the last roadblock to fulfilling President Obama’s historic plan to bring health care to millions of uninsured citizens.” California got a head start on expanding its Medicaid program in November 2010 with its “Bridge to Reform” program, which aimed to bring at least two million uninsured Californians into Medicaid (Office of Gov. Brown release, 6/28/12; DeBord, “KPCC News,” KPCC, 6/28/12).
  • Colorado*: Gov. John Hickenlooper (D) on Jan. 3 announced that his state will participate in the expansion. In a news release, his office said the move would extend Medicaid coverage to about 160,000 low-income residents and save Colorado an estimated $280 million over 10 years without affecting the state’s general fund (Stokols, KDVR, 1/3/13; Wyatt, AP/Denver Post, 1/3/13).
  • Connecticut: Gov. Dannel Malloy (D) was among the first governors to sign up for the Medicaid expansion after the ACA was enacted in March 2010. Soon after the Supreme Court ruling on June 28, Malloy said “it’s great … [and a] very important decision for the people of Connecticut. 500,000 people would have lost coverage if Republicans had their way” (Davis, WTNH, 6/28/12).
  • Delaware: Gov. Jack Markell (D) in a statement on June 28 said, “The Supreme Court’s ruling enables Delaware to continue to implement provisions of the Patient Protection and Affordable Care Act to provide access to health care benefits for Delawareans.” He added, “On the Medicaid front, Delaware already voluntarily expanded the state’s Medicaid coverage program in 1996 to cover many Delawareans not previously covered” (Office of Gov. Markell release, 6/28/12).
  • District of Columbia: D.C. Mayor Vincent Gray (D) in a statement on June 28 said, “The District is not at risk of losing any Medicaid funding as a result of this ruling, because District officials have already begun implementation of the ACA’s Medicaid-expansion provisions and will continue to implement the expansion” (Executive Office of the Mayor release, 6/28/12).
  • Florida*: Gov. Rick Scott (R) on Feb. 20 announced that the state will participate in the ACA’s Medicaid expansion, citing HHS’s conditional support for a waiver to shift most of the state’s Medicaid beneficiaries into a managed-care program. However, Scott said that Florida would only participate in the expansion for three years before reevaluating the decision. Supporters of the ACA heralded Florida’s shift as a major reversal; Scott mounted his successful campaign for governor in 2010, in part, by being one of the nation’s foremost critics of President Obama’s planned health reforms (Kennedy/Fineout, Associated Press, 2/20; Office of Gov. Scott release, 2/20/13).
  • Hawaii: Gov. Neil Abercrombie (D) in a statement on June 28 welcomed the Supreme Court’s ruling and said the ACA “is our ally” in the effort to “support a health care system that ensures high quality, safety and sustainable costs.” Pat McManaman, director of the state Department of Human Services, said Hawaii’s Medicaid eligibility requirements in July would fall in line with the law’ guidelines, meaning an additional 24,000 people will be eligible for the program by 2014 (Office of Gov. Abercrombie release, 6/28/12).
  • Illinois: Gov. Pat Quinn (D) on June 28 praised the court’s decision and said he “will continue to work with President Obama to help working families get the healthcare coverage they need,” including expanding Medicaid (Office of the Governor release, 6/28; Thomason, Rock River Times, 7/3/12; Ehley, Fiscal Times, 8/20/12).
  • Kentucky: Gov. Steve Beshear (D) on May 9 announced that Kentucky will participate in the Medicaid expansion. He called the decision “the single-most important decision in our lifetime for improving the health of Kentuckians” (Halladay, Louisville Courier-Journal, 5/9/13).
  • Maryland: Gov. Martin O’Malley (D) in a statement on June 28 said the Supreme Court’s decision “gives considerable momentum to our health care reform efforts here in Maryland,” adding that the state will move forward to implement the overhaul (Office of the Governor release, 6/28/12).
  • Massachusetts: Gov. Deval Patrick (D) in late June said Massachusetts is “an early expansion state as you know and we’re expecting further resources from the federal government to sustain the experiment here in Massachusetts.” Patrick called the ruling “good news for us” (Walker, YNN, 6/28/12).
  • Michigan*: Gov. Rick Snyder (R), in a statement released on Feb. 6, announced that his fiscal year 2014 budget proposal includes a plan to expand the state’s Medicaid program under the Affordable Care Act. The plan would extend Medicaid benefits to about 320,000 eligible residents. Snyder said the plan contains safeguards that will ensure the financial stability of the program and protect against changes in the government’s financial commitment to the expansion (Office of Gov. Snyder release, 2/6/13).
  • Minnesota: Gov. Mark Dayton (D) said in a statement on June 28, 2012, said, “Today’s ruling will be met with relief by the Minnesotans whose lives have already been improved by this law.” On Feb. 19, 2013, Dayton signed a bill authorizing expansion the state (AP/KARE 11, 2/19/13).
  • Missouri: Gov. Jay Nixon (D) on Nov. 29 announced that Missouri will participate in the Medicaid expansion. Nixon said he will include the expansion in the state budget proposal he submits to lawmakers. “We’re not going to let politics get in the way of doing the best thing for our state,” he said (Crisp, “Political Fix,” St. Louis Post-Dispatch, 11/29/12).
  • Montana: Gov. Steve Bullock (D) in January 2013 said he planned to expand Medicaid in Montana. However, the state Legislature defeated all bills that would expand the state health care program in 2013. On the last day of the legislative session, Bullock said, “Let me be clear, we will reform healthcare in Montana. We will do it with or without the Legislature’s help” (Johnson, Billings Gazette, 1/5/13; KXLH, 5/2/13).
  • Nevada*: Gov. Brian Sandoval (R) on Dec. 11 announced that the state will participate in the Medicaid expansion. “Though I have never liked the Affordable Care Act because of the individual mandate it places on citizens, the increased burden on businesses and concerns about access to health care, the law has been upheld by the Supreme Court,” Sandoval said in a statement, adding, “As such, I am forced to accept it as today’s reality and I have decided to expand Nevada’s Medicaid coverage” (Damon, Las Vegas Sun, 12/11/12).
  • New Jersey: Gov. Chris Christie (R) in his Feb. 26 budget address announced that New Jersey will participate in the Medicaid expansion. The ACA provision is expected to extended Medicaid coverage to about 300,000 uninsured New Jersey residents (Cheney, Politico, 2/26/13).
  • New Hampshire: Gov. Maggie Hassan (D) in her Feb. 14 budget address said that New Hampshire will opt into the ACA’s Medicaid expansion because “it’s a good deal…[that will] allow us to save money in existing state programs, while increasing state revenues.” A state report estimates that the expansion will cost New Hampshire about $85 million through 2020, but will bring in $2.5 billion in federal funds and help reduce the number of uninsured residents from roughly 170,000 to 71,000 (Ramer, AP/, 2/14)
  • New Mexico: Gov. Susana Martinez (R) on Jan. 9 announced that her state will participate in the Medicaid expansion, which potentially could extend health coverage to nearly 170,000 additional low-income uninsured residents. Martinez noted that contingency measures will be established if federal funding for the expansion diminishes, which would mean scaling back the expansion by dropping newly covered beneficiaries from the Medicaid rolls (Schirtzinger, Santa Fe Reporter, 1/9/13; Reichbach, New Mexico Telegram, 1/9/13).
  • North Dakota*: Gov. Jack Dalrymple (R) in January said the politics associated with the ACA should not prevent North Dakota from participating in the Medicaid expansion. In April 2013, he signed a legislation that expanded Medicaid in the state (AP/Prairie Business Magazine, 4/16/13).
  • Ohio*: Gov. John Kasich (R) on Feb. 4 announced that the state will be participating in the Medicaid expansion, the Cleveland Plain Dealer reports. He made the announcement in his two-year budget announcement, but warned that Ohio would “reverse this decision” if the federal government does not provide the funds it has pledged to the expansion (Tribble, Cleveland Plain Dealer, 2/4/13).
  • Oregon: Gov. John Kitzhaber (D) said on June 28 that he is confident that the Oregon Legislature will approve a state Medicaid decision. In an interview with the Oregonian just hours after the Supreme Court issued its ruling on the ACA, Kitzhaber said, “We’ll make a decision on whether or not to expand the Medicaid program really based on, I think, the resources we have available in the general fund for that purpose going forward” (Budnick, Oregonian, 6/28/12).
  • Rhode Island: Gov. Lincoln Chaffee (I) in a statement on his website on June 28 said, “I have fully committed to ensuring Rhode Island is a national leader in implementing health reform whatever the Supreme Court decision, and this just reinforces that commitment.” According to Steven Costantino, the state’s secretary of health and human services, “The expansion is easy to do and makes sense.” Moreover, on July 12, USA Today reported that Chaffee planned to participate in the expansion (Chaffee statement, 6/28/12; Wolf, USA Today, 7/12/12; Radnofsky et al., Wall Street Journal, 7/2/12).
  • Vermont: Gov. Peter Shumlin (D) on June 28 said Vermont’s Medicaid program already meets the requirements under the health reform law’s Medicaid expansion (Steimle, WCAX, 7/1/12).
  • Washington*: In an email responding to a query by American Health Line, Karina Shagren—a deputy communications director in Gov. Chris Gregoire’s (D) administration—in early July said “the governor supports the Medicaid expansion—and Washington will move forward.” U.S. Rep. Jay Inslee (D)—who supports the expansion—was elected governor on Nov. 6 (Shagren email, 7/5/12; Washington Secretary of State website, 11/12/12).
  • West Virginia: Gov. Earl Ray Tomblin (D) on May 2 announced that West Virginia will participate in the Medicaid expansion. “At the end of the day, we have weighed the options and believe expanding Medicaid is the best choice for West Virginia,” he said (Boucher, Charleston Daily Mail, 5/2/13).

Participating through an alternative expansion model (4 states)

  • Arkansas: Gov. Mike Beebe (D) in February announced that HHS had approved a plan to expand coverage to expansion-eligible residents through the health information exchanges. As with the Medicaid expansion, the federal government has agreed to cover 100% of the premiums for the first three years and 90% of the premiums after 2020 (Ramsey, “Arkansas Blog,” Arkansas Times, 2/26/13).
  • Indiana*: Gov. Mike Pence (R) has proposed a plan to expand coverage to expansion-eligible residents through Indiana’s Healthy Indian Plan (Sikich, Indianapolis Star, 4/1/13).
  • Iowa*: Gov. Terry Branstad (R) on May 22 said he will support a compromise deal that would extend health insurance coverage to 150,000 low-income state residents through a new state plan or through the state’s insurance exchange. The Senate approved the compromise deal on May 22, and the House approved it on May 23 (Lucey, AP/Modern Healthcare, 5/23/13; Petroski, Des Moines Register, 5/24/13).
  • Tennessee: Gov. Bill Haslam (R) on March 27 announced in an address to a joint session of the General Assembly that the state will not participate in the Medicaid expansion. Instead, he said he favors an alternative option, under which the state would use federal funds to shift Medicaid-eligible residents into private health plans (Humphrey, Knoxville News Sentinel, 3/27/2013; Goodnough, New York Times, 3/27/13).

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Affordable Care Act: Promise of Hospital Price Cuts in Limbo

Provision’s goal is to get insured, uninsured bill at same rates.


Published: Sunday, June 23, 2013 at 11:36 p.m.

WASHINGTON | Huge list prices charged by hospitals are drawing increased attention, but a federal law meant to limit what the most financially vulnerable patients can be billed doesn’t seem to be making much difference.

A provision in President Barack Obama’s health care overhaul says most hospitals must charge uninsured patients no more than what people with health insurance are billed.

The goal is to protect patients from medical bankruptcy, a problem that will not go away next year when Obama’s law expands coverage for millions.

Because the Affordable Care Act doesn’t cover everyone, many people will remain uninsured. Also, some who could sign up are expected to procrastinate even though the law requires virtually everyone to have health insurance.

Consumer groups that lobbied for a “fair pricing” provision are disappointed. A university researcher who’s studied the issue says the government doesn’t seem to be doing much enforcement, and at least one state, Colorado, enacted a stricter rule since the federal statute passed.

Critics say the law has several problems:

It applies only to nonprofit institutions, which means about 40 percent of all community hospitals are exempted. By comparison, the Colorado law also covers for-profit hospitals.

It lacks a clear formula for hospitals to determine which uninsured patients qualify for financial aid, and how deep a discount is reasonable. A California law spells out such a formula for that state’s hospitals.

More than three years after Obama signed his law, the Internal Revenue Service has not issued final rules explaining how hospitals should comply with the federal billing limits. Delay doesn’t signal a high priority.

“We still hear the same stories about patients who are being sent to (debt) collection,” said Jessica Curtis, director of the hospital accountability project at Community Catalyst, a Boston-based advocacy group that led the push for billing limitations. “It’s the same behavior that we were seeing before the passage of the Affordable Care Act.”

The Obama administration responds that fair pricing is the law of the land, and that hospitals are expected to comply even if the IRS has not finalized the rules. The agency has begun compliance reviews, a spokeswoman said.

The health law “helps to protect patients from hidden and high prices and unreasonable collection actions,” said Treasury Department spokeswoman Sabrina Siddiqui.

The American Hospital Association says it urges members to limit charges to the uninsured in line with the federal law. But neither the administration nor the industry has statistics on how many hospitals are doing so.

Health and Human Services Secretary Kathleen Sebelius recently took on hospital pricing policies when she released federal data that document wide disparities in what different hospitals charge for the same procedures.

Most patients never face those list prices because private insurers negotiate lower rates and government programs such as Medicare get to set what they will pay. The burden of paying list price falls on the uninsured and people with skimpy policies. It’s unclear that the federal requirements are helping at all.

Justin Farman, a nursing student from Watertown, in upstate New York, was diagnosed with a blood cancer in the fall, when he was uninsured.

Going without health insurance is a calculated risk taken by many young people starting out their careers. Farman, 26, said the $120 his employer charged monthly for premiums was too much for his budget. Besides, he was in good shape and an avid weightlifter. But months of deep tiredness and unexplained weight loss led him to consult doctors, and he was eventually diagnosed with lymphoma.

Treatment at Upstate University Hospital in Syracuse was successful, but Farman faced more than $54,000 in medical bills, between the hospital and doctors.

“After I went into remission, the bills started to roll in,” said Farman. The hospital did not tell him that financial assistance might be available, Farman said.

He had to fend off collection agencies.

A spokesman for Upstate said the federal fair pricing law does not appear to apply to the hospital because it is publicly owned and not incorporated as a nonprofit under federal law. Spokesman Darryl Geddes said he could not discuss individual cases, but the hospital does not decline care to anyone based on the individual’s ability to pay. Upstate maintains a financial assistance program that complies with state law, he added.

Partway through his treatment, Farman was able to get on Medicaid. With the help of a community agency, he also applied for assistance under New York law to help pay for his medical care during the period he was uninsured. On Friday, he received a letter saying his application had been approved and his debts would be greatly reduced.

Such discounts should be taken up front, advocates say. As written, the law leaves it up to hospitals to determine which uninsured people qualify for discounted bills, and that could create a whole new set of disparities.

[ Online: Health care law: ; White House:  ]

This story appeared in print on page A1

Copyright © 2013 — All rights reserved. Restricted use only.


Affordable Care Act multistate program not sparking competition

By: Brett Norman
June 24, 2013 05:07 AM EDT |
A program meant to beef up competition on Obamacare exchanges may not add much to the mix of insurance options after all.

The Multi-State Plan Program — which was the closest thing to a watered-down “public option” that made it into the final health law — is eventually supposed to provide at least two new insurance options in every state.

The problem is that the only insurers likely to be able to quickly scale up coverage across the country are already doing just that: selling their plans from coast to coast.

The Affordable Care Act calls for the federal government to contract with two multistate plans — and one has to be a nonprofit. They have to be available in at least 31 states next year, although they don’t necessarily have to be available in every community in a state at the outset. Within four years, they have to be available nationwide. Having failed to get a government-run public option, backers wanted at least one nationwide, nonprofit alternative to compete with the standard commercial plans.

So far, only Blue Cross Blue Shield has publicly declared that it will offer multistate plans. But the Blues already provide coverage in all 50 states, and the early indications are that their multistate plans will basically be clones of the standard plans they’ll be selling anyway in any given state. That means consumers won’t really be getting anything new.

“For all practical purposes, the [multistate] plan in Kansas is the same as the one they submitted to be their regular plan for the regular marketplace,” said Linda Sheppard, health policy director in the Kansas Department of Insurance. “I think for our state, it doesn’t really offer another option.”

Kansas has two Blue Cross insurers. One is in the Kansas City area, and the other covers the other 103 counties. And it’s that second one offering the multistate plan — in the same same 103 counties, Sheppard said.

The Office of Personnel Management, which administers federal employee health insurance across the country, must sign off on multistate plans before they can be offered on the new insurance marketplaces known as exchanges. It has yet to officially do so.

OPM declined to comment, other than to say that it was still reviewing more than 200 plan applications — they were due in late March — and will release more information after it contracts with insurers. But there are clear signs that one of the slots is for the Blues.

At least five states have publicly said that multistate plans will be offered on their exchanges next year — Arkansas, Kansas, Maryland, Michigan and Montana. All except Maryland have identified Blue Cross affiliates as the sponsors.

And some insurance regulators believe that the Department of Health and Human Services wrote the multistate plan regulations so that the Blue Cross Blue Shield Association, a nonprofit umbrella group of Blue Cross affiliates, could be counted as the nonprofit contractor, even though some of its members are for-profit companies.

Alissa Fox, senior vice president for the Blue Cross and Blue Shield Association, said although some states have made Blue Cross multistate offerings public, “it’s not a done deal yet.” She also said she didn’t know what other companies were being considered for the program.

“It’s a very competitive process so people have been keeping this information to themselves,” she said.

Many policy experts and insurance regulators have been skeptical of the program from the outset. The National Association of Insurance Commissioners had raised concerns that the plans would escape state regulation, possibly gaining an advantage over in-state plans. But that was addressed in the regulations.

The remaining question is whether any real competition is possible. Only a small group of insurers are capable of offering new plans in 31 states next year, said Sabrina Corlette, a research professor at Georgetown University’s Health Policy Institute and a consumer representative at NAIC. They’re the ones that have the presence and the provider networks already.

“The barriers that keep issuers from entering new markets have not changed,” Corlette said. “Probably the issuers that could qualify as a multistate plan in all 31 states in year one are probably already there in those states.”

The multistate plans will have that federal stamp of approval from OPM, which could set them apart, at least from a marketing perspective.

“That could appeal to a segment of consumers,” Corlette said. “But it’s hard to see how anyone could come in and offer something that is genuinely different.”



Republican battles over Medicaid turn to God and morality

Republican battles over Medicaid turn to God and morality

7:02am EDT

By David Morgan

(Reuters) – Ohio’s Republican governor, John Kasich, is no fan of President Barack Obama’s health reform law. But he has become an unlikely proponent of one element of Obamacare – expansion of Medicaid healthcare coverage for the poor – and he has a warning for his fellow party members about the moral consequences of blocking it.

“When you die and get to the meeting with St. Peter, he’s probably not going to ask you much about what you did about keeping government small, but he’s going to ask you what you did for the poor. You’d better have a good answer,” Kasich, a Christian conservative, says he told one Ohio lawmaker last week.

“I can’t go any harder than that. I’ve got nothing left.”

Most Republicans oppose Obama’s Patient Protection and Affordable Care Act as a costly, ineffective and unnecessary expansion of government. But some Republican governors, like Arizona’s Jan Brewer and Michigan’s Rick Snyder, have broken ranks to embrace the law’s Medicaid expansion as a practical way to help the poor while infusing their state budgets with billions of dollars in federal funding to pay for it.

Kasich has gone further. His message of morality goes straight to the Republican Party’s allegiance to traditional American values including charity, and should resonate with religious conservatives within its influential Tea Party faction.

“Those groups are important to the Republican Party these days, and thus religious appeals may well help GOP governors win approval from their colleagues in the legislature,” said John Green, political science professor at the University of Akron in Ohio.

The visibly frustrated Ohio governor offers no evidence that his fellow Republicans are responding to his comments. But political analysts say moral arguments by Kasich and others could eventually help them win over Republican lawmakers who otherwise fear an electoral backlash for propping up part of Obama’s health reforms.

“They’re trying to appeal to the more conservative side of that community of primary voters,” said Robert Blendon, who tracks the politics of healthcare for the Harvard School of Public Health.

“These state legislators are going to face primaries in less than a year, and on the Republican side, many of the people who turn out to vote will be very anti-Obamacare but also deeply religious,” he said.

In neighboring Michigan, Governor Snyder’s voice breaks a little when he talks about the potential human toll of not expanding Medicaid to more residents.

“How are you going to feel if you have to go into an emergency room?” he asked after fellow Republicans who control the state Senate left for the summer last week without a vote. “You’ll walk in there, and see chair after chair of working poor people – hard-working people – knowing that’s their healthcare system, when we could have given them a better answer.”


Allowing Medicaid to cover nearly everyone with incomes of up to 133 percent of the federal poverty line is central to Obama’s goal of providing health insurance to millions of uninsured Americans. On those terms, the effort is failing: Almost a year after the U.S. Supreme Court gave each of the 50 states the choice of opting out of the Medicaid provision, only 23 have committed to expand, according to the nonpartisan Kaiser Family Foundation.

As a result, more than 6.3 million people living below the poverty line – $11,490 for an individual and $23,550 for a family of four – are in danger of losing the opportunity to have health coverage next year, according to a Reuters analysis of data from states and the Urban Institute, a nonpartisan research group. That’s because they live either in 21 states, which have failed to move forward with the Medicaid expansion on ideological or financial grounds, or in six others that are still debating the issue: Ohio, Michigan, Indiana, New Hampshire, Pennsylvania and Tennessee.

The health reform law allows people with incomes at or above the poverty line to purchase federally subsidized private insurance through new online marketplaces in each state. But the Supreme Court left the law with no provision for helping those below the poverty line.

Analysts say Americans tend to believe falsely that most poor people are covered by the current Medicaid program, which was created in the 1960s and is jointly funded by states and the federal governments with oversight from Washington. But Medicaid covers only 29 percent of working-age people living below the poverty line, according to the Urban Institute. In many states, benefits are restricted to narrowly defined groups including pregnant women, children and the severely disabled.

Arizona’s Brewer raised hopes for the Medicaid expansion to go forward in “red states” after overcoming opposition from her own party members by calling a special legislative session and threatening to veto other bills until lawmakers approved the expansion.

Some states have sought to overcome impasses by striking political agreements that would impose new costs on would-be beneficiaries. But negotiations have not always borne fruit, and the federal government has yet to approve any innovations. In Michigan, Senate Republicans declined to vote on a compromise measure that would require new Medicaid enrollees to pay 5 percent of their income on medical expenses, rising to 7 percent after four years.

Other states have considered proposals to make the expansion temporary or use federal Medicaid funds to purchase private insurance plans that could require the poor to meet deductibles and co-pays.

The Obama administration is leaving the door open for states to reconsider their Medicaid position on a quarterly basis in hopes that more will sign on.


Meanwhile, Kasich and Snyder are struggling to make sure healthcare benefits are available for more than 820,000 people who live below the poverty line in their states – 474,000 in Ohio and 350,000 in Michigan, according to state estimates.

But the prospects for coverage in 2014 are slipping. Ohio lawmakers nixed Kasich’s Medicaid expansion proposal from the new state budget. Snyder says a decision for Michigan needs to come within the next few weeks, but the state’s Senate Republican leader, Randy Richardville, has said lawmakers will spend the summer reviewing the issue.

Kasich acknowledges that the Medicaid expansion may have to wait but believes his message will get through. “I will not give up this fight until we get this done, period, exclamation point,” he recently told reporters in a hallway briefing in Columbus. “This is not a support of Obamacare. This is a support of helping our communities, our healthcare systems – the poor, the disabled, the addicted and the mentally ill.”

The real change may come only after midterm elections for Congress next year, as state leaders wait to see whether Republicans retain control of the House of Representatives and gain control of the Senate.

“If Republicans get control of the Senate and the House, they’ll dramatically try to limit this bill. If they don’t get control, many of the states saying no to Medicaid will actually start saying yes,” said Harvard’s Blendon.

(Reporting by David Morgan; Editing by Michele Gershberg, Peter Henderson Douglas Royalty)

Compared with Medicaid enrollees, low-income uninsured adults are less likely to have chronic conditions

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Published on June 24, 2013 at 6:13 AM · No Comments

Under the Affordable Care Act (ACA), states have the option to expand Medicaid coverage to most low-income adults, an option that could add millions of new Medicaid enrollees. “In states choosing to implement the expansion, with full federal financing from 2014 through 2016, this would expand Medicaid’s traditional focus away from low-income pregnant women and children, very-low-income parents, and the severely disabled to new population groups. These include childless adults and parents whose incomes are too high to qualify for Medicaid under current state eligibility criteria. This is likely to affect the type of Medicaid patients seen by physicians in states choosing to expand Medicaid. State decisions regarding Medicaid expansion will likely consider the anticipated costs and health benefits to their populations,” according to background information in the article. “Uncertainty exists regarding the scope of medical services required for new enrollees.”

Sandra L. Decker, Ph.D., of the Centers for Disease Control and Prevention, Hyattsville, Md., and colleagues conducted a study to document the health care needs and health risks of uninsured adults who could gain Medicaid coverage under the ACA. Data from the National Health and Nutrition Examination Survey 2007-2010 were used to analyze health conditions among a nationally representative sample of 1,042 uninsured adults 19 through 64 years of age with income no more than 138 percent of the federal poverty level, compared with 471 low-income adults currently enrolled in Medicaid. The 1,042 uninsured respondents correspond to a weighted estimate of 14.7 million uninsured adults who could be eligible for Medicaid coverage under the ACA based on 2007-2010 demographic characteristics. The primary measured outcomes were prevalence and control of diabetes, hypertension, and hypercholesterolemia based on examinations and laboratory tests; measures of self-reported health status including medical conditions; and risk factors such as obesity status.

The researchers found that compared with those enrolled in Medicaid, the uninsured adults reported better overall health; were less likely to be obese and sedentary; less likely to report a physical, mental, or emotional limitation; and much less likely (by 15.1 percentage points) to have multiple health conditions.


Although the uninsured adults were less likely than those enrolled in Medicaid to have diabetes, hypertension, or hypercholesterolemia (30.1 percent compared with 38.6 percent), if they had 1 of these conditions, the conditions were more likely to be undiagnosed or uncontrolled. An estimated 80.1 percent of the uninsured adults with 1 or more of these 3 conditions had at least 1 uncontrolled condition, compared with 63.4 percent of those enrolled in Medicaid.

The weighted counts corresponding to the prevalence estimates translate to approximately 1.4 million uninsured adults potentially eligible for Medicaid with at least 1 condition undiagnosed and 3.5 million with at least 1 condition uncontrolled, compared with approximately 0.6 million and 1.4 million, respectively, among those currently enrolled in Medicaid.

“One-third of potential new Medicaid enrollees are obese, half currently smoke, one-fourth report a functional limitation, and one-fourth report their health as fair or poor—all factors that could require attention from clinicians. If Medicaid uptake is low, the uninsured adults who do enroll in Medicaid may be disproportionately drawn from those with more health problems than average among those made newly eligible. Because many of the uninsured adults have not seen a physician in the past year and do not have a place they usually go for routine health care, they are likely to need care on first enrolling in Medicaid,” the authors write.

Source: The Centers for Disease Control and Prevention



A Louisville Clinic Races to Adapt to the Health Care Overhaul

June 22, 2013


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LOUISVILLE, Ky. — One morning last month, a health clinic next to a scruffy strip mall here had an unlikely visitor: a man in a suit and tie, seeking to bring a dose of M.B.A. order to the operation.

A dozen clinic employees, who spend intense, chaotic days treating an unending stream of Louisville’s poor and uninsured, stared stonily at handouts he had brought as he made his pitch.

The visitor was Danny DuBosque, a “coach” hired to help the nonprofit clinic adapt to the demands of the federal health care overhaul. He had come to discuss a new appointment system, one that will let patients see a doctor or nurse within a few days of calling, instead of weeks or months.

“It’s a huge satisfier,” he declared — management-speak that fell flat with Dr. Michelle Elisburg, a pediatrician who was scheduled to see 26 patients that day.

“It puts me on edge,” said Dr. Elisburg, who has spent her career treating the poor. “Under this model, it’s first come first served, whoever calls fastest. But that’s not necessarily the patient who really needs to be seen.”

Mr. DuBosque, 35, raised his arms, a plea for patience. “We’re going to take the next few years going through and untangling all these issues,” he said before hurrying to another meeting.

“It’s frightening,” Dr. Elisburg, 42, murmured as Mr. DuBosque left.

The debate that morning was just one expression of the tensions rippling through medical offices around the country in the countdown to January, when the Affordable Care Act will require most Americans to have health insurance or pay a tax penalty. For doctors and their staffs, this is a period of fevered preparation for the far-reaching changes that are soon to come as the law moves out of the realm of political jousting and into the real world.

To follow how the historic law is playing out, The New York Times will look periodically at its impact in Louisville, a city of 600,000 that embodies both the triumphs and the shortcomings of the medical system in the United States.

The nation’s first hand transplant was performed here, as was the world’s first implant of a self-contained artificial heart. One of the nation’s largest insurers, Humana, is based here, and the city’s downtown area alone has four hospitals and a medical school. Health care increasingly fuels the local economy, accounting for many of the largest employers and a growing number of start-ups.

Yet for all the resources and expertise, the health outcomes in Kentucky remain “horrendous,” as Gov. Steven L. Beshear, a Democrat, put it recently. The state has some of the nation’s highest rates of smoking, obesity and deaths due to cancer and diabetes. At this point, the only sure thing about putting the law’s many pieces in place here is that it will not be easy.

The potential benefits are huge. Some 90,000 people could get medical coverage in this city alone. It could create thousands of jobs in Kentucky and, if its aspirations are realized, provide better care at lower cost. Yet the law still provokes suspicion and confusion, among both health care providers and the uninsured population it is meant to help.

Community clinics like the one Mr. DuBosque was visiting, one of seven in a network here called Family Health Centers, are at the front lines of the change. They expect that their patient load could double, even as they struggle to recruit doctors and other staff members. They serve people who, because of poverty or entrenched habits, often have a hard time staying healthy and tend to put off preventive care. Now these clinics are anticipating competition from private providers who may see newly insured patients — no matter how poor — as opportunities for profit. So they are working on improving the patient experience and their own efficiency.

The legislation allots $11 billion over five years to improve and expand community clinics across the nation. Family Health Centers is getting $5.4 million to renovate a clinic for the homeless and move a downtown clinic to a much bigger building, adding dental and X-ray departments and a pharmacy. The organization hopes to eventually serve 10,000 additional patients at that site alone, if it can hire enough doctors and nurses to treat them. Meanwhile, it is using federal stimulus money to convert 60,000 paper charts to electronic medical records, and trying to improve patient access with the new scheduling system and other changes.

“We have to change from being the provider of last resort to the first choice for the community we serve,” said Bill Wagner, the longtime executive director of Family Health Centers. “Everything we do needs to say, ‘You’re valuable to us.’ ”

Soft of voice and low-key, Mr. Wagner, 60, nonetheless acknowledges that the stakes for Family Health Centers are unnervingly high. He gets to work at 6:30 a.m. these days, relies on a steady stream of caffeine and clears his head with weekend motorcycle rides.

“We couldn’t have more balls in the air right now,” he said.

Patients and Problems

The West End of Louisville is a patchwork of poor neighborhoods, where asthma, high blood pressure and other chronic conditions are stubbornly common. In Portland, a neighborhood of one-way streets and faded shotgun homes, the biggest Family Health Centers clinic provides basic care to some 16,000 patients per year, regardless of ability to pay.

Here, Alaina Brohm, a brisk nurse practitioner, treats a diverse and challenging population: the unemployed, the chronically depressed, the obese, patients with advanced diabetes and feeble hearts. Ms. Brohm, 30, could be making more money at the retail clinics popping up in drugstores and supermarkets, diagnosing strep throats and bladder infections. Maybe someday she will. But for now, she wants a bigger challenge.

“I knew I would see it all here — a lot of chronic conditions, the worst of the worst,” she said. “I know a little bit about everything.”

Few in Louisville may feel the effects of the new health care law as tangibly as the uninsured patients who churn through Ms. Brohm’s cramped exam rooms — and how they will respond to the law is one of the crucial questions that will determine whether it succeeds. For now, many seem either wary of it or uninformed.

Marchelle Edwards, 55, had been absent from the clinic for more than a year when she arrived there one Monday in May. She had a painful infection in her foot, linked to uncontrolled diabetes. She had stopped taking medicine to control her blood sugar after her prescription ran out months earlier. She also had a bladder infection and a thyroid condition that was making her hoarse. Her daughter Tammy, who had driven her to the clinic, reported that she was subsisting on Pepsi and junk food and feeling tired all the time.

Ms. Edwards seemed to be a walking example of the potential benefits of the same-day appointment system that Mr. DuBosque had been pitching. “I just couldn’t get an appointment in here,” she said, alluding to the long wait time and why she had not bothered trying.

“Even if you made an appointment and it was two months out,” Ms. Brohm softly chided, “it would be a lot sooner than waiting a year.”

The last time Ms. Brohm had seen Ms. Edwards, in April 2012, she had referred her to a podiatrist affiliated with University Hospital, which provides most of the city’s specialized indigent care. But Ms. Edwards, a former food service worker, said she had stopped seeing the podiatrist because he charged $35 per visit.

“I stay at home and I hurt,” she said.

Ms. Brohm started her back on two medicines: one to regulate her blood sugar, and another to help with pain in her feet, a result of nerve damage from the diabetes. One would be free through a pharmacy discount program for the poor; the other would be $6 a month, an expense Ms. Edwards said was prohibitive.

“There’s only so much I can do with your toes, O.K., without surgery,” Ms. Brohm told her. “You’re going to need another referral to a podiatrist, another appointment with a financial counselor. Let me grab you a list.”

She left the room to get one, but Ms. Edwards stalked out, scowling, before she could return. Her daughter shook her head.

“Not having insurance,” Tammy Edwards said, “not being able to get the treatments and stuff that she really needs, it’s depressing for her.”

Ms. Edwards will almost certainly qualify for Medicaid under an expansion next year, which means she would pay nothing or a few dollars for most drugs and medical care, with a maximum of $450 a year.

Yet Ms. Brohm wonders whether Ms. Edwards will pursue the care she needs even if she gets Medicaid. “She’s scared of health care,” Ms. Brohm said after the appointment. “She’s one of the ones that’s more in denial. I guess it’s her defense mechanism: ‘If I don’t find out, then I won’t know.’ ”

Ms. Edwards’s case raises a crucial question about the health care law: Will insurance necessarily make unhealthy people healthier?

David Elson, 59, who has congestive heart failure and chronic kidney disease, skipped an appointment at the clinic in April because he could not afford the fee. He earns enough to pay the highest fee on the clinic’s sliding scale: $65 per visit, he said, and more if he needs blood work. He came one recent evening for an urgent visit, laboring to breathe.

Mr. Elson, who has his own business installing alarm systems, used to pay $125 a month for health insurance, he said. But then he developed diabetes, and his premium soared to more than $500 a month. He dropped the policy years ago.

His nurse practitioner, Susan Elrod, quickly determined that he had fluid in his lungs. Ashen and slumped, he had gained 50 pounds in two months — all water weight, she said — because his weakened heart had not been pumping efficiently enough. He now weighed 309 pounds, and his legs had swelled so much that large lesions had opened on them, fluid seeping out.

“We’re going to have to send you to the emergency room,” Ms. Elrod told him. “Do you feel strong enough to drive, or would you like me to call an ambulance?”

Mr. Elson grimaced, realizing he now faced a far greater expense than what he had saved by skipping his last appointment. He was already struggling to pay for his insulin — $240 a month, he said — and other drugs, which filled a plastic bag he had brought with him.

“I can’t afford to go,” he said, looking blank, after Ms. Elrod had left the room.

He went nonetheless, but not until the next morning, when a neighbor could drive him.

Mr. Elson said he earned about $24,000 a year, too much to qualify for Medicaid even under the expansion. It will cover people with incomes up to $15,856 for a household of one.

But Mr. Elson could still get federal subsidies starting next year to help him buy private coverage through the insurance marketplace, or exchange, that Kentucky is creating under the law. People with incomes up to 400 percent of the poverty level — about $46,000 for an individual — will be eligible for such subsidies if they buy coverage through an exchange. But Mr. Elson said he was certain the cost would still be too high.

“I don’t see it helping anybody,” he said, “just making everybody get insurance.”

In fact, Mr. Elson might pay about $130 a month for coverage if he signed up for a medium-cost plan, according to an estimate by the Kaiser Family Foundation, a nonpartisan research group. He would qualify for a subsidy that would cover 80 percent of his premium costs. The law will also prohibit insurance companies from turning him away or charging him more because he is sick.

Even Ms. Brohm, the nurse practitioner, is suspicious of the law and confused about the changes it will bring. For one thing, she worries that poor people who become eligible for Medicaid under the expansion will be required to pay a part of their medical costs.

“If it does help out with the expensive stuff, that will be very exciting,” she said. “But my concern is if they have to pay anything, will things still be done? Sometimes even a small percentage is too much for people.”

The law’s divisiveness, meanwhile, makes her uncomfortable. She knows of a restaurant chain that may be sold, she said, because the owner cannot afford to provide insurance for his employees, as the law will soon require.

“If it becomes something a lot of people argue about,” she said, “that frightens me.”

Changes on the Way

At a meeting of the Family Health Centers medical staff in May, Ms. Brohm and her colleagues listened as Dr. Peter Thurman, the medical director, delivered a pep talk of sorts. He was pressing them to complete a day’s worth of online courses about the electronic records system that the clinics were poised to adopt. More training would come later in the year.

“It’s self-preservation, in my opinion,” Dr. Thurman said.

The topic shifted to the new appointment system, which only one of the clinics, known as Fairdale, had adopted so far. The early news was good: the average no-show rate had dropped from 21 percent in March to 10.5 percent in May.

“This thing is working,” Dr. Thurman proclaimed, and went on to credit Mr. DuBosque. “Danny’s been a godsend for us, I’ll just be honest with you.”

Later that day, Mr. DuBosque drove to the Fairdale clinic on the south side of Louisville, to get some firsthand feedback. The staff had more good news: fewer patients were turning to private urgent-care centers, a growing source of competition for Family Health Centers.

“They’re acting shocked: ‘What, we can get in today?’ ” said Saundra Kay Webb, a receptionist.

Technically, Mr. DuBosque’s job is to help Family Health Centers get certified as a “patient-centered medical home.” Under that model, teams of providers take a highly organized approach to patient care, with a focus on customer service. Better access is a central goal, which is why Family Health Centers is cutting its wait time for appointments.

Electronic medical records are also essential to the medical home model, partly to reduce what Mr. DuBosque called “the sheer work of keeping tabs on things with paper charts.”

Among other things, he is learning that change sometimes comes more slowly in community clinics than in the fiercely competitive hospital sector, where he used to work. For example, Mr. DuBosque thinks it would be smart to start and end the workday later at Family Health Centers, because patients are reluctant to show up for early-morning appointments. But the idea is not catching fire.

“There’s a whole host of things we’re going to have to fight through with that,” he said. “We have a lot of staff with some established routines and schedules. But I think it’s a no-brainer.”

Doctors working full time at Family Health Centers earn about $127,000 a year, far less than many of their counterparts in private practice. In the last year alone, the clinics lost five doctors, including one who moved, one who retired and one who took a higher-paying job at a hospital. Nurse practitioners are filling the void. They now make up 60 percent of the medical staff at the seven clinics, and their role will continue to grow.

But they, too, are in high demand, and their salary at Family Health Centers, about $67,000 a year for a full-time position, comes up short compared with the private sector.

If Family Health Centers sees enough new revenue, raising salaries will be a top priority. But as with so much of the Affordable Care Act, there are still far more questions than answers.

“Will it allow a community health center to be competitive on M.D.’s against the hospitals?” Dr. Thurman asked. “I just don’t know.”

Financial Considerations

One afternoon last month, Mr. Wagner, the director of Family Health Centers, canceled his appointments and hurried to the Kentucky State Capitol in Frankfort, about an hour away. Governor Beshear was announcing that he would expand Medicaid in the state, a measure called for under the health care law but one that many states are opting out of. By the governor’s estimate, it would allow up to 308,000 additional Kentuckians into the program, almost half of the state’s uninsured population.

Mr. Wagner was eager to bear witness to an announcement that he deemed historic, the culmination of a goal he has spent his career trying to achieve. The Medicaid expansion could also solve Mr. Wagner’s budget problem. Family Health Centers is facing a deficit of about $3 million in its overall annual budget of $30 million, largely because so many of its 42,000 patients, 54 percent, are uninsured.

“Right now we’re living off our reserve fund, and that can only last so long,” Mr. Wagner said.

Then it was back to his office in Louisville to keep planning. That day he learned that community clinics around the country would receive $150 million to help sign up people for insurance. Family Health Centers anticipates getting about $300,000, which it will use to get the word out starting this summer. Under the law, people can start signing up in October for coverage that starts in January.

“We will undoubtedly be hiring staff who will sit in the lobbies with patients — with laptops, with tablets — to provide assistance in enrolling online,” Mr. Wagner said.

October will be a critical month at Family Health Centers. The insurance sign-up period will begin just as construction on the new downtown clinic gets under way. At the same time, the huge Portland clinic will go live with the electronic medical records, and it will have just adopted the new appointment system.

Ms. Brohm, the nurse practitioner, will be married by then, returning from her honeymoon to what may feel like a strange new world. Ms. Elrod, her colleague, will have cut her hours at Family Health Centers and started working in the relative calm of a private doctor’s office. Short of a miracle, neither Ms. Edwards nor Mr. Elson, their chronically ill patients, will have health insurance yet. But if the outreach campaign succeeds, they will have learned of their options and may be poised to sign up.

The day after Mr. Elson was admitted to the hospital, Ms. Elrod called to check on him. His breathing had improved, and the hospital had prescribed a different diuretic to help him excrete water. He had lost 10 pounds so far and would lose 20 more by the end of his five-day stay. She told him to follow up at the clinic after his release.

“Get on my schedule for Tuesday night, O.K.?” she said, then paused for his response. “O.K., if you have the money. I understand, Mr. Elson. O.K. Bye.”

Five Things You Might Not Know About the Affordable Care Act

Published on Modern Medicine (

Publish Date: JUN 21,2013

A big change in America’s health care system is coming at the beginning of next year.

The Affordable Care Act, also known as Obamacare, will go into full effect in 2014, giving millions of uninsured Americans access to health care.

However, there are still misconceptions about the law.

In today’s Just Explain It, we’ll tell you five things you might not know about Obamacare.

Number one… Contrary to what 42 percent of Americans think, Obamacare really is happening. In fact, people can start signing up for state-run health insurance on October 1st. That’s when states and the federal government will open marketplaces, called exchanges, to offer subsidized benefits to the nation’s 50 million uninsured.

Number two… Another survey found that a majority of Americans think the law cuts Medicare benefits and covers undocumented immigrants. It doesn’t.

Actually, the government expects the average Medicare recipient to save approximately $35,000 over the next ten years.

Number three… Tax credits. Next year, health insurance for eligible individuals or families will be subsidized.

For example, someone making just under $23,000 a year wouldn’t have to spend more than 6.3 percent of their annual income on health insurance. Based on a $3,030 plan, their contribution would be $1,450. Under Obamacare, they’d receive a tax credit of $1,580 to put towards their coverage.

Number four… The 80/20 rule. Insurers are now required to spend at least 80 percent of premium dollars on providing healthcare. The other 20 percent can be used on overhead expenses like excessive administrative costs and profits. In 2012, this provision saved Americans over two billion dollars.

If insurers don’t comply, they’re required to provide customers with a rebate. In 2011, over 13 million consumers received $1.1 billion in rebates – that’s around $150 per customer.

And finally… taxes. No matter what you’ve heard, your health benefits under Obamacare will not be taxed. The law does require that employers report the value of your annual coverage on your W-2, but the government says that’s just for workers’ information.

In the end, the Affordable Care Act is incredibly complex piece of legislation. It enacts sweeping reforms that involve every state and millions of Americans. Do you think it will work for you?

Let us know what you think. Do you have a topic you’d like explained? Give us your feedback in the comments below or on Twitter using #JustExplainIt.

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Health-Insurance Exchanges Are Falling Behind Schedule

By Louise Radnofsky | The Wall Street Journal – 15 hours ago


Government officials have missed several deadlines in setting up new health-insurance exchanges for small businesses and consumers—a key part of the federal health overhaul—and there is a risk they won’t be ready to open on time in October, Congress’s watchdog arm said.

The Government Accountability Office said federal and state health officials still have major work to complete, offering its most cautious comments to date about the Obama administration’s ability to bring the centerpiece of its signature law to fruition.

“Whether [the government’s] contingency planning will assure the timely and smooth implementation of the exchanges by October 2013 cannot yet be determined,” said the GAO in twin reports to be released Wednesday.

The 2010 Affordable Care Act created two exchanges, seeking to provide coverage for many Americans who now go without health insurance. President Barack Obama has said the exchanges will be ready on schedule in October, offering coverage to take effect Jan. 1, 2014, but he has cautioned that “glitches and bumps” are likely.

Around two million people are projected to receive insurance through the small business exchanges and seven million people will be enrolling in the individual insurance exchanges in 2014, according to the Congressional Budget Office.

The small-business exchanges in particular have had some early setbacks. The federal government said in April that contrary to initial plans, it wouldn’t allow workers in the first year to choose between a range of insurance options offered through employers. For the first year, companies will select one plan to offer to workers.

In some states, only one insurance carrier has expressed interest in the small-business exchange. In Washington state, officials have had to postpone the exchange altogether because they couldn’t find a carrier willing to offer small-business plans for all parts of the state.

Seventeen states are running their own small-business exchanges, with the federal Centers for Medicare and Medicaid Services carrying out the task on behalf of the remaining 33 states.

The GAO report on the small-business exchanges said officials still have big tasks to complete including reviewing plans that will be sold and training and certifying consumer aides who can help companies and individuals find plans.

It said that the 17 states running their own exchanges were late on an average of 44% of key activities that were originally scheduled to be completed by the end of March. “While interim deadlines missed thus far may not impact the establishment of exchanges, any additional missed deadlines closer to the start of enrollment could do so,” the report said.

The Obama administration has long said that it expects to be ready on Oct. 1. “We have already met key milestones and are on track to open the marketplace on time,” said Joanne Peters, a spokeswoman for the Department of Health and Human Services.

“This GAO report confirms our suspicions about the implementation of the health care law,” said Rep. Sam Graves (R., Mo.), chairman of the House Committee on Small Business. “With each passing day it appears the creation of the exchanges are very much in doubt.”

The administration has welcomed signs that the growth of health-care costs has tempered recently. Some economists believe that may be partly due to the new health law encouraging more cost-effective care. The Labor Department said Tuesday that its price index for medical care fell a seasonally adjusted 0.1% in May, the first monthly drop in almost four decades.

The administration and liberal groups are stepping up efforts to prepare people to enroll for coverage. For the economics of the exchanges to work, they must attract healthy people to balance the risk of those who have chronic diseases.

Enroll America, an administration-backed nonprofit group, opened its “Get Covered America” campaign Tuesday. “We are at a place where…78% of the uninsured aren’t even aware of what’s coming their way,” said Anne Filipic, the group’s president.

Republicans who oppose the health-care law are poised to highlight any glitches in the rollout, and many believe implementation of the law could be a key issue in 2014 elections.

Regulators in New Hampshire have said they received applications from only one carrier, Anthem Blue Cross and Blue Shield, a unit of WellPoint Inc., to sell small group plans or individual policies through the exchange next year.

Small-business owner Nancy Clark of North Conway, N.H., said she was disappointed more carriers didn’t apply because Anthem is already one of just two carriers that doctors in her area accept.

“I was hoping more [insurance] providers would step up to the table,” said Ms. Clark, whose firm, advertising agency Glen Group Inc., has 10 employees and has offered benefits to full-time staff since 1997 to attract and retain talented workers. “I had these rose-colored glasses on, thinking that doctors in our area would then accept more insurance plans, truly giving everyone a choice.”

Ms. Clark said she also worried that without more carriers in the exchange, the cost of a group health plan wouldn’t stabilize or go down as she had anticipated. She said her premiums have increased every year by double digits despite her work force’s good health.

Some Democratic members of Congress also are beginning to express concerns about particular aspects of the law relating to employers. Sen. Joe Donnelly of Indiana, who voted for the law as a member of the House, on Wednesday is expected to become the first Democrat who backed the law to support changing a requirement that larger firms must provide coverage to employees working 30 hours a week or more, his staff said.

Joe Trauger, vice president of human resources policy for the National Association of Manufacturers in Washington, D.C., said the trade group’s 12,000 members are “deeply concerned” about the lack of information available about the state exchanges. “It comes up in every meeting I’m in,” he said.

Backers of the law say that over time, competition between carriers and new restrictions barring insurers from setting small group premiums based on members’ medical history will keep costs in check for business owners and enable them to keep offering coverage.

Michael Brey, president of Brey Corp., a toy retailer in Laurel, Md., that does business as Hobby Works, said he was looking forward to being able to shop for a small-group plan from a variety of carriers through his state’s exchange. Currently he can choose from just three carriers. “I have some degree of confidence that it will be a good move for us,” he said.

Mr. Brey also said he expected to get a better deal through the exchanges. He covered 100% of the cost of premiums for his staff when he bought the business in 1992, but he said he can only afford to contribute 50% now, and only for full-time employees.

Jennifer Corbett Dooren contributed to this article. 

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