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Lack Of Public Understanding About Healthcare Reform Law

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This article from Public News Service highlights some of the hurdles the ACA faces in terms of public opinion. An attorney with the Colorado Center on Law and Policy notes that more than 50% of consumers think that the healthcare reform law is creating a new government-run health insurance policy. Given the general unpopularity of government-run programs in general, it’s not surprising that the healthcare reform law has struggled in the court of popular opinion. The public tends to be quite wary of new government programs, especially before they’re in place. Once they’re up and running – like Medicare for example -they sometimes get a bit more popular. But proposing a new government program is generally a good way to get people fired up.

If you’ve been paying attention to the mundane details of the ACA, you know that there’s no new government-run health insurance plan. The public option got nixed from the healthcare reform strategy right from the beginning. The law does expand some of our public health programs that already exist (like Medicaid and CHIP). It seeks to insure most of the currently uninsured population via increased enrollment in private health insurance plans and expanded access to public health insurance. The individual mandate and guaranteed issue individual health insurance will hopefully result in far fewer people without health insurance. In addition, the provision that allows young people to remain on their parents’ health insurance through age 26 is helping to cut down on the number of young Americans without health insurance. […]

The Challenge Of Shopping Around For Healthcare

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[…] Since most of us don’t have medical training, we might not even know the important questions to ask when we’re shopping around for healthcare. And even if we do, we also have to be able to discern whether the person we’re asking has any conflicts of interest (another excellent article in this week’s HWR from Dr. Roy Poses). Asking patients to have “skin in the game” sounds like a good idea until you really dig into what it means to be a healthcare consumer. Given the difficulty of comparing something as basic as prices for medical procedures – much less things like long-term safety and efficacy – it’s unlikely that patients can really be informed healthcare consumers unless things become a lot more transparent. More “skin in the game” probably just means patients pay more out of pocket for their healthcare (via higher health insurance deductibles and copays), or else put off healthcare until they can better afford it. Some might be shopping around, but it’s unlikely that many people are really able to be well-informed “comparison shoppers” yet – the information they would need just isn’t available.

1,000th Post

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This is our 1000th post. We started this blog in the fall of 2006. At the time, 100 posts seemed like a lot. And here we are at a thousand. We decided that needed something a little different from the fascinating commentary we usually provide, so here’s a picture of our dog, Lukky, and our cat, Larry. They’re best buddies, and on the few occasions that Lukky has had to wear the cone of shame, Larry has always been right there keeping her company. […]

The Subjective Nature Of The Affordability Of Health Insurance

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[…] Health insurance is definitely not cheap. For those who qualify for programs like Medicaid and CHP+, the subsidized or free coverage is likely a lifesaver. But what about middle class families who don’t qualify for public health insurance, but for whom health insurance premiums are a budget buster? Why is health insurance more of a priority for one family than for another (to the point that one family will cut their budget in other areas, like clothing and vacations and vehicles, in order to keep paying for their health insurance)? Is it all about personal experience? If you’ve had a medical scare or have a loved one who has had significant medical bills (especially at a young age, or for an out-of-the-blue medical condition), are you more likely to rearrange your priorities to make health insurance affordable, regardless of your income? If you’ve always been healthy, are you more likely to see health insurance as a money-pit and opt to spend your money elsewhere?

We know that the percentage of our income that is being spent on healthcare has climbed significantly over the past decade. For a lot of people, it’s becoming a much more significant monthly expense than it used to be. But whether or not it’s “affordable” really depends on the person being asked.

Would Premiums Without A Mandate Really Only Be 2.4% Higher Than With A Mandate?

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[…] Keep in mind that all of those prices are based on the fact that the individual policies are medically underwritten (which means that the rates can be increased during underwriting or the application can be denied based on medical history), while the group plans are guaranteed issue and the rates cannot vary based on the group’s health status. There’s a huge range of options available, both in the individual and small group markets. But the premiums in the small group market for our family of four (parents in their 30s with two young children) would be roughly double what they are in the individual market.

Although I realize that the RAND study is important and useful, I wonder why the real-life scenario of individual versus small group premiums is so different. And although the ACA does put a cap on how much greater premiums can be for older people versus younger people, it doesn’t stipulate what the base premiums have to be for the younger people. Premiums have to follow the MLR rules (with insurers spending at least 80 – 85% of premiums on medical expenses), but they will reflect claims expenses pretty closely. […]

Will The Colorado Health Benefits Exchange Be Integrated With Public Assistance Programs?

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[…] Last summer, lawmakers in Colorado were concerned that federal requirements that visitors to the exchanges be screened for eligibility for Medicaid, CHIP and federal health insurance subsidies would increase enrollment in Colorado’s safety-net health insurance programs. Given the budget woes that those programs have had, the lawmakers were hesitant to make the exchange a “one stop shop” for public assistance programs. But much has also been said about the importance of integrating the exchanges with public benefits programs in order to close the gaps that people can fall into if their incomes fluctuate between eligibility for federal health insurance subsidies and eligibility for Medicaid. This proposal calls for the exchange and the public benefits programs to be interoperable as of January 1, 2014 and integrated as of December 15, 2015. For the sake of simplicity and protecting the needs of low-income families, it seems that the more seamless we can make the health insurance enrollment process (particularly for those who go back and forth between Medicaid and private health insurance), the better.

It will be interesting to see how the separate/interoperable/integrated scenarios for the health benefits exchange and Colorado’s public assistance programs play out over the next couple years as the exchange is created and implemented.

Preauthorizations And Legal-eze: Why Health Insurers Have To Use Them

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[…] Starting in 2014, health insurance will be guaranteed issue and all of us will be required to have coverage. But until then, individual health insurance is priced based on medical underwriting and (in most cases) slightly less comprehensive benefits than group policies. That’s why it’s less expensive to have an individual policy than a group policy or a guaranteed issue policy like CoverColorado. If health insurance carriers (both individual and group) don’t go over their claims closely and utilize preauthorizations, they run the risk of being defrauded – which will only drive premiums higher than they already are. If they don’t use the specific legal-eze required by state regulations, they will run afoul of the Division of Insurance.

There are plenty of examples of health insurance carriers using unfair or deceptive practices. We’re lucky in Colorado to have a strong Division of Insurance that works hard to protect consumers. Regulations that protect patients and insureds from unfair business practices are largely beneficial (and tend to weed out the shady insurance carriers). But Jaan’s article highlights the fact that health insurance carriers also have to protect themselves. If they don’t, they will end up with premiums that are far higher than the rest of their competition – and that isn’t sustainable.

Too Much Paperwork

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[…] I don’t know what the solution is here. On the one hand, we need regulation. We know that without it, there are way too many cracks into which all sorts of things can fall. And regulation is meaningless without having a way to objectively measure compliance and progress. But when we reach the point where doctors feel that they’re spending more of their time doing clerical work (eg, filling out compliance paperwork, documenting everything for their lawyers and for their patients’ health insurance carriers, etc.) than interacting with patients, perhaps it’s time to re-evaluate.

This is especially important as the ACA rolls out over the next few years. One of the goals is to make healthcare more efficient. But if we inadvertently end up bogging down the healthcare professionals in a sea of red tape and bureaucracy, efficiency is likely to decline. Hopefully doctors and nurses and other healthcare professionals – who work in the healthcare field on a daily basis – can be consulted to provide input on how best to measure compliance with well-intentioned regulatory programs.

New T.R. Reid Documentary Highlights Greatness In Our Healthcare System

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[…] Overutilization – driven by supply rather than demand – was another common theme in the program. Basically, that the more healthcare supply we have (eg, scanning machines), the more utilization we have. This accounts for a large part of the huge variation in healthcare costs from one city to another. And in all of the hospitals and medical practices featured on the program, curbing over-utilization has been a high priority. One hospital figured out that blood transfusions during surgery aren’t nearly as necessary as they once thought (and indeed, the patients often do better without them). Given that the total cost of blood transfusions is about $1000/pint (!), that’s quite a cost-saving discovery. In another large clinic, pharmaceutical reps were no longer allowed to visit and they also removed the samples of brand name drugs that once filled their drawers. This was a controversial move, but they analyzed a lot of data provided by their local Blue Cross insurance carrier and found that they could optimize pharmaceutical care for a lot less money – patients had better outcomes and the clinic reduced overall Rx spending by $88/million a year compared with the state average.

The Program also showed and example of how patient-centered medical homes work in the real world. PCMHs are a huge buzz word these days, but the PBS documentary shows one in action, and they did a great job of making it easy for patients to visualize how such a program would work and how it would benefit us – including things like much more face time with doctors, and a reduction in the number of hospitalizations and ER visits. In addition to PCMHs, shared decision making between doctors and patients (another buzz word in healthcare reform) was highlighted as having a positive impact on both utilization and patient satisfaction. […]

Health Wonk Review At The Healthcare Economist

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[…] One of the most interesting pieces in this edition comes from Avik Roy, writing at Forbes about the historical relationship between political conservatives and individual mandates for health insurance. It’s a long article, but definitely worth reading. The individual mandate is going to be on everyone’s radar this year (if it wasn’t already) once it gets taken up by the Supreme Court. Roy’s piece gives us a bit of perspective on how political viewpoints regarding an individual mandate have changed over the decades.

Doctors, Patients, and The Exercise Discussion

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[…] Encouraging people to take responsibility for their health (specifically in terms of what they eat and how much they exercise) could be one of the keys to reducing our out-of-control healthcare spending (and in turn, help to control ever-increasing health insurance premiums). I think that discussions about exercise and nutrition have to become a cornerstone of every preventive care office visit, and hopefully also find a place in visits with specialists. But getting from here to there will take an adjustment of expectations on the part of both patients and their doctors. Kudos to Dr. Schattner for starting the discussion.

Nearly Half Of The Uninsured Believe The ACA Won’t Affect Them

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[…] One of the most interesting parts of the interview is the discussion about Americans’ awareness of the ACA details, and their expectation of whether the bill will impact them directly. Karen notes that a poll conducted by the Kaiser Family Foundation last August found that only half of uninsured Americans had a good understanding of the main provisions of the ACA. This is particularly interesting because the 50 million uninsured people in this country were one of the primary groups that the ACA was aiming to help. In addition, 47 percent of the uninsured felt that the ACA wasn’t going to affect them directly. I have to wonder if there is any overlap between the people who are unaware of how the major provisions in the ACA work, and the people who have expressed an opinion – one way or the other – about whether they support or oppose the ACA. Karen also pointed out that a lot of Americans are getting their information about the ACA from sources like talk radio and cable TV programs. The likelihood that this information is biased and/or overly hyped in one direction or the other is quite high. […]

Jon Stewart Interview With Sebelius Focuses Mostly On Health Insurance

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[…] I get the point that Stewart and Sebelius were making. They were addressing the aspects of the ACA that most directly impact people, since health insurance tends to be where most of us interact with healthcare costs. And the interview did – very briefly – touch on healthcare costs when Stewart mentioned that one of the reasons wages have stagnated is because “healthcare costs keep going up.” That is a key point, but they seemed to only be addressing it from the standpoint of health insurance premiums continuing to go up. It’s true that the actual check the employer writes each month to cover healthcare is paid in the form of health insurance premiums. But we have to address the root cause here, rather than just trying to figure out how to reign in premiums.

Steward did ask – in his usual joking manner – whether we all need to start exercising and eating better, which also touches briefly on the idea that a healthier nation would have lower healthcare costs. But overall, nearly the entire interview focused on how the ACA will impact health insurance. While that makes for an interesting interview, it also presents the ACA (at least as far as pop culture is concerned) as health insurance reform rather than healthcare reform. While there were definitely aspects of health insurance that needed reform, addressing health insurance as if it’s the crux of the issue is very much putting the cart before the horse.

A Look At Canadian And US “Mini-Med” Health And Dental Insurance

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[…] Glenn notes that although most people there have provincial health insurance policies, they often get additional coverage from their employers for things like prescriptions and dental care. And he points out that all too often, people think that they’re “covered” just because they have a health insurance card in their hands – even though the coverage might have very low annual limits. Of course that only becomes a problem when you have a catastrophic claim, which is of course when you need your health insurance the most.

Although the ACA has nixxed lifetime benefit maximums on health insurance policies here in the US, significantly increased annual maximum thresholds, and designated several categories of “essential benefits” that must be covered at specified levels, HHS has granted plenty of waivers for employers who are offering “mini-med” policies to their workers. These policies are far from being a safety net in the event of a catastrophic illness or injury, and often only cover a few thousand dollars in benefits per year. They remind me a lot of the type of policies Glenn is describing. […]

A Visual Of Our Healthcare Spending

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[…] This RAND Corporation infographic paints a pretty clear picture of how healthcare costs have increased over the past decade (specifically, the data refers to 1999 – 2009). Healthcare spending nearly doubled in that time frame, from $1.3 trillion to $2.5 trillion, but the second graphic shows how our complicated method of paying for healthcare makes it harder for the average family to see how their own healthcare costs have been impacted. The last graphic in the series shows what the average family could have done with the extra $2880 they would have had in 2009 if healthcare costs had grown during the 2000’s at the same rate they did in the 1990’s (GDP + 1%). Given how cash-strapped a lot of families have been for the past few years, I’m sure an extra three grand could have made a big difference. […]

Anthem Blue Cross Blue Shield’s New Medical Home Program In Colorado

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[…] I can obviously see how this structure can result in lower costs, and I particularly like the fact that it will be paying primary care doctors for “non-visit” services that are not currently reimbursed (the example given in the press release is “preparing care plans for patients with multiple and complex conditions” but I can see how this could be extended to other areas of care and could help to move away from the current ten minute visit + diagnosis + prescription scenario that is so common). But particular care will need to be taken to make sure that the end result is truly healthier patients, as well as lower healthcare costs.

A measure of patient satisfaction could also be beneficial here. This is a tough one though, as patients might tend to have less of a focus on the overall picture (outcome + cost) and more focus on the factors that directly and immediately impact them, such as outcome and convenience. Cost is a factor for patients, but since most of us have health insurance, we tend to be largely insulated from the immediate costs of our healthcare. We get the annual rate increase notification or a letter from our employer saying that our deductible and copays are going up, but most patients probably don’t consider how their own healthcare usage directly impacts the overall “big picture” of healthcare spending (and thus the resulting health insurance premium hikes). But in general, a program that results in an overall improvement in patient health and lower costs should also end up with satisfied patients. Things like more face-time with their primary care doctor (who is being compensated for keeping the patient healthy, not just fixing problems once they occur) ought to improve patients’ overall perception of the care they are receiving. […]

Health Wonk Review – Campaign 2012 Edition

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All of the vote candidates are well qualified and knowledgeable about healthcare, from many different angles.  And they all write quite convincingly.  Some take polar opposite positions, while others lean more toward the center.  I’ll summarize each candidate’s platform, and you can get all the details by clicking on the names.  Once you’re finished, cast your vote for your favorite in the comments.  Be warned, however – you will have a hard time choosing!

Ladies and gentlemen, here are your candidates for Wonkiest Health Wonk 2012:

Anthony Wright‘s camp is taking issue with Rep. Dave Camp’s position that the ACA is the reason for the decrease in the percentage of employers who offer health insurance benefits and the increase in premiums (both trends that were well established long before the ACA was crafted, and as Anthony points out, most of the provisions of the ACA haven’t been implemented yet).  Rep. Camp quoted Wright on his website, and mis-used the words to support his position that the ACA is to blame for the current problems.  Anthony is – quite understandably – unimpressed.

Joe Paduda‘s platform is all about taking aim at Mitt Romney’s enjoyment of firing people – and insurance companies.  Although it sounds nice (and very “free-market-y”) to say that if you don’t like your health insurance company you can just fire them, that isn’t usually the case.  Joe explains how most people have limited options (if any at all) when it comes to their health insurance, particularlySIA2008-1616 if they have any health conditions.  Firing ones health insurance carrier isn’t really a possibility for most of the population.  Joe’s common sense approach should win over a lot of voters.

Gary Schwitzer‘s campaign is focused on calling out half-truths and shoddy journalism.  He cites an example of an ABC News segment that purports to be a journalistic look at a new “lifesaving” technology.  But it might just be blatant self-promotion on the part of the doctor being interviewed.  And even worse, it might convince countless viewers that they need the same high-tech test (along with several others that are mentioned in the story), despite the far less flashy stories about the comparative effectiveness data that indicate that the tests in question aren’t really useful for low-risk individuals.  And that leads to over-utilization of healthcare.  Which leads to increased healthcare spending.  Which leads to higher health insurance premiums.  Which leads to more people […]

Retiree-Only Health Insurance Plans And The ACA

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[…] Sandy’s daughter ended up getting an individual health insurance policy for $143/month. But individual health insurance in Colorado is medically underwritten (and will be for almost two more years until the guaranteed-issue provision of the ACA begins in 2014), which means that she had to be relatively healthy in order to qualify for coverage and/or avoid an underwriting rate increase. The benefit of the ACA rule that allows young adults to remain on their parents’ plan is that there is no need for additional underwriting – the coverage is continuous, regardless of any new medical issues that might have arisen since the plan was originally purchased. This can be very useful for young adults with pre-existing conditions who haven’t yet secured a job that provides guaranteed issue group health insurance coverage.

I don’t know what percentage of the population is covered by retiree-only health plans, but it seems that group might be more likely than others to have children who are young adults. I’m sure Sandy and her husband aren’t the only parents to have found out that the ACA doesn’t apply to their retiree-only health plan. […]

A Brain Teaser Cavalcade Of Risk

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[…] Jaan Sidorov’s article about health insurance exchanges is really good (and I had to read it to figure out the correct answer to the question for his post – it was one of the two I missed). He notes that it’s a bit illogical that so many of us are willing to spend hours comparison shopping for a new TV, but feel put out if we have to spend much time at all comparison shopping for health insurance. And he laments the fact that health insurance exchanges are in their very early days but already are being dismissed by some as too complicated for the average consumer to figure out.

The Elusive Nature Of Healthcare Costs

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[…] I’m still a fan of consumer directed health plans, high deductibles, and HSAs. I think that they can be useful tools to help people keep their health insurance premiums as low as possible and also (if an HSA is involved) set aside pre-tax money to cover potential future medical bills. But they are not a panacea. They are probably not a good solution for anyone who has a chronic illness that needs ongoing, expensive care. They don’t work so well for people with very little money who would struggle to cover the relatively high out-of-pocket costs and would not likely be able to fund an HSA. And no matter how great the actual consumer directed health plans are, the fact remains that transparency with regards to healthcare costs is still quite elusive. For some procedures, it can be relatively easy to get a set figure up front in terms of how much it’s going to cost. But much of the time that number can be difficult or impossible to pin down. Obviously, complications can arise in any medical situation (and the resulting increase in costs would make earlier estimates irrelevant). But even without factoring in complications, “shopping around” for healthcare is often an exercise in futility. In order to make consumer directed health plans more effective, there is much work to be done with regards to cost transparency.

Colorado House Passes Resolution To Repeal ACA

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[…] Although the Republican-led Colorado House passed the measure, Democratic lawmakers were not impressed. They chided the Republicans for wasting time and money on a resolution that isn’t going to end up going anywhere (presumably because of the extremely slim chances of having two thirds of the states pass a similar measure).

Given the fact that the legality of the ACA is going to come before the Supreme Court this year, I agree that the new Colorado resolution seems like a waste of legislative time. The Supreme Court will tell us whether or not the federal government has the right to make health insurance mandatory, and the states that are taking the opposing position on the matter have already joined in a lawsuit to express their position. Hopefully Colorado’s lawmakers will work together from both sides of the aisle and move on to other issues that are facing the state.

Thoughts On The Supreme Court’s Look At The ACA

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[…] Joe’s take on the court battle is that the Supreme Court is unlikely to go against the majority of the lower courts that have ruled in favor of the constitutionality of the individual mandate. And he’s got lots of other well-thought-out opinions on the subject – his post is a must read if you’re interested in the legality of the ACA.

Personally, I’m with Joe on this one. I believe that opting to go without health insurance is in fact opting to self-insure, since the likelihood of people needing no medical care at all is slim. For people who can truly afford to self-insure, there might be an argument to be made in terms of their right to do so (Rush Limbaugh? Maybe. The rest of us who don’t earn $33 million per year? Not so much). But for the majority of the population, being uninsured means that potential healthcare bills – especially the big ones – will be paid by the rest of the population via higher healthcare costs and increased health insurance premiums. There’s no realistic way for hospitals to recoup costs from uninsured patients who have no ability to pay, especially if the bills are significant. And it might be well within the boundaries of the law to require people to not pass that risk off onto other people.[…]

Claims Expenses In New Colorado High Risk Pool Are Double The National Average

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[…] I realize that premiums cover a very small portion of the claims expenses incurred by the high risk pools, so perhaps it’s a better move from a financial standpoint to limit enrollment in the high risk pool. But expanding eligibility and increasing enrollment numbers have been discussed numerous times since the pools started operating in 2010. I haven’t seen any specific details explaining why Colorado’s per-member claims expenses are so much higher than they are in other states with similar programs. It could be that it’s random, but if that’s the case we should expect to see Colorado’s numbers even out with other states as time goes by. If we don’t, we can assume that there’s something specific to Colorado that is causing the difference – either healthcare is far more expensive here, or our federally funded high risk pool is enrolling applicants who are – on average – far sicker than applicants in other states. Once the program has had another year of claims data, it will be interesting to revisit the numbers and see whether Colorado is still spending significantly more than other states, or whether the numbers have started to equalize.

Cavalcade Of Risk In Its Sixth Year And Going Strong

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Political Calculations just hosted their fifth Cavalcade of Risk this week, with their trademark rating system for articles.  Be sure to check it out.  IronMan pointed out that blog carnivals have largely been surpassed by social media platforms when it comes to sharing interesting posts and getting exposure for new blogs – and he gives… Read more about Cavalcade Of Risk In Its Sixth Year And Going Strong

Obesity As A Factor In Healthcare Spending

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[…] I think that the dichotomy remains when it comes to discussions about obesity: on the one hand, we see lots of articles and advice telling us to love our bodies at any size, and on the other hand we have studies like the one that illustrates the cost to public health insurance programs that is directly attributable to obesity.

In addition to asking people to take a more objective look at whether any of their health problems could be related to weight, Maybe lifestyle issues should be more of a priority during doctor visits. I believe that most doctors do at least mention in passing the importance of eating a healthy diet and being physically active, but perhaps they could spend more time on the issue, and make a bigger deal of it. The ad campaign featured in the CHI article indicates that people are poor judges of where they stand when it comes to their own weight. So instead of asking people to just figure it out on their own, maybe it should get more attention as a cornerstone of healthcare interactions between patients and their doctors. This makes particular sense when the patient is suffering from obesity-related diseases or showing precursor symptoms. And since money is a powerful incentive, HHS could provide doctors with information to distribute to patients regarding the additional lifetime healthcare costs one will incur as a result of being obese. As health insurance deductibles continue to climb and patients find themselves responsible for more and more of their healthcare costs, this could be an incentive to focus on a healthy diet and daily physical activity.