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Updated: 21 hours 51 min ago

In The Event Of A Shutdown … How It Might Affect Your Health

January 19, 2018
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A government shutdown would have far-reaching effects for public health, including the nation’s response to the current, difficult flu season. It could also disrupt some federally supported health services, experts said Friday.

In all, the Department of Health and Human Services would send home — or furlough — about half of its employees, or nearly 41,000 people, according to an HHS shutdown contingency plan released Friday.

Here are some federal services and programs consumers might be wondering about:

CENTERS FOR DISEASE CONTROL AND PREVENTION

According to the HHS plan, the CDC would suspend its flu-tracking program. That’s bad timing, given the country is at the height of a particularly bad flu season, said Dr. Peter Hotez, dean of the National School of Tropical Medicine at Baylor College of Medicine in Houston. Without the CDC’s updates, doctors could have a harder time diagnosing and treating patients quickly, he said.

Although states would still track flu cases, “they won’t be able to call CDC to verify samples or seek their expertise,” said Dr. Thomas Frieden, who was the director of the agency during the 2013 government shutdown.

A government shutdown could also affect the CDC’s involvement in key decisions about next year’s flu vaccine, which are scheduled to be made in coming weeks, said Dr. Arnold Monto, a professor of global public health at the University of Michigan.

Beyond the flu, the CDC would provide only “minimal support” to programs that investigate infectious-disease outbreaks. The Atlanta-based agency’s ability to test suspicious pathogens and maintain its 24-hour emergency operations center would be “significantly reduced,” according to the plan.

That could prevent the CDC from identifying clusters of symptoms and disease “that are the earliest indicators of outbreaks,” Frieden said.

NATIONAL INSTITUTES OF HEALTH

Although the NIH would continue to treat patients at its clinical center in Bethesda, Md., the agency would not enroll new patients in clinical trials — which many people with life-threatening illnesses see as their last hope. The only exception would be an admission deemed medically necessary by the NIH director.

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MEDICARE

Beneficiaries would be largely unaffected by a shutdown, especially if it is short. Patients would continue to receive their insurance coverage, and Medicare would continue to process reimbursement payments to medical providers. But those checks could be delayed if the shutdown were prolonged.

MEDICAID

States already have their funding for Medicaid through the second quarter, so no shortfall in coverage for enrollees or payments to providers is expected. Enrolling new Medicaid applicants is a state function, so that process should not be affected.

States also handle much of the Children’s Health Insurance Program (CHIP), which provides coverage for lower-income children whose families earn too much to qualify for Medicaid. But federal funding for CHIP is running dry — its regular authorization expired on Oct. 1, and Congress has not agreed on a long-term funding solution. Federal officials announced Friday that the staff necessary to make payments to states running low on funds would continue to work during a shutdown.

COMMUNITY HEALTH CENTERS

According to the HHS plan, the Health Resources and Services Administration would continue to operate the nation’s 1,400 community health centers — clinics that serve about 27 million low-income people, providing preventive care, dentistry and other basic services. It would also continue the Maternal, Infant and Early Childhood Home Visiting Program, which targets low-income and at-risk families with house calls and lessons for healthy parenting. That program served about 160,000 families in fiscal year 2016.

But even those programs may not be at full speed. Funding for community health centers and the home visiting program was not renewed last fall — a casualty of Congress’ fight over the CHIP reauthorization — so, they are operating on left-over funds.

ACA PREMIUM SUBSIDIES

The shutdown would not affect some of the most politically charged health care programs, including ones created by the Affordable Care Act. Subsidies for people who get their health insurance through healthcare.gov or state marketplaces would not be affected, according to HHS.

VETERANS AFFAIRS

Staffing for the Department of Veterans Affairs will remain largely intact. “Even in the event that there is a shutdown, 95.5 percent of VA employees would come to work, and most aspects of VA’s operations would not be impacted,” said department press secretary Curtis Cashour in an email.

More than 99 percent of employees of the Veterans Health Administration, which runs the health care system, would continue working, according to the department’s contingency plan.

However, the Veterans Benefits Administration, responsible for overseeing benefits such as life insurance and disability checks, will face larger cutbacks. Over a third of its employees face furlough under a government shutdown.

FOOD AND DRUG ADMINISTRATION

In the short term, the crucial activities that protect consumers would get done, said Jill Hartzler Warner, who was the associate commissioner for special medical programs at the FDA during the 2013 shutdown.

Programs that are critical for the public safety would continue, as would positions paid for by user fees, including work under the Center for Tobacco Products, according to the HHS plan.

The hundreds of staff members who conduct sample analysis and review entry of products into the U.S. would continue to work. However, routine inspections and laboratory research would cease.

Warner, who left the agency in March 2017 and now works as an industry consultant, said grants for rare-disease drug development were determined in 2013 to not be necessary and were postponed.

NUTRITION SERVICES FOR SENIORS

The Administration for Community Living would not be able to fund federal senior nutrition programs during any shutdown, according to HHS officials. But it was not immediately clear how quickly clients would be affected.

A shutdown could delay federal reimbursements to independent Meals on Wheels programs, which serve more than 2.4 million seniors nationwide, according to Colleen Psomas, a spokeswoman for Meals on Wheels America. That could force programs to expand waiting lists for meals, reduce meals or delivery days, or suspend service, she said.

The magnitude of the effect could vary by the length of the shutdown and any final allocation. Some programs, however, could weather a shutdown, staffers said. In Portland, Ore., Meals on Wheel People spokeswoman Julie Piper Finley said meal delivery there would not be suspended. That agency receives about 35 percent of its funding through the Older Americans Act, but raises the rest of the money, ensuring that services are not disrupted.

Meanwhile, services connected to food and nutrition services for other needy populations are likely to keep operating with state partners who have funding through February and, in some cases, March, according to a Department of Agriculture spokesperson. Those programs include the Supplemental Nutrition Assistance Program, the Child Nutrition Programs and the Special Supplemental Nutrition Program for Women, Infants and Children.

FOOD SAFETY

The FDA’s food safety programs would cease, according to the HHS plan, but inspections conducted by Agriculture’s Food Safety and Inspection Service (FSIS) would continue.

Meat and poultry inspections are “such a critical, essential task, and the meat and poultry inspection acts require that inspectors be present continuously,” otherwise processing plants would have to close, said Brian Ronholm, former head of FSIS who now works for the law firm Arent Fox.

Ronholm added that many FSIS employees are “career folks” who have worked there through previous government shutdowns. “There was a lot of built-in knowledge of how to function during the [2013] shutdown,” he said, adding that this expertise would help the agency if there is another shutdown.

Staff writers JoNel Aleccia, Julie Appleby, Carmen Heredia Rodriguez, Shefali Luthra, Liz Szabo, Jordan Rau, Stephanie Stapleton, Sarah Jane Tribble and Lydia Zuraw contributed to this report.

Podcast: What The Health? Our First Live Show: What The Health Will Happen In 2018?

January 18, 2018

Congress is at the precipice of shutting down the government, unless lawmakers can quickly agree on another short-term spending bill. And this time, the Children’s Health Insurance Program is caught in the crosshairs. Republicans are offering six years of funding for CHIP as an enticement for Democratic votes on the spending bill, but Democrats are still balking because they want the bill to include protections for undocumented individuals brought to the U.S. by their parents when they were children.

Meanwhile, with the help of the Trump administration, states are looking at other ways to change the Medicaid program besides work requirements.

And Tom Scully, former head of the Centers for Medicare & Medicaid Services under President George W. Bush, offers his predictions for what might happen this year in health policy. His short answer: not much.

Julie Rovner of Kaiser Health News (left), Sarah Kliff of Vox.com, Paige Winfield Cunningham of The Washington Post and Alice Ollstein of Talking Points Memo speak at a live taping of this week’s “What The Health?” podcast. (Lynne Shallcross/KHN)

This week’s “What The Health?” panelists are Julie Rovner of Kaiser Health News, Stephanie Armour of The Wall Street Journal, Joanne Kenen of Politico, Sarah Kliff of Vox.com, Alice Ollstein of Talking Points Memo, Margot Sanger-Katz of The New York Times and Paige Winfield Cunningham of The Washington Post.

In the podcast’s first live taping before an audience, the panelists discuss these topics as well as whether states will pass their own individual insurance requirements now that the penalty for the federal “individual mandate” has been repealed, how the loss of that penalty will change the individual marketplaces and whether anyone will address the high cost of prescription drugs.

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Among the takeaways from this week’s podcast:

  • Although CHIP has long enjoyed a reputation as having bipartisan support, it appears that House Republicans are less committed to the program than in past years.
  • The addition of a work requirement gained many of the headlines in the Trump administration’s Medicaid waiver for Kentucky, but other important changes were given a green light, too. They include jettisoning the long-standing practice of giving enrollees retroactive coverage if they were eligible for it at that time, charging premiums, and locking people out of coverage if they fail to provide required premiums or paperwork.
  • Maryland officials are weighing the option of setting up a state-based requirement that people get insurance since the federal government has repealed the Affordable Care Act’s penalties for not having insurance. If it passes, other states could follow suit.
  • Scully says one of the biggest issues facing policymakers is trying to fix the gross inequities in Medicaid as different states use it for different populations and programs.

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HHS Nominee Vows To Tackle High Drug Costs, Despite His Ties To Industry

January 09, 2018
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Senate Democrats on Tuesday pressed President Donald Trump’s nominee for the top health post to explain how he would fight skyrocketing drug prices — demanding to know why they should trust him to lower costs since he did not do so while running a major pharmaceutical company.

Alex M. Azar II, the former president of the U.S. division of Eli Lilly and Trump’s pick to run the Department of Health and Human Services, presented himself as a “problem solver” eager to fix a poorly structured health care system during his confirmation hearing before the Senate Finance Committee. Azar said addressing drug costs would be among his top priorities.

But armed with charts showing how some of Eli Lilly’s drug prices had doubled on Azar’s watch, Democrats argued Azar was part of the problem. Sen. Ron Wyden of Oregon, the committee’s top Democrat, said Azar had never authorized a decrease in a drug price as a pharmaceutical executive.

“The system is broken,” Wyden said. “Mr. Azar was a part of that system.”

Azar countered that the nation’s pharmaceutical drug system is structured to encourage companies to raise prices, a problem he said he would work to fix as head of HHS.

“I don’t know that there is any drug price of a brand-new product that has ever gone down from any company on any drug in the United States, because every incentive in this system is towards higher prices, and that is where we can do things together, working as the government to get at this,” he said. “No one company is going to fix that system.”

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Azar’s confirmation hearing Tuesday was his second appearance before senators as the nominee to lead HHS. In November, he faced similar questions from the Senate Health, Education, Labor and Pensions Committee during a courtesy hearing.

If confirmed, Azar would succeed Tom Price, Trump’s first health secretary, who resigned in September amid criticism over his frequent use of taxpayer-paid charter flights. A former Republican congressman who was a dedicated opponent of President Barack Obama’s signature health care law, Price had a frosty relationship with Democrats in Congress as he worked with Republicans to try to undo the law.

Price and the Trump administration often turned to regulations and executive orders to undermine the Affordable Care Act, since Republicans in Congress repeatedly failed to enact a repeal. “Repeal and replace” has been the president’s mantra.

But at the hearing, Azar was circumspect about his approach, noting that his job would be to work under existing law. “The Affordable Care Act is there,” he said, adding that it would fall to him to make it work “as best as it possibly can.”

Senate Republicans touted Azar’s nearly six years working for the department under President George W. Bush, including two years as a deputy secretary. Committee Chairman Orrin Hatch (R-Utah) praised Azar’s “extraordinary résumé,” adding that, among HHS nominees, he was “probably the most qualified I’ve seen in my whole term in the United States Senate.” Hatch, who is the longest-serving Republican senator in history, has been a senator for more than 40 years.

In addition to drug costs, Azar vowed to focus on the nation’s growing opioid crisis, calling for “aggressive prevention, education, regulatory and enforcement efforts to stop overprescribing and overuse,” as well as “compassionate treatment” for those suffering from addiction.

Pressed about Republican plans to cut entitlement spending to compensate for budget shortfalls, Azar said he was “not aware” of support within the Trump administration for such cuts.

“The president has stated his opposition to cuts to Medicaid, Medicare or Social Security,” Azar said. “He said that in the campaign, and I believe he has remained steadfast in his views on that.”

But Democrats pushed back, pointing out that Trump had proposed Medicaid cuts in his budget request last year. Sen. Sherrod Brown (D-Ohio) said such cuts would hurt those receiving treatment for opioid addiction.

“What happens to these people?” he said.

Despite such Democratic criticism, Azar is likely to be confirmed when the full Senate votes on his nomination. An HHS spokesman Tuesday pointed reporters to an editorial in STAT supporting Azar, written by former Senate majority leaders Bill Frist and Tom Daschle — a Republican and a Democrat. “We need a person of integrity and competence at the helm of the Department of Health and Human Services,” they wrote. “The good news is that President Trump has nominated just such a person, Alex Azar.”

Despite Prod By ACA, Tax-Exempt Hospitals Slow To Expand Community Benefits

January 08, 2018
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The federal health law’s efforts to get nonprofit hospitals to provide more community-wide benefits in exchange for their lucrative tax status has gotten off to a slow start, new research suggests. And some experts predict that a recent repeal of a key provision of the law could further strain the effort.

The increased emphasis on community-wide benefits was mandated by the Affordable Care Act. The health law required hospitals that meet federal tax standards to be nonprofits to perform a community health needs assessment (CHNA) every three years, followed by implementing a strategy to deal with issues confronting the community, such as preventing violence or lowering the rates of diabetes.

A study released Monday in the journal Health Affairs shows spending in these areas has remained relatively stagnant.

The research showed average spending by tax-exempt hospitals on community benefits in 2010 was 7.6 percent of total operating costs and bumped to 8.1 percent by 2014. But the bulk of that spending goes toward unreimbursed patient care, such as charity care. The ACA was trying to spur more spending on broader community initiatives, which have remained below 1 percent of operating costs at the hospitals.

“This is not easy for hospitals to do,” said Gary Young, the study’s lead author and director of the Center for Health Policy and Healthcare Research at Northeastern University in Boston. “By tradition, by the nature of their resources, hospitals have not been oriented to prevention, they’ve been oriented to treatment.”

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New efforts by the Republican-led Congress may complicate the effort. The repeal last month of the ACA’s penalties for most people who don’t have health insurance has some experts questioning how some of these hospitals will be able to spend more on community benefits. The Congressional Budget Office has estimated that because of that change about 13 million people would give up their coverage by 2027, which could drive up costs for hospitals because there would be more uninsured patients.

“Anything that destabilizes the system and takes money out of the hospitals’ revenue stream is going to negatively impact them,” said Gregory Tung, assistant professor at the University of Colorado’s School of Public Health. “It’s tough for hospitals to be navigating that uncertainty.”

Jill Horwitz, professor of law at UCLA who specializes in health issues, said hospitals have trouble planning community efforts when they are unsure of their finances.

“It’s a very difficult context in which to operate a stable system,” Horwitz said. “One day to the next, it’s hard to know what the rules are, what the reimbursement is going to be and what kind of insurance your patients will have.”

More than half of the hospitals in the United States are private, nonprofit organizations that are tax-exempt.

Lawrence Massa, president & CEO of the Minnesota Hospital Association, said the repeal of the ACA’s individual mandate penalties will change hospitals’ calculations.

“We certainly expect to see our uninsured rate go up as a result of repealing the individual mandate,” he said, “so that’s going to have an opposite type of effect of where we thought the trend was going to be because we changed the rules in the middle of the game.”

But it’s too early to tell how hospitals will respond, according to Massa. Many are still grappling with the new requirements.

The ACA was enacted in 2010, but the provision requiring community-based action did not come into effect until the end of March 2012, and enrollment in ACA marketplace plans didn’t begin until 2014. Hospitals began early investments for assembling the needs assessments in 2011 and 2012, Massa said.

“In the later years, they’ll be using that data and comparing and reporting to the IRS how they’ve changed their community benefits spending as a result of those community health needs assessments,” he said. “If everything stayed the way it was, I think we would know by 2020 whether this had the kind of impact that was anticipated.”

Young and his research colleagues acknowledged in their study that “certainly, more time is needed” to assess the full impact of the law’s requirements on spending for community benefits.

Nonetheless, Young said, many hospitals lack the means to provide greater preventive care in the community.

They don’t have the necessary infrastructure, “the personnel or the knowledge to develop those strategies,” he said. “They don’t have the resources to necessarily invest in those areas.”

Horwitz agreed. “If we’re going to require this high level of spending on community benefits and paying for patients who can’t afford care, something else has to give,” she said.

Half Of Hospitals In Conn., Del. Hit By Medicare’s Safety Penalties

January 05, 2018

As the federal government penalizes 751 hospitals for having too many infections and patient injuries, some states are feeling the cuts in Medicare payments more than others.

This year’s punishments landed the hardest in Connecticut and Delaware, where Medicare penalized half of the evaluated hospitals, federal records show. In New York and Nevada, 4 in 10 hospitals were penalized. A third were punished in Rhode Island and Georgia. (These figures do not include specialty hospitals automatically exempted from penalties: those serving veterans, children and psychiatric patients, and “critical access” hospitals that are the only institutions in their area.)

While every state except Maryland — which is excluded because it has a different Medicare payment system — had at least one hospital punished, some got off comparatively lightly. Sixteen percent of hospitals or fewer in Alabama, Kansas, Massachusetts, Missouri, Ohio, Texas and nine other states were punished. (State summaries are below; a searchable list of individual hospitals penalized is here.)

The penalties — now in their fourth year — were created by the Affordable Care Act to drive hospitals to improve the quality of their care. Each year, hundreds of hospitals lose 1 percent of their Medicare payments through the Hospital-Acquired Conditions (HAC) Reduction Program.

The program’s design is stern: Out of the roughly 3,300 general hospitals that are evaluated each year, Medicare must punish the worst-performing quarter of them — even if they have reduced their number of potentially avoidable mishaps from the previous evaluation period.

“I have seen with my own eyes the improvement,” said Dr. Amy Boutwell, a quality-improvement consultant in Massachusetts. “I hear hospitals say straight up, ‘We don’t want to be in the lowest quartile, we want to get out of the penalty zone.’”

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The conditions Medicare considers include rates of infections from colon surgeries, hysterectomies, urinary tract catheters and central line tubes inserted into veins. Medicare also examines rates of methicillin-resistant Staphylococcus aureus, or MRSA, and Clostridium difficile, known as C-diff. The frequency of 10 types of in-hospital injuries, including bedsores, hip fractures, blood clots, sepsis and post-surgical wound ruptures, are also assessed. All these types of potentially avoidable events are known as hospital-acquired conditions, or HACs.

A mix of factors contribute to why more hospitals are punished in certain states. The penalties fall more frequently on teaching hospitals and hospitals with large portions of low-income patients. There are more of those in some states than in others. Some penalty recipients say Medicare isn’t adequately taking into account differences in patients, since those who are frailer are more susceptible to HACs.

There is also some element of statistical chance, since the number of reported conditions in one hospital on the edge of the bottom quartile might just have one or two more incidents than a hospital that narrowly escapes that designation.

Some repeatedly penalized hospitals, such as Northwestern Memorial Hospital in Chicago, say the program is flawed by what researchers call surveillance bias: The hospitals that are most diligent in testing and treating infections and injuries are going to appear to have more than comparatively lackadaisical institutions. The hospitals are responsible for reporting incidents to the federal government.

Medicare says it performs spot-checks, but Dr. Karl Bilimoria, director of the Surgical Outcomes and Quality Improvement Center at the Northwestern University Feinberg School of Medicine, said more policing is needed for the rates to be credible.

“In no other industry would this pass, where a program without an audit and voluntary data reporting would be considered valid,” Bilimoria said. “We know guys are gaming.”

Still, many hospitals that have large numbers of sicker and low-income patients, or that handle more complex cases, have avoided the penalties. Medicare issued no punishments this year to Cedars-Sinai Medical Center in Los Angeles; the Cleveland Clinic; Intermountain Medical Center in Murray, Utah; Massachusetts General Hospital in Boston; or New York-Presbyterian Hospital in Manhattan. While safety-net and teaching hospitals were penalized at a higher rate than other hospitals, two-thirds of each group escaped penalties this year.

Dr. Kevin Kavanagh, board chairman of Health Watch USA, a patient advocacy group, said that most hospitals are reducing their HACs each year, in part because of the penalties.

“That’s really the bottom line that everyone should support,” he said. “No system is perfect.”

Podcast: ‘What The Health?’ While You Were Celebrating …

January 04, 2018

The year in health policy has already begun: The Trump administration Thursday released a long-awaited regulation aimed at making it easier for small businesses and others to form “association health plans.” Now advocates and opponents will be able to weigh in with more specific recommendations.

Meanwhile, in December, the health policy focus was on the tax bill and its repeal of the Affordable Care Act’s “individual mandate” penalty for most people who don’t have health insurance. But some recent key court decisions could reshape the benefits millions of people receive as part of their health coverage.

This week’s “What the Health?” guests are Julie Rovner of Kaiser Health News, Paige Winfield Cunningham of The Washington Post, Alice Ollstein of Talking Points Memo and Margot Sanger-Katz of The New York Times.

They discuss these topics, as well as the prospects for pending health legislation on Capitol Hill.

Among the takeaways from this week’s podcast:

  • The Trump administration’s decision to expand association health plans faces a number of obstacles, including the lack of good oversight in many states and the poor track record of many past plans.
  • Consumer advocates fear that growth of association plans could leave many consumers without adequate benefits because some plans will not cover the same essential benefits that Obamacare plans guarantee. They also are concerned that healthy customers will migrate to the new plans and leave the ACA’s marketplace plans with an abundance of enrollees who are ill.
  • The prospects of the bill to stabilize the individual insurance market sponsored by Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.) appear to be dimming.
  • Two federal judges have ruled against the Trump administration rule to change the ACA’s contraception mandate. The decisions, though, are not based on the policy but on faulty rule-making.
  • In another highly watched court case, a federal judge has ruled that the Equal Employment Opportunity Commission has until 2019 to set new rules on what employers can require of workers in their wellness programs. Email Sign-Up

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Plus, for “extra credit,” the panelists recommend their favorite health stories of the week that they think you should read, too.

Julie Rovner: The New York Times’ “Care Suffers as More Nursing Homes Feed Money Into Corporate Webs,” by Jordan Rau (of Kaiser Health News).

Paige Winfield Cunningham: The New York Times’ “In Pursuit of Liquid Gold,” by David Segal.

ALSO: Bloomberg News’ “How Doctors Are Getting Rich on Urine Tests for Opioid Patients,” by Fred Schulte and Elizabeth Lucas (of Kaiser Health News).

Alice Ollstein: ProPublica’s “Want to Lower Health Care Costs? Stop Wasting Our Money,” by Marshall Allen.

Margot Sanger-Katz: The New York Times’ “Unfiltered Fervor: The Rush to Get Off the Water Grid,” by Nellie Bowles.

To hear all our podcasts, click here.

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Medicare Penalizes Group Of 751 Hospitals For Patient Injuries

December 21, 2017
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The federal government Thursday lowered a year’s worth of Medicare payments to 751 hospitals to penalize them for having the highest rates of patient injuries.

More than half also were punished last year through the penalty, which was created by the Affordable Care Act and began four years ago. The program is designed as a financial incentive for hospitals to avoid infections and other mishaps, such as blood clots and bed sores.

The penalties again fell heavily on teaching hospitals, although less than before. A third of them were punished this year, a Kaiser Health News analysis of the penalties found. Last year, the penalty was levied on nearly half of the nation’s teaching hospitals.

The 115 penalized academic medical centers this year include Denver Health Medical Center, Grady Memorial Hospital in Atlanta, The Mount Sinai Hospital in New York City, Northwestern Memorial Hospital in Chicago, Stanford Health Care hospitals in California and the University of California-San Francisco (UCSF) Medical Center, according to federal records.

“Academic medical centers serve patients with more-complex conditions who are at greater risk of hospital-acquired infections (HAIs) compared to community health care providers,” Stanford Health Care said in a written statement. “Hospitals with a high rate of immunocompromised patients will always seem to have higher HAIs.”

Hospitals that treat large proportions of low-income people also were fined more than hospitals with a more affluent patient base, the analysis found. About a third of those safety-net hospitals were penalized, roughly the same as last year.

More HAC Coverage

The penalties have been controversial from the beginning. The hospital industry faults them as unfairly punishing hospitals that treat sicker patients and those that do a better job of identifying infections and other patient complications. Patient advocates say that, while not perfect, the penalties have been a valuable prod to make hospital executives consider more than the bottom line.

“The program has been very instrumental in focusing hospitals on the problems of patient safety and improved quality,” said Dr. Kevin Kavanagh, board chairman of Health Watch USA, a patient advocacy group. However, he said, the financial uncertainty created by the Republican efforts to revoke the Affordable Care Act has not helped.

“Right now it’s hard for hospitals to improve patient safety when there’s been so much turmoil in the health care market,” he said. “The hospitals have the tools and knowledge to make it better, and they should do so.”

Dr. Atul Grover, executive vice president at the Association of American Medical Colleges, said that while teaching hospitals as a group fared better than last year, “we are still disproportionately affected.”

There were 336 hospitals that lost money a year ago but were spared this time, the analysis showed. They include Barnes Jewish Hospital in St. Louis, Brigham and Women’s Hospital in Boston, Cedars-Sinai Medical Center in Los Angeles, the Cleveland Clinic, Geisinger Medical Center in Danville, Pa., Hospital of the University of Pennsylvania in Philadelphia, Intermountain Medical Center in Murray, Utah, and the University of Michigan Health System in Ann Arbor.

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Medicare penalized 425 hospitals that it also had punished last year. For all the penalized hospitals, the reductions will retroactively apply to Medicare payments from the beginning of the federal fiscal year in October and through the end of September 2018. Medicare will cut by 1 percent its payments for each patient’s stay as well as the amount of money hospitals get to teach medical residents and to care for low-income people. The total amount for each hospital depends on how much they end up billing Medicare.

The factors considered in the Hospital-Acquired Condition Reduction Program include rates of infections from hysterectomies, colon surgeries, urinary tract catheters and central line tubes inserted into veins. It also encompasses rates of methicillin-resistant Staphylococcus aureus, or MRSA, and Clostridium difficile, known as C-diff. Medicare also takes into account the frequency of 10 types of in-hospital injuries, including bed sores, hip fractures, blood clots, sepsis and post-surgical wound ruptures. Together, these kinds of potentially avoidable events are known as hospital-acquired conditions, or HACs.

Some hospitals have been targeting the infections that Medicare not only penalizes but also publicizes on its Hospital Compare website. UCSF, for instance, said it has been focused on reducing surgical site infections and C-diff cases. “We remain committed to continually decreasing infection rates to provide the highest level of care for our patients,” UCSF said in a statement.

While the Centers for Medicare & Medicaid Services had tweaked its methods for assessing payments, the hospital industry remained displeased with the core design of the penalty. Congress decreed that Medicare penalize the worst-performing quarter of general hospitals each year, guaranteeing that more than about 750 hospitals lose money every year even if they had improved their safety records.

In some cases, the difference between penalized hospitals and those that escaped punishment was negligible, said Nancy Foster, vice president for quality and patient safety at the American Hospital Association. “It’s a ‘HACidental’ payment policy,” she said. “It’s frustrating that you know that many hospitals end up getting a significant penalty when their performance is not different from other hospitals.”

Several types of hospitals are excluded from being considered for penalties. They include hospitals that treat psychiatric patients, veterans or children. Also exempted are hospitals with the “critical access” designation for being the only provider in an area. Maryland hospitals are excluded from the program because Medicare has a separate method of paying them.

Despite Compressed Sign-Up Period, ACA Enrollment Nearly Matches Last Year’s

December 21, 2017
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A day after President Donald Trump said the Affordable Care Act “has been repealed,” officials reported that 8.8 million Americans have signed up for coverage on the federal insurance exchange in 2018 — nearly reaching 2017’s number in half the sign-up time.

That total is far from complete. Enrollment is still open in parts of seven states, including Florida and Texas, that use the federal healthcare.gov exchange but were affected by hurricanes earlier this year. The numbers released Thursday by the Department of Health and Human Services also did not include those who signed up between midnight Dec. 15 and 3 a.m. ET on Dec. 16, the final deadline for 2018 coverage, as well as those who could not finish enrolling before the deadline and left their phone number for a call back.

And enrollment has not yet closed in 11 states — including California and New York — plus Washington, D.C., that run their own insurance exchanges. Those states are expected to add several million more enrollees.

The robust numbers for sign-ups on the federal exchange — 96 percent of last year’s total — surprised both supporters and opponents of the health law, who almost universally thought the numbers would be lower. Not only was the sign-up period reduced by half, but the Trump administration dramatically cut funding for advertising and enrollment aid. Republicans in Congress spent much of the year trying to repeal and replace the law, while Trump repeatedly declared the health law dead, leading to widespread confusion.

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On the other hand, a Trump decision aimed at hurting the exchanges may have backfired. When he canceled federal subsidies to help insurers offer discounts to their lowest-income customers, it produced some surprising bargains for those who qualify for federal premium help. That may have boosted enrollment.

“Enrollment defied expectations and the Trump administration’s efforts to undermine it,” said Lori Lodes, a former Obama administration health official who joined with other Obama alumni to try to promote enrollment in the absence of federal outreach efforts. “The demand for affordable coverage speaks volumes — proving, yet again, the staying power of the marketplaces.”

“The ACA is not repealed and not going away,” tweeted Andy Slavitt, who oversaw the ACA under President Barack Obama.

The tax bill passed by Congress this week repeals the fines for those who fail to obtain health coverage, but those fines do not go away until 2019. Still, that has added to the confusion for 2018 coverage.

And it remains unclear whether Congress will make another attempt to repeal the law in 2018.

“I think we’ll probably move on to other issues,” Senate Majority Leader Mitch McConnell (R-Ky.) said in an interview Friday with NPR.

Podcast: ‘What The Health?’ 2017: The Year In Health Policy

December 21, 2017

This has been quite a year in health policy. In 2017, the Affordable Care Act survived numerous GOP efforts to repeal and replace it, although the year-end tax bill will eliminate fines for failing to obtain health insurance in 2019. And, ironically, the more Republicans talked the health law down, the more popular it got.

Meanwhile, Congress may have passed the tax bill, but lawmakers are still scrambling to finish legislation needed to keep the government open after Dec. 22. On the line in that bill is the Children’s Health Insurance Program that provides coverage to 9 million kids around the country. Its formal funding ran out in September.

This week’s “What the Health?” guests are:

Julie Rovner of Kaiser Health News
Joanne Kenen of Politico
Alice Ollstein of Talking Points Memo
Margot Sanger-Katz of The New York Times

They discuss these topics as well as health issues in 2017 that were less covered and remain unresolved.

Among the takeaways from this week’s podcast:

  • The Republican repeal of the individual mandate penalties will lead to higher premiums and higher numbers of uninsured, but the magnitude of that change is still unknown.
  • The promise Sen. Susan Collins (R-Maine) secured for bills to help stabilize the individual insurance market has faltered, and those bills will not be part of any end-of-the-year legislation. This time, she didn’t have other moderate GOP allies to help strengthen her negotiating position.
  • Two surprising year-end observations: Despite Republicans’ efforts to get rid of the Affordable Care Act, the health law seems to be resilient and the public appears to be more committed than ever to sustaining Medicaid, the health program for low-income residents.
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Plus, for “extra credit,” the panelists recommend their favorite health stories of the week they think you should read, too.

Julie Rovner: Politico’s “The stealth repeal of Obamacare,” by Joanne Kenen

Joanne Kenen: HuffPost’s “Health Insurers See Higher Prices And A Big Mess Ahead Without The Obamacare Mandate,” by Jeffrey Young

Alice Ollstein: Politico’s “HHS defends withholding comments critical of abortion, transgender policy,” by Dan Diamond

Margot Sanger-Katz: Bloomberg’s “A Hospital Giant Discovers That Collecting Debt Pays Better Than Curing Ills,” by John Tozzi and Vox.com’s “How well does bariatric surgery work? We asked 11 people who got it,” by Julia Belluz

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcher or Google Play.

No Sweeteners Added To Tax Bill To Spread Use Of Health Savings Accounts

December 19, 2017

The ongoing uncertainty about congressional changes to the health law — and their impact on insurance and the online marketplaces — continues to raise questions among consumers. Here are answers to recent queries.

Q: Does the GOP tax bill affect health savings accounts?

At this time, there are no changes aimed specifically at HSAs. These are savings accounts linked to high-deductible plans and exempt from tax liability.

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Congressional Republicans have been very interested in expanding the use of these tax-free accounts, and bills to repeal and replace the Affordable Care Act last summer included provisions to increase the maximum amount people could contribute to them or to allow people to use them to pay their health insurance premiums, among other things.  The GOP promotes the plans as a way to help consumers play a larger role in controlling their health spending and says that the tax advantages help people afford care.

The GOP tax legislation doesn’t incorporate any of those changes, said Roy Ramthun, president of HSA Consulting Services.

Some analysts say it’s still possible that HSA changes could be attached to other pieces of legislation, such as a spending bill or a bill to extend the Children’s Health Insurance Program.

“The GOP would like to get some of these HSA expansion provisions into one of these bills,” said Dorian Smith, a partner at human resources consultant Mercer.

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Q: Republicans are seeking to repeal the individual mandate as part of the tax bill. Would that go into effect next year? 

Probably not. The joint bill that House and Senate negotiators have agreed to doesn’t repeal the ACA’s requirement that most people have health insurance, called the individual mandate. But it does repeal the penalty for not having coverage. That change wouldn’t take effect until 2019, however.

So, assuming the bill is enacted, most people will face a penalty if they don’t have health insurance next year of the greater of 2.5 percent of household income or $695 per adult.

Many people, however, qualify for one of several exemptions to the mandate. Those include people who have suffered a hardship like eviction or bankruptcy and those whose earnings are low enough that health insurance is considered unaffordable.

In 2017, health insurance is considered unaffordable if the cheapest comprehensive coverage you can find would cost more than 8.16 percent of your household income.

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“Because premiums have gone up so high in 2017 and 2018, there will be more people who qualify for the affordability exemption,” said Timothy Jost, a professor emeritus of law at Washington and Lee University in Virginia who is an expert on health law.

If you’re pondering whether to “go bare” next year, it’s worth noting that the Internal Revenue Service won’t accept electronically filed returns unless you indicate whether you had coverage, an exemption or will pay the penalty.

Q: None of the marketplace plans in my area offer out-of-state coverage or any coverage for non-network providers. Why would an insurer limit what’s offered in that way?

Plans with broad provider networks have been steadily shrinking. Nearly three-quarters of plans sold on the ACA’s marketplaces in 2018 have restrictive networks, according to an analysis by the consulting firm Avalere Health. The percentage of such plans has steadily increased since 2015, when it was 54 percent, the analysis found.

Health maintenance organization (HMO) plans and exclusive provider organization (EPO) plans were categorized as restrictive because they typically have relatively fewer providers and don’t provide coverage for out-of-network care. Preferred provider organization (PPO) and point-of-service plans, on the other hand, were considered less restrictive because they generally have broader networks of providers and offer some out-of-network coverage.

The reason plans with restrictive networks are proliferating is because they help reduce costs, said Chris Sloan, a senior manager at Avalere.

“One of the ways to do that is to have a narrower network,” he said.

But there may be an upside for consumers. “It’s not just reducing costs for the sake of costs, it’s also to slow the premium growth,” he said.

Canada’s Single-Payer Health System: What Is True? What Is False?

December 18, 2017
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In the American health care debate, “single-payer” is hardly a new concept.

The idea has grabbed headlines and sparked countless political and policy discussions, not to mention campaign advertisements. Other countries with single-payer systems include South Korea and Taiwan. But “single-payer” merely means that the government pays all the bills. The mechanics can vary from country to country.

Sen. Bernie Sanders (I-Vt.) recently visited Canada, touting that system’s benefits. How much do you really know about it?

Take KHN’s interactive challenge to test your understanding.

ANSWER: FALSE. The Commonwealth Fund, an American nonprofit, ranks Canada’s system above America’s — but it fares poorly compared with some others, placing ninth out of 11 Western systems. (The United States is in last place.) The Commonwealth Fund used metrics such as equity, access to health care and outcomes in its rankings.

“It’s unclear to me that the Canadian model is necessarily the solution the United States wants. And I think there may be other models that can be considered,” said Dr. Peter Cram, an internal medicine doctor and health care researcher who recently moved from Iowa to Toronto. “The narrow focus on the Canadian system — it shortchanges the array of options.”

ANSWER: FALSE. For hospitals and doctors, Canadian patients won’t pay a dollar out-of-pocket. But Canada doesn’t cover dental and vision care, prescription medications, psychotherapists and physical therapy. About two-thirds of Canadians get private insurance to supplement Canadian “Medicare,” as it’s known, which accounts for about 70 percent of Canada’s health spending.

“I’ve had patients who could not afford their diabetic medications, so they would become acutely unwell,” said Dr. Ali Damji, a family medicine resident in Toronto. “They would become sick enough to go to the hospital, and [then] we would pay for the treatment.”

That being said, Canada does have price controls for medications. So, compared to the United States, prescription drugs tend to be far cheaper.

ANSWER: TRUE. The Canadian Institute for Health Information estimates that in 2017 the country will have spent about 11.5 percent of its gross domestic product on health care. The United States, by contrast, spends about 18 percent. And life expectancy up north is greater, according to the World Health Organization. This constitutes one of Sen. Bernie Sanders’ favorite talking points. But Canadian officials still want to bring down the nation’s health care spending, especially as the population ages.

“We are seeing increased costs,” said Ontario Premier Kathleen Wynne, whose administration is testing new programs to address health spending.

ANSWER: FALSE. On the 2016 campaign trail, then-candidate Donald Trump said, “When they need a big operation, when something happens, they come into the United States in many cases, because their system is so slow.” This doesn’t appear to be the case.

No evidence suggests Canadians are fleeing en masse for treatment in the United States. A recent report suggesting this has come under scrutiny, with experts raising serious methodology concerns.

There are certainly circumstances when the Canadian government will transport a patient out of the country for care that is not available — or unavailable in a timely manner — in Canada. When this happens, it is covered by Canadian Medicare.

ANSWER: FALSE. Wait times in Canada are typically longer for non-emergency, specialty procedures — think knee surgeries, diagnostic MRIs or cataract surgery. But emergency care is prioritized and usually placed at the front of the line. In fact, research suggests that when Canadians are sick most experience wait times comparable to those of their American neighbors.

“That’s one falsehood: that there’s these ridiculous wait times,” said Nate Kreiswirth, a dual citizen who lives in Toronto. “If you actually have something that’s a serious condition, or something that is urgent, you’re not going to wait. You are not going to die because you’re waiting.”

Comparing Canadian and U.S. wait times is difficult and an often-politicized discussion, Cram noted. The United States also doesn’t track wait times as rigorously as its northern neighbor — especially for people who can’t afford medical care — so it’s difficult to truly compare.

ANSWER: TRUE. Everyone is equal under the eyes of Canadian Medicare. It’s illegal to buy private insurance that competes with the government’s, so wealthier Canadians can’t buy their way ahead of the queue. (In other countries with universal health care, such as Germany and Great Britain, people can opt out of national systems and buy privately.)

Of course, theory and practice aren’t in perfect sync. Research suggests low-income Canadians may have more difficulty getting timely primary care, even though the single-payer system doesn’t give doctors a reason to prefer wealthier patients. It’s unclear how widespread this is. But, says Dr. Irfan Dhalla, a Toronto-based health quality researcher and general internist, insurance alone can’t fix that.

“Humans are humans and there are always — in any system — humans with discriminatory attitudes toward indigenous people, or people who are low-income,” Dhalla said.

 

ANSWER: FALSE. Primary care doctors work for themselves, but their fees are negotiated and paid by the government.

There was a serious exodus of Canadian doctors in the 1990s, but that has since reversed. In the mid-2000s, more Canadian doctors were returning from the United States than leaving. At this point, research suggests, southern migration is negligible.

And 2014 data from the Canadian Medical Association suggests that more doctors may be moving the other way, leaving the United States to practice in Canada, to avoid headaches like insurance paperwork and claims processing necessary south of the border.

ANSWER: FALSE. Canada spends far less on health care than does the United States, but it too is grappling with the climbing cost of medical treatment. Health care accounts for almost 40 percent of provincial budgets.

“The government gives provincial governments a bunch of money, and they pay the doctors and say, ‘As long as people aren’t dying, and voters are happy, we’re OK,’” said Dr. Kaveh Shojania, a Toronto-based internist who researches patient safety and health care quality. “Now they’re starting to realize there’s more that needs to be done.”

Meanwhile, left-leaning advocates are pushing to expand the single-payer system so that Canada also covers prescription drugs.

Podcast: ‘What The Health?’ Farewell, Individual Mandate

December 15, 2017

The compromise tax bill emerging from Republican efforts in Congress appears to have jettisoned a number of contentious health-related changes. Still, it seems likely lawmakers will repeal the penalties for not having health insurance. That so-called individual mandate was considered a linchpin of the Affordable Care Act, but now it seems possible the rest of the health law could survive without it.

This week’s “What the Health?” guests are:

Julie Rovner of Kaiser Health News
Joanne Kenen of Politico
Alice Ollstein of Talking Points Memo
Margot Sanger-Katz of The New York Times

They discuss these topics and other health news of the week, including the end of open enrollment for 2018 health insurance in most of the country.

Among takeaways from this week’s podcast:

  • It looks like the Republican tax bill will not take away Americans’ ability to deduct high medical expenses — in fact, lawmakers might temporarily make the deduction more generous.
  • The bill to restore the cost-sharing subsidies that helped some very low-income Americans pay for their out-of-pocket expenses appears to be losing steam as many people wonder if it’s too late.
  • Is the glass half-full or half-empty? With the Trump administration’s changes to the ACA enrollment process, sign-ups could easily be lower than last year — but even with those challenges, millions of people are enrolling.
  • Medicaid officials could announce their decision soon on whether to implement work requirements for nondisabled adults in the program. Such a move, though, is sure to be highly litigated. Email Sign-Up

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Plus, for “extra credit,” the panelists recommend their favorite health stories of the week they think you should read, too.

Julie Rovner: Kaiser Health News’ “Hospitals Find Asthma Hot Spots More Profitable To Neglect Than Fix,” by Jay Hancock, Rachel Bluth and Daniel Trielli.

Joanne Kenen: The Naples News’ “Florida’s disposable workers: Companies profit from undocumented laborers, dump them after injuries,” by Maria Perez.

Alice Ollstein: Vox.com’s “The tax bill destroys an important part of Obamacare. The states can save it,” by Nicholas Bagley

Margot Sanger-Katz: The New York Times’ “How to Be a Smart Obamacare Shopper,” by Margot Sanger-Katz and Haeyoun Park.

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcher or Google Play.

Good Deals For Some, Sticker Shock For Others As ACA Enrollment Winds Down

December 15, 2017

In most states, Friday night is the last chance to sign up for Affordable Care Act health insurance for 2018. The enrollment period is half as long as last year’s, and it got just a fraction of the marketing budget to tell consumers that.

But how did it go for individual consumers shopping for plans this year? Much depended on where you live and what your financial situation is.

In Tennessee, where state regulators approved average rate increases ranging from 20 percent to 40 percent, consumers might have reasonably expected to brace for a big hit to their wallets. But Brenda Linn saw the opposite happen.

Linn had been paying $750 a month in 2017 just to cover her own medical needs; so the retired kindergarten teacher and her husband logged on to HealthCare.gov to check the price of 2018 plans. To her surprise, the website brought up a great deal.

She thought it was a mistake. The price Linn was quoted was less than $5 a month. Why? A slight loss of income had made her eligible for a subsidy for 2018. “Because we didn’t qualify last year, I wasn’t really that hopeful,” Linn said.

But a large majority of marketplace shoppers do get subsidies. And for 2018, on aggregate, these subsidies are larger.

Tony Garr, a volunteer application assistant with the Tennessee Health Care Campaign, said more than ever this year, people needed to shop around on the exchange.

“Generally speaking, they will find out that help is there,” he said.

Any many people who got a subsidy in the past found even more for their money this year.

For example, Daniel Prestwood, who is self-employed and cleans fish tanks around Nashville, said he found a better plan for 2018, with monthly premiums that dropped from $300 to $200. He said he tries not to get too frustrated by the political wrangling over health care.

“All I know is that for 2018 I’ll have a good health care plan in place,” he said, “and that’s the best I can hope for at this point.”

And even with the Trump administration’s efforts to hobble the ACA, in Tennessee, the number of applications processed by federally funded insurance guides — known as navigators and certified application counselors — surpassed last year’s. With 10 days left in open enrollment, more than 1,200 individuals had applied with official help, eclipsing the total from all of 2016, when the enrollment period was several weeks longer.

While application assistants only work with a tiny fraction of the 235,000 Tennesseans who have marketplace plans, Sandy Dimick of Family and Children’s Services Nashville, said she expects total enrollment will exceed last year’s total, as well.

But many people across the country had a very different experience than Linn and Priestwood.

Gene Kern of Frederick, Md., has been an enthusiastic enrollee in Maryland’s health exchange since it began in 2014. The 63-year-old retired early from Fujifilm, where he sold professional videotape. “When the product became obsolete, so did I,” he said, “and that’s why I retired.”

This fall, Kern said, he received a letter from his insurer explaining that the cost of his policy’s premium would jump from $800 a month to $1,300 in 2018.

“Because of my income, I am slightly above the 400 percent poverty level,” he said, “and as a result I get no subsidy from the government.”

So Kern shopped around on Maryland’s exchange — which announced on Wednesday that it will be open an extra week, through Dec. 22 — and he found an HMO plan for around $900 a month. That’s more than 20 percent of his income, which comes partly from Social Security and partly from his retirement account. But, he said, “It’s the best I can get.” Kern wants to stay insured for the next two years, until he will qualify for Medicare.

Louise Norris, a health insurance broker and analyst in Colorado, said there are a number of people like Kern who earn too much for a subsidy and will pay more for health insurance next year than they did in 2017. “Rates are high,” she said. “There’s no way to sugarcoat that.”

But she warns her clients against the temptation to shop off the exchanges for a less expensive plan that doesn’t comply with the minimum standards set out by the ACA.

“It seems like a good deal because it’s cheap,” Norris said. “But then you find yourself being that person who has a heart attack and needs triple bypass. And hundreds of thousands of dollars later you wish you had that ACA-compliant plan.”

While people in states that use HealthCare.gov have until Dec. 15 to sign up, residents of nine states (California, Colorado, Connecticut, Maryland, Massachusetts, Minnesota, New York, Rhode Island and Washington) and the District of Columbia have slightly more time.

This story is part of NPR’s reporting partnership with local member stations and Kaiser Health NewsSelena Simmons-Duffin, a producer at NPR’s All Things Considered, is working temporarily with NPR member station WAMU, as part of an exchange program at the network. Blake Farmer is the health reporter at Nashville Public Radio.

Consumers Who Froze Their Credit Reports Could Hit A Glitch Enrolling In Insurance

December 13, 2017

Some Americans who froze their credit reports following the big data breach this year at the credit-rating firm Equifax may be in for a surprise if they try to purchase insurance on the federal health law’s marketplaces. That freeze could trigger a delay in the application process.

Signing up for a marketplace plan online requires consumers — especially first-time enrollees — to prove their identity by answering questions linked to their credit history. It can affect both those who are seeking a subsidy and those who are not.

But here’s the rub: Consumers who have blocked access to their credit reports often “cannot get past the ID-proofing part,” said Matthew Byrne, founder of the Spiralight Group, a brokerage in Dublin, Ohio.

That presents problems as the clock is ticking on open-enrollment season for the Affordable Care Act’s health coverage, which ends Friday in most states.

“Your identity wasn’t verified,” warns the healthcare.gov page. It suggests that the applicant call “the help desk,” which is run by another credit reporting firm — Experian — that works with the marketplace, or call the healthcare.gov call center, according to a screenshot sent to KHN by a broker.

That call to Experian sometimes solves the problem, if the applicant can successfully answer questions generated by the firm. Those can include queries about previous addresses, vehicles owned or current mortgage lenders, according to a 2016 report from the Center on Budget and Policy Priorities.

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But not always. Geoff Dellapenna said shortly after he and his broker entered some of his information onto the online application, the screen showed the warning that his identity could not be verified. They would need to make another call first.

“I just put a stop to it,” said Dellapenna, 46, of Canton, Ga. “I was so frustrated with how cumbersome the whole process was being that I just could not do it.”

He’s now working with the broker to see if he can get small-group insurance for his company — avoiding the healthcare.gov site altogether.

There are workarounds for consumers: Applicants may have to upload or mail in documents. Some brokers advise their clients to “unfreeze” their credit reports before enrolling in the ACA by calling the three major credit rating agencies: Equifax, Experian and TransUnion. The freeze can be restored once enrolled.

But those options may take time. With the Dec. 15 deadline fast approaching, brokers say some people will be upset if they wait until the last minute.

“None of this is simple,” said Kelly Fristoe, a broker in Wichita Falls, Texas.

Fristoe said the subject of credit freezes and the ID verification has come up frequently on broker forums this year. Otherwise, he added, the enrollment process has been smooth.

A spokeswoman for the Department of Health and Human Services said consumers using healthcare.gov, which serves 39 states, don’t need to unfreeze their credit in order to apply, “nor do we recommend that step for identity proofing.” Uploading or mailing the information will generally work, she said.

Most of the states that run their own marketplaces for ACA enrollment also use the Experian system for identity proofing, although at least two — New York and California — have modified the process to help avoid some of the delays, according to the policy report.

New York, for example, uses state motor vehicle records and other data in addition to Experian — and has a special call center that certified assisters can use to help applicants who can’t pass the online verification. California also uses assisters, who are registered with the state, to check documents and upload them for applicants, the report says.

Many people heeded warnings in the early fall to monitor their credit or place a “credit freeze” on their accounts with the three major reporting firms after Equifax revealed that hackers had stolen information on 143 million Americans, including Social Security numbers.

A freeze restricts access to a consumer’s credit report, which can make it more difficult for identity thieves to open new accounts using stolen information. Consumers must call or go online with each of the three credit-reporting agencies to create a freeze — and keep the PIN numbers needed to reopen the accounts.

Still, a credit freeze isn’t the only reason why applicants might face an ID delay, said Spiralight’s Byrne.

Sometimes applicants enter a number incorrectly — say, one digit in a Social Security number. They may have a fraud alert on their credit accounts because of a previous identity theft. Or the person is young and has little or no credit history.

But in all cases, they may get a notice saying more information is required and the application process comes to a standstill. But, so long as the process was started before the end of open enrollment, consumers should be able to finish their applications.

Once they get cleared after providing documents, applicants are eligible for a special enrollment period, said Shelby Gonzales, senior policy analyst at the Center on Budget and Policy Priorities. In that case, her advice is to telephone the “healthcare.gov call center and let them know you’ve been cleared for identity proofing, and they should be able to help you activate the special enrollment,” she said.

Why Do People Hate Obamacare, Anyway?

December 13, 2017

The Affordable Care Act, aka “Obamacare,” has roiled America since the day it was signed into law in 2010. From the start, the public was almost evenly divided between those who supported it and those who opposed it.

They still are. The November monthly tracking poll from the Kaiser Family Foundation found that 50 percent of those polled had a favorable view of the health law, while 46 percent viewed it unfavorably. Partisan politics drives the split. Eighty percent of Democrats were supportive in November, while 81 percent of Republicans were strongly negative. (Kaiser Health News is an editorially independent program of the foundation.)

That helps explain why Republicans are working to repeal a key element of the health law in the tax bill Congress is negotiating. The requirement that most Americans have health insurance or pay a tax penalty — the so-called individual mandate — is by far the most unpopular provision of the law, particularly among Republicans.

Still, while partisanship is a major reason why some people hate the health law, it’s far from the only one. Here are four more: 

Ideology

Conservatives and libertarians strongly object to the federal government becoming ever more involved in the nation’s health care system. While the refrain that the ACA represented a “government takeover” of health care was a significant exaggeration, the law did insinuate the government significantly further in its funding and oversight of health care.

Adding to that was the unhappiness with the ACA’s individual mandate. Although the idea was originally suggested by Republicans in the late 1980s, the GOP had mostly backed away from it over the years (with the notable exception of Massachusetts Gov. Mitt Romney, who supported that state’s health overhaul in 2006).

But conservatives are not alone in opposing the ACA on ideological grounds. Many liberals don’t like the law, either. They think it does not go far enough toward a fully government-run system and gives too much power to private insurance companies. 

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Lack Of Knowledge

A big part of why people don’t like the health law is that they don’t understand what it does or how it works. Some of that is because health care is complicated.

Even some of the main arguments made by the law’s supporters are not well understood. For example, the health law is responsible for some 20 million Americans gaining health insurance. Yet in 2016, when the uninsured rate hit an all-time low, only one-quarter of respondents to the Kaiser tracking poll knew that. A little under half thought the rate had remained unchanged, and 21 percent thought the rate had risen to an all-time high.

But some misperceptions follow intentional fabrications or exaggerations of the law’s impact. Many people came to believe (incorrectly) that the law would create “death panels” to decide the fate of seniors on Medicare, which became PolitiFact’s “Lie of the Year” in 2009. Other outlandish and untrue claims about the law included the idea that it would require people to be microchipped, that it would create a “private army” for President Barack Obama and that it would require hospitals to fire obese employees.

Even the derisive nickname “Obamacare” fed the confusion. In a now-famous skit by comedian Jimmy Kimmel, people on the street expressed a strong preference for the Affordable Care Act over Obamacare — unaware that they were the same thing. 

Confusing The Health Law With The Rest Of The Health System

Once the ACA became law, basically everything bad that happened in health care was attributed to it. This is the famous “you broke it, you bought it” problem — the law became the scapegoat for any number of problems in the health care system, regardless of whether they predated its enactment.

For example, rising prices for prescription drugs has been a problem for years. But the ACA did not seek to address that, except for one provision that sought to facilitate generic copies of some of the most expensive biologic medications.

Also, before the ACA, some insurers stopped offering plans in the individual market, while others raised premiums dramatically and often would not cover care at high-cost providers like teaching hospitals. 

Some People Actually Are Worse Off

The ACA did create some losers. Healthy people who managed to buy individual health insurance before the law’s passage have seen their premiums and out-of-pocket costs soar as insurers have raised prices to accommodate sicker people who had been largely shut out of coverage. Among those hardest hit are people who earn just slightly too much to qualify for federal premium subsidies, particularly early retirees and people in their 50s and early 60s who are self-employed.

Many of those people would have been helped if Democrats had been able to pass some of their original ideas for the ACA, including a “public option” plan run by the government, or a “Medicare buy-in” that would have given people age 55 and older the option of purchasing Medicare coverage before the normal eligibility age of 65. Both were rejected by more conservative Democrats in the Senate.

Some people found themselves in a “coverage gap” after the Supreme Court in 2012 ruled that the ACA requirement for states to expand Medicaid had to be optional. That meant people with incomes under the poverty line but still too high to qualify for Medicaid in their states have no affordable program available.

Others were forced to give up coverage that they liked, even if it did not offer many benefits, or were angry because their doctors and hospitals were no longer in their insurers’ networks. Obama’s promise that “if you like your health plan you can keep it” was PolitiFact’s “Lie of the Year” for 2013.

However, even some of those consumers have seen benefits from the law, although they might not realize it, like required rebates from insurers who charge too much for administrative costs.

But it is human nature for people who feel wronged to complain loudly, while people who are satisfied merely go on with their lives. In the end, that is why it seems so many more people hate Obamacare than actually do.

Sign-Up Deadline Is Friday, But Some People May Get Extra Time

December 12, 2017

Open enrollment on the federal health law’s marketplace ends Friday, and most people who want a plan for next year need to meet the deadline.

But some consumers who miss the cutoff could be surprised to learn they have the opportunity to enroll later.

“While a lot of people will be eligible … I am still worried that a lot of consumers won’t know it,” said Shelby Gonzales, a senior policy analyst at the Center on Budget and Policy Priorities.

Under the health law, people are entitled to a special enrollment period (SEP) when they have specific changes in their lives, such as losing other health insurance, getting married or having a child, or when they have a change in income that affects their eligibility for premium tax credits or cost-sharing reduction subsidies. Those special enrollment periods generally last at least 60 days.

Other circumstances can also qualify customers for a special enrollment period. But this year, consumer advocates are focused on two that could affect a substantial number of people: consumers whose 2017 marketplace policies are being discontinued in 2018 and people affected by the hurricanes that ravaged Texas, parts of the Southeastern United States and Puerto Rico.

It’s not clear how many consumers this will affect. In past years, people who sign up during an SEP made up a tiny fraction of overall marketplace enrollment. In the spring of 2016, 11.1 million people had a marketplace plan. Meanwhile, roughly 1.6 million signed up through a special enrollment period during 2015, according to the federal Centers for Medicare & Medicaid Services (CMS).

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The majority of people who use a special enrollment period do so because they’ve lost coverage under another plan. This applies to people who lose their job-based coverage as well as those with marketplace plans whose insurer discontinues their plan for the upcoming year.

Between 2014 and 2018 the average number of issuers per state declined from 5 to 3.5, according to the Kaiser Family Foundation. (KHN is an editorially independent program of the foundation.) Several big name companies, including Anthem, Aetna and Humana, dramatically pulled back in their 2018 offerings.

A growing proportion of people will likely qualify for SEPs now because of a loss of marketplace coverage, insurance analysts say. This story also ran on NPR. This story can be republished for free (details).

People who are eligible for that special enrollment period have up to 60 days after their coverage ends on Dec. 31 to sign up for a new marketplace plan. Meeting the regular Dec. 15 sign-up deadline is preferable because it allows coverage to start Jan 1. But eligible people who miss that date can apply through the marketplace for an SEP that will allow them to sign up until the end of February.

Even if the marketplace automatically re-enrolls customers in a plan that’s similar to the one that ended, they’re entitled to an SEP to pick a new plan, said Karen Pollitz, a senior fellow at the Kaiser Family Foundation.

But people shouldn’t count on getting a clear explanation of what the SEP is or how it works, said Pollitz, who has reviewed the consumer notices related to plan discontinuations.

“The notices are not what they could be,” she said.

Gonzales concurs.

“The bottom line here is many consumers experienced a discontinuation of their plan this year,” she said. “Notices are complicated, and these consumers in particular are going to get several notices which may result in more confusion, and it will not be easily understood by many what an SEP is or how and/or when to activate it.”

This year, there are also special enrollment periods for people who were affected by the hurricanes that slopped across all or parts of Texas, Florida, Georgia, Puerto Rico and elsewhere last fall.

The special enrollment period for 2018 applies to people who live in or move from counties designated by the Federal Emergency Management Agency as hurricane disaster areas. It gives them an extra two weeks, from Dec. 16 to Dec. 31, to sign up for January coverage. Officials said they’ll consider extending the timeframe if necessary.

To take advantage of the special enrollment period, people must request it through the healthcare.gov call center. They’ll be asked to attest that they resided in an affected area, but they won’t have to provide proof.

Consumer advocates who work on outreach for enrollment and help people sign up for coverage aren’t yet talking up the SEPs, said Gonzales.

“They want one clear message for everyone: Open enrollment ends Dec. 15,” she said. Starting Dec. 16, these groups will start getting the word out for people who have missed the deadline and may not realize they may have other options.

Please visit khn.org/columnists to send comments or ideas for future topics for the Insuring Your Health column.

Sen. Collins’ Strategy To Stabilize Insurance Market Raises Doubts Among Analysts

December 11, 2017

Sen. Susan Collins (R-Maine), whose vote was pivotal in pushing the GOP tax bill forward last week, thought she had a deal to bolster health care protections in exchange for her support.

But it’s now far from clear that her strategy to shore up part of the Affordable Care Act will prevail or that her deal would produce the results she anticipates.

The tax bill repeals the ACA’s fines for the “individual mandate,” which requires most people to have health insurance or pay a fine. Collins said she would vote for it if Senate Republicans promised to allow a vote on two other health bills.

One would reinstate payments to insurers in order to cover discounts that the ACA requires those insurers to provide to their lowest-income enrollees for out-of-pocket costs. President Donald Trump ended those “cost-sharing reduction” payments in October. The bill that Collins supports would extend the payments for two years.

The other bill she supports would provide temporary funding for “reinsurance” pools, which help insurers pay claims for the sickest – and most expensive – customers. Reinsurance would help bring down premium costs for everyone else.

Before the tax vote, Collins said in a statement she was “deeply concerned that the repeal of the individual mandate would almost certainly lead to further increases in the cost of health insurance premiums – premiums that are already too expensive under the ACA.” Senate Majority Leader Mitch McConnell (R-Ky.) said on the floor that he would support Collins’ demands.

McConnell added that he would seek to restore the cost-sharing subsidies, “ideally prior to the adoption of any final tax reform conference agreement and certainly before the end of the year.” He also said he would “support passage of your bill” to create the reinsurance program, with the same timing.

But it’s nowhere near that easy.

The tax bill is now the subject of final negotiations between the House and the Senate. First, even if the bills pass the Senate, there is little to suggest that the House Republicans would go along. On Tuesday, House Speaker Paul Ryan (R-Wis.) reportedly told other House leaders he was not a party to Collins’ health care deal with McConnell.  Ryan had previously expressed opposition to restoring the cost-sharing payments.

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In response to Ryan, Collins on Thursday signaled that she might not vote for the tax bill’s final passage.

But would Collins’ changes offset the elimination of the mandate? Some analysts question whether the bill restoring the federal cost-sharing subsidy payments could actually do more harm than good.

“It’s a mess,” said insurance industry consultant Robert Laszewski. Many states allowed insurers to raise premiums to make up for the loss of the federal cost-sharing reduction payments. So passing the law now, at least for 2018, would require insurers to make refunds to individuals and the federal government for those overpayments.

“It’s certainly too late to affect premiums for 2018,” agreed Aviva Aron-Dine, a former Obama administration health official at the Center on Budget and Policy Priorities, a progressive think tank. “It’s also too late to help with market disruption for 2018.”

Open enrollment for 2018 coverage on the federal marketplace ends Dec. 15, although some state-run exchanges have later deadlines.

One irony, Aron-Dine noted, is that state regulators have dealt with the loss of the federal payments in such a way that many customers can get unexpectedly large discounts on premiums, including bronze-level plans for no monthly premium or gold-level plans cheaper than the mid-level silver ones.

Going back to the original payment system, she said, would result in “a whole group of people who would actually see higher premiums.”

In addition, the tax bill’s elimination of the federal health law’s individual mandate penalty would also raise premium costs – beyond the expected yearly increases – by an average of 10 percent, according to the Congressional Budget Office. That’s because the CBO estimates that about 13 million people would give up their coverage by 2027. Fewer people buying insurance means that the insurance pools would have larger numbers of sicker enrollees and would be more expensive for insurers, who would likely raise premiums.

Industry analysts also predict that the loss of the mandate could disrupt the marketplace enough to drive out some insurers.

The elimination of the mandate penalties is permanent, but Collins’ bill would fund the cost-sharing and reinsurance programs for only two years. Because of that, said Timothy Jost, a former law professor and expert on the health law, “I don’t think it’s going to be much of a carrot” to encourage insurers to stay in the individual market.

Analysts were more upbeat about the potential impact of the reinsurance program. The program would be similar to one that existed in the first years of the health law, “and it did in fact reduce premiums by about 10 percent,” Jost said.

But in order to set up such reinsurance programs and be eligible for funding, states would have to apply for special waivers under the health law. Federal officials have been slow about approving those.

“States would have to get their act together politically,” said Jost. “And the money might run out before [the federal government] gets to your state.”

At least one organization thinks Collins is onto something.

The consulting firm Avalere Health estimated this week that the combination of funding the cost-sharing reductions and funding a new reinsurance program would offset the impact of the mandate repeal – at least temporarily.

“Funding CSRs and funding reinsurance is expected to decrease average premiums in the market by more than the 10 percent [increase] CBO is projecting” for getting rid of the mandate fines, said Chris Sloan, a co-author of the study.

But he warned that when the funding runs out, “we’re back where we started.”

Podcast: ‘What The Health?’ Is Health Care Spending Still The Hungry, Hungry Hippo?

December 08, 2017

 

Congress is trying to wrap up its work for the year, but unsettled questions remain about the Children’s Health Insurance Program, the fate of the individual mandate insurance requirement from the Affordable Care Act and other health issues. Meanwhile, outside Washington, major mergers are happening within the health care system and the federal government reports that the rate of increase in health spending slowed in 2016.

This week’s “What the Health?” guests are:

Julie Rovner of Kaiser Health News
Stephanie Armour of The Wall Street Journal
Alice Ollstein of Talking Points Memo
Margot Sanger Katz of The New York Times

They discuss these topics and other health news of the week, including the state of open enrollment for 2018 health insurance.

Among the takeaways from this week’s podcast:

  • The iron-clad promises on health care that Sen. Susan Collins (R-Maine) secured for her vote for the tax bill may be splintering.
  • Although a number of health programs could see funding cut as a result of the tax bill, lawmakers promise that they will protect Medicare.
  • Former Obama administration officials are worried that last-minute insurance enrollment on the federal marketplace could be anemic this year, because the Trump administration has not promoted the law.
  • The merger mania of the past week highlights insurers’ interest in having a piece of the action in other parts of the health care system. Email Sign-Up

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Plus, for “extra credit,” the panelists recommend their favorite health stories of the week they think you should read, too.

Julie Rovner: Tonic.Vice.com’s “Why Do People Hate Obamacare, Anyway,” by Julie Rovner

Stephanie Armour: The New York Times’ “Millions Pay The Obamacare Penalty Instead Of Buying Insurance. Who Are They?” by K.K. Rebecca Lai and Alicia Parlapiano

Alice Ollstein: The Washington Post’s “Rep. Trent Franks Of Arizona, Who Asked Staffers If They Would Bear His Child As A Surrogate, Says He Will Resign,” by Mike DeBonis and Michelle Ye Hee Lee.

Margot Sanger Katz: Vox.com’s “Emergency Rooms Are Monopolies. Patients Pay The Price,” by Sarah Kliff.

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcher or Google Play.

For Marketplace Customers Who Delay, Auto-Enrollment Could Be Nasty Wake-Up

December 08, 2017

Shopping to update your coverage on the health insurance marketplace may be annoying — didn’t you just do this last year? But letting the exchange automatically renew your coverage instead could be a big mistake. If you don’t like the plan you’re auto-enrolled in this year you may be stuck with it in 2018, unlike previous years when people could generally switch.

It’s all in the timing. This year, the open enrollment period, which started Nov. 1, will end a week from today, on Dec. 15 in most states. On Dec. 16, if you haven’t picked a new plan, the marketplace will generally re-enroll you in the one you’re in this year or another one with similar coverage.

But unlike previous years when the open enrollment period ran through the end of January, this year open enrollment will generally be over by the time you see which plan you’ve been assigned to.

“The deadline catches up with people,” said Karen Pollitz, a senior fellow at the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

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It’s important to affirmatively pick a plan to make sure you’re getting the right coverage at the best price. Federal tax credits that help pay for premiums are pegged to low-cost silver plans, called benchmark plans. It’s critical that each year you run the numbers to determine how your premium tax credit could be affected by changes in the benchmark plan and how that affects what you will pay out of pocket for coverage. Even if you are assigned to the same plan, your costs could be different next year.

Auto-enrollment doesn’t take premiums or benchmark plan changes into account, said Stan Dorn, a senior fellow at Families USA, an advocacy group.

Last year, 2.8 million people were auto-enrolled. That’s nearly a quarter of the 12.2 million people who enrolled in marketplace plans during the open enrollment period that ran from Nov. 1, 2016, through Jan. 31, 2017.

People whose plans will be discontinued by their insurer next year have a little room to maneuver if they’re auto-enrolled on Dec. 16. Because their plan will no longer be offered, that’s considered a loss of coverage, which triggers a 60-day special enrollment period. They can pick a plan through the end of February.

“But you have to pay the premium [on your existing plan], or you’ll have a gap in coverage,” said Pollitz, a risk that potentially exposes people to a penalty for not having insurance.

Please visit khn.org/columnists to send comments or ideas for future topics for the Insuring Your Health column.

Challenges Abound For 26-Year-Olds Falling Off Parental Insurance Cliff

December 08, 2017

Marguerite Moniot felt frustrated and flummoxed, despite the many hours she spent in front of the computer this year reading consumer reviews of health insurance plans offered on the individual market in Virginia. Moniot was preparing to buy a policy of her own, knowing she would age out of her parent’s plan when she turned 26 in October.

Marguerite Moniot recently purchased health insurance on the open market with the help of a health navigator. She and her parents began searching for a policy several months ago, but the details of each plan became too complicated for the family. (Courtesy of Marguerite Moniot)

She asked her parents for help and advice. But they, too, ran into trouble trying to decipher which policy would work best for their daughter. The family had relied on her father’s employer-sponsored plan through his work as an architect for years, so no one had spent much time sifting through policies.

“Honestly, my parents were just as confused as I was,” said Moniot, a restaurant server in Roanoke.

In defeat, just before Thanksgiving, she went with her mother to meet a certified health insurance navigator, buying a policy that allowed her to keep her current doctors.

A new crop of young people like Moniot are falling off their parents’ insurance plans when they turn 26 — the age when the Affordable Care Act stipulates that children must leave family policies.

They were then expected to be able to shop relatively easily for their own insurance on Obamacare marketplaces. But with Trump administration revisions to the law and congressional bills injecting uncertainty into state insurance markets, that task of buying insurance for the first time this year is anything but simple.

The shortened sign-up period, which started Nov. 1, runs through Dec. 15. That window is half as long as last year’s, hampering those who wait until the last minute to obtain insurance.

Reminders and help are scarcer than before: The federal government cut marketing and outreach funds by $90 million, and federal funding to groups providing in-person assistance was whacked by 40 percent.

“I think it’s definitely going to be difficult. There’s just additional barriers with [less] in-person help, just fewer resources going around,” said Erin Hemlin, director of training and consumer education for Young Invincibles, an advocacy group for young adults.

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Emily Curran, a research fellow at Georgetown University’s Health Policy Institute, said those actions combined with the Trump administration’s vigorous criticism of the health law could further handicap the uphill battle to entice young people to enroll. As of Dec. 2, more than 3.6 million people had enrolled through the federal marketplace, according to the Centers for Medicare & Medicaid Services. The data were not sorted by age.

“There’s already a barrier where young adults are having difficulty understanding what the value of insurance is,” she said. “Coming out … and saying prices are going up, choice is going down and this law is a mess doesn’t really get at the young adult population.”

Trouble Attracting Young Adults 

Before the Affordable Care Act, young adults had the highest uninsured rate of any age group.

The ACA made coverage more affordable and accessible. It allowed states to expand Medicaid to cover single, childless adults. Tax credits to help pay for premiums made plans on the individual market more affordable for people whose incomes fell between 100 and 400 percent of the federal poverty level (between $12,060 and $48,240 for an individual). And young adults were allowed to stay on their parents’ plan until their 26th birthday.

Dominique Ridley signed up for health insurance with the help of a broker. The college student lives with asthma and needs to carry her inhaler at all times. (Courtesy of Dominique Ridley)

In all, the uninsured rate dropped to roughly 15 percent among 19- to 34-year-olds in 2016. Still, young adults have not joined the individual market in the numbers as expected. About a quarter of marketplace customers in 2016 were ages 18-34, according to the Department of Health and Human Services. But that age group makes up about 40 percent of the exchanges’ potential market, according to researchers and federal officials.

If the Trump administration’s moves dampen enrollment, insurers could face additional challenges in attracting healthy adults to balance those with illnesses, who drive up costs.

“When you’re relatively healthy, it’s not something that you’re thinking about,” said Sandy Ahn, associate research professor at Georgetown University’s Health Policy Institute.

But illness does not recognize age. Dominique Ridley, who turned 26 on Dec. 6, knows this all too well.

Ridley has asthma. She always carries an inhaler and sees a doctor when she feels her chest tighten. The student at Radford University in Virginia relies on her mother’s employer-sponsored plan for coverage.

Ridley started peppering her parents with questions about health insurance as soon as she started seeing ads for this year’s open enrollment.

“I don’t want to just go out there and apply for health insurance, and it be all kinds of wrong and I can’t afford it,” she said.

Her parents didn’t have the answers, but her mother linked up Ridley with a friend that runs a marketing company tailored to promoting the Affordable Care Act. Ridley then connected with a broker who signed her up for a silver plan that will cost her less than $4 per month, after receiving a premium subsidy of more than $500 a month.

“If you don’t have health insurance, you don’t have anything,” Ridley said.

A Digital Campaign 

The Obama administration relied in part on partnerships to attract young enrollees to sign up. Last year, it collaborated with national organizations like Planned Parenthood Federation of America and Young Invincibles on a social media campaign called #HealthyAdulting. Emails, according to Joshua Peck, former chief marketing officer for healthcare.gov, were particularly effective for recruitment.

The Centers for Medicare & Medicaid Services, which oversees the marketplaces, said it will focus this year’s resources on “digital media, email and text messages.”

James Rowley sits in front of the counter at Vapology 101, an e-cigarette store in Herndon, Va. Rowley started his own business in 2015 called Virginia Vaping Co., which makes and sells e-cigarette flavorings to stores. (Carmen Heredia Rodriguez/KHN)

Hemlin said the government has not asked Young Invincibles to assist in marketing. Her group will use its own resources to pay for targeted ads on social media to reach the target demographic, she said.

“But obviously we can’t make up for $90 million in advertising” that’s been cut, said Hemlin.

One factor that might compensate is that 20-somethings are facile at shopping online, said Jill Hanken, director of Enroll! Virginia, a statewide navigator program.

“Our job is to make sure they understand to look at provider networks and drug formularies if they have health concerns. But they’re able to do the mechanics of enrollment on their own very often.”

James Rowley, a 26-year-old entrepreneur from Fairfax, Va., is among those who signed up without help. He started his own company two years ago while covered under his father’s health plan. When he turned 26, he signed up for health insurance on his own through a special enrollment period this year. After general enrollment opened this fall, he once again picked a plan.

“I might not 100 percent need it now, but there will come a time where health insurance is important,” said Rowley.

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