Drew Altman, president of the Kaiser Family Foundation, in a recent Politico op-ed, shared some thoughts on challenges in covering of the roll out of the Affordable Care Act.
Three of his main points – understanding the health law is not just a Washington story, knowing what to cover and finding solid resources to get at the facts instead of contrived “balance” – are topics we try to address on Covering Health and on the AHCJ health reform core topic site. Balance is fine – fair and essential – in complex stories where there are many points of view, different ideologies, and legitimate questions about how the health law will unfold over time.
It’s not “balance” if there is clear, solid data on a specific topic, and another side gets equal time just because they don’t like it (or because your editor insists that it get equal time). Knowing what’s in the law, what it does and what it doesn’t do, helps us report with authority and find that balance.
The aspect I want to address here, related to the “balance” question, is what Altman calls “judgment by anecdote.” Here’s what he’s worried about: Continue reading
As we noted yesterday, the special high-risk pools created by the federal health law to cover some people with pre-existing conditions will end in 2014. The people covered by the pools will be eligible for coverage in the state exchanges (or some may qualify for expanded Medicaid).
But about 35 states have some form of high-risk pools of their own, most of which predate the health law. The approximately 200,000 people they cover also will have new coverage options under the Affordable Care Act. Insurers won’t be able to reject them or charge them more because of pre-existing conditions.
But will states shut down these pools as soon as the exchanges open on Jan. 1? That used to be the thinking – Jan. 1 or soon after. Then came a wave of second thoughts about that — worry that putting some of the sickest, most costly people in the exchanges at the very beginning would warp the risk pool and raise prices for everyone. The concern is particularly acute about the first year as there is a lot of uncertainty about how robust enrollment will be in these new markets, and how many relatively young, healthy and low-risk people sign up.
The law contains several risk adjustment measures meant to reduce the risk for insurers, particularly in the early more uncertain stages. (Look at the glossary section of our Health Reform core topic area for definitions of risk adjustment, risk corridors, and reinsurance.) But precisely how much market turbulence there will be in the first few months remains an unknown. Continue reading
It’s a good time to take a look at the high-risk pools.
There are two basic kinds of high-risk pools – about 35 states have some form of high-risk pools that predate the Affordable Care Act, and all states have Pre-Existing Condition Insurance Pools created by the federal law.
Let’s look at the “PCIPs” first. (Here’s a federal website that explains them.)
Some states administer these “PCIPs” themselves, and some let the federal government run them. “Red” states tended to hand it to the feds, “blue” states tended to run it themselves but there were enough exceptions in both directions to make this less political than the fight over the state-run health insurance exchanges going online in 2014. Here’s a map.
These pools were supposed to be temporary — a bridge to get some uninsured people to 2014. They never were going to cover everyone and they never were going to be cheap for these individuals, despite the $5 billion in federal subsidies. Enrollment in states was slow and uneven, but after tweaks by the Department of Health and Human Services to the premium structure and more outreach, it picked up a bit. The pools were meant to provide a degree of help to people with serious and expensive medical conditions who hadn’t been able to get insurance for at least six months. It was not meant to be a permanent or comprehensive solution. According to HHS, about 100,000 people are covered.
But some of those people were very expensive to cover. By early this year, federal officials suspended enrollment. (In February for the federally administered ones, in early March for the states.) They wanted to make sure that the $5 billion didn’t run out. People who are in the pools will continue to be covered but new people can’t come in. In January, the PCIP pools will close and the people in them can be covered in the regular state exchanges like everyone else. Continue reading
We’ve written several times about the role of co-ops in the states (here and here) and posted a lot of resources for those of you in states with this option. But here’s a story from The Associated Press that surprised me – Vermont just rejected the Vermont Health Co-op, saying it was going to cost too much and was probably too optimistic about enrollment. (Regulators also raised questions about its solvency, which was less surprising if you’ve been following co-ops.)
The co-op is hoping to get that decision reversed so it may not be over. But this is noteworthy because it’s occurring in a small state that doesn’t have a lot of insurance participation in the exchange – something that backers of co-ops had hoped these nonprofit entities would address.
Vermont is a liberal state that backs health reform, and has created a framework for moving to a state version of a single-payer system a few years from now. And so far it has only two health plans set to offer coverage in its exchange next year. It’s the kind of state that – at least from the outside – one would have expected to work hard to find a space for the co-option. I welcome insight from anyone who knows Vermont well and has a different take.
We’ve posted a tip sheet from the National Immigration Law Center on how the Affordable Care Act affects immigrants. They let us put their guide on the site with one request – that we include their website and suggest that you check their site if you write on this topic in case there are updates.
There’s no sense in repeating what you can find on the tip sheet (undocumented immigrants don’t get covered, documented ones do under the circumstances described – generally, they can go in the exchanges with subsidies if they qualify but still face a wait to get into Medicaid). But it is worth addressing the nexis between the health law and the current debate over helping immigrants become documented.
The bill will go through changes before it passes – IF it passes (a big question mark, particularly in the House). But the key message from our perspective as health reporters: Given what’s been said so far by Democrats and Republicans alike, it is highly unlikely that undocumented immigrants will get health benefits WHILE they are going through what looks to be a multi-year process of becoming documented. However, once they are documented they will be treated like the rest of the documented immigrant population.
Insurers are beginning to file their rate requests and, naturally, they are beginning to generate headlines as well as more political fodder.
My impression is that the rate hikes (particularly for younger people) are getting way bigger attention than the rate decreases (particularly for older people). That’s partly because runaway costs are a better headline – and fit into a political narrative we’re all hearing.
It’s also because the price increases for younger, healthier people is a serious policy concern. If younger people don’t sign up for the exchanges, and only older sicker people do, the costs will keep rising and fewer people will get covered. That is precisely the opposite of what the Affordable Care Act is supposed to achieve.
But there are several caveats – and I explained several of them in an earlier post. The biggest ones to remember: these are “sticker” prices. Many, if not most, people in the exchange – millions of Americans – will be eligible for subsidies in the form of tax credits. These will be available on a sliding scale to individuals and families up to 400 percent of the federal poverty level. Continue reading
Here’s a great piece by Carla Johnson, an Associated Press medical writer and AHCJ board member. She highlights a little-known element of the Affordable Care Act and pulls together many strands of policy, hard numbers and real people’s needs.
The story addresses how the health law will expand access to treatment for addiction and substance abuse – but that the system may not be up to meeting a backlog of unmet human need.
Her vivid opening sentence sets the stage:
It has been six decades since doctors concluded that addiction was a disease that could be treated, but today the condition still dwells on the fringes of the medical community.
Every month we add to the resources and data sections of the health reform core topic area, with notes on how it can be used to report on reform. But I also wanted to point out a guide to data for health care reporters that our colleagues at Reporting on Health put together.
The Wall Street Journal and Louise Radnofsky did a nice package of interactive graphics and maps on state health spending. As Radnofsky noted, the high spenders are in the Northeast – but not only the Northeast. They are some rural states – but not all rural states. And Florida is up there.
It’s a fun and useful tool that gives you a snapshot of your state – and let you compare it with neighboring states or states with similar demographics.
But if you follow the work of the Dartmouth Atlas folks you’ll also know that spending doesn’t just vary by state – it varies by county, city – sometimes even neighborhood. Payment incentives is part – but only part – of the story. (They don’t explain why two hospitals in Manhattan may have such different utilization patterns, for instance). Local practice patterns, training, traditions, patient demographics all play a role.
We write a lot on this blog about state developments, the exchanges and Medicaid expansion, as that’s a huge part of the local health policy beat. Here’s a helpful detailed guide to covering exchanges from CJR’s Second Opinion.
It suggests Five Big Questions and gives some advice on how to think about each of them
- Will policies be affordable
- Who influences the exchange boards?
- Which policies can be sold?
- Do the networks have enough doctors and hospitals?
- How will the exchange sell its policies?
And it includes this basic advice:
For starters, look beyond the easy sources – those academics and think tank experts always eager to dish out a quote. In fact, don’t even worry about quotes at this point. The trick is to understand what’s going on, who are the players and their special interests, what are the nuts and bolts of how these exchanges work. And then: What big questions need to be addressed. Therein lie your stories.
The exchanges are a local, ongoing story, and the best sources will be the ones on the ground in your state. That means advocacy groups, local foundations, local stakeholders like insurance brokers and agents, medical societies, hospital associations, the head of the local exchange board, the staff at the exchange board, insurance regulators, consulting actuaries, and insurance companies (whose websites can be helpful even when their PR folks are not). In other words, good coverage of the biggest health story in decades requires old-fashioned reporting—schmoozing, cultivating sources, reading reports and testimony, even attending meetings of your local exchange board. That’s how you’ll find the dots to connect.
I would add that California is a good state for you to watch to see how some of these questions get asked, and answered. California is ahead of many states in setting up the exchange; they are already thinking about marketing and messaging and outreach, officials (including those who favor the Affordable Care Act) are having frank public conversations about affordability, and there is a lot of good reporting coming out of the state. CJR’s Second Opinion also has been tracking Connecticut’s exchange pretty closely.