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What's next for covering health reform: Trudy Lieberman

Trudy LiebermanTrudy Lieberman is the director of the health and medicine reporting program at the CUNY Graduate School of Journalism. She is a contributing editor for Columbia Journalism Review where she writes about health care and the media for the "Campaign Desk blog." She is a contributor to The Nation and the author of several books. Lieberman has won numerous awards for her reporting including two National Magazine Awards. She also was a Fulbright Scholar to Japan and a John J. McCloy fellow to Germany to study health care in those countries. She is immediate past president of the AHCJ board of directors.

Relevant work for CJR.org

Trudy Lieberman
Director, health and medicine reporting program
CUNY Graduate School of Journalism

The affordability issues tucked into the health reform law cry out for exploration. Through this whole debate, people have been told that they would get subsidies to help them buy coverage, but all the nuances of those subsidies available through the state exchanges, or shopping services, and the amounts people will actually pay out of pocket have barely been discussed. Some readers, viewers and listeners will be in for a big surprise. They may have to decide between buying subsidized insurance with a hefty out-of-pocket outlay for premiums along with high deductibles – perhaps as high as $4,000 – or taking a tax penalty that will be a smaller hit on the family purse.

Subsidies are based on family income; those at the low end of the income spectrum will get more help than those with an income of $88,000, the upper limit for government help. Families with middling incomes will find themselves paying nearly 10 percent of their income on a policy with the government paying the rest. So a family making $66,000 would spend $6,257 for a policy that may cover only 70 percent of their medical expenses, on top of the deductible.

These insurance-buying dilemmas will make interesting and readable stories. Plus they will also get at the question of how well the law is working and whether people are really getting coverage. That, after all, was the central goal of the law. How are families going to make choices? Where will insurance actually fit in?

Reporters could begin this story by looking at what's happening in Massachusetts. Many people there have dropped their coverage because of affordability problems and have taken the penalty. Since the Massachusetts reform law is the model for the national legislation, it's worth looking at what people are actually buying through the state's Connector; if they are buying at all. Almost half are choosing the lowest cost, bronze policy with its smaller benefit package. We need to keep tabs on whether consumers in other states will also flock to the low-cost bronze policy mandated by the law, which will cover only 60 percent of the benefits.

For help understanding how all the elements of a policy fit together, including the out-of-pocket limits specified in the law, I recommend working with health insurance actuaries such as those who work for the actuarial firm Milliman. Through the years I have found actuaries indispensable in helping me understand the ins and outs of insurance. Many can translate complex concepts into plain English for reporters and their audiences and can help untangle your prose when you get stuck.

Reporters may want to keep an eye on how insurance companies will try to get around the ban on pre-existing conditions. If they must cover sick people with all their expensive ailments, they will somehow have to bring money in the door to pay all those claims and make a profit on the side. What proxies for medical underwriting will they use? The new law sanctions age rating; in other words, looking at age in determining how much someone pays. While checking out Massachusetts, find out how older people, especially older women, are faring. In that state, insurers can charge an older person twice as much as a younger one for the same coverage in the same geographic area. Sometimes they must pay several hundred dollars more, making insurance unaffordable. Under the new law, insurers can charge three times more. While gender rating; that is, charging women more than men, will not be permitted, women who work for large companies with a predominantly female workforce can be charged higher rates until 2017.

Another story on the affordability beat will be employer wellness programs. HIPAA regulations allow employers to create wellness programs based on health factors. Workers who hit targets like having blood pressure readings below a certain number might get a discount on their premiums. But the value of the rewards can be no greater than 20 percent of the combined premium paid by the employer and employee. Workers who don't meet the targets could pay higher premiums. The new law allows employers to offer a higher reward to "good" workers, up to 30 percent of the combined premiums. The secretary of the Department of Health and Human Services can increase it to 50 percent. Employers argued for flexibility.

There are lots of stories here – equity and fairness issues, whether it's impossible for some workers to hit their employers' targets because of medical reasons, employment discrimination, backdoor underwriting by insurance companies. This story can be done in any community.

Check with business associations like the Chamber of Commerce, local business coalitions like the New York Business Group on Health and the National Business Group on Health for leads. Or you might try old-fashioned shoe leather reporting. Start calling businesses in your community and ask whether they are starting wellness program and then find out how they work. Follow-up stories and monitoring are important here.

For background on whether wellness programs work at all and what kinds might be more effective than others, do a literature search and scour journals like Health Affairs (AHCJ members get free access). This story needs a lot of context and the jury is still out.