The impact on coverage will vary, but the shifting landscape means that it's more important than ever for consumers to carefully evaluate the plans that are available in their area and choose the best one for their needs.
With the annual sign-up period for plans on the health law's marketplaces starting Nov. 1, many consumers are worried about rising premiums, shrinking provider networks and the departure of major insurers such as UnitedHealthcare, Aetna and Humana from many exchanges.
The impact on coverage will vary, but the shifting landscape means that it's more important than ever for consumers to carefully evaluate the plans that are available in their area and choose the best one for their needs. There are several elements to factor into that decision.
It's crucial to log into the marketplace and review plan details. Comparing plan premiums and deductibles only scratches the surface of what you should evaluate before selecting a plan this fall. Policy details can make an important difference in coverage and costs, but it may take some digging to uncover them.
Avoid Premium Sticker Shock
Premium increases for 2017 will generally be higher than last year's rate hikes, though with significant geographic variation. In the two-thirds of states where the federal government runs the marketplace, the average premium increase for the second lowest cost silver plans will be 25 percent next year, according to a recent report by the Department of Health and Human Services. Last year, the comparable premium increase was 7 percent. The average premium, before tax credits, for the lowest cost silver plan will be $433.
About 85 percent of marketplace customers have incomes of up to 400 percent of the federal poverty level (about $47,000 for one person) and qualify for federal tax credits to help pay their premiums. If you are one of these consumers, it may be necessary to switch plans to minimize your share of the premium because your tax credit is pegged to the second lowest-cost silver plan in your area, which often changes from year to year.
Next year, three quarters of people can find a cheaper plan at the same metal level if they come back to the marketplace to shop. Consumers who bought the lowest cost silver plan in 2016 can save an average $58 per month by switching to the cheapest silver plan next year, according to HHS.
People with subsidies "can insulate themselves from premium increases by selecting one of the lowest cost silver plans," said Caroline Pearson, a senior vice president at the consulting firm Avalere Health.
If you're currently buying an individual plan but not going through the marketplace, be sure to recheck your eligibility for subsidies. Federal officials estimated earlier this month that 2.5 million people who purchased coverage outside the exchanges have incomes that would qualify for financial assistance.
Look For Hidden Benefits
A close look at plan details may show that coverage is more generous than it appears. Even as deductibles continue to rise, many plans are offering coverage for certain services before the deductible is satisfied. So instead of having to pony up the entire cost of your visit to the doctor or your prescription drug until the deductible is paid off, you may just owe a copayment.
This year, for example, 66 percent of silver-level plans sold on healthcare.gov covered primary care doctor visits before the deductible. Half of plans covered generic drugs before the deductible. (In addition, the health law requires that many preventive care services, including tests and screenings, vaccinations and contraceptives, generally be covered without requiring people to pay anything out of pocket in all new marketplace plans.)
This practice can serve two purposes. Encouraging primary care may save insurers money down the road on more expensive treatment. And exempting some services from the deductible could help make plans more appealing to the relatively healthy people insurers want to attract and who might otherwise balk at policies with a typical deductible of around $3,000.
"Part of it is trying to give people some value even if they're not high users of health care," said Sarah Lueck, a senior policy analyst at the Center on Budget and Policy Priorities in Washington, D.C.
Sidestep Automatic Reenrollment
If your plan is continuing next year, you may be automatically renewed, but that may not be your best option. Do some comparison shopping on marketplace plans to see whether there are changes to plan benefits or provider networks that matter to you and how 2017 pricing will affect your subsidy.
If your plan is not going to be available next year and you don't actively pick a new plan, you may find yourself automatically enrolled in a plan with similar costs and benefits. But that can mean changes in the list of approved drugs or losing access to your favorite hospitals and doctors, among other things.
Pay attention to timing. Enrollment ends Jan. 31, but to have coverage that starts Jan. 1, you must make a choice by Dec. 15.
Check Out New Standardized Plans
Next year, healthcare.gov will join several state-based marketplaces in offering standardized plans that are expected to help consumers make apples-to-apples comparisons between plans at the bronze, silver and gold levels and cut down on confusion caused by a sometimes bewildering array of options. In these "simple choice" plans, the deductibles and annual limits on out-of-pocket spending will be standardized, as will many of the consumer payments for medical services. For example, the standardized silver plan will have a deductible of $3,500 and the maximum amount you will owe out of pocket for the year will be $7,100.
In addition to standardized benefits, many of the plans cover a number of services before the deductible is satisfied, such as primary care and specialist visits, drugs, urgent care and outpatient mental health.
Many standardized plans also rely on copayments (fixed amounts that you pay for a service), rather than coinsurance (a percentage of the cost of the service), to a greater extent than people may see in regular marketplace plans, said Sabrina Corlette, research professor at Georgetown University's Center on Health Insurance Reforms. Insurers aren't required to offer standardized plans in most states, but the federal government is promising that the plans will be prominently displayed on healthcare.gov.
Dig Into Prescription Drug Details
Drug coverage is a big concern for many people, but finding plan details can be tough. You can check out a plan's list of covered drugs through healthcare.gov, but determining what your share of the cost will be can be more challenging. That's because even though state marketplaces typically only show four cost-sharing tiers online, many plans have five, six or even more tiers. In 2016, 40 percent of silver marketplace plans had more than four cost-sharing tiers, according to Avalere data.
Also, insurers on the exchanges may require that your doctor or other health provider get prior authorization from the insurer before prescribing some drugs for you or demand that you try a less expensive drug before getting a more expensive one, a practice called step therapy, said Pearson.
"If you're a consumer that has a lot of drug costs or takes specialty medications, actually consulting the plan documents is important, because you need more granularity than is available on the website," said Pearson.
Check Provider Networks
You will be able to check which doctors and hospitals participate in the plans you're considering on healthcare.gov. That's increasingly important as networks continue to narrow and fewer plans offer any out-of-network coverage. An initiative by the federal government to communicate whether a plan's network is basic, standard or broad in all states using the federal marketplace has been trimmed back to a four-state pilot in Tennessee, Maine, Ohio and Texas.
Use Caution When Shopping Off The Marketplace
If the marketplace plans don't appeal and you don't qualify for subsidies, you can shop for individual market coverage off the exchanges, although the number of such offerings has been declining, said Katherine Hempstead, who directs health insurance coverage research for the Robert Wood Johnson Foundation.
Off-exchange plans can't be too wildly different from what's available on the exchange, because they also have to cover the essential health benefits and offer plans in metal tiers that cover the same proportion of care as those on the marketplace, among other things. But in some markets, plans may offer different or broader provider networks outside the exchanges, said Corlette.
There's a potential downside, however. If your income is too high to qualify for subsidies at the beginning of the year, you may qualify for them later if your income drops — for example, if you lose a major client. But that's only an option if you're already enrolled in a marketplace plan.
"If you're enrolled outside the exchange and you have a change in income, you can't qualify for a special enrollment period to sign up for a different plan," Corlette said.
A surprising group of patients are suffering from opioid poisoning at rates that have also marked a dramatic increase: adolescents, children and even toddlers.
As the nation continues to confront an epidemic of opioid and prescription painkiller addiction and overdoses, its victims seem to flood emergency rooms. But a study out Monday highlights a surprising group of patients suffering from opioid poisoning at rates that have also marked a dramatic increase: adolescents, children and even toddlers.
Because of what the authors call "the now widespread availability of prescription opioids in the United States" — with retail sales of these medications quadrupling from 1999 to 2010 — they sought to examine for the first time the rate of pediatric hospitalizations related to these drugs.
The findings, they say, indicate a need for comprehensive strategies that not only continue to tamp down on opioid prescriptions, but also step up efforts to raise awareness about the packaging and safe storage of these painkillers.
"It's exposure. Opioids are ubiquitous now," said Julie Gaither, a postdoctoral fellow at Yale School of Public Health and the study's lead author. "Enough opioids are prescribed every year to put a bottle of painkillers in every household. They're everywhere, and kids are getting into them."
Published in JAMA Pediatrics, the study analyzed hospitalization data for children between 1997 and 2012, examining more than 13,000 hospital-discharge records for opioid poisonings and using Census data to extrapolate how common these pediatric opioid overdoses were. They used discharge records collected every three years between 1997 and 2012 by the Agency for Healthcare Research and Quality.
One possible limitation: The data stops in 2012 and, therefore, rates may not reflect a dipping or plateauing because of increased awareness of the opioid epidemic. But the findings track with adult rates of abuse and addiction, which have dropped since 2012 but remain troublingly high, experts say.
Overall, researchers found the rates for children hospitalized because of opioid poisoning increased during the 16-year period — from about 1.40 per 100,000 kids to 3.71 per 100,000. Much of that is likely an effect of kids getting into their parents' medicine chests.
Specifically, the study found the rate of toddlers hospitalized more than doubled, going from 0.86 per 100,00 to 2.62 per 100,000. Many experts speculate these very young patients take the drugs because they think they are candy or a treat.
Teens are also at risk of overdosing on their parents' meds. Of all children, this age group is most likely to get hospitalized for opioid poisoning, and are more likely to do so deliberately — likely, the researchers wrote, because teenagers are at a particularly high risk of depression. In 2012, 10.17 per 100,000 teenagers were hospitalized for opioid poisoning.
Importantly, the research underscores the need for doctors to talk to patients about ways to keep the drugs safely, especially if children are in the household, Gaither said.
That's a good idea in theory, said Jonathan Chen, an instructor at Stanford Medical School who has researched the opioid issue. But doctors already face a lengthy list of sensitive subjects they should discuss with patients. And they aren't always conditioned to consider how a patient's health patterns may interact with the rest of the family.
"Conceptually, yes, of course that should be part of the conversation," Chen said. "But there's a lot of things we should discuss. … When I talk to a patient, I conceptualize them, and I don't conceptualize who else is in their household as much as I should." Chen was not involved with the study.
Pediatricians could also play a role, asking parents at well-child and well-baby visits about whether there's a risk of children being exposed to opioids. But that sort of screening hasn't traditionally been drilled into doctors the same way as discussing household risks, such as safe storage of cleaning supplies, whether the family has a swimming pool and even whether there are guns in the home.
Doctors also may not be conditioned to considering toddlers as particularly at risk of opioid poisoning.
"This is largely seen as an adolescent problem or an adult problem," said Sharon Levy, who directs the adolescent substance abuse program at Boston Children's Hospital and is an associate professor of pediatrics at Harvard Medical School. "But this paper really highlights that this really knows no age boundaries." Levy was also not involved with the study.
It's also unclear, Levy said, what the long-term health effects are for children who ingest opioids that weren't prescribed to them. Younger people in general are more at risk of addiction. And toddlers who take these drugs at adult doses face the danger of serious respiratory complications.
"Opioids cause respiratory suppression," she said. "If you are a 30-pound person and getting into the medication that was supposed to be for a 150-pound person, it's going to be a whopping dose for you."
The findings also suggest doctors should also be more thoughtful in prescribing to children, and especially teenagers. About 1 in 10 high school students reports having taken opioids for a non-medical reason — and close to 40 percent of them say they got those drugs through their own prior prescription. Meanwhile, the American Academy of Pediatrics notes, the rate of young patients being prescribed opioids almost doubled between the 1990s and 2000s.
The Centers for Disease Control and Prevention has been pushing doctors to prescribe pills in smaller amounts, so that people don't end up finding and taking leftovers. That could help. Large prescriptions — coupled with the fact that many people don't know how to dispose of drugs when they finish them — can make it easier for children and teens to get ahold of them, Gaither said.
That's an important factor to consider, Chen said. "Leftover pills aren't used, but do they get returned to the pharmacy, or thrown in the trash? Nope. They're stored in the medicine cabinet."
Smaller prescriptions will likely help, but they won't solve everything, Chen noted. After all, there are situations where a larger opioid dosage makes sense. For instance, someone suffering long-term cancer probably needs a larger amount of heavy duty painkillers, even if he or she has children in the house.
But children must be a part of the conversation, Gaither said.
"We've got to pay attention to children and the toll the opioid crisis is taking on them," she said. "Kids make up about a fourth of the U.S. population, and they're suffering from this crisis, too."
Premium assistance programs are under fire from insurers. They argue that it is not fair for hospitals to try to steer people who could be covered by Medicare or Medicaid into marketplace plans with higher reimbursement rates.
MADISON, Wis. — Having health insurance is vital for 21-year-old Mercedes Nimmer, who takes several expensive prescription drugs to manage multiple sclerosis. So Nimmer was thrilled to get health insurance last year through the Affordable Care Act's marketplace and qualify for a federal subsidy to substantially lower her cost.
Yet, the government assistance still left her with a $33 monthly premium, a hefty amount for Nimmer, who makes $11,000 a year as a part-time supply clerk.
Nimmer, though, doesn't have to worry about even that expense thanks to a United Way of Dane County program that has provided premium assistance to about 2,000 low-income people since 2014. The program, called HealthConnect, is funded by a 2013 gift of $2 million from UW Health, a large academic hospital system connected to the University of Wisconsin that also runs its own marketplace health plan.
"Oh my gosh, this is a big deal for me to get this help," Nimmer said, noting the insurance is vital to cover her medications. The money she saves from the assistance program goes to help pay for gas to get to work, she said.
HealthConnect is one of several community-based programs across the United States helping thousands of lower-income Americans with their Obamacare marketplace premiums. Similar efforts operate in Texas, Oregon, Washington, North Carolina and South Carolina.
But premium assistance programs have come under fire from insurers. They argue that it is not fair for hospitals, other health providers and disease advocacy groups financed by providers to try to steer people who could be covered by Medicare or Medicaid into marketplace plans with higher reimbursement rates.
The federal government has banned hospitals from directly subsidizing patients' health insurance premiums. But America's Health Insurance Plans, the industry's lobbying group, wants the Obama administration to prohibit all premium assistance programs that are funded directly or indirectly by hospitals and other providers with a financial interest in the patient's care.
"In many cases these practices are harming patients and undermining the individual market by skewing the risk pool and driving up overall health care costs and premiums," AHIP said in Sept. 22 letter to Andy Slavitt, the acting administrator of the Centers for Medicare & Medicaid Services. The letter notes specific concerns about plans assisting patients requiring kidney dialysis. It says one insurer saw its spending on those patients rise from $1.7 million in 2013 to $36.8 million in 2015 when the number of patients with serious kidney disease rose from 28 to 186.
AHIP officials also said patients could face consequences if the third-party groups stop paying premiums or the government determines patients are receiving a federal subsidy for which they are not eligible.
America's Health Insurance Plans wants the Obama administration to prohibit all premium assistance programs that are funded directly or indirectly by hospitals and other providers.
In response, CMS says it is considering new rules for third-party payment programs.
Nonetheless, insurers are taking action. Aetna, which announced this summer that it was scaling back its marketplace offerings, said that third-party groups steering patients to the individual market had contributed to an unhealthy mix of customers in its marketplace plans.
Blue Shield of California in July filed suit in a state court against CenCal Health, which manages the Medicaid program in Santa Barbara and San Louis Obispo counties. Blue Shield alleges that CenCal was avoiding millions of dollars in medical care claims by enrolling around 40 of its very ill members in Blue Shield's individual health plans and paying the premiums on their behalf. CenCal denied the allegations in lawsuit, saying it paid the patients' monthly Blue Shield insurance premiums so they could afford private insurance. It has since discontinued the practice.
UnitedHealthcare filed a lawsuit in federal court in July against kidney dialysis provider American Renal Associates, accusing it of encouraging patients in Florida and Ohio who were eligible for Medicaid or Medicare to move to the insurer's commercial plans to extract up to 20 times more than the $300 or so that the federal programs pay in reimbursements. American Renal Associates has said the suit is without merit.
The suit alleges that the patients' premiums were paid by the American Kidney Fund, an advocacy group for patients.
AHIP officials note that the fund is supported by dialysis providers who stand to benefit financially from patients gaining marketplace coverage over payments from Medicaid or Medicare.
The nonprofit American Kidney Fund has helped more than 6,400 people with their marketplace premiums. The fund's officials said it's not trying to steer people away from government coverage but trying to help those who otherwise couldn't afford coverage.
"It is critically important to emphasize that people with disabilities in general — and with end-stage renal disease in particular — should not be broadly excluded as a class from the insurance marketplace if they are unable to afford their health insurance premiums," LaVarne Burton, the fund's CEO, said in a statement.
Some patient advocates, like those at HealthConnect in Wisconsin, say third-party payers have an important role in helping low-income customers afford their coverage. UW Health said in a statement that HealthConnect helps all providers, including UW Health, by reducing the number of uninsured patients and potentially helping people seek care earlier in their illness.
The program pays an average of $109 monthly per person in premium assistance. For every dollar spent, HealthConnect generates $2.26 in federal subsidies, said Krystal Webb, a spokeswoman for United Way of Dane County.
United Way said it structured HealthConnect to avoid a conflict of interest. Eligible people first buy their policy, which can be any of several silver-level plans on the federal marketplace. After that, they can apply for a HealthConnect subsidy. The program is administered by United Way, and UW Health plays no role in patients' choice of health plan, although its marketplace plan, Unity Health, refers people who may be eligible there.
Despite AHIP's concerns, some health insurers in Dane County say HealthConnect is filling a need, according to interviews with several plans. "We support United Way's HealthConnect efforts as a way to provide affordable insurance options to the residents of Dane County," said a spokesman for Dean Health Plan, one of the larger marketplace plans in the county.
In Texarkana, Texas, Christus St. Michaels Health System donated $200,000 last year to an assistance program serving 138 people with marketplace coverage. The program is run by a local government agency called the Ark-Tex Council of Governments, and Christus has no control over who enrolls or what plan they choose.
"Our mission is to help the poor and this is certainly one of the ways to do that, and it gives people the opportunity to have health coverage when they normally wouldn't," said Mike Hargrave, the hospital's manager of employee assistance and community outreach services. People with incomes between 100 and 150 percent of the federal poverty level (about $11,880 to $17,820 for an individual) are eligible.
Hargrave doesn't deny the hospital could benefit when more people gain insurance, but he notes other hospitals in the region benefit, too.
The insurance industry is also troubled by premium assistance programs funded by anonymous donors since they could be hospitals looking to protect their identity, said AHIP spokeswoman Clare Krusing.
For example, PremiumHealth.org, run by United Way of the Greater Triangle in North Carolina helps more than 850 people with incomes between 100 percent to 175 percent of the federal poverty level in Durham, Orange and Wake Counties.
An anonymous donor provided $1.2 million in funding for the program, said Melanie David-Jones, a senior vice president for United Way. She would not say why the donor wished to remain anonymous.
Noel Pitsenbarger, 48, of Durham, said the program made it possible for him to have health insurance this year by covering the $200-a-month premium for his Blue Cross Blue Shield of North Carolina policy. With insurance, he said, he got a colonoscopy, physical exam and help paying for several medications. And it saved him from having to pay a $1,000 bill after he cut his finger and had to go to the emergency room.
The issue has attracted national attention recently after a black physician from Houston posted on social media that a flight attendant had dismissed her offer to help and disputed her credentials when looking for medical aid for a man who needed treatment mid-flight.
In July 2013, a man arrived in the emergency room of a California hospital seeking treatment for his child. But when the intern on call walked in to see him, the father looked at her name tag and demanded another physician. As a Palestinian, he didn't want his child treated by a Jewish doctor. The intern turned to her resident supervisor, Emily Whitgob, who told her colleagues about the incident.
The episode, Whitgob said, helped motivate her to study how doctors in training and their institutions should deal with patients' prejudice and to publish a report that outlines strategies offered by the professionals she and the other authors consulted. The recommendations, published Wednesday in the Association of American Medical Colleges' journal Academic Medicine, call for trainees to focus on their role as doctors by not taking hostile comments personally and meeting patients' anxieties with empathy.
Researchers recruited 13 experienced faculty members from the pediatric department at Stanford University School of Medicine in California to review a series of scenarios illustrating patient discrimination against a medical trainee. Participants shared their reactions to the situation and outlined strategies for diffusing the tension in such encounters.
The issue has attracted national attention recently after Tamika Cross, a black physician from Houston, posted on social media that a flight attendant had dismissed her offer to help and disputed her credentials when looking for medical aid for a man who needed treatment mid-flight. Her Facebook post went viral, garnering over 48,500 shares as of Wednesday.
It's not clear how often these episodes occur. But the journal article notes that a 2015 survey found 15 percent of pediatric residents at Stanford had experienced or witnessed mistreatment of medical residents by patients or families. Of those incidents, 67 percent involved discrimination by patients' families. Half the people in the survey said they did not know how to respond to the discrimination and a quarter thought that the hospital was not likely to take any action against the patients' families.
The situations can be complicated by the lack of racial and ethnic diversity in many hospitals. According to the most recent data available from the medical colleges association, black and Hispanics make up about 9 percent of U.S. doctors.
Whitgob, now a developmental behavioral pediatrics fellow at Stanford, said the results of her research can help create a set of guidelines to give hospitals and medical students a framework to handle patient discrimination in the field.
"I wanted to help create the tools so that they can cope with these events in the future," she said.
The experienced doctors in the study noted that if the patient needs immediate medical attention, providers should ignore any hostile comments and quickly deliver that care.
When the need is not immediate, the study participants also recommend doctors speak honestly to patients about underlying emotional triggers, which may perhaps allow a more constructive dialogue that will get to the patient's or family's hostility and may allow both sides to work toward establishing enough trust for care to be given.
Formal training is needed to equip doctors with the skills to engage in these discussions, according to the report. By developing self-awareness and sensitivity, medical personnel can shift the focus away from the discriminatory remarks and emphasize patient care. The group also advised providers to set expectations early in medical training by communicating that discrimination can happen to anyone.
Many of these concepts should not be new to trainees. As part of their accreditation, medical schools already are required to teach students about culturally competent health care.
Dr. Rebecca Parker, president-elect of the American College of Emergency Physicians, attended medical schools before cultural competency training was common and said she was initially surprised when patients objected to working with her because of her gender.
Today, Parker has made the issue a priority in her organization with a task force to promote diversity in medicine in part through campaigns that challenge the traditional notions of what a doctor looks like.
"We need to also educate our society about the diversification of our physician population," Parker said.
Medical training in the classroom alone generally doesn't fill all the needs, said Dr. Roderick King, associate professor in the department of public health sciences at the University of Miami and CEO of the Florida Institute for Health Innovation. Such training exposes medical students to cultural sensitivity, but that may not provide the necessary skills for developing the right approach for these situations. While he said he understands how the fear of insulting a patient could deter a provider from engaging with a patient from a different background, King views cultural competence as a skill that requires work to perfect.
"The more you practice it," he said, "the more comfortable you get."
Whitgob echoes King's emphasis on real-world training. But a safe learning environment is also important to shield trainees from discrimination, she said. While the experienced doctors admitted facilities can't protect trainees from every negative situation, peers and supervisors can alleviate the sting by offering their support. The report recommends institutions set up a chain of command for reporting incidents and affirm their commitment to protecting its personnel.
In the emergency room incident three years ago, Whitgob almost confronted the patient on her trainee's behalf. Ultimately, the intern worked through the situation, but Whitgob says she's now more aware of the potential for discrimination in the exam room.
"We can't prevent what comes through the door, "Whitgob said. "But we can think about it on our own time before."
SACRAMENTO, Calif.— The "public option," which stoked fierce debate in the run-up to the Affordable Care Act, is making a comeback — at least among Democratic politicians.
The proposal to create a government-funded health plan, one that might look like Medicare or Medicaid but would be open to everyone, is being advocated by some federal officials, and gaining traction here in California too.
Amid news that two major insurers were pulling out of Affordable Care Act exchanges, 33 senators recently renewed the call for a public option. The idea was first floated, then rejected, during the drafting of the federal health law, which took effect in 2010.
Democratic presidential candidate Hillary Clinton includes a public option in her campaign platform, and President Barack Obama urged Congress to revisit the idea in a JAMA article published in August.
Dave Jones, the elected regulator of California's private insurance industry, endorsed the idea of a state-specific public option in an interview last month with California Healthline, though he did not specify how it might work.
A public option "would look just like an insurance plan," except that the state or federal government would pay for medical care, potentially set up the network of doctors and hospitals, and make rules about paying providers, according to Gerald Kominski, Director of the UCLA Center for Health Policy Research. Private industry could be involved in these or other aspects of running the health plan, much as they do in Medicare Advantage and managed Medicaid plans.
California Healthline interviewed Kominski to better understand how a public option could work. The interview was edited for length and clarity.
Q: When we talk about a public option, do we mean a health plan for which the government takes the risk, sets the coverage rules and pays out the claims — and enrollees pay premiums just as they would to an insurance company?
That is what the public option would be. But that still leaves out the answer to a lot of questions about how actually that would occur. How would a government agency essentially become the insurer? So we have two examples. We have the Medicare program and we have the Medicaid program.
Medicare establishes the rules. It contracts with insurance companies to pay the bills. And that's the way that Medicare has operated for over 50 years.
Now we have Medicare Advantage plans, where the contracting is not to pay bills but is basically contracting with insurers to bundle the services. And rather than pay the doctors and hospitals, the government pays the insurer and puts the insurer at risk.
Q: Insurers have opposed this idea in the past, and they're opposing it again now that it's being raised by members of Congress.
Private insurers could participate as administrators or providers on behalf of the state. But here's one concern that I have with that model: California has four large insurance companies in the exchange that account for about 90 percent of the market.
Let's say the state of California wanted to create a public option and hire an insurance company to administer that product for it. What would be the reason or the incentive for any of those companies to agree to be the plan administrator for the public option when the public option would be competing with the product that they're already offering? They would be competing with themselves.
Q: Some provider groups may be opposed to a public option because they say that government programs like Medi-Cal pay very little and they believe a public option plan would also pay little. Is this necessarily the case that a government program would pay low rates?
It's not necessarily the case, but it is in fact what we observe in the Medicare and the Medicaid/Medi-Cal programs.
Q: Do you think a public plan would help bring down costs in the health care system by negotiating for lower payments to hospitals and doctors?
I think that is possible in other areas of the country, where there are markets with one or two health insurance plans in the exchange. I think California has one of the most competitive ACA marketplaces. And so would the public option in California dramatically reduce premiums? I think the answer is no. It would have little or no effect.
For some people, the advantage is that we think that the public option's going to be around because the state's not going to back out of its commitment, whereas private insurers come and go in the marketplace.
Q: Is there something about California's health care system that uniquely primes the state for a public option?
I think so. One of the things that's unique about California is the high percentage of managed care enrollment. The public option in California would probably include or be based on a managed care model and Californians are pretty receptive to that model.
Q: So if the public option could include private insurance, why are the insurers so opposed?
Well, the simple answer is they don't want more competition. And again it goes back to, why was this battle so intense during the development and enactment of the ACA back in 2009 and 2010? The insurance industry said we cannot compete with a plan, a government plan, that pays doctors and hospitals using Medicare fees or fee schedules.
You remember the fundamental rule of business is you don't want more competition. You want the market to yourself.
Q: Do you think it would be more effective or easier to implement a public option at a state or national level?
Well that's where you can't ignore the political environment. And so the short answer is in the current political environment, doing something at the national level is extremely difficult. Even though there might be arguments to develop a public option at the national level, it's very challenging in the current political environment to get the agreement.
Q: Is there something that's more efficient about a national public option?
Potentially. It's economies of scale. You know, the larger your potential market nationally, the lower the potential costs per person. You just get administrative savings and efficiency. But it's not easy to create a national program. One issue that's challenging is how to put together a national network of doctors and hospitals that would participate. That's a lot of work.
Q: Do you think the idea of a public option is more viable now than it was when it was debated before and ultimately stripped from the Affordable Care Act?
A: Well, I think that what makes it more attractive right now is the fact that we've got two large insurance companies that are pulling out of the exchange marketplaces. And because of that … the idea of a public option to provide stability and protection for people in the exchanges has resurfaced. And I think with good reason.
Provider directories for private Medicare Advantage plans are riddled with errors, according to the government's first in-depth review.
The results made public Monday, arriving amid the annual enrollment period through Dec. 7, validate gripes long made by seniors and consumer advocates. The level of errors still surprised regulators, said officials from the Centers for Medicare & Medicaid Services who disclosed their findings at an industry conference in Washington.
Incorrect information was found for almost half of the 5,832 doctors listed in directories for 54 Medicare Advantage plans checked last fall, they said. Only online directories were examined.
The government hopes that a new rule this year will help raise that bar because it requires Medicare Advantage plans to contact doctors and other providers every three months and update their online directories in "real time."
CMS did not identify the names of insurers that were surveyed.
CMS' survey found the most error-prone listings involved doctors with multiple offices that did not serve health plan members at each location, said Christine Reinhard, a health insurance specialist in the CMS Division of Surveillance, Compliance and Marketing.
Explanations could be that the doctor was retired, worked at a different location or never worked at the address. Or maybe the doctor never had a contract with the Medicare health plan — a less likely possibility, according to officials.
The review also uncovered:
Wrong phone numbers for 521 doctors' offices.
Wrong addresses for 633 doctors' offices.
Error rates that exceeded 60 percent of the doctors surveyed for five Medicare Advantage plans.
CMS has not issued any fines but that could still occur, said Jeremy Willard, also a health insurance specialist in the CMS surveillance division. Inaccuracies found in the Medicare Advantage directories could lead to penalties up to $25,000 a day per beneficiary or bans on new enrollment and marketing.
Senior citizens rely on provider directories when choosing a health plan to identify in-network doctors. They also use them when seeking referrals to specialists.
"Errors jeopardize the beneficiary's ability to be connected with a needed provider," Willard said.
CMS carried out the survey by randomly calling 108 doctors representing primary care, cardiology, ophthalmology and oncology for the Medicare Advantage companies. The highest error rates involved primary care physicians and cardiologists.
America's Health Insurance Plans, the industry trade group, said its companies work hard to make provider directories accurate and keep them up-to-date.
"That's what consumers need — and that's what we're committed to improving," said spokesman David Merritt, acknowledging that plans needed to do better.
More than 17 million Americans, or nearly a third of Medicare beneficiaries, get coverage through Medicare Advantage plans.
Medicare Advantage plans and most exchange plans restrict coverage to a network of doctors, hospitals and other health care providers that can change during the year.
CMS is also surveying Medicare Advantage companies this fall, and officials hope to survey every company by 2018 when the three-year review will be completed.
Registered nurses in the Golden State earn $100,000 a year on average, more than their counterparts anywhere else in the country, according to recently released data from the Bureau of Labor Statistics. The average hourly wage for registered nurses in California is $48.68 an hour, the 2015 data shows.
Deborah Burger, co-president of the California Nurses Association, says that when she started her career as an intensive care unit nurse in the 1970s, a grocery clerk made more money than she did.
Things have changed quite a bit since then, especially in California.
Registered nurses in the Golden State earn $100,000 a year on average, more than their counterparts anywhere else in the country, according to recently-released data from the Bureau of Labor Statistics. The average hourly wage for registered nurses in California is $48.68 an hour, the 2015 data shows.
California also employs the most registered nurses — 255,010 last year. The Los Angeles-Long Beach-Glendale metropolitan area alone employs 70,810 nurses. The only other region employing more than that is New York-Jersey City.
Burger, who practices in Sonoma County, said appreciation for the value of nurses has grown over time. Their wages started rising in the early 2000s, and the female-dominated field began to see some parity with other occupations, such as law enforcement. A 1999 California law mandating specific nurse-to-patient ratios also played a role in boosting registered nurse wages.
"I think nurses themselves really started to understand that hospitals don't function without them and they are indispensable for patient safety," Burger said.
Nurses in Hawaii and Massachusetts earn nearly as much as those in California, with average annual salaries of $90,000 and $88,000, respectively. The national average salary for a registered nurse is $71,000.
This makes sense, experts say, considering that living expenses in those three states are high. In addition, the nurse's union has a strong presence in California.
Dr. Joanne Spetz, a professor at the University of California, San Francisco School of Nursing, said that despite the high statewide average, it is important to consider regional wage differences. "California is a big state and there is lots of variation," she said.
A nurse working in Bakersfield probably isn't making the same salary as one in San Francisco, Spetz said. Incomes of nurses on the pricey Westside of Los Angeles, and in the Bay Area, most likely drive the averages up, Spetz said.
The ten locations in the U.S. that pay the highest salaries to registered nurses are all located in California. At top are nurses in San Francisco, who earn $133,000 per year, on average. The city is also known for having the highest rents in the nation.
Other high-paying regions for California registered nurses include Santa Cruz-Watsonville, Sacramento and Modesto.
Spetz said another reason behind the higher salaries for RNs is that California's licensed vocational nurses — who receive less training than registered nurses — are not allowed to do as much as their counterparts in other states. For example, LVNs in California cannot administer medication through an intravenous line. This results in a higher demand for registered nurses, who are paid accordingly, Spetz said.
In 1999, California passed a law that established minimum nurse-to-patient ratios in hospitals, driving up demand for registered nurses in particular. In a 2009 study, Spetz and colleagues found that from 2000 to 2006, registered nurses in California's urban centers saw their wages rise by as much as 12 percent more than RNs in other states.
After the implementation of the nurse-to-staff ratios, "wage growth for RNs far outstripped wage growth in other states without such legislation," the study says.
High demand, the high cost of living and union power underlie the higher salaries of California's registered nurses.
Burger said the nurse's union has also played a role in assuring that nurses have access to pension plans and that they retire with health benefits. And that's something that some non-unionized nurses still don't receive, she said.
There's also been a culture shift. A registered nurse's job is no longer to simply carry out a doctor's orders; there are more functions and responsibilities, Burger said. "We're also now writing orders that doctors sign off on," she said. "It's a little bit of everything."
Will Medicaid expansion save the country money as people stop using expensive emergency rooms for primary care? Not in the first years, says a study published in the New England Journal of Medicine.
The study found ER use among Medicaid patients in Oregon stayed high even two years after people gained coverage, and even as more patients visited doctors' offices, too.
All eyes have been on Oregon to answer this question because eight years ago, Oregon tried an experiment. It wanted to expand Medicaid, but it didn't have the money to cover every eligible resident.
So it held a lottery to give coverage to as many people as possible, in the fairest way possible. The result was something of a gift to researchers like Bill Wright, director of the Providence Center for Outcomes Research and Education in Portland. "You couldn't do this as a researcher," Wright said. "You couldn't design a study that randomly gave some people insurance and some people[none], because as a researcher, you don't want to put someone in that position, just to study it."
It wouldn't be ethical to leave some people without coverage just to be a "control group." But, since the state was doing it, it offered an invaluable chance to study the differences between people who have Medicaid and people who don't.
It was the first randomized study on the impacts of health insurance, and it's one of the largest, surveying 25,000 people.
The first findings reported earlier were that Medicaid was beneficial in many ways: it improved people's financial security; they went to the doctor when they were sick and it reduced rates of depression.
"These are all things that are really important benefits of Medicaid expansion," said Wright.
"That was a surprise to a lot of folks," said Wright.
It was widely believed that having insurance would encourage people to get primary care in doctors' offices or clinics, instead of waiting until they're really sick and heading to the ER, where care is most expensive.
After that study, experts scrambled to explain what was happening. Some thought it was pent-up demand from a group that hadn't seen a doctor in years because they didn't have insurance.
Others thought people just hadn't had time to establish a relationship with a primary care doctor. And that when they did, emergency department use would drop.
But now, after looking at two years of data, that's not what this latest study found, said Wright, who is one of the researchers.
"There was no sign that this ED use went down. So this idea of pent-up demand sort of fading away, at least in the first couple of years, it didn't happen."
Quite the opposite.
"If your hope is that in the short term, the first couple of years, you're going to see savings that come out of reduced ED use from Medicaid expansion alone. I don't think I'd be super optimistic about that. I think that it is going to cost money in the short term," he said.
Wright said there maybe savings in other areas, like an increased use of preventive services that could stave off problems that would become more expensive later.
And, Leslie Clement, with the Oregon Health Authority, said during the past two years, Oregon has seen avoidable emergency room use drop by 4 percent.
She said, that's because the state is coordinating care better, by doing things like helping people get to their doctors' appointments and take their medication.
"It is not just a 'open up coverage and let people used health care services as they have done historically,' " she said. "But it's reforming that system."
The Oregon study can't tease out much more information because the experiment had to stop when the state expanded Medicaid fully under the Affordable Care Act.
City Health Works contracts directly with primary care providers, like Mount Sinai Health System, to better manage its most difficult patients. Nearly all of City Health Works' clients are poor, juggling seven or more prescriptions and facing chronic illnesses that frequently spiral out of control.
NEW YORK— Destini Belton isn't a doctor or a nurse. She's a trained health coach, and as a trusted neighbor in Harlem, she goes where clinics and hospitals can't — into patients' homes to understand the mundane but vital details of their lives.
She visits people like Jessica Gonzalez who went blind at the age of 22 because of uncontrolled Type 1 diabetes. Now 33, Gonzalez has high blood pressure, high cholesterol and renal disease. Belton worries that Gonzalez isn't taking the right medication at the right time because she can't see the bottles.
Belton's work follows an example from half a world away. A nonprofit called Mamelani Projects brings health care into neighborhoods in Cape Town, South Africa by employing trusted community leaders. There are surprising similarities between South Africa, and the U.S.: a shortage of doctors in poor neighborhoods; widespread distrust of once segregated hospitals; concentrated and crippling poverty and a growing recognition that models of care that go beyond brick-and-mortar clinics are needed.
Belton is one of a small team of community health workers trained by Manmeet Kaur to help patients in New York City. Kaur trained with the Mamelani Projects in the townships of Cape Town. The organization she founded, City Health Works, contracts directly with primary care providers, like Mount Sinai Health System, to better manage their most difficult patients.
When chronically ill patients like Gonzalez do visit the doctor, researchers have found that half of them leave confused. Health coaches can help patients make sense of a doctor's directions and see up close the stresses of poverty they may be too embarrassed to share.
Gonzalez, for instance, is reluctant to admit her struggles to her doctor, but she trusts Belton to understand.
"With your doctor you don't really want to say what you eat," said Gonzalez, who is obese. "So I'm able to tell her like really, if I'm not going well, or if I sneaked and cheated I tell her the right things, and she helps me."
At weekly meetings, they discuss how patients, many disabled and with dementia, can stabilize their health and avoid costly visits to the emergency room and lengthy hospital stays. Nearly all of City Health Works' clients are poor, juggling seven or more prescriptions and facing chronic illnesses that frequently spiral out of control.
Kaur first witnessed the use of community health workers in sub-Saharan Africa, where doctors are in short supply and difficult to reach and later had an internship with Mamelani.
Long lines besiege clinics and hospitals in South Africa which are overwhelmed by endless needs. Apartheid-era laws created widespread poverty and desperate health conditions, especially in townships surrounding city centers like Cape Town.
But for conditions like HIV, hypertension and diabetes, life-saving drugs are useless — and even harmful — without proper nutrition. Too often in townships, daily diets are filled with junk food, fish and chips, meat and very few vegetables. So Mamelani Projects decided to teach local women about health and nutrition. They conduct classes in garages and visit people in their homes.
In the U.S., the need for health coaches is spurred in part by the Affordable Care Act and major changes in how hospitals are paid. Private and public insurers are testing out so-called bundled payments and other strategies that reward value instead of volume, and there are strong financial incentives to steady the lives of people like Jeanette Rodriguez, even when those needs seem to have nothing to do with health care.
A diabetic who suffers from back pain, Rodriguez was nearly done in by the stress of caring for her father. City Health Works' Belton intervened, helping her find a nursing home for him and guiding her appeal for disability benefits.
But she's also a liaison for Rodriguez's own medical needs, helping her keep track of appointments and drafting a list of ailments and questions for her doctor.
That's a big part of a health coach's job — teaching patients to be better advocates for themselves.
During an appointment at a nearby Mount Sinai clinic, that preparation has paid off. Dr. Joseph Truglio tells Rodriguez she likely had a mild stroke.
Rodriguez had dismissed the tingling on her right side as arthritis, but Belton's insistence — and long history working with her — ensured Truglio would take notice. And that is City Health Works' goal: identify patients careening toward catastrophe and intervene before it happens.
"Here we have a patient that had not been to the ER, but was slowly getting worse," said Truglio. "So that's the real success story, as opposed to sort of finding patients who are already in the hospital for something that we should have been dealing with for years before that."
Coaches use electronic health records to inform doctors about developments in the field, like whether patients are taking their medications or experiencing changes in their mental health.
Kaur wants to make coaches an indispensable part of the health care system by professionalizing their role and proving their financial value.
"Six years ago, the word 'community health worker' was foreign to most people we spoke to," she said. "Now it is written into almost every single grant or funding opportunity from [Medicare and Medicaid]."
But Kaur goes home each night to one of her biggest skeptics. Her husband, Dr. Prabhjot Singh, heads the department of health system design at Mount Sinai. He's weighing whether there's enough evidence that her program works and should be integrated into Mount Sinai's core business.
"Every time somebody sees one of these beautiful, well-designed, kind of custom engagement tools, I think the thought that comes up a lot with my colleagues, and frankly my own, is: How do you do this for 40,000 people? 50,000 people at the scale of the Mount Sinai Health System?" said Singh.
He added, "We actually have to know whether or not the relationship between Destini and her client is effective. It may feel really good, but from a health system perspective, we have to really understand, 'Is she getting healthier? And are we doing it in a cost effective way?'"
There are early signs the program is working: Patients with health coaches cost $600 a month less in medical care than a control group, a strong indication that coaches prevented expensive medical emergencies. For half the patients, coaches alerted doctors about patients' urgent needs.
City Health Works remains a small venture, supported largely by foundations interested in testing the model. But Kaur's ultimate aim is to have thousands of coaches like Destini Belton in neighborhoods around the country that can match the successes seen elsewhere in the world.
Without improving conditions and raising pay, which hovers at $10 an hour, it may be impossible to meet skyrocketing demand for skilled and devoted workers.
In recent months, health aides who care for elderly Americans at home appeared at scores of rallies calling for better pay and workplace conditions. President Barack Obama and some of the presidential candidates have pledged to improve the lives of these workers, who often struggle on the poverty-level wages they are paid.
Now, thanks to the "Fight for $15" movement hundreds of thousands of home care workers in at least five states will gradually receive significant hourly raises. And as result of a large organizing campaign, tens of thousands who have joined unions can negotiate for paid sick time, health and retirement benefits.
"The Fight for $15 and the simultaneous benefits is an amazing, unprecedented thing that I don't think anyone five years ago would have expected, given our hyper-polarized political environment," said Laura Dresser, a labor economist at the University of Wisconsin-Madison who studies the impact of low wages. "This is a workforce that's coming out of the shadows."
People with a deep understanding of eldercare policy say that without improving conditions and raising pay, which hovers at $10 an hour, it will be impossible to meet skyrocketing demand for skilled and devoted workers.
But they also argue that bigger paychecks and benefits will not have a significant impact on senior citizens unless their aides and assistants are also better screened, trained and organized.
"I think it's going to take time and a different mindset to professionalize this job and improve outcomes," said Carol Rodat, New York policy director for the Paraprofessional Healthcare Institute (PHI), which researches ways to transform eldercare. "Achieving better wages is a first step, but there are others that have to follow or you don't get to the end point — improved outcomes for the clients."
As it stands, the soaring number of Americans who choose home care over nursing homes have no organized national system to count on that guides the hiring, education or oversight of their caregivers. There is little or no data that tracks how well the home care is delivered. And yet, these workers, like those in a hospital, provide a lifeline, not only dressing, feeding, bathing and shopping for clients, but working with their health care providers and noticing when their illnesses progress or relapse.
"It's been a growth industry people can get into with little to no experience and few barriers," said Rodat, whose organization wants better state and federal oversight. "We have to totally re-engineer home care. It will take a massive change."
In the past 20 years, the Service Employees International Union, which organized nurses, has focused on home care workers, a largely non-white, female workforce that earns as little as $8 an hour and is often unable to piece together a full day's work. And earlier this year, these workers landed in the national spotlight when they joined the "Fight for $15" minimum wage campaign.
As a result, 500,000 home caregivers in 12 states have joined SEIU and can bargain for paid sick time and retirement benefits. And Massachusetts, California, New York, Washington and Oregon, and cities such as San Francisco, Seattle, Los Angeles, New York and Washington D.C., passed laws phasing in a $15 minimum wage or an equivalent indexed to inflation. An estimated 640,000 of the more than 2 million aides hired through agencies or hired privately will see raises.
Also, starting this year the federal Fair Labor Standards Act guarantees them minimum wage and overtime.
The raises and union protections are concentrated in Northeastern and Western states. And they do not even cover the largest share of workers, the unpaid family members who care for a loved one. Nonetheless, many people who have worked closely on these issues see the changes as an important step in stabilizing what has been a marginal workforce.
With an annual turnover of around 50 percent,home care workers now have among the lowest retention of any industry. Labor organizers say even those who wish to stay often leave for better pay and hours. Advocates note that a trusted caregiver can be pivotal to a person's health and well-being.
"When you keep the same worker that individual is going to see changes in the client's quality of life. They are more likely to say 'Mrs. Smith usually doesn't confuse her children,'" said Caitlin Connolly, the Home Care Fair Pay campaign coordinator with the National Employment Law Project.
But many people who work in eldercare or study it also say that paying workers more and keeping them on the job will not assure senior citizens a standard of care because of the large gaps in regulation. Currently, not all home care agencies even check applicants' criminal histories, something not every state requires.
In a widely-cited study, researchers at Northwestern University's medical school found that just 55 percent of the 180 agencies conducted a national background check. Only a third tested applicants for drug use, even though the job can mean frequent contact with medications.
The study, led by geriatrician Lee Lindquist, showed that many agencies hire unskilled workers off Craigslist and place them in homes of elderly people with physical and cognitive impairments.
Lindquist found aides, some of them illiterate, who mixed up medications or neglected to feed or move clients. Supervisors rarely checked in. And training was lax.
Federal law requires home health aides, who perform skilled nursing functions such as wound care, to have 75 hours of training. There is no mandated training for the largest, fastest-growing segment, the personal aides who assist with housekeeping and grooming. No continuing education is required.
"We see a huge prevalence of Alzheimer's and dementia and depression and pulmonary disease and cardiac disease," noted Rodat of PHI. "You'd think we'd want to give people extra training since they are on the front line."
The increased training she and others are calling for costs more than many agencies and states say they can afford.
Still, some home care agencies say they provide training well beyond minimum standards to meet their customers needs.
Home Care Associates, in Philadelphia provides up to 150 hours of training, along with continuing education and coaching from experienced supervisors.
"A lot of people who do this work have a real passion for it," said Karen Kulp, president and CEO of the company. "But even if they get $15 an hour it's not going to be any different without training, support and supervision. You're not going to improve the quality of the work."