Lawmakers are stalling in providing a plan to offer health care coverage for the estimated 790,000 uninsured people in Colorado. Although it's a top priority for the legislature this session, neither Republicans nor Democrats seem ready to hit taxpayers up for a major health care reform package on the November ballot. At the end of this month, the legislature will hear five proposals--from requiring Coloradans to buy health insurance or pay a tax penalty, to creating a single nonprofit insurance program for all residents. Covering children alone would cost an extra $200 million per year, according to one legislative estimate.
Medicare currently covers sleep apnea treatment for those diagnosed in a sleep lab. But last month it proposed to cover treatment for seniors diagnosed with home tests, with a final decision coming in March. The decision will have large ramifications for the booming sleep apnea devices market, which generated more than $85 million of revenue in 2005 and is expected to reach $135 million by 2012, and cut into business and reimbursement at independent and hospital-run sleep labs.
One of the causes of the Boca Raton (FL) Community Hospital's stunning $28 million financial loss in 2007 are private auditors hired by the government. These auditors are paid a percentage of any improperly billed Medicare payments. Several Florida hospitals, including Mercy Hospital and Jackson Memorial Hospital in Miami, have been cited by auditors for overpayments in 2007 as well. Appeals can take up to two years and even if the hospital is eventually proved right, the auditors may still keep their contingency fees.
Last week I wrote about the ongoing debate over the Healthy San Francisco program and whether a key provision for making the plan financially feasible is actually allowable under federal law.
Federal Judge Jeffrey White issued an order last month blocking the city from implementing the program's employer mandate, finding that a provision requiring employers to spend a minimum amount on healthcare coverage for their workers or to pay an equivalent amount into the city-run program is preempted by the federal Employee Retirement Income Security Act. The city appealed and may have found a friendly ear at the Ninth Circuit Court of Appeal.
A hearing last week before the Ninth Circuit focused on the city's request for an emergency stay of Judge White's order, and was not a hearing on the full appeal. However, reports from the hearing indicated significant support for the city's position that the mandate complies with ERISA and is not a benefit mandate.
But I'm writing this week not just to update the situation in San Francisco. I'm also interested in hearing your thoughts on the issue of ERISA preemption as it relates to the ongoing efforts at the state and local level to offer universal or near-universal coverage programs.
Is ERISA still the boogeyman that it's made out to be? A nearly insurmountable barrier to the pay or play ideas floating around state capitals and city halls? Or is Massachusetts' success in getting a program up and running evidence to the contrary? That ERISA preemption can be avoided even in cases where an employer mandate is involved? Or should legislators be looking in other areas beyond employer mandates?
Judge White in the San Francisco case noted that the program could avoid the ERISA issue entirely by pursuing other funding mechanisms, such as a sales tax hike or an assessment on all employers to fund the public health system and then provide a tax-credit for those employers who provide coverage.
Or should state legislatures back off the reform agenda altogether and leave the issue to Congress? After all, ERISA preemption was created to do just that--to ensure that regulation of employee benefits would be handled at the federal level thereby creating a level playing field in all markets.
So where does that leave us?
I'm not sure Massachusetts' success in creating a consensus that prevents an ERISA challenge from even being filed can be replicated in another market, but I'm almost positive that Congress will be unable to address the issue anytime soon.
Brad Cain is editor of California Healthfax and executive editor for managed care with HealthLeaders Media. He may be reached at bcain@healthleadersmedia.com.
UnitedHealth Group has announced its AmeriChoice unit plans to buy Pittsburgh-based Unison Health Plans, which serves about 370,000 people in government-sponsored health plans. The deal is expected to close by mid-2008 and is subject to regulatory approvals.
Texas based insurer HealthMarkets must improve its business practices--from training agents in ethics to speeding claims payments--following an unusual multistate probe prompted by numerous complaints. HealthMarkets faces a range of possible sanctions, including fines or being forced to re-assess denied claims.