Health reform: Another poll, another confused public
Every month, we all get those embargoed Kaiser Family Foundation tracking polls in our email. As I open it, I ask myself, “Now what did Americans forget they used to like about health reform this month?”
Or (and you may have heard me say this before – but it sums it up well, so allow me to repeat it) when are Americans going to figure out that this unpopular law is the sum of its popular parts?
What questions do you have about health reform and how to cover it?
Joanne Kenen (@JoanneKenen) is AHCJ’s health reform topic leader. She is writing blog posts, tip sheets, articles and gathering resources to help our members cover the complex implementation of health reform. If you have questions or suggestions for future resources on the topic, please send them to joanne@healthjournalism.org.
Remember these polls are about opinions about a law that isn’t, by and large, in effect yet. So people hear all sorts of things about it, but they aren’t actually experiencing most of it yet. We don’t know what will happen in 2014 when – if the law survives the political process and the courts – the public may finally reach the “try it you’ll like it” stage.
That brings us to a recent survey from EBRI (Employee Benefits Research Institute) and Mathew Greenwald & Associates, Inc., a Washington, D.C., market research firm. The 2011 Health Confidence Survey, which looks at trends in employer- and union-sponsored health coverage, came out a few weeks ago, based on a telephone survey conducted in May and June.
A press release and EBRI article came out a few weeks ago, but when I looked for more details and data, I found some dated September. Because I’m going to write in pretty broad brush strokes here, including a smattering of numbers without inundating you with them, you can find more specific figures in the press release here, the November article here, and a longer discussion from September here.
Guess what? People were confused – or at least amazingly contradictory – about what they have now, as well as what they expect in the future.
For instance, people were quite satisfied with their own health coverage (amongst those that had coverage) both in terms of their health insurance plan and the actual medical care they receive. But they also thought the whole system is a mess.
Sixty percent were extremely or very satisfied with their plan (a number which surprised me given how much time people – even outside our health policy world – spend complaining about health care) and 29 percent were somewhat satisfied. People also rated the actual care they had received quite high. But more than half say the system is poor or fair; a quarter think it’s good. Only 12 percent deemed it very good and only 5 percent grade it at excellent. Naturally people were not too happy about the costs, either.
They are less confident about the future of employer- or union- provided health benefits than they used to be (NOTE: This slide began, and was sharpest, quite a few years before health reform was enacted. It’s definitely not because of the new law, in case someone tries to spin you that way).
People think that if they lose access to work-related health benefits or their employer/union stops providing them, they will have a really tough time affording their own insurance – even if they are subsidized by the employer or union.
Yet – despite those high unaffordability scores – two-thirds said they would be able to buy it. (You still with me?)
On health reform, those surveyed basically had no idea what a health insurance exchange is – which doesn’t stop them from declaring that the government can’t run them.
Just 1 percent of respondents reported that they were “extremely familiar” with health insurance exchanges in the new law. Double that amount, a whopping 2 percent, was “very familiar” “Somewhat familiar” scored 15 percent (and they can’t all be in Massachusetts). Nearly two thirds - 62 percent - said they weren’t at all familiar.
But guess what. That didn’t stop them from having strong opinions on the inability of either the state or federal government – or even private insurers – to run them.
I wonder, if they go into the exchanges in 2014, will they report being “highly satisfied” with them – and still convinced the government can’t run them? Maybe it will be a variant of “get the government hands off my Medicare.”
Which reminds us – the poll didn’t find a lot of confidence in the future of Medicare either. For what it’s worth.
Related
- Reporters can explore states’ options for creating exchanges
- Study offers context for reporting on health insurance exchanges
Do small businesses in your area know about tax credit for offering coverage?
There’s been a fair amount of coverage about the lower-than-expected enrollment in high-risk pools created by the federal health reform law. Another available benefit – a tax cut for certain small businesses that offer coverage to workers – is also eliciting less of a response so far than the White House had anticipated.
What questions do you have about health reform and how to cover it?
Joanne Kenen (@JoanneKenen) is AHCJ’s health reform topic leader. She is writing blog posts, tip sheets, articles and gathering resources to help our members cover the complex implementation of health reform. If you have questions or suggestions for future resources on the topic, please send them to joanne@healthjournalism.org.
The tax credit hasn’t gotten a whole lot of attention, but an uptake update was tucked away in that annual Kaiser Family Foundation report on employer health benefits. The overall report got a lot of front-page press, but it’s worth taking a look at the small business tax credit too (and h/t to my colleague Jason Millman at Politico).
The Affordable Care Act provides a temporary tax credit for small employers – defined as having 25 full-time workers or the equivalent – with average wages less than $50,000. But not many know about it, or that they may be eligible, according to the survey. The White House has estimated that up to 4 million small businesses may be eligible for credits, which are meant to defray part of the insurance costs
The survey found that 29 percent of firms with fewer than 50 employees that offer health coverage tried to find out if they were eligible, and 65 percent did not. Of small businesses that did not offer insurance, half said they were aware of the tax credit and 48 percent said they did not know about it. Of those that were aware, only 13 percent said the availability of a credit had not led them to consider whether to start offering insurance to their workers
The tax credit can cover up to 35 percent of premiums. It rises in 2014 for two years for businesses buying coverage for workers through the insurance exchanges. To qualify, the business has to pay at least half the worker’s premium. Remember these smaller, lower-paying firms do NOT have to cover their workers, although the tax credit and some exchange features aim to encourage them to cover workers. Only larger employers have to contribute or pay a fee.
This is a pretty easy story to localize. How are businesses in your areas learning about the credit – or why aren’t they hearing about it? Perhaps more interesting – are they hearing misinformation? If so what’s the source of that?
The IRS says it’s working on improving outreach via the tax software industry, insurance brokers, agents and carriers, accountants and the small-business community. Do you see any signs of such outreach in your community? How much confusion do you find – do small businesses think they will have the same obligations as large employers? Do they understand the role of exchanges in helping the small-business market?
Related:
Rising medical debt spawns problems, fosters solutions
Filed under: Government, Health policy, Hospitals
Kelley Weiss, of the California HealthCare Foundation’s Center for Health Reporting, dug deep into the rising mountain of medical debt accumulating around American patients. Her package includes four pieces (one an extended forum, embedded below) on KQED as well as numerous companion stories online. Her stories consider both the causes of and solutions to medical debt, an issue which plagues hospitals as much as it does patients.
In her first piece, Weiss lays out the simple formula driving all that indebtedness: It’s “because health care costs continue to rise at the same time people are losing their jobs and health coverage.” She uses the story of an unfortunate, unemployed motorcyclist to show how the American billing, credit and insurance systems can quickly add debt to injury.
In the second piece, she looks at the debt from the other side, exploring the massive and largely ineffective lengths hospitals go to in order to collect what they’re owed. Since the recession began, even the most successful collections agencies have only been able to collect about 12 percent, one hospital official said. Confronted with this fact, Weiss asked the obvious question.
So why even bother, if you get such a low return? Maybe they could give those financially squeezed patients with no other options a break. Well, to a certain extent they can, and charity care is on the upswing.
But it turns out there are statutes in place that require hospitals to make collection efforts. Medicare is one of the biggest payers to hospitals and it says that hospitals must try to collect money from every patient. And if they don’t? Medicare won’t pay off its bills. Todd Nelson with the Healthcare Financial Management Association said that leaves hospitals in a tough spot.
As wallets remain tight and debt collection becomes increasingly difficult, both hospitals and patients are starting to take steps to become more up front about exactly how much their care is going to cost, Weiss writes in her third installment. Finally, when all else fails, Weiss finds in her fourth installment, patients can turn to California’s Hospital Fair Pricing Act, which “says hospitals must give patients who are at 350 percent of the Federal Poverty Level a discount on their bills if they’re uninsured or underinsured.”
Why are some patients stuck in hospitals for weeks, months?
Yanick Rice Lamb
Patients typically complain about being released from the hospital sooner than they would like. So Yanick Rice Lamb, associate publisher and editorial director of Heart & Soul magazine, became intrigued when when she heard about patients languishing in hospitals weeks and even months after being medically ready for discharge. This can happen to uninsured and underinsured patients who need long-term care.
This could potentially happen to anyone who loses a job and the health coverage that came along with it. Rice Lamb found that delayed discharge was an underreported topic and information was fragmented and spotty, at best.
Find out what she learned from her 10-month look at this narrow slice of the population – the sickest, poorest and most invisible patients. She includes an extensive list of story ideas and angles for other reporters to look into. AHCJ members, read more …
Uninsured face delays, increased risks en route to long-term care
Writing for Heart & Soul, Yanick Rice Lamb offers up a comprehensive take on the special challenges patients and hospitals face when it comes to long-term care for the uninsured.
… a growing number of uninsured people … need long-term care after hospital stays. They lack insurance because they can’t afford it, their employers don’t offer it or they were dropped by private carriers after taking out policies on their own. Consequently, these patients experience delays in moving on to the next step in their care once they are medically ready for discharge. They are stuck in the hospital, because it’s hard to place patients in long-term care facilities or send them home with a nurse when they have no coverage, especially when there are complications. Hospitals end up picking up the tab — sometimes even after patients leave. Those costs are ultimately passed on to everyone who pays taxes and anyone who has a medical bill.
Rice Lamb fleshes out this scenario not only with anecdotes, but with a raft of statistics and studies showing that the ranks of such patients are swelling rapidly, as is the financial toll they’re taking on the system. She ties it in with the hospital “frequent flyer” and charity care issues that have received so much ink in recent years. At the same time, she takes a deeper look at the issues faced by the patients themselves, from the difficulty of spending days and weeks away from family, to the lower levels of attention they may receive from hospital staff as their stays drag on, to the increased risk of hospital-acquired infections and lack of specialized rehab.
Some of the most surprising observations came in relation to undocumented immigrants, who present major challenges despite being a small part of the patient population.
In some cases, when community support can’t be found, Rice Lamb writes that hospitals “Often pay to transport immigrants back to their countries — if the patients agree — and sometimes cover medical bills in their homelands. This often costs less than absorbing the expense of continuous care in the United States.”
Furthermore, she says, “Even with U.S. citizenship, language barriers can contribute to discharge delays. When caregivers spoke little English, the length of stay increased to 6.1 days, compared to four days for the control group, according to a study published recently in the Archives of Pediatrics & Adolescent Medicine.”
Throughout her work, Rice Lamb takes advantage of sources which reporters around the country should find useful when localizing similar topics.
Rice Lamb completed this project while on an AHCJ Media Fellowship on Health Performance, supported by the Commonwealth Fund.
Shifts in health care delivery raise questions
Christopher Weaver at Kaiser Health News has done two stories recently on new care models driven by insurers eager to save money. Both stories lay out issues that AHCJ members can examine in their own communities, particularly regarding the influence insurers will have over health care delivery and how it differs – or does not differ – from the HMOs of the 1990s.
What questions do you have about health reform and how to cover it?
Joanne Kenen is AHCJ’s health reform topic leader. She is writing blog posts, tip sheets, articles and gathering resources to help our members cover the complex implementation of health reform. If you have questions or suggestions for future resources on the topic, please send them to joanne@healthjournalism.org.
The first story, in May, (Health Insurers Opening Their Own Clinics To Trim Costs) was about insurers (specifically Medicare Advantage plans) opening clinics to treat some of their patients that need a lot of health care, and tend to get it in costly (to the insurer) as well as unpleasant (to the patient) places like emergency departments. Giving high-needs patients easy access to care in a clinic – which one could think of broadly as a type of “medical home” – can give them continuity of care, avoid health crises, and cost less money in a closed system where the insurer can shape the payment incentives and share in savings.
The second, more recent, story (Managed Care Enters the Exam Room as Insurers Buy Doctor Groups) reported on a trend that isn’t getting too much attention. Big insurers are buying up physician medical groups, or launching physician management companies. Weaver wrote that it’s “part of a strategy to curb rising health costs that could cut into profits and to weather new challenges to their business arising from the federal health law.”
As Weaver and other reporters have noted, more doctors are giving up solo and small practices in favor of large groups, multi-specialty groups, or staff positions at hospitals. (This Washington Post piece looked at the related trend of hospitals hiring primary care physicians.) Many health policy experts believe the trend toward larger groups and more integrated practices will help reduce fragmentation and duplication, saving money and improving quality.
But what happens when the insurers control the purse strings? Weaver wrote:
“The doctors, at the end of the day, control the patients and currently [in the regular fee for service system, not this insurer-owned model] they’re financially incentivized to do more tests, more procedures,” said Chris Rigg, a Wall Street analyst for Susquehanna Financial Group. “But, if they’re employed by a managed care company, they’re financially incentivized” to do less.
That thought unnerves consumer advocate Anthony Wright of Health Access in Sacramento, Calif., who worries profit pressure could affect care decisions. But Wright also said there may be upsides to more tightly managed care: “No patient wants to get more procedures than they actually need.”
So that’s the dilemma. Will these insurer-owned and operated systems be curbing costs by getting rid of the unnecessary, wasteful and sometimes harmful care, or will they skimp on care? If they formally become Accountable Care Organizations under Medicare, they will have to be accountable for not only the cost but the quality, in defined and measurable ways. But if they are just slapping an “accountability” label on themselves, it’s less clear who they are accountable to, and what they are accountable for. It’s not a given that it will be a reprise of the HMOs.
The business environment – purchasers of insurance wanting quality and value – is different than the 1990s. State-based exchanges starting in 2014 may be able to inject more accountability into the system. Medicare and Medicaid as well as state governments are doing more on quality measurements, value-based purchasing etc. But it’s not clear exactly how all that will play out in the insurer-driven model and whether consumers will resist in ways reminiscent of the managed care backlash 10 or 15 years ago.
“There’s a gigantic Murphy’s law emerging here,” Weaver quoted a health care consultant as saying. “The very people who were the demons in all of this, that the public can’t stand” – managed-care firms – “are the big winners.”
Is reform adequately serving people in your area with pre-existing conditions?
This post is about high risk pools, so let’s get some confusing semantics out of the way.
The Affordable Care Act created special pre-existing condition insurance pools (known as PCIP). But many states already had high risk pools. The older state-based high risk pools (sometimes called legacy pools) still exist … but to further complicate matters, the health law gave states the option of running their own PCIP or having the feds do it. So some states have two state-run pools: one “high risk” and one “PCIP.” Some states have a “high risk” and the feds run the “PCIP.” And some states don’t run a high risk pools so they only have a PCIP - which either they run, or the federal government runs. Got all that?
What questions do you have about health reform and how to cover it?
Joanne Kenen is AHCJ’s health reform topic leader. She is writing blog posts, tip sheets, articles and gathering resources to help our members cover the complex implementation of health reform. If you have questions or suggestions for future resources on the topic, please send them to joanne@healthjournalism.org.
When the health care law passed last year, it included $5 billion for temporary insurance pools for uninsured people with pre-existing conditions. The widespread expectation was that the uninsured would rush to enroll, blowing through the $5 billion long before 2014, when the pools were supposed to shut down as national reform kicked in. Once the state exchanges are up and running, the uninsured will be able to buy coverage that way (with subsidies if they qualify based on income) and can’t be turned down because of pre-existing conditions or high-risk.
The conventional wisdom was wrong; enrollment in the pools was a trickle, not a flood. HHS has twice – once last fall and once just a few weeks ago – announced steps to bring down premium costs and streamline enrollment. The pace of enrollment has picked up a bit, but it’s still just about 20,000. That’s total, nationwide. (The health insurance law gave states the option of running the pre-existing pool, or having the federal government do it. Either way the feds fund it, with participants also paying premiums.)
The main barrier, of course, is cost – premiums in the pools are high. And people have to be uninsured for six months to get into the pre-existing condition pools. That means people who have decided to pony up for the older state high risk pools (which exist in 35 states and were created long before health reform) aren’t going to drop coverage and go without for six months so they can get into these newer federally funded pools, even if the new ones are less expensive.
The states running the pools, as well as their federal partners, have begun trying to do more outreach. In one little-noticed provision, HHS this fall will start paying insurance agents and brokers for connecting eligible uninsured people with the program.
Is any of this outreach happening in your state? Is it visible? How are people hearing – or not hearing – about the pools. Why are they staying uninsured rather than going into the pools. Obviously cost is a factor – but is anything else at play? Is the outreach adequate? What are the misperceptions? What is the psychology? Are they just crossing their fingers and hoping they don’t get sick, or are they assuming they can get free or charity care in the ER in a crunch? Are they going to community health clinics rather than pay the high cost of the pools?
To learn more about high risk pools, here are some resources.
- Pre-existing Condition Insurance Plan
- National Association of State Comprehensive Insurance Plans (This site has information about the 35 state-based high risk pools that existed before health reform)
- Health Affairs: RWJF Issue Brief: Pre-Existing Condition Insurance Plan (Updated June 2011)
- Gov’t cuts rates for hard-to-insure patients (AP)
- Realizing Health Reform’s Potential: Pre-Existing Condition Insurance Plans Created by the Affordable Care Act of 2010, The Commonwealth Fund
- State-by-state breakdown of Pre-Existing Condition Insurance Plans, from HealthCare.gov
- Insurance Protections for Children in the Affordable Care Act, from HealthCare.gov
- Entry Point: The Preexisting Condition Plan, by Joanne Kenen in Health Affairs (AHCJ members have free access to this health policy journal.)
- Changes to the Pre-Existing Condition Insurance Plan in Your State, from HealthCare.gov
Study offers context for reporting on health insurance exchanges
Filed under: Health care reform, Health journalism, Studies, Tools
The first tip sheet I wrote about covering health reform was pegged to the one-year mark of the Affordable Care Act. One topic I addressed was the creation of state-based health insurance exchanges, or marketplaces. I won’t rehash that here – here’s the link to the brief – but I do want to point out a useful resource that became available just a few days after we posted that first guide.
What questions do you have about health reform and how to cover it?
Joanne Kenen is AHCJ’s health reform topic leader. She is writing blog posts, tip sheets, articles and gathering resources to help our members cover the complex implementation of health reform. If you have questions or suggestions for future resources on the topic, please send them to joanne@healthjournalism.org.
It’s an in-depth look at the two states that already do have exchanges – Utah and Massachusetts. Those states help illustrate the decisions, both practical and ideological, legislators and governors must make as to how active the exchange is going to be in shaping the local insurance market and the consumer experience.
Those exchanges are of course dramatically different – Massachusetts covers a couple of hundred thousand people, and Utah covers a couple of thousand. Massachusetts was the inspiration in many ways for the national health reform, while Utah is the model for states that want to do a lot less and rely a lot more on the free market. But the study by experts at the Georgetown University Health Policy Institute and the Center for Children and Families also found those two state exchanges also had a lot more overlap than is widely assumed.
For those of you who are writing your first story on exchanges, this report isn’t the place to start. For help with the basics, check out ideas from Sarah Kliff, a Politico health care reporter, and some background from Noam Levey, health policy reporter for the Los Angeles Times. And the Alliance for Health Reform had an event last year that explained the basics (this link includes a webcast, transcript and lots of other resources to help you get started.)
For those reporters who have been tracking the state debate over the size, shape and structure of the exchange, or following the initial phases of implementing the exchange, the Georgetown study should help provide some context for concepts that you may have heard of like “active purchaser” (an exchange that can be more discriminating about which insurers get to sell policies in the exchange and which don’t versus an “open market” (open to any health plan that wants to play.) Here’s a taste:
To many, the Massachusetts and Utah exchanges represent opposite points on a continuum of what exchanges can provide for consumers and small businesses. Yet the stereotype of Massachusetts’ exchange as an “active purchaser” and the Utah Exchange as the open market model is, in the words of one observer, “a false stereotype … perpetuated by … a media that likes simple contrasts.”
So be part of a media that goes beyond simplistic contrasts … dig in.
Potter: Insurance industry taking advantage of media’s inattention to health reform
Filed under: Health care reform, Health journalism
Wendell Potter, the former insurance company public relations executive who has been critical of the industry, writes that journalists who were covering health reform have moved on and insurance companies have noticed the lack of scrutiny.
Potter, writing for the Center for Public Integrity, says some journalists consider the writing of regulations to implement the legislation boring and of little interest to the public.”
But insurance company lobbyists know the media are not paying much attention. And so they are able to influence what the regulations actually look like—and how the law will be enforced—with little scrutiny, much less awareness.
Consumer advocates tell Potter that the insurance industry is “pushing back” against rules that would give consumers clear information about their rights and would expedite appeals in urgent situations.
Those rules, which were written by the National Association of Insurance Commissioners, were scheduled to go into effect on July 1 but indications are that the Obama administration will push the implementation date back to Jan. 1, 2012, Potter says.
How can we help you cover reform and implementation?
As AHCJ’s health reform topic leader, Joanne Kenen is writing blog posts, tip sheets, articles and gathering resources to help our members cover the complex implementation of health reform. Her latest post is “Health reform battle entering a new phase.” If you have questions or suggestions for future resources on the topic, please send them to joanne@healthjournalism.org.
Coverage of insurance exchanges needs context
Filed under: Government, Health care reform, Health journalism
During the past few days, I have read quite a bit of local coverage about health insurance exchanges from about 10 different states (some “blue,” more “red.”) I was looking for good stories to hold up as an example of what’s at stake here.
New tip sheet
Affordable Care Act: The politics of health care, year two
The Affordable Care Act just hit the one-year mark, but that’s not likely to change the political dynamic in D.C. and many state capitals. Indeed, it may intensify as the 2012 campaign approaches. Following the complex legislative and budgetary procedures in Congress from a distance can be daunting. Joanne Kenen, AHCJ’s health care reform topic leader, has written a brief guide to some of what’s unfolding and likely to unfold in the next year or two.
I did not read every single state story from the whole country so maybe I missed something great. But I did read enough to conclude that most of the stories, unfortunately, were awfully heavy on process. They described political finger pointing: Republicans say no, Democrats say yes, the state legislature equivalent of he-said, she-said . There was very little explanation to readers about what exchanges are, and what kind of decisions states have to make about them , what’s at stake or why the heck the reader should care.
In case you are tempted to say it’s too complicated to explain in a short daily story: Look at Felice Freyer’s March 31 story in The (R.I.) Providence Journal. That is a short daily story, not a big takeout. But see how much context and explanation she was able to weave in with a deft clause here and there.
Sarah Kliff, of Politico, takes a slightly different tack that is also useful. It’s not a policy story, but politics, a state roundup. She makes two good points, which might help some of you covering the politics of implementation in your own state. First, how successful the Tea Party has been in driving the state-level implementation conversation to the right, and second “a widening rift within the Republican party, between those who say states should implement the law, retaining more power as it moves forward, and others who favor completely opting out of a law they because they believe it to be unconstitutional.”
I pulled together some resources about exchanges for the tip sheet on covering the first anniversary of reform. I’ll gather some more for a future update. If you see more good articles on the exchange, let me know by sending a note to joanne@healthjournalism.org.
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