Tagged Insurance

Sen. Markey Wants To Know Why Nurses, Other Good Samaritans Are Denied Life Insurance For Carrying Naloxone

Sen. Ed Markey (D-Mass.) wants to know how insurers determine if an applicant is prescribed naloxone because they are at risk for an overdose, or to save others; how often have applicants been denied life insurance for carrying naloxone; and whether there are guidelines to prevent wrongful denials. Other news on the national drug epidemic comes from Oregon and Texas.

Obama Strikes Serious Tone As He Implores People To Sign Up For Health Law Coverage Before Deadline

“No jump shots. No ferns. No memes. Not this time. I’m going to give it to you straight: If you need health insurance for 2019, the deadline to get covered is December 15,” tweeted former President Barack Obama, who in the past has taken more light-hearted approaches. “Pass this on — you just might save a life.” Enrollment news comes out of Maryland and Georgia, as well.

Health Industry Groups: Congress Must Act To Protect Patients From Surprise Medical Billing

“When doctors, hospitals or care specialists choose not to participate in networks, or if they do not meet the standards for inclusion in a network, they charge whatever rates they like,” wrote the groups, which include powerful lobbyists like the Blue Cross and Blue Shield Association, America’s Health Insurance Plans, the National Business Group on Health, and the Consumers Union. “The consequence is millions of consumers receiving surprise, unexpected medical bills that can often break the bank.”

Need Health Insurance? The Deadline Is Dec. 15

The woman arrived at the University of South Florida’s navigator office in Tampa a few weeks ago with a 40-page document describing a short-term health insurance plan she was considering. She was uncomfortable with what the broker had said about the coverage, she told Jodi Ray, a health insurance navigator who helps people enroll in coverage, and she wanted help understanding it.

The document was confusing, according to Ray, who oversees Covering Florida, the state’s navigator program. It was hard to decipher which services would be covered.

“It was like a bunch of puzzle pieces,” she said.

Encouraged by her wife, the woman eventually opted instead for a marketplace plan with comprehensive benefits.

The annual open-enrollment period for people who buy their own insurance on the Affordable Care Act’s marketplaces ends Dec. 15 in most states. Enrollment in states that use the federal healthcare.gov platform has been sluggish this year compared to last. From Nov. 1 through Dec. 1, about 3.2 million people had chosen plans for 2019. Compared with the previous year, that’s about 400,000 fewer, or a drop of just over 11 percent.

The wider availability of short-term plans is one big change that has set this year’s apart from past sign-up periods.

Another is the elimination of the penalty for not having health insurance starting next year. The Congressional Budget Office has estimated that as many as 3 million people who buy their own coverage may give it up when they don’t face a tax penalty.  But experts who have studied health insurance enrollment say that surveys so far indicate that the penalty hasn’t typically been the pivotal factor in people’s decision on whether to buy insurance.

They also caution against reading too much into the preliminary enrollment totals.

“There typically is a surge in enrollment at the end,” said Sabrina Corlette, research professor at Georgetown University’s Center on Health Insurance Reforms. “It’s hard to know whether it will make up for the shortfall.”

If they don’t pick a new plan, people who are enrolled in a 2018 marketplace plan may be automatically re-enrolled in their current plan or another one that is similar when the open-enrollment period ends. About a quarter of people who have marketplace plans are reassigned in this way.

Another factor that may be affecting enrollment is tighter federal funding for the health insurance navigators, like Jodi Ray in Tampa, who guide consumers through the complicated process. With fewer experts available to answer questions and help fill out the enrollment forms, consumers may fall through the cracks.

Across the country, funding for navigators dropped from $36 million in 2017 to $10 million this year. In Florida, federal funding for the Covering Florida navigator program was slashed to $1.25 million this year from $4.9 million last year, Ray said. The program was the only one to receive federal funding in the state this year.

The Covering Florida program reduced the number of open-enrollment navigators to 59 this year, a nearly 61 percent drop, Ray said. Navigators this year are available in only half of Florida counties; the organization is offering telephone assistance and virtual visits to people in counties where they can’t offer in-person help.

“It’s all we can do,” Ray said. So far, the group’s navigators have enrolled about half the number of people this year as they had last year.

It’s unclear the extent to which the Trump administration’s efforts to reduce health care costs by expanding access to short-term plans is affecting marketplace plan enrollment.

These plans, originally designed to cover people who expected to be out of an insurance plan for a short time, such as when they change jobs, can be less expensive. Unlike marketplace plans, short-term plans don’t have to provide comprehensive benefits or guarantee coverage for people who have preexisting medical conditions.

The Obama administration limited short-term plans to a three-month term. But in August, the federal government issued a rule that allowed their sale with initial terms of up to a year, and the option of renewal for up to three years.

Ten states either ban short-term plans or restrict them to terms of less than three months, said Sarah Lueck, a senior policy analyst at the Center on Budget and Policy Priorities.

Many people are seemingly not focused on their options this open-enrollment season, however. According to a recent survey, about half of adults under age 65 who were uninsured or who buy their own coverage said they planned to buy a plan for 2019. But only 24 percent of people in that age group said they knew what the deadline was to enroll in health insurance, according to the Kaiser Family Foundation’s November health tracking poll.

Must-Reads Of The Week On Health Care

Your regular Breeze correspondent, and its creator, Brianna Labuskes, is taking a break, but we didn’t want you to be without some semblance of a report today of things you don’t want to miss in health care.

So I’ll do my best at filling in. Be kind, and check back next week for the really good stuff.

One of the biggest bits of news this week was a coughed-up blot clot from the lung. Not sure why that seemed to fascinate people. We can skip that, but feel free to look.

The Atlantic: Doctors Aren’t Sure How This Even Came Out of a Patient

A more authentic bit of news was the report that health care spending slowed in 2017. It’s still growing, mind you, but growing more slowly. That’s not terribly surprising, because it has been slowing for a number of years. What Dan Diamond over at Politico calls “slowth.” It increased 3.9 percent to $3.5 trillion, while the year before it had grown 4.8 percent. Another way to look at it: Americans spend $10,739 per person on health care. HuffPost had a nice analysis:

HuffPost: America’s Health Care Spending Keeps Rising Really Slowly. Seriously.

Read the full report here.

The New York Times attempts to explain why enrollment in Obamacare is down. Any number of things could factor in, like higher employment at places that offer health insurance, no mandate forcing people to enroll or people signing up for Medicaid. Further study may present an answer.

The New York Times: Why Is Obamacare Enrollment Down?

This week, the Annals of Internal Medicine retracted a 2009 paper by Brian Wasinick, the now-discredited Cornell University researcher. The half-baked paper had claimed that the recipes in the more modern editions of the classic “Joy of Cooking” cookbook had more calories than the original. The always enlightening Retraction Watch website, which tracks medical and scientific research that has been undermined, has the whole story of the delightful sleuthing that led to the debunking. (And while you are on the site, peruse all the other Wasinick papers on food research that have been rescinded.)

Retraction Watch: The Joy of Cooking, Vindicated: Journal Retracts Two More Brian Wansink Papers

One of my favorite writers on health care makes an often overlooked point about health insurance: Its goal ought to be the same as other insurance, that is, to safeguard the financial health of beneficiaries. And Aaron Carroll, who is also a professor of pediatrics at Indiana University School of Medicine, says that several studies show it does exactly that.

Read the whole piece for yourself:

JAMA Forum: Medicaid as a Safeguard for Financial Health

As a bonus on this topic, here is an academic paper surfacing this week on the effects of the Affordable Care Act on mortgage delinquencies. Spoiler: The value of fewer evictions and foreclosures is substantial compared to the cost of the ACA subsidies.

The Effect of Health Insurance on Home Payment Delinquency: Evidence from ACA Marketplace Subsidies

The Commonwealth Fund, a foundation that seeks to improve health care,  wanted to know how the Affordable Care Act affected the uninsured and the insured. As its chart that summarizes its findings issued this week shows, there was considerable movement. The main finding was the number of young adults who switched from Medicaid to individual insurance — and the other direction as well.

The Commonwealth Fund: Who Entered and Exited the Individual Health Insurance Market Before and After the Affordable Care Act?

Commonwealth also conducted a forum on “Being Seriously Ill in America,” which dealt with the financial consequences.

Forbes likes to compile those “30 under 30” lists. (I’ve long wished someone would go back and look at one of those lists from 20 or 25 years ago to see how the luminaries are doing now.) Anyway, it put together a list of people in the health care industry. Most are on the cusp of 30, which might tell you something about how hard it is to get a fast start in the industry. But one person on the honor roll is only 18. In case you were wondering, because I was, Elizabeth Holmes, the founder of the ill-fated Theranos, was on a different “40 under 40” Forbes list in 2014. We hope these folks fare better.

Forbes: 30 Under 30 in Healthcare

This article ran a while back, but I got a kick out of it and just had to mention it. It looked at prehistoric health care. Researchers will never know how much Stone Age dwellers bored their hut mates with discussions of a paleo diet, but they are learning how they performed medical procedures that appeared to have worked.

The Atlantic: Neanderthals Suffered a Lot of Traumatic Injuries. So How Did They Live So Long?

May you survive another whirlwind week of health care news, until next Friday’s breezy recap.

Podcast: KHN’s ‘What The Health?’ Is Health Spending The Next Big Political Issue?

The Republican-led Congress was unable to repeal the Affordable Care Act in 2017, but the Trump administration continues to implement elements of the failed GOP bill using executive authority. The latest change would make it easier for states to waive some major parts of the health law, including allowing subsidies for people to buy insurance plans that don’t meet all the law’s requirements.

Meanwhile, in states that are transitioning from Republican governors to Democrats, GOP legislators are using lame-duck sessions to try to scale back executive power and lock in some key health changes, such as work requirements for Medicaid enrollees.

And there is growing evidence that even with health insurance, patients who use significant amounts of medical care are increasingly unable to afford their share.

This week’s panelists for KHN’s “What the Health?” are Julie Rovner of Kaiser Health News, Margot Sanger-Katz of The New York Times, Joanne Kenen of Politico and Rebecca Adams of CQ Roll Call.

Among the takeaways from this week’s podcast:

  • The Trump administration outlined last week what type of waivers it is willing to consider for states’ ACA markets. Options include changes in who gets premium subsidies and how much they receive, and making short-term insurance plans that are not as comprehensive as current marketplace plans eligible for subsidies.
  • Any changes are likely to end up in court, as have most of the revisions that the Trump administration has proposed.
  • In Wisconsin and Michigan, Republican legislatures are seeking to restrict what the new Democratic governors can do to change GOP policies on Medicaid and challenges to the ACA.
  • A recent study has highlighted that health problems can create financial hardships well beyond the illness. For example, loss of income from a debilitating illness can make paying other bills very difficult and sometimes other family members must give up their jobs to be caregivers.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read too:

Julie Rovner: NBC News.com’s “FDA Approves Drug for Dogs Scared by Noise,” by Maggie Fox

Margot Sanger-Katz: The Washington Post’s “An Experiment Requiring Work for Food Stamps Is a Trump Administration Model,” by Amy Goldstein

Joanne Kenen: The Atlantic’s “The CRISPR Baby Scandal Gets Worse by the Day,” by Ed Yong

Rebecca Adams: The New York Times’ “Why Hospitals Should Let You Sleep,” by Austin Frakt

Also mentioned in this episode:

The New York Times: “1,495 Americans Describe the Financial Reality of Being Really Sick,” by Margot Sanger Katz

Kaiser Health News: “No Cash, No Heart. Transplant Centers Require Proof of Payment,” by JoNel Aleccia

CBS News: “High Cost Has Many Diabetics Cutting Back on Insulin,” by Serena Gordon

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcher or Google Play.

Seniors Steamed Over Cuts To SilverSneakers Fitness Program

John Garland Graves was taken aback when he walked into his McKinleyville, Calif., gym in October and learned that his SilverSneakers membership was being canceled.

Since 2014, Graves, 69, has enjoyed free access to the gym through SilverSneakers, the nation’s best-known fitness program for seniors. He was disturbed by the news, as are many other people who have recently learned they’re losing this benefit.

A controversial business decision by UnitedHealthcare, the nation’s largest health insurance carrier, is causing the disruption. As of Jan. 1, the company is dropping SilverSneakers — an optional benefit — for 1.2 million customers with Medicare Advantage plans in 11 states (California, Connecticut, Illinois, Indiana, Iowa, Kansas, Missouri, Nebraska, Nevada, North Carolina and Utah) as well as 1.3 million customers with Medicare supplemental (Medigap) insurance in nine states (Arizona, California, Connecticut, Illinois, Indiana, North Carolina, Ohio, Utah and Wisconsin).

Graves, who works out four to five days a week and has a UnitedHealthcare Medigap policy, decided to seek coverage elsewhere after the company raised his policy’s rates and eliminated SilverSneakers in California. He has signed up for a new policy with Blue Shield of California.

Starting next year, UnitedHealthcare will offer members a package of fitness and wellness benefits instead of paying to use SilverSneakers — a move that will give the company more control over its benefits and may save it money.

Seniors with UnitedHealthcare Medicare supplemental policies will get 50 percent off memberships at thousands of gyms across the country, telephone access to wellness coaches and access to various online communities and health-related resources. Those with Medicare Advantage policies can join Renew Active, UnitedHealthcare’s fitness program, with a network of more than 7,000 sites, at no cost, and qualify for an evaluation from a personal trainer and an online brain-training program, among other services.

Steve Warner, who leads UnitedHealthcare’s Medicare Advantage product team, explained the company’s move by noting that over 90 percent of policyholders who are eligible for SilverSneakers “never step foot in a gym” or use this benefit.

UnitedHealthcare wants to reach “a broader portion of our membership” with a “wider variety of fitness resources,” he said, noting that the company’s shift away from SilverSneakers began last year and has accelerated this year. (Altogether, more than 5 million customers have been affected. But the company is making market-by-market decisions, and nearly 675,000 UnitedHealthcare Medigap policyholders and 1.9 million UnitedHealthcare Medicare Advantage plan members will retain access to SilverSneakers in 2019.)

“I think it’s a smart move,” said Connie Holt, an independent broker with Goldsum Insurance Solutions of Pleasant Hill, Calif.

But many of the company’s customers aren’t happy that SilverSneakers, which offers group classes tailored to seniors in addition to gym access at 15,000 sites, is disappearing. And confusion about alternatives is widespread.

It’s one of the “top topics” that seniors have been raising over the past few months when they call Ohio’s Senior Health Insurance Information Program, said Chris Reeg, the OSHIIP program director.

Michael Chanak Jr., 69, of Wadsworth, Ohio, had problems getting through to UnitedHealthcare’s customer relations department several times when he called with questions — a common complaint. “The way this is being implemented is a train wreck,” said Chanak, who has a UnitedHealthcare Medicare supplemental policy and spends an hour every day exercising at his gym.

People are “extremely upset,” wrote Margaret Lee of Arroyo Grande, Calif., in an email. “That’s about the only topic of conversation at my water exercise class!”

AARP has also become a target of anger because it endorses UnitedHealthcare’s Medigap and Medicare Advantage insurance policies — an arrangement that yields substantial royalties for the organization.

In an email, Mark Bagley, a spokesman for the organization, said, “UHC [UnitedHealthcare], not AARP, operates these plans and determines the benefits.”

“I will be dropping my AARP membership when it is time to renew,” wrote Shelley Holbrook, 67, of Yorba Linda, Calif., a UnitedHealthcare Medigap policyholder, in an email exchange about the loss of SilverSneakers. “I am a Parkinson’s patient who has been prescribed this type of exercise program,” she explained. “This program is under the guidance of certified instructors that make sure the exercise routines are performed correctly. … An ordinary gym membership provides no instruction on how to use the equipment safely for seniors.”

“A health coach is not what I need,” Holbrook continued. “I have used the health coaches before, and have found them to be totally worthless.”

For policyholders like Holbrook, the situation is complicated by another factor: Federal laws don’t ensure that seniors can switch Medicare supplemental insurance plans without undergoing new medical evaluations after an initial “guarantee issue” period. (This period occurs six months following a person’s enrollment in Medicare. Changes are allowed under a few specific circumstances and by laws in a few states.)

If seniors can meet medical standards, they’ll find SilverSneakers available from other insurance operators. In 2019, Tivity Health is offering the program through more than 65 health plans covering more than 15 million older adults and introducing a new digital platform that emphasizes its social benefits: SilverSneakers Connect.

“There are people we’ve learned who are alone but don’t want to go to the gym,” and the new platform can help them connect with each other as well as activities in their communities, said Donato Tramuto, Tivity Health’s CEO. Recent research suggests that SilverSneakers may help reduce isolation and loneliness in seniors who go to classes and form new relationships, he noted.

Whether UnitedHealthcare’s health plans will be less appealing because of the shift away from SilverSneakers is yet to be determined. Several years ago, Humana, another giant insurer, also began reducing the number of plans that offered SilverSneakers, but it faced a backlash from members and sales representatives. “The membership perceives [SilverSneakers] as a valuable benefit despite the fact that not everyone uses it,” said George Renaudin, Humana’s senior vice president of Medicare.

Humana subsequently reversed course and is now making SilverSneakers broadly available to about 3.5 million Medicare Advantage and Medigap policyholders.

Ray Liss, who retired seven years ago, just changed over from UnitedHealthcare to a Humana Medicare supplemental policy with his wife. The loss of SilverSneakers precipitated the switch, which has an unexpected benefit: The couple will save almost $60 a month next year on their new policy.

In an email, Liss, who declined to say where he lives, was philosophical about the value of exploring his options, writing, “I was pretty mad at the time, but it worked out for the best.”

We’re eager to hear from readers about questions you’d like answered, problems you’ve been having with your care and advice you need in dealing with the health care system. Visit khn.org/columnists to submit your requests or tips.


KHN’s coverage related to aging and improving care of older adults is supported in part by The John A. Hartford Foundation.

Seniors Steamed Over Cuts To SilverSneakers Fitness Program

John Garland Graves was taken aback when he walked into his McKinleyville, Calif., gym in October and learned that his SilverSneakers membership was being canceled.

Since 2014, Graves, 69, has enjoyed free access to the gym through SilverSneakers, the nation’s best-known fitness program for seniors. He was disturbed by the news, as are many other people who have recently learned they’re losing this benefit.

A controversial business decision by UnitedHealthcare, the nation’s largest health insurance carrier, is causing the disruption. As of Jan. 1, the company is dropping SilverSneakers — an optional benefit — for 1.2 million customers with Medicare Advantage plans in 11 states (California, Connecticut, Illinois, Indiana, Iowa, Kansas, Missouri, Nebraska, Nevada, North Carolina and Utah) as well as 1.3 million customers with Medicare supplemental (Medigap) insurance in nine states (Arizona, California, Connecticut, Illinois, Indiana, North Carolina, Ohio, Utah and Wisconsin).

Graves, who works out four to five days a week and has a UnitedHealthcare Medigap policy, decided to seek coverage elsewhere after the company raised his policy’s rates and eliminated SilverSneakers in California. He has signed up for a new policy with Blue Shield of California.

Starting next year, UnitedHealthcare will offer members a package of fitness and wellness benefits instead of paying to use SilverSneakers — a move that will give the company more control over its benefits and may save it money.

Seniors with UnitedHealthcare Medicare supplemental policies will get 50 percent off memberships at thousands of gyms across the country, telephone access to wellness coaches and access to various online communities and health-related resources. Those with Medicare Advantage policies can join Renew Active, UnitedHealthcare’s fitness program, with a network of more than 7,000 sites, at no cost, and qualify for an evaluation from a personal trainer and an online brain-training program, among other services.

Steve Warner, who leads UnitedHealthcare’s Medicare Advantage product team, explained the company’s move by noting that over 90 percent of policyholders who are eligible for SilverSneakers “never step foot in a gym” or use this benefit.

UnitedHealthcare wants to reach “a broader portion of our membership” with a “wider variety of fitness resources,” he said, noting that the company’s shift away from SilverSneakers began last year and has accelerated this year. (Altogether, more than 5 million customers have been affected. But the company is making market-by-market decisions, and nearly 675,000 UnitedHealthcare Medigap policyholders and 1.9 million UnitedHealthcare Medicare Advantage plan members will retain access to SilverSneakers in 2019.)

“I think it’s a smart move,” said Connie Holt, an independent broker with Goldsum Insurance Solutions of Pleasant Hill, Calif.

But many of the company’s customers aren’t happy that SilverSneakers, which offers group classes tailored to seniors in addition to gym access at 15,000 sites, is disappearing. And confusion about alternatives is widespread.

It’s one of the “top topics” that seniors have been raising over the past few months when they call Ohio’s Senior Health Insurance Information Program, said Chris Reeg, the OSHIIP program director.

Michael Chanak Jr., 69, of Wadsworth, Ohio, had problems getting through to UnitedHealthcare’s customer relations department several times when he called with questions — a common complaint. “The way this is being implemented is a train wreck,” said Chanak, who has a UnitedHealthcare Medicare supplemental policy and spends an hour every day exercising at his gym.

People are “extremely upset,” wrote Margaret Lee of Arroyo Grande, Calif., in an email. “That’s about the only topic of conversation at my water exercise class!”

AARP has also become a target of anger because it endorses UnitedHealthcare’s Medigap and Medicare Advantage insurance policies — an arrangement that yields substantial royalties for the organization.

In an email, Mark Bagley, a spokesman for the organization, said, “UHC [UnitedHealthcare], not AARP, operates these plans and determines the benefits.”

“I will be dropping my AARP membership when it is time to renew,” wrote Shelley Holbrook, 67, of Yorba Linda, Calif., a UnitedHealthcare Medigap policyholder, in an email exchange about the loss of SilverSneakers. “I am a Parkinson’s patient who has been prescribed this type of exercise program,” she explained. “This program is under the guidance of certified instructors that make sure the exercise routines are performed correctly. … An ordinary gym membership provides no instruction on how to use the equipment safely for seniors.”

“A health coach is not what I need,” Holbrook continued. “I have used the health coaches before, and have found them to be totally worthless.”

For policyholders like Holbrook, the situation is complicated by another factor: Federal laws don’t ensure that seniors can switch Medicare supplemental insurance plans without undergoing new medical evaluations after an initial “guarantee issue” period. (This period occurs six months following a person’s enrollment in Medicare. Changes are allowed under a few specific circumstances and by laws in a few states.)

If seniors can meet medical standards, they’ll find SilverSneakers available from other insurance operators. In 2019, Tivity Health is offering the program through more than 65 health plans covering more than 15 million older adults and introducing a new digital platform that emphasizes its social benefits: SilverSneakers Connect.

“There are people we’ve learned who are alone but don’t want to go to the gym,” and the new platform can help them connect with each other as well as activities in their communities, said Donato Tramuto, Tivity Health’s CEO. Recent research suggests that SilverSneakers may help reduce isolation and loneliness in seniors who go to classes and form new relationships, he noted.

Whether UnitedHealthcare’s health plans will be less appealing because of the shift away from SilverSneakers is yet to be determined. Several years ago, Humana, another giant insurer, also began reducing the number of plans that offered SilverSneakers, but it faced a backlash from members and sales representatives. “The membership perceives [SilverSneakers] as a valuable benefit despite the fact that not everyone uses it,” said George Renaudin, Humana’s senior vice president of Medicare.

Humana subsequently reversed course and is now making SilverSneakers broadly available to about 3.5 million Medicare Advantage and Medigap policyholders.

Ray Liss, who retired seven years ago, just changed over from UnitedHealthcare to a Humana Medicare supplemental policy with his wife. The loss of SilverSneakers precipitated the switch, which has an unexpected benefit: The couple will save almost $60 a month next year on their new policy.

In an email, Liss, who declined to say where he lives, was philosophical about the value of exploring his options, writing, “I was pretty mad at the time, but it worked out for the best.”

We’re eager to hear from readers about questions you’d like answered, problems you’ve been having with your care and advice you need in dealing with the health care system. Visit khn.org/columnists to submit your requests or tips.


KHN’s coverage related to aging and improving care of older adults is supported in part by The John A. Hartford Foundation.

Without Obamacare Penalty, Think It’ll Be Nice To Drop Your Plan? Better Think Twice

Dana Farrell’s car insurance is due. So is her homeowner’s insurance — plus her property taxes.

It’s also time to re-up her health coverage. But that’s where Farrell, a 54-year-old former social worker, is drawing the line.

“I’ve been retired two years and my savings is gone. I’m at my wit’s end,” says the Murrieta, Calif., resident.

So Farrell plans — reluctantly — to drop her health coverage next year because the Affordable Care Act tax penalty for not having insurance is going away.

That penalty — which can reach thousands of dollars annually — was a key reason that Farrell, who considers herself healthy, kept her coverage.

Now, “why do it?” she wonders. “I don’t have any major health issues and I’ve got a lot of bills that just popped up. I can’t afford to pay it anymore.”

Farrell is among millions of people likely to dump their health insurance because of a provision in last year’s Republican tax bill that repeals the Obamacare tax penalty, starting in 2019, by zeroing out the fines.

The Congressional Budget Office estimated that the repeal of the penalty would move 4 million people to drop their health insurance next year — or not buy it in the first place — and 13 million in 2027.

Some people who hated Obamacare from the start will drop their coverage as a political statement. For people like Farrell, it’s simply an issue of affordability.

Since Farrell started buying her own insurance through the open market in 2016, her monthly premium has swelled by about $200, she says, and she bears the entire cost of her premium because she doesn’t qualify for federal ACA tax credits. Next year, she says, her premium would have jumped to about $600 a month.

Instead, she plans to pay cash for her doctor visits at about $80 a pop, and for any medications she might use — all the while praying that she doesn’t get into a car accident or have a medical emergency.

“It’s a situation that a lot of people find themselves in,” says Miranda Dietz, lead author of a new study that projects how ending the penalty will affect California.

Dana Farrell

People like Farrell whose incomes are too high to qualify for tax credits are especially vulnerable, says Dietz, a research and policy associate at the University of California-Berkeley Center for Labor Research and Education. They must pay the entire premium themselves.

Premiums, even for a bronze plan with a deductible of more than $6,000, are enormous in some cases, she says. “The state’s done a great job of implementing the ACA,” she says, “but there are still Californians who just find insurance out of reach.”

Up to 450,000 more Californians may be uninsured in 2020 as a result of the penalty ending, and up to 790,000 more by 2023, boosting the state’s uninsurance rate for residents under 65 to 12.9 percent, according to the study. The individual market would suffer the biggest losses.

Covered California, the state health insurance exchange, predicts that enrollment in the individual market — both on and off the exchange — could drop by 12 percent next year, says agency spokesman James Scullary.

Exchange officials also blame the end of the penalty for a 3.5 percent average increase in premiums, because the departure of some healthy people from the market will lead to a sicker and costlier insurance pool.

Health insurance can be difficult to afford, but going without it is a “bad gamble,” Scullary says. Keep in mind: More than 22,000 Covered California enrollees broke, dislocated or sprained arms or shoulders in 2017, and 50,000 enrollees were either diagnosed with — or treated for — cancer, he explains.

“We know that none of those people began the year thinking, ‘This is when I’m going to break my arm,’ or ‘This is the year I get cancer,’” he says.

If you’re considering dropping your plan and risking the devastating financial consequences of an unexpected medical expense, check first to see if you can lower your premium.

“A big mistake for people is to look at the notice they get for their current health insurance and see it’s going up a lot and then throw up their hands and decide they’re going to go without,” says Donna Rosato, a New York-based editor at Consumer Reports who covers health care cost issues.

“Before you do that, look at other options.”

The most important thing to do is seek free help from a certified insurance agent or enrollment “navigator.” You can find local options by clicking on the “Find Help” tab on Covered California’s website, http://www.CoveredCA.com.

Next, see if you can qualify for more financial aid. For instance, if your income is close to the threshold to qualify for tax credits through Covered California or another Obamacare insurance exchange — about $48,500 for an individual or $100,000 for a family of four this year — check with a financial professional about adjusting it, Rosato suggests. You might be able to contribute to an IRA, 401(k) or health savings account to lower the total, she says.

Beyond that, be flexible and willing to switch plans, she advises. Consider different coverage levels, both on and off health insurance exchanges. If you’re in a silver-level plan (the second-lowest tier), you might save money by purchasing a less expensive bronze-level plan that has higher out-of-pocket costs but would protect you in case of a medical emergency.

This year, Farrell got a clean bill of health from her doctor after a round of tests. She’s nervous about being without coverage next year, but feels she doesn’t have a choice.

“It’s going to be the first time in my life I’m not going to have insurance,” she says.


This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California Health Care Foundation.

After Years Of Rising Deductibles For Workers, Some Employers Are Tapping The Brakes

Instead of continuing the trend of passing on the burden of higher costs to employees, some companies are looking to address the underlying reasons for the spending. Among other strategies, some organizations are bypassing insurers and negotiating deals with hospitals directly and a growing number are offering their own clinics. Meanwhile, experiments that work to improve a patient’s social factors, such as housing, are finding big savings.

After Years Of Rising Deductibles For Workers, Some Employers Are Tapping The Brakes

Instead of continuing the trend of passing on the burden of higher costs to employees, some companies are looking to address the underlying reasons for the spending. Among other strategies, some organizations are bypassing insurers and negotiating deals with hospitals directly and a growing number are offering their own clinics. Meanwhile, experiments that work to improve a patient’s social factors, such as housing, are finding big savings.

Readers And Tweeters Demand Action On Gun Violence, Mental Health Care Options

Letters to the Editor is a periodic feature. We welcome all comments and will publish a selection. We edit for length and clarity and require full names.


Behind The Bloodshed

In 2018 alone, there have been more than 300 mass shootings in the United States (“Gun Control Vs. Mental Health Care: Debate After Mass Shootings Obscures Murky Reality,” Nov. 19). That’s almost equivalent to the number of days in the year. When so many shootings occur in such a short period of time, it’s clear there’s at least one common reason behind them. But many people assume there’s only one reason and are divided over what that reason is. Some people say the underlying problem is gun control. Others say the underlying problem is mental health. Statistics prove that mental health is definitely one of the problems. In that case, why are the people, including the people in power, who blame mental health as the issue so hesitant to make reforms to the health care system and the way mental health is handled? They could at least attempt to fix the problem. Gun violence is becoming a prevalent issue in American society, one that simply can’t keep being ignored. We need to stop debating and start doing something to protect the lives of innocent civilians. How many more deaths will it take before people in power take action?

— Srija Ponna, San Jose, Calif.


An Untenable Solution On Mental Health Care?

So the family becomes the untrained caregiver (“With Hospitalization Losing Favor, Judges Order Outpatient Mental Health Treatment,” Nov. 13). From experience, it’s impossible to find good, timely assistance for a person with bipolar disorder. The patient can just disappear for days, wreak havoc in the community, hurt themselves or others. By the time the patient has reached the point of mandatory outpatient treatment, a lot of damage has probably already occurred and both the patient and family are desperate. How can they be certain a person with bipolar disorder is properly taking medicine? Such patients often shun their medicine, especially when experiencing mania. This is an unrealistic option for treatment of some mental health disorders. I think it places the patient, family and community in danger of further damage.

— Glenn McGahee, Fort Lauderdale, Fla.


More research couldn’t hurt, tweeted Daphne Chakurian of California:

— Daphne Chakurian, Roseville, Calif.


Lofty Praise

Excellent piece about air quality (“Smoke-Filled Snapshot: California Wildfire Generates Dangerous Air Quality For Millions,” Nov. 21). Once auto emissions plummeted, I never thought about any planetary forces except earthquakes. This raises awareness exactly as everything you do should. 😉 Thanks.

Lucy Johns MPH, San Francisco


Casting A Wide Net On Fish Oil Study

NPR and ABC covered these studies, and included positive results at the end of the articles. KHN didn’t even mention benefits (“Fish Oil And Vitamin D Pills No Guard Against Cancer Or Serious Heart Trouble,” Nov. 10). UPI reported an “overwhelming benefit of fish oil supplements for black participants, who had a 77 percent reduction in their risk of heart attack.” I think this shows a lack of thorough reporting on KHN’s part.

— Joy Thomas, Foster City, Calif.


Mixed messages about the study were prevalent online, one tweeter noted:

— Matt Jade, New York City

Echoing an expert in the KHN story, that’s what happens when researchers slice data into smaller segments, with fewer patients in each group. The results can prove unreliable when zeroing in on specific outcomes such as heart attacks among blacks.


Have A Whole Look At Medical Records, Holes And All

Not likely to be revealed in a medical record: any complication from treatment that results in harm or death to a patient and is not owned up to by the physician/surgeon or hospital (“In Days Of Data Galore, Patients Have Trouble Getting Own Medical Records,” Oct. 25). Thus, a medical record can be used as documentary evidence of not reporting an adverse medical or surgical event that should have been reported to the Centers for Medicare & Medicaid or other patient safety organizations. In my opinion, that is the primary reason for providers’ reluctance to furnish medical records related to a harmed/killed patient.

— Lars Aanning, Yankton, S.D.


Quality not quantity is what matters when collecting health data, one tweeter observed:

— Dr. Edward Chory, Lancaster, Pa.


It’s not as if solutions don’t exist; the challenge is executing them, reader Michael Millenson suggested on Twitter.

— Michael Millenson, Chicago


Monster Bills Only Scratch The Surface

This is the tip of the iceberg (Bill of the Month’s “That’s A Lot Of Scratch: The $48,329 Allergy Test,” Oct. 29). Medicine has become a medical-Industrial complex ever as powerful as the military-industrial complex that President Dwight Eisenhower warned us about. Hospitals all over the country use this same “scam” to maximize their profits. Recent schemes by private individuals involve the billing for medical laboratory studies done by private labs, but billed through rural hospitals such that a drug screen urine test costs $2,500. Other hospitals bill insurance companies up to $10,000 for an outpatient sleep study, for which Medicare allows $180.

Two hospitals here in San Antonio bill $8,000-$10,000 for inpatient sleep studies for which Medicare allows $950. A local, private cardiac catheterization laboratory bills $99,999 as a facility fee for a cardiac pacemaker change that literally takes 30-45 minutes — and they manage to collect $75,000.

Most private emergency room facilities bill out-of-network for thousands of dollars for routine visits. Medicare patients who go to these facilities are billed outside of Medicare and held responsible for all charges. Almost all ER facilities “upcode” to a higher level of care to maximize profit. Emergency rooms historically have been operated at a loss. They are now among the most profitable centers for hospitals.

This is a national scandal and costs the insurance companies and American patients hundreds of millions of dollars a year. No one does this to Medicare, because they might go to jail. But outside of Medicare, it is a civil matter.

— Dr. Michael Wooley, San Antonio


Exorbitant bills could be avoided altogether if prices for medical treatment were standardized and publicized, David Vuk argued on Twitter.

— David Vuk, Eastsound, Wash.


And some aspects of the convoluted health care system may simply be above a patient’s pay grade.

— Ben Carver, Charlotte, N.C.

Must-Reads Of The Week From Brianna Labuskes

Happy Friday! I don’t know about you, but I have been absolutely riveted by the ethics controversy that has sent the scientific community into a shocked-and-appalled, pearl-clutching frenzy this week. I’ll get to that in a second. First, another too-frequent example of the current pitfalls in our health system: A hospital turned down a woman’s heart transplant request because she lacked a secure source of financing for the drugs necessary for the procedure. The hospital’s suggestion for her? Use crowdfunding to raise the $10,000.

Now here’s what you may have missed as we enter that strange lull between holidays (though there certainly wasn’t a dearth of health news).

New guidelines released by the administration on Thursday, among other things, encourage states to flex their creative muscles on how to spend the subsidy money they get under the health law.

Currently, the subsidies are tied to income, and can be used only for insurance that meets federal standards and is purchased through public marketplaces. But the Centers for Medicare & Medicaid Services wants to lift those restrictions and let states do what they will with the pot of money. That could include: allowing the use of subsidies for short-term “junk insurance” plans; offering subsidies as incentive to woo in younger consumers; setting different income limitations; letting people with employer-based plans set up accounts to use the money, etc., etc.

If states acted on these options, that could steer the marketplace toward the geographical disparity that ran rampant before the health law. But it’s doubtful any state would want to take advantage of this offer in the first place. For one, it would be expensive for states to manage the pot of money. Secondly, even if a state received a waiver for the regulations, court challenges likely would follow. That could be more of a headache than it’s worth.

The Washington Post: New Insurance Guidelines Would Undermine Rules of the Affordable Care Act

Modern Healthcare: CMS Allows States to Get Creative With Federal Exchange Funds Under 1332 Waivers


The lagging numbers for this open-enrollment season are a bit at odds with what experts had seen as a stabilizing, if not quite flourishing, marketplace. While no one is Chicken Little-ing yet (there is still time left to see a boost, and the early weeks of November were busy ones for Americans), health law supporters are concerned that what they see as the administration’s attempts to “sabotage” the Affordable Care Act are coming to fruition.

Politico: Trump May Finally Be Undermining Obamacare

One statistic from the week that experts found “very troubling” was that for the first time in a decade the number of uninsured children rose, despite the improving economy and the low unemployment rate. Rural areas were particularly affected.

Los Angeles Times: Number of Uninsured Children Climbs, Reversing More Than a Decade of Progress, Report Finds


In what is certain to draw fierce pushback from patient advocacy groups and pharma alike, President Donald Trump is expanding Medicare’s negotiating power when certain drug prices rise faster than inflation. The idea has been kicking around for a while as both parties have been trying to come up with the silver bullet for high costs, but the political ramifications are unappetizing. Potentially cutting seniors off from needed drugs — whether it would play out that way or not — has always kept the idea on the back burner.

The New York Times: Trump Moves to Lower Medicare Drug Costs by Relaxing Some Patient Protections

File this under “I’m not sure that’s how it’s supposed to work”: A generic EpiPen is now available. The catch? It’s the exact same price as the one already out there.

The Hill: Generic EpiPen Not Any Cheaper Than Existing Version


FBI background checks were waived for caregivers and mental health workers who were in charge of caring for teens at an immigration detention center in Texas. The revelation ignited outrage, and the Department of Health and Human Services was quick to promise it would fingerprint the employees (officials warned it could take a while, though).

The government also allowed the company who is overseeing the operation of the facility to sidestep mental health requirements — youth shelters generally must have one mental health clinician for every 12 kids, but the contractor was allowed to staff the Texas facility with just one clinician for every 100 children.

The Associated Press: Lawmakers Press for Fingerprinting of Detention Camp Staff

Very quietly, family separations at the border have resumed.

ProPublica: Family Separations Are Still Happening at the Texas Border

Also, Baltimore is suing the Trump administration over its “public charge” policy that lets immigration officials use the acceptance of government aid, such as Medicaid, against those seeking green cards. The lawsuit might be the first of its kind, but it’s doubtful it will be the last.

The Associated Press: Baltimore Sues Trump Administration Over Immigration Policy


It is indicative of just how busy this week was that I haven’t gotten to the (aforementioned) ethics scandal rocking the scientific community yet, but we got here eventually. Chinese scientist He Jiankui dropped a bombshell (unverified and un-peer reviewed) on everyone that he gene-edited human embryos to make designer babies resistant to HIV infections.

This practice crosses an ethical line that many researchers had dug deep, deep, deep in the sand. “Deeply unethical,” “crazy,” “driven by hubris,” were just a few of the reactions from fellow scientists at the shocking news. One consensus that has come out of it, though, seems to be that there’s a crucial need for binding and international guidance on editing human genes. (Oh, and this isn’t over. He says there’s another pregnancy with gene-edited embryos underway.)

Los Angeles Times: Why Geneticists Say It’s Wrong to Edit the DNA of Embryos to Protect Them Against HIV

Stat: He Took a Crash Course in Bioethics, Then Created CRISPR Babies

NPR: Science Summit Denounces Gene-Edited Babies Claim, But Rejects Moratorium

Stat: NIH Director Says There’s Work to Do on Regulating Genome Editing


Medical device policy usually flies a bit under the radar, but it was a hot topic this week. Following a damning report on spinal implants causing severe injury to some patients, the Food and Drug Administration announced that it wants to revamp its (long-criticized and decades-old) approval system.

The Associated Press: FDA Says It Will Overhaul Criticized Medical Device System

And a look at whether the agency’s “first in the world” ambition contributed to a series of high-profile malfunctions.

The Associated Press: At FDA, a New Goal, Then a Push for Speedy Device Reviews


In the miscellaneous file this week:

• The combined suicide and opioid crises are taking a particularly grim toll on the country, sending us into our longest period of generally declining life expectancy since the slice of time that includes a little thing called World War I and the worst flu pandemic in modern history. I’m not going to lie, that’s not a great comparison.

The Associated Press: Suicide, at 50-Year Peak, Pushes Down US Life Expectancy

• A gut-wrenching personal story offers insight into the loved ones left behind in cases of suicides, and how they’re plagued with a forever-unanswerable question of “why”? The entire series is worth a deep read.

USA Today: Suicide: My Mom Took Her Life at The Grand Canyon

• An epidemic of extensive backlog of rape kits languishing on shelves in police departments recently drew a lot of attention. But an even more fundamental and low-profile issue? Those departments that trash them completely before the statute of limitations is up.

CNN: Destroyed: How the Trashing of Rape Kits Failed Victims and Jeopardizes Public Safety

• Johns Hopkins vowed to transform a Florida hospital’s heart surgery unit. Then patients started dying at an alarming rate.

Tampa Bay Times: Heartbroken

• Despite changes in policy, federal prisons are still failing to offer inmates proper mental health care.

The Washington Post/The Marshall Project: Federal Prisons Are Failing Inmates With Mental Health Disorders


As you can tell, it’s a good thing I started drinking coffee (for the first time ever, cue shocked faces) this week! No, I have not been spending my time Googling its health benefits. (OK, I have.) Have a lovely, possibly caffeine-fueled weekend!

Must-Reads Of The Week From Brianna Labuskes

Happy Friday! I don’t know about you, but I have been absolutely riveted by the ethics controversy that has sent the scientific community into a shocked-and-appalled, pearl-clutching frenzy this week. I’ll get to that in a second. First, another too-frequent example of the current pitfalls in our health system: A hospital turned down a woman’s heart transplant request because she lacked a secure source of financing for the drugs necessary for the procedure. The hospital’s suggestion for her? Use crowdfunding to raise the $10,000.

Now here’s what you may have missed as we enter that strange lull between holidays (though there certainly wasn’t a dearth of health news).

New guidelines released by the administration on Thursday, among other things, encourage states to flex their creative muscles on how to spend the subsidy money they get under the health law.

Currently, the subsidies are tied to income, and can be used only for insurance that meets federal standards and is purchased through public marketplaces. But the Centers for Medicare & Medicaid Services wants to lift those restrictions and let states do what they will with the pot of money. That could include: allowing the use of subsidies for short-term “junk insurance” plans; offering subsidies as incentive to woo in younger consumers; setting different income limitations; letting people with employer-based plans set up accounts to use the money, etc., etc.

If states acted on these options, that could steer the marketplace toward the geographical disparity that ran rampant before the health law. But it’s doubtful any state would want to take advantage of this offer in the first place. For one, it would be expensive for states to manage the pot of money. Secondly, even if a state received a waiver for the regulations, court challenges likely would follow. That could be more of a headache than it’s worth.

The Washington Post: New Insurance Guidelines Would Undermine Rules of the Affordable Care Act

Modern Healthcare: CMS Allows States to Get Creative With Federal Exchange Funds Under 1332 Waivers


The lagging numbers for this open-enrollment season are a bit at odds with what experts had seen as a stabilizing, if not quite flourishing, marketplace. While no one is Chicken Little-ing yet (there is still time left to see a boost, and the early weeks of November were busy ones for Americans), health law supporters are concerned that what they see as the administration’s attempts to “sabotage” the Affordable Care Act are coming to fruition.

Politico: Trump May Finally Be Undermining Obamacare

One statistic from the week that experts found “very troubling” was that for the first time in a decade the number of uninsured children rose, despite the improving economy and the low unemployment rate. Rural areas were particularly affected.

Los Angeles Times: Number of Uninsured Children Climbs, Reversing More Than a Decade of Progress, Report Finds


In what is certain to draw fierce pushback from patient advocacy groups and pharma alike, President Donald Trump is expanding Medicare’s negotiating power when certain drug prices rise faster than inflation. The idea has been kicking around for a while as both parties have been trying to come up with the silver bullet for high costs, but the political ramifications are unappetizing. Potentially cutting seniors off from needed drugs — whether it would play out that way or not — has always kept the idea on the back burner.

The New York Times: Trump Moves to Lower Medicare Drug Costs by Relaxing Some Patient Protections

File this under “I’m not sure that’s how it’s supposed to work”: A generic EpiPen is now available. The catch? It’s the exact same price as the one already out there.

The Hill: Generic EpiPen Not Any Cheaper Than Existing Version


FBI background checks were waived for caregivers and mental health workers who were in charge of caring for teens at an immigration detention center in Texas. The revelation ignited outrage, and the Department of Health and Human Services was quick to promise it would fingerprint the employees (officials warned it could take a while, though).

The government also allowed the company who is overseeing the operation of the facility to sidestep mental health requirements — youth shelters generally must have one mental health clinician for every 12 kids, but the contractor was allowed to staff the Texas facility with just one clinician for every 100 children.

The Associated Press: Lawmakers Press for Fingerprinting of Detention Camp Staff

Very quietly, family separations at the border have resumed.

ProPublica: Family Separations Are Still Happening at the Texas Border

Also, Baltimore is suing the Trump administration over its “public charge” policy that lets immigration officials use the acceptance of government aid, such as Medicaid, against those seeking green cards. The lawsuit might be the first of its kind, but it’s doubtful it will be the last.

The Associated Press: Baltimore Sues Trump Administration Over Immigration Policy


It is indicative of just how busy this week was that I haven’t gotten to the (aforementioned) ethics scandal rocking the scientific community yet, but we got here eventually. Chinese scientist He Jiankui dropped a bombshell (unverified and un-peer reviewed) on everyone that he gene-edited human embryos to make designer babies resistant to HIV infections.

This practice crosses an ethical line that many researchers had dug deep, deep, deep in the sand. “Deeply unethical,” “crazy,” “driven by hubris,” were just a few of the reactions from fellow scientists at the shocking news. One consensus that has come out of it, though, seems to be that there’s a crucial need for binding and international guidance on editing human genes. (Oh, and this isn’t over. He says there’s another pregnancy with gene-edited embryos underway.)

Los Angeles Times: Why Geneticists Say It’s Wrong to Edit the DNA of Embryos to Protect Them Against HIV

Stat: He Took a Crash Course in Bioethics, Then Created CRISPR Babies

NPR: Science Summit Denounces Gene-Edited Babies Claim, But Rejects Moratorium

Stat: NIH Director Says There’s Work to Do on Regulating Genome Editing


Medical device policy usually flies a bit under the radar, but it was a hot topic this week. Following a damning report on spinal implants causing severe injury to some patients, the Food and Drug Administration announced that it wants to revamp its (long-criticized and decades-old) approval system.

The Associated Press: FDA Says It Will Overhaul Criticized Medical Device System

And a look at whether the agency’s “first in the world” ambition contributed to a series of high-profile malfunctions.

The Associated Press: At FDA, a New Goal, Then a Push for Speedy Device Reviews


In the miscellaneous file this week:

• The combined suicide and opioid crises are taking a particularly grim toll on the country, sending us into our longest period of generally declining life expectancy since the slice of time that includes a little thing called World War I and the worst flu pandemic in modern history. I’m not going to lie, that’s not a great comparison.

The Associated Press: Suicide, at 50-Year Peak, Pushes Down US Life Expectancy

• A gut-wrenching personal story offers insight into the loved ones left behind in cases of suicides, and how they’re plagued with a forever-unanswerable question of “why”? The entire series is worth a deep read.

USA Today: Suicide: My Mom Took Her Life at The Grand Canyon

• An epidemic of extensive backlog of rape kits languishing on shelves in police departments recently drew a lot of attention. But an even more fundamental and low-profile issue? Those departments that trash them completely before the statute of limitations is up.

CNN: Destroyed: How the Trashing of Rape Kits Failed Victims and Jeopardizes Public Safety

• Johns Hopkins vowed to transform a Florida hospital’s heart surgery unit. Then patients started dying at an alarming rate.

Tampa Bay Times: Heartbroken

• Despite changes in policy, federal prisons are still failing to offer inmates proper mental health care.

The Washington Post/The Marshall Project: Federal Prisons Are Failing Inmates With Mental Health Disorders


As you can tell, it’s a good thing I started drinking coffee (for the first time ever, cue shocked faces) this week! No, I have not been spending my time Googling its health benefits. (OK, I have.) Have a lovely, possibly caffeine-fueled weekend!

Ruling Expected In Case Over Insurer Coverage Limits On Mental Health Care Services

The impact of the ruling in the consolidated cases of Wit v. United Behavioral Health and Alexander v. United Behavioral Health could ripple across the country as many providers and patients say that, despite laws requiring insurers to cover behavioral care on parity with care for physical conditions, they often encounter significant problems getting carriers to pay for needed treatment.

Ruling Expected In Case Over Insurer Coverage Limits On Mental Health Care Services

The impact of the ruling in the consolidated cases of Wit v. United Behavioral Health and Alexander v. United Behavioral Health could ripple across the country as many providers and patients say that, despite laws requiring insurers to cover behavioral care on parity with care for physical conditions, they often encounter significant problems getting carriers to pay for needed treatment.

Short On Federal Funding, Obamacare Enrollment Navigators Switch Tactics

Enrollment is down sharply on the federal health insurance marketplace this fall, and the consumer assistance groups that help with sign-ups think they know why.

They don’t have the staff to help as many customers as before because the Trump administration slashed funding. The federal government is spending $10 million this year on navigators who help individuals enroll in coverage. The government spent $36 million in 2017 and $63 million in 2016.

“We don’t have the people to provide the enrollment assistance nor to do the outreach and marketing to let people know what’s happening,” said Jodi Ray at the University of South Florida, who has overseen Florida’s largest navigator program since 2014.

Ray’s program received $1.2 million in federal funding this year, down from $5 million a year ago. Florida leads the nation in enrollment in the Affordable Care Act marketplace plans.

With less money, Ray can afford to pay only 59 navigators across the state this year, down from 152 a year ago. With fewer navigators, much of the group’s counseling is done by phone instead of in person. That complicates their job, she said, because it is much easier to talk with and show marketplace customers in person when looking at dozens of health plans with different costs and benefits.

Open enrollment in the Obamacare plans began Nov. 1 and will run until Dec. 15 for the 39 states covered by the federal exchange, healthcare.gov. The other exchanges — run by states — typically extend until the end of December or into January.

Obamacare plans are for people without workplace or government coverage.

Nationwide, navigator groups are scrambling to make up for the loss of federal funding to ensure they can help people make sense of their health insurance options.

  • In South Carolina, the Palmetto Project has transformed into the state’s first nonprofit insurance agency. Several of its former federally funded navigators are now licensed insurance agents. In their new role, they get paid a commission on their sales and don’t have to follow Trump administration rules that encourage navigators to talk to customers about short-term plans with limited benefits. The agents can also help customers enroll in Medicaid, Medicare and off-exchange plans.
  • The Community Council of Greater Dallas, which was funded last year to help with enrollment in 56 counties, has raised money from private donors to continue serving seven counties around Dallas. But it has 25 fewer navigators, so consumers seeking help must wait three days on average, compared with less than a day last year. Across Texas, 211 of 254 counties have no federally paid navigators.
  • In Wisconsin, the organization Covering Wisconsin has raised millions of dollars from cities, counties and local United Way chapters, as well as the state Medicaid agency, to make up for the federal cuts. Even still, it will be able to provide in-person assistance in only eight counties around Milwaukee and Madison. Twenty other counties are served by telephone.
  • The Kansas Association for the Medically Underserved is relying totally on volunteers to help consumers with in-person and telephone assistance. In the past year, the association was able to use government funding to pay about 20 navigators.

Nationally, nearly 800 counties served by the federal marketplace will not have any federally funded navigators this fall — up from 127 counties in 2016, according to the Kaiser Family Foundation. (KHN is an editorially independent program of the foundation.)

Federal officials said they were not providing funds for navigators in Iowa, Montana or New Hampshire because no organizations applied in those states.

Nearly 12 million people across the country — including nearly 9 million on the federal exchange — enrolled in Obamacare plans for 2018.

At the halfway point in the six-week enrollment period, 2.4 million people chose a plan for the 2019 coverage year on healthcare.gov, the federal health insurance exchange, according to data released Wednesday by the federal Centers for Medicare & Medicaid Services. That compares with nearly 2.8 million consumers who selected their coverage through the exchange during the first 25 days last year.

Among states with the largest enrollment drops: Pennsylvania (down 25 percent from last year), Missouri (down 25 percent) and Ohio (down 20 percent).

The annual enrollment tally is being closely followed in part because 2019 marks the first year since the marketplace plans began in 2014 that Americans won’t be fined for failing to have coverage.

But consumer experts think the lack of navigator funding could end up having a bigger impact on enrollment. Caroline Gómez-Tom, navigator program manager of Covering Wisconsin, said the end of the so-called individual mandate penalty has been a “non-issue” among people seeking coverage.

“Some folks mention it, but at the end of the day they still walk away with health coverage,” she said. “The ability to have coverage at affordable prices outweighs the penalty being gone because people still see health care insurance as important to have.”

Consumers generally have a greater choice of plans for 2019 as more companies enter the individual market and existing plans expand service areas. Plus, premiums are dropping in some areas, and where they are rising the rate of increase is among the lowest in several years.

Katrina McGivern, director of policy and public affairs for the Kansas Association for the Medically Underserved, said people in rural areas of the state will have the most difficulty getting help as a result of funding cuts.

After five years of experience, she said, she is hopeful that people are figuring out how to do it on their own. Still, she added, there are always “people who need assistance to get through it.”