Tagged Insurance

Pay Close Attention To Subtle Changes, Cost Savings During Open Enrollment Period For Medicare, Health Officials Warn

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Must-Reads Of The Week From Brianna Labuskes

Happy Friday! Yours truly is back from beautiful Vietnam and it seems I missed one or two … ahem … minor news events while traipsing around.

I come bearing no souvenirs but rather two health reminders (one via Sen. Bernie Sanders). Firstly, don’t forget your flu shot — Australia has had an unusually early and severe season, which rarely bodes well for our own. The second comes in the form of a hard-earned lesson from a 2020 candidate: Don’t ignore those heart attack warning signs! (This is especially directed at women, who are dying unnecessarily from cardiac events.)

Now enough mother-henning. (You missed me, didn’t you?) On to the news of the week!

The Supremes are back in action, and a look at the high court’s docket reveals a potentially doozy of a politically charged term (with rulings expected to land as the general election heats up in 2020).

In the health care sphere, a big case to watch is the Louisiana abortion suit. An essentially identical Texas law — which requires doctors performing abortions to have admitting privileges at nearby hospitals — was ruled unconstitutional by the court in 2016, but that means little with two new justices appointed by President Donald Trump weighing in.

The New York Times: As the Supreme Court Gets Back to Work, Five Big Cases to Watch

Oral arguments in two other health-related cases were held this week. The justices grappled with the moral and legal complexities of the insanity defense. The case prompted questions such as this one from Justice Stephen Breyer: One defendant kills a victim he thinks is a dog. “The second defendant knows it’s a person but thinks the dog told him to do it,” Breyer said. “They are both crazy. And why does Kansas say one is guilty, the other is not guilty?”

The New York Times: Supreme Court Opens New Term With Argument on Insanity Defense

Tuesday was all about LGBTQ rights. Although most of the justices were divided along ideological lines on whether federal civil rights legislation applies to sexual orientation and gender identification, Justice Neil Gorsuch hinted his vote might be in play. As an avowed believer in textualism, he suggested that the words of Title VII are “really close, really close” to barring employment discrimination for those workers. But don’t go placing bets on the outcome yet. He also noted that he was worried about “the massive social upheaval” that would follow such a Supreme Court ruling.

The New York Times: Supreme Court Considers Whether Civil Rights Act Protects L.G.B.T. Workers

On that note, the 2020 Democratic candidates participated in an LGBTQ forum on the eve of National Coming Out Day. There were a handful of notable moments through the night (including a zinger from Sen. Elizabeth Warren that was met with loud applause), but much of the spotlight was on protesters who demanded the candidates pay attention to violence against black transgender women. “We are hunted,” said one member of the audience.

CNN: Protesters Interrupt CNN LGBTQ Town Hall to Highlight Plight of Black Transgender Women

Elsewhere on the campaign trail this week, controversy over a pregnancy discrimination talking point from Warren’s stump speech prompted women — including Warren rival Sen. Amy Klobuchar — to speak out on social media about their own and their mothers’ experiences.

NBC News: Women Rally in Support of Elizabeth Warren by Sharing Their Own Pregnancy Discrimination Stories

Sanders’ campaign confirmed that the health scare from last week was indeed a heart attack. The 2020 candidate — who promised to return “full blast” to the race — said he hopes people learn from his “dumb” mistake of ignoring the warning signs. In true politician-running-for-office style, he also was able to use the scare as a way to emphasize the importance of his signature policy proposal, “Medicare for All.”

Reuters: Democratic Presidential Hopeful Sanders Says He Was ‘Dumb’ to Ignore Health Warnings

In a sign of what’s to come for Big Pharma, South Bend Mayor Pete Buttigieg, one of the field’s more moderate candidates, released a drug pricing plan that is decidedly not moderate. The move falls in line with a broader sense that there’s an ever-growing appetite among even middle-ground Dems for action to rein in drugmakers.

Stat: Buttigieg Unveils an Aggressive Plan for Lowering Drug Prices

And for you political wonks out there, this was an interesting read on the shifting political dynamics of doctors, who once used to be a sure thing for the GOP.

The Wall Street Journal: Doctors, Once GOP Stalwarts, Now More Likely to Be Democrats

A key ruling on the health law is expected in the next few weeks, but officials (on condition of anonymity,  mind you) said that if the ruling is against the ACA, the Trump administration will ask the court to put any changes on hold — possibly until after the election. The reports further support the idea that the law, which has been, uh, politically fraught (to say the very least) over its entire life span, is at the moment viewed as an Achilles’ heel for Republicans.

The Washington Post: Trump Administration Plans to Delay Any Changes If the ACA Loses in Court

Two other major news items out of the administration this week to pay attention to:

The Associated Press: Trump Signs Proclamation Restricting Visas for Uninsured

The Associated Press: Overhaul Is Proposed for Decades-Old Medicare Fraud Rules

The first teenager’s death in the outbreak of vaping-related lung illnesses drove home this week public health officials’ message that young people are “playing with their lives” when they partake. The number of cases jumped to 1,299 as of Oct. 8, with the number of deaths rising to 26.

The Wall Street Journal: New York City’s First Vaping-Related Death Is a Bronx Teen

Reuters: U.S. Vaping-Related Deaths Rise to 26, Illnesses to 1,299

Although Juul is facing a barrage of lawsuits, one filed this week was notable. It was believed to be the first from school districts, which claim that fighting the vaping epidemic has been a drag on their resources. While some legal experts are dubious about whether the school districts can establish their standing, others aren’t ruling it out.

The New York Times: Juul Is Sued by School Districts That Say Vaping Is a Dangerous Drain on Their Resources

And the ripple effect of the crisis is spreading to life insurance prices.

Bloomberg: Prudential Plans to Boost Life Insurance Prices for Vapers

Time for you to flex your ethical muscles for the week: Should there be boundaries to highly personalized medicine? A pricey drug designed — and named for! — just one patient sparked questions this week about how far researchers should go in the name of curing a single person. Especially when there are thousands of patients out there with rare diseases. Would only the wealthiest subset be given cures? Who would decide which patients deserve limited research hours over others?

The New York Times: Scientists Designed a Drug for Just One Patient. Her Name Is Mila.

And ProPublica shines a light on the practice of drug companies using flashy Facebook ads, cash incentives and other marketing techniques to woo Mexican residents over the border to donate plasma. It’s not as innocuous as it might seem — donating too much plasma can compromise the immune system. (Selling plasma has been banned in Mexico since 1987.)

ProPublica: Pharmaceutical Companies Are Luring Mexicans Across the U.S. Border to Donate Blood Plasma

In the miscellaneous file for the week:

  • An Ohio doctor is being charged in 25 fentanyl-related deaths. How on earth was such a lapse allowed to occur? The New York Times peels back the curtain on years of lapses and missed warnings in one Columbus intensive care unit.

The New York Times: One Doctor. 25 Deaths. How Could It Have Happened?

  • During the week of World Mental Health Day, research finds that Americans are starting to internalize all the political rhetoric (and myths) about the connection between mental health and violence. “People want simple solutions: They want to be able to neatly explain things,” said one expert.

Los Angeles Times: Americans Increasingly Fear Violence From People Who Are Mentally Ill

  • There’s more than one way to keep a community healthy, and that goes beyond doctor’s offices, clinics and hospitals. A growing number of medical professionals are embracing the notion that steady paychecks, stable housing and good food are crucial to supporting their patients before they get sick.

The New York Times: When a Steady Paycheck Is Good Medicine for Communities

  • In a sad sign of the times, a muppet on “Sesame Street” is going to have a mother struggling with addiction. The storyline is meant to help an ever-increasing number of children affected by the opioid crisis.

Stat: ‘Sesame Street’ Launches Initiative to Help Explain Parental Addiction to Kids

  • High levels of uranium were found in the blood of Navajo women and babies in a study that underscored the real costs of America’s atomic development. Lawmakers are pushing for legislation that would compensate those who have been exposed.

The Associated Press: US Official: Research Finds Uranium in Navajo Women, Babies

  • And the Nobel Prizes are given out this week: In medicine, scientists who worked with oxygen and cells were honored. Their work has the potential to be the building blocks for things like cancer treatments.

The Washington Post: Nobel Prize in Medicine Awarded for Discovery of How Cells Sense Oxygen

That’s it from me! It’s good to be back with you guys, and I hope you have a great weekend!

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Age-Old Health Care Debate Shifts From Insuring More People To Cutting Costs

In a new article in the BMJ journal, Julie Rovner, chief Washington correspondent for Kaiser Health News, examines the debate over the future of the U.S. health insurance system — a debate that has waxed and waned for the better part of a century. While political parties once argued over whether the government should make sure all residents have coverage, the discussion is changing. As the cost of medical services continues to grow faster than most Americans’ incomes, even people with private insurance coverage — which comes with ever-increasing expenses in the form of deductibles and copayments — are finding the cost of care becoming unaffordable. That’s true for Medicare as well. Read the article here.

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State Highlights: Strict Abortion Ban Divides Voters In Louisiana Governor’s Race Where Democrat Leads; NYC Public Hospital Back In Step With Surplus of $36M

State Highlights: Florida Community Still Struggles With 5,000 Homeless One Year After Hurricane; Troubled VA Medical Center Once Again Infested With Flies

VCU Health Will Halt Patient Lawsuits, Boost Aid In Wake Of KHN Investigation

VCU Health, the major Richmond medical system that includes the state’s largest teaching hospital, said it will no longer file lawsuits against its patients, ending a practice that has affected tens of thousands of people over the years.

VCU’s in-house physician group filed more than 56,000 lawsuits against patients for $81 million over the seven years ending in 2018, according to a Kaiser Health News analysis of district court data. Those suits will end and VCU will increase financial assistance for lower-income families treated at the $2.16 billion system, according to Melinda Hancock, VCU’s chief administrative and financial officer.

Melinda Hancock, CFO, VCU Health System(Courtesy of VCU Health)

Kaiser Health News recently reported that UVA Health, the University of Virginia system, had filed more than 36,000 suits over six years against patients who could not pay their bills. That revelation, published last month in The Washington Post, led UVA to pledge to “positively, drastically” reduce patient lawsuits.

VCU’s new stance on lawsuits goes beyond UVA’s, which promised to stop suing only patients whose income is below 400% of poverty guidelines. UVA officials did not respond to requests for comment.

VCU’s flagship hospital, VCU Medical Center, hasn’t filed patient suits in at least seven years, Hancock said in an interview this week. But its in-house physician group continued to sue patients and families for overdue bills.

That approach stopped as of last month, she said. VCU Health, a state-operated system including Richmond’s VCU School of Medicine and Community Memorial Hospital in South Hill, Va., will stop suing patients “as part of normal debt collection,” she said. It is also ending garnishment of patient wages and attaching liens to patient homes, she said.

Hancock said VCU has been considering changing its policies since last year but recent revelations about UVA “expedited” the decision. Starting in June, KHN had requested comment from VCU officials about the health system’s financial assistance and lawsuits.

“We don’t want to be part of that,” she said about patient lawsuits, which are a standard tool for many hospitals seeking to maximize revenue. “We feel that taking care of the patient’s financial health is taking care of their holistic health.”

The system, affiliated with Virginia Commonwealth University, is also considering “how we should address pending lawsuits and retrospective cases,” said spokeswoman Laura Rossacher.

VCU Health will continue to send unpaid debts to collections and report patients with overdue bills to credit agencies.

“We still need to get our bills paid,” Hancock said. “We do need to deploy reasonable collection efforts.”

Policy scholars said the new guidelines, which would make VCU’s collection and billing practices among the most liberal for Virginia hospitals, would still leave many patients vulnerable to credit downgrades, financial hardship and bankruptcy.

“This certainly seems like progress,” said Sara Rosenbaum, a health law professor at George Washington University. But even if no lawsuit is filed, “being an apparent deadbeat on a bill written off as bad debt has terrible and enduring consequences on folks.”

Negative credit reports from a hospital, even without a court case, can send families into a downward spiral, said Gerard Anderson, director of the Johns Hopkins Center for Hospital Finance and Management.

“If they send you to a collection agency, you’re not able to borrow any money because that’s going to put you in such a poor credit rating,” he said. “You cannot expect somebody to pay a $10,000 or $20,000 bill if they don’t have insurance.”

Analysts also criticized as inadequate VCU’s new discounts to the uninsured. Last year, the system started reducing list prices by 45% for those lacking coverage. The previous discount was 25%. Almost nobody pays list charges, which hospitals typically use as a starting point for negotiations with insurers.

But VCU’s average cost of care is 77% below list charges, according to 2017 government filings. That means the uninsured are still paying a big markup under the new policy.

“Most uninsured have very little income, and asking them to pay twice as much as it costs to deliver care is not appropriate,” Anderson said. “It is no wonder why so many cannot pay the bills.”

Uninsured patients paying promptly can receive discounts of up to 55%, Rossacher said. But few are able to do that.

Like UVA, VCU is raising the income threshold for patients seeking financial assistance ― in its case, awarding aid to families with income up to 300% above the federal poverty level, or $77,000 for a family of four. For most patients, the previous cutoff was 200%, or $52,000, for a family of four.

That aid threshold takes effect in November. VCU officials declined to give an estimate of what the new policies would cost the system.

KHN analyzed lawsuits filed by VCU and other hospitals using civil court data collected by Code for Hampton Roads, a nonprofit focusing on improving government technology.

“VCU Health System and its affiliated physicians are making important policy changes that are long overdue,” said Jill Hanken, a health care attorney for the Virginia Poverty Law Center. She urged “further and ongoing oversight” from lawmakers to ensure appropriate indigent care policies.

Virginia Gov. Ralph Northam, a physician, has said little publicly about the state hospitals and doctors under his leadership that often pursue patients for all they are worth.

“No one should go bankrupt because they get sick,” said Northam spokeswoman Alena Yarmosky. “Gov. Northam is glad to see health systems taking real steps to put Virginians first and address aggressive bill collection practices.”

VCU will continue reviewing its collections and assistance policies, Hancock said. “This is an ongoing process,” she said. “It doesn’t’ stop here.”

One impetus to dropping lawsuits was an increasing number of patients with health insurance who still have trouble paying, she said.

“With the rise of high-deductible plans,” in which patients pay thousands before insurance kicks in, she said, “we just felt that there are other collection efforts that were more suitable now.”

KHN analyzed civil case records from the Virginia district courts from 2012 to 2018, based on the date the case was filed. The case records were part of a dataset KHN acquired from Ben Schoenfeld, a volunteer for Code for Hampton Roads, a nonprofit focused on improving government technology. Schoenfeld compiled court records available directly from Virginia’s court system (from both circuit and district courts) and posted them on the website VirginiaCourtData.org. The analysis included all “warrant in debt” cases where the plaintiff was listed as MCV Physicians.

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CMS Wants To Make It Easier For Consumers To Find Out If Nursing Homes Have Been Penalized For Abuse, Neglect

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As Medicare Enrollment Nears, Popular Price Comparison Tool Is Missing

Millions of older adults can start signing up next week for private policies offering Medicare drug and medical coverage for 2020. But many risk wasting money and even jeopardizing their health care due to changes in Medicare’s plan finder, its most popular website.

For more than a decade, beneficiaries used the plan finder to compare dozens of Medicare policies offered by competing insurance companies and get a list of their options. Yet after a website redesign six weeks ago, the search results are missing crucial details: How much will you pay out-of-pocket? And which plan offers the best value?

That’s because the plan finder can no longer add up and sort through the prescription costs plus monthly premiums and any deductibles for all those plans. A mere human can try, but it is a cumbersome process fraught with pitfalls. One plan might have the lowest premium but not the lowest drug prices. Another could exclude a plan’s preferred pharmacy that offers lower prescription prices.

“We can’t guarantee you that you’re going to be in the best plan or the cheapest plan anymore,” said Howard Houghton, the former Fairfax County coordinator for the Virginia Insurance Counseling and Assistance Program who still helps with enrollment as a volunteer.

Using the old plan finder produced big savings. Counselors at Passages, the Senior Health Insurance Information Program (SHIP) serving five counties in Northern California, said in August they used it to save one woman $8,400 for this year and more than $5,000 when helping another client.

Medicare officials say the total cost calculator will be fixed in time for the annual enrollment season, which starts nationwide Oct. 15 and runs through Dec. 7. But they have yet to address multiple other issues raised by the Medicare Rights Center and industry groups.

“The new tool will provide more enhanced price and quality information” to assure informed health care decisions, Seema Verma, administrator at the Centers for Medicare & Medicaid Services, said when she unveiled the redesign in August.

During open enrollment, beneficiaries can sign up for Medicare Advantage plans, the alternative to traditional Medicare that offer drug coverage and often more benefits than the government program does. About a third of the 64 million people in Medicare choose this option. Next year, the average Medicare Advantage monthly premium is expected to drop 14% compared with 2019 to an estimated $23, according to CMS. 

This is also the only time most people in traditional Medicare can sign up for a drug plan, also known as Part D, to help cover their prescription costs. It’s a good idea to review plans every year since costs and covered drugs can change from year to year. Estimated average monthly premiums for these policies will be $30 next year, about 8% less than in 2019, CMS has reported.

Medicare Advantage plans next year are allowed to offer new additional benefits for people with certain chronic diseases, such as dementia, diabetes or heart disease. That’s on top of the non-medical benefits that are not tied to a person’s health problems they were allowed to add this year, such as home-delivered meals after a hospitalization, transportation to medical appointments and minor home improvements, such as grab bars to prevent falls in the bathroom.

Next year, the additional services some Advantage plans will offer hardly sound like insurance benefits: pest control, dog food for service animals, home-delivered meals and discounted groceries.

“It’s really shifting from reactive care to preventative care,” said Martin Esquivel, vice president for Medicare product management at Anthem, which will offer those and other new perks to some of its more than a million Medicare Advantage members.

Smaller Medicare Advantage plans have also expanded benefits. The 60,000 Alignment Healthcare members in some California, Florida and North Carolina plans will have access to free transportation to doctor appointments from Uber or Lyft.

To address social isolation, some California members who also have certain chronic diseases can receive visits from “Grandkids On-Demand,” college students who can help with light housekeeping and provide companionship for up to two hours a day. Humana and Aetna will also offer the service in some plans.

But most insurers are not embracing the opportunity to add extra benefits.

“Of those Medicare Advantage plans affected by the new rules, 10% (or about 500) offered new supplemental benefits in 2020 for people with serious chronic illnesses, such as in-home services, palliative care, respite support for people’s caregivers or adult day care,” said Robert Saunders, research director for payment and delivery reform at Duke University’s Margolis Center for Health Policy. He is still analyzing the other categories of extra benefits.

UnitedHealthcare, which controls 26% of the Medicare Advantage market, is focused“on providing the core medical benefits, which is why people purchase health insurance in the first place,” said Steve Warner, vice president of the UHC Medicare Advantage product team.”Most consumers don’t want to buy a plan that’s been loaded up with ancillary benefits that they don’t think they’re going to use.”

Instead, the insurer is offering more plans that do not restrict members to a network of health care providers and introducing specialized plans for people with diabetes or dementia, among other changes.

Because new extra benefits will not be accessible in every county, seniors may need to do some detective work to find out what’s available. Using the plan finder, it’s possible to narrow down the Medicare Advantage choices only to those plans that offer hearing, vision, dental, fitness and transportation coverage.

Bonnie Burns, a consultant to California Health Advocates, recommends that customers call insurers to confirm details before signing up.

Among the improvements in the new plan finder is the ability to compare estimated costs of Medicare Advantage plans against coverage under traditional Medicare with a separate drug plan and one of 11 kinds of Medigap supplement plans, which cover all or some of the out-of-pocket costs Medicare doesn’t pay for.

But the monthly premiums listed for Medigap policies ― at least in some areas ― are wildly off course. According to the plan finder, a senior in San Francisco can buy a Medigap plan for as little as $20.83 a month. Yet such a plan is not included in the rate chart published by the California Department of Insurance, which lists the cheapest bare-bones policy for a 65-year-old at four times more.

With a more complicated, slower enrollment process, it’s likely that older adults will need more help. And help may be scarce.

“It means fewer people that we get to see because we’re giving each one more time,” said Alicia Jones, administrator of the state SHIP program at Nebraska’s Department of Insurance.

To find your local SHIP program, call 1-877-839-2675 or visit www.shiptacenter.org/.

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Extent Of Health Coverage Gains From California Gig Worker Law Uncertain

A new California law that reclassifies some independent contractors as employees, requiring they be offered a range of benefits and worker protections, will likely expand health insurance coverage in the state, health policy experts say.

But it might end up harming some workers.

That’s in part because the law, which takes effect Jan. 1, could cut two ways. While inducing many employers to extend health insurance to newly reclassified employees, it might prompt others to shift some workers from full-time to part-time status to avoid offering them health coverage, or — in the case of some small firms — to drop such benefits altogether.

Some companies might trim their workforce to limit cost increases. Benefits typically account for about 30% of total employee compensation costs, and health insurance is the largest component of that.

“I think we will see more people classified as employees over time,” said Ken Jacobs, chair of the Center for Labor Research at the University of California-Berkeley. “And that is very likely to expand the number who are offered and take coverage. But the situation is definitely fluid.”

Adding to the fluidity: Some large employers are contesting the new law. Uber, the ride-sharing app company, has said the law does not apply to its drivers and indicated it is prepared to defend its position in court. The company has joined competitor Lyft in broaching the idea of a 2020 ballot initiative to challenge the law.

California Gov. Gavin Newsom has indicated a willingness to negotiate changes and exemptions with those companies and others.

Uber did not respond to requests for comment, and Lyft declined to comment.

In addition to shared-ride drivers, the law affects construction workers, custodians and truck drivers, among others.

Some independent contractors prefer the flexibility that comes with setting their own hours, but others are eagerly eyeing health coverage.

Steve Gregg, a resident of Antioch, Calif., is among them. Gregg, 51, is uninsured and makes too much to qualify for Medi-Cal, the state’s version of the Medicaid program. He hopes to be reclassified as an Uber employee in 2020, primarily to gain access to health insurance.

“The only medical care I can really afford right now is to use an online doctor for my blood pressure medicine,” said Gregg, who typically logs 50 hours or more a week driving for Uber in the Bay Area.

Under the Affordable Care Act, companies with at least 50 full-time employees must pay a penalty if they don’t offer health insurance to those who work 30 hours or more a week.

California’s new “gig economy” law requires employers to treat independent contractors as regular employees if the work they perform is central to the core mission of the company and they operate under the company’s direction.

Several kinds of workers are exempt from the law’s provisions, however, including insurance and real estate agents, investment advisers, doctors and nurses, direct sales workers and commercial fishermen.

Jacobs said other states will closely watch what happens in California, given that some tech companies hire large numbers of independent contractors.

New Jersey, Massachusetts and Connecticut have similar labor laws on the books. Lawmakers in Oregon and Washington state are eyeing legislation akin to California’s.

Independent contractors in the Golden State are nearly twice as likely to be uninsured as regular employees, according to an analysis by UC-Berkeley’s Center for Labor Research, known as the Labor Center. From 2014 to 2016, just under 70% of workers classified as employees had employer-sponsored health insurance, compared with 32% of independent contractors, the study shows.

An estimated 1.6 million of the state’s 19.4 million workers are full-time independent contractors, according to another analysis by the Labor Center. It is unclear precisely how many contractors are “misclassified,” but sponsors of the new law, led by Assemblywoman Lorena Gonzalez (D-San Diego), put the number at around 1 million.

Whatever the exact number, employers who rely on contract workers will need to make complex health insurance decisions.

A company whose contract workers average 35 to 40 hours a week, for example, could reclassify them as employees for the purpose of complying with the new law but try to limit their weekly hours to fewer than 29, thus avoiding the ACA coverage requirement, said Dylan Roby, an associate professor of health policy and management at the University of Maryland and an adjunct associate professor at UCLA.

A large proportion of small companies that are not required by the ACA to cover their employees do so anyway, and the ones that hire independent contractors will also face hard choices.

“If they have to expand that to reclassified employees, the cost could be substantial,” said Christen Linke Young, a health insurance researcher at the Brookings Institution in Washington, D.C.

A small firm with a skilled and relatively high-wage workforce might choose to absorb the cost of expanding coverage to reclassified workers, Young said, because those workers might not qualify for subsidies to buy health insurance on their own through Covered California, the state’s ACA marketplace. Offering insurance is also a retention tool.

Other small companies, however, could choose to drop coverage altogether rather than pay the tab for newly reclassified workers.

And some might be able to place the new employees in a separate category and offer them no health benefits, or less generous ones than the existing employees get. But under federal law, an employer can do that only if the new employees are doing a different kind of work than the current ones, Young said.

Companies of all sizes can wait a year before offering new employees coverage, to establish what their average weekly hours are. That buys firms with 50 or more employees time to decide whether the reclassified workers qualify for health benefits under the ACA.

The uncertainty about how the new law will play out is sowing confusion among many independent contractors.

Vanessa Bain, a resident of Menlo Park, Calif., who works full time as a contract worker for Instacart — a same-day delivery service for groceries — worries about what her employer will do.

Bain and her family are enrolled in Medi-Cal, California’s version of the Medicaid program for people with low incomes. But she would rather get insurance through Instacart.

“What will they offer us?” Bain, 33, wonders. “If the premiums are too high or the coverage crappy, we may be better off buying it on our own through Covered California. We’ll have to see.”

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

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Where Contraception’s A Lifestyle Drug Not A Medical Need — So Women Pay The Tab

KHN correspondent Shefali Luthra is reporting from Germany as a 2019 Arthur F. Burns Fellow.

HAMBURG, Germany — In the five years she’s lived in Germany, Erin Duffy doesn’t think she has paid more than 16 euros for medical care. Until now, that is.

Duffy, a 27-year-old American expat in Hamburg, has had an intrauterine device since she was 22. She got it before moving here from Virginia, where her employer-sponsored health insurance covered its entire cost.

Now, she’s due for a replacement. And since she receives her health care through the German public insurance program, it’s going to cost her 350 euros. That’s about $385, and almost a quarter of her monthly take-home pay. She hopes to pay it off in installments.

Coverage of birth control highlights a key difference between the U.S. and German health care systems. Virtually everyone in Germany has health coverage, and most get it through a government-funded system. Cost sharing here is capped at no more than 2% of household income.

But even though a doctor’s prescription is required for most types of contraception, it is not classified by the public insurance program as a medical need. It’s considered a lifestyle decision. Therefore, consumers bear the entire cost.

When asked about covering birth control, or treating it as preventive medicine, multiple medical experts and researchers said that, frankly, the idea hadn’t really occurred to them. The idea that birth control is an elective choice and that you pay for it yourself is culturally ingrained, they said — and since pregnancy isn’t an illness, the argument goes, covering contraception shouldn’t be part of the collective health project.

“I never, to be honest, thought about it as so weird that we don’t have it covered — because that’s what I grew up with, and how it’s always been,” said Dr. Katharina Schweidtmann, a German physician and consultant at the World Health Organization. “It’s not that big a discussion.”

It’s one of the rare ways in which American health coverage is more generous.

“I don’t make a whole lot of money,” Duffy said over coffee in Hamburg’s downtown. “It’s going to be an expense I have to figure.”

Duffy and her boyfriend even discussed whether the price meant they should abandon the IUD for another type of birth control, she said, but ultimately decided its medical benefits meant they could and should make the finances work. (IUDs are considered a highly effective means of preventing unwanted pregnancy.)

The issue resonates across the pond. The American contraceptive benefit is relatively new, and a political lightning rod. As part of the Affordable Care Act, health plans are required to cover preventive care at no cost — a provision that has been interpreted to include women’s birth control approved by the Food and Drug Administration.

Under President Donald Trump, the White House has sought to roll back the mandate, issuing rules to exempt employers with religious objections. In July, an appeals court blocked the effort. The White House hasn’t indicated if it will appeal.

Comparing the two nations’ approaches to birth control coverage highlights complex issues.

In the United States, research shows, the lack of copays have led to more women using oral contraception and IUDs.

Even without coverage, though, women in Germany are often able to pay for birth control. The fact that so much else is covered — such as prescription drugs, mental health services — and that out-of-pocket costs are capped makes it easier to absorb these costs, women’s health experts said.

But, interviews with German doctors and advocates suggested, there is still a burden for lower-income women.

Germany’s public health insurance, which covers 90% of people, covers birth control for women 22 and younger. After that, they’re mostly on their own. Some programs exist for low-income women, but they are far from universal.

The cost of the pill is about the same on both sides of the Atlantic. IUDs are much more expensive in the U.S., often north of $1,000.

Germany’s coverage decision is cultural, not economic, experts here said. Sex and much of reproductive health are seen as a private matter, and the government has not calculated what it would cost to cover contraception across the board.

“People here don’t want to pay for private things [for other people],” said Holger Pfaff, a medical sociologist at the University of Cologne. “Birth control? That’s lifestyle. If someone wants to have it, that’s their choice, but there’s no medical reason.”

Schweidtmann suggested this is part of a more conservative ethos in Germany when it comes to sexual health and talking about sex — a view other medical experts echoed. Meanwhile, the unintended pregnancy rate here is on the lower end, as is true of Germany’s birth rate overall.

Still, the policy is at odds with other European countries. France partially reimburses for birth control. The United Kingdom provides it without charge through the National Health Service. (Before 1989, the former country of East Germany also made contraception free, as part of a broader effort to reduce unintended pregnancies.)

The impact here is clear, said Dr. Helga Seyler, a gynecologist at Hamburg’s Family Planning Center, which serves low-income women. Often, she said, female patients will opt for a less expensive option — for instance, a copper rather than hormonal IUD — even when it is not the best choice for health reasons.

These patients, she said, tell her it is all they can afford.

Seyler’s clinic benefits from a project run by the Hamburg government and provides 200,000 euros per year to fund free family planning for low-income women. It’s nowhere near enough to meet the need, she said. Seyler estimates they turn away at least half of those seeking contraception, because of insufficient resources.

Three years ago, Pro Familia, a German family planning organization similar to Planned Parenthood, launched a government-funded program to give low-income adult women in certain areas free contraception. In the initiative’s evaluation — released this month — most of the beneficiaries interviewed said birth control would be unattainable without financial aid. Pro Familia is lobbying German officials to add a government-funded contraceptive benefit.

“We think that contraception is basic for the health of all people and contraception methods are essential for all,” said Regine Wlassitschau, a Pro Familia spokeswoman.

However, many experts doubt that the issue has much political support.

“Because it has historically developed like this, it’s difficult now to introduce this concept of women’s health and reproductive health as something that should be normal to be covered,” said Maria Wersig, a social work professor at the University of Applied Sciences in Dortmund, who researches reproductive rights in Germany.

Shefali Luthra is currently reporting from Germany as a 2019 Arthur F. Burns Fellow. The fellowship is an exchange program for German, American and Canadian journalists operated by the International Center for Journalists and the Internationale Journalisten-Programme.

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Trump Speech Offers Dizzying Preview Of His Health Care Campaign Strategy

President Donald Trump offered a preview of what his 2020 health agenda might look like in a speech Thursday — blasting Democratic proposals for reform and saying he would tackle issues such as prescription drug prices and affordability.

He outlined the pillars of his health care vision, which included protecting vulnerable patients; delivering affordable care and prescription drugs; providing choices and control; and improving care for veterans.

In the speech, delivered in The Villages, Fla., before the president signed an executive order to expand Medicare Advantage, Trump also took aim at overhaul plans being advocated by his Democratic opponents, claiming their approach would “put everyone into a single socialist government-run program that would end private insurance.”

He said he and Republicans are committed to protecting people who have preexisting conditions — a claim that PolitiFact and Kaiser Health News previously rated False, because of his administration’s policies.

And, in keeping with the Medicare Advantage theme, he spoke about a controversial move by the Obama administration to reduce future payments to that program by $800 billion. (This point, previously examined by PolitFact, was found to be Half True — but Trump didn’t note that the reductions didn’t affect the program’s beneficiaries, or that he has used a similar approach in projecting future Medicare spending reductions.)

He challenged Congress to approve legislation to curb surprise medical bills and lauded improvements in the veterans’ health system.

But the speech included several other claims directed at Democrats and the currently buzzy proposal of “Medicare for All” that could easily have left some people befuddled. We broke down a few.

Trump told his audience that “Democrats are draining your health care to finance the open borders.”

We asked the White House for the basis of this remark and never got a specific answer. But there are various issues to examine.

In August, the president argued that Democrats “support giving illegal immigrants free healthcare at our expense.” But that isn’t accurate. The statement, part of a Trump 2020 television advertisement, was rated Mostly False.

That claim examined Democratic candidates who had said during one of the televised debates that their health care plans would provide coverage to undocumented immigrants. But the question posed by a debate host didn’t ask whether coverage would be free. In fact, multiple candidates said coverage for undocumented people would not be free. Some, meanwhile, include copays and deductibles in their health care proposals. Plus, if any Medicare for All plan was financed through, for instance, payroll taxes, undocumented immigrants would also be subject to paying those.

Trump argued that Democratic proposals for universal health care “would totally obliterate Medicare” — adding that “whether it’s single-payer or the so-called public option … they want to raid Medicare to fund a thing called socialism.”

The argument here is nuanced but, fundamentally, Trump’s characterization misses the mark and is misleading.

The “single-payer” bill he refers to is the Medicare for All proposal pushed by Democratic Sens. Bernie Sanders of Vermont and Elizabeth Warren of Massachusetts. The bill would put all Americans — including the seniors currently covered by Medicare — into a single health plan. It would share Medicare’s name but look dramatically different: Unlike the existing program, the proposal envisions covering virtually all medical services and eliminating cost sharing. It would not be administered by private, for-profit contractors.

Predicting what this looks like is difficult since it’s grounded in hypotheticals. And one could argue that using the term “obliterates” is not completely off base because Medicare in its current form would no longer exist. But that misses the broader impact. Under the proposal as it’s written, seniors would be insured through a program at least as generous — if not more — than what they currently receive.

As for “public option” proposals put forth by candidates such as former Vice President Joe Biden and South Bend, Ind., Mayor Pete Buttigieg, they would leave Medicare more or less as it is, while also creating a public health plan uninsured people could buy into.

Describing Medicare for All, Trump said the plan would “reduce Americans’ household income by $17,000 a year.”

We contacted the White House to find out the source of this number. The administration acknowledged receipt but never sent an answer.

That said, it’s unclear where this number comes from, because the evidence simply doesn’t exist to make such a precise claim. After all, many details about Medicare for All are still being worked out. That makes it exceptionally difficult to figure out how much such a system would cost — let alone how an individual household’s finances might change under such a system. (This ambiguity is why the Congressional Budget Office has declined to estimate single-payer’s fiscal impact.)

And different households would likely make out differently under Medicare for All. Some might end up paying more. But others would likely pay more in taxes while still seeing their health care costs go down — meaning they could ultimately save money.

Trump said, “the Democrat plans for socialized medicine will not just put doctors and hospitals out of business, they will also deny your treatment and everything that you need.”

This statement relies on a talking point that’s been widely debunked.

We focused on the first part of this claim. Both conservatives and moderate Democrats have argued that single-payer health care, in particular, would drive hospitals and doctors to shutter en masse. (Conservatives have made this argument about a public option as well.) In a past related fact check, we rated this as False.

The argument springs from the way Medicare currently reimburses hospitals, at 87 cents for every dollar spent on health care. But the Sanders bill does not set a reimbursement rate, and instead would charge the federal government with devising an appropriate rate.

Some hospitals might struggle under a new system — but others, health care economists have previously told us, would likely do better.

“It really depends on which hospitals you’re talking about,” Gerard Anderson, a health policy professor at Johns Hopkins University and an expert in hospital pricing, told Kaiser Health News in July.

Tenn. Block Grant Experiment Would Boost Federal Funding, State Medicaid Chief Says

Tennessee wants to be the first state to test a radical approach for federal financing of Medicaid, the federal-state health care program for low-income people.

The proposal, Tennessee Medicaid Director Gabe Roberts said, would increase the federal government’s contributions by millions of dollars and allow Tennessee to improve care for enrollees, perhaps offering additional services such as limited dental care for some people. But critics fear the plan will harm the poor.

Tennessee, controlled by a Republican governor and legislature, has not expanded its Medicaid program as allowed under the Affordable Care Act.

The federal government pays each state a percentage of the cost of caring for anyone eligible for Medicaid ― varying from 50% to 77%. And all who qualify get covered.

Tennessee has proposed altering its federal funding (66% of its total Medicaid budget) into an annual lump sum. (Drug expenses would be excluded from the new program.) The state said the change would give it more flexibility to run the program ― which serves 1.4 million people ― and would save money.

Conservatives have pursued Medicaid block grants for decades to give states more power over the program. But Democrats oppose such efforts, arguing block grants could result in less coverage and limit enrollment. They also stress that states, over time, could see significant drops in federal Medicaid funding because it would not be based specifically on the number of enrollees.

Tennessee’s plan, which was submitted last week to the Centers for Medicare & Medicaid Services, would not change benefits or eligibility levels.

KHN senior correspondent Phil Galewitz sat down with Roberts last week to talk about the issue. His answers have been edited for clarity and length.

Q: Why are you seeking to turn Medicaid into a block grant now, especially as your state has been experiencing a budget surplus?

This isn’t a traditional block grant. We are calling it a modified approach. Tennessee Gov. Bill Lee has been a fan of the block grant idea for a while but also cares deeply about making sure that any approach isn’t going to reduce enrollment or services or people that we serve.

A state law passed this year instructing our administration to file a block grant waiver that would have a floor for federal dollars coming. So if enrollment fell, the money wouldn’t decrease. But if enrollment increased, the amount of federal payments would be indexed to account for that.

Gabe Roberts, Tennessee Medicaid director(Courtesy of Tennessee Medicaid)

Q: Can you discuss the shared-savings element that Tennessee is proposing?

Any savings from this program would be split in half with the federal government.

We have routinely underspent what the federal government projects for our costs by billions of dollars. So what this proposal does is to ask CMS to reimagine the state-federal funding mechanism as a value-based one, so that states that operate well and serve their populations well ― but also contain costs ― are rewarded with additional federal dollars to invest in that population without the requirement to come up with a state match. Right now, we don’t keep any of the money we save.

Q: As one of the poorer states, are you willing to risk getting less money from the federal government for Medicaid?

We believe the way the waiver is designed mitigates any concerns around a traditional block grant program. We do not believe this will result in fewer federal dollars coming to the state. This is an opportunity to bring more federal dollars to spend to enhance services or perhaps to provide services to additional people we are not serving today.

Q: Some experts question the legality of the Trump administration approving a type of Medicaid block grant without congressional authority. Why do you believe this is legal?

There are a variety of ways we can reach a mutually agreeable solution with CMS on this that clearly comports to federal law.

Q: Why is turning Medicaid financing into a block grant a better idea for the poor than expanding Medicaid under the Affordable Care Act, which would provide coverage to nearly additional 300,000 residents? The federal government pays 90% of the cost of these new enrollees, bringing billions of additional federal funding into the state.

These are two different and not mutually exclusive goals. This is an approach that rewards Tennessee for a well-run program, providing high-quality care to members with high member satisfaction and underspending CMS projections. This allows us to get access to some of those federal savings. Medicaid expansion requires a significant amount of money that the state has to come up with on an ongoing basis. I don’t know that it’s fair to pit the two approaches against each other.

Walmart To Give Workers Financial Incentives To Use Higher-Quality Doctors

Worried its employees aren’t getting good enough care from doctors in their insurance networks, Walmart next year will test pointing workers in northwestern Arkansas, central Florida and the Dallas-Fort Worth area toward physicians it has found provide better service.

If the employees use these “featured providers,” they will pay less out of pocket, Walmart officials said Thursday.

Walmart is working with Embold Health of Nashville, a recent startup company that uses data to analyze whether doctors provide “appropriate, effective and cost-efficient care.” Embold CEO Daniel Stein was a Walmart executive from 2013 to 2017.

“Rather than relying on word of mouth or social media to find a provider, patients can get information based on actual data and proven results,” said Lisa Woods, Walmart’s senior director of U.S. benefits.

Walmart, the nation’s largest private employer, would not disclose the percentage of its doctors in those geographic areas that have the new quality distinction or how much workers could save by using their services. The company hopes to take the program nationwide if successful, officials said.

About 60,000 employees and dependents in the three initial areas could be affected.

Ateev Mehrotra, associate professor of health care policy at Harvard Medical School, said Walmart’s strategy could raise questions about whether doctors are chosen more for lower cost or higher quality.

“This sounds awesome and great in theory, to identify the best doctors you have for your employees to go to, but what is in the black box formula that Embold Health is using, and how much is it the cost and how much is quality of care?” he said.

The effort to steer workers to certain doctors mirrors a similar approach Walmart uses with hospital care. Since 2012, Walmart has directed the 1 million employees and dependents on its health plan to better-performing hospitals for high-cost services, such as heart and transplant surgery.

While using these hospitals — including Mayo Clinic and Cleveland Clinic — may cost more than a local alternative, Walmart officials have said the strategy saves money by averting complications and unnecessary care. Several other large employers have followed a similar “centers of excellence” strategy.

Earlier this year, Walmart became the first large employer to direct its employees to diagnostic imaging facilities that it found provide more accurate care.

Employer health experts said Walmart’s initiative with physicians is a groundbreaking step — but is also fraught with risks such as alienating doctors and upsetting employees who don’t want to change doctors.

“It’s a bold move to use the data they have and share it with employees for their benefit,” said Steve Wojcik, vice president of public policy at the National Business Group on Health, a trade group of large employers. “It’s part of Walmart’s pattern to disrupt and transform health care for the better.”

Stein of Embold Health said his company uses various quality metrics that vary by specialty to rate physicians. The company shares its criteria with physicians, he said, so they know what areas they need to improve to get the quality distinction. This includes such measures as rates of cesarean sections for patients with low-risk pregnancies and infection rates for patients after elective knee or hip replacement, according to Embold Health.

Mehrotra noted, however, that it’s often difficult to identify which doctors provide the highest quality of care because most work in large groups where patients may see multiple physicians.

The initiative to identify better-performing doctors, he suggested, “can only be seen as a failure of their health plans,” noting that employers typically rely on the insurance companies that administer their plans to identify the best doctors for their networks.

Walmart’s test will include physicians specializing in primary care, cardiology, gastroenterology, endocrinology, obstetrics, oncology, orthopedics and pulmonology.

Walmart officials said the initiative is aimed at helping reduce the large amount of unnecessary care that doctors provide, which some studies say is as high as 30%.

“We hope to get a meaningful chunk of that removed from our costs and our associates’ costs,” said Adam Stavisky, Walmart’s senior vice president of U.S. benefits. “How much we can save? We don’t know, but we think it’s material.”

The initiative is one of several announced by Walmart officials Thursday, including pilot projects to expand access to telehealth doctors managing chronic care in Colorado, Minnesota and Wisconsin, and to help workers in North Carolina and South Carolina find doctors, provide assistance on billing questions or complex medical issues.

Georgia Sheriff’s Deputy Sues Over Lack Of Transgender Insurance Coverage

A sheriff’s deputy in Perry, Ga., filed a lawsuit in federal court Wednesday against the county where she works over its refusal to allow her health insurance plan to cover her gender-affirmation surgery.

Sgt. Anna Lange came out as transgender in 2017 after working in the Houston County Sheriff’s Office since 2006. She has taken hormone therapy and outwardly changed her appearance over the past three years to treat gender dysphoria, the distress resulting from the mismatch between her sex assigned at birth and her gender identity.

Her next step was going to be gender-affirmation surgery, but that plan came to a halt when her insurance provider denied coverage for the procedure based on an exclusion specified by her employer.

Now, Lange is suing the Houston County Board of Commissioners to remove that exclusion. Early Wednesday, she and her lawyer, Noah Lewis of the Transgender Legal Defense and Education Fund, filed suit in U.S. District Court in Macon, Ga., alleging unlawful discrimination under federal and state equal protection clauses, Title VII of the Civil Rights Act and the Americans With Disabilities Act.

County officials did not return calls for comment.

Houston County (Ga.) sheriff’s deputy Sgt. Anna Lange came out as transgender in 2017 after working in the department since 2006. Cards of thanks and encouragement are displayed in Lange’s kitchen in Perry, Ga., in March.(Audra Melton for NPR)

Lange’s case is the latest in the U.S. to challenge the exclusion of transgender care from state and municipal employee insurance plans ― and it could create legal precedents for cases across the South.

Other transgender people have won similar fights elsewhere. The managers of Wisconsin’s state employee insurance program excluded transgender employees from coverage but later reversed that decision. Separately, two University of Wisconsin employees sued the state and won. Another lawsuit successfully challenged transgender exclusions in Wisconsin’s Medicaid plan.

Earlier this year, Jesse Vroegh, a transgender employee of the Iowa Department of Corrections, won a lawsuit he filed after being denied coverage by his employer’s health insurance plan.

And in Georgia, the state’s university system recently settled an insurance exclusion claim for gender-affirmation surgery filed by Skyler Jay, known for his appearance on the Netflix series “Queer Eye.” In addition to changing its employee health plan to be inclusive of transgender care, the university system paid Jay $100,000 in damages.

“The university clearly agreed that it was discrimination,” said Lewis, who also represented Jay. “That’s why they wanted to do the right thing and remove the exclusion.”

In 2011, another Georgia case, Glenn v. Brumby, set the legal precedent protecting transgender people from employment discrimination. However, that case did not address discrimination in employee benefits and, like Jay’s, many of the cases that deal with benefits have been settled out of court, according to Lewis.

The Affordable Care Act, which took effect in 2014, specifically prohibits discrimination by health insurance issuers on the basis of gender identity, and Title VII of the Civil Rights Act has also been interpreted to prohibit such discrimination.

Despite broad legal consensus that transgender insurance exclusions are unlawful, state and local governments continue to pursue expensive legal fights to preserve them. The issue remains contentious for many social conservatives.

“Ultimately, what’s happening is that, politically, I presume they think it’s unpopular or they think they have to defend” the law or regulation, said John Knight, an attorney with the American Civil Liberties Union.

Resisting payment for such care can be more expensive than providing it. Not including the costs of state attorneys’ salaries or appeals, Wisconsin’s litigation against the employees of its university system cost the state more than $845,000, while Iowa’s cost about $125,000.

Furthermore, the cost of managing untreated gender dysphoria can outweigh the costs of providing transgender-inclusive health care, according to a 2015 study. “Given the small number of people who actually need this kind of care and the large pool of people, it will have absolutely no impact on the total cost of insurance for any state,” Knight said.

While settlements like Jay’s may be good for individuals, they do not require institutions to admit wrongdoing and do not result in a legal precedent that other, lower courts must follow.

“The court doesn’t have to look at that settlement and say, ‘Oh, this was discrimination,’” said Lewis. “Transgender workers in the South are being left behind, which is why we’re seeking a court ruling to clearly establish that this conduct is unlawful throughout the South.”

Lange’s suit argues that the county’s exclusion of transgender health care from coverage was deliberate: In documents Lewis obtained under the Freedom of Information Act, Kenneth Carter, the county’s personnel director, opted out of compliance with Section 1557 of the Affordable Care Act, which prohibits discrimination by health programs on the basis of gender identity.

“Houston County will be responsible for any penalties that result if the plan is determined to be non-compliant,” he wrote in a letter to a representative of Anthem Blue Cross and Blue Shield, which administers the plan.

Carter did not return calls for comment.

Lange’s case could end up before the 11th U.S. Circuit Court of Appeals, yielding a decision that could influence other courts in Alabama, Florida and Georgia. And, if the ruling is in Lange’s favor, Lewis said that would signal that transgender exclusions should be removed nationwide.

In its next term, the U.S. Supreme Court will hear three cases that will determine workplace protections of LGBTQ individuals, including one case involving a transgender woman.

Lange said she merely wants the same protections everyone else has. The co-workers with whom she shares a health plan might have used “something on the policy that I may never use or need, but it’s covered,” she said. “When it’s finally something that I need that one of my co-workers will probably never use or need, mine’s excluded. And that’s just not fair.”

The Deep Divide: State Borders Create Medicaid Haves And Have-Nots

ST. LOUIS — Patricia Powers went a few years without health insurance and couldn’t afford regular doctor visits. So she had no idea cancerous tumors were silently growing in both of her breasts.

If Powers lived just across the Mississippi River in Illinois, she would have qualified for Medicaid, the federal-state health insurance program for low-income residents that 36 states and the District of Columbia decided to expand under the Affordable Care Act. But Missouri politicians chose not to expand it — a decision some groups are trying to reverse by getting signatures to put the option on the 2020 ballot.

Powers’ predicament reflects an odd twist in the way the health care law has played out: State borders have become arbitrary dividing lines between Medicaid’s haves and have-nots, with Americans in similar financial straits facing vastly different health care fortunes. This affects everything from whether diseases are caught early to whether people can stay well enough to work.

It wasn’t supposed to be this way. The ACA, passed in 2010, called for extending Medicaid to all Americans earning up to 138% of the federal poverty level, around $17,000 annually for an individual. But the U.S. Supreme Court in 2012 let states choose whether to expand Medicaid. Illinois did, bringing an additional 650,000-plus people onto its rolls. Missouri did not, and today about 200,000 of its residents are like Powers, stuck in this geographic gap.

Powers briefly thought about moving to another state, just to be able to get Medicaid. “You ask yourself: Where do you go? What do you do?” said Powers, who was in her early 60s when diagnosed. “Do I look at what’s happening in Illinois, right across the river?”

A recent University of Michigan study found Medicaid expansion substantially reduced mortality rates from 2014 to 2017. The researchers said Illinois averted 345 deaths annually while Missouri had 194 additional deaths each year. The same trends held for other side-by-side states such as Kentucky (did expand) and Tennessee (did not), New Mexico (did) and Texas (did not).

Dr. Karen Joynt Maddox, co-director of the Center for Health Economics and Policy at Washington University in St. Louis, said health care providers in her border city see how the coverage differences affect people. When treating Medicaid patients from Illinois, she said, doctors know procedures, equipment and medicines will likely be covered. With uninsured Missourians, they must consider whether patients can afford even follow-up medications after heart attacks.

Nonetheless, Medicaid expansion faces significant opposition in Missouri, a red state led by a Republican governor with GOP supermajorities in both legislative chambers.

Patrick Ishmael, director of government accountability for the Show-Me Institute, a Missouri free-market think tank, said offering Medicaid to people with incomes above the poverty level would drain resources from the state’s underserved poor and push up taxpayer costs. Though the federal government pays 90% of the cost of the expansion coverage, he said, Missourians contribute to that through their federal taxes. Medicaid already accounts for about a third of the state’s budget, which he said puts pressure on other priorities, like education.

“Missouri and other states need to think about whether they are a government that provides health care or a health care provider that sometimes governs,” he said.

A Missouri Story

Powers, a minister in the St. Louis suburb of Hazelwood, used to get health insurance through her husband’s job selling lumber and hardware. After he was disabled in 2009, their coverage continued on and off for a while, and her husband eventually received Medicare, the federal insurance program for seniors and people with disabilities. But Powers had no insurance starting in 2012 as the couple struggled on, at most, $1,500 a month.

Medicaid wasn’t an option for her. Missouri could have opened the program to more adults as early as 2010, in preparation for the health care law’s expanded coverage taking effect in 2014. Without the ACA’s expansion, adults who aren’t 65 or older or disabled don’t qualify, no matter how low their income. Missouri’s program generally covers only pregnant women and children from low-income families, parents with incomes about 22% of the federal poverty level and people who are poor and blind, disabled or 65 or older.

Powers and her husband earned too little for her to qualify for subsidies on the federal ACA marketplace, so she couldn’t afford to buy her own plan. And without insurance, Powers never saw doctors for routine health visits or screenings. She stopped taking her prescribed medications for high blood pressure and anxiety — until she could no longer do without her anti-anxiety medicine, Lexapro.

In early 2016, she discovered a place to get help when she gave her friend a ride to a St. Louis clinic for the uninsured called Casa de Salud, where health services cost less than $30.

Powers figured she’d ask about getting back onto Lexapro there. She got a thorough checkup. The doctor found a walnut-sized lump in her right breast, and a mammogram found a tumor the size of a grain of rice in her left. A clinic caseworker helped her sign up for a Medicaid program for breast cancer patients. She underwent surgery in April 2016, then had 35 radiation treatments and took follow-up medications.

She kept thinking she could have found the cancer earlier if only she had insurance. That would have meant less treatment and lower costs for taxpayers, who ended up footing the bill anyway. Research shows breast cancer in its earliest stage can cost half as much to treat as in later stages.

“Even if you didn’t care about the human cost, you should care about the economic cost,” said Jorge Riopedre, president and CEO of Casa de Salud. “Treating a disease at its first stage is always going to be much cheaper than treating it at its advanced stage.”

An Illinois Story

In neighboring Illinois, getting Medicaid through the expansion helped Matt Bednarowicz avoid debilitating medical debt after a motorcycle crash. He was able to go back to work after he was injured while delivering a package in mid-May 2018.

The wreck crushed his left foot, requiring doctors to insert pins in it. Without Medicaid, he would have faced thousands of dollars in medical bills.

“The debt would have been greater than I could comprehend overcoming,” said Bednarowicz, who is now 29.

His Medicaid kicked in “just in the nick of time” to cover the surgery, he said. It also allowed him to get psychiatric help for depression. More than a year later, he’s able to get around well — even jog — and works as a caretaker for an elderly man.

Having insurance helps people like Bednarowicz stay productive, said Riopedre.

“The person who gets sick can’t work, can’t support his or her family, can’t be a consumer and buy goods. If they’re not working, they can’t pay taxes,” Riopedre said. “It just is a tidal wave of downstream effects that if we can’t get it right, it’s going to have repercussions across the nation.”

Amid Controversy, Future Uncertain For Missouri

As the ballot measure push continues, Missouri Gov. Mike Parson, a Republican, recently created a task force to look into expanding Medicaid through a waiver allowing states to skip some federal requirements. His office referred questions to the state’s Department of Health and Senior Services, which in turn referred them to the Department of Social Services. Rebecca Woelfel, a spokeswoman for that agency, said the department doesn’t typically comment on potential ballot issues.

Ishmael, of the Show-Me Institute, said he hopes expansion doesn’t happen. He said the Medicaid system overall is wasteful, with outcomes often not fully justifying the expense. The cost of an expansion would depend on how it’s structured, he said, but “it could be a real budget-buster.”

The impact of an expansion on Missouri’s budget remains unclear. A February analysis by researchers at Washington University estimated it would be “approximately revenue-neutral.” But their estimates range widely for the first year depending on enrollment and other factors, from up to $95 million in savings for Missouri’s Medicaid program to costing $42 million more than not expanding.

Powers, whose husband died last year, said she fully supports Medicaid expansion.

But whatever happens, especially now that she’s suffering from heart failure, she’s grateful she won’t have to worry about being uninsured again. At 66, she’s now old enough for Medicare.