Tagged Insuring Your Health

Treatment Gaps Persist Between Low- And High-Income Workers, Even With Insurance

Low-wage workers with job-based health insurance were significantly more likely than their higher-income colleagues to wind up in the emergency department or be admitted to the hospital, in particular for conditions that with good primary care shouldn’t result in hospitalization, a new study found.

At the same time, low-wage workers were much less likely to get preventive care such as mammograms and colonoscopies, even though many of those services are available without cost-sharing under the 2010 health law.

There’s no single reason for the differences in health care use by workers at different wage levels, said Dr. Bruce Sherman, an assistant clinical professor at Case Western Reserve University in Cleveland and the study’s lead author, which was published in the February issue of Health Affairs.

Michelle AndrewsInsuring Your Health

Finances often play a role. Half of workers with employer-sponsored insurance are enrolled in plans with a deductible of at least $1,000 for single coverage. As deductibles and other out-of-pocket costs continue to rise, low-wage workers may opt to pay the rent and put food on the table rather than keep up-to-date with regular doctor visits and lab work to manage their diabetes, for example.

Likewise, convenient access to care can be problematic for workers at the lower end of the pay scale.

“Individuals are penalized if they leave work to seek care,” Sherman said. “So they go after hours and their access to care is limited to urgent care centers or emergency departments.”

The study examined the 2014 health care claims, wage and other data of nearly 43,000 workers at four self-funded companies that offered coverage through a private health insurance exchange. Workers were stratified into four categories based on annual maximum wages of $30,000, $44,000, $70,000 and more than $70,000.

Workers in the lowest wage category were three times more likely to visit the emergency department than top earners, and more than four times more likely to have avoidable hospital admissions for conditions such as bacterial pneumonia or urinary tract infections. But they used preventive services only half as often, the study found.

There are no easy solutions. Varying premiums or deductibles based on workers’ wages could take some of the bite out of low-wage workers’ out-of-pocket costs, but very few employers have adopted that strategy, Sherman said. Offering plans that pay for certain services, such as care related to chronic conditions, before the deductible is met could boost the use of care. But preventive services are available without cost-sharing in most plans and many low-wage workers aren’t getting recommended services.

“Health literacy concerns are important,” said Sherman, but it may not be the only barrier. “Some focus groups I’ve participated in, employees have said, ‘I understand the services are free, but if an abnormality is found that requires further services, I’ll have to [pay for it]. So because I feel fine, I’m not going to go.’”

Please visit khn.org/columnists to send comments or ideas for future topics for the Insuring Your Health column.

Categories: Insurance, Insuring Your Health

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Judge Upends Effort To Limit Charity Funding For Kidney Patients’ Insurance

Every night, Jason Early attaches a catheter in his chest to a machine by his bed that, over the course of nine hours while he sleeps, removes his blood from his body, cleanses it and returns it because his kidneys are no longer able to do the job.

It’s been about 18 months since the 28-year-old Dallas resident started getting dialysis after his kidneys failed as a complication from the Type 1 diabetes with which he was diagnosed as a child.

Like many patients with end-stage renal disease, Early, who is completing a bachelor’s degree in finance at the University of North Texas at Dallas, turned to a charity for financial assistance to cover his health insurance costs.

Michelle AndrewsInsuring Your Health

Such “third-party payments” by nonprofit groups, health care providers and others are controversial. The federal government has expressed concern that providers and organizations they’re affiliated with might be inappropriately “steering” patients to marketplace plans instead of Medicare or Medicaid, for which they are often eligible. The public programs reimburse for the dialysis services at lower rates than most private plans. The efforts by charities have also long been a sore spot with health insurers, who say they encourage sick patients who have expensive health care needs to opt for private coverage.

Insurers suffered a setback recently when a federal judge temporarily blocked a new rule from the Department of Health and Human Services that was set to go into effect Jan. 13. It would require that dialysis centers inform insurers if the centers are making premium payments either directly or indirectly through a third party for people covered by marketplace plans. Insurers would then have the option of accepting or denying the payments.

In granting the preliminary injunction last month, U.S. District Court Judge Amos Mazzant in Sherman, Texas, criticized the government’s administrative process for establishing the regulation and said it hadn’t considered the benefits of private individual insurance or the fact that the rule would leave thousands of patients without coverage.

Jason Early has been getting dialysis for about 18 months and he turned to a charity to help cover his health insurance premiums. (Courtesy of UNT Dallas Marketing Communications | untdallas.edu)

Jason Early has been getting dialysis for about 18 months and he turned to a charity to help cover his health insurance premiums. (Courtesy of UNT Dallas Marketing Communications | untdallas.edu)

Insurers were not pleased. “Inappropriate steering and third-party payments increases costs for all consumers, and it risks harm to patients who are often eligible for public coverage options,” said Kristine Grow, a spokesperson for America’s Health Insurance Plans, an industry group. “We continue to urge [the Department of Health and Human Services] to prohibit these payments when there is alternative coverage for patients.”

But patient advocates were delighted. “We thought this was an important win for dialysis patients because it not only spoke to the procedural elements of the rule but to the substance, the potential of dialysis patients to have their coverage taken away,” said Hrant Jamgochian, the chief executive of Dialysis Patient Citizens, an advocacy group and the lead plaintiff in the lawsuit.

Premium assistance has been critical to improving Early’s quality of life. “Without the [American Kidney Fund] assistance I would be living to pay my medical costs,” he said. “They give me an opportunity to get a breather from medical costs so that I can live my life outside of my illness.”

Although some patients, such as Early, are able to undergo dialysis at home, many must spend four hours at a dialysis center three times a week. The process is debilitating and time-consuming.

Many people lose their employer-sponsored health insurance because they are unable to work. Medicare is often an alternative because under the law, people with end-stage renal disease — even those younger than 65 — are generally eligible for coverage.

Others may sign up for private coverage on the exchanges. Some may qualify for Medicaid.

Advocates for kidney patients say coverage on the individual market is better than Medicare for some people. In marketplace plans, the maximum amount that someone can be required to pay out-of-pocket for covered services in 2017 is $7,150. But there’s no cap on beneficiaries’ spending in Medicare, and patients are on the hook for 20 percent of the cost for doctor visits and other outpatient services such as dialysis. Supplemental “Medigap” plans can help cover out-of-pocket costs, but 23 states don’t require insurers to sell those plans to people with end-stage renal disease who aren’t yet 65.

Last year, Early bought an Aetna silver plan with a $1,500 deductible and a $6,000 out-of-pocket maximum on the Texas health insurance exchange. The American Kidney Fund paid the $359 monthly premium. The policy covered all of his diabetes drugs and equipment. By the end of the first month of dialysis copayments, Early reached his spending maximum and the plan paid everything after that.

But Aetna exited several marketplaces this year, including Texas, and Early signed up for Medicare in January. Now he’s responsible for a $134 monthly Part B premium, $65 for his prescription drug plan and $300 a month in copays for drugs. Medicare doesn’t cover the insulin pump he uses, so he’ll have to pay $300 monthly out of pocket for that too. At the moment he’s also paying $478 each month for the basic Medigap “A” supplemental plan available in Texas to patients younger than 65 with end-stage renal disease. The Medigap plan covers his 20 percent coinsurance payments for dialysis and other outpatient care.

He said he’s been told that the American Kidney Fund, a charity that provides assistance to about 20 percent of the more than 450,000 people who are on dialysis and receives funding from dialysis providers, will start picking up his Medigap premiums soon. He hopes so.

“I miss my Aetna plan,” he said.

Sixty percent of the people who receive premium assistance from the American Kidney Fund get help with their Medicare or Medigap plans rather than marketplace or other private coverage, said LaVarne Burton, the president and CEO. Even though the judge’s order doesn’t apply to people in public plans, she hopes it will discourage insurers that are increasingly erecting barriers to third-party payment.

“We want to protect the ability that these individuals have to make the choice that meets their needs,” Burton said.

Please visit khn.org/columnists to send comments or ideas for future topics for the Insuring Your Health column.

Categories: Health Industry, Insurance, Insuring Your Health, Medicare, Syndicate

Despite Prevention Guidelines, Few Smokers Seek CT Scans To Check For Lung Cancer

Lung cancer screening rates have barely budged in recent years, according to a new study, even though under the health law many people don’t have to pay anything out-of-pocket for them because the test is recommended by a panel of prevention experts.

In 2010, just 3.3 percent of eligible smokers surveyed said they had received a low-dose computed tomography scan in the past year to check for lung cancer. In 2015, the percentage had inched up to 3.9 percent, or 262,700 people out of 6.8 million who were eligible.

The analysis of data from the National Health Interview Survey, a large, ongoing in-person federal survey conducted by the National Center for Health Statistics, was performed by researchers at the American Cancer Society and published online in JAMA Oncology last week.

Michelle AndrewsInsuring Your Health

Despite steady declines in smoking, lung cancer is the number one killer among cancers, accounting for more than 150,000 deaths annually. Smoking is linked to up to 90 percent of lung cancers, according to the Centers for Disease Control and Prevention.

In 2013, the U.S. Preventive Services Task Force, an independent panel of medical experts, recommended annual low-dose CT scans for current or former smokers between the ages of 55 and 80 who smoked for “30 pack years” — the equivalent of a pack a day for 30 years — and currently smoke or quit within the past 15 years. Under the health law, health plans have to cover preventive services that are recommended by the task force without charging consumers for them. Medicare also covers the test for eligible beneficiaries, but coverage for Medicaid enrollees varies by state.

More than half of smokers that met the task force guidelines for screening were uninsured or had Medicaid, the federal/state health program for lower income people, the study found. For these people, the cost of the test, which can run several hundred dollars, could be a deterrent to screening, said Ahmedin Jemal, a vice president at the American Cancer Society and the study’s lead author.

But there are likely other reasons as well, Jemal said, including a “knowledge gap” among poorer, less educated people about the benefits of lung cancer screening. Physicians may also have a knowledge gap, he said. In one study cited in their report, nearly two-thirds of physicians surveyed didn’t know that low-dose CT screening should be done annually in people who are at high risk for lung cancer. In addition, it can be challenging to locate a medical center that has extensive experience with lung cancer screening and follow-up.

“It’s not as common as just going to any hospital in your neighborhood,” Jemal said.

Please visit khn.org/columnists to send comments or ideas for future topics for the Insuring Your Health column.

Categories: Insurance, Insuring Your Health, Public Health, Syndicate

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If Obamacare Is Being Repealed, Do The Uninsured Still Face Penalties?

In some recent emails, readers asked about what to expect as Republicans move to overhaul the health law. Should people bother paying the penalty for not having health insurance when they file their taxes this year? Will they be able to sign up on the exchange for 2018 after their COBRA benefits end? Here are some answers.

Q. I didn’t have health insurance for part of last year and thought I’d get stuck paying a penalty. Now the new administration is talking about not enforcing the insurance requirement. Could I really be off the hook at tax time?

As long as the “individual mandate” — which requires most people to have health coverage or face a tax penalty — is the law of the land, you should pay the fine for not having coverage in 2016 unless you qualify for an exemption, said Tara Straw, a senior policy analyst at the Center on Budget and Policy Priorities. Straw also manages a Volunteer Income Tax Assistance site, part of an Internal Revenue Service program that provides free tax filing services for low and middle income taxpayers.

Michelle AndrewsInsuring Your Health

Straw said she has heard that some tax preparers are advising taxpayers either not to pay the penalty or to delay filing because they anticipate changes in the law.

Bad idea. “It’s not a thing a reputable tax preparer would do,” Straw said. “The requirement that people have health insurance or an exemption [from the mandate] is still in effect.”

The confusion stems from uncertainty over Republican officials’ comments that they may do away with the individual mandate when they overhaul the health law. In addition, President Donald Trump signed an executive order in January that required federal agencies to waive or exempt health law-related provisions that would impose costs or penalties on individuals, to the extent permitted by law.

One strategy that has been discussed has been to broaden the hardship exemption so more people would qualify for it, which the secretary of Health and Human Services has the authority to do.

However, Straw says that approach might run into trouble. “A hardship has to mean something, you can’t say that everyone has a hardship,” she said. “Complying with the law is not considered a hardship.”

Some experts say changing the rules now could create even more confusion, since some people have already filed their returns. Those taxpayers might have to file amended returns, an extra expense if they use a tax preparer.

“Since the 2016 tax season is already underway, I would think it unlikely that the Treasury Department would say, ‘Don’t bother paying the penalty,’” said Mark Luscombe, a principal federal tax analyst at Wolters Kluwer Tax & Accounting, an information services company.

Q. I’m currently on a COBRA plan that ends on Dec. 31, 2017. Then I was going to choose a plan on the exchange for 2018. If the exchange exists in 2018, do you think there would be a special enrollment period allowed for new sign-ups like me when my current coverage ends?

Under the health law, people who have certain life changes, including losing other types of health insurance such as COBRA, are entitled to a special enrollment period to enroll in coverage on the exchange. But in your case, you wouldn’t actually need a special enrollment period because your COBRA will end during the regular annual open enrollment period that is scheduled to run from Nov. 1, 2017, to Jan. 31, 2018. (This coverage comes from a federal law that generally allows people who lose or leave their jobs to stay on the company insurance plan for up to 18 months if they pay the full price of coverage.)

Republican proposals to replace the health law typically include provisions that guarantee people will be able to buy coverage when COBRA or other coverage ends, said Timothy Jost, an emeritus professor at Washington and Lee University Law School who has examined and written about the proposals.

Insurers are skittish, however, about some of the Republican ideas, such as eliminating the individual mandate and the continuing uncertainty about what the individual market will look like next year. At this point it’s unclear what type of coverage will be available.

“The question is: Are the exchanges in place, are the subsidies in place and will premiums be affordable for those who don’t have subsidies?” said Laurel Lucia, manager of the health care program at the University of California-Berkeley Center for Labor Research and Education. “And will there even be an option to buy individual insurance in some parts of the country if no insurers are participating?”

Please visit khn.org/columnists to send comments or ideas for future topics for the Insuring Your Health column.

Categories: Insurance, Insuring Your Health, Syndicate, The Health Law