Tagged The Health Law

Viewpoints: Murkowski Explains Her Opposition To Individual Mandate; Cost-Sharing Burdens

Viewpoints: Murkowski Explains Her Opposition To Individual Mandate; Cost-Sharing Burdens

Podcast: ‘What The Health?’ Meanwhile, In Other Health News…

Most followers of health policy have been consumed lately by the potential repeal or alteration of the Affordable Care Act, as well as the ongoing open enrollment for individual insurance for 2018.

But that’s far from the only health news out there. In this episode of “What the Health?” Julie Rovner of Kaiser Health News, Joanne Kenen of Politico, Alice Ollstein of Talking Points Memo, and Sarah Jane Tribble of Kaiser Health News discuss some of the important but under-covered stories you might have missed this fall, including prescription drug price fights and women’s reproductive health.

Among the takeaways from this week’s podcast:

  • Lobbyists are coming out of the woodwork – spending more than $42 million over the last quarter — on a battle over whether Medicare should reduce what it pays for drugs at hospitals that primarily serve low-income patients.
  • Massachusetts has passed its own guarantee of no-cost contraceptives for women, after the Trump administration rolled back the federal health law provision.
  • The health law’s individual mandate is front and center in the tax debate, but it’s not clear how the Senate will come down on it. Some GOP moderates are suggesting that they might support the repeal if another bill to help stabilize the individual insurance market is approved. Yet at the same time, the White House is signaling that it might be fine dropping the mandate.
  • Of course, if Congress opts not to tackle the mandate, the White House could take some actions later to neutralize the provision. That could add another log on the fire as critics seek help through the courts to stop administration actions.

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

Julie Rovner: The Washington Post and Kaiser Health News’ “Ambulance trips can leave you with surprising – and very expensive – bills,” by Melissa Bailey.

Joanne Kenen: The New York Times’ “Skin Cancers Rise, Along With Questionable Treatments,” by  Katie Hafner and Griffin Palmer.

Alice Ollstein: The Washington Post’s “What the parasites in a defector’s stomach tell us about North Korea,” by Cleve R. Wootson Jr.

Sarah Jane Tribble: The Washington Post’s “How we got the story about monkeypox,” by Lena H. Sun.

To hear all our podcasts, click here.

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Related Topics

Health Care Costs Health Industry Insurance Multimedia Pharmaceuticals The Health Law

Viewpoints: Rising Medicare Premiums Pinching Budgets; GOP Needs Alternative To Individual Mandate

Mass. To Require Insurers Cover Contraception No Matter What Happens To Health Law

States That ‘Went All-In’ On Health Law Have Half As Many Uninsured As Those That Didn’t

Health Centers Desperate As Renewal Of Their Funding Languishes In Congress

Puertorriqueños desplazados enfrentan obstáculos para tener seguro médico

El gobierno federal otorgó a las personas afectadas por los devastadores huracanes que impactaron en los estados costeros y en Puerto Rico este verano 15 días adicionales para inscribirse y obtener cobertura médica bajo la Ley de Cuidado de Salud Asequible (ACA).

Sin embargo, los puertorriqueños que se han instalado en los Estados Unidos continental después que sus casas o negocios fueran destruidos enfrentan problemas más complejos que esa fecha límite.

Muchos de estos estadounidenses tienen preguntas complicadas sobre si su cobertura del Medicaid o Medicare de Puerto Rico puede modificarse (o incluso no funcionar) en sus nuevos hogares. Y para aquellos que buscan seguro privado, usar los mercados de ACA probablemente sea una experiencia nueva, ya que la ley federal de salud no se estableció en la isla.

Los miembros del Congreso de Florida dijeron el miércoles 15 de noviembre que les preocupa que muchos de estos recién llegados, así como las aseguradoras y los navegadores que ayudan a los consumidores con la inscripción, estén confundidos. El grupo envió una carta a Seema Verma, directora de los Centros de Servicios de Medicare y Medicaid (CMS), exigiendo que los funcionarios federales envíen una hoja informativa para “proporcionar la claridad necesaria y aliviar la confusión” entre los puertorriqueños que se han trasladado a los Estados Unidos.

Para la mayoría de las personas, el período abierto de inscripción para obtener cobertura a través de los mercados de la ley de salud termina el 15 de diciembre. Ante las dificultades causadas por las tormentas de agosto y septiembre, los residentes de las zonas más afectadas de Texas, Florida y Georgia tienen un período de gracia de 15 días extra para inscribirse, hasta el 31 de diciembre. Pero retrasar la inscripción significa que el inicio de su cobertura tendría que esperar hasta el 1 de febrero.

Muchos puertorriqueños expulsados ​​de sus hogares, sin embargo, están enfrentando un proceso más complicado. Además de aquellos que están aprendiendo cómo usar los mercados de seguros privados, algunos están aplicando para obtener una nueva cobertura del Medicare. En Puerto Rico, casi tres cuartas partes de los beneficiarios del Medicare tienen planes privados Advantage. Muchos tienen preguntas sobre si seguirán cubiertos por esos planes en el continente.

Además, el programa del Medicaid para residentes de bajos ingresos en Puerto Rico cubre casi a la mitad de los residentes de la isla, una tasa más alta que cualquier otro estado, por lo que las personas que se mudan a Estados Unidos continental pueden no calificar. Esto es especialmente cierto si su nuevo estado no expandió el Medicaid bajo ACA para todos los adultos que ganan hasta el 138 por ciento del nivel de pobreza federal (alrededor de $16,000 para un individuo). Tal es el caso de Florida.

Como mínimo, los nuevos residentes que deseen cobertura del Medicaid deberán volver a presentar una solicitud. Generalmente, la forma más efectiva de hacerlo es a través de los mercados de ACA. Ese proceso les mostrará si son elegibles para el Medicaid o tal vez para un subsidio federal con el cual podrían comprar un plan privado.

Según un memo de los CMS publicado en septiembre, los desplazados por los huracanes pueden llamar a la línea de ayuda de cuidadodesalud.gov (1-800-318-2596) y presentar una solicitud. La nota, que no proporciona detalles sobre qué documentación se necesita, también dice: “las personas pueden experimentar eventos que califican debido a un huracán que los hace elegibles para un período de inscripción especial (SEP)” para acceder a otro plan de salud. Por ejemplo, las personas que se mudaron temporalmente a Florida debido a un huracán y ahora están fuera del área de cobertura de su plan de salud podrían ser elegibles para un período especial de inscripción debido a la mudanza.

Después de las tormentas en agosto y septiembre, la Agencia Federal para el Manejo de Emergencias (FEMA) designó a todos los condados en Florida y Georgia, y 53 en Texas, para recibir “asistencia individual” o “asistencia pública”. En Puerto Rico, esta categoría fue otorgada a 31 de los 78 municipios de la isla.

Aun así, Anne Packham, directora del proyecto de mercado de seguros en Covering Central Florida, una organización con sede en Orlando, dijo que la atención debe enfocarse en alentar a los consumidores a registrarse antes del 15 de diciembre, el último día en que la gente puede inscribirse para la cobertura que comienza el 1 de enero.

“Todo es ya muy confuso, y creemos que decirles a los consumidores que pueden registrarse hasta el 31 de diciembre durante un período especial es agregar confusión”, dijo. “Estas personas necesitan un seguro en este momento, el 1 de enero, no en febrero”.

Después del huracán, más de 140,000 puertorriqueños llegaron a la zona central de Florida, según la oficina del gobernador Rick Scott, para quedarse durante meses, o para establecerse y comenzar una nueva vida. Buscar seguro y atención médica ha sido arduo.

Marni Stahlman, presidenta y CEO de Shepherd’s Hope Inc., una organización con sede en Orlando que ayuda a las personas a encontrar cobertura y servicios, recordó a una pareja de puertorriqueños que la pasó mal.

“El hombre tenía Medicare, y ella, quien es maestra retirada, tiene seguro de salud a través de su sindicato. Ambos se encontraron con obstáculos”, contó Stahlman. “El plan de Medicare del esposo no era aplicable en el continente y tampoco el plan privado de la esposa. Ambos han tenido que comenzar de nuevo. Él volvió a solicitar el Medicare y ella tuvo que presentar una solicitud por primera vez en un mercado de seguros. En este momento todavía están sin cobertura, algo que nunca tuvieron que enfrentar”.

Maria Gotay y sus hijos, Edwin Rodriguez (izq.) y Cristian Rodriguez. Los tres llegaron a Orlando, Fla., dos semanas después de la tormenta y tuvieron que realizar el proceso para tener cobertura de salud. (Foto: cortesía María Gotay)

Para muchas familias, la falta de documentos y suministros complica la situación. Los huracanes no solo devastaron vidas, hogares y se llevaron la electricidad, también arrasaron con medicinas, recetas, tarjetas de seguro médico y copias de declaraciones de impuestos.

“La ayuda para todos, pero para los puertorriqueños en particular, tiene que ser integral porque estas personas solo llegan con sus pasaportes”, dijo Jean Zambrano, vicepresidenta de operaciones médicas de Shepherd’s Hope.

Entre los recién llegados a Florida, hay al menos 18,000 niños y adolescentes que necesitan atención médica inmediata, debido a que se les exige exámenes de vista y audición, y presentar sus vacunas, para asistir a la escuela. Stahlman y Zambrano dijeron que no hay un esfuerzo coordinado a nivel estatal para allanarles el camino.

La articulación de estos procesos entre los territorios y Estados Unidos continental no es un mecanismo aceitado, y la atención médica puede pasarse por alto, lo que significa que el último recurso para muchos que necesitan un doctor es la sala de emergencias.

Aquellos que llegan con sus documentos importantes tienen el éxito un poco más asegurado. María Gotay, de 51 años, llegó a Orlando desde Bayamón, Puerto Rico, con sus dos hijos, Cristian, de 17, y Edwin, de 22, 10 días después que el huracán María devastara la isla.

“Guardamos nuestros documentos en un lugar seguro”, dijo, por lo que los tuvo listos cuando solicitó cobertura de salud para sus hijos.

La navegadora Doris Allen, de Covering Central Florida, la ayudó a inscribir a su hijo menor en el Programa de Seguro de Salud Infantil (CHIP) y al mayor en un plan privado por $33 al mes después de un subsidio. Maria Gotay ya estaba cubierta por el Medicare: tiene un status de discapacidad ya que sufre de fibromialgia.

“Fuimos muy afortunados de conocer a personas que nos apoyaron”, dijo Gotay. Recordó haber llegado al centro de salud y haber caído en los brazos de Allen llorando desconsoladamente. “Nunca quise salir de Puerto Rico, nunca imaginé estar al borde de la muerte”.

“Durante el huracán, todos estábamos juntos, nuestra casa se dañó e inundó, pero resistió el ataque de María”, dijo Gotay.

La mujer trajo a sus hijos a Orlando porque sus dos hijas ya viven allí. Su esposo se quedó en la isla cuidando a su padre, que muestra signos de Alzheimer.

Gotay dijo que vive con estrés y miedo desde el huracán, y que ha estado viendo a un psiquiatra en Orlando que la está ayudando a superarlo. A pesar de todo, regresará a Puerto Rico este mes, mientras que sus hijos se quedarán en Florida y comenzarán una nueva vida.

Esta historia fue producida por Kaiser Health News, un programa editorialmente independiente de la Kaiser Family Foundation.

Related Topics

Insurance Medicaid Noticias En Español The Health Law

Displaced Puerto Ricans Face Obstacles Getting Health Care

The federal government has granted people affected by the devastating hurricanes that wracked coastal states and Puerto Rico 15 extra days to sign up for health coverage under the Affordable Care Act.

But Puerto Ricans who fled to the mainland after the destruction face problems well beyond timing.

Many of those Americans have complicated questions about whether the Medicaid or Medicare coverage they had in Puerto Rico will shift with them to their new locations. And for those seeking private coverage, using the ACA’s insurance marketplaces will likely be a new experience because the federal health law didn’t establish those marketplaces in the U.S. territory.

Members of Congress from Florida said Wednesday they are concerned that many of these recent arrivals, as well as insurance companies and navigators, are confused. They sent a letter to Seema Verma, the director of the Centers for Medicare & Medicaid Services (CMS), requesting that federal officials put out a fact sheet to “provide much-needed clarity and alleviate confusion” among Puerto Ricans who have relocated to the States.

Insurance enrollment on the health law’s marketplaces ends for most people Dec. 15. In a bow to the hardships caused by the August and September storms, residents living in hard-hit areas of Texas, Florida and Georgia are allowed to sign up as late as Dec. 31. But waiting until those final 15 days means that the start of their coverage is delayed until Feb. 1.

Many Puerto Ricans driven from their homes, however, are negotiating layers of red tape. In Puerto Rico, nearly three-quarters of Medicare beneficiaries are in private Advantage plans. Many have questions about whether those plans will cover them stateside.

Also, the Medicaid program for low-income residents in Puerto Rico covers nearly half of the island’s residents  — a rate higher than any state — but it’s not clear that people moving stateside will continue to qualify because they may not meet the tighter eligibility standards. That is especially true if their new home state did not expand Medicaid under the ACA to all adults earning up to 138 percent of the federal poverty level (about $16,000 for an individual).

At the very least, they will have to reapply for Medicaid coverage. Often the most effective route is through the ACA marketplaces. That process will show them whether they are eligible for Medicaid or perhaps a federal subsidy to purchase a private plan.

According to a CMS memo released in September, they can call the healthcare.gov help line (1-800-318-2596) for help. The memo, which doesn’t provide details about what documentation is needed, also says that “individuals may experience qualifying events due to a hurricane that makes them eligible for a special enrollment period (SEP)” to access another health plan. For example, individuals who temporarily relocated to Florida due to a hurricane and are now out of their health plan coverage area could be eligible for a special enrollment period because of the move.

After the storms hit, the Federal Emergency Management Agency (FEMA) designated all counties in Florida and Georgia, and 53 in Texas, to receive “individual assistance” or “public assistance.” In Puerto Rico, this category was granted to 31 of the island’s 78 municipalities.

Still, Anne Packham, director of the insurance marketplace project at Covering Central Florida, an organization based in Orlando, said the focus should be on encouraging consumers to register before Dec. 15, the last day most people can sign up for coverage that begins Jan. 1.

“Everything is already very confusing, and we think that telling consumers that they can register until Dec. 31 during a special period is adding confusion,” she said. “These people need insurance right now, on Jan. 1, not February.”

Since the storms, more than 140,000 Puerto Ricans have arrived in the central area of ​​Florida, according to Gov. Rick Scott’s office. They may stay only for a few months or settle to start a new life. Seeking insurance and medical attention has proven arduous.

Marni Stahlman, president and CEO of Shepherd’s Hope Inc., an organization based in Orlando that helps people find coverage and services, recalled one Puerto Rican couple that had a tough time.

He had Medicare and she was a retired teacher who had insurance through her union, Stahlman said. “The husband’s Medicare policy was not applicable on the mainland and the wife’s was not honored either,” she said. “Both have had to start over. He with reapplying for Medicare and she had to apply for the very first time in a marketplace. They are at this time still ‘uninsured,’ something that they have never had to encounter.”

Maria Gotay and her sons, Edwin Rodriguez (left) and Cristian Rodriguez. They came to Orlando, Fla., two weeks after Hurricane Maria hit Puerto Rico. Having important papers helped them through the process to obtain health care. (Courtesy of Maria Gotay)

Complicating the situations for many families is the lack of records and supplies. The hurricanes not only devastated lives, homes and power, but they also took medicines, prescriptions, insurance cards and copies of tax returns.

“Help for everybody, but for Puerto Ricans in particular, it has to be integral because these people only arrive with their passports,” said Jean Zambrano, vice president of medical operations at Shepherd’s Hope.

Among the newcomers to Florida, there are at least 18,000 children and adolescents who need medical attention quickly because they are required to get vision, hearing and immunization screenings to attend school. Stahlman and Zambrano said there is no coordinated effort at the state level to pave the way for them.

Maneuvering between the territories and the States is not a well-oiled machine, and health care can fall through the cracks — which means the last resort for many needing medical attention is the emergency room.

Those who arrive with their important papers help ensure success. María Gotay, 51, arrived in Orlando from Bayamón, Puerto Rico, with her two boys, Cristian, 17, and Edwin, 22, 10 days after Hurricane Maria ravaged the island.

“We keep our documents in a safe place,” she said, so she had them ready when applying for coverage for her children.

Navigator Doris Allen, from Covering Central Florida, helped sign up Gotay’s younger son for the Children’s Health Insurance Program (CHIP) and the older one in a private insurance plan for $33 a month after a subsidy. Maria Gotay was already covered by Medicare because she has a disability from fibromyalgia.

“We were very fortunate to meet such supportive people,” said Gotay. She recalled arriving at the health center and falling in Allen’s arms crying hysterically. “I never wanted to leave Puerto Rico, I never imagined being at the edge of dying.”

“During the hurricane, we were all together, our house was damaged and flooded, but it withstood Maria’s onslaught,” said Gotay.

She brought her sons to Orlando because her two daughters were already living there. Her husband stayed on the island, caring for his father who shows signs of Alzheimer’s, she said.

She said she has enormous stress and fear following the hurricane, and has been seeing a psychiatrist in Orlando to get help. However, she will return to Puerto Rico this month, while her boys stay in Florida to begin a new life.

Related Topics

Medicaid The Health Law

Perspectives On Obamacare: Mandate Repeal Is Not A Tax Increase; Who Wins If Mandate Is Gone

Canadians Root For An Underdog U.S. Health Policy Idea

TORONTO — Ask people in Canada what they make of American health care, and the answer typically falls between bewilderment and outrage.

Canada, after all, prides itself on a health system that guarantees government insurance for everyone. And many Canadians find it baffling that there’s anybody in the United States who can’t afford a visit to the doctor.

So even as Canadians throw shade at the American hodgepodge of public plans, private insurance, deductibles and copays, they hold in high esteem a little-known Affordable Care Act initiative: the federal Center for Medicare & Medicaid Innovation (CMMI).

It was a hot topic on a reporter’s recent visit to Toronto to study the single-payer health care system.

Wonky as it seems, the center’s mission — testing innovations to hold down health care costs while increasing quality — has gotten noticed. Researchers and clinicians talk about its potential to foster experimentation and how it has led the United States to think out of the box regarding payment and reimbursement models.

“It is gaining traction in many circles here,” said Robert Reid, who researches health care quality at the University of Toronto.

“There have been some good efforts … they have tried more things than we have,” agreed Dr. Kaveh Shojania, a Toronto-based internist who studies health care quality and safety.

Despite the praise emanating from north of the border, the program doesn’t get the same love on the homefront.

Through the ACA, CMMI is armed with $10 billion each decade and sponsors on-the-ground experiments with doctors, health systems and payers. The idea is to devise and implement payment approaches that reward health care quality and efficiency, rather than the number of procedures performed.

Since taking office, though, President Donald Trump has rolled back its reach.

Canada has its own reasons for seeing potential in this sort of systemic test kitchen.

Health care’s growing price tag — and a payment system that doesn’t necessarily reward keeping people healthy — is hardly just an American problem. The vast majority of Canadian doctors are paid through what Americans call the “fee-for-service” model. And Canadian policymakers are also looking for strategies to curb health care costs — which, while greater in the United States, are a big budget here, too.

“The whole world is confronting the same issue, which is, ‘How do you pay and incentivize doctors to keep people out of the hospital and keep them healthy?’” said Ezekiel Emanuel, a former adviser to President Barack Obama who pushed for the center’s initial development. “Different places are looking at how to break out of that system, because everyone knows its perversions. This is one place where … we are in the world among the most innovative groups.”

Emanuel added that he wasn’t surprised to hear of the center’s appeal in Canada. He has received similar feedback from health ministers in Belgium and France, he said.

Even so, U.S. critics say CMMI’s work is a waste of money or a federal overreach.

And, so far, the Trump administration has reduced by half the size of one high-profile Obama administration project that would have bundled payments for hip and knee replacements — so that the hospitals performing those were paid a set amount, rather than for individual services. It also canceled other scheduled “bundling” projects targeting payment for cardiac care and other joint replacements.

CMS Administrator Seema Verma wrote in The Wall Street Journal in September that the Innovation Center was going to begin moving “in a new direction.”

A follow-up “request for information” from the federal government suggested that the center would emphasize cutting health care costs through strategies like market competition, eliminating fraud and helping consumers actually shop for care. It also suggested the Innovation Center would favor smaller-scale projects.

At least for now, it’s hard to interpret what this means, said Jack Hoadley, a health policy analyst at Georgetown University who has previously worked at the Department of Health and Human Services.

Limiting CMMI’s footprint would be problematic, Emanuel argued, while discussing CMMI’s status in the U.S.

The footprint in Canada, though, seems to be growing.

“We definitely looked to it as a model as something we can do. Like look, this happened, and why can’t we do the same thing here?” said Dr. Tara Kiran, a Toronto-based primary care doctor who also researches health care quality.

Related Topics

Cost and Quality The Health Law

Podcast: ‘What The Health?’ Tax Bill Or Health Bill?

Republican efforts to alter the health law, left for dead in September, came roaring back to life this week as the Senate Finance Committee added a repeal of the “individual mandate” fines for not maintaining health insurance to their tax bill.

In this episode of “What the Health?” Julie Rovner of Kaiser Health News, Sarah Kliff of Vox.com, Joanne Kenen of Politico and Alice Ollstein of Talking Points Memo discuss the other health implications of the tax bill, as well as the current state of the Affordable Care Act.

Among the takeaways from this week’s podcast:

  • The tax bill debate proves that Republicans’ zeal to repeal the Affordable Care Act is never dead. The new congressional efforts to kill the penalties for the health law’s individual mandate could seriously wound the ACA since the mandate helps drive healthy people to buy insurance.
  • One of the most overlooked consequences of the tax debate is that it could trigger a substantial cut in federal spending on Medicare.
  • A $25,000 MRI? That’s what one family paid to go out of their plan’s network to get the hospital they wanted for the procedure for their 3-year-old. Such choices are again drawing complaints about narrow networks of doctors and hospitals available in some health plans.
  • Although they don’t likely say it in front of cameras, many Democrats are relieved at President Donald Trump’s choice to head the Department of Health and Human Services, former HHS official Alex Azar.
  • Federal officials have given 10 states and four territories extra money to keep their Children’s Health Insurance Programs running but it’s not clear what couch they found the money hidden in.
  • And in remembrance of Uwe Reinhardt, a reminder that he always stressed that a health care debate was about more than money – it was about real people.

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

Julie Rovner: Statnews.com’s “This Tennessee insurer doesn’t play by Obamacare’s rules – and the GOP sees it as the future,” by Erin Mershon.

Also: Georgetown University Health Policy Institute’s “What’s Going on in Tennessee? One Possible Reason for Its Affordable Care Act Challenges,” by Kevin Lucia and Sabrina Corlette.

Sarah Kliff: Bloomberg Businessweek’s “How to Make a Fortune on Obamacare,” by Bryan Gruley, Zachary Tracer, and Hannah Recht.

Joanne Kenen: Politico Magazine’s “How Bourbon and Big Data Are Cleaning Up Louisville,” by Arthur Allen.

Alice Ollstein: Talking Points Memo’s “Trump’s Abrupt Policy Shift Fuels Misleading Obamacare Renewal Info,” by Alice Ollstein.

To hear all our podcasts, click here.

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Related Topics

Health Care Costs Insurance Medicare Multimedia The Health Law

Perspectives: A New Front For An Old Obamacare War; How Tax Reform Tees Up Medicare Cuts

Perspectives: A New Front For An Old Obamacare War; How Tax Reform Tees Up Medicare Cuts

Despite ACA Cost Protections, Most Adolescents Skip Regular Checkups

As children move through adolescence, some face health hurdles like obesity, sexually transmitted infections, depression and drug abuse. Regular checkups could help families address such problems, and the Affordable Care Act paved the way by requiring insurers to fully cover well-child visits, at no charge to patients.

But, both before and after the ACA was established, fewer than half of kids ages 10 to 17 were getting routine annual physical exams, according to a recent study.

“Most adolescents are pretty healthy, but a lot of them are headed for trouble with obesity” and mental illness and substance use, said Sally Adams, a research specialist on adolescents and young adults at the University of California-San Francisco, the study’s lead author. “These are things that can be caught early and treated, or at least managed.”

For the study, published online this month in JAMA Pediatrics, researchers analyzed data from the federal Medical Expenditure Panel Survey, which tracks health insurance coverage and health care use and spending. Researchers used data from 25,695 people who were caregivers of adolescents ages 10-17. About half were surveyed from 2007 to 2009 and the rest from 2012 to 2014.

Before the health law passed in 2010, caregivers reported that 41 percent of children had a well-child visit in the previous year. After the ACA’s preventive services protections became effective, typically in 2011, the rate climbed to 48 percent, a “moderate” increase, Adams said. The increase was greatest for minority and low-income groups.

Still, more than half of children in the survey didn’t go to the doctor for routine care over the course of a year, even though many families gained insurance and wouldn’t have owed anything for the visits.

That’s cause for concern, Adams said. A primary care provider can screen youngsters for risky behaviors and treat them if necessary. A checkup is also an opportunity to educate patients on health.

“The behaviors they pick up as adolescents have a strong influence on their adult health across their life course,” she said. For example, she noted, “if you can keep them from starting to smoke, then they probably won’t smoke.”

Young children typically have regular pediatrician visits for recommended vaccines, hearing and vision tests as well as school checkups. But those needs may change as children get older, and state requirements that kids get physicals before entering school vary. Some may require a checkup every year, others only at intervals.

“Healthcare professionals have told us that rates of well-child visits tend to be lower after the early childhood years,” Adams said.

The ACA required that most health plans cover preventive services recommended by four medical and scientific expert groups without charging consumers anything out-of-pocket. For children, many of these services are spelled out in the Bright Futures project guidelines, sponsored by the American Academy of Pediatrics and supported by the federal government, and by the U.S. Preventive Services Task Force, an independent group of medical experts that evaluates the evidence for clinical care.

About a fifth of adolescents ages 12 to 19 are obese, and between 13 and 20 percent of children have a mental disorder in any given year, according to the Centers for Disease Control and Prevention.

Some research has shown that parents may believe that adolescents do not need to go to the doctor unless they’re sick and that they can’t afford to pay for checkups, Adams said.

“What we would like is for families to understand that this is a right families have and that these are valuable services that can help their children,” she said.

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

KHN’s coverage of children’s health care issues is supported in part by the Heising-Simons Foundation.

Related Topics

Insurance Insuring Your Health Public Health The Health Law

About A Third Of Americans Unaware Of Obamacare Open Enrollment

While the Affordable Care Act’s fifth open enrollment season is off to a surprisingly good start, many uninsured people said they weren’t even aware of it, according to a survey released Friday.

Nearly a third of people overall — including a third of people without health insurance — said they had not heard anything about the sign-up period for individuals who buy health plans on their own, according to the survey by the Kaiser Family Foundation (KFF). (Kaiser Health News is an editorially independent program of the foundation.)

Open enrollment started Nov. 1 and runs through Dec. 15 in most states. Advocates fear enrollment will decline this year because President Donald Trump has been repeatedly saying the health law is “dead,” and his administration severely cut funding for publicity and in-person assistance.

Nonetheless, nearly 1.5 million people have enrolled on the federal health insurance exchange healthcare.gov, which handles coverage in 39 states, federal officials reported Wednesday.

One factor that could be pushing more people to sign up earlier this year is the open enrollment season was cut in half from three months to 45 days for the states relying on the federal exchange. Some state exchanges allow enrollment into January.

Several state health insurance exchanges have also said early sign ups are running higher than last year. The Colorado insurance exchange on Thursday said it has enrolled more than 22,000 people in the first two weeks — a 33 percent jump from last year’s first weeks.

In the previous open-enrollment season, 12.2 million people nationwide selected individual market plans through the marketplaces. The number dropped off during the year because not everyone paid and some found coverage elsewhere.

Forty-five percent of all respondents to the KFF survey and 52 percent who said they were uninsured said they have heard less about open enrollment this year compared to previous years.

Insurers are trying to pick up some of the challenges of publicizing enrollment, and some of those ads are getting noticed.

The percentage of survey respondents who said they saw ads attempting to sell health insurance increased from 34 percent to 41 percent between the October and November KFF tracking polls. The share who say they saw ads that provided information about how to get health insurance under the ACA increased from 20 percent to 32 percent.

The poll found that nearly 8 in 10 Americans were aware the Affordable Care Act was still in effect.

The survey of 1,201 adults, which was conducted Nov. 8-13, has a margin of error +/-3 percent.

Related Topics

Insurance The Health Law Uninsured

Medicaid Expansion Takes A Bite Out Of Medical Debt

As the Trump administration and Republicans in Congress look to scale back Medicaid, many voters and state lawmakers across the country are moving to make it bigger.

On Nov. 7, Maine voters approved a ballot measure to expand Medicaid under the Affordable Care Act. Advocates are looking to follow suit with ballot measures in Utah, Missouri and Idaho in 2018.

Virginia may also have another go at expansion after the Legislature thwarted Gov. Terry McAuliffe’s attempt to expand Medicaid. Virginia voters elected Democrat Ralph Northam to succeed McAuliffe as governor in January, and Democrats made inroads in the state Legislature, too.

An exit poll of Virginia voters on Election Day found that 39 percent of them ranked health care as their No. 1 issue. More than three-quarters of the Virginians in this group voted for Democrats.

study from the Urban Institute may shed light on why Medicaid eligibility remains a pressing problem: medical debt. While personal debts related to health care are on the decline overall, they remain far higher in states that didn’t expand Medicaid.

In some cases, struggles with medical debt can be all-consuming.

Geneva Wilson is in her mid-40s and lives outside of Lowry City, Mo. She has a long history of health problems, including a blood disorder, depression and a painful misalignment of the hip joint called hip dysplasia.

She’s managed to find some peace living in a small cabin in the woods. She keeps chickens, raises rabbits and has a garden. Her long-term goal is to live off her land by selling what she raises at farmers markets.

Her health has made it hard to keep a job and obtain the insurance that typically comes with it. And Missouri’s stringent Medicaid requirements — which exclude nondisabled adults without children — have kept her from getting public assistance.

Since graduating from college more than 20 years ago, Wilson has mostly had to pay out-of-pocket for medical care, and that’s left her with a seemingly endless pile of medical debt.

“As soon as I get it down a little bit, something happens, and I have to start all over again,” Wilson said.

Right now her medical debt stands at about $3,000, which she pays down by $50 a month. She desperately needs a hip replacement, but she canceled the surgery because, even with a deeply discounted rate from a nearby hospital, she couldn’t afford it.

“Approximately $11,000 is what would come out of my pocket to pay for the hip. That’s my entire pretax wage from last year,” Wilson said. “So it’s kind of on hold, but I don’t know if I can survive the year without going ahead and trying to get it done.”

For many people like Wilson, medical debt can be nearly as problematic as an illness. In 2015, 30.6 percent of Missouri adults ages 18 to 64 had past-due medical debt, the seventh-highest rate in the country. Kansas, at 27 percent, had the 15th-highest rate. In Maine, which voted to expand Medicaid this week, it was 27.7 percent.

Researchers Aaron Sojourner and Ezra Golberstein of the University of Minnesota studied financial data from 2012 to 2015 for people who would be eligible for Medicaid where it was expanded.

They found that in states that didn’t expand, the percentage of low-income, nonelderly adults with unpaid medical bills dropped from 47 to 40 percent within three years.

“The economy improved and maybe other components of the ACA contributed to a 7-percentage-point reduction,” Sojourner says. “Where they did expand Medicaid, it fell by almost twice as much.”

Those states saw an average drop of 13 percentage points, from 43 to 30 percent.

In Kansas, the rate of medical debt for nonelderly adults fell by 4 percentage points to 27 percent. In Missouri, the rate dropped 4 points to 31 percent, according to the Urban Institute. In Maine, it dropped only 1.4 percentage points from 2012 to 2015.

Medicaid, as opposed to private insurance, is the key, said the Urban Institute’s Kyle Caswell, because it requires little out-of-pocket costs.

Even if Medicaid patients need lots of care, they aren’t on the hook for big out-of-pocket costs in the same way someone with private insurance might be.

“We would certainly expect their risk to out-of-pocket expenses to be much lower, and ultimately the risk of unpaid bills to ultimately be also lower,” Caswell said.

But Medicaid’s debt-reducing advantages over private insurance could disappear under the leadership of the Trump administration.

Shortly after Seema Verma was confirmed as the administrator for the Centers for Medicare & Medicaid Services, she and Tom Price, then head of the Department of Health and Human Services, sent a letter to the governors outlining their plans for Medicaid.

The letter encouraged states to consider measures that would make their Medicaid programs operate more like commercial health insurance, including introducing premiums and copayments for emergency room visits.

Verma said that by giving recipients more “skin in the game,” they will take more responsibility for the cost of care and save the program money.

Republican proposals in Congress to repeal and replace the Affordable Care Act would have eliminated or limited Medicaid expansion. And that would have affected the last few years’ downward trend in medical debt.

“Anything that reduces access to Medicaid most likely would have the reverse effect of what we’re seeing in our paper,” Caswell said. “Reduced access to Medicaid would likely increase exposure to medical out-of-pocket spending and ultimately unpaid medical bills.”

As Geneva Wilson tends to her chickens, she said, she tries not to think too much about her medical debt or how she’ll pay for that hip replacement.

“It’s going to the point where, if I were to go shopping at Walmart, I would have to get one of the carts you drive because I can’t manage,” she said.

Wilson has already sold her jewelry, some furniture and a wood stove to pay down her debts. Now there’s not much left to sell except her cabin and her land.

“Probably the homestead and garden that I want, that I’ve been wanting and trying to work for, I don’t think they are a viable dream either,” Wilson said. “It’s hard losing your dreams.”

This story is part of a partnership that includes KCUR, NPR and Kaiser Health News.

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Trump Administration Plan to Add Medicaid Work Requirement Stirs Fears

The Trump administration’s recent endorsement of work requirements in Medicaid and increased state flexibility is part of broader strategy to shrink the fast-growing program for the poor and advance conservative ideas that Republicans failed to get through Congress.

Seema Verma, administrator of the Centers for Medicare & Medicaid Services, laid out her vision for the state-federal program in two appearances last week, saying her new course give states wide latitude over eligibility and benefits.

In a speech Nov. 7 to state Medicaid directors, Verma said the program needs to give people “hope that they can achieve a better future for themselves and their families, hope that they can one day break the chains of generational poverty and no longer need public assistance.”

She has noted other government assistance programs such as food stamps, have similar requirements.

But her outline scares advocates who see the changes as a way for states to kick millions of adults off the program and undermine its mission of providing health coverage to the poor. They note most nondisabled adults on Medicaid already work. Many who don’t are either too sick, go to school or care for relatives.

“Medicaid coverage is not something that should be earned,” said Robert Doherty, senior vice president at the American College of Physicians. “Medicaid is not a welfare program. It is a health care entitlement program, and anyone who meets the requirements should be able to have coverage.”

Verma’s plan to greenlight work requirements is only just the beginning of dramatic changes, these advocates said. They expect that she would allow more states to charge monthly premiums, as Indiana has proposed; approve drug testing of enrollees, as Wisconsin has requested; and putting a time limit on coverage, as Arizona has asked.

Katherine Howitt, associate director of policy at the Community Catalyst, a consumer health advocacy group that backs the federal health law and  expansion of Medicaid, said Verma has thrown open the door to allowing states to add more restrictions on coverage.

“This new approach is not really about promoting work or improving care or improving state flexibility,” she added. “At the end of the day, it is making it harder for low-income people to access health coverage.”

Nearly 75 million people are covered by Medicaid, including 16 million added since 31 states and the District of Columbia expanded their programs under the Affordable Care Act.

Verma said her goal for Medicaid is to move people out of the program by getting them into jobs that offer coverage or provide enough income so they buy it on their own.

“Her comments show she doesn’t understand the reality that many low-wage jobs don’t offer benefits,” Howitt said.

Several states, including Arkansas, Kentucky and Maine, have asked CMS to allow them to require Medicaid recipients to work or do volunteer work as a condition of enrollment. The Obama administration turned down such proposals.

Even some right-leaning pundits say work requirements could backfire because taking away health coverage could make individuals sicker and less likely to hold down jobs.

“This could run counter to the goal of Republicans to help put people to work,” said Jason Fichtner, a health policy expert at the conservative Mercatus Center at George Mason University in Fairfax, Va.

But Josh Archambault, senior fellow for the conservative Foundation for Government Accountability, said he was encouraged by Verma’s approach.

“I think the intent of the program depends on different populations it serves,” he said. “For someone in a nursing home, it’s a health program. But for people in the Medicaid expansion, it is more like a welfare program where able-bodied people are expected to move back into the workforce.”

Congress, with the blessing of President Donald Trump, tried earlier this year to make substantial changes to Medicaid as part of the bills to replace the ACA. Those efforts stalled.

The changes included offering states more flexibility, but federal funding would not be as generous. The nonpartisan Congressional Budget Office said millions fewer people would eventually be covered.

Verma, a former health consultant who helped Indiana expand Medicaid in 2015 under Obamacare, said the law should never have allowed so-called able-bodied adults into the program. That’s because Medicaid already had too many problems, including not enough doctors and wait lists for some people seeking coverage, she said.

Before the ACA, Medicaid mainly covered children, disabled people and pregnant women.

The health law broadened Medicaid to all low-income people, opening up the program to cover nondisabled adults without children with incomes up to 138 percent of the federal poverty level (about $16,600 for an individual).

“We put people on the Medicaid program — able-bodied individuals — in a program that is essentially designed for people that are going to be on the program for the rest of their lives,” Verma said Nov. 9 at an event sponsored by The Wall Street Journal.

Two-thirds of people on Medicaid are disenrolled within three years, according to a U.S. Census Bureau report.

Verma’s pointed criticism of Medicaid, the Affordable Care Act’s expansion and even state officials who helped implement that effort drew rebukes from state Medicaid directors.

Critics said her remarks were misguided and showed she doesn’t understand the program she runs.

Doherty said that by law Medicaid allows states to conduct experiments in how they run the program, but not by making it harder for people to get covered.

Nothing stops states, he added, from offering job training and other programs to help people on Medicaid get back to work. “But we can’t deny them access to health care just because they happen to be poor,” he said.

Robin Rudowitz, a Kaiser Family Foundation policy analyst, said Verma appears willing to let states experiment as never before.

“Some proposals [like work requirements] could create barriers to coverage for eligible beneficiaries and result in losses of coverage for Medicaid enrollees,” she said. (Kaiser Health News is an editorially independent program of the foundation.)

Some health experts said they see many contradictions in Verma’s approach. They said she wants Medicaid to focus only on the most needy — but she has been unwilling to criticize Congress for failing to reauthorize the Children’s Health Insurance Program (CHIP) that covers 9 million children. Federal CHIP funding ran out Sept. 30.

Verma also questioned why some states spend significantly more per enrollee than other states on Medicaid. But the reason, these experts note, is because states have flexibility to vary their benefits, eligibility rules and payments to providers.

As Medicaid has grown to cover more than 1 in 5 Americans, it has become more popular among beneficiaries, health care providers and even among some Republican governors who agreed to expand it. Howitt said the Trump plan would take Medicaid back to the 1980s when it was often linked to cash assistance welfare and carried a stigma.

Joan Alker, director of the Georgetown University Center for Children and Families, said backing work-requirement proposals helps the Trump administration further its ideological message that Medicaid is a welfare program and not a health program.

Judith Solomon, vice president for health policy at the Center on Budget and Policy Priorities, which supports the ACA, said Verma’s vision is simple: to undo the health law’s coverage gains.

“In 2010, Congress decided to expand Medicaid as the vehicle for low-wage workers to have coverage as part of health reform,” she said. “That is still the law and she [Verma] doesn’t get to disagree with that, she has to follow the law not sabotage it.”

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This is part of the KHN Morning Briefing, a summary of health policy coverage from major news organizations. Sign up for an email subscription.

Policy Thoughts: Weighing The Wisdom Of Using The ACA To Pay For Tax Cuts; Have Efforts To Scrap Obamacare Made It Stronger?

Opinion writers offer their thoughts on a range of health policy topics, including future congressional efforts to move on the Alexander-Murray bill, the importance of access to health insurance and the latest on Medicaid from Ohio and Iowa.

Los Angeles Times: Sabotage Obamacare To Finance More Tax Cuts For The Rich? No Thanks
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CT Mirror: Everyone Should Be Entitled To Health Insurance, Even The Middle Class
The Affordable Care Act, more commonly known as Obamacare, is a perverse twist on the Robin Hood tale. Rather than steal from the rich, Obamacare has taken from the middle class. Prior to ACA, the self-employed middle class had many options for comprehensive insurance. They were largely able to afford their premiums and deductibles, and out of pocket costs were manageable. Most importantly, they were free to choose their own doctors and hospitals from a nationwide provider network. (Martin H. Klein, 11/13)

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Ohio hospitals have long been committed to being part of the solution to curtailing health care costs while ensuring quality health care can be delivered efficiently; ultimately leading to a healthier Ohio for all citizens. But hospitals now are facing hundreds of millions of dollars in new Medicaid cuts. Ultimately, patients will be affected. (Dr. Kevin Webb, 11/13)

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This is part of the KHN Morning Briefing, a summary of health policy coverage from major news organizations. Sign up for an email subscription.