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Health Care Quickie: Yes on Prop 45
Where It All Began
Finding a Way
In the wake of Robin Williams’ death, we spent a lot of time talking about depression and mental health care on The Stephanie Miller Show this morning. Too often someone cites cost as a reason for not being able to get the help he/she needs. I recommended checking out one new option for access to affordable psychotherapy – Open Path Psychotherapy Collective. Founder Paul Fugelsang writes more about the Collective on The Huffington Post. An excerpt:
We now have more than 900 participating therapists in 42 states, and every month we enroll and connect between 60 and 80 new clients. My original concept has changed a touch, and we’re constantly evolving. For example, instead of taking a fee per session, we’ve chosen to collect a one-time, lifetime membership fee. That $49 allows a client access to our database of therapists anytime he wants to find help. I know people often start and stop therapy depending on need and circumstance. Our model accommodates that reality.
You can listen to the first 13 mins of my full hour here.
That’s What She Said
Since I’m planning to talk about this during my hour tomorrow morning on The Stephanie Miller Show, I wanted to make sure people had easy access to what I’m referencing.
One anti-health care reform talking point that’s been making the rounds for a good 4 years now is some variation of the following:
Nancy Pelosi said we have to pass the bill [the Affordable Care Act] so we can see what’s in it. Nobody read the bill!
A friend and well-known conservative I follow on Twitter brought it up again this week in reaction to the U.S. Court of Appeals for the DC Circuit ruling against the ACA on a wording technicality:
What I haven’t seen nearly as often (read: ever) is the truth about what the House Speaker at the time actually said. From the transcript of her remarks on March 9, 2010 at that year’s Legislative Conference for National Association of Counties:
“You’ve heard about the controversies within the bill, the process about the bill, one or the other. But I don’t know if you have heard that it is legislation for the future, not just about health care for America, but about a healthier America, where preventive care is not something that you have to pay a deductible for or out of pocket. Prevention, prevention, prevention—it’s about diet, not diabetes. It’s going to be very, very exciting.
“But we have to pass the bill so that you can find out what is in it, away from the fog of the controversy.
In context, what Pelosi says is obvious and not at all what opponents allege. She says we (the people) have heard more about conflict, contention, and politics than the policy content of the bill. But she and her colleagues (a totally different ‘we’) have to pass the bill so that we (the people) can see what the law really says away from the cloud of misinformation that’s been swirling around it.
Here’s the video from the actual event. Not an out-of-context clip. Not a sentence edited down to :10 or less. The speech in its entirety posted online by the National Association of Counties itself. The remarks in question are from 6:57 – 7:40:
It’s baffling to me why no one bothered to take this myth down right off the bat simply by going back to the original source. The official complete version of the speech has 557 views. That one sentence clipped out of context? The first 7 videos of it I found added together have more than 900,000 views. Even the official Youtube channel of outgoing House Majority Leader Eric Cantor posted a :04 version.
Feel free to use this post as a reference next time you hear someone say Nancy Pelosi said no one in Congress read the Affordable Care Act before it passed. Because, simply put, that’s not what she said.
On The Air
Part of my Thursday hour on The Stephanie Miller Show was archived this week. Listen here
Blue Shield Weighs In
If you’ve been listening to my weekly health care corner on The Stephanie Miller Show or following me on Twitter, you know I’ve been asking questions about California Blue Shield and its Covered California plans. Just coincidentally, I’ve had occasion to use my new Blue Shield insurance a handful of times over the course of the last few months. Nothing serious (thank goodness), but I needed (among other things) an x-ray for a sports-related strain, a routine mammogram, and a primary care visit for a toenail that decided to grow in instead of out. Over the course of my personal interactions, I discovered a handful of issues related to my new health insurance plan. First, Blue Shield’s website listed physicians and facilities as in-network with their PPOs when the physicians and facilities themselves insisted they weren’t. And I heard two different variations on why the physicians and facilities weren’t participating. The first was that they hadn’t been invited to participate. The second was that if they were invited to participate, they were offered reimbursement rates 30% lower than what they had agreed to in the past.
This led me to dig around a bit and speak out a lot, and in response, I got letters like the following from Scott in Humboldt County, CA that reads in part:
My wife and I signed up for the silver plan because the website said our doctor was on it. We were very excited when our rate was dropping from $500+ a month for catastrophic coverage ($6000/person deductible with $30 copay) to $94 a month for a great plan ($1500 deductible with similar copy). However, now that have tried to use it, we have learned that only one clinic in the entire county is truly on the plan. All the other doctors opted out because of the low reimbursement rate, which means if I – or most of the others in the country who are on this program – want to see a doctor in network we have to drive a couple of hundred miles (to the Bay Area).
When I called Blue Shield to confirm what was going on, they told me my doctor indeed was in network. I called his office and they said they definitely were not; the reimbursement rate was too low. I called back Blue Shield and they insisted he was. When I pushed on the rep, she said, “Oh, he’s in a different program, not yours.” I asked then “Why is he listed in my program?” She didn’t know. (I have been told by several people that their doctors are also listed but not on the program.)
You can read the letter (reprinted with Scott’s permission) in its entirety here.
I reached out to Blue Shield corporate to ask about physician participation, reimbursement rates, website “errors,” etc. To their communications department’s credit, they did get back to me quickly and as thoroughly as can be expected. And I do have to thank Jackie – their extremely proactive customer service representative – who reached out to me on Twitter and both followed up on a personal claim issue and handed me off to corporate for an official response to my policy and practices questions.
You can read my back and forth with corporate here. I believe full transparency is important. But if you’re looking for a short executive summary, here’s the gist:
- Contrary to my earlier assumption, Blue Shield says if you buy an individual or family plan (as opposed to a group plan), it will be the same regardless of how you buy it. Buying through the Covered California exchange allows you to get a subsidy (help paying for your premiums) if you qualify, but Blue Shield insists its plan offerings are the same on and off the exchange.
- Blue Shield claims it worked with providers over the past several years to negotiate plans with lower reimbursement rates in exchange for the promise of more patients. This is contrary to everything I’ve heard from doctors themselves. In fact, many of the physicians and facilities I’ve spoken with aren’t looking to beef up their patient load. They simply want to keep the patients they’re already seeing. But since many of those patients have switched to Blue Shield, and Blue Shield is cutting the network by cutting reimbursement rates, physicians aren’t gaining anything but frustrated patients.
- Blue Shield claims it updates its provider directory weekly. This may be true, but it’s not updating weekly with accurate information. You really have to call your doctor directly and ask if he’s in-network. And be aware, he may not even know for sure.
- And finally, there’s this:
It’s also important to note that between the 11 qualified health plans participating in covered California, consumers have access to a broad choice of over 80-90% of the practicing physicians in the state.
That’s great if one person has 11 plans. But telling me that your 11 plans together cover 80-90% of the market does not tell me anything useful as an individual consumer.
Again, I think I got as much out of Blue Shield corporate as I could at this stage, and while they had a lot to write, I’m fairly certain much of what they claim is wrong. I still believe slashing reimbursement rates is an insurance company scam to cut down on expenses while protecting profits. I find it unlikely any physician willingly agreed to a 30% cut.
So what can we do about all this? Well, we can start by giving the state insurance commissioner some muscle.
In November, Californians will be asked to vote for a ballot measure called the Insurance Rate Public Justification and Accountability Act. Right now, CA’s insurance commissioner can review proposed rate hikes, but he can’t do anything about them:
“At the end of the day, the companies can tell us to pound sand,” says Dave Jones, the insurance commissioner in California, one of 13 states where the rate reviews are not binding. “It’s very frustrating. Frankly, our hands are tied behind our back.”
When commissioner Jones found Aetna’s small-employer rate hikes unreasonable in April, the health insurance company ignored the ruling, raising those plans’ annual premiums by an average of 8%, and increasing some as much as 21%. “I have no authority to actually enforce a reasonable rate here,” Jones says. “At the end of the day, the health insurers and HMOs have the ability to set the rates wherever they see fit.”
Expect insurance companies to fight the ballot measure by claiming any additional regulation will force them to leave the marketplace, cut services, etc. But keep in mind, they’re already cutting networks but cutting payments and raising rates indiscriminately. And the ‘poor us’ song and dance loses a bit of its charm when you read this:
A July 2010 report from PricewaterhouseCoopers concluded that the law’s state-based health care exchanges provide private insurers with a lucrative new market in which they stand to gain up to $200 billion in revenue by 2019.
Are you encountering issues with a newly-purchased individual or family health insurance plan? Are you a physician or other health care provider running into health insurance obstacles? I’d love to hear more. Leave me a comment here OR send me a note on Facebook. Be sure to let me know where you live, who your insurer is, and what plan you have.
Let’s see if we can’t continue to get to the bottom of this together.
I made my usual weekly appearance on The Stephanie Miller Show this morning and fielded a lot of questions for which I didn’t have all the information handy. So as promised, here are some explanations and links to help you navigate a few of the issues that came up.
1. My husband and I are married but file taxes separately. Can we get subsidies through the health insurance exchange?
It looks like the answer to that question is no. According to Healthcare.gov, your spouse and you must file a joint tax return in 2014 in order to access the possibility of qualifying for health insurance premium assistance. H/t to @secondgen on Twitter for the link.
2. I am trying to help my sister in Arkansas qualify for a health insurance subsidy but am having difficulty finding the answers I need. What else can I do?
US News and World Report has a good, comprehensive Arkansas health insurance resource page which includes how to reach the Arkansas Insurance Department Consumer Services Division should you still have difficulty finding what you need through Healthcare.gov. In fact, USnews.com has a health insurance guide with a drop-down menu for every state.
3. When I retire, I will have a lower income than I do now. I may qualify for a subsidy. What income do I include when estimating how much I am going to make?
The tax link in answer 1 also includes this information. Here it is again. Note the drop-down menu at the bottom has some additional questions and answers.
4. Are newly available dental benefits under Medi-cal due to the Affordable Care Act?
Nope. It looks like the good news comes as the result of a state Assembly Bill that restores some dental benefits starting May 1, 2014. You can read more about it here (pdf) and here. The main website for these links is here.
Feel free to contact me either on Twitter (@jackischechner) or Facebook (/jackischechnertv) should you have any additional questions or concerns. Hope this helps!
Is That True, Blue?
I posted the following on my personal FB page about an hour ago. Reposting for wider consumption:
I’ve found that here in CA – as well as in other states – Blue Shield is offering plans through the Affordable Care Act exchanges that have limited networks. For example, the PPO you buy on CoveredCalifornia is not the same as the PPO you buy directly from Blue Shield. This is not supposed to happen. The exchange is supposed to be simply a marketplace where you can comparison shop for plans. It’s not supposed to be a marketplace for substandard plans.
So I sent a note to Blue Shield, and the letter below is what I got back. They’re claiming the on- and off-exchange plans should be the same. Oh really? Then why are they picking and choosing which doctors they include in their on-exchange networks? Every doctor I’ve spoken with has said this is the case. The doctors also tell me that when they are invited to participate – IF they are invited to participate – the reimbursement rates for on-exchange plans are prohibitively low.
The letter also says to check the website for which providers are in or out of network. That’s comical because the website is inaccurate, and people are signing up for plans thinking their doctors are covered and finding out once they get to the office that they aren’t. (In many cases, patients will call and ask their doctors if they are in network, and the doctors themselves don’t even know because the insurance company has been totally unresponsive). My GP says he has contacted Blue Shield several times now asking they either include him in the network or take the information that he is in-network off the site, and they have yet to do anything about it.
See, it benefits Blue Shield to keep the errors because they can draw in more customers with that misinformation. This way the networks appear to be larger than they truly are.
Feeding a Need
A caller this morning on The Stephanie Miller Show wanted to talk about the donut hole and Medicaid – explaining (incorrectly) the term referred to the people being stranded by Republican lawmakers refusing to expand health care coverage for the poor. We ran out of time to get into the issues on the air, but her confusion reminded me that people genuinely are baffled by most general health care-related terminology.
So for starters, let’s address Medicare v. Medicaid and that pesky donut hole.
Medicare is the federal government-sponsored health insurance program for people over 65. Some younger people with disabilities and some people with permanent kidney failure also can get Medicare. But the majority of the time, when we’re talking about people on Medicare, we’re talking about seniors.
Medicare has 4 parts (A, B, C, and D) and the official Medicare website has a very simple explanation of those 4 different parts. It’s worth a read.
Medicaid – without mincing words – is a government-sponsored health insurance program for the poor. Both the federal and state governments fund Medicaid, but the states are in charge of deciding who gets help. Each state is different, and while no state is required to provide Medicaid, all do.
Before we passed health care reform, low-income adults with dependent children and people with certain disabilities were able to get Medicaid. The Affordable Care Act expanded the pool to include all adults making less than 138% of the poverty level – whether or not those adults had dependent kids. Under the law, the federal government would pay for 100% of the cost of expanding Medicaid coverage for the first three years and then at least 90% of the cost after that. But the Supreme Court ruled in 2012 that states had the right to choose whether or not they wanted to participate in the Medicaid expansion plan, and if they opted out, they could not lose their current levels of federal funding.
Sadly, many Republican governors and state legislatures decided against expanding Medicaid, leaving many of their neediest residents uninsured and unable to access affordable health care.
The Healthcare.gov website has a good tool for finding out whether or not your state has expanded Medicaid and whether or not you may qualify.
Now to that donut hole thing…
Most Medicare Part D plans (the plans that seniors buy to help them afford prescription drugs) have a significant gap in coverage. It’s called the donut hole, and it’s nothing like the pastry. It’s neither adorable nor delicious.
Again, the official Medicare website is a good resource for more detail, and it’s an easy read. But the gist is that if you have a Medicare prescription drug plan, it gives you a discount until you (or you and your insurance company) spend $2800. Then you pay everything until you reach an out-of-pocket limit of $4550. At that point, aid kicks in again.
I should say the gist was because health care reform is closing the donut hole, and by 2020, it won’t exist anymore. One more thanks to Medicare.gov for this chart showing how the donut hole is shrinking gradually over the next 6 years.
I hope this is helpful. Next week, I’ll be joining Stephanie on Monday morning from 8-9am PT because I’ll be traveling the second half of the week. But for regular health care chat, you can tune in every Thursday morning from 11-12pm EST/8-9am PT or watch online at FreeSpeech.org.