sdrawkcab reform

Sorry, We Don’t Take Obamacare

By Elisabeth Rosenthal
The New York Times, May 14, 2016

Amy Moses and her circle of self-employed small-business owners were supporters of President Obama and the Affordable Care Act. They bought policies on the newly created New York State exchange. But when they called doctors and hospitals in Manhattan to schedule appointments, they were dismayed to be turned away again and again with a common refrain: “We don’t take Obamacare,” the umbrella epithet for the hundreds of plans offered through the president’s signature health legislation.

“Anyone who is on these plans knows it’s a two-tiered system,” said Ms. Moses, describing the emotional sting of those words to a successful entrepreneur.

The goal of the Affordable Care Act, which took effect in 2013, was to provide insurance to tens of millions of uninsured or under-insured Americans, through online state and federal marketplaces offering an array of policies. By many measures, the law has been a success: The number of uninsured Americans has dropped by about half, with 20 million more people gaining coverage.

Yet even as many beneficiaries acknowledge that they might not have insurance today without the law, there remains a strong undercurrent of discontent. Though their insurance cards look the same as everyone else’s — with names like Liberty and Freedom from insurers like Anthem or United Health — the plans are often very different from those provided to most Americans by their employers. Many say they feel as if they have become second-class patients.

Some early studies of the impact of the Affordable Care Act plans are proving patients’ grumbling justified: Compared with the insurance that companies offer their employees, plans provide less coverage away from patients’ home states, require higher patient outlays for medicines and include a more limited number of doctors and hospitals, referred to as a narrow network policy. And while employers tend to offer their workers at least one plan that allows them coverage to visit doctors not in their network, patients buying insurance through A.C.A. exchanges in some states do not have that option, even if they’re willing to pay higher premiums.

The research thus far suggests that the differences between plans offered through the A.C.A. and those offered by employers may be quite significant. A study in the policy journal Health Affairs found that out-of-pocket prescription costs were twice as high in a typical silver plan — the most popular choice — as they were in the average employer offering. In research conducted with the Robert Wood Johnson Foundation, Dr. Polsky found that 41 percent of silver plans offered a “narrow or very narrow” selection of doctors, meaning at best 25 percent of physicians in an area were included. The consulting firm Avalere Health found that exchange plans had 42 percent fewer cancer and cardiac specialists, compared with employer-provided coverage.

When designing the new plans, for-profit insurers naturally tended to exclude high-cost, high-end hospitals with whom they had little clout to negotiate discounts. That means, for example, that as of late last year none of the plans available in New York had Memorial Sloan Kettering Cancer Center in their network — an absence that would be unacceptable to many New York-based employers buying policies for their employees.

And when Simon F. Haeder of the University of Wisconsin and his colleagues studied the plans sold on the California exchange, they found that they included 34 percent fewer hospitals than those sold on the open market and tended to exclude the priciest medical centers, like Cedars Sinai, a highly regarded hospital that runs the largest heart-transplant program in the country.


Special Enrollment Periods for the Health Insurance Marketplace, May 6, 2016

Special Enrollment Periods

While SEPs provide a critical pathway to coverage for qualified individuals who experience qualifying events and need to enroll in or change qualified health plans (QHPs) outside of the annual open enrollment period, it’s equally important to avoid SEPs being misused or abused.  As it announced today, HHS is tightening the rules for certain special enrollment periods and making clear that SEPs are only available in six defined and limited types of circumstances.

An Interim Final Rule with Comment (IFC) published in the Federal Register provides that individuals requesting a “permanent move” SEP must have minimum essential coverage for one or more days in the 60 days preceding the permanent move, unless they were living outside of the United States or in a United State territory prior to the permanent move. This ensures that individuals are not moving for the sole purpose of obtaining health coverage outside of the open enrollment period.



By Don McCanne, M.D.

When explaining that health care reform seems to be moving backwards, does it improve communication to discuss reform that is sdrawkcab (ananym of backwards)?

NYT’s Elisabeth Rosenthal has provided us with another great article that describes how some of the supposedly forward advances in reform are really backwards. The ACA exchange plans are undoing some of the financial protection that health insurance should afford us, while impairing access through narrower provider networks. If we said that this reform is sdrawkcab, would that help us understand it better?

As small business owner Amy Moses stated, “Anyone who is on these plans knows it’s a two-tiered system.” Does it not seem absurd that the policies inherent in ACA would place a business owner in the lower tier of a two-tiered system? Isn’t that sdrawkcab? Yes and no. Actually what is sdrawkcab is that we would even have tiers in our health care system when it would be much more efficient, more equitable, and more effective to have a single high level system for everyone - an improved Medicare for all.

A specific example of the wrong direction in which too much of our policy is headed is provided by the new CMS rule that describes yet another technical reason to prohibit individuals from obtaining coverage through special enrollment periods. Although health reform supposedly was designed to expand access to insurance plans, this rule is sdrawkcab in that it prohibits access for certain uninsured individuals. True, the rule was designed to protect insurers from individuals who might have an acute need for coverage outside of the open enrollment period, but the entire system should have been designed to automatically enroll everyone instead of ignoring individual needs while providing insurers with their optimal business model.

No more sdrawkcab reform. Everybody in, nobody out!