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Helping Patients Understand Insurance Benefits is Key

Helping Patients Understand Insurance Benefits is Key | Healthcare and Technology news | Scoop.it

Over the past several weeks, I've had the task of helping my own dad through some health issues. The biggest issue that we have run into multiple times is insurance challenges.


I know that I typically give you hints and tips to help lower your accounts receivable, get you paid on time, and manage your billing staff. But I'm going to take a different tack this week; focusing on the patient's viewpoint.


Before I get into the details of our struggle to help dad see the appropriate specialists, I feel it's most important to note that you and I are healthcare professionals. We do this job, everyday. We are immersed in professional jargon that sounds foreign to the typical patient. We understand (for the most part) that the laws are in place to protect the patient. We have to learn how to play nice with the insurance companies so that our practices get paid. Our patients don't really see this. From a patient's standpoint, they simply buy an insurance plan; they ask the practice to file a claim; and the insurance company pays what the practice is due. However, you and I know this is certainly not the case.


There is a huge gap between reality and what the patient thinks happens with their insurance plan. They do not understand that not only is it a plan they purchased, but they must also understand the nuances of that plan. Is outpatient physical therapy a covered benefit? Does the plan have a deductible? Is there a copay or coinsurance associated with some visits and not others? Is the doctor in network? The typical patient is truly not aware that this type of information is their responsibility to know.


So, that said, let me share my story. My dad has a Medicare replacement plan. He still thinks he has Medicare primary and UnitedHealthcare as a secondary insurance. So, lesson one when explaining patients' benefits prior to being seen is that they understand if they have a replacement plan, and not Medicare with a secondary.

Next, his primary physician referred him to a specialist. The specialist was 50 miles away. I'm not kidding. Dad gets to the appointment, and the office manager took him aside and said they do not accept his insurance; but he could pay the $3,000 out-of-network rate if he wanted to. No phone call, no warning about the physician's out-of-network status, nothing. Dad walked out and drove back 50 miles to his house and called me a few hours later. The next morning, Dad and I did a conference call with his medical group. I asked them why there wasn't a specialist in their group that he could see? I also said that if there isn't a physician that fits the requirements of Dad's care, they would have to provide the authorization to see an out-of-network physician, as that was not Dad's problem they didn't fill up their network. A few hours later poof! They found a doctor only 10 minutes from his house that was just credentialed that day. Shocking, I know.


So, the medical group contacted the doctor's office and set up an appointment. They called us back on another conference call and let us know everything was taken care of. I asked, "Okay, I have my pen and paper, can you please provide the authorization number for this visit?" There was silence on the other end of the line. There were four people telling us seconds ago that everything was set up and ready to go and no one could provide the authorization number. They asked for a few minutes to call us back. The phone rang, an authorization for three visits was provided, I took names, phone numbers, etc.


My dad was so frustrated and completely confused about why things are so complicated, and wondered how was he supposed to know all of this?! Technically, he is supposed to know these things, but honestly, there is no way he would ever have been able to get this figured out without my help.


I suppose my point is when you have a patient that needs an authorization, or does not understand the difference between in-network and out-of-network status, please take the time to work with them. Be patient. Be kind. They are in pain or sick, and the last thing they want to worry about is their insurance plan.


It would be ideal if the insurance company took the time to explain plan details and teach patients how best to utilize their plan benefits. We know this will never happen, as it would be very costly for the insurance company.


Take it easy on your patients and find it in your heart to spend the necessary time with your patient; remember this likely someone's dad, mom, sister, or brother.

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Aetna to buy Humana for $37 billion in largest insurance deal

Aetna to buy Humana for $37 billion in largest insurance deal | Healthcare and Technology news | Scoop.it

 Health insurer Aetna Inc on Friday said it would buy smaller rival Humana Inc for about $37 billion in cash and stock, in the largest ever deal in the insurance industry.


The combination will push Aetna close to Anthem Inc's No.2 insurer spot by membership, and would nearly triple Aetna's Medicare Advantage business.


The deal will face antitrust scrutiny but if it goes through it would dwarf the previous largest insurance deal announced just this week, where Swiss property and casualty giant ACE Ltd announced it was buying Chubb Corp for $28 billion. It would also dwarf Anthem Inc's purchase of WellPoint in 2004 for $16.6 billion.


Analysts have said that M&A activity in the healthcare sector had been waiting for last week's Supreme Court ruling on Obamacare, which upheld key subsidies that underpin the reform and thus gave more certainty to healthcare insurers.


The bigger the insurer, the more power it has negotiating prices and improving its doctor networks.


Anthem has offered to buy Cigna Corp to create the largest insurer in the country, toppling UnitedHealth Group Inc .


Media reports have also said UnitedHealth could be eyeing Cigna and Aetna. On Thursday, Centene Corp said it would buy smaller rival Health Net Inc for $6.3 billion.


ANTITRUST ISSUES


Antitrust authorities, who were aggressive in their review of the failed deal between Comcast and Time Warner Cable , are expected to scrutinize how the combination of insurers will affect competition for each line of insurance: Medicare, Medicaid for the poor, individual insurance, commercial insurance for small and large businesses and the large employer business.


Aetna and Humana are in nine of the same states in Medicare Advantage. Combined, they would have market share of 88 percent in Kansas, 80 percent in West Virginia, 58 percent in Iowa and 51 percent in Missouri.


Wall Street analysts and some antitrust experts have said they expect the combination will be approved, although regulators may ask for some divestitures.


Others have said it is unclear that this group of regulators will stick to the usual review playbook for such a large deal and may add other restrictions.


The Justice Department, which reviews insurance mergers, will scrutinize deals city-by-city to see if the combination would have a monopoly in any metropolitan area, said Andre Barlow, a veteran of the department who is now at Washington law firm Doyle, Barlow and Mazard PLLC.


Aetna said the combined company is projected to have over 33 million medical members, based on memberships as of March 31. Operating revenue is expected to be about $115 billion this year, with approximately 56 percent from government-sponsored programs including Medicare and Medicaid.


Last week, the U.S. Supreme Court upheld subsidies for individuals under President Barack Obama's signature healthcare law, keeping a large chunk of patients intact under the Medicare and Medicaid programs.


Insurers have said subsidies are key to bringing in new customers and the ruling has removed uncertainty for insurers looking for acquisitions. It could also spur more deal making in the health insurance sector, which has already seen a blitz of merger activity this year.


U.S. Senate Majority Leader Mitch McConnell, of Kentucky, praised Humana's presence in his home state but also noted the role of the healthcare law in the merger.


"This morning's announcement, as I predicted during the debate five years ago, is the inevitable result of Obamacare’s push toward consolidation as doctors, hospitals, and insurers merge in response to an ever-growing government," the Republican said in a statement.


The deal includes a $1 billion break-up fee payable by Aetna to Humana, should the deal fail because of antitrust concerns, an Aetna spokeswoman confirmed. The fee was first reported by the Wall Street Journal.


CASH AND SHARES


Hartford, Conn.-based Aetna said it would pay Humana shareholders $125 in cash and 0.8375 Aetna shares for each share held. The offer of about $230 per share is a 23 percent premium to Humana's closing price on Thursday.


Following the deal, Aetna shareholders would own about 74 percent of the combined company with Humana shareholders owning the rest. Aetna Chief Executive Mark Bertolini will serve as chairman and CEO of the combined company.


The deal is expected to close in the second half of 2016 and add to operating earnings per share from 2017.


Humana's sale has been anticipated since May when it was first reported that Cigna Corp and Aetna were interested, and multiple sources confirmed to Reuters that the company was entertaining offers.


Humana, based in Louisville, Kentucky, has been under pressure for more than a year from investors, which include activist fund Glenview Capital Management, to produce higher returns.


Last year Humana hired a CFO from investment bank Goldman Sachs and went through a strategic review that included asset sales. But it missed several quarters of earnings targets and struggled with profits in its individual business, disappointing Wall Street.


Aetna said it has received commitments from Citi and UBS Investment Bank to finance the deal.


Citi and Lazard are financial advisers for Aetna and Davis Polk & Wardwell LLP is its legal adviser. Goldman Sachs is the financial adviser to Humana, while Fried, Frank, Harris, Shriver & Jacobson LLP is its legal adviser.

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Where are the most expensive hospitals?

Where are the most expensive hospitals? | Healthcare and Technology news | Scoop.it

Talk about sticker shock: Some U.S. hospitals charge patients more than 10 times the rates paid by Medicare.

Of the 50 U.S. hospitals with the highest charges, 49 are for-profit institutions, 20 operate in Florida, and half are owned by a single chain, according to a study published in the journal Health Affairs Monday.

That doesn't mean all or even most patients end up paying those charges. Private insurers are able to negotiate the sticker price down significantly. Patients paying out of pocket can often negotiate discounts or get charity care if they are low-income.

The average U.S. hospital charges a somewhat less staggering sum: 3.4 times the rates paid by Medicare, the federal health care plan for the elderly and disabled which pays fixed rates for procedures.

But for uninsured patients asked to pay full charges, insured patients who end up at an out-of-network hospital and patients whose treatment is covered by casualty or workers compensation insurance, these charges can matter a lot.

"Hopefully this is a wake-up call for people to recognize there's a problem," said Gerard Anderson, a professor of health policy at Johns Hopkins Bloomberg School of Public Health, and one of the authors of the study, which analyzed 2012 Medicare cost reports.

    "There is no justification for these outrageous rates but no one tells hospitals they can't charge them," Anderson said. "For the most part, there is no regulation of hospital rates and there are no market forces that force hospitals to lower their rates. They charge these prices simply because they can."

    Even after full expansion of coverage under the Affordable Care Act, 30 million Americans will remain uninsured and may face particularly high charges, the study said. The law requires nonprofit hospitals to offer reduced-cost or charity care to eligible patients, but the provision does not apply to for-profit hospitals.

    "Hospitals' high markups, therefore, subject many vulnerable patients to exceptionally high medical bills, which often leads to personal bankruptcy or the avoidance of needed medical services," the study said.

    Of the 50 highest chargers, half are owned by Community Health Systems, a for-profit chain with 199 hospitals. The company made $18 billion in profits in 2014 — 45 percent more than in 2013. The researchers looked at charges at nearly 4,500 Medicare-certified hospitals nationwide.


    Florida most likely had the most high-charging hospitals because it has an exceptionally high proportion of for-profit hospitals, consumer advocates said. North Okaloosa Medical Center, a CHA hospital in the Florida panhandle, had the highest charges of all: 12.6 times Medicare's rate.

    In a written statement, CHA spokesperson Tomi Galin said CHA provided more than $3.3 billion in charity care, discounts and other uncompensated care for patients in 2014, as well as "millions of dollars in taxes that help fund critically important services in every community where we operate."

    The charges examined by the study, Galin said, "are not relevant measures of what consumers, insurers or the government pay for services."

    Chip Kahn, president and CEO of the Federation of American Hospitals, a trade group representing for-profit hospitals, also argued that the charges examined by the study were not a fair assessment of hospital prices. If the study had instead examined the actual payments by patients, they would have found that hospitals on the list charge just 1.3 times what Medicare pays, compared to a national average of 1.2, he said.

    A hospital's charges can matter even for patients with private insurance, said Ge Bai, a co-author on the study and a professor at Washington and Lee University. Hospitals use those charges as leverage during negotiations with insurers, and starting from a higher price point can drive up even discounted prices.

    "Except for patients with government insurance, few consumers are immune from negative financial impacts caused by hospitals' high markups," Bai said.

    "We as consumers are paying for this when hospitals charge 10 times what they should," added Anderson. "What other industry can you think of that marks up the price of their product by 1,000 percent and remains in business?"

    The highest charging hospitals were in 13 states, mostly in the South. Besides Florida, the states included Alabama, Arkansas, Arizona, California, Kentucky, New Jersey, Oklahoma, Pennsylvania, South Carolina, Tennessee, Texas, and Virginia.

    The markups charged by the 50 hospitals on the list varied dramatically by procedure. Anesthesiology had the highest charges: an average of 112 times more than Medicare rates. The markup for nursery services, on the other hand, was three times the Medicare rate.

    The authors recommended that state and federal lawmakers enact policies to limit these charges. In Maryland and West Virginia, for example, state agencies set the rates that hospitals are allowed to charge for services. Requiring hospitals to disclose their charges for individual procedures could also help patients shop for the lowest-cost option, they said.

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    Ignoring the Penalty for Not Buying Health Insurance

    Ignoring the Penalty for Not Buying Health Insurance | Healthcare and Technology news | Scoop.it

    Obamacare’s big stick doesn’t seem to be scaring many people into buying health insurance.

    The health law includes many inducements for people to obtain health insurance — including free Medicaid coverage for many low-income Americans and subsidies for those with moderate incomes. But it also includes the notorious “individual mandate,” a fine for those who can afford insurance but don’t buy it.

    Because the law, and the fine, are new, many policy experts expected that some people would decline to sign up for insurance until they were hit with a penalty at tax time. Forecasters have estimated a big bump in marketplace enrollment next year, the first sign-up period after people have been fined. The Congressional Budget Office, for example, estimates 10 million more people will have Obamacare plans next year. The law’s structure relies on even healthy and otherwise disinclined consumers to enter insurance markets to help stabilize prices.



    Certainly, some people who might otherwise go uninsured have been persuaded by the penalty. Polls have shown that it is a well-known provision of the law. And studies of the uninsured have shown that mentioning the penalty changes some people’s thinking about health insurance. At the end of the normal enrollment period in February, about 11.7 million people had selected marketplace health plans or renewed their plans from 2014, according to the federal government.



    But the Obama administration just conducted a small experiment into how much the penalty would affect the behavior of the remaining uninsured. And the results leave some experts concerned that next year’s sign-ups will come in below expectations.

    Because of the timing of the sign-up season and tax filing deadlines, it turned out that many people would find out about the penalty only after it was too late to enroll for 2015 coverage. Consumer advocates argued that this situation would lead many people to face a needless second year of uninsurance — and penalties. So, in February, the administration and most states agreed that people who were uninsured in 2014, faced a penalty and were still uninsured for 2015 could sign up late for new health insurance. The eligible population is a small slice of the country, but precisely the sort of people whom you might expect to be most motivated by the fine, if they were going to be.

    The I.R.S. estimated that between 3 million and 6 million people faced penalties for being uninsured in 2014. On Tuesday, the federal government announced in a tweet that 147,000 people had signed up for the plans using the federal website that operates in most states during the new sign-up period. Not all of the states that run their own marketplaces and offered similar opportunities have published final numbers, but Charles Gaba, who tracks Obamacare enrollment data at his website, ACASignups.net, estimates that total national tax-time sign-ups are around 200,000. Only three states — Colorado, Idaho and Massachusetts — declined to allow penalty-payers to sign up during a special period.

    To be clear, the number of people eligible for the special sign-up period was probably quite a bit less than 6 million. Some who paid fines for 2014 may have gotten insurance with a new job in the intervening year. And some may have signed up for Obamacare insurance during the normal sign-up period, which ran from mid-November through mid-February. The Department of Health and Human Services has provided no estimates on how many people might have been eligible for the special sign-up period.

    Some advocates have criticized the way the special period was set up, saying the low sign-ups merely reflect the last-minute nature of the decision to extend deadlines. Given more time to prepare, tax preparers might have been able to help enroll more people in health insurance, said Brian Haile, a former senior vice president at the tax preparation firm Jackson Hewitt. “H.H.S. refused to provide any information until the very last minute,” he said in an email. “As a result, the companies were not able to plan effectively.”

    But several close watchers of the law say that the special enrollments look low enough to raise more substantial questions about whether the health law’s penalty will have the intended effect of increasing sign-ups for insurance in the coming years.




    “It makes me more pessimistic,” said Caroline Pearson, a vice president at the health care consulting firm Avalere Health. When the government announced the special enrollment period, she estimated that between half a million and a million people would take advantage of it. “All the evidence is enrollment is not going to be where people thought.”

    Ms. Pearson pointed out that people earning higher incomes, who would have to pay a higher proportion of their premiums, have been less eager to sign up than those whose low incomes qualify them for substantial government help with their health premiums. She recently published an analysis describing the penalty as “too low” to move many higher earners.

    Mike Perry, a partner at the polling firm PerryUndem, says focus groups he’s held with the uninsured are consistent with Ms. Pearson’s theory. “A lot of them seem to be making calculations throughout the year what their premium would be versus this fine,” he said.

    Behavioral economists who study incentives like the mandate penalty say it may just take time for people to learn about the incentive structure set up by the penalty. It is set to increase for the next several years, so people who remain uninsured will face not just repeated but rising bills for doing so.

    Some people who learned about the fine late may not have had enough time to make room in their budgets for an insurance premium, said Brigitte Madrian, a professor at Harvard’s Kennedy School who has studied how incentives affect 401(k) plan sign-ups. Next year, uninsured people may have more time to plan ahead, and may remember the unpleasant experience of paying a fine.

    “People learn from their mistakes, and this is true in the financial domain,” Ms. Madrian said. “The learning may be more effective a few years in as they see the penalty going up.”


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    Does the Affordable Care Act Guarantee Healthcare as a Right?

    Does the Affordable Care Act Guarantee Healthcare as a Right? | Healthcare and Technology news | Scoop.it

    In his recent celebratory remarks after the Supreme Court (SCOTUS) upheld the legality of subsidies/tax credits under the Affordable Care Act (ACA), President Obama had this to say: "Five years ago, after nearly a century of talk, decades of trying, a year of bipartisan debate -- we finally declared that in America, healthcare is not a privilege for a few, but a right for all." (1)


    It would be good if this were true, but it is not. Healthcare as a right has been debated over many years, but is still not in place for all Americans as this country remains an outlier among advanced industrial countries around the world. Instead, despite the ACA, we continue to have a patchwork of ever-changing programs assuring access to health care for some people some of the time.


    Let's look at what we do have in this respect. In the 1960s, Congress established a broad right to health care under statutory law by enacting Medicare, Medicaid, and the Children's Health Insurance Program (CHIP) for the elderly, disabled, people living in poverty, and children. In the 1980s it passed the Emergency Medical Treatment and Active Labor Act (EMTALA) requiring all Medicare-funded hospitals with emergency departments to provide appropriate emergency and labor care. More recently, Congress passed the Mental Health Parity and Addiction Equity Act (MHPAEA) in 2013, which assures a right to equal access to care for patients with medical and mental health problems. SCOTUS has established a right to health care for prisoners and has protected some limited rights for women's reproductive care (2), but has never interpreted the Constitution as guaranteeing a right to health care for all Americans. In fact, the words "health," "health care," "medical care," and "medicine" do not appear in the Constitution. (3) 


    It is disingenuous to claim that health care is a right in the U. S. when we consider these inconvenient facts:


    • 35 million uninsured, plus another similar number underinsured.
    • The first question asked of us in seeking care is "what is your insurance?"
    • 21 states have opted out of Medicaid expansion under the ACA.
    • Medicaid eligibility and coverage varies widely from one state to
    • another, in many cases falling far short of necessary care.
    • As the costs of insurance and health care continue to rise and shift
    • more to patients, a growing part of the population cannot afford either and forgo seeking care.
    • More than 40 million Americans now have an account in collection for medical debt. (4)


    This situation stands in sharp contrast to elsewhere in advanced societies. Healthcare has been recognized as a right since 1948 when the General Assembly of the United Nations adopted a Universal Declaration of Human Rights including access to health care. (5) The right to health care was also later adopted by the World Health Organization (WHO) in its Declaration on the Rights of Patients. (6) As a result, most of Western Europe, Scandinavia, the United Kingdom, Canada, Taiwan, and many other countries have one or another form of national health insurance assuring access to care for their populations. Here we spend twice as much and still have no universal access to health care.


    Can we ever see this country coming around to universal access to health care based on medical need, not ability to pay? The record shows that we never can, or will, as long as we permit corporate stakeholders in our medical-industrial complex to call the shots, and as long as they succeed in perpetuating our exploitive for-profit system. There is a fix -- single-payer national health insurance, as embodied in H. R. 676, Expanded and Improved Medicare for All.

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    The Supreme Court's Surprise Ruling Saves Obamacare

    The Supreme Court's Surprise Ruling Saves Obamacare | Healthcare and Technology news | Scoop.it

    The Affordable Care Act survived its second major challenge at the U.S. Supreme Court on Thursday. In a 6-to-3 decision, the justices ruled that the Internal Revenue Service can continue to provide health-insurance subsidies to middle-class people living in all states.


    At issue in the case, King v. Burwell, was whether the subsidies should go to residents of the roughly three dozen states that use the federal health-insurance exchange, in addition to those who live in states that run their own exchanges.


    It’s a highly technical difference, but had the decision gone the other way, Obamacare might have unraveled. Individuals who receive these subsidies make less than $48,000 per year, and many would struggle to afford health-insurance plans without the government’s financial help. Health-policy analysts feared that, without the subsidies in place, healthy people would withdraw from the health-insurance exchanges in large numbers. That, in turn, would cause premiums to skyrocket, making insurance unaffordable to almost anyone who does not receive insurance coverage through their jobs.

    The Affordable Care Act gave states the option to either set up their own exchanges or to rely on the federal government’s marketplace through Healthcare.gov. The part of the law that describes the subsidies said they should only apply to people in the exchanges “established by the state.” The plaintiffs in the King case said that clause meant the IRS was offering subsidies to residents of federal-exchange states illegally.

    In the opinion of the Court, Chief Justice John Roberts dismissed the idea that the fate of the entire Obamacare law should hinge on such a technicality.

    “In petitioners’ view, Congress made the viability of the entire Affordable Care Act turn on the ultimate ancillary provision: a sub sub-sub section of the Tax Code,” he wrote. “We doubt that is what Congress meant to do.”


    Many patient advocates cheered the decision. “It means that millions of people with serious health conditions such as cancer will continue to have access to essential treatment and care, and millions of others at risk for disease will be able to afford preventive screenings and tests that could save their lives,” said Chris Hansen, president of the American Cancer Society’s advocacy arm, in a statement.


    Justices Antonin Scalia, Clarence Thomas, and Samuel Alito dissented, writing, “Words no longer have meaning if an Exchange that is not established by a State is ‘established by the State.’”


    Roberts concludes by saying that the Court is attempting to respect what Congress hoped to accomplish in passing the law: “Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them.”


    There are still a few, more minor, legal challenges to Obamacare remaining. But at least for now, the law lives to see another day.

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    Jannell Alino's curator insight, August 27, 2015 7:43 PM

    Congress passed the Affordable Care Act and the Supreme Court ruled that the IRS will be able to continue to administer health insurance to middle class people to all in the United States. If this did not pull through Obamacare would have left thousands of people without insurance and helpless. Many who are on Obamacare make less than 48K a year and need assistance from the government. If this were to happen a large number of healthy people would withdraw from health insurances causing prices to go up and then no one would be able to afford health insurance! The Affordable Care Act gives states the option to set up their own exchanges or rely on the government. With the passing of this act people suffering from serious illness will be able to care and have access to treatment as well as others who are susceptible to illness. Some conclusions that can be drawn from this article are that by the passing of this act thousands of citizens are still able to have health insurance and do not have to pay with an arm and a leg. Yes this argument is logical because it would be irrational to take away a program that has aided so many Americans in getting the health care they need. This relates because if this act was to fail our health insurance prices would go up and going to get a simple checkup would cost a fortune! I think it is great that the congress passed this act because I would want everyone to be able to have the privilege to seek out help if they were ill. No there is no bias, it is objective to all citizens in the united states. 

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    More Patients, Not Fewer, Turn To Health Clinics After Obamacare

    More Patients, Not Fewer, Turn To Health Clinics After Obamacare | Healthcare and Technology news | Scoop.it

    Nurse practitioner Martha Brinsko helps a lot of patients manage their diabetes at the Charlotte Community Health Clinic in North Carolina.

    “Most mornings when you check your sugar, what would you say kind of the average is?” Brinsko asked patient Diana Coble.


    Coble hesitated before explaining she ran out of the supplies she needs to check her blood sugar levels, and she didn’t have the gas money to get back to the clinic sooner. Brinsko helped Coble stock up again.


    “If you need to get more than one box, get more than one box,” Brinsko said. “But you need to check them every morning so that we can adjust things.”


    Coble, who is unemployed, lives with her sister and can’t afford insurance even now that the health law is in place, relies on the clinic for health care.


    “They do a great job with everything,” Coble said. “I couldn’t do without them.”


    Nancy Hudson was the clinic’s director as Obamacare rolled out and now consults for the clinic. She expected the insurance exchange, or marketplace, established under the Affordable Care Act would reduce the number of uninsured patients the clinic sees. The opposite happened, she says.


    “What we found within our patient population and within the community is that a lot of the advertisement and information about the marketplace brought people [in who] didn’t know anything about free clinics and did not qualify for any of the programs within the ACA marketplace,” Hudson says.


    And now they get free or low-cost care at the clinic, which is designated by the government at an FQHC, or federally qualified health center.


    The health law was designed to cover the poorest people by expanding Medicaid, the federal-state program for low-income people. But the Supreme Court made that optional. The result in states that didn’t expand Medicaid is a gap, where some people make too much money to qualify for Medicaid but not enough to qualify for insurance subsidies. In North Carolina, about 319,000 people, like Coble, fall into the Medicaid gap.


    “Over half of the people that we see would’ve been eligible for Medicaid expansion had the state elected to exercise that option,” says Ben Money is president of the association that represents North Carolina’s community health centers.


    North Carolina is among the 21 states, including many in the South, that are currently saying no to Medicaid expansion. Louisiana is another.


    Dr. Gary Wiltz, the CEO of 10 community health centers in the southwestern part of Louisiana, says demand has surged. “We’ve gone from 10,000 patients to 20,000 in the last six or seven years, so we’ve doubled,” he says.


    Wiltz says other things are at play, too. The economic recovery hasn’t reached many of the poorest people, and some who do qualify for Obamacare subsidies say their options are still too expensive.

    “The need keeps increasing, and I think that’s reflected throughout all the states,” he says.


    Wiltz, who also heads the board of directors for the National Association of Community Health Centers, says clinics are packed even in states that expanded Medicaid. After all, most of the clinics treat Medicaid patients too.


    The Charlotte clinic’s Nancy Hudson says there’s another part of the health law helping fuel the growth: additional funding for community health centers.


    Hudson found out last week her clinic is getting about $700,000 to expand in partnership with Goodwill.


    “Many of their clients did not have any access to health care,” she says. “They can’t train and sustain a job if they don’t have the basic needs taken care of, and health care is one of them.”

    Nationwide, the federal government estimates its latest round of funding will lead to about 650,000 people getting better access to health care.


    This story is part of a reporting partnership with NPR, WFAE and Kaiser Health News.


    Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

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    Many States Will Be Unprepared if Court Weakens Health Law

    Many States Will Be Unprepared if Court Weakens Health Law | Healthcare and Technology news | Scoop.it

    A Supreme Court ruling this spring could upend health insurance markets in at least 34 states, eliminating the federal subsidies that make coverage affordable for millions of Americans.

    State governments, theoretically, have ways to forestall this outcome. But few have taken action. If they wait until the court rules, it may already be too late for a state to get started on an exchange so that it is ready for 2016.

    The case, called King v. Burwell, concerns whether subsidies can be given to consumers in every state in the country or only in those that have established their own state marketplaces as part of the Affordable Care Act. So far, more than a dozen states and the District of Columbia have such marketplaces. Should the high court rule that subsidies can be distributed only in states running their own exchanges, markets in the remaining states would be substantially disrupted. Prices for insurance plans would sharply rise. Millions of people would drop their coverage.

    A decision in the court case is expected in June; a new marketplace would need to be ready for shoppers in October in order to sell health plans for 2016. If those states want to make sure that subsidies keep flowing to their residents, they can build their own marketplaces. But it won’t be easy.



    “Anyone who thinks you can just snap your fingers and you’ve got a state exchange is just wrong,” said Timothy Jost, a law professor at Washington and Lee University, who supports the Affordable Care Act.

    Congress could prevent or eliminate a disruptive outcome by changing some language in the Affordable Care Act. That change may be more politically fraught than state-level actions in some parts of the country.

    The Obamacare law lays out a series of clear requirements for state exchanges — some political, some operational. None of them are trivial.

    The political challenges, for one, are substantial. States would need to endorse an exchange through legislation or executive action, as they have declined to do previously. The Affordable Care Act is so unpopular in some of these states that they have passed legislation explicitly barring the governor from establishing an exchange. And only eight states’ legislatures will even be in session in June when the court is expected to rule, according to David K. Jones, an assistant professor at the Boston University School of Public Health, who has studied the state exchange decision-making process and is a co-author on a recent essay in the New England Journal of Medicine spelling out the difficulties states will face.

    Then there are the operational challenges. Every state marketplace needs a staff and the ability carry out a series of core functions, including regulating insurance plans, running a call center and managing a website that can enroll people in insurance coverage. Some of the states relying on the federal government are doing one or two of these functions, in an arrangement known as a partnership exchange, but most are not.

    Most states will rely on contractors for major tasks, and state laws tend to require a lengthy process for contract procurement that can run six months or longer. Once contracts are signed, the states still need to hire call center employees, devise policies and build the website and its infrastructure.


    Many of the 15 state marketplaces that started up last fall struggled to accomplish all of those things. Several states experienced website crashes and failures. And those early states had had more than three years to approve and design their exchanges.

    Daniel Schuyler, a director at Leavitt Partners, a consulting firm that helped several states establish exchanges, estimates that building an exchange today would cost a typical state $40 million to $60 million and take between a year (if a state expedited its contracting schedule) and 18 months.




    That would be faster than most states with their own exchanges managed in recent years, as well as less expensive. Late adopters would have the advantage of accumulated wisdom that the early states didn’t. They also would benefit from software and computer network contractors with more experience building the necessary computer systems. This year, Massachusetts replaced its failed software with an off-the-shelf product from another contractor. But it still needed to be retrofitted to work with the state’s system.

    “You can buy an engine off the shelf, and an engine is the most important thing to make a car run,” said Nicholas Bagley, an assistant professor at the University of Michigan Law School, the other author of the New England Journal article.. “But you can’t drive something off the lot with just an engine.”

    States waiting until now to act won’t have access to a substantial pot of federal money to help them get off the ground. States that have established exchanges so far sought substantial establishment grants from the federal government. By law, that funding stream expires at the end of the year, and the deadline for the last round of grant applications has already passed. (A few states that have been considering creating an exchange put in for the money.)

    By law, all state exchanges must be financially self-supporting next year, which means that any states that start a new one will have to make a substantial initial investment.

    “States don’t have any appetite to dip into their own coffers,” said Mr. Schuyler, who said his firm has talked with a few states about the possibility of starting a state exchange.

    All of which means that the effect of a court ruling dismantling federal subsidies could be both substantial and lasting in large parts of the country. States will have the power to get subsidies to their residents. But not easily, and not right away.

    “This is really going to be much more difficult for states to do quickly than a lot of people think,” Mr. Jones said.



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