Health Insurance and You!

Section 1557 of the Affordable Care Act prohibits health insurance companies, employers, and others from denying consumers coverage or certain benefits based on their sex. Earlier this year, a transgender advocate wrote to Health and Human Services (HHS) Secretary Kathleen Sibelius asking her to issue guidance to clarify how this policy would affect transgender individuals. According to the reply from Leon Rodriguez of HHS’s Office for Civil Rights – a letter that’s being hailed by the LGBT activist community – the rules banning sex-based discrimination apply to transgender people as well.

This means that denying coverage based on transgender identity would be considered discriminatory, explains Michelle Andrews in an article for the Washington Post. “If discrimination is found and an organization doesn’t act voluntarily to resolve the problem, the [HHS Office of Civil Rights] may move to halt federal financial assistance, among other actions,” she writes. It’s a big victory for a group that tends to be medically underserved and has special health care needs, including gender reassignment surgery, hormone treatments, and counseling.

But it doesn’t mean that insurance companies have to cover the surgery or associated treatments, although many insurers do – one survey found that as of 2010, 14% of large employers covered gender reassignment surgery and 32% covered hormones and counseling. Rather, the letter means that being transgender cannot be considered a preexisting condition and used as a basis to deny coverage or deny certain benefits, as some individual market insurers currently do.

The HHS letter is part of a larger movement toward preventing discrimination against transgender people. In April, for example, the Equal Employment Opportunity Commission ruled that the Civil Rights Act of 1964’s ban on sex discrimination applied to transgender people, too.

Today, August 1, two major provisions of the 2010 health reform law that affect people in the private insurance market are set to take place, according to an article by Louise Radnofsky of the Wall Street Journal. And both of these measures will save consumers money – hundreds of dollars, in some cases.

The law’s medical loss ratio rule stated that each year, health insurance companies had to spend at least 80% of revenue from premiums on actual health expenses or improving the quality of care. For large employers, that standard goes up to 85%. If, in a given year, health and quality improvement costs did not add up to that percentage, insurers could refund the extra money to consumers (or their employers) as rebates at the end of the year. While many insurance companies already met this threshold, this was the first year it was legally binding. By the end of today, a total of $1.3 billion in rebate checks, which averages out to $127 per customer, will be sent out.

The other major provision taking effect today is of particular importance for women. Starting today, people who are newly enrolled in an insurance plan will be covered for birth control and other women’s health services without a co-payment or other fees. For those already enrolled in a plan, the requirement will take effect when the next cycle begins – usually January 1. Federal officials estimate that 47 million teens and women between 15 and 64 will be eligible for this coverage, though it’s uncertain how many will take advantage of it. In addition to contraception and contraceptive counseling, the requirement covers the morning-after pill (Plan B); sterilization; supplies and support for breastfeeding; and screenings for gestational diabetes, HPV infection, HIV infection, and domestic violence.

Readers, how do you expect these new requirements to affect you and your health?

For more information, see related blog posts:

• Apr. 27, 2012: Insurers Award $1.3 Billion in Rebates to Customers
• Mar. 2, 2012: Senate Upholds Contraception Coverage Requirement for Employers
• Aug. 1, 2011: Ending Out-of-Pocket Costs for Birth Control, Breast Exams, and More

Yesterday marked the start of this year’s International AIDS Conference, also called AIDS 2012, a six-day meeting in Washington, DC of HIV/AIDS scientists, community advocates, policymakers, and people living with the virus. It’s been more than 20 years since the meeting was last held in this country, due to a ban on entry to the United States for HIV-positive visitors, which was lifted in 2009.

Lifting the ban was one of many recent steps taken to improve the country’s response to HIV/AIDS. According to a recent opinion piece by Robert Greenwald and Amy Rosenberg of the Washington Post, the 2010 Affordable Care Act continued that trend, and these new policies are a lesser-known benefit of the Supreme Court’s decision last month to uphold the law.

For a number of reasons, they write, people with HIV are disproportionately uninsured when compared to the general U.S. population. Cost, for example, is a major factor. HIV/AIDS tends to affect low-income groups, who often don’t receive employer-sponsored coverage and can’t afford health insurance on the individual market. State-based online health insurance exchanges, which should be up and running by 2014, will make it easier for these low-income patients to access the care they need. In addition, states will have the option of federal funding to broaden Medicaid’s eligibility requirements, which will result in treatment for more patients – in the states that don’t opt out of the expansion.

In addition, even if they can afford coverage, people with HIV are often turned down by insurers because their diagnosis counts as a preexisting condition. Established by health reform with the HIV-positive and other groups in mind, preexisting condition health insurance plans (PCIPs) will allow people with these conditions to enroll in coverage.

Traditionally, payment for health care has followed what’s known as a fee-for-service model, where providers are paid per health service performed. It’s the same way you pay for most things in your life – a specific amount for a new pair of jeans, another price for a car wash…you get the idea. Even a managed care health insurance plan follows that logic to some extent, through copayments per appointment and partial coverage for certain services. And in both situations, you can shop around a little to find the best deals.

Recently, health insurance companies have begun considering and testing out a new approach: the global payment model, in which insurers receive a lump sum of money to cover all the care for a group of patients. According to a blog post by David Schultz of Kaiser Health News, Blue Cross Blue Shield of Massachusetts started using this model in 2009, when the state enacted a set of reforms to its health system. Eleven groups of providers were given a fixed budget to pay for all care for their patients, Mr. Schultz explained. The incentives to provide quality care and improve treatment outcomes were simple: provider groups that met the budget received a bonus, and those that went over budget had to cover the extra cost themselves. According to an article by Liz Kowalczyk of the Boston Globe, a total of about 4,800 doctors participated in the program, which was called the Alternative Quality Contract (AQC).

A study published Wednesday in the journal Health Affairs examined how the new model impacted quality of care and spending levels, and found that participating in the AQC led to lowered costs in the first two years: 1.9% in the first year and 3.3% in the second. They also found improvement in the quality of care that increased as time went on – specifically in management of chronic illnesses, adult preventive care, and pediatric care. Overall, write the study authors, “these results suggest that global budgets…can begin to slow underlying growth in medical spending while improving quality of care.”

Readers, what do you think of this model and would you want to participate? Why do you think it had the effects it did?

About a week ago, the Supreme Court voted to uphold the Affordable Care Act. Much attention was focused on the individual health insurance mandate, which was kept intact as a tax.

One major provision of the law was weakened, though: a set of expansions to eligibility for Medicaid, the federally-supported, state-administered health insurance program for low-income individuals and other groups. Originally, states were required to broaden eligibility for the program to include all adults with incomes up to 133% of the federal poverty level, or risk losing their federal funding for Medicaid. According to the Supreme Court, however, the federal government could not tie existing funds to the new eligibility rules – only new funds. This means, essentially, that states can choose whether or not to expand their Medicaid programs.

Between 2014 and 2016, states that do expand eligibility will receive 100% of the funding needed to do so from the federal government. Between 2017 and 2020, that percentage will slowly decrease to 90%, where it will remain for the foreseeable future.

In the week or so since the ruling, states have started to make their decisions on Medicaid expansion. According to an interactive map and commentary by Maura Calsyn and Emily Oshima of the Center for American Progress, 12 states (California, Connecticut, Hawaii, Illinois, Maryland, Massachusetts, Minnesota, New York, Oregon, Rhode Island, Vermont, and Washington) have committed to expanding eligibility and 7 states (Florida, Iowa, Kansas, Louisiana, Nebraska, South Carolina, and Wisconsin) have declined the extra funding. The remaining states and the District of Columbia have yet to decide.

Originally, when states were required to expand Medicaid eligibility, an estimated 17 million people would gain insurance coverage in the next ten years. Now, that number depends on each state’s decision on this issue.

According to an article by Phil Galewitz of Kaiser Health News, Medicaid expansion is already becoming a campaign issue in upcoming gubernatorial elections. Eleven states will be electing a governor this year, and in states where a Democrat has a chance to win, the health law and its impact on Medicaid are likely to play a role.

As you’ve likely read or heard by now (perhaps by way of our tweets!), the U.S. Supreme Court ruled this morning to uphold most of the 2010 Affordable Care Act, better known as health reform. We followed the decision as it was announced and then analyzed on the Supreme Court’s live blog. The final verdict was 5-4 in favor of the law, with Chief Justice John Roberts joining the four liberal justices in saying that the law was constitutional.

The individual health insurance mandate, which was on the receiving end of much speculation over the past few days, was upheld as a tax on those who do not maintain coverage. According to an article by Josh Levs of CNN, families who choose not to buy insurance will have to pay $285 or 1% of income, whichever is greater, in 2014 and 2015. In 2016, that penalty will go up to $2,085 per family or 2.5% of income. The mandate was not, however, found constitutional under the Interstate Commerce Clause, which allows the federal government some power to regulate trade between the states, and so was lawmakers’ original justification for it.

Since the individual mandate was central to many other provisions of the law – without it, insurance companies would have had a hard time complying with new requirements while keeping premiums competitive and affordable – other popular provisions were upheld as well. These include allowing young adults to stay on their parents’ plans till age 26, eliminating lifetime caps on benefits, requiring 80% of premiums to be spent on medical costs and quality improvement, requiring insurers to cover people with preexisting conditions, and continuing to develop state-based online health insurance exchanges.

The Court rejected one key part of the law by limiting its expansion to Medicaid eligibility, the largely state-run health insurance program for the poor. The expansion will go as planned, but now, states may choose to reject it and the federal government cannot place undue financial pressure on them to accept it – such as threatening to take away existing Medicaid funding. However, explains Jennifer Haberkorn in an article for Politico, that does not mean that all or any states will reject the expansion and the extra funds that go with it. Seven of the nine justices voted for these limits.

The dissent was written by Justice Anthony Kennedy, and began with the words, “In our view, the entire Act before us is invalid in its entirety.” According to an article by David Fahrenthold, Michelle Boorstein, and Rosalind Helderman of the Washington Post, the House of Representatives is already planning for repeal vote on July 11.

For more information, read the full, 193-page opinion on the Supreme Court’s website. If you’re curious about how the law has been implemented so far in your state, this list by the Associated Press may be useful.

Readers, are you surprised by this ruling or did you see it coming? How do you expect it to affect your own life and health?

Check out our previous coverage of this case as it made its way to and through the Supreme Court:

• June 21, 2012: The Lasting Effects of Health Reform, However the Supreme Court Decides
• June 1, 2012: Health Reform Decision Expected this Month
• March 29, 2012: Supreme Court Wraps Up Three Days of Health Reform Arguments
• March 19, 2012: Update: Supreme Court Will Not Allow Cameras in the Courtroom
• Jan. 30, 2012: Can Health Reform Survive Without the Individual Mandate? HHS Says Yes
• Jan. 6, 2012: Cameras in the Courtroom: Will Supreme Court’s Hearing of Health Reform be Televised?
• Nov. 14, 2011: Confirmed: Supreme Court Will Rule on Health Reform

Would you give up your pension plan in exchange for expanded health insurance benefits that cover out-of-network medical services? It’s an interesting question, pitting together two benefits that are rarely discussed together, and one that is currently being considered by Lockheed Martin and the bargaining committee of a union of its workers.

A group of machinists at Lockheed’s fighter jet plant in Fort Worth, Texas, and two other plants, belonging to the District Lodge 776 of the International Association of Machinists and Aerospace Workers, has been on strike since April 23 of this year. The strike began as a protest over possible changes to employees’ health benefits, including a plan to stop offering pensions to new workers. According to an article by Christopher Drew of the New York Times, the union was worried that if pensions for new employees were cut, those employees would not continue to support pensions for current workers.

On Saturday, the union agreed to support the elimination of pensions if the company would add health insurance coverage of out-of-network services. Lockheed also agreed to a one-year extension to its contract with employees, with an 11% increase in pay rates over the next four years, as opposed to a 9% increase over the next three years. Finally, current workers would continue to receive pensions and would receive a 14% increase in retirement benefits. In contrast, new workers would be enrolled in a traditional 401(k) plan.

Readers, with all the attention that is given to employer-sponsored health benefits, have you ever considered them in relation to other types of benefits, such as retirement contributions and pensions? When thinking about a new job offer, which benefits do you prioritize and why? Which do you find most important to your long-term well-being?

As we inch towards a Supreme Court ruling on the constitutionality of the 2010 Affordable Care Act, expected by the end of this month, it gives us a good chance to reflect on the changes that have already come from this law – many of which are unlikely to be reversed even if the law is fully overturned. (Other possible outcomes include repealing only certain parts of the law, such as the controversial individual health insurance mandate, or keeping the law intact and continuing with implementation.)

According to an article by Matthew Fleming of Kaiser Health News, the Obama administration is praising these early successes, which have been analyzed in a number of recent reports. As Kelly Kennedy of USA Today wrote earlier this week, the latest numbers show that more than 3.1 million young adults age 19 to 25 have gained coverage through a provision that allows them to stay on their parents’ insurance plans as dependents. In 2010, 64% of Americans in that age group had health coverage; today, that number has gone up to 75%. The increase in coverage rates was highest among young men, the group least likely to have insurance.

That policy and certain others – removing co-payments for screening and preventive care, and eliminating lifetime limits on benefits – were so popular that several insurance companies have announced their intention to keep them as part of their plans, regardless of what the Supreme Court decides. As we blogged last week and on Monday, there has recently been a flurry of such announcements from national and local insurers.

Similarly, the law also forced insurance companies to account for their spending more closely through its medical loss ratio (MLR) requirement, which states that insurers must spend at least 80% of revenue from premiums on medical costs and quality improvement, rather than administrative overhead or profits. Companies that did not comply had to refund the excess premiums to their consumers or their employers. The first wave of those rebates, which total $1.3 billion or about $127 per policyholder affected, began going out to consumers this spring,. However, writes Sarah Kliff in an article for the Washington Post, $1.1 billion of that has yet to be sent out, and whether the remaining consumers will ever receive their rebates depends on the outcome of the case.

Finally, the health law’s focus on preventive care included federal funding for community health centers all over the country. The goal of this funding was to improve access to care by expanding the centers’ locations, range of services, and hours. Last month, Mr. Fleming writes, the Department of Health and Human Services (HHS) gave out $728 million in grants to 398 centers. On Wednesday, HHS announced another $128.6 million in grants to 219 additional centers. During the next five years, community health centers are slated to receive a total of about $11 billion.

Readers, have you experienced any of the changes described above, and if so, how have they affected your health or life? Would you be content with these expansions of care, or are you hoping for the 2010 law to continue towards full implementation in 2014?

Today is the first day of June. With Memorial Day weekend just behind us, our eyes are to the future, curious and excited about what the coming summer has in store. Along with this new season comes a fresh wave of anticipation for the Supreme Court’s final decision on the constitutionality of the 2010 health reform law.

As we tweeted earlier this week, that decision is expected by the end of this month. These things are always unpredictable, but the justices’ summer travel schedules and their quick pace in recent years suggest that they will make their way through the remaining 17 cases by June 25, the last day the Court is in session. It’s gotten politicians, analysts, interest groups and others interested in what the outcome and its effects will be.

Yesterday, wrote Lisa Mascaro of the Los Angeles Times, Rep. Nancy Pelosi (D-California) predicted that the law would be upheld by a 6-3 vote. Most members of Congress have been reluctant to guess at the decision, but Pelosi professed her belief that those who wrote the bill were mindful of the Constitution. “I know the Constitution – this bill is ironclad,” Mascaro quotes her as saying.

Health providers, medical device and drug makers, and health insurance companies hope that is the case. Despite the new requirements that the law places on insurers – for example, eliminating lifetime caps on insurance claims, spending at least 80% of premiums on medical expenses, and setting in place a set of mandatory, essential benefits – repealing the law would probably send these companies’ stock prices down because of the uncertainty that comes with change, according to an article by Russ Britt of MarketWatch.

Even if only the individual mandate is eliminated, businesses will have to revise their plans and projections in response, and stock prices may still be affected. Since companies have been preparing for the law’s implementation since it was passed, upholding the law in its entirety is likely to make stocks go up.

For more information, see other recent coverage of this topic:

• May 24, 2012: Most Individual Health Plans Sold Today Wouldn’t Pass Requirements of Health Law
• March 29, 2012: Supreme Court Wraps Up Three Days of Health Reform Arguments
• Jan. 30, 2012: Can Health Reform Survive without the Individual Mandate? HHS Says Yes
• Nov. 4, 2011: Insurers Worried about Potential Repeal of Individual Mandate

With tonight’s premiere of HBO’s ‘The Weight of the Nation’ documentary miniseries, and the Centers for Disease Control and Prevention’s (CDC) prediction last week that 42% of Americans will be obese by 2030, overweight and obesity have been major news topics recently. It’s a public health problem that can be attacked on many fronts. These include individuals managing their diets and increasing their physical activity; city planners taking sidewalks, parks, and walkability into account in their work; schools and workplaces making sure that healthy meal options are available in cafeterias; politicians and funding organizations supporting obesity prevention programs and research; and of course, the medical system.

When visiting the doctor’s office for a checkup, most of us have our height and weight measured – along with blood pressure and other indicators of general health. But it turns out that not all doctors act upon this data. According to an article by Judith Graham of Kaiser Health News, published in the Washington Post, translating height and weight into a standardized measure of body fat known as body mass index or BMI is an important first step in screening for obesity. Yet, a survey found, fewer than half of family doctors reported checking BMIs for children older than 2.

That applies to adults, too. According to a report (PDF, p. 36-37) by the National Committee for Quality Assurance, an organization that works to improve the quality of health care and health insurance plans, only 40.7% of private HMOs and 11.6% of private PPOs keep track of patients’ BMIs. The numbers are slightly higher for Medicare and Medicaid insurance plans, but remain lower than they should be. However, Ms. Graham writes, certain providers and insurers have begun routinely collecting BMI measurements.

Of course, checking BMIs is only the first step in treating and reducing obesity. Once patients are found to be at risk for obesity-related medical issues, the next step is to steer them toward information and programs on nutrition and exercise. And therein lies the challenge – medical school does not train doctors on handling weight issues, and many doctors don’t have the expertise, awareness of quality programs, or clinical time to advise patients themselves.

In addition, insurance companies haven’t generally reimbursed doctors for BMI screening and follow-up counseling. However, health reform is slowly changing that. New rules state that insurers must cover preventive medical services for patients free of charge, which include screening for obesity and recommending behavioral changes to patients at risk. Medicare also covers up to six months of weight loss counseling for patients who are obese.

Insurers have also introduced their own weight management programs, Ms. Graham explains. Examples include UnitedHealth Group’s Join for Me, a year-long program for children and teens, and WellPoint’s effort to coordinate care for overweight children between primary-care doctors and dieticians. As we’ve described previously, many insurers are also using financial incentives to persuade members to adopt a healthy and active lifestyle.

Readers, does your health provider collect data on your height and weight, and do they act upon it? What would you like insurance companies to do to help you maintain a healthy weight?

For more information, see:

• HBO: The Weight of the Nation, airing May 14-15, 2012 at 8:00pm
• Institute of Medicine: Accelerating Progress in Obesity Prevention: Solving the Weight of the Nation, released May 8, 2012