By Michelle Andrews

The 2010 health-care overhaul creates state-based health plans for those who have medical conditions that make them uninsurable in the private market.

These “preexisting-condition insurance plans” (PCIPs) are intended to act as a bridge until 2014, when insurers will no longer be able to refuse to cover people with medical problems or charge them more than other consumers.

As of November, about 45,000 people had signed up for those plans, far fewer than the up to 400,000 that was originally projected.

However, there is a much larger group, more than 220,000 people, who have coverage through 35 state high-risk pools that were in existence before the overhaul was passed.

Because of restrictions in the new law, they can’t sign up for the PCIP plans, even though the coverage is often cheaper (thanks in part to federal funding) and more comprehensive. For these people, 2014 can’t come soon enough..

Together they pay $1,304 a month for coverage. Chris’s plan has a $2,500 deductible while Kristi’s is $1,000. The plans generally cover 80 percent of their medical bills.

Chris Petersen, who supported the health-care overhaul, nevertheless thinks the law failed him and his wife. “This is the biggest check I write out every month,” he says. “The new federal plan would have been a lot cheaper.”

If the Petersens had been allowed to sign up with the PCIP in Iowa, their combined premium would have been $958 for policies with $1,000 deductibles.

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People such as the Petersens, however, are stuck between a rock and a hard place: To qualify for a PCIP, they must first be uninsured for six months.

Experts say this requirement was included in the law to discourage people in the existing state high-risk pools and other private insurance plans from doing exactly what they would do if better, cheaper coverage became available: switch plans.

It’s clear why they might be tempted. Premiums in the new pools can’t exceed rates for standard individual coverage in the state, while the high-risk pools in some states charge twice that. The new plans must also cover preexisting conditions immediately, in contrast to the older state pools, some of which exclude such coverage for up to a year.

“Much as everybody would like to drop [the six-month requirement], if you did you’d have to increase expenditures,” says Sandy Praeger, the Kansas insurance commissioner, who chairs the health insurance and managed-care committee of the National Association of Insurance Commissioners. Federal funding for the program through 2013 is $5 billion.

Learn about Washington State’s Pre-existing Condition Insurance here.

Although enrollment in the PCIPs has been far lower than originally projected, health-care spending by the individuals who have signed up for coverage has been much higher than anticipated, say experts.

“The people coming into the PCIPs act more like the long-term uninsured,” says Jean Hall, an associate research professor at the University of Kansas who co-authored a report about the PCIPs for the Commonwealth Fund. “They’re not accustomed to managing on a day-to-day basis; they’re accustomed to going to the emergency department when things get bad.”

Nine states have asked the Department of Health and Human Services for more money to fund their PCIPs in 2012. However, it appears the program won’t run out of money soon. Through the end of September 2011, just $386 million of the $5 billion allocated had been spent, according to HHS figures.

(Some experts caution against relying too much on September spending figures, since enrollment has increased since then and claims may take months to clear.)

“As you would expect, some states have exceeded projections and others have not,” says an HHS spokesman. “We have the capacity to accommodate the needs of the program.”

For people who can’t get into the new plans, however, that’s small comfort.

Jill Judy and Mark Brown signed up for the Arkansas high-risk pool a few years ago when Mark’s benefits ran out after his retirement from a management job at a company that repossesses boats. Judy, 49, has mild cerebral palsy, which she hasn’t been treated for since she was a child, and Brown, 62, had an angioplasty 15 years ago and still sees a cardiologist.

Individual insurers wouldn’t cover them, so they ended up in the state’s high-risk pool. Although Judy says she’s grateful that she has coverage, it’s hardly ideal.

The premiums for the two of them come to just under $1,000 a month. But the plan has a $10,000 deductible and a $1 million cap on lifetime benefits. “People like my husband and myself are paying $12,000 a year for nothing,” she says.

She estimates they could get better coverage and save 30 percent in the Arkansas PCIP. “But we don’t qualify because we’re not willing to be uninsured for six months,” she says. “It’s screwy.”

Please send comments or ideas for future topics for the Insuring Your Health column to questions@kaiserhealthnews.org.

Local Resources:

• Statewide Health Insurance Benifits Advisors (SHIBA) provides free, unbiased advice from volunteers: www.oic.wa.gov/shiba/
• Benefits.gov: www.benefits.gov
• King County Project Access: www.kcprojectaccess.org
• Washington Basic Health (insurance assistance): www.basichealth.hca.wa.gov/understanding.shtml
• Washington Health Plan: www.washingtonhealth.hca.wa.gov
• Washington State Office of the Insurance Commissioner: www.insurance.wa.gov
• To search for a community clinic near you go to: http://findahealthcenter.hrsa.gov

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

(Kaiser Health News in an editorially-independent program of the foundation.)

Majority Of Americans Think Ideology Will Affect High Court’s Ruling On Health Law 

By Mary Agnes Carey
KHN Staff Writer

With the Supreme Court just two months away from hearing a historic legal challenge to the 2010 health law, nearly 60 percent of the public expects the justices to depend more on personal ideology than a legal analysis of the individual mandate, according to the Kaiser Family Foundation’s January health tracking poll.

Just 28 percent of those surveyed believe the justices will base their decision on the mandate without regard to politics and ideology, according to the survey.

The poll also asked about general views of the Supreme Court and found three quarters of the public believe that justices sometimes let their ideological views influence their decisions.

Seventeen percent of those surveyed say justices usually decide cases based on legal analysis.

The court will hear oral arguments in March in a case brought by 26 states and others.

As the Republican presidential nomination fight continues, the poll also found that most Republicans are not swayed by charges from GOP contenders that former Massachusetts Gov. Mitt Romney holds health policy views similar to those of President Barack Obama.

Romney’s opponents have repeatedly criticized him for signing a 2006 Massachusetts law that is similar in some aspects to the federal health law.

But the poll found that 49 percent of Republicans say the two men’s views are different, while three in 10 say they are similar. Twenty-two percent had no opinion.

However, when asked specifically for their opinions about the 2006 Massachusetts health law, 69 percent of likely GOP primary voters responded that they didn’t know enough to say whether they viewed the law favorably or unfavorably.

Furthermore, 64 percent of these voters said they don’t know enough to judge whether the Massachusetts law is similar to or different from the 2010 federal health law.

The poll also found that the individual mandate, a requirement that most Americans purchase health insurance by 2014 or pay a fine, remains unpopular, with 67 percent of Americans having an unfavorable view of the provision and 30 percent supporting it.

The January poll found that 37 percent of Americans have a favorable view of the health law while 44 percent have an unfavorable view.

In the foundation’s December tracking poll, 41 percent of Americans had a favorable view of the law while 43 percent had an unfavorable view.

The Kaiser poll surveyed 1,206 adults from Jan. 12 to 17. It has a margin of error of +/- 3 percentage points.

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

By Jessica Marcy

Vermont lawmakers are taking steps to move the state toward a publicly-financed insurance program and craft a state health exchange, which is required by the 2010 federal health law and which state officials hope to use as the groundwork for their eventual move to a unique single-payer system.

Under the new system, an independent five-member panel called the Green Mountain Board will also be in charge of reviewing hospital budgets and defining final Certificate of Need as well as making health insurance rate decisions.

That board is also working on a transition to a single-payer health system.

Gov. Shumlin

Shumlin, a Democrat, put Vermont on a path to single-payer health care last spring by signing a bill, known as Act 48, which seeks to create a new publicly funded and run health program called Green Mountain Care to replace the traditional insurance programs currently offered in the state.

“Act 48 really set up the roadmap for moving forward with single-payer. One stop along the way is the federal insurance exchange,” said Robin Lunge, the state’s director of health care reform.

She said the exchange will provide an infrastructure to help reduce administrative health costs and can “be reused as a platform for moving forward with single payer.”

The federal health care overhaul law requires all states to create an exchange by 2014 and provides funds to help; otherwise, states may opt to let the feds set up an exchange for them.

Vermont plans to use the federal funds to create an exchange but has already filed a waiver so that it can pursue the single payer system and not have to run two duplicative programs in the future.

Deb Richter, head of Vermont for Single Payer, stressed that the ultimate goal is to create a single-payer system, saying, “I look at this as we want to strengthen the exchange so that as many people can get broad coverage that’s affordable in the meantime.”

Vermont has several other key decisions to make, including how to pay for a single-payer health system. The state has held four public meetings in recent months, where people offered their financing recommendations, and is looking at how other countries, particularly Switzerland and Germany, finance their health systems, Lunge said.

In recent years, nearly a dozen states have introduced some type of single payer type legislation, according to Physicians for a National Health Program, but Vermont has been the only state to get this far.

For instance, California advocates saw their push to pass single payer legislation delayed Tuesday when the Senate Appropriations Committee postponed a vote after legislative analysis showed the state-funded program could cost the state general fund $200 billion a year, according to the Los Angeles Times.

Despite the setback, William Skeen, executive director of Physicians for a National Health Program in California, said, “I think that what’s happening in Vermont really energizes what’s happening in California.”

To learn more:

• Visit the Vermont for Single Payer’s website, which has links to extensive resources related to the single-payer approach.

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

By Michelle Andrews

If you saw that your doctor had written “SOB” in the notes he took during your latest office visit, you might be offended and wonder what you’d done to give him such a negative impression. But “SOB,” in physicians’ shorthand, simply means “shortness of breath.”

Concern about such misunderstandings is one of several reasons doctors are reluctant to share their notes with patients, according to a study published in December in the Annals of Internal Medicine.

The study surveyed 173 doctors and nearly 38,000 patients at primary-care practices about sharing information with patients. After the survey, the practices joined a project called OpenNotes, in which patients were give electronic access to their files.

Although federal law guarantees patients the right to examine and get copies of their medical records, providers haven’t always made it easy to do so.

But the movement to give patients direct access to their health information has picked up steam, and policymakers have encouraged it as a way to empower patients to help manage their health and their medical care.

Making lab test results available directly is more common, but it’s not routine, either. Just seven states and the District explicitly allow patients to get test results directly from the lab, and seven others permit it with provider approval.

Last fall, the Department of Health and Human Services proposed a rule giving patients in every state direct access to their lab test results. A comment period ended in November, but there’s no date set for release of a final rule, according to a spokesperson for the Centers for Medicare and Medicaid Services, which would release it.

Patients don’t share clinicians’ ambivalence about getting direct, easy access to their health information. No matter their age, education or health status, more than 90 percent of participants in the OpenNotes survey said they thought being able to see doctors’ notes was a good idea.

“In a way, that was the biggest surprise of the study,” says Jan Walker, the study’s lead author. Walker is a nurse at Beth Israel Deaconess Medical Center in Boston, whose practice participated in the study along with those at Geisinger Health System in rural Pennsylvania and Harborview Medical Center in Seattle. “It reflects consumers’ universal interest in their own care.”

In 2010, Quest Diagnostics, a large lab services company, introduced a free smartphone application called Gazelle that lets consumers in 33 states and the District download their lab test results directly. Since then, 125,000 patients have used the service, the company says. “[Gazelle] will help you have an educated conversation with your physician,” says Jon Cohen, chief medical officer for Quest.

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John Hadley downloaded the Gazelle app to his iPhone after he developed deep vein thrombosis and was prescribed a blood thinner to help prevent another blood clot.

At first, Hadley had to get a blood test every few days so his physician could adjust the medication dose if necessary; now he’s tested every few weeks.

Gazelle let Hadley, 53, track his results and make adjustments to his diet if they started to drift. (Foods high in Vitamin K can affect the ability of blood to clot.)

“It’s my health and my results, I should be able to get them as easily as possible,” says Hadley, IT manager who lives in Parsippany, N.J.

Giving patients direct access to their medical information may also help catch physician errors and omissions, say experts.

Walker says she has heard of patients in the OpenNotes project who have reviewed their doctor’s notes and realized that a test the physician called for hadn’t been ordered. Even more troubling, studies have indicated that as many as a quarter of abnormal test results don’t receive timely follow-up. If patients can look up their results online, that figure might decline.

On the other hand, increased patient access “has the potential to diffuse responsibility” for following up on test results if patients and their doctors both expect the other to check on the results, says Hardeep Singh, chief of the health policy and quality program at the Houston Veteran Affairs Health Services Research and Development Center of Excellence.

Many clinicians are troubled by the prospect that patients may get bad or confusing news without a physician or other health-care provider on hand to help put the information in context.

Patients who use the Gazelle app can’t get direct results on HIV, cancer or genetic diagnostic tests, says Cohen. There’s a 48-hour delay on releasing all other test results, to give physicians a chance to contact the patient and discuss the findings first.

Likewise, patients who participated in the OpenNotes project can’t access the visit notes until their physician has signed off on their release.

“No one wants to see their diagnosis of cancer on their own without a medical professional,” says Jonathan Darer, chief innovation officer for Geisinger Health System, which makes most patient information available online. “We try to manage that.”

At the same time, however, it’s important to ensure that patients get information promptly. “Not knowing is incredibly anxiety-provoking,” says Darer.

Please send comments or ideas for future topics for the Insuring Your Health column to questions@kaiserhealthnews.org.

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

Map by Jim Irwin (Creative Commons License)

By Sarah Varney, KQED

This story is part of a reporting partnership that includes KQED,  and Kaiser Health News.

In a cavernous room just east of San Francisco, an army of phone operators fields calls from their customers. A large computer screen blinks the number of people on hold: two, and the average wait time: one minute, 12 seconds.

These phone operators working in a non-descript office park in Alameda are employed by a large health insurance plan, and they’re willing to go the extra mile for their customers.

They’ll schedule a doctor to come to your home, a pharmacist to drop off a prescription, and they’ll even help you fill out an application for food stamps.

“We do things for them that a traditional, commercial health plan doesn’t do,” says Ingrid Lamirault, chief executive officer of the Alameda Alliance for Health, a county-run, not-for-profit insurer.

The much celebrated, and much maligned, public option may have died in Congress, but it’s alive and well in California.

Unique in the nation for having public health insurance plans that are run by counties, California has plans that stretch from San Francisco to the Mexican border and cover 2.5 million residents.

Looking Ahead To 2014

The Alameda Alliance for Health has a network of doctors and hospitals just like a private health insurance company, and it covers 200,000 people in Oakland and neighboring cities.

Just like private health insurance companies, the alliance also administers a managed care plan for Medicaid beneficiaries and additional plans for county workers.

The alliance’s CEO Lamirault doesn’t plan on stopping there.

In 2014, under the federal health overhaul law, millions of Americans will be able to buy coverage through state-based insurance exchanges.

In California, government-run public plans, like the Alameda Alliance for Health, will go head-to-head with private insurance companies to compete for all those new customers, and those who run the county plans believe they can offer a robust network of doctors and hospitals to bargain shoppers looking for low-cost coverage.

“I think when some people get to make a choice,” says Lamirault, “having local offices they can walk into and get help with things and get their questions answered, and when they call customer service they get their calls answered in under two minutes. Those kinds of things are important to them.”

Throughout California, county plan members largely go to public health clinics and county hospitals. But many counties also contract with private physicians and top-notch research hospitals.

They even share the same lobbying group as the big-named insurance companies, the California Association of Health Plans.

Some of those companies don’t have a lot of love for their public brethren. “Certainly, there are some health plans that didn’t like the idea of having to compete with these public plans,” says Anthony Wright, a public plan booster and executive director of Health Access, a Sacramento-based health care consumer advocacy group. “Especially ones that, having come out of the Medicaid program, are used to providing care at cheaper rate.”

A Continuum Of Care?

In 2010, when California became the first state in the nation to pass legislation establishing an insurance exchange under the Affordable Care Act, Anthem Blue Cross tried to bar public plans from the new marketplace.

Wright, and others, argued successfully that almost half of those expected to buy insurance through the exchange are likely to be low- and moderate-income consumers, and many of them may have, at one point, been on Medicaid or another government-sponsored health program.

“Some of these folks who are close to the poverty line may have already been in these public plans previously,” says Wright. “And so it made sense that this might actually be a good environment for them, to be an option and for people to continue their care with them even as they move up the income ladder.”

“I think insurance companies have made a bad name for themselves, deservedly so,” says Kim Burke, an art school teacher in San Francisco, who was turned down for coverage by private insurers because of pre-existing medical conditions.

For the last several years, Burke has paid a low-monthly premium for coverage in San Francisco’s public health plan. She says when the exchange opens in 2014, she’ll hold on to her public plan–and her grudge.

“I applied to four different insurance companies, all of which denied me for pre-existing conditions,” says Burke. “So I’m not really too keen on purchasing their product since they already denied me care when I really wanted it.”

For many health insurance customers, though, the ultimate selling point may simply be who has the cheapest product.

Insurance companies in California say they will happily compete on price so long as the public plans do not get preferential treatment.

Today, doctors and hospitals accept low reimbursement rates from public plans, in many cases as part of their charity care. That allows the public plans to keep their premiums low, but private plans say they are charged higher prices.

The preferential treatment is not likely to last into the new world of insurance exchanges. When the exchange opens in 2014 in California to people with higher incomes, the government-run plans will have to pay providers more than they do now, says Sumi Sousa, officer of policy development at the San Francisco Health Plan.

Sousa says the utopian belief that public plans always cost less just doesn’t pencil out. “Some commercial providers, because they’re so large, they’re able to spread their cost over a much broader network,” says Sousa. That’s not the case for many county-run health plans in California, which tend to be quite small.

Still, says Sousa, the public plans do have low overhead: Executives like her earn a fraction of the salary paid to the big CEOs, and they don’t have stockholders.

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.