Friday, January 22, 2016

Catastrophic Care

I did laugh when President Obama said that the Affordable Care Act was his signature legacy that he was most proud.  He must have an illegible signature.

I get that he passed little to no legislation due to a Congressional gridlock that veered past politics at one point and seemed at a point almost a personal vendetta that race had to be a factor in the odd behaviors and lack of professionalism for many members.  That said I have never actually "got" Obama and that is his own personal nature and approach to governing that also contributed to many of the problems that dominated his term in office.

I will never respect, like or "get" the ACA.  That was a bill that was premature and utterly a hot mess of bullshit.  As we come to the now end of enrollment once again, finding that the ability to sign up later after the window closes will become nearly impossible and that Kentucky has decided to take all the monies given to them by the government is pulling out while other states are trying to figure out how to actually get in the Medicaid bonus that enabled thousands to receive coverage shows how politicized and fractured this program has become. 

Add to this its scope and scale that has enabled more loopholes and ways to push more costs and less coverage onto individuals that it did little to offset rising medical costs and lastly did nothing to cover vision or dental when those are all part of health care, the ACA is just this burdensome legislation that frankly only gave us two things people do agree - eliminating pre-existing conditions as prohibitive in gaining coverage and that "kids" up to age 26 can be covered on their parents plans.    Otherwise it appears that seems to be the only two things that anyone likes, the "free" care is neither free nor fair as many people do not need or want those elements and frankly should be just part of care and if deductibles and co-pays were reasonable and affordable they don't need to be free at all to ensure they are done to maintain annual health care.  They are instead now offset by what - rising deductibles and co-pays.  See how free that is?

And now smaller businesses that used to offer catastrophic coverage, which was perfectly acceptable for many as frankly that is when the costs rise and the need is real, it is what I had when I faced my life debilitating injury and when I could not pay the care, I was able to qualify for charity care, it worked and I am lucky.  Today that policy doesn't exist and charity care is still available but it too is finding challenges as that donors and exemptions are changing in response to the ACA.  So if you think medical bankruptcy is a thing of the past think again.

Below is another loophole and issue that the ACA has allowed and for many in need it means more debt and more struggles to get care that is needed and in turn affordable.

Obama really needs to look again at his signature legacy and think less Reagan and more LBJ when it comes to truly stepping up to fight for what is right.  But that it all too late now.  Will the next President do the heavy lifting needed to fix this? Just hope they don't throw their back out. 

Employers push limit of Obamacare by excluding outpatient surgery in plans 
Employers are trying to save money by excluding outpatient surgery in plans, but workers might be left with crippling bills. 

  By Jay Hancock
The Washington Post
 January 21 2016

Libbi Stovall couldn’t believe it last month when she looked at the fine print in her company’s 2016 health plan, which supposedly meets the strictest standard for employer obligations under Affordable Care Act rules. The insurance paid for inpatient hospital care, office visits and diagnostic imaging. But it provided no coverage for outpatient surgery, which accounts for two out of every three operations in the nation, according to hospital industry data.

“I knew their policy would not give my family the coverage we need,” said Stovall, 52, who lives in Carrollton, Tex., and has a history of back problems, including outpatient surgery in 2014 to remove a cyst. Her doctor, she added, said that “I absolutely have to be on an insurance plan that covers both outpatient and inpatient hospitalization.”

Worse for her, being offered such a plan through her workplace, an international staffing firm called Open Systems Technologies, barred Stovall from federal subsidies to buy more comprehensive coverage in online insurance marketplaces.

Her experience illustrates the latest chapter in the story of employers and insurance designers pushing the limits of the Affordable Care Act. Last year regulators blocked companies with millions of lower-wage workers from claiming that coverage with no inpatient hospital benefits met the Affordable Care Act’s strictest standard for large employers. Now that those “skinny plans” aren’t allowed, insurance administrators and many cost-conscious employers are purporting to meet the rules with a new version that excludes another major category: outpatient surgery.

The new plans may not survive regulatory scrutiny any more than the old ones did, some experts say. “I really wonder whether they can do that,” said Timothy Jost, a law professor at Washington and Lee University in Virginia who is an authority on the health law. “Refusing to cover any outpatient physician surgical services is arguably a violation.” Outpatient surgeries — those without an overnight hospital stay — happen in a hospital or a freestanding surgery center. Hernia repairs, knee replacements or bone fracture repairs are typical.

They normally cost less than an inpatient operation but can still come to tens of thousands of dollars. Leaving such procedures out of a plan can save money for employers but leave workers with crippling bills. Large employers are not required to offer a list of “essential health benefits,” unlike insurers that sell insurance to individuals and small businesses through online marketplaces. Instead, large employers must offer minimum value — roughly comparable to that of a high-deductible, “bronze” marketplace plan — as determined by an online calculator and regulatory guidance, or face a penalty. There is also a lesser standard for large employers — “minimum essential coverage” — that triggers different fines for noncompliance. But nearly all workplace-based plans that offer some types of preventive care meet this requirement.

“It was clear that hospitalization had to be covered” by large employers after regulators ruled in February that skinny plans lacking inpatient benefits did not meet minimum value, said Anne Lennan, president of the Society of Professional Benefit Administrators, a trade group for claims processors.

“But then the question was, ‘How much?’ ” For 2016, insurance lacking outpatient surgery benefits has been marketed primarily to staffing companies, hoteliers and other lower-wage employers that had historically never provided major medical coverage. Those are the same firms that were sponsoring skinny coverage a year ago, industry consultants say. It’s unclear how many companies said yes for this year, although last year about half the 1,600 corporate members of the American Staffing Association were interested in the plans with no inpatient coverage.

The trade group didn’t conduct a similar study for the latest skinny plans, said senior counsel Edward Lenz. More than 30 employers working with EBSO, a Minnesota-based benefits company, have implemented 2016 minimum-value plans that cover inpatient hospitalization but not outpatient surgery, said President Bruce Flunker. JFC Staffing, based in Camp Hill, Pa., offered a skinny plan lacking outpatient surgery benefits to nearly 700 eligible employees this year, said Cathy Reichelderfer, the company’s chief financial officer JFC struggled with simultaneously conforming to Affordable Care Act rules, offering coverage that wouldn’t break the budget and giving workers insurance they wanted, she said. “As an employer, we want to do the right thing,” she said. On one hand, offering a minimum-value plan means “potentially somebody losing their subsidy” to buy alternative coverage in the marketplaces, she said.

On the other hand, overpaying for insurance or offering no insurance — and subjecting JFC to fines — could wipe out hundreds of jobs “because we can’t stay in business,” she said. This is the second year under the health law that large employers must offer affordable, minimum-value coverage or face penalties of up to $3,000 per worker Temp companies, restaurants and others that never offered major medical coverage before are “certainly keen to minimize this cost,” said Kevin Schlotman, vice president of employee benefits at Benovation, an Ohio consultant.

 For many workers at such employers, even plans lacking inpatient benefits or outpatient surgery — but paying for office visits, emergency-room care and prescriptions— are a significant improvement, say consultants selling them. OST, Stovall’s employer, offered a minimum-value plan for 2016 without outpatient surgery benefits that is designed and administered by Key Benefit Administrators, one of the country’s largest independent claims-processing firms. KBA was one of the leading promoters of last year’s skinny plans.

 After Kaiser Health News and The Washington Post wrote about those policies in 2014, federal regulators issued clarifying rules saying that large-employer plans must provide “substantial coverage of inpatient hospital and physician services” to qualify as minimum value.

The debate now is whether “substantial coverage” of “physician services” includes outpatient surgery. Not surprisingly, the American Hospital Association “is deeply concerned” about plans that exclude it, a spokeswoman said. New York-based OST, which says it is one of the largest privately held staffing firms in the world, declined to comment, as did Key Benefit Administrators’ general counsel Wallace Gray.

 A spokesman for the Department of Health and Human Services declined to comment on specific plans. Libbi Stovall turned down OST’s minimum value plan and bought insurance on that covers both inpatient care and outpatient surgery.

“I fear that other contracting companies are giving their employees the same substandard insurance coverage,” she said. “I am standing up for these people, because I don’t want to see anyone go bankrupt” from uncovered medical bills

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