As early as this Monday, the Supreme Court is expected to issue a ruling on a case that would strip health insurance subsidies from 6.4 million people.  The plaintiffs in the case, which is called King v Burwell, claim that Congress intended to withhold subsidies from states that chose not to establish a state-based health insurance exchange.  Though the history of the Affordable Care Act’s (ACA) passage suggests that this was never the case, there are signs that the Supreme Court may indeed strip subsidies from states with federally facilitated marketplaces.  

Consumers in New Mexico are protected from a bad decision since our state operates a state-based exchange, but it has the potential to negatively affect New Mexico in a number of ways, depending on how Congress handles the fallout of the decision.  President Obama has called on Congress to simply fix the language in the ACA to clarify that the subsidies are available to all states.  However, congressional Republicans are seeking to extract concessions in exchange for a continuation of subsidies.  Instead of re-capping the news of the week, Health Action NM has thoroughly investigated the concessions being called for by congressional Republicans and the implications that they have for consumers.

 Repeal the Individual Mandate

The Individual Mandate, which requires all Americans to acquire health coverage or else pay a penalty, has long been a target for repeal since it is the most unpopular part of the ACA.  However, it is the glue that holds the rest of the law together, including the popular components such as a ban on denying insurance based on pre-existing conditions, guaranteeing that consumers can purchase any coverage that they want, and ending the practice of charging women more than men for insurance.  

Without the individual mandate, the incentive to purchase insurance would be greatly weakened, creating a dysfunctional market in which only the sickest consumers sign up for coverage.  This would cause premiums to soar, causing more consumers to drop out of the market, leading to what economists call a death spiral.  The nonpartisan Center for Budget and Policy Priorities estimates that 22 million fewer uninsured people would be able to access insurance without the Individual Mandat

Repeal the Employer Mandate

The Employer Mandate requires all companies with 50 full-time employees or more to offer affordable health coverage to employees.  According to the US Treasury Department, 96% of businesses in the US are exempt from the Employer Mandate because they have less than 50 employees.  96% of those that are required to offer coverage already do so and less than .2% of firms are expected face fines for not offering coverage.

The reason lawmakers included the Employer Mandate in the ACA was to ensure that companies didn’t drop their employee’s coverage and push them on to individual marketplace.  A repeal of the provision has serious budgetary considerations as well.  It would increase the amount spent on subsidies because more people would get coverage on exchanges that offer coverage.  Still, it would not shake the ACA at its core the way a repeal of the Individual Mandate would. 

 Repeal the Medical Device Tax

 The Medical Device Tax applies a 2.3% tax on medical device manufacturers’ sales. The ACA is designed to reduce the deficit even as it expands coverage.  To do that, lawmakers cut spending in some areas and increased revenues on industries that stood to benefit from the law.  Since medical device manufacturers enjoy some of the greatest profit margins in the health care industry and stood to greatly benefit from increased utilization of their products as a result of the ACA’s coverage expansion, lawmakers included this tax as a way to finance the law.  

   

Many have claimed that the tax gets passed on to consumers through increased prices, though Consumers Union (a consumer advocacy organization) disagrees, given the high profit margins and rate of growth that medical device manufacturers enjoy and the benefits it will reap from the ACA.  Repealing the Medical Device tax would increase the deficit by $26 billion between 2015-2024, unless Congress could make up for the loss of revenue by increasing taxes or decreasing spending in other areas. 

Repeal the Independent Payment Advisory Board

The Independent Payment Advisory Board (IPAB) is a committee of experts that would be convened if Medicare spending grew at an exorbitant rate.  IPAB has not yet been convened because of the recent slowdown in health spending.  If triggered, IPAB would be tasked with finding ways to restrain spending without impacting Medicare benefits.  Congressional Republicans have long sought to repeal IPAB, claiming that it will lead to rationing of care, restrict Congress’ role in Medicare, and give bureaucrats too much control over patients.

However, the ACA specifically prohibits IPAB from rationing care, increasing premiums or cost sharing, cutting benefits, or limiting eligibility.  Cost controls can only achieve savings through payment and delivery reforms. Congress will still play a central role in Medicare policy when IPAB is active.  If Congress can produce equivalent savings, IPAB’s recommendations won’t go in to effect.  It is likely to be the most effective cost containment program built in to the law and is vital to the sustainability of Medicare.  Future generations need access to this important program for seniors and IPAB will play a critical role in ensuring the its integrity.

Repeal the Cadillac Tax

The Cadillac Tax refers to a 40% excise tax on health plans with unnecessarily excessive benefits. It is designed to discourage employers from offering benefits that drive up costs for everyone else and raise revenues to increase health coverage.  Congressional Republicans claim that the tax limits employers’ ability to compete for employees on benefits and restricts access to the high quality health coverage.  

In the 2008 presidential campaign, John McCain proposed ending the $250 billion a year tax break on employer sponsored health insurance to finance a new health care program.  The Cadillac Tax achieves a similar result, only on a much smaller scale and on the upper echelon of high-end plans offered by employers. 

Reduce Subsidies

Currently, those making under 400% of the Federal Poverty Level (FPL) are eligible for premium tax credits under the ACA.  Some congressional Republicans have proposed that those subsidies be reduced, limited to those under 300% FPL, be based on age rather than income, and be a fixed dollar amount rather than based on the cost of insurance.  This would seriously weaken the effect subsidies have on access to affordable insurance, especially for low and moderate income households.  The way subsidies were initially designed was to ensure longterm affordability for individuals and families across the economic ladder.  Reducing financial assistance just as so many have begun to feel the security of health coverage would be irresponsible and detrimental to consumers.

Health Action

The Department of Health and Human Services releases new enrollment data for New Mexico.  As of March 31st, 44,085 individuals are enrolled in New Mexico Health Insurance Exchange (NMHIX) plans, 33,244 of whom qualify for premium tax credits and 21,149 of whom qualify for cost sharing subsidies.  The average premium tax credit in NM is $200.   

There are 5 tiers of health plans that consumers can choose from, each of which covers a certain percentage of the cost of care.  Catastrophic plans cover less than 60% of costs, Bronze plans cover 60% of costs, Silver plans cover 70% of costs (but up to 94% with cost sharing reductions), Gold plans cover 80% of costs, Platinum plans cover 90% of costs.  Enrollees can access cost sharing reductions only if they purchase a Silver plan.  Here’s a breakdown of how New Mexico compares to the nation as a whole:  

There is still a great deal of work to do to get people living in New Mexico who are eligible for benefits enrolled in NMHIX coverage.  Only 33,244 of the 118,000 New Mexicans who are eligible for premium tax credits have taken advantage of this opportunity.  Health Action NM will continue to track the implementation of health reform and work to raise awareness about new options and benefits in hard-to-reach communities.

- Barbara Webber, Executive Director

New Mexico is safe from a negative King v Burwell ruling.  This month, the Supreme Court is expected to release a ruling on a lawsuit alleging that consumers in states with federally-operated health insurance exchanges aren’t eligible for premium subsidies.  New Mexico is in a special situation in terms of the lawsuit since our state has established an exchange but continues to use the federal web portal, known as healthcare.gov.  The Centers for Medicare and Medicaid Services has consistently affirmed that New Mexico is classified as a state-based exchange, meaning that we will be protected from an adverse ruling.  Health Action NM has reached out to legal experts to confirm this.  Consumers in New Mexico can rest assured that subsidies will remain in place regardless of the outcome of King v Burwell.

- Colin Baillio, Communications and Outreach

Americans use less care but pay way more than other industrialized countries.  Many claim that the reason health costs are so high in America is because Americans visit the doctor too much.  But new data show the exact opposite - Americans utilize services less than any other industrialized country with the exception of Switzerland, which has system similar to the US.  The real problem: extraordinarily high prices.  Americans are charged much more for services than those in any other country.  Here are some highlights from the most recent study:

• Along with Switzerland, the U.S. has the fewest physician consultations per capita among higher-income OECD countries. Consistent with this lower physician use, the U.S. also has fewer physicians per capita and about one in every ten adults (11%) report that they either delayed or did not receive needed medical care due to cost in 2013.
• U.S. patients on average experience shorter hospital stays than in other OECD comparable countries.
• The U.S. performs fewer angioplasties and more coronary bypass surgeries than comparable countries, but for both procedures prices are substantially higher than in other countries where data are available. According to the International Federation of Health Plans, the national 95th percentile average for an angioplasty in the US is $61,184.
• The average price per coronary bypass surgery in the U.S is 2.4 times higher than in other countries where data are available. 
• The average cost per Caesarean section in the U.S.  is 1.7 times higher than in comparable countries where data are available.  Normal delivery in the U.S. averaged $10,002 in 2013.

Prices for nearly all services are remarkably high compared to similar countries.  Despite high prices, quality outcomes remain lower than other industrialized countries.  This trend is even worse for uninsured consumers, who are regularly charged up to 10 times the rate of those with insurance.  Health Action NM will continue to keep an eye on this trend and what can be done to limit adverse effects on consumers.

• DeAnza Sapien, JD, Advocacy Coordinator 

Hillary Clinton will make substance abuse and mental health treatment a priority in her presidential campaign.  Clinton has made clear that drug abuse and mental health issues should be given the same attention as any other chronic disease.  Her policy advisors are reaching out to stakeholders to gather input on how to craft effective policies to address the needs of patients with mental health and substance abuse disorders.  Clinton stated that adequate funding to treatment facilities and insurance coverage of addiction treatment are often not priorities in our current health care framework.  Although the ACA classifies substance abuse treatment and mental health services as essential health benefits, the issue of access for these remains, as patients who seek treatment are often unable to. The ACA plays an important role in shifting the perception of mental health and substance abuse issues from neglected aspects of overall wellbeing to a fundamental part of our health care system. New Mexico’s population would greatly benefit from increased support for these services and Health Action will continue to advocate for greater access. 

- Andrea Andersen, Health Policy Intern   

Former insurance executive Wendell Potter says the American health care system is not the best in the world.  Americans are big spenders on health care, but our outcomes don’t seem to reflect it. We fall far behind in important categories like life expectancy and infant mortality rates compared to every other developed country in the world, but we continue to buy into the idea that the more money spent, the better health care we receive. Unfortunately, our system is more often dictated by insurance and pharmaceutical companies, than the needs of our people and this has dangerous consequences for our health and our pocketbooks. Our system lacks the policies needed to help protect consumers from the high costs set by drug companies and providers that our insurance carriers inevitably pass down to us. It’s time for consumers to start demanding more accountability and transparency of our health care dollars. 

- Ellie Perkins, Health Policy Intern

Health Action

New York’s State Assembly passes a universal health care bill. The legislation proposes that the state eliminate the private health insurance system and instead cover services through a single program operated by the state.  This type of system is often referred to as “Single-Payer.”  Several other countries, including the UK, Canada, and Taiwan, have implemented this type of system with great success. The benefits of such a system include universal access to health services, lower costs, and better coordination of care.  The NY bill now heads to the state Senate where it’s expected to face an uphill battle. Be sure to check out the Vox.com cardstack on single-payer health care systems. A single-payer system is on Health Action NM’s radar as states begin to consider the future of health reform. 

- Barbara Webber, Executive Director

New proposed rules for Medicaid managed care organizations (MCOs) aim to increase insurer & provider accountability and access to care.  The Department of Health and Human Services (HHS) proposes 1) that Medicaid MCOs must spend at least 85% of Medicaid dollars on medical services, 2) enhanced requirements to ensure the continuation of care when a beneficiary moves between programs or switches to a private health plan, 3) annual reviews of provider networks to ensure that beneficiaries have accurate information about the number and location of providers in their network, and 4) a system designed to give consumers information on provider quality ratings.  Since New Mexico decided to shift the state’s Medicaid program from a fee-for-service model to the MCO model, these new rules will have far-reaching effects on our Medicaid system.  Health Action NM is pleased to see that steps are being taken to improve a program that covers over 1/4 of New Mexico’s population.

- Colin Baillio, Communications and Outreach

Blue Cross and Blue Shield (BCBS) of New Mexico requests a 51% premium increase for all individual plans. The premium hike would affect about 35,000 consumers who are enrolled in plans both on and off the New Mexico Health Insurance Exchange. The request is subject to the rate review process, meaning it must be approved by the New Mexico Office of the Superintendent of Insurance. This request is by far the largest filed so far.  Presbyterian’s Health Plan and New Mexico Health Connections are requesting single digit increases and other plans have yet to file rate requests.  BCBS is citing higher than anticipated costs as the reason for increase.  Please inform Health Action NM if you are facing a rate increase of this magnitude.  Click here to view all rate increase requests in the state.  Health Action NM will continue to track this development and advocate on behalf of consumers whose rates are raised arbitrarily.

- Andrea Andersen, Health Policy Intern

A survey by AARP and the Urban Institute finds that uninsured rates among individuals aged 50-64 dropped 31% over one year. The drop in the number of older adults who are uninsured is largely a result of the Affordable Care Act (ACA), which prevents insurance companies from denying coverage due to pre-existing conditions, eliminates the practice of charging those with greater health needs higher premiums than those in good health, limits the amount insurance companies can increase premiums based on age, and expands coverage. The study also found that states that expanded Medicaid under the ACA have seen a greater decrease in the number of uninsured between 50 and 64 than states that chose not to expand Medicaid.  These findings are a sign that the ACA is serving older adults who are more likely to utilize health care services.

- Ellie Perkins, Health and Dental Policy Intern

Health Action

74% of consumers with Affordable Care Act (ACA) health plans are happy with their coverage – but those with high deductible plans were deeply unsatisfied. The Kaiser Family Foundation’s recent report on ACA plan satisfaction holds a great deal of positive news, with some very concerning insights as well.  Overall, people are happy with their plans, have access to primary and specialty care doctors, and have a sense of financial security with their coverage.  However, 32% of those with deductibles (the amount you pay before your insurance kicks in) above $1,500 rated the value of their plan as being poor whereas only 9% of those with deductibles below $1,500 thought that of their plan’s value.  In addition, cost continues to be the main barrier to care and a large majority of second-year shoppers aren’t looking for new plans even though new high value plans may be available. Health Action NM will continue to advocate for higher value plans and inform consumers about the risks associated with high deductible plans.

- Barbara Webber, Executive Director

Health system expert Uwe Reinhardt makes an important point: when we focus our freedom to choose our health insurance carrier we sacrifice our freedom to choose our health care providers.  A recent study showed that Americans want to be able to decide what kind of health insurance is best for them.  Many debates about health care revolve around the freedom choose the health plan that you want.  And while Americans value this choice, many don’t realize that insurance carriers restrict access to many providers even as they permit access to others.  Some may remember the tragic story told by Dawnelle Keys, whose daughter died when she took her to a hospital that didn’t accept her insurance and was denied care.  If we didn’t organize our system in a way that restricted access to providers on the basis of insurance, consumers would have more opportunities to get care when they need it from the provider they choose.  This may be a conversation worth reigniting.

- Colin Baillio, Communications and Outreach

Study shows that in-person assisters play a very important role in ACA enrollment, especially those in minority populations.  A recent report by Enroll America found that consumers who received help from an assister were 60% more likely to enroll in health coverage than those who attempted online enrollment on their own. The role of in-person assisters varies by state but includes Navigators, Certified Application Counselors (CACs) and health insurance agents/brokers that all help bring greater consumer awareness of ACA health insurance coverage. The most successful assistance programs are those that work in collaboration with other state entities and utilize a nationwide assistance-scheduling tool called the Get Covered Connector. This tool works to link consumers with assisters regardless of location and streamline the enrollment assistance appointment process, as well as strengthen data monitoring and alliances with like-minded organizations. Use of in-person assisters in New Mexico is vital to enrolling hard-to-reach communities throughout the state.

- Andrea Andersen, Health Policy Intern   

Health reform is influencing physician provider practices in some interesting ways.  A collaborative initiative between aethenaResearch and the Robert Wood Johnson Foundation called ACAView closely monitored the impacts of the ACA on medical practices in 2014. They found that: 1) A feared surge of new patient volume did not occur. Although many anticipated that primary care providers would be burdened by an influx of new patients, the overall change was less than 0.3%. This lack of change may be due to continued use of urgent care clinics or emergency services by the newly insured and this was not monitored ACAView; 2) Physician offices in states that expanded Medicaid have seen sharp decreases in uninsured patients. In states that decided to expand Medicaid there was a 39% decrease in uninsured patients seen between 2013 and 2014, while those in non-expansion states only saw an 11% decline; and 3) More commercially insured patients are switching to Medicaid. Medicaid is often a better option for those in low-incomes jobs who don’t want to pay the higher out-of-pocket costs that come with private insurance.  Health Action NM is pleased that the ACA hasn’t overwhelmed doctor’s offices & hospitals and that Medicaid expansion is serving our population well.

- Andrea Andersen, Health Policy Intern   

Health Action

The White House takes action on three major consumer issues: surprise medical bills, inaccurate provider directories, and the enforcement of free birth control coverage.  1) As we reported last week, about 1/3 of those with private health insurance received surprise medical bills over the last two years.  2) According to New Mexico’s Superintendent of Insurance, inaccurate provider directories are the number one consumer complaint his office receives.  3) And a National Women’s Law Center study found that hundreds of insurance plans fail to fully cover FDA-approved contraceptives, despite the federal requirement to do so. 

The White House is working to address each of these issues administratively.  1) Next year, healthcare.gov will likely come with an out-of-pocket cost calculator that gives consumers a better idea of the overall value of their plan than, say, a premium.  The administration hopes that this will reduce unexpected costs for consumers.  2) Insurers must now update their provider directories each month, and will face a fine if they don’t.  3) New regulations clarify that insurers must cover every type of birth control without any out-of-pocket costs.

Health Action NM has been reporting on these issues to our national partners for the past year.  We are pleased to see that they are being addressed.  While progress is being made on all three of these issues, there is much more work to be done on each of them.  Health Action NM will continue to follow them closely.

- Barbara Webber, Executive Director

 

NM Medicaid expansion enrollments reach 214,000 by the end of April and are expected to grow to 241,000 by June of 2016.  The Human Services Department (HSD) announced another positive month of enrollment growth in the state’s Medicaid program.  The Medicaid expansion has been a huge success story in New Mexico.  While original estimates suggested that about 170,000 people were eligible for expanded Medicaid, we’re now expecting closer to 250,000 - the need was much greater than we anticipated.

Since the expansion began in 2014, the federal government has paid for it in full.  In 2017, the state must pick up 5% of the cost of expansion. HSD estimates that the state will need to devote about $43 million to cover these costs during fiscal year 2017.  Now is the time to start talking about how best to pay for NM’s portion of the incredibly successful Medicaid expansion.

- Joe Martinez, Outreach Coordinator

 

Employers take a new approach to reducing health costs: set your own price.  Hospitals have come under scrutiny in the past for charging exorbitant and unreasonable medical bills, driving up costs for everyone.  After one employer was charged $600,000 for a an employee’s three day stay in a local hospital, they hired a consulting firm to look in to what had happened.  The firm assessed the services and found that they cost a small fraction of what the hospital was charging.  They added a modest profit for the hospital to their calculation and sent the payment back. “We wrote a check to the hospital for $28,900 and we never heard from them again,” said the business owner.

Prices in US health care are notoriously high.  And, as this story shows, they are also extremely unreasonable.  How could a hospital get away with charging $600,000 for a procedure that they wound up accepting $28,900 for in the end?  This is why many advocates continue to push for a system where prices are transparent and set based on how much the services cost rather than backdoor deals between hospitals and insurance companies.  There is little consumers can do to stand up against this type of pricing scheme.   Isn’t it time to formally address the problem of arbitrary pricing?

- Colin Baillio, Communications and Outreach

 

Maryland implements pilot programs that may be the next big step in controlling costs for consumers.  The state is experimenting with how it pays hospitals to reduce readmissions.  It provides a lump sum of money to a hospital for any admission and doesn’t pay anything for readmissions within the next 30 days.  The hope is that hospitals will provide the best possible treatment for the patient during the first admission without providing costly and unnecessary care and will reduce the likelihood of a readmission.  Health Action NM will continue to keep an eye on this model and its impact on costs and the quality of care.

- DeAnza Sapien, JD, Health Advocacy Coordinator

Health Action

A small ACA program saves $384 million over two years.  The Affordable Care Act (ACA) created opportunities for hospitals to experiment with alternative payment models that would theoretically incentivize doctors to provide higher-quality care for lower costs.  While some were unable to do so, the Pioneer Accountable Care Organization model seems to be showing positive results: the hospitals in the program saved an average of $300 per patient, amounting to a total of $384 million over two years.  According to health journalist Sarah Kliff, “if hospitals in the Pioneer ACO program covered Medicare patients at lower-than-expected costs, they kept 70 percent of the savings in 2014 (the other 30 percent went back to the federal government). But if they spent more than expected, they would have to pay the feds back the difference.  All of a sudden, the Pioneer ACO program gave doctors a reason to spend less in a system that typically rewards anyone who spends more.”  Presbyterian Healthcare Services in New Mexico experimented with this model but has since backed out to focus on its Medicare Advantage program.  Hopefully, the ACO Pioneer model can be replicated and produce savings for consumers here in New Mexico and throughout the nation.

-          Barbara Webber, Executive Director

Consumers Union survey finds that nearly 1/3 of Americans with private health coverage were hit with surprise medical bills over the past two years.  Among those who dealt with a billing issue, only 28% were satisfied with how the issue was resolved, 75% of whom wound up having to pay the bill in full.  As we wrote about several weeks ago, states are examining how best to protect consumers from these costs.  We hope that New Mexico will begin to do so during the next legislative session.  Until then, here’s what you can do if you believe your doctor or insurance company have wrongly charged you for any service: First, file an internal appeal with your insurance company.  If your claim is denied, you can request an external review from the NM Consumer Assistance Bureau.  Note that if your employer self-insures its employees, the US Department of Labor will handle your claim.  Medicaid appeal assistance is available through Law Access NM (ABQ: 998-4529; Statewide: 1-800-340-9771).  Now is the time to start thinking about policy solutions to curb the negative outcomes of surprise medical bills.

-          Colin Baillio, Communications and Outreach

Many health plans are violating ACA standards for Essential Health Benefits (EHB) that influence women’s health. A report released this week by the National Women’s Law Center analyzed health plans in 15 states and found that many had not been adhering to Affordable Care Act’s contraceptive and maternity/newborn care benefit requirements.  Although New Mexico was not included in the report, these findings imply that issuers in other states may be following the same pattern.  These essential services are especially important for women who need access to birth control. About 99% of all women use contraceptives at some point in their lives to control when and if they become pregnant. This is extremely important considering the overwhelming data showing the age and timing of a pregnancy is highly correlated with education and employment opportunities, as well as lifetime earning capacity. New Mexico’s women deserve the right to adequate and timely access to contraceptives.  

-          Andrea Andersen, Health Policy Intern

Texas Medical Board votes to restrict use of telemedicine to remotely treat patients. When many states are making efforts to increase the availability of telemedicine, Texas has decided to take the opposite action. In mid-April of 2015, the Texas Medical Board voted to approve rules to limit the use of telephone and video technology to diagnose and treat patients remotely. This is concerning, given the serious health service access problems faced by rural areas in Texas and throughout the United States.  While patient safety is a serious concern, scaling back an important technology in a state with such great rural access needs is troubling, especially when comprehensive safety guidelines are available.  The medical board claims that the components of a successful doctor-patient relationship are not sufficiently satisfied through the use of telemedicine – but a digital doctor-patient interaction is better than no interaction. Health Action New Mexico believes that all people should have convenient access to medical advice and consultation, and supports the use of telemedicine as a device for improving this access. 

-          Ellie Perkins, Dental Health Intern

Dr. Atul Gawande says that Americans are over-tested, over-diagnosed, and over-treated. Since doctors are in an authoritative position, patients tend to trust their judgement on the best path to health.  However, sometimes less treatment is the key to reaching that goal.  “[Doctors] can recommend care of little or no value because it enhances our incomes, because it’s our habit, or because we genuinely but incorrectly believe in it, and patients will tend to follow our recommendations,” says Dr. Gawande.  The problem is that prescribing too much care is often detrimental to the patient and make care more costly for everyone.  “Our ever more sensitive technologies turn up more and more abnormalities—cancers, clogged arteries, damaged-looking knees and backs—that aren’t actually causing problems and never will. And then we doctors try to fix them, even though the result is often more harm than good.”  While well-informed consumers are key to a smart health care system, doctors play a critical role in making our system more efficient and improving treatment for patients.  Sometimes that means doing less than more.

-          DeAnza Sapien JD, Advocacy Coordinator

Health Action

 

My name is Andrea Andersen and I am the newest intern at Health Action New Mexico. I will complete my Master’s in Public Health from the University of North Carolina at Chapel Hill this winter and am very excited about being involved in the wonderful work at HANM! My main passion is helping women, children and families through access to and adequate coverage of health care services via community health work and policies.  I am a native New Mexican and understand the unique needs of our communities, so a group like HANM is a perfect fit for my interests in advocacy and equity. My interest in the maternal and child health population is grounded in a belief that strong and healthy family units, whatever they may look like, are the foundation to happy, healthy and productive communities that nourish future generations. I also have a strong interest in the connection between education and health status and I believe that policies that target this also impact the health of children in our state. This summer I will be focusing on the exploration and implementation of Certified Application Counselors and their role in increasing enrollment in the New Mexico Health Insurance Exchange (NMHIX). This is an important step in creating greater access to health care services for individuals and families throughout the state, which can ultimately lead to better health outcomes for the long-term.

Health Action

by Elizabeth Perkins
Health Policy Intern at Health Action NM

 

In a time when the term Obamacare still elicits mixed and often passionate reactions, new research suggests that shoppers are happy with their Obamacare-enable plans – even more so than those who get health coverage from an employer.  The J.D. Power 2015 Health Insurance Marketplace Exchange Shopper and Re-Enrollment (HIX) Study, released on April 23, 2015, shows a significant improvement in plan satisfaction during 2015 as compared to 2014 (the first year plans were available). Satisfaction among new members and re-enrollees that purchased plans through the marketplace exchanges created by the Affordable Care Act (ACA) is equal to or higher than with plans not purchased through an exchange.  J.D. Power reports cost to be the most significant factor influencing member satisfaction among Marketplace members.

 

As someone who has been uninsured, on Medicaid, on employer provided insurance, and having recently purchased an individual plan from the New Mexico Health Insurance Exchange (NMHIX), I like to think I offer a unique perspective on the successes and downfalls of each option. As a working adult with zero dependents it has been a long time since I have qualified for Medicaid (but I was glad the option was there when I needed it), and there are no upsides to being uninsured, so I will focus this discussion on employer provided vs Marketplace coverages.

 

When the ACA (or what many call “Obamacare”) went into effect at the end of 2013, I was working full time for a company who decided to obtain group coverage – a type of coverage that many large firms obtain.  I was excited about this decision because I was uninsured at the time and I knew the ACA required me to obtain some form of health coverage.  When I learned how much my monthly premium was going to be (and, mind you, I was only paying half, my employer paid the other half) I was shocked. I was also shocked to learn that my plan had a pre-existing condition clause!

 

Just my luck, I seriously sprained my ankle during a company softball game on the first day my plan became active. I found out about the pre-existing condition clause when I received a bill for $1200 dollars from the MRI despite having gotten a pre-authorization. I couldn’t believe that I was paying almost $200 per month (remember this is only half of the total premium) and the first time I tried to use the insurance it didn’t even pay for anything. I was irritated. Here I was, insured by a coveted employer based plan, and I was scared to use it due to the pre-existing condition clause (it only lasted 6 months, but it sure wound up costing me) and my $5,000 deductible.  But what was I going to do?  The only other option I had was the “Gold” option which would reduce my deductible to only $2,500 but nearly double my premium. I was stuck with what my employer had chosen to offer.

 

On February 18, 2015 I suddenly became unemployed, and would soon revert back to being uninsured. I was in the middle of some routine medical procedures, so I knew I needed to get coverage back sooner than later. I looked at trying to get coverage on my significant other’s insurance but the required paperwork and red tape that arose because we are not married was a lot to overcome.  So, I decided to look at the NMHIX for coverage.  I am pretty tech savvy and understand health insurance pretty well so I didn’t have much problem navigating the website, but I can see how difficult it must be for consumers who aren’t familiar with the system. However, my experience was great: I was clearly shown what financial help was available to help me pay for my premium (via a subsidy that appeared as a discount) and offered a wide range of plans ranging from $18-250 for my out-of-pocket costs.

 

I looked through the options using the website’s “compare” feature and chose a plan that I knew my current doctors would take.  It had a reasonable premium and $0 dollar deductible. What?! I didn’t believe this could be true. I was paying half of what I was paying under my employer insurance – I couldn’t  believe the plan really had no deductible (the cost that you have to pay before your insurance kicks in).

 

I decided to buy the plan and an accompanying dental plan and figured I would brace myself for when I found out what my real deductible was when I got my information packet in the mail in a few days. I received my information booklet in the mail that included a summary of benefits and my eyes focused on the section that said Deductible: $0, Out of Pocket Maximum: $2,250. I continued to read through the booklet trying to find the catch, but I found none.

 

I have only had the plan for about two months; I have used it, and encountered no issues. I have searched and searched for where the deficiency in my new Marketplace is and have so far come up empty handed; I cannot find one reason not to be satisfied with my new Obamacare plan.  Hopefully, and it seems this is so, this is the experience that other shoppers have had as well. 

Health Action

Health Action

The behavioral health shakeup continues to cripple the state’s fragile behavioral health system.  In 2013, the Martinez Administration shut down the offices of dozens of mental health providers, claiming that they fraudulently overcharged Medicaid for services.  Two years later, the administration has yet to provide evidence that the charges were fraudulent and the system remains in disarray.  The human cry now is for a roadmap forward.  Systemic reform has been attempted before several times in New Mexico.  And still, too many people, including thousands of children, are not getting the critical services they need, and they pay with the quality of their lives.  And ultimately everyone pays - not to mention the basic right to health care. Isn't it time for a well-thought-out reorganization of a system that builds on what can work?  

-       Barbara Webber, Executive Director

New York to offer more affordable coverage options to low/moderate income residents.   New York is moving forward with its Basic Health Plan, a health coverage option available to those making between 133% and 200% of the Federal  Poverty Level (FPL).  Many consumers still struggle to pay the monthly premiums offered on the private marketplace.  This new program will reduce barriers to care and reduce the “churn” between Medicaid and the exchange for people whose incomes fluctuate month-to-month.  According to the Times Union, “consumers with income at or below 150% FPL ($17,655 for a household of one, or $36,375 for a household of four) will pay no monthly premium. Those with slightly higher incomes at 200% FPL ($23,540 for a household of one, or $48,500 for a household of four) will pay $20 a month.”   

Given the state of New Mexico’s economy, it would make sense to consider this option.  State Senator Gerald Ortiz y Pino introduced a memorial to have legislative staff study the idea, but it didn’t come to a vote in the House.  Affordability remains the key barrier to accessing health coverage and care.  It’s time for New Mexico to start taking this idea seriously.

-       Colin Baillio, Communications and Outreach

New Mexico keeps its exchange but will continue to use the federal website.  Several weeks ago, the board of the New Mexico Health Insurance Exchange (NMHIX) voted to scale back funding for their IT system in order to prioritize other goals, such as providing outreach and enrollment services, marketing, and continuing the current level of staffing.  This decision was made after the federal government rejected a $90 million grant proposal drafted by NMHIX.   Without that funding, the board had to decide how to best use current funds.  Our view is that this was the best choice, given that the federal website is functional while many state websites continue to struggle.  Plus, the benefits of coordinated outreach and enrollment efforts are more important than having our own website.  After the first two years of sign-ups, we know that these services are the most effective way to inform consumers about new coverage options and help decide what kind of coverage they want.  Moving forward, outreach and enrollment assistance should be the exchange's primary tools for increasing understanding about new coverage options and enrollment numbers.

-       Joe Martinez, Consumer Outreach Coordinator

The tax season health coverage enrollment period is almost over!  Consumers who found that they owed a penalty for lacking insurance in 2014 can get covered and avoid next year’s heightened penalties.  So far, 68,000 people have taken advantage of this opportunity, which ends on April 30, 2015. Health Action New Mexico has created a bilingual consumer resource for those who want enrollment assistance during the tax enrollment period.  We hope a similar opportunity will be in place for consumers next year when the penalty increases to the greater of $625 per person or 2.5% of income.  However, more coordination needs to take place between NMHIX and tax preparers so that consumers can take advantage of the opportunity when they file taxes.  Don’t miss out on this opportunity to get covered if you are uninsured!

-       DeAnza V. Sapien, MS JD, Administration and Grant Development

 

Health Action