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Between ACA and Medicare, Some Americans May Have Too Much Health Coverage

Ever since the Affordable Care Act’s insurance marketplaces opened for business in 2014, the Obama administration has worked hard to get Americans to sign up. Yet officials now are telling some older people that they might have too much insurance and should cancel their marketplace policies.

Each month, the Centers for Medicare and Medicaid Services (CMS) is sending emails to about 15,000 people with subsidized marketplace coverage. The message arrives a few weeks before their 65th birthday, which is when most become eligible for Medicare.

“In most cases you won’t want to keep your Marketplace plan because once your Medicare coverage starts, you’ll no longer be eligible for any premium tax credits or other cost savings you may be getting,” says the email, which goes to enrollees in the 38 states using the federal “To avoid an unwanted overlap in Marketplace and Medicare coverage . . . tell us you want to end your Marketplace plan.”

And last month, CMS also began mailing letters to people already covered by Medicare as well as enrolled on the marketplace and getting financial assistance. That notice, required under the health-care law, says that they can keep dual coverage — without subsidies — but urges them to discontinue their marketplace policy since in most cases it duplicates their Medicare benefits.

Enrollees who do not follow that advice — and only the individual can terminate marketplace coverage in this situation — will have their subsidies cut. Inaction also means paying back any coverage assistance received after they should have joined Medicare.

Read the full article here.

The Ethical Stain on U.S. Medical Care

Bill Bestermann, MD, Medical Director at QualityImpact (COSEHC) Practice Transformation Network in Greenville, South Carolina, has spent the past few years training other physicians to optimize the care of patients with cardiometabolic disease. In a project sponsored by Louisiana Blue Cross, Dr. Bestermann worked with 700 primary care physicians to improve care and outcomes for patients with multiple risk factors. In 3.5 years, the percentage of hypertensive patients who achieved their goals rose from 47% to 67%, a 42.5% increase. Even more noteworthy, diabetics reaching their goals rose from 14% to 30%, a 114% improvement.

These results are clearly strong, no question. But most striking is that the treatments Dr. Bestermann advocates for are based on solidly established science. They have been disregarded, not because most physicians don’t believe in science, but because healthcare’s scientific foundation has been trumped by financial incentives. 

Dr. Bestermann’s most difficult ethical dilemma

A few days ago Dr. Bestermann shared a short response he had written to an ethics survey that, among other questions, asked this: “What is the most difficult ethical dilemma that you have faced in your career?” He wrote:

“A mountain of evidence shows that, in stable angina patients, optimal medical therapy (OMT) alone—simple application of proven drugs and lifestyle changes rather than surgical interventions—is as effective as OMT plus a stent. After a heart attack, OMT compared with usual care saves $22,000 per patient per year while reducing cardiovascular- and all cause-mortality 10-fold. In patients with type 2 diabetes, OMT reduces heart attack 4-fold, reduces stroke 5-fold, and reduces dialysis 6-fold. Louisiana Blue Cross has shown that, with the proper support, ordinary practices can easily produce OMT. Despite irrefutably strong evidence, financial incentives continue to dominate, framing bypasses and stents as answers.

The pervasiveness of inappropriate care is our medical system’s biggest ethical stain. We harm by delivering high-risk care that patients should not receive and by not providing the safe inexpensive care they should receive. This ethical collapse is everywhere, occurring every day in every state. We violate that fundamental medical aphorism ‘First do no harm!’”

This is a remarkable and heartrending statement, and all the more damning from a respected and field-experienced physician. It articulates the profound frustration of a doctor who puts patients’ welfare first, and whose confrontation with medicine’s “ethical collapse” is professionally and personally excruciating.

Read the full article here.

IRS Sets 2017 HSA Contribution Limits

Aside from a modest increase of $50 in the amount that individuals may contribute annually to their health savings accounts (HSAs) for self-only coverage, HSA-related limits for 2017 are holding firm.

In Revenue Procedure 2016-28, issued April 29, the IRS provided the inflation-adjusted HSA contribution limits effective for calendar year 2017, along with minimum deductible and maximum out-of-pocket expenses for the high-deductible health plans (HDHPs) that HSAs are coupled with.

These rate changes reflect cost-of-living adjustments, if any, and rounding rules under Internal Revenue Code Section 223.

“The contribution limits for various tax advantaged accounts for the following year are usually announced in the fall, except for HSAs, which come out in the spring,” explained Harry Sit, CEBS, who edits The Financial Buff blog. “Due to mild inflation and rounding rules, the 2017 HSA contribution limit for family coverage will stay unchanged.”

An HSA is always in an individual’s name. There are no joint HSAs, even when the HSA is linked to a family coverage HDHP and subject to the higher family coverage contribution limit.

Some employer plans include an “employee plus one” tier in addition to self-only and family coverage. An “employee plus one”—such as an eligible employee and her dependent child—would fall under the HSA family coverage limits.

Read the full article here.

Inside the Affordable Care Act’s Arizona Meltdown

When Affordable Care Act insurance marketplaces launched in fall 2013, Arizona seemed like a success. Eight insurers competed to sign up consumers, offering a wide variety of plans and some of the lowest premiums in the country.

Today, with ACA enrollment starting Nov. 1, Arizonans will find in most counties only one insurer selling exchange plans for 2017. Premiums for some plans will be more than double this year, some of the biggest increases in the nation. Only last-minute maneuvering prevented one Arizona county from becoming the first in the nation to have no exchange insurers at all.

A similar dynamic is playing out in other states’ exchanges, which are a critical centerpiece of the 2010 health law. About one-third of U.S. counties will have just one exchange insurer next year, up from 7% this year, estimates the nonprofit Kaiser Family Foundation, which studies health-care issues. In many cases, remaining insurers are seeking significant rate increases.

 look at what happened in Arizona shows problems with the design and implementation of the ACA, combined with early missteps by insurers. Some priced plans aggressively, angling for market share and betting special programs built into the law would protect them from losses. Those protections didn’t work as expected. Enrollees’ health-care expenses repeatedly overshot the projections of nearly all Arizona’s insurers. The result: a flood of red ink, then withdrawals and premium increases.

Read the full article here.

Estimates of Eligibility for ACA Coverage among the Uninsured in 2016

The Affordable Care Act (ACA) extends health insurance coverage to people who lack access to an affordable coverage option. Under the ACA, as of 2014, Medicaid coverage is extended to poor and near poor adults in states that have opted to expand eligibility, and tax credits are available for low and middle-income people who purchase coverage through a health insurance Marketplace. Millions of people have enrolled in these new coverage options, and the uninsured rate has dropped to the lowest level ever recorded.1 However, millions of others are still uninsured. Some remain ineligible for coverage, and others may be unaware of the availability of new coverage options or still find coverage unaffordable even with financial assistance.

This analysis updates national and state-by-state estimates of eligibility for ACA coverage options among those who remained uninsured. It is based on Kaiser Family Foundation estimates based on the 2016 Current Population Survey, combined with other data sources. We estimate coverage and eligibility as of 2016. An overview of the methodology underlying the analysis can be found in the Methods box at the end of the data note, and more detail is available in the Technical Appendices available here.

Background: How Does the ACA Expand Health Coverage?

The ACA fills historical gaps in Medicaid eligibility by extending Medicaid to nearly all nonelderly adults with incomes at or below 138% of the federal poverty level (FPL) ($27,821 for a family of three in 2016).2 With the June 2012 Supreme Court ruling, the Medicaid expansion essentially became optional for states, and as of July 2016, 31 states and DC had expanded Medicaid eligibility under the ACA. Under rules in place before the ACA, all states already extended public coverage to poor and low-income children, with a median income eligibility level of 255% of poverty in 2016.3 The ACA also established Health Insurance Marketplaces where individuals can purchase insurance and allows for federal tax credits for such coverage for people with incomes from 100% to 400% FPL ($20,090 to $80,360 for a family of three in 2015).4,5 Tax credits are generally only available to people who are not eligible for other coverage.

Read the full article here.