Health Care Sharing Ministries

Last week, Washington State fined one of the larger health care sharing ministries $150,000 and banned it from offering its product in the state because it was operating as an unauthorized insurer. Other states are warning consumers to watch out for these plans, which can look like insurance but are not.  Health care sharing ministries (HCSMs) are organizations in which members share common religious or ethical beliefs and agree to make payments to (or share) the medical expenses of other members.

The groups originated in the 1980s in small religious communities and were exempted from following coverage guidelines mandated by the ACA. An estimated 1 million people belong to a HCSM, up from 200,000 before the ACA was passed a decade ago. 

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Federally Qualified Health Centers Do It All

Did you know that 1 in 12 people rely on Federally Qualified Health Centers (FQHC) for health care?

What is a FQHC? It’s a community-based organization that provides comprehensive primary care and preventive care to all persons, regardless of ability to pay or health insurance status.

The care includes health, oral, and mental health/substance abuse services. FQHCs operate under the Health Resources and Services Administration (HRSA), which is part of HHS.

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Reductions in Medicare Hospital Readmissions: Real or Illusory?

Source: Lehigh Valley Hospital-Muhlenberg

Hospital readmissions pose serious risks to patients, especially to Medicare patients who are older and typically sicker than other patients. Hospital stays increase the risk of infection and medication error, put patients through physical and psychological stress (i.e. being woken up multiple times a night, falls on the way to the bathroom), and increase Medicare expenditures. Under the Hospital Readmission Reduction Program (HRRP) created by the Affordable Care Act, hospitals are penalized by Medicare if beneficiaries are readmitted (to any hospital) within 30 days of discharge. The goals of the HRRP are to:

  1. Improve care transitions
  2. Reduce the burden of readmission for Medicare beneficiaries
  3. Reduce the cost of readmissions to the taxpayer
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Thank U, Next: The 116th Congress Gets to Work

Image Source: Getty Images

The 116th Congress was sworn in at noon on Wednesday, January 3, 2019. The Senate remains under Republican control but the House of Representatives is now firmly in the grasp of the Democratic Party. How the business of legislating flows between the two houses remains to be seen, but it is fair to assume that health policy will be a focus for the new Congress. A Kaiser Family Foundation poll taken before the 2018 midterm election reported that seven in ten voters (71%) indicated healthcare as “very important” in making their voting decision. In comparison, 64% said the same about the economy and jobs, 55% about immigration, and 53% about tax cuts and tax reform.

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Time for More Health Policy Education in Medical School

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On a short study break, a classmate and I were discussing how the public health and health policy courses we took in graduate school influence our view of the healthcare system as medical students. It was the most productive form of procrastination (nerding out about public health and health policy) but it was also supremely frustrating to talk about all the problems in the healthcare system. The ACA was such a monumental step forward and now it seems like we’ve taken many steps back–only 34 states have expanded Medicaid, states are implementing work requirements for Medicaid, and Congressional Republicans have tried to repeal the ACA dozens of times with no real replacement or effort to fix the provisions that aren’t working well.

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The ACA Goes to Court Again (and again, and again…)

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I’ve been enjoying a few days at my parents house after an exam and it’s given me a chance to catch up on the nitty gritty health policy news of the past few months. And hoo boy, is there a lot going on. Congress might be in recess until after the election, but that doesn’t mean things are slowing down in the health policy arena!

Today we’re taking a look at two lawsuits that could have an immense impact on the future of the ACA. The Texas v. Azar lawsuit, which was filed in February 2018 by Texas and 19 other states, builds on the repeal of the individual mandate tax penalty by the Tax Cuts and Jobs Act of 2017. The lawsuit argues that because this tax penalty was reduced to $0 in 2019 by the 2017 tax legislation, the individual mandate will become unconstitutional. Since the ACA is dependent on the mandate, the lawsuit calls for the ACA to be invalidated by the court. After the U.S. Justice Department declined to defend the ACA in this lawsuit, Democratic state attorneys general from 16 states and D.C. were allowed to intervene on behalf of the law.

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The ACA & Medicare

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Medicare provides health insurance to nearly 57 million individuals (17% of the U.S. population) in three categories: those who are over the age of 65; those under 65 who receive social security disability insurance; and those under 65 with end-stage renal disease (ESRD). As described by the Commonwealth Fund’s Medicare at 50 Years series, Medicare beneficiaries are “the nation’s oldest, sickest, and most disabled citizens.” In 2013, 30% of Medicare beneficiaries were either over 85 or disabled and under 65. Seventy-five percent of beneficiaries have one or more chronic condition and 25% rate their health status as fair or poor.

Before the Medicare program, 48% of adults over the age of 65 did not have health insurance; that figure has fallen to 2%. The intentions of the Medicare program were and are two-fold: (1) ensure that beneficiaries have access to health care; and (2) protect beneficiaries from health care-related financial hardship. By the numbers, Medicare has been an immense success. Only 13% of older Americans now pay out of pocket for their health care costs (versus 56% in 1966). Medicare has also increased life expectancy at 65 by five years.

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Legal Timeline of the ACA

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On March 23, 2010, the ACA was enacted into law and quickly plunged into seemingly never-ending, ever-evolving litigation. If you’ve found our site, you’re most likely not a lawyer, which makes it a bit more challenging to understand how we’ve gotten to this point in health law as it regards the ACA. 

Two key points that every individual should know: (1) the requirement that every state expand Medicaid was deemed unconstitutional however, the U.S. Supreme Court (SCOTUS) ruled that states could opt-in to the expansion [34 states including D.C. have expanded Medicaid]; and (2) the individual mandate is constitutional and still the law of the land [the Tax Cuts and Jobs Act repeals the financial penalty for not having insurance, but does not repeal the language of the mandate].

Below are some of the big milestones in the ACA’s legal history.

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The Triple Aim

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The singular best assertion of the connections between health policy, clinical medicine, and public health comes from none other than Dr. Donald Berwick. As the former Administrator of the Centers for Medicare and Medicaid Services (CMS), former Vice Chair of the U.S. Preventive Services Task Force (USPSTF), a pediatrician by training, and dozens of other accolades, there is hardly anyone better versed in the interwoven web of medicine and policy. His expertise, coupled with experts in health care quality improvement and patient safety, resulted in The Triple Aim, a set of interconnected goals aimed at improving U.S. health care through political, rather than technological or biomedical, avenues.

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The Marketplace Olympics

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 Choosing a plan on the Marketplace is like the Olympics. After completing the Herculean task of actually selecting the best plan, you get rewarded with a medal. Or in this case, metal. Bronze. Silver. Gold. Plus an additional metal, platinum! All plans offered on the Marketplace must meet the Essential Health Benefits (EHB) standards created by the ACA.

The metal level refers to the amount of health care costs covered by the plan, called the actuarial value (AV).The ACA specifies that plans offered on the Marketplace must be at one of four levels of actuarial value: 60% (bronze), 70% (silver), 80% (gold), 90% (platinum). For example, a silver plan has an actuarial value of 70%, which means that the plan will pay 70% of the of the health care expenses, while enrollees will pay the remaining 30% through a combination of deductibles, copays, and coinsurance. The ACA also requires that plans have a cap on out-of-pocket expenses for enrollees. The current limits are $7,350 for an individual plan and $14,700 for a family plan. These out-of-pocket maximums are adjusted annually based on premium increases. Bronze plans typically have lower monthly premiums and higher out-of-pocket costs when an enrollee seeks care. In contrast, platinum plans typically have the highest monthly premiums and lowest out-of-pocket costs.

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