From time to time this space will offer a roundup of interesting, well-done, and useful stories about healthcare and health policy, including, of course, the Affordable Care Act. Sometimes they will offer leads for others to pursue; sometimes they will focus on under-reported topics; and sometimes they may simply deserve a shout-out for exceptional reporting or writing.
Your check’s no good here. So says Blue Cross and Blue Shield of Louisiana, which turned away hundreds of people with HIV/AIDS in the state who thought they had purchased policies with the carrier under the Affordable Care Act. That news came via a scoop from Reuters’ Sharon Begley and Julie Steenhuysen, who presented a fresh look at the inner workings of Louisiana’s state insurance apparatus.
In November, the federal Centers for Medicare and Medicaid Services warned hospitals and insurers that it had “significant concerns” about supporting third-party payments for premiums, deductibles, and other costs, citing fraud risks. That meant, Blue Cross argued, that it couldn’t accept funds from the Ryan White program, which was created by the federal government in 1990 to help HIV/AIDS patients pay their insurance premiums and purchase AIDS drugs—even though in September, the federal government specifically said Ryan White funds could be used to cover costs for Obamacare exchange plans.
Begley and Steenhuysen checked in with CMS again, and were told the Ryan White funds could indeed be used to pay premiums for exchange plans when that use could save the program money. A Reuters follow-up the next day reported CMS is now thinking about requiring insurers to accept the funds. Blue Cross didn’t immediately respond to Reuters’ request for comment on the government’s latest statements.
The Louisiana story will be an angle for reporters there to follow. But the Reuters team may have stumbled on to something bigger: insurers’ potential use of tactics to limit who they insure. The new Obamacare rules require insurers to take all comers—even the very ill, like some patients with HIV/AIDS. Advocates for patients with diseases likely to produce high claims and big hits to the insurers’ bottom lines have worried for awhile that insurance companies would get creative in excluding them from coverage.
Blue Cross denies that anything like that is happening here, but Begley and Steenhuysen got a hold of an email from a Senate aide, who wrote: “BCBS LA told me their decision was not due to the CMS guidance or any confusion (as we thought before) but was in fact due to adverse selection concerns.” Whatever the truth about motives here, if insurers do try to pick and choose customers, this coverage shows that limiting third party payments may be one way.
Too little choice; too little oversight? Anna Wilde Mathews and Christopher Weaver of The Wall Street Journal dug around a bit as good reporters do and expanded the usual reportage about the narrow provider networks in those exchange policies. What did they find? A lot of déjà vu. Dial back to about 1997, when consumers realized they didn’t like HMOs telling them which doctor they could see. The docs didn’t like the restrictions either, fearing their patients would go elsewhere, and state legislatures rushed to pass “any willing provider laws” that let every Tom, Dick, and Harry be part of an HMO’s network. Insurers grumbled they could no longer control the quality of care their doctors delivered—though it wasn’t really clear that the insurers were picky about quality to begin with.
Fast forward to the present. Mathews and Weaver reported Mississippi, Pennsylvania, and other states are wrestling with bills that would force health plans to add more hospitals and doctors to their networks, and the feds have proposed a tougher review process for providers included in health plans sold next year. Some of this is a response to consumers who don’t like losing their doctors. A 37-year-old New Hampshire man told state regulators he would have to drive some 40 minutes to the nearest hospital. The new plans didn’t include his current doctors.
It remains to be seen how hard insurers will fight back. A spokesman for the industry trade group America’s Health Insurance Plans gave the standard line: Narrow networks are a way to keep cost increases in check. A WellPoint spokesman was more detailed about New Hampshire. “Insurance plans would cost about 30 percent more if they didn’t have a limited networks.” In other words, insurers still want to control their doctors and hospitals, and the doctors and hospitals don’t want to be controlled. It will be a continuing story the Journal has nicely mapped out.