AIDS patients in limbo, Latino sign-ups lag, and other ACA shout-outs

Our healthcare expert shines a light on some strong recent coverage

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.

It’s tough to sign up for Obamacare if you’re Latino. In coverage of the Affordable Care Act, we’ve sometimes forgotten who the law is for. First and foremost it’s for people with low incomes, as Drew Altman, head of the Kaiser Family Foundation, pointed out in my post Wednesday.

And lower-income Latinos may be of particular importance for the bill. Latinos are the largest uninsured ethnic group in the country, so getting Americans covered means getting Latinos covered. They are also younger and thus healthier than the rest of the US population, which makes them attractive to insurance companies and state exchanges. As PBS’ News Hour reported last week, “both here [California] and nationally, Latinos are considered key to the overall success of the Affordable Care Act.”

But as the News Hour made clear, success is proving elusive. Its piece was a good one, detailing the barriers Latinos in California face, and moving beyond the press releases from Covered California, the state’s exchange. The News Hour visited La Clinica De La Raza in Oakland, where CEO Jane Garcia said it was not a big surprise that people in the community don’t always understand what a deductible or a copay is. La Clinica’s staff has provided help to some 900 patients filling out applications, but only about 25 percent have actually enrolled. The reasons for the poor enrollment range from the application not being made available in Spanish to less-than-stellar customer service at Covered California. But as important as these translation and customer service issues may be, something else is going on.

Garcia said patients are often reluctant to reveal information about undocumented family members during the enrollment process. Many families have mixed immigration status, Garcia explained, only citizens and legal residents can get healthcare under the Affordable Care Act. It’s no surprise, then, that as families get further into the enrollment questions, they don’t complete the application. Families worry that information they share on an insurance application could be used against them for immigration purposes. What’s needed, Garcia believes, is for a high level government official to make some reassuring remarks that applying for insurance won’t negatively affect a family member’s immigration application. “I think that would go a long ways toward easing people’s minds,” she said.

The News Hour put a lot of unreported threads on the table. The New York Times has just picked up the story too, but there’s more here waiting for other journalists.

What facility fee? Connecticut Mirror health reporter Arielle Levin Becker reported on the latest twist in efforts by the state’s hospitals to extract more dollars from patients. In the last few years, “facility fees” have become common. As Becker explained in an earlier piece several months ago, these fees are charged to patients who receive procedures in a doctor’s office owned by a hospital or who use hospital-owned equipment. These fees are on top of the doctor’s bill for their services—and they can cost thousands of dollars. What’s worse, patients often don’t know about these fees until they get their bills.

On Wednesday, Levin Becker reported on recommendations by the Connecticut Hospital Association for more transparency, including a proposal that member hospitals give patients specific information about these fees if they get care at a hospital-owned medical office. State Attorney General George Jepsen praised the trade group’s effort, saying it was the first of its kind in the country, but added he will continue to pursue legislation requiring hospitals to tell patients about these fees before arriving at the facility. Victoria Veltri, the state’s HealthCare Advocate, agreed, saying making fee information available beforehand would give patients a “full and fair choice on where they choose to get their health care.” She recommended consumers ask their insurance carriers whether these fees are covered. “Not all plans cover these fees, and consumers should be able to go to a facility knowing whether they might be facing significant out of pocket costs.”

This story presents a familiar dilemma: Are voluntary efforts from industry sufficient, or do we need laws with teeth? But there’s more. This is healthcare we’re talking about, not a credit contract, a point Levin Becker touched on this as she set the context for her piece. Why are such fees necessary in the first place? Hospitals say facility fees reflect overhead costs of the doctors’ practices and high standards such practices must meet. Veltri says they inflate the cost of care. She hinted there may be bigger fish to catch in the regulatory net, and she would prefer to see more transparency in how hospitals set their fees. So would Time’s Steven Brill, The New York Times’ Elisabeth Rosenthal, and other commentators who have examined why healthcare costs so much. Facility fees, then, may be a reportorial entry-point into a much bigger problem. We hope Levin Becker stays on the case.

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Trudy Lieberman is a longtime contributing editor to the Columbia Journalism Review. She is the lead writer for The Second Opinion, CJR's healthcare desk, which is part of our United States Project on the coverage of politics and policy. She also blogs for Health News Review. Follow her on Twitter @Trudy_Lieberman. Tags: , , , , ,