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.
Brill Is Back. On Monday, Steve Brill began a new column in Time with “Bungling the Easy Stuff,” a piece that details the government’s tardiness in implementing a rule intended to protect lower-income patients from predatory hospital billing practices. As Brill writes, under a provision of the ACA, nonprofit hospitals can lose their tax-exempt status for failing to inform lower-income patients of financial aid options and for using collections agencies and even lawsuits to force them to pay inflated “chargemaster” prices.
But as with all legislation, what counts are the rules that implement it. The rules for this provision, he writes, were not drafted and published in the Federal Register until late June 2012, more than two years after Obamacare became law. And at that point, the American Hospital Association, writes Brill, “complained—no surprise—that the drafted rules were too prescriptive.” No final regulations have been issued since, and “there are still no restraints on hospital bill collections or chargemaster charges for the neediest patients.”
With very occasional exceptions, the federal rulemaking process is not usually the stuff reporters cover or editors want. Consider much of the media’s gee-whiz reaction to the insurance cancellation letters this fall—it was as if reporters hadn’t paid attention to the grandfathering provisions of the ACA and the rules written to interpret them, which made those cancellations predictable. In the end, the outcry got ahead of sensible coverage.
But Brill’s column is a sharp example of how digging into these regulations can lead to stories that matter, even for a mass audience. And he flags another item to watch in the same column. A separate section of the ACA called for hospitals to establish and make public a list of their standard charges for items and services—the “chargemasters” that were a focus of Brill’s acclaimed “Bitter Pill” article. That provision should bring meaningful transparency to opaque hospital pricing. But here too, the Department of Health and Human Services has yet to write rules. An HHS spokesman told Brill the department had no update on a timeline for implementing the provision.
Not Grandma’s Insurance Any More. Earlier in December another Time writer, health correspondent Kate Pickert, took a hard look at what’s happening to health insurance provided through employers—the kind that 160 million Americans get. Guess what? Many of the same changes we’re seeing in the individual market policies sold on the new exchanges are mirrored in employer-based coverage. A series of gradual shifts are “beginning to accelerate,” Pickert writes, and, “No matter what you do for a living, you will increasingly be forced to think about health care the way you might think about getting a new car or television—as an engaged consumer, not a passive beneficiary.”
In other words, the consumer-oriented focus that undergirds the Affordable Care Act—and that was appearing across the insurance landscape before Obamacare—is making its way to employers’ HR departments. Pickert’s piece tied together a lot of threads in employer-based insurance, touching on the special private exchanges some businesses are using to reduce their costs, the so-called “Cadillac tax” on high-priced insurance that may make generous employer coverage close to extinct after 2018, and corporate wellness programs that encourage workers to meet certain health targets or pay higher premiums.
As with the rest of the ACA, these changes create winners and losers compared to the previous status quo. Reform supporters have an argument that the overall effect is positive. But one thing’s clear: changes are in the air. That means, Pickert writes, that Obama’s promise that people could keep insurance they liked “may have a hollow ring for those with employer-based coverage as well.”
Healthcare’s Stepchild. Like the federal rulemaking process, stories about dental care have rarely been high on any editor’s wish list. But we finally got a good one this week from Catherine Saint Louis of The New York Times. The article, headlined “A Gap in the Affordable Care Act,” reported that pediatric dental care is considered one of 10 “essential benefits” of insurance under the law, and according to one analysis three million children were expected to gain coverage. But the way the law is being implemented—those pesky regulations again—mean children’s dental coverage “has gone from a guarantee to a quote-unquote guarantee” in some states, one analyst tells Saint Louis.
The issue is that while dental coverage is sometimes “embedded” in a general health insurance policy, it is still often sold separately—and in some states, only “stand-alone” dental plans are available on the insurance exchanges. That shouldn’t necessarily be a big deal. But the IRS has ruled that stand-alone pediatric dental plans aren’t eligible for the subsidies that are designed to make coverage affordable for working-class and middle-class families. Stand-alone plans are also subject to separate out-of-pocket spending caps. These extra expenses may deter families from buying coverage. And because there’s no mandate for pediatric dental coverage in many states, the families that do buy plans are likely those that have higher dental costs, which raises premiums even further. That thing about a broad mix in the risk pool again!
According to Saint Louis, “more than a dozen senators and several advocacy groups” have asked the IRS to reconsider its decision on subsides for stand-alone plans. Sounds like another regulation for reporters to keep an eye on.
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