As we head into the second Obamacare open enrollment season, the media have a chance to redeem themselves from last fall, when skepticism was sometimes left at the door and coverage was dominated by website screw-ups, cancelled policies, presidential false promises, and anecdotes that blew up under scrutiny. All of this noise drowned out the crucial point: what do people really need to know about how to choose–and use–an insurance policy.
When the exchanges re-open on November 15 and in the weeks that follow, reporters should not lose sight of these key questions: How are consumers faring as they sign up on the federal and state exchanges? How are they faring as policy-holders and patients? Is the Affordable Care Act making healthcare affordable (“for many, yes, but not for all,” concluded The New York Times this week) or adding new cost barriers? Among privately insured adults, 19 percent said they did not go to the doctor when they were sick or injured because of costs and 29 percent of those with high deductibles didn’t seek treatment, according to a recent AP-NORC Center for Public Affairs Research poll funded by the Robert Wood Johnson Foundation. There’s a lot going on here. What follows are six areas to probe as open enrollment Round Two begins.
Scrutinize rates and premiums As I’ve reported, basing a story on average rate increases doesn’t cut it as good consumer information. What people need to know is what they actually pay, and whether it’s more or less than last year for exactly the same coverage. That means they have to know the deductible, out-of-pocket limits, copays and coinsurance amounts and what they apply to. An insurer may appear to offer the same silver plan but may have tweaked the coinsurance. An outpatient procedure with some pricey diagnostic tests and coinsurance of 20 or 30 percent could leave someone with a much higher out-of-pocket expense than the policy with a higher premium. Last year, I interviewed a Pennsylvania woman who kept her old Aetna policy because it had no general deductible, but it also had $600 copays for hospital stays and a $1,500 deductible for brand drugs. To really help your readers out, you need to show the interplay between all the elements of an insurance policy and discuss how much risk shoppers are willing to assume.
Rates have been super politicized. Beware of slipping into a political piece about averages with the vested interests touting high or low rates to suit their point of view. Keep an eye on states where rates seem very low and insurance officials are eager to tout the news.
Examine narrow networks These networks have become the cost containment method of choice, since the government doesn’t want to negotiate prices of medical services with providers the way most other countries do. Reporters need to probe the consequences, because the resulting choices for consumers aren’t clear, consistent, or easy to navigate. Insurers allow policyholders to see only providers who’ve agreed to prices the insurers want to pay. Going out-of-network means patients pay most or all the bill themselves. Finding out if your doctor is in the network–the standard advice in those “shop around” stories–doesn’t guarantee patients will be spared large medical expenses. Lots of patients have followed that advice only to find an in-network doctor is not taking new patients, or they’re stuck with big bills from out-of-network docs working at in-network hospitals.
One great way to help keep tabs on the shifting provider lists is to construct a database of doctors, as Los Angeles Times reporter Chad Terhune and his colleagues did in California. If reporters can’t do that, Terhune suggests calling local providers and insurers to see if they both agree they’re in a particular plan and then reporting any mismatches.
Check out other cost-shifting tricks On Sunday, New York Times reporter Elisabeth Rosenthal detailed how, “as insurers and providers fight over revenue in an era of cost control, patients often find themselves caught in the middle, nickel-and-dimed.” Hospitals have been tacking on “facility fees” to patients’ bills for a while now, but Rosenthal found another one, the “noncritical activation fee” for calling a trauma team into action. On the doctor side, she found ophthalmologists charging special refraction fees. If patients don’t write a check for these fees, docs withhold prescriptions for glasses.
Is this a new form of unbundling services, coming at a time when the ACA aims to move the financing system in the direction of more inclusive payments? Pointing out this contradiction will help with context, but why not call a bunch of providers in your area and ask if these new fees are cropping up and how much they are. And while you’re at it, look at the new tiering arrangements for generic drugs that are part of The Great Cost Shift. Insurance drug benefits now call for two tiers of generics–one preferred and one non-preferred, an arrangement similar to that for brand drugs, which require more cost-sharing from patients. Non-preferred generics can now require higher copays or coinsurance for patients who had much lower out-of-pocket costs when there was only one tier for all generic drugs.
Investigate the experience of last year’s shoppers What’s happened to those who shopped the exchanges last year? If you wrote about some, revisit them and see what they plan to do for this year. How did they use their coverage? What care did they get? Did they stay in the exchange? Whether the people you check back with ended up buying a policy or not offers a window into what’s happening in the insurance market. In late September, Colorado Health News reported that exchange managers expect to lose about 30 percent of enrollees due to attrition by year’s end. Why did people drop out and what will they do this year?
Interview people and see where insurance premiums–even with subsidies–fit into family budgets. One New York woman shopped the New York exchange several times, completed an application, but kept her insurance from the Freelancers Union because she said she wasn’t confident about what the exchange plans were offering. This year she will have to buy new coverage because the Freelancers pulled out of the market. Company officials said because of Obamacare requirements, they needed a 14 percent rate increase across the board and that ran counter to the aims of the organization.
Look into “skinny” plans These haven’t gotten much attention, but they should, because some small and large companies will offer them this fall. Employers can satisfy the ACA employer mandate by offering at least one plan that meets baseline requirements. They can also offer other plans, including these “skinny plans,” that don’t. While the ACA was supposed to make these plans obsolete (they were called mini-meds ), the newer versions still have traction among employees who don’t want to or are unable to spend much of their paycheck on insurance.
In August, the National Business Group on Health surveyed large employers and found 16 percent planned to offer “skinny plans.” Typically they cover preventive care, primary care, prescriptions, and pay for a fixed number of doctor visits, says Steve Wojcik, vice president of public policy at the Business Group. What they don’t cover are hospital visits. “It’s not extensive coverage,” he said. Which employers in your community are offering them and which employees are choosing them? Profiling some of these workers and discussing what they understand about the risks of being uninsured for big ticket medical care would make for some interesting stories that get to the heart of the ACA’s affordability questions. Unless workers pay more than 9.5 percent of their income for their employer coverage, they can’t receive subsidies in the exchange.
Revisit Medicaid. Over the months we’ve urged reporters to look at those people left out of the Medicaid expansion–some 4.8 million in the 23 states that have declined to bring new recipients onto the rolls. Yet at the same time, Medicaid has been one of the ACA’s successes, responsible for some 7.5 million sign-ups. Both threads provide opportunities for reporters. As Al Jazeera America showed recently, the human cost of not expanding Medicaid is substantial and the stories of those disenfranchised from the health care system are poignant.
But being on Medicaid can also be no picnic, and the stories of what people on the program experience also make for worthwhile reporting. Virgil Dickson of Modern Health Care has reported on the skin-in-the-game approach requiring recipients to make small copayments for services, which can be too onerous for those with very low incomes, and many newly enrolled beneficiaries are getting little or no guidance from states about the services they’re eligible to receive. If they don’t know what they are entitled to receive and have trouble paying for those services, is the ACA living up to its promise?
The task for reporters is to make sure people understand how to use the law and to point out where it falls short.
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The Great Cost Shift comes into focus
Trudy Lieberman is a longtime contributing editor to the Columbia Journalism Review. She is the lead writer for CJR's Covering the Health Care Fight. She also blogs for Health News Review and the Center for Health Journalism. Follow her on Twitter @Trudy_Lieberman.
