The splashy Obamacare media story of the week was Jon Stewart’s Daily Show interview with Health and Human Services Secretary Kathleen Sebelius Monday night. It was worth watching, even if not as sharp as The Daily Show’s 2012 sit-down with Sebelius; the secretary stuck to her talking points, never really giving a good reply to Stewart’s repeated questions about why the individual mandate isn’t being delayed like the employer mandate. (Business Insider’s Josh Barro takes a crack at a better answer here.)
But the continuing rollout of the insurance exchanges is in many ways a state and local story, and the much of the interesting coverage from the past week was in the states. Here’s a look:
A shout-out. Steve Koff, the Washington bureau chief for the Cleveland Plain Dealer, deserves kudos for his deep dive into the roots of recent budget cuts at the Cleveland Clinic, a major healthcare provider in the PD’s backyard —and also the region’s largest employer. In mid-September, the clinic announced that it was cutting as much as $330 million from its 2014 budget. Spokeswoman Eileen Shiel said that an early retirement package would be offered to about 3,000 employees in October, and layoffs may be in the works. “Healthcare reform has really changed things, and the burden of the cost is going to be falling on patients,” Shiel said at the time. “We want to make sure we can keep care affordable.”
The news prompted a lot of to-do about the consequences of Obamacare. But this week, Koff took a methodical, clear, objective look at the factors actually shaping the Clinic’s finances—and teased out the effects of the Affordable Care Act as it was passed, subsequent court rulings and state-level policy decisions, and long-term industry trends. He deciphered the “disproportionate share,” or DSH, payments some hospitals got under Medicare to help care for the poor. These will be reduced under Obamacare—but there have been further, larger cuts under sequestration and other congressional budget deals. Koff also discussed the fallout from the decision of many states—including Ohio, thanks to the Republican-controlled state legislature—not to expand Medicaid, which will deprive hospitals of an expected revenue source. John Graves, a health policy professor at Vanderbilt, told Koff that between the DSH money and the failure to expand Medicaid, roughly 20 to 30 percent of hospitals’ uncompensated care money is being cut.
And Koff also looked at another hospital worry: the new policies on the exchanges, especially the low-premium-cost bronze and silver models that many consumers are expected to choose, and that have been heavily touted by the Obama administration. These high-deductible, high-co-payment plans will leave patients on the hook for thousands of dollars after a hospital visit. With bad debt from insured patients’ unpaid bills already on the rise, that may mean the law will reinforce an existing trend. At the same time, Koff’s piece acknowledges, most patients will now have at least some insurance—which reduces the chance that a patients’ entire bill will go unpaid. So how that issue shakes out is a little ambiguous. Either way, the PD’s detailed take was the kind of behind-the-scenes look at stakeholder claims—and check on political rhetoric—that we need more of.
The return of “narrow networks.” The Kansas City Star’s Alan Bavley and Diane Stafford cast a critical eye on the policies offered by insurance companies in their region on the new exchange, focusing in particular on which of the area’s providers were in or out of network. Blue Cross and Blue Shield of Kansas City is selling versions of many plans with just seven hospitals in its network, rather than the 19 hospitals the carrier typically includes. Coventry, the only other seller in the area, has eliminated the St. Luke system but includes others. The reporters offered good context for readers to understand the trade-off between cheaper premiums for bronze and silver plans and the limited provider choices those plans offer, along with a debate among wonks and professionals about the costs and benefits of different approaches. One point often missed in the limited coverage of the narrow network issue is that narrow networks have been tried before, when HMOs became dominant in the 1990s. Back to the future, perhaps?
Sticker shock—for some. Tracy Seipel of the San Jose Mercury News examined another aspect of the new landscape—insurers are beginning to cancel individual market policies not grandfathered under the law. That means cancellation letters advising of higher prices for new insurance are in the mail, as Bay Area residents Cindy Vinson and Tom Waschura discovered. They told the paper they are big believers in the Affordable Care Act but “were floored last week when they opened their bills.” If they choose to enroll in the policies offered by their insurers, Vinson will pay $1,800 more a year for an individual plan, while Waschura will pay nearly $10,000 more for coverage for a family of four. The reasons: the new minimum benefits that policies must offer, plus annual medical inflation costs that companies would pass along with or without Obamacare. Health insurance expenses are also especially high in the Bay Area, in part because of reduced competition among hospitals. Then there’s the fact that the law is designed to reduce costs for sicker and lower-income consumers—a group that doesn’t include Vinson or Waschura, neither of whom quality for subsidies in the California exchange because their incomes are too high. Said Waschura:
“I really don’t like the Republican tactics, but at least now I can understand why they are so pissed about this. When you take $10,000 out of my family’s pocket each year, that’s otherwise disposable income or retirement savings that will not be going into our local economy.”
In its focus on the law’s impact on upper-middle-class households, the Mercury News article has some overlap with a Fox News segment we dinged last week—but done with much more balance and context. Whether there will be backlash from other relatively high-income folks—and how they respond—will be a story to watch.
Opening shots for 2014. If you doubt that Obamacare will be an election year issue again in 2014, check out a report this week from the Omaha World-Herald. Well-funded political newcomer Ben Sasse is one of four Republicans vying for a Senate seat being vacated by Mike Johanns, and the paper reported that at his official kick-off event, Sasse delivered this line about the Affordable Care Act: “If it lives, America as we know it will die. If the idea of America is to live, it must be stopped.” How exactly the country would “die” from a healthcare reform measure wasn’t pinned down in the story, though Sasse did say the law created a “dependency culture” and “insinuates” government into every aspect of American life.
Reporters covering politicians who offer this sort of rhetoric might want to ask them to grapple with a point made recently by Avik Roy in the conservative flagship National Review: long before Obamacare was passed, the government was pretty thoroughly “insinuated” into healthcare policy.
The World-Herald article did note that Sasse pledged to talk more about “patient-centered health policy solutions” to replace Obamacare. If he proves to be a serious candidate, we hope the paper holds him to this promise—and carefully probes this rhetoric.
Looking ahead. The focus so far has been on the technical glitches at the federal exchange’s website, but the navigator story is a good one to jump on. It’s not too soon to take a deep dive into how navigators—the people who are supposed to guide consumers through the new marketplace as they search for the right policy—are faring. Where do people find them? Are they accessible to everyone? Are they missing in some areas? How good a job are they doing? Reporters: find a candidate for exchange coverage and observe him or her going through the process of talking with a navigator and signing up. It’s the best way to answer the question.