Some highlights and observations from the coverage of week three of Obamacare’s rollout:
Double shoutout. “The Unfulfilled Promise of Obamacare” by Time’s Kate Pickert (paywalled), and “National health care comes up against a very sick state,” by the Reno News & Review’s Dennis Myers, share last week’s shoutout.
Pickert offered Time readers a clear look at the Medicaid dilemma—that is, that the poorest of the uninsured won’t receive subsidies in the exchanges because their states opted out of the Medicaid expansion called for by the Affordable Care Act—and the opposition, by government officials in states that have opted out, to the rollout of Obamacare. In Florida, Gov. Rick Scott has blocked navigators from enrolling people at county health departments; in Missouri, the lieutenant governor advised residents not to sign up; in Texas, the insurance department said it would not enforce insurance rules set by the law; in Georgia, the insurance commissioner has said his department will do “everything in our power to be an obstructionist.” Time concluded that the “federal law will look very different depending on what part of the country you’re in.” Indeed it might, and Time showed how it looks for one woman in Texas.
Pickert told the story of Nicolette Cooksey, a part-time worker at a Houston day care center whose employer caps her hours at 19.5 a week—under its own 20 hour threshold so it doesn’t have to provide health insurance. She is also the mother of an autistic child and owes some $13,000 in medical bills she can’t pay on her salary of $8.10 an hour. “If I want anything in life I have to pay my medical bills first,” she said. Obamacare was to make this a thing of the past for her and others in similar predicaments. She is one of 1.7 million Texans without insurance, a number that gives the state the dubious honor of having the highest number of uninsured in the nation. Pickert noted that many local clinics that treat people like Cooksey receive federal funding which they are happy to take, a contrast with the governor who has declined federal dollars to expand Medicaid.
The health law pumps some $11 billion to what are called federally qualified health clinics to help treat the uninsured—a drop in the proverbial bucket compared to what’s needed, a point not often noted by reporters. Cooksey’s clinic, owned by Legacy Community Health Services, has grown. So have others in Houston. Harris Health, the county health care system, was expecting that some 400,000 annual visits would have been covered by Medicaid. According to Harris CEO David Lopez, even with more new clinics, the system won’t be able to meet the needs of Houston’s uninsured. Many will have to wait for care. “Honestly, we can double our volume today, and it still won’t be enough,” Lopez says. The story of where the poorest of the uninsured, now excluded from Obamacare, will get medical help will be a continuing story for years. Time has shown how it can be done, and done well.
For the Reno News & Review, Dennis Myers took a refreshing look at a another topic often ignored by the media. He reported on the poor health conditions in Nevada and what are commonly called the social determinants of health—things like poverty and income, housing, food, jobs. He wrote:
Nevada is a medical mess. It has become a local cliché to say that the Silver State is at the top of every bad list and the bottom of every good list. That problem has just been dropped on the federal doorstep.
To offer a flavor of what he meant, Myers noted the state’s minors are the most uninsured in the country. There is a shortage of doctors and nurses, and, Myers wrote, “in any other state, the Nevada mental health system would be a scandal.” He did point to a few improvements in rates of teen pregnancy and immunizations after the state embarked on educational campaigns. But, he noted, Nevada has rarely invested in such educational endeavors, and “The Affordable Care Act isn’t in the business of changing infrastructure, of creating programs or building facilities or training healthcare providers.” So can this law, Myers asked, “merely by providing insurance, upgrade a state that could easily be named Downgrade?”
Poverty and how much healthcare the working poor can afford compound the state’s weak health report card. To drive home these points, Myers wove in an interview with Dr. Mary Guinan, who served two stints as the state’s health officer. Guinan said early in the health reform debate that Congress was not constructing a healthcare program but a health insurance program. Myers asked her if her experience dealing with the state’s “deep-seated and seemingly unsolvable healthcare problems has shown that the new health law will cure the state’s problems or contribute to easing them?” Myers wrote:
It was the only moment when the ever optimistic Guinan sounded at all discouraged. She sighed, then said, “I don’t know. I’m hoping that it will, because access to healthcare has been a terrible problem for Nevada.”
And that, dear colleagues, is the thread to follow as Obamacare continues its rollout.
The Tennessean’s unhelpful premise. With a “Navigating health reform” landing page, The Tennessean offers information for readers to help them get the gist of the new law, and uses a common approach—chunking facts into boxes. There is an “Ask A Question” box, offering health reporter Tom Wilemon’s email address. There’s a “Health Care Expenses” box, linking to a database the paper created on hospital prices. There is a “Subsidy Calculator,” a nice dollars and cents translation of how much subsidies would be worth to families with different incomes along with what their maximum out-of-pocket costs would be. And, there are two boxes detailing health reform’s “winners” and “losers.” The “winners” include people with preexisting conditions and those with incomes between $11,490 and $45,960 who qualify for subsidies. The “losers,” per the paper, are the richest who will pay more taxes and the poorest who won’t benefit from Medicaid expansion, as Time and others have reported.
After being in Canada for several weeks examining Canadian healthcare, I am struck at the inappropriateness of this “winner, loser” frame, and how it contributes to the misunderstanding of what the ACA does (calls for a modest amount of wealth redistribution) and doesn’t do (provide much equity in healthcare). The notion of “winners” and “losers” might help fuel the backlash against the law. In a post two weeks ago, I noted that the wealth redistribution the law calls for is not well understood, including by those groups who are taxed or will pay more to fund the subsidies. It’s time to ditch the inflammatory concept of “winners” and “losers,” even if it means using more words to tell a more complete story.
Deciphering the deductible trade-off. Chicago Tribune reporter Peter Frost offered a thoughtful and balanced take on the trade-offs people face when shopping in the exchanges—something we’ve been urging reporters to do. The Trib analyzed policies that insurers will be offering on the Illinois exchange and found that 21 of the 22 lowest-priced plans offered on the exchange for Cook County will carry deductibles of more than $4,000 for individuals and $8,000 for families. Frost cut through the pre-enrollment debut spin about those premium plans in the exchanges.
He interviewed some Chicago-area insurers and brokers who were pretty blunt about what consumers will face. Said Dave Stumm, executive vice president at Stumm Insurance, a Chicago-based brokerage: “Yes, rates are really low, but that’s like saying ‘Here’s a free car,’ but if it costs you $500 a month to run, it’s not really a free car.” Frost also reported on the problem of narrow networks—at least a problem for some consumers who want a broad choice of providers. Narrow networks may be the price shoppers pay for lower premiums. So where does all this leave consumers?
For that answer, Frost consulted Karen Pollitz now of the Kaiser Family Foundation. Pollitz once worked in the Office of Consumer Information and Oversight at the Department of Health and Human Services and knows the insurance business well. Frost noted that people who don’t qualify for subsidies or very large ones and have little savings might suffer if illness strikes. “They could get slammed,” said Pollitz. “They just won’t have the money. They just won’t.” That won’t be much different than things are now for people who can’t afford the cost sharing their policies demand.
Tip for doing shopping and trade-off stories. Remind audiences of a disclosure statement that might help them understand the deductibles and other cost sharing required by policies. It’s called the Summary of Benefits and Coverage. Insurers are not required to provide it, but shoppers have a right to see it if they ask. Given how confusing the whole task is, it’s a good idea to ask.
Looking ahead. I was speaking at a grand rounds lecture at a Toronto hospital last week, and a man asked about what Obamacare does for prevention. That question prompted me to think about what happened to the prevention fund called for by the Affordable Care Act. Health and Human Service Secretary Kathleen Sebelius borrowed $13 million from a fund set aside for disease prevention and is using the money for grants to organizations that will train navigators. This is a good one for eager-beaver reporters to explore. What prevention programs will lose funding, at least in the short term? What effect might that have on patients? When will the loan be repaid and how will the navigator program be funded in the future given the emphasis on budget cutting? Was enough money allocated for both programs in the first place?
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