Healthcare regulation by exposé

Subscribe to xpostfactoid via box at top right (requires only an email address; you'll get 2-3 emails per week on average)

It's been said that shaming by journalists doth not a regulatory regime make. But in 2019, national healthcare reporters are giving it a go.

Back in January, Sarah Kliff, then at Vox (now at the NYT), reported that Zuckerberg San Francisco General Hospital, a go-to destination for trauma victims, did not accept any private insurance plans. Every private who enters the hospital gets balance billed (or did at the time of writing) -- often for tens of thousands of dollars. The stories were vivid and egregious.

The next shoe dropped in April:

Zuckerberg San Francisco General Hospital announced Tuesday it has overhauled its billing policies, a move that comes three months after a Vox story drew national attention to the hospital’s abnormal and aggressive billing tactics.

Do we have to repeal the ACA to find out what's in it?

No one is claiming that the ACA led us into health access paradise. The ACA marketplace and wider individual market as open enrollment for 2017 began. But they were (and are) troubled markets, in need of adjustment, e.g. along lines sketched by scholars at Georgetown and the Urban Institute. The networks keep narrowing, premiums and out-of-pocket costs have spiked, and choice has narrowed in many markets. The roughly half of marketplace enrollees with strong Cost Sharing Reduction subsidies are partly but not wholly insulated from this deterioration.  Those who are unsubsidized or lightly subsidized have in many cases been hit hard.

The Medicaid expansion has been a clear boon to those who gained access through it, as well as to state budgets, state economies, state public health, and access to drug treatment. It's also, to some extent, highlighted the law's political weakness, apparently triggering a fair amount of Medicaid envy and resentment among the somewhat more affluent and the fact that the ACA's most direct beneficiaries are generally the poor and near-poor.

As mentioned in a prior post, I have a piece shopping that spotlights very mixed experiences of unsubsidized marketplace enrollees with pre-existing conditions -- grateful for access but dealing with rising costs.

Another piece relaying a wide variety of experience and perception, by Jay Hancock of Kaiser Health News, is a striking contrast to the polarized praise/denunciations that used to be common fare in ACA coverage. There is a really striking degree of nuance in these mostly Republican reflections, as well as a refreshing awareness in some cases of the ACA's different component parts. If nothing else, the rough number of people who have gained insurance through the law seems finally to have been hammered home. I hope Hancock doesn't mind my extracting all of the article's citizen testimony, as I do think it has a strong cumulative effect:

An add-on health benefit for same-sex couples who marry

Jay Hancock of Kaiser Health News notes that the Supreme Court decision granting same-sex couples the right to marry in any state is likely to boost employer coverage of same-sex couples:

The logic is simple. Fewer than half of employers that offer health benefits make the insurance available to same-sex partners who aren’t married. Virtually all of them offer coverage to spouses.

By marrying partners with employer health plans, people in same-sex relationships are likely to get coverage in states that banned gay marriage until now, as well as in those that welcomed it. Thanks to rapidly shifting legal ground, 37 states recognized gay marriage before last week’s ruling, up from nine in 2012.

Footnote: as-yet-unmarried gay employees whose employers do currently offer health insurance to partners will, if they marry, be able to get that coverage on a tax-free basis.

Employers, HSAs and the ACA

Jay Hancock at Kaiser Health News reports that significant numbers of small businesses may stop offering health insurance to their employees, sending them instead to the ACA exchanges. This could be a good thing for employees who earn little enough to qualify for strong ACA subsidies -- win-win for employer and employee at the federal government's expense.

According to the Kaiser Family Foundation, small employers in 2014 paid an average of nearly $5,000 for solo coverage and a bit more $10,000 for a family premium. What if an employer wants to compensate employees for dropping a benefit that constitutes such a large share of their compensation?  There's a problem with straight salary increases: they reduce employees' ACA subsidies and so give a portion of the extra income back. At healthinsurance.org, I examine three scenarios in which a pay hike worth about 70% of a typical employer premium contribution triggers subsidy reductions ranging roughly from about 25-- 80%.

An employer who really wants to help employees can avoid this problem by getting creative about compensation.  One striking way to do so would be to fully fund Health Savings Accounts (HSAs) that employees can use with HSA-qualified plans on the exchanges. Here's how I described the possibility in the healthinsurance.org piece:

Having some health insurance is better than having none. But American insurance...

Those of us engaged in the long struggle to pass and implement the ACA have (not wrongly) fixated on how vital it is to have health insurance, and we've been cheered by the roughly 25% reduction in the nation's uninsured in the ACA's first year. We've also celebrated the ACA's ending of arbitrary policy rescissions, yearly and lifetime coverage caps, medical underwriting, and plans lacking essential benefits like childbirth and drug treatment.

Some coverage is better than none. But recent good reporting is also highlighting the extent to which much if not most health insurance in America remains inadequate, exposing plan holders to sometimes substantial, sometimes damaging and sometimes ruinous costs. The incidence of such exposure may be rising rather than falling, as employers continue to offload the cost of care onto employees.