How about a national reporter hotline for Coronavirus balance billing?

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It's been a running joke on healthcare Twitter for some time that Americans' best defense against egregious surprise billing and relentless hospital debt collection is to call a reporter.

With Sarah Kliff (now at the NYT) crowd-sourcing outrageous emergency room bills at Vox and Kaiser Health News maintaining a Bill of the Month series, there's been saturation coverage of these practices that render health insurance effectively illusory for tens for millions of Americans.

With almost comic frequency, ERs caught out billing patients thousands for minimal work and hospital systems exposed for suing thousands of low income patients have forgiven bills or announced that they are changing their dunning practices after being exposed in the national press. For example....

Zuckerberg San Francisco General rolls back a $20,000 ER bill sent to an insured patient after a bicycle accident -- then reviews its practice of balance-billing every privately insured patient brought to its doors. A behemoth dialysis provider cancels a half-million dollar bill. A week after KHN's Jay Hancock reports that University of Virginia has sued 36,000 patients, garnished thousands of paychecks and put liens on homes, the hospital admits it was too aggressive and revamps its financial aid guidelines. Just today we learn that another predatory debt collector in Virginia, VCU Health, will stop garnishing wages and putting liens on people's houses.

Healthcare regulation by exposé

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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.

What to expect when Democrats are weighing single payer

Last week, Kamala Harris was asked about her support for single payer healthcare and responded, with respect to employer-sponsored insurance, "let's eliminate all that. Let's move on." Then Cory Booker was asked an imprecisely worded question  -- would he "do away with private health care" --  and gave an equally imprecise answer (no..) that left ambiguous whether health care or health insurance was under discussion. Ever since, warnings have been percolating on healthcare Twitter against framing single payer as all-or-nothing -- no more private insurance, or no Medicare for all.

Now cometh Sarah Kliff to inject some nuance. One point: "even countries we think of as single-payer still have some level of employer-provided health insurance." In Canada, everyone has "Medicare" -- fairly comprehensive insurance in which government (provincial and federal) does pay the providers. But most people also have employer-provided supplemental insurance to cover prescription drugs, dental, vision, and/or other services not covered by Canadian Medicare.

Another point: whether a transition away from private primary insurance in the U.S. is successful depends mainly on what people are asked to transition to:

Transitioning half of all Americans from one type of health insurance to another is no-doubt a huge undertaking. But whether or not it’s successful, I think, rests on what kind of coverage is on the other end. If it’s a government plan where Americans feel like they can afford to go to the doctor, then I’d expect any frustration with the transition to eventually dissipate. If it’s a government plan where co-payments and deductibles are high — especially if they’re higher than employer-sponsored coverage — then frustrations would almost certainly only grow over time.

Quite so. But I'd like to add some nuance to the nuance, on a couple of fronts.

Managed Medicaid for all? A compendium

In an illuminating string about what she's learned from ACA enrollees, Sarah Kliff highlights a point that's come sharply into focus in the last year:

Medicaid is *way* more popular than marketplace plans. No deductibles or co-pays! (6/15)

This point has been driven home by enrollee surveys and focus groups as well as by good reporting from many, including Kliff. The negative counterpoint to Medicaid enrollees' satisfaction is Medicaid envy among those forced to pay more than they consider affordable in premiums and out-of-pocket costs -- particularly those on the wrong side of the ACA's deductible cliff.

"What have you got to lose?" -- Republicans' latest lie about the ACA

As they gear up to repeal all or part of the ACA, Republicans in Congress are coming out with a new (or recycled) lie about the benefits they'll be taking away, with or without a replacement. The lie has some basis in truth, but it is a gross distortion.

Here's the ur-iteration as voiced by Sen. Johnny Isakson, R-Georgia, to Politico's Jennifer Haberkorn, who asked Isakson what might become of the roughly 20 million people who have gained coverage through the ACA. His response:

Most of those 20 million got bronze policies with a great big deductible and not much insurance, so I don’t know that there’s going to be a big backlash,..There are some minefields out there but we can deal with them.

In a note, Politico points out that "most people on the exchanges choose silver plans, which provide a higher level of benefits." But that only clears one level of the mendacity expressed here.

For starters, more than 60% of those who gained coverage through the ACA did so via the Medicaid expansion (though not in Isakson's Georgia, which has refused to implement it). Medicaid generally has no premium and covers all, or very close to all, out-of-pocket expenses. People who have obtained Medicaid coverage through the ACA express high levels of satisfaction -- 88% of new Medicaid enrollees were satisfied with their coverage, according to the Commonwealth Fund's 2016 tracking survey.

Two reasons the proportion of young adults in ACA marketplace may be rising

Sarah Kliff has marshaled good evidence that the individual mandate is working over time to pull more young adults into the ACA marketplace. As the penalty ratchets up each year, the proportion of young enrollees increases. The evidence in brief: 1) that's how it worked in Massachusetts; 2) young adults identify the mandate as a chief motivator in polling data; 3) HHS and Enroll America have brought the mandate to the fore in marketing messages; and 4) the proportion of enrollees under 35 (including children) has risen modestly this open season, from 35% in OEII to 38% so far this time around.

All of this is convincing. But the perspective of Anne Filipic, of Enroll America, also indirectly highlighted something I've put forward as a secondary cause of this year's modest spike in young enrollment: Because prices are higher this year, more young adults qualify for subsidies. Here's Filipic:

Filipic and her team already think the mandate could play a bigger role in their messaging going forward. Right now, Enroll America has a calculator that lets potential enrollees see how much financial help they'd be eligible to receive if they signed up for coverage.

Pet insurance: permission to spend?

Sarah Kliff has a good article about pet insurance that poses the right two questions at the outset -- courtesy of Jennifer Fitzgerald, co-founder of an excellent online insurance market called PolicyGenius:

The first question is the easier one: How much can I afford to spend on my pet? If I got a really expensive bill, maybe something upward of $5,000, would I be able to pay it off myself? If the answer is yes, she says, you might not need pet insurance: You could take a gamble and essentially act as your own insurance company. But if the answer is no, then there's a follow-up question:

How much am I willing to spend to save my pet's life? Don't think about the constraints of your budget for a moment — think about whether you'd think it was worth it to pay $5,000, $10,000, maybe even $20,000 to save your pet's life.

I have been mulling the second question on and off for some years. When we adopted our dear departed beagle mutt Merlin fourteen years ago, I used to joke that he had a $2,000 lifetime health savings account. That was because I was bemused by tales of people paying for cancer operations for their dogs -- $5k or $10k.  I thought that was ridiculous. But changing cultural norms have a tidal pull. When we adopted the beguiling dachshund mutt Walter two years ago, I started testing my mental limits for what I'd be willing to pay down the line -- especially as we read that dachschunds are prone to spinal troubles (we hope the 1/4 pit bull in him may spare him that).

Well, Ezra Klein, Republicans may not have "plan" to save insurance markets after King. But they may deal

Republican Senators Orrin Hatch Lamar Alexander John Barrasso are out today with a lightly sketched "plan" to salvage premium subsidies credited through the ACA's federal exchange if the Supreme Court rules for the plaintiffs in King v. Burwell.  The proposal closely resembles the  possible post-King negotiation that former HHS Secretary Michael Leavitt outlined to me. Here's Hatch et al:

First and most important: We would provide financial assistance to help Americans keep the coverage they picked for a transitional period. It would be unfair to allow families to lose their coverage, particularly in the middle of the year....

Second, we will give states the freedom and flexibility to create better, more competitive health insurance markets offering more options and different choices. Republicans understand that what works in Utah is different from what works in Tennessee or Wyoming. We want to give states the time and flexibility to design health-care systems that work for them, not for the bureaucrats in Washington.

People who live in states that have state exchanges will continue to be subject to Obamacare’s costly mandates and rules, along with the subsidies. But their states could also have the benefit of our solution. Every state would have the ability to create better markets suited to the needs of their citizens.

And here's Leavitt last week:

Footnote to a Kliff note

Walmart announced earlier this week that it would stop offering health insurance to 30,000 employees who work less than 30 hours per week. Sarah Kliff points out that many of them will be better off on ACA plans:

Think of the 36-year-old Walmart employee here in Washington, D.C. who works 29 hours per week at the company's average wage of $12.73 per hour. She earns just about $19,000 annually if she works every week of the year.

If Walmart doesn't offer her insurance, the Kaiser Family Foundation's subsidy calculator shows that she qualifies for a $1,751 subsidy from the federal government to help buy coverage on the exchange. With that financial help, she can buy insurance for as little as an $7 per month. As a low-wage worker, she gets some of the most generous financial help.

But if Walmart does offer her coverage, it becomes her only option. She doesn't qualify for federal help and the $7 plan disappears. Walmart's plan, meanwhile, is way more expensive. The average premium there works out to $111 per month.

For many Walmart part-timers, the ACA offers an even better deal than this snapshot shows.  In addition to a premium subsidy that covers three quarters of the monthly premium, this person (if single) is eligible for generous Cost Sharing Reduction (CSR) that dramatically reduces her deductible and maximum out-of-pocket (OOP) costs. DC is not on healthcare.gov, so I checked what would be on offer if she lived in Fairfax, Virginia. There, she could choose a silver plan that costs $64 a month, with a $600 deductible and a $2250 OOP max -- or a plan that costs $74 per month but has no deductible and a $2250 OOP max.

Look what the GOP can get for $300 billion

In July 2011, Obama was reportedly ready to sign off on a grand bargain for deficit reduction that would include $800 billion in new revenue and somewhere in the neighborhood of $3 trillion in spending cuts over ten years. David Brooks said that Republicans would be crazy not take such a deal.  And that decision may pay off for them.

If Republicans can stomach the sequester and withstand pressure from defense contractors and other constituent groups, they can close the books on ten-year deficit reduction with some $2.7 trillion in spending cuts and the measly $600 billion in new revenue that Obama unaccountably settled for on Jan. 1 (plus additional interest savings).

The double catch is that even Republicans profess to dislike the sequester's indiscriminate swing of the meat ax, and Republicans also purportedly want to cut and "reform" entitlements -- though they would prefer to induce Obama to do the dirty work on that front.  And the funny thing is that he will -- if Republicans would only give ever so little on revenue. My educated guess is that if they would agree to say $200 billion worth of tax loophole closures or tightenings, Obama will go quite far in altering the structure of Medicare, Medicaid and Social Security.

There's one other catch. Republicans would have stop doing their utmost to strangle Obamacare in the crib. That's their ticket to privatizing Medicaid and Medicare.

Consider the Rubicon on Medicaid that's been stealthily crossed in the last month. Sarah Kliff explains:

Smart messaging, with a large dollop of denial, from Aetna's Bertolini

The health insurance industry has sensed and seized -- or created -- a PR opportunity amid the mounting tension in the runup to the Supreme Court's decision on the constitutionality of the Affordable Care Act. First, UnitedHealth announced that it would continue to allow parents to cover adult children up to age 26, a requirement of the law, regardless of whether that part of the law was struck, and adhere to other ACA mandates, such as providing preventive services without copay and forgoing lifetime coverage caps. Aetna and others made similar announcements. Mark Bertolini, CEO of Aetna, has been particularly out front, giving interviews to the Wall Street Journal and Washington Post emphasizing Aetna's innovation in improving healthcare delivery and reducing costs.

There's some disingenuity in Bertolini's message as it's evolved over the past two weeks, however. Yesterday he told WonkBlog's Sarah Kliff that the Supreme Court decision doesn't matter, that Aetna and the industry will continue with innovation regardless of the decision, and that a deficit reduction deal is more important than the ACA.  That's backwards. If the ACA's new rules for health insurers and array of cost-cutting incentives for healthcare providers and insurers are left in place, they will likely have a bigger long-term impact on government spending than any tax-and-spending deal the Congress strikes. Bertolini's own boasts about Aetna's recent accomplishments and strategy indicate as much, though he's now working to unmoor their origin and continued impetus from the ACA.  Check out the denial in his exchange with Kliff: