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What health reform means for the people of Illinois

A blog by IllinoisHealthMatters.org

Thursday, December 22, 2011

Essential Health Benefits: What’s it mean for people with HIV?

On December 16, 2011, the U.S. Department of Health and Human Services (HHS) announced that states would decide what essential health benefits will be provided under health care reform.  Although we had urged HHS to adopt a uniform, national benefits floor that states could build on, the federal proposal offers important flexibility for states. (Check out our essential health benefits archive.)

So, what does the essential health benefits announcement mean for people with HIV?  The short answer is that we’re working on it.  Here are some of the hoops we’ll have to jump through just to figure out what the benefits might look like in a state.

Which plans are we talking about?
  HHS gives states the choice of:

(1) the largest plan by enrollment in any of the three largest small group insurance products in the State’s small group market;
(2) any of the largest three State employee health benefit plans by enrollment;
(3) any of the largest three national FEHBP [Federal Employee Health Benefit Plan] plan options by enrollment; or
(4) the largest insured commercial non-Medicaid Health Maintenance Organization (HMO) operating in the State.

Yeah, we weren’t sure where to start either.  There’s no centralized federal repository of health plan data, since states regulate health insurance.  Every state publishes plan information online differently, or not at all.  We’ll probably have to submit a special data request to each of the 50 state insurance departments.

What benefits does each plan offer?
  Once advocates identify the largest plans, the next step is to determine exactly what benefits they offer.  You can bet that Blue Cross doesn’t publish on their website a description of each of their hundreds of plans offered in a state.  We’ll might have to ask companies directly for plan descriptions, or pour through regulatory filings at state insurance departments.

Once we have this information, we can start to figure out what the plans will look like for people with HIV.  Of course, we’ll partner with national and state advocates to gather and analyze information.  At the state level, it’s more essential than ever that advocates work together to figure out the benefit puzzle and don’t duplicate effort.

And here’s an idea:  Could advocates, employers and insurance companies collaborate to gather all this information?  Sure, old adversaries would have to sit at the same conference table to share opinions and information – but that might be just “what the doctor ordered” in the new world of health care.

Read the federal fact sheet
Read the HHS Essential Health Benefits Bulletin
Federal white paper on benefits in small group and state and federal plans
Federal fact sheet on individual market benefits

John Peller, VP of Policy
AIDS Foundation of Chicago

Originally posted here on HIVHealthReform.org 

Wednesday, December 21, 2011

What lies ahead for the Patient Protection and Affordable Care Act in 2012?

2011, the first full year for the Patient Protection and Affordable Care Act (ACA), is coming to a close. As we’ve written about in the past blog posts, Facebook posts, tweets or on our home page, the year saw many ACA developments, from the announcement of the definition of “essential health benefits” that are guaranteed under the law, to the initial stages of Illinois’ health insurance exchange legislation, to the rescission of the CLASS Act. This year also saw the early effects of the law’s impact – from the young adults who can now stay on their parents’ health insurance plan, to the seniors whose prescription drug costs in the Medicare “doughnut hole” are shrinking, to the people with chronic conditions who are no longer uninsured due to the availability of the state’s federally funded pre-existing condition insurance plan. 

Of course, many provisions of the ACA will not take effect until 2014, but several provisions of the law are slated to start in 2012, including:
  • A series of demonstration projects designed to strengthen Medicare by eliminating fraud, waste, and abuse;
  • The Medicare Independence at Home demonstration, which will test out coordinated care medical teams providing care to certain high-need Medicare patients in their own homes;
  • A Medicaid demonstration, which will allow bundled payments for medical care that include hospitalizations, as well as extending the Medicaid Accountable Care Organizations savings to pediatric providers within those organizations; 
  • A new annual tax on pharmaceutical companies; and
  • On October 2012, Medicare payments for hospital readmissions will be reduced, to offset excessive readmissions to hospitals, such as early discharges from a hospital, which could result in a return visit.
What will undoubtedly become the biggest news of 2012 will be the Supreme Court case on the constitutionality of the ACA, beginning on March 26, 2011. Due to the number of different arguments against the ACA – ranging from the validity of the individual mandate to the constitutionality of the Medicaid expansion - the outcome of the case could take many different forms, from keeping the law in its entirely, striking down the whole law or portions of the law. The decision is expected in June 2012.

Also in 2012, it will be important to watch how the implementation of pieces of the ACA that are already in effect will continue, most notably, the establishment of a health benefits exchange in each state. Many states, have already begun the implementation, and are at various stages in the process, such as the 15 states (like Illinois) that have already enacted an exchange or intent of establishment legislature. Other states are working to pass such legislation, and others have not taken any steps towards establishing an exchange, either deferring to the federal government to run their exchanges, or riding on the assumption that the ACA will be struck down in the upcoming Supreme Court case. (See here for a recent news article about the status of the Illinois Exchange).

There are still many unknowns about the future of the ACA; however, what’s clear from our eight-part Neighborhood Stories series is that we have a lot of work to do to educate the communities in Illinois about the benefits of the law for small businesses, individuals/families and community organizations. Stay tuned to Illinois Health Matters for interactive features in early 2012, to help YOU understand how health care reform will impact you, your family and your community.

Happy, Healthy Holidays! 

Sunday, December 18, 2011

Ensuring Young Adults’ Coverage Now Saves Us All Money Down the Line

Because of the Affordable Care Act, millions of Americans now have access to affordable health care and millions more will soon have coverage, as well. One group of Americans that is especially benefiting from our new law is young adults.

According to the Obama administration, 2.5 million previously uninsured young adults ages 19 through 25 are now covered. The majority of those who have recently gained coverage took advantage of a provision in the Affordable Care Act that allows young adults to stay on their parents’ plan until age 26.

Historically, young adults have been the age group most likely to go without health insurance. Almost 28 percent of 18- to 25-year-olds were uninsured in 2010 compared to only 9.8 percent of children under 18 years of age and 20.5 percent of 26- to 64-year-olds. For young adults, the recession hit particularly hard.

In fact, many recent college graduates had a hard time finding a job with health insurance, or finding a job at all. As a result, even more young adults went without health coverage.

Thanks to the health reform law, young adults no longer have to take this gamble. And, millions of parents have peace of mind, knowing that their young adult children will get good, affordable health care when they need it. For millions of parents around the country, this provides a huge sigh of relief:

They don’t have to worry about going bankrupt if disaster strikes and their child winds up in the emergency room with piles and piles of costly medical bills.

Insuring young adults is not only good for parents and kids; it’s good for us all. Because young adults are typically healthier and are less likely to need expensive medical services, their presence in the insurance pool means that costs for everyone are lower.

Without health reform, millions of young adults would be uninsured once they left college or even high school and the costs of their health care would ultimately be paid for by the insured when they eventually do seek medical attention.

Ensuring young adults are covered now saves us all money down the line and gives parents and their kids the peace of mind that they’ll have coverage they can count on when they need it the most.

Originally posted here on the Health Insurance Resource Center
Ron Pollack, Families USA Ron Pollack is the Founding Executive Director of Families USA, the national organization working to achieve high-quality, affordable health coverage for everyone in the U.S. The Hill, a weekly newspaper covering Congress, named Mr. Pollack one of the nine top nonprofit lobbyists. Modern Healthcare named him one of the 100 Most Powerful People in Health Care.

Wednesday, December 7, 2011

Let’s Hear it for Prevention

Prevention is not only the best medicine, it’s the cornerstone of the Affordable Care Act (ACA). To ensure that prevention is integrated into our nation's health care systems, the ACA created the National Prevention, Health Promotion, and Public Health Council, composed of the heads of 17 Federal agencies and chaired by the U.S. Surgeon General.

Earlier this year, the Surgeon General announced the National Prevention Strategy,  which is a comprehensive plan to increase the number of Americans who are healthy at every stage of life by moving health care away from a system focused on sickness and disease, to one focused on wellness and prevention.

So how do we turn this plan into reality? The answer is that everyone has a role to play in a healthier community, state and nation.

The Surgeon General, Dr. Regina M. Benjamin, is visiting regions around the country to launch this vision. She believes everyone – businesses, educators, health care institutions, government, communities and every single American – has a role to play.

Thursday December 8, 2011, Dr. Benjamin stopped in Chicago, and urged Illinois community leaders and public officials to take a pledge, committing themselves to do what they can to make healthier choices easier choices for themselves and the people in the communities they serve.
“I will be a leader to make healthier choices easier choices where I live, learn, work, play and pray.”
This is an unprecedented call to action is for individuals, communities, schools, faith institutions and employers to all take part. The pledge, and more information about the National Prevention Strategy is hosted by Community Commons and managed by Health & Disability Advocates and the Trust for America’s Health.

So what are you waiting for? Ask not what your country can do for your waistline. Ask what you can do to make your country healthier.

Take the prevention pledge today.

Tuesday, November 29, 2011

States Taking the Lead in Strengthening Consumer Protection

Recently, five more States strengthened their laws protecting consumers in disputes with their health insurance plans. The District of Columbia, Massachusetts, New Hampshire, Ohio and Wisconsin have bolstered their laws surrounding the part of the appeals process known as “external review.”  These five States join 33 others that provide these State-based external review protections that ensure consumers have a voice. The remaining States’ consumers are protected by a Federal process.

The strengthened appeals rights are one of several common-sense consumer protections and insurance market reforms established by the Affordable Care Act. Having a meaningful appeals process ensures that you actually receive the benefits that your insurer has promised.

So, what exactly is an external review

It means having an independent third party review your insurer’s decision, no matter where you live, thanks to the Affordable Care Act. Often, you can resolve disputes with your health plan by asking your insurer to reconsider its decision, in a process known as an “internal appeal.” But if, for example, your insurer still denies payment after the internal appeals process, you now can ask for an external review by an independent review organization to decide the matter.  Insurance companies must accept the outcome of this external review.  This means that your insurance company no longer gets the final say, and that patients and doctors get a greater measure of control over health care decisions.

These protections are important because when an insurer refuses to pay for a covered health care service, consumers could be faced with a large unplanned bill, and may not be able to afford the care their doctors say they need.

The Affordable Care Act sets these new important appeals standards for consumer protections and encourages States to take the lead in ensuring their own residents benefit from them.  Where States have not yet passed laws implementing these consumer protections, HHS has set up a process to ensure that consumers in these States also benefit from the same protections and standards.  If a State changes its external review process in the future, the State may request a new determination at any time. 

Having DC, Massachusetts, New Hampshire, Ohio and Wisconsin step up to the plate to ensure consumers’ external review rights is a perfect example of how the Affordable Care Act empowers States to protect consumers.

This post was originally published on The HealthCare Blog on November 22, 2011
By Eliza Bangit, Acting Director of the Consumer Support Group

Tuesday, November 15, 2011

Communications Tips – Supreme Court and the Affordable Care Act

This week, the Supreme Court may grant a writ to hear a case questioning the constitutionality of the Affordable Care Act. There will be a number of questions raised by this action. Consider the following points in talking with colleagues and the press.

Main Points:

1. The Affordable Care Act is supported by the text of the constitution and years of judicial precedent.
a. If one reads the constitution, including the amendments, there is no question that this law is supported by the words in the constitution.
b. At the Appellate level, two very conservative judges have supported the constitutionality of the law (Silverman appointed by Reagan and Sutton appointed by G.W. Bush).
c. The DC Circuit upheld the constitutionality of the health law on 11-8-11.

2. People challenging the law are playing politics—using the courts to attempt to accomplish what they didn’t succeed at through the legislative process.
a. Some people don’t want to rein in insurance companies.
b. They have other priorities; ordinary American families are not one of them.

3. This law provides protections for American families:
a. A child getting sick is no longer a reason for a lifetime of denial of care;
b. Preventive services will give our children and our parents better chances for healthier and longer lives;
c. Insurance companies can no longer take unfair advantage of ordinary Americans with practices like charging women more than men for health insurance.

Those trying to manipulate our judicial process and the constitution for political expediency should reflect on America’s history. George Washington couldn’t clothe his troops because the Articles of Confederation didn’t allow the government to raise funds for his army. The constitution was written so, as our first President said, ‘we can have national solutions to national problems.’

Wednesday, November 9, 2011

Top Five Facts That Illinois Social Workers Should Know about the Affordable Care Act

Illinois Health Matters will be an exhibitor at the National Association of Social Workers (NASW) Illinois Statewide Conference today, Thursday November 10. We are excited to meet the hundreds of social workers who will be in attendance and to talk about what else? Health reform! As a short primer, we thought we'd list, the top five facts that all Illinois social workers should know about the Affordable Care Act - i.e., the national health care reform law.

1. Demand for Your Services Will Grow 
In 2014, as a result of the Affordable Care Act, over 1.1 million people in Illinois will become eligible for insurance through Medicaid or the new subsidized insurance product on the exchange; thus, social workers will have more insured paying patients.

2. REALLY, Demand for Your Services Will Grow 
Essential Health Benefits are still being defined now but include behavioral health and habilitative and rehabilitative care - services provided by and important to social workers.

3. Your Role Will Be More Important Than Ever
The Affordable Care Act emphasizes coordinated care arrangements through new initiatives such as Accountable Care Organizations and Health Homes both of
which rely primarily on the care coordination provided by professionals such as social workers.

4. You Will Be Instrumental in Improved Health Outcomes
In 2014, hospitals will no longer be reimbursed for certain re-admissions so presumably they will invest in discharge planning and social workers to provide transition care to the home and community and avoid re-admissions.

5. More Jobs for Social Workers
Community Health Centers are receiving large increases of funding to provide primary care and coordinated care to the newly insured population and will need to hire social workers to provide care coordination and linkage and referral to low income populations who have not had experience getting into care.

If you have health reform questions, you can find us on twitter at @ilhealthmatters. We will be live tweeting from the NASW conference using the hashtag #NASWIL. Hope to see you there! Or you can always email us at info@illinoishealthmatters.org. We will answer your questions directly and possibly feature them on our website.

Lastly, we are having a one-day raffle for a $50 Amazon.com Gift Card for people who sign up for our e-newsletter today, November 10, 2011. So, be informed and enter to win! Entrants will be notified by email.

Care Transitions & Health Reform: What's the Big Deal?

You may have heard the buzz about care transitions as an aging professional, or health care professional, or even if you are simply keeping up on current events. Transitions in care are a form of care coordination during a transitional event. Care transitions are broadly defined. Here are a few examples: transitioning within a hospital from the emergency room to an in-patient floor; transitioning from a nursing home back home; transitioning from private payer health insurance to Medicare. Right now the focus is on the transition from the hospital—and there’s good reason for this. Here’s a few key numbers to explain why:

19.6% According to a study published in the New England Journal of Medicine in April 2009, 19.6% of Medicare beneficiaries discharged from a hospital stay were readmitted to a hospital within 30 days. That means almost 1 out of every 5 Medicare beneficiaries to leave the hospital returns in 30 days or less! If you open the window of time after discharge to 90 days, this number jumps to 34%–this is more than 1 out of 3 Medicare beneficiaries. In Illinois, the study showed our 30-day readmissions to be slightly higher than the national average at 21.7%.

$17.4 Billion According to the same article referenced above, the cost of the readmissions for Medicare beneficiaries totaled $17.4 Billion for one year! This is almost 17% of the $102.6 billion that Medicare reimbursed hospitals for the year of the study. With health care costs in the United States continuing to increase, care transitions are understandably an identified area for health care systems improvement.

$500 Million In accordance with section 3026 of the Affordable Care Act, CMS made $500 Million available for the new Community Care Transitions Program (CCTP). CCTP is a unique funding opportunity for community-based organizations (CBOs) to lower readmissions to the hospital. CBOs are able to apply for reimbursement of care transition service provision through a Medicare fee-for-service mechanism. CCTP requires CBO partnership along the continuum of care including: hospitals, skilled nursing facilities, home health agencies and more.

2014 The Illinois Hospital Association is partnered with Blue Cross Blue Shield of Illinois to address high hospital readmission rates through the “PREP” Program. PREP stands for Preventing Readmissions through Effective Partnerships, and 201 hospitals in Illinois have pledged to lower hospital readmissions in the state by 2014. One of the five initiatives of the PREP Program is improving transitions of care.

3025 Section 3025 of the Affordable Care Act introduces penalties to hospitals for preventable readmissions. Starting in 2013, Section 3025 allows CMS to withhold up to 1% of Medicare payment reimbursement to hospitals. By 2015, up to 3% of Medicare reimbursement to hospitals may be withheld due to preventable readmissions. This means that hospitals that do not improve their readmission rates will receive an overall reduced Medicare reimbursement from CMS. For medium to large hospitals, a 1% reduction in reimbursement is estimated to cost from $500,000 to $1,000,000 in lost revenue. If hospitals don’t figure out how to lower readmissions, it is going to cost them a lot of money.

12 Let’s take a look at what’s happening in Illinois with care transitions from the hospital. The Illinois Transitional Care Consortium (ITCC) was formed to more effectively address needs of older adults transitioning from the hospital to the community by linking hospital based services with the aging network through intensive care coordination. ITCC consists of 12 partners: community-based organizations, hospitals, a university research facility, and a policy and advocacy research organization. ITCC developed the Bridge Model: a unique social work led model of transitional care that builds upon the Care Coordination Unit (CCU) system and Aging Network in Illinois. ITCC is currently developing a proposal for funding through the Community Care Transitions Program (CCTP), described above.

For more information on care transitions, please feel free to contact me, Kristen Pavle, Associate Director of the Center for Long-Term Care Reform at Health & Medicine Policy Research Group.

This post was originally posted on the Chicago Bridge's blog site. For more information on older adults, visit the Chicago Bridge website.

Monday, November 7, 2011

CLASS Act, Voluntary Long-Term Care Insurance Program of Affordable Care Act, is Called-Off

On October 14, 2011, the Obama Administration announced that the voluntary long-term care insurance program of the Affordable Care Act, the “CLASS Act,” is not viable for implementation. The announcement came from Kathleen Sebelius, Secretary of the United States Department of Health and Human Services, in the form of a letter to the Speaker of the House of Representatives. In this letter, Ms. Sebelius describes the thorough research done on the financial and structural solvency of the CLASS Act if implemented. The bottom line: the CLASS voluntary long-term care insurance program will not work because the cost will be too high for individuals who need care.

What is Long-Term Care?

Let’s take a look at what long-term care is before getting into why we need long-term care insurance. Long-term care (LTC) covers a broad range of services and supports for individuals requiring medical and/or social care over an extended period of time. 

  • This includes activities of daily living (ADLs) like feeding and bathing; and instrumental activities of daily living (IADLs) like grocery shopping and doing laundry. 
  • Long-term supports and services (LTSS) can be delivered in two main areas: institutions (like nursing facilities) or the home and community based setting (Assisted Living, Supportive Living, private apartment or home).
To learn more about how Illinois LTC measures compared to other states, read my blog post about a recently published study on LTC across the country.

What does this announcement mean to people with long-term care needs?

The CLASS Act offered a way for the United States to start addressing the long-term care needs of millions of Americans.  Persons with disabilities and older persons are the largest populations with LTC needs.  For more information on what the CLASS proposed to do, read Illinois’ Health Matters Blog Post by Lisa Ekman on the CLASS Act.

According to the National Clearinghouse for Long-Term Care Information, over 20 million people had LTC needs in 2008, with more than half of these people being over age 65. According to Politico Pro, only 7 million of these individuals have the private insurance to cover their LTC needs.

With the advance of medical technology and the aging of our population, people are living longer and with chronic conditions that require LTC. Here are some statistics:

  • The number of adults 65 years and older will more than double from 40 million today to over 85 million by 2050. See Census Bureau data here and here 
  • An estimated 130 million Americans live with at least one chronic disease, and at least 65 million older adults experience multiple chronic conditions[1]. 
  • 25% of older adult Medicare beneficiaries have more than four chronic conditions and are responsible for at least 80% of Medicare spending[1].

Now that the CLASS Act has been called off, the American public should be asking: “What is our country going to do for people who need long-term care?” Right now, we simply do not have a LTC system that can handle the number of people who need LTC. Medicare only pays a small portion of long-term services and supports; Medicaid requires people to spend down their savings in order to access LTC. And both Medicare and Medicaid are constantly under attack at a federal level for budget cuts. Meanwhile, the millions who require LTC will continue to have LTC needs, many of which will go unmet.

What Can You Do?


  • You are a person with a disability or an older adult who requires long-term care, OR 
  • You know someone who requires LTC, OR  
  • You support the program for those who have LTC needs


Share your story, and call your Senators and other elected officials! Simply call their offices and tell them that you support, and would like the Senator to also support, Medicare and Medicaid because these programs help you address America’s (perhaps your) LTC needs. More specifically, you can tell them that you do not want any cuts to benefits or changes to eligibility for these programs.

For your reference:

  • Senator Dick Durbin’s Illinois office phone number is: (217) 492-5089 
  • Senator Mark Kirk’s Illinois’ office phone number is: (217) 492-4062

Your voice and your stories are important and are a way to tell our elected Congressmen WHY we need LTC programs, and WHY we need to protect Medicare and Medicaid.  

Questions? Comments? Please let me know, I look forward to hearing from you and continuing the conversation.

For additional resources on how the Affordable Care Act addressing LTC, please download the Health Care Reform Impact in Illinois, Long-Term Care Reform Provisions Brief.

Kristen Pavle
Associate Director
Center for Long-Term Care Reform
Health & Medicine Policy Research Group
312.372.4292 x 27

[1] Boult, C., Karm, L., & Groves, C. (2008) Improving chronic care: The “Guided Care” model. The Permanente Journal. 12 (1), 50-54.

Friday, November 4, 2011

Latest Developments in the implementation of an Illinois Health Benefits Exchange: Senate Bill 1313

Back in the spring, the Illinois General Assembly passed a bill enacting the intent to create a health benefits exchange, a state-wide marketplace called for by the federal Affordable Care Act that will act as a tool to aid consumers to shop for insurance. The exchange has the potential to create a competitive and regulated environment that will keep health insurance costs at reasonable levels, and thus more available to individuals and small businesses, while also making the process of shopping for insurance more straightforward and manageable. In order for the health benefits exchange to operate this way, it is important that the exchange is created with the needs and protection of consumers and small businesses in mind. Earlier this fall, the study committee on the exchange released a report on their findings.  This past week, during the Illinois General Assembly Fall veto session, steps were taken to establish the exchange. State Representative Mautino introduced his amendment (House Amendment 2) to SB 1313, a bill which dictates the makeup of the health benefits exchange governing board.

Decisions that have been made in SB1313, House Amendment 2:

The composition of the health exchange governing board has been outlined in the amendment to SB 1313 in a way that supports a board that is likely to take interest in consumers and small businesses. The board, as outlined in the amendment, will be made of 9 members:

·         2 from the Attorney General’s office
·         1 small business owner
·         1 employee of a small business
·         1 consumer representative
·         1 community-based health care provider who primarily serves individuals under 200% of poverty
·         1 health actuary or economist
·         1 member of organized labor
·         1 individual who qualifies for Medicaid

None of the seats on the board will go to legislators, brokers, or insurers. There are also pieces in the amendment that support the creation of a racially and geographically diverse board, as well as clauses that protect against board members who have conflicts of interest in the governing of an exchange board.

Decisions not made in SB 1313:

The amendment puts the board in charge of deciding how the exchange will be financed.  There are many options outlined in the amendment, some that support the interest of the consumer, such as a fee levied on insurance companies, and some that are less supportive, such as a fee to users of the exchange.

What will happen next:

Now that the bill has been filed, it needs to be approved. On November 8th, the House Insurance Committee will be holding a hearing to discuss SB 1313.   The Committee has 11 Democrats and 9 GOP members.  In order for the bill to pass the House, it will need to get support from 71 votes, opposed to the normal 60, due to rules of the veto session. If you want to see a health benefits exchange that supports the interests of individuals and small businesses, call your state representative and tell them to vote Yes on SB1313.

Monday, October 24, 2011

Making the Grade: A Scorecard for State Health Insurance Exchanges

According to the Illinois Department of Insurance, health insurance premiums have risen on average 181 percent since 2005. This could be the week action is taken in Illinois to fix our health insurance marketplace for Illinois families and small businesses.

Lawmakers are expected to consider legislation that would create an Illinois health insurance exchange that, if designed right, would help increase choices and lower costs for Illinoisans purchasing health insurance.

There’s no need to start from scratch though. Many states have already taken action to create health exchanges to deliver better value for consumers, and Illinois should follow their lead.

In fact, a report recently released by Illinois PIRG, "Making the Grade: A Scorecard for State Health Insurance Exchanges," closely examines the 12 states that have already created exchanges and rates them according to how accountable they will be to consumers and the public, how much they can do to lower premiums and improve the quality of care, how friendly they will be to consumers, and how stable they will be.

Not all exchanges are created equal.  That’s why it’s important to evaluate the policies that will matter most to consumers, including whether the exchange will be protected from insurance industry influence, and if it will negotiate with insurers for better rates.

Among the important policies to consider to make an Illinois exchange consumer-friendly include:

  • Giving it the power to leverage enrollee’s buying power to negotiate with insurers for higher-value, more affordable coverage. 
  • Barring insurers and other industry representatives from serving on the exchange board, so it will be more accountable to the public and to consumers.
  • Making sure consumers will have an easier time shopping for coverage through easy-to-use tools and comparisons between plans.
For the sake of our pocketbooks, let’s hope Illinois lawmakers do their homework and ensure that our exchange makes the grade.

Brian Imus, Director

Illinois PIRG

Friday, October 21, 2011

Guest Post: Why Health Reform Holds No Fear For One Pediatrician

Reprinted with permission from CommonHealth WBUR.org

I remember the bad old days. By which I mean, I remember the 1990s era of “capitation” and all its ills — the rigid HMO spending limits that made money come between patients and their physicians.

But I’m not scared that they’re coming back.

Some worry that the coming “global payment” phase of Massachusetts health reform — in which health care providers are put on annual “global” budgets for each patient’s total care rather than paid for each procedure — will mean a return to capitation.

That would be terrible. As a pediatrician of 25 years, I remember the problems with capitation. It discriminated against special-needs children. It drove a wedge into the doctor-patient relationship, creating conflicts of interest by making doctors responsible for controlling costs. Access was restricted. Chronic disease management was not a priority.

But I welcome the impending era of global fees. If the concept of the Medical Home is incorporated — with its family-centered care incentives and rewards for innovations that save families money and time as well as improving quality — it could work.
Some see global payments as “capitation in sheep’s clothing.” However, if negotiated properly, there can be enormous opportunity for physicians to unleash their creative skills as never before in collaboration with families. It could be an opportunity to empower and educate families to manage more of their own minor health-care issues if they so choose — and as their deductibles increase, they will so choose.

Also, in our current system, insurance rate increase are coming more and more out of families’ pockets, not employers. Will there be a day when they just simply can’t afford going to the doctor? We need to act!

My practice, Westwood-Mansfield Pediatric Associates, is preparing for global fees. In our office, the most common reason for an illness visit is a sore throat. We responded to this by giving patients (at certain routine check-ups) a free home strep test to be used if certain criteria are met, with the proviso that patients must be seen in the office if the home test is positive or if the individual is not feeling better within 48 hours.
Since 65%-75% of rapid strep tests are negative in our office, we have been able to reduce office visits for sore throats by 20% and replace them with healthy lifestyle visits for overweight children.

We also give a prescription for a course of oral steroids, along with a written “Nighttime Asthma Attack Plan,” to parents whose children have asthma and instruct them on how to manage an asthma attack in order to prevent an ER visit. In addition, we have produced and posted, ourselves, videos of many common problems and how to avoid the emergency room.

The old fee-for-service system has stifled our capacity to be creative. The existing categories of services that can be billed for has also contributed to these barriers. Our own fear of change also plays a role.

The late Steve Jobs and Apple have been successful because they have been able to give people what they want before they realize they need it. This is what we strive to do. By empowering families to manage minor illnesses themselves (through patient handouts, websites, YouTube videos, and even “Apps”) we can shift the focus to the top health care problems of children – obesity, asthma, ADHD/learning style issues, mood disorders and allergies. In this model pediatricians can have a very rewarding job and make a good living.

Ultimately, the fact is that pediatrics has changed, and we have to change with it. Immunizations have eradicated most serious infectious diseases. Pediatrics must redefine itself as a specialty focused on wellness, seriously ill children, and chronic disease management and less on volume.

We can work on the concept of the Medical Home to improve care for our families in a team-based manner. In market terms, we need to give parents more value for either their co-pay dollars or their deductibles. Empowering our families is where our value will be coming from in the future, and global payments can help us get there.

Dr. Lester Hartman
Guest blogger
Dr. Hartman is a senior associate at Westwood-Mansfield Pediatrics, a Masters in Public Health candidate at Harvard and vice president of the Haitian Organization Program for Education and Health. 

Wednesday, October 19, 2011

Neighborhood Stories: The Importance of Community-Based Health Organizations

Today, Illinois Health Matters launched the third release in their ongoing multimedia series, Neighborhood Stories. This installment reveals through video and investigative journalism the importance of community based organizations, such as neighborhood health centers and grassroots health coalitions. Such organizations provide a variety of comprehensive services to people in underserved communities, such as the South and West Sides of Chicago, who often do not have health insurance or access to quality, affordable care.
In “Community-Based Organizations Play a Critical Role in Reform,” author Jeffrey Steele finds community organizations act as a vital link between the federal level ACA, the state-level policies that result from the act, and the people who will benefit from the health care reform. Steele describes various ways that community organizations in Chicago are helping to implement the ACA. For example, there is an individual in every community-based organization that Celine Woznica, program director for the Asian Health Coalition in Chicago, calls a “mother hen.” They are usually trusted and respected members of community that people come to and ask questions. Inquiries may range from where to go for a flu shot to how to get heating assistance to when to go for citizenship classes. “These staff are the very people who have to be well versed on the Affordable Care Act, and how to help people take advantage of it -- from preventive care to the health exchange,” Woznica says.

Community organizations are integral to distributing accurate information about the health reform process. At
Erie Neighborhood House, a west side social service organization and community service agency, they are focusing on more “in person” workshops while other groups may utilize ethnic media and webinars. As Jim Duffett, Executive Director of Campaign for Better Health Care, sums up, “The more people who take ownership at the local level, the stronger we’ll all be in winning comprehensive reform.”

The video, “Wellness on the West Side,” profiles the story of Eliazar Mejia, a woman diagnosed and treated for diabetes at Lawndale Christian Health Center (LCHC). LCHC is a shining example of “coordinated care” – where they provide a multitude of different types of care and programs all in one place. Many people who do not have insurance, such as the 38% of LCHC’s patients, end up letting a health problem develop and worsen until it sends them to the emergency room. LCHC fills the gap between no care and the emergency room for its 60,000 patients. Bruce Miller, the CEO of LCHC, sums up the organization’s overall commitment to its patients: “Our goal as a community-based organization is to provide care for everybody who needs care. Whether they have insurance, whether they don’t have insurance, we’ve never cared. So, as we think about the future, what the impact could be of health care reform, it’s our hope certainly, that many of our uninsured patients will have…better access to care, and will use that care more frequently.”

“Wellness on the West Side” is just one in the Neighborhood Stories series, presented by Illinois Heath Matters. Previous videos profile individuals and families, small businesses, and the importance of a consumer-focused health policy in Illinois. All videos and articles are featured in the “Neighborhood Stories" section of the Illinois Health Matters website, along with articles that share how community organizations, including Health & Disability Advocates, local Chambers of Commerce and others are educating and informing underserved groups about their health care coverage options under the new law. The multimedia series is part of the Local Reporting Initiative, supported in part by The Chicago Community Trust.

Tuesday, October 11, 2011

Making Progress Toward a Health Insurance Exchange in Illinois

Last week was an important one for Illinois consumers and small businesses as lawmakers inched closer to establishing a state-run Health Insurance Exchange.  

Why is this important? As Timothy Jost, exchange expert writes in a Commonwealth Fund blog: “The health insurance exchange is the centerpiece of the private insurance reforms in the Affordable Care Act (ACA). If the exchanges function as planned, they will expand coverage to more Americans, reduce insurance costs, and improve the quality of coverage and perhaps of health care itself.”  However, if designed poorly, “experts warn, healthy people could avoid the exchanges, leaving them to sicker people with rising premiums."

First, some background:

On July 14, 2011, Senate bill 1555 was passed and signed by Governor Quinn, which created the Illinois Legislative Health Insurance Exchange Study Committee to aid in going forward with the establishment of a health insurance exchange (also known as the competitive insurance marketplace) in Illinois. The legislative study committee held five meetings, and commissioned two reports, one from Deloitte Consulting on the current state of healthcare in Illinois, and the second from HMA/Wakely Consulting Group, on the possible options and directions the exchange could take. On September 27, 2011, the Committee released a draft report of their findings from the five meetings and the two consultant reports. Although no definite decisions were made in the report, it is still the most substantive picture of the Illinois exchange to date.

Response to the Report:

Most of the report focused on the possibilities that Illinois must consider and decisions that must be made regarding the type of governance and the financing of the exchange. Many organizations weighed in with written comments in response to the report. Below are some of the issues and concerns that have been raised over the policy options outlined in the report:

·         The HMA/Wakely report listed two options for the operating model of the exchange: either as a “market organizer” or “market developer.” The market organizer approach means that the exchange would simply certify any health insurance plan that met the requirements for the exchange, relying on the competition of the marketplace to keep the cost of insurance down. The market developer style would have the exchange taking a more active approach to use their leveraging power in order to get the best possible value of plans from insurance agencies. Much support has been shown for the market developer option, aligning the exchange model with the interests of consumers for quality, affordable insurance.

·         Out of the three options presented for the governmental structure of the exchange, the overwhelming majority of opinions expressed have been in favor of a “quasi-governmental” model, as opposed to the “state-run” and “non-profit” models. The quasi-governmental model would keep the exchange in connection with other state-run agencies that it may need to coordinate with and promote a high level of transparency and accountability, while remaining a higher level of political neutrality.

·         The membership of the exchange governing board is one of the hot button topics in the report. The report underscores that members of the board should be well versed in the domain of health care, but should not have conflicts of interest, specifically noting that insurers, agents/brokers, HMOs, Prepaid Service Providers and other individuals with an interest in the Exchange should not be voting members of the board, though they could be members of an advisory committee. Some groups are advocating for a list of constituencies that must be represented on the board (for example, more representative of minority populations who are over-represented among the uninsured), while others think that a list of that nature would cause more problems for the board than it would solve.  Another major concern is whether or not legislators should be allowed on the board. Many groups have expressed their disapproval of legislators holding seats on the board – so that the exchange could be truly independent, non-partisan, and non-political — although some see their presence as non-voting members as a possibility. 

·         To finance the exchange, there are many options on the table, including charging consumers a fee to access the exchange, assessments on health plans offered in the new marketplace, assessments on all Illinois health insurance companies, the use of state general revenue, levying a fee on all health care stakeholders in the state (a list that could include prescription drug and medical supply companies, providers, hospitals, etc.), or assessing a progressive surtax on the revenues of all insurance providers. Many advocacy groups are against the idea of a fee to consumers, as the exchange targets those who are currently uninsured, who typically tend to have lower incomes, and could be put off or prevented from using the exchange if there is a fee. However, there are doubts that a funding option like the insurance revenue surtax would be approved. Some groups have stated that the best option might be for the enacting legislation to leave open the description of funding, so as to allow for multiple sources. 

Stay tuned! The final report will be issued this week and we’ll let you know if there are any changes.

Wednesday, September 28, 2011

Policy to the People - Illinois Policymakers Weigh In about ACA Implementation in Illinois

Health care reform in Illinois may originate from the federal law, the Affordable Care Act, but it is up to each state to implement many pieces of the law. For that reason, we made Illinois' implementation of health care reform the focus of our latest multimedia Neighborhood Stories series. The video, Policy to the People (by Jay Dunn) is the third in our series, and is accompanied by an article, Making Health the Best Policy (by Jeff Steele).

As health reform policies take shape in Illinois, it is important to make sure they benefit the citizens of the state. In the video, Senator Donne E. Trotter (IL -17th District) explains what he sees as necessary to keep policy geared towards the people, specifically those who are currently uninsured or underinsured. He advocates a “three pronged attack,” that involves policymakers, medical care providers and the citizens and health care consumers themselves, in the establishment of reform. “What we’re looking at,” Sen. Trotter explains, “is not as much what this law is going to do for people like myself, but for the future of America. We’re going to have a healthier society.”

The accompanying article, Making Health the Best Policy, explains the steps that Illinois policymakers have taken since 2010 to establish health care reforms right here in the Prairie State. Those who back the Affordable Care Act are attempting to impart positive messages, to counter the law's opponents working daily to ensure its provisions never go into effect.

We spoke to key policymakers in the Governor's Office, the Department of Health & Family Services (HFS) and the Illinois General Assembly about their vision of how reform will impact west and south siders' ability to gain insurance. Under the new health care law, HFS Director Julie Hamos says: “We believe there will be one million more people who will have access to private health insurance through the exchange, or public insurance through Medicaid...These are people who have not had a doctor, or a health checkup, in many years.” Michael Gelder, Governor Quinn's senior health policy advisor and Chair of the Illinois Health Care Reform Implementation Council says, “People on the west and south sides should see this as an opportunity to get health insurance. They should also see it as an opportunity to make their elected representatives, both federal and state, hear that they’re enthusiastic about [reform], and that they expect us to deliver on that.”

Check out these two great new pieces, as well as the other articles and videos in the Neighborhood Stories section of the Illinois Health Matters website, or on our new high quality Vimeo channel here. Stay tuned for the next installment where we look at how the Affordable Care Act is impacting local community organizations.

Tuesday, September 20, 2011

"Ask Wendell" - Things To Consider If You Are Looking for Health Insurance

Earlier this month I wrote that the Center for Public Integrity and I would soon launch "Ask Wendell" to help people who are at wits end trying to resolve a problem with their health insurer or who are trying to find decent affordable coverage but don't know where to find it.

Your emails and tweets starting flowing in immediately. As I suspected, there will be no shortage of problems to tackle in the weeks and months ahead. We in the United States have one of the most complicated, confounding and unfair health care systems on the planet. But I hope to be of at least a little help to the people who write. So here goes.

Dear Wendell,

Our COBRA will run out next June and I've started to look for something cheaper. My 24-year-old daughter and I both have some made-up preexisting conditions, according to a few insurance companies that we've applied to, even though my doctor says that mine is not even a medical problem.

This has prevented us from getting individual plans. My husband and I are self-employed and my daughter's employer doesn't provide insurance. I don't really want to go without insurance for six months in order to get on Pennsylvania's high-risk plan so I have been looking into an indemnity plan. I know it's not major medical, but (the company has) a plan called "Hospital Confinement and Surgical Fixed Indemnity Plan". The premium is lower but I'm not entirely sold on what I was told about it. Is this an OK avenue to pursue?


Dear Audrey,

Your situation illustrates all too well why Americans who would like to go into business for themselves or to start a new business are reluctant to do so, especially if they've ever been sick in the past. That's what job lock is all about. Millions of our best and brightest are locked into corporate jobs because their employers offer health care benefits not available at an affordable price to small businesses and individuals.

That should change in 2014 when the state exchanges are up and running, as required under the health care reform law enacted last year. As you probably know, the law requires every state to have an exchange--an online marketplace where people can go to shop and compare health plans and buy coverage if it is not available to them through the workplace. If your state hasn't demonstrated by 2013 that it will have its exchange up and running by Jan. 1, 2014, the federal government will step in and operate it.

COBRA coverage--available to people who lose their jobs and, along with them, their employer-subsidized coverage--is extremely expensive, as you have found out. Federal law mandates that COBRA coverage is available to you, but because your former employer does not have to subsidize the premiums, you're on your own. As a result, only a small fraction of the people eligible for COBRA coverage takes advantage of it. And, of course, it runs out after several months.

The reform law also will eventually prohibit insurers from refusing to sell coverage to anyone because of a preexisting condition. The prohibition already applies to children. It will apply to adults in 2014. But because 2014 is still a long way off, your options are limited, unfortunately, as you have found out. The plan you are considering is a limited benefit plan. If the reform act is implemented as Congress intended, limited benefit plans, which are often very inadequate and often little more than junk insurance, will be phased out.

Before you decide, be sure you see in writing exactly what benefits are covered and what is excluded. Also be sure you know what your total costs will be, should you or a family member get sick or injured. Thousands of Americans lose their homes and file for bankruptcy because of medical debt, and many of those people have what they thought was adequate health insurance. They found out too late that it was not adequate--or they gambled too much that they would not get seriously sick or injured. The United States, by the way, is the only country in the developed world where people can go bankrupt and lose their homes because of medical debt.

Before making a final decision, I suggest you go to www.healthcare.gov. That's the new Web site created by the Department of Health and Human Services following the enactment of the reform law. This site has a wealth of information for anyone looking for coverage or who has questions about health care reform. When you visit the site, click on the tab, "Find Insurance Option." Then fill out the demographic information and hit "submit."

You will see a listing of the options available to you in your state and with at least some information that should help you make a more informed choice. You might find that you can qualify for better coverage than you thought.

But if you decide to go with the limited benefit plan, I suggest you call your state's insurance department and ask questions, such as how long the company has been operating in your state, how many complaints have been filed against them and how many enrollees they have in your state.

In 2014, if all goes as planned, you will have better options, and you'll be able to compare plans with each other in ways never before possible.

Good luck!

Wendell Potter
Analyst, Center for Public Integrity; Former insurance company executive; Author
(This article originally appeared here in the Huffington Post)

Have a health care question for Wendell? Email him at wpotter@iwatchnews.org

Thursday, September 15, 2011

It’s Finally Happening

A legislative taskforce is working right now on ways to increase competition in the Illinois health insurance marketplace, and they’ll make recommendations by September 30th. Insurance lobbyists have come to Springfield to prevent anything that might mean more competition and better choices for Illinois consumers. 

Specifically, a Springfield legislative taskforce is considering setting up what is known as an insurance exchange. Done right, this will pool the buying power of hundreds of thousands of Illinoisans so all of us can get a better deal on health care. Done wrong, the exchange will be an ineffective website with the same expensive plans and spotty coverage.

Done right, the exchange will level the balance of power between you and the health care industry — driving the industry to cut the waste and prioritize high quality, bang-for-the-buck care.

Done right, the exchange will also cut through the confusing clutter and allow you to compare different health care plans in a simple, apples to apples way. You'd even be able to take your plan from one job to another.

Done wrong, the exchange will be merely an online listing of the same over-priced plans and inadequate coverage.

The legislative taskforce will make recommendations by September 30th on how to create the exchange in Illinois. In the meantime, insurance lobbyists don’t want more competition and are working to kill an effective insurance exchange in our state.

Click here to make sure state officials hear from you.

Brian Imus
Illinois PIRG State Director

Wednesday, September 14, 2011

Medicaid Cuts Could Leave Hundreds of Thousands of Illinoisans Facing Life-Threatening Health Challenges

Report Details Number of Illinoisans with Cancer, Heart Disease, Stroke, Diabetes, and Chronic Lung Disease Who Depend on Medicaid for Treatment

Cuts to Medicaid would pose a specific and dangerous threat to hundreds of thousands of Illinoisans who depend on the program for regular treatment for such medical conditions as cancer, diabetes, chronic lung disease, heart disease, and stroke. Without Medicaid, many of these seriously ill Illinoisans would no longer be able to fill essential prescriptions, keep up with key screenings, or see a doctor if their condition worsens or recurs.

The importance of Medicaid to Illinoisans is detailed in a report released jointly today by the American Cancer Society Cancer Action Network, the American Diabetes Association, the American Lung Association, and the health care consumer group Families USA.

Hundreds of thousands of Illinoisans are covered by Medicaid. Of this number:
  • An estimated 23,760 Illinoisans with Medicaid have cancer, including 1,000 children, 15,780 adults, and 6,980 seniors;
  • An estimated 97,170 Illinoisans with Medicaid have diabetes, including 7,360 children, 64,490 adults, and 25,320 seniors;
  • An estimated 263,750 Illinoisans with Medicaid have chronic lung diseases such as asthma, chronic obstructive pulmonary disease (COPD), and cystic fibrosis, including 146,650 children, 100,610 adults, and 16,480 seniors; 
  • An estimated 243,990 Illinoisans with Medicaid have heart disease or stroke, including 23,540 children, 164,600 adults, and 55,850 seniors.
Although Illinois directly administers its own Medicaid program, every dollar the state spends for health coverage for low-income individuals is matched dollar-for-dollar by the federal government. Particularly during difficult economic times, this federal match helps Illinois to provide health coverage for hundreds of thousands of residents.

The treatment of chronic and life-threatening diseases can be extremely costly, and people with these illnesses often become eligible for Medicaid when they have exhausted all their financial resources paying for medical care. As an example, the average hospital charge nationally for a stay associated with a heart attack is nearly $63,000, and for people with no health insurance or with inadequate coverage, such costs can quickly drive them into poverty and qualification for Medicaid.

“Hard-working Americans with diseases such as cancer can get health coverage through Medicaid after having lost their health insurance because they are too ill to work or run through their savings,” said Christopher Hansen, President of the American Cancer Society Cancer Action Network. “This program is a safety net for American families, and losing access to the program could force them to stop treatment that could save their lives.”

“Diabetes has a disproportionate impact on the Medicaid population, because Medicaid provides important health coverage to people facing elevated health risks. Children and adults eligible for this valuable program are more likely to be in poor health and thus require the services Medicaid provides to a greater extent than individuals with private insurance,” said Gina Gavlak, RN, BSN, Vice Chair of the National Advocacy Committee, American Diabetes Association. “Cuts to Medicaid funding would be harmful to the millions of children, pregnant women, and adults with diabetes who rely on the program to manage their disease and avoid dangerous and costly diabetes complications such as blindness, amputations, and kidney dialysis.”

“Medicaid is the lifeline for millions of children, adults, and seniors who suffer from chronic lung disease such as asthma, chronic obstructive pulmonary disease (COPD), and cystic fibrosis,” said Paul Billings, Vice President of National Policy and Advocacy for the American Lung Association. “If denied this critical healthcare coverage, it will result in higher healthcare costs, such as increased emergency room visits. We need to set politics aside and protect the health of our nation’s most vulnerable population, particularly our children, who will be most impacted by cuts to Medicaid.”

“Medicaid is a program that works and a program that provides urgently needed care to hundreds of thousands of people in Illinois suffering from serious but controllable diseases. It helps Illinois children get a healthier start in life and school, it helps to maintain a healthy Illinois workforce, and it helps head off medical debt, a leading cause of bankruptcies and home foreclosures,” Ron Pollack, Executive Director of Families USA, said today. “It should be crystal clear that with rising health care costs hurting family pocketbooks and with the economic downturn driving more families to depend on Medicaid, that this is precisely the wrong time to cut Medicaid funding to Illinois and other states.”

Families USA contracted with The Lewin Group to develop the estimates in this report.

Dave Lemmon, Families USA, 202-628-3030
Alissa Havens, Anerican Cancer Society Cancer Action Network
Christine Fehely, American Diabetes Association
Mary Havell, American Lung Association

Monday, September 12, 2011

5 Ways Health Care Reform Will Benefit Illinois Small Businesses

Illinois has strong, vibrant neighborhoods and small businesses play a vital part in those communities. However, while small businesses are working to meet their bottom line, it can be challenging for them to afford to provide health insurance for their employees. According to the Small Business Majority, an average of 86% of small businesses owners who don't offer health coverage to their employees say they can't afford to provide it. The Affordable Care Act (ACA) has put into place reforms – some right now and some rolling out later – that will make it easier for the owners of small businesses to buy affordable insurance. Below we list five ways that health care reform will benefit Illinois small businesses and their employees.

At Ruby's Restaurant, Health Care May Be On The Table - Images by Jay Dunn

1. RIGHT NOW: Since March 2010, tax credits are being offered to small businesses owners with 25 or fewer full time equivalent employees in order to help them offset the costs of providing health insurance. Until 2014, small businesses who pay for at least half of their employees’ health care premiums will receive a tax credit to offset 35% of those premium costs. Starting in 2014, the tax credit will increase: for those small businesses who buy insurance through the insurance exchange (see #5 below), the tax credit increases to 50%. September 15th is an important deadline for filing so check out the tax credit calculator here to see if you are eligible.

2. RIGHT NOW: Small businesses often struggle with unpredictable and often steep health insurance premium increases from year to year. One of the priorities of the Affordable Care Act is to implement consumer protections so that insurance companies are more transparent and accountable with things like premium increases. As of September 1, 2011, health insurers seeking to increase their premium rates by 10 percent or more must submit their request to state or federal reviewers to determine whether they are reasonable or not. This rate review program will bring more predictability to health insurance costs and in many cases will lower costs for small business owners.

3. RIGHT NOW: Many small business owners cannot purchase affordable insurance, because they have a pre-existing condition. A pre-existing condition is a physical or mental health condition, disability or illness that you have before you enrolled in a health plan. If you or your employees are uninsured and have a pre-existing condition, you may be eligible for the Illinois Pre Existing Condition Insurance Plan, which is an insurance plan that was established by the Affordable Care Act. Questions? Call the Toll Free Number: (877) 210-9167, or email your question directly to IPXPInquiry@healthalliance.org.

4. LATER: Under the Affordable Care Act, denying health coverage or excluding benefits due to a pre-existing condition will no longer be allowed. As a result, if you have a pre-existing condition that has prevented you from buying affordable insurance for yourself and your employees, on January 1, 2014, it will not make you uninsurable any longer. This change is already in place for children under age 19.

5. LATER: The new health reform law establishes a competitive healthcare marketplace, commonly known as an “insurance exchange” run by each state or the Federal government. Slated to be up and running by the beginning of 2014 in Illinois, the Exchange will make purchasing insurance easier for individuals and small businesses by giving them the power to compare health care plans in one digital hub. The Exchange will also ensure that quality health insurance options are available – and that subsidies are also available to those who need them. These online marketplaces will create competition among insurance companies that will help to drive down the costs of insurance. More information about Illinois’ progress toward establishing an Exchange, can be found here.

If you have questions about the new health care law and how it affects you or your small business, submit your questions here and we will write you back.

An employee and customer at Ruby’s. The owners of the restaurant currently can’t afford to pay for health insurance for their employees, but that could change with the Affordable Care Act reforms

Friday, August 26, 2011

Common Questions about the Competitive Health Care Marketplace

If done well, proponents say, the Competitive Health Care Marketplace (formerly called the insurance exchange) would make it easier to buy health insurance and lead to lower prices because of increased competition. But, if designed poorly or if this process is controlled by the insurance industry and their friendly allies in the Illinois General Assembly, experts warn, healthy people could avoid the exchanges, leaving them to sicker people with rising premiums.

Here are some common questions:

What is a Competitive Health Care Marketplace, as envisioned by the health law?
It's a marketplace where individuals and small employers will be able to shop for insurance coverage. They must be set up by Jan. 1, 2014. The exchanges will also direct people to Medicaid if they're eligible.

Will all states have Competitive Health Care Marketplaces?
States have the option of setting up their own Competitive Health Care Marketplace, forming coalitions with other states to create regional exchanges - or opting out altogether. In that case, the federal government will run the Competitive Health Care Marketplace for their residents.

Will anyone be allowed to buy from the Competitive Health Care Marketplace?
No. Initially, exchanges will be open to individuals buying their own coverage and employees of firms with 100 or fewer workers (50 or fewer in some states). Most Americans will continue to get insurance through their jobs, not via the Competitive Health Care Marketplace. The Congressional Budget Office estimates 11.5 million people will use the Competitive Health Care Marketplace in 2014 and 27.1 million in 2018. Most will be people who are eligible for subsidies, which will average an estimated $4,600 per person in 2014. Undocumented immigrants will be barred from buying insurance on the Competitive Health Care Marketplace.

What about federal workers?
Members of Congress and their staffs will be required to buy through Competitive Health Care Marketplace if they want coverage from the federal government. Other federal employees won't be required to use a Competitive Health Care Marketplace.

Will exchanges be like travel websites or some existing health insurance sites? In some ways. People will be able to compare policies sold by different companies. Purchasing insurance is complex and can be confusing, so information on the plan benefits will be standardized in an effort to make it easier to compare cost and quality. Plans will be divided into four different types, based on the level of benefits: bronze, silver, gold and platinum.

What will the coverage sold on the Competitive Health Care Marketplace look like?
Plans will have to offer a set of "essential benefits." Those details, still being developed by the Obama administration, will include hospital, emergency, maternity, pediatric, drug, lab services and other care. Annual cost-sharing, or the amount consumers must fork over before insurance payments kick in, will be capped at the amounts allowed for health savings accounts -- currently, nearly $6,000 for individual policies and $12,000 for family plans.

How much will the policies cost?
The premiums will vary by type of plan and location. Insurers won't be able to charge more based on gender or health status. They will be able to charge older people up to three times more than younger ones.

Will the states negotiate premiums with the insurers?
The law doesn't require states to set or negotiate premiums. However, states may have some influence over prices. For example, states can decide whether to open the Competitive Health Care Marketplace to all insurers, or to limit the number. State insurance commissioners will be able to recommend whether specific insurers should be allowed to sell in the Competitive Health Care Marketplace, partly based on their patterns of rate increases.

What if I can't afford the premiums?
People who earn less than 133 percent of the federal poverty level, $14,484 this year, will qualify for Medicaid in all states, under the law. Above that, sliding scale subsidies for private insurance on the exchanges will be available for residents who earn up to 400 percent of the poverty level, about $43,560 this year. Most people will be required to have coverage of some sort beginning in 2014.

Will all insurers have to offer policies through the Competitive Health Care Marketplace?
No. Insurers won't be required to sell through the Competitive Health Care Marketplace.

Will all state Competitive Health Care Marketplaces be the same?
No. States can design their Competitive Health Care Marketplace differently, an issue that's sparking debate in statehouses nationwide. Some states may choose to set additional standards for insurers beyond the federal law. Another important issue: The makeup and power of the governing boards overseeing the Competitive Health Care Marketplace. Some states, such as Maryland, are considering barring insurance industry and sales agents from their governing boards. Others, like North Carolina, have pending legislation that includes representatives from those groups on their governing boards.

Kathleen Duffy
Campaign for Better Health Care