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Staying covered is a nonstop battle |
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In the wealthiest nation on the planet, health care should be a right, not a privilege only for the wealthy. For too many of us, however, health insurance continues to be a wobbly, evolving fundamental — affecting the affordability, access, and even the safety and quality of our care. The long battle over the federal push to provide tens of millions of people with affordable coverage via Obamacare seems mostly over. Still, critics say, Republicans’ almost theological opposition to any role for the federal government in health care will lead to millions of poor and lower-middle-class Americans losing their coverage under Medicaid. During the coronavirus pandemic, the Biden Administration and Democrats in Congress pushed through legislation to protect as many people as possible, especially those who can least afford medical care, by enhancing Medicaid funding and keeping patients continuously enrolled. But these pandemic-related efforts are coming to an end, and states now must “unwind” the benefits that have led to major increases in Medicaid enrollment and a reduction in the number of Americans lacking even basic health coverage. As the Washington Post described this situation: “This Medicaid ‘unwinding,’ as it is called, is a reprise of a pre-pandemic practice of requiring low-income people to demonstrate each year that they qualified for the coverage. But federal and state health officials and grass-roots advocates are bracing for what they say looms as the nation’s biggest health-insurance disruption since the Affordable Care Act came into existence more than a decade ago. That disruption is among the most profound ways the government is gravitating away from a pandemic footing, retreating from generous policies it adopted to help Americans in an emergency. “The scale of the undertaking has no precedent. The number of Americans relying on Medicaid has soared by about one-third — to 85 million as of late last year — since just before the coronavirus pandemic took hold in early 2020. Those who joined during that time did not need to pay attention to renewal notices from their states — which now could cost them their insurance. And within state governments, many Medicaid agencies are strained by shortages of eligibility workers and call-center staffers to advise beneficiaries, while employees hired in the past three years have not until now needed to learn how to conduct renewals.” The states, of course, have differed sharply in how they have regarded Medicaid and its benefits to lower-income people and children in need. Where patients live will become significant in whether their states make vigorous or lax efforts to keep them covered. Some recipients, for example, could afford to move to coverage under the Affordable Care Act. Others could keep their Medicaid if they properly re-enroll. It is up to states, though, to ensure that they do not create coverage roadblocks, as some have in the past, for example, by making Medicaid eligibility confusing or requiring poor individuals to sign up only via computers they don’t have or lack access to. The Medicaid travails are occurring even as Republicans in the House are howling about the federal budget and the program, notably by advocating for work requirements for recipients. (Research and experience have shown such requirements don’t work.) Life changes, coverage shifts In the meantime, millions of heretofore better-off Americans will be racing to check their health coverage as companies across many different sectors (including tech, banking and finance, and entertainment) announce waves of layoffs. With inflation a persistent problem and interest rates increasing, economists are fretting about the possibility of a recession and even greater job losses. The unemployment rate, however, is staying low and steady. Employers may try to cushion the blow for their laid-off workers by providing them with varying periods of health coverage. The jobless can qualify for “COBRA” coverage, which can be pricey. Obamacare, especially with changes pushed by the current administration, can be an option for many (click here to see a federal website that outlines options for health coverage for the newly jobless). Losing a position is painful and dealing with vanished benefits can be disheartening. But those who have gone through the nightmare also can testify that they listen more carefully and collect documents more robustly from their subsequent employers about health coverage and other work-related offerings. |
Positive changes promised on dreaded pre-authorizations |
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The battle’s far from won. But doctors and patients have made positive gains in attacking insurers’ pernicious paperwork in the preapproval process for treatment. An argument once could have been made that insurers were acting in a good way to contain the soaring costs of medical care by raising at least some questions about doctors almost reflexively ordering the most expensive therapies and prescription drugs. Insurers struck back by requiring doctors — and patients — to seek approval in advance for the priciest of these, such as major surgeries and advanced medications, notably in cancer care. But the profit-mongering in this process, critics say, has gotten out of hand, with insurers requiring pre-authorization for a widening array of medical care, including routine prescription refills and imaging studies. The delays in care that this has caused, as well as the dubious reasons (or lack of explanations) and rates at which insurers rejected claims, has incensed doctors and patients. For doctors, the pre-authorization process has become a major drain on their time and resources, too often pitting them — and their education, training, experience, and expertise — against clerical billing staff at health insurers in long calls and email exchanges. Patients, as always, find themselves stuck as pawns in a maddening, bureaucratic, and risky mess, as CNN reported: “Waiting for health insurers to authorize care comes with consequences for patients, various studies show. It has led to delays in cancer care in Pennsylvania, meant sick children in Colorado were more likely to be hospitalized, and blocked low-income patients across the country from getting treatment for opioid addiction. In some cases, care has been denied and never obtained. In others, prior authorization proved a potent but indirect deterrent, as few patients have the fortitude, time, or resources to navigate what can be a labyrinthine process of denials and appeals. They simply gave up, because fighting denials often requires patients to spend hours on the phone and computer to submit multiple forms.” The Biden Administration — through the Centers for Medicare and Medicaid Services (CMS), the regulators of hospitals, nursing homes, and other care facilities via the giant federal programs — has taken note of the rising fury about this consumer horror. Federal officials say they are especially concerned about sketchy data surfacing about Medicare Advantage plans and their eyebrow-raising rates of rejecting claims and pre-authorization requests. Even as federal regulators rumble ahead with proposals on ways to reduce and streamline the pre-approval process, several major insurers apparently are seeing the writing on the wall and promising to make changes on their own, the Wall Street Journal reported: “The paperwork required by health insurers to get many medical procedures or tests — one of the biggest gripes of doctors and patients — is getting rolled back. “UnitedHealth Group Inc.’s UnitedHealthcare, the largest health insurer in the U.S., said … it would cut its use of the prior authorization process. Starting in the third quarter, it will remove many procedures and medical devices from its list of services requiring the signoff. The insurer also said it would eliminate, starting next year, many prior-authorization requirements for so-called gold-card doctors and hospitals whose requests it nearly always approves. And it aims to automate and speed up prior authorization, though that will likely take a few years … [As] complaints have increased, health insurers have been making tweaks. Cigna Group, another large insurer, said it was reducing prior authorization, including removing the requirement for about 500 services and devices since 2020. Meantime, CVS Health Corp.’s Aetna health insurance arm said it was working to automate and simplify prior authorization.” While some of the insurer concessions sound promising, let’s see how and if this paperwork menace really recedes. |
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