Cooperating for better care.

Kaiser Family Foundation

Tag Archives

Kaiser unit: 27% of adults uninsurable without the ACA


The Kaiser Family Foundation reports that 52 million adults under age 65  (or 27 percent)  have pre-existing conditions that would probably have made them impossible to insure before the Affordable Care Act barred insurers from refusing to cover people with pre-existing conditions.

KFF examined data from the National Health Interview Survey and the Behavioral Risk Factor Surveillance System, as well as pre-ACA underwriting manuals used in the individual market .

Becker’s Hospital Review pulled out these four findings from the report:

1. “In 11 states, at least 30 percent of non-elderly adults would have a declinable condition pre-ACA, ranging from West Virginia (36 percent) to Tennessee (32 percent) to Kansas (30 percent).

2. “The three states with the most people estimated to have pre-existing conditions are California (5.9 million) Texas (4.5 million) and Florida (3.1 million).

3. “Colorado and Minnesota have the lowest number of individuals with pre-existing conditions, with at least 22 percent of adults under age 65 having declinable conditions.

4. “KFF projects the estimates are conservative, as the survey does not include details about several declinable conditions before the ACA like HIV/AIDS and hepatitis C. ”

To read more, please hit this link.

Tougher times seen coming for hospitals under Trump


Tougher times may be coming to hospitals under the Trump administration.

Whatever changes, including repeal, of course, occur to the Affordable Care Act, there will probably be “less coverage, or less generous coverage” in  insurance, Gary Claxton, vice president at the Kaiser Family Foundation, told CNBC.

“If you start with the hospitals, it seems unlikely that as many people will have coverage that is as generous as currently exists. So that means that when they go to the hospitals, they’ll have less money to pay with, or less insurance. So it seems unlikely this will be good for hospitals.”

Mr. Trump has pledged to repeal the ACA and replace it with a yet-to-be-announced plan. Congressional Republicans vow to back him.

Minda Wilson, a Los Angeles healthcare lawyer and author warned CNBC about potential damage to hospital reimbursement from the plan to changing Medicaid to a block-grant program for the states. “I think the hospitals are not going to do well, period,” she said.

This may be reflected  in the fact that the stocks of the for-profit hospital chains have all fallen a lot since Mr. Trump’s  election.

To get the CNBC report, please hit this link.

Julie Rovner: Deconstructing Trump’s healthcare remarks

Healthcare finally came up as an issue in the second presidential debate in St. Louis Sunday night. But the discussion may have confused more than clarified the issue for many voters.

During the brief exchange about the potential fate of the Affordable Care Act, Republican Donald Trump said this: “Obamacare is a disaster. You know it. We all know it. It’s going up at numbers that nobody’s ever seen worldwide. Nobody’s ever seen numbers like this for health care.”

Let’s parse that discussion of costs piece by piece. Because when it comes to health care, there are many different types of costs: those for governments, employers and individuals. And those costs don’t always go up and down at the same time.

First, the federal government’s spending on the Affordable Care Act’s insurance is coming in under budget projections. According to the official scorekeeper, the Congressional Budget Office (CBO), in March, the net cost of the insurance coverage provisions of the law — including tax credits to subsidize some lower-income customers’ premiums and costs for adding people to Medicaid — “is lower by $157 billion, or 25 percent” than the estimate when the law was enacted in 2010.

Much of that is because CBO originally estimated that large numbers of employers would stop providing insurance to workers and send them to the law’s online marketplaces, where many of them would get federal subsidies. That didn’t happen. Medicaid spending increased more than CBO projected, but that was more than offset by the lower spending on tax credits.

What Trump was almost certainly referring to when he talked about costs going up were reports of increases in premiums for the marketplace plans. Those are for people who don’t have employer coverage and don’t qualify for a public health plan, such as Medicare or Medicaid. About 18 million Americans use those marketplaces, or exchanges.

And on average, premium prices in states that have announced their rates are going up next year at much higher rates than for the previous two years, although the final tallies won’t be known until all the rates are released later this month. Charles Gaba, who crunches numbers for his blog,, estimates a national average premium increase of around 25 percent.

Earlier in the debate, Trump noted that under the law, “your health insurance and healthcare is going up by numbers that are astronomical, 68 percent, 59 percent, 71 percent.” And there are reports of very large increases like those, including in Oklahoma, where premiums in the individual market could rise anywhere from 58 to 96 percent. Even in California, which has what is generally considered a successful marketplace, rates are going up an average of 13.2 percent for next year.

There are several reasons for the increases. One is that insurers charged premiums that were simply too low to begin with, and now they are catching up in order not to go broke. Another goes back to the CBO prediction above, about employers sending workers to the individual market to buy their own insurance. When that didn’t happen, insurers didn’t get the influx of generally healthier people to offset the costs of the sicker people who the law made eligible for coverage for the first time.  A recent study from researchers at the Brookings Institution found that premiums in that market are actually lower than they would have been had the law not been passed.

But even with premiums rising in many (though certainly not all) areas of the country, about half the people who buy insurance on the individual market won’t feel much of that increase. Tax credits will increase to cover most of the hikes for those who bought through the exchanges, and in many places consumers can save money by changing plans. Even with an estimated 25 percent premium increase, the federal government projects, 78 percent of marketplace consumers should be able to find a plan that costs $100 per month or less. Another estimated 2.5 million people are purchasing coverage on their own who could be getting tax credits.

Meanwhile, the majority of Americans get coverage through an employer, and that market is seeing historically low premiums increases. A recent report from the Kaiser Family Foundation found family premiums for employer-coverage rose an average of 3 percent in 2016, continuing several years of much-lower-than-average hikes. (Kaiser Health News is an editorially independent project of the Kaiser Family Foundation.)
However, consumers at every level are feeling more financial pain when it comes to health care. While premiums for most people  have increased slowly, workers and individual insurance purchasers are being asked to pay much larger deductibles before their health insurance kicks in. When insurance does pay, patients also are being asked to contribute more for their share of the services. And even the slow rate of premium increases is often more than the growth in workers’ wages, so it eats more of their paychecks.

At the same time, however, healthcare spending overall (as measured by the federal government) continues at a historically slow rate. Spending in 2014 (the last full year analyzed) was up 5.3 percent. That was only slightly higher than the five previous years, which included the smallest increase (2.9 percent in 2013) recorded since government officials began keeping track more than a half century ago.

Nonetheless, health spending is going up faster than the economy as a whole, thus consuming more of the nation’s resources. And Trump is correct about U.S. health spending not looking good next to the rest of the world. The U.S. spends one-third more per person on health care than the next highest-spending country (Switzerland), and more than twice the average for industrialized nations. Yet Americans are not healthier than most of our international counterparts.

Some employers paying lump sums for employees’ care episodes


for Kaiser Health News

Insurance policies that pay a lump sum if workers get cancer or another serious illness are being offered in growing numbers by employers. Companies say they want to help protect their workers against the financial pain of increasingly high deductibles and other out-of-pocket costs. But it’s important to understand the limitations of these plans before buying.

Critical-illness plans have been around for decades, but they have become more common lately as employers have shifted more health care costs onto their workers’ shoulders.

Forty-five percent of employers with 500 or more workers offered the plans last year, up from 34 percent in 2009, according to benefits consultant Mercer. Employees are generally responsible for the cost of coverage, although in some cases bosses contribute to the premiums.

“What we have seen is a very clear and steady rise in the number of employers offering high-deductible plans,” said Barry Schilmeister, a principal in the health and benefits practice at Mercer. “More employers are looking at the reality of pulling back on the value of health plans but looking to offer something else that would make people feel a little more comfortable about taking on that additional risk.”

Forty-six percent of workers covered by insurance on the job faced a deductible of at least $1,000 in 2015, up from 22 percent in 2009, according to the Kaiser Family Foundation’sannual survey of employer sponsored coverage. (KHN is an editorially independent program of the foundation.)

Critical-illness policies typically provide a lump sum if someone is diagnosed with cancer, heart attack, stroke, kidney failure or needs a major organ transplant. They may also pay benefits for other medical problems such as loss of vision or paralysis; plans have an average of 19 eligibility triggers, according to a market survey by Gen Re, a company that offers insurance to insurers to help manage the risk from underwritten policies. In addition, some employers also offer a policy that pays only in the event of a cancer diagnosis.

Nine out of 10 critical-illness policies are sold through the workplace, according to Gen Re. These plans provide an average $15,000 payout to workers diagnosed with one of the conditions covered under the policy. Plans sold on the individual market pay $31,000 on average, Gen Re said, but applicants generally have to go through medical underwriting to qualify. Employer plans usually don’t require that.

The average annual premium was $283 for $25,000 worth of coverage in 2013, according to financial-services research company LIMRA.

In addition to deductibles and cost-sharing for pricey drugs and treatment, the payments can be used to help cover many expenses associated with serious illness that even generous employer health plans don’t cover, including travel costs to see a specialist, time off from work and extra charges for out-of-network doctors or hospitals.

But benefits from the critical-illness policies can be limited by very specific requirements, so it’s important to understand the coverage before you buy. Here are some of the details to look for:

Pre-Existing Conditions

If you’ve had cancer or a heart attack in the past, check to see whether the plan will cover those conditions in your case or impose a waiting period before doing so.

Excluded Benefits

“Understand that maybe not every cancer and heart attack is covered,” said Stephen Rowley, vice president at Gen Re. For example, non-invasive prostate or breast cancers may be excluded from some policies. However, a growing number of critical illness insurers are covering such early-stage cancers, said Karen Terry, assistant managing director for insurance research at LIMRA.

Partial Payouts

Rather than excluding coverage altogether, plans may make a partial payout for things like non-invasive cancer, heart-bypass surgery or angioplasty.

One-Time vs. Repeat Payouts

If you get cancer a second time, will the plan pay out again, in full or in part? Does it matter if the second incidence is the same or a different type of cancer?

Unrestricted vs. Specified Schedule Of Benefits

Critical illness policies typically pay out a lump sum to use as the policyholder wishes. Cancer policies may do the same or pay set amounts for hospitalization, chemotherapy or radiation treatments, for example.

Age-Related Benefit Reductions

Some plans reduce how much they pay out after policyholders turn 65 or 70.

Waiting Periods

Plans typically won’t pay benefits for 30 to 90 days after a policy becomes effective.

As people’s financial exposure for medical care has increased, “they’re really spooked, especially when they’ve had a serious illness in their family, and they know all that goes along with that,” said Bonnie Burns, a longtime consumer-health advocate and a policy specialist with California Health Advocates, which assists Medicare beneficiaries. “I think these [coverage] holes are going to proliferate and people are going to fill them where they can.”

However, some researchers suggest that the increasing interest in critical-illness policies does not compensate for less generous health insurance policies. “Why don’t they just offer people a better [health insurance] policy in the first place?” said Karen Pollitz, a research fellow at the Kaiser Family Foundation.


Many millions more could be insured


Most want negotiated Medicare drug prices

A survey says that vast majority of Americans want  Medicare to be able to negotiate with drug companies to set lower medication prices, a practice currently prohibited by law.

The poll,  by the Kaiser Family Foundation, found that 87 percent of people surveyed want Medicare to have the authority to press drugmakers for greater discounts, as the Department of Veterans Affairs  does for vets.

The soaring prices for crucial medicines have hit both health insurers and consumers, who are being asked to cover a higher proportion of their medications’ cost though bigger co-pays. While the Republican Congress is unlikely to allow such negotiations, political pressure and insurance-industry lobbying may make it happen within a few years.

“People don’t understand why these drugs cost so much, and they don’t understand why, in America, you can’t negotiate for a better price,” Mollyann Brodie, executive director of public opinion and survey research at Kaiser Family Foundation, told Reuters.

Efforts to allow Medicare to negotiate drug prices have not been successful because, of course, of pharmaceutical industry opposition and because of ideological opposition to government interference in the marketplace despite the seeming contradiction seen in the government’s right to negotiate drug prices for vets.

Drug makers say their prices reflect the billions of dollars they spend in research and development,  for approved treatments and the new drugs  that fail. But critics charge that too much of the money is spent on marketing.


America’s Health Insurance Plans, an industry lobby group, may bring increase pressure on drugmakers now that AHIP has named Marilyn Tavenner, the former head of the Centers for Medicare and Medicaid Services, as chief executive.



Contact Info

(617) 230-4965

Wellesley, Mass