Book chronicles Hall's 40-year battle for health, against poverty

By Molly Burchett
Kentucky Health News

Eula Hall has been called an angel, dynamite, a force to be reckoned with, and a living legend. She has dedicated her life to combating poverty in Appalachia and providing health care to those in need. Some say that she has done more for health care in Eastern Kentucky than any other single person.

Even at age 86, Hall continues to fight against poverty, providing health care to those who need it. Hall’s story will be told in a new biography, Mud Creek Medicine: The Life of Eula Hall and the Fight for Appalachia, written by Pikeville native Kiran Bhatraju.

Hall grew up in Pike County and moved to the Mud Creek community in adjoining Floyd County at the age of 16. She witnessed the devastating impact of poverty, including lack of health care, and became a staple in the Mud Creek community, someone to whom people would turn when they were sick or hungry.

In 1973, at age 46, Hall opened the doors to The Mud Creek Clinic in Grethel, Ky., a rural community in Floyd County, with a $1,400 donation and the help of two local doctors. The clinic rented space at first, but Hall quickly moved her family out of a nice home in Mud Creek so the home could be converted into a clinic to provide health care regardless of patients' ability to pay.

For 40 years, Hall’s clinic has weathered hard times, reports Jonathan Meador of WKMS in Murray. But, with resiliency and the help of the community, the clinic now operates in five locations and continues its mission: To provide Appalachia’s poorest residents with health care and dental services they can afford.

Hall says things have improved in Appalachia in the last 40 years, but she is still concerned that growing income inequality in America is leaving too many of her patients behind, reports Meador. Appalachians still face numerous economic and health disparities that are deeply rooted in poverty.

"We still have people who don't have enough to meet their needs," Hall told Meador. "These are good people; these are honest people, hard workin' people, when they were able. But you know, they're disadvantaged now, and they just don't have the means to meet their needs and stuff, and somebody has to be concerned; somebody has to look out for 'em."

Bhatraju says that proceeds of his book will go toward funding the clinic. Click here to purchase a copy of the book.

Not only may you not get to keep your plan under Obamacare, you might not be able to keep your doctor; there are reasons

By Molly Burchett
Kentucky Health News

Part of the sales pitch for the federal health-care reform law was that people could keep their doctors, but many Americans and some Kentuckians won't because insurers are excluding some hospitals and doctors from policies in an effort to make the new, standardized plans on the insurance exchanges more affordable.

Eleven Kentucky hospitals have filed complaints with the state Department of Insurance, saying Anthem's policies on the state's exchange include only a narrow network of providers, excluding them. Limiting the number of providers on the exchanges is one seldom-mentioned way insurers are trying to reduce premiums for new policies.

The department upheld three of the complaints because the hospitals said they would be able to serve at least four of the state's eight Medicaid regions, a concern that led to their original exclusion. The department has since ordered Anthem to accept applications from those hospitals- UK Healthcare, Our Lady of Bellefonte in Ashland and Highlands Regional Medical Center in Prestonsburg, reports Mike Wynn of The Courier-Journal.

Insurance-company research shows that consumers’ highest priority when shopping for insurance is price. To compete on price, insurers contract with doctors and hospitals who charge them the lowest fees. Some prestigious and well-known academic medical schools that charge higher prices are being excluded from exchange plans, Forbes magazine reports.

These same market forces may also limit the ability for small hospitals and providers to provide care through exchange plans if their health systems lack economies of scale that enhance their negotiating power. UK has already negotiated a deal with Anthem, and the company's negotiations with Highlands and Bellefonte are ongoing.

Anthem is not the only insurance company with narrow networks. Stephen Miller, vice president of finance for the Kentucky Hospital Association, said other Kentucky insurers are also using network restrictions to "steer patients to hospitals with the best rates for the insurer," Wynn reports. Around the country, many plans have more narrow networks than previous plans in order to limit premiums, Politico reports.

This tactic lowers expenses for the insurers by bypassing higher-priced health systems but means that some patients may have to change doctors or hospitals, report Sandhya Somashekhar and Ariana Eunjung Cha in The Washington Post: "The result, some argue, is a two-tiered system of health care: Many of the people who buy health plans on the exchanges have fewer hospitals and doctors to choose from than those with coverage through their employers."

Consumer advocates say tighter networks will disrupt care and limit access for middle-and lower-income consumers, who may be sicker than the average consumer, reports Kaiser Health News: "Narrow networks present the opportunity for lower costs via discounts from select hospitals and doctors in return for patient volume. But smaller networks can require members to travel farther for care or make it hard to get appointments."

Anthem says limiting networks helps insurers save money, which is passed on to patients through reduced premiums. Critics say healthy people must pay more than their fair share to help provide coverage for sicker people. Health-reform advocates say the law's trade-offs are acceptable costs in exchange for getting health coverage to more needy people, but some wonder about that if they have to drive 30 miles to get it.

What is a narrow network?

An insurance company's health-care network is a group of physicians, hospitals and other providers that agree to provide medical services at pre-negotiated rates. The wider the insurance company's network, the more doctors and hospitals from which you can choose without paying more to see an out-of-network provider.

Anthem spokesman Tony Felts said the smaller networks are an attempt to keep exchange plans affordable and that the company worked hard to design products that would attract consumers to them. Four other companies are offering policies on Kynect, the state exchange: Humana, United Healthcare, Bluegrass Family Health and the Kentucky Health Cooperative. Anthem and the cooperative are the only two insurers offering individual plans statewide.

"Many companies have selectively entered the exchanges because they are concerned that they will be dominated by risky, high-using populations who wanted insurance and couldn't afford it" before the law took effect, Gail Wilsensky, a UnitedHealth director, told U.S. News. "They are pressed to narrow their networks to stay within the premiums."

The reform law requires insurers to provide enough doctors and hospitals to ensure quality care, but the federal government offers little guidance on how this is defined. The Kentucky Heath Benefit Exchange says at least 20 percent of available essential community providers in an exchange service area must be in its network, and insurers must contract with at least one of these providers in each county in the service area. However, these regulations don't specify a penalty for not adhering to the recommendation, and there is no guarantee that the network includes your doctor.

Consider a plan's network, premiums and out-of-pocket amounts

Patients may not realize whether or not their doctor is in a plan's network until January, when the new policies take effect. Therefore, consumers should be careful to check the details about an exchange plan's network. Consumers should also be aware of the plan's out-of-pocket costs; the cheapest exchange plans have high deductibles.

On Kynect, insurance shoppers can filter plans to see if a specific provider is included. Insurance Department spokeswoman Gwenda Bond said the agency relies on insurance companies to provide network information to be posted on the exchange. She said the department has experienced some minor issues with this process due to insurers using different names for the same provider.

To address this problem, Kynect also provides a link to each issuer’s web site for their provider directory, said Bond. "The issuer’s provider directory web site should contain the most current list of providers available in the issuer’s network. We continue to work with insurance companies to improve the lists," she said.

"Under Obamacare’s exchanges, people who really want to keep their doctor, at any price, will often have to pay higher premiums for the privilege. And people who prefer lower premiums, above all, might need to choose a different doctor," writes Avik Roy of Forbes.

As Medicaid enrollment grows, fewer providers accept it

At the same time some providers are being excluded by insurance companies or are choosing to exclude themselves, some providers are opting out of the exchanges and are not accepting Medicaid patients. A recent survey by the Medical Group Management Association found that 40 percent of its members are still deciding if they are going to accept insurance offered on the Obamacare marketplaces, CNN reports.

About 56,000 Kentuckians have enrolled in Kynect plans as of Nov. 22, and 82 percent of those are Medicaid plans. According to the Centers for Medicare and Medicaid Services, which administers the Medicaid program, three times more doctors are refusing Medicare patients than three years ago.

Doctors cite Medicare's increasing rules and lowered payment rates as reasons for not accepting Medicaid, and those who will see some Medicaid patients are limiting the number, reports The Wall Street Journal. Doctors also say administrative hassles and delays in getting paid also discourage them from accepting Medicaid, says the Center for Studying Health System Change.

Hospitals across the state have expressed concern about delayed payments from Kentucky's managed care companies as a result of the state's quick transition to a managed care model, and state officials are working to address this problem. Still, Kentucky's Medicaid payment rates are about 72 percent of Medicare rates. The reform law raised Medicaid fees to match what Medicare pays primary-care doctors, but only for two years and after much administrative hassle.

Humana allows policyholders to keep old plans without paying more; Anthem is still deciding

Humana, one of the three insurance companies offering individual health policies on the state's insurance exchange, will allow Kentuckians to keep their insurance coverage for another year without charging them more for it.

The other two companies on the individual market are Anthem and the Kentucky Health Cooperative. Anthem hasn't responded to recent inquiries about the old policies; it said last week that it was still deciding whether or not it would extend policies that don't comply with federal health reform. Since the non-profit cooperative is a new insurance organization, it is only offering policies that comply with the law.

A Humana spokeswoman told Kentucky Health News Monday that the company communicated premium amounts to individual policyholders in October when presenting policy owners with coverage options for 2014, including the option to continue their current plan. Those premium amounts for individual policies have not changed since the most recent changes to the Affordable Care Act, she said.

Some insurance experts have warned that consumers renewing noncompliant plans will be predominantly younger and healthier, while older and sicker people will migrate to the subsidized marketplaces, which could drive up costs for plans. Some states aren't allowing insurers to renew policies. For example, Washington Insurance Commissioner Mike Kreidler said he would not allow insurers to extend the policies “in the interest of keeping the consumer protections we have enacted,” reports Kaiser Health News.

In Kentucky, at least for Humana policyholders, this is not the case. President Obama said people whose policies were being canceled because they didn't comply with the law could renew them for another year if state regulators allow it. Gov. Steve Beshear gave insurers the green light to decide whether or not to renew these policies. Humana has decided to do so without charging additional premiums short-term.

Meanwhile, Anthem is deciding what to do and some existing policy owners in other states face as much as a 24 percent increase in their premiums. Obama's extension allows non-compliant policies to stay in place only for a year. This time next year, the transition must be made to plans that are qualified under the law.

Most Kentucky hospitals will pay Medicare penalties under health reform, one the country's largest; look them up here

More Kentucky hospitals are receiving penalties than bonuses in the second year of Medicare’s quality incentive programs, one of the federal health reform law’s changes designed to create financial rewards for doctors and hospitals to provide better care. Pineville Community Hospital is being assessed the highest penalty in the country for its readmission rates.

Medicare has two quality-care incentive programs for hospitals. Value-based purchasing gives bonuses and penalties based on 24 quality measures, and the other program levies penalties for readmissions. Thirty-one Kentucky hospitals were assessed a penalty while 26 were given a bonus for improved performance, says an analysis by Kaiser Health News. Here's a screen shot of the beginning of the list:

The law allows the federal government to withhold a portion of a hospital's Medicare reimbursement money, up to a 1.25 percent penalty or bonus for every bill paid between October 2013 and September 2014, based on assessments of these quality standards.

"The incentives are among the law’s few cost-control provisions that have kicked in, but it is too early to tell how effective they will be in making hospitals operate more efficiently," reports Kaiser's Jordan Rau.

Large value-based bonuses are going to some major teaching hospitals and smaller institutions, such as Pikeville Medical Center. The state's average bonus is 0.25 percent, compared to the national average of 0.24 percent; Kentucky's penalties averaged minus 0.20 percent, for a total average of zero. It won't be known how much hospitals will receive or pay in dollar figures until next October since this depends on how much the hospital ends up billing Medicare, Kaiser reports.

However, as a result of the readmission program, Pineville Community Hospital is losing 2.57 percent of its reimbursements,the largest penalty in the country. Considering the impact of both the value-based program and readmissions program, Kaiser reports, two out of three hospitals are losing money starting last month.

Here's how the value-based score was figured: 45 percent on hospitals' use of clinical processes of care; 30 percent on patient experiences; and 25 percent on death rates. Hospitals were are also assessed by how they compared to other hospitals and how much they improved from two years ago, says Qualitynet.org.

Researchers are unsure whether the penalties are significant enough to trigger major improvements, writes Rau. And, some hospitals that have made improvements are still losing money because they haven't improved as much as other hospitals. On the other hand, some hospitals with subpar quality rankings are still getting more money because they showed improvement.

Nationwide, Medicare has raised payment rates to 1,231 hospitals and reduced payments to 1,451. Hospitals that are designated as critical access facilities and certain cancer hospitals were excluded from the program. But these facilities aren't immune to other portions of the health law, such as cuts in Disproportionate Share Hospital (DSH) program payments,for having a high percentage of Medicare and Medicaid patients.

New quality measures will be added to the value-based program for 2015, including comparisons of how much patients cost Medicare at different hospitals and rates of medical mishaps. In addition, the maximum readmission penalties grow to 3 percent next year, and a third incentive program will take an additional 1 percent of payments away from hospitals that have the most injuries or infections during patients' stays.

"Combined, these three quality programs have the potential to strip away as much as 5.5 percent of Medicare payments from the worst performing hospitals starting next October," reports Rau.

Dr. Patrick Conway, Medicare’s chief medical officer, says "We're moving away from volume and toward quality." Yet, to remain viable, some hospitals are being forced to make up for payment cuts by seeing more patients. Click here for the interactive chart.

15 to 25% of uninsured Kentuckians may be eligible for free, non-Medicaid coverage, but watch those out-of-pocket costs

Millions of Americans who don't quite qualify for Medicaid could still get free health insurance through federal subsidies, but this free coverage hasn't gotten much attention, since most of the zero premium plans come with some trade-offs.

An analysis by an independent consulting firm, McKinsey and Co., found that 5 to 6 million uninsured Americans will qualify for subsidies greater than the cost of the cheapest "bronze" or "silver" plan. However, many insurers have been careful not to publicize this free coverage because these plans have high out-of-pocket costs and some people will be better off paying higher premiums to get more coverage, reports The New York Times.

In a zero-net-premium plan, the federal subsidy covers the entire premium, but many people still face significant out-of-pocket costs for health services. Most zero-net premium plans are bronze plans, which are the least expensive available on exchanges and cover about 60 percent of a person's medical costs; the consumer must pay for the remaining 40 percent. So, choosing this type of plan means that you may sacrifice coverage compared to other plans on the exchange.

As the metal level increases in value from bronze to platinum, so does the percentage of medical expenses that the plan will cover. Silver plans cover about 70 percent, gold plans cover about 80 percent and platinum plans cover about 90 percent of medical costs. Regardless of the plan tier, all plans must cover standard benefits like prescription drugs, maternity care and mental health treatment. Preventive services are free in all plans.

The McKinsey report says 15 to 25 percent of Kentucky's non-elderly uninsured will be eligible for a zero-net-premium plan that will either be a bronze or silver plan. Nationwide, about half of the individuals who qualify for a zero-net-premium plan are younger than 39 and are uninsured.

Individuals with lower incomes are more likely to be eligible for these plans and most will have income levels not far above the Medicaid coverage threshold, which is 138 percent of the federal poverty level. Remember persons with income up to 400 percent of the poverty line qualify for federal tax subsidies to assist with premium payment.

Experts say the higher deductibles and higher annual out-of-pocket costs of the bronze plans may not be suited for someone with a lower income. “They may be getting zero premiums, but they’re also leaving a lot of money on the table if they don’t enroll in a silver-level plan,” Sabrina Corlette, a professor at Georgetown University’s Health Policy Institute told The New York Times.

Low-cost plans may encourage younger, healthier people to enroll in Obamacare, but they have the highest out-of-pocket cost limit and highest deductible amounts. Out-of-pocket costs, including the deductible, co-payments and co-insurance (a percentage of charges), are limited to $6,350 for individuals and $12,700 for families in bronze plans. So, for some, the silver plan may be a better option, and some individuals may also qualify for a zero-net premium silver plan.

When choosing a lower-tier plan, be ready for significant cost sharing, and be careful to check that your doctors and nearby hospitals are in the plan's network. When it comes to health insurance coverage, for individuals who don't qualify for programs like Medicaid and Medicare, there's free coverage but no free lunches.

New CEO of Owensboro Health says hospitals are working to improve care, regardless of federal health reform

Philip Patterson, the new CEO of the Owensboro Health, says hospitals are moving towards health reform regardless of what happens with the Patient Protection and Affordable Care Act.

Patterson is coming to Owensboro from Bon Secours Charity Health System in New York and New Jersey, a three-hospital system with net patient revenue of nearly $500 million.  Patterson says he wants to build a stronger network for regional care in the Owensboro area.

The Affordable Care Act has changed physician and hospital payment structures, encouraging wellness participation, Patterson said in an interview with Ryan Alessi of cn|2's "Pure Politics." Patterson said the law creates incentives for hospitals to keep patients from being readmitted, and to only provide necessary care.

Regardless of what happens with the law, health organizations and providers need to be more than providers, Patterson said: They need to be health partners to their communities, to improve community members' overall health by managing care through screenings and education.

The health care law penalizes health systems for providing care that is not needed, and it encourages a change in thinking for providers who need to start providing care more economically, said Patterson. One way to do that is by building a strong network of providers who coordinate care.

"To create a sustainable system, you've got to cover a unique and significant population," he told Alessi. To cover a larger geographic area in New York and New Jersey, Patterson said, he created a loosely affiliated network of independent facilities that all worked toward the common goals of improving care coordination and quality.

As a result of Medicaid expansion in Kentucky, which now covers households earning up to 138 percent of the poverty level, an additional 400,000 people may have health insurance coverage that have never had it before.

"There's always a cost when you build something new and try to integrate a population into it," said Patterson. Unfortunately, those who lack insurance tend to have lower education levels and potentially neglected health care needs as a result of not having coverage or the perception of not having access to health care, Patterson told Alessi.

"The process of making this [integration] work is going to be clearly on the structure of health care providers as they try to manage that population to keep them out of the hospital where the most expense is," he said. Provider networks can coordinate to manage disease processes before they require care, and education and communication about how to access care is crucial, Patterson told Alessi.

Asked what will happen to hospitals if the health law is delayed or repealed, Patterson said, "It really hasn't been rolled out yet. We are still in a wait and see mode in a lot of these pieces." He said if health care systems buy into the law's overall goals, and they are already working towards the goal of better health care management. "The issue is the infrastructure and how to pay for it," he said.

"Repeal? I don't know what's going to happen there. I think as long as the goals are to create a better health model for a community, you're going to work towards them anyway," said Patterson.

Uninsured young adults may qualify for high-deductible health coverage for $50 or less per month on state exchanges

Almost half of single young adults who are uninsured may qualify for coverage for $50 or less per month under federal health reform, according to a report from the U.S. Department of Health and Human Services.

HHS says young adults often qualify for lower costs on monthly premiums through tax credits based on family size and income. A single person's income must not be more than $45,960 to qualify for a tax credit, according to the Kynect website, and lower-income families receive the most assistance.

The federal report examined the 34 federally facilitated and state-partnership marketplaces and found that 46 percent of single young adults (ages 18-34) who may be eligible for coverage could purchase a "bronze" plan with high a deductible for $50 per month or less after tax credits, and 66 percent may be able to pay $100 or less for coverage. The report also found that "an additional 1 million eligible uninsured young adults may qualify for Medicaid in the states that have opted to expand the program in 2014."  (Read more)

Find out about your eligibility at Kynect, Kentucky's online insurance marketplace.

A Ky. guide to the Patient Protection and Affordable Care Act

By Molly Burchett
Kentucky Health News

Few laws have generated as much confusion, opposition or news coverage as the Patient Protection and Affordable Care Act. Despite the flood of news stories about the law widely known as Obamacare, there is still much confusion about it.

That's not surprising. The 906-page law is complex and is accompanied by 10,535 pages of regulations. This guide to the law is designed to clear up confusion and offer various perspectives about how the law may affect you, your family or your business.

What does the Affordable Care Act do?

The law is a set of reforms that impose many requirements on insurance companies and requires all Americans, with very few exceptions, to have health coverage or pay a penalty starting Jan. 1.

Kynect home page

In addition to those mandates, the law created online health-insurance marketplaces and encouraged states to expand the federally subsidized Medicaid program for the poor and disabled. Gov. Steve Beshear expanded Medicaid and decided the state would run its own marketplace or exchange, Kynect, which launched Oct. 1.

Why did Congress pass the law?

The law is designed to extend health coverage, either through private insurance or Medicaid, to Americans without health insurance. More than 47 million Americans were uninsured in 2012, says the Kaiser Family Foundation, and about 640,000 of them were Kentuckians.

The law's rules for insurance will increase costs for many, so it provides Medicaid or subsidized coverage to help qualifying individuals pay for coverage. Those with incomes under 138 percent of the federal poverty threshold qualify for Medicaid, and those with incomes up to 400 percent of the poverty line get premium subsidies. The line for a family of four is $23,550, so such a family would qualify for subsidies if it makes less than $94,200 a year.

Who will be affected by the law?

Obamacare will affect almost everyone, but it will have less impact on people 65 and up because they're eligible for Medicare. Virtually everyone must have health insurance coverage by 2014 or pay a penalty. Beginning in 2015, employers of 50 or more full-time workers (defined as working at least 30 hours a week) must provide coverage for their employees.

Insurance companies can no longer deny coverage because of pre-existing conditions such as a disability, pregnancy, or chronic disease. Under one part of the law that took effect early, parents are able to keep their children on their insurance until the children turn 26.

The law aims to help people who can't get affordable insurance through an employer or who aren't ineligible for public coverage through Medicare or Medicaid. It also affects the self-employed, small businesses and employees of businesses that don't provide coverage.

Because the law is making fundamental changes in the health-insurance system, "In the long run, pretty much every American will be affected by Obamacare," reports Abby Hayes of The Dough Roller, a financial-advice site. "Next year, employer-sponsored insurance premiums are likely to fluctuate as insurance companies adjust their offerings."

Will the law lower health costs?

It's too soon to tell what impact the law will have on costs. Remember, there are two types of health costs: the country's overall cost and the cost that you feel in your pocketbook from the money your household spends on health services.

If you buy an insurance policy through the state exchange, www.kynect.ky.gov, your cost will depend on your individual situation, such as the size of your household and the number of smokers in it, and your income, which will determine your eligibility for subsidies or Medicaid.

Most people who buy coverage in the individual market will pay higher premiums in 2014, mainly because companies are required to cover people with pre-existing conditions and a broader range of services, such as prescriptions, than many people have been paying for.

Rates in the individual market will change yearly, as explained in a report from the Kaiser Family Foundation. It says the broader coverage, and limiting surcharges due to age, will spread the overall cost of care across the insurance marketplace, tending to lower premiums for people who are older and sicker and raise them for people who are younger and healthier. Thus, the trade-off for pre-existing coverage is the individual mandate, which requires everyone to purchase coverage to spread the cost.

Think of it this way: When you go out to eat with two grade-school children, they can order off the kids' menu, so you pay less for their smaller portions. The total bill is $30. Your kids' chicken finger platters are $5 each, and you and your spouse both have $10 items. However, if the restaurant must charge all patrons equally for the same meal, the $30 cost would be assessed differently. The cost for each individuals would be $7.50; the cost of your kids' meals would be higher and you and your spouse's meal would cost less.

Many Kentucky businesses have expressed concern about rising premiums for employee coverage. Some are moving to high-deductible plans that require employees to pay a larger share of their costs, and some may drop coverage, letting employees obtain insurance and subsidies through the government exchanges.

How do I get coverage from the exchange?

The Kynect website will determine your eligibility for Medicaid or subsidies, allow you compare plans and process the insurance application. If you don't have a computer, you can call toll-free to 1-855-459-6328 to apply or locate a local "Kynector."

Unless you qualify for a special enrollment period, you must enroll in a health plan by March 31, 2014. A "life-changing event," such as moving to a new state, major changes in income and changes in family size, can make you eligible for a special enrollment period, says Healthcare.gov, the federal website. (Kentuckians do not use the federal site because the state has its own site, Kynect.)

The date coverage starts depends on when you buy it. If you enroll before Dec. 15 and pay your first premium, your coverage starts Jan. 1. Likewise, in succeeding months, if you enroll between the 1st and 15th, your coverage starts on the 1st of the next month. If you enroll after the 15th, coverage starts the month after the next one.

What do the health plans cover?

Regardless of which plan you chose, the law requires all plans offered by any insurance company to cover these essential health benefits:

1. Ambulatory patient services (outpatient care)
2. Emergency services
3. Hospitalization
4. Maternity and newborn care
5. Mental health and substance abuse services (including behavioral health treatment)
6. Prescription drugs
7. Rehabilitative and habilitative services/devices
8. Laboratory services
9. Preventative, wellness, and chronic disease management services
10. Pediatric services (including oral and vision care) 

What will I pay for a plan?

Premiums depend on individual circumstances, such as income and the level of coverage, such as the amounts of deductibles and co-payments. Kynect is connected to federal databases — including Internal Revenue Service databases — to determine whether you qualify for assistance in paying a premium. People on Medicaid do not pay premiums.

Plans on Kynect vary widely. In addition to comparing premiums, it is important to consider deductibles, co-payments and other plan details. Kynect offers four basic types, labeled bronze, silver, gold and platinum. Bronze plans have the lowest premiums but have a $6,300 deductible. As you move up the plan spectrum to platinum, your premiums increase and your deductibles decrease. The exchange also offers people under 30 a plan that provides only catastrophic coverage with a "very high deductible" and no subsidy.

Let's consider a basic example. A 45-year-old Floyd Countian named John Smith earns $36,000 a year, which means he is eligible to buy subsidized insurance through Kynect.

The individual market in Floyd County is limited to two companies, Anthem Blue Cross and the non-profit Kentucky Health Cooperative; Humana Inc. isn't offering individual coverage there. Depending on the type of plan John chooses, his premiums will range from $182 (bronze) to $421 (platinum), with deductibles ranging from $6,300 (bronze) to $500 (platinum).

Kynect shows selected plans' ranges of premiums, 
deductibles and out-of-pocket limts.

John has several options. Let's say he decides that he needs to keep his premium payments below $250 per month because he just bought a house and is on a tight budget. He doesn't expect to have many doctor visits because he's pretty healthy, but he doesn't have enough money saved to afford a $6,300 deductible if things went south.

Considering his obligations, John decides to set aside 15 percent of his monthly income for health care. Based on this budget, he narrows his options down to three plans. The Kynect website displays them.

After eliminating the gold plan, John decides he would prefer to pay an additional $40 per month to reduce his deductible to $2,000, so he purchases the cooperative's PPO Silver plan. About 7 percent of his income each month will go toward the premium. He will save the other 8 percent ($240) to apply to his deductible, prescription drug costs and co-pays for office visits.

A $2,000 deductible means that John must pay all of his medical costs, excluding certain preventive services like immunizations and screening, until he reaches this threshold. Co-payments and premiums cannot count toward the deductible.

John really likes his family doctor, whom he's been seeing for 20 years, and the doctor is in the cooperative's network. This plan has a $30 co-pay for primary care and mental health services, and he feels comfortable paying this amount for an office visit. If he were to see an out-of-network doctor, he would pay co-insurance: 60 percent of the doctor's full charge for the visit. For prescription drugs, there is a $500 deductible, and John will pay $20 per prescription for generic drugs after reaching this amount.

John has peace of mind knowing that he's covered if he were to have an accident. The total amount he may have to pay each year is his out-of-pocket limit of $6,350, and since he has purchased this plan during the enrollment period, he will not face a penalty for not having coverage.

As he navigates the site, John sees that he qualifies for a payment assistance in the form of a tax credit that will either reduce the amount John will pay in taxes or increase his refund, depending on his personal situation; or it will reduce his monthly premiums, if he so chooses.

What happens if I don't get covered?

The penalty for 2014 will be the larger of either $95 per adult and $47.50 per child under 18, up to a total of $285 per family or 1 percent of household income in excess of $10,000 for an individual or $20,000 for a family.

For example, let's say an individual making $40,000 per year doesn't buy health insurance in 2013. This person would would pay 1 percent of $30,000, or $300, in 2014. What about a family with a $50,000 household income? It would pay a penalty of 1 percent of $50,000, or $500.

The initial penalties are much less than the cost of health insurance, but will go up each year. The minimum penalty may increase to as much as $695 per person by 2016.

What if I'm on Medicare or Medicaid?

Almost nothing will change if you have coverage through Medicaid, but there are some changes for Medicare beneficiaries. The law doesn't require Medicare beneficiaries to buy more insurance and won't force beneficiaries to see different doctors, reports Andrea Adleman of U.S. News.

Obamacare does, however, increase premiums or prescription-drug costs for some Medicare beneficiaries, and it mandates $716 billion in Medicare payment reductions over the next 10 years. These cuts are made by changing payment formulas for hospitals, nursing homes, home-health agencies, hospice agencies and Medicare Advantage plans, says the Congressional Budget Office.

The law already affects higher-income Medicare beneficiaries. Those who earn more than $85,000 ($170,000 for a couple) are paying higher Part B premiums, which cover physician and outpatient services, and for Part D, which covers prescription drugs, says Kaiser Health News. As a result of this sliding scale, about 5 percent of Medicare beneficiaries are paying more for premiums and prescription drugs.

It is projected that by 2019, 7.8 million beneficiaries will be paying the higher Part B premiums and of that group, 4.2 million will pay the higher Part D premiums. Kaiser estimated the combined premium in 2019 would be $299 to $683 a month, depending on income.

However, typical Medicare beneficiaries, those below the $85,000/$170,000 income threshold, will pay less for their premiums since the the law closes the "doughnut hole," the coverage gap in prescription benefits, by 2020. The National Council on Aging estimates the savings could reach $1,800 for some beneficiaries.

Also, both Medicaid and Medicare beneficiaries will qualify for more free preventive care, such as a yearly wellness visit, vaccinations and colorectal screenings, starting Jan. 1.

What if my employer covers me?

About 57 percent of Americans have health insurance through an employer with fewer than 200 employees, and those who are covered do not have to purchase a new plan on Kynect. If your employer’s plan covers less than 60 percent of allowed medical expenses, or costs you more than 9.5 percent of your household income, you can shop on the exchange.

Over the past 10 years, employers have been shifting more health costs to employees. Worker contributions increased 89 percent during the decade, and are 14 percent higher than in 2009, Kaiser Health News reports. So, while the nature of your work plan may be changing, this is not a direct result of the health law.

If you aren't covered by your employer or if your employer decides to drop your coverage, you must obtain coverage or face a penalty. Religious conscience and hardship exemptions to this mandated coverage exist, and you will need to complete an application to request such an exemption.

What if I'm an employer?

Steve Wilson, senior vice president of Benefit Insurance Marketing in Lexington, said in an email that employers with fewer than 50 employees are facing 2014 premium increases that may lead them to drop coverage for their employees.

Wilson said unless companies act quickly to renew early based on 2013 underwriting rules, the average 2014 renewal for his company's small business clients will increase 63 percent. He said his clients represent a broad range of industries that will, on average, pay $3,508 more per employee for coverage next year.

On the other hand, a study by the RAND Corp. says Obamacare could alleviate some of the difficulties for small employers by putting their employees into a single risk pool. The study predicts that the number of workers offered coverage will increase after the reform, mainly because more small businesses will offer coverage.

If you have a small business with 25 or fewer employees, there may be significant tax credits available through Kynect to help cover the cost of insurance.

Kentucky Health News is an independent news service of the Institute for Rural Journalism and Community Issues, based in the School of Journalism and Telecommunications at the University of Kentucky, with support from the Foundation for a Healthy Kentucky.

Health reform law is debated and explained on KET

By Molly Burchett
Kentucky Health News

Two Kentucky Educational Television programs addressed the federal health-reform law Monday night, providing opportunities for Kentuckians to debate the Patient Protection and Affordable Care Act and ask questions about how "Obamacare" would affect them.

First, "Kentucky Tonight" host Bill Goodman sat down with a bipartsan panel to discuss the law, which went into effect Oct. 1 with the roll-out of Kynect, the state's online insurance marketplace. Then Renee Shaw hosted state officials who answered questions from callers.

The panelists were Dr. Peter Thurman, medical director of Family Health Centers in Louisville; Democratic state Rep. Mary Lou Marzian of Louisville, who was a nurse for 35 years ; Rep. Robert Benvenuti, ranking Republican on the House Health and Welfare Committee, and Dr. Ralph Alvarado, a Winchester internist and pediatrician who has run for the General Assembly three times and is planning a fourth race for the legislature.

Goodman began by asking the panelists to rank Obamacare's roll-out as an overwhelming success, an abysmal failure or somewhere in between.

Thurman, an Obamacare supporter, gave it a C even though Kynect has had many fewer problems than the federal system. He said Obamacare may not solve the huge issue of health care costs, but will those who can't afford health care access to it.

Alvarado called the roll-out a disaster, noted that not all physicians are accepting Kynect plans, and said people at the Kynect call center are getting minute-by-minute changes about the plans.

"That's not accurate," Marzian said. "You've talked to two people who had problems." She said the rollout has been a success and Kentuckians are hungry for insurance coverage, which is access to health care, and such access should be a right for all Kentuckians. "I would have been happy if we put everyone in the country on Medicare," she said.

Benvenuti said the premise of Obamacare is a failure. He said that it took $252 million of federal seed money to start Kynect, which has a $39 million annual operating budget, and that if the state could have taken the money in a block grant and used it in ways that work best for the state, a much more sustainable system could have been created.

Benvenuiti said many Kentuckians won't be able to afford the large deductibles in the Kynect plans, so the state and country are creating a dependency that can't be afforded. "Over $3 trillion will be spent over 10 years and over 35 million Americans will still be uninsured," he said.

Thurman said there has been a trend toward high deductible plans for years to shift costs to employees. Marzian said that while some deductibles are high, insurance coverage prevents you from going bankrupt if you have a serious accident, and she said the law's free preventive care will ultimately save money.

"Nothing is free," Benvenuti replied. Alvarado said about 83 percent of private physicians oppose the law, and there won't be enough doctors to provide preventive care. He said the law will not fulfill its two main goals, to reduce costs and to provide coverage to all Americans.

Alvarado objected to Obamacare's requirement to buy insurance, but Marzian said the mandate is necessary for the law to be successful. So far, she said, it has been a success. The Kynect site has has 175,000 visitors, more than 22,000 people have started insurance applications, and almost 15,000 applications have been completed.

Jean Prowse, a caller from Muhlenberg County, complained about all the political rhetoric and asked where she could get reliable, non-partisan information. Marzian directed her to the Kynect website, where Kentuckians can learn if they are eligible for Medicaid or government subsidies to help buy insurance.

Questions about Obamacare enrollment

The second show must have been more to Prowse's liking. It featured Cabinet for Health and Family Services Secretary Audrey Haynes, Kentucky Health Benefits Exchange Executive Director Carrie Banahan and Medicaid Commissioner Lawrence Kissner, who answered questions from Kentuckians about buying insurance through Kynect -- after a little bragging.

Haynes and Banahan said Kentucky's implementation of the law has exceeded expectations. In addition to the over 22,000 Kentuckians who have started applications on Kynect, more than 209,000 small businesses have started applications, Haynes said, adding, "In Kentucky, when we're trying to reach over 640,000 uninsureds, this is success."

The questions and answers on the second show were practical, not political, touching on many basic facts and a few unknown details of the law.

Regarding income limits for subsidies through Kynect, Haynes said it is important for people to call or to go online because this process is very individual. "That's why we didn't publish an individual insurance rate," she said, because there is no average.

All plans will offer the 10 essential health benefits required by the law, said Banahan.  There are four tiers of plans, with the bronze plans offering the lowest premiums and highest deductibles, and the platinum plans offering the highest premiums and lower deductibles. A catastrophic-only plan is avaialble to people under 30.

One Kentuckian with a $14,000 annual income called to ask about Medicaid eligibility, and Kissner said she would be eligible.

On the website, there is a calculator where you can enter preliminary information to determine eligibility. You can anonymously browse the website to view the "sticker price" of the plans based on this information before you register and apply, said Banahan.

If you already receive coverage from your employer or from a state program, you are only eligible for subsidies if the employer's premium that you have to pay for single coverage is more than 9.5 percent of your family income.  More than likely, you would not qualify for premium assistance, said Banahan, and you would have to pay full price for coverage through Kynect.

What if you have veteran's benefits?  Banahan said you may want to check out your coverage eligibility on Kynect.

What if you don't have a computer?  You can call the toll-free Kynect number at 1-855-459-6328 to apply or locate a local "Kynector." Kissner said the public library in your county may provide access to a computer and the Internet services.

When will the fines for not getting covered begin and how much will they be? The fines will begin in 2015. If you don't have insurance for at least nine months in 2014, the fine is $95 per household member or 1 percent of your income, whichever is greater, said Banahan. If your income is below 100 percent of the poverty line, you are not required to have health insurance. People with incomes up to 138 percent of the poverty level are now eligible for Medicaid.

If you are planning to buy insurance or sign up for Medicaid through Kynect, you must be enrolled by Dec. 15 to get coverage starting Jan. 1, said Haynes. If you want premium assistance or a tax credit, you need to purchase insurance through the exchange, but otherwise, insurance can be purchased outside of the exchange.

To explore your eligibility for premium assistance or coverage through Medicaid, visit the Kynect website.  All three experts stressed the importance of visiting the website or calling the Kynect toll-free number with any additional questions and for information specific to your needs.

Watch out for specious claims about health-reform law in highly politicized debate; Sen. Paul among those found off base

The biggest story in the state and nation is about to be Tuesday's opening of online health-insurance marketplaces, or exchanges, under the federal health reform law. "Obamacare" has been politicized from the start, and the current debate has featured several specious claims that journalists should be on the lookout for as they report, edit, present and choose commentary (including letters to the editor and person-on-the-street interviews) on the subject.

"There’s plenty of fodder for fact-checkers in Sen. Ted Cruz’s looong attack on Obamacare, and in President Obama’s defense of it," says FactCheck.org, the oldest of the nonpartisan political fact-checking services. It says the Texas Republican falsely claimed that spouses of United Parcel Service employees will be “left without health insurance” and forced into “an exchange with no employer subsidy.” UPS is dropping coverage only for who can get insurance with their own employer.

Conversely, "Obama greatly exaggerated when he credited the health care law for bending the cost curve on health care spending," FactCheck says. "Experts say the down economy is the overwhelming reason that national health care spending has been growing at historically slow rates in recent years."

FactCheck also took on Cruz ally Sen. Rand Paul (R-Ky.) for saying “everybody is going to pay more” for health insurance under the Patient Protection and Affordable Care Act. "The fact is, some will pay more and some will pay less," the service says. "Some currently uninsured Americans will pay little or nothing because of the law’s expansion of Medicaid."

As usual, FactCheck has a detailed accounting for its analyses, with plenty of references, here.

Critics say new Medicare rate-setting board has too much power; former budget chief says new system requires it

Critics as diverse as Republican state Rep. Addia Wuchner and former national Democratic chairman and Vermont governor Howard Dean, a physician, are criticizing the Independent Payment Advisory Board, a panel created by the federal health-care reform law to hold down health-care costs. But a finance executive who helped create the board says the critics are off base.

Dean wrote recently in The Wall street Journal that the board "is essentially a health-care rationing body," and Wuchner said in an op-ed piece in several Kentucky newspapers that the board's recommendations "will result in reduced care access" and "would intrude and erode the physician-patient relationship."

Despite Dean's assertion, the law "specifically states that the board is not allowed to make any recommendations that would ration care," Peter Orszag wrote for Bloomberg View. Orszag is vice chairman of corporate and investment banking at Citigroup, and was President Obama's budget director after running the bipartisan Congressional Budget Office.

Orszag says Congress already sets Medicare rates, and the board is designed to "be more facile and dynamic" as the law changes the medical funding system from the current fee-for-service" model "toward paying for value in health care." He says that is already happening faster than expected, because the CBO says Medicare's net costs have risen only 2.7 percent in the current fiscal year, which ends Sept. 30. "Redesigning the payment system is a fundamentally different approach to containing costs," which requires "a process for tweaking our evolving payment system in response to incoming data and experience," Orszag argues.

Wuchner, a registered nurse bioethicist from Florence, says the board has too much power. She notes, "Unlike typical advisory-board recommendations that have to be accepted or rejected by Congress, IPAB’s recommendations become law unless Congress passes its own plan with a three-fifths majority in the Senate in relatively short order that brings comparable savings."

New survey shows physicians feel need to limit health-care costs but make that secondary to the interests of their patients

A new survey about health-care costs reveals that 85 percent of U.S. physicians feel a responsibility to address costs but say other professionals have more of a responsibility to do that, because physicians' obligation toward patients' interests is more important than cost reductions.

While 36 percent of physicians said they have a "major responsibility" to reduce costs, other major players in health care, such as lawyers, insurance companies, hospitals and drug companies, bear that major responsibility, says the study published in this week’s Journal of the American Medical Association.

“Physicians feel stuck in a difficult position,” lead author Dr. Jon Tilburt says in a Mayo Clinic release. “Despite their sense of responsibility to address health care costs, physicians consistently express a commitment to the best interests of patients even when it is expensive. Given this finding, we recommend that cost-containment strategies aimed at physician behavior should focus on innovations that not only promote savings but also preserve physicians’ commitment to individual patients.”

Physicians expressed general agreement with quality initiatives that may also reduce health costs, but were less enthusiastic about cost-containment measures involving changes to payment models, says an American Medical Association release. For example, physicians opposed the idea of cuts in Medicare fees for hospital readmissions and eliminating fee-for-service models.

A strong majority of physicians (69 percent) were enthusiastic about promoting chronic disease care coordination and limiting corporate influence on physician behavior (63 percent). The survey also found that 76 percent of physicians are aware of the costs of tests or treatments they recommend, says the Mayo release.

Physicians said costs can be reduced by improving quality, efficiency and continuity of of care through evidence-based initiatives and cost transparency, says the AMA release. Results of the random survey of 2,500 U.S. physicians indicate ways in which policymakers can collaborate with physicians to address rising health care costs.

“Moving toward cost-conscious care in the current environment in which physicians practice starts with strategies for which there is widespread physician support might create momentum for such efforts...," writes the study's authors in the journal article. Tilburt says physicians want to do the right thing, but when push comes to shove, they will do what's best for patients. Let's start with win win strategies that physicians support and that will cut costs and improve care, he said in a MedPage Today video interview. Click here to watch that video.

Health Watch USA hosts chief medical director of Center for Medicare and Medicaid Services in Lexington and online July 31

Dr. Patrick Conway, chief medical director of the federal Center for Medicare and Medicaid Services, will be presenting to Kentucky-based Health Watch USA on July 31 at 5 p.m., and with a few clicks on the computer, you can attend virtually.

Conway will be discussing CMS goals and the results of its value-based quality improvement programs, physician fee schedule quality proposals and future opportunities for CMS collaboration aimed to drive health-care quality.

Using your computer, you can attend and participate in the discussion through an online chat while listening to Conway's presentation and viewing the slides. Just click here to log into the conference's webpage and Adobe Connect will download to your computer free of charge.

The online login will be active 15 minutes before the presentation on July 31, and the presentation slides will be available to download as a PDF from the conference page. You can also attend the presentation at the Northside Library in Lexington. Click here for more information.

Health Watch USA, based in Somerset, was founded by Dr. Kevin Kavanagh to promote health care transparency and patient advocacy, says its website.

Kentucky expands Medicaid reimbursement for telehealth services, but lets managed-care firms keep authority over fees

By Molly Burchett
Kentucky Health News

Recent changes in Kentucky's telehealth regulations are making it easier for providers around the state and country to deliver health-care services to Medicaid patients, thus improving access to specialty care for many patients in Kentucky's rural areas. But the amount of their reimbursement can still be determined by Medicaid managed-care companies.

Patients in rural Kentucky sometimes need the care of a specialist not in their home community, and programs like the University of Kentucky’s telehealth program and the statewide Kentucky TeleHealth Network use videoconference tools to bring these physicians to the patients.

Kentucky has been among the leading states for driving reimbursement of telehealth services. As of July 2012, it was one of the 13 states requiring some level of private insurance coverage of telehealth. It is also one of the 15 states that requires reimbursement from Medicaid for some services, which are mostly mental-health and specialty services.

The new regulation expands the types of services eligible for Medicaid reimbursement. While the Kentucky TeleHealth Network has been operating since 2000, the old regulations limited the use of this type of technology, Rob Sprang, director of Kentucky TeleCare and chair of the state's Telehealth Board, told Greg Stotelmyer of Public News Service. "The previous regulations were very restrictive on who could see a patient on television, what services they could deliver on TV, and where those services could be delivered," he said.

The new rules lift restrictions on both the type and number of services covered by Medicaid. A much longer list of providers can be reimbursed for telehealth services, "including people like social workers, speech language pathologists, physical therapists, occupational therapists, a very broad group of providers outside of just physicians," said Sprang.

The regulation also includes certain services provided by a physician, psychiatrist, nurse practitioner, psychologist, dietitian and certified nutritionist. To provide telehealth services in Kentucky, a provider has to be approved for membership in the Kentucky Telehealth Network.

Reimbursement is technically the same as the amount paid for face-to-face services, but the regulation says managed-care firms are not required to reimburse those amounts. Thus, the role that telehealth will play in Kentucky could depend on how much the companies and the state decide to pay for it.

Still, the Foundation for a Healthy Kentucky has endorsed these changes to telehealth coverage and reimbursement, saying "it has the potential to help make quality specialty health services more accessible throughout Kentucky," reports Stotelmyer.

Telehealth will play a big role in health reform, said Sprang. "It's not rocket science," he told Stotelmyer. "You know, if you look at where providers are located today, there are no nephrologists, no kidney doctors, in most of our small communities. There are no child psychiatrists, there are no psychiatrists. There's so many medical specialties that are not available in our rural communities."

A recent report by Deloitte Consulting recommends increasing reimbursement for telehealth to address the state's doctor shortage problem, and that reimbursement needs to include primary care. "Given the potential benefits of using technologies such as telehealth to reach rural areas, where Medicaid populations can be large, the lack of Medicaid reimbursement for primary care could be a barrier to the overall effectiveness of Kentucky’s current and future investments in telehealth," says the report, which was released before the new regulations were issued.

Employers welcome delay in coverage mandate, but individual mandate remains and many uninsured people are unaware of it

By Molly Burchett

Kentucky Health News

The Obama administration's decision to delay, for a year, the health-reform law's mandate that employers of more than 50 workers offer them coverage could jeopardize the success of the law -- which already faced several challenges.

The linchpin holding the wheels of "Obamacare" together is an individual mandate, which remains in effect. Millions of people must sign up for insurance coverage -- especially those who are healthy. About 50 million, including 640,000 Kentuckians, who haven't bought or been able to buy health insurance will have to do so or pay a tax penalty, unless they qualify for the expanded Medicaid program.

The delay in the employer mandate could reduce the number of uninsured people who will use state-based insurance exchanges to shop for insurance coverage starting Oct. 1, said Sara Rosenbaum, a professor of health law and policy at George Washington University and an advocate of the law. A White House spokeswoman disputed that, but Obama and his allies face four other broad challenges in implementing the law, as outlined in a recent Politico story by Jason Millman and Joanne Kenen:

1. Uninsured don't know they must get health coverage or pay a tax penalty

Many people know about Obamacare, but a large percentage of the uninsured do not know that they will soon be required to buy coverage, according to the most recent Gallup poll:

2. Middle-class and low-income Americans don't know about subsidies

Another part of the Obamacare message that hasn't yet gotten through to millions of Americans, at least those who need to know, is that the law offers subsidies for coverage, based on income. The challenge is that this message must get to a hard-to-reach population without inflating the law's benefits, Millman and Kenan write. And, many of those who qualify for Medicaid or subsidized coverage are low-income, may not speak English well, or may know little about health insurance.

On top of these obstacles, there can't be a consistent, nationwide message because the coverage criteria is different for states like Kentucky that aren't using a federal health insurance exchange. Kentuckians can visit the exchange website, Kynect, to see if they qualify for special discounts or tax credits to help cover the costs of coverage. For example, the website indicates that a family of four making $48,000 a year will get an estimated $252-per-month tax credit for buying insurance. For a PDF fact sheet about payment assistance, click here.

3. Appealing to young invincibles and businesses

For the new system to work, it is critical that young, healthy people buy insurance to cover the cost of care for older and sicker individuals and keep overall premium costs down. Many young people don't know what an insurance premium or co-payment is, and many don't think they need health coverage. Still, Obama administration officials have said they’re hoping 7 million people sign up for private insurance through exchanges in the first year, including 2.7 million young adults.

The delay in the employer mandate came as a relief to many employers who say it will put their businesses at the brink of survival. But the requirement has only been delayed to 2015, not repealed. Before the delay, some companies with payrolls slightly above or below the 50-employee threshold said they would cut or keep their number of full-time workers below that figure to avoid providing coverage.

Many businesses with 50 or fewer employees don't know they won't be penalized for not offering health coverage and that they can get tax credits for providing it. Kentucky businesses can use Kynect to buy coverage if they have 50 or fewer employees. Significant tax credits may be available through the site for businesses that have fewer than 25 employees with an average annual salary under $50,000; the employer must pay at least 50 percent of the premium for each employee. See the chart below or click here for more details.

4. Threats to public messaging campaigns from the opposition

While the success of Obamacare may depend upon public awareness and outreach efforts, the efforts of those opposing it create additional challenges for supporters. Many Republicans used the delay announcement to advance the cause of overall repeal or delay of the individual mandate. House Speaker John Boehner said, “I hope the administration recognizes the need to release American families from the mandates of this law as well. This is a clear acknowledgment that the law is unworkable.”

Senate Republican Leader Mitch McConnell of Kentucky said, “The White House seems to slowly be admitting what Americans already know, and what I hear consistently in my travels around Kentucky regarding the regulatory burden on employers.”

On the other hand, former White House health policy adviser Ezekiel Emanuel said on MSNBC’s "Morning Joe" that the delay of the employer mandate will affect a relatively small number of companies and is no big deal. The provision only applies to about 200,000 employers who have 50 or more employees working full-time (which the law defines as 30 hours or more a week), he said, and “94 percent already offer health insurance.”

As Medicaid eligibility expands in Kentucky, so will subsidy of undocumented immigrants' health care

As Washington lawmakers struggle to find consensus on immigration reform, U.S. taxpayers continue to shell out money to subsidize health care for illegal, undocumented immigrants. Those expenses will probably increase, with the full effect of the Affordable Care Act and Medicaid expansion in Kentucky.

Although rarely talked about, There is an "emergency Medicaid" that reimburses a hospital for emergency care to an immigrant who is in the country illegally, reports Sandhya Somashekhar of The Washington Post. The program defines "emergency" a "sudden-onset conditions that threaten life or could cause serious impairment." It reimburses hospitals for emergency and maternity care given to people who, based on their income and other factors, would be eligible for regular Medicaid if they were legal citizens.

So, if an undocumented immigrant meets Kentucky's requirements for Medicaid, which will soon be expanded to 138 percent of the federal poverty line, he or she qualifies for the emergency program.

In 2011 alone, the federal government paid out $1.3 billion under the program, reports Somashekhar. A large percentage of those illegal immigrants receiving care are pregnant women, and so the care that's being provided is labor and delivery for children that will become U.S. citizens. "From the perspective of our health-care system, when people show up and they’re sick, the health-care system is obligated to take care of them,” Diane Rowland, executive vice president for the nonpartisan Kaiser Family Foundation, told Somashekhar.

Fewer families report having trouble paying medical bills; near-poor struggle more than poor families

Fewer American families are having problems paying medical bills, but 20 percent of them, particularly those without insurance and those that are "near poor" but not :poor," still struggle with health costs, says a study released Tuesday by the National Center for Health Statistics.

The report says 54.2 million people, or 20.3 percent of families headed by someone under the age of 65, had difficulty covering medical expenses in the first half of 2012. During the first half of 2011, 21.7 percent of families, or 57.8 million people, found it difficult to pay medical bills.

Hispanics (25.2 percent) and blacks (27.9 percent) were more likely than whites (20.1 percent) or Asians (10.3 percent) to report trouble paying their medical bills, says the report. It says families with incomes from 100 to 199 percent of the poverty line were most likely to have difficulty paying medical bills, probably because those below the poverty line qualify for Medicaid. State income limits vary; in Kentucky, income-based Medicaid is available to those with incomes less than 70 percent of the poverty line.

'Poor' are below the poverty line. 'Near poor' had incomes of 100 to 199 percent of the poverty line. 

Among families with insurance, 14 percent of those with private insurance and 25.6 percent  with Medicaid or other public insurance had similar problems paying bills in the first half of 2012, which represents a 1.7 percent and 2.5 percent decrease from 2011, respectively. For a report on the study, click here.

Business leaders discuss possibility of expanding Medicaid through private insurance

By Molly Burchett
Kentucky Health News

Some Kentucky business leaders are discussing a possible endorsement of expanding Medicaid through private insurance, in a plan similar to one the federal government approved for Arkansas.

The Health Policy Council of the Kentucky Chamber of Commerce discussed the idea last Friday. A talking paper for the meeting highlighted presumed benefits of the approach, in which people newly eligible for Medicaid could use federal funds to buy private insurance through the insurance exchange that the state is constructing.

The health council has yet to decide the chamber's position on Medicaid expansion, but the council's talking paper said expanding Medicaid privately might be a better option than expansion of traditional Medicaid, considering the state's tight budget and already problematic managed care system.

The paper says a private plan would be beneficial to Kentucky because it would allow market forces to control costs and ultimately result in better health care. Private expansion would also prevent a flood of newly eligible people from entering the managed care system. "If Kentucky accepts the traditional Medicaid expansion, everyone that qualifies would be put into the already struggling managed care system, which until changes are made, cannot support the influx," the paper asserted.

The Obama administration has encouraged states to consider the Arkansas approach, the paper says.  To do so, states need to apply for a waiver, and the administration has provided information on how a state would apply. "Florida, Ohio, Louisiana, Maine and Pennsylvania are all looking into this option," the paper said.

An estimated 181,000 uninsured adults would become eligible for Medicaid in 2014, if Kentucky decides to accept the funds offered by the health law to provide coverage to those earning up to 138 percent of the federal poverty level.

Gov. Steve Beshear has said he will make his decision about Medicaid expansion no later than July 1. His office has declined to say whether the privatized option is under consideration, saying, "The governor is considering multiple issues as he determines whether Kentucky will expand Medicaid eligibility.  Along with affordability for the state, he is also looking at potential economic impact through jobs and investment created by possible expansion, as well anticipated changes in health outcomes for newly-eligible Kentuckians."

Poll shows health care costs are a burden for many Kentuckians

A recent statewide survey shows health-care costs are a burden for many Kentuckians, especially for those who are poor and don't have insurance and put off getting care they need because they can't afford it.

More than 60 percent of Kentucky adults in the poll said high costs forced them or a family member living in their home to delay getting care in the past year. Not surprisingly, almost 90 percent of uninsured respondents reported going completely without care in the past year.

The Kentucky Health Issues Poll also showed that 48 percent have relied on home remedies when they are sick instead of going to a doctor, 43 percent have postponed care they needed, 37 percent have not filled a prescription or skipped a dental visit or checkup, 36 percent skipped a recommended medical test or treatment, and 16 percent have cut pills in half or skipped doses of medicine for financial reasons. Overall, 64 percent answered "yes" to at least one of those questions.

“Although our economy is improving, many Kentucky families are still struggling financially. Our research shows healthcare costs have a significant impact on Kentuckians’ actions,” said Dr. Susan Zepeda, president and CEO of the Foundation for a Healthy Kentucky, which co-sponsored the poll. “Timely access to quality, affordable healthcare is important to restore and maintain Kentuckians’ health and productivity. When we delay or go without care, illness severity and costs can escalate. Based on the KHIP results, many Kentuckians are taking risks with their overall health because of the expense.”

Rising costs of health care do not affect all Kentuckians in the same way; almost 40 percent of Kentucky adults reported that paying for health care and health insurance is not a financial burden. Those who did say costs were a burden said they were burdened equally by the costs of doctor visits, prescription drugs and insurance premiums or deductibles.

The poll was funded by the foundation and the Health Foundation of Greater Cincinnati. The poll was conducted Sept. 20 and Oct. 14 of last year by the Institute for Policy Research at the University of Cincinnati. A random sample of 1,680 adults from throughout Kentucky was interviewed by telephone, including landlines and cell phones, and the poll has a margin of error of plus or 2.5 points.

Beshear vetoes prompt-pay bill but takes several steps to address problems in Medicaid; he and Haynes say it's working

Gov. Steve Beshear has vetoed the bill designed to make Medicaid managed-care firms pay health-care providers more quickly, but is taking administrative steps to address the issue.

Beshear said he agreed with the intent of House Bill 5 but it might have interfered with the contractual relationship between the state and the four managed-care companies. The bill would have subjected that relationship to the state Department of Insurance's review and investigation process for private-insurance payment complaints. 

"That language would have resulted in excessive costs for state government and taxpayers due to the expansion of the review process beyond the current parameters used for private insurance," Beshear's office said in a press release.

Instead, Beshear ordered the department to take over responsibility for review of prompt-payment complaints from the Department for Medicaid Services. "If improper payment practices are discovered, DOI can impose sanctions," the release said. He also ordered the department to audit each of the managed-care firms operating statewide – Wellcare, Coventry Cares, and Kentucky Spirit – at their cost.

Meanwhile, the firms have agreed to meet with every hospital they have under contract to reconcile outstanding accounts.  "This effort will begin immediately and continue until every hospital’s accounts receivable has been reconciled," the release said.  "The results will . . . be made public, in order to provide transparency and accountability." The firms have  agreed to meet with any other provider who wants a meeting.

Also, the Cabinet for Health and Family Services will hold eight regional forums for providers, managed-care firms, and Insurance Department representatives to discuss concerns and how to improve the system. Part of this effort will focus on "emergency room management that meets community needs without an ER operating as a de facto primary-care office," the release said. "A key component of controlling costs and improving health in a healthcare system is to provide the right treatment in the most cost-effective setting."

CHFS Secretary Audrey Tayse Haynes said the switch to managed care, made in November 2011, is working. “We are already seeing a tremendous increase in the use of preventive services, which improve health-care outcomes, while also reducing the enormous costs for treating chronic health conditions” such as diabetes-related amputations, she said.

Beshear said his plan would solve "lingering implementation problems" with managed care "while preserving the significant improvements in patient care and health care cost savings."

"Getting our people healthy and keeping them that way is not just good health policy, it’s good economics," Beshear said. "That’s why we will never return to the old fee-for-service system.  This is a significant cultural shift in medical care that has already happened across the country in both the private insurance market and in the Medicaid system."