Tag Archives: coverage

Doctors, hospitals say ‘show me the money’ before treating patients

Tai Boxley needs a hysterectomy. The 34-year-old single mother has uterine prolapse, a condition that occurs when the muscles and ligaments supporting the uterus weaken, causing severe pain, bleeding and urine leakage.

Boxley and her 13-year-old son have health insurance through her job as an administrative assistant in Tulsa, Oklahoma. But the plan has a deductible of $5,000 apiece, and Boxley’s doctor said he won’t do the surgery until she prepays her share of the cost. His office estimates that will be as much as $2,500. Boxley is worried that the hospital may demand its cut as well before the surgery can be performed.

“I’m so angry,” Boxley said. “If I need medical care I should be able to get it without having to afford it up front.”

At many doctors’ offices and hospitals, a routine part of doing business these days is estimating patients’ out-of-pocket payments and trying to collect it up front.

Eyeing retailers’ practice of keeping credit card information on file, “there’s certainly been a movement by health care providers to store some of this information and be able to access it with patients’ permission,” said Mark Rukavina, a principal at Community Health Advisors in Chestnut Hill, Massachusetts, who works with hospitals on addressing financial barriers to care.

But there’s a big difference between handing over a credit card to cover a $20 copayment versus suddenly being confronted with a $2,000 charge to cover a deductible, an amount that might take months to pay off or exceed a patient’s credit limit. Doctors may refuse to dispense needed care before the payment is made, even as patient health hangs in the balance.

The strategy leaves patients financially vulnerable. Once a charge is on a patient’s credit card, they may have trouble contesting a medical bill. Likewise, a service placed on a credit card represents a consumer’s commitment that the charge was justified, so nonpayment is more likely to harm a credit score.

Approximately three-quarters of health care and hospital systems ask for payment at the time services are provided, a practice known as “point-of-service collections,” estimated Richard Gundling, a senior vice president at the Healthcare Financial Management Association, an industry group. He could not say how many were doing so for higher priced services or for patients with high-deductible plans, situations that would likely result in out-of-pocket outlays of hundreds or thousands of dollars.

“For providers, there’s more risk with these higher deductibles, because the chance of being able to collect it later diminishes,” Gundling said.

But the practice leaves many patients resentful.

After arriving by ambulance at the emergency department, Susan Bradshaw lay on a gurney in her hospital gown with a surgical bonnet on her head, waiting to be wheeled into surgery to remove her appendix at a hospital near her home in Maitland, Fla. A woman in street clothes approached her. Identifying herself as the surgeon’s office manager she demanded that Bradshaw make her $1,400 insurance payment before the surgery could proceed.

“I said, ‘You have got to be kidding. I don’t even have a comb,’” Bradshaw, a 68-year-old exhibit designer, told the woman on that night eight years ago. “I don’t have a credit card on me.”

The woman crossed her arms and Bradshaw remembers her saying, “You have to figure it out.”

As providers aim to maximize their collections, many contract with companies that help doctors and hospitals secure payments up front, often providing scripts that prompt staff to talk with patients about their payment obligations and discuss payment scenarios as well as software that can estimate what a patient will owe.

But as hospitals and doctors push for point-of-service payments to reduce bad debt from patients with increasingly high deductibles, the risk is that patients will delay care and end up in the emergency room, Rukavina said. “Patients are essentially paying for their procedures up front,” he said. “It may not be a significant amount compared to their salary, but they don’t necessarily have it available at the time of service.”

The higher their deductible, the less likely patients are to pay what they owe, according to an analysis of 400,000 claims by the Advisory Board, a health care research and consulting firm. While more than two-thirds of patients with a deductible of less than $1,000 were likely to pay at least some portion of what they owe, just 36 percent of those with deductibles of more than $5,000 did so, the analysis found.

Fifty-one percent of workers with insurance through their employer had a deductible of at least $1,000 for single coverage this year, according to the Kaiser Family Foundation’s annual survey of employer health insurance. (KHN is an editorially independent program of the foundation.)

Boxley pays $110 a month for her family plan. She could not afford the premiums on plans with lower deductibles that her employer offered. She plans to talk with the doctor and hospital about setting up a payment plan so she can get the surgery in January.

“I’ll make payments,” Boxley said, although she acknowledged what she could pay monthly would be small. If that doesn’t pan out, she figures she’ll have to use student loan money she got for graduate school to cover what she owes.

Still, experts say that trying to pin patients down for payment in more acute settings, such as the emergency department, may cross a line.

Under the federal Emergency Medical Treatment and Labor Act (EMTALA), a patient who has a health emergency has to be stabilized and treated before any hospital personnel can discuss payment with them. If it’s not an emergency, however, those discussions can occur before treatment, said Dr. Vidor Friedman, an emergency physician who is the secretary-treasurer of American College of Emergency Physicians’ board of directors.

Bradshaw finally got her appendix removed by calling a friend, who read his MasterCard number over the phone. The surgery was uneventful and Bradshaw was home within 24 hours.

“It’s a very murky, unclear situation,” Friedman said of Bradshaw’s experience, noting that a case might be made that her condition wasn’t life threatening. “At the very least it’s poor form, and goes against the intent if not the actual wording of EMTALA.”

Please visit khn.org/columnists to send comments or ideas for future topics for the Insuring Your Health column.

Published courtesy of Kaiser Health News.

Minnesota court overturns ban on transition-related surgery

A Minnesota district court ruled this week that transgender people on the state’s Medical Assistance program deserve access to medically necessary services related to gender transition.

Since 2005, surgical treatments for gender dysphoria have been excluded from coverage even though equivalent treatments were covered under the federal Medicare program and private insurance plans.

In December 2015, the American Civil Liberties Union, along with the ACLU of Minnesota, filed a lawsuit on behalf of OutFront Minnesota and Evan Thomas, a transgender man, challenging Minnesota’s ban on coverage.

Thomas was denied coverage for transition related surgery, despite being diagnosed with gender dysphoria.

In a statement to the press released on Nov. 16, Thomas said, “I’m so happy we’ve won. The judge’s ruling is a forceful statement that transgender people deserve equal treatment under the law. Right now, when we’re suddenly facing a path that’s so much rougher than it looked a few days ago, this victory looks even more important, and I’m proud to have been part of this case. I thank the ACLU for taking it on and winning such a good ruling — it’s been a privilege to work with these wonderful, dedicated people.”

OutFront, Minnesota’s largest LGBTQ rights organization, also was a  plaintiff.

“OutFront Minnesota is delighted by this ruling, confirming what we knew all along: targeting transgender people like this is discriminatory, unconstitutional, and wrong.  Since filing this suit, we have been contacted by many individuals and families whose access to health care has been unjustly harmed. At last we can provide some hopeful news that the care they need may now be within reach,” Phil Duran, legal director of OutFront Minnesota, said in a news release.

Added Joshua Block, senior staff attorney with the ACLU’s LGBT Project: “The victory will bring immediate relief to the scores of transgender people living in Minnesota being denied the medical care they need. Singling out groups of people and denying them medically necessary care for no legitimate reason is wrong and harmful. We are glad the court agreed with respecting the dignity of people.”

The case was filed in Ramsey County District Court against Emily Johnson-Piper, the commissioner of Minnesota’s Department of Human Services.


What each of the TV networks are planning for election night

The long-running television drama known as Campaign 2016 reaches its conclusion tonight, and tens of millions of Americans will be following the results on their television screens.

The record election night audience of 71.5 million viewers came on the night of Barack Obama’s first victory in 2008 (it was 66.8 million in 2012).

Given the consistent level of interest throughout the 2016 campaign, it’s not hard to imagine that record being broken.

Besides following on TV, many of those viewers will have second or third screens at hand to dive deeper into results.

Here’s a thumbnail sketch of network plans:


NBC is the defending election night ratings champion and that’s a major point of pride for a television news division.

With Brian Williams now exiled to MSNBC, the main network is taking the team approach with Lester Holt, Savannah Guthrie and Chuck Todd as headliners for its coverage.

Tom Brokaw is a comforting presence as an analyst: He’s been involved in every NBC election night since 1968.

As in the past, NBC is dressing up New York’s Rockefeller Plaza, with the front of its headquarters lighting up in red and blue to mark the electoral progress of Hillary Clinton and Donald Trump and a map of the United States superimposed on the famed skating rink.

Todd will be NBC’s guru of exit polls and the electoral map.

Andrea Mitchell will report live from the Clinton campaign headquarters, with Katy Tur doing the same at Trump’s.

Each of the three top broadcasters will air elections coverage from 7 p.m. to 2 a.m. ET.


The current and two former anchors of ABC’s flagship “World News Tonight” broadcast will be on the set election night, but George Stephanopoulos will lead the coverage.

Stephanopoulos is ABC’s top man in politics, and it will be his first election night as the chief anchor.

Election night is all hands on deck, however, and Charles Gibson is coming out of retirement to be on the set. Diane Sawyer, who anchored ABC’s coverage four years ago, will also participate, along with current “World News Tonight” anchor David Muir.

ABC’s coverage will originate from Times Square, and Michael Strahan of “Good Morning America” will be outside to get public reaction.

ABC is stationing Robin Roberts at Hillary Clinton’s headquarters and Amy Robach at Donald Trump’s.

ABC News also has the closely watched prognosticator, Nate Silver of the FiveThirtyEight website, giving state-by-state analysis.

ABC will also air a special edition of “Nightline” from 2 to 4 a.m. ET.


CBS is stressing the ensemble approach for its coverage and showcasing its entire morning show team.

Rather than declare Scott Pelley as its chief anchor, CBS News is giving equal billing to seven different personalities: Besides Pelley, they are the morning show team of Charlie Rose, Gayle King and Norah O’Donnell, the network political director John Dickerson, correspondent Elaine Quijano and semi-retired anchor Bob Schieffer.

Rose will showcase his interviewing and also lead a panel of experts for analysis.

Anthony Mason is CBS’ man at the maps.

Major Garrett will cover Trump headquarters and Nancy Cordes will be with Clinton.

The CBSN streaming service, which celebrates its second birthday this weekend, will also stream a continuous news report Election Day and night.


Election night coverage on CNN begins before any of the polls close, at 4 p.m. ET, with Wolf Blitzer, Jake Tapper, Anderson Cooper and Dana Bash tag-teaming it.

Actually, Election Day coverage begins 16 hours earlier, with CNN appealing to insomniacs with a live overnight political show hosted by Poppy Harlow.

The network is stationing 25 correspondents to report from polling sites at swing states across the country.

John King is back in front of CNN’s Magic Wall of data, David Chalian will cover exit polls and Mark Preston is stationed at the network’s decision desk. Gloria Borger, David Axelrod, Nia-Malika Henderson and Michael Smerconish are at the analysts’ desk.

For overseas viewers, CNN International will simulcast the main network’s elections coverage all over the world.


No longer on the main network, Williams will anchor MSNBC’s coverage as part of a team with Rachel Maddow and Chris Matthews.

MSNBC’s coverage starts at 6 p.m., an hour earlier than NBC, and will draw on the same bench of experts used by the main network.


Judy Woodruff and Gwen Ifill will anchor PBS’ election night coverage, which begins at 8 p.m. ET on the public broadcasting network.

John Yang will be at Clinton headquarters in New York and Jeffrey Brown will be following Trump.

PBS’ list of analysts include David Brooks of The New York Times, Amy Walter from the Cook Political Report, veteran broadcaster Jeff Greenfield, Mitt Romney’s former campaign chief Stuart Stevens and former Obama pollster Cornell Belcher.


If you tire of television analysts, C-SPAN offers an alternative.

The network will dart around the country to hear victory and concession speeches by candidates running for various races.

The network will also take viewer calls and sample comments from social media throughout the night, beginning at 8 p.m. ET.

Policy Prescriptions: Clinton and Trump and health care

Hillary Clinton has been involved in the nation’s health care debate for more than 20 years and, as her campaign likes to say, she has the scars to prove it.

The Democratic presidential candidate failed in her 1990s effort to steer her husband’s universal coverage program through Congress, as the complex plan collapsed for lack of political support. Since then, she has tacked sometimes to the right on health care, and sometimes to the left.

Clinton is campaigning as the candidate of continuity and would leave all major health care programs in place. She has a long list of tweaks and adjustments that reflect her familiarity with policy and would expand the government’s role in health care.

Donald Trump calls President Barack Obama’s health care law “a disaster,” and vows to repeal it. He’d provide a new tax deduction for health insurance premiums, but also limit federal support for Medicaid, which covers low-income people. An independent analysis recently estimated his seven-point plan would cause 20 million people to lose coverage.

Trump’s ideas on health care have shifted over time, and his latest plan hews to basic GOP talking points. He’s expressed a belief that an economically advanced country like the United States can’t have people “dying in the street” for lack of medical care.

Here is a summary of their proposals:


The government’s premier health insurance program covers about 57 million people, including 48 million seniors and 9 million disabled people under age 65. It enjoys strong support from voters across the political spectrum, although its long-term financial outlook is uncertain.

CLINTON: She would authorize Medicare to negotiate drug prices with pharmaceutical companies, and she supports allowing patients to import lower-cost prescriptions from abroad. Medicare beneficiaries represent a big share of the market for medications.

Clinton would also allow people ages 55-64 to buy into Medicare, although her campaign has not released much detail on how that would work.

TRUMP: He promises not to cut Medicare, and has suggested that other Republicans like House Speaker Paul Ryan made a political mistake by calling for major changes. But it remains unclear how Trump’s proposed repeal of “Obamacare” would affect its improvements to Medicare benefits, including closing the prescription drug coverage gap known as the “doughnut hole.”

Earlier, Trump spoke approvingly of giving Medicare legal authority to negotiate prescription drug prices, but that idea currently is not mentioned in his health care plan. Instead, he also supports allowing drug importation.


The federal-state program for low-income individuals covers more than 70 million people, from pregnant women and children to elderly nursing home residents. Under Obama’s health care law, states can expand the program to include more low-income adults. Medicaid has sometimes carried a social stigma, but polls show the program has a solid base of public support.

CLINTON: She’d work to expand Medicaid in the 19 states that have yet to take advantage of the health law. She’s proposing three years of full federal funding for those states, the same deal given to states that embraced the law right away.

TRUMP: In 2015 Trump told an interviewer: “I’m not going to cut Social Security like every other Republican. And I’m not going to cut Medicare or Medicaid. Every other Republican’s going to cut.”

But his campaign plan would convert Medicaid into a block grant, ending the open-ended federal entitlement and capping funding from Washington. Over time, such an approach is likely to result in a big cut.


About 177 million people under age 65 have private health insurance, with nearly 9 in 10 getting their coverage through an employer. Rising out-of-pocket costs such as insurance deductibles and copayments are a sore point with consumers.

CLINTON: She has proposed a new tax credit of up to $5,000 per family, or $2,500 for an individual, for households that face “excessive” out-of-pocket costs. The credit would be refundable, meaning that people who don’t owe income tax could still get money back. An independent analysis of her plan defined “excessive” costs as exceeding 5 percent of household income.

Clinton would also require insurers to cover three sick visits to the doctor each year without patients needing first to meet their plan’s deductible, the annual amount patients pay before their insurance kicks in.

TRUMP: He has no similar proposals on out-of-pocket expenses but has called for requiring hospitals, clinics and doctors to disclose prices so patients can shop around to reduce costs. And he would expand the use of tax-sheltered health savings accounts, used to pay for medical expenses not covered by insurance.


More than half of U.S. adults take prescription drugs, and according to a recent Kaiser Family Foundation poll most of those patients report no major problems affording their own medications.

But consumers have been alarmed by the introduction of breakthrough drugs costing tens of thousands of dollars a year, along with a spate of seemingly random price hikes for older medications. More than 3 out of 4 say the cost of prescription drugs is unreasonable. A majority favors government action to curb costs.

CLINTON: She has several proposals, including a new government board with the power to penalize drug companies for “unjustified, outlier price increases,” a monthly limit of $250 on patients’ copayments for prescription drugs, lowering the period of protection from generic competition for biologic drugs from 12 years to 7 years, and requiring drug companies to provide rebates for medications used by low-income Medicare recipients.

Those ideas are on top of Medicare negotiations and allowing patients to import lower-cost prescription drugs from abroad.

TRUMP: In addition to backing drug importation, he also has called on Congress to remove barriers to competition from lower-price, equally effective medications.


The 2010 Affordable Care Act expanded coverage for the uninsured and made carrying health insurance a legal obligation for most people. It offers subsidized private insurance for people who don’t have access to a job-based plan, along with a state option to expand Medicaid.

About 11 million people are covered through the law’s private insurance markets, while the Medicaid expansion has added at least 9 million to that program. It’s unclear if all those people were previously uninsured, but experts say the law deserves most of the credit for 21 million gaining coverage since its passage. Americans, however, remain deeply divided over “Obamacare.”

CLINTON: She wants to strengthen Obama’s signature law. Clinton would resolve a “family glitch” that denies health insurance subsidies to some dependents, sweeten subsidies for people buying coverage on the health law’s markets, and offer a new government-sponsored insurance plan to compete with private companies.

Her proposals would expand coverage to about 9 million more uninsured people, according to a recent study by the Commonwealth Fund and the RAND Corporation.

But Clinton would repeal the law’s tax on high-cost insurance, known as the “Cadillac Tax.” Many economists are critical, saying repeal of the tax would eliminate a brake on costs.

TRUMP: He would completely repeal the 2010 law and start over again. Trump has proposed a tax deduction for health insurance premiums, and also allowing insurers to sell policies across state lines, a longstanding GOP idea.

Critics say a deduction, usually claimed after the end of the tax year, wouldn’t do much to help lower-income people squeezed to pay premiums.

And the idea of selling across state lines has been opposed in the past by state insurance commissioners and attorneys general, who warned that it would undercut consumer protections. The insurance industry is divided, with smaller companies fearing it would favor major insurers.

Complaint: Wisconsin transgender researcher denied coverage

A transgender researcher has filed a complaint against the University of Wisconsin School of Medicine and Public Health, Wisconsin and an insurance company for denying her coverage of gender confirmation surgery.

The American Civil Liberties Union filed the complaint with the U.S. Equal Employment Opportunity Commission on behalf of Shannon Andrews, a cancer researcher at the medical school, the Wisconsin State Journal reported.

The complaint names the school and the Group Insurance Board, which oversees state workers’ health benefits for through the state Department of Employee Trust Funds. One of the companies that provide health insurance to state workers, Monona-based WPS Insurance, is also named in the suit.

ACLU says state worker health benefits include health care related to sex hormones and surgery associated with gender reassignment.

The board approved ending its exclusion of services and benefits related to sex transformation or gender reassignment on July 12, effective January 2017. A board document shows that the board’s lawyers recommended the change after the federal government issued final regulations regarding a portion of the Affordable Care Act related to discrimination in May.

ACLU says the policy change “comes too late” for Andrews, but didn’t say why. Andrews couldn’t immediately be reached for comment Tuesday.

“Notwithstanding the medical community’s agreement about the medical necessity of treatment for some transgender individuals, many employers continue to offer health insurance coverage that specifically targets transgender people and denies them coverage for life-saving medical care,” said Larry Dupuis, legal director for ACLU of Wisconsin.” These exclusions arbitrarily target transgender people for discrimination by forcing them to pay out-of-pocket for medically necessary services.”


Baldwin pushes for Medicaid expansions with new bill

New reform introduced by U.S. Sen. Tammy Baldwin would ensure that states that opt to expand eligibility for Medicaid can access the same federal funds as states that expanded the health care program before 2014, under the Affordable Care Act.

“I support this legislation because it is my hope it will point our state in the right direction,” Baldwin, a Democrat from Wisconsin, said in a news release.

The Affordable Care Act has provided federal financial support for states to expand Medicaid programs to provide health care coverage to individuals up to 138 percent of the federal poverty level.

The federal government, under the ACA, pays the cost of expansion for the first three years for the states that enrolled in 2014 and phases down to a 90 percent match rate for the sixth and subsequent years.

In a lawsuit over the expansion program, the U.S. Supreme Court ruled that states could opt-in or opt-in and 19 states — mostly those with Republican governors — opted out.

Republican Gov. Scott Walker has refused to expand Medicaid eligibility in Wisconsin and instead he shrunk the BadgerCare program.

Baldwin said the governor has put “politics ahead of progress and taken our state in the wrong direction,” kicked Wisconsinites off their coverage and created a coverage gap.

She said she hoped the States Achieve Medicaid Expansion Act of 2016 would provide the incentive for states to opt-in and expand Medicaid programs, as well as assist the seven states that expanded after 2014.

“In the states that haven’t expanded Medicaid, many adults living near the poverty level are now unable to afford health care,” said Jon Peacock, research director of the Wisconsin Council on Children and Families.

He said existing law makes expanding Medicaid a good deal but the SAME Act would create an even better deal. “It would be fairer to give all the states the same incentive to close a gap in affordable coverage for adults near the poverty level,” Peacock said.

Studies show states that expanded Medicaid eligibility saw direct and indirect benefits in job growth, earnings growth, increased gross state product, increased state and local revenues and reduced uncompensated care and hospital costs.

In an analysis released last year, the Kaiser Family Foundation estimated the economic impact of expanding eligibility in Wisconsin would be $1.3 billion and the creation of 10,500 jobs.

“Congress should pass this bill. The president should sign. And Gov. Walker and the Legislature should … expand BadgerCare to cover 83,000 more people and save state taxpayers more than a billion dollars over the next 10 years,” said Mike Bare of Community Advocates Public Policy Institute.

Baldwin introduced the bill along with Democrats Mark Warner of Virginia, Debbie Stabenow and Gary Peters of Michigan, Claire McCaskill of Missouri, Jon Tester of Montana, Tim Kaine of Virginia and independent Angus King of Maine.

Report finds wide health coverage gap for Hispanic kids in Wisconsin

About 9.3 percent of Hispanic children in Wisconsin in 2014 were uninsured, leaving nearly 14,000 kids without coverage according to a new report from Georgetown Center for Children and Families and the National Council of La Raza.

This is comparable to the national uninsured rate for Hispanic children, which reached a historic low of 9.7 percent.

However, the findings also show that Wisconsin has stagnated in making progress.

“While Wisconsin is on par with the national average, it did not reduce its rate of uninsured Hispanic children in 2014. There are still steps the state can take to move forward and be more of a leader in coverage,” said Sonya Schwartz, a research fellow at the Georgetown University Center.

The report highlights health inequities for Hispanic children when compared to all children. The uninsured rate for Wisconsin’s Hispanic children was more than double the percentage of all children in the state who were uninsured — 4.4 percent.

“We’re eager to move the needle in 2016, so Wisconsin can truly be a leader when it comes to health coverage for all our communities,” stated Sashikala Gregory, health care policy analyst for the Wisconsin Council on Children and Families.

In particular, the council urged state lawmakers to accept federal funding for Medicaid expansion, which would make health care more affordable for adults. When parents have access to health coverage, their children are also more likely to be covered.

“Every single child, no matter their background, deserves access to high-quality, affordable health care,” said Gregory. “Accepting federal Medicaid dollars helps all Wisconsinites, including Hispanic families. It’s time we close the health coverage gap and help kids get the health coverage that gives them a better chance to succeed in school and in life.” 

Ending trans exclusions in Dane County health care coverage

Transgender* people face major barriers to proper health care in Dane County. Estimates suggest that 0.3 percent of the population is transgender, and many will seek some form of medical care for gender transition, such as hormone therapy or gender confirming surgery.

This care is essential to our health and well-being and insurance coverage for it has been proven not to increase overall costs or premiums.

Yet nearly all of Dane County’s local insurance providers have “trans exclusion” policies, denying transgender patients otherwise standard medical care if the person is using it for gender transition. For example, a cisgender (non-transgender) woman can get hormone medication during menopause, but a transgender woman needing this medication for transition will be denied, specifically because she is transgender.

“Trans exclusion” policies are discriminatory by definition, even though gender identity is a protected class in Dane County and the city of Madison. Transgender people already face disproportionately higher rates of discrimination, assault, suicide attempts, HIV infection, and other health and safety issues. Being denied transition care only exacerbates this problem. Without it, we are even more vulnerable to discrimination, face a dangerous decline in our mental health, and may resort to unsafe substitutions for proper transition care. This discrimination has a serious negative impact on our life chances. We need health care justice now.

Dane County can help change this situation, and has a duty to take action. In addition to being a public health and safety issue, this is also a pressing matter of equity. In solving it, Dane County will join the first wave of states, federal programs, and local municipalities that are ruling in favor of trans-inclusive health care policies. Currently, local insurance providers do not even offer plans that include transition care. As a major employer, Dane County can directly change the market by asking insurance companies to create plans that do. Numerous studies show that this is highly cost-effective, with minimal charges to employers. The need for transition care within a given population is fairly low (though critical for those who need it) and so is the cost of transition care, relative to more common medical needs. Employers who cover transition care have had so small an increase in extra costs that their premiums didn’t change at all.

Our ultimate goal is universal health care for all people. Dane County can and should lead the way closer to this goal, by addressing one of the most obvious forms of health care discrimination: Trans-exclusion policies in health insurance plans.

We are asking that the County contract for an insurance plan that removes exclusions and covers “gender-confirming” surgery (also called “sexual reassignment” surgery), hormone therapy, and all other trans health needs.

*Transgender is an umbrella term for people who do not identify with the gender they were assigned at birth.


Gabe Javier, Director UW Madison LGBT Campus Center

Anders Zanichkowsky, community advocate

Z! Haukeness, community advocate

Nyle Biondi, LMFT

Alex Hanna, PhD candidate, UW Madison Sociology Department

The Wisconsin Gazette welcomes opinions and letters. Email lweisberg@www.wisconsingazette.com or lmneff@www.wisconsingazette.com.

Democrats focus on fixing skimpy insurance coverage

A different health care issue has emerged for Democrats, in sync with the party’s pitch to workers and middle-class voters ahead of next year’s elections.

It’s not the uninsured, but rather the problem of high out-of-pocket costs for people already covered and the difficulty of finding health care providers who accept coverage purchased off the health care exchange.

Democrats call it “underinsurance.”

More and more consumers are calling it a rip-off.

“By law I have to buy health care insurance,” said Marcella Graziano of Bradenton, Florida. “So I did. It costs $428 a month and after paying for the insurance, I’m having trouble finding a doctor who will accept the plan. And can’t afford treatment. I want to know who to blame.”

After paying premiums, many low- and middle-income patients like Graziano face high costs when trying to use their coverage. There’s growing concern that the value of a health insurance card is being eaten away by rising deductibles, the amount of actual medical costs that patients pay each year before coverage kicks in.

“I think it’s going to be the next big problem,” said U.S. Rep. Jim McDermott, D-Wash., a congressional leader on health care.

“We’ve got some 17 million more people covered …but they can’t access the care they seem to be entitled to,” McDermott said. “It costs too much to use the care. That’s the deceptive part about it.”

Mandated coverage

Since virtually all U.S. residents are now required to have health insurance by the health care law, McDermott said Democrats have a responsibility to make sure coverage translates to meaningful benefits.

Several liberal-leaning organizations have recently focused on the issue.

• A Commonwealth Fund study found that 31 million adults were underinsured last year. Half of them had problems with medical bills or medical debt. Seven million were underinsured due to high deductibles alone.

“The steady growth in the proliferation and size of deductibles threatens to increase underinsurance in the years ahead,” the study concluded.

• A study by the advocacy group Families USA found that one-quarter of the people with individual health insurance policies went without care in 2014 because they could not afford the out-of-pocket costs. The study singled out high deductibles.

What’s happening is people are paying for their health insurance coverage as mandated by the Affordable Care Act. However, after paying for their premiums, they can’t afford to pay for their health care.

• The Center for American Progress, a think tank often aligned with the White House, found that employers have been shifting a disproportionate burden of health care costs onto workers.

As a result, the report said, employees and their families have not shared in the benefits of a prolonged lull in medical inflation. The group recommended several policy changes, including rebates for workers under certain conditions.

“Cost shifting is part of what makes people underinsured,” said Topher Spiro, vice president for health policy at the center. “There’s an effort to raise the issue generally, and there’s general recognition that this is a problem that needs to be addressed.”

Insurance industry answers

The insurance industry says the focus on deductibles and cost sharing is misplaced. It says the real problem is that the United States pays too much for medical care.

Deductibles can be a legitimate tool for employers and insurers to steer patients to doctors and hospitals providing high-quality care at a reasonable cost. Some plans set lower amounts for services provided within a network.

“It can’t be looked at in isolation,” said Karen Ignagni, outgoing head of America’s Health Insurance Plans, the main industry trade group.

Some consumers may prefer a high-deductible plan in exchange for lower monthly premiums, she added. “They are making a conscious decision to make that trade-off.”

However, consumer advocates stress that many people may be new to buying insurance and may not be completely aware of what they are getting. And, once they buy coverage and the enrollment window shuts, they can’t change their coverage until the next enrollment period.

Some of these people are paying hundreds of dollars of month for health care insurance and then either cannot afford actual treatment or can’t find doctors who will accept the coverage they purchased of the health care exchange.

A wide body of research shows that out-of-pocket costs discourage people from getting medical care, but there is no agreed-upon standard of what constitutes “underinsurance.”

The Commonwealth Fund, a private foundation that aims to improve the health care system, defines underinsurance as out-of-pocket costs that add up to 10 percent or more of household income, in most cases, or a deductible that amounts to 5 percent of income or higher.

The Affordable Care Act set annual limits on out-of-pocket costs for most insurance plans, currently $6,600 for an individual policy and $13,200 for a family plan. It’s better than no limit, but a stretch for many people — individuals or families.

Annual deductibles for employer plans averaged about $1,200 for employee-only coverage last year, according to the Kaiser Family Foundation.

Deductibles can be much higher for plans sold through the health law’s insurance exchanges, averaging about $2,500 for single coverage under a midrange silver plan.

Improving the ACA

Democrats need an election-year health care narrative about how to improve Obama’s law, said Robert Blendon, a professor at the Harvard T.H. Chan School of Public Health.

“The issue that has come up repeatedly is the impact that high deductibles are having on moderate income people,” he said.

D.C. announces comprehensive health care plans for transgender citizens

D.C. Mayor Vincent Gray on Feb. 27 announced that public and private health insurance plans regulated by the D.C. government are required to cover transition-related care.

Local activists, the National Center for Transgender Equality, the Center for American Progress and D.C. officials worked on the initiative.

“This victory reaffirms growing agreement among advocates and the medical community that D.C.’s health care nondiscrimination laws require that insurance cover medically necessary transgender health care,” said Andy Bowen, NCTE policy associate.

Andrew Cray of CAP’s LGBT Research and Communications Project added, “This policy will make D.C.’s health care programs and insurance coverage the most comprehensive in the country for the full scope of health care that transgender people need throughout their lives. But more importantly, this announcement tells transgender people in the district that their health matters.”

D.C.’s Department of Insurance, Securities, and Banking released an advisory on Feb. 27 that said it will view “attempts by companies to limit or deny medically necessary treatments for gender dysphoria, including gender reassignment surgeries, to be discriminatory.”

DISB also stated, “It is the position of the Department that treatment for gender dysphoria, including gender reassignment surgeries, is a covered benefit…”

Gray, in a news conference, said D.C. Medicaid and government employee plans will conform to DISB’s explanation of D.C. law.

“The insurance bulletin means so much to transgender people,” said Mara Keisling, NCTE’s executive director. “It means health care is affordable and means we can access that care without delay or limitation. Here in the nation’s capital, transgender people won’t be forced to choose between paying the bills or paying for health care.”

Other partners in the campaign included the D.C. Trans Coalition, Casa Ruby, Gay and Lesbian Activists Alliance, Whitman Walker Health and the Gertrude Stein Democratic Club.

The announcement follows similar policies in California, Oregon, Vermont, Colorado and Connecticut.