Posted by on December 18, 2013 - 10:30am

As enrollment statistics in the new health insurance marketplaces start to become available, there is a growing focus on whether the enrollment of so-called “young invincibles” will be sufficient to keep insurance markets stable according to the Kaiser Family Foundation excerpted below.

Why does the age distribution of enrollees matter?

The Affordable Care Act (ACA) requires insurers in the individual market to cover anyone who wishes to enroll and restricts how insurers can vary premiums based on enrollee characteristics. Premiums cannot vary at all based on health status or gender. Premium variations based on age are limited to a ratio of three to one (meaning the premiums for a 64 year-old is three times the premium for a 21 year-old). Previously, premium variations based on age were more typically about five to one.

The limit on age rating means that, on average, older adults will be paying premiums that do not fully cover their expected medical expenses, while younger adults will be paying premiums that more than cover their expenses. For this system to work, young people need to enroll in sufficient numbers to produce a surplus in premium revenues that can be used to cross-subsidize the deficit created by the enrollment of older people. If that does not occur, premium revenues will fall short of expenses and insurers may seek to raise premiums the following year.

While enrollment in the federal and state-based marketplaces have tended to receive the most attention – and are the only enrollment statistics currently being reported – it is the age distribution across the entire individual market that matters from the perspective of the risk pool. That is because insurers are required to set premiums based on a “single risk pool” that encompasses all plans newly-purchased or renewed after January 1, 2014, both inside and outside the marketplaces.

Also, risk pooling occurs state by state, so if one state enrolls a substantial number of young adults, it will not help the insurance market in a state that is less successful.

What happens if enrollment among young adults falls short?

Because young adults will be cross-subsidizing older adults, they need to enroll in sufficient numbers for that cross-subsidy to be sufficient. If enrollment among young adults falls short, then the total amount of premiums collected by insurers will be less than the total health care expenses of enrollees plus administrative overhead and profit. And, if insurers believe that those enrollment patterns will continue into 2015, then they may raise premiums higher to compensate for the loss.

However, because premiums are still allowed to vary substantially based on age, the financial consequences of lower enrollment among young adults are not as great as conventional wisdom might suggest.

To learn more on this topic, read the full report from the Kaiser Family Foundation.

Posted by on November 26, 2013 - 12:33pm

The Supreme Court on Tuesday, November 26,  agreed to hear cases on whether corporations may refuse to provide insurance coverage for contraception to their workers based on the religious beliefs of the corporations’ owners.   President Obama’s health care law has exempted many religious groups from the law but did not exempt for-profit corporations because of owners' religious objections.

The National Women’s Law Center (NWLC) will be submitting a “friend of the court” brief to the Supreme Court that lays out how birth control advances the health and rights of women. Nearly 99 percent of women use contraception at some point during their reproductive years who come from a variety of religious faiths.  And currently nearly 27 million women can get free birth control without copays — a number that will increase as the health care law continues to go into effect.

Most women's organizations believe that allowing bosses to make women’s health care decisions is a dangerous precedent that could lead to companies refusing to abide by other laws that protect their employees, such as employment protections like minimum wage or equal pay. 
Sign the pledge to say all women deserve to make their own birth control decisions — no matter where they work.




Posted by on March 24, 2013 - 9:44am

As the three-year anniversary of the Affordable Care Act approaches, the Kaiser Family Foundation has updated its interactive quiz that allows users to test their knowledge about what’s in – and what's not in – the health reform law.

Quiz takers can compare their health reform knowledge to that of their friends by sharing their quiz results on Facebook and Twitter. The quiz also includes links to more information about specific provisions of the law.   There's a lot posturing and misunderstanding out there so take the quiz and see how informed you are.  I got 9 out of 10, not bad.   Let us know how you do.

Posted by on February 25, 2013 - 7:36am

During a visit with Illinois Governor Pat Quinn on February 13,  Health and Human Services (HHS) Secretary Kathleen Sebelius announced that Illinois has been conditionally approved to operate a State Partnership Marketplace (Exchange), which will be ready for open enrollment in October 2013. This partnership will allow Illinois to make key decisions and tailor the marketplace to local needs and market conditions.

“I applaud efforts by Illinois to build a new health insurance marketplace,” Secretary Sebelius said.  “Working together, we will be ready in eight months when residents of Illinois will be able to use the new marketplace to easily purchase quality, affordable health insurance plans.”

“Here in the home state of President Barack Obama, we are forging ahead to make the promise of the Affordable Care Act a reality,” Governor Quinn said. “Access to decent health care is a fundamental right. Hundreds of thousands of people in Illinois will gain quality health coverage through the Health Insurance Marketplace. They will also gain the peace of mind that comes from knowing that the care will be there if they need it. We are going to be working very hard between now and October 1st to educate the people of our state about the health care coverage options they will have through the Marketplace, thanks to President Obama's leadership.”

With today’s conditional approval of Illinois, twenty states and the District of Columbia have been conditionally approved to partially or fully run a marketplace – with the remaining states having until Feb. 15, 2013, to apply for a State Partnership Marketplace.

Because of the Affordable Care Act, consumers and small businesses will, beginning next January, have access to a new marketplace, where they can access quality, affordable private health plans.  These comprehensive health plans will ensure consumers have the same kinds of insurance choices as members of Congress, and will not be able to be denied coverage because of a pre-existing condition.

Consumers in every state will be able to buy insurance from qualified health plans directly through these marketplaces and may be eligible for tax credits and cost sharing assistance to help pay for their health insurance and out of pocket costs.

For more information on the new health insurance marketplace, visit:

Posted by on November 25, 2012 - 1:46pm

As many as 129 million--or 1 in 2--non-elderly Americans have some type of pre-existing health condition, ranging from a life-threatening illness like cancer to chronic conditions like heart disease, diabetes, or asthma.   In most states, these individuals can be denied individual health insurance coverage or have benefits for certain conditions excluded by insurance companies.   Even if some small groups desire to cover all conditions, there is little that can be done to prevent exorbitant premium increases.

Starting in 2014, the proposed rule  of The Affordable Care Act (ACA) prohibits denying coverage because of pre-existing conditions.  It does state that individuals would have to buy coverage during open enrollment periods.  In addition, individual would have new special enrollment opportunities in the individual market when they experience certain losses of other coverage.

Health insurance issuers in the individual and small group markets would only be allowed to vary premiums based on age, tobacco use, family size, and geography.   All other facts--such as pre-existing conditions, health status, claims history, duration of coverage, gender, occupation and small employer size and industry---would no longer be able to be used by insurance companies to increase the premiums for those seeking insurance.

Under the ACA, states can choose to enact stronger consumer protections than the above minimum standards.  In addition, starting in 2017, states have the option of allowing large employers to purchase coverage through the Exchanges*.  For states that choose this option, these rating rules also would apply to all large group health insurance coverage.   These proposed rules standardize how health insurance issuers can price products, bringing a new level of transparency and fairness to premium pricing.

Health insurance issuers would be required to maintain a single statewide risk pool for each of their individual and small employer markets, unless a state chooses to merge the individual and small groups into one pool.   Premiums and annual rate changes would be based on the health risk of the entire pool.  This provision prevents insurers from using separate insurance pools within markets to get around the market reforms and to charge people with greater health problems higher rates for their pool,   than rates in other healthier pools (Note:   This practice has often been called "cherry-picking" , i.e, limiting certain pools to  healthy people in a.)

This proposed rule also covers individual and employee renewals, prohibiting issuers from refusing to renew coverage because an individual or employee suddenly becomes ill with a chronic or severe condition.  There is also a provision for enrollment in catastrophic plans, providing affordable individual coverage options for young adults and people for whom coverage would otherwise be unaffordable.  To see the proposed rule, visit

*Exchanges are the mechanism through which low and moderate-income individuals receive premium and cost-sharing subsidies to make health coverage more affordable. Many states have started implementing them, some have not.   They must be implemented by January 1, 2014.  In states who have not established an exchange, a federally-facilitated exchange will be implemented.  Some states are delaying action until all lawsuits against the ACA have been settled.



Posted by on September 27, 2012 - 9:55am

The 2012 election cycle has seen unprecedented coverage (and often misinformation) on women’s reproductive health care due to the Affordable Care Act’s immediate impact and nonstop campaign gaffes related to women’s health.

Last Thursday, the National Women’s Law Center (NWLC) launched a new campaign to improve access to women’s health information called This Is Personal. The mission of the campaign is to target, engage and inform younger women about reproductive rights and help disseminate information related to women’s health topics ranging from contraception, maternity care, and what Congress is presently voting on.

It is therefore vitally important that women get involved in the decision-making process to ensure that the women impacted by these deeply personal issues have real world input.  “Decisions about women’s reproductive health are personal. Period.” said NWLC Co-President Marcia Greenberger. “These decisions should be a woman’s to make with the important people in her life. The personal beliefs of lawmakers should not trump a woman’s ability to take care of her health.” Despite the private nature of decisions impacting reproductive health care, they are often made at the federal, state or local levels instead of the individual level.

The This Is Personal campaign hopes that through social media, celebrity involvement in videos and satire, young women (and men) will become increasingly active and interactive about reproductive rights. For example, through the new website’s interactive action tabs women can gather more information about state and federal health care decisions, sign petitions and contact legislators.

Decisions about women’s reproductive health care are greatly personal and deserve intimate involvement from women themselves. This Is Personal has a Facebook, Twitter and website with data and satirical videos which should be used as an educational tool and a place for women to educate themselves for the upcoming election. It is also a place where women can actively use their beliefs and knowledge to have their voices heard by decision makers.  Sharing of ideas and knowledge is the only way to put decision making into the hands of the women who will be affected by the policies of the 113th Congress.

Posted by on September 13, 2012 - 7:56am

This week a public meeting will be held in Chicago to determine which Essential Health Benefits (EHB) Illinois will cover in future health insurance plans. The Affordable Care Act has tasked each state with creating a set of EHB, which are a comprehensive package of health benefits.

Beginning in 2014, all health plans are required to begin offering the EHB to beneficiaries in the individual and small group markets. These state-based benchmark decisions are due by September 30, 2012, and could eventually affect nearly 70 million Americans, many of whom are women. The law mandates that 10 basic categories must be covered. These inlcude:

1. Ambulatory Patient Services

2. Emergency Services

3. Hospitalization

4. Maternity and Newborn Care

5. Mental Health and Substance Use Disorder Services

6. Prescription Drugs

7. Rehabilitive and Habilitive Services

8. Laboratory Services

9. Preventative and Wellness Services and Chronic Disease Management

10. Pediatric Services

Governor Pat Quinn will choose a benchmark plan that will then serve as the mandatory minimum for insurance plans in the state. The greatest importance of these EHB decisions will be the amount of coverage required in each category and the costs of insurance due to those new requirements. At first glance, it might seem the package of services related to maternity and new born care will have the most impact on women, however, it is likely that the mental health and substance use disorders services may be most needed given that women are far more likely to suffer from a wide range of anxiety disorders and depression. Despite enthusiasm for more even coverage and plan equality, the minimum categories will require that almost all insurance plans offer more than they do at present, certainly impacting the cost of health insurance.

Posted by on August 24, 2012 - 7:40am

The U.S. can learn from Mexico's recent efforts at health reform, especially as it relates to transferring care from specialists back to primary care physicians, researchers said.

Mexico created its national health insurance program, called the Seguro Popular in 2003, and achieved universal coverage for its 100 million citizens earlier this year, Felicia Knaul, PhD, of Harvard Medical School and colleagues wrote in the Aug. 16, 2012 edition of The Lancet.    The program now provides coverage to 52 million previously uninsured Mexicans, they noted.

Its list of essential covered services grew from 91 in 2004 to 284 in 2012 -- covering treatment for more than 95% of conditions in ambulatory units and hospitals, Knaul and colleagues wrote.  Meanwhile, Mexico also built 15 high-specialty centers, more than 200 hospitals, and almost 2,000 ambulatory clinics.

As the country slowly expanded coverage, its state-run specialty care centers became overcrowded with patients. To avoid facing a similar problem, the U.S. could learn to strengthen primary care's ability to provide follow-up treatment to patients recovering from catastrophic illnesses such as cancer, Knaul said in an interview with MedPage Today.

"That's not what primary care has been able to do well," she said.

The real challenge for the medical community will be how to train primary care doctors to handle that, Knaul said. It's not good for patients to continue to seek treatment at the specialty level, but it can be complex to link that follow-up care back to primary care doctors.

Regardless of how that's done, Mexican reform has shown it's possible to build financially responsible ways to treat chronic diseases alongside prevention, Knaul and colleagues wrote.

"Part of the global community has been convinced that middle-income and especially low-income countries should limit their activities to prevention in the case of chronic and noncommunicable diseases," the paper stated. That line of thinking is wrong and would conflict with the point of health reform, which is to provide affordable healthcare to all citizens, Knaul said.

For example, although treating a chronic illness like childhood asthma isn't expensive from month to month, Knaul pointed out that it adds up over time and can be financially burdensome.

Knaul knows of Mexican families living in the U.S. that have developed serious medical conditions, lost their jobs and their work visas as a result, and have returned to Mexico because they can be treated there. "Hopefully, this will change as a result of reform in the United States," she said.

Health reform in Mexico has spurred economic growth while improving health, Knaul noted. The infant mortality rate dropped from from 18.2 to 14.1 per 1,000 live births from 2000 to 2010. The percentage of deaths from communicable diseases also fell -- from 15.4% to 10.8% -- during the same period.

Meanwhile, the gross domestic product per capita in Mexico increased from $11,852.70 in 2000 to $12,440.90 in 2010.

Posted by on August 6, 2012 - 1:44pm

In a recent weekly press briefing, House Speaker John Boehner signaled that Republicans would not pursue legislation challenging the federal contraceptive coverage rules, Talking Points Memo reports. The requirement took effect on Aug. 1. The rules implement a provision in the Affordable Care Act  that requires health plans to cover preventive services without copayments or deductibles. In February, the Obama administration announced that it would alter the rules so that religiously affiliated employers will not have to offer contraceptive coverage for their employees, but their health insurance companies will be required to provide no-cost coverage directly to women.

House GOP members have said the requirement is an attack on religious freedom. Boehner himself has said that if the Obama administration does not rescind the requirement, "then the Congress, acting on behalf of the American people and the Constitution we are sworn to uphold and defend, must."

However, Boehner took a different tone on the issue last Thursday. He said, "We're continuing to work with those groups around the country who believe that their religious liberties are being infringed to try to come to a resolution of this issue." He added, "Sometimes resolving this issue can be done other than legislative avenues. So we're continuing to work with them on the best way forward".

Posted by on August 1, 2012 - 12:52pm

A hotly contested provision of the Affordable Care Act (ACA) that requires employers and insurers to offer free contraceptive coverage takes effect today despite ongoing legal challenges.

Starting August 1, 2012, all new insurance policies must cover birth control and certain other preventive health services with no copay, coinsurance, or deductible. The move has riled political conservatives who say it encroaches on their religious freedom by forcing some faith-based employers to provide contraceptive coverage against their will.

While efforts to repeal the change in Congress seem to have cooled, some legal challenges (in Colorado and Michigan)  are still under way to the law, which has already been delayed for certain faith-based organizations by the Obama administration.

Other women's health services for which mandated coverage begins Wednesday include free annual breast exams, prenatal care, HPV screenings, and pelvic exams. Although the changes take effect today, insurance plans won't be required to start providing the free contraception until the insurance plan's next renewal date -- Jan. 1 for most plans.   Unfortunately, many state plans were renewed July 1 so it may take a full year to implement everything mandated by the ACA.    The Department of Health and Human Services estimates 47 million women will be effected by the ACA's mandate.

Despite some Republican concerns about the birth control mandate, they have yet to take a vote in the House of Representatives.  Efforts to repeal parts of or the entire ACA have stalled in the Democratic-controlled Senate, despite repeated efforts by the House.

But the Obama Administration has already taken steps to soften the change. A final rule issued in March says religious colleges and universities who object to contraception do not have to pay for or arrange coverage for their students or employees.

In addition, all nonchurch religious organizations that object to the policy don't have to pay for birth control; instead, their health insurers would be required to reach out to beneficiaries separately and offer such coverage free of charge. Religious organizations such as churches are exempt from the rule entirely.