2017 Individual and Family Medical Plans Require a Primary Care Physician

Beginning January 1, 2017 all individual and family health plans in California will require that members select a Primary Care Physician (PCP) or have one recommended by their health plan.

The terminology used in this case is confusing. A PCP has historically been a physician who is associated with an HMO which limits your choice. This is not the case in this instance.

You must choose a general physician who is in the network of your insurance company. If you do not choose a physician the insurance company will assign one to you. I know that at least one company will review your claims history in order to assign a physician that you have seen in the past.



The thought behind this is that if one is attached to a name of a physician, it is less likely that one will go to Urgent Care or the Emergency Room. An office visit or a phone call supposedly will lower health care spending.

In Summary, choose a physician or have one chosen for you.

Rate Increases for 2017 Medical Insurance Plans

There will be a significant rate increase for 2017 plans. The reasons given are the end of funding that was available in the first three years to offset rates, the rise in specialty medication and claims from those who enroll during Special Enrollment Periods.

In regard to the specialty medication, sometimes pharmaceutical companies are raising prices of medications when the need for a medication increases. Newer specialty medications can approach $100,000 per course of treatment and/or per year.

Below is the press release from Covered California on July 19, 2016

SACRAMENTO, Calif. — Covered California unveiled its rates for 2017 on Tuesday and announced that some health insurance plans will be expanding into new areas throughout the state to compete for consumers in California.

The statewide weighted average change will be 13.2 percent, up from approximately four percent in each of the last two years. However, most consumers will see a much smaller increase — or pay less next year — if they switch to another plan.

“Shopping is going to be more important this year than ever before,” Covered California Executive Director Peter V. Lee said. “Almost 80 percent of our consumers will either be able to pay less than they are paying now, or see their rates go up by no more than 5 percent, if they shop and buy the lowest-cost plan at their same benefit level. That’s the power of shopping.”

Lee said the opportunities to shop and save show that California has succeeded in building a competitive marketplace for health insurance, with rate increases that are still below trends in the individual market before the Affordable Care Act was passed.

“This is a new era of health care, where the consumer is in the driver’s seat with the power to look easily for a better deal, and where subsidies help absorb the impact of rate changes,” Lee said. “These options did not exist before the Affordable Care Act.”

Some consumers who choose to keep their plan will see a significant increase in their premium for 2017, while others will see a more modest increase, depending on where they live and what insurance plan they have. Consumers will begin receiving notices in October, when they will have an opportunity to review their new rates and change plans for their 2017 health coverage.

For many of those insured, the bulk of the premium increase will be absorbed by the subsidy paid by the government to help enrollees buy health insurance. Approximately 90 percent of Covered California enrollees get help to pay for their premiums. The average subsidy covers roughly 77 percent of the consumer’s monthly premium, and while premiums will rise, the subsidies will rise as well.

“Even though the average rate increase is larger this year than the last two years, the three-year average increase is 7 percent — substantially better than rate trends before the Affordable Care Act was enacted,” Lee said.

Lee said the average rate increase reflects the cost of medical care for consumers, not excessive profit.

“Under the new rules of the Affordable Care Act, insurers face strict limits on the amount of profit they can make selling health insurance,” Lee said. “So, while all plans are experiencing different cost pressures, we can be confident their rate increases are directly linked to health care costs, not administration or profit, which averaged 1.5 percent across our contracted plans.”

For consumers who get a tax credit to lower their costs — which is about 90 percent of those who sign up through Covered California — the amount they pay is impacted not only by the premium choice, but by changes in their tax credit. While the average rate increase is higher than past years, Covered California’s risk mix — the ratio of consumers who are healthy vs. sick — remains one of the best in the nation according to the Centers for Medicare and Medicaid Services (https://www.cms.gov/CCIIO/Programs-and-Initiatives/Premium-Stabilization-Programs/index.html).

Other reasons for rate increases include:
A one-year adjustment due to the end of a funding mechanism in the Affordable Care Act known as reinsurance, which was designed to moderate rate increases during the first three years when exchanges were being established. The American Academy of Actuaries estimates this will add between 4 percent and 7 percent to premiums for 2017.
Special enrollment by some consumers who may be enrolling in health insurance only after they become sick or need care, which seems to have had a significant impact on rates for two insurance plans.
The rising cost of health care, especially specialty drugs.
Pent-up demand for health care now being accessed by those who were locked out of the health care system before the Affordable Care Act was enacted.
Lee said Covered California is working to address some of these issues on multiple fronts. The exchange is aggressively marketing to attract healthy consumers year-round, and it is working to ensure special enrollment is available only to those who meet qualifying circumstances. It is also sampling the special enrollment population to better understand how to make any further improvements needed.

“We work hard to build a robust exchange that drives competition by attracting as many consumers as possible,” Lee said. “Now, consistent with the vision of the Affordable Care Act, we will redouble our efforts to make sure our consumers and potential consumers understand the importance of signing up during open enrollment and remaining covered throughout the year.”

Lee said Covered California’s 11 health insurers are competing across the state for its 1.4 million members.

“The sheer number of enrollees and their overall health means consumers in the individual market are benefiting from competition,” Lee said.

Below is the complete list of the companies selected for the 2017 exchange:
Anthem Blue Cross of California
Blue Shield of California
Chinese Community Health Plan
Health Net
Kaiser Permanente
L.A. Care Health Plan
Molina Healthcare
Oscar Health Plan of California
Sharp Health Plan
Valley Health Plan
Western Health Advantage
Rate details by pricing regions can be found in “Covered California’s Health Insurance Companies and Plan Rates for 2017,” posted online at:http://coveredca.com/news/pdfs/CoveredCA-2017-rate-booklet.pdf

The preliminary rates are subject to a 60-day public comment period and regulatory review by the California Department of Managed Health Care. In addition, the California Department of Insurance will review Health Net’s EPO.

Some insurance carriers will be increasing their coverage areas in 2017:
Oscar will be entering the market in San Francisco, Santa Clara and San Mateo counties.
Molina will expand into Orange County.
Kaiser will be available in Santa Cruz County.
With the expansion of its current carriers, almost all consumers (92.6 percent) will be able to choose from three or more carriers, and all will have at least two to select from.

In addition, more than 93 percent of hospitals in California will be available through at least one Covered California health insurance company in 2017, and 74 percent will be available in three or more plans.

Covered California also is improving its patient-centered benefit designs by increasing a consumer’s access to care by reducing the number of services that are subject to a consumer’s deductible.

Starting in 2017, consumers in Silver 70 plans will save as much as $55 on an urgent care visit and $10 on a primary care visit. In addition, consumers in Silver, Gold and Platinum plans will pay a flat copay for emergency room visits without having to satisfy a deductible, which could save them thousands of dollars.

These improvements build on features already in place that ensure most outpatient services in Silver, Gold and Platinum plans are not subject to a deductible, including primary care visits, specialist visits, lab tests, X-rays and imaging. In addition, some Enhanced Silver plans have little or no deductible and very low copays, such as $3 for an office visit. Even consumers in Covered California’s most affordable Bronze plans are allowed to see their doctor or a specialist three times before the visits are subject to the deductible.

In addition, the contract with health insurers for 2017 ensures consumers select or are provisionally assigned a primary care physician within 60 days of effectuation so they have an established source of care.

“Health care reform isn’t just about making insurance affordable, it’s about doing things to make it easier for consumers to get the right care at the right time,” Lee said.

In May, the Centers for Disease Control and Prevention announced that California’s uninsured rate had fallen to 8.1 percent at the end of 2015, down from 17 percent at the end of 2013, right before the Affordable Care Act began offering coverage.

“We can all be very proud of the extraordinary gains we have made in reducing California’s uninsured rate to a historic low,” Lee said.

About Covered California
Covered California is the state’s marketplace for the federal Patient Protection and Affordable Care Act. Covered California, in partnership with the California Department of Health Care Services, helps individuals determine whether they are eligible for premium assistance that is available on a sliding-scale basis to reduce insurance costs or whether they are eligible for low-cost or no-cost Medi-Cal. Consumers can then compare health insurance plans and choose the plan that works best for their health needs and budget. Small businesses can purchase competitively priced health insurance plans and offer their employees the ability to choose from an array of plans and may qualify for federal tax credits.

Covered California is an independent part of the state government whose job is to make the new market work for California’s consumers. It is overseen by a five-member board appointed by the Governor and the Legislature. For more information about Covered California, please visit www.CoveredCA.com.

This article is from the Los Angeles Times date July 20, 2016

California Obamacare rates to jump

Premiums are set to go up an average of 13.2% next year. Rising medical costs are one reason, officials say.


Premiums for Californians’ Obamacare health coverage will rise an average of 13.2% next year — more than three times the increase of the last two years and a jump that is bound to stir debate in an election year.

The big increases come after two years in which California officials had boasted that the program helped insure hundreds of thousands people in the state while keeping costs moderately in check.

Premiums in the insurance program called Covered California rose just 4% in 2016 after rising 4.2% in 2015 — the first year that exchange officials negotiated with insurers. The program insures 1.4 million Californians.

On Tuesday, officials blamed next year’s premium hikes in the program on rising costs of medical care, including expensive specialty drugs and the end of a mechanism that held down rates for the first three years of Obamacare.

Two of the state’s biggest insurers — Blue Shield of California and Anthem Inc. — asked for the biggest hikes. Blue Shield’s premiums will jump an average of more than 19%, according to officials, and Anthem’s rates will rise more than 16%.

For consumers, the effect will depend on whether they get taxpayer-supported subsidies for their premiums and whether they are willing to switch to less-expensive plans that may come with higher co-pays and deductibles. Changing plans could also mean a new network of physicians, which could be disruptive to care for those with chronic conditions.

The rates vary significantly by region and insurer. Los Angeles and the rest of southwest Los Angeles County will see an average increase of almost 14%.

Blue Shield’s preferred provider organization rate in Los Angeles, chosen by 21% of those using the exchange, is increasing by an average of 19.5%. For a 40-year-old single person making $17,820 to $23,760, choosing a silver level plan, the monthly rate currently is $122, while the government pays Blue Shield $196. Next year that same person would pay $170, while the government would chip in $211 a month.

“We’re paying more for less,” said Jamie Court, president of Consumer Watchdog in Santa Monica. “Insurers are limiting access to doctors and hospitals while also demanding a higher price.”

Horacio Chavez, 34, of Boyle Heights said he made less than $25,000 last year as an education coordinator at a youth center. He currently pays a $100 premium for a Covered California plan that he uses for an annual checkup and a safety net in case of emergencies.

“I do want healthcare — I want the peace of mind that if anything happens to me that there’s some kind of coverage,” Chavez said. But “a 13% hike … that’s going to affect people.”

He said he’s already barely making ends meet trying to pay his rent, student loans from the University of Chicago, car payments and his health insurance premium.

“I’m already living check to check,” Chavez said.

Covered California officials defended the system Tuesday, saying that the competition among insurers offering coverage on the exchange was working to keep rates lower than they otherwise would be.

“California has a very competitive marketplace,” said Peter Lee, executive director of Covered California.

Obamacare has significantly reduced the number of uninsured Californians. Since the state’s health insurance exchange began offering coverage in 2014, the share of Californians without health insurance has fallen from 17% at the end of 2013 to 8.1% at the end of last year, according to officials.

Rates are expected to jump in other states too, although complete details won’t be available until later this year.

An analysis of 14 metro areas that have already announced their 2017 premiums found an average jump of 11%. The changes ranged from a decrease of 14% in Providence, R.I., to an increase of 26% in Portland, Ore., according to the analysis by the nonpartisan Kaiser Family Foundation.

The federal healthcare-  .gov   exchange provides insurance under the Affordable Care Act in 38 states. California and a few other states operate their own exchanges.

Around the country, several insurers, including giant UnitedHealth, have stopped selling health plans on the exchanges, and a number of new nonprofit health insurance co-ops have gone out of business.

Those decisions have fueled charges from the law’s critics that Obamacare isn’t working.

Former Secretary of State Hillary Clinton, the presumptive Democratic presidential nominee, is pushing a number of specific steps to ease price pressure on consumers, including allowing Americans ages 55 to 64 to buy into Medicare.

Republican presidential nominee Donald Trump has argued the health law should be repealed.

The health law’s next enrollment period begins a week before election day.

The state and federal health insurance exchanges provide coverage to about 12 million people nationally, representing just a fraction of the nation’s total insurance market. The vast majority of Americans — more than 250 million people — are in health plans purchased through an employer or provided by a government plan such as Medicare or Medicaid.

But the exchanges are a pillar of the Affordable Care Act’s program for guaranteeing Americans’ insurance coverage. And monthly premiums have become a closely watched barometer of how the law is performing.

Covered California’s Lee told the House Ways and Means Committee on July 12 that 2017 would be “a transitional year” for Obamacare, with rates seeing “significant adjustments” across the nation.

He said one reason for the increase was the end of a program designed to keep rates down during the insurance exchange’s first three years. The program had assessed a fee on all health insurers and then redistributed those funds among carriers whose members had the highest medical expenses, Lee said.

Lee added that some insurers had also not charged enough in the first two years because they didn’t have full data on the medical costs or health status of those signing up. Now they’re adjusting to account for those higher costs.

Mia Campitelli, a Blue Shield spokeswoman, said Tuesday that the insurer’s average 19.9% premium increase was “driven by our members using more healthcare services than we expected,” as well as the phaseout of the federal mechanism that had kept rates down in the law’s early years.

Anthem spokesman Darrel Ng said: “Factors such as increased use of medical services and added costs of drugs and medical therapies put upward pressure on rates and underscore the additional work that needs to be done to moderate the growth in healthcare costs.”

The financial pain for most Californians getting insurance through the exchange will be muted because 90% get taxpayer assistance to cover the premiums.

Americans making less than four times the federal poverty level — about $47,000 for a single adult or $97,000 for a family of four — qualify for the assistance.

Nonetheless, Americans who make too much to qualify for subsidies are likely to feel the brunt of the higher premiums. That will probably increase pressure on the new president — Democrat or Republican — to review the exchanges in 2017 for ways to make health plans more affordable.

A year ago, Lee wrote an op-ed in The Times saying that Covered California’s power in negotiating with insurers was allowing Obamacare to work in the state.

“We now have the full picture in California, where we are proving that health insurance exchanges can keep prices in check,” he wrote.

Though the Affordable Care Act has improved care for millions of Americans — for example, insurance companies can no longer set lifetime limits on care or exclude anyone because of a preexisting condition — the 6-year-old law contains few controls on overall costs.

Spending on the country’s medical system averages more than $10,000 for every American, according to statistics released by the Obama administration this month, far higher than any other nation. melody.petersen

@ latimes.com   noam.levey@latimes.com   Times staff writer Soumya Karlamangla contributed to this report.


“CALIFORNIA has a very competitive marketplace,” said Peter Lee, executive director of Covered California. Above, Lee discusses the program last year.

Firm Accused of Bilking Medicare

From the Los Angeles Times Business Section, dated May 26, 2016

Firm bilked Medicare, U.S. says
Justice Department joins whistle-blower case accusing Prime Healthcare of overbilling.
The U.S. Justice Department has joined a whistle-blower case against Prime Healthcare Services, adding significant weight to allegations of widespread Medicare overbilling at 14 of the company’s hospitals in California.

A Los Angeles magistrate judge granted the agency’s request to intervene in the case Tuesday, one day after the government declared in a court filing that its investigation of the Ontario- hospital operator has “yielded sufficient evidence” that the facilities “submitted or caused the submission of claims to Medicare for unnecessary inpatient stays.”

Prime finds itself under federal scrutiny because of a whistle-blower complaint submitted in 2011 by Karin Berntsen, a registered nurse and director of quality and risk management at Alvarado Hospital in San Diego. Berntsen’s lawsuit accuses Prime of routinely making Medicare patients’ illnesses seem more severe than they really were in order to justify billing for additional services and increasing hospital admissions.

Berntsen alleged that this practice occurred not only at Alvarado but also at 13 other Prime properties. Most of these hospitals are in Southern California, including Centinela Hospital Medical Center in Inglewood, Encino Hospital Medical Center, Sherman Oaks Hospital and Huntington Beach Hospital.

Berntsen’s litigation estimates the total amount of overbilling at $50 million, an amount that now could result in a significant financial payoff for her — and potentially large damages against the company.

Anti-fraud statutes allow fines of $5,500 to $11,000 — plus triple damages under certain circumstances — for each false or inaccurate bill submitted by hospitals and other healthcare companies . Whistle-blowers are entitled to 15% to 25% of the money recovered in cases involving the Justice Department.

In 2012, for example, pharmaceutical giant GlaxoSmithKline agreed to pay $2 billion to the federal government to resolve accusations that it overbilled for the prescription drugs Paxil, Wellbutrin and Avandia. In 2006, Tenet Healthcare was crippled after paying $900 million in a case involving alleged Medicare bill-padding, kickbacks and changing of billing codes to obtain higher reimbursements.    Prime has denied Berntsen’s allegations, calling them “speculative nonsense” after her complaint was unsealed in 2013.

In a new statement issued after the federal government’s intervention, the company was a bit more subdued. It said Medicare billing is complex and that there is a “lack of clarity between what federal regulators and physicians believe is necessary to adequately document medical necessity for hospital admissions.”

Prime also said its hospitals have successfully undergone Medicare billing audits conducted by an array of organizations, including the Joint Commission, the Healthcare Facilities Accreditation Program, the California Department of Public Health and government “recovery audit” contractors who are rewarded for spotting billing irregularities. The company currently owns 43 hospitals across14 states.

“Over 600 medical records that were appealed to the Administrative Law Judges and Medicare Appeals Council, all had rulings in Prime Healthcare’s favor, with no exception,” Prime’s statement said. “Given this precedence of successful appeals on thousands of claims, Prime Healthcare is confident it will prevail and ultimately be exonerated.”

But the Justice Department in a wide-ranging investigation referenced in its court filing this week cited “multiple witnesses who have worked at different Prime hospitals” who told the government that Dr. Prem Reddy, Prime’s chairman, president and chief executive, criticized emergency department physicians and demanded “their termination if he decided they were passing up opportunities to cause the admission of Medicare beneficiaries.”

The agency said those witnesses also accused Reddy of requesting “increased work schedules for [emergency department] doctors whose patients had a relatively high rate of admission,” of decreasing or discontinuing such shifts for physicians with low rates and of telling emergency department doctors “to find a way to admit all patients over 65 because they all have insurance.”

In contrast, the government said, Reddy allegedly worked to minimize hospital stays for uninsured patients — instructing that they should stay in the emergency department for only six to eight hours to get test results and then be discharged.

The Justice Department also cited the results of a Medicare contractor’s review of the company’s hospital admissions that “put Prime on notice of the same pattern of seemingly unnecessary inpatient admissions.”

Kathleen Clark, a Washington attorney who is an expert on the False Claims Act that governs whistle-blower cases, said the government’s involvement raises the stakes, given that federal regulators participate in only about one-quarter of such cases.

“It is actually quite significant when the government decides to intervene in one of these cases. The government brings to bear significant investigatory resources and leverage,” Clark said. “Intervention is seen not as a guarantee of a win, but it’s a very good sign for the whistle-blower and [his or her] lawyers.”

Marlan Wilbanks, an Atlanta attorney who is one of several lawyers representing Berntsen, said the government’s involvement could turn up additional evidence in the case disproving Prime’s assertion that previous audits proved the company’s billing practices are sound.

“Those entities were not designated to look for fraud,” he said. “Prime was given the benefit of the doubt. However, those entities did not have the evidence and the documents that the government and [Berntsen’s party] now possess.”

It’s unclear how long the legal discovery phase might take, especially because the Justice Department’s intervention will likely spur a series of procedural adjustments in the case. paul.sisson

@ sduniontribune.com

Reduction in Hospital Readmissions

The article that follows is from The New England Journal of Medicine. The Affordable Care Act includes disincentives for readmission of certain conditions. Research on this topic is discussed.

Readmissions, Observation, and the Hospital Readmissions Reduction Program
Rachael B. Zuckerman, M.P.H., Steven H. Sheingold, Ph.D., E. John Orav, Ph.D., Joel Ruhter, M.P.P., M.H.S.A., and Arnold M. Epstein, M.D.
February 24, 2016DOI: 10.1056/NEJMsa1513024

Hospital readmissions within 30 days after discharge have drawn national policy attention because they are very costly, accounting for more than $17 billion in avoidable Medicare expenditures,1 and are associated with poor outcomes. In response to these concerns, the Affordable Care Act (ACA), which was passed in March 2010, created the Hospital Readmissions Reduction Program. Since October 2012, the start of fiscal year (FY) 2013, the program has penalized hospitals with higher-than-expected 30-day readmission rates for selected clinical conditions. In FY 2013 and 2014, these conditions were acute myocardial infarction, heart failure, and pneumonia. Total hip or knee replacement and chronic obstructive pulmonary disease (COPD) were added in FY 2015. The program penalizes hospitals that have readmission rates that are higher than would be expected on the basis of readmission performance over 3 previous years. For example, FY 2015 penalties are based on readmissions from July 2010 through June 2013. Initially, in FY 2013, the maximum penalty was 1% of a hospital’s Medicare base diagnosis-related-group (DRG) payments, but the penalty has been increased to 3% for FY 2015 and the years beyond.
Despite the importance of readmissions, there has been little study of the effect of the program. Published epidemiologic data suggest that overall national rates of readmission decreased through 2012.2,3 There is also evidence that stays in observation units have increased during this same period.4,5 Critics of the Hospital Readmissions Reduction Program have worried that hospitals might be achieving reductions in readmissions by keeping returning patients in observation units rather than formally readmitting them to the hospital.6,7 In this article, we address four hypotheses: that changes in rates of readmission in response to the ACA were greater for targeted conditions than for nontargeted conditions, that the decreasing trend in readmission rates persisted after the initial implementation of the program, that the trends in use of observation units did not change after adoption of the ACA, and that hospitals that had a greater increase in observation-unit stays did not have a greater reduction in readmission rates.
Data Sources and Study Variables
We used Medicare Part A and Part B claims for fee-for-service beneficiaries 65 years of age or older who were enrolled for 1 year before they had an index hospitalization in an acute care hospital during the period from October 2007 through May 2015. We identified index stays using the inclusion and exclusion criteria for the hospital-wide readmission measure of the Centers for Medicare and Medicaid Services (CMS).8 We then identified index stays for the three conditions targeted by the Hospital Readmissions Reduction Program (acute myocardial infarction, heart failure, and pneumonia), using the program’s inclusion and exclusion criteria.9 Admissions for total hip or knee replacement and for COPD were excluded from the analysis sample, since these conditions were added to the program only after the first 2 years of implementation. All remaining admissions as specified by CMS criteria were considered to be admissions for nontargeted conditions.
We identified readmissions within 30 days after discharge, using the definition of readmission that is used for the hospital-wide readmission measure of the CMS.8 We also examined whether patients used observation services within 30 days after discharge. Finally, we looked at the combined outcome of any return to the hospital within 30 days after discharge (either readmission or observation). Readmission and observation-service rates were risk-adjusted with the use of covariates from the CMS hospital-wide readmission measure (age, 31 coexisting medical conditions, and principal discharge diagnosis).8 The risk-adjusted rates were calculated for each hospital and for each month, for both targeted and nontargeted conditions. We excluded 437 hospitals that did not have admissions for targeted conditions both before and after the passage of the ACA. Additional details are provided in the Supplementary Appendix, available with the full text of this article at NEJM.org.
Statistical Analysis
We first examined patient and hospital characteristics of index hospitalizations for targeted and nontargeted conditions for the first year (October 2007 through September 2008) and the last year (June 2014 through May 2015) of the study period (Table 1TABLE 1
Annual Index Admissions According to Hospital and Patient Characteristics.
). In these descriptive statistics, the index hospitalization was the unit of analysis, and patients could have more than one index hospitalization.
We then analyzed the trends in readmissions and observation-unit stays from FY 2008 through May 2015. We based these primary analyses on interrupted time-series models, which we implemented using generalized estimating equations, to examine the linear trends in monthly, hospital-level, risk-adjusted readmission and observation-service rates. In the main analysis, we analyzed the change in trend between time periods, for three separate periods: pre-ACA (October 2007 through March 2010), implementation of the Hospital Readmissions Reduction Program (April 2010 through September 2012), and long-term follow-up after penalties were initiated (October 2012 through May 2015). We also tested a sensitivity model that included an additional 6-month initiation period after adoption of the ACA (April 2010 through September 2010), since hospitals may have taken some time to implement policies to reduce readmissions after the law was passed.
The linear generalized-estimating-equation models used the monthly, hospital-based, risk-adjusted readmission rate as the outcome and included an independent working correlation matrix and robust empirical standard errors to account for within-hospital correlation over time. We modeled the differences in time trends between readmissions for targeted conditions and those for nontargeted conditions, after adjusting for seasonal variation and after weighting by the monthly number of index stays in the hospital. We estimated changes in readmission rates over time using a linear term for time as well as linear splines at each change in time period (April 2010 and October 2012 in the primary model). The model allowed the seasonal effects and time trends to differ between targeted and nontargeted conditions by including interaction terms with type of condition (targeted or nontargeted) and separate initial intercepts for targeted and nontargeted conditions. We used four hypothesis tests during each time period: first, were there significant trends in readmission rates during the time period? Second, did the trend differ between targeted and nontargeted conditions (the interaction between time and targeted or nontargeted conditions) during the time period? Third, within targeted or nontargeted conditions, did the trend during the current time period differ from the trend during the previous time period (based on a statistically significant spline term)? Fourth, did the magnitude of the change in trend between the current and previous time period differ between targeted and nontargeted conditions (the interaction between the change in slope and targeted or nontargeted conditions)? Significance was based on 95% confidence intervals. We used similar models and tests for the other outcomes within 30 days after discharge: use of observation service and any return to the hospital (either readmission or observation).
We then evaluated within-hospital changes in the use of observation services and the changes in readmission rates for targeted conditions during the program implementation period (from April 2010 through October 2012). Using a weighted Pearson correlation coefficient, we assessed whether these changes were correlated.
Index Hospitalizations
Our data set included 7,175,558 index stays for targeted conditions and 45,495,870 index stays for nontargeted conditions in 3387 hospitals, among patients discharged between October 1, 2007, and May 31, 2015. On average, hospitals had 24.7 (range, 1 to 321) stays per month for targeted conditions and 151.9 (range, 1 to 2268) stays per month for nontargeted conditions. A larger proportion of index stays for nontargeted conditions than for targeted conditions was observed in larger hospitals, in teaching hospitals, and in hospitals in urban areas. Patients hospitalized for targeted conditions were more likely than those hospitalized for nontargeted conditions to be older and to be men. Between 2007 and 2015, there was very little change in the characteristics of patients who were admitted for targeted or for nontargeted conditions or of the hospitals to which they were admitted.
From 2007 to 2015, risk-adjusted rates of readmission for targeted conditions declined from 21.5% to 17.8%, and rates for nontargeted conditions declined from 15.3% to 13.1% (Table 1). Trends in readmissions are shown in Figure 1FIGURE 1
Change in Readmission Rates for Targeted Conditions and Nontargeted Conditions within 30 Days after Discharge.
and Table 2TABLE 2
Rate of Change over Time in Readmission Rates and Observation-Service Use for Targeted and Nontargeted Conditions.
. Monthly readmission rates for targeted conditions were already decreasing before passage of the ACA (slope of monthly rate, −0.017 [95% confidence interval {CI}, −0.022 to −0.012]), fell even more rapidly after implementation of the ACA (slope, −0.103 [95% CI, −0.107 to −0.098]), and then slowed during the long-term follow-up period to −0.005 (95% CI, −0.010 to −0.001). Readmission rates for nontargeted conditions were falling at a monthly rate of −0.008 (95% CI, −0.010 to −0.006) before passage of the ACA and then decreased significantly after its enactment (post-ACA slope, −0.061 [95% CI, −0.063 to −0.059]); however, the rates for nontargeted conditions were not decreasing as quickly as the rates for targeted conditions (difference between targeted and nontargeted slopes, −0.042 [95% CI, −0.046 to −0.037]). Finally, readmission rates for nontargeted conditions slowed to a slope of −0.004 (95% CI, −0.006 to −0.002) during the long-term follow-up period.
The change in slope between the pre-ACA period and the implementation period was significant for both types of conditions (targeted: −0.086 [95% CI, −0.094 to −0.078]; nontargeted: −0.054 [95% CI, −0.057 to −0.050]), as was the change in slope between the implementation period and the long-term follow-up period (targeted: 0.097 [95% CI, 0.090 to 0.105]; nontargeted: 0.057 [95% CI, 0.054 to 0.060]). The change in slope between the pre-ACA period and the implementation period differed significantly between the targeted and the nontargeted conditions (difference, −0.032; [95% CI, −0.041 to −0.024]), as did the change in slope between the implementation period and the long-term follow-up period (difference, 0.040 [95% CI, 0.033 to 0.048]), which implies that targeted conditions had a change in trajectory that was significantly larger than that of the nontargeted conditions at the passage of the ACA and again at the long-term follow-up period (Table 2).
The sensitivity analysis that included a 6-month initiation period after the passage of the ACA showed that readmission rates decreased most rapidly during the initiation period (Fig. S1 and Table S1 in the Supplementary Appendix), which implies that hospitals began reducing readmission rates shortly after the ACA was passed.
Use of Observation Services
From 2007 to 2015, rates of observation-service use for targeted conditions increased from 2.6% to 4.7%, and rates for nontargeted conditions increased from 2.5% to 4.2%. We observed consistent increases in observation-service use throughout the analysis period (Figure 2FIGURE 2
Change in Observation-Service Use for Targeted Conditions and Nontargeted Conditions within 30 Days after Discharge.
and Table 2). Monthly observation-service use was rising significantly and similarly for both targeted and nontargeted conditions before enactment of the ACA, with monthly slopes of 0.020 (95% CI, 0.017 to 0.023) and 0.021 (95% CI, 0.019 to 0.023), respectively. There were no significant changes in slope at the passage of the ACA. Rates for targeted conditions rose faster during the long-term follow-up than during the implementation period, with a change in slope of 0.008 (95% CI, 0.001 to 0.014), whereas the monthly slope for nontargeted conditions did not change significantly between these study periods.
Other Outcomes
We evaluated the outcome of any return to the hospital — either readmission or observation — within 30 days after discharge as a measure of sensitivity (Fig. S2 and Table S2 in the Supplementary Appendix). We found that these rates decreased for both types of admissions during the implementation period, but more so for targeted than for nontargeted conditions — a finding similar to that for readmissions alone. Monthly slopes were slightly positive before enactment of the ACA for nontargeted conditions and in the long-term follow-up period for both targeted and nontargeted conditions.
Figure 3FIGURE 3
Relationship between Change in Readmission Rate and Change in Observation-Service Use.
shows the within-hospital relationship between changes in observation-service use and readmissions for targeted conditions during the implementation period among 2936 hospitals with admissions in April 2010 and October 2012. There was no significant correlation between the change in readmission rate and the change in observation-service use (Pearson correlation coefficient, −0.03; P=0.07).
Our study has four key findings. First, readmission rates for both targeted and nontargeted conditions began to fall faster in April 2010, after the passage of the ACA, than before. Readmission rates continued to decline from October 2012 through May 2015, albeit at a slower rate. Second, the passage of the ACA was associated with a more substantial decline in readmissions beginning in April 2010 for targeted than for nontargeted conditions. Third, the rate of observation-service use for both types of conditions was increasing throughout the study periods. Finally, there was no significant association within hospitals between increases in observation-service use and reductions in readmissions during the implementation period.
The nonexperimental design of our study limits our ability to draw a firm causal link between the Hospital Readmissions Reduction Program and the outcomes of interest. Nonetheless, the interrupted time-series design allows us to draw credible implications about the associations between the program and rates of readmission and observation-service use. We think it is likely that hospitals responded at different times to the incentives from the program to reduce readmissions. There was national concern about readmissions well before enactment of the ACA. In its June 2007 and June 2008 Reports to Congress, the Medicare Payment Advisory Commission (MedPAC) explored changes in payment policy that were designed to reduce readmissions,10,11 and Medicare began publicly releasing data on discharge planning and readmission rates well before 2010.12 Thus, we think that it is plausible that passage of the ACA catalyzed behavioral change by many hospitals. In addition, other CMS efforts to reduce readmissions after the passage of the ACA could have aided hospitals during the implementation period.13 For example, the CMS Partnership for Patients established the Hospital Engagement Networks in 2011 to identify and disseminate best practices, including efforts to reduce readmissions,14 and hospital readmissions are outcomes in other Medicare quality programs besides the Hospital Readmissions Reduction Program.15
At the passage of the ACA, readmission rates for both targeted and nontargeted conditions fell, which implies that changes in the organization of care in response to the Hospital Readmissions Reduction Program, along with other factors noted above, may have had an effect beyond the targeted conditions. However, we still observed a greater change in rates of readmission for targeted conditions. Although this effect could be in response to the Hospital Readmissions Reduction Program, the higher baseline readmission rates for targeted conditions made it easier to reduce readmissions for these conditions than for the nontargeted conditions, which probably contributed to the greater decrease in readmission rates for targeted conditions. Some policymakers and MedPAC have proposed expanding the Hospital Readmissions Reduction Program to cover all clinical conditions.16 This could create incentives for hospitals to more aggressively reduce readmissions for nontargeted conditions, more accurately highlight the intent of the program, and simplify the program by using a single readmission measure.
We found that readmission rates for both targeted and nontargeted conditions continued to fall during the long-term follow-up period but at a slower rate than during implementation. Presumably, hospitals made substantial changes during the implementation period but could not sustain such a high rate of reductions in the long term. The trends in observation-service use are less clearly associated with the passage of the ACA. We saw a steady increase in observation-unit stays during the entire analysis period, with no significant changes at the passage of the ACA. It seems likely that the upward trend in observation-service use may be attributable to factors that are largely unrelated to the Hospital Readmissions Reduction Program, such as confusion over whether an inpatient stay would be deemed inappropriate by Medicare recovery audit contractors.17 Within hospitals, there was no significant association between changes in observation-service use and changes in readmission rates after implementation of the ACA. For this reason, our analysis does not support the hypothesis that increases in observation stays can account in any important way for the reduction in readmissions.
Our findings are consistent with previous research on trends in readmissions and observation-unit stays. Gerhardt et al. examined readmissions after all index stays and found a very modest decrease between 2007 and 2011 and a larger decrease in 2012. They also found an increase in observation-unit stays over time but concluded that the increases were too small to account appreciably for the decrease in readmissions.4 The 2014 Medicare Hospital Quality Chartbook noted that there was a significant cross-sectional correlation between observation-unit stays and readmissions for targeted conditions, although the correlations were very small.5 Carey and Lin found that readmission rates for targeted conditions fell faster than rates for other medical conditions in New York State between 2008 and 2012. They also found an increase in observation-unit stays.3 We went beyond these cross-sectional analyses to evaluate whether hospitals that reduced their readmission rates after the ACA was passed were, at the same time, increasing their observation-service use.
Our study has limitations. Although our findings are consistent with hospitals changing their practices to reduce readmissions, we cannot be certain why we saw a reduction in readmissions after implementation of the ACA or why we saw another change in October 2012. Attribution of changes in readmissions to a specific time point is also confounded in any statistical analysis because of possible time lags between enactment of the program and any resulting change in the rate of readmissions. In our sensitivity analysis, we found that, on average, the change in trajectory in readmission rates seemed to happen quickly after the passage of the ACA. For observation-unit stays in particular, the presence of a dedicated observation unit may have affected trends in an individual hospital, but we could not evaluate such trends with our data.
In summary, we found a change in the rate of readmissions coincident with the enactment of the ACA, which suggested that the Hospital Readmissions Reduction Program may have had a broad effect on care, especially for targeted conditions. In the long-term follow-up period, readmission rates continued to fall for targeted and nontargeted conditions, but at a slower rate. We did not see large changes in the trends of observation-service use associated with the passage of the ACA, and hospitals with greater reductions in readmission rates were no more likely to increase their observation-service use than other hospitals. Given the change in patterns of care during the analysis period, it will be important to continue monitoring these trends.
Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.
This article was published on February 24, 2016, at NEJM.org.
From the Office of the Assistant Secretary for Planning and Evaluation, Department of Health and Human Services, Washington, DC (R.B.Z., S.H.S., E.J.O., J.R., A.M.E.); and the Department of Medicine, Division of General Internal Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston (E.J.O.).
Address reprint requests to Ms. Zuckerman at the ASPE Office of Health Policy, Department of Health and Human Services, 200 Independence Ave. SW, Rm. 447D, Washington, DC 20201, or at rachael.zuckerman@hhs.gov.

Insurance premiums spark new front in Obamacare war

In this the second year of implementation of the Affordable Care Act, premiums have not stabilized but it is probably an unreasonable expectation of the giant upheaval in a the health insurance system. The coming years will be the litmus test, hopefully the trend of large rate increases will turn around.

Below is an article from the Washington Examiner, date July 6, 2015.

Republicans target big increases as evidence that healthcare law isn’t working

Insurance premiums have quickly become a new front in the Obamacare fight, with opponents pouncing on big increases and supporters and experts countering the increases won’t be so bad.

The fight started last month when insurers were required to disclose estimated 2016 rates of 10 percent or more for Obamacare customers. Some figures grabbed headlines, especially with certain insurers calling for 50 to 70 percent increases.

The premium spikes vary by state and insurer. For instance, some plans in Florida are actually proposing reduced premiums, but 13 plans want rate increases of 10 percent or more, including Time Insurance Co.’s 63 percent hike.

Republicans say the higher rates are evidence that the law is hurting Americans and not lowering healthcare costs.

“The whole point of Obamacare was to make health care more affordable. But premiums aren’t going down; they’re going up — way up,” said Rep. Paul Ryan, R-Wis., chairman of the House Ways and Means Committee, in a recent hearing.

“The model we’re on in the Affordable Care Act is not sustainable,” said Rep. Mike Kelly, R-Pa., at the same hearing.

This is the first time since Obamacare’s passage that insurers can look at a full year’s worth of claims data and calculate premiums, Rep. Pete Roskam, R-Ill., said at the hearing. He added that the premium spikes are not growing pains.

“The law created a number of temporary programs to pay out billions in taxpayer funds during the first few years to lower costs seen by individuals and to protect big insurance companies against financial losses,” he said. “But those programs are beginning to phase out, and as the government is slowly taking off the training wheels, Obamacare is looking pretty wobbly.”

Supporters counter that any increases aren’t finalized and will have a modest impact overall.

“We have just the bad news,” said Kathy Hempstead, who directs coverage issues for the Robert Wood Johnson Foundation.

One analysis found that Obamacare customers as a whole may only see a modest increase.

The research firm Avalere looked at proposed rate filings in seven states and the District of Columbia. The average premiums for silver plans, the second cheapest option and a popular choice for Obamacare enrollees, will increase nearly 6 percent, Avalere said.

Avalere also noted that the low-cost silver plan options are likely to be smaller than the silver plan as a whole. Premiums for the lowest- and second-lowest silver plans in the seven states and D.C. will increase on average 4.5 percent and 1 percent.

A separate analysis from the nonpartisan Kaiser Family Foundation found that in 11 major cities the cost of a regular silver plan would be on average 4.4 percent higher in 2016 than this year.

Premiums must be finalized by October. That way customers facing a high premium can choose a different plan during the next open enrollment this fall.

Another reason why the rates could change is states need to conduct reviews themselves.

Obamacare requires states to report on any premium increase trends and recommend whether certain plans should be excluded from the exchanges, according to the National Conference on State Legislatures.

In 2011, the federal government started to work with states to strengthen or alter their rate review programs. If a state doesn’t have the resources to conduct the required review, the Department of Health and Human Services will do it, the National Conference on State Legislatures said.

“The carriers really have to be able to explain their rates, and that is part of the point of the whole medical loss-ratio regulations,” Hempstead said.

The medical loss ratio is another new regulation installed under Obamacare. It requires insurers to devote 85 percent of the cost of a premium on medical care and the other 15 percent on administrative costs.

The ratio ensures that insurers don’t devote too much of their costs to overhead.

Amid the rhetoric over the premium increases are certain trends that could affect the insurance market as a whole.

Many Blue Cross Blue Shield insurers kept premiums in marketplaces comparatively low with small increases from year to year, but that varies considerably across the country, according to a study of trends for market place plans done by the foundation and the left-leaning think tank Urban Institute.

The report looked at the cheapest silver plans in 30 states. Some insurance companies were reluctant to enter the Obamacare marketplaces in 2014 and when they did the plans were more expensive.

However, the report projects insurers will lower premiums to keep prices low to attract enough customers buying insurance through the Obamacare marketplaces.

But for opponents of Obamacare, the proposed increases represent a long-standing criticism about the law’s ability to battle healthcare costs, which was levied even before the exchanges opened in 2014.

Summer Health Tips from Health Net


Investor Relations – News Release

Emergency Room or Urgent Care? Just in Time for Summer, Health Net Relays Helpful Information
LOS ANGELES–(BUSINESS WIRE)–Jun. 24, 2015– June 21 marked the official start of summer – a season that, while generally associated with outdoor fun, can also often bring a host of injuries and illnesses.

According to the U.S. Centers for Disease Control and Prevention, the most prevalent summer aliments are:

  • Falls and sports injuries (resulting in strains, sprains, fractures or abrasions);
  • Head injuries (such as from skateboarding, bicycling or rollerblading);
  • Insect bites (stinging insects, as well as ticks, are plentiful this time of year; bug bites can cause severe allergic reactions, and ticks can carry Lyme disease);
  • Heat cramps, heat exhaustion and heat stroke (heat stroke is particularly concerning because it can be fatal);
  • Burns (from fireworks, grills, campfires and overexposure to the sun); and
  • Food poisoning (often occurs when perishable items are left outdoors for extended periods).

While it’s hoped that the summer will unfold without incident, if an accident or illness occurs, individuals are advised to educate themselves – ahead of time – regarding where to seek care.

As Patricia Buss, M.D., Medical and Health Care Services operations officer for Health Net, Inc., explains, “There’s no question that hospital emergency rooms play a vital role in our communities by providing lifesaving services, but many injuries and illnesses are more appropriate for an urgent care center. Unnecessary emergency room visits,” she added, “can result in increased cost and prolonged wait times.”

When to Visit an Emergency Room

The American College of Emergency Physicians (ACEP) offers the following list of warning signs – for adults – that may warrant emergency-room treatment:

  • Difficulty breathing, shortness of breath;
  • Chest or upper abdominal pain or pressure lasting two minutes or more;
  • Fainting, sudden dizziness or weakness;
  • Changes in vision;
  • Difficulty speaking;
  • Confusion or changes in mental status, unusual behavior or difficulty waking;
  • Any sudden or severe pain;
  • Uncontrolled bleeding;
  • Severe/persistent vomiting or diarrhea;
  • Coughing or vomiting blood;
  • Suicidal or homicidal feelings;
  • Unusual abdominal pain; or
  • Severe headache or vomiting following a head injury, unconsciousness or uncontrolled bleeding.

When to Choose Urgent Care

According to the National Institutes of Health (NIH), an urgent care center is recommended if the condition is not life threatening or risking disability, but you are concerned and you cannot see your doctor soon enough. The NIH notes that the types of problems or conditions an urgent care clinic can deal with may include:

  • Colds;
  • Sinus infections;
  • Allergies;
  • Coughs;
  • Flu;
  • Earaches;
  • Burning with urination;
  • Sore throats;
  • Migraines;
  • Low-grade fevers;
  • Rashes;
  • Sprains;
  • Back pain;
  • Body aches;
  • Mild nausea, vomiting or diarrhea;
  • Non-severe burns or cuts;
  • Minor broken bones; or
  • Eye irritation, swelling or pain.

The NIH advises that if you have a problem, do not wait too long to get medical care. If you are unsure where best to seek treatment, and you do not have one of the serious symptoms or conditions above, the NIH suggests that you contact your physician.

Medical Advice Disclaimer

The information provided is not intended as medical advice or as a substitute for professional medical care. Always seek the advice of your physician or other health provider for any questions you may have regarding your medical condition and follow your health care provider’s instructions.

About Health Net

Health Net, Inc. (NYSE:HNT) is a publicly traded managed care organization that delivers managed health care services through health plans and government-sponsored managed care plans. Its mission is to help people be healthy, secure and comfortable. Health Net provides and administers health benefits to approximately 6.0 million individuals across the country through group, individual, Medicare (including the Medicare prescription drug benefit commonly referred to as “Part D”), Medicaid, dual eligible, U.S. Department of Defense, including TRICARE, and U.S. Department of Veterans Affairsprograms. Health Net also offers behavioral health, substance abuse and employee assistance programs, and managed health care products related to prescription drugs.

For more information on Health Net, Inc., please visit Health Net’s website at www.healthnet.com.

Follow Health Net

Like Health Net on Facebook: https://www.facebook.com/healthNetInc
Follow Health Net on Twitter: https://twitter.com/healthnet
Visit Health Net on YouTube: https://www.youtube.com/user/HealthNetInc
Connect with Health Net on LinkedIn: http://www.linkedin.com/company/health-net


View source version on businesswire.com: http://www.businesswire.com/news/home/20150624006402/en/

Source: Health Net, Inc.

Health Net, Inc.
Lori Rieger, 602-794-1415602-794-1415



“Safe Harbor” Statement under the Private Securities Litigation Reform Act of 1995: Statements in this press release regarding Health Net, Inc.’s business which are not historical facts are “forward-looking statements” that involve risks and uncertainties. For a discussion of such risks and uncertainties, which could cause actual results to differ from those contained in the forward-looking statements, see “Risk Factors” in the Company’s Annual Report or Form 10-K for the most recently ended fiscal year.


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Cigna Completes Acquisition of Sterling Life

An announcement from Cigna dated July 1, 2015  follows.

Cigna recently completed its acquisition of Sterling Life Insurance Company (“Sterling”). Based in Bellingham, WA, Sterling primarily offers Medicare Supplement policies to individuals. We will integrate Sterling within Cigna’s U.S. Individual segment and currently plan to migrate business processing to our Austin, TX, facility, which services our existing individual Medicare Supplement business. We are working directly with Sterling’s management on the transition, which we expect to take about 12 to 18 months.

Roberts again shows independent streak

This article from the Los Angeles Times dated June 26, 2015 is a follow up to the Supreme Court decision to uphold the Affordable Care Act.

WASHINGTON — Since becoming chief justice 10 years ago, John G. Roberts Jr. has been determined to show that the court he leads is made up of impartial jurists, not politicians in robes.   In the phrase he used at his confirmation hearings, each justice is “like an umpire” at a baseball game — not favoring one team over the other.   On Thursday, Roberts showed again his willingness to brush aside partisan politics and forge a middle ground on some of nation’s most divisive issues, writing a 6-3 decision that upheld the broad reach of President Obama’s healthcare law.   It was the second time in three years that Roberts had led the Supreme Court to uphold the Affordable Care Act, also known as Obama-care. The decision surprised and disappointed some of the conservatives who had once hailed his appointment.   “We might as well call the law … RobertsCare,” said Ilya Shapiro, a lawyer at the Cato Institute, a libertarian think tank in Washington.   When Roberts spoke of being an umpire, “a lot of people on the left sneered,” said Neal Katyal, who served as acting U.S. solicitor general in Obama’s first term. “Today’s decision shows he really meant what he said. It’s a profound statement about the difference between law and politics.”   Roberts cringes at the regular references to the “conservative bloc” or the “liberal wing” of the court. Last year, he was pleased when the justices were able to agree unanimously in a much higher percentage of their cases.   Thursday’s decision sent a particularly loud message about a nonpartisan court because the chief justice gave a generous reading to a liberal law passed by a Democratic-controlled Congress.   But the decision is not a sign that Roberts has become a liberal or shifted strongly to the left, as some allege.   On the same day, Roberts joined three conservatives in dissent when the majority held that the Fair Housing Act forbids practices that have a “discriminatory effect” on racial minorities even if there is no intentional discrimination. In 2013, he voted with conservatives to strike down part of the Voting Rights Act.   His decisions on easing campaign finance rules, including Citizens United, which gave corporations and unions the ability to make unlimited contributions to political causes, firmly established Roberts’ record as a conservative.   But on most issues, the chief justice has shown himself to be most comfortable in the moderate middle and unwilling to push the law too far to the right or too quickly.   In April, he joined with the court’s four liberal justices to uphold a Florida law that prohibited elected judges from personally soliciting campaign contributions. Roberts supports the 1st Amendment right to spend freely on campaigns, but judges are not politicians, he said.   In other alliances with liberals, he helped forge a 6-3 majority to rule that a police officer may not detain a car stopped for a traffic violation so a drug-sniffing dog may be brought to the scene. He also joined a 5-4 opinion by Justice Ruth Bader Ginsburg that freed a Florida fisherman from federal obstruction-of-justice charges for having tossed overboard several undersized red grouper.   Further evidence on how Roberts sees his role could come as early as Friday in the court’s decision on gay marriage. It’s widely expected that a majority of justices will declare the right of gays and lesbians to marry nationwide, but given Roberts’ growing independent streak, combined with the impact that case will undoubtedly have on his legacy, some are wondering whether the chief justice will find a way to side with liberals in what would be a landmark decision.   Roberts’ reasoning in the healthcare case showed several of his characteristic traits — a desire for moderation as well as a concern over the real-world impact of the court’s decisions, particularly on business.   Had the justices ruled for the conservative activists who sued the administration, more than 6.4 million people could have lost their health coverage. That in turn could “well push a state’s individual insurance market into a death spiral,” Roberts said.   It would be “implausible,” he said, to think the Congress that passed the healthcare law intended to limit its tax subsidies to the 13 states that established an exchange, or marketplace, of their own.   He rejected the claim brought by conservative activists who pointed to one part of the law that said subsidies were limited to insurance policies bought on an exchange “established by the state.” This hyper-technical reading of one phrase did not make sense and was contradicted by other parts of the law, he said.   “Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them,” he wrote.   Duke Law professor Neil Siegel called the majority opinion “a masterpiece of legal craft, good sense and fidelity to the law at a time when political polarization threatens to spill over into the judiciary.”   But the three conservative dissenters accused the majority of “interpretive jiggery-pokery” and “somersaults of statutory interpretation” to fix a political, not legal, problem.   “This court’s two decisions on the [healthcare] act will surely be remembered through the years,” wrote Justice Antonin Scalia, joined by Justices Clarence Thomas and Samuel A. Alito Jr. “And the cases will publish forever the discouraging truth that the Supreme Court of the United States favors some laws over others, and is prepared to do whatever it takes to uphold and assist its favorites.”   In most cases, Roberts is still more likely to vote with the court’s conservatives. University of Chicago Law professor David Strauss said the final word about the Roberts court wouldn’t come until it weighs in on broad major issues like abortion and race.   “But the chief justice has made it clear that he meant what he said in his confirmation hearings: The big decisions should be made by the people who won an election, whether the court agrees with them or not, as long the justices don’t have to distort the law to do that,” Strauss said. david.savage@latimes.com

Getty Images   CHIEF JUSTICE reenforced his statement that each justice is “like an umpire.”

WIN MCNAMEE Associated Press   JOHN G. ROBERTS JR. says he dislikes the references to the “conservative bloc” or the “liberal wing” of the U.S. Supreme Court, which he’s led for a decade.

Supreme Court Upholds the Affordable Care Act

The article below from the Los Angeles Times, dated June 26, 2015 explains the decision
Supreme Court rejects serious threat to health reform

WASHINGTON — The Affordable Care Act, upheld in a decisive 6-3 Supreme Court ruling Thursday, is now virtually assured of surviving as a permanent feature of the American healthcare system.   Republicans’ chances of repealing the law, which provides health coverage to more than 20 million Americans, all but evaporated after the strongly worded decision written by Chief Justice John G. Roberts Jr.   It was the second time in three years that the high court had turned aside a legal threat to the law, one of President Obama’s signature achievements.   With no serious Republican alternatives and a historic expansion in medical coverage well underway, Obamacare is about as firmly ensconced as a new law can be in a politically divided country.   The ruling came in a lawsuit that had threatened to strip insurance subsidies from more than 6 million Americans in at least 34 states.   The law’s wording was at times “inartful,” the majority said, but Congress clearly intended for the aid for low- and moderate-income Americans to be available everywhere. The justices rejected claims from the challengers that a handful of words in the statute made subsidies available only in a few states.   “We must read the words in their context,” the chief justice wrote.   In the decision, Roberts also explicitly blessed the law’s sweeping system for guaranteeing coverage, noting that the model, pioneered in Massachusetts, had accomplished what other attempts to extend insurance protections to Americans had not.   “The Affordable Care Act adopts a version of the … reforms that made the Massachusetts system a success,” he wrote.   Congressional Republicans, meanwhile, still have no plan to replace the law enacted more than five years ago.   Speaking to reporters after the court’s decision, House Speaker John A. Boehner (R-Ohio) repeatedly refused to commit to any new strategy to repeal or revise the health law.   And across the country, as millions of previously uninsured Americans have gained coverage, a growing number of Republican governors are signaling their interest in moving on.   Still, political battles over the law won’t end anytime soon.   In the presidential campaign, Republican hopefuls need to appeal to conservative voters — many of whom deeply dislike the law and the president who championed it. That guarantees that cries for repeal will remain prominent, particularly during next year’s primaries.   “This is not the end of the fight,” former Florida Gov. Jeb Bush said Thursday. “We need to repeal and replace Obamacare.”   Nearly all of the other major candidates for the nomination echoed Bush’s statement.   But away from the campaign trail, implementation of the law and its coverage expansion will continue.   “We appreciate that the deep uncertainty of this issue has been resolved,” Michigan Gov. Rick Snyder, a Republican, said Thursday after the court issued its decision. “The health and well-being of the people of Michigan is always a top priority.”   In his state, more than 200,000 low- and moderate-income residents stood to lose insurance assistance if the court backed the challengers, who argued that no subsidies should be available in any state that did not establish its own insurance marketplace through the law.   Michigan is one of the 34 states that instead deferred to the federal HealthCare  .gov   marketplace.   Like many other Republican governors, Snyder has been more focused on expanding access to healthcare than continuing the battle over the law.   Michigan is working to secure approval from the Obama administration for further changes to the state’s Medicaid program, which was expanded under the law to guarantee coverage to the poorest residents .   Michigan is one of 29 states that have accepted federal aid in the law to broaden Medicaid coverage   — a number that has steadily grown over the last several years to include even very conservative states such as Indiana.   In the last two years, some 11 million people have newly enrolled in Medicaid, mostly in states that expanded their programs.   An additional 10 million Americans, many of them previously uninsured, now get health coverage through marketplaces created by the law.   That has fueled a historic coverage expansion. In the first quarter of this year, 11.9% of adults in the U.S. lacked insurance, down from 18% in the third quarter of 2013, before the current expansion began, according to Gallup.   And more red states, including Utah, Tennessee and Wyoming, have been exploring ways to expand Medicaid coverage.   In Washington, by contrast, GOP congressional leaders kept up their criticism of the law.   “Republicans are ready to reduce the cost of healthcare so more people can afford it, put patients back in charge, and restore freedom and choice to the healthcare market,” said Senate Health Committee Chairman Lamar Alexander (R-Tenn.).   But it is unlikely there will be significant new legislation, at least until after next year’s presidential election.   To date, Alexander and most other congressional Republicans have offered little more than general outlines rather than real legislation that would fulfill such promises.   Several GOP blueprints even incorporate key protections from the current law, including guaranteeing coverage and providing government assistance to help consumers purchase insurance.   On the other side of the debate, supporters of the health law redoubled their calls on Republicans to stop fighting.   “It’s time for people on both sides of the aisle to accept that the law is working and take important steps to fully implement it,” said Sue Berkowitz, head of South Carolina Appleseed Legal Justice Center, a nonprofit that has been working to expand coverage in that state despite Republican officials’ resistance to Medicaid expansion.   The president joined the chorus, speaking from the White House Rose Garden on Thursday afternoon.   “The Affordable Care Act is here to stay,” he said. noam.levey@latimes.com   Twitter: @NoamLevey

JIM LO SCALZO European Pressphoto Agency   SUPPORTERS of the Affordable Care Act cheer outside the Supreme Court after justices ruled 6 to 3 that the healthcare law’s tax credits can go to residents of any state.

CHIP SOMODEVILLA Getty Images   HOUSE SPEAKER John A. Boehner (R-Ohio), at a news conference after the decision, wouldn’t commit to any new strategy to repeal or revise the law.

ALEX WONG Getty Images   “THE AFFORDABLE Care Act is here to stay,” said President Obama, with Vice President Biden at the White House Rose Garden after the ruling was announced.

Assurant Health to Exit the Medical Insurance Market

Important information for our sales partners from Assurant Health
April 29, 2015We want to share a recent announcement made by Assurant Health’s parent company, Assurant, Inc. Following a strategic review of its portfolio of businesses, Assurant has decided to focus on housing and lifestyle specialty protection products and services.

With this decision, Assurant, Inc. will explore options for two of its business units, Assurant Health and Assurant Employee Benefits, including a separate sale of each business. Assurant believes there are better owners for each business with more focused health care and benefits portfolios.

Absent a sale of Assurant Health, Assurant, Inc. will begin the process to exit the health insurance market this year for all of its product offerings, and will not participate in the next Affordable Care Act Open Enrollment period in November. Assurant’s exit will be substantially complete in 2016.

At this time, we continue to accept new business in all product lines, and there are no changes to your clients’ policies and benefits, nor to your appointment or commissions with Assurant Health. For those eligible, we will be modifying our commission advance program. Additional information will be provided separately.

Throughout the process ahead, we will uphold our commitments to our customers, and continue to support our valued agent partners.

While we can’t speculate on how long this process will take or the outcome, as the process moves along and more information is available, we will update you.

For your convenience and reference, here’s a copy of the news releasethat was distributed by Assurant, Inc. on April 28.


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