Living Well November December 2016

consumers will have less choice new sign-up season Q&A blame game in drug price fight

health insurance planning NOVEMBER/DECEMBER 2016 A Publication of the

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NOVEMBER/DECEMBER 2016 VOL. 38

IN THIS ISSUE HEALTH INSURANCE PLANNING

SIGN UP SEASON

CONSUMERS

will have less choice

BLAME GAME

CHOOSING HEALTH INSURANCE

drug prices

Q&A

as a senior

Page 4

ALSO IN THIS ISSUE

Page 10

Page 8

HOW TO CHOOSE A PHYSICIAN Page 14

Page 12

Also

Your Paycheck

COMPARISON TOOL FOR HEALTH PLAN NETWORKS Page 20

Page 30

INSULIN PRICE SPIKE Page 26

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3

Health law consumers face least choice in program’s history

By MEGHAN HOYER and RICARDO ALONSO-ZALDIVAR Associated Press

WASHINGTON – Americans in the health insurance markets created by President Barack Obama’s law will have less choice next year than any time since the program started, a new county-level analysis for the Associated Press has found.

The analysis by AP and consulting firm Avalere Health found that about one-third of U.S. counties will have only one health marketplace insurer next year. That’s more than 1,000 counties in 26 states – roughly double the number of counties in 2014, the first year of coverage through the 4

livingwell ~ November/December 2016

program.

With insurance notices for 2017 in the mail, families are already facing difficult choices, even weighing whether to stay covered.

“At this point we are at a loss,” said Ryan Robinson of Phoenix. “We don’t know what the next step is.” He and his wife, Nicole, only have plans from one insurer available next year, and the company doesn’t appear to cover an expensive immune-system medication for their 11-yearold daughter.

Phoenix is the market hardest hit by insurer exits, shrinking from eight carriers to one. With many other communities affected, however, the problem of dwindling choice may create even bigger political headaches than the rising premiums announced earlier this week.

Largely as a result of the Affordable Care Act, the nation’s uninsured rate has dropped to a historically low level, less than 9 percent. But the program hasn’t yet found stable footing, and it remains politically divisive. Insurer participation rose in 2015 and 2016, only to plunge.

Dwindling choice could be a trickier issue than rising premiums for the Obama administration and advocates of the 2010 law, including Democratic presidential candidate Hillary Clinton.

Most customers get financial assistance, and their subsidies are designed to rise along with premiums, which are increasing an average of 25 percent in states served by HealthCare.gov. But there is no comparable safety valve for disruptions caused by insurers bailing out. “Rising premiums get all of the political attention, but November/December 2016 ~ livingwell

5

lack of choice between insurers could be a bigger problem for consumers,” said Caroline Pearson, a senior vice president with Avalere.

Five states – Alaska, Alabama, Oklahoma, South Carolina and Wyoming – have one participating insurer across their entire jurisdictions. Only Wyoming and South Carolina had faced that predicament this year.

Another eight states – Arizona, Florida, Georgia, Missouri, Mississippi, North Carolina, Nevada and Tennessee – have only one participating insurer in a majority of counties.

Citing big financial losses, several marquee insurers sharply scaled back their participation for next year.

United Healthcare exited from more than 1,800 counties, and maintains only a minuscule presence, according to the analysis. Humana nearly halved the number of counties where it offers plans.

Insurers say enrollment was disappointing, patients were sicker than expected, and an internal system to help stabilize premiums didn’t work well. The Obama administration says insurers are correcting for initially pricing their plans too low.

HealthCare.gov has taken steps to help consumers whose insurer is leaving by matching them to the closest comparable plan on the marketplace next year.

Administration officials also point out that many private employers offer workers just one plan.

The upheaval in the health insurance markets has consumers scrambling to figure out options. Sign-up season starts Nov. 1 and ends Jan. 31.

South of Minneapolis, in Goodhue County, Minnesota, farmer Eugene Betcher said his Blue Cross Blue Shield family plan is going away. The insurer is dropping its popular preferred provider plan, which covers more than 100,000 area residents.

Betcher has an appointment with his insurance adviser, but he expects sharply higher premiums and having to switch doctors.

In his early 60s, he’s mulling just keeping his wife on the plan. “I’m thinking of not covering myself and hoping to get to 65 and Medicare,” said Betcher. He’d risk a fine, but he says that financially he would probably come out ahead even if he had to pay out of pocket for medical care.

In Birmingham, Alabama, property insurance adjuster Jacob Bodden said his Humana plan is pulling out and Blue Cross Blue Shield remains his only option. He gets no subsidy from the government, so he’d have to cover the entire premium increase himself.

“I don’t trust the incompetents who created this mess can fix it,” Bodden said.

In Phoenix, Ryan and Nicole Robinson are at the epicenter of the health law’s latest troubles. Maricopa County has seen the most insurers bail out, and premiums for a 6

livingwell ~ November/December 2016

benchmark plan are spiking 145 percent next year, beyond any other major market on HealthCare.gov.

Ryan Robinson, who works in sales for an out-of-state health care company, said the family’s premium will go from $821 to $1,489. It’s more than their mortgage and they don’t qualify for an income-based subsidy.

But what the Robinsons most worry about is that neither of their daughter’s two medications appears to be covered by the remaining insurer. That includes an immune-system drug costing about $5,000 a month.

“I shouldn’t be getting government assistance, but I shouldn’t be offered a plan that’s ludicrous,” said Ryan Robinson. He says the idea behind the law “was good and principled,” but “there have got to be other solutions out there.”

The Obama administration says consumers in such situations can seek an exception. “The law guarantees access to necessary prescriptions, even if they aren’t on a formulary, through an exceptions process,” said spokesman Aaron Albright.

Avalere is a consulting and data-crunching firm that provides nonpartisan analysis for health care industry and government clients. It compiled insurance marketplace data from 49 states and the District of Columbia for the analysis. That represents markets in 3,129 counties, where 12.3 million people selected plans for 2016. Only Massachusetts was unable to provide 2017 data by this week. ☐

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For many counties, dwindling insurance choices

Major insurers are pulling out of the health insurance markets created by the Affordable Care Act (ACA), citing financial losses. Their departure leaves about a third of U.S. counties with a single insurer.

ACA health insurance providers in 2017 No data

1

2

3+

Counties served by major insurance carriers, by year: Anthem

Aetna

Cigna

Humana

UnitedHealthcare

2,000 counties 1,500 1,000 500 0

880 251

’14 ’15 ’16 ’17

109 ’14 ’15 ’16 ’17

’14 ’15 ’16 ’17

SOURCES: Department of Health and Human Services; Avalere Health

156 ’14 ’15 ’16 ’17

’14 ’15 ’16 ’17

November/December 2016 ~ livingwell

7

48 AP

Q&A: RICARDO ALONSO-ZALDIVAR Associated Press WASHINGTON – President Barack Obama is leaving the White House in a few months, but the troubles of his signature health care law continue to make headlines. With premiums rising by double digits and many consumers scrambling to replace coverage because their insurer bailed out, the 2017 sign-up season that starts Nov. 1 looks challenging.

Obama says it’s just “growing pains” but critics see the threat of market collapse, a death spiral. Here are some questions and answers for consumers ahead of the law’s fourth open enrollment season:

New sign-up season; new woes for health law

I BUY MY INSURANCE DIRECTLY. SO WHY ARE MY PREMIUMS GOING UP SO MUCH IF I DON’T USE HEALTHCARE.GOV? The 2010 health care law aimed to create a single market in each state for health insurance purchased by individuals. That’s increasingly true as older plans that predate the law fade away.

So consumers who bypass the public insurance exchanges and buy individual policies from an insurer are not insulated from premium increases. And they lack the income-based subsidies available to customers inside the government marketplaces.

The administration estimates that 6.9 million people currently buy coverage outside the marketplaces, and of those, nearly two-thirds would not be eligible for

People line up to enroll in a health insurance plan at HealthSource RI in Providence, R.I., in 2014. President Barack Obama is leaving the White House in just a few months, but his namesake health care law will still be generating headlines. With premiums rising significantly and some insurers bailing out, the 2017 sign-up season that started Nov. 1 could get tricky.

AP Photo/Stephan Savoia 8

livingwell ~ November/December 2016

subsidies if they looked within the exchanges.

Another group, roughly 1.5 million people, buy policies through the exchanges but make too much to qualify for subsidies.

The people in these two groups will bear the brunt of premium increases.

Minnesota dairy farmers Dave and Ann Buck say their monthly premium of $1,650 for a family plan could jump to more than $3,000 next year.

“Our rates have gone up since the implementation of the Affordable Care Act, and they just keep going up to the point where it is unaffordable,” said Ann Buck.

WHAT DOES THE OBAMA ADMINISTRATION SAY ABOUT RISING PREMIUMS?

Officials finally acknowledged the price jump, revealing that premiums for a midlevel benchmark plan are going up an average of 25 percent across the 39 HealthCare. gov states. (It’s slightly less – 22 percent – when remaining states running their own marketplaces are factored in.)

The administration calls it a temporary market “correction” because insurers had set their premiums too low in previous years. Officials estimate that 72 percent of HealthCare.gov customers still will be able to find a plan for less than $75 a month after taking into account subsidies.

Caveat: Those large subsidies tend to go to lowerincome consumers, not those in the solid middle class. And switching to reduce your premiums may mean having to accept higher out-of-pocket costs, or a different network of doctors, or a new list of preferred medications.

ARE PREMIUMS GOING UP BECAUSE SOME INSURERS ARE LEAVING THE MARKET?

While there’s strong evidence that competition among insurers helps to keep premiums in check, it’s not clear that insurers bailing out is the main reason driving doubledigit increases.

Insurers say their new customers turned out to be sicker than expected, and not enough younger, healthier people have signed up to help defray costs. Also, the law’s internal system to help balance out gains and losses among insurers has not worked well.

About 1 in 5 HealthCare.gov customers will only have a single carrier in their communities next year.

UnitedHealthcare, Aetna and Humana have scaled back.

More than a dozen nonprofit insurance co-ops have shut down because of financial problems.

try to automatically match you up with a similar plan from another carrier. You don’t have to accept that match, but it could be a starting point for shopping.

Administration officials say a smoother website should make it easier to compare plans on features that consumers care about, such as which doctors participate. HealthCare. gov has been improved for mobile devices.

Depending on availability, consumers will have a new option of picking “Simple Choice” plans, clearly flagged on the website. These plans make it easier to compare premiums and provider networks.

Tip: Make sure to check your income information and update if needed.

I’M A NEW CUSTOMER. WHAT SHOULD I BE AWARE OF?

Instead of focusing on insurer brands, you might want to get familiar with the tiers of coverage on the marketplace: bronze, silver, gold and platinum.

Silver plans definitely deserve a close look because they’re the only ones that come with extra financial help for out-of-pocket costs like deductibles and copayments.

The so-called “cost sharing reductions” are keyed to a consumer’s income and are available for people making up to 250 percent of the federal poverty level, which is about $50,400 for a family of three.

For many families help with cost sharing makes the coverage affordable.

Tip: If you’re unfamiliar with health insurance jargon, seek out an enrollment counselor in your community.

Also, make sure to correctly enter your family information, citizenship, immigration status and income. Missing details or mistakes can create big problems later.

I PAID A FINE FOR BEING UNINSURED. IS IT WORTH MY TIME TO LOOK FOR COVERAGE?

It can’t hurt to run the numbers, because the basic fine now starts at $695 and it will creep up each year.

Don’t be shocked if you get a letter from the IRS reminding you about open enrollment season. The nudge from the taxman is part of the administration’s outreach effort this year.

WHAT ARE THE KEY DATES TO REMEMBER?

Dec. 15 is the last day you can sign up or make a change in time to take effect Jan. 1. That has been traditionally been HealthCare.gov’s busiest day. And open enrollment ends Jan. 31, after Inauguration Day for the next president.

Online: healthcare.gov ☐

I’M A RETURNING CUSTOMER TO THE HEALTH INSURANCE MARKETPLACE. WHAT SHOULD I LOOK FOR THIS TIME? It probably makes more sense than ever to shop around.

If your insurer left the market, HealthCare.gov will

November/December 2016 ~ livingwell

9

In Washington’s drug price

fight,

plenty of blame to go around

By ANNA EDNEY and ROBERT LANGRETH Bloomberg News (TNS) WASHINGTON – The health-care industry’s fingerpointing over drug costs is heating up. Insurers and pharmacy benefit managers blame pharmaceutical companies.

Drugmakers blame insurers. And have you seen how much money the hospitals spend?

Whether Hillary Clinton or Donald Trump wins on Nov. 8, most of the players are betting that something will get done on the cost of prescription drugs. They’re laying defensive and offensive groundwork for when new laws are drawn up by a Congress that has spent the last year holding hearings on the issue.

A prime example is a new ad out recently from the Biotechnology Innovation Organization, the Washington lobby group, making the case that high list prices don’t represent what drugmakers really get and that middlemen take a big cut.

“While the list price is often used in stories about prescription drug costs, it’s not what the drug company makes,” says a narrator. “Most of the control over the final cost to you, the patient, rests with your insurance company, or employer, or the PBM.” The ad push began last month and the group has plans for more, said Matt Gorman, a spokesman.

The blame game is getting more intense as lobbying groups see a must-pass piece of legislation to fund the Food and Drug Administration as a vehicle for price regulation.

Every five years, the pharmaceutical industry negotiates “user fees” they’ll pay the FDA to review new drug applications. The current authorization of the law ends in September.

“We are very much focused on user fees as an opportunity,” KJ Hertz, senior legislative representative on AARP’s federal health and family team, said in an interview.

“Everyone is looking for this to be an issue in 2017.”

AARP, which represents seniors, is part of the Campaign for Sustainable Rx Pricing, along with Anthem Inc., one of the U.S.’s biggest health insurers, Wal-Mart Stores Inc. and the Blue Cross Blue Shield Association. The coalition has 10

well ~ November/December 2016 livingwell

proposed having drugmakers submit for government review any price increases over 10 percent, and making it easier for generics to come to market.

Health insurers, who just six years ago were painted as villains during the passage of Obamacare, are relishing the turnabout now that drugmakers are the focus.

“These increases have got to stop,” said John Bennett, chief executive officer of Capital District Physicians’ Health Plan Inc., or CDPHP, a not-for-profit health insurer in Albany, New York. Last year, 22 percent of the premiums Capital took in for its commercial plans was spent on drugs.

“They are unsustainable for us as a society and they are morally wrong,” Bennett said in a telephone interview.

“They are extracting profit out of a scarce resource that people need to survive.”

Hospitals have jumped in as well. Two industry trade groups this month released a report that found average annual inpatient drug spending at community hospitals rose 23 percent from 2013 to 2015.

“The industry has proven time and time again it can no longer regulate itself,” Scott Knoer, chief pharmacy officer for the Cleveland Clinic, said in an Oct. 11 call discussing the report.

Clinton has released a plan for combating price increases that includes penalties for unjustified hikes, a federal group charged with overseeing drug prices and emergency importation of treatments from developed countries.

If Democrats win the Senate, there’s a chance Bernie Sanders, an independent representing Vermont, could chair the Senate Health, Education, Labor and Pensions Committee, which oversees the FDA legislation. Sanders this month denounced corporate “greed” in a tweet from his official account that called out Ariad Pharmaceuticals Inc. for the $199,000 price tag on its leukemia drug, sending the company’s shares down as much as 15 percent.

Drugmakers have another powerful message – their treatments save lives.

Pfizer Inc. in May introduced a TV ad where a male narrator ticks off the research, business and regulatory hurdles to bringing a new drug to market. Then the camera cuts to the man closing a medicine cabinet as he sees his young son behind him. “So after it became a medicine, someone who couldn’t be cured, could be – me.”

Pfizer declined to say how much it was spending on the ad campaign. “Our hope is that if more people understand what it takes to bring a new medicine to patients, that together we can create a better environment for discovering treatments,” said Neha Wadhwa, a spokeswoman.

Anna Edney reported from Washington. Robert Langreth reported from New York. With assistance from Katherine Doherty and Chloe Whiteaker. ☐ November/December 2016 ~ livingwell

11

choosing

health

insurance

as a

senior

By SARAH BASS

One of the biggest questions seniors face is what kind of health insurance will best meet their needs. While there are good resources to help you navigate these waters, such as your local agency on aging, it is good to understand the basics before you delve in too deep.

Before you start to study plans ask yourself some questions:

1. What can I afford to pay for insurance premiums? This is the yearly or monthly amount that you owe to be covered by an insurance provider. Look at savings, retirement income, and existing expenditures and decide what is in your budget.

2. How important is it that I keep my doctor? Some insurances require you to 12

livingwell ~ November/December 2016

use a doctor and a hospital that is in their network.

3. What deductibles and co-pay amounts are reasonable for me? A deductible is the amount you owe out of pocket before insurance will begin to pay.

Co-pay amounts are a percentage you owe for doctor’s office visits, hospital stays and other medical transactions.

4. What are some of my current health needs and what is my family’s medical history? Some insurance plans have a dollar limit that they will cover in a year or over a lifetime. If you anticipate high costs, you will want to know ahead of time that your coverage will last.

In looking at plans, one of the most common choices for seniors over 65 is whether to enroll in original Medicare or in a Medicare Advantage Program. There are some differences and it is good to know these basics before you look at plans.

Original Medicare is administered through the federal government. It includes Part A, which covers hospital expenses, and Part B, which covers medical – doctor’s visits, durable medical equipment and therapies.

You will not owe a premium for Part A if you have worked at least 10 years, but most people pay a monthly premium for Part B. Your co-pay for medical care under original Medicare is 20 percent for outpatient services.

With original Medicare, you have the option to purchase supplemental insurance to cover these co-pays. Under original Medicare, you can see any doctor or go to any hospital that accepts Medicare. You don’t need a referral or pre-authorization to see specialists or to receive services. Original Medicare doesn’t cover prescriptions, so you will want to look at Medicare Part D drug plans.

Your local pharmacists or area agency on aging is a good resource for information on these plans.

Medicare Advantage Programs are administered through private companies. They are required to cover the same Part A and Part B benefits as original Medicare.

This is Big Sky Country.

Many Advantage Programs also cover dental and vision.

Each plan sets its own deductibles or co-pay amounts for doctor’s visits, hospital stays or purchase of medical equipment. Under Medicare Advantage Plans, you will still pay a Medicare premium and may owe an additional premium depending on your plan. Most Advantage plans require you to see a doctor or go to a hospital that is within the plan’s network and you may need prior authorization for certain services or referrals to see specialists. Under Medicare Advantage plans you cannot purchase a supplemental insurance to cover co-pays or deductible. You cannot purchase a separate prescription plan, but many Advantage plans include drug coverage.

Advantage plans also have a yearly limit on your out of pocket expenses, meaning that once you have met a certain amount, you will pay nothing for services for the rest of the year.

Though health insurance choices can seem confusing and overwhelming, once you understand a few basic facts, you are armed to delve in. Talk to your doctor, your family and trusted friends as you research and remember that the more you know, the better you will feel with your final choice. ☐

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13

How to Choose a Physician

14

livingwell ~ November/December 2016

Greenshoots Media Your physician will learn many confidential things about you — things that you may even feel uncomfortable talking about with your closest friends. It’s important to find a physician you can trust when discussing health-related details.

Thanks to the Affordable Care Act, the number of people with health insurance has increased dramatically. With this influx into the healthcare marketplace, it may actually be a challenge to find the perfect physician for you.

Don’t get discouraged, and definitely don’t settle when you’re making this very important decision.

Questions to Ask

Does your physician accept your insurance? Most insurance companies offer a directory, revealing all physician offices that accept their clients. For added assurance, call the physician’s office to make sure it hasn’t dropped your insurance plan.

Are you comfortable with the hospital your physician is affiliated with? If your physician deems that you need to be admitted to a hospital, you may not have a choice on where you go. If there is a hospital in the area you are opposed to visiting for some reason, you may need to find a physician who isn’t affiliated with that particular hospital.

Comfortability at the Office

Feeling comfortable with your physician is a critical factor when making your choice. It also is important to pay attention to the other members of your physician’s staff.

Remember, the people who are scheduling your appointments, relaying messages to your doctor and greeting you as you enter their building were put in place by your physician. Disrespectful or inefficient staff should be a red flag about the physician’s practices.

A study by The Associated Press-NORC Center for Public Affairs Research discovered that over half of Americans focus on personality and relationship when it comes to choosing a physician. Look for a physician who seems interested in what you’re saying. Someone who interrupts your sentences or inadequately answers your medical questions should convince you to keep shopping for a different physician.

Office Policies Each physician’s office has different policies, but there are a few that should be industry standard. Consider finding a different physician if scheduling a routine appointment takes more than a week.

It also can be helpful to find out if the doctor offers same-day visits and ask how much time to expect to spend in the waiting room. ☐

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Consumer Checklist

What to Look for in an Insurance Policy It can be a challenge to find coverage that meets your health care needs and fits your budget. Health insurance that covers more tends to cost more. Some tips as you are shopping for insurance: • Do your best to balance the cost (monthly premium) of a policy with the protection it offers.

• Determine what you will have to pay yourself for covered services (deductible, co-insurance, copayments, and out-of-pocket limit).

• Estimate costs for noncovered care (services excluded or limited by the policy) and charges (fees above what the plan recognizes).

• Check whether the plan covers the health care services and medications you require.

• Check whether the plan’s health care providers include your current providers, are located conveniently for you, and are high quality.

• Avoid policies that don’t have some kind of maximum out-of-pocket limit on covered charges.

• Don’t mistake insurance-like products for comprehensive coverage.

• If you have questions, call your state’s Department of Insurance or Consumer Assistance Program.

— HealthCare.gov 18

FAQs: From How much will my policy cost me?

The answer is more complicated than you might think. The cheapest policy may not provide you the best overall value.

The most obvious feature of any policy is the premium — the amount you pay (usually monthly) to an insurance company for a health insurance policy.

Just as important as the premium cost, however, is how much you have to pay when you get services. Examples include: • How much you pay before insurance coverage begins (a deductible) • What you pay for services after you pay the deductible • How much in total you will have to pay if you get sick (the out-of-pocket maximum) Often, there is a direct tradeoff between how much you pay for health insurance and the extent of the covered benefits. • As you weigh this tradeoff, remember that buying the policy with the cheapest premium or with a very high out-ofpocket maximum may leave many services and treatments uncovered. This could leave you vulnerable to high medical bills.

Can I keep my current doctor?

Private health insurance plans often have networks of hospitals, doctors, specialists, pharmacies, and other health care providers. Networks include health care providers that have a contract with an insurer to take care of the plan’s members.

livingwell ~ November/December 2016

When choosing a plan, review the list of providers that give care under the policy. If staying with your current doctors is important to you, check to see if they are included.

Depending on the type of policy you buy, care may be covered only when received from a network provider. To get care from a specialist you may need a referral from your primary care doctor.

Types of plans and network restrictions Traditional HMOs (health maintenance organizations) and EPOs (exclusive provider organizations) may restrict coverage to providers outside their networks. If you use a doctor or facility that isn’t in the network, you’re likely to pay the full cost of the services provided.

Other types of insurance plans give you a choice of getting care within or outside of the provider network, although the portion of health costs covered by insurance may be much lower for out-of-network care. This means you will pay more to use out-ofnetwork providers. Plans like these may be called PPOs (preferred provider organizations) or POS (point-of-service plans). Fee-for-service plans usually don’t have networks.

What’s not health insurance?

Among the many kinds of private health insurance sold today, you may see products that look and sound like health insurance but don’t provide comprehensive health insurance protection. Here are some examples.

HealthCare.gov Dread Disease Policies Dread disease policies pay only for costs related to treatment for specific diseases, such as cancer. One state has banned their sale and other state insurance regulators have posted advisories cautioning people about these policies. Most dread disease policies aren’t guaranteed renewable.

Most insurance experts recommend buying a good comprehensive policy instead. Dread disease policies tend to be a poor value, and some sellers try to mislead people and prey on their fears about cancer or other diseases.

Accident-Only Policies Accident-only coverage pays for care you need as a result of an accident that isn’t due to illness. Since a good comprehensive policy will cover costs associated with accidents as well as illness, accident-only policies generally aren’t a good value.

Supplemental Policies Supplemental policies are typically designed to add on to more comprehensive health coverage. They “wrap around” and complement basic health insurance.

For example, a hospital indemnity policy is a supplemental policy that pays cash benefits for each day you’re in the hospital. Usually, however, the cash benefit will be nowhere near the cost of hospital care.

Another example is supplemental prescription drug coverage.

In either case, you should carefully evaluate supplemental policies before buying to ensure you aren’t “over-insured” and aren’t paying more than necessary for insurance you’re unlikely to use.

You may also consider buying a Medicare supplemental policy known as “Medigap” if you have Original Medicare.

A Medigap policy is health insurance sold by private insurance companies to fill the “gaps” in Original Medicare coverage and helps pay some of the health care costs that Original Medicare doesn’t cover. There

are 12 standard Medigap policies (Medigap Plans A – L), and insurers selling Medigap must follow state and Federal laws designed to protect you.

If you’re enrolled in a Medicare Advantage Plan, you don’t need to buy (and can’t be sold) a Medigap policy.

For more information about Medigap policies, visit www. medicare.gov.

Discount Plans Discount plans aren’t health insurance, and they won’t protect you from high medical expenses. Some people may mistake discount health plans for health insurance because of the insurance-like features of these products: • Discount plans charge a monthly premium, issue an ID card, and offer “coverage” for a broad range of health services.

• Discount plans also typically advertise a network of providers who will discount charges by, say 25 percent or 30 percent to people who are cardholders.

• Some people have reported problems getting promised discounts even on smaller-ticket health care services.

Unfortunately, because discount plans aren’t health insurance, insurance regulators often can’t help. A number of state insurance regulators and attorney generals have issued alerts warning people away from discount medical plans.

Stacked Policies A number of licensed insurers sell products that have been described by regulators as “stacked” policies.

These join together several limited coverage products — for example, an accident-only policy combined with a supplemental hospital policy or dread disease policy and a discount plan.

The combination may sound similar to comprehensive health coverage, but it isn’t. ☐

November/December 2016 ~ livingwell

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HOW NARROW IS IT?

Government begins limited test of comparison tool for health plan networks

MICHELLE ANDREWS Kaiser Health News (TNS) The incredible shrinking provider network is nothing new in marketplace plans. One way insurers have kept premiums in check on the individual market is by reducing the number of providers available in a plan’s network. Earlier this year, the federal government said that it would introduce a tool this fall to help consumers who are shopping on HealthCare.gov gauge how narrow a plan’s provider network is compared with others in the area.

But most consumers who want that information will have to wait at least another year. The Department of Health and Human Services recently announced that the pilot project to test the network breadth tool just got a little, well, narrower.

Consumers can already check whether specific doctors or hospitals are included in a marketplace plan’s provider network on HealthCare.gov. But there’s currently no way to easily measure the breadth of a plan’s provider network.

This can be an important factor for some consumers, especially given the growing number of plans with no out-ofnetwork benefits.

The new tool will designate marketplace health plan networks as “basic,” “standard” or “broad” based on how they compare with other health plan networks in a county.

The label will reflect the availability of three types of providers: primary care, pediatricians and hospitals.

Originally, network-breadth information was going to be available for the 35 states on HealthCare.gov, the federally facilitated marketplace. But in August HHS announced it would make the tool available in just six unnamed states.

In September, HHS said it would shrink the pilot still further, to four states – Maine, Ohio, Tennessee and Texas.

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livingwell ~ November/December 2016

The information will be available sometime during the open-enrollment period for 2017 coverage that runs from Nov. 1 until Jan. 31.

The government will consider expanding the pilot to additional states and types of providers in future years, the notice said.

In 2015, an analysis by the management consultant firm McKinsey & Company found that 55 percent of hospital networks for marketplace plans were broad, meaning more than 70 percent of hospitals in a specified area participated.

Twenty-two percent of networks were classified as narrow, defined as those in which 31 to 70 percent of hospitals participated, and 17 percent were labeled ultranarrow, meaning 30 percent or less participated.

Labels like “health maintenance organization” and “preferred-provider organization” aren’t necessarily meaningful in communicating whether a network is broad or narrow anymore, said Sabrina Corlette, research professor at Georgetown University’s Center on Health Insurance Reforms who has written about the network breadth pilot project.

Although the tool will let people compare networks in their area, still, “it’s all relative,” Corlette said. “If you’ve got a market where every single network is narrow, this network breadth rating is less useful.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation. ☐

November/December 2016 ~ livingwell

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For seniors, teeth need care – but insurance coverage is rare

Ada Anderson helps her mother, Violeta Anderson, brush her teeth before her dentist in November 2015.

HEIDI dE MARCO/KHN

Aging can take a toll on teeth, and for many seniors paying for dental services is a serious concern because they can’t rely on their Medicare coverage.

By MICHELLE ANDREWS Kaiser Health News Low-income seniors, in particular, are struggling. More than a third with incomes below 200 percent of the federal poverty level (about $23,000 annually) had untreated tooth decay between 2011 and 2014, according to an analysis of federal data by the American Dental Association.

“What ends up happening is that almost everybody, when they get to be 65, is sort of on their own and they have to pay for dental care out of pocket,” said Dr. Michael Helgeson, chief executive officer of Apple Tree Dental. Apple Tree is a Minneapolis-based nonprofit organization operating eight clinics in Minnesota and California that target underserved seniors, as well as mobile units that provide on-site dental care at nursing homes and other facilities.

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Traditional Medicare doesn’t usually cover dental care unless it’s related to services received in a hospital. Medicare Advantage managed care plans generally provide some dental care, but the coverage can vary, and often is minimal, dental advocates say. The plans often are “a loss leader,” said Dr. Judith Jones, a professor of dentistry at Boston University.

“It’s meant to attract people. It gets people in but the coverage is really limited.”

In a way, older people are victims of dentistry’s success. Regular visits to the dentist, along with daily tooth brushing and water fluoridation, have all contributed to improvements in oral health. In the first half of the 20th century, by the time people reached their 30s or 40s many had already lost all their teeth, Helgeson said, while today more than 60 percent of people in nursing homes still have at least one tooth.

“I know people who are spending sometimes more than $10,000 on what they consider essential dental care, like implants, none of which is covered.”

But teeth need tending. Without regular dental care, tooth problems can cause pain and limit how much and what type of food people are able to eat. Similarly, gum disease can loosen teeth and allow bacteria to enter the body. A growing body of research has linked treating periodontal disease with lower medical costs for diabetes and heart disease, among other conditions.

People’s lives are affected in other ways by their oral health. “You use your mouth to eat and kiss and smile and interact socially,” said Jones.

“It’s a source of great embarrassment and suffering for many adults without access to care.”

With limited income and no insurance, seniors may skip visiting the dentist regularly, even though many report that their mouths are dry and painful, and they have difficulty biting and chewing, not to mention avoiding smiling and social interaction if they have missing or damaged teeth.

Medicaid, the state-federal program for lower income people, covers dental care for children in every state, but coverage for adults is much spottier. Most states cover emergency dental care, but eight states offer no adult dental benefits at all, according to a study by Oral Health America, an advocacy group.

Even trying to purchase private dental insurance, which typically covers a few thousand dollars worth of dental care, may not provide good

value, said Marko Vujicic, vice president of the American Dental Association’s Health Policy Institute. “When you add up the premiums and copays, for the vast majority of adults it’s not worthwhile to have dental insurance,” he said.

Seniors with traditional Medicare spent $737 on average out-ofpocket on dental care in 2012, said Tricia Neuman, director of the Program on Medicare Policy at the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

But the figures may be much higher for people who need major restorative work.

“I know people who are spending sometimes more than $10,000 on what they consider essential dental care, like implants, none of which is covered,” Neuman said.

Seniors with limited means have few options for help affording dental care. Federally qualified health centers may provide geriatric dental services on a sliding-fee scale, and clinics like Apple Tree help a limited number of seniors who live in their service area. But they’re a Band-Aid, said Jones.

She and other advocates want Medicare to add a dental benefit to Medicare Part B. Their proposal would provide a basic bundle of diagnostic and preventive services through a premium increase, and seniors would only be responsible for copayments if they need pricey restorative work like crowns and bridges.

“Over the years, there has been some interest in expanding Medicare to include dental coverage,” Neuman said. But a dental benefit has faced stiff competition from other priorities, including adding a prescription drug benefit in 2006 and preventive coverage under the health law in 2010.

But some people think this time might be different. “There are 250,000 people every month who are turning 65, and 30 percent of dentists say they could use more business,” said Beth Truett, president and CEO of Oral Health America, which supports the proposal. “It’s a perfect storm.” ☐

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Study finds significant differences in plans sold on or off the exchange

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livingwell ~ November/December 2016

MICHELLE ANDREWS Kaiser Health News Three years after opening their online doors, the health insurance marketplaces remain under intense scrutiny, but individual health plans that are not sold through these exchanges have largely escaped attention.

New research sheds some light on what these plans are like and how they fit into the overall individual market.

The analysis by the Robert Wood Johnson Foundation found that the mix of 2016 plans sold outside the exchange by brokers or insurers is very different from those sold on the marketplace. On the marketplace, silver plans, which pay for 70 percent of covered expenses on average, are by far the most popular, comprising about two-thirds of all plans.

Bronze plans make up 16 percent and gold and platinum plans 12 percent of marketplace offerings.

Off the marketplace, only about a third of plans available are silver.

Another third of plans are bronze offerings that pay for 60 percent of expenses on average, while 25 percent are gold plans that pay for 80 percent of expenses or platinum plans that cover 90 percent.

In addition, more than half of plans sold off the exchange offered some sort of out-of-network coverage, compared with 36 percent of plans sold on the exchange.

Premiums and deductibles were higher in off-exchange plans, the analysis found. The average monthly silver premium was $314 compared with $279 for marketplace plans, while off-exchange silver plan deductibles were more than $1,200 higher on average, $3,273 versus $2,053.

“Off-exchange plans may offer out-of-network benefits and other features that are more useful to people,” said Katherine Hempstead, who directs the health insurance research work for the foundation.

People who are interested in off-exchange plans might have family members who are being treated for a medical condition and want access to a broader provider network or to out-of-network providers, for example, she said.

Though provider networks may be more extensive off the exchange and coverage details may vary, plans sold on and off the exchange must be similar in many ways. The health law created standards that all individual plans must meet, no matter where they’re sold. They must all cover essential health benefits, including hospitalization, prescription drugs and doctor visits, for example. They also all have to fit into the four metal coverage tiers that reflect the varying percentages of overall health care expenses they cover.

The obvious advantage to buying a plan on the marketplace is that people can receive premium tax credits that make coverage more affordable only if they buy a plan there. About 85 percent of marketplace customers qualify for the subsidies that are available to people with incomes up to 400 percent of the federal poverty level (about $47,000 for one person). The federal government recently reported that an estimated 2.5 million people may eligible for subsidized coverage but are paying full price for coverage off the exchange.

But for people whose income is too high to qualify for subsidies, there’s less reason to limit their shopping to the marketplace.

Off-exchange plans make up about a quarter of all individual market offerings, the analysis found. But while it’s easy to compare marketplace plans, there’s no easy way to do that with plans sold off the marketplace, Hempstead said.

“Right now the off-exchange market is kind of the Wild West in terms of how consumers know what’s available,” she said. ☐ November/December 2016 ~ livingwell

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Insulin price spike leaves diabetes patients in crisis

Carla Cox sits in her office at the St. Patrick Hospital Diabetes Care and Prevention Center in Missoula Aug. 17. TOM BAUER/Missoulian ANDREW SCHNEIDER Special to Lee Newspapers A massive spike in insulin prices is causing a health crisis for millions of diabetes patients who depend on the lifesaving drug, doctors say.

Now, after years of rapid increases having nothing to do with available supply and not matched elsewhere in the world, those in the U.S. insulin supply chain are blaming one another.

Tens of thousands of medical professionals are engaged in an intricate therapeutic ballet performed to protect the health, limbs and lives of the almost 30 million people in the U.S. suffering from diabetes.

But their efforts have been dramatically complicated by the soaring increase in the cost of insulin. They find themselves balancing the cost of the essential medication and their patients’ ability to pay.

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“The manipulation of insulin cost is a medical crisis in Montana and everywhere else in this country,” said Dr. Justen Rudolph, a diabetes specialist at St. Vincent Healthcare in Billings. “My patients having trouble with their insulin availability range from teenagers to a 90-year-old man, and there’s not a day that goes by when I’m not talking to a patient about the cost of their insulin.

“They try to spread out the insulin they have to make do, and that’s not how you can control diabetes,” said Rudolph.

This hit-or-miss medicating concerns many practitioners.

“Precision is needed to ensure the patient is getting the best type of insulin for their specific condition, in the right doses, at the right time to achieve the greatest benefit,” said Dr. Irl Hirsch, professor of medicine in the Division of Metabolism, Endocrinology and Nutrition at the University of Washington in Seattle.

State statistics and those of the American Diabetes Association show that 65,000 to 70,000 people have been diagnosed with diabetes in Montana, and another approximately 26,000 are believed to have the disease but have not been officially diagnosed.

In Missoula, Certified Diabetes Educator Carla Cox of the Providence Medical Group cautioned that switching to other forms of insulin “can present a greater risk because it is less like the action of insulin produced by the pancreas.”

Prices soaring

From 2011 to 2013 the wholesale price of insulin went up by as much as 62 percent. From 2013 to 2015 the price jumped again, from a low of 33 percent to as much as 107 percent, said Dr. Mayer Davidson, professor of medicine at the Charles R. Drew University of Medicine and Science in Los Angeles, who has carefully tracked the rapid and repeated increases.

“This borders on the unbelievable,” Davidson said, citing an extremely concentrated insulin which “in 2001 had the wholesale price of $45. By last year, the cost had skyrocketed to $1,447” for the same monthly supply.

Susan Pierce, a diabetes educator at Philadelphia’s Chestnut Hill Hospital, said she’s seeing similar increases, with her patients reporting that the cost of their insulin is doubling, tripling or worse.

“People who paid $200 or less are now getting bills of $400, $500 and even more for the same amount of insulin. Meanwhile, most insurance is paying less for medications and the required co-pays are higher, so it is a double whammy that prevents the patient from getting the insulin to stay alive,” said Pierce.

The medical community is concerned about patients who can’t afford their insulin, “so what they have to do is they ration it,’’ said Davidson, who has been heralded for his creation of programs to get quality diabetes treatment to underserved communities.

“They take it only three or four times a week instead of every day, in order to make it stretch, and that’s dangerous,” he said.

Diabetes specialists attack their patient’s increase or decrease of blood sugars with the finesse of a commander plotting how to use limited troops and supplies in a continuing battle.

Patients and their practitioners live in a world where they must select and prescribe insulin which either institutes immediate changes in glucose or blood-sugar levels, or is long-lasting and doles out the vital medication over hours.

“We are not talking about concierge medicine, or just fine-tuning insulin therapy or something that a patent can live without. We’re talking about survival. Don’t let anyone sugarcoat it,” warns Hirsch.

‘As much as her mortgage’

The effects of diabetes are enormous. The disease is a leading cause of blindness, strokes, kidney failure, heart attacks, nerve pain and amputation of the feet and legs.

Hirsch and many of his colleagues are not subtle when they describe what “price gouging of a medication required for survival” is doing to their patients.

“I had a patient tell me her insulin bill is suddenly costing her as much as her mortgage,” Hirsch said.

Others tell similar stories.

Dr. Claresa Levetan, chief of endocrinology at Chestnut Hill Hospital, said “just about 100 percent of them are having problems affording the higher cost of insulin.

“I see people every day in the hospital because they can’t get their required doses of insulin. Many are in the ICU with what is called diabetic ketoacidosis, a life-threatening condition. This lack of insulin brings the patients to a critical juncture, where they will become extraordinarily sick, go into a coma and could ultimately die.

“I have patients who tell me that they have to make a decision between food and insulin, and their rent and insulin.

“I mean, seriously, food, rent or insulin,’’ she said.

Where prices get hiked

Pricing of insulin, as with other medications, is controlled by the

manufacturers, the insurance companies and pharmacy benefit managers – the middlemen who negotiate the prices that the insurance companies pay.

“Both the pharma company and the pharmacy benefit managers jack up the cost,” said Hirsch, a former editor-in-chief of the journal Clinical Diabetes, published by the American Diabetes Association.

“We don’t know what the benefit manager is paying for the insulin from the pharma company. It’s backroom deals,” Hirsch said. “You can call them rebates, you can call them kickbacks, you can call them bribes, but those are secret deals on which we don’t have the details.”

Pharmacy trade associations are pushing congressional committees and state regulators to investigate the pricing practices of these powerful benefit administrators. Of significant concern is a “clawback fee” that the benefit controllers demand the pharmacies impose on patients on top of their copays.

Most professionals on the front lines blame the snowballing costs on the almost complete lack of regulation of pharmacy benefit managers.

“But the companies say, ‘No, no, no. It’s not us,’ ” said educator Pierce.

“You may not be able to prove who’s behind the price rigging, but remember these prices are not an issue in Canada or in Europe or other countries where the governments keep the drug makers from going wild.

It’s only in America.”

Nevertheless, some diabetes experts say the pharmacy industry should not be tarred with the same critical brush.

“Think of all the good things they actually do,” said Cox in Missoula, and ticked off programs for many low-income, uninsured people, as well as the industry’s support of children at diabetes camps and professional conferences.

Drug makers blamed

Three major pharmacy benefit companies were asked to comment on the insulin price increase. Only one, Express Scripts, the largest benefit manager in the U.S., replied.

The cost of insulin is high for patients because “drug makers continue to increase prices significantly each year, and there is no generic insulin available on the market,” said Jennifer Leone Luddy, Express Scripts spokesperson, who added that her company’s mission is “to keep prescription medication affordable and accessible.”

She described a major effort “to ensure patients get the right medication, are using and achieve the best results from their medication.”

The company seeks the most cost-effective medications, she said, but added that Express Scripts does not establish the price a patient pays for any medication, and its clients – employers, health plans and government agencies – decide how much will be paid by a patient.

In Gainesville, Texas, Jerry Meece, a clinical pharmacist and certified diabetes educator, said he spends far too much time trying to figure out what patients can afford versus what meds are most appropriate for them.

“These patients are desperate. They do without their insulin, skip doses, lower their prescribed dose to stretch out the insulin they have, and end up in the emergency room or ICU with long-term complications such as kidney failure, leg amputations or vision problems,” Meece said.

Even some patients who can afford the higher prices are endangered because the benefit managers are playing musical chairs with the different brands of insulin they authorize, some doctors said.

“I’m being told to make patients switch their insulin for no good reason except to make somebody more money,” said Dr. Loren Wissner Greene of New York University’s Langone Medical Center.

Greene, an NYU clinical professor of medicine, worries that her patients are confused by the flip-flopping.

“I just barely taught them that the orange pen is the fast-acting insulin and is to be taken with meals and the gray one is the slow-acting insulin to take at night. Now, suddenly, I have to switch them to a different brand to keep the pharmacy game-players happy,” she said.

“Big business wins again and the patients lose.”

Three pharmaceutical companies control almost all the world’s supNovember/December 2016 ~ livingwell

27

ply of insulin.

In addition to Eli Lilly, headquartered in Indianapolis, there is the Danish company Novo Nordisk, which says it makes half the insulin used by diabetics around the world, and the French company Sanofi, which says it has 18 percent of the market.

All three companies were asked why people buying their insulin were suddenly paying significantly more. Novo Nordisk and Sanofi did not respond to the question.

Lilly said it could not speculate on why individual costs went up.

“Lilly does not set the final price a patient pays for our medicines.

Wholesalers and pharmacies ultimately price the product at retail,” said communication manager Julie Herrick Williams.

“The patient’s insurer, the type of plan and the individual pharmacy all play a role in the price,’’ she said. “Changes to the U.S. healthcare system are the primary driver for increased insulin cost for consumers. With the adoption of cost-sharing plans, like high-deductible health plans, more direct costs are shifting to the people who need treatments.”

Insulin production earns pharmaceutical companies tens of billions of dollars. The three pharmaceutical giants made an estimated $12 billion to $14 billion in profits from the sale of insulin last year, according to preliminary figures gathered by industry watchdogs.

Insulin first hit the market in 1920 when three Canadian scientists donated the patent for their life-saving discovery to the University of Toronto for either one Canadian dollar, or free – accounts differ.

Almost immediately, the university gave pharmaceutical companies, including Eli Lilly, license to produce insulin without payment to 28

livingwell ~ November/December 2016

the school or the scientists, who won the Nobel Prize for Medicine for its creation. The magical concoction – extracted from the pancreases of pigs and cows – was distributed almost worldwide within months. Since there was no pharmaceutical treatment at the time, only rigid and unhealthy diets, countless lives were saved.

Eli Lilly’s corporate history reports that it took more than 4,000 pounds of animal pancreases to produce a cup – 8 ounces – of insulin.

Each year the company used organs from 60 million animals to produce enough insulin for U.S. diabetics.

Lilly looked for a better way to produce the vital medication, and in 1978, in a landmark in genetic engineering, Genentech came up with the answer. Genentech’s scientists cloned a synthetic insulin from a human insulin gene and a benign strain of the food-poisoning bacteria E. coli. It was the first laboratory synthesizing of DNA that resulted in a muchneeded medication, and animal-based insulin was on its way out.

Physicians are insisting that a less-expensive alternative has to be found, and questioning why a medicine nearing its 100th birthday is still so expensive.

Hirsch and his colleagues are lobbying hard to end the price gouging.

“The government is going to have to get involved and it’s going to get ugly,” said Hirsch, who has lived with the disease since his youth. He was diagnosed with diabetes when he was 6, and his younger brother was told he had the disease when he was 15.

“The well-being of our diabetes patients must come before the profit-driven games being played over the price of the clear liquid that keeps them alive,” he said. ☐

Dr. Justen Rudolph is pictured at St. Vincent Healthcare in Billings Aug. 12. LARRY MAYER/for the Missoulian November/December 2016 ~ livingwell

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Why health care eats more of your paycheck every year

By TOM MURPHY Associated Press Millions of Americans are finding out that the price of their health insurance is going up next year – as it did this year, last year, and most of the years before that.

And it’s not just that the price is going up, it’s that it goes up faster than wages and inflation, eating away at our ability to pay for other things we want (beer, televisions, vacations) or need (rent, heat, food).

Does it have to be this way? Why does health care grow so much faster than almost any other spending category so consistently?

And will it ever stop?

“At some point it’s not going to be worth it to have less food, less travel in order to spend money on health care,” said Louise Sheiner, a health economist at the Brookings Institution. “That’s what really stops it.”

Insurance premiums, which reflect spending on medicines, doctor visits, tests and hospital stays, have climbed 213 percent since 1999 for family coverage purchased through an employer, according to the Kaiser Family Foundation, which studies health care. Wages, by comparison, have risen 60 percent, while inflation is up 44 percent.

Here’s why the price of health care doesn’t grow like, say, the price of dishwashers or blue jeans – and why that’s unlikely to change anytime soon.

IT’S HARD TO SHOP FOR HEALTH CARE

Insurers and employers have been trying for years to make patients better health care shoppers and force doctors and hospitals to compete on price. They’ve raised deductibles or out-of-pocket costs on coverage and given tools to patients so they can compare prices and quality.

The idea is that patients become more motivated to price shop when they first have to pay several hundred dollars toward the bill due to a high deductible.

Many see this push as a key to curbing health care spending, since insurance tends to hide the full cost of care from the patient.

This can work ... for small stuff, said Renya Spak of the benefits consultant Mercer. Patients will shop if they need an MRI exam on their shoulder. But Spak isn’t convinced it will do much for things like surgeries, when the insurer or employer will wind up covering much of the bill anyway and the best deal might involve travel away from family.

“It’s not human nature to be rational thinkers about health care cost decisions,” she added. “It will never be just like buying a lawnmower.”

Consumers also prioritize health care purchases over other buying decisions, especially if they have basics like food and shelter covered. You’ll have back surgery to alleviate chronic pain before you take that long-awaited trip to Paris.

“What good is a better house if you are too sick to enjoy it?” said Charles Roehrig, an economist and vice president of the nonprofit Alta-

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rum Institute’s Center for Sustainable Health Spending.

TECHNOLOGY DOESN’T HELP

A carmaker can knock down the cost of making a vehicle by replacing auto workers with robots in parts of the assembly line. Treatment advances in health care are geared more toward making something more effective, not cheaper, noted Paul Fronstin, an economist with the Employee Benefit Research Institute.

A device maker may come up with a new hip that improves a patient’s quality of life, but it’s likely more expensive and the surgery might require the same number of doctors and nurses or more, A drugmaker might produce a new treatment that dramatically improves a condition but it may come with a bill of more than $50,000 in the meantime.

Device and drugmakers have been producing a steady stream of new products for consumers, and insurers that pay the bills have a limited ability to keep prices for those devices and drugs down.

“Every year, it’s kind of like Christmas, they deliver all this new stuff and of course they deliver it at high prices and insurance covers it,” said Mark Pauly, a health economist with the University of Pennsylvania’s Wharton School.

are still trying to balance out claims they pay in this relatively new coverage.

All told, health care costs, including the insurance bill and money paid out of pocket, made up 7.8 percent of the average consumer’s total expenses in 2015, up from 5.7 percent in 2006, according to the Bureau of Labor Statistics.

Meanwhile, much bigger portions of personal budgets like housing, food and transportation all slipped.

WHEN DOES THIS END? Health care spending now accounts for more than 17 percent of the U.S. economy. In 1980 it was just half that.

Economists and benefits experts say this trend has to slow at some point, or consumers won’t have enough money left to spend on things unrelated to health care. Some think big, disruptive changes in how we buy and use care may be needed.

That might mean that more insurers could drastically restrict a patient’s doctor choice in order to gain better negotiating leverage over the cost of care, a trend that is growing on the ACA’s exchanges.

Mercer’s Spak thinks employers need to lead, since they cover so many people. She noted that some companies have started contracting directly with big hospital systems for health care, cutting out the insurance middleman.

Sheiner, the Brookings Institution economist, says health spending may slow if drug and device makers stop developing new technology or drugs as quickly. But she thinks health care will keep climbing until people decide they aren’t going to burn any more of their pay check on it – and we’re not there yet.

“You never say never, but I don’t think we should expect that any time soon,” she said.

Associated Press Economics Writer Josh Boak contributed to this report. ☐

CONCUSSION TREATMENT UNIQUE TO EACH INDIVIDUAL INJURY

HOW IT ADDS UP

People with coverage through their employers should expect premium hikes of 5 percent or 6 percent next year, depending on where the employee lives and what adjustments a company makes. That’s double the forecast for inflation next year.

And the rising rates may keep them from getting a raise, too. Employers often pay most of the bill for employee coverage, leaving them less money to increase salaries when rates rise.

Customers shopping on the Affordable Care Act’s public insurance exchanges will see premium hikes of 20 percent or more in many markets, though those increases aren’t just because of rising health care spending. The exchanges have seen wild price swings in part because insurers

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Focusing on Preventive Care

H

igh costs have traditionally caused many Americans to skip out on crucial preventive care services, as some experts estimate that people seek out preventive care at half of the recommended rate.

Greenshoots Media That is a staggering number considering the powerful impact that preventive services can have on curbing dangerous diseases and debilitating illnesses.

The Affordable Care Act aims to substantially increase the utilization of preventive care services by making many of them free.

If your plan is eligible for free preventive care, you may not have to pay a copayment, co-insurance or deductible to receive the recommended services that can help foster longer, healthier lives.

Centers for Disease Control and Prevention.

An even more alarming fact is that these diseases are often preventable. So why are they not being caught early enough in some cases?

Chronic Diseases Some experts Chronic diseases are blame cost sharing — responsible for 7 of 10 copayments, deaths among co-insurance and Americans each year deductibles — for and account for 75 reducing the likelihood percent of the nation’s that people will seek health spending, out preventive according to the services.

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livingwell ~ November/December 2016

smoking, alcohol use, losing weight and treating depression.

The Affordable Care Act requires new health plans to cover and eliminate cost sharing for preventive services recommended by the U.S. Preventive Services Task Force, the Advisory Committee on Immunization Practices, and the Bright Futures Guidelines recommended by the Academy of Pediatrics.

What is Covered?

There is a wide range of services that could be covered by

Services for Women Especially concerning for women are studies showing that even moderate copays for preventive services such as mammograms or pap smears result in fewer women obtaining this care. the Affordable Care Under the Act, all of which are Affordable Care Act, necessary to reduce the number of serious women’s preventive health care services diseases and illnesses – such as facing our country. mammograms, According to screenings for heathcare.gov, these services include blood cervical cancer, and pressure, diabetes and other services – are already covered with cholesterol tests, as no cost sharing well as routine under some health vaccinations against plans. The law also diseases such as makes recommended measles, polio or preventive services meningitis. free for people on The law also is Medicare. ☐ designed to cover individual counseling on topics like quitting

MALLWALKERS FITNESS PROGRAM

GET FIT step by step Be a part of Missoula’s longest running free health program. Join us in Southgate Mall’s Community Room at 9 a.m. Mondays, Wednesdays and Fridays.

COME SEE WHAT’S

in store

SHOPSOUTHGATE.COM

November/December 2016 ~ livingwell

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YOUR DAY TO BE BRAVE. OUR EXPERTISE.

With every challenge you face, we’ll face it with you.

Whether it’s you or a loved one, a cancer diagnosis is a scary proposition. We’re here to help you strike back.

Community Medical Center’s team of board-certified oncologists, surgeons, hematologists, and radiation oncologists are supported by breakthrough technology and an extensive support staff that combine to provide the most comprehensive and comfortable care available.

No matter what today brings, you don’t have to go it alone.

Fight back. Discover why Community Cancer Care is the right choice.

Visit communitymed.org.

Community Cancer Care communitymed.org 4

livingwell ~ November/December 2016