Blog: Contraception Coverage and the ACA

A “viewpoint” article published in JAMA this week (authored by March C. Politi, Adam Sonfield, and Tessa Madden) briefly summarizes how the Affordable Act Act (ACA) expands access to contraception, but also describes the various “challenges” that thus far have prevented the full implementation of this provision.

To my mind, the points they make demonstrate how the underlying, structural flaws of our health care system make even relatively straightforward and useful reforms like the ACA’s contraception mandate enormously difficult and complex to realize in practice.

As they briefly summarize in the article (“Addressing Challenges to Implementation of the Contraceptive Coverage Guarantee of the Affordable Care Act”), the ACA includes a provision that mandated that contraception-related health care – including medications, devices, services (including sterilization), office visits, and education – be covered by privates insurers without “cost sharing” (i.e. copayments or deductibles).

This is unquestionably a good and useful measure: contraception-related care is a fundamental component of comprehensive reproductive health care. There is no plausible reason to punish women who use contraception by imposing out-of-pocket payments at the time of use (the same could be said of all medically-necessary health care, in my opinion, but that’s a story for another time).

The article then briefly summarizes the various games insurers have played in preventing the implementation of this rather straightforward provision.  For instance, they note that some insurers have left out coverage for certain modes of contraception (though they assert that this should be addressed by new federal rules), and also that insurers have not been reliably covering contraception-related clinical care.  “Inappropriate insurance practices,” they write, “may therefore lead to patients being erroneously charged for services that should be covered with no out-of-pocket costs, potentially interfering with patients’ ability to practice contraception consistently and effectively.”

But it is when they turn to the issue of billing and coding that the ridiculous complexity of our health care system – and the harm that this complexity causes – becomes most evident.  As a result of the vagaries of billing codes, what is theoretically fully covered may not be in practice.  As they write:

Physicians, other clinicians, and health care organizations may find it difficult to appropriately bill for contraceptive services in a way that ensures that patients are properly exempt from cost sharing. If a patient receives contraceptive counseling as part of a well-woman examination, the situation is straightforward because the well-woman examination has a specific Current Procedural Terminology code and is considered a covered preventive service. However, if a patient has an office visit solely for contraceptive counseling (which does not have a specific billing code), the clinician or health care center must bill an appropriate evaluation and management code (which can be used for many purposes) and billing modifier (ie, 33) to specify that the visit was for the preventive service, contraceptive counseling. Many clinicians and health organizations are unaware of this modifier, and some insurers have been slow to program their billing systems so that this modifier automatically triggers the patient’s exemption from cost sharing when the included diagnosis codes (formerly International Classification of Diseases, Ninth Revision [ICD-9], now ICD-10) indicate that primarily preventive services were provided.

Of course, it is ultimately women who are penalized by this byzantine structure of coding.

But the complexities don’t end there.  As they describe:

An additional challenge arises if care that involves diagnostic testing is provided during a visit, even when the initial visit was scheduled for contraceptive counseling or maintenance. Under the ACA provision, a visit should be considered preventive—and therefore exempt from cost sharing—if the primary purpose of the visit is for preventive care. However, the primary purpose may not always be clear to patients, clinicians, and payers when additional care is provided. Clinicians can use 2 separate billing codes, one for the preventive care and an additional code for the diagnostic care, but this could lead to confusion and disagreement about when patients will be charged. Greater transparency could help clinicians and health care centers communicate with patients about these potential fees.

This is of course ridiculous.  In reality, office visits can be a combination of things, and attempts to classify them as purely “preventive” or not is a fiction.  It’s also entirely unnecessary: if office visits for both “preventive” care and “non-preventive” both didn’t have cost sharing, none of this would matter (at least from the patient’s perspective).

They finally note that none of these protections are available for women who obtain contraception-related services “out-of-network.”  Yet this may happen unwillingly: as they describe, a women may undergo a sterilization procedure at a facility that’s inside of the insurance network, but the anesthesiologist involved in the case may be out-of-network.

The story of the contraception coverage mandate of the ACA thereby speaks to the enormous difficulty of effectively – much less efficiently! – moving towards universal health care within a structure dominated by private insurers.




Blog: Latest Results from the National Health Interview Survey

Uninsurance remains a problem in America, even in the age of the Affordable Care Act (ACA). That’s one conclusion that can be drawn from the latest survey results released two weeks ago by the National Center for Health Statistics.

The report (“Early Release of Estimates From the National Health Interview Survey, January–September 2015”) compares survey data on health insurance coverage gathered over the first nine months of 2015 with that of previous years, extending back to 2010. The estimates rely on a civilian, non-institutionalized sample, which for 2015 consisted of some 79,847 individuals in 37 states.   I’ll briefly summarize some of the key results in this post.1

The survey demonstrates a substantial reduction in the uninsured population in the years following the implementation of the ACA. In 2010, 22.3% of non-elderly adults were uninsured at the time at which they were interviewed. In contrast, for the first 9 months of 2015, this had fallen to 12.9%. This comes after about a decade of rising uninsurance, beginning in the late 1990s:

Screenshot 2016-02-16 11.24.46

The time trends by age groups are as one might expect. For younger adults (ages 18-24), the reduction in uninsurance occurred over 2010 and 2011. This makes sense, as the dependent coverage provision of the ACA was implemented in September 2010 (the law required coverage of children below age 26 under family health insurance plans). For other age groups, in contrast, uninsurance fell between the years 2013 and 2015. This squares with the fact that the main coverage expansion provisions of the ACA – i.e. the individual mandate and the Medicaid expansion – went into effect in 2014.

Inequalities in insurance status by class persist. In 2015, among non-elderly adults, 26.1% of the poor and 24.1% of the near-poor were uninsured at the time the interview was conducted, as compared to 7.7% of those who weren’t poor. However, there were notable reductions in uninsurance among the former two groups between 2013 and 2015:

Screenshot 2016-02-16 11.25.32

Coverage inequalities by race – despite improvements – also persist. In 2015, among non-elderly adults, 27.9% of Hispanics and 14.6% of non-Hispanic blacks were uninsured, as compared with 8.8% of non-Hispanic whites and 7.3% of Asians:

Screenshot 2016-02-16 11.25.49

Addressing racial health inequalities, clearly, requires addressing these inequities in coverage (among many other things).

There were also inequalities by geography. Unsurprisingly, uninsurance among non-elderly adults was higher in states that have not yet expanded Medicaid under the ACA as compared to those that have (see this analysis for estimates of the number of deaths that have needlessly resulted from this “opt out”).

Finally, the survey reveals the evolving character of insurance: high-deductible heath insurance plans are on the rise. The percentage of the privately insured non-elderly with high-deductible health care plans (whether or not they are associated with a health savings account) rose from 25.3% in 2010 to 36.2% in 2015:

Screenshot 2016-02-16 11.26.08

This is but one glimpse at a much larger story of rising deductibles and copayments – of underinurance more broadly – in the United States.

In sum, the ACA has clearly expanded coverage in the United States. In 2010, among those of all ages, 48.6 million were uninsured (determined based on the time they were interviewed) according to the estimates of this survey. For the first nine months of 2015, this had fallen to 28.8 million. This is no doubt a meaningfully and important change for the many millions who are now newly insured. Yet, the law is now in full effect, and millions are still excluded from coverage. Moreover, inequalities in coverage – along the lines of both race and class – persist. High-deductible health plans are on the rise. Universal health care has not yet been achieved.



1 Note that all the figures reproduced here from the report are in the public domain. All numbers cited in this post are from this survey. When I say “2015,” I am referring to the first nine months of 2015. “Non-elderly adults” describes those aged 18-64.

Salon: The Obamacare “private option”

Imagine you’re a conservative state politician ideologically opposed to government-provided health insurance for those with low incomes, but you nonetheless recognize the folly in forgoing billions of dollars in federal funds available to states that expand Medicaid simply to prove a Dickensian point (of questionable popularity) … Read the article at Salon here.


Jacobin: The Neoliberal Turn in American Health Care

Last year’s three-ring Congressional shutdown circus — for many little more than a desperate rearguard action by an isolated rightwing fringe to undo the fait accompli of Barack Obama’s health care reform — reinforced with each passing day the gaudy dysfunction of the American political system. But we miss something crucial if we construe the perseverance of Barack Obama’s 2010 Affordable Care Act (ACA) as nothing more than the overdue victory of commonsense health care reform over an irrelevant and intransigent right, or, even more, as the glorious culmination of a progressive dream for American universal health care long deferred.  In Jacobin here.

Salon: A pro- single payer doctor’s concerns about Obamacare

As a single-payer advocate who is also a doctor, I was concerned after the Affordable Care Act was passed that it didn’t do enough to combat rising underinsurance. A recent study by the Commonwealth Fund, which used new data to demonstrate that in 2012 some 31.7 million Americans were underinsured (i.e. insured, but still with heavy additional out-of-pocket health care expenses), argued that the burden of underinsurance will likely lessen as the ACA fully unfolds. But is there really reason for such optimism?  See the article here in Salon.

Blog: Underinsured in the Commonwealth?

There has been much talk in recent weeks about the ability of the Affordable Care Act (ACA) not only to reduce uninsurance, but also underinsurance, which is the state of being inadequately insured, such that medical expenses remain a threat to one’s financial health.

The health care reform that Massachusetts launched in 2006 to no small degree provided the model on which the ACA is based.  Therefore, the current state of affairs in the Commonwealth provides a good basis for predicting the impact of the ACA.  Such an evaluation, unfortunately, gives grounds for pessimism on the issue of underinsurance.

Continue reading

Salon: Republicans’ biggest misunderstanding about Obamacare

The battle for universal healthcare is not over. This is not because of the reason you might suspect – that Republicans will obstinately endeavor to obstruct Obamacare in every way they can (though that seems to be the case). Instead, even after the smoke clears from the government shutdown (presumably with the law intact), the battle over universal healthcare will still not be over, but for a more fundamental reason: Obamacare, whatever its advantages (and despite the right’s worst fears), does not create a system of universal healthcare…

Read it on Salon here.