April 26, 2024

Your Money Adviser: Locked Out of the Insurance Marketplace

But if you are a low-income resident of one of 25 states, including Louisiana and South Carolina, you may miss out on financial help offered by the exchanges. That’s because those states haven’t expanded their offerings under Medicaid, the federal-state health program for low-income people, as the law envisioned. A list showing the expansion status of all 50 states and the District of Columbia is available on the Kaiser Family Foundation Web site.

A result is the frustrating situation in which you could qualify for financial help to buy coverage on the marketplaces — if only you made more money.

How did this happen? The health law aimed to cover as many people as possible in two main ways: creating marketplaces where people who don’t have insurance through an employer could buy affordable private policies; and expanding the number of people covered by Medicaid, which mostly has covered children and pregnant women.

In general, if you earn from one to four times the federal poverty level — about $11,500 to $46,000 for an individual — then you qualify for subsidies, given as tax credits, to lower the cost of policies bought on the exchanges.

Coverage for people earning below the poverty level was supposed to be handled by a federally funded expansion of Medicaid. But the Supreme Court ruled in June that expanding Medicaid was optional — and half the states chose not to do it, contending that the added costs would be too burdensome for taxpayers. The law didn’t anticipate the lack of Medicaid expansion, so there is a gap in coverage for those who don’t qualify for their state’s existing Medicaid plan, and who earn too little to qualify for financial help on the exchanges.

(It’s not clear precisely how many people are affected by the gap. But roughly seven million uninsured adults earn below the poverty level in the states that haven’t expanded Medicaid, according to the Kaiser Foundation.)

If you fall into the income gap, you can buy a policy on the exchanges — but you’ll pay the full premium. That’s “unrealistic” for someone making less than poverty income, said Ron Pollack, executive director of Families USA, which advocates for broader health care coverage. According to the Kaiser Foundation’s premium calculator, a 40-year-old man or woman who doesn’t smoke and earns $10,500 a year — below the poverty level — wouldn’t qualify for subsidies and would pay nearly $3,200 a year, or roughly a third of his or her income, for a “bronze” plan on the exchanges.

“The irony is that people with higher incomes can and will get help,” said Mr. Pollack.

One small consolation: If you would have qualified for Medicaid under the A.C.A. expansion, but your state isn’t participating, you’re exempt from the law’s requirement to buy coverage. So you won’t pay a penalty for not buying it.

Here are some questions to consider:

If my income is low and I’m uninsured, but I live in a state that didn’t expand Medicaid, should I apply for coverage on the marketplace anyway?

There’s no penalty for applying. And it may turn out that you qualify for coverage under your state’s existing Medicaid rules, but didn’t know it.

Could my state expand Medicaid coverage in the future?

Possibly. There’s no deadline for states to expand their programs, and some are still considering it.

Where can I seek medical treatment if I don’t have any insurance?

Check to see if there is a community health center near you; the cost of care at such clinics varies based on your income. You can search by ZIP code on the federal health care Web site: healthcare.gov/where-can-i-get-free-or-low-cost-care/

Article source: http://www.nytimes.com/2013/09/24/your-money/locked-out-of-the-insurance-marketplace.html?partner=rss&emc=rss

Economix Blog: What the Oregon Health Study Can’t Tell

The Oregon Health Study — one of the most important public-policy studies of the last decade — released a new round of results on Wednesday, showing that Medicaid coverage does not seem to make low-income adults much healthier, judging by biometric data. At least, that is one fair way to interpret the results, and it is basically the way the authors put it at the top of their new paper.

But here is another good way to put it: The Oregon Health Study released a new round of results on Wednesday, showing that Medicaid coverage does not seem to improve low-income adults’ blood pressure, blood sugar or weight in a two-year time frame. It says nothing about the chance of diagnosis of, eventual health outcomes for or costs associated with any form of cancer, Alzheimer’s, Parkinson’s or dozens of other debilitating medical conditions. It also says nothing about health results outside of a two-year time frame.

It does tell us that Medicaid coverage increases the chance that diabetes will be diagnosed in a low-income adult. It also tells us that diabetes in these low-income adults does not seem to improve much within the first 24 months or so, judging by blood-sugar tests. But the study is silent on whether Medicaid might reduce the amputation rate.

The study presents strong evidence that Medicaid recipients spend more on health care, and not just because of pent-up demand: they just seem to spend more, full stop. But it does not say anything about whether Medicaid coverage might reduce spending on avoidable but high-cost procedures, like treatment for advanced cervical cancer that was never caught with a Pap smear.

The Oregon Health Study results are extremely closely watched, given how rare the opportunity to perform a textbook randomized control experiment is in public economics, and given the pending Medicaid expansion.

Where it says something, it says a lot: it provides strong evidence that Medicaid recipients will spend more, use more tests, experience less depression, have fewer bills sent to collection agencies, and so on. It shows health insurance working just the way insurance is supposed to work: protecting the financial stability of the people purchasing it.

The biometric results are compelling, too. The authors chose a handful of conditions that were common, important, easy to test for and treatable to include in the study. Medicaid does not seem to do much to improve health outcomes related to those conditions in two years.

But there are many more questions that the Oregon Health Study simply cannot answer, despite the overheated rhetoric out there today. Does Medicaid improve health over a decade? What might Medicaid do for lifetime health costs? We do not know, even if the study provides some clues. Nor could this study answer the question of whether the Medicaid expansion will be “worth it,” and why. What study could?

Article source: http://economix.blogs.nytimes.com/2013/05/01/what-the-oregon-health-study-cant-tell/?partner=rss&emc=rss

U.S. Accuses Novartis of Providing Kickbacks

“Using the lure of kickbacks disguised as rebates, Novartis co-opted the independence of certain pharmacists and turned them into salespeople for one of its drugs,” Preet Bharara, the United States attorney for the Southern District of New York, said in a statement.

The drug involved, Myfortic, is an immune suppressant used to help prevent rejection of transplanted kidneys. It competes with the Roche drug CellCept and, since 2009, with generic versions of CellCept.

The lawsuit, filed in Federal District Court in Manhattan, contended that Novartis promised rebates and discounts to 20 or more pharmacies if they would persuade doctors to switch patients to Myfortic from CellCept, or to keep patients on Myfortic after the cheaper generic versions of CellCept reached the market.

Novartis said in a statement that it disputed the government’s claim and would defend itself.

In filing the suit, the federal government is intervening in a whistle-blower lawsuit that remains under seal, as does the identity of the whistle-blower.

Pharmacies can profit if the amount they are paid for a drug by patients, or their insurers, including Medicare and Medicaid, exceeds what they pay to buy the drug. Getting a discount on the drug from a manufacturer can increase a pharmacy’s profit.

Prosecutors say in their lawsuit that Medicare and Medicaid paid tens of millions of dollars in claims for Myfortic that were “tainted” by the kickbacks.

That does not mean, however, that Medicare and Medicaid lost that much. CellCept and Myfortic cost about the same, according to the lawsuit, so switches from the brand name CellCept to Myfortic would not have appreciably raised federal costs.

Moreover, the suit notes, there are hundreds of pharmacies that prescribe Myfortic and the purported kickback scheme involved only about 20 of them, affecting just “hundreds, possibly thousands” of patients.

The suit says, however, that Novartis chose particularly influential pharmacies which could earn tens or hundreds of thousands of dollars in rebates.

The suit says that pharmacies couched their advice to doctors to use Myfortic as professional recommendations, concealing any mention of the financial inducement the pharmacy was receiving from Novartis.

While the contracts between Novartis and the pharmacies mentioned the discounts, the commitments Novartis received in return were left out of the contracts, the suit says.

In one example, the suit says that Novartis directed more than $650,000 in kickbacks to Bryant’s Pharmacy in Batesville, Ark., which submitted 8,300 Myfortic claims to Medicare Part B alone, receiving more than $3.2 million in reimbursement.

The suit, citing an internal memo by a Novartis account manager, says Bryant’s drove its annual Myfortic sales to more than $1 million a year from $100,000. And when the generic version of CellCept arrived in 2009, the pharmacy argued to doctors that patients doing well on Myfortic should not be switched.

Steve Bryant, owner of Bryant’s Pharmacy, said doctors made the decisions on which drug to use. He said the discounts were given by Novartis to make it affordable for the pharmacy to dispense Myfortic without losing money from inadequate Medicare reimbursement.

None of the pharmacies was named as a defendant in the lawsuit.

Myfortic is one of Novartis’s top 20 drugs, though not a star. Sales in the United States were $239 million in 2012, up 20 percent from 2011. Global sales were $579 million.

Article source: http://www.nytimes.com/2013/04/24/business/us-accuses-novartis-of-providing-kickbacks.html?partner=rss&emc=rss

In Downturn, Medicaid Takes Up More of State Budgets, Analysis Finds

That is one of the changes that the lingering economic downturn and the changing American economy have wrought on state finances, according to an analysis of state spending over the last few years released Tuesday by the National Association of State Budget Officers.

The increased spending on Medicaid, the state and federal health program for the poor, was driven by steadily rising medical costs, an infusion of money from the federal stimulus bill and a significant rise in the number of people who became poor enough to qualify for the program as the downturn wore on. The Medicaid program accounted for 21.9 percent of all state expenditures in 2009, 22.3 percent in 2010, and is estimated to account for 23.6 percent in 2011, the report found.

At the same time the share spent on elementary and secondary education has declined, dropping to 20.1 percent in 2011 from 21.5 percent of all state expenditures in 2009.

Education used to make up a bigger share of state spending: when the association first began compiling the report in 1987, elementary and secondary education made up the biggest share of state spending, and higher education the second biggest share. Medicaid surpassed higher education as the second biggest state program in 1990, and in 2003 it became largest state program for the first time. Since then it has vied with schools for the biggest share of state spending, but for the past three years it has been in the lead, with an increasing margin.

The report said that after the recession hit, spending from state funds declined in 2009 and 2010, but federal aid from the stimulus package allowed states to continue to increase overall spending. But a summary warned that the uncertain economy, the likelihood of reduced federal aid, the expected costs from the health care overhaul and continuing pressure to pay for pensions and health care for retired workers means that “states are likely to face austere budgets for at least the next several years and will continue to make difficult spending decisions.”

Article source: http://feeds.nytimes.com/click.phdo?i=17b2db7982b3cf32a91e81ee792ae688

Asian Markets Rally on Optimism Over Europe

Opinion »

Op-Ed: Fight Health Care Fraud

We should be much more aggressive in recovering money stolen from Medicare and Medicaid.

Article source: http://www.nytimes.com/2011/09/28/business/daily-stock-market-activity.html?partner=rss&emc=rss

Union Struggle at Target

But the arrows are about to come flying at Target’s famous bull’s-eye logo. The nation’s largest union for retail workers has embarked on its first broad campaign to unionize Target workers.

The union, the United Food and Commercial Workers, is trying to organize 5,000 workers at 27 Target stores in the New York City area. A majority of workers at the Target store in Valley Stream, N.Y., have already signed cards supporting unionization, and a government-supervised election there on June 17 will be the first time in more than two decades that Target workers will vote on whether to join a union.

“A lot of people are going to be shocked that Target workers would consider unionizing because of its very good image and because it’s known as such a fantastic philanthropic organization,” said Burt Flickinger, a retailing consultant who has worked on projects for both the union and Target suppliers.

The union decided to focus on Target after employees in Valley Stream, on Long Island, asked for help in unionizing. Echoing longstanding complaints by some Wal-Mart workers, the store’s employees complained that many of them earned too little to support a family or afford health insurance, forcing some to rely on food stamps and Medicaid for their children.

“What we want from Target is simply this: we need a living wage where we can get by,” said Sonia Williams, a logistics employee in Valley Stream who said she earns $11.71 an hour, plus a $1-an-hour night differential.

Target says its wages are competitive and its employees do not need a union.

Interviews with 10 of the store’s employees suggest that an important issue behind the unionization drive is frustration about being assigned too few hours of work, sometimes just one or two days a week.

Retailers are increasingly assigning such short workweeks as they seek to build an extensive roster of workers to fill their ever-changing scheduling needs. But some Target workers say that means they are offered too few hours to qualify for the company’s health plan.

Ms. Williams, who receives $200 a month in food stamps to help her and her 18-year-old son, complained that she was often assigned just three days of work each week, down from full time when she started nearly nine years ago.

So far, the union’s organizing efforts have not turned belligerent as it hopes to convince Target employees that it wants to work with the company, not hurt it. In contrast, the union has never been shy about attacking Wal-Mart — hurling invective, organizing protests and lobbying officials to block the retailer’s plans to expand in New York, Chicago and other cities unless it agrees to improve wages and benefits.

Union officials assert that Target’s wages and benefits are only slightly better than Wal-Mart’s.

Jim Rowader, Target’s vice president for employee and labor relations, said the company provided “great benefits, flexible scheduling and great career opportunities for workers in all stages of life.”

He said Target emphasized building trust between managers and employees. “When you talk about bringing a union into that mix, certainly based on the culture we have and the one we’re trying to build, we don’t think a union or any third party will improve on anything,” he said.

None of Target’s 1,755 stores in the United States are unionized, nor are any of Wal-Mart’s 4,420 American stores. The union has tried over the last decade to unionize Wal-Marts in Minnesota and Las Vegas and a Target in Minnesota, but fierce antiunion campaigns by the retailers deflated the efforts before they even came to a vote.

Mr. Flickinger said unions had been loath to undertake large-scale organizing drives against retailers, like the new one against Target in New York, because of obstacles like high employee turnover, the fear of some workers that they would be fired for supporting a union and the aggressive opposition by many companies toward unionization.

Article source: http://feeds.nytimes.com/click.phdo?i=36cf785ce0a78750fc21cf6e4bdf4fe2