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Interest groups push to fill margins of health coverage

By ABBY GOODNOUGH

New York Times

POSTED:
LAST UPDATED: 01:31 a.m. HST, Dec 06, 2012



The chiropractors were out in force, lobbying for months to get their services included in every state's package of essential health benefits that will be guaranteed under the new health care law.

"We've been in constant contact with our state chapters, just telling them, ‘Look, you've got to get in the room,"' said John Falardeau, senior vice president of government relations at the American Chiropractic Association.

The acupuncturists were modest by comparison, ultimately focusing on a few states, like California, where they had the best odds of being included.

"Our profession really didn't have a million dollars to spend on a lobbyist," said Jeannie Kang, the immediate past president of the American Association of Acupuncture and Oriental Medicine.

Instead, the profession mobilized 20,000 acupuncturists and their patients in a letter-writing campaign.

Both efforts seem to have shown results. Most of the roughly two dozen states that have chosen their essential benefits — services that insurance will have to cover under the law — have decided to include chiropractic care in their package. Four states — California, Maryland, New Mexico and Washington — included acupuncture for treating pain, nausea and other ailments. It is also likely to be an essential benefit in Alaska and Nevada, according to the Department of Health and Human Services.

"To me, six is huge," said Kang, an acupuncturist in Los Angeles, who helped coordinate the lobbying effort.

The main goal of the health care law has always been to guarantee medical coverage to nearly all Americans, but as states finalize their benefits packages, it is becoming clear that what is received will depend partly on location.

According to proposals that the states have submitted to the Department of Health and Human Services, insurance plans will have to cover weight-loss surgery in New York and California, for example, but not in Minnesota or Connecticut. Infertility treatment will be a required benefit in New Hampshire but not in Arizona.

Overall, the law requires that essential health benefits cover 10 broad categories, including emergency services, maternity and newborn care, hospitalization, preventive care and prescription drugs. But there is room for variation in those categories. Whether insurance will pay for hearing aids, foot care, speech therapy and various medications will vary significantly by state.

The Obama administration originally planned to impose a single set of essential benefits nationwide, so groups like Kang's lobbied federal officials at first. But last year, amid complaints that the health care law was too rigid, it decided to allow each state to choose its own guaranteed benefits within the 10 broad categories.

The law stipulates that starting in January 2014, the essential benefits will have to be covered by insurance plans offered in individual and small-group markets. These are the plans that people will shop for to comply with the law's mandate that almost everyone have health coverage or pay a penalty. They will be available through health insurance exchanges, online markets where the uninsured can shop for coverage, often with federal subsidies to help pay for it.

The essential benefits will not be guaranteed to people who get coverage through large employers, but such plans already tend to be relatively generous. In comparison, many plans currently sold on the individual market do not cover maternity care, for example, or mental health services.

For the most part, states are defining their essential benefits as those provided by the largest health plan in their small-group insurance market. In Washington state, for example, that plan covers 12 acupuncture visits and 10 chiropractic visits per year. It does not cover in vitro fertilization, weight-loss programs or routine foot care for anyone except diabetics.

"Everybody really was conscious of the cost impact that the plan was going to have," said Stephanie Marquis, a spokeswoman for the state's insurance commissioner. "That's something we're working very hard at keeping an eye on and making sure we're not adding benefits unnecessarily."

Alan Weil, executive director of the National Academy for State Health Policy, said that while the essential benefit packages vary at the margins, they are similar overall. Every state's package will cover visits to primary care doctors and specialists, for example, and diagnostic tests like X-rays and blood work.

"To people who care about particular diseases or conditions or provider groups, these don't feel like the margins," Weil said. "But at the end of the day, the core benefits are very standardized, and the differences are at the periphery."

Some states have declined to choose an essential benefits package, saying that the law does not give them enough latitude. In those states, the default will be the largest plan available in their small-group insurance market, according to the Department of Health and Human Services.

Gov. Dave Heineman, R-Neb., chose an insurance plan with a high deductible as his state's benchmark, reasoning that such lower-cost plans were popular in the state. But the Obama administration recently informed him that the plan did not meet legal requirements, he said.

"The point we were trying to make is that the minimum coverage should not be above what people need," Heineman said. "The overriding concern is that the cost will be too great."

Other states delayed choosing a benchmark plan on the grounds that the Obama administration had not provided enough guidance. Last month, the administration published a proposed rule that sought to answer questions.

The rule makes clear, for example, that insurers can substitute one covered service for another as long as they are in the same broad category and "substantially equal." It clarifies that pediatric services, one of the 10 required categories, must be provided to everyone 18 and under.

States can still change or choose a benchmark plan, but they are running out of time. They generally have until Dec. 26, when the comment period for the proposed rule will end. So far, 23 states and the District of Columbia have chosen plans, according to Avalere Health, a consulting company.

Interest groups that did not succeed in getting a particular service covered may have another chance to do so. States will most likely be able to change their benchmark plans after 2015.

This means that groups like the Obesity Action Coalition will keep making their case.

"There's going to be a great deal more effort on this issue," said Chris Gallagher, a policy consultant for the coalition. "At a minimum, if plans are going to try to exclude obesity treatment services, there must be some kind of exception for medically necessary treatment. It's a serious medical condition that affects 1 in 3 Americans."

Likewise, Kang's group will keep presenting state decision-makers with patient testimonials and research studies on the benefits of acupuncture. Its next targets are New York and Florida, which have more licensed acupuncturists than any state except California.

The chiropractors, meanwhile, are focused on California, where the essential benefits package that Gov. Jerry Brown signed into law in September does not include chiropractic services. Falardeau said the American Chiropractic Association was still hoping for a change.

"We're ready, if we have to, to go to war on it," he said.






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