{"id":34042,"date":"2013-09-27T06:12:42","date_gmt":"2013-09-27T10:12:42","guid":{"rendered":"http:\/\/asweetlife.org\/?post_type=feature&p=34042"},"modified":"2016-01-09T06:18:04","modified_gmt":"2016-01-09T11:18:04","slug":"obamacare-and-diabetes","status":"publish","type":"post","link":"https:\/\/asweetlife.org\/?p=34042","title":{"rendered":"Obamacare and Diabetes: Will the Affordable Care Act Live Up to Its Promises?"},"content":{"rendered":"

Perhaps you are one of the millions of Americans currently wondering what is going to happen on October\u00a0 1st<\/sup>, the day when the Health Insurance Marketplace of the Affordable Care Act<\/a>\u00a0(aka \u201cObamacare\u201d) opens for business.\u00a0 This is a particularly important question for people with diabetes because at the moment, the fact that we have a pre-existing condition leaves us with very few \u2013 if any — options for getting health insurance without an obliging employer or spouse (or other access to a group plan).<\/p>\n

I can\u2019t personally answer the question of what\u2019s going to happen because, as I\u2019ve learned by attending multiple diabetes- and healthcare-related conferences over the past several months, no one<\/em> knows the answer to that question. Certainly not the patients \u2013 but also not the doctors, not most government employees, and not even representatives from the health insurance companies themselves. The New\u00a0 York Times is publishing a series of articles revealing details as they become available (for the latest, click here<\/a>) – -but the best source of consumer information at the moment is healthcare.gov, which has a short, anonymous intake questionnaire you can fill out to get a sense of what your options may be on October 1st<\/sup>. However, as the site itself says, the detailed cost, coverage and enrollment info won\u2019t be available till that date.<\/p>\n

What is<\/em> currently clear \u2013 and what I want to encourage awareness and discussion about here \u2013 is that the law is already affecting the insurance market (and physician reimbursement) in tangible ways. And as a result, some of the things we\u2019ve been promised, like coverage for preexisting conditions and the option to buy insurance on our own (presumably while still being able to see our current doctors) may not work out exactly how many of us have hoped or expected.<\/p>\n

I recently attended the World Congress Summit on Patient Advocacy and Engagement<\/a>, a conference designed to bring together pharmaceutical companies and patient advocacy groups. One of the speakers was John Rother, the CEO of an organization called the National Coalition on Healthcare<\/a>,\u00a0a non-profit, non-partisan\u00a0 \u201corganization of organizations\u201d that Rother founded to \u201chelp achieve comprehensive healthcare change.\u201d As part of his talk, he referred to a September 22 article in the New York Times by Robert Pear titled \u201cLower Health Insurance Premiums to Come at Cost of Fewer Choices.\u201d<\/a>\u00a0\u00a0According to Rother, it lets the cat out of the bag about how, exactly, insurance companies are planning on complying with the pre-existing condition mandate while still controlling their premiums and costs. And from the perspective of a complicated disease like diabetes, it doesn\u2019t look good.<\/p>\n

The article\u2019s lead paragraph explains the crux of the issue: \u201cFederal officials often say that health insurance will cost consumers less than expected under President Obama\u2019s health care law<\/a>. But they rarely mention one big reason: many insurers are significantly limiting the choices of doctors and hospitals available to consumers.\u201d<\/p>\n

They\u2019re doing so through what Rother referred to in his talk as \u201cnarrow networks,\u201d and which the Times describes as follows: \u201cTo hold down costs, insurers say, they have created smaller networks of doctors and hospitals than are typically found in commercial insurance. And those health care providers will, in many cases, be paid less than what they have been receiving from commercial insurers.\u201d<\/p>\n

As the Times points out, this approach has consumer advocates and health care providers quite concerned, in part because \u201cdecades of experience with Medicare, the program for low-income people, show that having an insurance card does not guarantee access to specialists or other providers.\u201d Translation: come October you\u2019ll have the right (and, indeed, obligation) to purchase an insurance plan, regardless of preexisting medical conditions — in fact, the current expectation is that once the exchanges open, they\u2019re going to be flooded with people with pre-existing conditions who are elated to finally have the option of buying health insurance on their own. But here\u2019s the catch: that plan may not cover the services or providers that these people are accustomed to or need.<\/p>\n

How much more restricted will these networks be? A few examples cited by the Times: In New Hampshire, Anthem Blue Cross and Blue Shield, a unit of WellPoint, will be the only commercial carrier offering health plans in the state\u2019s exchange. Its network excludes 10 out of the state\u2019s 26 hospitals.<\/p>\n

In California, the statewide Blue Shield plan\u2019s new network for the health exchange plans has only 53 percent of the doctors in its broadest commercial network (30,000, down from 57,000) and 78 percent of the hospitals in its broadest commercial network (235 versus 302). If that doesn\u2019t sound like a big deal, consider that all five of the medical centers of the University of California are excluded, as is the Cedars-Sinai medical Center near Beverly Hills. Too bad that the UC centers offer some of the best diabetes care in the country \u2013 if I still lived in CA and were in an exchange, I\u2019d have to find an entirely new diabetes center and team. (Also worth noting: many physicians are associated with hospitals even if they don\u2019t practice at the hospital itself; if the hospital\u2019s not in the network, these doctors likely won\u2019t be, either.)<\/p>\n

The executive vice president of Blue Shield of California defended its decision to limit its network for the exchange, saying that \u201cnot many folks who are uninsured or near the poverty line live in wealthy communities like Beverly Hills.\u201d But as a senior vice president of an organization that represents 9,000 community health clinics around the country told the Times, \u201c\u2019We serve the very population that will gain coverage \u2013 low-income, working class uninsured people. But insurers have shown little interest in including us in their provider networks.\u2019\u201d<\/p>\n

And as for reimbursements, according to Barbara McAneny, a cancer specialist in Albuquerque interviewed by the Times, the insurers in the New Mexico exchange \u201cwere generally paying doctors at Medicare levels, which she said were \u2018often below our cost of doing business, and definitely below commercial rates.\u2019\u201d This highlights the serious but often unacknowledged issue of physician reimbursement: many doctors already refuse to accept patients on Medicare or Medicaid because it doesn\u2019t make financial sense. So why would a competent doctor agree to be a part of a new network with reimbursement rates that low? And, if all <\/em>networks begin to offer reimbursements at Medicare rates \u2013 again, which are often below the cost of doing business (that\u2019s part of the reason hospitals bill private insurers and non-insured patients at such exorbitant rates) — why would anyone want to enter the field of medicine to begin with?<\/p>\n

Low reimbursement rates are an issue that\u2019s already contributing to the United States\u2019 severe shortage of endocrinologists<\/a>\u00a0\u2013 which, is really quite shocking. According to a 2011 estimate<\/a>, there may be as few as 1,000 board-certified endocrinologists serving the country\u2019s 6,000 or so hospitals.\u00a0The American Diabetes Association estimates<\/a> that 25.8 million Americans currently have diabetes, and seven million are thought to have pre-diabetes. \u00a0Divide 33 million patients by a thousand endocrinologists, and you\u2019re left with one endocrinologist per 33 thousand <\/em>people with diabetes (and remember, endocrinologists are often concentrated at particular hospitals, and don\u2019t necessarily specialize in diabetes).<\/p>\n

Getting back to insurance networks, there are obviously situations in which the breadth of an insurance network might not matter: if you\u2019re one of the millions of relatively healthy Americans who cannot afford health insurance, then some of the plans on the exchanges \u2013 which the Times estimates may cost less than $100 a month per person after federal subsidies \u2013 may be fantastic options. They\u2019ll provide preventive and catastrophic coverage, as well as access to a consistent primary care physician, which many people in America don\u2019t currently have.<\/p>\n

However, I\u2019m beginning to get the frightening feeling that those of us with chronic, complicated and expensive diseases may be about to be in for a huge bait-and-switch. Sure, we\u2019ll have the ability <\/em>to buy insurance through the exchanges \u2013 insurers can no longer just say no. But if the insurance plans being offered don\u2019t cover the services or doctors that we need to manage our diseases, then what\u2019s the point of signing up for the plan? Access to health insurance doesn\u2019t really mean very much when that health insurance doesn\u2019t provide access to the medical care its members need. It\u2019s like receiving a paycheck in imaginary dollars.<\/p>\n

The irony is that most of the concern over the health exchanges that\u2019s been expressed so far<\/a> has been about healthy<\/em> people: why would someone with no medical issues bother to sign up and pay for a health plan, especially when the penalty is so low?\u00a0It\u2019s a genuine concern, based on the possibility of creating a health insurance \u201cdeath spiral of adverse selection\u201d that\u2019s already caused disasters in the private market (see this article about Harvard\u2019s experience<\/a> as an example. \u00a0The basic idea is this: sick people are expensive; healthy people are cheap. You need healthy people to keep costs down. Presumably many people with pre-existing conditions are going to flock to the new health exchanges, since it\u2019s their (our) only option to get insurance. But preexisting conditions like diabetes are expensive. If these \u201csick\u201d patients are not balanced out by healthy patients, then the health care plan\u2019s costs will rise beyond what its premiums can cover, which will make its premiums have to go up, which will make the remaining healthy people more likely to leave it, which leaves it with an even sicker population base, which makes its costs go up, which makes premiums go up, and on and on and on. (And as an interesting psychological side note, penalties for not having insurance will come off of your tax refund. But since most people think of any <\/em>tax refund as positive, having a slightly lower one is not going to feel as punitive as having to pony up new money out of your pocket. In fact, I\u2019d argue many people won\u2019t even notice it.)<\/p>\n

The issue of getting healthy people to join exchanges is extremely important. However, what\u2019s been lost from this debate is the effect on \u201csick\u201d people — those of us with diabetes and other chronic diseases or conditions that require access to particular specialists or higher cost treatment and medications. Many of us are quite likely to flock to the exchanges, under the belief that we\u2019ll finally be able to get group coverage at an affordable rate \u2013 that\u2019s one of the major selling points of the whole Affordable Care Act. But what\u2019s not <\/em>being discussed is what will happen if the new narrow networks don\u2019t actually cover the doctors and services we need. If that\u2019s the case, we may be left with two equally unappealing choices: either we opt out of buying insurance coverage, pay the penalty, and continue attempting to cover our enormous medical bills out of pocket, or we sign up for a plan through the exchange despite the fact that the network is so narrow \u2013 and then pay enormous medical bills out of pocket. As Adam Linker, a health policy analyst at the North Carolina Justice Center, warned the Times, \u201cunder some health plans, consumers can end up with astronomical costs if they go to providers outside the network.\u201d It\u2019s a heads-you-win, tails-I-lose kind of situation. But hey, at least in one option you\u2019ll have your flu shot covered.<\/p>\n

As for those of you with access to commercial insurance \u2013 whether it\u2019s through your employer or your spouse \u2013 don\u2019t rest too easy: as John Rother, the speaker I listened to yesterday described, employer-sponsored health insurance may not be long for this world. This isn\u2019t directly due to the Affordable Care Act (though ACA may well accelerate it); it\u2019s a trend that\u2019s been coming for years. But that doesn\u2019t mean it\u2019s not worrisome.<\/p>\n

As Rother explained, just as most employers have ditched traditional pensions in favor of contributing to accounts like 401ks, they will soon begin to ditch traditional healthcare plans in favor of simply providing employees with money to use on the exchanges. Again, that might be okay if the exchanges provide the option <\/em>of paying more money for a better plan. (Some of us really do need so-called \u201cCadillac plans\u201d!) But if there is no better option, if the only plans on the exchange are narrow networks of providers who have agreed to accept reimbursement rates that may be lower than their cost of doing business . . . it doesn\u2019t leave me feeling too optimistic about the future implications for my (and our) health.<\/p>\n

In his talk, John Rother suggested that the health exchanges will be a large improvement over the ill-fated HMO movement of the mid-1990s, the health managed organizations that made getting an appointment with anyone other than your designated primary care doctor an enormous pain in the ass. Supposedly, this improvement is due to the way that coverage will be decided: it will be \u201cevidence-based,\u201d rather than simply about cutting costs.<\/p>\n

But I\u2019m not convinced: in HMOs, doctors controlled access to which specialists a patient could get a referral to see. In the new narrow networks, the insurance company gods will limit your options via the network of covered providers. As for \u201cevidence-based medicine,\u201d it\u2019s a great concept (who doesn\u2019t like evidence?) but there\u2019s a problem: a treatment that might work for the aggregate might not work at all for you as an individual. (For example, my father has a fatal allergy to statins, but Medicare will not reimburse him for pharmaceutical levels of niacin pills because \u201cevidence\u201d and \u201cbig data\u201d show that statins are the most effective treatment for high cholesterol.) Science is only beginning to understand the genetic differences between people that affect their disease risk and the way they respond to certain drugs. These differences, which sometimes can be fatal, are not yet well enough understood to be captured in government or insurance company data. Indeed, \u201cevidence-based\u201d treatments for a population (the government\u2019s direction) and \u201cpersonalized medicine\u201d<\/a> (science\u2019s direction) are fundamentally incompatible.<\/p>\n

Lastly, the idea that \u201cbig data\u201d knows best ignores the fact that in cases like diabetes, patients themselves <\/em>are often the experts in the management of their disease. I know, for example, what approach to carbs works the best for me, and I\u2019ve worked to find a healthcare team that will support me. Yes, there are many situations \u2013 say, an emergency appendectomy \u2013 where certain treatment options work better than others in ways that big data readily reveals, and which the average patient would not know.\u00a0 But diabetes is often not one of them.<\/p>\n

There is no easy solution to any of this. Too many people are uninsured, good healthcare is expensive, and it is na\u00efve to think that health insurance companies could ever absorb the pre-existing-condition population without developing strategies to control their costs. But while I don\u2019t have the answer to America\u2019s health care crisis, I do know this: we are all slightly different, whether it\u2019s in how we interact with our doctors, or in how our bodies respond to particular drugs. Big data and \u201cevidence-based\u201d medicine do not reveal those nuances. \u201cNarrow networks\u201d are not going to pay for them. And that makes me scared.<\/p>\n

 <\/p>\n","protected":false},"excerpt":{"rendered":"

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She has written for publications including The Best American Science Catherine Price is a professional journalist who was diagnosed with Type 1 diabetes when she was 22 years old. Her work has been featured in publications including The Best American Science Writing, The New York Times, Popular Science, The Los Angeles Times, The San Francisco Chronicle, The Washington Post Magazine, Salon, Slate, Men\u2019s Journal, Health Magazine, The Oprah Magazine, and Outside, among others. 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