The Obama administration is seeking to clarify rules for the coverage of elective abortion in health insurance exchanges. That is the issue that almost scuttled the Affordable Care Act before it became law.

A complicated compromise that got the final few anti-abortion Democrats to agree to vote for the measure in 2010 required every exchange to include health plans that do not cover abortions except in the cases of rape, incest or a threat to the life of the pregnant woman. Plans that do offer abortion other than in those cases are required to segregate funds and bill for that abortion coverage separately.

But that did not happen, at least not in the first year of exchange coverage. Twenty-three states passed laws banning coverage of elective abortions in all the plans offered on the exchange. A Government Accountability Office report in September looked at the 27 remaining states and found that in five every plan covered elective abortions. And many failed to separately bill for the abortion coverage, as the law required.

Asked about the report in October, Health and Human Services Secretary Sylvia Burwell insisted that no money is being improperly spent.

“There are no federal funds being used for abortions except, as the law states, cases of rape or incest or questions of the life of the mother,” she said. With regard to the specifics of the GAO report, “it’s one where we believe we need to ensure the law is being enforced, and right now [the Centers for Medicare & Medicaid Services] is working on the ways we’re going to communicate with states and insurers.”

A huge proposed regulation issued last Friday that outlines health plan standards for 2016 seeks to make abortion coverage rules clearer.

The regulations, among other things, specify ways in which insurers can assess and collect separate payments for abortion coverage, which must total at least $1 per month.

But anti-abortion groups are complaining that the guidance in the new rules does little to address the bigger problem: It is still extremely difficult  for the average consumer to tell which plans include elective abortion coverage and which do not.

“It’s just not easy to find and it should be,” said Chuck Donovan, president of the Charlotte Lozier Institute, an anti-abortion research group.

“I know websites can be tricky,” he said. “But you can do these things with a checkmark and a box and I wish that they’d just come up with something simple two years ago as part of the upfront disclosure from the insurance companies.”

In an effort to make the information more widely available, the Lozier Institute has been doing the work itself, contacting individual insurance companies and their customers to discern which plans do and do not offer elective abortion. The resulting website, obamacareabortion.com, was unveiled last week in conjunction with the Family Research Council, another anti-abortion group.

Donovan said the project is still in progress because information has been difficult to find, even with direct calls and individual scouring of companies’ policy summaries. “They don’t always know” if abortion is covered, he said. In some cases, he said, “we’re finding contradictory information.”

But he insists that it’s imperative for consumers to know which plans cover abortion and which do not. “I’ve heard the argument that it stigmatizes the [abortion] coverage, but it’s kind of a settled thing that this is controversial,” he said. “I don’t think it does anything other than let people act in alignment with their conscience while we’re sorting out bigger issues.”

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

The Obama administration took another step to close what many see as a health-law loophole that allows large employers to offer medical plans without hospital coverage and bars their workers from subsidies to buy their own insurance.

“It has come to our attention that certain group health plan designs that provide no coverage of inpatient hospital services are being promoted,” the Department of Health and Human Services said in proposed rules issued late Friday.

Under the new standard, companies with at least 50 workers “must provide substantial coverage of both inpatient hospital services and physician services” to meet the Affordable Care Act’s threshold for a “minimum value” of coverage, the agency said.

As reported previously by Kaiser Health News, insurance analysts were surprised this summer to learn that HHS’ online calculator for determining minimum value approved plans without inpatient benefits.

Responding to aggressive marketing by consultants, numerous lower-wage employers had already agreed to offer the low-cost plans for 2015 or were considering them.

Because a calculator-approved plan at work makes employees ineligible for tax credits to buy more comprehensive insurance in the law’s online marketplaces, consumer advocates feared the problem would trap workers in substandard coverage.

Large employers aren’t required to offer the “essential health benefits” such as hospitalization, physician care and prescriptions that the law orders for plans sold to individuals and smaller employers.

But few expected the official calculator to approve insurance without inpatient benefits. Meeting the minimum-value standard spares employers from penalties of up to $3,120 per worker next year.

HHS also proposed granting temporary relief to employers that have already committed to calculator-approved plans without hospital coverage for 2015. It also would allow workers at those companies to receive tax credits in the marketplaces if they choose to buy insurance there instead.

For 2016, no large-employer plan will meet the minimum-value test without inpatient benefits, HHS proposes.

“A plan that excludes substantial coverage for inpatient hospital and physician services is not a health plan in any meaningful sense and is contrary to the purpose” of the minimum-value standard, the agency said.

“Minimum value is minimum value,” said Timothy Jost, a consumer advocate and Washington and Lee University law professor who welcomed the change. “Nobody ever imagined that minimum value would not include hospitalization services.”

As it said it would, Calculator-tested plans lacking inpatient coverage, designed by Key Benefit Administrators and others, have drawn strong interest from large retailers, restaurant chains, staffing companies and other lower-wage employers seeking to control costs, benefits consultants say. Typically the coverage costs half as much as major-medical insurance including hospital benefits.

Edward Lenz, senior counsel for the American Staffing Association, said the trade group has no problem with requiring hospitalization to meet the minimum-value standard for 2016. But it will seek more leeway for employers that had moved to implement plans without inpatient benefits for 2015.

“Many employers were well along the road” to committing to such plans but delayed signing contracts after Kaiser Health News reported that the administration might move against them, he said. Rather than punishing such companies for their caution, HHS should allow them to temporarily offer such coverage next year, he said.

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

Dr. Oliver Korshin is a 71-year-old ophthalmologist in Anchorage – and he is not happy about the federal government’s plan to have all physicians use electronic medical records or face a Medicare penalty. A few months ago when he applied for an exemption to the latest requirement, he had to pick a exemption category that fit.

“The only one that possibly applied to me was disaster,” Korshin says. “So I picked disaster and I described my disaster as old age and I submitted as my supporting document a copy of my passport.”

Korshin knew that argument probably wouldn’t work, but he still won’t make the switch. Starting next year, the federal government will penalize him – withholding 1 percent of his Medicare payments.

EHR,  ICD-10 and PQRS may sound like alphabet soup. But most doctors around the country know exactly what those acronyms stand for. They are programs championed by the federal government to improve quality and bring medicine into the electronic age. But in Alaska, where small medical practices and an aging physician workforce are common, the new requirements can be a heavy burden.

Korshin practices three days a week in the same small office in east Anchorage he’s had for three decades. Many of his patients have aged into their Medicare years right along with him.

Korshin has just one employee, a part-time nurse. And his lease runs out in four years, when he will be 75 and expects to retire.  He says for his tiny practice, an electronic medical records system would cost too much to set up and to maintain.

“No possible business model would endorse that kind of implementation in a practice situated like mine, it’s crazy,” he says.

Korshin will lose another 1.5 percent of his Medicare payments next year for failing to enroll in PQRS, a federal program that requires doctors to report quality data.  And then there is ICD-10, a new coding system for medical bills — also set to take effect the fall of 2015.

“This flurry of things one has to comply with,” Korshin says, “means that unless you work for a large organization like a hospital that can devote staff and time to dealing with these issues, there’s no economy of scale, I can’t share these expenses with anybody.”

Korshin is not alone, according to the Alaska State Medical Association. The association’s Executive Director Mike Haugen says half of the doctors in Alaska are over the age of 50 and very few are employed by large organizations.

“Most practices in Alaska are small practices,” Haugen says. “They’re one-, two- and three-doctor practices. The number of really large practices — and that’s relative in Alaska — you can probably count them on one hand.”

Haugen says he hears a lot of complaints from doctors who are feeling overwhelmed by the federal requirements. And he worries the burden is forcing many — especially older doctors, to consider retiring early.

“There won’t be some flashing neon sign we ever see that says ‘X number of doctors have left.’ It’s a very quiet process,” Haugen says. “That for me is the scary part, because you take a look at the medical association membership a year or two from now, and it may be smaller and access to care in this state is a real issue.”

But Rebecca Madison, executive director of Alaska eHealth Network, thinks a lot of doctors would decide to stay in practice if they had help with the transition to electronic health records.

Madison encounters a lot of resistance, but she tries to sell doctors on the benefits. She reminds them electronic records can make their offices more efficient and give them better data on patients. And it will make it easier when it comes time to sell their practices. Madison also sees the issue from the patients’ perspective:

“My whole goal and the reason I got into this process is to give the data to the patient,” she says. “They deserve to have it — it’s their data — they should be able to access it.”

This story is part of a partnership that includes APRN, NPR and Kaiser Health News.

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

You hear it so often it’s almost a cliché: The nation is facing a serious shortage of doctors, particularly doctors who practice primary care, in the coming years.

But is that really the case?

Many medical groups, led by the Association of American Medical Colleges, say there’s little doubt. “We think the shortage is going to be close to 130,000 in the next 10 to 12 years,” says Atul Grover, the group’s chief public policy officer.

But others, particularly health care economists, are less convinced. “Concerns that the nation faces a looming physician shortage, particularly in primary care specialties, are common,” wrote an expert panel of the Institute of Medicine (IOM) in a report on the financing of graduate medical education in July. “The committee did not find credible evidence to support such claims.”

Gail Wilensky, a health economist and co-chair of the IOM panel, says previous predictions of impending shortages “haven’t even been directionally correct sometimes. Which is we thought we were going into a surplus and we ended up in a shortage, or vice versa.”

Those warning of a shortage have a strong case. Not only are millions of Americans gaining coverage through the Affordable Care Act, but 10,000 baby boomers are becoming eligible for Medicare every day. And older people tend to have more medical needs.

“We know essentially with the doubling of the population over the age of 65 over the course of a couple of decades, they’re driving the demand for services,” says Grover.

In addition to a numerical shortage, there’s also a mismatch between what kind of doctors the nation is producing and the kind of doctors it needs, says Andrew Bazemore, a family physician with the Robert Graham Center, an independent project of the American Academy of Family Physicians.

“We do a lot of our training in the northeastern part of our country, and it’s not surprising that the largest ratio of physicians and other providers, in general, also appear in those areas,” says Bazemore. “We have shown again and again that where you train matters an awful lot to where you practice.” That ends up resulting in an oversupply in urban centers in the Northeast and an undersupply elsewhere.

Even aside from geography, there are other questions, he says, such as “do the providers reflect the populations they serve? And that means by their race and ethnicity, by their age, by their gender?”

While few dispute the idea that there will be a growing need for primary care in the coming years, it is not at all clear whether all those primary care services have to be provided by doctors.

“There are a lot of services that can be provided by a lot of people other than primary care doctors,” says Wilensky. That includes physician assistants, nurse practitioners, and even pharmacists and social workers.

“How many physicians we ‘need’ depends entirely on how the delivery system is organized,” Wilensky says. “What we allow other health care professionals to do; whether they are reimbursed in a reasonable way that will increase the interest in having people go into those professions.”

Currently, physicians who are specialists make considerably more than those who practice primary care, which many experts say is a huge deterrent to doctors becoming generalists, particularly when they have large medical school loans to pay off.

At the same time, “team-based care,” in which a physician oversees a group of health professionals, is considered by many to be not only more cost-effective, but also a way to lower the number of doctors the nation needs to train.

“All of the efforts to the future…are to mold and morph our medical system into one that is less ‘single-combat warriors’ practicing medicine here and there, and physicians and others practicing in efficient systems,” says Fitzhugh Mullan, a professor of medicine and health policy at George Washington University.

Until that happens, though, Atul Grover of the AAMC says the nation needs to be training far more physicians.

“We don’t think we should put patients at risk by saying ‘Let’s not train enough doctors just in case everything lines up perfectly and we don’t need them,’” Grover said in a recent appearance on C-SPAN.

Wilensky is among those who find that attitude wasteful. “Are you really serious?” she says. “You’re talking about somebody who is potentially 12 to 15 years post high school, to invest in a skill set that we’re not sure we’re going to need?”

And it’s not just the individuals who could be at risk for wasteful spending. “Training another doctor isn’t cheap,” says Mullan. “Isn’t cheap for the individual doing the training, isn’t cheap for the institution providing the education, and ultimately isn’t cheap for the health system. Because the more doctors we have, the more activity there will be.”

Princeton health economist Uwe Reinhardt points out that groups like the AAMC have a self-interest in saying there’s a shortage, to move more money towards the medical schools and hospitals it represents.

“Anything that would move money their way they would favor,” he says.

Reinhardt also says that a small shortage of physicians would probably be preferable to a surplus, because it would spur innovative ways to provide care.

“My view is whatever the physician supply is, the system will adjust. And cope with it,” he says. “And if it gets really tight, we will invent stuff to deal with it.”

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

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