06.30.15
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Supreme Court Reprieve Lets 10 Texas Abortion Clinics Stay Open For Now

Tuesday would have been the last day of operation for 10 Texas clinics that provide abortion. But on Monday the U.S. Supreme Court, in one of its final actions this session, said the clinics can remain open while clinic lawyers ask the Court for a full review of a strict abortion law. Two dozen states have passed regulations similar to the ones being fought over in Texas.

Two years ago, when Texas passed one of the toughest laws in the country regarding abortion, the number of clinics offering the procedure dropped from 41 to 19. Amy Hagstrom Miller, chief executive of Whole Woman’s Health, has already closed two clinics in Texas because of the law and was about to close two more.

“Honestly I just can’t stop smiling,” Hagstrom Miller said. “It’s been so much up and down … so much uncertainty for my team and the women that we serve.”

The Texas law says doctors who perform abortions must have admitting privileges at a nearby hospital. But some hospitals are reluctant to grant those privileges because of religious reasons or because abortion is so controversial.

The law also requires that clinics meet the same standards as outpatient surgery centers. Those upgrades can cost $1 million or more.

“It’s an example of the rash of laws … that have taken a sneaky approach by enacting regulations that pretend to be about health and safety but are actually designed to close down clinics,” said Nancy Northrup, chief executive of the Center for Reproductive Rights, which is representing clinics in their fight to overturn the Texas law.

Supporters of the law say every woman deserves good medical care whatever the procedure.

“While we hope that she would not be compelled to choose abortion, we hope that her life would of course not be at risk should she choose to do that,” said Emily Horne of Texas Right to Life. “Pro-life does not just mean care for the life of the unborn child, it’s care for the life of the woman undergoing the abortion as well.”

The law has had a drastic effect in Texas, the country’s second most populous state, leaving most of the remaining clinics in major cities.

There’s just one clinic left along the Mexican border and one in far west El Paso – they were among the nine about to shut down.

If they had closed, the women there faced roundtrips of 300 miles or more to get an abortion.

Hagstrom Miller says all these clinic rules and the doctor restrictions are a deliberate strategy waged by anti-abortion groups. “They’re going state by state by state,” she said. “They can’t make it illegal, so they’re basically making it completely inaccessible.”

Other states that have passed similar laws are also facing legal challenges.

Emily Horne, of Texas Right to Life, says her group would welcome a legal review by the U.S. Supreme Court.

“With this case, issuing some more guidance on that could be very helpful for the pro-life movement in determining what courses to pursue, which laws they might pass in other states in the future.”

The clinics in Texas can stay open at least until the fall. If the court decides to take the case, it would hear arguments in its next term that starts in October.

This story is part of a reporting partnership that includes Houston Public Media, 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.

06.30.15
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Your Colonoscopy Is Covered, But Surprise! The Prep Kit May Not Be

With summer vacations coming up, one reader this week asked about travel insurance, while others had questions about coverage of preventive services, including costs related to colonoscopies.

Q. We know now that anesthesia for a screening colonoscopy is covered with no cost sharing  as a preventive service under the health law. As a plan administrator, I am also struggling to find guidance on how to handle bowel prep kits for colonoscopies. Can you help?

A. Without some sort of bowel cleansing preparation–often a powerful laxative that scours out the colon–the exam, which involves inserting a flexible tube with a camera on the end into the rectum and snaking it through the large intestine to look for polyps and other abnormalities, couldn’t be done. When the federal government clarified last month that under the health law’s preventive services provisions consumers can’t be charged for anesthesia they receive as part of a screening colonoscopy, it didn’t address other services that are generally part of the exam, including bowel prep kits.

“The federal coverage mandate doesn’t include any ancillary services,” including bowel prep kits or even the pre-screen consults that can cost as much as $250, says Citseko Staples-Miller, senior specialist for state and local campaigns for the American Cancer Society Cancer Action Network. Some states may impose additional coverage requirements on insured plans. But aside from anesthesia, plans can generally decide for themselves under federal law whether to cover such services without cost sharing.

Q. Why should I buy travel insurance if it won’t cover pre-existing medical conditions? That’s exactly what I’d probably need it for.

A. It’s often easy to get that coverage if you need it. Most comprehensive travel insurance policies cover pre-existing conditions if you buy coverage within 14 to 21 days of making your first trip payment, says Lynne Peters, insurance product manager at insuremytrip.com, a website that offers plans from 25 companies.

Even if you miss that window, as long as you haven’t recently needed medical attention for your diabetes or bad back, for example, you may not run into trouble.

“Most policies have relatively short ‘lookback’ periods,” Peters says. That means that if you file a claim, the insurer will only review your medical records for pre-existing conditions for a specified period before your policy’s effective date, typically 60 to 180 days. As long as you haven’t received any medical treatment, testing, medication changes or recommendations from a physician related to your pre-existing condition during that timeframe, the claim wouldn’t be denied on that basis, Peters says.

Q. With too many children affected by prenatal exposure to illicit drugs, alcohol or tobacco, why doesn’t the federal government include prenatal screening in its list of preventive services that must be covered without cost sharing?

A. It’s standard practice to screen pregnant women for alcohol, tobacco and illicit drug use and intimate partner violence during their initial visit with an obstetrician/gynecologist, says Dr. Lisa Hollier, an obstetrician/gynecologist at the Center for Children and Women in Houston who is assistant secretary of the executive board of the American Congress Of Obstetricians And Gynecologists.

Screening involves asking a series of questions about substance use. It doesn’t involve urine or other tests that might discourage women from getting appropriate prenatal care because they fear running into legal problems, according to ACOG. 

In addition, the health law requires most plans to cover preventive services recommended by the U.S. Preventive Services Task Force without requiring consumers to pay anything out of pocket. The task force recommends that tobacco and alcohol screening be performed and counseling provided if necessary for pregnant women. It concludes that there’s not enough evidence to assess whether screening pregnant women for illicit drug use is clinically useful.

As a practical matter, the task force’s lack of endorsement for drug screening for pregnant women doesn’t mean plans won’t cover it.

While screening isn’t generally a concern, treatment can be.

“There are not many professionals who have specific expertise in managing these problems with pregnant patients,” Hollier says.

Please contact Kaiser Health News to send comments or ideas for future topics for the Insuring Your Health column.

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

06.29.15
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The ACA Survives for Now, But We Still Don’t Have Real Healthcare Reform

Perhaps the best window to the top winners in the Supreme Court ruling on the Affordable Care Act could be seen 200 miles up the road, on Wall Street.

Within minutes of the decision, health care industry stocks were soaring, led by hospital and insurance corporations.

HCA, the biggest U.S. hospital chain, stock immediately jumped 9 percent.  Stock for another giant for-profit hospital chain Tenet Healthcare rose 6 percent. Health insurance stocks were also booming for corporate giants Aetna, Cigna, and Anthem.

The bubbly reaction by the traders was a punctuation mark for the most quoted phrase from Chief Justice John Roberts’ 6-3 majority decision, “Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them.”

The Court ruling does provide a reprieve for several million low and moderate-income people who depend on federal tax subsidies to buy private health insurance, as now required by the ACA.

Yet, as Roberts signaled, the decision is ultimately a reminder that the ACA, based on a model developed by corporate think tanks and a Massachusetts law enacted under former Republican governor Mitt Romney, has served first and foremost to further cement and expand the insurance-based private healthcare system in the U.S.

Following passage of the ACA, healthcare industry profits, which dipped during the 2008 Wall Street collapse, have soared to record levels.

The ACA mandated millions of new customers for the private insurance companies. With its financial incentives for electronic health records, the law encouraged a huge windfall for information technology firms. Added payments for drugs, and the refusal to allow the federal government to negotiate bulk discount rates from the pharmaceutical giants, encouraged accelerated drug profits.

And big hospital chains are also back making record profits, with the assist of more payments from insurers and the failure to set any real limits on hospital price gouging. In fact, the ACA encourages corporate consolidation that drives up prices.

Those are all the “markets” Chief Justice Roberts so adroitly noted the Act was intended to improve.

But in daily practice, the world nurses see every day at the bedside, the picture is decidedly mixed.

With its limits on disgraceful insurance restrictions, the ACA has certainly helped patients and families who were shut out by insurers for pre-existing conditions, dropped when they got sick, or financially devastated by caps on coverage.

Yet un-payable medical bills remain the leading cause of personal bankruptcy as the law’s failure to set meaningful cost controls still leaves far too many patients with bills they can not pay, or choosing to skip needed medical care because of the high cost.

In a comprehensive analysis on the eve of the Court ruling in Harpers magazine, Columbia Journalism Review contributing editor Trudy Lieberman aptly deconstructs “the failed promise of the Affordable Care Act.”

At the center of this huge shortfall is what Lieberman calls the “Great Cost Shift” – how the law promotes “the transfer of the growing price of medical care to patients themselves through high deductibles, coinsurance, copayments, and limited provider networks,” especially by encouraging employers to offer scaled back or skeletal health coverage.

For patients sent into the ACA’s health exchanges, whether the state or federal versions, average deductibles, even in the least expensive bronze policies, are a whopping #5,181 for individuals and $10,545 for families.

Even for families on limited incomes who will, as a result of the Court ruling, still get the federal subsidies to buy the health plans in the first place, that math is daunting – one reason, Lieberman quotes an analyst noting we’re replacing the crisis of un-insurance with underinsurance, and a reason from a fourth to a third of people who signed up on the federal or state exchanges the first year have declined to renew.

The key point here, as Lieberman emphasizes, is the conservative ideological framework of market-based medical care, which undergirds the ACA. Without effective controls on profiteering and price gouging, the ACA and market solution for cost controls is, as one of her health policy experts Jonathan Oberlander of the University of North Carolina notes, “making sick people pay more.”

Ultimately, it means the ACA has helped a number of people get into a system that previously shut them out, but it has not come close to solving our long healthcare nightmare. And, by its structure, it never will.

America’s nurses have long campaigned for genuine, comprehensive health care reform, the fundamental idea, as most other industrialized countries have long held, that everyone should be guaranteed access to a single standard of safe therapeutic care.

Until we have a humane healthcare system in place that is not based on ability to pay, age, gender, ethnicity, or where you live, healthcare will continue to be a privilege, oriented to profits, not based on patient need.

That is precisely why nurses are continuing to campaign for expanding and updating Medicare to cover everyone.

July 30 marks the 50th anniversary of the enactment of Medicare, achieved against the considerable opposition of the healthcare industry (including one of their leading spokesmen, an actor named Ronald Reagan).

National Nurses United will be joining with labor, community, and healthcare activists across the country in events across the U.S., to mark the occasion, and remind us of the need to continue fighting for the real solution for healthcare reform. To join the actions, look for details at http://www.medicareturns50.org.

06.29.15
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High Court’s Decision On Same Sex Marriage Expected To Boost Health Coverage Among Gay Couples

The right to marry in any state won’t be the only gain for gay couples from last week’s Supreme Court ruling. The decision will probably boost health insurance among gay couples as same-sex spouses get access to employer plans, say analysts and benefits consultants.

How much is unclear, but “it’s going to increase coverage” in a community that has often had trouble getting access to medical services, said Jennifer Kates, a vice president at the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

The logic is simple. Fewer than half of employers that offer health benefits make the insurance available to same-sex partners who aren’t married. Virtually all of them offer coverage to spouses.

By marrying partners with employer health plans, people in same-sex relationships are likely to get coverage in states that banned gay marriage until now as well as in those that welcomed it. Thanks to rapidly shifting legal ground, 37 states recognized gay marriage before last week’s ruling, up from nine in 2012.

New York legalized gay marriage in 2011. The next year there was a big increase in same-sex couples covered by employer-sponsored health insurance, according to a study published Friday by the Journal of the American Medical Association.

Although the court found a constitutional right to same-sex marriage, lawyers gave mixed messages on whether employers must now offer health insurance to same-sex spouses if they offer it to opposite-sex spouses.

Edward Fensholt, a benefits lawyer with brokers Lockton Companies, expects most companies to cover same-sex spouses if they already offer benefits to opposite-sex spouses. But the decision does not require them to, he said.

“Employers get confused about this,” he said. “They’ll see that ruling and they’ll start to think they have to offer coverage to same-sex spouses.”

But Lambda Legal, which advocates for gay rights, said employers refusing to offer health insurance to all married couples would violate federal law prohibiting sex discrimination.

“You should be able to add your [same-sex] spouse to your health insurance,” Lamba Legal and other civil rights groups wrote in an online FAQ.

The court ruling, “coupled with existing federal protections, would set up a strong case that employers could not discriminate,” Kates said.

Also, state laws may require equal benefits for same-sex spouses.

Big companies also like the simplification the ruling brings to their human resources departments.

“We’re relieved because this basically means you won’t have to do a state-by-state analysis” of how the law applies to same-sex couples, said Gretchen Young, senior vice president of health policy at the ERISA Industry Committee, which represents very large employers. “We always want uniform treatment.”

Weirdly, a constitutional right to same-sex marriage may harm some same-sex couples: those with domestic-partner benefits who don’t want to get married.

Last year Verizon told same-sex partners in states where gay marriage is legal they had to wed if they wanted to qualify for benefits. Now that the high court has placed same-sex and opposite-sex marriage on the same level, other companies are likely to follow, say benefits specialists.

“We would certainly expect to see a falloff in domestic partner benefits,” said J.D. Piro, a health benefits lawyer with Aon Hewitt, a consulting firm. “Given the decision, employers might want to be asking, do we still need to do that?”

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

06.26.15
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ACA Ruling, June 2015

The Pennsylvania State Nurses Association (PSNA) applauds today’s U.S. Supreme Court’s ruling to uphold the Affordable Care Act (ACA) by preserving tax credit subsidies that have allowed more than 10 million Americans to obtain health insurance coverage.

The number of adults without health insurance dropped to its lowest level in seven years in 2014 as the ACA took full effect. Without the tax credits, many people would have been unable to obtain health insurance, thus limiting their access to routine preventive care and causing insurance costs to rise.

“It remains PSNA’s goal to explore legislative avenues to increase access to quality, affordable health care which results in better patient outcomes,” states PSNA Chief Executive Officer Betsy M. Snook, MEd, BSN, RN. “We laud the work of ANA and continue to stand with our patients as we ensure that every citizen of the Commonwealth receives the health care they need and deserve.”

In conjunction with the American Nurses Association (ANA), PSNA has been a steadfast supporter of the 2010 health care reform law and its provisions to expand access to health care; protect consumers; improve the quality of care; emphasize primary care, care coordination, disease management, and prevention; increase community-based care; and utilize nurses to their fullest capabilities as leaders and essential members of multi-disciplinary health care teams.

In May of this year, Governor Wolf invited PSNA and other stakeholders to take part in a discussion surrounding State-based exchanges should this ruling have gone against the ACA Act. PSNA thanks Governor Wolf for the inclusion of registered nurses throughout this discussion and we look forward to continued health care-related conversations.

06.26.15
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Judge Strikes California Law That Allowed Nursing Homes To Make Medical Decisions For Mentally Incompetent Residents

A California law allowing nursing homes to make medical decisions on behalf of certain mentally incompetent residents is unconstitutional, a state court ruled this week.

The law, which has been in effect more than 20 years, gave nursing homes authority to decide residents’ medical treatment if a doctor determined they were unable to do so and they had no one to represent them.

Alameda County Superior Court Judge Evelio M. Grillo wrote in the June 24 decision that the law violates patients’ due process rights because it doesn’t require nursing homes to notify patients they have been deemed incapacitated or to give them the chance to object.

Grillo acknowledged the decision is likely to “create problems” in how nursing home operate but wrote that patients’ rights are more compelling.

“The stakes are simply too high to hold otherwise,” the judge wrote. Any error could deprive patients of their rights to make medical decisions that “may result in significant consequences, including death.”

The fact that nursing homes are making end-of-life decisions without patient input is a big concern, according to the ruling. The decision cited one nursing home resident who was found to be mentally incapacitated and who had no representative. The facility staff made a decision to take him off life-sustaining treatment and he passed away in 2013.

The ruling came after the California Advocates for Nursing Home Reform, an advocacy group, filed a lawsuit in 2013 against the state Department of Public Health. The suit alleged that nursing homes used the law to administer anti-psychotic drugs, place residents in physical restraints and deny patients life-sustaining treatment.

Tony Chicotel, a staff attorney for the group, said the ruling will dramatically impact the lives of the most vulnerable nursing home residents.

“What [nursing homes] used to do was routinely make decisions big and small for their residents without really any regard to due process,” Chicotel said. “Now the residents are finally going to have their rights acknowledged and honored.”

Even patients who are compromised should still have a say in their medical care, he added.

“They have been ignored,” he said. “Unrepresented residents and the way they are treated in nursing homes has never been a priority of the Department of Public Health.”

The department is reviewing the decision, a spokesman said. Department officials declined to comment further or say whether they planned to appeal.

The law was enacted in 1992 because nursing facilities needed a way to give medical treatment to their incapacitated residents without having to wait up to six months for state approval, according to the ruling.

But the decision could make it challenging for nursing homes to provide routine medical care or to offer hospice care to residents who lack the mental capacity to make their own decisions and have no designated representatives, said Mark Reagan, an attorney representing the trade group, California Association of Health Facilities, which is not part of the lawsuit.

“If the person objects, then what?” Reagan said. “That can put patients and facilities in a difficult place.”

And seeking court approval to provide anti-psychotic medication to residents who truly need it would be costly and time-consuming for nursing facilities, he said. “How do you keep that person safe and how do you keep the other residents of the skilled nursing facility safe?” he said.

Reagan believes the ruling could have an unanticipated outcome: Patients without decision-makers could have a hard time finding a nursing facility willing to take them.

“If this decision makes it more difficult to supply necessary care at the bedside, this population is going to be less served,” he said.

The judge, however, wrote that informing patients and allowing them to object is not likely to result in any significant burdens on nursing homes.

agorman@kff.org

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