With the new Healthcare.gov beginning this year, we decided to focus on the new Independent Patient and what shopping on a healthcare marketplace will mean for all our care from primary to urgent.
Meet Two Experts in the field who we think will help us get up to speed. They both advocate for a marketplace but with different voices. And they both believe in the patient being smart enough to manage their care.
Chief Marketing Officer, Network Health
Health care is a market. It's not a well-functioning market, but Americans should understand that they're paying the bill and start demanding things like price transparency, rational pricing, value for their money, convenience, and getting a doctors appointment outside of 10-3. How about staying open until 7:00? How about publishing your price list?
Interview by Heidi Legg
What are you trying to do?
I have two desks. I run marketing for a health plan, and at that desk the most important thing I'm focused on is this transition from the Massachusetts Health Care Reform experience to the Affordable Care Act.
My other desk is as an Eisenhower Fellow. I was awarded this fellowship to go overseas and study health care programs in other countries where exchanges work.
The Eisenhower Fellowship is a program that sends mid-career leaders who've achieved something but have room to still do more overseas to gain a new perspective, to meet new people, and to see how other parts of the world handle the thing the fellow is interested in. I went to Australia, New Zealand, and Singapore to study how these high-performing health systems leverage the consumer in that success. My Eisenhower Fellow desk is covered with notes, ideas, and business cards from these travels. What I did see that we could deploy here to really improve how our health care system works? Despite the political view that the US has the best health care system in the world, I really think anyone who knows where the data is understands that that's fundamentally not true.
What is true?
We pay the most of any country in the world, and as we have talked about - we have forty five million people who go uncovered.
When I was in Australia, they looked at me and almost accusingly said, 'how can you people do that?' They would say their system is better because while it's not perfect, at least they don't leave people out in the cold. Morally they couldn't get behind our way, and no one could call Australia a socialist country.
I had many conversations on a very consistent theme which was something like, 'what is all the fuss about Obamacare anyway? It doesn't even solve your whole problem.' When we talk about forty five million people being uncovered in the US, Obamacare only really attempts to close that gap.
Expectations will be that with the ACA, if it works, we will only cover maybe twenty to thirty million people over the next five years. That still leaves fifteen to twenty million people uncovered.
By 2019, we expect something like twenty eight million people to buy insurance on an exchange, and so between the Medicaid expansion and the exchanges, you would only make small strides to close the gap.
Fast Facts from Debbie:
- The 1099HC is the magic card, because your health care company will send you this for tax filing. Without it, the government will know you are not insured. Starting January 1st, 2014 you will be penalized up to $290 per month
- If you lose your job, you lose your coverage. The figure we often hear is 44 million Americans not having health insurance at one moment in time.
- 10-15% of all Americans are not covered.
- 17 % of Americans thought the Affordable Care Act (ACA) would benefit them, while a larger group thought it would not help them or were not sure if it would help.
There are two main categories of people who will go to the exchange. One is the group just above the Medicaid level. And the second group is people who might be higher income earners but simply don't have access to group insurance: a solo practitioner, a freelancer, a lawyer who might earn enough money to buy insurance, but they don't have an employer providing them that choice.
This second group can now go buy their benefits on an exchange, like what Kayak and Expedia have done for travel. That's what the exchange should do for health insurance. It puts all the options together on a virtual shelf, exposes the pricing, exposes the benefits, and creates an actual shopping experience.
Historically, a broker is not going to call on you as an individual, because you're just unlikely to be worth their time. Brokers serve groups. Instead you’re doing your own research and you're piecing together your options, and now what you have is a much more streamlined place to go to find your options. In Massachusetts, we have ten carriers selling individual and small group plans on the exchange.
What public opinion do you hope to change?
I would like to change the opinion that consumers are helpless and that health care can't be a market. Health care is a market. It's not a well-functioning market, but Americans should understand that they're paying the bill and start demanding things like price transparency, rational pricing, value for their money, convenience, and getting a doctors appointment outside of 10-3. How about staying open until 7:00? How about publishing your price list?
In Australia, one of the things I saw was that they're implementing something called Informed Financial Consent. Before you go get a procedure in Australia, you now get an estimate, and you have to sign saying you understand what you've been given.
It sounds more expensive.
There's a whole movement, a whole set of health care delivery reforms, that's happening alongside of this. There’s a company on the West Coast, based in Seattle, that has taken primary care out of the insurance system, and they have a membership model. You pay forty or sixty or twenty bucks a month, and you can have unlimited access to your primary care doctor. That is new. That is innovative.
What about those who can't afford to pay for services?
Their idea in Seattle is that it's like concierge medicine for the masses. It's pretty affordable. The fundamental fact is that everywhere you look in health care, things need to change.
How is the new exchange addressing poverty?
People who are low income can have penalties waived. There are a number of circumstances that would qualify. For example:
- If the lowest-priced coverage available would cost more than 8% of household income
- If you don't file taxes because your income is too low. Given the mechanism for the penalties is through the income tax system when you file a '1099 HC', you document your health coverage and if you have had more than 3 months uninsured you're exposed to the penalty in the form of tax liabilities. Therefore, if someone is too poor to file taxes, they would not be expected to pay the penalty.
My understanding is that people can get hardship waivers if they are homeless, have been evicted or face foreclosure, have filed for bankruptcy in the past 6 months, or have had medical expenses they couldn't pay in the last 24 months.
On the Massachusetts exchange, which remember we’ve had for a while, we've had a subsidized program for people who earn between zero and 300% of the federal poverty level, and the zero to 100% are people who don't qualify for Medicaid. Medicaid, historically, has not just had income level requirements, but if you're a child, you qualify for Medicaid at zero to 100%. If you are a caregiver, you qualify. If you're disabled, you qualify. But if you're an able-bodied, single, adult male who earns anywhere from zero to 100% of the federal poverty level, you typically did not qualify for Medicaid.
Massachusetts addressed that issue and said for adults who don't have access to insurance, we're going to cover them. We're going to expand Medicaid and create this new program for people who just don't have access otherwise, but who are still very low income and very vulnerable from a financial perspective. We have had Commonwealth Care since 2006 and we've covered something like 250,000 people this way.
What are you fixing?
I am working to build tools that help consumers make good decisions. You're putting millions of people into the position to shop for health insurance, and they haven't done it before because employers have curated the choices for them. I'm writing about it and trying to influence any aspect of the system, because I fundamentally believe that American consumers will drive change. In other consumer markets, having purchasing power has led to product and service innovation, and I believe we can lower the costs.
We can push to find out what doctors charge. What do drug companies charge? What do biotechs and device companies charge? What do health plans add? What do brokers add? This is an equation. It's a very long, complex, layered equation of cost. My argument is that consumers are becoming more and more the end of that chain, right?
I want to empower consumers to make demands. I believe that through consumer empowerment and demand, we can push for reform that needs to happen up and down the system.
This is hard stuff because there are entrenched interests in every aspect of this system. When we say we will reduce costs we are not talking about somebody's revenue, we are talking about somebody's income. It's not easy for the people who earn their living on the current system to give that up. The only way it’s going to happen is through external pressure, and the best source that we have yet to fully tap in this country, in my opinion, is the consumer.
In Singapore, for example, the government says this is what we're willing to pay. If you want to charge more, you have that conversation with the consumer, and the consumer can decide if they are going to pay it or not.
In Australia, a woman told me a story about her dad who would negotiate with his doctor and say, 'well, my buddy down the road just got his hip replaced for this much money and you're charging me that much more. What gives?' In Australia, they’ll just negotiate. That's one way to do it. In Singapore, they won't set a price. They'll simply set a government reimbursement amount. It's a free market.
In the US, we're not comfortable with those kind of measures. We're fighting over markets. The Republicans shut down the government because the federal government had put in place markets. Just pause on that for a minute. We're kind of in a Twilight Zone when that's happening. So, we're certainly not going to set prices or anything that's like setting prices. We're not going to have government-controlled prices. We're not going to use the government levers for price controls in America. What do we do in America? We consume. We're shoppers. We love markets. We love buying things. We love product innovation. We love competition.
Where do you get your NEWS?
I use Twitter the most. It's kind of like email. I get hundreds of emails a day and I can only read the line that shows up on my phone in the preview pane. If I don't get the gist from the preview pane, I probably will miss the point.
Twitter to me is like the preview pane on my email box. I get the gist, I get the headline, and I understand what's going on. When I have a minute, I can dig in.
Who do you follow?
I follow NPR and BUR. I also like the overseas news.
I think Central Square is a little overlooked and a friend of mine started a group, Vision Central Square, to raise the profile of Central Square.