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“After Supreme Court Ruling on the Health Care Law, Focus Turns to the States … and November,” Larry Levitt’s June 2012 post for The JAMA Forum, is now online.
This brief describes the oral health of Medicare beneficiaries, examines sources of dental coverage for the Medicare population, and examines the utilization of dental services, out-of-pocket spending on dental care, and access problems. This analysis uses data from the National Health and Nutrition Examination Survey (NHANES), the Medicare Current Beneficiary Survey Cost and Use file (MCBS), the National Health Interview Survey (NHIS) and the Kaiser Family Foundation Survey of Health Care Among Nonelderly People with Disabilities and Seniors on Medicare, 2008.
Issue Brief (.pdf)
This policy brief provides data and analysis of coverage and access to oral health care for low-income nonelderly adults. Lack of resources to pay for dental services, either through dental insurance or out-of-pocket, is a major barrier to oral health care for many low-income Americans. The problem is particularly acute for low-income adults, who are more likely to be uninsured than low-income children.
Issue Brief (.pdf)
If the Supreme Court acts within the next couple of weeks to overturn the individual mandate in the Affordable Care Act (ACA) while leaving the rest of the law intact, expect to hear a lot about how the individual insurance market will be destined for a “death spiral.”
When compared with implementing the ACA in full as planned, there’s a consensus that eliminating the mandate would increase premiums and mean that far fewer of the currently uninsured would become covered. But, it is by no means inevitable that the individual insurance market will enter a spiral of death. In fact, there are some good reasons to believe that may not happen.
What is a death spiral and why do some people believe it could happen?
If the individual mandate were overturned by the court with the rest of the ACA untouched, we would be left with an individual insurance market beginning in 2014 where everyone would be guaranteed access to insurance, even if they have pre-existing health conditions requiring expensive medical care. Insurers could not turn people down based on health status, restrict their coverage, or surcharge their premiums. People who are healthy could choose to forego insurance, knowing that they could start buying it if they get sick (although they’d have to wait until the next open enrollment period).
It’s pretty clear that in a system like that, sicker people would be more likely to buy insurance, and premiums would rise as a result. This is known as “adverse selection.” As premiums rise, insurance would look like even less of a good deal for people who are healthy, leading some of them to drop coverage and forcing premiums even higher. And so on. A mandate can prevent such a spiral by requiring that healthy people buy insurance, even if they don’t perceive it to be in their financial interest.
States that have implemented insurance market reforms without an individual mandate – such as New York, New Jersey, and Washington – have seen premiums rise substantially and coverage in the individual market fall. Whether or not the insurance markets in these states have truly spiraled out of control is probably of more semantic interest than anything else. There’s no question premiums rose quite significantly for the average person shopping for coverage.
So, why would invalidating the individual mandate not lead inevitably to a death spiral under the ACA? Two reasons:
First, and most importantly, the ACA includes federal tax credits to make insurance more affordable for people buying on their own in the new health insurance exchanges. This means that for many people, health insurance will be a very good deal, even if they are healthy. The primary reason that people remain uninsured is because they believe they cannot afford to buy insurance, and the subsidies address that directly. Our analysis of Congressional Budget Office (CBO) estimates suggests that over half of people in the individual insurance market beginning in 2014 will be receiving a tax credit towards their premiums.
An example might illustrate this best, using our subsidy calculator:
Consider a healthy 30-year old with an income of 225% of the poverty level (expected to be a little under $26,000 in 2014). Under the ACA, she could face an estimated unsubsidized annual premium of $3,440 for a silver plan. But, she would be eligible for government tax credit of $1,583, leaving her to pay just $1,857. Because her premium cost has been lowered by 46%, there’s a good chance she would choose to buy coverage even if not required to do so.
These subsidies – totaling over $50 billion a year by 2017, according to CBO estimates – won’t eliminate the potential for adverse selection and higher premiums. That’s in part due to the fact that they phase out as income rises, disappearing entirely for people with incomes over four times the poverty level. But they should mitigate it enough to avoid a full on death spiral.
Second, the ACA allows significant variation in premiums due to age. Young people generally have less need for health care services, and they will pay lower than average premiums as a result. This was not true under insurance reforms in New York and (originally) in New Jersey, where insurers were required to charge “pure” community rates, meaning the same premium to everyone, irrespective of age. Predictably, younger people fled the market and older people remained. This should not generally happen under the ACA. (Note that the ACA does limit the variation in premiums due to age, requiring an insurer to charge its oldest enrollee no more than three times the premium for its youngest enrollee for equivalent coverage. In the current market, age-based premiums can vary by a factor of five to one or more. This could lead to some adverse selection based on age, but the effect should be relatively modest because there will still be significant variation in premiums allowed for age.)
There’s tremendous uncertainty involved in how predicting how individuals would react to a complex combination of guaranteed access to insurance, limited age rating, premium tax credits, and no requirement to buy insurance. And not surprisingly, there are a wide range of estimates of what it would mean for premiums and the number of people who gain insurance under the health reform law. CBO’s estimate is instructive, in part because it’s roughly in the middle of the range of projections produced by think tanks and consulting firms, but also because it carries far more weight than others in federal policy debates.
CBO estimates that 16 million fewer people would gain insurance under the ACA without an individual mandate, cutting the reduction in the number of Americans uninsured as a result of the law roughly in half. CBO estimates that premiums in the individual insurance market would be 15-20% higher than if the ACA were implemented in full. A 15-20% increase is non-trivial. But few would consider it to be a death spiral. And, it’s not uncommon to see insurers increase premiums by that magnitude in any given year. In fact, it was a 39% premium increase imposed by Anthem Blue Cross in 2010 on some enrollees in California that may have helped galvanize political support for the ACA.
It’s also important to keep in mind that CBO’s estimate reflects their projection of how much premiums will rise on average if there is no individual mandate, based on changes in the mix of people who buy insurance by health status and age. But, because insurers are permitted to vary premiums by age under the ACA, this average premium increase overstates how much more someone at any given age would pay without a mandate. For example, RAND estimates that average premiums without a mandate would rise by 9.3%, but the premium for any given individual would be just 2.4% higher than if the ACA were implemented in full because of the effects of age rating.
No one, of course, knows yet what the Supreme Court will do. Or, more precisely, the few people who do know aren’t talking. If the court invalidates the individual mandate, it may also invalidate the insurance market reforms as inextricably linked, rendering any fears of a death spiral entirely moot (though also rendering the individual insurance market inaccessible to people with pre-existing health conditions). But even if the mandate alone goes, the consequences may not be as dire as some will undoubtedly claim. And, in addition to the subsidies and age-based premiums already included in the ACA, there are other mechanisms being discussed that the federal government and states could pursue to even out the risk pool in the absence of a mandate (which we plan to address in a future post).
A new nationally representative survey of 500 health insurance agents and brokers working in the individual and small group markets by the Kaiser Family Foundation explores their outlook on market trends and views on the Affordable Care Act (ACA). The survey finds that many agents are seeing steep increases in premiums and deductibles for individuals and small businesses purchasing health insurance. When asked to estimate what they expect to be the typical premium increase in 2012 based on what they have heard from insurers, four in ten agents (39 percent) say they expect premiums to increase between 11% and 20% and another third (33 percent) expect them to increase between 6% and 10%. Deductibles are also increasing: about half of agents (51 percent) report that currently, the most common deductible amount for single coverage plans is $2,000 or more, compared to one in five who say deductibles were in this range two years ago.
HIV Testing Events at Select Walgreens Locations in 20 CitiesBetween June 27-29, from 3 p.m. to 7 p.m. DailyWalgreens, the nation’s largest pharmacy chain, and Greater Than AIDS, a coalition of public and private sector partners united in response to the domestic epidemic, are teaming with health departments and local AIDS organizations to provide FREE HIV testing at 47 Walgreens stores in 20 cities across the nation in June in support of National HIV Testing Day (June 27). An additional 138 Walgreens stores in the participating communities will help publicize the free testing through in-store messaging, including posters, post cards and in-store audio. Walgreens will help promote National HIV Testing Day with special messages on June 27 on its Times Square digital display, the largest billboard of its kind in the country.
More than 50 state and local health departments and AIDS service organizations are coordinating the testing and providing results on site at participating Walgreens locations, as well as supporting outreach. Free HIV tests will be available June 27-29 from 3 p.m. to 7 p.m. at select Walgreens locations in Atlanta, Baltimore, Chicago, Dallas, Denver, Detroit, Ft. Lauderdale, Houston, Indianapolis, Los Angeles, Miami, New Orleans, New York City, Oakland, Philadelphia, San Francisco, St. Louis, Washington, D.C. and West Palm Beach.
This marks the second year in a row Walgreens has teamed with Greater Than AIDS and local organizations to bring free HIV testing to communities with more than twice the number of stores and markets participating in 2012 than last year. The U.S. Centers for Disease Control and Prevention’s (CDC) Act Against AIDS initiative and the National Association of People Living with HIV/AIDS, the official sponsor of National HIV Testing Day, also are supporting the effort.
“These testing events provide valuable and vital opportunities to help the communities we serve,” said Glen Pietrandoni, Walgreens senior manager of HIV/AIDS and Hepatitis. “Walgreens has supported people living with HIV/AIDS since the beginning of the epidemic through its ability to offer accessible pharmacy, health and wellness guidance to patients, wherever they live. Our pharmacists are developing relationships, listening to concerns and providing education and support.”
“Greater Than AIDS is about communities working together to achieve a greater goal. This is a powerful example of what can be achieved when the public and private sector come together in response to HIV/AIDS,” said Tina Hoff, Senior Vice President and Director, Health Communication and Media Partnerships, Kaiser Family Foundation, a founding partner of Greater Than AIDS.
Of the more than 1.2 million people living with HIV in the U.S. today, an estimated one in five, or nearly a quarter of a million people, do not know it. One third of those who are positive are diagnosed so late in the course of their infection they develop AIDS within one year. Early diagnosis and treatment saves lives and is known to reduce the spread of HIV. The CDC encourages everyone to know their status.
“CDC supports testing as one of the most powerful HIV prevention tools we have. It is the pivotal first step in linking people to treatment, care and prevention services,” said Jonathan Mermin, M.D., director of CDC’s Division of HIV/AIDS Prevention. “CDC recommends all adults and adolescents be tested for HIV at least once as a routine part of health care and that those at increased risk—including gay and bisexual men, injection drug users, or persons with multiple sexual partners—be tested at least annually. Testing makes a difference.”
Throughout the year, Walgreens and Greater Than AIDS distribute HIV informational resources and services at more than 550 Walgreens pharmacies in heavily affected communities. Designated by Walgreens as “Centers of Excellence,” these stores have pharmacists on hand to offer one-on-one medication counseling and other support services that provide customers living with HIV/AIDS – and their families – with compassionate, confidential care.
For more information, including participating Walgreens stores in each city, visit: www.greaterthan.org/walgreens.
Walgreens
As the nation’s largest drugstore chain with fiscal 2011 sales of $72 billion, Walgreens (www.walgreens.com) vision is to become America’s first choice for health and daily living. Each day, Walgreens provides nearly 6 million customers the most convenient, multichannel access to consumer goods and services and trusted, cost-effective pharmacy, health and wellness services and advice in communities across America. Walgreens scope of pharmacy services includes retail, specialty, infusion, medical facility and mail service, along with respiratory services. These services improve health outcomes and lower costs for payers including employers, managed care organizations, health systems, pharmacy benefit managers and the public sector. The company operates 7,889 drugstores in all 50 states, the District of Columbia and Puerto Rico. Take Care Health Systems is a Walgreens subsidiary that is the largest and most comprehensive manager of worksite health and wellness centers and in-store convenient care clinics, with more than 700 locations throughout the country.
Greater Than AIDS
Greater Than AIDS is an unprecedented coalition of public and private sector partners united in response to the HIV/AIDS crisis in the United States, in particular disproportionately affected groups. Through media campaigns and targeted community outreach, Greater Than AIDS works to increase knowledge and understanding about HIV/AIDS and confront the stigma surrounding the disease, while promoting actions to prevent its spread.
The Kaiser Family Foundation — a leader in health policy and communications — provides strategic direction and day-to-day management, as well as oversees the production of the media campaign. The Black AIDS Institute — a think tank exclusively focused on AIDS in Black America — provides leadership and expert guidance and directs community engagement. Greater Than AIDS is developed in support of Act Against AIDS, an effort by the U.S. Centers for Disease Control and Prevention (CDC) to refocus attention on the domestic epidemic. Additional, financial and substantive support is provided by the Elton John AIDS Foundation, Ford Foundation and MAC AIDS Fund, among others. www.greaterthan.org
NEWS RELEASETuesday, June 12, 2012
New PSAs Promote Free and Low-Cost Testing Services Provided by CDC, State and Local Health Departments and AIDS Service Organizations
New Spanish-language HIV/AIDS Messages Debut on Univision Network in Lead-Up to National HIV Testing Day (June 27)
Menlo Park, Calif. – Greater Than AIDS, a leading national public information response to the domestic epidemic, today unveiled new outdoor media messages urging Americans to get tested for HIV. The “I Got Tested” campaign features real people’s stories of testing and encourages others to “join the movement.”
Of the more than 1.2 million people living with HIV/AIDS in the U.S. today, according to the U.S. Centers for Disease Control and Prevention (CDC) one in five, or nearly a quarter of a million people, do not know they are positive; one third is diagnosed so late in the course of their infection that they develop AIDS within one year. The CDC encourages everyone to know their status, yet even those individuals at higher risk still are not getting tested.
The new campaign helps to connect people with free and low-cost testing in their communities by promoting hotlines and web-based resources provided by CDC, state and local health departments and AIDS service organizations. Univision Network, one of the top five network in the country regardless of language and the top-rated Spanish-language network, also joins Greater Than AIDS this month to debut the campaign’s first “en español” messages in the lead up to National HIV Testing Day (June 27).
“Despite overwhelming evidence that early diagnosis and treatment play an important role both in the health of those who are positive and in reducing the spread of HIV, many Americans at highest risk for infection still have not been tested,” said Tina Hoff, Senior Vice President and Director of Health Communication and Media Partnerships at the Kaiser Family Foundation, a co-founding partner of Greater Than AIDS. “This campaign is about helping to reduce the stigma surrounding HIV testing and connect people with services in their communities.”
Out-of-home PSAs, including billboards, eco-posters, transit shelters, and interior bus and rail posters, begin appearing this month in 21 priority markets in June, including: Atlanta, Baltimore, Chicago, Columbus (GA), Dallas, Detroit, Houston, Los Angeles, Macon, Miami, New Orleans, New York City, Newark, Oakland, Orlando, Philadelphia, San Francisco, Savannah, Tampa, Washington, D.C., and West Palm Beach. The campaign is supported by CBS Outdoor, Clear Channel Outdoor and other Greater Than AIDS partners who provide donated space for the PSAs.
Jason George (GREY’S ANATOMY/ABC), Nadine Ellis (LET’S STAY TOGETHER/BET), Jessie Williams (GREY’S ANATOMY/ABC), Naturi Naughton (THE CLIENT LIST/LIFETIME), Dennis Haysbert (24/FOX, THE UNIT/CBS), and other celebrity supporters of Greater Than AIDS, appear in complementary new TV and radio PSAs, also issued in support of National HIV Testing Day, speaking out about the issue and proudly proclaiming their own decisions to get tested, asking “Have you?”
“With what we know about HIV and what it will take to end the AIDS epidemic, HIV testing has never been more important. Fortunately, it has never been easier either,” said Phill Wilson, President and CEO of the Black AIDS Institute and a co-founding partner of Greater Than AIDS. “We are thrilled to have members of the Institute’s Black Hollywood Task Force on AIDS join in this effort to help bring attention to the importance of knowing your status.”
New Spanish-language TV and radio public service ads (PSAs), presented as SOMOS>SIDA, feature both Latinos living with and affected by HIV/AIDS, sharing how the disease has touched their lives. Among those profiled are: Eddie, who has been living with HIV for more than two decades and speaks of the importance of his family’s love and support in maintaining his health; Gladys, Eddie’s sister, who was the first family member her brother disclosed to and has been a source of support; Yuri, a young HIV positive gay man who overcame his reluctance to start treatment and is now realizing the benefits; and Yvette, a researcher working with HIV positive women and children who speaks to the importance of regular testing. Additional extended videos and HIV/AIDS facts and resources are available on Univison.com/másquesida.
“As part of our mission to inform, entertain and empower Hispanic America, Univision is pleased to join with Greater Than AIDS and its partners, including the CDC, health departments and local AIDS organizations, to increase awareness and help Hispanics understand the importance of getting tested for HIV/AIDS,” said Ivelisse Estrada, Senior Vice President, Corporate and Community Relations, Univision Communications Inc.
Together with the National Association of People with HIV/AIDS, the founder of National HIV Testing Day and other partners, Greater Than AIDS is also making available 100,000 posters and postcards, as well as other informational materials, free of cost to AIDS services and other community groups to support local outreach in June. Visit the Greater Than AIDS online store to view all available items: www.greaterthan.org/store.
“People living with HIV/AIDS are living longer and healthier lives than ever before,” said Frank Oldham, Jr., President and CEO of the National Association of People with AIDS. “It is more important than ever to know your HIV status. AIDS deaths have steadily decreased in recent years and with new treatment therapies, we are proving we are indeed greater than AIDS. Now is the time to Take the Test, Take Control on National HIV Testing Day and beyond. Every day is testing day.”
The National Association of People with AIDS (NAPWA) will host a special media conference call Thursday, June 21. This will serve as an opportunity to answer questions about the 18th annual National HIV Testing Day (NHTD), provide a comprehensive overview of local and national activities as well as share specific goals that NAPWA is working to achieve with our partners as part of this year’s NHTD. Specific time and call-in information forthcoming. To sign up for the call, please contact Paul DeMiglio, NAPWA Special Assistant to the President and CEO, by e-mailing him at PDeMiglio@napwa.org.
While economic challenges facing the country continue and the Supreme Court is deciding the fate of the Affordable Care Act (ACA), May’s Health Tracking Poll finds that the problems and concerns related to health care costs and access are wide-spread. A quarter report they have had problems paying medical bills in the past year and six in ten say they have cut corners to avoid health care costs. The survey also finds that health care can be a point of stress as many Americans report being worried about losing their health insurance or not being able to afford needed care. Health care-related problems and worries are particularly intense among the uninsured, those with lower incomes, and those in poor health. For example, eight in ten of those who say they are in poor health report they have delayed or skipped care due to cost in the past year. To read more, check out the full Health Security Watch here.
The May 2012 update to the Health Security Watch finds that delaying health care to avoid cost is common. While economic challenges facing the country continue and the Supreme Court is deciding the fate of the Affordable Care Act (ACA), May’s Health Tracking Poll finds that the problems and concerns related to health care costs and access are wide-spread. A quarter report they have had problems paying medical bills in the past year and six in ten say they have cut corners to avoid health care costs. The survey also finds that health care can be a point of stress as many Americans report being worried about losing their health insurance or not being able to afford needed care. Health care-related problems and worries are particularly intense among the uninsured, those with lower incomes, and those in poor health. For more, read the full May 2012 Health Security Watch Update.