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Coffee CAHC policy round-up: January 3, 2018

Coffee CAHC is a twice-weekly newsletter where we round up and comment on the latest health coverage policy developments both nationally and here in Maine. We hope you find these updates helpful!

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Coffee CAHC

115th Congress, 1st session

128th Maine Legislature, 2nd regular session


Wednesday, January 3, 2018


We’re back!

I hope all of you enjoyed an absolutely wonderful stretch over the holiday season. I know my break was lovely.

I’ve got a few milestones to celebrate in today’s edition.

  • We made it through 2017! (Let’s not kid ourselves, that was a rough year.)
  • I’ve now been on the job for a year, which means we are coming right up on the one year anniversary of the launch of Coffee CAHC. Thanks again to all of you for the support. I mean that.
  • CAHC is turning 30! 2018 marks the 30th anniversary of CAHC’s founding in 1988. 30 years of fighting to make sure that everybody in Maine can get the quality and affordable health care that they need. To celebrate this anniversary, we’re throwing a big party on June 7th. More details will follow, but for now, keep that evening free.

Now, let’s get to it!


National level

I think by far the biggest news since last I wrote was the release of the final enrollment numbers for Open Enrollment 5. All I can say is, holy moley.

8.8 million people nationwide enrolled in the federal exchanges, including over 76,000 from here in Maine. All despite ongoing and blatant sabotage from the Trump Administration to do everything short of literally setting CMS on fire to prevent people from getting coverage. To put those numbers in perspective, they’re just shy of last year’s enrollment tallies – more than impressive given the halved enrollment window.

CMS Administrator Seema Verna, and the agency itself, have been trying to pat themselves on the back for this, bleating on about how “efficient” they were. That is 100% pure hogwash. These enrollment numbers had nothing at all to do with CMS somehow finding a new magic formula for helping people enroll, and everything to do with assisters, navigators, and an army of volunteers and nonprofits and other organizations who stepped up to the plate and did the work that CMS refused to do.

I am dazzled, yet again, by the commitment and dedication of our enrollment community. You all stepped up huge and knocked it outta the park. Because of your work, millions of people will have coverage, people who would otherwise have had the door slammed in their faces by a gleefully callous Trump Administration. I hope you are all incredibly, and deservedly, proud of yourselves. This is your win.


State level

Scroll back up to the top of this message for a second (I’ll wait). …did you notice it? Up near the very top? 128th Maine Legislature…2nd regular session.

They’re back, baby!

Yes, later this morning, the Legislature shall “gavel in” to the second act of their two-year biennial session. Which means, at the time that I’m writing and sending this message, that I’m technically inaccurate: they’re actually still in adjournment, and will be until around 10am. I guess I’m just so excited that I may have jumped the gun a bit.

But, wow, this is gonna be a doozy. The second session is shorter than the first: last year they had to adjourn by the end of June (well, excepting that dumb shutdown), and this year they have to adjourn by the end of April. That means only about three and a half months to get through all of the bills they carried over from last year, plus any new bills that were introduced. And there are some big ones looming.

Of course, nothing is bigger in Augusta right now than Medicaid expansion. I’m very, very curious to see how this debate evolves over the next few months.

We have a few bills in particular that we’re keeping an eye on, and I’ll be sharing details about those – and our perspective on them – as the session moves forward. Keep an eye on this space for more, very soon.

Meanwhile, two new health care bills that were passed last session officially took effect on Monday, with the new year.

One is the so-called “right to shop” law, which puts in place some new rights for consumers to get information about how much health care services are going to cost before plunking their credit card down at the doctor’s office. This new law also gives folks some ways to “share in the savings” with their insurance company if they find a service they need at a lower cost than what their in-network options would charge. It also contains a very important provision that we are very pleased with, which says that insurers can no longer deny payment for a service purely on the grounds that the referral for the service came from an out-of-network doctor. We’ve seen consumers get caught up in this in the past, where they change insurers without ever realizing that their doc is now out of network, and end up getting whacked for referred services that would have been covered otherwise.

The second law, well, now, that’s one that we’re especially pleased with, and that’s the one putting an end (we hope) to consumers getting hit with surprise medical bills. A “surprise medical bill” is what happens when a consumer goes to a facility (usually a hospital) that is in-network for their insurance plan, but then ends up seeing an out-of-network provider at that facility. The “classic” scenario here is surgery at an in-network hospital, but your anesthesiologist is out of network. We also see it a lot with lab work, and radiology – your time in the x-ray machine is covered, but the doc who looks at it for 60 seconds to diagnose your fracture is out of network so here’s a nice fat bill for you.

We encouraged the introduction of this bill and worked hard to help it pass. Consumers who do all of their homework and do everything right should not be getting nailed for something they had no way of knowing was happening in the first place. It’s not like anybody asks them “hey, is it ok with you if your anesthesiologist is actually out of network?”

And, to be clear, the new law allows consumers to knowingly elect to see somebody out of network if they choose. If they choose – not if the choice is made for them.

So, what happens in these situations now if they come up?

First of all, the consumer pays whatever their standard in-network “cost share” would be – their copays, coinsurance, any portion of their deductible – and then they’re off the hook. As it should be. As it would be if the entire service stayed in-network anyway.

Providers in Maine are now prohibited from “balance billing” consumers in these situations. Balance billing is when a provider bills for a service, takes whatever the insurance company will pay toward the service, then goes after the consumer for the remainder. Prohibiting this leaves the consumer out of it once they’ve paid their share.

Then, it’s up to the docs and the insurer to hash it out. In a case where the Bureau of Insurance finds that the insurance company’s network was “inadequate” (an official designation based on BOI review), then the insurer owes the provider the entire billed charge. If the network was adequate, and the hospital simply used an out-of-network provider (for whatever reason), then the insurer pays the out-of-network doc their average in-network rate for that service.

This is a huge leap forward for Maine consumers, and a really important protection. We’re not sure exactly how widespread this problem is, because it’s very hard to track (how many people never report it at all? How many people never even realize it happened? How many times have you gotten a bill from the doc/hospital and just paid it on the assumption that your insurance paid whatever they were supposed to?). But when it happens to somebody, it’s a huge deal to that person. Getting a bill sprung on you for hundreds or even thousands of dollars when you least expect it is harrowing at best and devastating at worst. Now, Mainers are protected.


Would you like to know more?

The New York Times has a very good report on a fascinating new study that looks at why Americans pay so much more for health care than other, comparable countries. My key takeaway: it’s not because we use more health care or go to the doctor more.

So can we finally put that pernicious, false claim to bed forever? I’m really tired of listening to consumers get blamed for high health care costs because of this false idea that we’re somehow reckless spendthrifts who go to the doctor willy-nilly. We aren’t, and we don’t. You cannot nickel and dime consumers to death to change a system that’s stacked against them. As that New York Times article notes, the problem is exactly what health care economist Uwe Reinhardt once said: “it’s the prices, stupid.”


Until next time, friends, I remain,


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