If the federal match rate drops, Illinois would have two options: come up with more than $40 billion to cover expansion costs or drop it altogether.
Photo: Freestocks.org/StockSnap
by Judith Ruiz-Branch Illinois News Connection
CHICAGO -
As Congress continues to threaten deep cuts to the Medicaid program, a new KFF report shows how some of the proposed changes could end coverage for an estimated 20 million people nationwide, more than 800,000 in Illinois. One idea targets the Medicaid expansion federal match rate. The federal government currently pays 90% of the costs for people covered under what's known as the Medicaid expansion, that extended coverage to nearly all low-income adults.
Liz Williams, senior policy analyst with KFF, explained that if the federal match rate drops, Illinois would have two options: come up with more than $40 billion to cover expansion costs or drop it altogether.
"Illinois has a law where the state is required to automatically end expansion coverage if the match rate drops, so in those trigger law states, there's 12 of them, enrollees are at greater risk of losing coverage," she explained.
Nearly 30% of Medicaid enrollees in Illinois have health-care coverage because of the Medicaid expansion and would be at risk of losing it should these changes go through.
The Medicaid expansion under the Affordable Care Act was enacted to reduce the number of uninsured people nationwide. It provided states with an increased federal match rate to help pay for their health-care costs. Williams added that if states can't afford to pick up the added costs from decreased federal support, the number of uninsured people will dramatically increase, and any gains in financial security and health outcomes associated with the expansion would be reversed.
"Medicaid is jointly funded by states and the federal government, so any restrictions in federal Medicaid spending really leaves states with tough choices about how to offset reductions," she continued.
She said states have a few options, including increasing state tax revenues, decreasing spending on non-Medicaid services such as education, or decreasing coverage for other groups. Governor J.B. Pritzker has already proposed eliminating Medicaid coverage for non-citizen adults aged 42 to 65 as a way to make up for the state's $1.7 billion-budget gap.
KHN - When Michael Adams was researching health insurance options in 2023, he had one very specific requirement: coverage for prosthetic limbs.
Adams, 51, lost his right leg to cancer 40 years ago, and he has worn out more legs than he can count. He picked a gold plan on the Colorado health insurance marketplace that covered prosthetics, including microprocessor-controlled knees like the one he has used for many years. That function adds stability and helps prevent falls.
Prosthetic coverage by private health plans varies tremendously. Even though coverage for basic prostheses may be included in a plan, many insurance companies will cap payouts for devices and impose restrictions on the types of devices approved.
Photo: ThisisEngineering/Unsplash
But when his leg needed replacing last January after about five years of everyday use, his new marketplace health plan wouldn’t authorize it. The roughly $50,000 leg with the electronically controlled knee wasn’t medically necessary, the insurer said, even though Colorado law leaves that determination up to the patient’s doctor, and his has prescribed a version of that leg for many years, starting when he had employer-sponsored coverage.
“The electronic prosthetic knee is life-changing,” said Adams, who lives in Lafayette, Colorado, with his wife and two kids. Without it, “it would be like going back to having a wooden leg like I did when I was a kid.” The microprocessor in the knee responds to different surfaces and inclines, stiffening up if it detects movement that indicates its user is falling.
People who need surgery to replace a joint typically don’t encounter similar coverage roadblocks. In 2021, 1.5 million knee or hip joint replacements were performed in United States hospitals and hospital-owned ambulatory facilities, according to the federal Agency for Healthcare Research and Quality, or AHRQ. The median price for a total hip or knee replacement without complications at top orthopedic hospitals was just over $68,000 in 2020, according to one analysis, though health plans often negotiate lower rates.
To people in the amputee community, the coverage disparity amounts to discrimination.
Fewer than half of people with limb loss have been prescribed a prosthesis
“Insurance covers a knee replacement if it’s covered with skin, but if it’s covered with plastic, it’s not going to cover it,” said Jeffrey Cain, a family physician and former chair of the board of the Amputee Coalition, an advocacy group. Cain wears two prosthetic legs, having lost his after an airplane accident nearly 30 years ago.
AHIP, a trade group for health plans, said health plans generally provide coverage when the prosthetic is determined to be medically necessary, such as to replace a body part or function for walking and day-to-day activity. In practice, though, prosthetic coverage by private health plans varies tremendously, said Ashlie White, chief strategy and programs officer at the Amputee Coalition. Even though coverage for basic prostheses may be included in a plan, “often insurance companies will put caps on the devices and restrictions on the types of devices approved,” White said.
An estimated 2.3 million people are living with limb loss in the U.S., according to an analysis by Avalere, a health care consulting company. That number is expected to as much as double in coming years as people age and a growing number lose limbs to diabetes, trauma, and other medical problems.
Fewer than half of people with limb loss have been prescribed a prosthesis, according to a report by the AHRQ. Plans may deny coverage for prosthetic limbs by claiming they aren’t medically necessary or are experimental devices, even though microprocessor-controlled knees like Adams’ have been in use for decades.
Cain was instrumental in getting passed a 2000 Colorado law that requires insurers to cover prosthetic arms and legs at parity with Medicare, which requires coverage with a 20% coinsurance payment. Since that measure was enacted, about half of states have passed “insurance fairness” laws that require prosthetic coverage on par with other covered medical services in a plan or laws that require coverage of prostheses that enable people to do sports. But these laws apply only to plans regulated by the state. Over half of people with private coverage are in plans not governed by state law.
The Medicare program’s 80% coverage of prosthetic limbs mirrors its coverage for other services. Still, an October report by the Government Accountability Office found that only 30% of beneficiaries who lost a limb in 2016 received a prosthesis in the following three years.
Cost is a factor for many people.
“No matter your coverage, most people have to pay something on that device,” White said. As a result, “many people will be on a payment plan for their device,” she said. Some may take out loans.
Working with her doctor, she has appealed the decision to her insurer and been denied three times.
The federal Consumer Financial Protection Bureau has proposed a rule that would prohibit lenders from repossessing medical devices such as wheelchairs and prosthetic limbs if people can’t repay their loans.
“It is a replacement limb,” said White, whose organization has heard of several cases in which lenders have repossessed wheelchairs or prostheses. Repossession is “literally a punishment to the individual.”
Adams ultimately owed a coinsurance payment of about $4,000 for his new leg, which reflected his portion of the insurer’s negotiated rate for the knee and foot portion of the leg but did not include the costly part that fits around his stump, which didn’t need replacing. The insurer approved the prosthetic leg on appeal, claiming it had made an administrative error, Adams said.
“We’re fortunate that we’re able to afford that 20%,” said Adams, who is a self-employed leadership consultant.
Leah Kaplan doesn’t have that financial flexibility. Born without a left hand, she did not have a prosthetic limb until a few years ago.
Growing up, “I didn’t want more reasons to be stared at,” said Kaplan, 32, of her decision not to use a prosthesis. A few years ago, the cycling enthusiast got a prosthetic hand specially designed for use with her bike. That device was covered under the health plan she has through her county government job in Spokane, Washington, helping developmentally disabled people transition from school to work.
But when she tried to get approval for a prosthetic hand to use for everyday activities, her health plan turned her down. The myoelectric hand she requested would respond to electrical impulses in her arm that would move the hand to perform certain actions. Without insurance coverage, the hand would cost her just over $46,000, which she said she can’t afford.
Working with her doctor, she has appealed the decision to her insurer and been denied three times. Kaplan said she’s still not sure exactly what the rationale is, except that the insurer has questioned the medical necessity of the prosthetic hand. The next step is to file an appeal with an independent review organization certified by the state insurance commissioner’s office.
A prosthetic hand is not a luxury device, Kaplan said. The prosthetic clinic has ordered the hand and made the customized socket that will fit around the end of her arm. But until insurance coverage is sorted out, she can’t use it.
At this point she feels defeated. “I’ve been waiting for this for so long,” Kaplan said.
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
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This article first appeared on KFF Health News and is republished here under a Creative Commons license.
CHICAGO - Open enrollment for Medicare ends on Dec 7. The federal health insurance program is for anyone aged 65 or older. Some people younger than 65 with certain disabilities or conditions, limited income and resources can also get coverage.
Health research organization KFF reports 43% of Illinoisans have Medicare Advantage and 57% opted for traditional Medicare coverage.
Stephani Becker, associate director of health care justice at the Shriver Center on Poverty Law in Illinois, explained the program.
"It covers inpatient care in hospitals, services from doctors and other health care providers, outpatient care, home health care, durable medical equipment and many preventive services," Becker outlined. "That's your Medicare Part A and Part B. Then there's a part D, which is a drug-coverage program."
KFF also noted in 2025, Medicare beneficiaries will pay no more than $2,000 out of pocket for prescription drugs covered under Part D, Medicare's outpatient drug benefit, due to a provision in the Inflation Reduction Act of 2022.
Another important distinction to know is the difference between the original Medicare and Medicare Advantage. Traditional Medicare does not cover dental, vision and hearing insurance. However, many Medicare Advantage programs do. Becker emphasized it is important to review all documentation carefully to understand exactly what is in private plan coverage.
"One is the premium, which is what you pay monthly to your health insurance company," Becker pointed out. "Then the second is your out-of-pocket costs, so things like copays and coinsurance and deductibles, and that's the type of payment that you use when you use your insurance."
JustPlainClear.com and MedicareMadeClear.com are good websites to explain various health care plans for members and caregivers.
Becker adds someone who is self-employed and not eligible for Medicare can buy a plan for themselves on the marketplace and may be eligible for premium assistance. A slightly larger business with two or more employees, for example, can work with a broker and buy a small group health plan.
Meanwhile, open enrollment dates vary for other types of health plans. People with employer-sponsored coverage typically select a plan during a two-to-three week period between September and December. And open enrollment for plans on the Health Insurance Marketplace generally runs from November 1 to January 15 in most states. More information is available at www.UHCOpenEnrollment.com.
BPT - According to McKinsey & Co., 82% of U.S. consumers consider wellness a top priority, with more than half saying they prioritize it more than they did a year ago. However, rising healthcare costs pose significant challenges to consumers, and an unpredictable healthcare payment landscape can leave them with substantial out-of-pocket expenses.
These expenses can force people to forgo the care they want or need, leading to poorer health outcomes.
Photo: PEXELS/Pixabay
Given these realities, it's important to consider the following steps to inform financial decisions about potential out-of-pocket health and wellness costs.
1. Research the cost of your procedures or services in advance. Many websites provide estimated costs of various procedures by region or provider. You can also get estimates by calling your insurance company or the provider directly in advance of your appointment
2. Check if you qualify for subsidized coverage or financial assistance. People with incomes below certain levels may be eligible for health coverage at reduced or no cost. Hospitals may offer free or discounted care, known as charity care, to people not able to pay.
3. Confirm with your provider and insurance company that you are maximizing health plan coverage. Take advantage of your annual benefits, including getting recommended preventive screenings and visiting in-network providers that usually cost less than those who are out-of-network.
4. Enroll in an employer-based program that uses pre-tax dollars. Flexible Spending Accounts (FSA) and Healthcare Spending Accounts (HSA) allow employees to set aside money from their pay for qualified medical expenses.
5. Consider promotional financing options. Health and wellness credit cards, such as CareCredit, that offer deferred interest financing, enable you to pay for care over time with the opportunity to avoid interest charges, making out-of-pocket costs more manageable. Here are a few things about deferred interest financing to consider:
Deferred interest: No interest is assessed if the balance is paid in full by the end of the promotional period.
How deferred interest promotional financing works. Deferred interest financing allows consumers to avoid interest charges on larger expenses if they are paid off before the promotional period ends. If you don't pay off the full balance before the promotional period ends, you will have to pay interest that has accrued as of the transaction date.
The required minimum monthly payments. Understand the required minimum monthly payments and if those payments will pay the balance off in time. Online calculators, such as CareCredit's payment calculator, are a valuable resource to estimate possible monthly payments needed to pay off the balance within a given promotional period. Those payments may be more than the lender's monthly minimum payment requirement.
Mark your calendar for when the promotional period ends. It is important to track and pay the balance of the purchase before the end of the promotional period to avoid paying the deferred interest that has accrued on the purchase.
In the end, it's important that people have access to health and wellness care for themselves, their family and pets. As healthcare costs continue to rise, it is critical consumers be aware of the various benefit programs and payment options to plan for health and wellness costs. Financial literacy is key!
CHICAGO - Addressing mental illness in America is a source of continued debate and a new report outlined areas in need of change.
The study detailed the role of response teams in a mental health episode.
Andy Wade, executive director of the National Alliance on Mental Illness-Illinois, sees a need to strengthen the disconnection between the 988 system and the services and facilities supporting post-crisis recovery services.
"The progress has been positive but we need more," Wade asserted. "The crisis system isn't just the phone call. It's also about having a safe and appropriate mental health response, even if that means someone coming out to the house."
He called the system "a work in progress" and emphasized 988 operators should have the tools they need to make immediate handoffs to the right services. Wade acknowledged while law enforcement does a good job, there is often an overdependence on police officers who are not always the best responders. He is encouraged by Illinois legislators' commitment to the crisis system, and wants to continue the forward momentum on funding started by state lawmakers.
The crisis system in Illinois allows people to use it regardless of their ability to pay, which the report highlights as a success.
Angela Kimball, chief advocacy officer for the mental health advocacy organization Inseparable, said state lawmakers are the key to change.
"Lawmakers across the country need to understand, one, what does the system look like? And two, what is their role in helping make this happen?" Kimball outlined. "There is no one entity, no one person, that can make a new crisis response system happen."
She added the challenge for lawmakers is to navigate the complex emergency service regulations in place in order to create effective legislation. Illinois Gov. JB Pritzker signed House Bill 2595 in 2021, requiring insurance companies to cover medically necessary mental health care services.
BPT - It's here - your yearly opportunity to make changes to your Medicare coverage. Medicare Annual Enrollment happens every year Oct. 15 through Dec. 7, during which you can review your current plan, compare your coverage options, and make any necessary updates. Any changes you make then go into effect on Jan. 1, 2024.
Whether you're enrolling for the first time or not, it can be a lot of information to sift through. To help you stay organized and make sure you check every box, ClearMatch Medicare created the following handy checklist. Follow these steps to find the coverage that works for you.
1. Create a provider list
Make a list of all your current medical providers, including your primary doctor as well as any specialists or services you use regularly. This should also include the clinics or hospitals you visit most. Listing this information will help you decide which Medicare plan is right for you.
2. List your prescriptions
Do you take any prescription drugs? If so, write them down. Medicare plans change each year, and it's possible that your current plan may stop covering your prescriptions. Have your medications top of mind before comparing plans for the coming year.
3. Plan ahead
If possible, have a conversation with your doctor about what screenings, tests or medications you might need in the coming year. While you can't see into the future, try to note any healthcare changes you expect over the next 12 months.
4. Review your plan's Annual Notice of Change and Evidence of Coverage
If you have any coverage outside of Original Medicare (Parts A and B), your plan sends an Annual Notice of Change (ANOC) and Evidence of Coverage (EOC), which you should receive in September. If you don't receive one, contact your plan. These documents provide details about upcoming changes to your coverage. Compare them to your current and projected medical needs to determine if it's time to change plans.
5. Review your current Medicare and other insurance coverage
Think about your existing plan. Is it meeting your needs? Are you OK with the cost? Reflect on what's working and what's not - then plan for any changes you need to make for next year.
And if you have other health insurance benefits besides Medicare, talk to your benefits administrator to determine how your Medicare enrollment impacts your additional health coverage.
6. Review Medicare Advantage options
Many Medicare Advantage plans offer benefits not covered by Original Medicare, such as prescription drug coverage and routine dental and vision care. You may find that a Medicare Advantage plan saves you money thanks to this increased coverage. These plans also have a yearly out-of-pocket maximum, unlike Original Medicare.
7. Confirm your total cost
The total cost of your Medicare plan may include monthly premiums, deductibles, co-pays and co-insurance. When comparing plans, dig a little deeper for an accurate picture of total costs so you're prepared for the year and know what you can afford. Keep in mind:
* For Part D plans, you need to consider the monthly premium, co-pays and the drug formulary. Most insurers use tiered pricing for prescription drugs. If your prescriptions are on one of the upper tiers, your co-pay could be substantial.
* Most Medicare Advantage and Part D plans with extremely low premiums have higher co-pays, deductibles and out-of-pocket maximums.
Overwhelmed by all these steps? Don't worry, free help is just a phone call away. ClearMatch Medicare is dedicated to making Medicare easier to understand so you can choose the plan that's right for you. Their highly trained and licensed insurance agents are patient and helpful, and if they find you're already in the right plan, they'll tell you so.
Call 1-888-441-7382 (TTY:711) for a free Medicare review, Monday-Friday, 9 a.m.-9 p.m., Saturday, 9 a.m.-3 p.m. (ET) or visit ClearMatchMedicare.com, open 24-7.
Medicaid re-determination will happen on a rolling basis through mid-2024, meaning not everyone will lose eligibility at once.
CHICAGO - Millions of Medicaid recipients are losing coverage as the program's pandemic-era Continuous Enrollment Provision unwinds. In Illinois, the number could reach close to three-quarters of a million, even if many are still eligible for benefits.
In just the first month since states started to whittle down their Medicaid rolls, more than 47,000 people in Illinois have lost coverage. They may still qualify, but simply failed to re-enroll in time to avoid a coverage lapse or didn't respond to the government's request for information.
Marcus Robinson, UnitedHealthcare's president of markets for the indivicual and family plan business, said suddenly losing coverage can be frightening, but it also disrupts the doctor-patient relationship.
"And keeping access to that relationship for your overall well-being is really important," he said. "Regular doctor's visits for yourself or your family, of course - you can continue to obtain your preventive care, critical screenings."
Robinson said disrupting that relationship means at-risk patients could fail to manage chronic conditions or miss emerging illnesses. He added that UnitedHealthCare has online tools to help people determine if they are still Medicaid-eligible, and offers options if they're not.
People were not required to prove Medicaid eligibility during the pandemic, but now that is changing. Illinois Gov. J.B. Pritzker has said to avoid a "coverage cliff," Medicaid re-determination will happen on a rolling basis through mid-2024, meaning not everyone will lose eligibility at once. But UnitedHealthCare's Robinson said people who do lose coverage can still access health insurance, because losing Medicaid allows them coverage options outside of a normal enrollment period.
"It's determined you are not longer eligible for Medicaid - well, that's a loss of coverage," he said, "and that allows you a qualifying event to enroll in the individual exchange marketplace. "
The individual exchange marketplace is online at healthcare.gov.
ST. JOSEPH -- Yesterday, Loman-Ray Insurance Group announced the company will open a new office in St. Joseph. The company, which currently has 12 offices in Illinois, will be located at 104 N. Main in St. Joseph.
An independent insurance company, Loman-Ray was started in 1981 by Lyle Loman and his wife Sue. The husband-wife team, who were also teachers, discovered selling insurance was financially rewarding beyond their expectations and purchased a small property/casualty firm in 1981. The company has expanded to locations in Atwood, Broadlands, Cissna Park, Clifton, Danville, Hoopeston, Tolono, Sullivan, and Villa Grove.
Loman-Ray, which expects to open the St. Joseph office this summer, specializes in auto, home, commercial, group and individual health, and agribusiness insurance coverage.
Americans keep hearing that it is important to test frequently for covid-19 at home. But just try to find an “at-home” rapid covid test in a store and at a price that makes frequent tests affordable.
Testing, as well as mask-wearing, is an important measure if the country ever hopes to beat covid, restore normal routines and get the economy running efficiently. To get Americans cheaper tests, the federal government now plans to have insurance companies pay for them.
The Biden administration announced Jan. 10 that every person with private insurance can get full coverage for eight rapid tests a month. You can either get one without any out-of-pocket expense from retail pharmacies that are part of an insurance company’s network or buy it at any store and get reimbursed by the insurer.
Congress said private insurers must cover all covid testing and any associated medical services when it passed the Families First Coronavirus Response Act and the Coronavirus Aid, Relief and Economic Security, or CARES, Act. The have-insurance-pay-for-it solution has been used frequently through the pandemic. Insurance companies have been told to pay for PCR tests, covid treatments and the administration of vaccines. (Taxpayers are paying for the cost of the vaccines themselves.) It appears to be an elegant solution for a politician because it looks free and isn’t using taxpayer money.
1. Are the tests really free?
Well, no. As many an economist will tell you, there ain’t no such thing as a free lunch. Someone has to pick up the tab. Initially, the insurance companies bear the cost. Cynthia Cox, a vice president at KFF who studies the Affordable Care Act and private insurers, said the total bill could amount to billions of dollars. Exactly how much depends on “how easy it is to get them, and how many will be reimbursed,” she said.
2. Will the insurance company just swallow those imposed costs?
If companies draw from the time-tested insurance giants’ playbook, they’ll pass along those costs to customers. “This will put upward pressure on premiums,” said Emily Gee, vice president and coordinator for health policy at the Center for American Progress.
Major insurance companies like Cigna, Anthem, UnitedHealthcare and Aetna did not respond to requests to discuss this issue.
3. If that’s the case, why haven’t I been hit with higher premiums already?
Insurance companies had the chance last year to raise premiums but, mostly, they did not.
Why? Perhaps because insurers have so far made so much money during the pandemic they didn’t need to. For example, the industry’s profits in 2020 increased 41% to $31 billion from $22 billion, according to the National Association of Insurance Commissioners. The NAIC said the industry has continued its “tremendous growth trend” that started before covid emerged. Companies will be reporting 2021 results soon.
The reason behind these profits is clear. You were paying premiums based on projections your insurance company made about how much health care consumers would use that year. Because people stayed home, had fewer accidents, postponed surgeries and, often, avoided going to visit the doctor or the hospital, insurers paid out less. They rebated some of their earnings back to customers, but they pocketed a lot more.
As the companies’ actuaries work on predicting 2023 expenditures, premiums could go up if they foresee more claims and expenses. Paying for millions of rapid tests is something they would include in their calculations.
4. Regardless of my premiums, will the tests cost me money directly?
It’s quite possible. If your insurance company doesn’t have an arrangement with a retailer where you can simply pick up your allotted tests, you’ll have to pay for them — at whatever price the store sets. If that’s the case, you’ll need to fill out a form to request a reimbursement from the insurance company. How many times have you lost receipts or just plain neglected to mail in for rebates on something you bought? A lot, right?
Here’s another thing: The reimbursement is set at $12 per test. If you pay $30 for a test — and that is not unheard of — your insurer is only on the hook for $12. You eat the $18.
And by the way, people on Medicare will have to pay for their tests themselves. People who get their health care covered by Medicaid can obtain free test kits at community centers.
A few free tests are supposed to arrive at every American home via the U.S. Postal Service. And the Biden administration has activated a website where Americans can order free tests from a cache of a billion the federal government ordered.
5. Will this help bring down the costs of at-home tests and make them easier to find?
The free covid tests are unlikely to have much immediate impact on general cost and availability. You will still need to search for them. The federal measures likely will stimulate the demand for tests, which in the short term may make them harder to find.
But the demand, and some government guarantees to manufacturers, may induce test makers to make more of them faster. The increased competition and supply theoretically could bring down the price. There is certainly room for prices to decline since the wholesale cost of the test is between $5 and $7, analysts estimate. "It’s a big step in the right direction," Gee said.
As the covid-19 pandemic burns through its second year, the path forward for
American workers remains unsettled, with many continuing to work from home
while policies for maintaining a safe workplace evolve. In its
2021 Employer Health Benefits Survey, released Wednesday, KFF found that many employers have ramped up mental
health and other benefits to provide support for their workers during
uncertain times.
Meanwhile, the proportion of employers offering health insurance to their
workers remained steady, and increases for health insurance premiums and
out-of-pocket health expenses were moderate, in line with the rise in pay.
Deductibles were largely unchanged from the previous two years.
“With the pandemic, I’m not sure that employers wanted to make big changes in
their plans, because so many other things were disrupted,” said Gary Claxton,
a senior vice president at KFF and director of the Health Care Marketplace
Project. (KHN is an editorially independent program of the foundation.)
Reaching out to a dispersed workforce is also a challenge, with on-site
activities like employee benefits fairs curtailed or eliminated.
“It’s hard to even communicate changes right now,” Claxton said.
Many employers reported that since the pandemic started they’ve made changes
to their mental health and substance use benefits. Nearly 1,700 nonfederal
public and private companies completed the full survey.
At companies with at least 50 workers, 39% have made such changes, including:
31% that increased the ways employees can tap into mental health services,
such as telemedicine.
16% that offered employee assistance programs or other new resources for
mental health.
6% that expanded access to in-network mental health providers.
4% that reduced cost sharing for such visits.
3% that increased coverage for out-of-network services.
Workers are taking advantage of the services. Thirty-eight percent of the
largest companies with 1,000 or more workers reported that their workers used
more mental health services in 2021 than the year before, while 12% of
companies with at least 50 workers said their workers upped their use of
mental health services.
Thundermist Health Center is a federally qualified health center that serves
three communities in Rhode Island. The center’s health plan offers employees
an HMO and a preferred provider organization, and 227 workers are enrolled.
When the pandemic hit, the health plan reduced the copayments for behavioral
health visits to zero from $30.
“We wanted to encourage people to get help who were feeling any stress or
concerns,” said Cynthia Farrell, associate vice president for human resources
at Thundermist.
Once the pandemic ends, if the health center adds a copayment again, it won’t
be more than $15, she said.
The pandemic also changed the way many companies handled their wellness
programs. More than half of those with at least 50 workers expanded these
programs during the pandemic. The most common change? Expanding online
counseling services, reported by 38% of companies with 50 to 199 workers and
58% of companies with 200 or more workers. Another popular change was
expanding or changing existing wellness programs to meet the needs of people
who are working from home, reported by 17% of the smaller companies and 34% of
the larger companies that made changes.
Beefing up telemedicine services was a popular way for employers to make
services easier to access for workers, who may have been working remotely or
whose clinicians, including mental health professionals, may not have been
seeing patients in person.
In 2021, 95% of employers offered at least some health care services through
telemedicine, compared with 85% last year. These were often video
appointments, but a growing number of companies allowed telemedicine visits by
telephone or other communication modes, as well as expanded the number of
services offered this way and the types of providers that can use them.
About 155 million people in the U.S. have employer-sponsored health care. The
pandemic didn’t change the proportion of employers that offered coverage to
their workers: It has remained mostly steady at 59% for the past decade. Size
matters, however, and while 99% of companies with at least 200 workers offers
health benefits, only 56% of those with fewer than 50 workers do so.
In 2021, average premiums for both family and single coverage rose 4%, to
$22,221 for families and $7,739 for single coverage. Workers with family
coverage contribute $5,969 toward their coverage, on average, while those with
single coverage pay an average of $1,299.
The annual premium change was in line with workers’ wage growth of 5% and
inflation of 1.9%. But during the past 10 years, average premium increases
have substantially exceeded increases in wages and inflation.
Workers pay 17% of the premium for single coverage and 28% of that for family
coverage, on average. The employer pays the rest.
Deductibles have remained steady in 2021. The average deductible for single
coverage was $1,669, up 68% over the decade but not much different from the
previous two years, when the deductible was $1,644 in 2020 and $1,655 in 2019.
Eighty-five percent of workers have a deductible now; 10 years ago, the figure
was 74%.
Health care spending has slowed during the pandemic, as people delay or avoid
care that isn’t essential. Half of large employers with at least 200 workers
reported that health care use by workers was about what they expected in the
most recent quarter. But nearly a third said that utilization has been below
expectations, and 18% said it was above it, the survey found.
At Thundermist Health Center, fewer people sought out health care last year,
so the self-funded health plan, which pays employee claims directly rather
than using insurance for that purpose, fell below its expected spending,
Farrell said.
That turned out to be good news for employees, whose contribution to their
plan didn’t change.
“This year was the first year in a very long time that we didn’t have to
change our rates,” Farrell said.
The survey was conducted between January and July 2021. It was published in
the journal
Health Affairs
and KFF also released additional details in its
full report.
Scientists and lawmakers agree that over-the-counter covid tests could allow desk workers to settle back into their cubicles and make it easier to reopen schools and travel.
But even as entrepreneurs race their products to market, armed with millions of dollars in venture capital and government investment, the demand for covid testing has waned. Manufacturing and bureaucratic delays have also kept rapid tests from hitting store shelves in large numbers, though the industry was energized by the Food and Drug Administration’s greenlighting of two more over-the-counter tests Wednesday.
Corporate giants and startups alike plan to offer a dizzying array of test options, most costing between $10 and $110. Their screening accuracy varies, as does the way consumers get results: collection kits mailed back to a lab, devices synced with artificial intelligence-enabled apps on a smartphone that spit out results within 15 minutes, and credit card-sized tests with strips of paper that must be dipped into a chemical substance.
"At-home tests are one of the key steps to getting back to normal life," said Andy Slavitt, a member of the White House COVID-19 Response Team, during a February briefing.
The Biden administration announced in March it will allocate $10 billion from the recently passed stimulus package for covid testing to expedite school reopenings, and earlier said it would invoke the Defense Production Act to manufacture more at-home tests. Separately, the federal government has already sent millions of Abbott Laboratories’ BinaxNOW rapid tests to states, and California, for instance, is giving 3 million of them to its most disadvantaged school districts for free.
Large employers, like Google, sports leagues and the federal government, have already shelled out millions to regularly test their workers. Amazon just received emergency use authorization from the FDA for its own covid test and home collection kit, which it intends to use for its employee screening program.
In February, the Biden administration cut a $232 million deal with Ellume, whose rapid antigen test was authorized by the FDA in December. Paired with an app, the test takes 15 minutes to analyze after a nose swab.
Individuals who want to buy over-the-counter tests can bill their health insurance plans, which are required by the federal governmentin most cases to fully cover covid tests that have been authorized by the FDA.
Everlywell, based in Austin, Texas, is an at-home diagnostic company that already sells its collection kit to consumers through its website and Walgreens, and will soon offer same-day delivery via DoorDash in a dozen cities. Dr. Marisa Cruz, Everlywell’s executive vice president of regulatory and clinical affairs, said buyers can seek reimbursement from their insurance plans for the kit’s $109 cost. The tests are also eligible for purchase with pretax dollars from health savings or flexible spending accounts, she said.
Even with vaccines, epidemiologists say, rapid tests are desperately needed because more testing, along with mask-wearing and physical distancing, will get people back in offices and classrooms and help catch cases that go undetected. A report by the Centers for Disease Control and Prevention found that, of people with active infections, 44% reported no symptoms.
But the market for over-the-counter tests is risky. Demand for testing has plunged dramatically since the height of the winter surge and may not rebound as more people are vaccinated.
'You clearly are at risk of missing the market,' said Michael Greeley, co-founder and general partner at Flare Capital Partners, a venture capital firm focused on health care technology.
But Douglas Bryant, president and CEO of Quidel Corp., remains unfazed, even after the diagnostics manufacturer’s testing demand dropped by about one-third in the past two months.
"The level of testing for people with symptoms and the 'worried well,' who see others getting tested and think they should, too, is subsiding," Bryant said. "But once we start to get more people vaccinated, the government will move from campaigning to get people vaccinated to saying, 'Please test yourself regularly so we can get back to work.'"
Quidel, headquartered in San Diego, recently unveiled its latest test, the QuickVue At-Home COVID-19 Test, which takes 10 minutes to detect the coronavirus by homing in on specific proteins, called antigens. The FDA authorized the test for over-the-counter use Wednesday, and Quidel plans to announce retail partners in the coming weeks.
The FDA said in mid-March it would speed the pipeline for “screening testing,” including at-home covid tests that don’t require consumers to have symptoms or a prescription.
In February, the Biden administration cut a $232 million deal with Ellume, whose rapid antigen test was authorized by the FDA in December. Paired with an app, the test takes 15 minutes to analyze after a nose swab.
The Australian company currently ships hundreds of thousands of test kits a week to the U.S. from its factory in Brisbane to large companies and the Department of Defense. It plans to be on the shelves of multiple pharmacies by the second half of the year and in one major retailer in April, said Dr. Sean Parsons, the company’s founder and CEO.
"We are going as fast as we can possibly go," he said.
The main holdup for Ellume has been getting enough swabs for its production line. The company is building a factory in the U.S. to reduce international shipping costs and increase production.
Abbott, which dominates the rapid-test market, said in January it expects to sell 120 million BinaxNOW antigen tests to consumers in the first half of the year. People who take the test now must do so under observation by telemedicine platform eMed. But Abbott received authorization from the FDA this week for an over-the-counter version that won’t require remote observation or a prescription. The test will be available in U.S. stores in the coming weeks, the company said.
Throughout the pandemic, the government has depended heavily on medical device behemoth Abbott’s testing options. The company’s rapid-diagnostics arm alone has snared $673 million in federal contracts to combat the coronavirus, according to a ProPublica database. This includes bulk purchases made by the Defense Department, the national prison system, Immigration and Customs Enforcement, the State Department and former President Donald Trump's office.
But antigen tests sometimes report false negatives, particularly among people without symptoms, noted Dr. Jac Dinnes, who co-authored a review of 64 covid test studies. By comparison, polymerase chain reaction (PCR) tests — generally employed by commercial labs — are more sensitive. PCR tests search for the virus’s genetic material over multiple testing cycles, which magnifies what’s in the swab sample, requiring a much smaller viral load for detection.
Antigen tests are the basis for most at-home screening, but the FDA has also authorized two at-home options — made by Lucira Health and Cue Health — that use molecular processes similar to a PCR test.
"I always like to tell people that it is as easy to use as toothpaste."
Still, many experts support the widespread distribution of cheap, rapid tests, even if they aren’t as sensitive as lab-run alternatives, and see a demand. In Germany, the supermarket chain Aldi began selling rapid tests in early March, roughly $30 for a five-pack, and sold out within hours. One recent study found that if a pack of tests was mailed to every household in the U.S. — even assuming that up to 75% would go into the garbage — they would save thousands of lives and avert millions of infections.
"Don’t let perfect be the enemy of good," said study co-author and Yale University professor A. David Paltiel. "This doesn’t have to work perfectly to make a huge difference."
Some companies are working on rapid-testing options that more precisely read samples, such as Gauss.
The Menlo Park, California, health tech company, which before the pandemic created an artificial intelligence-based app to measure surgical blood loss in real time, aims to harness its expertise to improve on the basic antigen test. It took about a week for CEO Siddarth Satish to raise $30 million of venture capital last October.
Its covid-testing app uses facial recognition software to confirm that test-takers correctly swab their noses. The app provides step-by-step instructions and timers. After 15 minutes, an algorithm based on thousands of sample tests interprets the result — which displays as a colored line, as with a pregnancy test — using the phone’s camera.
Gauss and Cellex, which manufactures the Gauss tests, await FDA authorization. In the meantime, they have produced more than 1.5 million kits and struck deals with supermarket chain Kroger and e-pharmacy site Truepill to sell them for about $30.
"A huge part of the accuracy issue with rapid tests is that you have to visually interpret them," Satish said. "Sometimes you get really faint lines, just like with a pregnancy strip, and there’s some guesswork."
Lucira Health, based in Emeryville, California, uses something called loop-mediated isothermal amplification technology, which is similar to PCR tests in precision. In February, the company went public, raising $153 million largely to fund the manufacturing of its all-in-one testing kit, currently prescribed by doctors across the country. The kit comes with a nose swab and a vial of chemicals analyzed by a hand-held device — taking up to 30 minutes for results.
Kelly Lewis Brezoczky, Lucira’s executive vice president, envisions the test kit on the shelf in local pharmacies, perched next to the NyQuil. "I always like to tell people that it is as easy to use as toothpaste," she said.
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