Health care expansion is a story waiting to be told

The bruising political battle in Congress and the high-court drama have passed. Now the curtain is about to go up on the real action: health reform itself.  Huge changes are underway in advance of the 2014 deadline: Health insurance exchanges are being built, the individual mandate will go into effect, and the uninsured will have unprecedented opportunities to receive care.

Yet so many questions remain unanswered: How will the state health exchanges operate? How many new enrollees will sign-up for Medicaid? How much will participating states have to pay for expanded coverage? And ultimately, will it all work?

The complexities are enough to make anybody’s head seize up, let alone the diligent health reporter who is expected to serve as guide to all the policy changes.

Luckily for reporters participating in the 2013 California Endowment Health Journalism Fellowship this week, Kaiser Health News Senior Correspondent Sarah Varney and Marian Mulkey, director of Health Reform and Public Programs Initiative at the California Health Care Foundation, were on hand to provide a primer on the health care law and spotlight some story angles worth pursuing.

While the details of the act and the argument for its existence defy quick summary, a few basic points are worth highlighting. The new law was designed in response to the fact that we spend an inordinate amount of money on health care in this country and receive very mediocre results in return, at least by international standards. Employer-based coverage is steadily declining, as health insurance premiums grow much faster than the overall economy and inflation. The reforms aim to address these problems by expanding coverage and addressing system-wide issues.

To do this, the law undertakes a major expansion of Medicaid, the federal name for the program providing low-income health coverage. Beginning next January, those making less than 133 percent of the federal poverty level will qualify for the program – if a state chooses to participate (click here for information on Center for Health Journalism Digital’s March 5, 2013, webinar on the subject). “That’s a sea change really, because there’s been all these categorical rules before,” said Mulkey. The new law also forbids health insurance plans from denying coverage to individuals based on their health history. But the law also mandates that all individuals have health coverage. That’s crucially important for keeping costs down, because even as insurance plans are forced to accept the less healthy, the broader cross-section of insurees generated by the individual mandate should balance out the risk pool.

For those who aren’t insured through their employer, they can buy coverage through the newly created health insurance exchanges. The marketplaces will require plans to meet certain benefits and costs and should allow people to readily shop plans before applying and enrolling in coverage. The idea is to make complicated plans easier to understand and compare, as well as more affordable — federal subsidies will be offered to address the latter.

“The extent to which they will succeed really remains to be seen,” Mulkey said. “Health insurance is not a simple product, it’s not a fun product to shop for. I don’t anticipate that overnight in January 2014, when these rules go into place, it will be something that everyone is eager to do.”

Nonetheless some governors have openly worried about the so-called woodwork effect, where people who were previously eligible for Medicaid, but not enrolled, begin enrolling as the health insurance mandate kicks in. In California, an additional 1.5 to 2 million enrollees could be added to the Medi-Cal ranks, Mulkey said, depending on how effective marketing and outreach campaigns are, as well as how difficult the enrollment process proves to be (making Medicaid enrollment a bureaucratic labyrinth is one way states could potentially limit new enrollees and costs).

As all this might suggest, tracking the implementation of the Affordable Care Act promises to be a colossal challenge to reporters, particularly right now as so many details and negotiations are being ironed out behind closed doors. To help journalists looking for a few angles to begin covering the implementation of the new law, seasoned health reporter Sarah Varney offered a handful of possible story threads for consideration while covering the issue this year and next:

• Under the new law, people who have long been unable to get health insurance will now be able to get it. What does that mean for them? How will this change their lives?
• There’s a long history of animosity between purchasers of health insurance and insurance plans. “I would be looking for people who have good stories about that,” Varney said.
• Visit a public health clinic and document what people must go through to sign up for Medicaid, and then compare that with what the experience is supposed to be like. Are potential enrollees being helped or thwarted at every turn?
• Consider stories on people who haven’t historically had insurance and are now required to obtain it. “Do they see the value in it?” Varney asks.
• What’s happening with those receiving offers for insurance? Are the subsidies from the federal government enough? (Open enrollment is set to begin by the end of this year.)
• How will reforms impact smaller employers? Will they decide to continue offering insurance (if they already do), or rather send their employees to the exchange?
• The public health system has often been the place of “last resort” for many. But newly insured Medicaid enrollees may choose to start going to private practices or other providers. How will this affect public health departments if they lose a sizeable share of their patients? Will patients choose to go elsewhere?
• Is there evidence of insurers still “cherry picking?” Are insurers heavily marketing to certain higher-profit, healthier demographics?
• Consider following a medical-device maker and how they’re lobbying to ensure their product is covered in the state’s health insurance exchange.
• Cash-only clinics: Some such clinics don’t accept Medicaid or other insurance plans. If some of their low-income patients enroll in Medicaid and go elsewhere, how will this affect these clinics and the roll they fill in serving indigent and undocumented patients?
• Seek out where stories in which ideology runs head-first into pragmatism. For example, very conservative Kern County California voted to accepted federal funds to expand Medicaid. How are politics reconciled with practice?

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