Is that what the Department of Health and Human Services doing in their denial of a request to have special, continual open enrollment for a new qualifying life event of pregnancy?
The Department of Health and Human Services has denied a request from Democrats to create an open enrollment period under the Affordable Care Act for women when they find out they are pregnant, The Hill reported. Secretary Sylvia Matthews Burwell said HHS does not have “the legal authority to establish pregnancy as an exceptional circumstance.”
I am not a lawyer and I don’t even play one on the internet, so I’ll defer to the legal interpretation but I completely understand from a policy perspective why HHS does not want to go this route for Exchanges.
Pregnancies are common, and moderately expensive on a per-event basis ($8,000 to $15,000 for non-complicated pregnancies). A reasonably high level of people know if there is a reasonable chance of their being pregnant in the next year as all guys, women of a certain age over 45, women with tubal ligation etc all know that they can’t get pregnant. Within the pool of women who could be potentially pregnant, there is a reasonably decent intuition as to who may or may not get pregnant. For instance, I know my sister-in-law is wearing my brother out right now trying to get pregnant. My younger sister has no intention of being pregnant this year. Pregnancy is a very straight forward adverse selection problem.
If there is continual open enrollment on the private insurer Exchange policies, either there will be a pricing problem as the policies get more expensive as the women who only got insurance because they thought there was a decent chance of pregnancy in the policy year opt out en masse and then only the pregnant women re-enroll which makes the net risk pool more expensive on average or health plans will race to the bottom and offer as unattractive maternity care options as possible so as to shift the health risk to another insurer that offers a decent network with decent co-insurance.
The Democrats who requested a special enrollment period identified a real policy problem. Every pregnant woman should receive good pre-natal care, and a childbirth should not be a financial crisis for a family. However, the appropriate policy response in a rational political world would be to expand Medicaid coverage to make pregnancy an automatic qualifier with full federal funding as the back-stop of private insurance. Medicaid does not care about adverse selection, so it can handle constant spike claims without destroying the rest of the program.
brantl
Only when it’s intentional, consensual, and planned.
beth
I can see the logic behind this; after all you wouldn’t have a special cardiac open enrollment for heart attack victims but shouldn’t all this be covered under the ACA anyway? if everyone is supposed to obtain coverage what women does this affect? Is this meant for poor women in red states who can’t get Medicaid but can’t afford private insurance? If so, just one more way we screw the poor in this country.
Richard Mayhew
@beth: For someone who is in a non-Medicaid expansion state, they were already screwed as they are making under 100% FPL (someone at 100% FPL gets Enhanced Silver at 94% AV and 2% family income)…My guess is that this is targeted at women who make between 151% FPL and 300% FPL (that is where cost sharing subsidies go down, policy prices go up, and likelihood of employer sponsored insurance is iffy)
@brantl: On an individual basis, I completely agree with you, on an aggregate basis, pregnancy is a fairly easy statistical problem.
Fred
The more I read about ACA the more I think Americans all need to get a masters in health insurance. And also reduce work hours to part time so everybody can devote 20 hours a week to shopping for insurance.
I’m so glad I live in a sane country where health care is taken for granted and we just pay our taxes. The taxes are high but not as high as healthcare is in America.
Single payer is the only solution and the cheapest.
WereBear
Richard has schooled us all so well I understood that whole thing.
Wow.
JPL
The law won’t be tweeked until the democrats regain control of the house and senate.
Robert Sneddon
@Fred: They also need to spend another ten hours a week keeping up with the continuous changes and alterations to the assorted schemes, rates, qualifying periods, earnings levels, State variations, HSAs and other complexities that encumber the US health system.
As a British person covered by the NHS I look askance at the other European systems of public/private healthcare which are held up by USians as improved models of healthcare delivery to customers and my mind boggles — insurance cards, co-pays, annual fees, different insurance companies regulated by law etc. Why?
The NHS = you’re covered. No cards, no co-pays, no dancing around with public/private insurance, no annual fees etc. It might be I’ve got the idea that this level of simplicity is best since I’ve never known anything else but it seems that way. Is it the case that spending some effort (a few dozen hours a year, maybe) digging through various options does actually improve a person’s or family’s healthcare over a simple “you’re covered” system like the NHS?
Iowa Old Lady
@beth: Right. I thought “qualifying events” were supposed to be those in which you lost the health insurance you already had because you retired or divorced or whatever. You had to change insurance.
But you’re supposed to have it.
Unless you’re poor and your politicians are merrily refusing Medicaid because Kenyan secret Muslim.
Baud
@Robert Sneddon:
I would think it depends on how much coverage you get under the national health care program. In the U.S., where people have to spend a significant portion of their personal income for insurance, some level of choice may be preferable that a single pricing model. If coverage is very good and people don’t have to think about how to spend their money, however, the NHS model would be better.
Aleta
Women over 45 have been getting pregnant since before I was born.
rikyrah
interesting post, and it seems to be a bad decision that didn’t need to be made.
My great grandmother had my grandmother at 46
My grandmother had my mother at 44
My mother had me at 40
what world do these people live in?
Richard Mayhew
@rikyrah: Should I rephrase it to women over a certain age….
Robert Sneddon
@Baud: British folks can spend more money and buy medical services and insurance if they wish. Friends of mine have spent large amounts for private treatment outside the NHS (pardon me if I don’t go into details) but they are upper/middle-class and earning very good money and chose to do so for what they believe were good reasons.
I have an irregular income between periods of unemployment and the NHS is always there for me providing a very good baseline level of service. I couldn’t afford to “go private” as they say and given my excellent health up till now there was no real point in making financial sacrifices to do so.
When I am working I pay taxes, part of which is called National Insurance (NI). It’s a percentage of my earnings before tax, topped up with matching funds from my employer. The NI contributions are not ring-fenced in any way, it all goes into the Big Pot of Money the government uses to fund everything including the NHS. When I’m not earning and not paying NI I’m also covered by the NHS in exactly the same way I’ll be covered when I retire with no Medicare/Medicaid split to deal with. The simplicity of the NHS system makes up for a lot in my eyes — no co-pays, no age limits, no pre-existing conditions to worry about since it covers everyone from pre-natal to grave.
schrodinger's cat
@Robert Sneddon: I was watching BBC World News on PBS yesterday and they did a segment on the upcoming elections. Most of it went straight over my head, they devoted a fairly large part of the coverage on NHS, Katy Kay called it the national religion. So what’s the deal, is Cameron’s party going to win again? And have they proposed making changes to the NHS.
schrodinger's cat
Haven’t the pregnant women already been screwed?
Cervantes
@schrodinger’s cat:
“Nixon’s the One!”
Blue Galangal
@WereBear:
I wanted to just say I concur heartily. Thank you, Richard.
Alex
Pregnant women are eligible for Medicaid up to 250% or more of Federal Poverty level in 10 states and DC, from 200-250% in 22 states, and 138 to 200% in the remaining 18 states. As a result, Medicaid covers 40% of births in the US. http://kff.org/medicaid/fact-sheet/where-are-states-today-medicaid-and-chip/
It’s not universal coverage for pregnant women, but it is more generous than the ACA Medicaid expansion in most states, and it covers even states that didn’t expand Medicaid under the ACA.
Robert Sneddon
@schrodinger’s cat:
Yes no maybe sort-of but Cameron is probably not going to be the next Prime Minister. The polls suggest neither Labour nor the Conservatives will have an overall majority on May 8th. The Lib Dems might go into a formal coalition[1] again with the Tories but that probably still wouldn’t produce a majority. The SNP who are looking to make big gains this election won’t ally with the Tories under any circumstances. They WILL support a Labour government on supply and confidence votes (budget proposals and a new election if the government loses the confidence of the House, basically) in return for a shopping list of demands.
Everybody proposes making changes to the NHS because The Other Side has been doing it All Wrong. Right now the parties are in the “throw extra money at the NHS!” phase of their pleading for votes. I expect they’ll soon move towards reorganisation, reducing waste (a perennial, this one), more doctors and nurses (see “throw money…” pledges), reducing waiting times etc. etc. Somehow even if all the pledges are met the Other Side will claim it’s not enough and They would do better. Step and repeat.
No-one, and I mean NO-ONE in the UK political sphere messes with the NHS. It’s like the War Department in the US.
[1]The Deputy PM is Nick Clegg of the Lib Dems. It’s possible he’ll lose his seat to the SNP this time around, not because he’s not popular with his constituents but the SNP are on a roll and the electoral boundaries have shifted.
Steve
Here’s a novel idea, don’t get pregnant is you can’t afford to pay for it.
Barbara
To what Alex said — Medicaid comes as close to being universal for pregnant women as it does for any other population. It’s even higher than 250% of the FPL in a few states (Maine and Vermont, I think, or it used to be). So this means that many women who might have qualified for an exchange plan, even one with subsidies, will easily qualify for Medicaid for services related to their pregnancy and delivery.
Cervantes
@Robert Sneddon:
Seems to me Labour is committing to (and not only paying lip service to) (horrible, Thatcherite) Tory sentiments and policies — and losing support to the SNP, Plaid Cymru, and others. I don’t see how it’s a winning strategy, either.
CONGRATULATIONS!
THIS POST WAS NOT AT ALL WHAT I THOUGHT IT WAS GOING TO BE
Fr33d0m
There seems a bit of a difference between “a decent chance” and “find out they are.” I don’t think age or any other factor other than a doctors diagnosis is considered a qualifying event and the whole point is that women who get proper care during their pregnancy have healthier kids–which seems like a cost savings over the long haul. Also, Don’t you pay extra taxes if you don’t have insurance that at least theoretically helps balance-out the risk pool?
Bobby B
There was an episode of “Louis” last week that dealt with this fraught matter.
Richard Mayhew
@Steve: Do you support policies to make sure every woman has access to extremely affordable/free contraception, abortion on demand without hassle, and policies that allow people to appropriately balance work/life/family committments?
If yes, then you’re just amazingly insensisitive and classist
If no, STFU
Richard Mayhew
@CONGRATULATIONS!: I try
Steve
Richard. In a word, no.
Steve
And just to clarify I support the stunningly novel idea, again, that if you can’t afford to have a child, don’t get pregnant.
Ruckus
@Robert Sneddon:
I think that maybe the closest thing we have in the US to NHS is the VA. There is still a qualified class (military vets and not all of them) but once enrolled (OK if your income goes above a set level, not so much) you get covered.
To answer your question, yes it is easier and yes it would cost less. Of course because it costs less people here question how could the service be as good. The entire system of health care that we have is screwed up. But it is what we have and changing that completely is not going to happen.
Fixing the big problems, getting most if not all into the system, controlling costs at least somewhat, these are things that are being done. And you are correct that having several systems, Medicare, Medicaid, VA, employer provided, open market is very ineffective. But then I follow the KISS methodology, Keep It Simple, Stupid. Every layer, every restriction, these are all cost increasing layers. And in a country that at least used to spout equality, noting is equal in US healthcare.
Richard Mayhew
@Steve: So you are arguing that poor people should not have sex at all, and therefore you live in lala land where evidence does not need to come into play… good to know
Ruckus
@Steve:
You are proving to be one complete fucking idiot.
Maybe you should stop while you are behind.
Barbara
@Fr33d0m: As a female, I have two thoughts. The first is, I want all babies to be well taken care of, including in utero. On the other hand, as a woman, I find it irritating to implement policies or exceptions based on the notion that women can’t be expected to behave like adults, especially when those exceptions could exacerbate a problem that is already making the ACA less robust than it should be (people not getting coverage based on the assumption they don’t really need it). Women and men alike were supposed to sign up for exchange coverage, and although I think the consequences to young children might be greater if a woman doesn’t and then realizes that, oops, my risk calculus was not what I thought it would be, still, what message does it send to women — that they can sit back and not sign up but still get coverage if they REALLY need it. The fact that most of these women will qualify for Medicaid and that SOME might have to pay some expenses out of pocket seems to me to be an okay result.
SA
@rikyrah:
It’s not about being coy about a woman’s age or her fertility. “Women over 45 … know that they can’t get pregnant” is not accurate. Babies born to unwilling women and/or serious health risks have resulted from assuming infertility too early.
Robert Sneddon
@Ruckus: Well you could describe the VA as being like the NHS, that is if the NHS had a in/out qualification system like the VA, if the NHS required people to register to be treated like the VA, if it required changing documents and paperwork if you move home like the VA, if you had to make co-pays for incidental items like the VA, if there was a financial test for VA treatment, if pre-existing conditions from before service disqualified you from free treatment for them, if if if…
“You’re covered”. That’s the NHS. No bullshit paperwork, no exceptions, no qualifications, no co-pays. Turn up, get examined, get treated, goodbye, see you next time. Heck, in Scotland even medical prescriptions don’t cost you anything, and England is moving that way.
Ruckus
@Robert Sneddon:
Why I said closest, not like. And you left out it’s a pretty small subset of the population. The total pool of possibly eligible is something like 8% or less, rather than 100% of the population.
Steve
Richard, I’m not arguing poor people should have sex. They can. And they can probably figure out how to do it in a way so as to not get pregnant and not have somebody else but themselves pay for it. It’s really not that hard. No pun intended.
Steve
Sorry… Shouldn’t have sex.
Mnemosyne (tablet)
@Steve:
If you’ve figured out a 100 percent effective means of contraception that still allows people to have sex, you know more than the scientists who have been working on the problem for hundreds of years. Vasectomies and tubal ligation can reverse themselves. The pill is 99 percent effective even when taken perfectly.
So, please, if you have a method by which people can have sex and be 100 percent certain it will not result in a pregnancy, make sure to share it with the rest of us. Until then, you can have a chat with my friend and her “Pill baby,” or explain to my cousin why it was her fault her Depo-Provera shot failed.
Oh, and both of those women were married at the time of their unplanned pregnancies so, again, explain what magic alternatives married people have other than having a celibate marriage.
Ruckus
@Mnemosyne (tablet): It seems like a lot of work to add up all the things that Steve knows nothing about. The only positive thing is that he is willing to let us know each and every area so we can keep score.
Cervantes
@Steve:
I see you don’t like the government using your money going to help other people — or is it just the poor? Do you know how much you spend on government subsidies given to corporations? Which do you think is the larger amount?
Steve
I never posited that prevention was 100 percent effective. But the effort and awareness to not have children if you cannot afford them is. And if you fail, I understand. But don’t ask me to pay for your issue.
Steve
Cervantes, corporations employ what? People?
Katy
@Steve: Just theoretically, is it possible that after a pregnancy commenced – THEN a woman and/or her beloved lost her job?