Story Originally Appeared in Bloomberg News
Prince William’s wife, Kate, cast aside British tradition when she picked the team that helped her deliver her baby yesterday.
Instead of turning to a midwife, the method provided by the National Health Service and used by Queen Elizabeth II, the Duchess of Cambridge followed the U.S. practice of having doctors on hand for the birth of the boy who will be third in line to the British throne.
The royal birth was supervised by Marcus Setchell, 69, who serves as the queen’s gynecologist, and Guy Thorpe-Beeston, 53, an obstetrician who practices at St. Mary’s Hospital in Paddington, central London, where Kate’s son was born yesterday. The baby, weighing 8 pounds, 6 ounces (3.8 kilograms), is heavier than the average weight of boys born in the U.K., which has risen about 2 ounces to about 7 pounds, 8 ounces since 1971.
Kate, the first woman from outside royalty or the aristocracy to marry so close to the throne for 350 years, probably picked what seemed like the safest approach for the high-profile birth of her first child, said Nancy Chescheir, an obstetrician at the University of North Carolina’s School of Medicine in Chapel Hill. Yet scientific evidence suggests a hospital delivery under the care of an obstetrician isn’t necessarily best for routine births.
A 2008 Cochrane Collaboration review found women who used midwives have fewer interventions such as caesarean sections and episiotomies to widen the vagina during delivery, said Holly Powell Kennedy, a midwife and professor at Yale University’s School of Nursing.
Not America
“We are all baffled as to why Kate is having an obstetrician,” Sheena Byrom, a midwife based near Preston in northern England, said in an interview before the birth. “It’s not like America.”
The Duchess of Cambridge’s decision to pay for private care has hit a nerve in a country where almost two-thirds of births are supervised by midwives, the only option covered by the government-run health service for low-risk births. Queen Elizabeth II delivered her four children at home with midwives, said Louise Silverton, director of midwifery at the Royal College of Midwives.
“It’s a cultural thing,” Silverton said. “I don’t wait for doctors to tell me what to do, I make my own decisions.”
Midwives focus on high-touch, low-tech deliveries that can yield better results at a lower cost for healthy women, particularly because they’re less likely to use unnecessary medical equipment, said Angela Ferrari, a certified nurse midwife from Massachusetts General Hospital in Boston.
The role of midwives is so established in the country that it’s inspired the popular British Broadcasting Corp. television series entitled “Call the Midwife.” Obstetricians tend to step in for high-risk pregnancies or when complications develop.
Family Event
In the U.S., the system for prenatal care and delivery is based on the mother’s preference for a midwife or an obstetrician, according to the University of North Carolina’s Chescheir. Certified nurse midwives, the primary type of midwife in the U.S., care only for low-risk pregnancies and are supervised by an obstetrician.
Chescheir, herself an expert in complex, high-risk deliveries, is a fan of midwives, who she says tend to be more holistic, foster less of a medical environment and create a family event. Midwives delivered almost 12 percent of the 2.65 million infants born vaginally in 2011 in the U.S., the most recent statistics available, according to the National Center for Health Statistics.
No Slight
“I don’t think British women should feel they are being slighted as long as they have access to obstetrical specialists if a problem arises,” said Meg Berreth, a midwife and instructor at the University of North Carolina at Chapel Hill. “A very brief perusal of literature would show you the average woman is getting exceptional, if not better care, with a midwife in the U.S. and Britain.”
Women can also get epidurals and pain medicine even if they are delivering with a midwife, according to Berreth.
“I don’t envy Kate Middleton,” she said, referring to the Duchess of Cambridge by her maiden name. “Every decision she makes becomes a statement.”
Some experts said it made sense for Kate to rely on an obstetrician, given the high-profile pregnancy and its accompanying stress, and risks that can quickly spiral out of control if a delivery starts to go wrong.
High Stakes
“I don’t like to think of one birth being any more important than another’s, but the stakes are extraordinarily high in this case,” Chescheir said. “When there is that much pressure on, it probably makes sense to have a lot of people on board. In obstetrics, when things go bad, they can go bad extraordinarily quickly.”
In the end, Kate made a personal decision choosing obstetricians over midwives, just as her late mother-in-law, Diana, did when she delivered both her boys in the same London hospital in the 1980s under doctor supervision.
“It’s very important that women feel safe during labor,” Berreth said. “For some women that means a hospital and for others that means a home.”
17 July 2013
Most health care records now are electronic
Originally Appeared in USA TODAY
An ever-expanding amount of the nation's medical records — millions of prescriptions, medical reports and appointment reminders — are now computerized and part of an ambitious electronic medical records program, the Obama administration reports.
Since the start of a 2011 program in which the government helps finance new health records systems, doctors or their assistants have filled more than 190 million prescriptions electronically, according to data provided by the Centers for Medicare & Medicaid Services.
Providers have also shared more than 4.3 million health care summaries with colleagues when patients change doctors, according to the data.
More than half of the nation's health care providers and more than 80% of hospitals now have electronic records.
"It has real-world implications for real-life patients," said Farzad Mostashari, a physician and national coordinator for health information technology with the Department of Health and Human Services.
The goals of electronic medical records include better and faster exchanges of information between doctors who share a patient, reducing duplication of tests and procedures, eliminating errors on prescriptions, and providing patients with quicker access to their own records.
The data also says that health care providers have delivered:
• More then 4.6 million electronic copies of health information to patients;
• More than 13 million reminders about appointments, required tests, or check-ups;
• More than 40 million checks on drug and medication interactions.
To date, the Obama administration has provided $15.5 billion to nearly 310,000 health care providers that have moved to "EHR," the government's term for electronic health records. The program was part of the 2009 stimulus bill.
The law also includes financial penalties for Medicare providers that do not move to electronic records, starting in 2015.
The transition to electronic medical records has not always been a smooth one.
Margret Amatayakul,a health information systems consultant in the Chicago area, said some providers have had a hard time deciding what kind of computer system might work best for them. She said installing and learning how to use new electronic systems take time, and some providers have had to use "a trial and error" approach.
"Overall, it's been a good thing," she said. "But we have to look at the lessons we're learning."
Mostashari said switching to electronic records is "a big change," and health care officials are willing to work with providers by supplying data and other forms of assistance.
"I can tell you one thing," Mostashari said. "Once they make the change, they'll never go back to paper."
A June report from the Centers for Medicare & Medicaid Services said that 4,024 hospitals — 80.3% of those eligible — have adopted an EHR system.
So have more than 305,000 health care professionals, 55.3% of the total.
An ever-expanding amount of the nation's medical records — millions of prescriptions, medical reports and appointment reminders — are now computerized and part of an ambitious electronic medical records program, the Obama administration reports.
Since the start of a 2011 program in which the government helps finance new health records systems, doctors or their assistants have filled more than 190 million prescriptions electronically, according to data provided by the Centers for Medicare & Medicaid Services.
Providers have also shared more than 4.3 million health care summaries with colleagues when patients change doctors, according to the data.
More than half of the nation's health care providers and more than 80% of hospitals now have electronic records.
"It has real-world implications for real-life patients," said Farzad Mostashari, a physician and national coordinator for health information technology with the Department of Health and Human Services.
The goals of electronic medical records include better and faster exchanges of information between doctors who share a patient, reducing duplication of tests and procedures, eliminating errors on prescriptions, and providing patients with quicker access to their own records.
The data also says that health care providers have delivered:
• More then 4.6 million electronic copies of health information to patients;
• More than 13 million reminders about appointments, required tests, or check-ups;
• More than 40 million checks on drug and medication interactions.
To date, the Obama administration has provided $15.5 billion to nearly 310,000 health care providers that have moved to "EHR," the government's term for electronic health records. The program was part of the 2009 stimulus bill.
The law also includes financial penalties for Medicare providers that do not move to electronic records, starting in 2015.
The transition to electronic medical records has not always been a smooth one.
Margret Amatayakul,a health information systems consultant in the Chicago area, said some providers have had a hard time deciding what kind of computer system might work best for them. She said installing and learning how to use new electronic systems take time, and some providers have had to use "a trial and error" approach.
"Overall, it's been a good thing," she said. "But we have to look at the lessons we're learning."
Mostashari said switching to electronic records is "a big change," and health care officials are willing to work with providers by supplying data and other forms of assistance.
"I can tell you one thing," Mostashari said. "Once they make the change, they'll never go back to paper."
A June report from the Centers for Medicare & Medicaid Services said that 4,024 hospitals — 80.3% of those eligible — have adopted an EHR system.
So have more than 305,000 health care professionals, 55.3% of the total.
16 July 2013
Four Drugmakers Face China Probes as Glaxo Woes Widen
Originally Appeared on Bloomberg
China is investigating at least four multinational drugmakers as it widens its probe of GlaxoSmithKline Plc (GSK), according to a lawyer in Hong Kong whose firm advises companies on cross-border anti-corruption.
The investigations point to an increased targeting of the pharmaceutical industry in corruption probes as the world’s most populous country faces rising health-care costs and seeks to lower drug prices. While the drugmakers are being examined by local regulators, the results may draw added questions from officials in Beijing and scrutiny by the U.S. government under the Foreign Corrupt Practices Act.
“We are aware of four pharmaceutical companies who are facing” investigation by local anti-corruption units, said the lawyer, Wendy Wysong, the head of anti-corruption practice in Asia-Pacific at law firm Clifford Chance. Wysong declined to identify the companies. Yesterday, Chinese officials said Glaxo used travel agencies as a conduit for bribes, that company executives received “sexual bribes,” and that other drugmakers have transferred money to the agencies.
“As to whether these companies are also involved in illegal dealings, you can go and ask them,” said Gao Feng, head of the economic crimes investigations unit at China’s Public Security Ministry. “Of course they won’t answer. But you can ask them one question: ‘Can you sleep well at night?’”
Gao didn’t identify the other companies linked financially to the travel agencies at a news conference yesterday. His comments were unusual, given that Chinese police rarely speak publicly to foreign media about ongoing investigations. The Glaxo case, Gao said, included bribes that went to “government officials, medical associations, hospitals and doctors.”
Drugmaker Target
China, the world’s fastest-growing market for medicines, has become an important target for the pharmaceutical industry as more and more best-selling therapies have gone off patent.
Glaxo’s revenue from China increased 17 percent last year to 759 million pounds ($1.1 billion), while product sales for London-based AstraZeneca rose 20 percent in China to $1.5 billion. Pfizer Inc. and Merck & Co., the two biggest U.S. drugmakers, together employ about 14,000 people in China. AstraZeneca, Pfizer and Merck haven’t been identified by China as targets of their probe.
Glaxo said in an e-mailed statement it is “deeply concerned and disappointed” and will stop using agencies identified in the probe. The drugmaker is reviewing all third-party agency relationships and will cooperate with Chinese authorities, according to the statement.
U.S. Act
The U.S. Foreign Corrupt Practices Act bars corporate employees or their agents from paying bribes to government officials to obtain or retain business or to secure an improper advantage. Glaxo is among several drugmakers that have already been contacted by U.S. authorities in an ongoing industrywide probe into possible violations of the act. That Glaxo probe, begun in 2010, covers practices in countries that include China, according to the company’s 2012 annual report.
AstraZeneca, in its 2012 annual report, also said it is investigating indications of inappropriate conduct in countries that include China. The company said it received inquiries from U.S. authorities related to “among other things, sales practices, internal controls, certain distributors and interactions with health-care providers and other government officials in several countries.”
“This is an ongoing matter and AstraZeneca is co-operating with the inquiries,” Esra Erkal-Paler, a spokeswoman for London-based AstraZeneca said in an e-mail, referring to the U.S. inquiry. “We have no update to provide at this time.”
China President
In China, President Xi Jinping has vowed to combat official corruption since becoming head of the Communist Party in November. At the same time the country has been moving aggressively to get drugmakers to lower prices as it prepares to widen health coverage, with the top economic planning agency probing the costs and prices of 60 drugmakers including Glaxo, Merck, Novartis AG and Baxter International Inc.
Foreign drugmakers in regular contact with Chinese officials overseeing the health system are an obvious target for anti-corruption probes, said Willy Wo-Lap Lam, an adjunct professor at the Chinese University of Hong Kong who studies the politics of that country.
“The medical system is a disaster zone when it comes to high-level corruption,” Lam said in a telephone interview. “Since they instituted the anti-corruption campaign, areas of abuse within the medical system could be targets.”
Regulatory Agencies
In China, every province and city have local agencies that regulate commercial activity. These units, formally known as the Administration for Industry and Commerce, or AIC, hold broad powers to investigate possible malfeasance, seize evidence and impose financial penalties without a warrant, according to a note from consulting firm Control Risks. They also have the authority to order the disgorgement of profits earned through unfair commercial practices.
In some cases, if a company operates in more than one community, a probe can begin in one jurisdiction and spread to others, with the different AIC branches exchanging information, said Wysong, who wasn’t commenting specifically on Glaxo.
Finding by these local agencies could trigger further scrutiny under the U.S. foreign practices act, said Sam Williamson, a partner who specializes in anti-corruption law at the Shanghai offices of Kirkland & Ellis LLP.
The settlement of AIC corruption charges “could have significant implications back in the U.S.,” said Williamson, a former U.S. prosecutor. The Justice Department is “familiar with the AICs and often ask companies questions about this -- for example what AIC investigations a company has had and how did they play out.”
‘Most Shocked’
China may also take its cues from the U.S. At yesterday’s press conference, the Chinese investigator Gao mentioned Glaxo’s 2011 agreement to pay $3 billion to settle U.S. claims the company marketed drugs for unapproved uses and other matters.
“We were most shocked” by the settlement, Gao said. “At the time, we were very puzzled as to what actually happened at the company and, through our investigations, we have found the answer.”
Whistle-blowers can also drive investigations by anti-corruption agencies, said Kelly Austin, partner-in-charge of the Hong Kong offices of law firm Gibson, Dunn & Crutcher.
“Sometimes they’re started by a whistle-blower, sometimes by a disgruntled competitor, and sometimes it can be a result of their own enforcement action,” Austin said in an interview.
Police Investigation
The Glaxo probe is a result of police investigations, not a whistle-blower’s complaint, Gao said at the press conference.
Half of all the overseas bribery cases settled last year involved activity conducted in Asia Pacific, according to the U.S. Securities and Exchange Commission’s website.
Glaxo’s troubles in China began surfacing last month. The company spent four months investigating a whistleblower’s claims of corruption and bribery at its China business. Glaxo said that it found no evidence of wrongdoing. That same week, Glaxo fired its head of Chinese research and development after finding that a paper he helped write for a medical journal contained data that had been misrepresented, according to the company.
A police investigation followed. China detained four senior Glaxo executives on suspicion of economic crimes involving 3 billion yuan ($489 million) of spurious travel and meeting expenses, and receiving sexual favors.
The alleged offenses date to 2007 and involved 700 travel agencies, Gao said at yesterday’s briefing. The ministry has been handling the Glaxo case for more than half a year following police investigations, Gao said.
China’s probe of drugmakers will probably continue to expand, said Lam of the Chinese University of Hong Kong.
“We are only at the beginning of an anti-corruption campaign which will last for at least one year,” Lam said.
China is investigating at least four multinational drugmakers as it widens its probe of GlaxoSmithKline Plc (GSK), according to a lawyer in Hong Kong whose firm advises companies on cross-border anti-corruption.
The investigations point to an increased targeting of the pharmaceutical industry in corruption probes as the world’s most populous country faces rising health-care costs and seeks to lower drug prices. While the drugmakers are being examined by local regulators, the results may draw added questions from officials in Beijing and scrutiny by the U.S. government under the Foreign Corrupt Practices Act.
“We are aware of four pharmaceutical companies who are facing” investigation by local anti-corruption units, said the lawyer, Wendy Wysong, the head of anti-corruption practice in Asia-Pacific at law firm Clifford Chance. Wysong declined to identify the companies. Yesterday, Chinese officials said Glaxo used travel agencies as a conduit for bribes, that company executives received “sexual bribes,” and that other drugmakers have transferred money to the agencies.
“As to whether these companies are also involved in illegal dealings, you can go and ask them,” said Gao Feng, head of the economic crimes investigations unit at China’s Public Security Ministry. “Of course they won’t answer. But you can ask them one question: ‘Can you sleep well at night?’”
Gao didn’t identify the other companies linked financially to the travel agencies at a news conference yesterday. His comments were unusual, given that Chinese police rarely speak publicly to foreign media about ongoing investigations. The Glaxo case, Gao said, included bribes that went to “government officials, medical associations, hospitals and doctors.”
Drugmaker Target
China, the world’s fastest-growing market for medicines, has become an important target for the pharmaceutical industry as more and more best-selling therapies have gone off patent.
Glaxo’s revenue from China increased 17 percent last year to 759 million pounds ($1.1 billion), while product sales for London-based AstraZeneca rose 20 percent in China to $1.5 billion. Pfizer Inc. and Merck & Co., the two biggest U.S. drugmakers, together employ about 14,000 people in China. AstraZeneca, Pfizer and Merck haven’t been identified by China as targets of their probe.
Glaxo said in an e-mailed statement it is “deeply concerned and disappointed” and will stop using agencies identified in the probe. The drugmaker is reviewing all third-party agency relationships and will cooperate with Chinese authorities, according to the statement.
U.S. Act
The U.S. Foreign Corrupt Practices Act bars corporate employees or their agents from paying bribes to government officials to obtain or retain business or to secure an improper advantage. Glaxo is among several drugmakers that have already been contacted by U.S. authorities in an ongoing industrywide probe into possible violations of the act. That Glaxo probe, begun in 2010, covers practices in countries that include China, according to the company’s 2012 annual report.
AstraZeneca, in its 2012 annual report, also said it is investigating indications of inappropriate conduct in countries that include China. The company said it received inquiries from U.S. authorities related to “among other things, sales practices, internal controls, certain distributors and interactions with health-care providers and other government officials in several countries.”
“This is an ongoing matter and AstraZeneca is co-operating with the inquiries,” Esra Erkal-Paler, a spokeswoman for London-based AstraZeneca said in an e-mail, referring to the U.S. inquiry. “We have no update to provide at this time.”
China President
In China, President Xi Jinping has vowed to combat official corruption since becoming head of the Communist Party in November. At the same time the country has been moving aggressively to get drugmakers to lower prices as it prepares to widen health coverage, with the top economic planning agency probing the costs and prices of 60 drugmakers including Glaxo, Merck, Novartis AG and Baxter International Inc.
Foreign drugmakers in regular contact with Chinese officials overseeing the health system are an obvious target for anti-corruption probes, said Willy Wo-Lap Lam, an adjunct professor at the Chinese University of Hong Kong who studies the politics of that country.
“The medical system is a disaster zone when it comes to high-level corruption,” Lam said in a telephone interview. “Since they instituted the anti-corruption campaign, areas of abuse within the medical system could be targets.”
Regulatory Agencies
In China, every province and city have local agencies that regulate commercial activity. These units, formally known as the Administration for Industry and Commerce, or AIC, hold broad powers to investigate possible malfeasance, seize evidence and impose financial penalties without a warrant, according to a note from consulting firm Control Risks. They also have the authority to order the disgorgement of profits earned through unfair commercial practices.
In some cases, if a company operates in more than one community, a probe can begin in one jurisdiction and spread to others, with the different AIC branches exchanging information, said Wysong, who wasn’t commenting specifically on Glaxo.
Finding by these local agencies could trigger further scrutiny under the U.S. foreign practices act, said Sam Williamson, a partner who specializes in anti-corruption law at the Shanghai offices of Kirkland & Ellis LLP.
The settlement of AIC corruption charges “could have significant implications back in the U.S.,” said Williamson, a former U.S. prosecutor. The Justice Department is “familiar with the AICs and often ask companies questions about this -- for example what AIC investigations a company has had and how did they play out.”
‘Most Shocked’
China may also take its cues from the U.S. At yesterday’s press conference, the Chinese investigator Gao mentioned Glaxo’s 2011 agreement to pay $3 billion to settle U.S. claims the company marketed drugs for unapproved uses and other matters.
“We were most shocked” by the settlement, Gao said. “At the time, we were very puzzled as to what actually happened at the company and, through our investigations, we have found the answer.”
Whistle-blowers can also drive investigations by anti-corruption agencies, said Kelly Austin, partner-in-charge of the Hong Kong offices of law firm Gibson, Dunn & Crutcher.
“Sometimes they’re started by a whistle-blower, sometimes by a disgruntled competitor, and sometimes it can be a result of their own enforcement action,” Austin said in an interview.
Police Investigation
The Glaxo probe is a result of police investigations, not a whistle-blower’s complaint, Gao said at the press conference.
Half of all the overseas bribery cases settled last year involved activity conducted in Asia Pacific, according to the U.S. Securities and Exchange Commission’s website.
Glaxo’s troubles in China began surfacing last month. The company spent four months investigating a whistleblower’s claims of corruption and bribery at its China business. Glaxo said that it found no evidence of wrongdoing. That same week, Glaxo fired its head of Chinese research and development after finding that a paper he helped write for a medical journal contained data that had been misrepresented, according to the company.
A police investigation followed. China detained four senior Glaxo executives on suspicion of economic crimes involving 3 billion yuan ($489 million) of spurious travel and meeting expenses, and receiving sexual favors.
The alleged offenses date to 2007 and involved 700 travel agencies, Gao said at yesterday’s briefing. The ministry has been handling the Glaxo case for more than half a year following police investigations, Gao said.
China’s probe of drugmakers will probably continue to expand, said Lam of the Chinese University of Hong Kong.
“We are only at the beginning of an anti-corruption campaign which will last for at least one year,” Lam said.
01 July 2013
Prognosis varies for self-insured under health law
Originally Appeared in USA TODAY
Gail Harriman's health insurance costs rose four times in slightly more than two years, from $550 a month to $1,171, an amount "more than my mortgage." But when the self-employed San Francisco resident tried to switch insurers, she was rejected because of a minor health problem.
Harriman, 60, is among the estimated 15 million Americans who buy their own insurance and face far bigger hurdles getting and keeping it than those with job-based coverage.
"Most people who work for a company have absolutely no clue about what goes on with people who buy their own insurance," said Harriman. "I would never consider going without. But there have been moments when I feel it's the bane of my existence."
Most of the debate on how the law will change the individual market has centered on whether consumers will experience "rate shock" from higher premiums when key changes go into effect next year. But there's a flip side: New rules that broaden benefits prohibit discrimination against those with health issues and cap consumers' out-of-pocket costs, which can cut far deeper than premiums.
Currently, about one in five plans sold to consumers makes them responsible for at least half their medical costs after they've paid premiums and met deductibles, according to an analysis of government data by U.S. News & World Report and Kaiser Health News. It could not be determined how many consumers have such plans.
"The individual market before and after Jan. 1 will be fundamentally different places," said Robert Laszewski, a former insurance executive who now consults for the industry.
Get a break or pay more
The new rules bar insurers from rejecting applicants with health problems, set limits on how much more they can charge older residents and require most Americans to carry coverage or face a fine.
Whether individuals will be better or worse off under those rules depends on their age, health status, where they live — and perhaps most important, whether they end up needing substantial medical care in the coming year.
Generally speaking, those who are younger and healthier will pay more than they would have in the old market, while older and sicker people are likely to be better off.
Coverage under the health law will still require cost-sharing, potentially running into thousands of dollars. But those amounts will be clearly laid out — helping those who now "might buy insurance that looks cheap, but when they get sick, they realize they didn't read all the fine print, and it doesn't cover what they thought it did," said Uwe Reinhardt, a Princeton economics professor.
The single biggest change is that insurers will no longer be able to reject people with health problems or charge them more based solely on their health history — a practice that has effectively barred some people from the market, and prevented others from being able to switch plans.
Insurers were already forbidden from doing that to enrollees in group health plans, such as those sold to employers.
The change will be a huge relief for Maureen Mitchell, 58, of St. Augustine, Fla., who has spent most of the past decade uninsured after being rejected for coverage because of a heart rhythm abnormality.
Last September, Mitchell awoke with a stabbing pain in her chest and did a mental calculation: If she called for help, she would face large bills for hospital care and the ambulance ride. If she didn't call, she might die. "I just didn't have that money," said Mitchell, who did not call 911.
Deductions from deductibles
The law will also put limits on high-deductible policies such as those chosen by Laurie Simons, 62, and Mary McVey, 50 — meaning they pay significant sums out of their own pockets before their coverage kicks in.
Starting in January, new policies must cap annual "out-of-pocket" costs, which include deductibles and co-insurance payments, to about $6,350 for an individual, or $12,700 for a family — amounts that could still be a stretch for many consumers.
"There aren't that many Americans who have that kind of cash just sitting around," said Karen Pollitz of the Kaiser Family Foundation.
Nonetheless, the law's caps will reduce the cost-sharing in many plans currently sold, including those purchased by Simons and McVey.
Almost a third of plans currently offered to consumers exceed those caps, according to the U.S. News/Kaiser Health News analysis.
When Simons, a self-employed mental health counselor in Portland, Maine, switched to a high-deductible plan to reduce her monthly costs, she was healthy. But earlier this year, she was diagnosed with melanoma. Now, she must find $11,000 to pay for her surgery.
"If you don't have money, I don't know what you do," Simons said.
She hopes that next year, she can buy coverage that would protect her against five-figure medical bills
McVey, on the other hand, wants to keep her current policy, saying she is not willing to pay much more than her current $500 per month premium for a family of five. The self-employed accountant in Cape Elizabeth, Maine, has a policy that carries a $15,000 deductible, which could rise to $30,000 if two or more family members fall seriously ill in the same year.
McVey acknowledges she's been lucky that no one in her family has ever faced serious medical problems. She hardly ever goes to the doctor, she said, and offers cash when she does, hoping for a discount. While she would love "a health policy where I don't have to pay $700 to get a checkup for my kids," she said she would not like it if the trade-off is higher premiums.
"Paying $1,200 or more a month for health insurance seems like craziness," she said.
Steve Sternberg and Chris Young of U.S. News & World Report contributed to this report by Kaiser Health News, an editorially independent program of the Henry J. Kaiser Family Foundation, a non-profit, non-partisan health policy research and communication organization not affiliated with Kaiser Permanente.
Gail Harriman's health insurance costs rose four times in slightly more than two years, from $550 a month to $1,171, an amount "more than my mortgage." But when the self-employed San Francisco resident tried to switch insurers, she was rejected because of a minor health problem.
Harriman, 60, is among the estimated 15 million Americans who buy their own insurance and face far bigger hurdles getting and keeping it than those with job-based coverage.
"Most people who work for a company have absolutely no clue about what goes on with people who buy their own insurance," said Harriman. "I would never consider going without. But there have been moments when I feel it's the bane of my existence."
Most of the debate on how the law will change the individual market has centered on whether consumers will experience "rate shock" from higher premiums when key changes go into effect next year. But there's a flip side: New rules that broaden benefits prohibit discrimination against those with health issues and cap consumers' out-of-pocket costs, which can cut far deeper than premiums.
Currently, about one in five plans sold to consumers makes them responsible for at least half their medical costs after they've paid premiums and met deductibles, according to an analysis of government data by U.S. News & World Report and Kaiser Health News. It could not be determined how many consumers have such plans.
"The individual market before and after Jan. 1 will be fundamentally different places," said Robert Laszewski, a former insurance executive who now consults for the industry.
Get a break or pay more
The new rules bar insurers from rejecting applicants with health problems, set limits on how much more they can charge older residents and require most Americans to carry coverage or face a fine.
Whether individuals will be better or worse off under those rules depends on their age, health status, where they live — and perhaps most important, whether they end up needing substantial medical care in the coming year.
Generally speaking, those who are younger and healthier will pay more than they would have in the old market, while older and sicker people are likely to be better off.
Coverage under the health law will still require cost-sharing, potentially running into thousands of dollars. But those amounts will be clearly laid out — helping those who now "might buy insurance that looks cheap, but when they get sick, they realize they didn't read all the fine print, and it doesn't cover what they thought it did," said Uwe Reinhardt, a Princeton economics professor.
The single biggest change is that insurers will no longer be able to reject people with health problems or charge them more based solely on their health history — a practice that has effectively barred some people from the market, and prevented others from being able to switch plans.
Insurers were already forbidden from doing that to enrollees in group health plans, such as those sold to employers.
The change will be a huge relief for Maureen Mitchell, 58, of St. Augustine, Fla., who has spent most of the past decade uninsured after being rejected for coverage because of a heart rhythm abnormality.
Last September, Mitchell awoke with a stabbing pain in her chest and did a mental calculation: If she called for help, she would face large bills for hospital care and the ambulance ride. If she didn't call, she might die. "I just didn't have that money," said Mitchell, who did not call 911.
Deductions from deductibles
The law will also put limits on high-deductible policies such as those chosen by Laurie Simons, 62, and Mary McVey, 50 — meaning they pay significant sums out of their own pockets before their coverage kicks in.
Starting in January, new policies must cap annual "out-of-pocket" costs, which include deductibles and co-insurance payments, to about $6,350 for an individual, or $12,700 for a family — amounts that could still be a stretch for many consumers.
"There aren't that many Americans who have that kind of cash just sitting around," said Karen Pollitz of the Kaiser Family Foundation.
Nonetheless, the law's caps will reduce the cost-sharing in many plans currently sold, including those purchased by Simons and McVey.
Almost a third of plans currently offered to consumers exceed those caps, according to the U.S. News/Kaiser Health News analysis.
When Simons, a self-employed mental health counselor in Portland, Maine, switched to a high-deductible plan to reduce her monthly costs, she was healthy. But earlier this year, she was diagnosed with melanoma. Now, she must find $11,000 to pay for her surgery.
"If you don't have money, I don't know what you do," Simons said.
She hopes that next year, she can buy coverage that would protect her against five-figure medical bills
McVey, on the other hand, wants to keep her current policy, saying she is not willing to pay much more than her current $500 per month premium for a family of five. The self-employed accountant in Cape Elizabeth, Maine, has a policy that carries a $15,000 deductible, which could rise to $30,000 if two or more family members fall seriously ill in the same year.
McVey acknowledges she's been lucky that no one in her family has ever faced serious medical problems. She hardly ever goes to the doctor, she said, and offers cash when she does, hoping for a discount. While she would love "a health policy where I don't have to pay $700 to get a checkup for my kids," she said she would not like it if the trade-off is higher premiums.
"Paying $1,200 or more a month for health insurance seems like craziness," she said.
Steve Sternberg and Chris Young of U.S. News & World Report contributed to this report by Kaiser Health News, an editorially independent program of the Henry J. Kaiser Family Foundation, a non-profit, non-partisan health policy research and communication organization not affiliated with Kaiser Permanente.
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