Seventeen year old Paxton Enstad, a transgender male, sought chest-reconstruction surgery as part of his gender dysphoria treatment. When his parents, Cheryl and Mark Enstad, sought to obtain pre-authorization for the surgery, PeaceHealth St. Joseph Medical Center, a Catholic organization, denied the services without offering a rationale as to why it was denied.
The Enstads filed suit in U.S. District Court, claiming that PeaceHealth’s refusal to cover the services violates the Affordable Care Act (“ACA”) and the State of Washington’s anti-discrimination laws. Specifically, they claim that the refusal to authorize the surgery enforces gender stereotypes and amounts to gender discrimination.
In an article dated February 28, 2017, the author discussed a GOP plan to make health insurance more portable by allowing consumers to take their plans with them if they move, retire, or change jobs. Although a popular idea for many, it does present some structural concerns due to the setup of insurance markets and networks.
From NPR, “What If You Could Take It With You? Health Insurance, That Is”
Except from the article:
“To be truly portable, consumers must be offered plans regardless of their health status, age or other considerations. Before the health law was enacted, insurers could reject people with medical conditions. But the ACA prohibits insurers from redlining sick people or charging them higher premiums. Although popular in opinion polls, those Obamacare provisions may face some changes under the GOP plans.”
Since the implementation of the Affordable Care Act (“ACA”), millions of Americans have enrolled in Medicaid. However, the government has not ensured that the new beneficiaries will have access to doctors. In fact, many Medicaid recipients are finding that they have to wait months due to shortages of doctors who accept Medicaid. Daniel R. Levinson, the inspector general of the Department of Health and Human Services, blames the lack of access on variations in standards between states. More specifically, most states rely on private insurance companies to comply with Federal rules in providing Medicaid beneficiaries with “adequate access to all services covered.” However, “adequate” is defined by each state. Some states opt for a “time and distance” standard for access, others set a maximum number of days a patient may have to wait to see a doctor, and some base the standard on a doctor/patient ratio. The result has left many Medicaid patients waiting up to 60 days to see a specialist, while others are forced to travel great distances because their state only requires one primary care provider for every 2,500 beneficiaries.
Mr. Levinson believes that the federal government should be more involved in developing and enforcing state standards of access. However, insurance companies worry that if the federal government forces a larger pool of doctors who accept Medicaid, it will upset the low premiums resulting from insurers limiting access.
According to an anonymous source working for Health and Human Services, a “malicious code” was inserted into the healthcare.gov website in July. The website contains personal information about millions of Americans who purchased health insurance following implementation of the Affordable Care Act. Although it appears that no personal information was compromised, the hacker bypassed the website’s security in an attempt to control the website during future attacks, raising concerns about the website’s vulnerability.
Other than carve outs for pregnancies caused by rape, incest, or where the life of the mother is in jeopardy, the Affordable Care Act prohibits the use of taxpayer funds for abortions. However, a recent report issued by the Government Accountability Office asserts that taxpayers are illegally funding abortions. The report reviews 18 issuers of health plans offered through the exchanges. All 18 issuers offer abortion services, but only three were found to be in compliance with the law. The non-complying plans offered no restrictions or limitations on abortion services even though the health-care law requires that issuers must estimate and segregate the cost of an abortion from premiums collected by the plan.
Recently, Wal-Mart has begun promoting itself as a “primary medical provider” in order to sway customers into becoming patients. The retail giant has opened five primary care facility clinics in South Carolina and Texas, with plans to double the number of clinics by the end of the year. Wal-Mart is using its “vast rural footprint” to bring primary care to areas of the country where people have limited access. CVS and Walgreens already offer some medical services, but unlike Wal-Mart, they are not equipped to treat patients as a primary medical provider.
Wal-Mart relies on physicians to supervise the clinics’ operations rather than actually to treat patients. Medical assistants and nurse practitioners will administer the bulk of the patient care. Wal-Mart’s focus is becoming the first stop for patients, but some experts are concerned that stores like Wal-Mart will be unable to provide care for more complex medical issues.
The Affordable Care Act (“ACA”) allows states to expand Medicaid to cover more low-income individuals, as well as cover alcohol and substance abuse treatment programs. However, a Federal rule enacted half a century ago prohibits Medicaid coverage for “community based” rehabilitation facilities that have more than 16 beds. As a result, many facilities are unable to provide treatment to the increased number of individuals now eligible for substance abuse treatment under the ACA’s Medicaid expansion. Although some facilities have sacrificed beds to fit within the guidelines and others have simply absorbed the cost of taking in more patients, only Congress has the power to change the rule to provide Medicaid coverage for larger treatment facilities.
The Affordable Care Act mandates that childhood immunizations be covered at no “out-of-pocket” cost. However, many people are finding it difficult to receive immunizations because doctors have stopped offering them. This is due to the high cost of vaccines and the poor reimbursement from insurers. For example, Prevnar 13, which prevents pneumococcal bacteria diseases, has increased in price at “an average of 6 percent each year” since 2010. Currently at $136 per dose, many states require children receive up to four separate shots of Prevnar 13. Because of this, more and more doctors feel that they are left with little choice but to stop providing immunizations.
The Supreme Court recently held in Burwell v. Hobby Lobby Stores, Inc.that the Department of Heath and Human Services (“HHS”) could not require three closely held corporations to provide health-insurance coverage for “methods of contraception that violate the sincerely held religious belief’s of the companies’ owners.” Justice Alito’s opinion stated that such regulations violate the Religious Freedom Restoration Act (“RFRA”) of 1993 by creating a substantial burden on the free exercise of religion. The Court’s 5-4 decision rejected HHS’s argument that owners of a corporation forfeit RFRA protections.
Florida is one of the twenty-four states that declined to expand their Medicaid programs. As a result, approximately 760,000 Florida residents who would qualify for Medicaid under an expanded Medicaid program do not qualify so qualify. In addition, these residents do not qualify for federal subsidies to help them purchase health insurance. Recently, some Florida legislators honed in on an obscure provision in the Affordable Care Act, which allows low-income documented immigrants to qualify for federal subsidies in order to buy health insurance. The legislators intend to publicize this information in an effort to get the Medicaid expansion approved during the next legislative session. Republican state Sen. Rene Garcia of Hialeah stated that the issue is one of “fairness,” and not immigration.