拥有健康保险对于21岁的梅赛德斯·尼默（Mercedes Nimmer）至关重要，后者服用了几种昂贵的处方药来管理多发性硬化症。因此，Nimmer去年通过《平价医疗法案》的市场获得了健康保险，并有资格获得联邦补贴，以大大降低其成本。
然而,政府援助仍然留给她a $33 monthly premium, a hefty amount for Nimmer, who makes $11,000 a year as a part-time supply clerk in Madison, Wisconsin.
不过，尼默（Nimmer）甚至不必担心这笔费用，这要归功于戴恩县计划的联合方式，该计划自2014年以来为大约2,000名低收入人士提供了高级援助。该计划称为HealthConnect，由2013年资助200万美元的礼物from UW Health, a large academic hospital system connected to the University of Wisconsin that also runs its own marketplace health plan.
“Oh my gosh, this is a big deal for me to get this help,” Nimmer says, noting the insurance is vital to cover her medications. The money she saves from the assistance program goes to help pay for gas to get to work, she said.
HealthConnect is one of several community-based programs across the United States helping thousands of lower-income Americans with their Obamacare marketplace premiums. Similar efforts operate in Texas, Oregon, Washington, North Carolina and South Carolina.
But premium assistance programs have come under fire from insurers. They argue that it is not fair for hospitals, other health providers and disease advocacy groups financed by providers to try to steer people who could be covered by Medicare or Medicaid into marketplace plans with higher reimbursement rates.
(Image credit: AP Photo/Andrew Harnik, File)
The federal government has banned hospitals from directly subsidizing patients’ health insurance premiums. But America’s Health Insurance Plans, the industry’s lobbying group, wants the Obama administration to prohibit all premium assistance programs that are funded directly or indirectly by hospitals and other providers with a financial interest in the patient’s care.
“In many cases these practices are harming patients and undermining the individual market by skewing the risk pool and driving up overall health care costs and premiums,” AHIP said in Sept. 22 letter to Andy Slavitt, the acting administrator of the Centers for Medicare & Medicaid Services. The letter notes specific concerns about plans assisting patients requiring kidney dialysis. It says one insurer saw its spending on those patients rise from $1.7 million in 2013 to $36.8 million in 2015 when the number of patients with serious kidney disease rose from 28 to 186.
AHIP官员还表示，如果第三方团体停止支付保费，或者政府确定患者正在获得未符合条件的联邦补贴，则患者可能会面临后果。
In response, CMS says it is considering new rules for third-party payment programs.
尽管如此，保险公司仍在采取行动。阿特纳（Aetna）今年夏天宣布将扩大其市场产品的扩展，他说，将患者转向单个市场的第三方团体已导致其市场计划中的客户不健康的组合。
Blue Shield of California in July提起诉讼在州法院反对CenCal Health, which manages the Medicaid program in Santa Barbara and San Louis Obispo counties. Blue Shield alleges that CenCal was avoiding millions of dollars in medical care claims by enrolling around 40 of its very ill members in Blue Shield’s individual health plans and paying the premiums on their behalf. CenCal denied the allegations in lawsuit, saying it paid the patients’ monthly Blue Shield insurance premiums so they could afford private insurance. It has since discontinued the practice.
UnitedHealthcarefiled a lawsuitin federal court in July against kidney dialysis provider American Renal Associates, accusing it of encouraging patients in Florida and Ohio who were eligible for Medicaid or Medicare to move to the insurer’s commercial plans to extract up to 20 times more than the $300 or so that the federal programs pay in reimbursements. American Renal Associates has said the suit is without merit.
该诉讼称，患者的保费是由患者倡导组织美国肾脏基金会支付的。
AHIP officials note that the fund is supported bydialysis providerswho stand to benefit financially from patients gaining marketplace coverage over payments from Medicaid or Medicare.
The nonprofit American Kidney Fund has helped more than 6,400 people with their marketplace premiums. The fund’s officials said it’s not trying to steer people away from government coverage but trying to help those who otherwise couldn’t afford coverage.
“It is critically important to emphasize that people with disabilities in general — and with end-stage renal disease in particular — should not be broadly excluded as a class from the insurance marketplace if they are unable to afford their health insurance premiums,” LaVarne Burton, the fund’s CEO, says in a statement.
Some patient advocates, like those at HealthConnect in Wisconsin, say third-party payers have an important role in helping low-income customers afford their coverage. UW Health said in a statement that HealthConnect helps all providers, including UW Health, by reducing the number of uninsured patients and potentially helping people seek care earlier in their illness.
该计划平均每年支付109美元的保费援助。戴恩县联合之路的女发言人克里斯塔尔·韦伯（Krystal Webb）说，每花费每一美元，HealthConnect就会产生2.26美元的联邦补贴。
United Way said it structured HealthConnect to avoid a conflict of interest. Eligible people first buy their policy, which can be any of several silver-level plans on the federal marketplace. After that, they can apply for a HealthConnect subsidy. The program is administered by United Way, and UW Health plays no role in patients’ choice of health plan, although its marketplace plan, Unity Health, refers people who may be eligible there.
尽管有AHIP的担忧，但戴恩县的一些健康保险公司表示，健康企业正在满足需求，根据几项计划的采访。该县较大的市场计划之一Dean Health计划发言人说：“我们支持United Way的HealthConnect努力为戴恩县居民提供负担得起的保险选择的一种方式。”
在德克萨斯州的德克萨卡纳州，克里斯托斯·圣迈克尔斯卫生系统去年向一项援助计划捐赠了200,000美元，该计划为138人提供市场覆盖范围。该计划由一个名为ARK-TEX政府理事会的地方政府机构运行，克里斯图斯无法控制谁的入学或他们选择的计划。
“Our mission is to help the poor and this is certainly one of the ways to do that, and it gives people the opportunity to have health coverage when they normally wouldn’t,” says Mike Hargrave, the hospital’s manager of employee assistance and community outreach services. People with incomes between 100 and 150 percent of the federal poverty level (about $11,880 to $17,820 for an individual) are eligible.
Hargrave doesn’t deny the hospital could benefit when more people gain insurance, but he notes other hospitals in the region benefit, too.
AHIP女发言人克莱尔·克里斯（Clare Kruse）说，保险业也受到匿名捐助者资助的高级援助计划的困扰，因为他们可能是希望保护其身份的医院。
For example, PremiumHealth.org, run by United Way of the Greater Triangle in North Carolina helps more than 850 people with incomes between 100 percent to 175 percent of the federal poverty level in Durham, Orange and Wake Counties.
United Way高级副总裁Melanie David-Jones说，一位匿名捐助者为该计划提供了120万美元的资金。她不会说为什么捐助者希望保持匿名。
Noel Pitsenbarger, 48, of Durham, says the program made it possible for him to have health insurance this year by covering the $200-a-month premium for his Blue Cross Blue Shield of North Carolina policy. With insurance, he says, he got a colonoscopy, physical exam, and help paying for several medications. And it saved him from having to pay a $1,000 bill after he cut his finger and had to go to the emergency room.
他说：“这非常有益。”
ThisKaiser Health Newsstory also ran inUSA Today。
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