A local school district loses its federal funding money over teacher behavior. A group of D.C. residents sue to block a homeless shelter in their neighborhood. And a Republican activist in Montgomery County successfully petitions to get term limits on the ballot—but a legal challenge looms.
Guest Host: Marc Fisher
More than 8 million federal workers and their families have two more weeks to choose a health insurance program, a process known as “open season.” The 50-year-old ritual, which offers more than 250 health plans, is a bright spot for a federal government still struggling to fix glitches in its HealthCare.gov marketplace. We explore what’s new in federal health plans, how consumers can save money and what non-government workers sorting through health exchanges and their own private sector open enrollment periods can learn from “open season.”
- Walton Francis Health economist; Editor, Washington Consumers' Checkbook; Author, "Guide to Health Plans for Federal Employees" 2014 edition
- Robert Ellis Editor and Director of Operations, Washington Consumers' Checkbook
MR. MARC FISHERFrom WAMU 88.5 at American University in Washington, welcome to "The Kojo Nnamdi Show," connecting your community with the world. I'm Mark Fisher sitting in for Kojo. Coming up later this hour, the explosive growth of running in the Washington area. But, first, it's been nearly two months since healthcare.gov debuted. And since then, politicians on both sides of the aisle have declared open season on the flawed health insurance site and the Obama administration itself. But for millions of federal workers, another kind of open season has ticked along quietly and in most case glitch free.
MR. MARC FISHERThis is the time of year when about 8 million government workers, not to mention the rest of us in the private sector, have a few weeks to evaluate, recalibrate or choose new health insurance plans. It's an important but intimidating task and for federal workers who have up to 250 plans to choose from, it can be altogether overwhelming. That's probably why only about 5 percent of them change plans each year. But, if you use the right tools and do a little digging, you can save thousands. So how can you find the best care at the best price and how do you begin to sort through the options?
MR. MARC FISHERJoining us with many of the answers are Walton Francis, Health Economist and Author of the Washington Consumers' Checkbook, 2014 "Guide to Health Plans for Federal Health Employees," that's a very long title; and Robert Ellis, who is the editor of Washington Consumers' Checkbook. And they have been studying this material intensively for some weeks, but really for many years. And, Walton Francis, tell us what is different this year about previous years? Does Obamacare really change things at all for federal workers and their choices?
MR. WALTON FRANCISIt, for most federal workers, it has little or no effect. And that's positive. And it didn't even start this year, a couple years ago, covering your adult children up to age 26 for example. And there have been some modest improvements in other areas. The federal employees' program already had met virtually all the standards that were in the Affordable Care Act. You know, you could join any plan you wanted without regard to preexisting conditions, for example. No gotcha limits on various benefits.
MR. WALTON FRANCISThe only -- there's a small group who are affected this year -- the Congressmen and their staff, personal staff are being put into the exchanges.
FISHERAnd very much made part of the political battle as well.
FRANCISRight. Right. It's been a red-hot button issue. But for the vast majority of federal employees and retirees, there's no effect. I might say, though, there are some cases where a family, for example, might want to have one person on the federal employee program and one person on an exchange. So the exchange problems, you know, we have four exchanges that work well in the world: Massachusetts and three federal exchanges, Medicare Part A, Medicare drug benefit, and FEHBP. If you're not in one of those four, you could be in trouble.
FISHEROkay. Well, if you're a federal employee thinking about changing your health plan this year, give us a call, tell us what's most important to you when deciding on a health plan. If you need help sorting through the options, you can give us a call at 1-800-433-8850, or email us at kojo, K-O-J-O, @wamu.org. You can also send a Tweet to @kojoshow. And, Robert Ellis, in this open-enrollment season, federal employees in the Washington area make up about 14 percent of the workforce here. And we're about halfway to the December 9 deadline.
FISHERSo with all of this bad news lately about government health care plans, is there any good news for federal workers going into the enrollment this year?
MR. ROBERT ELLISWell, I think on the FEHB, one of the things everybody looks at every year is how much did the rates go up. And, luckily, this year was not a bad year for a big rate increase on the federal exchange program. I think the other thing is that there are new plans that came into the FEHB this year. We actually watched plans kind of trickle out for a number of years. And we had a little resurgence of both health and standalone dental plans come back in this year. So there's a few more options to choose from.
MR. ROBERT ELLISAnd I think the tools that at least we're able to provide and some of the information that the press is putting out is making the choices at least a little more transparent, if not totally easy, because health care is not easy. Our goal is to try to make the health insurance choice thing an easy process. So I think all of those things combined give a little bit of bright spot on what's been basically just nothing but doom and gloom on the health insurance front recently.
FISHERAnd, Walton Francis' Guide to Health Plans" is available on the Web at guidetohealthplans.org. Now the rollout healthcare.gov was so rocky that lawmakers on Capitol Hill are wondering if the federal health benefits process can somehow replace this federal health exchange. Walt, this is what Darrell Issa, that congressman from California, is proposing so that basically all Americans would have access to federal health benefits. Is that a new idea? And would it be difficult to translate that program to all of the country?
FRANCISIt's not a new idea. It's been around for decades. It actually almost became a basis of a Carter Administration legislative proposal. Not to put all Americans in the federal employees program, as such, but to provide an identical or similar program for all Americans. Congressman Issa's bill, I think, is a bit more symbolic than serious, but it illustrates the point that we have a smoothly functioning program. The difficulties would be immense. You know, federal employees have their premiums deducted from their paycheck or their retirement check.
FRANCISWell, that doesn't work all so well for, you know, people who work for 10 million different employers, et cetera, or, you know, are unemployed. And there are other problems. But, in theory, you could do it. And, actually, the Affordable Care Act is modeled in part after, well, it's modeled largely after the Massachusetts exchange, which was actually modeled in large part after the federal employee exchange. I think it's one of those cases where there was a slip between the cup and the lip. But the basic idea that you can choose from among a lot of health plans is a great one.
FISHERWell, and for most private-sector employees, there's very little if any choice at all among health plans. And so, when people hear about the workers having more than 250 plans across the country, and we're sitting there and, you know, it's take it or leave it, basically, from most employers that I'm familiar with. So why is there such a gap between what federal workers have as options and what most other people have.
ELLISWell, you know, I think in the case of OPMs and the exchanges, they had a lot of leverage in trying to create a national presence. They have a national base. It was really easy for them to kind of line up a national platform. Now, on top of that, you know, D.C. is representative of a lot of other metropolitan areas that have large federal workforce bases. And so you end up with a lot of HMOs participating. You end up with a lot of CDHP or HD plans.
ELLISBut, that said, other than that kind of core national base, which was a real breakthrough for the system, you go out into the rural areas where there are only a few federal employees, you may only find one HMO or one CDHP. So, even in this system...
FISHERWhat's a CDHP?
ELLISLike a consumer-driven, a high-deductible type of plan.
FISHERLike catastrophic coverage.
ELLISWell, no, it's not catastrophic. It's mostly just has a high deductible with a limit in the middle, so that you don't have quite as much exposure. The plan doesn't have quite as much exposure. It's kind of a middle ground between a catastrophic plan and an HMO, for example. But the key being that it's largely geographically driven. So D.C., you see a lot of plans, because D.C. is where all the feds are.
FISHERLet's hear from Dennis in Great Falls. Dennis, it's your turn.
DENNISWell, you know, I have this--the Blue Cross plan under the federal retirement and now I'm going to get Medicare. How does that work? Should I be looking at different options under Blue Cross or just stay with the same one?
FRANCISWell, are you in standard or basic?
FRANCISOkay. That's one of the higher priced plans in this system. And there are about a dozen national plans. All of them but one, Blue Cross basis, offer what I like to call wrap-around coverage. If you have Medicare Parts A and B, you are covered 100 percent for hospital and physician bills. You will pay nothing out of pocket. But since they all give that same deal, what you want to do is be in one with the lower premium than the one you're in. And so I'd recommend you take a look at GIHA standard option, NALC, National Association of Letter Carriers high option; APWU high option.
FRANCISOf those three, GIHA has a weaker prescription drug benefit. So, you know, and that's not part of this guarantee I mentioned. So you're going to have to do a little picking and choosing. You could go to Blue Cross basic and rely on Medicare. They don't give you the special deal, but it's a very economical premium, very good coverage. And you can use Medicare to go out of network. So you have a lot of choices, but where you are is probably not where you want to wind up after open season.
FISHERThank you, Dennis. Let's hear from Courtney in Leesburg, Virginia. Courtney, it's your turn.
COURTNEYHi. My question is, my husband's a federal employee and we're a family of five. One of our children is autistic. So how do we go about finding a plan that is affordable considering, you know, we have a lot of prescriptions for her and things like that, and a lot of expensive therapy. You know, what will give us the most coverage.
FRANCISThere's no simple answer to that, but let me tell you the basic approach to take, and not just in your case, but many other circumstances. Talk to your providers, okay? So, if you're using occupational therapists, for example, you talk to the occupational therapist. Which plans are going to pay better next year? That's a benefit area where the plans have traditionally been quite weak, okay? So it's quite an ordeal to find one that's going to cover your situation well. That's one of the areas in which the benefits though have improved a bit in the last couple of years.
FRANCISAnd I think that's part of the results of the Affordable Care Act impetus. So I think you'll probably be able to find it's not quite as horrific and limited as in past years. So talk to your providers.
FISHERThank you, Courtney. And Walton Francis is author of the Washington Consumer Checkbook 2014, "Guide to Health Plans for Federal Health Employees." And Robert Ellis is the Editor of Washington Consumers' Checkbook. And, Robert Ellis, are there a lot of big changes other than the whole Obamacare discussion, which is really almost tangential to the federal workers' choices. But what are the big changes for federal employees as they sort through their options this year?
ELLISWell, I think the, you know, first of all, overcome the inertia to do nothing, right? I mean, as you mentioned, very few people make a change, and yet many could and should make a change. One of the reasons, of course, is that this is usually perceived as just a painful process with a lot of numbers that no one, even the leading economist cannot model these numbers. It's one of the reasons we've been doing our tool for 35 years, because you can't do it on your own. You have to have a lot of sophisticated modeling behind it. And we try to reduce it to a very simple process.
ELLISIn our tool, you're looking at a single dollar comparison of out-of-pocket costs, you're looking at a risk comparison. Is your doctor in the plan? Very important to most people. And, you know, what kind of quality ratings do they get? If you're trying to do it on your own, then you just need to weight a lot of factors and try to make some tradeoffs. Don't just look at premium. Your out-of-pocket costs may be high. Don't just rely on the published deductible, because there may be many things in the plan's brochure that are either excluded or not excluded from the deductible.
ELLISSo the single number doesn't get you there. You know, if you're planning on having a baby, for example, how is childbirth and maternity dealt with in a given plan? The single figure that they give for inpatient hospital may not be the same. So, if you don't use a good tool -- and then we think every consumer should kind of press whoever is providing them their care to provide good tools -- you have to just do a lot of looking at a lot of numbers. And that's why a lot of people don't do it.
FISHERAnd one of the impacts that we're seeing in the coverage lately about Obamacare, it appears that a lot of people are going to face much more narrowly constricted networks of providers that are available under some of these new policies. Is that an issue at all for federal workers? And are federal workers, perhaps, reluctant to change plans because it means they won't necessarily be able to see their own doctor?
ELLISWell, we haven't seen the explosion of restricted networks in FEHB yet, that we're seeing out in the exchanges that are happening. We actually do a lot of work in doctor directory work, trying to provide merged exchange-wide doctor directories, both in our guidetohealthplans.org in the greater Washington area, but also we're actually trying to help a couple of states build that kind of functionality into their tool. But it's there, it's coming. You can't believe that it won't affect the exchange, the FEHB going down the road.
ELLISAnd you have to then look at, is your doctor in the plan's network and is your hospital in the plan's network, something that we rarely used to think about. Almost every hospital used to be in every network. Not true anymore.
FISHERAnd you mentioned what happens when you're having a baby. We have an email from Kyle who says, "I have a simple yet complicated process question related to," his FEHB benefits. He and his wife are both federal employees with separate plans. They just got married and are looking to get onto one insurance plan. But for the options they're considering, the price is actually more expensive to be on one plan together as against being on the two individual plans.
FISHER"Now here's the catch," he says. "We're looking to start a family in the next year. How does the process work when we have a child? Could we switch to a group plan once she's pregnant or would it have to wait until the baby is born?"
FRANCISGreat question or two -- there's two big questions there. First, it is true that two self-only premiums generally are less expensive than one family premium, but there's a -- and this is the case where you're both federal workers. So you could in theory, and some people do, go that way. The problem is you may now face two different out-of-pocket limits. So, for example, in many of these plans, Blue Cross Standard being an example, a wonderful catastrophic limit, 6,000 bucks either for you or for you and your family. But if two of you are in a car accident and you have two self-only enrollments, it's 6,000 each, okay.
FRANCISSo you want to be very careful about that. That's much less of a problem in an HMO but in the fee-for-service plans it's a big issue. Secondly, you -- there are a lot of ways you can -- there's an annual open season, one month a year where -- and the deal is look ahead for the year. You're very smart to be looking ahead. We may have a baby. Now when she gets pregnant and when the baby comes -- maybe even be two years down the road, okay depending -- but -- and there are certain occasions where you have a little private open season, if for example, you move to a different part of the country, you're allowed to change from one HMO to another.
FRANCISBut having a baby is not a triggering event. So what I strongly recommend is you think now about what you want to be in as a family, okay, for sure starting next year, which gives you, you know, two weeks plus to make your decision.
FISHERAnd do you have an overall sense of what the breakdown is between those who choose HMOs versus fee-for-service?
FRANCISWell, among active employees still employed, about a fourth choose HMOs, okay. Among retirees it's over -- very few do so, fewer than 10 percent. And the reason is they move to one of these national plans that's got this 100 percent wraparound with Medicare. The HMOs, very few of them offer anything like that. It's unfortunate but you're sort of forced out of your HMOs.
FISHERLet's hear now from Barbara in Falls Church. Barbara, you're on the air.
BARBARAHI. I've got that classic kind of dental question. We know we have a lot of big dental expenses coming the next year. We're in Standard Blue Cross, which has terrible dental coverage. And my question is, are there any general overall plans that do have good dental coverage or should we be looking at adding a supplementary dental plan. And if so, what, for things like root canals and, you know, crowns, all that stuff.
FRANCISYeah, among the national plans -- or I should say plans we have in the D.C. area -- the best dental benefit that's in the health plan is MDIPB. So take a look at that. You may or may not be willing to join an HMO. None of the others are really going to cover you for crowns and bridges. Most of them not at all. I make clear, many of the health plans do have modest dental coverage like your annual checkup, but the expensive stuff, no.
FRANCISSo you want to look probably at the standalone dental plans. And the good news it there are lots of them available this year. There are three new companies, for example, in the program. FEP Blue, which is a Blue Cross national network, Delta Dental, another national network and Dominion, which is an east coast regional network but covers this area. But here's the key thing on dental. Talk to your dentist. What network is he or she in because the network discount you get in one of these plans is where you're going to get most of your savings.
FISHEROkay. Well, thank you very much, Barbara. And let's go now to Glenna in Cambridge, Md. Glenna, you are on the air.
GLENNAYes. My question is, why when they built the exchange network they did not look to the FEHBP as a model and also to Medicare Part B. Because you all already have a network that functions beautifully.
FRANCISThey made probably many wrong decisions in building the federal exchange, but I think the crucial one -- and I know why they did it -- in our guide and in the Medicare Advantage, which is on the Medicare.gov website, a wonderful plan-choosing -- plan-finder tool there. The idea is you shop before you buy. So you get to look at all the plans. You get to see the cost, the premium and you get to see the benefit structure and the cost sharing, okay. And then only when you're comfortable with a particular plan are you sort of forced to go to, you know, the checkout counter, okay. The Amazon model, all the online stores do it that way.
FRANCISFor reasons that you could understand, that was not done in the exchanges primarily because people might not understand what a good deal they could get if they got these tax advantage subsidies, okay. Our response would've been, put those into the online model, you know. It's possible to do. We're working on it ourselves.
FISHERAnd Robert Ellis, how long has Washington Consumer's Checkbook been doing these guides to health plans? And does it ever get any less complicated?
ELLISI wish that were the case. This is the 35th year of us doing this work. In the early years it was all in a book which in some ways made it more complicated. The last dozen years or so we've been able to do it online, so we can do a lot more tailoring to the individual who's coming in and their family needs. But the programs get more complicated. The way the plans structure the programs get more complicated. And since we model costs for someone like you, the someones like you have gotten more complicated. So everything's gotten more complicated. Our job is to make it simple.
FISHERAnd how is that -- how do you actually put it all together? What -- I mean, is it just Walton Francis sitting there for week after week doing the research or...
FRANCISNo, no, no. Let me tell you a little bit about my part and then the more important part that Robert does. Actually, we do this altogether so it's just a joint project. Sort of the crucial first step and the step that uniquely defines what we do is that we try to estimate the cost to you for both the premium and the likely out-of-pocket costs in each plan. And we estimate it both in the typical scenario and if your costs are unusually low or high. So we try to give you a single dollar number. What's likely to happen to you in plan A versus plan B?
FRANCISAnd what's not so likely? Because if you're going to have a baby, for example, there may be a different scenario. Or if you expect a major operation. But the important part then is to join it with -- now, Robert.
ELLISYeah well, we think the four key things that consumers constantly ask us for is a simple way to compare price and that's what Walt's talking about, that actuarially modeling the out-of-pocket plus the premium. Is my doctor in the plan? And that's when we do all of this doctor merging and bringing networks together so that you can put in a doctor's name and we'll tell you which plans they're in, as opposed to going out and trying to dig them out, right. What's my maximum risk, right? And that's a combination of what could happen in a really bad year?
ELLISAnd what's your probability of having such a bad year? And how do the plan's bad-year limits hold up? Do they have gaps and loopholes in them? We make adjustments for that so you see an apples-to-apples comparison. And lastly, what's the quality metric for the plan? Do the other people in the plan like it? Those four things on our first presentation screen are what we try to communicate.
FISHERIf it works too well, the federal government's going to come after you to redo Obamacare. Well, you can take a look for yourself at GuideToHealthPlans.org. Robert Ellis is the editor of Washington Consumer's Checkbook and Walton Francis is the author of the Checkbook's 2014 "Guide to Health Plans for Federal Health (sic) Employees." Thanks very much for being here. When we come back after a short break, running in the Washington area.
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