Las tarifas que Medicare paga a los hospitales se calculan cuidadosamente para cubrir el costo real en un centro de atención médica eficiente. Pero Anthem, Cigna, United y otras aseguradoras de salud comerciales en Colorado están pagando mucho más que Medicare, según un nuevo informe del Centro para Mejorar el Valor en la Atención de Salud.

Kristin Paulson, del Centro, dice que tendría sentido que los hospitales cobraran a las aseguradoras comerciales un poco más que Medicare, para ayudar a ampliar los servicios y reforzar los resultados del hospital.

"Pero los datos que acabamos de publicar demuestran que los hospitales reciben cuatro, cinco o incluso hasta seis veces más de lo que paga Medicare," asegura Paulson. "Y eso va mucho más allá de lo que simplemente esperamos para fortalecer los resultados de una empresa o ampliar la atención."

Utilizando una nueva herramienta de comparación de pagos de atención médica, el Centro descubrió que, si bien las aseguradoras comerciales están pagando más, los pagos generales en comparación con Medicare disminuyeron en un 4% entre 2019 y 2022 en todos los tipos de instalaciones en el estado. Paulson señala que los programas que incluyen los nuevos planes de Colorado Option, que se mantienen en un porcentaje de las tarifas de Medicare, pueden ayudar a mantener bajos los costos.

Los planes comerciales que operan a través de 'ConnectForHealthCO.com' deben destinar el 80% de las primas del consumidor en atención a los pacientes, y sólo el 20% puede destinarse a costos administrativos y ganancias. Pero no hay incentivos para desafiar los altos precios. Paulson señala que si las aseguradoras recaudan $1 millón en primas, sólo pueden obtener $200,000 en beneficios. Si los costos se duplican, las aseguradoras pueden aumentar primas y ganancias.

"Si cubren a las mismas personas por los mismos servicios, tendrían que cobrar $2 millones de dólares en primas, y podrían quedarse con hasta $400,000 dólares, dice ella. "Así que los pagadores también ganan dinero cuando suben los precios."

Paulson dice que los habitantes de Colorado pueden hacer su parte para reducir los costos sanitarios utilizando la herramienta Shop for Care del Centro en 'civhc.org/shop-for-care', que compara los precios de los procedimientos en las diferentes instalaciones.

"Cuanto más paguemos por la atención medica de nuestro propio bolsillo y a través de nuestras compañías de seguros médicos, más seguirán aumentando las primas. Entonces, como consumidores, debemos ser conscientes de que estas diferencias de precios existen y debemos buscar oportunidades para obtener atención de alta calidad a menor costo," agrega Paulson.

World Hepatitis Day is this Sunday, and for the Oregon Health Authority, it's an opportunity to promote its plan to eliminate hepatitis across the state.

Released in March, the plan includes major goals and strategies to limit the spread of hepatitis A, B and C over the next six years. It's gotten new attention after 2,400 patients in Oregon hospitals were potentially exposed to hepatitis and HIV earlier this month.

Concerns are high, but epidemiologist Dr. Dean Sidelinger, Oregon's state health officer, said people should be aware of the threats of hepatitis, but not anxious.

"In day-to-day times, people should feel safe and confident in going to the doctor," he said. "The risk of exposure to these viruses is extremely low in most cases."

Hepatitis is inflammation of the liver, and contagious viruses are among the causes. Sidelinger said he's confident Oregon has the technology and resources to fully eliminate the threat.

While many people may have heard of hepatitis, they may not fully understand how prevalent it is in their communities. According to OHA data, the proportion of chronic hepatitis C cases among people in their 20s tripled between 2010 and 2019.

Sidelinger said there's a good chance most Oregonians know someone who is affected by chronic hepatitis.

"It can seem out of the blue to be talking about hepatitis and [a] hepatitis awareness day, but this is a disease that affects many individuals," he said. "But the good news is, everyone can take steps to protect themselves."

The OHA says you can help prevent the spread of hepatitis by washing hands and fresh produce, staying current on vaccinations, avoiding sharing needles, and getting tested regularly. These tips and more are part of the state's plan to eliminate hepatitis by 2030.


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CoveredCA announced Wednesday that the average premium for plans on the marketplace will rise 7.9% in 2025, but subsidies are expected to blunt the impact and even lower costs for many consumers.

The Biden-Harris administration's Inflation Reduction Act caps premiums at 8.5% of income for many, and goes even further for those with low incomes.

Rachel Linn Gish, director of communications for the nonprofit Health Access California, said the state has put the federal funds to good use.

"Because of this financial help," she said, "California has been able to take even further steps to lower costs for many CoveredCA enrollees by eliminating deductibles and reducing copays for many health services such as doctors' visits, lab work, generic drugs."

However, the enhanced premium subsidies in the IRA will expire next year, sending costs soaring unless Congress extends them. If not, Gish said, she expects premiums to rise 60% to 80%, costing thousands more per year. Opponents of the extension have cited the need to limit federal spending.

Gish said if the federal premium help ends, people could start seeing much higher deductibles.

"Without the federal assistance, California stands to lose $1.7 billion in assistance, which the state can only backfill a fraction of," she said, "which means consumers could again see deductibles of $5,000 or more."

Other big changes are on the way. Starting Nov. 1, about 40,000 income-eligible DACA recipients in California will be able to apply for premium subsidies through Covered California.

Connecticut insurance companies are requesting rate increases. Companies want a more than 8% increase for individuals and an almost 12% increase for small groups. However, insurance costs are already problematic for residents. A 2022 survey shows 46% of people delayed important medical care due to coverage costs.

Liz Dupont-Diehl, associate director of the Connecticut Citizen Action Group, said unaffordable insurance is all too common.

"It is an unfortunate American right of passage to spend hours a week appealing claims denials, or dealing with rising copays, and surprise costs. Even those of us lucky enough to think we have good coverage are continually surprised by hings that are not covered," she said.

Of the legislative solutions lawmakers can take, polls show voters across party lines support the government setting limits on out-of-pocket medical care costs for people with insurance.

Connecticut's Insurance Department will host an informational meeting for people to share their experiences and hear testimony. It will be held from 9 a.m. to 1 p.m. on August 20 at the Legislative Office Building in Hartford and over Zoom.

One way Connecticut's General Assembly can better regulate insurance companies is by increasing transparency surrounding pharmacy benefit managers. A recent Federal Trade Commission report finds the six largest pharmacy benefit managers manage 95% of the country's prescriptions.

Dupont-Diehl said this can help people better understand why certain claims get denied.

"We would be interested in knowing exactly which claims are denied based on ZIP code, based on race and ethnicity, based on age, based on gender," she continued.

She notes that much of what needs to be done to fix health care can be done at the federal level, although states can take the lead. Part of Connecticut's 2023 budget calls for the state's Insurance Department to work with the Office of Health Strategy to study ways to make care more affordable.