By: Ronda Polansky, MS, CCC-SLP, TSHA Business Management Committee Co-Chair
This four-part series will discuss the vulnerability of healthcare, insurance contracts, data collection, government contacts, and contract negotiation.
A History of Insurance as We Know It
Health insurance, as we know it in the U.S., began in the 1930s during the Great Depression. Commercial carriers began offering hospital coverage for more catastrophic events in 1934 and then expanded to surgical coverage in 1938. During this time, basic physician coverage was not provided (Morrisey, 2013). For nearly a century, American elected officials have attempted to guarantee the right to health care. This concept came close to being successfully accomplished a few times over history: during the New Deal, when health insurance was initially part of the proposal for Social Security; in the aftermath of World War II, when President Harry Truman made a national health plan his top domestic priority; and then again between 1970 and 1974, when President Richard Nixon was open to a compromise on a plan that would ensure universal health insurance coverage (Morrisey 2013). The 1980s saw the creation of managed care, which was prompted by increasing healthcare costs and the emergence of self-insured employer plans. A backlash against managed care developed because of their ability to selectively contract revolutionized healthcare markets by introducing price competition. In the 2000s, healthcare costs again rapidly rose, and efforts encouraged insured individuals to pay more out of-pocket through the use of high-deductible health plans with tax-sheltered health savings accounts. In 2009–2010, the Affordable Care Act introduced major changes to the U.S. health insurance market, requiring virtually all citizens to purchase health insurance and creating penalties for those who failed to do so. The law also expanded the Medicaid program for ages 19 to 64 years of age (Morrisey, 2013).
Football fans may have seen ads from the Better Medicare Alliance, “the leading voice for Medicare Advantage,” featuring seniors hanging out and fretting about Medicare Advantage cuts on Super Bowl commercials. The Better Medicare Alliance spent over $13.5 million on an ad campaign, while the American Action Network piled on with $2 million in Super Bowl commercial ads of its own. The Better Medicare Alliance is a 501(c)(3) nonprofit that appears to have been created with funding from insurance companies by APCO Worldwide, a Washington influence firm with a long history of running front groups for its clients (Porter, 2015). Better Medicare Alliance’s membership includes Medicare Advantage insurers Aetna and United Health as well as Humana and WellMed. Health insurance companies and private-equity firms are buying up primary care and other entities. A bipartisan group of lawmakers are becoming increasingly concerned that these same insurance companies, specifically the Medicare Advantage Plans (MAPs), are not only preying on seniors but denying the care that would otherwise be approved and covered by traditional Medicare. The visceral fear response from people and practices across this country who feel cheated and threatened by the practices of their insurance companies should be a wake-up call to everyone in the health care system and those who oversee the practices of these plans, including Medicare itself. If the government hoped Medicare Advantage plans would reduce the costs of care, that has not been the outcome. The MedPAC report found that Medicare pays the plans 6% more than it would spend if plan enrollees were covered under regular fee-for-service Medicare. The same report had already projected that Medicare payments to the plans will total $27 billion more in 2023 than if patients were enrolled in traditional Medicare.
Unfortunately, the same healthcare challenges we face today have existed for at least half a century. The rising healthcare costs and growing uninsured population are nothing new, but there are now newer challenges that are unique to the 21st century. Recent data from the Kaiser Family Foundation reveals Americans $220 billion in medical debt (Claxton, 2024), with approximately 100 million struggling with healthcare costs despite paying for health insurance coverage. Reimbursement rates to healthcare providers are lower than they have ever been, and small practices are going out of business. All insurance payors base their rates on Medicare rates. Everyone, even those who do not use Medicare, should be concerned when Medicare rates are low because insurance payors often drop payments even lower than the Medicare fee schedule.
What Can Organizations Such as the TSHA PAC Do To Help?
Small medical practices are typically located within local communities, making healthcare services more accessible and convenient for residents. For small speech-language pathology and audiology practices, being ignored and disregarded by your payor sources is frustrating. Although state associations can certainly advocate at a government level, the state associations as an organization cannot and do not have the power to negotiate reimbursement rates for any of their member providers. Legal firms strongly advise against this as it risks violating antitrust laws. The laws are designed to protect the consumer, and we, as the providers, are considered the sellers, just as insurance companies are considered the buyers and also the consumers to services. Any state association must use caution not to encourage nor promote negative publicity such as a boycott of an insurer, including on social media platforms, to avoid the risk of a legal response. The role of any state association can be supportive in the education of members by providing resources and collecting data.
A political action committee (PAC) is a group that bands together under a unified mission to support candidates for public office. Operating as a nonprofit, unincorporated and nonpartisan group, a PAC can receive and distribute contributions to election campaigns. A PAC can only solicit contributions from individuals associated with a specific organization/association. A PAC gives an organization greater ability to advocate before elected officials and in state capitals. It provides the resources to hold elected officials accountable. PACs are identified with a core set of issues that the sponsoring organization seeks to advance.
The Texas Speech-Language-Hearing Association (TSHA) PAC protects your license and right to practice in the state of Texas, which is dictated by state law, not federal law. The TSHA PAC monitors issues that affect your job, licensure, reimbursement, and quality of service. They are your organizational voice at the Texas Capitol, advocating to lawmakers and state agencies and offering support including legislative advocacy and the monitoring of state licensure rules and regulatory agencies on your behalf. The TSHA PAC is a group of speech-language pathologists and audiologists who operate as a separate legal entity from TSHA so they can receive and distribute contributions to Texas election campaigns.
The mission of the TSHA PAC is to support legislative candidates for state office whose records and policy positions demonstrate an understanding of our fields and those in a position to further the goals of TSHA in the areas of licensure, education, and healthcare. Biennially in Texas, legislation is enacted that greatly impacts members of our professions and individuals with speech, language, and hearing disorders. It has become more and more evident over the years that financial support through campaign donations to legislators who are not only in a position to assist our professions but also devote time and effort to support our causes is increasingly important.
The TSHA PAC uses contributions to effectively represent our fields. Contributions to the TSHA PAC are used to create a collective political force that can influence social and governmental policy dealing with the issues relating to our professions by way of donations to election campaigns. We contribute to candidates who share our concerns on matters such as licensure, education, and healthcare. These issues do not divide neatly among party lines, and as a result, donations are made to election campaigns of candidates who are in a position to support our professions. The TSHA PAC does not give by party affiliations but rather to candidates who support TSHA and who are in a position to help our mission.
Can One Person Make a Difference?
What can you do? As President John F. Kennedy said, “One person can make a difference, and everyone should try.” There are ways to advocate for your insurance and medical billing issues with government agencies. Consumers can call the No Surprises Help Desk at 1-800-985-3059 or submit a complaint online if they receive a surprise medical bill. The No Surprises Act was signed into law in 2020 and protects consumers from surprise medical bills by limiting cost sharing and prohibiting balance billing. The Biden administration issued interim rules governing the law’s independent dispute-resolution (IDR) process that didn’t match the law Congress passed and were skewed in favor of insurance companies. The impact of the administration’s rules on this could have long-term impacts on the ability of physicians to negotiate fair contracts with payors and the ability of patients to access in-network services or, eventually, any care at all. Physicians across the country are already experiencing take-it-or-leave-it payment cuts to long-standing contracts with payors, and many physician practices have had their contracts terminated as a result of the No Surprises Act regulations.
Consumers can check if their state has State Consumer Assistance Programs (CAPs) to help with surprise billing questions. Consumers can report fraud and abuse against federal healthcare programs to the OIG Fraud Hotline by calling 1-800-HHS-TIPS (1-800-447-8477) or by mail. As a patient, you can ask the hospital if they have a patient advocate on staff or search online for one. Medical societies can advocate for patient care by providing comments on proposed rules and regulations, meeting with government officials, and filing complaints with regulatory agencies.
Contact Your Legislator
Get Washington involved or your state involved by contacting your representatives in the House and Senate. Becoming a successful communicator on the legislative front is learning about your new audience. The halls of Congress and the state capitol housing the legislators and their staffs have their own rules and accepted methods and approaches, like any other institution or industry. You must learn about those to develop and maintain the relationship you want and need to establish with the lawmakers and their staffs for any grassroot advocacy. It is important to build a relationship with your legislators and not just contact them when legislation is pending. While a legislator may be an expert on one or two issues, it is impossible for every lawmaker to master every issue likely to come before Congress or the Texas Legislature. Elected officials rely on staff, outside expertise, and constituent input to effectively represent the people of their district or state. An ongoing dialogue with your elected officials is the best way to ensure they understand how their decisions will impact their constituents back home. No one can better explain the complexities of healthcare delivery and the impact policy changes would have on your organization’s ability to continue delivering care than people like you on the front line.
Writing Letters or Emails
A well-thought-out letter or email is common practice in this setting, and legislative and congressional offices are specifically set up to receive these messages and to respond to constituents. The written letter or email should be polite, clear, concise, focused, and limited to no more than one page. The message should make a strong case with convincing evidence and broad statements. Your opinions should be backed up with facts, but do not hesitate to use your credentials to establish your level of expertise in the area.
Social Media
Social media provides an opportunity to participate in the dialogue to make sure your voice is heard about what is happening in your community and/or professions. What makes social media an effective avenue is that it is a public way to communicate and be heard. A social media post is similar to a public statement. In our digital age, nearly all members of Congress have a Facebook and X account. Follow your senators and representative to see what issues are most important to them and use these social media platforms to share your views with them. Many members of Congress limit two-way communication to avoid ugly public exchanges. Yet, if you post on their sites, you tag them, and it will be publicly viewable and will continue to show up in the feeds of those to whom you and the member of Congress are connected with.
Example:
We need strong oversight of the Medicare Advantage Plans and their compliance to the CMS final rule of 2024 @SenatorCornyn. #NoMoreCuts to these healthcare providers and patients.
Because of the influence of social media in our world today, Congressional offices often will reply more quickly to Facebook or X messages than to a letter or email. Although you can use social media as a sole means of communication, don’t limit yourself. It will be much more effective when this avenue is used to heighten the impact of a letter, email, phone call, and/or in-person meetings.
Phone Calls
Sometimes the best way to contact your elected officials is by phone. Phone calls often can be more beneficial than written forms of communication because the person receiving the call must listen to what you have to say instead of skimming words on a page. It is important to recognize that phone calls will take longer for the elected official’s staff to respond to. Elected officials keep track of how many people call about each issue of concern. Therefore, if one topic is getting a lot of calls, it will prompt them to pay more attention to that problem. If you choose to call only one office, call the district office closest to where you live. Members of Congress have both national and district offices, and members of the Texas Legislature may have more than one office. They likely will ask if you are a constituent, as the elected officials care the most about calls coming from people who can vote for them. Do not call elected officials who do not represent your area, as you will likely not get anywhere.
An In-Person Meeting
You are an essential advisor to members of Congress, so there is nothing to stop you from stopping by local offices and establishing relationships with the staff. The congressional district office has staff members whose sole job is to communicate with their constituents. A personal visit can have a more immediate impact, leaving a lasting impression. When the member of Congress is home, call and make an appointment to meet with them. You also can invite members of Congress to visit your department so they can see what you do firsthand. They enjoy this because it is a prime opportunity for public relations. If you are visiting Washington, D.C., set up an appointment at the D.C. offices. When you arrive, have an agenda, and don’t just chat. Don’t be disappointed if you only get to meet with staff because they truly play a key role in advising elected officials. Follow up your visit with a personal note and summary of your requests.
Other Things You Can Do
Did you know that there are more than 500,000 elected offices in the U.S. and that most of them sit within 90,837 local governments? Local government touches every aspect of your life and affects how well you and your fellow community members can thrive in society. Attend local government meetings, develop a media strategy, contact local media outlets, join social media platforms, and work with other volunteer and community-based groups in your professions.
References
Advocacy in action: Fairness in out-of-network billing disputes. (2023, June 7). American Medical Association. https://www.ama-assn.org/health-care-advocacy/access-care/advocacy-action-fairness-out-network-billing-disputes
American College of Healthcare Executives. (2023). Ache.org. https://ache.org
Centers for Medicare and Medicaid Services, CMS.gov
Claxton, G., Wager, E., & Ortaliza, J. (2022, March 10). The Burden of Medical Debt in the United States. KFF. https://www.kff.org/health-costs/issue-brief/the-burden-of-medical-debt-in-the-united-states/
Dayen, D. (2023, April 11). Insurance Lobbyists Force Government to Heel on Medicare Advantage. The American Prospect. https://prospect.org/health/2023-04-11-insurance-lobbyists-medicare-advantage/
Fraud. (2021, March 31). Office of Inspector General | Government Oversight | U.S. Department of Health and Human Services. https://oig.hhs.gov/fraud/
Guide to Communicating with Elected Officials Guide to Communicating with Elected Officials NATIONAL VOLUNTEER FIRE COUNCIL. (n.d.). https://www.nvfc.org/wp-content/uploads/2015/10/ElectedGuide.pdf
kpage_drupal. (n.d.). Senate investigates Medicare Advantage coverage denials and delays | AHA News. Www.aha.org. https://www.aha.org/news/headline/2023-05-17-senate-investigates-medicare-advantage-coverage-denials-and-delays
Morrisey, M. A. (2020). Health insurance. Health Administration Press; Arlington, Virginia.
The Better Medicare Alliance is not what it appears - PNHP. (2015). PNHP. https://pnhp.org/news/the-better-medicare-alliance-is-not-what-it-appears/
TSHA Political Action Committee. (2024). Txsha.org. https://www.txsha.org/About/Advocacy/tsha-political-action-committee