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A Project of The Annenberg Public Policy Center

A Game of Telephone in Colorado

A Crossroads GPS ad exaggerates a few personal anecdotes to claim that “many Coloradans pay roughly 100 percent more for health insurance since Obamacare.”

The ad, attacking Democratic Sen. Mark Udall, also tries to pin a shortage of doctors in rural areas on the health care law. But there’s no evidence the law caused a change in the ratio of residents to primary care physicians.

The ad, titled “Yes,” began airing on Aug. 19 and was still airing in the Denver market on Sept. 2, according to Kantar Media’s Campaign Media Analysis Group. The ad focuses on rural and resort area residents’ premiums and access to doctors, and criticizes Udall for supporting the Affordable Care Act.

The ad doesn’t say this, but its claims on premiums are about the individual market, where 7 percent of Coloradans get their insurance. It also doesn’t say that Coloradans living in rural and ski resort areas faced higher health costs before the Affordable Care Act, as the news articles cited in the ad make clear.

When a Few Anecdotes Become ‘Many’

Crossroads engages in an old game of telephone — in which a story gets exaggerated each time it’s told — when it claims that “many Coloradans” were paying roughly double for their insurance because of the health care law. While an announcer says that, an on-screen graphic reads, “resort area residents paying roughly 100 percent more for health insurance.” That’s a truncated quote that leaves off the word “some” — not “many” — from the Aspen Daily News, which said that “some resort area residents” were paying that much more and gave two personal anecdotes: a couple who say they are paying about double since the ACA launched and a woman who says her premiums have gone up 66 percent.

So the graphic is deceptively edited, and the voice-over leaves the false impression that the increase in premiums pertains to many of the state’s residents. In fact, the four resort counties — Pitkin (where Aspen is located), Garfield, Eagle (Vail) and Summit — have a total population of nearly 154,000, or 3 percent of the state’s 5 million residents, according to the 2010 Census.

The author of the May 10, 2014, Aspen Daily News article, Nelson Harvey, told us the sentence about “some resort area residents paying roughly 100 percent more” was based on a few select examples as well as what public officials had said they had heard from residents. Nelson, a freelance journalist, said that he had “no way to quantify” how many were paying 100 percent more and that he had never used the word “many.”

Resort area residents have been upset about their individual-market insurance rates — which the Kaiser Family Foundation determined were the highest in the nation on the ACA-created exchanges, based on the lowest-cost “silver” plan. The resort counties made up one of the state’s geographic rating areas, which insurers could use to price plans on the individual market and exchange. Garfield County officials even threatened to sue the state for including it as part of the four-county resort area, and the Colorado Division of Insurance ultimately proposed new geographic rating areas to distribute costs across broader regions. Rates for 2015, which will be based on the new areas, haven’t yet been released by the Division of Insurance but are expected later this month, a DOI spokesman told us.

Still, the rates won’t say much, if anything, about how premiums changed overall from before the ACA to now. As we’ve explained before, the law changed the way insurers can price plans on the individual market, which was historically volatile to begin with, with policyholders switching plans or exiting the market after short periods of time, reports in the journal Health Affairs have shown. Before the law, insurers could price plans based on health status or decline coverage due to medical conditions. The ACA required insurance companies to accept any applicant — regardless of preexisting conditions — and premiums can now only vary based on family size, geography and, to a limited extent, age and tobacco use. Prices can’t vary based on someone’s health.

On top of that major change in the way the market prices plans, individual (and small-group) plans also have to include certain essential benefits, including maternity coverage, prescription drug coverage and preventive care benefits. That means whether someone’s premiums on this market have gone up or down depend on individual circumstances. Those with health conditions were likely to see a drop in premiums; healthy folks with bare-bones plans were likely to see increases. And they may or may not have welcomed the more robust coverage in benefits.

The overhaul of this market made it difficult — if not impossible — to provide apples-to-apples comparisons of how premiums have changed. We contacted the Colorado Health Institute, a nonprofit, nonpartisan research and analysis organization, to ask whether rural or resort area residents had seen increases overall in premiums due to the Affordable Care Act. Amy Downs, senior director of policy and analysis, told us via email that “it’s hard to compare plan premiums before and after the Affordable Care Act was implemented. The whole playing field changed. Plan design requirements, provider networks, how premiums can be set by insurers all changed. People who could never purchase health insurance due to pre-existing conditions are now in the market.”

Said Downs: “To do a before and after comparison would be difficult because we wouldn’t have anything similar to compare.”

The nonpartisan Kaiser Family Foundation, normally the primary source for just such a comparison, also said it simply couldn’t be done, explaining in a September 2013 report that the new benefit requirements and ban on pricing by health status “make direct comparisons of exchange premiums and existing individual market premiums complicated, and doing so would require speculative assumptions and data that are not publicly available.”

High Costs for Rural and Resort Residents Pre-ACA

Coloradans living in ski resort areas or sparsely populated rural areas faced higher health costs before the health care law, and it’s unclear if the law caused an overall increase in premiums. The Colorado Division of Insurance says the new exchanges made the price variation across the state more transparent, so residents in high-cost areas could see how much more they were paying compared with other Coloradans for the first time. That information, in fact, shows the lowest-cost bronze plan on the exchange in 2014 for a 40-year-old in Denver and Boulder was $186.20, but in the resort area, it was $349.31.

It’s clear, however, from local news reports that there was outrage after the exchanges or marketplaces launched last fall. The Crossroads ad begins with text that reads, “rural residents confront higher health care costs,” citing a March 30 Associated Press story. That article said: “Health care has always been more expensive in far-flung communities, where actuarial insurance data show fewer doctors, specialists and hospitals, as well as older residents in need of more health care services. But the rural-urban cost divide has been exacerbated by the Affordable Care Act.” The AP noted that geography was one of the few factors insurers could use to vary rates.

The AP story quoted the spokesman for the America’s Health Insurance Plans, a trade group, as saying the prices reflected the higher medical costs in sparsely populated areas, and that wasn’t new. “Health insurance premiums track the underlying cost of medical care. This was true before the ACA, and it’s true now,” spokesman Robert Zirkelbach was quoted as saying. “Hopefully, the exchanges will shine a spotlight on the variances that exist in the cost of medical care.”

Another story cited by Crossroads, from the April 16 Colorado Independent said: “There have always been fewer – and, therefore, often more expensive — insurance options in the state’s rural and mountain areas.” The story said that rates in resort communities “have skyrocketed” but also noted that it wasn’t clear whether the ACA has caused in increase in rural areas. “Lawmakers are working to find out if the ACA has prompted hikes in rural health care costs or simply brought higher rates into clearer view as more rural Coloradans look for coverage, which long has been more expensive than in urban communities,” the story said.

We spoke with Vincent Plymell, communications manager for the Colorado Division of Insurance, who also said that health care, as well as other costs, have long been higher in mountain areas of the state. “The recent challenge had to do more with transparency,” he said. “People in the mountain areas could now more easily see and compare what people in Denver, Colorado Springs or Fort Collins were paying for their health insurance.”

An actuarial study commissioned by the Division of Insurance this year determined that health costs (including major medical and pharmacy costs) in the resort areas were 37 percent higher than the state average in 2012. (See Exhibit 5.) The figures were adjusted for age and gender.

Plymell said the geographic rating areas insurers had to use for 2014 rates on the individual market “didn’t cause any increase.” The essential benefit requirements under the ACA did cause an increase in some cases, he said, depending on what type of plan an individual had before. “That was true all over the state,” Plymell said.

All we can say with certainty is that some residents of resort and rural areas were upset with their individual market premiums — whether that was because the rates increased under the ACA or because those residents could see they were paying a lot more than people in other parts of Colorado.

ACA Causes Lack of Doctors?

The Crossroads ad also implies that the Affordable Care Act has affected the ratio of patients to doctors when it says, “On the eastern plains, patients now outnumber doctors five thousand to one.” That figure comes from a study released in February by the Colorado Health Institute. But there’s no indication in the study that the ACA has caused a change in the scarcity of primary care doctors in rural areas of the state.

The data is from 2013, and it’s the first time the study was conducted. The ad says this is “now” the case, as if there’s been a change, but we don’t know what the situation was in the past. The Health Institute’s Downs confirmed that the study wasn’t blaming the ACA for the problem. “Because the analysis was conducted prior to the launch of the major insurance reforms in the ACA, we don’t attribute the Affordable Care Act as a reason why there are few primary care physicians on the eastern plains,” she said in an email to FactCheck.org.

The institute found that statewide, Colorado had a “pretty good ratio” of residents to full-time equivalent primary care physicians from a “big-picture perspective,” it said. But there were large discrepancies between certain areas of the state.

Colorado Health Institute report, February 2014: When you look closer, though, our study shows that while many areas have enough primary care physicians to care for the population, a number of others – primarily rural and underserved urban areas – likely do not have enough. …

Denver County has 1,348 residents for each full-time practicing primary care physician. Less than an hour’s drive to the east, in a rural region consisting of Cheyenne, Elbert, Kit Carson and Lincoln counties, there are 5,636 residents for each full-time primary care physician – or more than four times as many.

The study found that the state “appears to have a suitable number of practicing primary care physicians” overall, but certain regions did not. In the rural counties listed above, it suggested a tripling of the current number of full-time equivalent primary care doctors.

The ACA didn’t cause the problem — after all, this is a ratio of the population to doctors, not how many patients each doctor has. And there isn’t any past data with which to compare the study. The study gives several reasons for a challenging situation — fewer physicians choosing to be primary care physicians, an aging population that needs more care, and doctors who are also aging and retiring.

The Colorado Independent article cited in the ad noted that this ratio of doctors to residents was one of the reasons, among a “complex constellation of factors,” for higher health costs in rural areas. Without much competition, providers had little incentive to charge lower prices.

— Lori Robertson