Insurance shoppers likely will have several choices for individual health coverage this fall. The bad news? There’s no guarantee they will cover certain doctors or prescriptions.

Health insurers have stopped fleeing the Affordable Care Act’s marketplaces and they’ve toned down premium hikes that gouged consumers in recent years. Some are even dropping prices for 2019. But the market will still be far from ideal for many customers when open enrollment starts Thursday.

Much of the insurance left on the marketplaces limits patients to narrow networks of hospitals or doctors and provides no coverage outside those networks.

Plus these plans can still be unaffordable for people who don’t receive help from the ACA’s income-based tax credits, and they often require patients to pay several thousand dollars toward their care before most coverage starts.

“People understand that things are kind of screwed up,” said Chicago-area broker Robert Slayton. “My objective is to give them what reality is, to give them options. Their job is to choose what may work.”

The ACA expanded coverage to millions of Americans when it established state-based marketplaces where people can buy a plan if they don’t get insurance through work or qualify for government programs like Medicaid. But the expansion has been rough.

Several insurers pulled back from these markets after being swamped with higher-than-expected costs. Many that remained jacked up prices or started limiting the hospitals and doctors included in their coverage networks.

Those narrow networks give insurers leverage to negotiate better rates that can lead to lower coverage prices, and the consulting firm McKinsey & Co. has found that the quality of their hospitals is comparable to broader networks.

Plans with narrow networks will cover necessary specialists like cardiologists, but they often exclude out-of-state care providers or academic medical centers, which tend to be more expensive.

They can pose problems for patients who have more than one physician or want to keep a doctor covered under a previous plan.

Jodi Smith Lemacks is nervous about changing or losing her job because that could mean cutting off her 15-year-old son Joshua from heart specialists he’s seen his entire life. The Richmond, Virginia, resident said she looked last year for options on the ACA’s marketplace to trim the coverage bill she pays through work.

She didn’t find any plans that would cover his current doctors, including some at the Children’s Hospital of Philadelphia, who treat his congenital heart disease.

“The issue with kids like Joshua is, it really matters, it’s life or death where you go,” she said.

Plans with some form of a limited network made up more than half of the choices offered for 2017 on the ACA’s marketplaces, according to the latest numbers from McKinsey. That coverage was particularly common in the price range where most consumers shop, which is within 10 percent of the lowest-priced plan.

These plans grew more common from 2014 to 2017, especially in cities where insurers could choose between competing hospital networks. But that trend has since stabilized, said McKinsey’s Jim Oatman.

Even so, brokers aren’t expecting narrow networks to go away. In some markets like St. Louis, they were the only option shoppers had among 10 plan choices for this year.

The narrow networks are grouped by hospital systems, and broker Kelly Rector has several customers who see doctors in different systems. She advises them to pick their coverage based on which doctor is most important and drop the others for in-network options.

Plans with narrow networks can make it harder to simply get to the doctor, especially if it’s a specialist.

Wichita Falls, Texas, residents with individual coverage have to drive nearly two hours to see an in-network neurologist, insurance agent Kelly Fristoe said. That can be stunning to customers who buy an individual plan after having coverage through work, which tends to come with wider networks.

“They don’t like it,” Fristoe said. “They’re forced to make a change, and they have to go establish themselves with a new specialist.”

Debbie Dean lives 15 minutes from a suburban Chicago hospital, but she’ll have to travel about an hour to an in-network location if she wants surgery on her injured shoulder. Dean couldn’t find affordable coverage that included the nearby hospital when she bought her 2018 plan.

Instead, she settled on insurance that comes with a $6,000 annual deductible she has to pay before most coverage starts. That, plus the travel distance, keeps her from seeking help.

“I’m grateful that I have coverage, but it’s really cruddy coverage,” she said. “I sit here with my shoulder killing me every day.”

Narrow-network plans with their lower prices can be good for shoppers who aren’t tied to a doctor and just want protection from big medical bills, said Paul Rooney, a vice president with the online insurance broker eHealth.

“They’re younger and they’re healthier and they’re thinking, ‘I’m going to get this coverage in case I hurt my knee playing basketball,’” he said.

But it can be tough for consumers when shopping to know if there’s a decent selection of doctors nearby until they need one.

People who “have the most to lose from having a narrow-network plan are those who have something unexpected happen to them,” said Daniel Polsky, a University of Pennsylvania economist.
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The U.N. refugee agency is urging Washington to allow people fleeing persecution and violence, including those who are traveling with the Central American caravan, to request asylum on U.S. territory.

U.S. President Donald Trump has vowed to prevent a caravan of thousands of immigrants from Honduras, Guatemala and El Salvador from entering the United States.  The Pentagon has announced plans to send hundreds of troops to the border in what is described as a support role.

The U.N. refugee agency will not weigh in on whether it is legal for a country to close its borders to refugees and asylum seekers. But it says international law clearly states any person whose life may be in danger has the right to seek asylum and benefit from international protection.

UNHCR spokesman Andrej Mahecic told VOA his agency has alerted countries along the caravan’s route that it is likely to include people in real danger.

“Our position globally is that the individuals who are fleeing persecution and violence need to be given access to territory and protection including refugee status and determination procedure. And, if the people who are fleeing persecution and violence enter Mexico, they need to be provided access to the Mexican asylum system and those entering the United States need to be provided access to the American asylum system,” he said.  

Mahecic said the UNHCR is very concerned about the developing humanitarian situation along the migratory route.  He said there are kidnapping and security risks in the areas where the caravan may be venturing.  

He said it is urgent to stabilize the situation, to provide proper reception and to improve basic conditions for people on the move. In regard to people seeking asylum, he says their international protection needs must be properly assessed before any decision is taken on their return or deportation.

The Mexican Ministry of the Interior reports more than 1,740 asylum claims have been registered in Tapachula in the state of Chiapas.
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Authorities investigating the mass shooting at a Pittsburgh synagogue that left 11 people dead are calling the mayhem a “hate crime,” saying Sunday the suspected gunman shouted anti-Semitic threats as he opened fire.

Charging documents said the suspect, Robert Gregory Bowers, armed with an AR-15 assault rifle and three handguns, wanted all Jews to die and that Jews “were committing genocide to his people,” an apparent reference to his belief that a Jewish refugee agency assisting foreign nationals entering the U.S. endangered non-Jews in America.

In a message he apparently posted online just minutes before the attack, Bowers, 46, said that the refugee agency, the Hebrew Immigrant Aid Society, “likes to bring invaders in that kill our people. I can’t wait while my people are getting slaughtered… I’m going in.”

Scott Brady, the U.S. attorney in western Pennsylvania, told a news conference, “We are treating it as a hate crime.”

Officials said eight men and three women killed, ranging in age from 54 to 97, and six were wounded, including four police officers, before Bowers was tracked down, shot and apprehended.

Bowers was hospitalized in fair condition with multiple gunshot wounds, authorities said. He was charged with 11 counts of criminal homicide, six counts of aggravated assault and 13 counts of ethnic intimidation.

The FBI said Bowers was not previously known to law enforcement, but apparently had posted a string of anti-Semitic threats online, particularly on the Gab.com website, where conspiracy theories are common.

On top of Bowers’s page, one quote said, “jews are the children of satan,” according to screenshots of the now-suspended account released by the SITE Intelligence Group, which tracks extremist views.

Police had responded to emergency calls about 9:45 a.m. Saturday morning as regular religious services were being held by three congregations at the the Tree of Life Synagogue. Witnesses said that Bowers, as he entered the synagogue, shouted, “All these Jews must die!”

Authorities said they found victims at three locations inside the synagogue, located in Pittsburgh’s Squirrel Hill neighborhood. The local medical examiner, Dr. Karl Williams, said, “Lots of shots were fired, there were casings everywhere.”

The Anti-Defamation League, which has tracked hatred and violence against Jews since the 1970s, said the mayhem is “likely the deadliest attack on the Jewish community in the history of the United States.”

“We are devastated,” said the group’s head, Jonathan Greenblatt. “Our hearts break for the victims, their families, and the entire Jewish community.”

The White House has ordered all U.S. flags on government property to be flown at half-staff through Wednesday “as a mark of solemn respect for the victims of the terrible act of violence.”

World leaders denounced the attack, deploring it as an affront to humanity.

U.S. President Donald Trump told a political rally late Saturday, “This evil anti-Semitic attack is an assault on all of us. We must stand with our Jewish brothers and sisters to defeat anti-Semitism and vanquish the forces of hate.”

On Twitter, Trump said, “All of America is in mourning over the mass murder of Jewish Americans at the Tree of Life Synagogue in Pittsburgh. We pray for those who perished and their loved ones, and our hearts go out to the brave police officers who sustained serious injuries. This evil Anti-Semitic attack is an assault on humanity. It will take all of us working together to extract the poison of Anti-Semitism from our world. We must unite to conquer hate.”

Former U.S. President Barack Obama said, “We grieve for the Americans murdered in Pittsburgh. All of us have to fight the rise of anti-Semitism and hateful rhetoric against those who look, love, or pray differently. And we have to stop making it so easy for those who want to harm the innocent to get their hands on a gun.”

Pope Francis at the Vatican called the massacre an “inhuman act of violence.” He prayed “to help us to extinguish the flames of hatred that develop in our societies.”

In Israel, Prime Minister Benjamin Netanyahu said, “It is hard to overstate the horror of the murder of Jews who congregate on the Sabbath and who were murdered only because

they were Jews. On my behalf, on behalf of the government of Israel and the nation of Israel I convey our heartfelt condolences to the families that have lost dear ones. We all pray for the speedy recovery of the wounded.”

German Chancellor Angela Merkel called the assault an act of “blind anti-Semitic hatred,” while United Nations Secretary General Antonio Guterres called for a united world effort “to roll back the forces of racism, anti-Semitism, Islamophobia and other forms of racism.”

 
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A battle is brewing between the Trump administration and some of the president’s biggest supporters in Congress who are concerned that sanctions to be reimposed on Iran early next month won’t be tough enough. 

As President Donald Trump prepares to reimpose a second batch of Iran sanctions that had been eased under the 2015 nuclear deal, conservative lawmakers and outside advisers have become worried that the administration may break a promise to exert “maximum pressure” on Iran. They are angered by suggestions that measures to be announced Nov. 5 won’t include a provision cutting Iran off from a key component of the global financial system. 

The self-described Iran hawks are concerned enough that they have drafted legislation that would require the administration to demand that Iran be suspended from the international bank transfer system known as SWIFT. 

“The president asked for maximum pressure, not semi-maximum pressure,” said Richard Goldberg, a former aide to a Republican senator and senior adviser to the Foundation for the Defense of Democracies, a group that supports punishing Iran with sanctions. “Maximum pressure includes disconnecting Iranian banks from SWIFT.” 

Trump pledged Thursday to do whatever it takes to pressure Iran to halt what he refers to as its “malign conduct,” such as nuclear and missile development and support for terrorism and groups that destabilize the Middle East. 

“On Nov. 5th, all U.S. sanctions against Iran lifted by the nuclear deal will be back in full force,” he told a gathering at the White House to commemorate the 35th anniversary of the 1983 attack on the Marine Corps barracks in Beirut, Lebanon, which is blamed on Iranian-backed extremists. “And they will be followed up with even more sanctions to address the full range of Iran’s malign conduct. We will not allow the world’s leading sponsor of terror to develop the world’s deadliest weapons. Will not happen.” 

Energy, banking sectors

The Nov. 5 sanctions cover Iran’s banking and energy sectors and will reinstate penalties for countries and companies in Europe, Asia and elsewhere that do not halt Iranian oil imports. They could also include measures to force Iran out of SWIFT. 

Despite Trump’s tough stance, the hawks are worried about recent comments from Treasury Secretary Stephen Mnuchin and his staff that suggest Iran will be able to stay connected to SWIFT. They are also concerned the administration will back down on its stated zero-tolerance policy for Iranian oil purchases by granting waivers to certain countries and companies that do not fully stop buying it. 

Iran deal supporters, like the other parties to the agreement, argue that pushing Iran out of SWIFT, the Belgium-based Society for Worldwide Interbank Financial Telecommunication, will lead to the creation of alternate mechanisms that could supplant it as the leading global institution for financial institutions to send and receive information about banking transactions. They also say expulsion will make it harder for Iran to conduct transactions, such as humanitarian purchases, that will still be allowed after Nov. 5. 

Allowing Iran to remain in SWIFT would make it easier for Tehran to import humanitarian goods like medicine permitted under U.S. sanctions and “would help the United States make clear that its critique of Iran is directed at the regime, not the people of Iran,” said Elizabeth Rosenberg, a former Treasury official now with the Center for a New American Security. She added, though, that disconnection would be a “fast track” to isolation. 

The debate underscores the challenges the administration faces as it tries to isolate Iran without the full backing of other world powers who remain supportive of the nuclear deal. 

Although the hawks had been pleased by Trump’s decision to withdraw from the nuclear deal in May and cheered the August reimposition of an initial set of sanctions, they are now seething that Treasury may opt to use existing safeguards to isolate Iran instead of hitting SWIFT members with sanctions if they don’t disconnect Tehran. 

Treasury coy

Treasury has been coy about its intentions, saying only that Mnuchin and the agency have led “an intense economic pressure campaign against Iran as part of this administration’s comprehensive strategy to address the totality of Iran’s malign and destabilizing activity, with much more to come.” 

“Treasury has made it very clear that we will continue to cut off bad Iranian actors, including designated banks, from accessing the international financial system in a number of different ways,” it said. “We will also take action against those attempting to conduct prohibited transactions with sanctioned Iranian entities regardless of the mechanisms used.” 

That less-than-categorical position has rallied the hawks around the legislation prepared by Sen. Ted Cruz, R-Texas, that would require the administration to impose sanctions on SWIFT members, including some U.S. banks, should it not suspend Iran on its own. 

Federal law currently gives the administration authority to act against Iran’s central bank and other banks covered by terrorism and money-laundering sanctions. Cruz’s legislation, however, would authorize the administration to hit all of Iran’s banks with sanctions and require it to act against SWIFT if it connects any Iranian bank under sanctions to its system, according to a copy seen by the AP. 

In August, Cruz led a group of 16 GOP senators, including Trump allies Tom Cotton of Arkansas, Marco Rubio of Florida, Thom Tillis of North Carolina and John Barrasso of Wyoming, in demanding action against SWIFT if Iran is not suspended. Congressional aides say they believe support for his proposed legislation will be strong. “The administration’s maximum pressure campaign will not succeed if the Islamic Republic remains connected to SWIFT,” the senators told Mnuchin.  
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