- Nurses are angels – not all of them and not all the time, but most of them and most of the time. From the one who after checking the pulse on my leg at two in the morning gave my ankle a squeeze of reassurance after I had told her how unsettled I was, to the one who laughed at my lame jokes when I was trying to think about anything but my heart. Nurses do a tremendous amount of work, have an incredible amount of knowledge and move through their day in a caring and concerned manner. They truly make the system work
- WTF, I was offered oxycodone – of course, not everything was positive (this is the real world after all) – I was shocked and appalled that when I said I had a headache, I was told I had been pre-approved for receive oxycodone for pain. I was there for heart issues, I wasn’t having surgery (catheterization is much less invasive), and there was no reason for me to have anything but Tylenol (which is what I took). Given what we now know about substance abuse issues, I should not have been offered such a powerful drug
- I like the hub and spoke/feeder system of smaller hospitals sending patients to centers for specific complicated procedures. That’s how it works in Maine for the placement of stents – while the community hospital I started at did a diagnostic catheterization when it was determined I needed stents places, I was sent on to Maine Med. This means that the only people doing the procedures are the ones most qualified to do so. Makes sense, doesn’t it? Of course, there are financial implications both for the system and for low-income family members, but those are complications to be addressed, not reasons to abandon the approach
- Riding in the back of an ambulance I was not checking prices, network participation or quality statistics. Talking about health care, I’ve often said that people don’t comparison price riding in an ambulance – so of course, when I was actually riding in one, I couldn’t help but consider the irony. But it was true, the last thing I was thinking about was being a good consumer – and call me crazy, but I don’t think we want to put that kind of stress on patients needing care by expecting them to do so
- Electronic records actually work – In the space of 72 hours I was at a doctor’s office and two hospitals – everyone knew who I was, what was going on, and what had come before. The interventionist had seen the film of the diagnostic catheterization; they knew my PCPs name (and had sent her my hospital records). EMRs get a lot of well justified bad press, but my experience reminded me that they are worth the trouble to get right
Saturday, September 2, 2017
Thursday, July 20, 2017
- The Federal Employee Benefit Plan (FEBP) has insurers offering plans in every county in the country. For underserved counties, require the two largest FEBP plans to offer a silver plan on the marketplace
- Medicaid buy in - Offer a “plan” on the marketplace allowing individuals to receive Medicaid coverage for a specified cost (can be thought of as a stop-gap public option)
- Incentivize insurance companies to participate by requiring those firms in a state bidding for Medicaid contract to offer an exchange plan, or by requiring any insurer that wants to sell off the exchange in a state to sell in every county on the exchange as well.
- Enforcement of the mandate (there is currently a provision in the House budget to prevent the IRS from spending money on mandate enforcement)
- Sufficient marketing efforts supporting/encouraging enrollment (the administration cut advertising and promotion during the end of the open enrollment period)
- Enrollment support through the hiring and promotion of navigators
- Utilize the bones of the Medicare Part D risk corridor program
- Utilize a reinsurance program modeled on Alaska’s (which just received a waiver from CMS for 2018 to help fund their reinsurance program).
- “Another idea is to require insurers to participate in broad regions, which would limit their ability to selectively work in more profitable ones and shun ones that are less so, like rural areas. This would be consistent with Medicare Part D, which requires insurers that offer stand-alone drug plans to do so in multi-state regions.“ Austin Frakt writing in the NY Times
- CSR payments
- In underserved counties, buy from DC exchange (like Congress does)
- Permanent reinsurance provision
- CSR payments
- In underserved counties: a) suspend tax, b) public option c) buy into FEBP
- “Second, Congress should ensure coverage for bare counties. The Federal Employees Health Benefits Program (FEHBP) offers private insurance coverage from multiple insurers in every county in the nation. For 2018 and 2019 only, the largest two FEHBP insurers in any county should be required as a condition of continued participation in the program to offer at least one silver-level plan through the federal exchange in all counties that would otherwise be without coverage. These plans should be eligible for premium tax credits and could otherwise charge actuarially appropriate premiums.”
- CSR payments
- Coverage for bare counties (Federal employee health benefit plan)
- Risk Corridor
- Mandate enforcement
- More generous tax credits for young
- Deductibility of premiums for individuals
- Replace mandate w late enrollment penalties used in Medicare Parts B and D
- End employer mandate
- Replace Cadillac Tax with cap on tax exclusion for employer-sponsored insurance
- Reduce premium and cost-sharing for low-income individuals, cap premium at 8.5% of income for all
- Given 4, relax 3:1 age band
- Reevaluate essential health benefits
- Increase marketplace enrollment
- Address insurer/provider concentration by capping rates in those markets (use Medicare or Medicare Advantage rates)
- Use broad revenue source to fund reinsurance
Monday, June 26, 2017
Friday, June 23, 2017
Better Care Reconciliation Act – No, the bill title is not a joke, just another sign that irony is dead
- The cost-sharing reduction provision of the ACA is eliminated after 2020
- Individuals eligible for employer coverage would be ineligible for premium tax credits regardless of the affordability of the employer coverage
- States can change rating bands from 3:1 to 5:1. As you may recall, that means premiums for older people will go up.
“The provisions of the ACA subject to 1332 waivers (and not otherwise repealed by the Senate bill) include the essential health benefits, actuarial value, out-of-pocket limits (for individual plans), and other qualified health plan requirements, as well as the ACA’s exchange provisions (which are not otherwise repealed by the Senate bill) and its premium tax credit provisions. Under the Senate bill, these can be waived if a state describes how it would “provide for alternative means of, and requirements for, increasing access to comprehensive coverage, reducing average premiums, and increasing enrollment.””
- Senate GOP bill would gut critical public health funding this fall
- The Senate health bill would hugely roll back women's health care
- GOP health bill is a disaster for opioid crisis
Wednesday, May 17, 2017
Friday, May 5, 2017
- The ACA slightly transferred some funds from the rich to the poor, but the AHCA massively transfers money from the poor to the rich. It is an $880 billion transfer from people on Medicaid to people making more than $200K a year.
- The bill passed without hearings, with the final text made available mere hours before the vote, with many members of the House saying they had not read it, and without a CBO analysis.
- There was no public support for the bill: no provider groups, no patient groups, and no hospitals came out in support of the AHCA.
- As written it may benefit a few young healthy people, but it will harm many old, sick and low-income people.
- Finally, note that supporters of the AHCA are still telling lies about the ACA – but now they are also telling lies about the AHCA (basically trying to convince people it’s not as bad as it is).
Stein said there’s nothing wrong with the structure of a reinsurance program like MGARA, but the key is how well it’s funded.
“In the end, it all comes down to how much money is put in,” Stein said.
And the invisible high-risk pool, Stein says, is just one small proposal within the larger health bill.
“There’s nothing inherently wrong with it, but it doesn’t really fix all the other problems of the bill,” he says.
Stein says those include changes to essential health benefits and cuts to the Medicaid program.
High-risk pools can work in theory, but only if they’re properly funded, said Mitchell Stein, a health policy expert who worked for the advocacy group Consumers for Affordable Health Care when Maine passed PL 90. They usually aren’t and historically have failed, leaving people with pre-existing conditions facing unaffordable premiums, he said. “It all comes down to money, as it usually does,” Stein said.
Under congressional Republicans’ plan, $110 billion would fund a high-risk pool over 10 years. One study estimates that it would cost at least $178 billion every year to adequately fund it. “The dollar amounts the Republicans are talking about are woefully inadequate chump change,” Stein said.
Saturday, March 25, 2017
- Why Medicaid Work Requirements Won’t Work
- Everything You Need To Know About Block Grants — The Heart Of GOP’s Medicaid Plans
“No federal benefits program -- not Medicare, not Medicaid, not the marketplace -- can thrive without constant adjustment, from administrators and legislators. Since inception, the ACA marketplace has been denied such essential adjustment, and has in fact had to withstand outright sabotage from Republicans -- who threw up hurdles to the training of enrollment counselors, undercut funding for a crucial risk adjustment program, and refused to fix obvious flaws, such as the so-called "family glitch" that renders many whose employers offer family coverage they find unaffordable ineligible for marketplace subsidies.” Xpostfactoid
- First, we need to create balanced risk pools that include both healthy and less healthy persons in individual insurance markets.
- Second, we need to extend subsidies higher up the income scale than the ACA’s limit of 400% of the federal poverty level.
- Third, if we want private insurers to participate in ensuring that Americans have access to affordable insurance, the business of selling this product must be viable.
- Fourth, and perhaps most important, public and private stakeholders must accelerate efforts to control the costs of health care services, which are the primary determinants of the cost of health insurance in all markets, including employer-sponsored, individual, and public.
Sunday, February 26, 2017
- Fri AM - First analysis of the net financial impact on Americans of the proposed Republican modifications to health care premiums after tax credits, plus cost sharing.
- Fri PM – Leaked full text of Republican legislation presumably presented to CBO for scoring (dated February 10, 2017)
- Fri PM – updated Medicaid details leaked
- Sat – Presentation to National Governor’s Association on the impact of ACA replacement
- For funding, the plan would eliminate all of the ACA taxes and instead limit the tax deductibility of employer-sponsored health insurance. This is an approach that has been supported by economists on both the right and the left for years (think Cadillac tax), but the forces stakeholders will marshal to prevent this change are formidable.
- Regarding Medicaid, the draft eliminates the expansion and changes the entire program to a per-capita funding basis. These changes have been called a “non-starter” by some in Congress and by several governors (including prominent Republicans).
- Regarding private insurance, the essential health benefits definition is eliminated, a continuous coverage requirement for pre-existing condition coverages is added, and the individual mandate is eliminated. Taken together, these changes are a recipe for market instability.
- Kasich says Dems, Republicans need to work together to fix ObamaCare
- Republican Governor Scott Walker Warns Against Medicaid Cuts
- GOP Rep. Mo Brooks says town hall protests may prevent Obamacare repeal
- Repeal of Health Law Faces Obstacles in House, Not Just in Senate “While the 218 votes needed in the House to get the ball rolling remain likely, it is no longer the slam dunk that Republicans had with previous bills to repeal the law, when lawmakers knew their efforts would die in the Senate or on Mr. Obama’s desk.”
- Leaked Draft Shows GOP Plan Will Not Only Replace Obamacare, But Transform Medicaid “The draft would replace Obamacare’s means-tested tax credits with tax credits that are not adjusted for income. This is the key flaw in the House leadership plan, because it means that millions of highly vulnerable people—those near the poverty line and those with poor health status—will not receive enough in tax credits to afford the coverage they need.” – Avik Roy (He was a health care policy advisor to Mitt Romney's 2012 campaign and was the senior advisor to Rick Perry's 2016 campaign. After Rick Perry withdrew from the race, Roy joined the 2016 presidential campaign of Marco Rubio as a policy advisor.)
- Continuous coverage requirement for pre-existing condition coverage
- Tax credits by age, not income, not adjusted for premium costs
- 5:1 rating band based on age (as opposed to current 3:1)
- Essential health benefits package up to each state
- Continue to allow “grandfathered” plans and allow to enroll new members
- Eliminate funding for Medicaid expansion
- Turn Medicaid into a per-capita program, sending each state fixed sum (on a scale of 1-10, with 1 being block grants, per-capita is a 2.
- $100 billion over a decade to finance state programs that would cover people with the highest medical costs (including but not limited to high-risk pools)
- “The impact would vary by state, but in a sample state that expanded Medicaid, it's estimated that:
- The state would lose $635 million in federal funding, a 65 percent decrease.
- 110,000 current enrollees would no longer be able to afford a plan.
- 20,000 currently uninsured people would buy a plan with the new tax credit provided by the GOP plan.
- Additionally, 115,000 low-income people may lose Medicaid coverage, with no affordable alternative on the individual market.
- A per capita cap — which would limit funding for each person in the program — would reduce federal spending by 24 percent over five years, requiring the state to spend $6.2 billion to close the gap.
- The state would lose $885 million in federal funding, an 80 percent decrease.
- 130,000 current enrollees would no longer be able to afford a plan.
- 10,000 currently uninsured people would be able to buy coverage with the new tax credit.
- A per capita cap would reduce federal spending by 6 percent over five years, requiring states to spend $1.5 billion to close the gap
- Medicaid caps are likely to result in state funding gaps
- Capped funding is likely to be paired with more flexibility for states on coverage and benefits
- Because states must balance their budgets annually, reductions in federal funding may lead to cuts in eligibility, benefits, or payment rates
- Per capita caps offer more flexibility to respond to enrollment growth, but they cannot easily adapt to new products or technology (e.g., high-cost drugs)
Tuesday, February 14, 2017
Representative Poliquin of Maine’s second district has prepared a handy form letter to send to constituents who write or call his office expressing support for the ACA. I thought it would be helpful to walk through some of his statements to see how they hold up. A full copy of the letter is at the end of this post (I’ve removed the name of the recipient who shared the letter with me).
Just for fun, along with each of my comments, I’ll include sources for my statements – you know, facts. Before we get started, a note about my perspective. As many of you know, I support the ACA and continue to think it is a great step forward. Twenty million more people have health insurance now than before the law was passed. However, no one denies that the law needs adjustments. Changes are often required after a complicated law gets passed. Unfortunately, in this case, due to the partisan rancor in DC, once the law was passed there were no fixes permitted by Congress, leading to the current issues.
Now let's look at some specifics.
“…suffocating under the spiking ObamaCare monthly premiums...”
Yes, premiums went up for 2017 at a greater rate than they did the previous two years - but let’s remember how premiums acted before the passage of the ACA – they went up in even greater increments. It is also worth noting is that the headlines regarding spiking premiums refer to averages across carriers and across the country. In many states, the market is working well. States that have chosen to expand Medicaid (MaineCare) have seen lower premium increases than states like Maine that have not. Additionally, the subsidies received by many of the enrollees will shield them from the increases.
“…losses of more than 30 million of taxpayer dollars...”
He is referring to Maine Community Health Options (MCHO), one of the COOP plans that were created through the ACA. These plans do not receive federal money. What they have received is loan guarantees from the Federal Government. While MCHO had a bad year in 2016, they are recovering; as noted by Maine’s Bureau of Insurance: “CHO's ability to stabilize its operations in 2016 and achieve plan results up to this point is encouraging and merits its re-entry into the Maine individual health insurance market for 2017.”
“…supported the Obamacare repeal initiation vote...”
Many times, over the past several years the house has voted to repeal the ACA. In all that time, they have not come up with a replacement plan. It’s easy to vote for a bill that you know will be vetoed – it’s a lot harder to come up with workable policy proposals.
This link is a walk through the history of promises by the Republicans to come up with a replacement plan: https://storify.com/JeffYoung/just-in-time
“…replacement includes coverage for pre-existing health conditions...”
Slogans are easy; policy is hard. What does Rep. Poliquin mean by including coverage for pre-existing conditions? If, as in the ACA, it means they will be charged the same rate as everyone else then there will need to be a mechanism, like the mandate, so that people do not just purchase coverage when they need it. If they mean something else, we need details – it will be easy to say it includes coverage but how much might that coverage cost? Will they require "continuous coverage" - an ideal state that in the real world is hard to execute?
“…eliminate job-killing taxes...”
My question here is how will the replacement plan be financed if the taxes associated with the ACA are eliminated? Providing Medicaid or subsidies takes money. If the taxes are repealed, how will the replacement plan be funded? What do you think the chances are that the Republican House and Senate will impose new taxes to cover their “replacement” plan?
If they don’t intend to provide subsidies at least as large as the current ones, millions of people will lose coverage, contrary to the current promises of Republican leadership and the President. Don't be fooled by the phrase "universal access”. Access is not coverage. I have access to purchasing a Lamborghini, but that doesn't mean I have the funds to do so.
To sum up, the letter below contains several half-truths and misdirections. It also gives no credit to the positive impact the law has had. As the debate over the future of the ACA continues, let's try and stick to the facts.