A look back at the week's health policy news with a
focus on ACA implementation
Expecting a holiday lull?
Sorry but health policy waits for no one. This week in addition to a new
Surgeon General (finally!) we have poll results, enrollment numbers and lots of
Medicaid news. Also CMS was busy with announcements (see the special section
below) and we will talk about a dramatic announcement in a socialist state, as
well as what’s going on in Cuba (fooled you). The socialist state I refer to
(out of deference to Bernie Sanders) is Vermont, where the Governor announced
this week he was giving up the pursuit of a single payer health system.
Please note, there
will be no issue next week but I will return with Issue 42 on Friday January 2.
I hope everyone enjoys the holidays and has a happy and safe New Year.
Since this is the last issue of the year, we’ll start off with
a brief look back at 2014:
Remember Ebola? It’s
still a severe problem in West Africa, but in spite of all the fear mongering many
in the US seem to have forgotten all about it. This week Politifact called the
false claims about Ebola the Lie of the Year: 2014
Lie of the Year: Exaggerations about Ebola.
But it wasn’t alone the only lie, here Vox lays out The 8 most bogus
health claims of 2014. And finally, as a
tribute to the geek in all of us, the Top
Ten Healthcare Charts For 2014. Now on to this week’s news.
ACA: Polls/Opposition
In addition to their Health Policy Tracking Poll (see
below), Kaiser looks at what news events people are paying attention to (Kaiser
Health Policy News Index: December 2014)
Two interesting piece from this month’s results: First over half the
population does not know the marketplace is working better than last year - “When
asked how the website’s functionality compares with last year, nearly half of
the public (48 percent) say there have been fewer problems, 31 percent say the
number of problems is about the same, and only 9 percent say there are more.” And
second, concerning the subsidy case that will be heard by SCOTUS in the spring
- “A large majority (84 percent) of the public say they have heard “only a
little” (29 percent) or “nothing at all” (55 percent) about the case before the
Supreme Court.”
This month’s health tracking poll didn't have any real
surprises with respect to the raw numbers, but the focus on how changeable
people’s opinions are is fascinating (Kaiser
Health Policy Tracking Poll: December 2014) “Kaiser found that support (for
the employer mandate) and opposition (to the individual mandate) are a lot less
firm than one might think” (Obamacare
Isn't As Divisive As You Thought) and Public
Easily Swayed On Attitudes About Health Law, Poll Finds “The poll also
found that a year into full implementation, most Americans, and most of those
without insurance, remain unaware about many of the health law’s major
features.”
More confirmation of the success of the law in reducing the
number of uninsured, as Time magazine reports Number of Uninsured
Americans Near Historic Low “The data released Thursday from the National
Center for Health Statistics’ National Health Interview Survey found that 11.3
percent of Americans were without coverage in the second quarter of 2014, down
from 13.1 percent in the first quarter and 14.4 percent throughout 2013. An
analysis by the White House Council of Economic Advisers finds the drop in the
uninsured to be the largest in four decades, amounting to roughly 9.7 million
Americans getting insurance, consistent with other Affordable Care Act
estimates.”
While those newly covered are much better off now, they are
not the only ones benefitting. The LA Times takes a look and reports the health
care industry isn’t doing too badly either: Uninsured
rates fell under Obamacare, but who's reaping the benefit?
Here
is an interesting perspective on what Republicans would do if the SCOTUS
disallows subsidies in Federal Marketplace states. Remember, states that had
set up their own marketplaces would continue as before, potentially setting up
a two tier system in the country – would Republican’s really allow that to
continue? If
the Supreme Court Breaks Obamacare, Will Republicans Fix It?
ACA: Enrollment/Marketplaces
This past week saw the formal deadline for enrolling in
coverage effective January 1. Lots of effort went into the last minute rush. Here
in Maine: Mainers
rush to enroll in health exchange The Federal
Health Exchange Sees Enrollment Flurry and in spite of that, HealthCare.gov
holds up amid record traffic on deadline day.
The deadline was Monday – unfortunately, the weekly
enrollment reports (released each week on Tuesday) run Saturday through Friday,
so the numbers we have so far aren’t complete. In spite of that we saw Obamacare’s
Best Week Yet Brings 1 Million New Sign-Ups. You can see the HHS release
here: Open
Enrollment Week 4: December 6 – December 12, 2014.
In addition to
the million on the Federal Marketplace, we saw More
than 700,000 enroll through state insurance exchanges in first month. Putting
that all together, a research firm revised its projections: Avalere
Analysis - Exchange Enrollment Outlook: 10.5 Million to Sign Up by End of 2015.
Although things went well with this initial deadline, there
were some who couldn’t get through to the call center. They will be given extra
time to enroll and still have their coverage begin January 1: Call
center wait won't stop Jan. 1 insurance coverage. In some states (not Maine)
insurers also made special allowances for the deadline: Insurers
have pushed back a key Obamacare deadline in 37 states.
There were some other circumstances where people will be given extra time, as
outlined by Tim Jost: Implementing
Health Reform: Enrollment And Reenrollment For 2015 “The FFM has, however,
established special enrollment periods for a small group of qualified
individuals who should have been passively reenrolled with coverage effective
January 1, 2015, but for some reason were not.”
Before continuing, let’s take a minute to review the
calendar. The 12/15 deadline was to get coverage beginning January 1. That
applies to those who are seeking coverage for the first time and to those who
are renewing coverage. Both groups still have two months to select a plan (open
enrollment ends 2/15), it’s just that for those who are going to be
auto-reenrolled (about 80% of those with marketplace coverage from last year)
it will be more complicated to switch plans since their existing coverage will
already have been renewed.
With that in mind, the expectation had been that if people
were going to alter their reenrollment choice, many will have done so by the
12/15 deadline. The numbers above show that while some of those who had
existing coverage have done so, the vast majority have not. Two pieces look at
that situation: Obamacare
Is Only Human
(alternative title, Obamacare Has A Problem: Human Nature) and this one that
looks at the impact of inertial on pricing decisions of carriers: Most
Obamacare enrollees are ignoring tonight’s deadline, and it will cost them
“The ACA exchanges were constructed with that idea that transparent competition
would help act as a check on unreasonably large premium hikes. But that could
also depend on people wanting to shop around for a better deal on coverage.”
ACA: Employers
After two years of delay, part of the employer mandate takes
effect on January 1. Employers with 100 or more employees will need to offer
coverage or face penalties – it seems like the delay may have served to ease
the impact with the economy (somewhat) improving: ACA
employer mandate: Not as bitter in better economy.
For small businesses who are not required to offer coverage,
things are still challenging: Round
2 for the ACA Health insurance options still a challenge for small businesses. Small
employers face a tough decision on if they should offer coverage or not –
remember, some employees are actually better off if their employer doesn’t
offer coverage because of the availability of subsidies on the individual
marketplace. So it was inevitable that Small
Businesses Drop Coverage As Health Law Offers Alternatives.
Although, as this story highlights, some small businesses are seeing a benefit:
Taking
the pulse of SHOP exchanges
ACA: Other
In news that saddened single payer advocates everywhere, After
years of effort, Vermont's governor reportedly gives up on single-payer health
care. “It became clear that risk of
economic shock is too high at this time to offer a plan that I can responsibly
support for passage.” Governor Peter Shumlin (Governor
Abandons Single-Payer Health Care Plan). While this is unfortunate for
those who think single payer has merit, it is important to realize that it
isn't working in Vermont because people don't accept the tradeoff of higher
taxes vs. no insurance premiums, not because the theory is bad. My take is that
optics, not finance is what doomed those efforts.
On a positive note, the Press Herald took a look at one of
the predicted benefits of the ACA, that the presence of affordable individual
insurance would allow individuals to give up their “day job” and pursue new
opportunities: Affordable
Care Act swelling ranks of self-employed, report says.
Costs
How does your doctor or hospital decide how much to charge
for a test? “Testing has become to the
United States’ medical system what liquor is to the hospitality industry: a
profit center with large and often arbitrary markups.” (The
Odd Math of Medical Tests: One Scan, Two Prices, Both High) – Sounds like yet another compelling case
for price negotiations/controls on the Federal level (like just about every
other country does).
Need more reasons?
How about “nonprofit” hospitals forgetting what it means to be a “nonprofit”
or charitable institution: From
the E.R. to the Courtroom: How Nonprofit Hospitals Are Seizing Patients’ Wages.
In the case discussed, if the charges had been incurred just a few months
later, they would have been waived. But instead the hospital is taking full
advantage of every legal recourse, seriously harming the family involved.
That is one case at one hospital (although we can imagine it
is not an isolated incident). What is going on across the country? The NY Times asked, here’s a look at How
the High Cost of Medical Care Is Affecting Americans.
These examples are important to keep in mind when (if?) we
start to discuss changes to the ACA. Some (me!) would say the law needs to do
more to help some of these people experiencing affordability issues while
others (the bad guys) want to get more “blood from a stone” and increase
low-income individuals share of expenses (can you say Copper Plan). Stay tuned!
For those who want to argue that the free market can take
care of all this, here are 10
reasons why healthcare isn't a free market Spoiler alert!
My favorite is number one: “Nobody in the
middle of a heart attack shouts, “Let's go shopping!””
With all that in mind, there is still a cost (and price)
crisis in health care – and we need to be doing things differently if we want
to fix it. Unfortunately, in the current environment it’s hard to have open
discussion on difficult topics: Forbidden
Topic in Health Policy Debate: Cost Effectiveness.
We can’t do
everything for everyone – but in our current system, we don’t discuss how
tradeoffs are made, thus all but guaranteeing that they are made in an
arbitrary and inefficient way.
Last week, we talked about an editorial in Health Affairs Why
I Oppose Payment Reform. This week, part 2 of the editorial was published: How
To Succeed At Payment Reform (By Really Trying) “Given the concerns I
raised in my prior post, I believe payment reform will only achieve its
intended goals if it occurs in a broader context that includes other strategies
— for example, defining spending targets and launching initiatives to improve
health outcomes by reallocating resources to the social sector.” Or to put it
another way, we need extreme solutions to these extreme problems.
CMS Announcements
As I've complained about before, figuring out a taxonomy for
this newsletter is hard. Many items could go in multiple categories, yet I don’t
want so many categories that each item ends up in a category of one (kind of
defeats the purpose). This week, throwing up my hands I’m including this
special category to handle a flurry of year end announcements from CMS.
Medicare
Cuts Payments To 721 Hospitals With Highest Rates Of Infections, Injuries
“In its toughest crackdown yet on medical errors, the federal government is
cutting payments to 721 hospitals for having high rates of infections and other
patient injuries, records released Thursday show. Medicare assessed these new
penalties against some of the most renowned hospitals in the nation, including
the Cleveland Clinic, Brigham and Women’s Hospital in Boston, the Hospital of
the University of Pennsylvania in Philadelphia and Geisinger Medical Center in
Danville, Pa.”
More
hospitals to get bonuses than penalties in 2015 under value-based purchasing
“A total of 1,698 hospitals will have their Medicare payments boosted in 2015,
467 more than in 2014, according to a Modern Healthcare analysis of data the CMS
posted Wednesday. … A total of 1,360
U.S. hospitals will have their Medicare payments docked next year.”
Details about the previous two items can be found on the CMS
website there: Fiscal
Year 2015 Results for the CMS Hospital-Acquired Condition Reduction Program and
Hospital Value-Based Purchasing Program.
But wait, there’s more!
Public
reporting of 2013 quality measures on the Physician Compare and Hospital
Compare Websites “CMS has added new quality data to the Physician Compare
website. Additionally, CMS has updated quality measures on the Hospital Compare
website and released data on new measures. These websites are part of an
Administration-wide effort to increase the availability and accessibility of
information on quality, utilization and costs for effective, informed decision-making.”
And finally: Providers
balk as CMS announces penalties for 2013 EHR issues “A CMS announcement
that many doctors will see their 2015 Medicare payments cut by 1% for failing
to meet federal electronic health-record incentive-payment program standards
has provoked strong reactions from physician and hospital groups.” However, note that this was a voluntary
program: “More than $25.7 billion in EHR incentive payments were made between
early 2011 and Oct. 1 this year, including about $10.3 billion to physicians
and other EPs, and $15.4 billion to hospitals, CMS data show. More than 414,000
physicians and other EPs, and 4,695 hospitals have been paid to date.”
Medicaid
CMS released new Medicaid enrollment data this week: Medicaid
and CHIP Enrollment Milestone Achievement: Enrollment Grows by Approximately
9.7 Million Additional Americans “As of October 2014, approximately 9.7
million additional Americans were enrolled in Medicaid and CHIP – a 17 percent
increase over the average monthly enrollment for July through September 2013,
the months before the Marketplaces first opened.”
The NY Times took a look at the numbers, focusing on states
that had not expanded Medicaid: Medicaid
Rolls Surge Under Affordable Care Act. We’ve talked before about the
“woodwork” or “welcome mat” effect – that just the talk about health coverage
will get some to apply for Medicaid who had not applied before even though they
were already eligible. These numbers show its impact. A side note, when looking
at the chart in the article you’ll see Maine is not included. According to the
footnote, Maine did not report enrollment figures to CMS. But while we don’t
have exact numbers, we do know that here in Maine, enrollment is now under
300,000 for the first time in many years as people who were terminated earlier
this year lose their transitional benefits.
That brings up the topic of Medicaid expansion – lots of
news this week from states who have not yet expanded, and some from those who
have.
We’ll start with some observations from Drew Altman about
the increasing number of Republican Governors who opposed the ACA that are now
considering expansion: Medicaid
Expansion in Red States “These days, momentum in the states lies with
pragmatism over conservative ideology and anti-Obamacare sentiment–that is,
provided the details of the deal between the administration and these states
are just right. But momentum could swing back, depending on developments in
Congress and the Supreme Court.” The
Washington Post also observed that Three
Republican governors have now endorsed the Medicaid expansion since the
midterms.
And talking about swinging back, one of the earliest
examples of a “red” state expanding, the original private option state
Arkansas, is now considering rolling back its expansion: Arkansas'
model Medicaid experiment in jeopardy.
Before continuing, let’s remember that there is a difference
between a Governor stating that they will expand under certain conditions, and
CMS accepting those conditions by granting a waiver. Secretary Burwell has said
she will speak to any Governor that wants to talk, but keep in mind what George
Burns had to say about prayers in the movie Oh God: I answer all of them, but
sometimes the answer is no.
To date, waivers have been approved in Arkansas, Iowa,
Michigan and Pennsylvania. Despite the ongoing conversations, nothing has yet been
approved for Alaska, Tennessee, Utah or Wyoming.
Here is some of the state specific coverage:
- Alabama governor open to Medicaid expansion
- Alaska may have to wait months for Medicaid expansion
- With Hospitals Under Stress, Tennessee’s Governor Pursues Medicaid Expansion “In perhaps the most unusual part of Mr. Haslam’s plan, the Tennessee Hospital Association has agreed to pay expansion costs beyond what the federal government covers. The Affordable Care Act calls for the federal government to cover all costs through 2016, with a gradually decreasing share thereafter, though never less than 90 percent. … Mr. Haslam described his proposal as a two-year pilot program that would need reauthorization.”
- Virginia Gov. McAuliffe to renew push to expand Medicaid (unfortunately, this is purely symbolic – the Republican controlled state legislature has shown no interest in expansion)
- Wyoming lawmakers endorse Indiana-style Medicaid expansion “Mead and state health officials negotiated the deal with the federal Department of Health and Human Services, but the state will have to go back to HHS to win a waiver for the new program.”
Medicare
Need another reason to be concerned about the future of
Medicare? Here you go: Paul
Ryan's bid to overhaul Medicare to resurface in new Congress.
His plan is to replace the program with vouchers for private coverage.
But we see this week yet again, that the benefit of private
Medicare plans (Medicare Advantage) often goes to the insurers, not the beneficiaries:
How
much do beneficiaries gain from higher Medicare Advantage payments “One of
the main arguments in favor of Medicare Advantage is that competition provides
the greatest value to beneficiaries. Even if one believes that to be the case,
according to this study, Medicare Advantage may not achieve levels of competition
to come close to fulfilling its potential. Beneficiaries are supposed to be
better off under competition. The less competitive the program, the less clear
it is that they are.”
Drugs
In 2012 there was a meningitis outbreak that killed 64
people. It was traced to tainted drug injections made by a “compounding
pharmacy”. This week, Compound
Pharmacy Owners and Employees Arrested for Meningitis Outbreak “The most
serious charges were made against Barry Cadden, a co-founder, and Glenn Chin, a
supervisory pharmacist who oversaw the sterile room, who were charged with 25
counts of second-degree murder for causing the deaths of patients in seven
states. Cadden and Chin face a maximum of up to life in prison if convicted on
all counts.”
In light of the charges, Modern Healthcare asked the
question: Are
compounding pharmacies safer now? The answer is yes, partially due to a law
passed by Congress in 2013 as a result of the incident.
Also in legal arena a Judge
halts Alzheimer's drug swap until July. There is a common practice
whereby a pharmaceutical firm takes a drug who’s patent is about to expire,
tweaks the drug (such as taking a two pill a day drug and making it one pill a
day), takes out a new patent and then removes the old drug from the market. That
means the patient is forced to change the way they use the drug, then when the
generic comes out a few months later it is harder to get individuals to switch
to it, since it represents another “change”. The ruling could have a sweeping
impact on the ability of the drug company to remove the original drug from
market (Court
Rules on Alzheimer’s Drug: Decision Could Reduce a Common Industry Practice)
thus making it easier to switch to the generic when it is available.
System Transformation
Thirteen months after his nomination, this week Vivek Murthy
was confirmed as Surgeon General. His nomination was contentious because he had
the audacity to say that guns (and the injuries they cause) are a public health
issue. In part due to Ted Cruz’s objections to the Cromnibus (see last week’s
issue), his nomination was finally brought to a vote by the full Senate and approved
(Senate
Confirms Gun-Control Advocate as Surgeon General - Vivek Murthy became the
nation's top doctor Monday, but only after a protracted fight over firearms).
Here are more details on the man and what a Surgeon General actually does: Vivek
Murthy is the new surgeon general. Who is he, and what the heck is his job?
Also in the news this week was a historical change in the
dynamic of US-Cuban relations. Why am I talking about that in a health policy
blog? Primarily because of something
called the Cuban Paradox. That is the term used because while Cuba is
considered a poor country, their health system is one of the best in the world
when measured by the health of the population. That begs the question, Can
Cuba Escape Poverty but Stay Healthy?
Also, this piece takes a look at how both countries health care systems
can benefit from improved relations: Renewed
U.S.-Cuba relations could impact both nations' healthcare
The Washington Post takes a deep dive into end-of-life care:
‘Warehouses
for the dying’: Are we prolonging life or prolonging death? ““I think if
someone from Mars came and saw some of these people, they would say, what have
they done to deserve this punishment?” said Marik, gesturing to the surrounding
rooms. “People might say we are prolonging life, but we end up prolonging
death.”” An important piece of the puzzle is palliative and hospice care. Here are
some thoughts on each: How
to introduce palliative care to patients and Too
Little, Too Late For Many New Yorkers Seeking Hospice.
Two developments in patient care worth noting this week: Belly
Fat Tied to Sudden Cardiac Death and For
First Time, Treatment Helps Patients With Worst Kind of Stroke, Study Says.
On the technology front, a mind boggling look at the near
future: Fantastic
Voyage: Tiny Sensors May Soon Monitor Seniors’ Medicines From Inside and a reminder that
technology can also help with some of the more mundane tasks: Doctors
no match for computers at accurately recording patient symptoms, study finds
A new study out this week looked at Shared
Decision Making And The Use Of Patient Decision Aids. It reinforces the point that we still have a long
way to go to achieve the goal of providing: “the care patients need and no
less; the care they want and no more.”
Handing someone a PDA (no not a public display of affection or a
personal digital assistant, a patient decision aid) is NOT shared decision
making. After the patient reviews the material there needs to be a two way
conversation with the provider if it is truly going to be a shared decision.
And finally, while we've picked on Dr. Oz before, it’s both appropriate
and fun. So let’s end the year with a classic and do it one more time: Half
of Dr. Oz’s medical advice is baseless or wrong, study says
All
comments and suggestions are welcome; please let me know what you think. And as
always, thanks for reading!
Funded by support from
the Maine Health Access Foundation
*The title is a tribute to the BBC show, the NBC show and the
amazing Tom Lehrer
album "That Was The Year That Was"
