Friday, May 30, 2014

That Was The Week That Was* - Issue 12

A look back at the week's health policy news with a focus on ACA implementation


Three new polls out this week on the ACA telling us that little has changed in the way of public perceptions.  A reminder out of Kentucky by none other than the Senate Minority leader that people still want to "eat their cake and have it too" when it comes to health reform.  Some interesting but not surprising information about cost sharing and its impact on the use of health services (spoiler alert, having skin in the game doesn't really help that much, in fact it hurts).  Lots on the VA situation and of course much much more... 

ACA: Polls/Opposition
Polls out this week from Kaiser (Kaiser Health Tracking Poll: May 2014), Gallup (Few Americans Say Healthcare Law Has Helped Them) and AP-GfK (AP-GfK Poll: Sign-up success fails to translate into broad approval for Obama’s health law).  While lots of different stories on each of them sighting the results of one question or another, there really is not much new to report.  For those interested, the links above can provide some of the details, but basically public opinion on the law has not shifted in spite of the success of the initial open-enrollment period.   The most interesting point to me was this headline on the Kaiser poll: Tired of hearing about Obamacare? You're not alone.  A sentiment I'm sure no reader of this newsletter shares but understandable that those not immersed in these issues feel that way.

With all that in mind, it is not surprising that the political situation is cloudy.  It is an open question how supporters of the law will frame the issue as they run for reelection (Health law: Embrace, avoid or in between for Dems).  If nothing else, the uncertainty leads to some entertainingly inconsistent headlines:  Democrats won't run on Obamacare vs. GOP candidates show signs of retreat on full Obamacare repeal as midterms approach vs. Health insurance rate hikes may affect elections: Republicans are vowing to make failures of Obamacare a main theme.

Remember repeal and replace?  Some conservatives are pushing to finally come up with the "replace" part (Steve Scalise to push GOP leaders on Obamacare alternative) although signs are that the house won't vote on a replacement  plan anytime soon (since differing factions of the GOP can't agree on what replace would include).

Which brings us to Kentucky.  We have a conservative state, home to the Senate Minority Leader, that has both created their own Marketplace (KYNECT) and expanded Medicaid.  In fact, KYNECT is one of the most successful state run marketplaces and is incredibly popular within the state, as is the Medicaid expansion.  So what's an ACA opponent to do?  Apparently Mitch McConnell: Repeal Obamacare, except maybe keep everything it does in Kentucky.  He's trying to keep the people who have benefited from the ACA in his home state happy while sticking to his ideological guns...  His Democratic opponent in the Senate race sees the disconnect in the situation (Grimes On Obamacare: McConnell Can't Tell The Difference 'Between Fact And Fiction ).  My favorite was when he said KYNECT was unconnected to the ACA (What did Mitch McConnell mean when he suggested the Kentucky state exchange was ‘unconnected’ to Obamacare?)

ACA: Cost Sharing
The concept of "skin in the game" is one you can't get away from when discussing health policy and plan design. There is a school of thought that says if something is free, people will waste it, and with the presence of health insurance the only way people will use health services responsibly is if they have to spend their own money. One of the cornerstones of that theory is a Rand study done in the 1970s. But now in the 2010s there's reason to be skeptical about its continued applicability. Here is a review: Health Care Cost-Sharing Works — Up to a Point (side note, for those who have not subscribed "The Upshot" stop and do so now, a great new resource from the NY Times).

My favorite response to the skin in the game school is this quote: "I have never woken up and thought: 'It's free, let's have some chemotherapy.'" (Do people really overuse healthcare when it's free?).

We also have empirical evidence that When Medicaid has premiums, enrollees drop out, even when the premium is small it serves as a barrier to people receiving the care they need.

ACA: Premiums/Costs
No new 2015 premiums released this week, but lots of speculation Obamacare Sticker Shock? Unlikely For Most In 2015 and Why the major test for Obamacare premiums might wait until 2017 and Big insurance rate hikes in the future?.

Also this week we saw White House: O-Care has cut health cost growth. 

ACA: Marketplaces
With all the problems they've had with their marketplace, Oregon: Suit Sought Over Health Site.
Some reflections on the marketplaces coming to the conclusion that it's Too Early To Calculate Success Of ACA Marketplaces

The SHOP was a disappointment during the first open-enrollment.  While functionality for the individual market was quickly fixed after the troublesome launch, the SHOP was not.  The current timetable is for full functionality to be rolled out this fall, and signs are that Health care law’s small-business exchange right on track — with one glaring exception.  The exception is that states will have the option of allowing employee choice on the marketplace  - even though the Federal Marketplace will have the technical capability (assuming they stay on schedule).

Some good news in that Insurers Once on the Fence Plan to Join Health Exchanges in ’15

Medical Group Management Association (MGMA) ACA Exchange Implementation Survey Report , a survey of physician practices was released.  Results show that the practices are not overwhelmed with new patients but are having issues with insurance administration (confirming eligibility, network participation of specialists)  and concerns about liability (higher copays/deductibles, 90 day grace period rule).

ACA: Employers
More this week on two issues we've discussed before. First, confirmation that I.R.S. Bars Employers From Dumping Workers Into Health Exchanges. Meaning that an employer cannot provide pre-tax money for an employee to use the Marketplace. An employer could give them a raise to help them pay for individual coverage, but it would be taxable and would not meet the employers obligations to provide coverage (if they are large enough to have such obligations).

Second, another review of the "reference pricing" topic: 7 Things You Should Know About The Next Big Benefit Change. Remember the Feds rules on the topic only apply to large self-funded plans so concern on the impact of this technique on the individual insurance market are premature.

ACA: Other
An important story out of Florida regarding possible attempts by insurance companies to game the system.  A Complaint accuses 4 Fla insurers of discrimination.  Specifically, that they designed their prescription drug coverage to discourage individuals who are HIV positive from selecting their plans.  They did this by putting all relevant medications (including low price generics) in the highest cost sharing tier.  An reminder that there is the letter of the law and then there is the implementation...  Implementation has to be monitored to keep just such gaming from occurring.

Coverage on how hospitals are faring, with expansion states experiencing An Obamacare winner: Safety-net hospitals -  higher Medicaid coverage they are seeing fewer uncompensated cases.  This is leading to  Hospitals Look to Health Law, Cutting Charity - changing their policies so that they are not paying for charity care for individuals who could be enrolled in Marketplace plans or Medicaid. 

Also this week a  wide-ranging look at 21 things Obamacare does that you didn't know about. As well as a new report looking at The Patient Protection and Affordable Care Act of 2010: Impacts on Rural People, Places, and Providers: A Second Look (Executive Summary).

VA
The VA scandal continues.  As I was writing this, word came out that Shinseki Resigns as Veterans Affairs Chief Amid Furor Over Hospitals.  This followed the release of the Inspector General report:  Severe Report Finds V.A. Hid Waiting Lists at Hospitals.

Some analysis of the politics of the situation: Analysis: Seeking political gain over VA issues and The real problem with the VA? Congress.

But it's not just the VA, Hagel orders review of Pentagon health-care facilities.  And if that confuses you, here is an explanation of the differences between the VA and active duty medical care:  FAQ: VA And Military Care Are Different, But Often Confused.  And a primer on the VA system specifically: Q&A: How do US veterans get health care?.

And finally, a reminder that Veterans aren’t the only ones waiting for health care.  An excerpt (note to anyone with the Alexander Group reading this - you give a source, then you put quotation marks around the material from that source - you can even indent large passages to make it even clearer that it is not your work):
"But the big question with these stories about the VA is, "compared to what?" This scandal wouldn't exist if the VA didn't have performance metrics on its employees. If it didn't measure or care whether veterans get prompt appointments it could just do what the rest of the health-care system has done and not hold people responsible for these metrics. Now, certain people seem to have cheated on this metric. But that's far better than what goes on in the rest of the health-care system where no one is accountable for this at all."

Medicaid
And segueing into Medicaid, a story talking about There’s another scandal in American health care, meaning all the states that have not expanded coverage.  An excerpt:
"As appalling as the wait times are for VA care, the people living in states that refused the Medicaid expansion aren't just waiting too long for care. They're not getting it at all. They're going completely uninsured when federal law grants them comprehensive coverage. Many of these people will get sick and find they can't afford treatment and some of them will die. Many of the victims here, by the way, are also veterans."

A great piece on the ramifications here in Maine of not expanding:  What a Medicaid expansion would have meant for Maine’s poor adults. 

Drugs
The cost of Sovaldi and how health systems deal with Hepatitis C patients continues to be an issue (and will continue to be one for some time to come).  Sarah Kliff writes The fiercest debate in health care is about a $1,000 pill.  She asks the question  how much is too much to charge for a drug? This is being discussed now because  "...if every hepatitis C patient in the US were treated with Sovaldi at its list price, it would cost $227 billion. Right now, we currently spend $260 billion for all drugs."  So we have a ‘National Dialogue’ Urged On Cost Of New Hepatitis C Drug but with no clear conclusions in site.

A look at The dramatic shift in heroin use in the past 50 years: Whiter, more suburban.  "How people come to use heroin has also greatly changed. In the 1960s, more than 80 percent said heroin was the start of their opioid use. In the 2000s, though, that had reversed dramatically, with 75 percent reporting they used a prescription opioid before turning to heroin."  At the same time some thoughts from a physician saying: It’s time for doctors to say no to drugs

System Transformation
Another case study this week from the change is hard files. A House committee voted to allow school systems to apply for waivers from school lunch nutrition rules. This is an issue the First Lady has been working on including an editorial in the NY Times: The Campaign for Junk Food: Michelle Obama on Attempts to Roll Back Healthy Reforms. Unfortunately the GOP rejects FLOTUS in school lunch battle. As you're reading coverage of this issue, please note that the " School Nutrition Association" often characterized as the "lunch ladies" actually represents not only school nutrition professionals but also the food companies that supply the program. I'll leave it to your imagination why they are not happy about more fresh fruits and vegetables being part of the requirements.

Moving on to the "future is now" files, we have two updates in wearable technology - why carry a "fitbit" if your shirt can monitor your heart rate and more... Not quite flying cars, but still cool: Intel Shows Off ‘Smart’ Wearable Shirt, Samsung Stakes Claim on Wearable Tech That Monitors Health.

An item from a few weeks ago that I missed: Ever wonder what Doctors think about end of life care? A survey asked the question Do Not Resuscitate: What Young Doctors Would Choose and the answer was overwhelming: "So the researchers asked what choices they would make for themselves if they were terminally ill. Their reply: 88.3 percent would choose a do-not-resuscitate or “no code” status. An allow-me-to-die status, in other words."

Georgia Looks To Reopen Some Closed Rural Hospitals As E.R.s - Stumbling towards an effective hub and spoke system of care? Rural areas can't always support full hospital facilities, so try and put and ER/Urgent Care hybrid in their place. Seems this may be what DHS had in mind this week but that's just a guess on my part: State requires Lincoln County Healthcare to provide urgent care round-the-clock on Boothbay peninsula

And finally, this week's laundry list of articles talking about the transformation taking place around us.



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"
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Friday, May 23, 2014

That Was The Week That Was* - Issue 11


A look back at the week's health policy news with a focus on ACA implementation


This week while the Veterans Affairs scandal dominated the headlines, there were many other health care developments:  New information about how much is being spent to oppose the law, more information on premiums, a few Medicaid and Medicare updates, lots of information on unnecessary spending on pharmaceuticals and more...  So let's get started.

VA
Although not directly related to the ACA, we'll start here.  I won't pretend to do justice to the full scope of the problem, but there are a few points I want to note.  Let me start by saying this is a disgrace.  Our veterans have served us and deserve, as we all do, access to appropriate treatment when they need it.  Clearly, there is a problem that needs to be addressed.  That said, the VA has at times in its history been a trendsetter in healthcare (initial adoption of EMRs is one example) and by all accounts, once seen by providers the care provided is still excellent.  These facts and others are being distorted in some of the coverage (I'm sure you're shocked).   You may have read that "40 veterans died" as a result of the waiting list problem.  What actually happened is that 40 veterans died while waiting for an appointment - sad to say that chances are most would have died anyway.  Again, I don't want to minimize the issue, but let's be mad about what really happened.  Some decent reviews of the issue can be found here The VA scandal, explained ad here Everything you need to know about the VA — and the scandals engulfing it and here History and Context of an Embattled Department of Veterans Affairs and finally here The Veterans Affairs Scandal Was Decades in the Making: Yes, you should be angry. But at whom?

Burwell
The Senate Finance Committee voted overwhelmingly (21-3) to confirm her (Burwell gets committee approval for health post) although there are still some who want to make more of a spectacle of the proceedings (Conservatives Want a Bigger Obamacare Fight Around HHS Nominee).  Even with the objections, she is expected to be confirmed sometime in June when the Senate returns from their Memorial Day recess.

ACA: Polls/Opposition
Some mind boggling numbers on how much has been spent on political ads relating to the ACA.  A  showed that Study: Political TV ads on health law total $445M with spending on negative ads outpaced positive ones by more than 15 to 1.  Remember that communications problem supporters of the law are still having swaying public opinion?  Obamacare Buried By Avalanche Of Negative Ads probably has something to do with it.  And it's still going on:  $10-million ad campaign joins 'avalanche' of anti-Obamacare ads.

One writer looked at How The Army Solar Power Program Is Like The Affordable Care Act.  Note that the answer is not my interest in both topics - rather it is that in the face of extreme opposition (financed by a pair of brothers who shall remain nameless) the success of both is starting to change the dialogue.

The week wouldn't be complete without more polls on the ACA and its impact on the mid-term elections.   Still six months out we have competing views on what effect the ACA will have.  Here is some of this week's coverage: Morning Plum: What does the polling really tell us about Obamacare?, The Politics Of Health In 2014 Aren’t What You Think.

ACA: Premiums/Costs
While no new rates were released this week, lots of talk about what is to come as well as a look at the impact that competition in the Marketplaces had on this year's rates.  The study asked the question How much lower could Obamacare premiums be with better competition? and answered it Study: Limited Competition Raised Obamacare Prices.  The Marketplaces were designed to increase competition, in states where there were more options that proved to be the case.  In many states (including Maine) we expect more insurers to participate in the Marketplace for the 2015 plan year (Insurers Joining More Obamacare Exchanges for Next Year).  That will help keep rates down.

With the topic of premiums getting so much attention, several attempts to explain how the process works.  If you always wanted to be an actuary, then you'll find this one fun: What to Expect for 2015 ACA Premiums: An Actuary Opens the Black Box.  If not, then this might be helpful Putting 2015 Health Care Premium Rates into Context.  And as Insurers, regulators prepare to negotiate 2015 health coverage costs I found Report: Fear of high ObamaCare premiums ‘unfounded’ to be reassuring.

Last week we reviewed the three "Rs" and budget neutrality.  The administration added some clarity to help insurers appropriately set their 2015 rates by saying that Federal funds earmarked to offset Affordable Care Act insurer losses.  But Critics call Obama funding plan for health insurer losses a 'bailout', even though the funding is temporary and designed to smooth out the transition period.

While the law is trying to increase access, it is also trying to rein in costs.  Here is a helpful review of one way that might happen: Meet Obamacare's secret weapon in the war on exorbitant health-care costs.

We all know that health care policy is complicated -at times a desired result has undesirable impacts.  Health Care is not a jobs program, so even though it is unfortunate when individuals lose their jobs, if we are to cut spending it is inevitable that some positions are eliminated as the system becomes more efficient.  We saw some small signs of this occurring this week with reports nationally Affordable Care Act, spending cuts slow health care hiring and locally MaineGeneral Health eyes budget that would lay off 16 employees, cut 128 positions.

ACA: Marketplaces
A reminder that the ramifications of some of the healthcare.gov's problems have yet to be resolved.  Federal health-care subsidies may be too high or too low for more than 1 million Americans.  This does not necessarily mean that a million people will have their subsidies adjusted, but it does mean there is a lot of work still to be done resolving these discrepancies.  And while $250K fine for lying on health insurance forms is the regulation, we don't expect very many will end up paying that size penalty (note that is for willfully lying, not for inadvertent mistakes).

In addition to completing healthcare.gov, there are other reasons that Obamacare enrollment doesn’t get any easier going forward.  Two of them are getting new people to enroll and getting those already enrolled to renew. 

Regarding functional websites, It’s crunch time for Obamacare’s broken exchanges.  We know that several states will be either changing vendors or using the Federal Marketplace (Health Site Under Fire, Nevada Alters Path).  And in an effort to clarify why some states had so many problems, US subpoenas Oregon insurance website documents to aid the investigation.

ACA: Employers
I wrote last week about the law that passed the house to amend how expats were handled under the ACA.  Here is a very helpful analysis detailing some of the law's problems by our friends at Georgetown Universities Health Policy Institute: The Expatriate Health Coverage Act: Like “Using a Bat to Swat a Fly?”.

Some agitation this week over the concept of "reference pricing".  Although nothing new happened, a few lines in regulations previously released were rediscovered.  The New Republic takes a looks at the issue : A New Obamacare Detail That Could Save You Some Money—Or Cost You Even More: Economists love this idea, consumer advocates hate it, and both may be right as does Tim Jost: Implementing Health Reform: Third-Party Payments And Reference Pricing.

ACA: Other
Last Friday, CMS released final rule for Exchange and Insurance Market Standards for 2015 and beyond (CMS Announcement).  I've previously described this for MeHAF grantees.  For those interested who have not seem my summary, it's copied at the bottom of this post. 

The Center for American Progress released a report saying that in order to continue successful implementation of the ACA A New Management Structure for a New Phase of the Affordable Care Act is needed.  Their bottom line is that the White House needs an ACA CEO. 

Last week we also reviewed the new recommendations regarding HIV prevention.  The question was then asked A Reader Asks: Are Insurers Required To Cover HIV Prevention Medication Recently Recommended By CDC?  The answer is no, since the recommendation was not made by the body specifically referenced by the ACA with respect to what preventative services are covered.

And finally, before we leave the ACA for this week, a comment by retiring Senator Rockefeller:  Senator: Race is part of criticism of Obama health law.  He said (and I personally agree) that while there are many reasons why individuals object to the ACA, one of them, for some people, is the race of the President.  When pressed, Rockefeller stands by Obama race remark.

Medicaid
Good reviews of how some Republican Governors  found it impossible to turn down the money associated with Medicaid Expansion: Republican governors have found something they like about Obamacare, The right starts to fold on Obamacare: How conservative governors are suddenly coming around (although we note with sadness that it hasn't happened here in Maine yet).

Some additional thoughts on last week's announcement by Gov Pence that even he saw the wisdom in accepting Federal Funds:  Indiana’s Gov. Pence taking the Obamacare money and running with it.

Medicare
Medicare continues to work to cut spending without jeopardizing care: Medicare May Be Overpaying Hospitals For Short-Stay Patients and Following Abuses, Medicare Tightens Reins On Its Drug Program and Bundled payments could cut Medicare fraud, experts say.

Drugs
Sometimes we pay more because one drug is used instead of another for no good reason.  We've talked before about how the use of Lucentis instead of Avastin is wasting money - now we have some dollar figures and they are not pretty:  Eye Treatment for Seniors: How Lucentis Wastes More Than $1 Billion per Year

And sometimes we pay more because drugs are used in general for no good reason: Thousands of Toddlers Are Medicated for A.D.H.D., Report Finds, Raising Worries and Way too many doctors are prescribing antibiotics in error, study says.

And sometimes we pay more because the price of a drug is obscene, even if it is the right drug used at the right time:  U.S. health insurers say Gilead hepatitis C drug too costly

And finally, sometimes we pay more because the "free market" pushes us in  that direction even though "...for many patients the profusion of choices has often led to confusion, not better treatments, as well as skyrocketing costs." (Type 2 Diabetics Face a Flood of Drugs and Tests)

Costs
Information on the cost of large employers covering their workers (note that this cost includes what the employees contribute).  This number will be important as we approach 2018 and the imposition of the "Cadillac Tax" on these plans *Health insurance coverage now costs $23,215 for a typical family).  For now, the Study: Care costs continue slower growth in 2014.

Price transparency is one way these costs might be kept under control.  One estimate is that Solving the mystery of health-care prices could save $100 billion.  (Also see the information in the employer section on "reference pricing".)

There are times when we need to spend a little more now to keep costs down long-term.  The care of chronic illnesses is one of those cases.  If there is too much of a barrier to the maintenance drugs then people will skip them and end up with acute problems.  That's why some advocate Why Patients With Chronic Illnesses Should Pay Less.

System Transformation
Need a reminder of how bad things are?  Take a look at this video and let me know if it makes you laugh or cry (or both): The insanity of the American health care system, in one hilarious video.

Meanwhile, there are efforts to bring our hospitals into the future (or at least the present) Athenahealth CEO Jonathan Bush: A prescription for fixing hospitals: Health insurance reform isn’t perfect, but it’s here. Now it’s time to remake how medical centers operate and The Hospital Of Tomorrow: Redefining Hospitals Under The Affordable Care Act.

Fascinating work around making the patients full "chart" available to the patient.  Opening Up Clinicians’ Notes—The Robert Wood Johnson and Cambia Health Foundations Funding a Movement and Pilot at Boston’s Beth Israel Deaconess gives patients electronic access to therapists’ notes

Reminders that Health care is ultimately a social enterprise and How Being Poor Makes You Sick.

Several cautionary notes out this week:

And finally, this week's laundry list of articles talking about the transformation taking place around us.




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"




Review of last week's CMS final rule for Exchange and Insurance Market Standards for 2015 and beyond. 

Here are links to the information:
CMS Announcement - General announcement

CMS FAQ - Technical, most of you can ignore

Tim Jost Blog Part 1 - "This post will address five of the most important and controversial issues addressed by the final rule: the regulation of navigators; changes in the premium stabilization programs; the regulation of fixed-indemnity plans; provisions for state regulators to veto employee choice in the SHOP exchange for 2015; and procedures for enrollees to obtain an exception to formulary restrictions in exigent situations. "

Tim Jost Blog Part 2 - "This post covers the remaining issues. It will also analyze guidance issued on May 16, 2014 by the Centers for Medicare and Medicaid Services and the Internal Revenue Service."
Some of what I consider the highlights:

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Friday, May 16, 2014

That Was The Week That Was* - Issue 10


A look back at the week's health policy news with a focus on ACA implementation


Have you had time to recover from the first ACA open-enrollment period?  I hope so, because although November is still six months away it's time to start talking about the next one.  This week we saw the first premiums for 2015 trickle out.  We also saw lots more evidence about what a problem it is getting the word out on the benefits of the ACA.  Medicaid and Medicare were in the news as well as some fascinating technical developments you'll find under the System Transformation heading.  So let's get started.

ACA: Premiums
As Drew Altman (the CEO of the Kaiser Family Foundation) put it so aptly, it's time now for The Next Big Health-Care Issue.  Namely what will the premiums look like for the next open enrollment period.  Or to put it another way, How Will 2015 Health Insurance Premiums Compare to 2014? 

A couple of key points to keep in mind that are going to get lost in the coming frenzy.  Health care costs have been going up since way before passage of the ACA.  Also remember that there is not one "Obamacare" plan or one health insurance market - there are over 500 separate rating areas in the country and each will have different experience.  Sarah Kliff reviews those issues and more here: Six reasons Obamacare premiums are going up next year. 

There are some actual data points already (Early data suggests Obamacare premiums aren't skyrocketing, One health insurer wants to cut rates 6.8 percent. Another wants to hike them 26 percent. What gives?) but they are probably useful primarily as a Rorschach test to gauge your opinion of the law as opposed to an indication of where rates will actually land.

One of the reasons so much of this is guesswork is the uncertainty of how the "three Rs" (Reinsurance, Risk Corridors, and Risk Adjustment) will work.  These programs were designed to smooth out rates between insurers in the first few years of the ACA's implementation but there is continuing uncertainty about how they will be implemented (Risk Corridors And Budget Neutrality).

ACA: Polls/Opposition
Another non-event this week in Sylvia Burwell path to confirmation as Secretary of HHS.  In her second Senate hearing once again, among those introducing her was a conservative Republican, this time Senator Tom Coburn from Oklahoma.  And while she was questioned about certain ACA implementation issues, there were no fireworks.  She is expected to be confirmed by the full Senate before the Memorial Day recess (Another Breezy Hearing for Obama Health Pick).

This week yet another reminder of the amount of work left to be done in communicating the law (enough already with the reminders).  In a McKinsey report we saw that "About two-thirds of the respondents who were subsidy-eligible but didn't sign up for health insurance were unaware of their eligibility."  One way to understand this is that The dirty truth about the GOP attack on Obamacare: It worked.  You can read the full report here:  Individual market: Insights into consumer behavior at the end of open enrollment (McKinsey report).

Yet another poll showing people want to keep and improve the law rather than repeal it (CNN Poll: Should Obamacare be kept or repealed?).  And a look at how the battle is raging in our neighboring state of New Hampshire (Democrats struggle to win over skeptical Americans on Obamacare).

Since we're on the topic of reminders, more evidence that a rose by any other name would not smell as sweet.  Or in this case, a law by any other name would be much more popular (Kentuckians only hate Obamacare if you call it Obamacare). 

There were efforts this week by supporters of the law to embrace the positive (Bill Clinton urges Dems to defend Obamacare, Liberal groups launch campaigns to boost turnout based on Obamacare support).  While opponents of the law (at least in Congress) continued to be subdued (GOP goes quiet on ObamaCare, The GOP's Incredible Disappearing Quest To Repeal Obamacare).

ACA: Marketplaces
We've talked about the Marketplaces before and the wisdom (or folly) of trying to reinvent the wheel by building them state by state.  Here is a look at what was spend on some of the failures ($474M for 4 failed Obamacare exchanges) and a more detailed look at two of them (How Massachusetts screwed up Obamacare, Insurance CEO: Shut down Hawaii health exchange).

ACA: Employers
The Urban institute came out with a study regarding the impact of eliminating the employer mandate.  Spoiler alert, they did not think it would have much impact (Axing Obamacare's employer mandate would do little harm, study says).  Read the full report here Why Not Just Eliminate the Employer Mandate?  and if you are interested, my reaction to the report here:  Employer Mandate: Theory, practice and those pesky federal deficits . . .

ACA: Other
In the courts, we saw an Appeals court hears health care tax credit case.  This is the case where opponents are arguing that the law did not intend for the Federal Marketplace to offer premium subsidies.  Every time there has been a decision on this question it has been in favor of offering subsidies, but the filers of the suit continue to appeal and this was another step in the case's inevitable journey to the Supreme Court.

Kaiser released a report looking at Women and Health Care in the Early Years of the Affordable Care Act: Key Findings from the 2013 Kaiser Women’s Health Survey.

From Families USA a study to highlight that not all Silver plans are created equal:  Designing Silver Health Plans with Affordable Out-of-Pocket Costs for Lower- and Moderate-Income Consumers.

Have you hugged your broker recently?  Maybe you should, evidence that in CA at least they played a key role with Marketplace enrollment, for individuals as well as for small businesses (Insurance agents played key role in California's Obamacare enrollment).

Medicaid
While not the case here in Maine we this week did see Another conservative governor finds a way to expand Medicaid.  The Governor of Indiana is as ant-ACA as they come. And yet, even he has admitted what a great deal the Medicaid expansion is for his state.  The plan put forward, apparently after negotiations with the Feds, uses an existing state plan to expand coverage.  It also includes premiums of up to $25 a month for those earning over 100% of FLP.  You can read more about it here Another red state just caved on Obamacare and here Indiana Seeks More Coverage for Poor, but Many Would Pay.

And while Indiana is the latest, it was not the first,  Arkansas and Michigan prove Republicans can compromise on Medicaid.

On a positive note, we did have more evidence this week that even among non-expansion states enrollment is up among those who were already eligible (Avalere Analysis: Medicaid Non-Expansion States Experience Up to 10% Enrollment Growth Due to Woodwork Effect).

But while some individuals are helped, it is not enough.  The cost of not expanding is being made clear in several ways.  One is seen as hospitals report earnings for the first quarter  Hospitals see blue-red divide early into Obamacare’s coverage expansion.  Another cost can be seen as States’ Medicaid Decisions Leave Health Centers, Patients In Lurch.

Here in Maine we saw some numbers putting a lie to the statement that most of those who would have benefited from expansion can get help anyway.  While 70,000 would have been eligible if expansion had passed, only 8,000-10,000 of them ended up in a Marketplace plan (Up to 10,000 marketplace enrollees eligible for Medicaid if it had been expanded in Maine).

Medicare
We've talked about the costs of the Hepatitis-C cure before.  This week saw rapid developments with respect to its coverage by Medicare.  A story highlighting the case of a Medicare enrollee who had been denied coverage for the treatment (Medicare Struggling With Hepatitis-C Cure Costs) led just a few days later to Medicare Reverses Denial Of Costly Treatment For Hepatitis C Patient.  Setting a precedent of coverage for many Medicare enrollees.

Another item that could end up costing Medicare significantly is the recommendation that certain people get annual CT scans if they are at heightened risk for lung cancer.  These scans could end up costing $2 billion annually (Lung cancer screening could cost Medicare billions).  

That said, we know there is money in the system that is not currently being spend appropriately as shown again by a Harvard: Overused Medical Services Cost Medicare Billions.  Now if we could just have a rational conversation about what we should and should not be paying for (and how much we should be paying...).

Drugs
Another recommendation, this one by the CDC, that could end up with a large bill is with respect to those at risk for AIDs.  Recommending this course of prophylactic treatment is not without controversy, you can see the details here: Advocating Pill, U.S. Signals Shift to Prevent AIDS. 

The number of people at that group pales with those at risk of ending up with Alzheimer's.  And while this week's news is far from a recommendation or a course of treatment, it holds out the prospect that sometime in the future the disease could be prevented:  Preventing Alzheimer's disease — with an antidepressant.

System Transformation
An unprecedented agreement this week as three large insurers (Aetna, UnitedHealthcare and Humana) committed to sharing their cost data with the Health Care Cost Institute so that it is available to consumers in a price comparison tool (Want to shop around for health care? A tool to compare prices). 

Some good reminders that you shouldn't believe everything you read.  Overall, Should you trust the latest health news? Here's how to tell.  And specifically Don’t take dietary advice from non-experts. 

And finally, this week's laundry list of articles talking about the transformation taking place around us, the first few highlighting new and exciting uses of technology.


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"
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Friday, May 9, 2014

That Was The Week That Was - Issue 9

A look back at the week's health policy news with a focus on ACA implementation


Perhaps the top story of the week was the anti-climax that Burwell's first confirmation hearing (for Secretary of HHS) turned out to be.  Also more numbers on topics ranging from public opinion to cost to the impact of insurance on mortality figures in MA.  And that's just the beginning of this week's news, so here we go.

ACA: Burwell Hearings
When Sebelius resigned and Burwell was nominated to replace her, it was assumed that the confirmation hearings would be a circus.  We shared some of that speculation in last week's issue.  The speculation continued earlier this week (Confirmation Hearings Loom for Health Services Nominee) leading up to Thursday's hearing (note this was the first of two Senate Committees that will hold hearings).  So what happened?  Probably the biggest anticlimax yet in the world of ACA politics: Not only did HHS nominee Burwell gets friendly treatment in Senate hearing, among those presenting her to the committee was Senator John McCain (R).  The Health Services Nominee Questioned and Praised at Senate Hearing.  Yes, there were some questions about the ACA, but nothing at all negative focused on the nominee.  In her remarks and answers before the committee she offered no surprises and from first hand reports it may have been one of the most boring hearings in recent memory (Fixing HealthCare.gov would be top priority, HHS nominee Sylvia Mathews Burwell says).

ACA: Polls/Politics
While not as boring, a hearing before the House Commerce Committee of insurance company executives also proved to be a bit of a dud for opponents of the law.  The Committee had issued a report last week presenting a ridiculously low number as the projection for how many enrollees will pay their premium.  The hearing was supposed to be a show where they would ask the insurance executives to confirm what a disaster enrollment was.  Unfortunately from their perspective, reality intervened.  Now I don't expect everyone to click on all these links, but I can't resist sharing the various headlines of that hearing's coverage: An Obamacare Hearing Just Backfired on the Republicans, Another Obamacare Attack Goes Bust, Called by Republicans, Health Insurers Deliver Unexpected Testimony, GOP struggles to land punches at ObamaCare insurance hearing, Insurers Say Most Who Signed Up Under Health Law Have Paid Up, and finally Sorry, Republicans, Obamacare enrollees are paying their bills.

In other good news we saw this month's Gallup estimates of the number of uninsured in the country, and they were the lowest ever (Gallup: Number of Uninsured Lowest We've Ever Recorded).  According to Gallup, the number of uninsured now stands at 13.4%, down from the 15.6% we got so excited about last month and the 18% last fall before the coverage provisions of the ACA took effect (U.S. Uninsured Rate Drops to 13.4% (direct link to Gallup data)).

The public's opinion of the ACA continues to be both problematic and unclear with competing polls (and headlines) disagreeing with each other (Poll: Obamacare hits new low, Is support for Obamacare edging up? Maybe so, polling results show., Springtime for Obamacare)

Some say that in the best case scenario, the law due to its very nature will never be popular (Why Obamacare isn’t getting any more popular — and probably won’t).   Another interesting poll indicates that health care continues not to be a priority for many.  It showed that Workers would rather save up for retirement than pay for health care.  To sum up the one thing that is clear is that much remains to be done helping the public understand the law. 

ACA: Impact
One of the questions opponents of the law like to raise is if increasing access to insurance is even a goal worth pursuing. The New England Journal of Medicine published a survey this week that should help put that question to rest.  It seems that the passage of the MA health law increasing access to health coverage (the law that was the model for the ACA) lead to a drop in mortality rates. While no one study can permanently settle the question, it is yet another piece of evidence supporting the increasingly strong argument that access to health coverage saves lives (More Good News for Obamacare: It May Be Saving Lives After All, Mortality Drop Seen to Follow ’Health Law). (It even points to the likely mechanism - steady access to care and medications for chronic conditions, something not available in the emergency room.)

It's important to note that while the study just looked at mortality, an obvious conclusion to draw is that if Health insurance saves lives. That means it improves health, too.  And on a related note, we're also starting to get an indication that the implementation of the law is having a real impact on hospitals' bottom lines.  Hospitals are reporting that they are seeing lower levels of "private pay" patients coming into their emergency rooms (How reform is boosting Nashville's public hospital companies).  And while "private pay" is sometimes a choice, many of these people are uninsured and their treatment will result in uncompensated care.  The hospitals reported the lowering of the private pay percentage as a positive to their financial results indicating it led to lower rates of uncompensated care.

ACA: Premiums/Costs
We tend to talk about the ACA in broad terms, but here is a good reminder that, to paraphrase Tip O'Neil, all health care is local.  There are 502 separate ratings areas in the country.  Also incredibly important is that some states have expanded Medicaid while others have not (What People Don’t Realize About the Affordable Care Act).  So we shouldn't be surprised that there is tremendous variation across the country in everything from enrollment rates to premium increases.

For more detail that you ever wanted to know about variation in Marketplace plans, RWJ has published: Eight million and Counting: A Deeper Look at Premiums, Cost Sharing and Benefit design in the new Health insurance marketplaces - really wonky look at premiums (7027) and plan designs (1208) for all Silver plans sold in the Federal and State Marketplaces across the country (note the same plan design is often sold in multiple rating areas accounting for the discrepancy between the two numbers).

We saw some good news from insurers on premiums as we saw reports that  Slim Ranks of the Young and Healthy Don't Faze Obamacare Insurers.

While the rates will vary based on a State's actions and other factors, there is no denying that there will continue to be levels of uncompensated care across the country - and how we pay for that is still a question  Health care’s $85 billion challenge – uncompensated care in the Obamacare age.

ACA: Other
Some new regulations were released by CMS and others this week.  For a review take a look at Tim Jost's Health Affairs Blog post: Implementing Health Reform: COBRA/ACA Interaction And Other Developments

More developments this week with regard to the Marketplace websites.  One state that had a head start actually decided to scrap their site: Massachusetts Starts Over on Health Website After Troubles.  Another state that had problems with their website was Hawaii’s Obamacare exchange cost nearly $24,000 per enrollee.  In comparison, the Federal website spent $647 per enrollee (Report: Federal Exchange A Comparative Bargain). 

So we see again that there are such things as economies of scale... In the original House version of the ACA, there was only going to be one Marketplace working off the theory that there was no need to duplicate efforts in all 50 states.  It was the Senate version, and it's offering to state autonomy, that came up with the idea that there could be a different website for each state.  From my perspective, the results are in, we should be working to make the one site as good as possible - and then everyone should use it, cheaper and more efficient is a good way to go.

Some developments this week in the continuing legal battles over the ACA.  No new decisions but oral arguments in two cases and the possibility of yet another case coming to court.  You can find a full summary here: New legal battle opens over Obamacare and contraceptives.

And finally on the ACA front, we saw public discussion of a bizarre scenario where employers may try and game the system by sending their most expensive health care employees to the marketplaces.  Note that this would only be of benefit to self-funded plans.  While it may not be explicitly illegal (yet) it certainly goes against the spirit of the law.  That said, it does serve to highlight the illogic of our current system (or lack of system) that such a strategy might actually work (Employers Eye Moving Sickest Workers To Insurance Exchanges).

Drugs
On the pharmaceutical front, continuing discussion of Who Should Get Pricey Hepatitis C Drugs?  Also a look at how health system consolidation impacts costs in all sorts of ways, such as Chemo Costs In U.S. Driven Higher By Shift To Hospital Outpatient Facilities (see the next section for another example).

On the M&A (mergers and acquisitions) front, another deal was announced with Germany's Bayer AG to buy Merck's consumer biz for $14.2 billion.  And signs that in spite of AstraZeneca's stated negativity to a deal, with their Profit Off, Pfizer Again Aims to Lure AstraZeneca.

Costs
Speaking of system consolidation's impact we had more evidence that  Hospitals’ Purchase Of Doctors Leads To Higher Prices, Spending, Study Finds.  On a positive note the Feds announced regulatory changes designed to save providers money: Press release: Reforms of regulatory requirements to save health care providers $660 million annually.

System Transformation
End-of-Life care is not something we handle well in this country.  Part of the reason for that is the lack of direction from patients.  Republican Senator Tom Coburn of Oklahoma would like to change that.  He has proposed making a payment to Medicare eligible individuals for completing an advanced directive (Lawmakers propose incentives for end-of-life planning).  Those of  you who recall the "death panel" debacle (a provision where Medicare would have paid the physician to have such a conversation was distorted into ghost stories about killing grandma) will see the irony in the proposal being introduced by a Republican. 

There is at least one city (La Crosse, Wisconsin) in the country that already sees the value in these conversations with over 96% of hospital patients having advanced directives (as opposed to the national figure of 30%).  They were recently highlighted in a CBS Sunday morning report Preparing for the final days .  You can also read about them in this NPR story from a few weeks ago: Town Where Everyone Talks About Death.

Even when an individual's wishes are clear, implementation of them can still be problematic.  The advent of for-profit players in the hospice industry has caused problems: Terminal neglect? How some hospices decline to treat the dying

National focus on dental coverage with a Maine spin:  USA Today reported on dental therapists, highlighting the Maine law that was passed this legislative session:  Dental therapists aim to fill in oral health shortfalls.  The scope of practice battles that occur in both dental and physical practice are to the detriment of consumers.  No one argues that safety must come first and practitioners should not practice beyond their education - but with that in mind there is much that mid-level practitioners can do which will not only help with costs but also help with perceived doctor (and dentist) shortages: How bad regulations enrich dentists and doctors at the expense of patients.

Speaking of safety, some positive reports this week here Hospitals Boost Patient Safety, But More Work Is Needed and here New HHS data show quality improvements saved 15,000 lives and $4 billion in health spending.  No one is saying the work is done, but it's nice to report good news for a change.

One of the ways we try and insure safety in the future is with quality metrics.  If you are new to this topic (and even if you aren't), Families USA released a great intro/primer on quality measures:  Measuring Health Care Quality: An Overview of Quality Measures.

And finally, this week's laundry list of articles talking about the transformation taking place around us.


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"
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