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)
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:
- Doctors' Ignorance Stands In The Way Of Care For The Disabled
- Patients Lose When Doctors Can't Do Good Physical Exams
- Privacy advocates warn of ‘nightmare’ scenario as tech giants consider fitness tracking
- The United States takes the spoiled rich kid approach to health care
And finally, this week's laundry list of articles talking
about the transformation taking place around us.
- A holistic view on integrative medicine
- Ex-Senators on Both Sides of Aisle Join Forces on Health Care (importance of tele-medicine and having it reimbursable by insurance)
- Raising kids who can talk with their doctors
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: