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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