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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