That Was The Week That Was - Issue 16

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

Be careful what you wish for is this week's theme.  We'll look at proposed regulations out for re-enrollment in marketplace plans and how advocates getting what they asked for might lead to problems.  Then later on we'll look at a slowdown in healthcare spending and how that impacted the economy in the first quarter.  We haven't hit a summer slowdown yet so in addition to those topics there's lots more to discuss, so here we go:

ACA: Polls

Gallup is turning into the go-to source for ongoing data - this week's results add more texture to what we know about the previously uninsured - After Exchanges Close, 5% of Americans Are Newly Insured: More than half of newly insured in '14 got insurance through exchanges.  There is also information on the health status of the newly insured purchasing on the marketplace vs. off.  And while they are a little less healthy, remember that insured plans sold on or off the marketplace will be part of the same risk pool, so that particular breakdown will not impact future premiums.  As I've been trying to do when reporting on surveys and reports, here is the link to the primary source:  Gallup: Most newly insured Americans used Obamacare's exchanges.

Here in Maine, our own MeHAF tracking survey continues with new results being released recently: Mainers’ Awareness of Obamacare Health Plans Doubles Following First Open Enrollment Period

ACA: Opposition

Opponents of the law are not taking any time off this summer.   A certain right wing foundation (that actually designed the ACA) has a piece out about what a failure it is. As this is a family friendly post, I won't use the appropriate adjectives to describe the piece, instead I'll link to a detailed rebuttal: Dear Sharyl Attkisson: Stop it, you're just embarrassing yourself now..

As we approach November, there are some wondering What a GOP Senate Would Mean for Obamacare (not actual  repeal since Obama will still be President, but plenty of votes on it) and others preparing to Get ready for the next (fake) Obamacare freakout.

While this week the Supreme Court did NOT rule on the remaining ACA related case for this session, it did rule on one that some think could foreshadow a case winding its way through the appellate courts:  What The Supreme Court's Greenhouse Gas Ruling Should Mean For Obamacare.  I include this in the interested of presenting differing views.  The author makes the argument that the Supreme's decision regarding the EPA will impact the cases regarding the presence of subsidies on the Federal Marketplace (as opposed to the state marketplaces).    I disagree - the case regarding the subsidies is based on ambiguous language, HHS was attempting to clarify, not add new regulatory authority as could be argued in the case of the EPA.  Of course many of us were least worried about the Medicaid expansion when it came to the original Supreme Court review, so never say never...  (Note that the subsidy case is still winding its way through the appeals courts and has not yet reached the Supreme Court.)

Of course as these arguments and others (see Costs below) continue to be made, Paul Krugman argues that opponents are Zero for Six - The Incompetence Dogma: So Much for Obamacare Not Working.

ACA: Premiums/Costs

Proposed premium rates out for two more states this week, again, no large spikes to be seen anywhere: D.C. health insurers propose rate hikes for 2015 and Colorado’s 2015 Premiums: Up, Down And Holding The Line.

ACA: Marketplaces

Be careful what you wish for (part 1). 

HHS released proposed regulations for how re-enrollment will work for consumers on the marketplace as their plans expire.  Here is a good general overview: Most Will Be Able to Automatically Renew Coverage Under Health Law and here are links to the proposed regulations: HHS announces auto-enrollment plans for current Marketplace consumers for 2015 (Primary Source).

One of the keys pieces of the proposed regulations is that people will automatically be reenrolled in their current plan if they take no action.  That is something that the advocacy community was hoping for since it means by default people will continue to have insurance coverage.  On the face of it, that makes a lot of sense as that's what happens with coverage people have at work and with other insurance people buy on their own.

But...  While it's clear the intent was to keep people covered and enable the marketplace (and navigators and assistors) to focus on those still uninsured, there will be unintended consequences that may cause problems (and higher costs) for individuals. 

First, note that the marketplace will send out a notice to individuals it decides will qualify for automatic renewal.  Those notices will contain the individuals new estimated subsidy, but they WILL NOT contain the new premium amount for the next year for the plan they will be automatically reenrolled in (why we're not sure as the marketplace systems will have access to those amounts).

Second, note the new analysis from Avalere Health regarding shifting premiums (Exchange Plan Renewals: Many Consumers Face Sizeable Premium Increases in 2015 Unless They Switch Plans - Primary Source).  The analysis points out that  with changing premium rates (even in states like Maine where the increases will be small) it is very likely that the subsidy "benchmark  plan" will change.  So the plan on which the premium subsidies are based may very well be a different plan.   This means that Obamacare enrollees may have to switch plans next year, or else pay more.

So the question is that while Most can auto-enroll for insurance, but should they? 

Bottom line - during the next open-enrollment period in addition to reaching the individuals who are still uninsured it will be important to educate those currently enrolled about their options - and potential cost savings - even though by default they will not have to take any action.  It would be helpful if the notices the Marketplace sends out had more information than is currently in the draft notices, but I'm not holding my breath.

Moving on to other Marketplace related issues, for those that have implemented their own marketplaces, many States don't know how they'll pay for year two of Obamacare (remember the Federal grants were for design and build, not for ongoing operations).  And a Deal reached on botched Mass. health site.

A report by the Commonwealth Fund that State Restrictions on Health Reform Assisters May Violate Federal Law, although I'm happy to note that while Maine has a law regarding navigators it does not have any laws that violate Federal regulations.

Community Catalyst reminds us of something we already knew here in Maine, namely How state-based advocates made open enrollment a success.

And finally, some thoughts on shifting the open enrollment period away from the end of the year: The Obama administration chose the worst months of the year to sell health insurance and Study: Tax refunds could boost health coverage .

ACA: Employers

Employer Health Costs Forecast To Accelerate In 2015 But note that the acceleration predicted is 0.3%: " If health plans stay unchanged, PwC sees medical costs rising by 6.8 percent in 2015, up from a projected increase of 6.5 percent this year."  (Primary Source:  Slight uptick in expected growth rate ends five-year contraction)

At times I (and others) have noted that there are no subsidies for those who have access to health coverage at work.  That is not completely true.  You could argue that the tax deductibility of premiums paid through an employer-sponsored plan is simply a different type of subsidy.  The CBO released a report looking t the Coverage Effects of Limiting the Tax Exclusion for Employment-Based Health Insurance.  Bottom line, they are not pretty.  At the end of the day the tax exclusion is worth more than individual subsidies, so if you scaled it back (or eliminated it) you would end up increasing the number of uninsured.

ACA: Other

Meanwhile...

The Hobby Lobby Decision Is Coming Soon—and It Won't Just Affect Contraception  - A helpful review of the case, we'll see the Court ruling released on Monday (6/30) so stay tuned.

And while a certain former Secretary of State is not officially running for any office, Hillary Clinton wants 2014 Democrats to run on Obamacare.

Finally, Is Obamacare Living Up to Its Preexisting-Conditions Promise? More focus on the problem in FL concerning coverage of AIDS medications (even generic ones) being put in the most expensive tier.  The article is a little hyperbolic - this is clearly a violation of the law and while it may take time to be resolved, it doesn't mean the law if failing.

Medicaid

Activity in Virginal around expansion continues, with the Va. House tosses out governor’s vetoes.  Remember from last week those vetoes were meant to preserve his right to expand Medicaid without legislative action.  There were also dueling experts in the state with  Va. House Republicans tout report saying Medicaid expansion is a legislative decision.  But the Governor does not seem to have given up yet, so stay tuned.

Not getting a lot of attention, but a report out on how Medicaid Managed Care plans are not necessarily getting the financial oversight they need:  The Medicaid Black Hole That Costs Taxpayers Billions.

A review of The Truth About Health Reform’s Medicaid Expansion and People Leaving Jail.

And finally, for those into infographics:  Visualizing Health Policy: Understanding the Effect of Medicaid Expansion Decisions in the South

Medicare

With respect to hospital quality, the leverage the Federal Government has is the Medicare program.  In an attempt to use that leverage, Medicare will penalize hospitals with the worst patient safety records.  When releasing the preliminary numbers, More Than 750 Hospitals Face Medicare Crackdown On Patient Injuries.  For the local story note that Maine hospitals could face penalties for high rates of infections, complications.

VA

More information on how bad things were at the VA with Investigator Issues Sharp Criticism of V.A. Response to Allegations About Care.

With both houses of Congress having passed similar bills, the conference committee is now meeting but Congress Has One Hurdle Left to Pass a VA Bill, But It's a High One.  Namely how the fixes will be paid for.  It's grown so contentious that some, since they can't agree on how to pay the estimated price tag, are saying the price tag is wrong: Lawmakers slam veterans health bill cost estimate.

Drugs

Two stories on the 340B program that provides discounted outpatient drugs for certain facilities.  Questions about what facilities are/should be eligible as well as how those facilities are using the money:  Drug Discount Policy For Hospitals, Clinics Under Scrutiny, Drug Discount Program Has Drugmakers Crying Foul.

Meanwhile the NY Times Editorial Board looks at the ramifications of Refusals to Pay High Drug Prices.

And some proof that the promise of big data can be realized as the FDA Harnesses Power of Claims, EHR Data for Monitoring Drug Safety .

Costs

Be careful what you wish for (Part 2).

If you wish for lowering health care spending, be prepared for the impact that has on the economy:  Good News on Health-Care Spending Is Making U.S. GDP Look Bad

"The BEA initially estimated that health care spending climbed 9.1 percent in the first quarter of 2014 — a potentially worrisome increase. The agency released their second revision of that number today: now they believe that health care spending has fallen by 1.4 percent (Health spending actually fell while Obamacare insured Americans)."

This piece (towards the middle) explains how the initial estimate was so far off (spoiler alert, they guessed): The economy just had its worst quarter since the Great Recession. Here’s why you shouldn’t worry.

And finally, I would say you won't believe this one but I'm sure you will.  A look at how you damned if you do and damned if you don't:  Here Is the Most Shameless Anti-Obamacare Argument Yet.

Remember those pesky "facilities charges"?  Well with that in mind it's no surprise then that Hospital Outpatient Prices Much Higher than Community Settings for Same Services .

And for those of you who have been worrying about doctors because of all those reports of how bad things have gotten for them, relax.   Doctors have it pretty good since Nine of America's ten top paid jobs are doctors.  Personally, I'll take the tradeoff discussed and replace our system with the French one - lower medical school costs and lower provider salaries. Anyone else in?

Vaccination

A subject I think it critically important gets its own section this week.  We'll start with a look back to the year 2000 and How Congress Brought the Measles Back.  This in light of the continued measles outbreaks across the county.  Here's a little science to go with your policy:  Measles cases are spreading, despite high vaccination rates. What’s going on?

Some good news with a Court ruling: parents don't have the right to send their unvaccinated kids to school.

And as we see in Ohio Amish Reconsider Vaccines Amid Measles Outbreak a plea that If you believe in vaccines, please speak up.

System Transformation

While the appropriate timing and frequency of breast cancer screening continues to be debated, reports that 3-D Mammography Test Appears to Improve Breast Cancer Detection Rate.  But all is not as it seems.  I note that the equipment manufacturer paid for the study.  Based on the results of the study it is not clear if the new technology truly represents a benefit.  The equipment is twice as expensive, and there are still those pesky questions about who should really be screened and when.  The new technology may turn out to be useful, but the evidence isn't there yet.

And speaking of cancer, the question is asked Is America better at treating cancer than Europe?  One of the counterarguments to last week's stories on the US's health system rankings was "but when people are treated we do a better job".  The article looks at the question but the bottom line is that while it's really hard to tell we probably are not better than Europe.   The piece is worth a read in order to understand the fallacy of just looking at survival rates.  (Spoiler alert - if you improve detection (finding the cancer earlier than you previously did) but don't treat it, the survival rate still goes up.)

One the positive side, there are studies that will lead to improved treatment and outcomes:  Longer Heart Monitoring Backed for Stroke Patients.

And some more good news:

• Abortion Funding for Peace Corps' Volunteers Advances With Republican Support (matching for Peace Corps volunteers what is available for Federal employees and the military)
• Without fanfare, Obama advances transgender rights

A very thoughtful piece that makes the valid point that protocols and guidelines as written should not be followed blindly.  I would state it differently, I would say that the protocols and guidelines need to be written with flexibility and grey areas in mind.  A "good" protocol would account for variation in individual patients and the lack of clarity in the existing evidence.  How does evidence-based medicine affect the art of medicine?

Some additional pieces looking at quality issues:

• We need more clinical time outs
• We should value quality when we shop for health care
• Don’t mistake patient satisfaction for patient-centeredness
• Why patient satisfaction surveys are riddled with problems

A long read shining light on behavioral health care: Cost of not caring: Stigma set in stone - MENTALLY ILL SUFFER IN SICK HEALTH SYSTEM.

A look at how some people end their days At Acute Care Hospitals, Recovery Is Rare, but Comfort Is Not.  Also looking at end of life issues, this week's grab a tissue piece:  Empowering patients: Emergency department palliative care

And finally, it seems comedic medical videos are a new thing.  Last week I shared Doctor House of Cards, this week what ER treatment would look like if homeopathy was medical care:  What if homeopathy invaded the ER?  This.

All comments and suggestions are welcome; please let me know what you think.  And as always, thanks for reading!

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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"

That Was The Week That Was - Issue 15

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

New information this week on the number of previously uninsured purchasing on the Marketplaces, a report on financial assistance on the Marketplaces, more premium information, a look at how the US health care system stacks up and much much more...

ACA: Polls/Opposition

Big news this week from a Kaiser survey that said: Survey: Most Buying On Insurance Exchanges Weren’t Previously Covered.   This contradicts opponents of the law who said the uninsured were not being covered.  While there was a great deal of (justifiable) excitement over this announcement, it is worth noting that this survey shows much higher numbers for people on the exchanges being covered than shown by previous surveys.  The differences may be due to the way  the question was asked.  This coverage takes a look at the differences:  (Most Obamacare exchange enrollees were previously uninsured, survey finds).  Part of the question is how people categorized themselves if their previous policy was canceled as well as the issue of churn, some may have been covered for part of the previous year but not all of the previous year.  There is no question many of the people purchasing coverage on the exchanges were previously uninsured, but for now there is still some question as to exactly what the percentage is.  (You can find the full survey results here: Survey of Non-Group Health Insurance Enrollees.

A new spin out on the ongoing question, if people like most of the elements of the ACA, why does public opinion continue to be so negative?  Some think it is a reaction to the President and to false stories about the law, this piece says  " Instead, the public’s disapproval of Obamacare considered as a whole points to Americans’ broader relationship with the government, and our unwillingness to trust that it can accomplish what it sets out to do." (Americans’ Faith in Government Shapes How They Feel About Obamacare — Trust Me ) .  Sad to say the initial problems with healthcare.gov probably exacerbated those feelings.

And yet, opponents of the law continue to have problems sticking to a story.  The GOP's Latest, Embarrassing Retreat from the Obamacare Wars and This Is What It Looks Like When an Obamacare Attack Backfires.

ACA: Premiums/Costs

HHS came out with a report on premium affordability and the marketplace (primary source: PREMIUM AFFORDABILITY, COMPETITION, AND CHOICE IN THE HEALTH INSURANCE MARKETPLACE, 2014).  The report showed that Obamacare costs $82 for subsidy-eligible people and $264 for the feds on average while here in Maine, Mainers paying average of $99 in monthly premiums on exchange.  Or to put it another way, Millions of Americans are paying less for Obamacare than cable.  The importance of this report can't be overstated.  Surveys have shown that among the people who did not sign up for coverage, the most cited reason was concerns over affordability.  As we hear up for the next enrollment period (starting in November) it will be critical to spread the word on just how affordable the subsidies make health insurance.  (Of course acknowledging that this will not be the case for all, even with subsides some will find the premiums too expensive and some will not be eligible for subsidies.)

Health insurance premiums rise every year, that was a fact of life before the ACA, and it will continue to be one at least for now.  The question is, are the increases more moderate than they otherwise would have been?  Here is a look at the public filings so far:  Avalere Analysis: Average Exchange Premiums Rise Modestly in 2015 and Variation Increases.  Although it's worth noting that these look at the rates that were filed and are not final (they may be changed during the process). 

One of the factors to keep in mind is that More Insurers in Obamacare Mean Lower Premiums.  As we'll see in the next section, lots of good news this week about participation in the exchanges.

ACA: Marketplaces

It seems that Healthcare.gov's terrible rollout didn't scare away insurers.  You can find the full report by the Advisory Board here, it says: In every state so far, more insurers are asking to participate in Obamacare.

We also had a report this week from McKinsey looking at narrow networks - the reason given for creating them is that they are less expensive without giving up anything on quality.  And that's what the report found (Hospital networks: Updated national view of configurations on the exchanges ).  Although it's worth keeping in mind that this looks at the networks overall, it is possible (and probable) that there are bad narrow networks as well as good ones and in fact some states are taking a closer look: California probes Obamacare doctor networks at Anthem and Blue Shield.

The Kaiser Media Fellowship sponsored a trip to Washington State for some reporters, leading to two stories making the same important point: Obamacare struggles, even where it’s succeeding and Washington state loves Obamacare — and still has challenges making it work.  Even when all is going as well as possible, there are still challenges both in implementing the law and with certain ramifications of the law as written.

ACA: Employers

While much of the business related coverage of the law has focused on the negative, this week Forbes takes a look at Four Reasons The Affordable Care Act Is A Boon To Entrepreneurs.

ACA: Other

As we near the end of June, the Supreme Court decisions will be coming fast and furious.  Since we might get a decision any day, here is a A guide to the Supreme Court’s upcoming birth control decision.  (This is the Hobby Lobby case which will decide if a corporation can have a religious objection to a law...)

As a supporter of the law, the hardest issue to come to grips with has been the difference between policy and implementation.  The policy pieces of the law may not be perfect, but if fully implemented they would go a long way towards bringing all of us a better health care system. We all know about some of the larger implementation issues and probably have some sympathy when it comes to rolling out a mammoth computer system... but when the administration ends up Bungling the Easy Stuff it is particularly frustrating.  To date, no final rules have been issued on the simple piece of the ACA saying that those who need financially assistance have to be charged the average rate paid at the hospital - not the "chargemaster" rate.  As I said, frustrating.

And speaking of some of the frustrations, here's a (depressing) assessment on What would it cost to ‘fix’ Obamacare?

On the positive side, a study out this week that Young adults healthier after passage of Obamacare, study finds - evidence that the law is having positive effects, not only on coverage rates, but on people's health (primary source: Young adults report better health following Affordable Care Act).

To try and address some of the implementation issues, the new Secretary appears to be following earlier recommendations regarding managing the implementation as HHS’s Burwell makes management changes.

Also activity this week on getting various messages out:  First a new campaign to help enrollees get the most out of their coverage (From Coverage to Care: A roadmap for using your new coverage).  Second a campaign to let people know about special enrollment periods (New O-Care enrollment campaign targets millennials) and finally, Enroll America Pushes Ahead To Second Enrollment Period (because November will be here before you know it).

VA

On the Veteran's Administration front, an updated report shows that VA chief: More vets wait 30 days for appointment. 

Also this week the House VA bill advances and the House creates VA conference committee (including our own Congressman from Maine's second congressional district).  The conference committee will work with the Senate (who passed a bill the week before) to create a final version.  Meanwhile some info on The costs of the Senate VA bill.

But not everyone is happy, as some say: The VA Reform Legislation Is a "Trojan Horse" for Privatization: It would do more harm than good. 

One form of "privatization" has been the ARCH pilot (being tried here in Maine, in rural Virginia and a few other locations).  While most reports of the pilot have been positive, still no word on if it will be continued (Future Uncertain For VA Rural Health Pilot Program).

Medicaid

More maneuvering in Virginia with respect to Medicaid Expansion as McAuliffe to sign budget, veto Medicaid amendment.

One piece of the ACA was the temporary increase in primary care reimbursement rates for Medicaid.  Now Physicians Push for Extension of Medicaid Reimbursement Increase although if you look above at the cost fix story, getting that done is no small matter.

The Urban Institute took a look at 14 large cities, half having expanded Medicaid and half in states that have not.  Not surprisingly, These 7 major cities are losing out on a big part of Obamacare (the ones who haven't expanded).  You can see the full report here: The ACA and America's Cities: Fewer Uninsured and More Federal Dollars.

Medicare

We've talked before about "observation status" in a hospital (as opposed to being "admitted".  Here is a very useful piece to help you understand what's involved: FAQ: Hospital Observation Care Can Be Costly For Medicare Patients.

One reason hospitals may be more inclined to use observation status instead of admission is the importance of readmission statistics.  For this and other reasons, Senators Offer Bill To Ease Readmission Penalties On Some Hospitals.

Drugs

Are you tired of me reporting on Sovaldi (the Hepatitis C treatment) yet? Sorry, but the topic is not going away - this week reports on the overall impact here in the US:  $1,000-a-pill Sovaldi jolts US health care system.  The possibility that the U.K. Cost Regulator May Reject Gilead’s Sovaldi Treatment.  And an attempt to come up with a shorter (and less expensive?) course of treatment: Exclusive: A four-week hep C cure? Bristol to test drugs with Gilead's Sovaldi.

Costs

On the cost front, the former Director of the CBO and OMB and now a Vice-chair with Citigroup says Orszag: It's time for some optimism about health care spending.  The piece looks at a variety of factors leading him to conclude that "If this continues, it's massive — everything you think you know about the nation's long-term fiscal gap would be wrong."

Also on the cost front a report looking at Insurers Push Back Against Growing Cost Of Cancer Treatments.  And a reminder that Mental illness isn't just a health issue. It's an economic issue.  This second piece continues the ongoing thread reminding us that what happens in the provider's office is only one (small) piece of keeping people healthy.

System Transformation

The Commonwealth Fund released its annual comparison between the US health care system and those of other countries.  Lots of coverage so I'll provide just a small sample.  First, the primary source for those who want to read the study: Mirror, Mirror on the Wall, 2014 Update: How the U.S. Health Care System Compares Internationally.

Here is a basic overview: Once again, U.S. has most expensive, least effective health care system in survey , and here is a story that includes a look at ACA implications of the survey:  U.S. health care system ranks last among industrialized nations.  In spite of this, according to a Gallup survey out this week, Most Americans Remain Satisfied With Healthcare System. 

On the technology front, Google and Apple want to be your doctor, and that’s a good thing.  And not just them WebMD Wants to Collect Your Health Data in One Place — Just Like Everyone Else.  Aggregation of data on the consumer front has been tried before (by some of these very same players) but the hope now is that the interest is greater and technology has caught up with the aspirations.  And while some (including me) see great promise, there are those who say Apple’s HealthKit Probably Won’t Bring a New Age.

A key to the above efforts being successful would be integration with the individual's EHR.  For years we've been hearing negative stories about how all they are doing is interfering with the doctors work.  But that is not everyone's opinion:  Why this doctor loves her EHR.  And increasing use of an interim step to help doctors with the technology (Why have scribes become so pervasive in health care?).

Again, policy vs. implementation, there is no question that the switch to EHRs has not gone smoothly: Electronic health records: A 'clunky' transition.  But I continue to have hope and Embrace the age of digital medicine.  And finally, a success story: How Google Glass Automates Patient Documentation For Dignity Health.

If you watch House of Cards and bemoan those who object to safe and effective vaccinations, take a minute to watch Doctor House of Cards:  Going House of Cards on anti-vaxxers: Why we need Frank Underwood.   Think this is much ado about nothing?  This week CA announced that whooping cough had reached "epidemic proportions" (We have a vaccine for whooping cough. So why's it an epidemic in California?).

This week we'll end with a laundry list

Some concern overtreatment and inappropriate treatment:

• Maybe we don't all need annual physicals
• New Heart-Valve Procedure Sparks Doctors' Concern: Less-Invasive Treatment Is Unproven for Many Patients - "Compared with surgery, TAVR results in higher rates of some serious complications, including blood-vessel damage, stroke and the need for pacemakers after the procedure, studies have shown."
• Consumer Group Urges Hospitals To Stop Promoting Questionable Screenings

Some concern exciting new research:

• In Single Gene, a Path to Fight Heart Attacks
• The end of aging Do naked mole rats have the secret to long, healthy lives?

Some concern the triumph of rationality:

• Dr. Oz Grilled In Congress, Admits Weight Loss Products He Touts Don't Pass 'Scientific Muster'
• Fewer Women Are Having Labor Induced Early  

And last but not least a reminder that the system may be working perfectly when nothing is being done:

• Watching people die is sometimes the compassionate thing to do  (have your tissues out for this one)

Thanks for reading!

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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"

That Was The Week That Was - Issue 14

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

This week's issue is brought to you by the letter M with everything from uninsured rates in Minnesota and Massachusetts, More premium numbers, Marketplace developments, Medicaid battles, MaineCare backlogs and so much More...

ACA: Enrollment

While we can all get caught up in the enrollment numbers game/hype - (myself included!) the real win is when more people have access to care.  The way we measure that is by looking at the change in the number of uninsured.  Previously we've seen very encouraging national numbers from Gallop - this week, more detailed evidence from two states that have seen a precipitous drop in the number of uninsured:  Obamacare cut Minnesota's uninsured rate by 40 percent and Mass. Inches Toward Health Insurance For All.

ACA: Opposition

It is also easy to get caught up in the story of the moment - but when we do that we can sometimes lose our perspective.  Trust Ken Burns (of Civil War and Baseball documentary fame) to take the long view:  Ken Burns: Go Ahead, Campaign on the Affordable Care Act - It will likely go down in history as 'one of the great pieces of social legislation,' the documentary filmmaker said.  At the same time a reminder from Paul Krugman that in fact the worst did not happen: Meanwhile, On the Health Front

While I won't fully cover this week's big political story, one side effect of Cantor losing his primary is that it makes it even less likely that the Republican's will vote on an ACA replacement: No Eric Cantor, no Obamacare ‘replace’ vote.  Of course saying this is like saying it's less likely that immigration reform will pass this year - the truth is neither issue was very likely result in a Congressional vote even before Cantor's defeat. 

ACA: Premiums/Costs

More information this week on proposed rate increases.  "Good" news out of California where Anthem's Obamacare rates to increase less than 10% in California.  Good being in quotation marks since a 10% increase is not really good, but it is better than CA residents may have otherwise seen in the absence of the ACA.  Also encouraging out of that report is that  " the age and projected medical costs of new enrollees are in line with the company's expectations thus far" .  This was always the key, not that enrollees looked like the population as a whole, but that they met expectations. 

Very mixed results in Maryland where CareFirst seeks price hikes for individual health plans (of 23 to 30 percent) while at the same time "Two other insurers, Kaiser Foundation Health Plan and Evergreen Health Cooperative, are proposing to lower rates for next year, by 12 percent and about 10 percent".

Meanwhile, a look back at existing rates (for the first open-enrollment period) showed that overall, Report: Health plans cheaper on exchanges. 

ACA: Marketplaces

Another sign of the Marketplaces success (in addition to states announcing low premium increases) is the raw number of insurers offering plans.  Not only are More insurers joining ObamaCare but Obamacare is adding insurers where they’re most needed.  Here in Maine we will see a third insurer (Harvard Pilgrim) join the marketplace, while our neighbor to the southwest (NH) will go from having only one insurer participate to having 5!

Last week we took a look at the number of cases on the marketplace that had data inconsistencies.  This week the GOP Says Tax Man Cometh for Health Law Enrollees by claiming that many of those people will see a tax bill due to receiving subsidies that are too high.  Of course they failed to note that most of the inconsistencies would result in no change to the subsidy already calculated and among those who may be receiving incorrect subsidy amounts, there is a limit as to what they will have to repay (chart on page 8: http://www.cbpp.org/files/QA-on-Premium-Credits.pdf).

And finally, an in-depth look at the technical state of healthcare.gov and how in the next open-enrollment period we won't be seeing similar problems to last year: Why the New Obamacare Website Is Going to Work This Time.

ACA: Employers

Unfortunately, as much as the individual marketplace became a delicious glass of lemonade last year, the small business marketplace stayed a lemon (SHOP flop: Obamacare for small businesses). 

Discussions regarding the employer mandate continue Obamacare’s employer mandate is under attack from both sides. Will it survive?.  (Here is a look back at some of my thoughts on the topic:  Employer Mandate: Theory, practice and those pesky federal deficits . . .)

For those interested in following the employer side of things, Mercer Launches Health Care Reform Content Portal to Provide Latest News, Research, and Commentary on Implications for Employers, Employees.  Anyone is free to sign up for the site - but be warned, for most of you it's way more information than you want.

ACA: Other

Some court developments this week.  First, another Court upholds Obama's birth control mandate although this is far from the last word on the topic.  Also, the Obamacare Hill subsidy case to go to court - for those not familiar with this one, it involved the ability of the Federal Government to contribute to congressional staff's health coverage on the individual marketplace.  Remember, as a rule employees with coverage available at work don't use the individual marketplace, so the law doesn't cover this circumstance.  However the ACA requires congressional staff to use the marketplace (for purely political reasons) leading to a situation not planned for by the law. In an attempt to continue to treat congressional staff like the rest of the federal workforce, their existing employer contributions were carried over to the marketplace, creating an uproar among opponents of the law.

November (and the next open-enrollment period) is just around the corner, so this week Community Catalyst released a report that "showcases the many successful strategies employed throughout the country by consumer health advocates and their partners": Connecting Consumers to Coverage: Mobilizing for Enrollment.

Also this week, AHIP (America's Health Insurance Plans) made recommendations about how they would like to see the law changed:  Health care reform: Insurers propose changes to Affordable Care Act (surprising only for the restraint of those recommendations which can at most be looked at as tinkering).

A review of where various states stands re the renewal of noncompliant plans: The Extended "Fix" for Canceled Health Insurance Policies: Latest State Action

A look at narrow networks, as we've said in the past, They Annoy Patients. They Scare Docs. But Narrow Networks Might Be a Good Thing.

And finally a review on where Vermont's efforts to create a single payer system for their state stand: A progressive alternative to Obamacare.

VA

Over the past few weeks I've been reporting on the VA scandal due to its prominence, its interaction with the ACA (at least in people's perceptions) and its importance to the health care system as a whole.  However, as I continue to cover pieces of it please understand that I don't claim to offering full coverage of the topic.  With that in mind:

Last week we saw the deal made between McCain and Sanders, this week the Senate passes VA reform bill.  The house passed its own version as well and Lawmakers Hope To Send Unified VA Bill To Obama By Late June.

Results from the audit were released: VA audit: 57,000 veterans waiting more than 90 days for appointment at medical facilities and the F.B.I. Begins Criminal Inquiry in V.A. Scandal.

Meanwhile as the  VA takes first steps to address scandal others were looking at solutions.  A Pilot program in Maine could be model to ease VA backlogs nationally but warnings that Privatization won’t fix the VA.

And finally, while the focus is on waiting times within the VA, a reminder that Outside the VA, waits for doctors can vary widely.

Medicaid

Lots of focus on the goings on in Virginia this week.   The Governor has been trying to pass Medicaid expansion and a budget.  Coverage at the beginning focused on Virginia is having an insane fight over Medicaid expansion.  Previously, the VA state senate had been evenly split between Democrats and Republicans - the a Democratic Senator resigned breaking the deadlock.  There was talk that Virginia Governor May Try to Expand Medicaid on His Own but finally, the Republicans prevailed and Virginia passes budget with Medicaid restriction (although as of this writing the Governor still had several days to decide if he would sign the budget).

An insightful look at the difference Medicaid expansion can make - by looking at a town where you have expansion on one side of the street but not the other: In Texarkana, Uninsured and on the Wrong Side of a State Line.

While the Michigan approach to expansion is not my preferred approach, you can get a good understanding of what they are trying to do here:  Michigan To Reward Medicaid Enrollees Who Take ‘Personal Responsibility’.

Additional reminders this week of the continuing hangover from the technology problems with the healthcare.gov rollout with More Than 1.7 Million Consumers Still Wait For Medicaid Decisions.  And here in Maine, Thousands stuck in MaineCare application backlog.

And finally, it's not too soon to start worrying about CHIP reauthorization - without congressional action the program ends in 2015: The clock is ticking on funding health insurance for kids

Drugs

The NY Times takes a look at the widening use of naloxone by first responders (and family) to treat drug overdoses:  Anti-Overdose Drug Becoming an Everyday Part of Police Work.  You may recall that Maine passed its own bill (enacted when unsigned but not vetoed by the Governor) during the last legislative session (Maine Enacts Life-Saving Naloxone Bill).

In an effort to combat prescription drug interaction, Hospitals Put Pharmacists In the ER To Cut Medication Errors.

Meanwhile, those altruistic pharmaceutical companies which always have the consumers interests at heart say PhRMA, Advocates: Specialty Drug Costs For Patients Too High.  The industry group that supports sky high prices for certain drugs  is shocked that insurance companies are seeking higher cost-sharing for some of those drugs.  It  reminds me of something, not sure what (Shocked!).  Anyway... while it is certainly true that some prescription cost sharing is too high, we should recall that it's only a symptom of a more fundamental pricing problem with those drugs.

Costs

Reports of some successes from the ACO arena: Anthem, HealthCare Partners save $4.7 million by coordinating care.

A reminders that there is still a long way to go: Coast-to-Coast Health Care Woe: Cost and some additional data on the disparity of costs - sometimes without any rational basis: Most expensive for a doc visit? San Francisco. Least costly cholesterol test? Pittsburgh.

And finally, highlighting the paradox of payment/system reform - if hospitals do everything we ask them to, they will see less revenue Maine Hospital's Dilemma: Improved Care Shrinks Bottom Line.

System Transformation

The social determinants of health - a clunky but crucially important phrase.  We've talked before about the need to treat the whole person.  One way to put it is Prescriptions Must Address More than Medicines "...in the U.S. patients may get top notch medical care and then return to a life guaranteed to keep them in ill health – because where we live, learn, work, and play can have a far greater impact on our well-being than the treatment administered in a clinic or hospital."

We can see evidence in the need to Address the racial disparity of colorectal cancer and a case study of Two New Mexico Counties: One’s Healthy, One’s Not. Why?.

Our friends at vox.com review Four ways to fix American health care that neither Republicans nor Democrats will touch.  I'd like to think that all four can be implemented as we work to fix the system. 

What, you do want another reminder that the system is broken?  Here you are: Hit by a car, an emergency doctor experiences firsthand the shortcomings in ER care.

And speaking of ERs we can ask the question when is an ER not an ER?  Stop the war being waged in the emergency department and look at ways to redefine emergency and urgent care to make the best (and most cost-effective) use of existing facilities.

This week's winner for misleading headline yet interesting article goes to: Patients Can Face Grave Risks When Doctors Stick to the Rules Too Much.  Our very own healthcare click bait.  The real issue is not with rules per say, but with rules that have firm cut-offs.  These types of rules lead to the presence of the "cliff effect" (which we discussed last week in a very different context).  Rules with a firm boundary lead to treating cases very differently even though they present with only marginal differences.  To me the problem is the way the rules are written, not with the presence of the rule.

One of the ever present issues when discussing quality is how and what do you measure.   Here's a look at Some Costly Hospital Complications Not Tracked by Medicare, Analysis Finds. 

As suspicious as we all must be with respect to unsolicited phone calls, sometimes they can help us.  A Health Insurer Calls, With Questions.  When in doubt about the source of the call, thank the person, hang up and find the phone number for the insurer yourself.  But remember, your insurance company may be calling based on your claims information with a program that is in fact in your best interest.

I haven't gone off on a rant about the need to vaccinate in several weeks, so we'll end with a this piece which makes the point in a much more clever and unique way than I could ever hope to do:  Applying the anti-vaccine mentality to car seats.

All comments and suggestions are welcome; please let me know what you think.  And as always, thanks for reading!

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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"

That Was The Week That Was - Issue 13

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

We have a new Secretary of Health and Human Service, confusion among the law's opponents on how to proceed, some peeks at next year's premiums, national Medicaid numbers and much much more.  So here we go.

Burwell

One of reasons I love pulling these together each week is that it gives me the opportunity to track how issues change over time, and how often media predictions turn out to be wrong.  If you look at the stories written when Burwell was first nominated it sounded like we were in for a huge firestorm of a confirmation process.  That was not to be.  Yesterday (Thursday) Burwell Wins Confirmation as Secretary of Health by a vote of 78-17.  And even some of the 17 (all Republicans) said they weren't voting against her as much as they were voting against the ACA.  The NY Times took a look at her roots (New Health Secretary Is Never Far From Her Roots).  Finally, it's worth noting that she has been called the anti-Sebelius in her relationship with Congress (New Obamacare chief ran textbook campaign).  It will be interesting to see if she can work with Congress to help fix some of the issues with the law that everyone acknowledges.  While it wouldn't happen until after the next election, even then a lot of good could be done.  I continue to believe that there are deals waiting to be made and find hope in the VA deal discussed below.  Perhaps it can be used as a model moving forward.

ACA: Polls/Opposition

Gallup is out with its monthly figures on number of uninsured and the U.S. Uninsured Rate Holds Steady at 13.4%. I'll let the release speak for itself:  "The percentage of U.S. adults lacking insurance coverage in the first two months of the second quarter of 2014 is down from 17.1% in the fourth quarter of 2013 and from the 15.6% average in the first quarter of 2014. The current 13.4% average for the second quarter of 2014 is the lowest level recorded since Gallup began tracking this measure in 2008."

Repeal and replace; it certainly sounded good, but for a variety of reasons, Republicans could never get their act together with the replace part.  And so again this week we see The Vanishing Cry of ‘Repeal It’.  One of the reasons for the lack of progress is that the House GOP conflicted on health law alternative. 

ACA: Premiums/Costs

Baselines are important.  If you want to understand how a policy or law is working, you need to know where things stood before the changes were made.  When talking about health insurance premiums and the ACA, to say it's complicated to come up with baselines is like saying the Sahara is a little dry.  Fifty different state markets (and additional premium regions within the States) and widely different benefits make it hard to create a solid baseline when evaluating this year's premium changes.  Of course that doesn't stop people from trying.  A new study out this week from the Commonwealth Fund says that Premiums grew average of 10% before Affordable Care Act.  While not a perfect number (as the authors are the first to acknowledge) it does give us something to work with.

So, when the Maine Superintendent of Insurance announced that  the range of requested increases for Marketplace plans here in Maine for 2015 is from .1 percent to 3.1 percent, you'll forgive me for nearly doing a spit-take (Maine ACA Insurers Seek Far Lower Rate Hikes Than Expected). 

Now let's be clear, these are preliminary AVERAGE increases.  They have not yet been reviewed and for all we know, they may still be too high.  Also, these assume a steady state - meaning it compares what a 30 year old would pay in 2014 vs. what a 30 year old will pay in 2015.  But sad to say we all age, and so each year our personal premiums go up because we are subject to a different rate.  Also worth keeping in mind that these are for individual marketplace plans in Maine, so they impact fewer than 10% of the population. 

Filed increases were also released for small group plans which while showing a slightly wider range among the carriers (-10% to +7.8%) were still below the types of increases we've historically seen (the BDN story includes an interactive chart where you can see more details: Maine insurers selling Affordable Care Act plans seek rate increases in 2015).

One of the ways the ACA will help costs overall is by reducing the number of uninsured (see Gallup numbers above), and so reducing the need to cover uncompensated care.  So when we ask the question, Will Obamacare cut the $84.9 billion we spend on the uninsured? We can say that so far the answer is yes, and that it should be one of the factors keeping rates low moving forward.  (Another factor not covered in this discussion is that having more people covered means they have access to preventive care - that should lead to better management of chronic conditions which will help reduce overall costs.)

ACA: Marketplaces

Coverage this week of issues around inconsistent applications (2 million Obamacare enrollees asked for more info, Now application 'inconsistencies' vex health law).  When individuals completed their applications, the "Federal Data Hub" would check the information entered against multiple records.   For a variety of reasons, the data hub information did not always match up with the information manually entered by the individual.  The Feds are in the process of working their way through the list.  While it is inevitable that some of these discrepancies may result in changes to an individual's subsidy levels (or eligibility) it seems as if the vast majority of these cases will be resolved in the individual's favor leading to no changes (The Latest Obamacare Glitch and Why It's (Probably) No Big Deal).

Another issue with respect to application processing is the seamlessness of Medicaid applications (The Hidden Failure of Obama's Health Care Overhaul).  The way it was supposed to work was that if an individual applied on the Marketplace and instead of being eligible for insurance subsidies was eligible for Medicaid, their information would be transferred to the state department responsible for Medicaid eligibility.  Unfortunately, for a variety of reasons there were problems with the transfer.  Here in Maine while those problems continue, DHHS reports that they expect their account transfers to be running by mid-June (page 5 of this PDF:  Exchange Advisory Committee June 3 Meeting Materials).

It's probably a good time to mention that the Health Exchange Advisory Committee (which I am a member of) resumed meeting this week.  Under its charter, it does not meet during the legislative session, so this was our first meeting since last Fall.  The group will meet three more times before submitting its report to the Legislature.

Over the past few weeks we've discussed problems many state-run Marketplaces (Exchanges) have had and how some of them are going to instead use healthcare.gov.  Some interesting thoughts and history how by default, this may be leading to a national marketplace and the GOP’s Obamacare fears come true. 

Although it should be noted that instead of the Fed platform, one state is looking towards CT (Maryland looks to Connecticut for health exchange answers). 

Stephan Brill writes about The Hidden Cliffs in Obamacare.  He discusses the "cliff effect" - which we see in many programs - for example, earning one dollar more in income can result in losing thousands of dollars of benefits.  As discussed in the article, there are ways to fix this, but they all cost money.

See the next session for news this week around the small business marketplace (SHOP).  (While I do my best with the categories, sometimes it's a coin-toss as to where an item should go...)

ACA: Employers

During the initial open-enrollment period, the Fed's small business marketplace (SHOP) had very limited functionality.  The technical functionality of the site is now on-track for rollout in November but there are still questions (The uncertain future of Obamacare’s small business exchanges).  Among them is the issue of employee choice - this was supposed to be a major selling point of the SHOP - the ability of an employer to let his employees go to the SHOP and select among different plans (potentially from different insurers).  Now, even though it should be technically possible, the Feds are giving the states who use the Federal SHOP the option of turning off that functionality (Implementing Health Reform: State Opt-Outs From Employee Choice In SHOP And Other Developments) and many states (including Maine) are saying they want to take them up on the offer (These states want another Obamacare delay).

More thoughts on the employer mandate from one of the best thinkers in the business: Repeal, And Replace, The Employer Mandate.

ACA: Other

Continued focus this week on networks.  A report from the Georgetown University Center on Health Insurance Reforms and The Urban Institute:  Narrow Provider Networks in New Health Plans: Balancing Affordability with Access to Quality Care.   The report calls for a balance to be struck.  While narrow networks (or focused networks as some in the industry prefer) have been around a long time, with the creation of new marketplace plans we've seen their use skyrocket.  Some have been Thrown a curve by health networks and their existence has caused states to take a closer look (US law prods states to revisit health care rules).  This is an issue that will be looked at here in Maine by the Exchange Advisory Committee.

As if we needed more evidence that yes, the law is complicated, the CBO throws in the towel on scoring ObamaCare.  It said (in a footnote) that while it will continue to track some of the laws impacts, some changes were so integrated with other programs that their impact could not be isolated.

Estimates out this week that Just 13 percent of uninsured people will pay the Obamacare penalty, report predicts.

A look at some individuals taking advantage of marketplace coverage showing that For Some, Affordable Care Act Provides Key to 'Job Lock'.

VA

Progress this week of a bipartisan nature (never thought I would write that again) when Senators Reach Accord Easing Worries Over Veterans’ Health Measure.  The two most dissimilar Senators imaginable Bernie Sanders, John McCain strike VA deal.

Also a front-runner has emerged as to who will head the VA (Key facts about potential VA nominee Delos Cosgrove).  He is currently the head of the Cleveland Clinic, and while in the past Potential VA secretary critical of ObamaCare, Here’s why the head of the Cleveland Clinic could help Obama fix the VA.

In addition to Cosgrove, other thoughts on addressing the issues: Two ways to fix the VA for free — and one that could cost money and on the reasons why the crisis developed:  Screwed-up bonus payments are at the heart of the VA scandal.

Medicaid

While we discussed above some of the technical issues around Medicaid enrollment through the marketplace, that has not stopped Medicaid Enrollment Surges By More Than 1 Million In April.  Note that with combination of eligibility changes (implemented in some states) and what has been called the woodwork effect (or as I prefer to refer to it, the welcome mat effect), One in five Americans is now on Medicaid.

That expansion is having a very real financial impact with Hospitals Saving Millions In States That Expanded Medicaid: Study.

And for those who still question the value of expanding Medicaid, a long term study shows How Medicaid lowers high school dropout rates and leads to more college grads.

Medicare

As you may have gathered, I have never been a fan of the Medicare Advantage program, now there are 70 billion reasons why Medicare Advantage just got harder to defend.

Medicare also released hospital pricing data this week.  It provided Further evidence of how weird hospital pricing is.  While nationally,  Hospital Charges Surge for Common Ailments, Data Shows, here in Maine we are Below National Average in Medicare Expenditures (although as one observer put it "You want to be cautious about drawing too many conclusions just from some top line numbers," Stein says, "which aren't telling the whole story.").

And talking about prices, an estimate of how the Lucentis/Avastin issue could impact Medicare (Cheaper eye drug could save Medicare $18 billion).  Also a look at how random Part D placement is not the most cost effective way to assign individuals who have not made their own plan selection (Medicare Could Save Billions By Scrapping Random Drug Plan Assignment).  And finally, a cautionary note about the impact Sovaldi might have on the Medicare budget (The Cost Of A Cure: Medicare’s Role In Treating Hepatitis C).

Costs

An interesting look at ACO Results: What We Know So Far.  While the detailed results have value, overall it reinforces the fact that ACO development is still in its infancy - some are successful, some are not and there is still little consistency in what they are accomplishing and just as important, little consistency in what they are publically reporting. 

More thoughts on transparency, both a caution: Why ‘transparency’ isn’t enough for health care prices and suggestions for improvement: How to Maximize the Value of Data Transparency in the Health Sector

System Transformation

Some talk of a primary care physician shortage, but some say that if everyone practiced at their appropriate level, there isn't one.  Here is The 90 second case for nurse practitioners.

We know that what is done in the practitioner's office is only a (small) part of keeping an individual healthy - we need to take into account (and help with) the rest of a person's life:  Can food stamps help improve diets, fight obesity and save money?, How An Increase in Minimum Wage Can Improve Health.  And how other countries try and get at the same thing: Rwanda: The little country that could.

Some of you may have read about Apple's developer conference announcements earlier this week.  But what was not covered in most of the stories was that Apple's most important health news has nothing to do with fitness tracking - instead it has to do with an effort to integrate with EPIC electronic health records (EHR) (EPIC is the category leader with approximately 40% of Americans having information in an EPIC record).  While trying not to overstate the potential, the fact that this could be a two way interchange gives raises the possibility that it could be significant.  As one example, imagine information about your workout being part of your EHR, and subsystems within the EHR watching out for problems.

Babies spit up, it's normal, but where do you draw the line between a normal amount and too much?  Calling an Ordinary Health Problem a Disease Leads to Bigger Problems if that line is not drawn broadly enough. 

And in case you needed another reminder why we so desperately need PCORI, a review of Heralded medical treatments often fail to live up to their promise.

And speaking of reminders, it's always helpful to review just how An Unhealthy System we have...

More evidence that not only don't patients like to talk about end of life issues, neither do doctors (Doctors Hesitate To Ask Heart Patients About End-Of-Life Plans).  However, there are some great tools available to make the conversation easier for both parties:  Videos aim to inform patients about their medical options at the end of life

And finally, to end on a positive note, some reminders of Clarke's third law (Any sufficiently advanced technology is indistinguishable from magic): Drugmakers find breakthroughs in medicine tailored to individuals’ genetic makeups and In a First, Test of DNA Finds Root of Illness.  Our medical technology can really work miracles.

All comments and suggestions are welcome; please let me know what you think.  And as always, thanks for reading!

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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"