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!
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"
