Mitchell on Health Care: That Was The Week That Was

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).

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: