Friday, June 27, 2014

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:

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:

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!
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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