That Was The Week That Was - Issue 20

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

Another big court ruling this week, a look at MLR season, new IRS regs and more.  And if you make it all the way to the end (or just skip down) I'll make you cry, then I'll make you happy.

ACA: Halbig & Company (this is a lengthy review of the topic, for those experiencing Halbig overload feel free to skip down to the next section)

As you may have heard, on Tuesday two Courts issued conflicting rulings on cases related to subsidies available on the Federal Marketplace (remember, in the legislation the Marketplace is referred to as the Exchange) (Appeals Courts Split On Legality Of Subsidies For Affordable Care Act.)  The question before the two courts (and before two others) relates to one sentence in the law that describes the subsidies as being available “through an Exchange established by the State...”. 

The opponents of the ACA who brought these various cases argue that since it says "by the State" an Exchange established by the Federal Government cannot offer subsidies.  Here's a look at the history of the argument: Obamacare's Single Most Relentless Antagonist.  As the four cases (in four separate parts of the country) have worked their way through the Courts, Tuesday's DC Appellate ruling is the first to find in favor of the plaintiffs (the people opposed to the law and objecting to healthcare.gov offering subsidies). 

Here is a sample of local Maine coverage Two rulings split on legality of subsidies under Obamacare and Federal courts disagree over Obamacare, creating uncertainty about Mainers’ health insurance subsidies.  Note that I invoke the "Mitchell Rule" which states that if Mitchell is writing a blog he gets to include articles where he's quoted.

Here is a detailed view from Timothy Jost on the legal cases (caution, heavy reading alert): Implementing Health Reform: Appellate Decisions Split On Tax Credits In ACA Federal Exchange

If the DC Appellate decision had been the only court to decide this issue it would have put at risk the financial assistance available in the 36 states where the marketplaces are run by the federal government.   But No, the Halbig case isn't going to destroy Obamacare.  The key thing to remember is that nothing is happening to the subsidies - so take a deep breath and don't panic:

"In the meantime, to be clear, people getting premium tax credits should know that nothing has changed; tax credits remain available," said Emily Pierce, deputy director of the Justice Department's office of public affairs.

Memo to Democrats: This is what happens when you pass a law where you can’t fix simple drafting errors (Democrats still haven't learned Obamacare lesson).  One way to look at this is it's just another consequence of the way the bill was passed (with the House forced to pass the Senate's draft bill due to the death of Senator Kennedy).

Part of the legal question goes to the intent of the legislation - while we can't ask the Founding Fathers about intent when it comes to the Constitution, in this case (since it was written 4-5 years ago) we can ask.  So Here’s what Obamacare’s authors said they actually meant and Yes, Congress Wanted Obamacare Subsidies. It Just Did A Terrible Job Of Saying That.

So what happens next?  The Feds have already said that they will appeal the DC decision and request an "en banc" ruling of the entire Circuit Court.  What does that mean?  The DC Court is comprised of eleven judges but usually only three hear a case.  "En banc" means that all the Justices would decide the case instead.  The make-up of the DC Court leads observers to think they would find differently than the three judge panel and allow the subsidies on healthcare.gov (Harry Reid Might Have Saved Obamacare by Going Nuclear).  The timing for the entire court to hear the case is probably this Fall.  After that the situation becomes more murky since we don't know how the other three cases will move forward (appeals, no appeals) or what the timing would be. 

For the sake of argument, what if all four cases are resolved, would that be the end of it?  The answer is maybe or maybe not.  It is possible that the Supreme Court will ultimately decide the case:  While that's less likely if all of the various courts end up agreeing that subsidies can be offered by the Feds it is still possible (Fourth Circuit ruling doesn't increase odds of Supreme Court review). 

If the Supreme Court does take the case, that might not be until 2015 or even 2016.  And how would they decide?  In the aftermath of Hobby Lobby, I'm not making any predictions.  For those who are bolder, there is evidence that they could rule either way:  First, making it look like they would not allow subsidies: Did the Supreme Court already tip its hand on Obamacare subsidies?  and then making it look like they would allow them: What the D.C. Circuit Got Wrong About Obamacare.

Given the DC court's decision and the somewhat inflammatory coverage of this story, the most immediate impact of all of this will be added confusion and uncertainty during the next open-enrollment period (starting November 15); despite the fact that nothing has changed. 

For those wondering what if the worst case scenario comes to pass and the Supreme Court says that the Feds can't offer subsidies?  Even then there would be several ways forward (If Obamacare subsidies go, states may have workarounds):

• At once the easiest and most difficult solution would be for Congress to amend the law by adding a few words to the sentence quoted above so that instead of saying "state" it said "state or Federal Government".  I'll leave it to your imagination to consider how likely that is.
• States that are currently using healthcare.gov could enter into agreement to continue using but as platform for their own exchange.  This option would require each state to cooperate and take action - which as we learned with the Medicaid expansion situation may be problematic.
• States could build their own marketplaces - but remember Federal funding to pay for that is not available after this Fall.               

Also worth noting is that without subsidies many more people would qualify for the financial hardship exemption from the mandate.

Still confused about the latest Obamacare lawsuits? Let Jon Stewart explain.

ACA: Additional Court Cases

It's now been over two years since the Supreme Court upheld the law - you would think that would have put an end to this nonsense, but no.  So here is a rundown of additional court developments this week.

A victory for reason over hyperbole as a Federal judge throws out Ron Johnson's Obamacare lawsuit .  This was the case against congressional staff using the DC small business marketplace (instead of the individual one).  This came about because a piece was added to the ACA saying that Congress had to use the marketplaces.  This was done in spite of the fact that no other employees of large employers would do so.  When the rules were written, in order to preserve the ability of the employer (the Feds) to contribute to their employees insurance it was decided they would use the small business marketplace instead of the individual one.  Opponents said this was an outrage, an example of special treatment for congressional staff.  And yes it was, if by special you mean being singled out to get worse treatment than they otherwise would have received. 

So a victory for rationality as the suit was thrown out by the judge.  For the legal details, we turn as usual to Timothy Jost:  Implementing Health Reform: Senator Rebuffed In Challenge To Congressional Participation In ACA Exchanges (sorry South Park fans, I'm not going to include a "Timmy" video every time I site Mr. Jost, it gets old).

On the Hobby Lobby front the administration announced they are working on new procedures so that the workers of objecting employers still get contraceptive coverage: In response to court ruling, administration works to ensure contraceptive coverage.  Also, a clarification on Fox news coverage (or should I say misrepresentation): Megyn Kelly Misrepresented My Article About Contraception - I'm an OB-GYN. She's Not.

And finally, coming in a strictly party line vote, House panel backs Obama lawsuit.  (You know, the one where the Republican's are upset because there was a delay in the employer requirements they didn't want to begin with.)

ACA: Polls/Opposition

Another day Another survey shows Obamacare driving down the uninsured rate.  More evidence, this time in a New England Journal of Medicine article: Health Reform and Changes in Health Insurance Coverage in 2014 (Primary Source).

And a Poll: Most say Obamacare working although to be fair, most means 53%.

ACA: Premiums/Costs

"Nearly 20 states have released preliminary information about premiums for insurance policies sold on their insurance exchanges, and the nightmare scenarios have not come to pass. In most of those states, the average increase across all exchange plans is in the single digits." Obamacare Premiums Aren't Living Up to Doomsayers’ Predictions

But remember, health premiums are a local - so while overall the news is positive, there are some outliers: Florida’s Biggest Health Insurer Signals Rate Hikes Ahead

ACA: Marketplaces

To all my friends who continue to help individuals get coverage, it will come as no surprise to hear that the Federal Health Exchange Stays Busy After Open Enrollment Ends.

But that's not to say that healthcare.gov and ACA implementation overall is working perfectly.  The GAO released preliminary information on their investigation of healthcare.gov and the results were not pretty: Federal undercover investigation signs up fake applicants for ACA coverage, subsidies.    However, the final word is not in: GAO: Too early to draw Obamacare fraud conclusions.  And lest we forget, as Rep. Joseph Crowley (D-N.Y.) put it:  “What is the ultimate prize for the criminal? Is it a free colonoscopy?”

Another sign of bumps in the road as the Washington Post looks t examples where Varying health premium subsidies worry consumers.

And looking forward, some thoughts on the difficulties inherent in the next open enrollment period: How Obamacare’s Progress Makes Expanding Coverage Harder.

ACA: Employers

The UC Berkley Labor Center created a great review of what employers need to know: AFFORDABLE CARE ACT: Summary of Provisions Affecting Employer-Sponsored Insurance.

And the IRS released the draft forms that employers will use to report on health insurance (IRS prepping for Obamacare employer mandate in 2015).  However the instructions that go along with the forms won't be released until next month - and since these are drafts they are subject to change (Draft Forms).

ACA: Other

It's MLR season - that means insurers who haven't met the MLR (medical loss ratio) requirements are sending out checks: U.S. health insurers to pay $330 million in premium rebates.  As part of this annual announcement, HHS projected the impact of the MLR rule in general: Consumers have saved a total of $9 billion on premiums (Primary Source).  But for some perspective note that Obamacare saved consumers $9 billion, but that's not as much as it sounds.  Once again invoking the "Mitchell Rule" (see above) here is local coverage: Rebates on insurance divvied out to 20,000 Mainers and Maine to receive $1.8M in health insurance rebates.  Here in Maine only Aetna did not meet the requirements of the rule and had to send out rebates - they operate only in the small and large group market so no individuals will be receiving checks (this despite an early and incorrect Press Herald headline).  While it's nice to talk about people getting money back, the ideal situation is all insurers are complying with the rule to begin with so no checks end up being mailed.

Consider this next item a warning.  Business Groups, Consumer Advocates Draw Lines In The Sand About Essential Benefits.  Remember, initially we thought there would be a single national set of Essential Health Benefits.  Instead, while we have 10 standard categories, they are defined independently by each state.  These definitions were only meant to last for two years (as a transition period perhaps).  Well the two years is up at the end of 2015, so it's not too soon for stakeholders to begin jockeying for position.  At this time it's unknown if there will be a single national definition, if the existing state definitions will remain, or if there will be some other approach.  Don't worry, I'm sure we'll be talking about this a lot more moving forward.

More on "narrow networks" this week.  We have continued consumer frustration (Obamacare: Anger over narrow networks).  Thoughts on potential changes in regulations (To Prevent Surprise Bills, New Health Law Rules Could Widen Insurer Networks).  And a reminder that they were created for a reason and It’s Probably Not a Good Thing for Regulators to End Narrow-Network Plans.  To the last item I'll add the qualification that while I agree we should keep them we need to be sure that members can access the care they need - (something not always happening now).

The IRS also announced the maximum mandate penalty: IRS: Uninsured face max fine of nearly $2,500.  Remember, this year the penalty is $95 or 1% of income, whichever is greater.  But that one percent of income is maxed out at the cost of coverage (in this case the average cost of a bronze plan), hence the calculation of a maximum dollar amount.

Some thoughts on the health insurance literacy of enrollees: New challenge for Obamacare: Enrollees who don’t understand their insurance plans.

And on the management front, Secretary Burwell announces steps to further strengthen HHS management team - Leslie Dach to join HHS as Senior Counselor.

Medicaid

Before diving into some state specific developments, some good news: Study: Medicaid's benefits start in the womb.  On the not such good news front, a study showing that States that deny anti-psychotics to the poor have lots of mentally ill people behind bars.

Meanwhile:

• Arkansas: Arkansas Weighs Plan To Make Some Medicaid Enrollees Fund Savings Accounts (or how to screw up the private option, a suspect strategy to begin with)
• Virginia: A cancer-sufferer’s agonizing choice: marriage or Medicaid? (a flip on the better off not married story, in this case the person who doesn't want to be married would be better off if they were)
• Oregon: APNewsBreak: Medicaid enrollees strain Oregon (some growing pains, hopefully nothing insurmountable)
• Tennessee: Groups Sue Tennessee Over Medicaid Enrollment Delays (slow implementation being challenged in the courts)

Medicare

Highlighting Medicare flexibility this week: Medicare Modifies Controversial Hospice Drug Rule and Medicare Testing Payment Options That Could End Observation Care Penalties

VA

As McDonald moves to a positive confirmation vote (probably the week of the 28th) Obama nominee McDonald pledges to ‘transform’ VA. 

While a survey shows that: Survey: New veterans like medical care they got from VA it also highlights problems they face as they try to reacclimate to civilian life.

At the beginning of the week, we thought we saw Progress on VA reform deal, as of the time of this writing (Friday morning) VA reform hits stalemate as the House and Senate continue to disagree about the cost of the bill and how to pay for it.

Drugs

Seems like I could have a Sovaldi section every week.  For background, see last week's post or this great overview: The drug that’s forcing America’s most important – and uncomfortable – health-care debate. Initial sales figures released by the manufacturer show that Gilead’s Hepatitis C Drug, Sovaldi, Is on Pace to Become a Blockbuster.  And as Medicaid Directors, Insurers and other payers try and figure out how to handle the situation, Patient Cures Spur Demand for $1,000 Hepatitis C Pill.

But it's not just Sovaldi, the NY Times looks at The $300,000 Drug.  More expensive than Sovaldi but needed by a much smaller population.

Looking at the cost of drugs, a big development as the first application was accepted by the FDA for a "biosimilar" drug.  Biosimilars are to biologics (a complex drug made from proteins of living organisms) what generics are to chemical drugs.  (We are one step closer to a new generation of cheaper drugs).

At the same time we see A Dearth in Innovation for Key Drugs (few new antibiotics in the pipeline) which could be problematic since Antibiotic resistance could be 'next pandemic,' CDC says

On the vaccine front, a different kind of story - adoption of the HPV vaccine is going much slower than hoped: Doctors still hesitant to urge HPV vaccine for teenagers.  Meanwhile, the same old story as Student filmmakers find themselves drawn into the vaccine/autism fray.

Do we really know what we are doing when it comes to medical care?  Not as much as you might think (or hope).  Although many people are doing this, Tylenol won't help your back pain. Here's what you need to know .

And in a disturbing but not surprising story the Safety profile of blockbuster blood thinner comes under question as a pharmaceutical company puts profits before patient safety.

System Transformation

Do you have to pay more for better quality medical care?  I hope my regular readers know that nothing could be further from the truth - study after study have shown there is no correlation between price and quality in our system, but Half of Americans think expensive medical care is better. They're wrong.  You can find the full results of the survey here: Finding Quality Doctors: How Americans Evaluate Provider Quality in 

No question that HIPPA is complicated.  But the confusion that comes from the regulation is not helped when provider groups either abuse it or outright lie about its provisions: When Federal Privacy Laws Protect Hospitals Instead Of Patients.

We know there are Bottlenecks in Training Doctors.  In CA, Governor signs bill to let doctors graduate faster to help alleviate the problem.

A look at how our current reimbursement method is not helping the system: Busy Doctors, Wasteful Spending and a look at a promising alternative: The Alternative Payment Methodology In Oregon Community Health Centers: Empowering New Ways Of Providing Care.

Siri and Watson are getting married, what will that mean for our system: IBM-Apple Deal: Healthcare iOS Nirvana?  And is this what their children will be like?  The Future of Robot Caregivers

As promised, since I haven't made you cry in a few weeks (at least intentionally), here you go: Doctors are not the only ones who can keep a painful secret.

And ending on a Happy note, to commemorate the week of Weird Al Yankovic a different type of parody video: Choosing Wisely Video.

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 19

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

Summer in Maine, where the sun is shining, the birds are singing and health policy activities keep chugging along.  This week a look at the ACA disasters that weren't, more Hobby Lobby fall-out, more Sovaldi developments (look under Drugs below if you don't remember what that is) and as always, much, much more.

ACA: Opposition

We're approaching the midway point between the end of the first open enrollment period and the start of the second.  What better time to pause and look back at some of the predictions of failure.  Paul Krugman (Obamacare Fails to Fail) and Vox (7 predicted Obamacare disasters that never happened) have done just that. 

A senior fellow at the Center on Budget and Policy Priorities notes that Obamacare doesn’t cover media bias. No wonder it’s not more popular., reflecting on law's success lack of impact on public opinion.

Both Ezra Klein (How conservatives won with Obamacare) and Drew Altman (What’s Trending in Health Care? Conservative Ideas.) remind us that based strictly on facts, Conservatives should be jumping up and down with glee over the ACA's success.

ACA: Court Cases (Hobby Lobby, etc.)

More fall-out from the SCOTUS Hobby Lobby decision.  The week started with a look at how A Two-Page Form Spawns a Contraceptive Showdown (providing a look at the details of the exception process that was too onerous).  Then Senate Democrats Launch Fight To Reverse Supreme Court, State Abortion Restrictions with two bills, one a reaction to the Hobby Lobby decision and the second meant to address increasingly restrictive state laws on abortion.  Of course neither has any hope of passing the Senate, let alone passing the House (Democratic Effort To Override Hobby Lobby Ruling Fails), but that's not the point.  Rather, they are part of Democrat's election year strategy: Bills with little chance of passing are part of Congress’s campaign to urge women to vote.

The week ended with one concrete step to assure transparency of employers actions in the wake of Hobby Lobby: White House: Employers Must Disclose Objections To Covering Birth Control.

To be filed under the heading of expected developments, Post-Hobby Lobby, there's been a rapid turnaround in public opinion of the Supreme Court with Poll: Most GOP approve of SCOTUS.  Basically, if SCOTUS makes a decision you agree with, you think they are doing a good job.

Moving on to the pending Boehner lawsuit over implementation of the employer mandate, here are answers to 5 questions about John Boehner’s lawsuit against Barack Obama and a look Behind the GOP focus on Obamacare.

And while Partisanship Infuses Hearings on Health Law and Executive Power, Democrats seek cost estimate of Barack Obama suit. While few expect the suit to gain traction in the courts, we can expect to be hearing about it for a long time to come.

Finally, no recap of court cases would be complete without mentioning the case alleging that the Federal Marketplace can't provide the advance premium tax credits.  So here is a review: How the Courts Could Still Doom Obamacare.

ACA: Marketplaces

The Kaiser Family Foundation released a survey showing that 10.6 million people were helped during the first open enrollment period: Groups Under Health Act Are Said to Aid Millions (Primary source:  Survey of Health Insurance Marketplace Assister Programs).

But there was also more proof that the help was needed for enrollment: Even with Obamacare, shopping for health insurance isn’t as easy as buying a plane ticket and a reminder that once covered, they'll continue to need help understanding the basics of insurance: New challenge for Obamacare: Enrollees don’t understand their insurance plans.

In a startling turnaround, UnitedHealthcare, who did not participate in any Marketplaces last year, announced they will be offering plans on at least half of them this year:  Biggest Insurer Drops Caution, Embraces Obamacare. 

A thoughtful look by Tim Jost on Income Verification On The Exchanges: The Broader Policy Picture (Timmy).  Worth a read as he explores both implementing the current system and how else  it might be structured .

The Feds issued guidance related to how individuals who were terminated for non-payment should be handled during the next open-enrollment period:

CMS has finalized a series of processes and policies regarding enrollment and termination for issuers participating in Marketplaces using the CMS system, including Federally-facilitated Marketplaces (FFM), which include State Partnership Marketplaces. This set of guidance covers topics related to issuers in the individual market regarding grace periods related to terminations for non-payment of premiums coinciding with enrollment in coverage for the next benefit year.

Finally, a look at various state marketplace developments:

• Connecticut: Access Health CT finds glitch behind cancellations
• Maryland: Md. officials provide update on health exchange
• Louisiana:  Some insurance carriers looking for double-digit increases for Affordable Care Act policies
• Washington DC: D.C. Health Exchange Assessments Violate The Affordable Care Act
• Rhode Island: Health insurance commissioner OKs 2015 premiums

ACA: Employers

Although we've seen lots of numbers and analyses on individual enrollment in Marketplace plans, we still know very little about the success (or lack thereof) on the business side (SHOP enrollment): Why we still don’t know how many small businesses signed up through Obamacare - And why it’s probably not very many.

A look at how the Affordable Care Act Oriented Products Will Help Boost ADP And Paychex's Sales - basically employers need help with reporting and will turn to their current vendors for support.

Some continue to ask the question, What will Obama do on employer mandate?  To recap, it was announced earlier that firms with 50-99 FTEs would have until 2016 to begin to offer coverage but those with 100 or more would be subject to the penalty beginning in 2015.  It is unlikely that those broad parameters will change but we're still waiting on final reporting requirements.

ACA: Other

The Commonwealth Fund continues to be busy, this week they issued a report on individual market reforms in each state.  Remember, the ACA provided certain minimum standards for insured health coverage, but insurance continues to be regulated individually by each state so they way those standards are implemented can vary (Implementing the Affordable Care Act: State Action to Reform the Individual Health Insurance Market Primary Source).

Remember the battles over the MLR definition?  No, just me?  OK, to recap, the MLR (medical loss ratio) is the measure of how much of each premium dollar an insurer spends on medical claims.  The ACA imposes minimum standards that if not met, result in rebates being sent to policyholders.  When the regulations were first released, there were arguments over if brokers commission belonged in the calculation or if they should be counted separately.  Currently they are part of the calculation, but if removed it would result in potentially higher insurance company profits (and potentially lower consumer rebates).  Since apparently no decision is ever final, insurers are once again lobbying to change the definition in their favor: How an Obamacare Tweak Could Save Insurers Millions.

Under the category of misleading headlines:  The administration just took Obamacare away from the territories.  Here's the real story - the way the law was originally written, part of the law applied to the territories (insurance reforms such as guaranteed issue) while part (individual mandate, availability of subsidies) did not - you can see how that could cause problems.  Here is an older piece explaining the situation: Think your state has Obamacare problems? They’re nothing compared to Guam.  So what the administration did this week is clarify that since the whole law did not apply to the territories.  A good reminder of how the individual mandate, the subsidies and the insurance reforms all go hand-in-hand.  You can't take away one of the three and expect the others to function as intended.

Medicaid

The administration released its latest figures for new Medicaid enrollment, through may there have been 6.7 million new enrollees:  U.S. Medicaid enrollment nears 7 million since Obamacare rollout.  However, the number should be even higher for two reasons - the first obvious one is that half the states have not expanded Medicaid eligibility, but the second is that in some of the states that have expanded, there continue to be application backlogs.  The feds have had it with Medicaid backlogs and have six states a deadline to come up with plans to eliminate those backlogs.

Need an example of continued waste in the system?  Then you might want to ask Why Are Obstetricians Top Billers For Group Therapy In Illinois? (Hint, there is no good reason.)

Medicare

Did you know that health care is complicated?  This article looks at hospital admissions:  Hospitals, regulators spar over in-patient care policy.  Lots of conflicting interests over the definition of hospital admission vs. observation status.  As is often the case, a lawsuit has resulted - this time creating strange allies of consumers and hospital executives.

VA

Although the House-Senate conference committee continues to meet (to align their respective versions of the bill), Cost debate slows VA reform bill as Lawmakers seek lower price for bill on vets’ care.

At the same time, the Acting VA chief seeks $17.6 billion.  This request, separate from the bills being discussed, muddies the waters: VA request complicates reform push.

The reform bills include increased ability for Veterans to seek care in their community and have the VA pay for it.  Here is a look at the problems involved with that approach, including with the HERO program that is being piloted in Maine: Veterans' Needs 'Should Drive Where They Get Their Care'.

Drugs

Sovaldi continues to be in the news.  That's the Hep C drug that was recently introduced at the price of $1,000 a pill (and $84,000 for a course of treatment).  The prevalence of Hep C, the stunningly improved results with the new treatment and the treatment's cost lead to the inevitable question:  How do you pay for a drug that costs $84,000?

Many think the price is too high (Poll: 4 in 5 say $1,000-a-pill drug cost ‘unacceptable) and some states are moving to limit access to the treatment (Oregon moves closer to limiting access on hepatitis C drugs as Senate investigation begins).  More widely the question is Will Gilead’s Hepatitis C Drug Bust State Budgets?

Congress is looking at the issue.  We've all heard the drug company line that these high prices are needed to recoup the high cost of research. While that argument ignores the fact that much of the basic research continues to be paid for by the Feds, in this case we have a more pressing question.  Gilead, the current producer of the treatment, actually bought the fully developed drug when it purchased the drug's developer.  In the purchase documents filed we see that

"Pharmasset, the drug's original developer, priced the treatment at $36,000, the senators wrote, citing documents filed with the Securities and Exchange Commission. Gilead acquired Pharmasset in 2012 for $11 billion." (U.S. senators ask Gilead Sciences to explain high cost of hepatitis C drug)

Stay tuned, this issue will be around for a long time.

Interesting results from a study that show Changing a pill's color has big health consequences. It's the little things - if you move someone to a generic drug, and the pill looks different, compliance with taking medications goes way down.

Also a reminder that we're not always getting the most appropriate treatment.  Asking the question  Why are doctors still prescribing Zetia?  "The author concluded that it must be that the manufacturer (Merck) has been very effective at marketing ezetimibe and that patients’ and doctors’ fixation on reducing the cholesterol numbers has made it attractive in defiance of its lack of efficacy."

Costs

New CBO deficit estimated brought renewed attention to the fact that those estimates of future health care costs are falling.  While the headline highlighted that the budget deficit was still going to be a problem (CBO: Slowing health-care costs yield big savings, but not enough to bring down our big debt) the numbers are startling. 

Are Hospitals Responding to a Health Reform That Hasn't Happened Yet?  That's one theory as to what's happening.  But perhaps the most honest appraisal came ""At a Tuesday meeting of health economists in Washington on the subject, Uwe Reinhardt, a Princeton professor (and occasional Upshot contributor), cautioned against over interpreting the recent good news.  “We don’t know what the hell is going on,” he said at the Altarum Symposium on Sustainable U.S. Health Spending." (emphasis added, Expected Health Spending Declines (Again)).

But of course that doesn't mean we don't still have cost problems.  Take proton beam therapy, no really, take it and hide it as if it didn't exist.  We know that it is no more effective than older treatments that cost half as much. Using the new Medicare database, an analysis was done as to how much money the treatment is wasting:  Prostate Cancer Treatment: Unproven Proton Radiation Therapy Wastes Millions of Dollars - The High Price of Unnecessary Treatment.  And speaking of wasting money, non-profit hospitals continue to pay exorbitant CEO, and ex-CEO salaries: At NewYork-Presbyterian Hospital, Its Ex-C.E.O. Finds Lucrative Work.

Finally, in the interests of showing all sides, I offer this link to a NY Times piece stating Why Improving Access to Health Care Does Not Save Money.  I disagree with the authors conclusions and have problems with how he reaches them.  He states you can't improve access, quality and cost and still save money.  I think that is wrong.  Very simply, we know from multiple sources that cost and quality are not correlated.  Thus we can provide more high quality care using less money than we are currently spending - thereby freeing up funds to pay for increased access.  The authors inability to understand this basic fact, coupled with his incomplete understanding of the use of emergency rooms by the newly insured (yes, use goes up initially but then falls off in subsequent years) negates his conclusions.  The piece appears in a relatively new section of the Times called "The Upshot".  And while it is clear to me this is an opinion piece, it is not so labeled potentially leading people to assume the author knows what he is talking about.

System Transformation

Nurses and nurse practitioners getting some love in the news this week (as they should every week).  Their importance in our current system and in making that system better can't be overstated.  Take a look:

• Nurses could manage chronic care on doctors’ orders
• Nurses Know Best: Empowering Medical Professionals To Reinvent Medicine
• Registered Nurses Are Delaying Retirement, A Shift That Has Contributed To Recent Growth In The Nurse Workforce
• Stop calling nurse practitioners mid-level providers

Also getting attention is the concept of seeing a doctor on-line (or some other remote method).  While Convenience, fixed prices boost demand for doctor visits via Web, text some are concerned - More doctors are a click away, but some say it’s not a healthy trend.  My take, inevitably this will be one path to care - it can help in many cases.  The key will be the on-line providers knowing when to send the patient elsewhere and the use of a universal EHR so that any treatment received is known to the all of the individuals providers.

More proof that economic status is a key determinant of health status, surprisingly even more so than pre-natal drug exposure: 'Crack baby' study ends with unexpected but clear result.

I could do a weekly blog just on the topic of patient safety - since I don't it's lucky others focus on the topic.  This week over thirty patient advocacy organizations and activists asked Congress for an increased focus on the topic: Launching Today: Patient Safety Call to Congress

How do we tell the quality of a provider?  It is not easy - here is an excellent high level review of the issues involved: It’s very difficult to assess a doctor’s true skill or performance.

And finally, a look at the common warning not to go to a hospital in July when the new residents are starting.  Interesting results, while the new residents potentially do have an impact, July is still a safer month than most to be treated in a hospital (despite the misleading headline): The July effect is real: new doctors really do make hospitals more dangerous.

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 18

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

Lot's going on this week; the aftermath of the Hobby Lobby decision (and Wheaton College order), new numbers on how many people in the country are uninsured (less than before!), Medicare's surprising cost projections and lots more.  So let's get to your light summer reading for today

ACA: Polls/Opposition

This week, Gallup and The Commonwealth Fund released additional data on the decline of the uninsured. How much data is enough to convince the naysayers? (That was rhetorical, there is not enough data in the world to convince some people...)   Gallup (In U.S., Uninsured Rate Sinks to 13.4% in Second Quarter - Primary Source) reported that the percent of uninsured in the country dropped from 18% at the end of the third quarter of 2013 to 13.4% at the end of the second quarter of 2014.  The Commonwealth Fund (Gaining Ground: Americans' Health Insurance Coverage and Access to Care After the Affordable Care Act's First Open Enrollment Period - Primary Source) reported a drop from 20% to 15% for those between 19 and 64 during a similar time period.   Any way you slice it, there are millions of people who have insurance coverage today who did not have it last year (Obamacare Haters, Your Case Just Got Weaker - New report suggests number of uninsured declined, just as expected  and It sure looks like Obamacare is driving down the uninsured rate and The verdict is in: Obamacare lowers uninsured).

But wait, there's more good news.  The Commonwealth Fund survey results also showed that Newest Health Insurance Customers Are Generally Happy  and It looks like Obamacare patients can see their doctors, after all.

Meanwhile the House GOP stuck on Obamacare replacement.  They can't agree on a plan or even if they should introduce one.  After all, it's easier to take pot shots at something than to come up with a workable alternative.

Opponents also got some additional bad news:  Under the heading of there is no such thing as bad publicity a study found that in states where opponents spent more money enrollment was up (even after accounting for confounding factors): How the Koch brothers' campaign to hurt Obamacare may have actually helped it

ACA: Holly Lobby etc:

The Hobby Lobby decision and Wheaton College order continued to make the news.  In last week's issue I extensively covered the decision.  You can find a detailed look at the aftermath here: Implementing Health Reform: A Follow-Up Supreme Court Contraceptives Decision At Odds With Hobby Lobby.

It is worth noting that the Supreme Court did not make it easier for lower courts as Conflicting Views Of Supreme Court’s Contraception Decision Cloud Other Cases. 

Some think that those who applauded the decision may have lost site of the long game: GOP’s culture war disaster: How this week highlighted a massive blind spot

Those who were opposed to the decision quickly moved to address the inequities it introduced: Obama Weighs Steps to Cover Contraception and Harry Reid: ‘We’re going to do something’ on Hobby Lobby.  Then the Democrats introduce bill requiring employers to pay for contraception and in Congress, Pingree backs Democrats’ push to overturn Supreme Court’s Hobby Lobby ruling.  And while it's doubtful any of these will pass in partisan land, as they  look towards the long game U.S. Democrats aim to turn contraception into campaign drive.

Meanwhile, the Courts actions led to lots of discussion about how contraception works (The Medical Facts About Birth Control and Hobby Lobby—From an OB/GYN), its use as birth control (Women like sex. Stop making 'health' excuses for why we use birth control) as well as for other medical purposes (One Big Thing Everyone Is Missing in Hobby Lobby - The ruling is not just about sex, it’s about health.)

Finally, questions of cost were discussed.  While most say that Birth control saves money. Lots of it. there is a competing view that No, Contraception Coverage Does Not Usually Pay for Itself.  When you dig into the two arguments you see that in fact there is no disagreement, just different frames of reference.  There is no disputing that birth control prevents unwanted pregnancies and that paying for birth control is cheaper than paying for the births.  In the Medicaid realm, offering no co-pay birth control saves Medicaid money because those in the program cannot always afford to pay for it themselves.  In the private insurance realm it becomes a little cloudier.   The private insurance plan may not see lower costs if their customers were already paying for birth control on their own.

ACA: More Court Cases

Holly Lobby was not the only ACA related case in the news this week, there are also two other cases in progress and one new one.  First the issue of if individuals who use the Federal Marketplace can receive subsidies (Forget Hobby Lobby. The Bigger Legal Threat to Obamacare Still Has Life.).  While several courts have rejected the argument, it was heard again this week by the D.C. Circuit Court of Appeals and seemed to find a more sympathetic audience.  Whatever happens in that Court this case now seems destined to eventually get to the Supreme Court.

The second existing case is the one concerning congressional staff's use of the marketplaces.  To refresh your memories, individuals working at large employers are not supposed to use the marketplace.  But in a fit of egalitarianism, the ACA contains a provision that says congressional staff must do so (so they can experience it for themselves).  The problem is that typically an employer can't contribute to marketplace plans - but if that were enforced in this case, the congressional staff would lose their employer contribution (and the tax advantages of employer-sponsored coverage) making it harder for Congress to retain staff.  So a compromise regulation was worked out - to the dismay of opponents of the law who decided that was unfair.  The case is still winding its way through the courts:  Judge to mull senator's suit over health exchanges.

Finally, the new case is the one the Speaker of the House has promised to bring against the President on behalf of the House of Representatives.   This week Boehner releases his plan to sue President Obama   and not surprisingly it focuses on the ACA.  Specifically it argues that the Administration was violating the law by delaying the employer mandate.  How will it proceed?   "Yale Law professor Akhil Reed Amar said, "I'm doubtful that merely because you've waived or extended some deadline that you've done something illegal." The Constitution calls on the president to make sure that the laws are "faithfully executed," he pointed out. "Who do you trust to make Obamacare work? Obama, or the guy who's voted against it 3,000 times who doesn't want it to work?""

For background and history on Congress suing the President, see this story:  Suit Against Obama to Focus on Health Law, Boehner Says.

ACA: Marketplaces

A study of the Federal Marketplace looked at why the site was so difficult to navigate, even for the computer savvy: HealthCare.gov site stumps 'highly educated' millennials. Here's why.  And JD Powers, of consumer satisfaction fame, in its first report on the Federal Marketplace also reported that customers found the experience lacking:  Health Plans Need To 'Retool' Obamacare Enrollment, J.D. Power Study Says

In Washington D.C. a private exchange opened geared specifically to restaurants who want to offer coverage to their staff (Restaurant-specific insurance exchange debuts in D.C.).  I call attention to this story because one of the offerings on the private exchange is a skinny plan.  These are plans that do not cover the Essential Health Benefits - some think self-funded employers can still legally offer them.  The reasoning goes that these plans meet the employer requirements (again, of self-funded plans, not insured plans) only leaving the employer on the hook for fines if the employee goes to an ACA marketplace and qualifies for the tax credits.  (You can read more about Skinny Plans here : Why Health Law's 'Essential' Coverage Might Mean 'Bare Bones' Skinny Plans FAQ.)  While these plans have been talked about, this is the most visible broad use of them I've seen.  If allowed to continue they represent a threat to the integrity of employer-sponsored coverage.

Finally, some assorted developments for state-specific marketplaces:

• Massachusetts is making progress: State reports progress in fixing health website
• Colorado exchange expects more to drop health coverage
• Missouri governor vetoes health navigator limits (note this happened because the ALEC model legislation had an incorrect citation that was copied into the state law)
• Six months into Obamacare, some D.C. insurance brokers still wait to be paid

ACA: Other

Until  now those saying that the employer mandate provisions would lead to more involuntary part-time workers did not have any evidence.  But as the employment picture overall (slowly) improves, the Rise in part-time workers worries some experts.

In CA a Lawsuit Accuses Anthem Blue Cross Of 'Fraudulent' Enrollment Practices over how it disclosed narrow networks in its plans.

A reminder that when it comes to no co-pay preventative services, it's Not just birth control: here are 7 other things Obamacare covers for free.  Although what services you get can depend on the provider: Preventive services differ between primary care docs and OB/GYNs

Medicaid

Getting impatient with the backlog of applicants, this week the Feds Demand Medicaid Backlog Fixes By Six States (and no, Maine was not one of them).

The debate (or should I say battle) in Virginia continues.  While the Governor continues to look for a way to expand without the legislature, In Va. legislature, Republicans plan Medicaid debate in late September.

Under the banner of unintended consequences,  a fifty year old law that was meant to prevent Medicaid dollars from going to state psychiatric hospitals is now keeping many of those newly covered by Medicaid from getting in-patient addiction treatment:  Obscure Rule Restricts Health Law’s Expansion of Care for Addicts

And finally, a reminder of the real life costs of states not expanding Medicaid as in Tennessee Couple splits up to stay insured.

Medicare

A sensational yet accurate headline: The amazing, mysterious decline in Medicare's price tag.  The story is that over the past four years, the baseline estimate for the per beneficiary cost of Medicare has gone down by $1,000.  The impact that has on the solvency of the program (and indeed on the Federal deficit overall) can't be overstated.  The big question though is can it last?  The Mystery of the Missing $1,000 Per Person: Can Medicare’s Spending Slowdown Continue?

And speaking of saving money, the Feds seek new authority to recoup Medicare Advantage overcharges . 

While there was this study showing one way Medicare wasn't overpaying: Study: Hospitals Not Bilking Medicare Using Electronic Medical Records some said that the study was looking for fraud in the wrong places, and did not in fact prove its case.

And in an attempt at parallel structure with the Medicaid section, we'll conclude here with a report on a new Kaiser tool that shows Why most seniors can't afford to pay more for Medicare.

Drugs

Coming in September is a new website where you will be able to see What are drug companies paying your doctor?

A story about how often physicians are Guessing if medications are covered by a patient’s insurance company - it shouldn't be so hard, we have the technology to put the information in front of the physician, we just need the will (and resources) to do so.

Elisabeth Rosenthal in her continuing work at the NY Times on health care pricing reports that Rapid Price Increases for Some Generic Drugs Catch Users by Surprise.  And you thought generic drugs were supposed to save money... Silly rabbit.

In the old days, we would say that your right to free-speech ended when it put other people in jeopardy (you don't have the right to yell fire in a crowded movie theater).  Apparently, that is no longer always the case as the FDA grapples with how it can continue to regulate manufactures marketing of off-label uses for their drugs: FDA has free-speech, safety issues to weigh in review of ‘off-label’ drug marketing rules.

System Transformation

Urgent care centers can be a useful part of our health care system -  a place that is not an emergency room where you can see a provider and get care, without an appointment and during extended hours, can be a huge help.  As these centers gain in popularity the Race Is On to Profit From Rise of Urgent Care.  A note of caution, as helpful as they can be they need to be integrated with an individual's overall care (though EMRs and data exchanges).

In the week when the CDC found vials of small pox in an old refrigerator (Oops: Forgotten vials of smallpox were just found in an old storage room) and when the new Planet of the Apes movie opens (where humanity is decimated by a virus) there were several other stories about scary infectious diseases (hopefully none of them lead to our demise):

• If Tuberculosis Spreads ...
• Never mind SARS or MERS, worry about measles
• Why you should never, ever touch that hospital elevator button

We've talked about big data before, this month Health Affairs devotes an issue to the topic (Using Big Data To Transform Care -Primary Source).  You can read a brief look at the topic here: What big data could do for health care 

Technology has the power to transform care, if we can keep up:

• FDA regulation can’t keep pace with new mobile health apps
• Google Glass is the tip of the iceberg for wearable technologies
• Will This Tech Tool Help Manage Older People's Health? Ask Dad
• Exploring a Culture of Health: Detecting Signals of Wellbeing

Payment reform experiments continue:

• Doctors May Soon Be Paid For Not Making You Wait
• Health Insurers Are Trying New Payment Models, Study Shows
• One insurer’s answer to the skyrocketing bills for cancer care

We're reminded of how much care provided isn't needed:

• 4 medical tests that are awkward, embarrassing, and unnecessary
• One third of people getting knee replacements don't need them

And finally Let’s Talk About ‘Death Panels’ - It’s time to revisit a good idea that was distorted by demagoguery.  And a reminder of why those conversations (and additional reforms are needed: Diane Rehm: My Husband's Slow, Deliberate Death Was Unnecessary.

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"