Friday, July 11, 2014

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:

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):

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:

Payment reform experiments continue:

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

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!
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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