Friday, August 1, 2014

That Was The Week That Was - Issue 21

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


And they're off...  with the exception of some House grandstanding on Immigration, Congress is adjourned for the summer (Congress on working in August: It’s against the law!).  As they were packing up to go the approved the new head of the VA and passed compromise VA legislation.  Also this week more court developments, a GAO report on healthcare.gov, the annual Medicare Trustees report, and as always much much more.

ACA: Court Cases
This week as the House and Senate prepared to leave for their August recess the House managed to find time to pass a bill (not surprisingly on a party line vote) to allow them to sue the President (House clears way for lawsuit against Obama).  The basic premise of this case is that the President is not enforcing the laws passed by Congress, specifically the employer mandate provision of the ACA (whose implementation has been delayed).  Obviously they are doing this because they support the law and want to see it fully implemented - NOT - they are trying to score political points.  Here is  A Primer on Boehner v. Obama.  And a look at the potential impact of the case: Why suing Obama could become a bigger GOP headache than impeachment talk.

In other court news an Appeals court rejects tax challenge to Obamacare.  This is the issue of where the bill started (House or Senate).  The Constitution says revenue generating measures must start in the House, but the ACA started in the Senate...  The court found that the revenue was a side-effect of the law, not its primary purpose and so did not need to start in the House.  For more details, as we often do we turn to Tim Jost's analysis: Implementing Health Reform: Origination Clause Challenge To ACA Dismissed.

And of course, Halbig continued to be the case that keeps on giving.  As you recall (if not, take a look at last week's post for a full review) there are four cases on the same topic winding their way through the courts.  This week in one of them the plaintiffs who lost (that court upheld the subsidies in the federal marketplace) petitioned the Supreme Court to take the case (Supreme Court asked to hear Obamacare subsidies case).  They did this in the hope that the Supremes would rule during the next session.  It is questionable if the Supremes will take the case at this juncture, but there is no denying that Obamacare is another step closer to the Supreme Court. Again..

Lots of thinking about what it might mean if the Supreme Court did eventually take the case.  We have Tim Jost asking the question: What Makes A State Exchange? and Kaiser looking at The Potential Side Effects of Halbig.  Here in Maine a local review of the options with reaction from our Gubernatorial candidates (Maine could be in danger of losing Affordable Care Act subsidies).   Although the headline is a bit over the top the article quotes some knowledgeable people (you'll get the joke if you read the article).  Interestingly my print edition headline is "Court Decision Clouds Subsidies for Health Care" which seems more appropriate.

Remember, nothing is changing now and won't change for the next open enrollment period.  In a guest blog on enroll207 I try and remind people: What's the prescription for ACA whiplash? Take a deep breath and don't panic.

Meanwhile, lots of digging into the history of the law.  The plaintiffs support the theory that it was the intent of Congress, not a typo, that the law says state exchange instead of state and federal exchange.  Most who were there at the time say there is no truth to that argument (Congress had lots of Obamacare fights. Ending some subsidies wasn't one of them. and Senate documents and interviews undercut ‘bombshell’ lawsuit against Obamacare).  They ask the question Why Are Conservative Health Journalists Covering for Halbig Truthers?.

And of course there is still the aftermath of Hobby Lobby to grapple with.  In Minnesota Legislature, contraceptives coverage bill to be proposed thereby making it a state requirement that was not subject to the federal religious exemption rule.

And finally, Katie Couric, now with Yahoo (of all places) did a great interview with Justice Ginsburg.  Here is one piece: Exclusive: Ruth Bader Ginsburg on Hobby Lobby Dissent (once on that page you'll see links to the rest of the conversation).

ACA: Polls/Opposition
The results are out today for the Kaiser Health Tracking Poll: July 2014 (Primary Source).  The survey saw a spike in the unpopularity of the law.  No one is really sure why this happened now, it could be a statistical blip or it could have some fundamental meaning we're all missing...  Suddenly, Obamacare is more unpopular than ever

From the Urban institute a look at who Are the Remaining Uninsured as of June 2014? (Primary Source).  The Survey Finds 1 In 5 Uninsured Don’t Want Coverage.

ACA: Premiums/Costs
Good news out of HHS with a report on the savings resulting from the closing of the donut hole: HHS: O-Care saved billions in drug costs.

The New York Times take another look at narrow networks  A Health Trade-Off That’s Here to Stay: Lower Cost, Limited Choice.

Meanwhile, more information coming out of the states on 2015 premiums:


ACA: Marketplaces
A report on the federal marketplace this week: GAO Report: HEALTHCARE.GOV - Ineffective Planning and Oversight Practices Underscore the Need for Improved Contract Management (Primary Source).

This report was released a day before a House Panel Focuses 'Microscope' On Marketplace Open Enrollment and Investigators Warn of Possible Perils in Fall With Health Site.  The report and panel looked at everything that went wrong with the initial build of the site and at what is going on now.  Moving forward, while healthcare.gov is functional and much better than at rollout, there will still be some bumps during the next open enrollment period.

There’s a way around HealthCare.gov, but it’s still not all that great - the direct enrollment option through an e-broker or insurer website.  While partially operational, the process still sends you back to healthcare.gov for a subsidy determination.  Personally, I'm not sad to see this option delayed.  When fully functional it will allow people to enroll without necessarily seeing all of their options as they would on the marketplace itself.

Another reminder that Plan to simplify 2015 health renewals may backfire .  Bottom line is the system the Feds will be using is “... setting people up for large and avoidable premium increases,”.

ACA: Other
The IRS released rules and forms related to the tax credits and employer reporting.  For details, here's Tim Jost's review: Implementing Health Reform: IRS Releases Premium Tax Credit Rules And Draft Forms

It's worth remembering, that when "mature", the marketplaces are supposed to be more than just a place to see prices, they should be providing additional information to facilitate an individual's choice.  Quality information will be a piece of that and the Commonwealth Fund took a look at State Action on Quality Improvement in State-Based Marketplaces .

A great map showing how a state can (and did) change the number of uninsured when the Governor fully supported ACA implementation: Kentucky's uninsured rate, before and after Obamacare.

Medicaid
Part of the ACA was temporarily increasing primary care compensation in Medicaid (2013 and 2014).  With the end of 2014 in site, 6 States, D.C. Extending Medicaid Pay Raise Next Year To Primary Care Doctors.  On the national front, a Bill Would Keep Medicaid Raise for Primary Care Through 2016.  While the national bill has the support of provider groups, it's future in the House is questionable.

A look at The Impact of the Children’s Health Insurance Program (CHIP): What Does the Research Tell Us?  As we move forward, we'll be talking a lot more about CHIP as it comes up for renewal in 2015.  Getting a jump on some of the inevitable arguments against renewal, a study showed that Moving Children From CHIP To Exchange Plans Would Increase Costs.

Medicare
The Medicare Trustees released their annual report this week (2014 ANNUAL REPORT OF THE BOARDS OF TRUSTEES OF THE FEDERAL HOSPITAL INSURANCE AND FEDERAL SUPPLEMENTARY MEDICAL INSURANCE TRUST FUNDS (Primary Source)).

Bottom line, costs are not going up as anticipated, pushing back the day when the fund goes "bankrupt" (Medicare isn’t going broke, but don’t celebrate just yet).  Of course, there are some who say that day will never arrive, given how often it's been pushed back (Medicare isn't going bankrupt. This chart proves it.).  The truth is there is a problem.  While cost increases seem to be under control (Medicare finances improve partly due to ACA, hospital expenses, trustee report says) there is still the demographic issue ahead to content with.  We are getting older as a nation, so even if we reduced cost increases to zero, the bill for Medicare would still be going up. 

There are signs that the cost containment is so successful we're even making progress on the demographic front by spending less per person(The amazing news buried inside a 283-page Medicare report).  But those results are preliminary at best.    

And for those who really want to get into the depths of the report, here is The big health wonk news in today's Medicare report - the need for an annual adjustment to the physician reimbursement rates (known as the doc fix) is built into this year's assumptions instead of being treated as a special case every year. 

In other Medicare news, the Senate held a hearing on hospital admitting procedures - specifically the two midnight rule and observation status.  A Maine hospital official to testify before Senate on admitting practices.  For a review of the issue: Seniors pay the price for Medicare’s two-midnight rule.

VA
Two big pieces of news this week as the Senate Confirms Obama’s Choice to Lead V.A. and the Senate sends VA, transportation bills to Obama on eve of summer recess.

For more details, here is A simple summary of the new VA bill and a look at The new VA-reform deal, and how the costs shrank over time.  It's worth noting that many members of Congress thanked our own Mike Michaud for his contributions to the effort " And during testimony in the U.S. House on Wednesday afternoon, which preceded the House’s overwhelming approval of the bill, several representatives thanked Michaud by name.   They included Rep. Steny Hoyer, D-Maryland; Rep. Jackie Walorski, R-Indiana; Rep. Sheila Jackson Lee, D-Texas; Rep. Mark Takano, D-California; Rep. Gus Bilirakis, R-Florida; Rep. Nick Rahall, D-West Virginia; Rep. Ron Barber, D-Arizona; Rep. Pete Gallego, D-Texas; and Rep. Scott Peters, D-California. Michaud also garnered praise from Rep. Jeff Miller, R-Florida, who is the chairman of the House Veterans Affairs Committee and House Minority Leader Nancy Pelosi has also publicly acknowledged Michaud’s work on the bill." (LePage camp says Michaud deserves no credit for VA fix bill; in Congress disagree)

Drugs
We've been talking about Sovaldi for a long time, now it seems everyone else is as well.  Just a sample of this week's coverage:

A fascinating BDN Series looking at our prescription monitoring program as it turns 10: Prescription tracking at 10: Why it still has much to prove, but could be Maine’s best weapon against drug abuse - Part 1  Prescription tracking at 10: Disagreement on more stringent monitoring, even as drug abuse picture improves - Part 2  The basics of Maine’s prescription monitoring program.

An overview of Drugs and Dollars from the Commonwealth Fund.

And speaking of drugs and cost, Vox makes the argument that The business model for antibiotics is broken. Here are three alternatives you didn't know about and the New York Times looks at Why Crucial Vaccines Are Sometimes Unavailable.

Finally, a bit of advice: Shop like a pharmacist: Don't buy Advil.  Or to put it another way, buy generic or store brand pain relievers and save yourself some money.

Costs
There's a reason some hospitals are big supporters of the ACA: Obamacare Dividends Pile Up for Hospitals as Patients Pay.  Of course in non-expansion states, the picture isn't quite so pretty.

The Washington Post invites us to look at Keeping up with the Joneses, hospital edition - a study shows that hospitals are more likely to buy expensive (and unproven) technology if their closest neighboring hospital buys the technology.  I'll leave it as an exercise for the reader to think about how dangerous that approach is to overall cost containment.

System Transformation
With the beginning of August, I'm guessing many of you will be heading to vacations soon.  When you go consider taking some or all of The best New Yorker articles on health care.  (The magazine has temporarily made its post-2007 archives open to the non-subscribing public).

In more recent news, this week an Expert Panel Recommends Sweeping Changes To Doctor Training System.   There were strong supporters of the report: IOM Graduate Medical Education Report: Better Aligning GME Funding With Health Workforce Needs but it also caused controversy:  Report Touches Off Fight Over Future Of Doctor Training Program.  Any changes to the program recommended in the report would have to go through Congress, so don't hold your breath.

Meanwhile, other health workforce coverage:
And a reminder that yes, we still have D.O.s as well as M.D.s: The D.O. Is In Now

If you thought the anti-vaxers couldn't get more obscene, think again.  The Anti-Vaccination Movement Has Become an Anti-Vitamin Movement, and Babies Are Suffering.

Here's a reminder to please have your heart attack during normal business hours:  Heart attack survival rates 'influenced by time of arrival at hospital'.

Yes, gun ownership is a public health issue, but no, we're not allowed to treat it as one: Do You Own a Gun? In Florida, Doctors Can’t Ask You That.  And for the medical perspective on why it is in fact a public health issue: I'm a Doctor. Here's Why I'll Ask You About Guns. Florida court decision is a disturbing intrusion on medical practice.

We'll close this week with two pieces about initiatives to broader the perspective of healthcare to outside of the exam room:  Medical-legal alliances help low-income patients and New York Debates Whether Housing Counts As Health Care.



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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