A look back at the week's health policy news with a
focus on ACA implementation
This week a reevaluation of the role the ACA will play in
this year's election, diverging views on the role of employers in the future of
health care, Medicare makes a revolutionary addition to their reimbursement
strategy, plummeting teen birth rates, medical data security and as always,
much more.
ACA: Polls/Opposition
Interesting developments this week regarding the approaching
elections and how the ACA is portrayed. First we have this take by The New
Republic: This
Is How Democrats Win on Obamacare - "But people’s feelings about the
health care law are complicated. Whatever the attitudes of American voters
towards “Obamacare” per se, large majorities seem to approve of what Obamacare
actually does. They like the idea of making sure anybody can get insurance,
regardless of income or pre-existing conditions. They want to make sure
policies are reasonably comprehensive, so that people with insurance don’t
still face financial ruin. Sometimes they even like the law as a whole, as long
as they don’t associate it with the president."
But wait, there's more (while I usually try not to provide repetitive
links, in this case I think it's interesting that so many are saying the same
thing): Morning
Plum: Obamacare disappearing as major issue and Obamacare
Fades Right on Schedule and Obamacare
Losing Power as Campaign Weapon in Ad Battles.
What's gotten everyone talking about it is the add being
used by Senator Pryor of Arkansas touting his support: From
a vulnerable red state Democrat, a strong pro-Obamacare ad.
Some good news on the "price" of health care - but
remember, cost is a lot more than price so this is only one piece of the
puzzle: Good
news for Obamacare: Health coverage is soaring, but health care prices aren't.
(When we talk about the cost of health care we consider not only the unit price
but also the quantity of units and the mix of services that make up the units.)
ACA: Court Cases
Another quiet week on the court front but we did see Obamacare
Opponents Who Won On Subsidies Ask SCOTUS To Take The Case. Their
motivation is to get the issue onto the Supreme Court docket before events
progress to the point where SCOTUS might not take the case (as is possible if
the en banc review reverses the original decision).
ACA: Premiums/Costs
We continue to see more proposed rates dribble out from the
states. PriceWaterhouseCoopers continues to track developments. Using that
information, here is a look at the changes and a discussion of the variability both
based on the state and based on who is "spinning" the numbers
(remember numbers on the map are pre-subsidies): Here's
What's Going On With Obamacare Premium Increases .
And from the Association of Health Care Journalists (yes
there is such an organization, no I am not a member) a primer on how to
understand rate increases - as useful for understanding the articles as it is
for writing them How
to understand 2015 exchange plan insurance rate changes.
ACA: Marketplaces
Can you feel November and the beginning of open-enrollment
getting closer? Certainly those who will be working on enrollment can. CMA issued
a bulletin (CMS
Enrollment Assister Bulletin: 2014-01) and updated their resource page: CCIIO
In-Person Assistance in the Health Insurance Marketplaces. At the same
time, the Georgetown Policy Institute updated their resources: Navigator
Resource Guide Helps Answer Consumers’ Questions about Health Insurance &
Coverage.
We've talked before about how some individuals don't need to
wait for open-enrollment to enroll in plans, Enroll America released a report
estimating that there are 7 million of them out there: Study: 7
Million Could Get Affordable Care Act Coverage Outside of Open Enrollment.
More talk about adding another plan level to the marketplace
offerings, a "copper" plan. The problem with this idea is that it would
cause problems for those who purchased them not be able to pay their
deductibles and copays - the plan would only have an actuarial value of 50% (as
compared to the Bronze 60%, Silver 70% and Gold 80%): 'Copper
plans' could cut subsidies, lower deficit, but would consumers bite?
Matching the success of the first open-enrollment won't be
easy. First a look at CA learning from its mistakes the first time around with
respect to its Latino population: Hurdles Remain to Signing Up
More Latinos for Health Coverage.
And a look at Alaska where there are issues concerning the
underfunding of the Indian Health Service and the difficulties with trying to
get ACA coverage to help fill the gap: The
trouble with trying to sign people up for health insurance when care is already
free.
ACA: Employers
The future role of employers was another hot topic this
week, unlike the repetitive articles regarding the ACA and elections, here are
several conflicting takes on the issue.
We start with a helpful overview of the role of employers in
health care from The Economist: Paternalism
2.0 - American employers are rethinking their role in workers’ health care.
Next up some thoughts on how the law is freeing people to make decisions on
their jobs independent of decisions on health coverage (the end of job lock). "
But just because the ACA may encourage some people to leave their jobs does not
mean that “Obamacare is a job killer,” as some political operatives have put
it. People who leave their jobs once they are able to find health insurance
elsewhere, do so voluntarily. The law is not forcing anyone to stop working.
And by leaving the labor force, those Americans open their jobs to others who
are hungry for the work." (How
the Affordable Care Act might transform the labor market - ).
Then there are those who focus on the mandate pushing people
to accept employers' offer of insurance, as it was meant to do: Why
More, Not Fewer, People Might Start Getting Health Insurance Through Work, And
finally, from Brookings the perspective that the true answer to the Hobby Lobby
decision is taking the employer out of the equation completely: Bye,
Bye Employer-Sponsored Health Insurance?.
A survey showing that while the health care continues to be
important to small employers, it's not the biggest thing on their minds
anymore: - "Conversely, health care, which has been one of the most
controversial political issues for small firms in recent years, has fallen to
fourth on that list, now behind immigration issues and income inequality (the
economy was first)." (Small
business owners aiming to unseat incumbents in midterms, poll shows ).
ACA: Other
I try to break this publication into sections so that people
can focus on their interests. The problem with that is that many topics cut
across categories. These first two items could have been under the Marketplace
section, but they also apply to health coverage in general, regardless of where
it comes from. First, 5
reasons health insurance didn't pay your bill (some useful reminders about
how insurance works) and second, HMO,
PPO, EPO: How's A Consumer To Know What Health Plan Is Best? (reviewing the
basics of different plan types).
Advocates sent a letter to CMS about potentially
discriminatory plans: Patient
Advocates Say Insurers Avoiding the Sick. While we need to stay vigilant, and
there is no doubt some abuse going on, we have to separate those problems from
issues of plan design and actuarial value. (Remember the tradeoff between
premiums and cost-sharing means that some plans require higher cost sharing
until the out-of-pocket maximum is met.)
Another area where we need to separate ramifications of plan
design from malicious practices - narrow networks. While they aren't inherently
bad, they are different and represent a choice that must be reached with full
information resulting from clear communications. In this case it seems like the
information needed was not provided by the plan: Anthem
Blue Cross sued again over narrow-network health plans.
Continuing the theme, Some
Insurers Refuse To Cover Contraceptives, Despite Health Law Requirement. Here
it's a clear case that the insurers need reminding about the specifics of law.
And it's not only insurers, some employers need reminding
about what they are allowed to do as well. We saw this as the First
Wellness Program Firing Suit Filed by U.S. Agency occurred. Remember, wellness
programs can be helpful (whether they save money is another question) but they
also have a great potential for employer abuse.
And finally, Hospitals
Reconsider Charity For Patients Who Decline Health Coverage. We saw talk of
this here last year although no changes have yet been made in Maine.
Medicaid
The Center on Budget and Policy Priorities issued a report
telling you everything you always wanted to know about the private option
expansion waivers but were afraid to ask: Approved
Demonstrations Offer Lessons for States Seeking to Expand Medicaid Through
Waivers -
Also this week, a problem in Oregon we'll be watching
closely: Oregon
health reforms threatened by new federal directive, officials say. The
whole point of the Oregon waiver was to allow new ways of providing care, if
not changed the most recent letter from the Feds would be a big step backwards.
(The short version of the waiver is that Oregon wants to be able to buy an
asthmatic an air conditioner for $300 to avoid a $3,000 (or more) hospital stay,
the government said yes but now seems to be backpedaling.)
Medicare
Lots on the Medicare front this week. Starting with the announcement
that Medicare
to Start Paying Doctors Who Coordinate Needs of Chronically Ill Patients. This
is big - for the first time Medicare will pay not for a specific treatment but
for the time it takes to keep the chronically ill well.
An intriguing look at Medicare Advantage plans: Medicare
Advantage Is More Expensive, but It May Be Worth It. I'm not convinced, but
if true we need to find a way to pay for providing those benefits to all
Medicare recipients (remember, Medicare Advantage cost the Feds more than
straight Medicare).
At the same time, we know there is money in the system that
is not being used effectively. Once again we see that Pervasive
Medicare Fraud Proves Hard to Stop. And a look at the history of one of the
most prevalent scams - motorized wheelchairs (remember the Scooter Store) - now
thankfully under control: A
Medicare scam that just kept rolling -
We saw last week that the new website showing provider
payments had hit a problem. Now the Doctor
Payment Website Is Back on Schedule After Bogus Data Are Discovered. However;
Government
Will Withhold One-Third of the Records from Database of Physician Payments.
Given all the criticisms of the database - including its very existence - the
Feds want to make sure the information they do post, even if incomplete, is
correct
Kaiser released a comprehensive look at the Medicare Part D program
and how it's evolved: Medicare
Part D in Its Ninth Year: The 2014 Marketplace and Key Trends, 2006-2014.
Meanwhile, another look at the plan over time shows the
plans may be stumbling: "...forgoing basic needs to pay for drugs. Close
to 9 percent of beneficiaries reported doing that in 2005; by 2009, only 4
percent did. But in 2011, the proportion climbed back to 5.3 percent — a
statistically significant change" (Part
D Gains May Be Eroding). Note that this article doesn't mention the closing
of the "donut hole", made possible by the ACA, and the impact that
will have going forward.
Drugs
It's hard to talk about prescription drugs without talking
about money - First a look at an issue over the naming of biologics - will the
new "generic" versions be able to have the same name as their therapeutic
equivalents (A
drug naming dispute, with billions on the line)?
Speaking of money, several years ago the FDA sped up its
approval times for new drugs. But along with the speed-up we now see there has
been an increase in the need for "black box" warnings: The
Role Of Black Box Warnings In Safe Prescribing Practices.
And it's not just the pharmaceutical companies, it can also
be providers who are profiting from drugs (and thus possibly having a conflict
of interest in what they prescribe): Oncologist
pay and chemotherapy: Buy and bill needs to stop.
Finally, because a week can't go by without a Sovaldi story here
is a perspective that says we don't need to restrict the number of prescriptions,
we need to expand the number: Waging
War on Hepatitis C
System Transformation
Lots of attention on falling teen birth rates. And we don't
just mean a slight decline, we're talking a dramatic drop as in the teen birth
rate has fallen 57% since its peak in 1991. First the numbers: Five
fascinating charts on the plummeting teen birth rate. Last week we talked
about one state that had a private benefactor pay for birth control (How
Colorado’s teen birthrate dropped 40% in four years), this week the media
has widened its focus (in the wake of new CDC numbers) to look at the whole country:
The
historic and uneven decline in teen births.
Conflicting views on why this is happening. First from Sarah
Kliff: The
mystery of the falling teen birth rate. She looks at various reasons why
this may be happening. From another perspective, it's not that complicated: Give
Teens Access to Birth Control and, Amazingly, the Teen Pregnancy Rate Drops
although this argument seems a bit simplistic to me.
Also, in light of a the announcement this week of a data breach
impacting Community Health Systems (4.5 million records in 206 hospitals in 29
states - Chinese
hackers may have stolen your medical records) there was a renewed focus on
health data security: Health
care data breaches have hit 30M patients and counting.
Kaiser provided this FAQ: Are
Your Medical Records Vulnerable To Theft? as the FBI
warns healthcare firms they are targeted by hackers.
Meanwhile, while healthcare.gov does not contain any medical
records, in a related story the US
won't reveal records on health website security .
This is all going on during a period when the use of
electronic information is only going up as Hospitals
must help patients access digital records — or else. (This is the
implementation of stage 2 of the meaningful use standards - and if you think
stage 1 was hard, it was a walk in the park compared to stage 2.)
While everyone enjoys watching their friends get doused in ice
water, It’s
going to take a lot more ice buckets to fill the NIH funding gap - the
campaign alone is not going to solve the NIH funding cutbacks: " NIH says
its budget has effectively been cut by 22 percent in the past decade when
accounting for medical inflation" and the s sequester didn't help ("the
sequester's automatic 5 percent cut to the NIH resulted in 8 percent fewer
research grants in the 2013 fiscal year compared to the previous year")
While police forces doing the wrong thing have been
(appropriately) dominating the headlines, some police forces are doing the
right thing: San
Antonio Police Have Radical Approach To Mental Illness: Treat It. Not only does
this yield a better outcome for all involved, it saves money too.
Two reminders that solutions to long standing problems don't
need to be complicated. In the first case, Simple
measures made hospital patients 70% more likely to quit smoking. And the
second shows that One
way to boost organ donations: Just keep asking.
On the vaccination front this week, data showing Why
States Should Aim For 100 Percent Vaccination. And a reminder that it's not
just small children - there are vaccinations that teenagers need including the
HPV one that is being grossly underutilized: Let’s
Not Talk About Sex.
More on the OpenNotes movement (allowing patients to see
their full medical record): "Ninety-nine percent of the patients wanted
OpenNotes to continue, and no doctor withdrew from the pilot. Instead, they
shared anecdotes like mine. When patients see their records, there's more trust
and more accuracy." (When
Patients Read What Their Doctors Write)
NPR had a great interview where a Cardiologist
Speaks From The Heart About America's Medical System. While the interview
is broad, at the end he touches on end of life care. Also on end of life care,
the Washington Post continued it's series on hospice coverage by looking at the
dangers associated with the rise in for profit hospice providers: As
more hospices enroll patients who aren’t dying, questions about lethal doses
arise. And speaking of for profit hospice providers, here is a useful FAQ: End-of-life
care: An industry with soaring profits, funded by taxpayers. But to be clear
- hospice is often an appropriate approach and can be a blessing for both the
patient and family. However recent trends in the industry seem to have lead to
an increase in the rate of misuse of the concept as well as outright abuse.
It's also worth remembering that it's not just the profit
motive that leads to improper decisions. Sometimes we just don't want to let
go: Food
and the Dying Patient.
And finally, on a subject near and dear to my heart - the
need to have a true health care system. A look at how one piece of that would
be Incorporating
urgent care into the medical home. While new and innovative ways to provide
care are helpful (we've looked at some in past issues) they need to be part of a
coordinated continuum of care.
Thanks for reading!
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"
