A look back at the week's health policy news with a
focus on ACA implementation
This week we saw the release of new contraception rules for
some employers, the appointment of a CEO for healthcare.gov , Medicaid
expansion developments everywhere but here in Maine, more good budget news re Medicare,
and as always, lots more.
ACA: Polls/Opposition
Remember last week when we talked about how Senator Pryor's
new commercial (talking about the ACA but not mentioning it by name) was going
to change the political landscape? Well
there are as many opinions about what's going on as there are fish in the sea...
From Why
that one Democratic Obamacare ad didn’t signal a new trend to Democrats
Are (Slowly) Learning to Love Obamacare to The
Word on Obamacare: It’s Shrinking as a Political Issue. Why so many views,
the short answer is it's complicated. There is still a general lack of
knowledge as to what the ACA is, couple that with a segment of the population
that will reject anything supported by our President and you can see why confusion
reigns.
I'll leave this topic with one more (scary) example: "
Only 37 percent of the public understood that people shopping in the new health
insurance marketplaces could choose from a variety of private plans." (Obamacare
doesn't poll well. So why is an Arkansas senator running on it?)
ACA: Court Cases
While we had no new court rulings this week, there was still
lots of activity. Most of it stemmed from the release last Friday afternoon(8/22)
of new rules to address providing birth control to employees at both non-profit
religious organizations and some closely held for-profit firms: Administration
Proposes New Health Rules Addressing Religious Objections.
For details on the new rules, here is an FAQ from Kaiser (FAQ:
Administration’s New Contraception Rules Explained), a CMS Fact Sheet (Women’s
Preventive Services Coverage and Non-Profit Religious Organizations) and a
review and explanation from Tim Jost (Implementing
Health Reform: New Accommodations For Employers On Contraceptive Coverage).
Does this mean the end to the controversy? Probably not. While the New
Birth Control Rules Appear To Track Supreme Court Suggestion, one author takes
the view that some employers won't go for the accommodation because it means
their employees still get birth control: Nice
Try, Obama - The president’s latest
accommodation to the contraception mandate has one problem: Religious employers
won’t go for it.
Meanwhile, on the subsidy case front, here is a detailed
look at the petition for the DC Court to reject the Administration's en banc request: Republican
Lawyers' Latest Sneak Attack on Obamacare Is Their Most Brazen Yet -
And finally on the court front, the news that the House
to spend $350K on Barack Obama lawsuit because our Federal budget had an
extra three hundred and fifty thousand dollars lying around that they wanted to
flush down the toilet.
ACA: Premiums/Costs
More states reporting out their Marketplace rates for next
year. Good news both in Arkansas (Health-care
premiums fall in Arkansas) and Maryland (Md.
approves smaller rate hikes for CareFirst, lowers rates for 3 others).
ACA: Marketplaces
As of Tuesday afternoon, There’s
finally someone in charge of HealthCare.gov. The Leader
of Connecticut’s Health Marketplace Is Named to Run Federal Program. You'll
remember that one of the reasons cited for healthcare.gov having so much
trouble was that there was no one person in charge, now there is. You can get
to know him here: An
interview with Healthcare.gov's new chief executive. While it's indisputable
that this was a needed step, there be dragons ahead, as one observer put it: Better
Late Than Never: Obamacare Gets a C.E.O. - He worked wonders in Connecticut.
But D.C. is a different beast.
Also related to the Federal website, a government audit was
released that show How
you end up spending $800 million on HealthCare.gov.
A study from the University of PA shows that State
sites outperform U.S. marketplace in Affordable Care Act signups - no
surprise here as we know that the states that created their own exchanges were
more involved and had additional funding streams.
Meanwhile, all is not rosy on the state marketplace front.
In DC we see that Even
a Harvard-educated lawyer has ‘nightmare’ with D.C. health insurance site .
But as noted in the article: " The correct lesson to draw is that
government needs to place a higher priority on efficiency and customer service.
Otherwise, a jaded public will give up on extending benefits that people need,
such as universal health care, but that the private sector can’t or won’t
provide."
The Federal audit moves forward of the Maryland state site: Federal
auditors sought documents related to troubled Md. health exchange launch. And
in Oregon, the second shoe drops. Remember a few weeks ago, Oracle sued the
state. Now Oregon
sues Oracle over failed health care website.
ACA: Employers
We haven't heard much about the SHOP (small business
marketplace) this summer. Remember many states did not introduce one last year
and the Federal one had severely limited functionality (employers could not use
it to enroll). This review looks forward thinking that Health
Law May Benefit More Small Businesses In The Fall as more states and the
Feds get themselves together. But read that piece with a dose of skepticism, we
still have not been given a date when enrollment will be available on the
Federal SHOP.
And for those questioning if the employer mandate is really
going to go into effect (it's supposed to start for those with 100+ employees
Jan 1) signs that the government is serious this time as the IRS
releases O-Care employer mandate guidance after long wait.
ACA: Other
An in-depth reminder that while in the post-ACA world
consumers have a lot more protections, there are still ways for insurers to
game the system: 3
ways insurers can discourage sick from enrolling. The public and the advocacy
community has to remain on-guard for these potential abuses.
And a reminder that while you can't be charged more if you go
to an emergency room that is out-of-network, if you are admitted and it is an
out-of-network hospital, you would have to deal with the out-of-network in-patient
charges: Beware
Of Higher Charges If You Go To An Out-Of-Network Emergency Room.
As most of you reading this already know, the premium
subsidies offered through the marketplace are actually advanced tax credits. That
means there will be a reconciliation when you file your taxes. For the 2014
plan year, that will come in early 2015. It's worth remembering that Early
tax planning may be needed because of the Affordable Care Act. And if you
have not been diligent about updating your financial information on healthcare.gov,
Tax
refunds may get hit due to health law credits.
One part of the ACA that has not received much attention
before now is The
obscure part of Obamacare that takes on executive pay. That changed this
week as a report was released that showed $72 million has been taken in so far
under this provision (Obamacare
has a CEO tax — and it just raised $72 million).
We'll conclude this section with a local note, as we
received word that Mega
insurance company no longer doing business in Maine. While they were not
selling plans on the marketplace, they continued to offer off-marketplace
individual and small group products. I was somewhat restrained in my public comments
(quoted in the article), but my bottom line reaction to the news was yippee! To call their products health insurance,
gives all health insurance a bad name.
Medicaid
Several states saw significant Medicaid expansion news this
week, none more impactful than PA while due to the deal reached between their
Governor and CMS, 300,000 people will be newly eligible for coverage: Pennsylvania’s
GOP governor will expand Medicaid to 300,000 poor people.
Now we have to take a step back and understand what is and
is not happening there. First of all, although the state originally asked for
24 waivers from CMS, only 4 were granted. Most importantly, the work
requirement they wanted as a condition of eligibility was not allowed (Pennsylvania
is expanding Medicaid. Here's how.).
It's also worth noting that while some headlines said Pennsylvania
to Purchase Private Care for Its Poor , that's a bit misleading. This is
NOT a private option plan (similar to Arkansas). This is having the individuals
enrolled in Medicaid Managed Care plans (as previously eligible residents of
the state already were using).
Finally, regarding PA I'll note that Corbett is currently in
a re-election battle (and behind in the polls). His Dem opponent has said he
prefers straight expansion to the form just approved, so it remains unclear
what will actually happen there. Although at least we know people will gain
coverage.
In Wyoming a Republican administration is also moving
forward towards expansion, realizing it made no sense to continue to forgo the
federal funds: Another
GOP state may be signing up for Medicaid, and the reason is obvious.
In Arizona
Medicaid appeal to be heard by court as Gov. Brewer continues to try and
move forward with implementation there.
And finally, with no movement in sight here in Maine, a
reminder from Sara Gagne Holmes that Expanding
Medicaid is good for the economy, health of Maine.
Medicare
Starting off with some good news, Yes,
Obamacare is cutting the deficit. " The difference between the current
estimate for Medicare’s 2019 budget and the estimate for the 2019 budget four
years ago is about $95 billion dollars. That sum is greater than the government
is expected to spend that year on unemployment insurance, welfare and Amtrak —
combined." (Medicare:
Not Such a Budget-Buster Anymore).
Last week we discussed an analyses saying the Medicare Advantage
plans might finally be delivering better outcomes. This week a rebuttal taking
the position that No,
We Still Don’t Have Proof That Private Medicare Plans Are Better.
A caution about the way Medicare rates nursing homes: Medicare
Star Ratings Allow Nursing Homes to Game the System.
And a caution about the ACO hype... " The PGP
demonstration, which used a payment model similar to the Medicare Accountable
Care Organization (ACO) program, resulted in small reductions in Medicare
expenditures and inpatient utilization, and improvements in process quality
indicators. Judging from this demonstration experience, it is unlikely that
Medicare ACOs will initially achieve large savings. Nevertheless, ACOs paid
through shared savings may be an important first step toward greater efficiency
and quality in the Medicare fee-for-service program." (Financial
and Quality Impacts of the Medicare Physician Group Practice Demonstration).
VA
Several developments regarding veterans this week. Starting with
some result from the VA investigation stating that the deaths in Phoenix were
not caused by the waiting list issues: Probe:
No Proof VA Delays Caused Phoenix Veterans To Die.
The President discussed more of the changes that have been
ordered in the system: Obama
orders aimed at VA delays.
A fascinating story that is sure to get the black helicopter
conspiracy folks excited as New
Obama plan calls for implanted computer chips to help U.S. troops heal. This
is real science that has the promise of incredible benefits, as long as we can
get past the headline.
And finally, a story I'm including for multiple reasons: The
Number Of Homeless Veterans Really Is Falling. Homelessness is an important
factor in health care, so it falls within the range of topics covered here. But
additionally I wanted to share because I consider this reporting at its finest.
The author takes a government report of good news and tests the data to make
sure it's true - and finds that it is!
(Primary Source: HUD,
VA, AND USICH ANNOUNCE 33% DROP IN VETERAN HOMELESSNESS SINCE 2010)
Drugs
The ethics of who should get an experimental drug and when
they should get it are discussed in this fascinating review of the Hardy case: " We discuss
several issues raised by the Hardy case, including the overarching question of
whether it is fair for social media or influence of any form to play a role in
determining which patients get access to experimental treatments; whether
rescuing individual patients in need can be reconciled with an evidence-based
regulatory approval process for new therapies; and whether there is a duty to “rescue”
terminally ill patients by paying for access to experimental therapies." (Rescue
Me: The Challenge Of Compassionate Use In The Social Media Era)
Meanwhile, across the country continued focus on opiate addiction
in all its many forms. First, Chicago
and 2 California Counties Sue Over Marketing of Painkillers. Andhere in
Maine Once-a-month
shot that blocks high from opiates making inroads in Maine.
Costs
It's not often I find myself agreeing with a surgeon about
health reform, but to the author of this article, I want to give a heartfelt
amen: Robots
and health costs: Can either be tamed?
And under the heading of what's old is new again, house
calls are back: Study:
House calls for frail elderly save money.
And finally, a interesting and practical interim solution
for getting our countries health care costs under control quickly: The
125 Percent Solution: Fixing Variations In Health Care Prices. But if you
think it's going to happen any time soon, I have a
bridge for sale in Brooklyn you might be interested in.
System Transformation
An individual's health is determined by a lot more than what
goes on in a doctor's (or provider's) office. This week a review of various
studies on The
Relative Contribution of Multiple Determinants to Health. Sadly we know
that one of those determinants is race. "Even when you control for
education and income, black people still fare more poorly than white people,
and he thinks one key cause is everyday racism." (White
privilege is the best medicine).
The ACA helped give more people coverage for mental health
services, but we know that access takes more than coverage, it takes providers:
Expansion
of Mental Health Care Hits Obstacles. In CA, one response is Urgent
Care Centers Opening For People With Mental lllness "Mental health urgent care centers, also
known as crisis stabilization units, are opening throughout California in
response to the shortage of psychiatric beds and the increase in patients with
mental illnesses showing up at hospital emergency rooms with nowhere else to
go, experts and advocates said. In Los Angeles County, four such centers have
opened and several more are planned."
Speaking of having enough providers, here is one physician's
perspective on use of various types of providers based on real world experience,
instead of being based on protecting "turf": Doctors
and nurse practitioners: We’re failing the reality test.
Under the heading of making progress, after last week's
scary letter to Oregon from the Feds, the Feds
back down from directive that undermined Oregon Health Plan reforms. I
believe the technical term for my reaction to this news is "phew!"
A physician looks back at some lessons from medical school
that still guide him. All I can add is these apply much more broadly than to
just the practice of medicine: 4
things I learned in medical training that still apply today.
And finally for this week, we'll end with pieces the deal
with the end. First, Operator?
Business, Insurer Take On End-of-Life Issues By Phone - While far from
ideal, but as one person put it in the article: "“Would I prefer that we
live in a health care systems where doctors, nurses, nurse practitioners and
social workers who knew the patient were having these conversations? Yes,” he
says. “This is better than what patients have currently been getting.”"
Even if you deal with these issues all the time, you don't always
know what you don't know: 7
assumptions about end of life care. And furthermore, even if you think you
are prepared and doing everything right, that is no guarantee your wishes will
be carried out: DNR/DNI:
More code than status.
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"
