That Was The Week That Was - Issue 26

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

I always say lots to talk about this week, this week that's an understatement! We have news of an en banc review by the DC court, a look at marketplace premiums, details of the reenrollment process, news of a data breach at healthcare.gov, cost projections, drug innovations, and on and on ending with the funny medical video of the week.

One formatting note, in the study discussed below, the Office of the Actuary at the Centers for Medicare and Medicaid Services is no longer separating out ACA effects from their overall cost projections. If they say that the ACA is now so much a part of the system those effects can't be separated, it must be true. So, I'm now combining the ACA Cost and Cost sections.

And speaking of sections, some pieces are so broad that they transcend any attempt to classify them. That's the case with this exceptional piece: 8 facts that explain what’s wrong with American health care. We've talked about pieces covered in other issues, but this is the best collection of current thinking I've seen. Read and share widely!

ACA: Court Cases

Movement this week on the cases around if subsidies should be available on the Federal Marketplace. Early in the week, the clerk of the Supreme Court granted a 30 day delay for the Feds to respond to the petition to have the case brought to them immediately:  Delay on health care subsidies case. Among the reasons the Feds asked for the delay was to see if the D.C. Circuit would grant the petition for an en banc review, that is for the full court to hear the case instead of the 3 judge panel that turned in the earlier ruling prohibiting the subsidies. Later in the week, that en banc review was granted: This is good for Obamacare: DC Circuit court will review Halbig.

This makes the chances of an expedited review by the Supremes much less likely as well as raising the probability that they may never get the case (if all the Circuit rulings end up agreeing). This piece looks in detail at the situation: Obamacare Lawsuits Just Suffered a Big Setback - What it means and how the legal challenge could play out. The piece from our friends at scotusblog tell us about the timing, reminding us that the wheels of justice turn slowly:  "In ordering rehearing, the D.C. Circuit set the case for a hearing on December 17. It laid out a briefing schedule beginning on October 3 and due to be completed on November 17. The parties were cautioned that they had little chance of gaining extra time to file briefs." (Full D.C. Circuit will rule on health care subsidies)  For even more on the topic, here is Tim Jost's take: Implementing Health Reform: DC Circuit Vacates Halbig Judgment, Grants Rehearing

ACA: Polls/Opposition

The Editorial Board of the NY Times is tired of the Endless Assault on Health Care Reform, and so am I.

Ezra Klein notes that "The electorate moving on means Obamacare's mounting achievements don't get nearly the attention of its early failures. But the law, at this point, is doing more than simply defying the doomsayers; it's proving to be a real policy success."  (The Obamacare train keeps not wrecking - for more detail on the Kaiser premium study referenced, see the ACA: Premium section below).

Meanwhile, the critics aren't going away, not that they have anything new to say as Karl Rove recycles years-old attacks on Obamacare.

Also this week, Tim Jost takes a look at what is probably the most complete "alternative" to the ACA offered by opponents, and not surprisingly he finds parts of it lacking: Transcending Obamacare? Analyzing Avik Roy’s ACA Replacement Plan.

At the end of his review, he talks about the issue of the complexity of the ACA (this alternative would do nothing to change that) and notes: "One of the greatest defects of the ACA is its complexity. That complexity has required the Obama administration to exercise considerable creativity in implementing the law. But the law’s complexity simply follows from the fact that the drafters of the ACA attempted to build on, rather than to radically change, our current, impossibly complex, health care system."  Or to put it another way, the complexity of the law arises because it's not a government takeover of health care, not because it is. It builds on the existing complex system, so you end up with a complex law.

ACA: Premiums

Kaiser released an analysis of preliminary marketplace premiums. In 16 markets they looked at the benchmark silver plans (the second least expensive plan on which the subsidies are based) and the lowest cost Bronze plans (one of the markets included is our very own Portland Me). The Early Results: Average 2015 Exchange Premiums Decline Slightly. This is more evidence that all those naysayers who said rates would explode in the second year were wrong  You can read the full report here: Analysis of 2015 Premium Changes in the Affordable Care Act’s Health Insurance Marketplaces (Primary Source).

Part of the reason for the results may be the direct competition found in the marketplaces. Austin Frakt asked the question What Happens When Health Plans Compete and found the answer was that, as theorized in the creation of the marketplaces, rates do in fact go down.

ACA: Marketplaces

As the summer ends and we get closer to the next open-enrollment (11/15) lots to report regarding the marketplaces.

Starting off, CMS announced the auto-enrollment process that will be used for those currently enrolled in a marketplace plan: Fact sheets: CMS finalizes auto-enrollment process for current Marketplace consumers (Primary Source). The motivation for the auto-enrollment is to keep people covered (similar to what happens with your life or auto insurance). However the process does not come without its pitfalls: "Consumers who auto-renew their policies will get the same dollar value of subsidies they got last year—even though changes in the marketplace all but guarantee that will no longer be the right subsidy amount for millions of people. ... "That's the totally crazy part," Pearson said. "They're basically going to send them what they know to be the wrong subsidy."" (If You Like Your Obamacare Plan, It'll Cost You)

In addition to the subsidy issue the individual will also be impacted by a change in what the benchmark plan is in their area. Remember, the subsidy is based on the second lowest cost silver plan. If that is now a different plan, depending on the relative cost of their current plan, the individual may now be responsible for a larger share of their premiums if they don't switch to the new benchmark plan (or another lower cost option). For more details on the process (for now, we'll have lots more in the coming weeks) here is a review of the final rule: Implementing Health Reform: Exchange Eligibility Redeterminations Final Rule.

The NY Times takes a look at this and other issues coming up: Bracing for New Challenges in Year 2 of Health Care Law. While we're reminded that Consumers Will Owe Uncle Sam If They Got Health Insurance Subsidies Mistakenly.

Health insurance is complicated for everyone. Drew Altman reminds us that there is A Perilous Gap in Health Insurance Literacy - "46% of enrollees in the new insurance marketplaces say they’re getting a subsidy, when official numbers indicate about 85% actually get them."  And here is a look at what this means in practical terms: Enrolling People In Obamacare Who Have No 'Concept Of Insurance'. And a little data to drive home the point, while this survey involved people choosing their employer-sponsored plans, we can be sure it's not much different in the individual market: Many spend 15 minutes or less picking health insurance.

Today (9/5) is the deadline for some who had documentation issues with their applications to get their paperwork filed. Unfortunately, the full court press of the past month has not yielded the hoped for results as Problems abound with health law immigration papers.

Also this week, reports that Hackers Breach Security of HealthCare.gov . This breach does not seem to be too serious: "“Our review indicates that the server did not contain consumer personal information, data was not transmitted outside the agency and the website was not specifically targeted,” said Aaron Albright, a spokesman at the Centers for Medicare and Medicaid Services, which runs the website. “We have taken measures to further strengthen security.”" However that doesn't mean we won't be hearing about it now and next week when Congress returns as GOP chorus attacks Obamacare over Healthcare.gov hack.

I'll note that while any security breach is serious, and we want the administrators of healthcare.gov to be more diligent, this issue is not unique to healthcare.gov. The issue of computer security is in the news every week (this week with Apple cloud storage and use of credit cards at Home Depot ), it's a major issue that needs to be addressed. That said it should have no bearing on the discussion of the usefulness of the Federal Marketplace.

ACA: Employers

Some good news on the employer front as CMS announced that Five States To Get Early Access To Small Business Health Insurance Marketplace. Last year the SHOP (small group marketplace) went lacking as all the focus was on getting the individual marketplace up and running. This announcement that the new SHOP functionality (on-line enrollment and in some states employee choice) will be piloted in five states in advance of a national rollout in November is the most concrete sign we've had that the promised upgrades to the SHOP are on track.

A look at how High Health Plan Deductibles Weigh Down More Employees. This is an issue for those in employee plans and for those in individual plans as well. Remember, high deductibles (and other cost sharing) has been shown to reduce expenses, but it does so indiscriminately by reducing both needed and less critical care. We also have these survey results on employer-sponsored plans: How People Feel About Their Employer-Sponsored Health Plans. Note that part of the results are that some have trouble with high deductibles and co-pays.

Also this week, another look at the issue of if the ACA is forcing an increase in the use of part-timers. The Urban Institute found Little Evidence of the ACA Increasing Part-Time Work So Far. While this is good data there is no denying the anecdotes of employers that are cutting hours due to the ACA. We can debate the scope of the issue, but not that it exists. (We can make also make an educated guess that opponents of the law are overstating the problem as supporters of the law are understating it.)

ACA: Other

Taxes... Yes we have to get through open-enrollment before we hit tax time, but it's worth talking about as the actions people take now and during enrollment will impact their returns. H&R Block certainly thinks so as they are gearing up: H&R Block getting ready for the Affordable Care Act’s impact on tax season next year. At the same time, the IRS released instructions for some of the forms employers (and others) will be filing: Implementing Health Reform: Tax Form Instructions. One of those "and others" is healthcare.gov itself - the marketplace will need to be getting forms to individuals indicating the amount of subsidies advanced to enable individuals to fill out their returns. Some say that the Tax Forms Could Pose Challenge For Healthcare.gov.

Costs

As I said up top, since the Since Office of the Actuary at the Centers for Medicare and Medicaid Services (CMS) no longer separates out ACA effects from cost projections. If it's good enough for CMS it's good enough for me. Going forward I will have a single cost section instead of one labeled ACA: Cost and one labeled Cost. (This also highlights the issue inherent in any taxonomy including mine, coming up with mutually exclusive categories is hard!)

The big news this week was the release by the above referenced CMS Office of the Actuary of their annual report on healthcare costs. Buckle up as we move forward, it could get a little bumpy. Fist the report: National Health Expenditure Projections, 2013–23: Faster Growth Expected With Expanded Coverage And Improving Economy (Primary Source).

Before we look at what they said, let's review some basics. Costs are made up of the price of the item and how many of them you use. The same is true in health care, except were not talking about a single item, but lots of different components (services, drugs etc) that make up health care. When you look at costs over time, you need to project how the prices will change and how the volume will change. Compounding the complexity for health care you also need to figure out the introduction of new components and how the use of existing components will change. (One of the biggest factors in the change in use of existing components is the aging of the population - the older we get the more health care services we use.)

So what did the report say?  We'll start with the bottom line, costs are continuing to go up and if these projections are correct, at the end of the ten year period health care will make up one fifth of our economy (CMS: Health spending to hit $5.2T within years). But that's a big "if". Which brings us to our next point. After Slow Growth, Experts Say, Health Spending Is Expected to Climb. We've been seeing historically slow growth in health care spending. No one is really sure why although it's clear part is due to the overall economic slowdown and part is due to systemic changes (some brought about by the ACA). The question is, what is the proportion of each of those factors. If it's more the economy then costs increases will start to accelerate - and that's exactly what the CMS actuaries expect to happen (The end of health care’s historic spending slowdown is near).

So if you agree that most of the recent slowdown in costs is the result of the economy you would agree with this report, if you don't then you might consider it overly conservative. My favorite headline comes from the New Republic which tries to cover all the bases: New Report: Health Care Costs Are Escalating Much More Slowly - But still not clear how long slowdown will last—or why it's happening.

This report comes on the heels of last week's CBO report on Medicare spending. A very exciting chart extracted from that report shows that Per Capita Medicare Spending Is Actually Falling.

Taken together (and adding other factors) Vox gives us Five reasons health care is no longer seen as monstrous budget buster. Since even if the CBO report is accurate, the projections still represent a substantial improvement over previous year's projections.

As if that's not enough, we have a report on MA state based efforts to go at the cost problem: Massachusetts wants to upend health care. Again.

We also have a new paper from the Center from American Progress where Democrats borrow a GOP idea on health care costs and put the onus for innovation on the states. (Accountable Care States - The Future of Health Care Cost Control (Primary Source))

Last week we talked about the idea of the 125% solution. For once I was ahead of Ezra - this week he takes a look at the idea( again, not a bad step, but not going to happen): The 125 percent solution for American health care.

Medicaid

Last week, PA announced they would be participating in the Medicaid Expansion. This week the Washington Post (23 states still haven’t expanded Medicaid. Which could be next?) and Kaiser (Indiana, Several Other States Look To Expand Medicaid Next Year) take a look at who could be next.

One thing we learned from PA is that while CMS is willing to negotiate (too much so in some people's opinions), there is A bright 'red line:' What the White House won't do to woo GOP governors into Obamacare, namely Medicaid coverage can't be made contingent on employment.

Maine was the focus of national attention with the same article appearing last weekend in USA today and then during the week on the Kaiser website: Maine's health care model: Go smaller / Maine Rolls Back Health Coverage Even As Many States Expand It.

A Reminder yet again how misguided it is not to participate: States that decline to expand Medicaid give up billions in aid. And not just for the state, but for the state's hospitals as well: Obamacare Is Big Business for Hospitals - Hospital profits are soaring in states that accepted the Medicaid expansion.

Medicare

More talk about Medicare Advantage plans. This week not debating their merits but identifying their abuses: Upcoding in Medicare Advantage: Transparency can clean the mess. At the same time, Medicare offered hospitals the option to settle outstanding claims - expedited payment but at a reduced rate: Medicare Will Settle Short-Term Care Bills

VA/Military

This next story is not directly related to the VA issues we've been covering, but still worth mentioning: Smaller Military Hospitals Said to Put Patients at Risk. In addition to the travesty of putting active duty personnel and their families at risk, this story is a cautionary tale regarding small hospitals. Namely, if they are not doing sufficient volume, patient care will suffer. So while many have the knee jerk reaction that it's not a good idea to close hospitals, in fact doing so may have both cost and quality benefits.

Drugs

This week we'll take a break from all the problems of the drug industry and focus on three exciting new developments:

• Cholesterol Drug Halves Heart Attack and Stroke in Early Test
• New Novartis Drug Effective in Treating Heart Failure
• F.D.A. Allows First Use of a Novel Cancer Drug

System Transformation

So many stories, so little time... Before I start this section I have to tell you that I've cut out half the items I wanted to share this week, so no complaining that the post is to long :)

First up, two pieces that to put it bluntly, tell us to question authority:  Beware your doctor’s knee jerk reflex: 3 questions to ask and Is much of the annual physical a waste of time? spoiler alert... yes

We often talk about big data and its promise, but here is a cautionary note about how it works in light of the need for a patient-centered approach: Can Big Data and patient-informed consent coexist?  But in case that piece gave you pause, here is a reminder of how much it is needed: Big Data And The Public’s Health: Building Resilience For The 21st Century

CVS made good a month early on its pledge to stop selling tobacco products: CVS Stops Tobacco Sales Today, Changes Name To Reflect New Era. Straight from the source a piece by company executives as to why they did it: Integrity In Retail Health Care: Rethinking The Sale Of Tobacco Products .

Bad vaccination news out of CA as Plunge in kindergartners' vaccination rate worries health officials. And a look at why it's happening (and worse in CA then elsewhere): Rich, educated and stupid parents are driving the vaccination crisis. It has been said that as climate change denial is to the right, anti-vaccination beliefs are to the left. Both deny science and reality. I would not disagree...

Also on the vaccination front, a reminder that it's not just children. Take up rates for the shingles vaccine among seniors have not been as high as hoped for: A Vaccine Mystery Hits Older Americans

Also on the public health front, this review of the Angelina Jolie effect: Dueling studies: The ‘Angelina Jolie effect’ is influencing women fighting cancer — but the influence may not do much good.

And this look at all the conflicting diet studies that get covered by the media: The one thing you need to know about weight loss and diet studies.

Lots on the end of life front this week (get your tissues ready).

First a long well written piece on Alzheimer's:  We Are Entering the Age of Alzheimer's - You and everyone you know will touched by the disease. How are we going to get through this?

Next some hope as Coverage for End-of-Life Talks Gaining Ground. Five years after one of the biggest lies in the health care debate, death panels, coverage for these crucial conversations is growing (and may even make it to Medicare next year).

An important part of end of lie care can be hospice, but Is one hospice the same as any other? No. Why it’s important to choose carefully.  My take (feel free to ignore) is that while there are some good for-profit hospice organizations and some bad not-for-profit ones, those are the exceptions. It's not a bad idea to start out looking at the not-for-profit organizations available.

Read at your own risk: This surprising request brought an emergency doctor to tears  "“But now, I’m done. I’m ready to ‘go home’ and I need hospice to help my sweet wife to get ready for me dying,” he said as he reached out his wrist nub to pat my hand."

OK, everyone dry your eyes.

We'll end with a smile by bringing back the funny medical video of the week with this parody of the movie Divergent:  SNACKPOCALYPSE with Chloe Grace Moretz, Tyler Posey, and First Lady Michelle Obama

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"