A look back at the week's health policy news with a
focus on ACA implementation
We are now less than a month from Marketplace open
enrollment. So in spite of the fact that the media was obsessed with Ebola
and decisions
the Supreme Court was making without issuing any decisions, there's still a lot of health policy to talk
about. Candidates talking about repealing the ACA, getting ready for the 7
million enrolled in marketplace plans to reenroll, rural ACOs joining the
party, Medicare open-enrollment starting and more. So here we go:
ACA: Polls/Opposition
We're in the height of campaign season. That means that candidates
say things they know not to be true. So, even though no one thinks the ACA will
be repealed, the GOP
can’t give up Obamacare repeal talk. Also this week, we saw an actual
"replace" plan. Ed
Gillespie, Senate candidate in Va., unveils alternative to Affordable Care Act.
We won't go into it in detail except to say that it rolls back the Medicaid
expansion, eliminates the mandate and subsidies, and provides tax credits
instead. In other words, it shifts costs to individuals - regardless of if they
can afford it or not. It also lacks the systemic changes designed to actually bring
costs down.
At the same time, a
new poll about showing that people are still worried about their health care
bills. These concerns seem to fall into two categories - those concerned with
bills they may need to pay (such as those with a $5,000 deductible) and those
who don't understand their coverage, and that they may be better protected than
they know. We know that the out-of-pocket maximum still represents a burden to
some people - although there is also the concern that some may have been
eligible for cost-sharing help if they
had purchased a silver plan instead of something else. Bottom line, the data in
this survey highlights the need for better communications, increased health
literacy and a review of what is truly affordable: Poll:
Many Insured Struggle With Medical Bills
ACA: Marketplaces
November 15 and the start of the next open-enrollment period
is right around the corner. Unlike last year, when until the very last minute
we were hearing that everything would be fine, this year the Administration is
being a bit more guarded: New
strategy: Underselling Obamacare for Year 2. For example, they say the site
"will be improved but won't be perfect" and are not releasing any
projections for the three month open-enrollment period.
This year's open-enrollment will be fundamentally different
because there are two distinct populations: Those enrolling for the first time
and those who are back to reenroll - either in the same plan or a new one. This
week, CMS
kicks off effort to help Marketplace enrollees stay covered (press release).
They announced that they were mailing letters (one of six different ones) to individuals who had already enrolled in a
plan and would need to reenroll to continue their coverage. Here is Tim Jost's
explaining the process: Implementing
Health Reform: Renewing Coverage For 2015
Less traumatic than the five stages of grief
CMS provided this outline of 5
steps to staying covered through the Marketplace. The key here is that
while most people could be automatically reenrolled in their current plan, it
is in the individual's best interest to go back to the marketplace, update
their information and compare plans to see if their current plan is the best
choice. Along with the brilliant Andrea Irwin, I wrote a blog on the topic for
the enroll207 website: Avoiding
"Scandalous" Marketplace pitfalls: put shopping for health insurance
at the top of your “to-do” list.
And for another take on how to approach reenrollment, even
though it's not Passover,
here are 4
questions to ask before renewing health coverage. Finally on this topic,
Robert Pear of the NY Times does a good overview piece, even if the headline
writer doesn't seem to have read it closely: U.S.
Says Consumers Must Renew Health Insurance Policies (you don't have to
renew the policy you currently have).
Also this week a reminder from Kaiser that Consumers
Whose Income Drops Below Poverty Get Break On Subsidy Payback.
ACA: Employers
A few weeks ago we talked about an online calculator from
CMS that seemed to say certain plans without hospital benefits were
"credible coverage". Until now CMS has not responded to requests for
clarification. But finally, the Administration
Signals Doubts About Calculator Permitting Plans Without Hospital Benefits.
A couple of looks at what's happening to employer costs. In
the first, Obamacare
Refutes Warning of Corporate America Cost Surge - the story reviews some of
the dire predictions of what would happen to employer-sponsored coverage and
how they have not come to pass. In the second, a look at renewal costs for
businesses: Modest
Premium Hikes, Higher Consumer Costs Likely For Job-Based Plans
That said, a survey for ADP found that Mid-sized
businesses still very concerned about (and unprepared for) Obamacare.
ACA: Premiums
Why are some of the states with the most competitive Senate
races seeing the biggest premium spikes?
"... a big factor, according to Levitt, is whether states promoted
ACA enrollment and got enough customers to cover the costs of sick people.
Louisiana, Iowa and Alaska — all states where the political leaders have been
vocally opposed to the health care law — did particularly poorly in enrollment
compared to their potential market of customers, he said. ... “Iowa
is at the bottom of the list. Alaska’s not too far behind, and Louisiana is
well below average,” Levitt said. He said Iowa enrollment has likely been hurt
by the fact that Wellmark isn’t participating in the health insurance exchange."
(An
Obamacare October surprise?)
Here is a story that if not for the media being distracted
would surely have gotten more national attention. Last year's most successful
insurer on the Minnesota Marketplace announced a 63% average increase for
individual customers. Once you pick your jaw up off the floor, two important
things to keep in mind. 1) Their 2013 premiums were among the lowest in the
country (they bought business but couldn't sustain it). 2) They will NOT be
selling on the Marketplace in 2015 (so anyone with subsidies was going to be
changing insurers anyway (Big jump for
PreferredOne premiums).
ACA: Other
Remember the risk corridor payments? Those are one of the ways that the ACA will
smooth the transition for health insurers by spreading the risk of getting
"sicker" enrollees among all insurers. Some opponents of the law have
called this an "insurer bailout" - even though the idea is that it is
merely redistributes the fees paid by the insurers. Opponents have tried to
claim that it would require congressional action to make the payments, but that
appears not to be necessary: GAO:
Administration Can Make Health Reform’s “Risk Corridor” Payments.
Another day, another story about the high cost of
prescriptions: Got
Insurance? You Still May Pay A Steep Price For Prescriptions. This is what
happens when you provide health insurance as opposed to health care - when you
are sick, you do need to pay more. At least with the ACA, the amount you pay is
capped with the out-of-pocket maximum - which would apply to specialty drugs
covered by your plan, regardless of the co-pay. Of course for some, the out-of-pocket
maximum of $6,350 is still a problem.
Costs
One of the favorite suggestions of opponents of the law is medical
malpractice reform. They seem to think that this (along with selling insurance across
state lines, which we won't discuss today) is a magic bullet for lowering costs.
Unfortunately, the facts don't back them up as a new study looks at three
states that have instituted significant limits on malpractice awards and have
not seen the "expected" savings: Study:
Don’t expect big health-care savings from medical malpractice reform
Accountable Care Organizations continue to be all the rage. In
an attempt to extend the model to more rural areas, a new CMS
loan program offers rural providers entry to accountable care. The idea is
to provide upfront dollars to help the rural groups afford the infrastructure
improvements to allow them to participate in the new model.
Medicaid
Some thoughts on additional states expanding Medicaid: Are
Medicaid Boosters Too Optimistic?
The piece asks the question if it's realistic to expect the rest of the
states to fall in line any time soon.
Also this week a new study says that the Spike
in ER, Hospitalization Use Short-Lived After Medicaid Expansion "While
the Medicaid expansion may lead to a dramatic rise in emergency room use and
hospitalizations for previously uninsured people, that increase is largely
temporary and should not lead to a dramatic impact on state budgets, according
to an analysis from the UCLA Center for Health Policy Research released Wednesday."
Kaiser's annual Medicaid report was released: Implementing
the ACA: Medicaid Spending & Enrollment Growth for FY 2014 and FY 2015
(Primary Source).
Here is a brief summary: Many
On Medicaid See Boost In Benefits As Economy Improves and here are two more in-depth look at some of
the results: Tracking
Medicaid Enrollment and Spending and New
Kaiser Survey Finds More States Intend to Extend Primary Care Rate Increase.
Medicare
While we're a month away from the Marketplace
open-enrollment period, the Medicare one (which ends December 7) has already
begin: Once-a-year
Medicare open enrollment allows switch in Advantage and drug plans.
Meanwhile, not all is perfect as U.S.
Finds Many Failures in Medicare Health Plans and there is A
call for more scrutiny of private Medicare Advantage plans.
Drugs
We haven't talked about Sovaldi for at least a week, well
this week it's time for "Son of Sovaldi" as Harvoni,
a Hepatitis C Drug From Gilead, Wins F.D.A. Approval. This is a combination
pill containing Sovaldi and another drug - previously the patient would have to
take other medications along with Sovaldi, now it's a single pill regimen. But
the cost issues have not gone away: Will
‘Son of Sovaldi’ Cause State Medicaid Programs to Erect High Hurdles?
And under the category of dog bites man, Texas
AG Lawsuit Claims AstraZeneca Improperly Marketed Seroquel. Imagine, a drug
company trying to sell its wares for unapproved uses. Shocking...
System Transformation
As much as I would like to ignore it, I feel I have to say something
about Ebola. First, it is a tragedy of historic proportions for many of the
African countries facing the epidemic. Second, people in the US are crazy and
have a lot of other things they should be worrying about instead of worrying
about an epidemic here. Think I'm being too harsh? How about this case of a teacher who had only
visited Dallas, had no contact with anyone remotely connected to treating the
Ebola patient but was told to stay away from school for 21 days (School
teacher in Strong put on 21-day leave over Ebola fears). To call that an
overreaction is to give the term overreaction a bad name.
One of the best cases against this kind of behavior came
from Sam Shepard of Fox News (yes, I said Fox News). Watch it for yourself: Fox
News' Shepard Smith destroys Ebola fear-mongering in 4 minutes.
What should you be doing instead of worrying about
Ebola? Going out and getting a flu
shot: Ruth
Marcus: Actually, flu is the virus you should really be worrying about
"If you are worried about contracting Ebola, I have two suggestions.
First, stop. Second, get a flu shot."
And finally on this topic a look at Why
travel bans will only make the Ebola epidemic worse.
OK, back to our regularly scheduled discussions...
In addition to worrying about the flu, enterovirus 68 may be
of some concern. That's the infection
that has been going around the past few months and has unexpectedly resulted in
several deaths. There is now a new test:
Faster
lab test will check for rare respiratory virus, which means a surge in
confirmed cases is coming. So the stats will go up, but that won't mean the
number of cases are increasing.
On the health IT front, a new way to get electronic health
records to talk to each other has been recommended - if adopted it would be a
great leap forward: EHR
interoperability solution offered by key IT panels. Also close to home a Portland
group announces ‘historic’ plan to become a health information destination.
It's a great goal but I have to admit to being a bit skeptical. That said, I'd
love them to be successful.
On a positive note: Breakthrough
Replicates Human Brain Cells for Use in Alzheimer’s Research. This will
allow for the first time the testing of drugs outside of human subjects with
some expectation of being able to gauge their effectiveness. To this point, lab
animals have been used before human trials and none of the substances effective
in those lab animals has made the transition to being effective in people.
We talked placebos last week - but here's another story
reminding us that Placebos
Help. Just Ask This Health Economist.
And finally, A
palliative care dilemma on the first day of the job. Sometimes figuring out
the right answer is hard - a great reminder of why we need to have end-of-life
conversations before we need to have end-of-life conversations.
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"
