That Was The Week That Was - Issue 38

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

You wouldn't think I'd have much to say in the midst of a short holiday week – or if you know me, maybe you would – anyway, Friday’s release of over 300 pages of proposed regulations, the continuation of open enrollment, more fallout from enrollment numbers-gate, and other developments mean that I've pulled together some reading for you to do over the holiday.  A warning, I’ve written the section on the regulations to serve as a resource so it’s a little long.

Before we begin let me take this opportunity to wish everyone a happy and safe holiday. For those seeing family and friends that may not agree with all your opinions, Vox has provided this helpful guide: How to Survive Your Family's Thanksgiving Arguments. However, you’ll note the ACA is not on the list, so I offer you this piece from last year: A guide to surviving Obamacare debates at Thanksgiving.

As I await the start of the snow here in Maine, a reminder for everyone traveling: let’s be careful out there.

ACA: Opposition

More discussion this week of the lawsuit filed by the House. It was expected that the lawsuit criticized the delay of the employer mandate (even though these are the people who want to do away with the mandate). What was not expected was the attack on the cost-sharing subsidies included in the law and administered by HHS: House GOP lawsuit wages surprising fight over federal purse strings.

We've talked in the past about how the ACA is the only major legislation not to get a “clean-up” bill or any minor modifications as implementation began. This piece takes a look  at that issue: In Partisan Washington, Health Law Faces Grave Legal Technicalities “Today the Affordable Care Act faces grave danger before the United States Supreme Court because such legislative repair work, once routine, has grown impossible.”

Here in Maine, an in-depth look at how the architect of the subsidy cases may have impacted our Governor’s response to setting up a state Marketplace: Outspoken critic of Obamacare helped to turn LePage against state exchange.

And finally, Schumer, one of the most powerful Senate Democrats, is saying the timing of passing the ACA was a mistake. Note that this is not a new point for him, but he repeated it this week in front of a large audience so it’s back in the news: Chuck Schumer Is Trash Talking Obamacare Again—And He's Still Not Making Any Sense.

ACA: New Regulations

Last Friday (11/21) CMS issue 324 pages of proposed regulations (Press release: CMS Issues the HHS Notice of Benefit and Payment Parameters for 2016 Proposed Rule). Here is their 6 page fact sheet: Proposed HHS Notice of Benefit and Payment Parameters for 2016 and for those interested, here is the link to the full document: Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2016.

At the same time, the IRS released notices regarding the shared responsibility payment (mandate) and hardship exemptions, and the Bureau of Personnel Management released proposed rules on the Multi-state plans. For a full picture of what is going on we turn to our reliable Sherpa, Tim Jost. He has posted three documents:

Implementing Health Reform: 2016 Benefit And Payment Parameters Proposed Rule, Consumer Provisions; Hardship Exemptions - Addresses the consumer-facing provisions of the BPP proposed rule, focusing on changes in benefits.

Implementing Health Reform: 2016 Benefit And Payment Parameters Proposed Rule, Insurance Provisions - Addresses provisions of the rule more relevant to insurers, such as proposed changes in the reinsurance, risk adjustment, and risk corridor rules.

Implementing Health Reform: Minimum Essential Coverage And The Multi-State Plan - Addresses the IRS rule, which is primarily a finalization of proposals and guidances already made public, and the OPM multi-state plan rule.

Below I have tried to extract some of the “highlights” (note that this is not an exhaustive list):

• Hardship exemptions – In a welcome change from the existing rule, individuals who live in states that have not expanded Medicaid (such as Maine), earn less than 138% of the Federal Poverty Level and are not eligible for traditional Medicaid or Medicare are granted an automatic hardship exemption. Previously the rules said they had to either apply for Medicaid and be denied or applied for an exemption on the Marketplace. This will make life much easier for those eligible.
• States to select new EHB benchmark plans based on 2014 plans for the 2017 plan year – despite speculation there will be no national EHB definition at this time. When asked, CMS the rule was for one year with future changes to be determined.
• Change in drug coverage design standards to be effective for the 2017 plan year
• Update and standardize formulary exception process
• Formulary publication standards (available to the public on-line for the 2016 plan year)
• Inpatient hospital required for any plan to be considered “minimum value coverage”
• No new network adequacy standards - as the preface to the rules notes that NAIC is working on model legislation, CMS will await the completion of the model before proposing changes to its requirements
• Provider directory standards including monthly updates and indications if the provider is accepting new patients. As with the formulary, it must be viewable on-line by the public
• Maximum out of pocket adjustments for the 2015 plan year to $6,850 per individual ($13,700 family)
• Quality improvement strategy requirements
• Risk adjustment, Reinsurance and Risk Corridor (the 3Rs) program updates
• Rate setting transparency requirements and rate review by plan (e.g. Bronze PPO with specific cost sharing) instead of product (e.g. all PPO plans regardless of metal level or cost sharing)
• Auto reenrollment default changes to avoid cost increases to consumers – this is one of the provisions that received the most attention, here in Tim Jost’s words is a description:

“For 2015, exchange enrollees were auto-reenrolled in their 2015 plan unless they affirmatively change plans. Where premiums have changed significant from year to year, however, or where the lowest or second-lowest cost silver plan ceases to be so, enrollees may see their premium or required contribution increase significantly. HHS, therefore, is considering changing the default rule so that enrollees who do not affirmatively change plans would be auto-reenrolled into a low-cost plan (perhaps randomly) in the same metal level if the cost of the enrollee’s plan increased, or increased more than a threshold amount (5 or 10 percent). Consumers could opt into this alternative hierarchy in 2015, and it would be applied for the first time in 2016 for enrollments for 2017. Consumers could, of course, switch plans during open enrollment if they did not like the plan they ended up in.“

At first glance this sounds like a good change, however concerns have been raised regarding how the new plans are chosen and potential for disruption due to different networks and cost sharing. Below I link to several in-depth discussion of this proposal.

• Change in open enrollment period to 10/1 – 12/15 each year. The idea is to better align open-enrollment with the new plan year (beginning Jan 1), with Medicare open enrollment and with the typical employer plan open enrollment. Objections have been made that from a financial perspective, this is a difficult time for low income consumers, in fact some advocates have suggested moving the open enrollment to correspond to tax time instead of the end of the year. The comments on this proposal (as on the one above) will be interesting.
• SHOP changes (nothing major)

There have been several articles written focusing on different aspects of the rules. The issue generating the most discussion is the default options for auto reenrollment. This include: Change in Health Care Law Would Take Aim at Consumer Inertia, No Easy Fix for One of Obamacare's Hardest Problems, Auto-renewal is a problem that defies easy solution and Auto-renewal is a problem that defies easy solution — ctd.

Other areas of focus include transparency rules for provider networks and formularies: Tougher transparency rules proposed for health exchange plans and the changes to the multi-state plan rules: White House wants to boost multistate insurance plans sold on exchanges.

ACA: Marketplaces

This week, Kaiser released a fun (for me, anyway) new tool from that looks at local ACA enrollment: Mapping Marketplace Enrollment. For small areas of a state (there are 10 in Maine) it lines up uninsured and ACA enrollment to date showing the remaining potential market.

While HHS has been cautious with enrollment projections, Wall Street is more optimistic (Wall Street Is Bullish On 2015 Obamacare Enrollment) as ”Health sector analyst Carl McDonald of Citi Investment Research said he expects about 11 million people to enroll in individual health plans, based on his firm’s survey of clients in October.” (vs. the 9 million projected by HHS).

Part of the debate of one Federal Marketplace vs. 50 state ones is the question of cost – it may not be the most efficient to create 50 versions of the same platform. Once a state Marketplace is up and running, the Federal money stops meaning they have to be self-sustaining. This is proving to be problematic for many states: Financial health of insurance marketplaces to be tested in 2nd year; must be self-sustaining.

Here in Maine, several developments. First the Legislature’s Exchange Advisory Committee issued its final report: Final Report of the Maine Health Exchange Advisory Committee (disclosure, I served on the committee). Unfortunately given the current makeup of the state legislature, I’m not optimistic about any of the recommendations moving forward.

Our own Maine Community Health Options announced they are getting more local help to meet the demands of open-enrollment: Call center in Fort Kent to help health insurance provider meet demand. And finally, Maine Public Broadcasting took another look at the family glitch: 'Family Glitch' Locks Mainers Out of Health Insurance Marketplace. (More disclosure, I’m quoted in both those articles.)

ACA: Employers

A new flowchart (yippee) from Kaiser reviewing Employer Responsibility Under the Affordable Care Act. A very helpful way to explain their responsibilities. And from the NY Times a review of which employees an employer has to cover (if they have to cover anyone): Answering the Hard Questions on the A.C.A.: Which Employees Must Be Covered?

The Administration Warns Employers: Don’t Dump Sick Workers From Plans. The issue here is that some employers have been considering taking their sickest employees and sending them to the individual market instead of being part of their group coverage as a way to save money – this is a no-no. At the same time, HHS Formally Moves To Close Loophole Allowing Plans Without Hospital Benefits. On the face of things, it always seemed wrong that a plan could not cover hospital stays and still be considered essential coverage – now it is clear that the coverage must include hospital benefits.

The evidence just keeps getting stronger that workplace wellness programs do not save money: Workplace Wellness Produces No Savings. Employers may still want to continue these programs, but if they do they need to have a clear understanding of what they accomplish and what they don’t.

ACA: Other

In the aftermath of last week’s disclosure that certain enrollment figures were wrong, U.S. Health Chief Calls Review After Obamacare Inflation. Increased transparency can only be a positive (Push for more openness after Obamacare data mix-up) as even supporters of the law have been frustrated by the lack of enrollment data – especially now during the open enrollment period.

Forgive the duplication, this item was discussed in the regulations section above, but since it has a direct impact here in Maine I wanted to make sure everyone saw it. In a welcome change from the existing rule, individuals who live in states that have not expanded Medicaid (such as Maine), earn less than 138% of the Federal Poverty Level and are not eligible for traditional Medicaid or Medicare are granted an automatic hardship exemption. Previously the rules said they had to either apply for Medicaid and be denied or applied for an exemption on the Marketplace. This will make life much easier for those eligible. Individual Shared Responsibility Payment Hardship Exemptions that May Be Claimed on a Federal Income Tax Return Without Obtaining a Hardship Exemption Certification from the Marketplace

New calorie count label requirements were part of the ACA. This week those rules were released and The White House's new calorie label requirements are way more aggressive than expected. Some of the surprising items included are movie popcorn and alcoholic beverages listed on a menu. While some have argued that the presence of the calories does not impact an individual’s choices, it is clear that People literally have no idea how many calories are in their food.

I continue to be amazed that people tell me “I’m healthy, I don’t need insurance”. Here is a look at What happens when your pregnant sister-in-law is paralyzed in an accident — and has no insurance. Note that there are several issues in this case. One of them is the lack of medical insurance to meet the initial need. The other is the way disabilities and the need for ongoing care is handled, some of these issues were not addressed by the ACA.

Also this week, some thoughts from Dr. Caper on How ACA fuels corporatization of American health care.

Costs

Earlier this month there was an op-ed in the NY Time criticizing new reimbursement methods. This week an excellent piece debunking all of their arguments: Is Pay for Performance Corrupting Medicine?  (Here is the original piece How Medical Care Is Being Corrupted.)

Some attention this week to premium hikes for grandfathered (in effect before the law was passed) and grandmothered (transitional plans that don’t meet the law’s requirements but are allowed to be renewed) plans: Anthem’s 13.4 percent rate hike to hit more than 11,000 Mainers. What is happening here in Maine is that so many people are leaving their existing plans to get coverage on the Marketplace that the old plans are seeing increasing rates as their pool of covered lives shrinks. Ironic that these large increases are exactly what opponents of the law thought would happen to new ACA compliant plans in year 2 which instead saw more modest increases.

An issue with health care costs has always been the lack of good data regarding what people actually pay (as opposed to the list prices). Insurers have long argued that their provider contracts were proprietary. However, the truth is, on each individuals EOB (explanation of benefits) we get a peek at contract prices. To try and get at this data, One reporter is crowdsourcing the price of health care. I wish this effort all the best, it has the potential to be a great resource.

EBOLA

Before I begin, my usual disclaimer that the crisis continues in West Africa (although there are some glimmers of hope there). Here in the US it has been noted that the Ebola Panic Mysteriously Disappeared Last Tuesday. I will note that the day was coincidentally was Election Day. As Drew Altman noted, Ebola Was a Bigger Story Than the Midterms. How these factors came together to impact the elections I can’t say. But I can’t help but also note that there has been a Notable Absence of New Ebola Quarantines at New York Area Airports.

Drugs

Continued focus on the price of generic drugs as the question is asked Should Generic Drug Makers pay Medicaid Rebates Tied to Inflation? “In a statement, the lawmakers said their legislation would help save Medicaid an estimated $500 million over the next years, citing Congressional Budget Office data. This is a portion of savings that could be generated by various programs to bolster Medicaid rebates, according to Congressional sources. “Brand-name drugs are required to pay this rebate if their drugs go up faster than inflation, but generic drug companies are exempt,” Sanders said in a statement. “Congress should fix this loophole immediately.””

Here is a look at the issue including a discussion of Maine’s law allowing cross boarder purchases: Lawmakers Look for Ways to Provide Relief for Rising Cost of Generic Drugs.

Express Scripts, one of the country’s largest pharmacy benefit managers, is moving forward on their own as More Medicine Goes Off Limits in Drug-Price Showdown. However their actions are not going without notice as Express Scripts is Sued by Compound Pharmacies for Denying Claims.

System Transformation

I write a lot about new innovative programs. However, I found this piece to be very compelling, making the argument that Health Care Needs Less Innovation and More Imitation. The bottom line is that there are a lot of good programs out there and we would be well served by seeing some of them duplicated instead of each organization trying to reinvent the wheel. Going hand-in-hand with that approach is the need to appropriately evaluate programs: ““We have these one-off stories of the miracle cure, and now we have to test it,” he said. “The only way to know if our intervention is truly effective is to do a randomized trial.”” (How to Arrive at the Best Health Policies).

Also under the heading of we need to be duplicating what works, the idea that Clinical pathways can lead to better cancer care.

And let’s not be limited in where we look for new ideas as Africa Inspires A Health Care Experiment In New York. This is one version of community health workers being tried in NY. At the same time, a Health Affairs column asks What Is The Future For Community Health Workers? – Weil talks about two models, both of which we have moving forward here in Maine. I hope there is room for both approaches as I think they each can provide distinct benefits.

Finally this week, it’s Flu season. Big Data asks Have There Been Lower Vaccination Rates This Flu Season?  (spoiler alert, probably not though it’s too soon to tell) and also warns that Flu Season Striking Early this Holiday Season. So if you haven’t gotten your flu shot yet, go get it, it’s not too late.

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"

That Was The Week That Was - Issue 37

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

What a week: Between Gruber, subsidy case angst and yesterday’s enrollment number revelation, you might think that this is the worst stretch of ACA news since the botched launch of healthcare.gov last year. However, to think that would ignore the fact that the law continues to immeasurably improve the lives of tens of millions of people.

With that in mind, this week we’ll take a look at all of the above, check in on open-enrollment and more. (Note that I've tweaked the section heads again, hopefully these will allow you to better jump to the areas you’re interested in.) Here we go…

ACA: Opposition

As open enrollment starts, several thoughtful pieces this week on why if it’s working, opposition hasn't softened. First up, this post showing the possibility that communication failures are not the only reason for the ACA's unpopularity (spoiler alert – income redistribution might have something to do with it): The ACA is working. So why is the opposition to it so strong and persistent? And this one saying the conflict won’t stop any time soon: Here's Why Conservatives Will Never Give Up Their War on Obamacare. And finally, this one putting to light the absurdity of some of the criticisms: Can someone explain this to me? (You have to read this to believe it, and you still won’t believe it.)

For opponents of the law, Gruber is the gift that keeps on giving. Here is a man who apparently is a very smart economist but who has no filter when it comes to speaking in public. Here is an excellent summary of the “controversy”: What Jon Gruber said was dumb, but the Gruber controversy is much dumber. Here is a piece by a reporter who worked with him closely, providing some context: What Jon Gruber's Quotes Really Tell Us About Obamacare—and American Politics.

Here is a thoughtful piece reminding critics that they should be careful what they wish for – and stop objecting when they get it. Markets are messy, remember that plans changing and people needing to shop around the second year plans are available is simply the market working as it’s supposed to: People who wanted market-driven health care now have it in the Affordable Care Act.

And finally, while Uber had its own share of problems this week, the CEO of Uber Just Stuck a Knife in the Republican Party’s Heart “Kalanick told reporters that Obamacare had been a crucial element in his firm’s success. “It’s huge," he said, according to BuzzFeed. “The democratization of those types of benefits allow people to have more flexible ways to make a living. They don’t have to be working for The Man.””  So maybe the law is in fact the opposite of the “job killer” some said it would be.

ACA: Polls

This month’s Kaiser tracking poll is out and A Quarter Of Uninsured Say They Can’t Afford To Buy Coverage. “About half of uninsured expect to find coverage in the coming months, though another quarter say they won't because they do not believe they can find an affordable plan.” Here is the direct link to the full results: Kaiser Health Tracking Poll: November 2014.

Two polls out from Gallup this week. First, continuing the decline of recent years Majority Say Not Gov't Duty to Provide Healthcare for All. The percent who thought it is government’s responsibility peaked in 2006 at 69%. Interestingly, this year the group with the lowest agreement was the oldest age group – only 39% of 55+ agree. I guess Medicare doesn’t count.

In the second poll, In U.S., Ratings of Healthcare Coverage Generally Steady “Americans' ratings of healthcare coverage in the U.S. have generally held steady, despite the opening of the healthcare exchanges in 2013 and the decline in the uninsured rate this year. Thirty-eight percent of Americans now rate healthcare coverage in the U.S. as "excellent" or "good," within the range of the combined”.

ACA: Court Cases

First, remember the House lawsuit of the president over delaying the employer mandate?  After two lawyers dropped the case, The House GOP finally found a lawyer to sue Obama. Then on Friday, the suit was filed: House Republicans Sue Obama Administration Over Health Law. The suit as filed not only questions the mandate delay, but in a bit of a surprise, it also questions the payment to insurance companies for the out-of-pocket costs subsidies. At the time I’m writing this it is unclear if the issue is the difference between the full out-of-pocket subsidy and the sequester cuts – which have not been implemented to the cost sharing subsidies – or the full subsidies. Here is a post from earlier in the year looking at the sequester issue: Does the sequester apply to cost-sharing subsidies?

Next, in the aftermath of Hobby Lobby, another Birth Control Challenge Rejected as “The United States Court of Appeals for the District of Columbia Circuit rejected a claim that the accommodation imposes a substantial burden on the groups’ expression of religion.” Or in other words, the governments accommodation is appropriate.

And finally, the week wouldn't be complete without an update on the subsidy case.  First, from last week a reminder that “There is simply no way to describe what the court did last Friday as a neutral act.” (Law in the Raw ). From Drew Altman some numbers: How 13 Million Americans Could Lose Insurance Subsidies and a review of the impact of a negative decision on subsidies: How The Supreme Court Can Kill Obamacare Without Overturning It. And finally, for those who can’t get enough Meet Michael Cannon, the man who could bring down Obamacare.

ACA: Enrollment Numbers

As you all know, I support the ACA. But that does not mean I support bad behavior. It was revealed yesterday that when HHS gave out enrollment numbers, they were including stand-alone dental plans. While we all acknowledge the importance of oral health, no one wanted those numbers mixed together. The story was first reported by Bloomberg: Obamacare Sign-Ups Were Inflated With Dental Plans. The administration quickly acknowledged the problem and said it was a mistake. I am inclined to believe them for the simple reason that if you were going to inflate the numbers, you would do so by more than 4-5%. Remember, while the consumer facing portions of healthcare.gov are working well (for the most part), there is still a lot of back-end work to be completed: Health Enrollment Counting Error Shows Where System Is Still Broken. Here in Maine, Jackie Farwell asked the question Are Maine’s Obamacare enrollment totals inflated too?  There was some entertainment as the issue led to this extraordinary headline: The Affordable Care Act's Embarrassing Moment of Tooth.

ACA: Marketplaces

Amidst all the above issues, open enrollment began last Saturday (11/15). What a difference a year makes for the ACA. For the most part, things got off to a good start as Some Hiccups, but Federal Health Exchange Website Is in Good Health. On Sunday morning, Secretary Burwell announced that there were 100K new O-Care applications on first day.

That said, things were not perfect as Immigrants Baffled By Healthcare.Gov Lapse (they could not easily upload their green card information to show proof of eligibility).

Since some people think everything is better with cats, to prepare for open enrollment, here are 9 Things You Need to Know About Obamacare and Your Health Insurance, Gif-splained By Cats (personally I think they should have used dogs).

Here in Maine, there was a kick-off event in Portland as Maine Obamacare advocates trumpet health insurance options. The event took place at Becky’s Diner where the Owner of Becky’s Diner hopes to serve up health insurance for employees. Dan Corcoran, President of Anthem Maine wrote that Affordable Care Act offers options aplenty under your fingertips.

ACA: Employers

While we mostly talk about open enrollment on the Marketplaces, for many who get coverage at work, this is also the time of year when they select their coverage for the year. Kaiser warns that with Big Changes For 2015 Workplace Plans: Watch Out For These Six Possible Pitfalls.

Despite opponents’ talking points, Few employers dropping health benefits,  “A year after the advent of new insurance marketplaces for individuals and small businesses under the health-care law, just 1 percent of employers said they have decided to stop offering health coverage for 2015, one survey said.”  Although as expected, Employers Watching Insurance Costs Closely.

ACA: Other

With the President’s address last night, it is important to note that Obama’s order won’t extend Obamacare to undocumented immigrants  Although that’s the case, some who will now be able to work legally may be eligible for benefits at work (Undocumented immigrants won't get Obamacare - but Latino coverage could rise).

In an interesting turn, the NY Times highlighted that Health Law Turns Obama and Insurers Into Allies. This is similar to my own experiences over the past year where I have found a new communality of interest between insurance companies and the public.

That said, while some interests coincide not all do – case in point California regulator knocks Anthem, Blue Shield on Obamacare networks “More than 25% of physicians listed by Anthem Blue Cross and Blue Shield of California were not taking Covered California patients or they were no longer at the location listed by the companies, according to state reports released Tuesday.”

And more broadly concerning networks: Providers, advocates seek tougher rules on network adequacy

Costs/Premiums

With the start of open enrollment, a focus on premium changes in year two: How Much Did Health Insurance Rates Go Up? It’s Complicated  and Kaiser took a look at some of the details: Change in Benchmark Silver Premiums, 2014 – 2015.

In addition to the network adequacy questions asked in the section above, a Former HHS Official Calls For ‘Smarter’ Networks That Deliver Cost-Effective Care. Transparency on the standards for how the networks are built would be an important step.

A reminder that payment reform still has a long way to go as An Obamacare program helped poor kids and saved money. It was also doomed to fail. The issue here is despite all the talk, we still live in a predominantly fee-for-service world.

And in case you missed the headlines, here is How a Canadian woman ended up with a $950,000 bill giving birth in America.

EBOLA

While pushed out of the headlines, here is Why It's Too Early To Forget About Ebola. Although out of site, it’s not out of mind as Americans are more worried about Ebola than actual leading causes of death. In case you’re interested, here are the things we should really be afraid of: What kills us, in one chart.

And finally, a request from Kaci Hickox: Stop calling me 'the Ebola nurse'

Medicaid

Here in Maine, Federal appeals court rejects LePage administration attempt to trim Medicaid rolls. The case had to do with the maintenance of effort provision in the law. In reaction, LePage Says Maine's Medicaid Battle Likely to go to Supreme Court. But not so fast, If LePage wants Medicaid case before Supreme Court, he needs a credible case.

Nationally, new numbers released this week show that Medicaid and CHIP Enrollment Grows by over 9.1 Million People. Hand-in-hand with the enrollment increase, U.S. states get more, spend more on Medicaid under Obamacare.

Regarding states that have not yet expanded, some developments: Alaska's Medicaid future uncertain despite pro-expansion governor and in what would be a huge shift Hospitals seek a Texas Way to expand Medicaid (although I’m not holding my breath).

Medicare

A new Commonwealth fund survey looking across 11 countries found American Seniors Face Health Care Gaps, Despite Medicare “Americans older than 65 are more likely to have chronic illnesses and to say they struggle to afford health care – despite qualifying for the federal Medicare program – than are seniors in other industrialized countries” (Primary Source: 11-Nation Survey: Older Adults in U.S. Sickest, Most Likely to Have Problems Paying for Care)

The ACA included provisions for testing new ways of delivering care for dual eligible (those receiving both Medicare and Medicaid). But change is hard as California’s Managed Care Project For Poor Seniors Faces Backlash.

“A GAO review of health cost and quality transparency tools available from CMS found the tools lacking in relevant and understandable information and recommends steps for improvement. GAO identified characteristics of effective tools, including the need for information on specific procedures that allow consumers to compare providers based on performance.” (Health care transparency: Actions needed to improve cost and quality information for consumes)

Drugs

A “report” from the pharmaceutical industry this week raised questions: $2.6 Billion to Develop a Drug? New Estimate Makes Questionable Assumptions.

Even if that figure were true (and I don’t think it is) it would not apply to generic drugs (which have already been developed). Yet over the last year some generic prices have soared: Soaring generic drug prices draw Senate scrutiny “Some low-cost generic drugs that have helped restrain health care costs for decades are seeing unexpected price spikes of up to 8,000 percent, prompting a backlash from patients, pharmacists and now Washington lawmakers. A Senate panel met Thursday to scrutinize the recent, unexpected trend among generic medicines, which usually cost 30 to 80 percent less than their branded counterparts.”

A look from Kaiser at how providers are dealing with the issue: Hospitals And Pharmacies Grapple With Rising Drug Prices.

An unusual issue but worth a read: Payout From Drug Raises Questions for Cystic Fibrosis Group.

And on the positive side, this week a Study Finds Alternative to Anti-Cholesterol Drug “For the first time since statins have been regularly used, a large study has found that another type of cholesterol-lowering drug can protect people from heart attacks and strokes.”

System Transformation

It is taken as gospel by some that we don’t have enough doctors in this country, but is that true?  NPR took a look: Doctor Shortage Looming? Maybe Not

There is no doubt we do have an organ shortage, the question arises, is there a better solution than convincing more people to donate: An organ shortage is killing people. Are lab-grown organs the answer?  While we’re not ready to “print” a whole new organ (yet), it is astounding what we can print: PRINT THYSELF: How 3-D printing is revolutionizing medicine.

Everyone agrees on the need for quality measures, but the devil is in the details. What are they, who determines them, how many different sets are needed?  Amidst all the ongoing controversies, it is refreshing to see validation of at least one set of measures: The Inverse Relationship Between Mortality Rates And Performance In The Hospital Quality Alliance Measures.

As we strive for better quality care, should we as patients be required to tell our providers how to behave?  One answer: Patients should not have to advocate for their own safety  “It’s a bad turn of events when health care quality programs need to work around physicians by asking patients to engage in dialog with their health care providers to avoid dirty hands and unnecessary care.”

But we do bear individual responsibility in some areas (like vaccination). The ramifications of some decisions is disturbing as There were more measles cases in 2014 than any year during the last two decades.

Finally, I haven’t made you cry for a while – OK, maybe I have with continued reports of the threats to the ACA and people’s health coverage – but not in the good way. So here you go: What does a good death mean to you?

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"

That Was The Week That Was - Issue 36

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

More on SCOTUS and other threats to the ACA, surveys and more surveys, and in case you haven't heard, open enrollment starts tomorrow (so we better talk about that).  (With the focus on those stories, I’ve made the other sections shorter than most weeks.)  Let’s get started.

ACA: Court Cases/Opposition

There have been no concrete developments since the Supreme Court announced last week they would take one of the ACA subsidy cases.  But that hasn't kept people from writing and speculating. Here’s a sample: Some are trying to reassure us (Eight Reasons to Stop Freaking Out About the Supreme Court's Next Obamacare Case), some are trying to give us advice (How states could avert a Supreme Court Obamacare disaster), some are warning us of the ramifications (A bad SCOTUS ruling could deepen polarization of health care system and Here's What the Supreme Court Could Do to Insurance Premiums In Your State) and some are trying to give advice to the Chief Justice (How John Roberts Can Preserve His Conservative Cred and Save Obamacare at the Same Time). 

To me, this is a much more serious threat than any of us thought when the first suit was brought.  We’ll talk about Congress below but I think SCOTUS is the more serious threat.  That said, my crystal ball is broken so I really have no idea what will happen.  In the coming weeks and months we’ll see a lot more speculation, but at the end of the day no one really knows what those nine men and women are going to do.  (OK, we probably have a pretty good idea what eight of them will do, but we still don’t know the outcome.)

Amidst all the talk about the case, you might have heard reference to Jon Gruber (The Jon Gruber controversy and what it means for Obamacare, explained) (that’s Jon, not Hans of Die Hard fame: The Hans-Gruber-Story!).  Short version, he is an MIT economist who contributed to the design of RomneyCare and of the ACA (the degree of his contribution is subject to debate), he is also the guy who wrote the ACA comic book. He does not have much of a filter on what he says; videos and quotes of his have been seized by the laws opponents to try and show how bad the ACA is and how the President pulled one over on the American people.  Sigh.  For those interested in the gory details of what he said, here are some additional sources: Congress Relies on the "Stupidity of the American Voter" All the Time: Obamacare is just one of many examples—and both parties do it, The Jonathan Gruber Controversy and Washington’s Dirty Little Secret (“Legislators frequently game policy to fit the sometimes arbitrary conventions by which the Congressional Budget Office evaluates laws and the public debates them.”) and finally a reminder that The Obamacare Debate Was One of the Most Transparent in Recent Memory. 

Meanwhile, Congress is still at it.  This week the House GOP Re-Ups O-Care Repeal Bill After Big Election Wins (because 50 votes were not enough). In the Senate we have An army of one: Ted Cruz is leading the charge against Obamacare. But no one's following. Here is a reminder Why Republicans Will Vote to Repeal Obamacare, But Not on How To Replace It (basically they know how hard real reform is and don’t want to open themselves to the same type of criticism they’ve been making for the past six years).  Here’s a reminder of some of the Republican Alternatives To Obamacare (from last year courtesy of The Onion ;) ) And here is a report of a new alternative that may be coming Rubio, Ryan crafting Obamacare alternative.

And finally, one writer’s thoughts on The congressional deal that could save Obamacare.  I have two comments on the idea, 1) I’d take the deal, 2) no one has offered it (and I’m not holding my breath while I wait).

ACA: Polls

In the ramp up to open-enrollment, several new surveys that shed light on what people think about their new coverage, what those still uninsured are planning and how ready we all are to use out health coverage.

First, from Gallup: Newly Insured Through Exchanges Give Coverage Good Marks “Americans who obtained new health insurance policies in 2014 using the government exchanges are roughly as positive about their healthcare coverage and the quality of healthcare they receive as the average insured American, and are more satisfied with the cost of their coverage. More than two-thirds of the newly insured who purchased coverage through federal or state exchanges intend to renew their exchange policies, while another 7% plan to look for a different policy through the exchanges.”

Next, also from Gallup: In U.S., 55% of Uninsured Plan to Get Health Coverage “55% of uninsured plan to get health insurance, 35% say they will pay the fine for not having insurance, and seven in ten are aware of requirement to have insurance”

And finally from Kaiser: Assessing Americans' Familiarity With Health Insurance Terms and Concepts. Kaiser also gives you the chance how you would stack up with the Health Insurance Quiz which will show you how you’re responses stack up to the survey results.

ACA: Premiums

We've had indications earlier, but also as part of the ramp up to open-enrollment, two new studies looking at premiums: First Look at Health Insurance Rates for Next Year Is Encouraging “That’s the conclusion of two studies of data about newly public insurance rates. One, from the Kaiser Family Foundation, a health research group, looked at 49 cities and found that prices for a popular type of plan are actually going down, on average. A second, from the actuarial firm Wakely Consulting Group, looked at the largest county in each of the 34 states with marketplaces run by the federal government and found an average rate increase of zero.”

Of course we've known for a while that rates here in Maine were very stable, it’s good to see many other parts of the country (but not all) are seeing similar positive results.

ACA: Marketplaces

Let’s start with the basics (feel free to skip ahead if you know all this). Open enrollment begins Saturday November 15^th and will last three months instead of six.  This year the website should work.  Finding new customers will be harder since those most motivated enrolled the first time around. Returning customers will need to renew their coverage (and many will be auto-reenrolled if they don’t shop around).

According to the National Review, these are The 3 Biggest Questions for Obamacare’s Second Year: 1) will the website work, 2) will existing customers shop around, 3) how many will sign up.  All important questions! In the Marketplace section this week, we’ll take a look at each one, then I’ll provide links to some resources.

The Website

All signs point to a better experience than last year (could it be worse?  I remember last year sitting at a computer at 5 AM hitting refresh and starting to panic…).  The site has been tested over the past several weeks and while no one is saying it will be perfect, the administration is expressing confidence it will be good (HealthCare.gov Can Now Handle Twice As Many Shoppers, Obama Administration Says). At the same time forgoing last year’s hubris, Obama officials work on health site contingency plans as enrollment nears. Not an expectation of failure, but appropriate contingency planning.  Among the improvements, it’s now very easy to look at plans and rates without registering (Consumers now able to window-shop for insurance on HealthCare.gov).

Existing Customers

This is going to be complicated…  As with most insurance, individuals enrolled in Marketplace plans will need to reenroll every year.  Plans change each year as do rates and an individual’s needs.  In addition to all that, about 80% of enrollees are receiving subsidies.  Those subsidies will change each year based both on the individual’s circumstances and based on what plans are offered at what price (the subsidies are always based on the second cheapest silver plan available). 

Faced with all that, everyone with a current plan is encouraged to update their personal financial information (to determine the correct subsidy) and to shop available plans (instead of defaulting to their current plan).  The Feds will auto-reenroll the majority of people if they don’t do so, but that could be problematic: Surprises Lurk for People Re-Enrolling on HealthCare.gov   “In a twist, an influx of lower-priced health plans on HealthCare.gov could lead many Americans to pay more for coverage next year thanks to smaller insurance tax credits.”

We’ll be watching closely to see how this goes.

How many will sign up

Last year the Feds enlisted celebrities and generally made a lot of noise as enrollment started.  This year The selling of Obamacare 2.0  will be a lot quieter, if no less important, as the Feds will be more targeted in their approach.

The feeling seems to be that there needs to be less work telling everyone about the law (not sure I agree, but they didn’t ask me).  Enroll America, one of the leading national organizations involved, saw Donations drop for ObamaCare enrollment (their budget is $20 million down from $27 million last year).

So what will the number be?  HHS revealed new estimates that are lower than CBOs estimates from several years ago: Estimate of Health Coverage Enrollment Leaves Room to Grow. Here is the actual projection: How Many Individuals Might Have Marketplace Coverage After The 2015 Open Enrollment Period? (Primary Source).  And here is the reliable Tim Jost’s take: Implementing Health Reform: New HHS 2015 Marketplace Enrollment Estimates – he reviews the estimates, thinks they are probably low.  Given the HHS range of 9-10 million is probably conservative, I think the top end of the range is a safe estimate.  (Yes, this is in writing, you can mock me if I’m wrong.)

Resources

• Health Insurance Explained: The YouToons Have it Covered (the basics from Kaiser)
• The most confusing words in your health insurance forms, explained (from Vox)
• Affordable Care Act Enrollment FAQs (from the NY Times)
• Kaiser Health Insurance Marketplace Calculator calculate your subsidy, now updated with 2015 premium data
• Web Briefing For Journalists: Consumer Issues Ahead Of The Affordable Care Act’s Second Open Enrollment Season  Handy facts in the PowerPoint available on the site

For those thinking about not getting covered, you have one more option, the Luck Plan  J  Get Covered Illinois launches seriously funny ad campaign to sign Millennials (Video) When visiting the site, take a look at the quotes that are available

ACA: Employers

We’ve known for a while that the small business marketplace (SHOP) was not successful last year, here are some numbers underscoring that fact: O-Care enrollment lags for small businesses. With increased functionality, there is hope that things will get better this year (Small Business Insurance Exchanges Seek Rebound).

Also this week some clarifications from CMS and the IRS regarding what employers can and can’t do (Implementing Health Reform: Defining Group Health Plans And More).  These notices confirm what we've been saying, that there is no way for an employer to give employees pre-tax dollars to purchase subsidized coverage in the individual Marketplace. 

ACA: Other

You may recall that there were issues in Florida with accusations that insurance companies were using their drug formularies to discriminate against individuals with certain conditions (such as HIV).  This week without admitting any wrongdoing, Cigna Agrees to Reduce H.I.V. Drug Costs for Some Florida Patients.

Also this week an in depth look at The Family Glitch through a RWJ Foundation Health Policy Brief.  And a review of Who is still uninsured under Obamacare — and why.

Costs

We’ll start our cost discussion this week with a focus on affordability.  A new Commonwealth Fund study shows that Even with Health Insurance, Many Americans Find It Hard to Pay for Health Care “More than one of five 19-to-64-year old adults who were insured all year spent 5 percent or more of their income on out-of-pocket costs, not including premiums, and percent spent percent or more. Adults with low incomes had the highest rates of steep out-of-pocket costs. About three of five privately insured adults with low incomes and half of those with moderate incomes reported that their deductibles are difficult to afford. Two of five adults with private insurance who had high deductibles relative to their income said they had delayed needed care because of the deductible.”

While some have criticized the ACA for this state of affairs, Don't blame Obamacare for high deductible plans Remember, “”It was not uncommon before last year to see nongroup plans with $10,000, $15,000, or $20,000 deductibles," says Karen Pollitz, a health-insurance researcher at the Kaiser Family Foundation.”

In addition to deductibles, consumers also grapple with the issue of in vs out of network charges: Network Blues: Big Bills Surprise Some E.R. Patients. The Maine Exchange Advisory Committee included recommendation that this issue be investigated to see if it is happening in Maine, although given current conditions in Augusta it is unclear of those recommendations will be carried out.

The affordability issue are important, but in this continuingly partisan political environment, I’m not holding out much hope of them being addressed.

ACOs continue to make the news, here in Maine the announcement of a new effort by Anthem (Insurer reform on doctor reimbursements benefits patient care).   And reports of other efforts finding success in Massachusetts: To lower health costs, change the ways doctors get paid “… a new study by Harvard Medical School researchers has concluded that the accountable care effort by the insurance provider Blue Cross Blue Shield of Massachusetts is indeed bending the curve of health care spending.”

But not all efforts are created equal:  High Quality, Affordable Care: Making The Case For Smarter Networks “In the following blog post, I argue that policymakers should consider that there are different types of narrow networks and should be careful not to adopt policies that inhibit new contractual arrangements among payers, providers, and hospitals, such as Accountable Care Organizations, which hold the promise of better quality care at lower cost. At the same time, issuers must provide accurate and current information on which hospitals and providers are in the network and are accepting new patients, and must make the case that smarter networks can lead to better outcomes at lower cost.”

And we must be cautious as to what claims we believe, always demanding evidence: JAMA Forum: Hospital Consolidation Isn’t the Key to Lowering Costs and Raising Quality.

EBOLA

The tragedy of Ebola continues in Western Africa.  But here, the U.S. is now Ebola-free, and the panic is gone as well.  There are now NO Ebola patients in the US as both Dallas and NY put their incidents behind them (Dallas Closes the Door on Its Ebola Scare and Plenty of Hugs as Craig Spencer, Recovered New York Ebola Patient, Goes Home).

To me it is a sign that in spite of a few initial stumbles, we appropriately handled the issue.  But if that were the case, why the panic (and the possible impact that panic had on the elections)?  Here’s one take on Why no one could calm your Ebola fears — and why that mattered in this crisis “… when we face an uncertain prospect that we deeply fear, we evince what Cass Sunstein calls "probability neglect": we tend to conflate the horror of what might happen with the likelihood that it will.”

One of the victims of that panic here in Maine announced that now that her 21 days had passed and she continued to be disease free, she is moving (Ebola nurse Kaci Hickox moving to southern Maine).  But there are continuing impacts of the panic as Ebola Volunteers Wrestle With Quarantine Mandates. As the outbreak continues and the need for American volunteers remains, what harm will our fears do to the efforts to end the crisis everywhere?

Medicaid

Interesting theorizing this week on if the Feds Have New Leverage in Medicaid Showdown. Can they use lower payments for uncompensated care – which are supposed to be reduced in light of Medicaid expansion – to encourage states to proceed with expansion? 

Regardless, we will see More States Expected To Expand Medicaid in 2015.  But will they include Florida and Texas (Florida Hospitals Could Lose Billions Without Medicaid Expansion, Group Warns and Perry-Appointed Board Backs Health Coverage Expansion )?

More evidence of the positive impact expansion can have as in Iowa, Medicaid expansion slashes hospitals’ uninsured burden “the number of hospitalized Iowans lacking health insurance dropped by nearly half in the first six months of the year, mainly because the state decided to expand its Medicaid program, hospital leaders said Wednesday.”

One of the knocks on Medicaid is that recipients can’t get good care.  But is there really a Shortage of Medicaid Doctors? Not if You Ask Patients.

Medicare

Both good and bad news from Medicare this week.  On the positive side a look at How The Health Law Is Using Medicare To Improve Hospital Quality and Medicare Proposes Covering Lung Cancer Screening. While disturbing news of waste as Doctors Cash In on Drug Tests for Seniors, and Medicare Pays the Bill.

VA

Since Veterans’ Day was this week, seems like a good time to check in on the Veterans’ Administration.  Things are not improving as fast as some had hoped leading some to ask Is the New VA Secretary Already Losing His Luster?  Meanwhile, the Secretary is trying to recruit more providers to help improve the system (Needing to Hire, Chief of V.A. Tries to Sell Doctors on Change).

Drugs

More focus on generic drug pricing this week Justice Department Probes Generic Companies After Price Hike Reports and Generic drug competition and pricing nightmares.  We’ll see if it leads to any changes.

System Transformation

A scary story as A doctor tried to make medicine more transparent. She got death threats instead.

A new study found that email would be a good way for doctors and patients to communicate.  But How To Get Doctors To Email Their Patients?  Spoiler alert! You make it a reimbursable service (pay them to do it).

Electronic communications and records are a fact of life, but that doesn't mean we know how to build them (or use them) correctly (Electronic Medical Records, Built For Efficiency, Often Backfire and Your electronic health record may lack vital information).

And some still have trouble getting their hands on their own information: Medical Records: Top Secret

Finally, on a lighter note, a reminder that just because you want social media to behave a certain way is no guarantee it will behave that way.  Dr. Oz gets what's coming to him on Twitter

(and for more examples Here's what happened when Dr. Oz asked Twitter for health questions).

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"