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!
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"
