Friday, January 2, 2015

That Was The Week That Was - Issue 42

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

While you were (hopefully) celebrating (something) with family and/or friends, the world continued to rotate and HHS continued to release enrollment numbers. In this special two week holiday recap you'll find looks back, looks forward and looks at where things stand now with a myriad of ACA provisions. We'll also discuss that it’s now possible Texas and Florida could expand Medicaid before Maine. That along with two weeks’ worth of other updates means we better get started…

Looking backwards and forwards
We'll start with a list that would be funny if it weren't true: The 8 most bogus health claims of 2014. We've discussed many of them during the year (lies about Ebola, lies told by Dr. Oz), take a look and try and estimate the damage they've caused. To help prevent more of these in the coming year consider this next piece a vaccine against ignorance: 11 Ways To Sniff Out Clickbait Health Journalism. The Commonwealth Fund took a look at the 8 most important health care stories of the year, this piece also includes stories familiar to most of you. From the lowering of the rate of uninsured to Ebola to Sovaldi, here is their The Health Care Year in Review.

And speaking of the uninsured, it’s hard to argue that the story that should top anyone’s list was ACA implementation. Courtesy of Larry Levitt (Kaiser Foundation) here is Obamacare's first year, in one tweet:
10 m ↓ in uninsured
Benchmark premiums ↑ 2% on avg
6.7 m in marketplaces
9.7 m ↑ in Medicaid
3.8 m in the Medicaid gap

Before we change direction, a reminder that 2014 Has Seen Largest Coverage Gains in Four Decades, Putting the Uninsured Rate at or Near Historic Lows.

We’ll start our look forward with the Press Herald: In Maine, health care changes in store as new laws take effect. They review changes taking place in 2015 such as the employer mandate (also an invocation of the Mitchell rule since I’m quoted). Vox also takes a look forward, focusing on 5 health challenges the world will face in 2015.

Brookings take a look at what the new make-up of Congress means for the ACA. Worth reading for many reasons not least of them being this sentence “Following the travails of President Obama’s health reform is a bit like watching successive episodes of the movie serial, The Perils of Pauline, in which the eponymous damsel weekly faced death from assorted villains.”: Republican Control of Congress: What Does it Mean for Health Reform?

How things play out in Congress will be interesting. The President has already said he expects to use his veto pen: Obama Warns GOP He Plans To Use Veto Pen In 2015  “He added: "I'm going to defend gains that we've made in health care. I'm going to defend gains that we've made on environment and clean air and clean water."”  Will that be enough to get the Republicans to the table?  There are tradeoffs that supporters of the bill would be willing to make – the question is after the Kabuki Theater of votes to repeal followed by the veto, will there be a willingness to compromise?

And finally from our friends at the Maine Medical Association, Top Ten Predictions for Health Care in Maine and the Nation in 2015. Some optimistic predictions and some less so. I won’t attempt to judge their accuracy, but I’d be happy if some of them came true (they predict MaineCare expansion and SCOUS upholding the availability of subsidies).

ACA: Status/Opposition
I’m starting this section with a “small” story - it talks about just one person – but in this one person we can see all the good the ACA can do, and all the harm that’s been done by its opponents. The Washington Post dissects the story for you: The substance and politics of Obamacare, in one citizen. And here is the original NY Times piece that got so many people talking: Success of Kentucky’s Health Plan Comes With New Obstacles.

SCOTUS announced that it will hear the subsidy case on March 4 (Supreme Court to hear King v. Burwell on March 4, decision likely in June). We’ve reviewed in the past how little most states are doing to prepare. On the Federal level, during a news conference, Secretary Burwell would not discuss any contingency planning being done by HHS (HHS won’t say if it’s preparing for a Supreme Court Obamacare nightmare). But the enrollment numbers (that we review below) highlight the need for figuring out what can be done if the worst happens: New Enrollment Numbers Show Importance of Coming Supreme Court Case.

Famed Princeton economist Uwe E. Reinhardt writes about Gruber, and so much more: Rethinking The Gruber Controversy: Americans Aren’t Stupid, But They’re Often Ignorant — And Why  He talks about the ignorance of the public when it comes to the details of the policy debates going on and how that enables the “spinning” of the facts. For example: “Consumer driven health care … aka rationing by income. How many politicians, for example, would forthrightly and bluntly proclaim on the campaign trail that, to control the growth of health spending, they favor the rationing of health care by income class, that is, by price and ability to pay?”  (If you read one full link this week, read this one.)

ACA: Enrollment Reports
HHS continued with their policy of releasing weekly enrollment reports. They also released the first state breakdowns reflecting the first month of open-enrollment. Let’s start with the most recent number: 8.8 million plan selections as of 12/31!  That is courtesy of http://acasignups.net/, the analyst combines Federal and State data and provides the most comprehensive number (including auto-reenrollments). His numbers have proven to be incredibly accurate, but for those looking for a more main stream media source, the Washington Post had reported At least 7.1M signed up for 2015 Obamacare plans so far (not including all the states full data).

Here in Maine, the first month saw Health care sign-ups in Maine start strong at 36,000 (36,000 Mainers pick Obamacare insurance plans). A great start thanks to the incredible work of the local assisters. We are less than halfway through open-enrollment, so there is still lots of time for those without coverage to sign-up. That said, without Medicaid Expansion here in Maine there are still many who have no good options.

Two interesting results from the reports, reflected both in Maine and nationally. First, People Are Shopping for Health Insurance, Surprisingly. Some, myself included, were worried that most people who were going to be auto-reenrolled would not shop for plans this year. The numbers show that here in Maine over 60% of those with a plan shopped around, while nationally more than a third did so. I believe the numbers here in Maine reflect the concern and focus of those working on the issue and doing everything possible to get the message out.

Also, the reports show that More HealthCare.gov enrollees seeking financial aid in 2015. Both nationally and in Maine the number approaches 90% of those selecting a plan qualifying for some subsidy. As noted above, this highlights the importance of the decision SCOTUS will make regarding the subsidy case this year.

Finally, for those interested in the raw numbers, below are links to the HHS reports:


ACA: Marketplaces
While many are firmly focused on this enrollment period, reaction continues to the CMS proposals to the next one.

How reenrollment is managed continues to be an issue – should CMS change an individual’s plan for the next year based on cost?  Many are not pleased with that proposal: Obamacare re-enrollment into lower-cost plans draws objections. Here is a detailed look at the issue: Health Policy Brief: Reenrollment

Subject to discussion are other aspects of the proposed rules, including network adequacy standards and accessibility of provider lists and formularies. Not surprisingly, hospitals want better network standards (so they can be included in more networks). More surprising (and sad) is that insurers are objecting to machine readable networks and formulary lists – something sorely needed if tools are going to be developed to make appropriate comparisons (CMS enrollment proposals spark criticism on range of issues).

Also being discussed is that actual timing of the open enrollment period. It’s been argued that the end of the year is one of the worst possible times: The administration could be missing a major chance to boost Obamacare enrollment.

Finally, a look at two start-up companies that are creating decision support tools to help consumers select plans. Given the confusing nature of health insurance these types of tools have the potential to offer real benefit: Startups help consumers navigate insurance exchanges

ACA: Premiums
Two pieces released by the Commonwealth Fund, one on premium changes and one on rate review:

“A new analysis of the Affordable Care Act’s health insurance marketplace costs finds that, nationwide, marketplace premiums did not increase at all from 2014 to 2015, though there were substantial average premium increases in some states and declines in others. The average premiums for the second lowest-cost silver plan—or benchmark plan for calculating the federal subsidy in a given state—were also unchanged. And the average deductible for a marketplace plan increased by just 1 percent year to year. (Analysis Finds No Nationwide Increase in Health Insurance Marketplace Premiums)

“Highlighting the essential role states continue to play in shaping the legal and regulatory landscape for health coverage, a new Commonwealth Fund issue brief examines the variety of state approaches to implementing the Affordable Care Act’s rating standards for insurance premiums.” (Premium Rating Practices: How States Are Implementing the ACA's Reforms)

And a reminder that one it comes to rate review, some states could do a much better job: Health Insurance Rate Setting: Time To Raise The Bar And Lift The Veil Of Secrecy.

ACA: Employers
Despite fears to the contrary, a Kaiser sponsored Urban Institute study confirmation that employers did not drop coverage in response to the ACA: “Before Obamacare launched in June 2013, 71.2 percent of workers had employer-sponsored health plans. That number ticked upwards just slightly to 71.2 percent as of September 2014, a change that the researchers say is not statistically significant. Numbers held constant at both large and small firms… ” (Obamacare has not killed health insurance at work, survey finds)

While that’s good, the process is still far more complex than we would like it to be. This is true for individuals as well as employers. Read here about one small employers attempt to make sense of his choices and help his employees through the process: Is This Any Way to Pick a Company Health Insurance Plan?

ACA: Other
The Bangor Daily News in partnership with the Sun Journal are taking an in-depth look at the ACA one year after the first open enrollment. The initial article looked at the difference a year can make: From ‘hellish’ to health care: The Affordable Care Act in Maine 1 year later. The full series (including future installments) can be found here: Affordable Care Act 201.

The New York Times took a detailed look at how taxes and the ACA intersect: Affordable Care Act’s Tax Effects Now Loom for Filers and How Affordable Care Act Rules Affect Your Taxes. Expect to hear much more about this as the public starts completing their tax returns and is faced with the complexities of the penalties and subsidies.

While enrollment is going well this year, that’s not to say that everything is smooth sailing. There are continuing concerns that some plans are trying to get around the “no preexisting exclusion” rule by adjusting their benefits for costly conditions. The Feds are taking a look: Obama Administration to Investigate Insurers for Bias Against Costly Conditions. Although some advocacy groups are not waiting for the Feds to act: Group Sues Aetna, Claiming Discrimination Against H.I.V. Patients .

Fallout continues from VT’s decision not to proceed with single-payer. Sarah Kliff takes a detailed look: How Vermont's single-payer health care dream fell apart. But while the VT developments dashed the hopes of many, some are not so easily discouraged: Single-payer is dead — except not at all for young voters “Well, this new poll from Northeastern U bears out that point. It shows that, among this so-called "Generation Z (defines as Americans aged 16 to 19 years old)," 64 percent believe that government should provide health care to its citizens ... free of charge. Just 20 percent disagree -- a three-to-one margin.”

As a sign of just how smoothly healthcare.gov is operating this year, the lead consultant on the project just received a contract renewal: Accenture wins $563M contract to continue with HealthCare.gov.

And finally, both because the topic is important and not at all because this is the best article title ever, a report by Milliman on the risk corridor program and how it may be impacted by a few lines in the Cromnibus legislation: Risk corridors episode IV: No new hope.

Medicaid
As we start January, primary care physicians Medicaid rates are being reduced in many states (As Docs Face Big Cuts In Medicaid Pay, Patients May Pay The Price). As of now Maine providers have not been notified of a rate change, but we don’t yet have clear word on what the future (and the budget) have in store.

Also with the New Year, the topic of CHIP renewal is getting more attention. Here is one look: Health Law Helped Adults. Now, What About Children?

Lots to discuss with respect to Medicaid expansion. Vox took a look at how Red states are using Obamacare to rip themselves off. Basically, what should have been a transfer of Fed money from Blue states to Red so far has been the opposite as Red states refuse the Fed money for Medicaid expansion.

Regarding the Red states that did expand “In a new Commonwealth Fund issue brief, George Washington University’s Sara Rosenbaum and Carla Hurt examine the variety of Medicaid reforms that Arkansas, Michigan, Iowa, and Pennsylvania are currently testing” (How States Are Expanding Medicaid to Low-Income Adults Through Section 1115 Waiver Demonstrations). And Kaiser provides the Status of State Action on the Medicaid Expansion Decision.

Regarding state specific developments, in news that surprised many, hints that both Texas and Florida (yes, you read that correctly) may be considering expansion: Medicaid expansion effort in Florida could get sunnier in 2015 “The Florida Chamber of Commerce told CNBC it its taking "a fresh look" at Medicaid expansion and is moving to change its current position on the issue.” And Is Texas, the biggest domino, about to topple on Medicaid expansion? “That would be a dramatic departure from the state's stance under departing Gov. Rick Perry, who called Medicaid expansion "a fool's errand" and made his state the national epicenter of opposition to the ACA.”

Finally, under the category of two steps forward, one step back, Arizona Supreme Court Allows Medicaid Plan Lawsuit. If successful, the suit could nullify the expansion already underway in Arizona.

Medicare
Two piece of good news on the Medicare front:

“Starting next year, the government will offer some seniors enrolled in private Medicare Advantage insurance an opportunity to leave those plans if they lose their doctors or other health care providers.” Medicare To Offer Help To Some Seniors When Advantage Plans Drop Doctors

“The federal office responsible for appeals for Medicare coverage has cut in half the waiting time for beneficiaries who are requesting a hearing before a judge. The progress follows an announcement last January that officials were going to work through a crushing backlog by moving beneficiaries to the front of the line and suspending hearings on cases from hospitals, doctors and other providers for at least two years.” Seniors’ Wait For A Medicare Appeal Is Cut In Half

And a reminder that there is still work to do as Medicare Patient Skips Mortgage to Cope With $20,000 Bill. This and other stories like it highlight two important points. First that while generally a strong benefit, there are people who fall through the cracks in the program. Second, Note that unlike ACA compliant plans, there is no out-of-pocket maximum for Medicare patients. Its presence is one of the unsung heroes of insurance reform and should be a part of Medicare as well.

Costs
Lots going on in the Accountable Care Organization (ACO) world. HHS announce that 89 ACOs will join Medicare Shared Savings Program in January. Remember, the Medicare Shared Savings program is just one flavor of ACO, although for now one of the predominant flavors. The article discusses how while some more groups are signing on to the program, there are changes in store.

Regarding current participants in the program, a piece in the Press Herald regarding MaineHealth’s bonus payment: Redefining care saves federal money, earns MaineHealth a $9.2 million windfall “It’s a good sign, but this is all still very preliminary,” Stein said. Why did I say that? After the announcement of the Shared Savings results was the announcement of penalties for hospital infections, where MaineHealth also made the list (Feds penalize Maine Med and five other hospitals in the state for patient injuries). Kudos to them for the achievements so far, but there are questions regarding the completeness and appropriateness of the measures being used by the current program.

Also on the cost front, a frightening story out of Alabama regarding the lengths one hospital is going to collect unpaid bills: In Alabama, A Public Hospital Serves the Poor — with Lawsuits

A look at the years before the ACA and the recent health cost increase slowdown, much if not all of you potential raise went to pay for increased benefits costs while salaries stayed stagnant: You may have been getting a raise for years. It's just not going to your bank account.

Drugs
Time to once again talk Hepatitis C treatments. There are now three treatments available, Sovaldi (old new), Harvoni (approved in October and like Sovaldi from Gilead), and the newest of them all, Viekira Pak (from AbbVie).

First, Harvoni, it is an improvement over Sovaldi because there is no need for companion Interferon injections and is proving to be wildly popular: This drug costs $1,125 per pill and is about to shatter sales records. Although no cheaper than Sovaldi, it does have the potential to cost less for some patients because they will be cured with a shorter treatment length.

The AbbVie drug is an alternative but has some drawbacks compared to the Gilead drugs – it requires four pills a day (vs. one) and requires an additional drug that sometimes has severe side effects. Still for many, this can be as effective as the Gilead entrants.

Stepping into the fray, Express Scripts has entered into an agreement with AbbVie saying all their customers will try their drug before the Gilead ones: AbbVie Deal Heralds Changed Landscape for Hepatitis Drugs –Express Scripts, insurer moves could signal tougher drug bargaining tactics. An understandable approach given the costs involved but needs monitoring.

Switching focus, here is a fascinating look at opioid abuse and its history: Painkiller Abuse, a Cyclical Challenge “Despite the growing recognition of the limitations of opioids for pain, we are still in the midst of an epidemic. Policy makers continue to struggle to balance access to appropriate medications with their risks, while the pharmaceutical industry provides and promotes new formulations of narcotic painkillers.”

Now let’s talk about antibiotics and antibiotic resistant infections: “My incredibly sick patient also highlights the need for more robust antibiotic development so medical professionals aren’t resorting to toxic antimicrobial agents as last line therapies because no other safer, effective antibiotics exist. This last point is concerning because despite the current landscape of antibiotic resistance in the U.S. there is a dearth of new antibiotic development today.” (How antibiotics are killing us and the new ones can’t come fast enough). According to the President, antibiotic resistance is a threat to national security. There is work being done to try and get the situation under control: Hospitals focus on antibiotic overuse as CMS prepares new mandate. But damage has already been done.

A new paper looks at C. difficile, how it developed and spread (Homegrown bioterror). This one bug is causing much more harm in the US than Ebola, even though it gets little attention: Our fascination with Ebola exposes a double standard “But that same level of caution and concern does not exist when it comes to preventing the spread of C. diff and other hospital-acquired infections. In fact, CDC figures from 2011 reported 722,000 U.S. hospital-acquired infections that year, resulting in approximately 75,000 unnecessary deaths. …  Given these staggering statistics, how is it possible for caregivers not to wash their hands when they go in and out of a patient’s room?”  While we wait for new drugs, there is something simple you can do. Although it won’t fix everything, if you find yourself in a hospital, remember to wash your hands, and make sure the staff does so as well.

System Transformation
Let’s start this section with a great summary of what ails our health care “system”: Fixing our broken health care system: Sometimes David wins. The victory he refers to concerns smoking rates, but he also outlines the areas where a lot more work is needed.

One of the biggest issues we face is that we often don’t address the underlying problems: When doctors aren't enough to help patients keep diabetes in check “Among a group of 411 patients being treated for Type 2 diabetes in the Boston area, those who suffered from food insecurity and those who tried to save money by skimping on their meds were only half as likely as their more financially secure counterparts to be managing their disease.”   ““Addressing access to food and to medication together may be important to improve clinical diabetes control,” they concluded.”

Sometimes there is nothing that can be done. A new look at cancer shows that Biological bad luck blamed in two-thirds of cancer cases  “"They like to believe there's a reason. And the real reason in many cases is not because you didn't behave well or were exposed to some bad environmental influence, it's just because that person was unlucky. It's losing the lottery."”

And sometimes something can be done, regardless of why you get cancer, we have made advances in its treatment. A report found that More than 1.5 million cancer deaths averted in last two decades. And more help is on the way as researchers look at different ways of tackling disease: In a New Approach to Fighting Disease, Helpful Genetic Mutations Are Sought. The idea here is not looking for mutations that cause problems, but look for mutations that prevent them.

One disease we’re able to prevent sometimes is the flu. This year, not so much as it looks like the early numbers were correct and As Feared, It’s a Season of High Flu Intensity. “The worrisome outlook is the result of a confluence of factors: an early start to the flu season, with more people sick in December than usual; a strain that tends to make people sicker; a relatively low vaccination rate; and a mismatch between this year’s flu vaccine and the virus that’s making people sick.” So far, it’s worst in the Southeast and Midwest, but the rest of the country could still be in for a bad time.

Since I’m on my ninth page of writing this morning, I’ll leave it as an exercise for the reader to write the transition from the flu to vaccinations in general J 

Maine bill seeks to halt surge in vaccination avoidance. The bill would make it harder for parents to obtain a philosophic exemption to having their children vaccinated by requiring them to meet with a primary care provider and have them sign the request. While vaccination opponents argue that puts too much of a burden on providers, the Maine Medical Association, is in favor of the bill.

The Washington Post continues its stellar coverage of end-of-life issues. First observing that 2014: The year we finally learned how to talk seriously about dying. The also looked at the quality of hospice organizations. First by examining visits by hospice staff in the last days of life: The many hospices that fail patients just before they die and then be looking at the for-profit/nonprofit status of organizations and how that impacts quality: Dying and profits: The evolution of hospice. Among the findings “Nonprofit hospices typically spent about $36 a day per patient on nursing visits; for-profit hospices spent $30 per day, or 17 percent less. The gap between for-profits and nonprofits remains whether the hospices are old or new.” (Link to full series: The Business of Dying - Patients in Peril)

Finally, a look at the growth of urgent care clinics here in Maine: Opening of urgent care clinic adds to Maine trend and nationally: Blockbuster Is Out, the Doctor Is In. While these centers can fill an important role in our system, they need to be integrated with an individual’s overall care. Also the growth in the number of for-profit centers seems to indicate there are large profits being made, something out system can’t afford.


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"
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