Friday, January 9, 2015

That Was The Week That Was - Issue 43

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

This week we saw the rate of uninsured continue to go down and enrollment in the marketplace continue to go up. We saw a bill pass the house that would reduce some workers hours and raise the deficit, it’s called the “Save America’s Worker’s Act” (proof once again that we need a truth in labeling act for legislation). Also this week; two new projections on what happens if SCOTUS disallows subsidies (spoiler alert: bad things happen), and Harvard changed its health plan and starting a media frenzy. We’ll discuss all that along with affordability issues, Medicaid, Medicare, Flu, measles, and more. Let’s get started.

ACA: Enrollment
Here’s this whole section in one headline: Health Care Sign-Ups Steady as Uninsured Rate Hits New Low. The details:

Gallup released its quarterly survey showing the rate of uninsured in the country fell again, now down to 12.9%. This number is for the fourth quarter of 2013, so technically it does not include any sign-ups from the current open enrollment period. That said, while some of the drop is probably the result of Medicaid and ER coverage take-up (due to employer open enrollment and increased employment), part is also probably an early peek at the impact of marketplace open enrollment. Since this is a survey, respondents may not have been thinking about their effective date of coverage and may have responded yes even if coverage were to start 1/1.

The survey also highlighted that the biggest gain in insurance happened at the lowest income levels: “Since it went into effect, the uninsured rate has fallen by 6.9 percentage points among those making $36,000 or less. While it’s very likely that a lot of those people are benefiting from the Medicaid expansion, a lot of them are undoubtedly gaining coverage thanks to the subsidies.” (In U.S., Uninsured Rate Sinks to 12.9%)

Also this week, HHS released its weekly enrollment report (Open Enrollment Week 7: December 27, 20– January 2, 2015). Sign-ups continued at a slower pace after the peaking on the 15th. Including the Federal and state exchanges, the number of sign-ups is now estimated to be 9 million. ACASIGNUPS.NET takes a detailed look at the numbers and where he expects them to go from here: 9 MILLION QHPS Estimated Nationally, and where things go from here.
  
ACA: Definition of Full Time Workers
On Thursday, the house passed the “Save America’s Worker’s Act”. This bill is designed to change the definition of full-time worker used by the ACA from 30 hours a week to 40. This would impact who would be offered coverage as a result of the employer mandate. (House Fires Shot at Health Care Law, Seeking to Alter Critical Coverage Rule).  Earlier in the week I did a separate post on the issue (Changing the ACA definition of full-time worker from 30 to 40 hours a week) but here are the basics:

Those in favor of the change say that the 30 hour definition is causing employers to cut back employees hours to avoid having to offer them coverage. The problem is that the 40 hour definition has the potential to be more harmful than the 30 hour definition.

What we are seeing is policy by anecdote - you talk to someone who is impacted so you think everyone is. The actual numbers tell a very different story. According to the Bureau of Labor statistics: 7.4% of the workforce work 30-34 hours a week, while 43.8% work 40 hours a week. So having the “cliff” at 40 hours leads to the potential for employers to drop coverage for many more employees.

Additionally, according to the Bureau of Labor statistics, the percent of involuntary part-time workers is actually shrinking - 18% down from its peak of 20% peak.

While those who don't get coverage at work can go to the marketplace, as more individuals do so and qualify for subsidies, the deficit rises. In fact, the CBO estimated changing the ACA's definition of full-time work from 30 to 40 hours would cost the budget $57.5 billion (The GOP's latest Obamacare "fix" will be a total disaster if it passes and Health Reform Not Causing Significant Shift to Part-Time Work But Raising Threshold to 40 Hours a Week Would Make a Sizeable Shift Likely).

To sum up, this change would have exactly the opposite impact that its proponents say they want. Fortunately, the President has already said he will veto the bill (President pledges first veto in 2014 Obamacare wars).

Interestingly, even some conservatives have realized, regardless of what they think of the ACA overall, this is a stupid bill: National Review Opposes The GOP's First Big O-Care Bill Of The Year

The Senate version of the bill was co-sponsored by Maine’s Senator Collins. The local coverage focused on the plight of home health care agencies. The issues around those agencies and their workers need to be addressed (reimbursements aren’t adequate to offer benefits to their workers) but this bill is not the way to do it (What's Considered 'Full-Time' Under the ACA? Collins' Bill Would Define it as 40 Hours).

Also this week, the House passed a bill saying the veterans don’t count toward determining if an employer has to provide coverage. I guess the idea is to encourage hiring veterans but its impact us questionable (House Bill: Firms Could Skirt Health Law by Hiring Vets).

ACA: Courts and Opposition
Lots of talk and some new information regarding the subsidy case. First a reminder that as open-enrollment continues, the Court Case Shouldn’t Scare Off Marketplace Enrollees (individuals would not need to repay subsidies). As Congress returned, we also saw Republican legislators join lawsuit attacking exchange subsidies.

Meanwhile, Brian Beutler at the New Republic observed: “If you believe that the King challenge is garbage—clever garbage, perhaps, but garbage nonetheless—and you think John Roberts is aware enough to smell the garbage, then the consequences suddenly become very relevant. Justices shouldn’t vouchsafe bad arguments under any circumstances, but they’re more likely to play along if the repercussions are likely to be modest.” (Conservatives Know the Latest Obamacare Challenge Is Weak—That's Why They're Trying to Spin John Roberts)

Following that line of reasoning (and I’m not sure I do), two reports out this week should show the Court how damaging a decision against the subsidies would be (Supreme Court Ruling Against Obamacare Would Take Insurance From Millions: Reports).

From Rand: Study: 9.6 Million People Would Lose Insurance If SCOTUS Guts O-Care “RAND Corp, a non-partisan think tank, estimated that coverage in the HealthCare.gov states would drop from an estimated 13.7 million in 20to 4.1 million if the Court rules against the Obama administration. The study also projected that premiums in the HealthCare.gov markets would increase by 47 percent.”   I think it would be even worse. Primary Source: The Effect of Eliminating the Affordable Care Act's Tax Credits in Federally Facilitated Marketplaces

And from the Urban Institute: The Implications of a Supreme Court Finding for the Plaintiff in King vs. Burwell: 8.2 Million More Uninsured and 35% Higher Premiums

Drew Altman asked what might happen after the SCOTUS decision. He thinks a decision allowing the subsidies would end some of the opposition, but personally I’m not so sure: Which Path for Health-Care Politics in 2015?

Also this week, in what might be considered a pro-ACA version of the Gruber video, a Republican Governor Caught On Tape Demolishing The Legal Case Against Obamacare. As fun as it is to see Scott Walker on tape saying the Fed exchange would be just like a state exchange and provide subsidies, it must be noted that just as Gruber didn’t win the case for subsidy opponents, No, Scott Walker didn't demolish the legal case against Obamacare.

In other court news, yet another challenge – this time to the Independent Payment Advisory Board that was created by the ACA. Given that the Board has not yet been appointed, you don’t need to lose any sleep over this one (Challenge to Obamacare's IPAB could get Supreme Court hearing).

After the change in the definition of full-time, the next piece of legislation regarding the ACA we’re likely to see is a repeal of the medical device tax. The Washington Post fact checker took a look at the claims about the impact of the tax (Has the medical device tax eliminated ‘thousands’ of jobs?) and found them dubious. USA Today agrees, coming out with this editorial: Keep medical device tax: Our view

ACA: Harvard Plan Changes
Early in the week, the NY Times published a report that the Faculty of Harvard was upset because of changes made to their health plan: Health Care Fixes Backed by Harvard’s Experts Now Roil Its Faculty

This story has been widely covered (at least in the health policy media – if that’s a thing). Interestingly, it has become the Rorschach test of health policy. You can see anything in it - for or against the ACA: The New Obamacare Sport: Poking Fun At Harvard's Faculty (Uwe Reinhart guest post at Forbes) and Harvard, Obamacare, and the Conservative Information Bubble.

The changes involve increasing the deductible TO $250 A YEAR. Sorry for shouting, it’s just hard to understand the uproar when the average deductible for employer-sponsored plans was $1,217 last year (http://kff.org/private-insurance/press-release/employer-sponsored-family-health-premiums-rise-3-percent-in-2014/).

With the plan changes came a drop in premiums (Higher math: Harvard's insurance premiums drop despite drama) highlighting that age old trade-off between cost sharing and premiums.

Harvard mentioned the approach of the Cadillac tax as one of the reasons why they needed to change their plans. (That’s the tax going into effect in 2018 on employer plans costing over a certain amount.)  The problem is, if you do the math it wouldn’t hit Harvard until 2029 (No Cadillacs at Harvard).

Here is one of my favorite observations: “The result is a system where everyone complains that we spend much too much on health care--and the very same people get indignant if anyone suggests that they, personally, should maybe spend a little bit less. Everyone wants to go to heaven--but nobody wants to die.” (Whining Harvard Professors Discover Obamacare)

And finally, from our friends at the Incidental Economist: Another view of changes to Harvard’s health insurance plan  and  Harvard is Exhibit A on why health reform is so challenging.

ACA: Marketplaces
Although we are still in the midst of this year’s open-enrollment period, talk continues on what the process will be for the next one. Should the Feds continue with auto-reenrollment?  Should the process be changed? A Rhode Island Rule on Health Enrollment Offers a Consumer Experiment “The divergence has led to an interesting experiment in consumer behavior. In the federal marketplace, so far, 35 to 40 percent of 20customers came back to HealthCare.gov and picked a plan for this year, according to the Department of Health and Human Services, while the remainder were automatically renewed. In Rhode Island, 78 percent of people have gone back to the marketplace to shop, according to state officials.”

ACA: Affordability
Houston, we have a problem…  The same measures that are being used to reduce health care costs end up preventing needed care. This is not news, but it needs repeating amidst the drum beat for “skin in the game”: Dilemma over deductibles: Costs crippling middle class: Rather Than Pay So Much Out-Of-Pocket, Many Skip Checkups, Scrimp On Care

Higher deductibles and cost sharing are more prevalent now more than ever. Given the plan design tradeoff between premium and cost sharing (raise one and you lower the other), we see employers going for the lower premium designs (since that’s what they pay a share of), marketplace plans also do so (since consumers gravitate towards the lower up front cost, not always looking in detail at cost sharing). We see this in two Commonwealth Fund reports issued this week:

The Share of People with High Medical Costs Increased Prior to Implementation of the Affordable Care Act “The percentage of Americans who spend more than percent of their family income on out-of-pocket health care expenses increased to 19.2 percent in 2011, from 18.2 percent during 2007–09. Medical cost burdens were highest for people with private non-group insurance coverage, who are among those most likely to benefit from the Affordable Care Act’s coverage expansions.”

State Trends in the Cost of Employer Health Insurance Coverage, 2003-2013 “From 2010 to 2013—the years following the implementation of the Affordable Care Act—there has been a marked slowdown in premium growth in 31 states and the District of Columbia. Yet, the costs employees and their families pay out-of-pocket for deductibles and their share of premiums continued to rise, consuming a greater share of incomes across the country.“

What impact does all this have? Unfortunately increased medical debt: Medical Debt Among Insured Consumers: The Role of Cost Sharing, Transparency, and Consumer Assistance “Increasing deductibles and other cost sharing have helped to make insurance premiums more affordable, but the flip side has been to expose even people with insurance to risk of medical debt. When cost-sharing under health insurance exceeds the ability of consumers to pay their medical bills, cases of health-related bankruptcy and credit problems are inevitable. Greater transparency in the details of health insurance plans cannot eliminate medical debt, but they can help consumers distinguish plan differences to make more informed choices and to plan ahead financially. Greater transparency, as well as consumer assistance, can also help consumers use their coverage more effectively and resolve billing questions and disputes when they arise.”

The reports listed above reflect long-term trends. The ACA helps somewhat with the institution of an out-of-pocket maximum. But at $6,350 for an individual, the costs before reaching that point still represent a significant, and at times insurmountable burden for many.

ACA: Other
Remember Steven Brill?  He wrote the seminal Time’s article “A Bitter Pill”. He’s now written a book about the implementation of the ACA. The New Yorker provides an in-depth review of the book: The Bill: Steven Brill on how health-care reform went wrong. And the Washington Post talks to him about his ideas regarding health reform: Steven Brill: Obamacare won’t lower America’s health-care bill, but it was still worth it. Meanwhile, what impact did that original article have? The Bitter Truth: Brill's 'Bitter Pill' Changed Nothing  “In fact, "the average consumer has not seen a lot of improvement" since Brill's story appeared two years ago, he adds. "Americans still do not know the cost of their care, and [generally] aren't empowered to ask what that price is."”

With the start of the New Year, thoughts inevitable turn to taxes. OK, maybe not but they should…  The ACA, through the individual mandate and premium subsidies, will have an impact on returns for 2014 and onwards. To help handle this, the Feds launch effort to help people prepare ObamaCare tax filings.

In the words of Treasury Secretary Lew: “For the vast majority of Americans, tax filing under the Affordable Care Act will be as simple as checking a box to show they had health coverage all year. A fraction of taxpayers will take different steps, like claiming an exemption if they could not afford insurance or ensuring they received the correct amount of financial assistance. A smaller fraction of taxpayers will pay a fee if they made a choice to not obtain coverage they could afford. We are working to ensure that whatever their experience, consumers can easily access clear information since this is the first year they will see certain changes to their tax returns.” (Statements by Secretary Lew and Secretary Burwell on preparing for the upcoming tax season).

For most it will be simple, but for some, not so much: Health insurance may muddle tax time for some “About 75% of taxpayers will only have to check a box saying they had health insurance in 2014, the Department of Health and Human Services says. Those who received subsidized coverage through the Affordable Care Act exchanges or decided not to enroll, will have to go through a more complicated process.”

Also this week the Bangor Daily News continued its series: Affordable Care Act 201 with this entry: Supreme uncertainty: The future of the Affordable Care Act in Maine.

Medicaid
As part of the ACA, Medicaid payments to primary care physicians (PCPs) were raised to be comparable to the usually higher Medicare payments. For budgetary reasons, that was only set to last for two years (2013 and 2014). This resulted in PCPs facing reimbursement cuts (Doctors face big cuts in Medicaid pay). Some states have decided to continue the enhanced payments, this week we confirmed that Maine was going to be one of them: Maine to fill funding gap in Medicaid payments to physicians.

More discussions by red state governs about expanding Medicaid, this week some met with the president on the issue: Red-state governors discuss expansion of Medicaid with Obama.

Here are some of the most recent developments:


Medicare
Let’s start off with a new graphic from Kaiser: Visualizing Health Policy: Medicare Spending: A Look at Present, Short-Term and Long-Term Trends.

Next a look at penalties, as Modern Healthcare observes: Medicare penalties begin taking toll

In addition to these penalties, Medicare is changing some of its reimbursements. Can that be done painlessly? Some think the answer may be no: Do No Harm? It May Be Hard to Avoid With Health Law’s Medicare Cuts

Of course, there is waste in the system: Medicare's top-paid cardiologist accused of unnecessary testing. The trick is removing that without removing needed expenditures…

Also this week, as Insurers gird for new fight regarding planned reductions in Medicare Advantage payments, two studies take a look at relevant pieces of the puzzle: Health Affairs Article: At Least Half of New Medicare Advantage Enrollees Had Switched From Traditional Medicare During 2006-11 and Variations in County Level Costs Between Traditional Medicare and Medicare Advantage Have Implications for Premium Support.

Drugs
Amidst all the talk about antibiotic resistant superbugs, finally some good news: A New Drug in the Age of Antibiotic Resistance. This potential new class of antibiotic comes from work exploring a field here in Maine (From Maine dirt comes the seed for defeating ‘superbug’ illnesses). While no drugs have been tested in humans yet, the physiology of how they work give some hope that not only will they be effective on bacteria resistant to current antibiotics, they will also be harder for bacteria to develop resistance to.

On the vaccination front, a story from CA reminding us to vaccinate: Anti-vaccination update: How the measles crisis struck Disneyland.

Ever wonder why pharmaceutical firms advertise so much if their drugs are so good?  Turns out that the drugs that they advertise the most aren’t: Pharma's terrible secret: companies spend the most to promote their least helpful drugs and The Drugs That Companies Promote to Doctors Are Rarely Breakthroughs.

Finally, in this week’s episode of As Sovaldi Turns (I’m going to need a new name since there are now three new Hep C treatments) more deal making…  Last week we reported on AbbVie (the manufacturer of a competitor to Sovaldi) making a deal with Express Scripts. This week in response, Gilead Strikes Hepatitis Drug Deal With CVS Health and Gilead Strikes Hepatitis C Deal With Anthem. Looks like there may be something to this competition stuff after all.

Flu
The flu season continues to be a bad one (Flu is 'widespread' in 43 states as deaths and illnesses mount, CDC says and Yes, this is one of the worst flu seasons in recent memory. Until recently, Maine was spared the worst of it, but that’s no longer the case as Maine reports swift surge in reported cases of flu. A new regulation in New York attempts to help prevent bad outbreaks: New York City Requiring Flu Shots for Preschoolers.

For those who've heard that this year’s vaccine missed the mark, here is a blast from the past, an oldie but a goodie: The flu vaccine is imperfect, but please get it anyways “Both nature and science can do good and harm, and which is friend and which foe depends entirely on context and circumstance. Ideology tends to obscure that. So I will take epidemiology over ideology every time.”

What if you do get the flu, Is Tamiflu actually helpful? “Scott Gavura, a pharmacist who writes on the blog Science-Based Medicine, summed up the antiviral dilemma very nicely: "If you have a tidal wave coming at you and someone hands you a pair of water wings," he told me, "you’ll probably take them because they might help you and they won't do you harm."”  But is it worth the cost to use the mostly ineffective water wings?  Probably not.

System Transformation
Let’s start off this section with some good news. Here is a fascinating look at how to provide pediatric dental services to the Medicaid and CHIP populations. It’s being done through a self-sustaining non-profit: Disrupting Dentistry. Definitely a model that needs to be expanded, although as the article points out, some state dental organizations are trying to prevent that.

Next, a primer to understanding the studies you read about with The one chart you need to understand any health study. It looks at different methodologies and how they compare. If you’re in the mood to geek out on methodology some more, here is a look at Can Big Data Solve the Fundamental Problem of Causal Inference? Mining big data for answers to what works and what doesn’t in health care (instead of randomized clinical trials) may not be that easy.

A reminder that with all the talk of care coordination and payment reform, we still have a long way to go: The problem with home health care communication.

Ezekiel Emanuel is at it again, today reminding us with an op-ed in the NY Times to  Skip Your Annual Physical “There is only one problem: From a health perspective, the annual physical exam is basically worthless.”  While all the evidence supports that position, the idea of an annual check-up is so ingrained in how we practice medicine it will be hard to overcome.

This week is the Consumer Electronics Show – why bring that up in a health care blog?  Because “At this year's Consumer Electronics Show, there are nearly 300 "health and biotech exhibitors" — up 35 percent from last year.” (Self-Tracking Gadgets That Play Doctor Abound At CES). An issue is many of these gadgets have not been reviewed, and in the past some have proven to be problematic: When Medical Apps Do More Harm Than Good. We need to strike a balance between keeping people safe and stifling innovation. I’m afraid where medical apps are concerned, we are not doing a great job t keeping people safe (and away from misleading apps).

No one wants to be in an institution, we’d much rather receive care at home, but that is easier said than done. It can be a question of being able to pay for the home (When Home And Health Are Just Out Of Reach) or it can be finding the right help Lots Of Responsibility For In-Home Care Providers — But No Training Required and As Caregiving Shifts To The Home, Scrutiny Is Lacking. We also need to remember Why you shouldn’t count on your family members to take care of you when you’re old.

As you know, I’m a big fan of end of life planning. But many people are not prepared when faced with a dire situation. Some providers have been hesitant to have these conversations after a bad diagnosis, but new evidence suggests they are wrong: ““Many health professionals suggest that (advance care planning) may make patients anxious, however like this study there is no evidence this is the case – there is some evidence suggesting the opposite,” said Dr. Karen Detering of the Respecting Patient Choices Program at Austin Health in Melbourne, Australia.” (End of life planning does not make cancer patients hopeless or anxious).

And finally: Rural Doctor Launches Startup To Ease Pain Of Dying Patients. One doctor’s story of trying to help people who are near the end of their time yet have no access to the help they need.


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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