A look back at the week's health policy news with a
focus on ACA implementation
CMS Administrator resigns, ACA opposition continues and enrollment
proceeds at a target busting pace. We’ll also talk taxes, affordability and
learn how Medicaid is an even better investment than we thought. Those topics, an
intriguing quote from an Aetna executive (at the end of the first section), the
flu, public health and much, much more.
Editorial note, I’ve added sub-heads to the System
Transformation section – hope that helps you zero in on topics of interest.
ACA: Courts and Opposition
Marilyn Tavenner, administrator of the Centers for Medicare
and Medicaid Services, announced her resignation today effective at the end of
February (Key
Obamacare Official Stepping Down). She was there for the disastrous launch
of the website and for the quick recovery, having served two years as acting administrator
before being approved last year.
Some say her most important legacy is not the initial
implementation of the ACA, but her work to release more information to the
public: “During her two years as Medicare's head, she's presided over some of
the agency's more sweeping data releases. Some of this has to do with mandates
in the Affordable Care Act, like disclosing the payments that doctors get from
pharmaceutical companies. But some of it wasn't.” (Obama’s
Medicare head is resigning. Here’s the most important thing she did in office.)
Nerd alert – the next two pieces get a little wonky, they
have to do with the process of reconciliation and how Republicans may use that
process to repeal/change the ACA. The process involves the budget and passing
bills that are filibuster proof in the Senate. Feel free to skip, remember you’ve
been warned. Explaining the process: Republicans
Consider ‘Reconciliation’ in Taking on Health Law and understanding the
impact the Senate Parliamentarian can have on the process: Obamacare's
little secret: Meet the most important person you don't know.
Speaking of changes to the ACA, last week we focused on
changing the definition of full-time employee. This week it’s the medical
device tax. It is a small part of the overall funding mechanism, but for
various reasons (a strong lobby) it gets a lot of attention. In fact, some of
the ACAs most ardent supporters are willing to change it: Medical-device
tax repeal wins bipartisan support. Unfortunately,
the desire to change it (and the stated reasons) have little basis in fact: Tax
Has Modest Effects on Medical Device Makers, Report Says.
Going back to the definition of full-time employee, Yes,
Some Companies Are Cutting Hours In Response To ‘Obamacare’. The fact that some firms would do this was never in
doubt – the issue is that changing the definition would make that strategy attractive
for many more employers, thus impacting many more employees.
These changes are still nibbling at
the edges of the law. We still have not seen the laws opponents solidify around
a “replacement” plan. Vox takes a look at Why
Republicans can't come up with an Obamacare replacement.
In advance of SCOTUS deciding the subsidy case we’re still
not seeing much contingency planning in the states: States
Stand Pat Ahead of Supreme Court Health-Law Ruling. However, for the first
time we’re hearing that Republicans in Congress may be getting a plan together:
GOP
plotting response to ObamaCare SCOTUS case.
What might that look like?
In an interesting report, Reuters says U.S.
healthcare executives say Obamacare is not going anywhere. Of particular note is this quote: “Aetna Inc., the third
biggest health insurer, said it is talking to Republicans and Democrats about a
possible "grand bargain" to salvage Obamacare if the Supreme Court
up-ends the healthcare law later this year. ”Blowing up the (Affordable Care
Act) is like shutting down the government," Aetna Chief Executive Officer
Mark Bertolini told a small group of investors. "So we are having
conversations on both sides of the aisle about what ... things you change in
the ACA, what we could introduce, about how to make a grand bargain should the
Supreme Court decide." Intriguing if true!
Also this week, SCOTUS actually refused to take up a new ACA
case. While no one thought this case had merit, that hasn’t stopped them
previously: Supreme
Court Rejects New Challenge to Obamacare Law.
Some of you may have seen last week’s 60 Minutes report on
the ACA. If you haven’t don’t bother, it was terrible. If you have, here is a
review of everything they got wrong: '60
Minutes' Just Called Obamacare A Disaster. Here's What They Didn't Tell You. 60 Minutes basic mistake was basing the entire report on
one person’s opinions. As we discussed last week, as important Brill’s original
Time’s article was, and as useful as his book is, he is just one person, and
not that well versed in some of the healthcare issues he discusses. Here’s more
on what his recent book gets wrong: What
Brill's 'Bitter Pill' Gets Wrong on Obamacare.
ACA: Enrollment
Another week, another enrollment report. This week we passed
a landmark as: At
least 18 States have reached HHS Goal for 2015 with over 5 weeks to go Note
this is based on the VERY conservative revised goal HHS set just before the
start of open-enrollment. But whatever the target you want to go by I think it’s
safe to say Looking good!
This week’s report (Open
Enrollment Week 8: January 3, 2015 – January 9, 2015) includes state specific numbers. Here in Maine, selections
are up to 59,126 which represents 107% of the HHS target. The number breaks
down as follows, about 22,000 are new enrollees and about 37,000 are
re-enrollments. (Source for breakdown and target numbers is acasignups.net.)
While that is all good news, there are some states not doing
as well: Where
Obamacare Is Still Struggling: Some states haven’t recovered from low
enrollment in the law’s first year.
ACA: Marketplaces
Subsidies in states that created their own Marketplaces are
not in jeopardy, but some of those states are facing other issues as Funding
woes imperil future of state-run exchanges. Forgive me
for repeating myself, but creating 50 separate sets of infrastructure to
accomplish the same task and expecting them to be self-sustaining was never going
to work.
On the COOP plan front, while Maine’s own COOP plan
continues to do well, other COOP plans have had very different experiences. We
learned this week that Iowa’s COOP was shut down (Health
Insurance Startup Collapses In Iowa). We also learned that the Tennessee COOP plan had to pull
itself off the Marketplace because it felt it couldn’t handle any more
customers: Community
Health pulls plans after meeting ACA goals.
ACA: Taxes
Most
Marketplace Customers Have New Filing Requirements This Tax Season, but at the same time people are grappling with them, The
IRS will answer less than half your calls this filing season. Due to ever shrinking budgets “Taxpayers will face
the worst levels of service in more than a decade from the Internal Revenue
Service this filing season, with as few as 43 percent of callers getting
through to an agent and then only after waits of 30 minutes or more, according
to a report released Wednesday.”
Take these two stories together and it’s clear that for
some, tax season is going to be ugly.
Those who received subsidies will be getting a new form in
the mail (Got
help paying for health care? Watch your mailbox)
“Called 1095-A, the forms come filled out with information from HealthCare.gov
or your state's insurance exchange. They list who in each household got
subsidized coverage, and how much the government paid each month to help with
premiums. You don't actually file the form with your tax return, but you can't
complete your return without the information it contains.”
For more information, here are 5
Things to Know About Tax Filing and Obama's Health Law and a more detailed
FAQ from CMS: Implementing
Health Reform: FAQs On Taxes And The ACA
Form
1095-A Frequently Asked Questions (FAQS).
ACA: Affordability
An important new survey out this week from The Commonwealth
Fund: The
Rise in Health Care Coverage and Affordability Since Health Reform Took Effect
(Primary Source). The survey showed that Financial
Distress Connected to Medical Bills Shows a Decline, the First in Years and
that For
the first time in a decade, Americans say health care is getting more
affordable.
Another way to look at the results is that, unlike the
claims of the ACA’s opponents, Obamacare
Is Actually Reducing Health-Care Rationing “In the U.S., health care is
"rationed"—i.e., scarce resources are allotted—based on people's
ability to pay for it. The Commonwealth survey found that significantly fewer
Americans aged 19 to 64 were skipping needed doctors' visits or prescriptions
in 2014 than two years earlier.”
This is all good news, but there is an important
qualification: “From 2012 to 2014, the percentage of Americans who did not
visit a doctor or clinic despite having a medical problem in the previous 12
months fell to 23% from 29%. The percentage who did not fill a prescription
fell to 19% from 27%. And the percentage who did not get needed specialist care
declined to 13% from 20%.” (Fewer
Americans delayed needed medical care in 2014, survey says). In other
words, about 20% of people still put off care because of costs. Here’s a look
at some of what that 20% face: Skipped
Care A Side Effect Of High-Deductible Health Plans.
Also this week, For
Nonprofit Hospitals Who Sue Patients, New Rules. These are designed to help
protect the uninsured by providing them with information about what programs
are available to them.
Costs
Good and bad news this week on the cost front. On the
positive side, one year in we’re not seeing some of the initial cost bump expected
from the newly insured: Exclusive:
No rush to high-cost care among newly insured Obamacare patients “Fears that Americans who signed up for
Obamacare were more likely to be sicker than those with employer health
programs may have been unfounded, according to data reviewed by Reuters.
Although people who bought private health insurance through Obamacare were keen
to book appointments for preventive care in 2014, they were no more likely to
seek out commonly seen, costly specialists, the data showed.”
We’re also continuing to see historically low cost growth,
this week in the hospital sector: Hospital
prices grow at slowest rate in a decade “The price for acute-care hospital
care increased last year at its slowest pace in the 10 years for which
comparable data is available, Producer Price Index figures show.”
Less positive is a reminder of why we run pilot projects –
not all ideas work: Health-Law
Test To Cut Readmissions Lacks Early Results “Obama administration officials have warned that ambitious
experiments run by the health law’s $10 billion innovation lab wouldn’t always
be successful. Now there is evidence their caution was well placed. Only a
small minority of community groups getting federal reimbursement to reduce
expensive hospital readmissions produced significant results compared with
those from sites that weren’t part of the $300 million program, according to
partial, early results.”
Medicaid
An important new study out this week on the “investment”
potential of Medicaid. “Expanding Medicaid may be a better investment than many
states realize. Kids eligible for the public program earn more as adults, a new
analysis of Internal Revenue Service data, published as a National Bureau of
Economics Research working paper, shows. They pay more taxes on those earnings
and, over the course of their lifetime, researchers estimate that they'll
ultimately repay 56 percent of the Medicaid dollars spent on them.” (Study:
Medicaid expansion boosts kids' incomes and government tax revenue) Here is
the study: Medicaid as an
Investment in Children: What is the Long-Term Impact on Tax Receipts?
(Primary Source)
And more analysis of the study: The
return on investment for Medicaid “In other words, children eligible for
Medicaid or SCHIP were more “productive” members of society. They paid more in
taxes and took less in entitlements.” And The
Costs of Stinginess in Medicaid “With a new Republican majority in Congress
looking to further the cause of low taxes and less spending, it is easy to
forget that tightfisted government imposes very real costs. That we can’t
easily measure them doesn’t mean they don’t exist.”
Next week SCOTUS will actually hear a case that has nothing
to do with undermining the ACA. “On January 20, 2015, the United States Supreme
Court will hear oral argument in Armstrong v. Exceptional Child Center, a case
that has the potential to impact the future ability of private parties to sue
states in federal court to enforce the requirements of the Medicaid Act” (Explaining
Armstrong v. Exceptional Child Center: The Supreme Court Considers Private
Enforcement of the Medicaid Act) In
the past, suing the state has been a tactic to help there is sufficient access
to care for Medicaid recipients. This case has the potential to eliminate that
tactic.
We’ve talked a lot about Red states reconsidering their
opposition to Medicaid expansion (and we will again below). One of the ways
this has expressed itself is that many fewer states signed on to the current
SCOTUS case than signed on to the initial challenge to the law: Health-Law
Suit Hints at G.O.P. Divide.
That said, it is inevitably two steps forward one step back,
as some states who have expanded are reconsidering: Medicaid
expansion may contract: After the midterms, there is a renewed assault in some
states.
Regardless of one’s politics, there is no disputing the
positive impact expansion has on a state. More confirmation from Tenet’s financial
report (Tenet
Releases 2015 Outlook) where they state that their uninsured
admissions were down 22% overall, while in Medicaid expansion states they were down
an astonishing 62%.
Now this week’s round-up of expansion developments in the
states:
TN - Republican
Tennessee Gov. Bill Haslam has found a part of Obamacare he loves and Study
says Insure Tennessee could bring $1.14B to state
Medicare
Kaiser come out with a new analysis of Medicare spending: “To
inform discussions about Medicare’s role in providing coverage for an aging
population and to assess the relationship between Medicare spending and
advancing age, this report takes an in-depth look at patterns of Medicare
spending by age, overall and by type of service” (The
Rising Cost of Living Longer: Analysis of Medicare Spending by Age for
Beneficiaries in Traditional Medicare)
For those who don’t want to read the
full report, here is the storify version: “In a series of tweets,
Tricia Neuman, Senior VP and Director of the Kaiser Family Foundation’s Program
on Medicare Policy highlights key findings from a KFF study recently published
in Health Affairs on trends in Medicare per person spending by age.” (The
Rising Cost of Living Longer: Medicare Spending by Age)
Ebola
Remember the
Ebola epidemic? It's still not over. Here's the report from the ground. Although there are some positive developments:
UN:
At Least 50 Ebola Hotspots Remain, But New Cases Falling. Also reported
this week, Two
Ebola vaccines headed for clinical trials in West Africa.
Drugs
Drug pricing in the news again (still). In the aftermath of
last week’s series of deals regarding Hepatitis C treatments: Big
Pharma faces up to new price pressure from aggressive insurers “The world's
biggest drug makers face a new reality when it comes to U.S. pricing for their
products as insurers use aggressive tactics to extract steep price discounts,
even for the newest medications.”
Some are asking: Are
hep C exclusivity deals taking power from doctors? But that’s
not a question or situation unique to these new deals. Payers (PBMS, Insurers, and
Employers) have long made deals as to what drugs were on or off formularies. They
are supposed to be exception procedures for individuals who need one of the
other drugs. That was a fact ignored by a NY Times piece Why
Drugs Cost So Much. The piece made good points in looking at what happens
in Europe: “As a consequence of the stand taken by those countries, prices in
Europe for prescription drugs are 50 percent below what we pay, according to a
McKinsey study from 2008. Gleevec costs $4,500 per month in Germany today, and
$3,300 per month in France, less than what Americans paid in 2001.” However, it
would have been a more powerful piece if he had gotten some of the other facts
straight.
One issue we should be more concerned with is access to data:
“In medicine, clinical trials inform the choices health professionals and
regulators make about the safety and effectiveness of drugs and devices. An
estimated half of these studies are never published, and those with negative or
unpromising results are more likely to remain hidden from view (a phenomenon
called 'publication bias.')” (Drug
researchers hide thousands of negative studies. A new campaign is trying to
change that.)
And another: “Extended-release therapies, taken by many
Americans to moderate a drug’s effect over a stretch of time, face stricter scrutiny
from U.S. regulators questioning whether the therapies work as intended. While
such medicine from companies like Teva Pharmaceutical Industries Ltd. (TEVA)
and Wockhardt Ltd. (WPL) has been withdrawn or recalled before,
modified-release drugs are more difficult to test and may require different
standards than regular pills. “ (Extended-Release
Drugs Get Extra Scrutiny in U.S. Quality Focus)
And finally on the drug front, biosimlars. We’ve talked
about them before, they are a type of generic drug but they are copies of biologics
- complex and costly treatments made from living organisms that help patients
battle some of the most severe diseases. This week the Washington Post takes an
in-depth look at the issues involved in bringing the first biosimlars to market:
The
coming revolution in much cheaper life-saving drugs .
Flu/Infectious Diseases
I am going to sound like a broken record, and Aaron Carroll
is going to help me. We don’t pay nearly enough attention to the flu, and we
don’t give the flu vaccine enough credit: It
may make for clickbait to marginalize the flu, but it comes at a cost “I
don’t want to lecture, but I feel like this has to be said. As of this week, 45
children have died of influenza-related illness so far this season. Nineteen of
those deaths occurred in the first full week of this year.”
We get titles like this (and worse that I’m not going to
include here): Just
how ineffective is this year's flu shot? CDC experts do the math. But
remember, This
year’s not-as-great flu vaccine is still totally worth getting. Let’s go
back to another quote from Aaron Carroll: “I see headlines telling people the
vaccine is “only 23% effective”. I’d like a list of all medicines people take,
diets they go on, behaviors they change, devices they employ, and procedures
they undergo which are better than 23% effective. I’m willing to wager the
number is quite low.”
Also in flu news, more efforts to have health care providers
fully vaccinated as Flu
Vaccination Pressure Ratchets Up at Hospitals “Healthcare worker
vaccination rates vary immensely, from 2% to 100%, and hospitals are cracking
down because data on rates of vaccination is now public.”
Also hope that New
Flu Shot Rules in New York City May Fan Debate Elsewhere, Including Calif. (the new rule discussed previously that all children in
preschool must be vaccinated).
And finally regarding the flu, hope
that eventually we can avoid having these annual battles over vaccination as Scientists
Edge Closer To Universal Flu Vaccine.
Speaking of vaccinations, more on the Disneyland measles
outbreak: Disneyland
measles outbreak spreads to 22 cases statewide.
System Transformation
Franklin County and Public Health
National attention this week on the incredible 40 year
effort in Franklin County to improve cardiovascular health: Long-term
heart health initiative pays off in Maine. Here is
local coverage of the JAMA article that prompted the well-deserved attention: Maine's
Franklin County Beats the Odds in Combating Chronic Disease.
Sadly, the same week a review by the
Maine Public Health Association concluded that the proposed state budget would
curtail some of the efforts highlighted in the Franklin County success: Public
health group slams LePage budget cuts to tobacco program, Maine CDC staffing.
An important aspect of the Franklin County success is the
public health component. Unfortunately there are many aspects of that lesson
that we fail to put into practice. Here are two stories highlighting how
societal factors impede keeping people healthy: Treating
chronic illness with cough syrup: Life in the coverage gap and Why
the wealthy stopped smoking, but the poor didn’t.
Overtreatment
Shifting from public health to treatment, two examples of
how we spend money where it’s not needed. First, Doing
More for Patients Often Does No Good a look at
providing “basic” life support vs. “advanced” life support (data shows no
difference in outcomes). Next, in the dental arena, a look at wisdom teeth: Dentists
remove million wisdom teeth each year. That's probably way too many. “But a 2012 Cochrane review of randomized
clinical trials found there's no evidence that removing wisdom teeth will
prevent or reduce crowding of other teeth down the line. And a different
Cochrane review found that watching and waiting can "may reduce the number
of surgical procedures by 50 percent or more.””
Hospital Acquired Infections
Of course in addition to providing unneeded treatments, we
sometimes do bad things to people we’re treating, like giving them infections. Data
this week that we’re not making enough progress, both nationally: Hospitals
fall short on infection goals “U.S. hospitals made significant strides in
the past several years in reducing the number of infections acquired within
their facilities but fell short of the Obama administration's targets,
according to a new federal report.” And here in Maine: Despite
progress, Maine hospitals fall short of goals to reduce common infections.
End of Life Care
An excellent look from Vox on How Americans'
refusal to talk about death hurts the elderly A quote in the story helps to
highlight part of the inherent conflict in how we approach the issue: “"We
want autonomy for ourselves and safety for those we love,"” And here in
this week’s second storify, Ezra Klein’s twitter
comments on the Vox end of life story.
A powerful reminder that as useful as understanding the five
stages of grief can be, every situation is unique: Getting
Grief Right.
And less than positive look at for-profit hospice care: How
the drive for profits is shaping end of life care.
Etc.
To
Treat Depression, Drugs or Therapy? Previously studies pointed to no
difference in effectiveness between CBT and medication for treating depression.
It now looks like they do have levels of effectiveness for different people: “Because
some patients respond better to psychotherapy than medication — and vice versa
— or prefer one type of treatment over another, we need to learn much more
about how various types of psychotherapy compare with medications clinically as
well as at the level of the brain.”
This year’s annual Quality Counts
conference (April 1) will highlight the differences between delivering
health care and promoting the wider goal of health for individuals and our
communities. Along with the conference, QC is holding a year-long webinar
series dedicated to this theme and highlighting the differences between getting
more health care, and delivering better health. The first webinar was Thursday
Jan 15 – you can find the material (replay and presentation) here: Delivering
Health Care or Health? Time for a New Conversation! Full disclosure, I am
on the planning committee for this conference and include here both for
informational and promotional reasons J
Under the category of too cool not to include, take a look
at this: What CT
scans can see inside the human body today is just insane
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"
