That Was The Week That Was - Issue 17

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

NOTE I'VE UPDATED THIS POST ON JULY 4, 7AM WITH A NEW PARAGRAPH AT THE END OF THE HOBBY LOBBY SECTION COVERING THE SUPREME COURT'S ORDER RE WHEATON COLLEGE v. SYLVIA BURWELL, SECRETARY OF HEALTH AND HUMAN SERVICES, ET AL.


The big story of the week was the Supreme Court Hobby Lobby decision.  We'll start off with a special section on the case.  Following that we'll take a look at the rest of this week's news in my normal format;  including a report stating that 20 million individuals have health coverage because of the ACA, more premium previews, Medicaid expansion news and of course much, much more.

Hobby Lobby

The Basics

On Monday June 30 in a 5-4 ruling the Supreme Court ruled that Hobby Lobby, a "closely held" corporation, had the right to a religious objection to the ACA birth control coverage mandate (Supreme Court Rejects Contraceptives Mandate for Some Corporations).

The ruling said that based on the  Religious Freedom Restoration Act (RFRA, signed by President Clinton in 1993) a closely held corporation (defined as having 50% or more of its stock owned by five or fewer people) could be exempted from the ACA requirement that health coverage include no cost sharing birth control as part of their coverage and so did not have to provide that benefit to their employees.  Note that the decision was based on a law passed by Congress and did not address any constitutional questions.

There was disagreement between the majority opinion and the decent as to how wide ranging the ruling is.  The New York Times does a good job of quoting the relevant parts of the documents: Between the Lines of the Contraception Decision.   This is as good a place as any to provide the link to the full decision:  BURWELL, SECRETARY OF HEALTH AND HUMAN SERVICES, ET AL. v. HOBBY LOBBY STORES, INC., ET AL.

Kaiser Health News prepared this FAQ document:  FAQ: High Court's Hobby Lobby Ruling Cuts Into Contraceptive Mandate. 

It is worth noting that the ruling did not overturn any aspect of the Affordable Care Act, it also did not question the requirement that birth control be provided by plans with no cost-sharing.  What it did was say that some employers can refuse to pay for that part of the coverage due to their religious objections.

Below I will cover several aspects of the decision, but please note that the "sections" are an imperfect artifact and so there is overlap between them.  I will also examine the decision with

Before proceeding, I'll pause to say that I personally am appalled at the decision.  It puts an individual's employer in the position to make decisions regarding their employees health care.  We'll see below that while the short-term impact will probably be minimal, it shows a obtuseness on behalf of the court as to what they are actually saying.  (That's the most restrained way I can phrase what I'm really thinking.)  I will also take some time to highlight one way of looking at the majority decision - namely that it comes from a limited male-based perspective.

What Happens Now?

The first question is what happens now?  Certain religious organizations (such as churches) already have the right to a partial exemption from the same birth control coverage requirement.  In fact, the majority opinion states that the work-around already in place can be used here so that the employees of these firms are not denied the benefit (What the White House Can Do Now on the Contraception Mandate).  It is very likely that this same approach will be used (at least initially) for these employees.  However, as discussed in the previous link there are already objections to that work-around winding their way through the courts (a bit more on that below).  The other alternative mentioned by the Court, a legislative solution, is highly unlikely given the current political environment.  You can read a description of how the existing exemption works here:  Religious Exemptions to Contraceptive Coverage.

In Maine the pool of employers who can object is smaller than in many other states.  That is because insured plans sold in Maine are subject to a state mandate requirement them to offer contraceptive coverage (Contraception ruling likely to have little immediate effect in Maine),although self-funded plans are not subject to that requirement.   The RFRA is a Federal law that in this instance does not preempt the state requirement.  A state version of RFRA was proposed during the previous legislative session but it did not pass (Maine House deals another blow to Republican senator’s ‘religious freedom’ bill).

Differing views of impact

As alluded to above, the dissent written by Justice Ginsburg worries that the majority opinion opens a Pandora's box of future exemptions: How Justice Ginsburg’s Hobby Lobby dissent helps shape the debate about reproductive vs. religious rights.  That said, others see the ruling as more limited: Court Suggests Narrow Application Of Birth Control Case, But Others See Broader Impact.  More seeing concern over possible broad impact: Gay rights groups wary of Supreme Court's Hobby Lobby ruling and more seeing in fact bad news for certain cases winding their way through the courts: Hobby Lobby Win Could Spell Trouble For Religious Nonprofits.

Corporate Personhood

In the age of Citizen United, it is common to bemoan rulings that seem to affirm that corporations are people and have rights.  But it's important to get into the weeds and understand that this has always been the case.  If there was no such thing as corporate personhood you could not enter into a contract with a corporation.  This piece lays out some of the common myths:  5 mistakes liberals make about corporate personhood and Hobby Lobby.

Birth control

Missing in some of the discussion is that often, birth control is not being used as contraception: For Me, Birth Control is Medicine First, Contraceptive Second - Issues other than sex rarely come up when we talk about birth control, but that is only part of the picture.   That when it is used as contraception it has far reaching impacts: Social and Economic Benefits of Reliable Contraception - Why providing women more options to control pregnancies is in the interest of everyone.  As we enter those waters, we can also ask why the continued need for a prescription: Seven reasons birth control pills shouldn't require a prescription.

Misogyny?

"The majority opinion is largely about the rights of corporations, employers and those with religious beliefs; the dissent is very much about women — about their health, the sums they spend to access care and the costs they pay when none is available." (The 49-page Supreme Court Hobby Lobby ruling mentioned women just 13 times)

Am I using too strong a term for this section?  I'll leave it to the reader to decide.  To quote Neil Gaiman as he was treating about #yesallwomen "...I can empathize & try to understand & know I never entirely will."  I think the conversations that led to #yesallwomen hashtag are instructive in understanding the context of this decision: Why #yesallwomen is the most important thing you'll read today.   

For those who continue to wonder at the pervasiveness of these attitudes I'll point out that in this day and age, Women are a minority in every state legislature in America.  On the culture front,  Half of 2014's movies fail this basic test of sexism.  Before getting back to the court case under discussion, I'll add this inspiring argument that Yes, All Men (should be feminists).

Politics

The above section, along with the case in general, inevitably has political implications.  It is A Ruling That Both Sides Can Run With.  And while Democrats pick up GOP tactic: Campaign against Supreme Court on a broader scale, there are those who say that To Hold Senate, Democrats Rely on Single Women and that this will be one of their motivations to vote.

Court cases to come

As mentioned above, there are objections to the work-around that has already been made for religious organizations.  There are several cases winding their way through the courts saying that the work-around is itself too onerous a burden as it makes the organization complicit in providing contraceptive coverage (by filling out a form saying they object to providing coverage).  As I write this on Thursday morning (7/3) we are waiting for the Court to decide about an injunction in a case before a lower court.  You can read about it here: U.S.: Don’t expand Hobby Lobby exemption.  It will be an opportunity to get more of a sense if the tea-leave readers are correct.  Did The Supreme Court Tip Its Hand On Contraception Cases Yet To Come? Those who say yes read the tea leaves as saying that the work-around will be upheld by the court.  The math is that all the four who voted against the decision would join with Kennedy who wrote positive things regarding the work-around.  Stay tuned because the one thing we can say for certain is The birth control fight isn’t over.

The big picture

I spend my days worrying (obsessing?) about the practicalities of our existing system and on incremental changes that will help. Ultimately, we will need fundamental change to make this all work.  This case highlights the fact that when that point arrives, removing the connection between employers and health coverage clearly needs to be part of that change:  Hobby Lobby decision shows we need to get rid of the employer-based health insurance system and The Illogic of Employer-Sponsored Health Insurance.  Although a cautionary note that as always we'll need to be careful what we wish for: Hobby Lobby shows why single payer could hurt reproductive rights

ADDED JULY 4:
Wheaton College
"“Those who are bound by our decisions usually believe they can take us at our word,” Justice Sotomayor wrote. “Not so today.”

In an apparent contradiction of the majority opinion in Hobby Lobby, the court ruled, albeit in a temporary injunction technically applying to only the plaintiff, that the Administration's accommodation for how religious institutions can opt-out of providing birth control still infringed on their rights.  For a brief summary, see the NY Times story: Birth Control Order Deepens Divide Among Justices

For a more complete review of the court's order, see the SCOTUS blog piece: Broader right to object to birth control.

You can find the full order here:  WHEATON COLLEGE v. SYLVIA BURWELL, SECRETARY OF HEALTH AND HUMAN SERVICES, ET AL

END OF ADDED SECTION


Now on to the rest of the week's news.

ACA: Enrollment numbers/Polls

A new report out indicates that 20 Million Americans Get Insurance Under Obamacare, Report Says.  One of the reasons to like this number is that it provides an updated estimate for the number of individuals under 26 who have coverage on their parent's plan because of the law.  Previous estimates used the optimistic 3 million while this report uses the more credible 1 million number.

 "Taking into account all the health insurance expansions initiated by the Affordable Care Act (ACA), an estimated 20 million Americans have gained coverage as of May 1, 2014. These include young adults who gained coverage under parents’ policies, people who bought plans in the marketplaces, individuals who purchased coverage directly from insurers, and adults and children who enrolled in Medicaid or the Children’s Health Insurance Program." (Health Care Coverage Under the Affordable Care Act—A Progress Report Primary Source).

This week Kaiser released tracking poll numbers (Kaiser Health Tracking Poll: June 2014).  While there was not much change in public perceptions, they focused questions this month on Wellness programs (Poll: Americans Bristle At Penalties In Wellness Programs). 

ACA: Marketplaces

More news this week on the eligibility problems regarding subsidies as the HHS Inspector General issued a report indicating that HHS can't tell if all people getting Obamacare subsidies are supposed to be eligible.  (Not All Internal Controls Implemented by the Federal, California, and Connecticut Marketplaces Were Effective in Ensuring That Individuals Were Enrolled in Qualified Health Plans According to Federal Requirements Primary Source).

Also another analysis from Avalere (who have provided tremendous insight with their various reports over the past several months).  This one reminding us again of the importance of comparison shopping.  In this case when it comes to the cost sharing subsidy available for some people.  Remember, for those qualifying, they basically get a different plan with different cost-sharing amounts.  But all the plans do not make their adjustments in the same way.  For example, one adjusted plan could have a lower deductible and higher drug copays than a second plan and yet both have the same adjusted actuarial value  (Avalere Analysis: Cost-Sharing Reductions Unevenly Applied Across Services in Exchange Plans).

More noise regarding adding an additional tier to the metal plans, this one would be "copper".  Given the calendar this could not happen for 2015 but the issue bears watching as these plans would have very high cost sharing amounts for all services (Proposal To Add Skimpier ‘Copper’ Plans To Marketplace Raises Concerns).

More premium news continues to come out, some not great numbers from NY: Insurers on New York State’s Health Exchange Seek Significant Rate Increases (although the article stresses these are preliminary filings and the increases don't take into account subsides) and some better numbers from Georgia:  An early, encouraging glimpse of 2015 rates.

ACA: Other

In one of her first public appearances since leaving HHS, the former Secretary admitted she did not focus enough on technology:  Kathleen Sebelius: I 'made some mistakes'.

While attention was focused on the Supreme Court and the Hobby Lobby decision, another potentially more harmful case continued to make its way through the courts.  Decision Looms In Lawsuit That May Actually Crush Obamacare.  This is the one challenging the ability of the Federal Marketplace to offer subsidies.  At first many of us laughed when this case was first introduced, but it continues to progress.  It would not be surprising if it made its way to the Supreme Court in their next session.

VA

Former head of Proctor & Gamble will be nominated as the new head of the VA (Barack Obama taps ex-Procter and Gamble exec Robert McDonald to lead VA).  While he is an unusual pick and  had some issues before leaving P&G (V.A. Nominee McDonald Faced Criticism at Procter & Gamble) some say his corporate management experience is just what is needed to get the VA into shape (What Bob McDonald could bring to Veterans Affairs).

Also this week another resignation: After Criticism, Investigator Steps Down From the V.A..

And while not directly related, the VA issues have led to renewed focus on care provided to active duty military.  The New York Times investigated and found In Military Care, a Pattern of Errors but Not Scrutiny.

Medicaid

A report out about the MISSED OPPORTUNITIES: THE CONSEQUENCES OF STATE  DECISIONS NOT TO EXPAND MEDICAID (Primary Source).

And developments in several states regarding expansion: 

• Oklahoma: Oklahoma is winning its Medicaid standoff with the feds — for now
• Indiana: State submits HIP health care plan for federal approval
• New Hampshire: ‘A Uniquely New Hampshire Approach’ To Medicaid Expansion

Drugs

A disturbing look at the price of vaccinations: The Price of Prevention: Vaccine Costs Are Soaring.  And a look at The Crazy Way the Government Buys Billions of Dollars of Drugs.

System Transformation

Speaking of vaccines, we didn't need more proof but we get it anyway as A review of 166 independent studies confirms vaccines are safe and effective.  And on the topic, this week's comic video selection:  Who are the vaccine denialists? Hint: It’s not who you think.

Disagreement between The American College of Physicians and The American College of Obstetricians and Gynecologists as the first group came out with recommendations that Healthy women do not need routine pelvic exams, influential physicians group says.  The second group quickly came out with a statement saying yes they do.  In either case, note that they are talking about Pelvic Exams, not the need for regular Pap smears (Not So Fast, Ladies: Annual Pelvic Exams May Be Unnecessary, But You Still Need Pap Smears).

Positive news in this look back at What the Reduction in Tonsillectomies Teaches Us About Medicine. Although Waste, errors in health care remain huge issues, experts agree.

Great work from the Commonwealth Fund as they released A State Policy Framework for Integrating Health and Social Services.

While Medical Boards Draft Plan to Ease Path to Out-of-State and Online Treatment, a look at How telehealth is shaping health care.

And finally, Robert Pearl, CEO of The Permanente Medical Group asks the question Why do we think more care is better for us? (when we know that often it is not).

All comments and suggestions are welcome; please let me know what you think.  And as always, thanks for reading!

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Funded by support from the Maine Health Access Foundation

*The title is a tribute to the BBC show, the NBC show and the amazing Tom Lehrer album "That Was The Year That Was"

That Was The Week That Was - Issue 16

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

Be careful what you wish for is this week's theme.  We'll look at proposed regulations out for re-enrollment in marketplace plans and how advocates getting what they asked for might lead to problems.  Then later on we'll look at a slowdown in healthcare spending and how that impacted the economy in the first quarter.  We haven't hit a summer slowdown yet so in addition to those topics there's lots more to discuss, so here we go:

ACA: Polls

Gallup is turning into the go-to source for ongoing data - this week's results add more texture to what we know about the previously uninsured - After Exchanges Close, 5% of Americans Are Newly Insured: More than half of newly insured in '14 got insurance through exchanges.  There is also information on the health status of the newly insured purchasing on the marketplace vs. off.  And while they are a little less healthy, remember that insured plans sold on or off the marketplace will be part of the same risk pool, so that particular breakdown will not impact future premiums.  As I've been trying to do when reporting on surveys and reports, here is the link to the primary source:  Gallup: Most newly insured Americans used Obamacare's exchanges.

Here in Maine, our own MeHAF tracking survey continues with new results being released recently: Mainers’ Awareness of Obamacare Health Plans Doubles Following First Open Enrollment Period

ACA: Opposition

Opponents of the law are not taking any time off this summer.   A certain right wing foundation (that actually designed the ACA) has a piece out about what a failure it is. As this is a family friendly post, I won't use the appropriate adjectives to describe the piece, instead I'll link to a detailed rebuttal: Dear Sharyl Attkisson: Stop it, you're just embarrassing yourself now..

As we approach November, there are some wondering What a GOP Senate Would Mean for Obamacare (not actual  repeal since Obama will still be President, but plenty of votes on it) and others preparing to Get ready for the next (fake) Obamacare freakout.

While this week the Supreme Court did NOT rule on the remaining ACA related case for this session, it did rule on one that some think could foreshadow a case winding its way through the appellate courts:  What The Supreme Court's Greenhouse Gas Ruling Should Mean For Obamacare.  I include this in the interested of presenting differing views.  The author makes the argument that the Supreme's decision regarding the EPA will impact the cases regarding the presence of subsidies on the Federal Marketplace (as opposed to the state marketplaces).    I disagree - the case regarding the subsidies is based on ambiguous language, HHS was attempting to clarify, not add new regulatory authority as could be argued in the case of the EPA.  Of course many of us were least worried about the Medicaid expansion when it came to the original Supreme Court review, so never say never...  (Note that the subsidy case is still winding its way through the appeals courts and has not yet reached the Supreme Court.)

Of course as these arguments and others (see Costs below) continue to be made, Paul Krugman argues that opponents are Zero for Six - The Incompetence Dogma: So Much for Obamacare Not Working.

ACA: Premiums/Costs

Proposed premium rates out for two more states this week, again, no large spikes to be seen anywhere: D.C. health insurers propose rate hikes for 2015 and Colorado’s 2015 Premiums: Up, Down And Holding The Line.

ACA: Marketplaces

Be careful what you wish for (part 1). 

HHS released proposed regulations for how re-enrollment will work for consumers on the marketplace as their plans expire.  Here is a good general overview: Most Will Be Able to Automatically Renew Coverage Under Health Law and here are links to the proposed regulations: HHS announces auto-enrollment plans for current Marketplace consumers for 2015 (Primary Source).

One of the keys pieces of the proposed regulations is that people will automatically be reenrolled in their current plan if they take no action.  That is something that the advocacy community was hoping for since it means by default people will continue to have insurance coverage.  On the face of it, that makes a lot of sense as that's what happens with coverage people have at work and with other insurance people buy on their own.

But...  While it's clear the intent was to keep people covered and enable the marketplace (and navigators and assistors) to focus on those still uninsured, there will be unintended consequences that may cause problems (and higher costs) for individuals. 

First, note that the marketplace will send out a notice to individuals it decides will qualify for automatic renewal.  Those notices will contain the individuals new estimated subsidy, but they WILL NOT contain the new premium amount for the next year for the plan they will be automatically reenrolled in (why we're not sure as the marketplace systems will have access to those amounts).

Second, note the new analysis from Avalere Health regarding shifting premiums (Exchange Plan Renewals: Many Consumers Face Sizeable Premium Increases in 2015 Unless They Switch Plans - Primary Source).  The analysis points out that  with changing premium rates (even in states like Maine where the increases will be small) it is very likely that the subsidy "benchmark  plan" will change.  So the plan on which the premium subsidies are based may very well be a different plan.   This means that Obamacare enrollees may have to switch plans next year, or else pay more.

So the question is that while Most can auto-enroll for insurance, but should they? 

Bottom line - during the next open-enrollment period in addition to reaching the individuals who are still uninsured it will be important to educate those currently enrolled about their options - and potential cost savings - even though by default they will not have to take any action.  It would be helpful if the notices the Marketplace sends out had more information than is currently in the draft notices, but I'm not holding my breath.

Moving on to other Marketplace related issues, for those that have implemented their own marketplaces, many States don't know how they'll pay for year two of Obamacare (remember the Federal grants were for design and build, not for ongoing operations).  And a Deal reached on botched Mass. health site.

A report by the Commonwealth Fund that State Restrictions on Health Reform Assisters May Violate Federal Law, although I'm happy to note that while Maine has a law regarding navigators it does not have any laws that violate Federal regulations.

Community Catalyst reminds us of something we already knew here in Maine, namely How state-based advocates made open enrollment a success.

And finally, some thoughts on shifting the open enrollment period away from the end of the year: The Obama administration chose the worst months of the year to sell health insurance and Study: Tax refunds could boost health coverage .

ACA: Employers

Employer Health Costs Forecast To Accelerate In 2015 But note that the acceleration predicted is 0.3%: " If health plans stay unchanged, PwC sees medical costs rising by 6.8 percent in 2015, up from a projected increase of 6.5 percent this year."  (Primary Source:  Slight uptick in expected growth rate ends five-year contraction)

At times I (and others) have noted that there are no subsidies for those who have access to health coverage at work.  That is not completely true.  You could argue that the tax deductibility of premiums paid through an employer-sponsored plan is simply a different type of subsidy.  The CBO released a report looking t the Coverage Effects of Limiting the Tax Exclusion for Employment-Based Health Insurance.  Bottom line, they are not pretty.  At the end of the day the tax exclusion is worth more than individual subsidies, so if you scaled it back (or eliminated it) you would end up increasing the number of uninsured.

ACA: Other

Meanwhile...

The Hobby Lobby Decision Is Coming Soon—and It Won't Just Affect Contraception  - A helpful review of the case, we'll see the Court ruling released on Monday (6/30) so stay tuned.

And while a certain former Secretary of State is not officially running for any office, Hillary Clinton wants 2014 Democrats to run on Obamacare.

Finally, Is Obamacare Living Up to Its Preexisting-Conditions Promise? More focus on the problem in FL concerning coverage of AIDS medications (even generic ones) being put in the most expensive tier.  The article is a little hyperbolic - this is clearly a violation of the law and while it may take time to be resolved, it doesn't mean the law if failing.

Medicaid

Activity in Virginal around expansion continues, with the Va. House tosses out governor’s vetoes.  Remember from last week those vetoes were meant to preserve his right to expand Medicaid without legislative action.  There were also dueling experts in the state with  Va. House Republicans tout report saying Medicaid expansion is a legislative decision.  But the Governor does not seem to have given up yet, so stay tuned.

Not getting a lot of attention, but a report out on how Medicaid Managed Care plans are not necessarily getting the financial oversight they need:  The Medicaid Black Hole That Costs Taxpayers Billions.

A review of The Truth About Health Reform’s Medicaid Expansion and People Leaving Jail.

And finally, for those into infographics:  Visualizing Health Policy: Understanding the Effect of Medicaid Expansion Decisions in the South

Medicare

With respect to hospital quality, the leverage the Federal Government has is the Medicare program.  In an attempt to use that leverage, Medicare will penalize hospitals with the worst patient safety records.  When releasing the preliminary numbers, More Than 750 Hospitals Face Medicare Crackdown On Patient Injuries.  For the local story note that Maine hospitals could face penalties for high rates of infections, complications.

VA

More information on how bad things were at the VA with Investigator Issues Sharp Criticism of V.A. Response to Allegations About Care.

With both houses of Congress having passed similar bills, the conference committee is now meeting but Congress Has One Hurdle Left to Pass a VA Bill, But It's a High One.  Namely how the fixes will be paid for.  It's grown so contentious that some, since they can't agree on how to pay the estimated price tag, are saying the price tag is wrong: Lawmakers slam veterans health bill cost estimate.

Drugs

Two stories on the 340B program that provides discounted outpatient drugs for certain facilities.  Questions about what facilities are/should be eligible as well as how those facilities are using the money:  Drug Discount Policy For Hospitals, Clinics Under Scrutiny, Drug Discount Program Has Drugmakers Crying Foul.

Meanwhile the NY Times Editorial Board looks at the ramifications of Refusals to Pay High Drug Prices.

And some proof that the promise of big data can be realized as the FDA Harnesses Power of Claims, EHR Data for Monitoring Drug Safety .

Costs

Be careful what you wish for (Part 2).

If you wish for lowering health care spending, be prepared for the impact that has on the economy:  Good News on Health-Care Spending Is Making U.S. GDP Look Bad

"The BEA initially estimated that health care spending climbed 9.1 percent in the first quarter of 2014 — a potentially worrisome increase. The agency released their second revision of that number today: now they believe that health care spending has fallen by 1.4 percent (Health spending actually fell while Obamacare insured Americans)."

This piece (towards the middle) explains how the initial estimate was so far off (spoiler alert, they guessed): The economy just had its worst quarter since the Great Recession. Here’s why you shouldn’t worry.

And finally, I would say you won't believe this one but I'm sure you will.  A look at how you damned if you do and damned if you don't:  Here Is the Most Shameless Anti-Obamacare Argument Yet.

Remember those pesky "facilities charges"?  Well with that in mind it's no surprise then that Hospital Outpatient Prices Much Higher than Community Settings for Same Services .

And for those of you who have been worrying about doctors because of all those reports of how bad things have gotten for them, relax.   Doctors have it pretty good since Nine of America's ten top paid jobs are doctors.  Personally, I'll take the tradeoff discussed and replace our system with the French one - lower medical school costs and lower provider salaries. Anyone else in?

Vaccination

A subject I think it critically important gets its own section this week.  We'll start with a look back to the year 2000 and How Congress Brought the Measles Back.  This in light of the continued measles outbreaks across the county.  Here's a little science to go with your policy:  Measles cases are spreading, despite high vaccination rates. What’s going on?

Some good news with a Court ruling: parents don't have the right to send their unvaccinated kids to school.

And as we see in Ohio Amish Reconsider Vaccines Amid Measles Outbreak a plea that If you believe in vaccines, please speak up.

System Transformation

While the appropriate timing and frequency of breast cancer screening continues to be debated, reports that 3-D Mammography Test Appears to Improve Breast Cancer Detection Rate.  But all is not as it seems.  I note that the equipment manufacturer paid for the study.  Based on the results of the study it is not clear if the new technology truly represents a benefit.  The equipment is twice as expensive, and there are still those pesky questions about who should really be screened and when.  The new technology may turn out to be useful, but the evidence isn't there yet.

And speaking of cancer, the question is asked Is America better at treating cancer than Europe?  One of the counterarguments to last week's stories on the US's health system rankings was "but when people are treated we do a better job".  The article looks at the question but the bottom line is that while it's really hard to tell we probably are not better than Europe.   The piece is worth a read in order to understand the fallacy of just looking at survival rates.  (Spoiler alert - if you improve detection (finding the cancer earlier than you previously did) but don't treat it, the survival rate still goes up.)

One the positive side, there are studies that will lead to improved treatment and outcomes:  Longer Heart Monitoring Backed for Stroke Patients.

And some more good news:

• Abortion Funding for Peace Corps' Volunteers Advances With Republican Support (matching for Peace Corps volunteers what is available for Federal employees and the military)
• Without fanfare, Obama advances transgender rights

A very thoughtful piece that makes the valid point that protocols and guidelines as written should not be followed blindly.  I would state it differently, I would say that the protocols and guidelines need to be written with flexibility and grey areas in mind.  A "good" protocol would account for variation in individual patients and the lack of clarity in the existing evidence.  How does evidence-based medicine affect the art of medicine?

Some additional pieces looking at quality issues:

• We need more clinical time outs
• We should value quality when we shop for health care
• Don’t mistake patient satisfaction for patient-centeredness
• Why patient satisfaction surveys are riddled with problems

A long read shining light on behavioral health care: Cost of not caring: Stigma set in stone - MENTALLY ILL SUFFER IN SICK HEALTH SYSTEM.

A look at how some people end their days At Acute Care Hospitals, Recovery Is Rare, but Comfort Is Not.  Also looking at end of life issues, this week's grab a tissue piece:  Empowering patients: Emergency department palliative care

And finally, it seems comedic medical videos are a new thing.  Last week I shared Doctor House of Cards, this week what ER treatment would look like if homeopathy was medical care:  What if homeopathy invaded the ER?  This.

All comments and suggestions are welcome; please let me know what you think.  And as always, thanks for reading!

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Funded by support from the Maine Health Access Foundation

*The title is a tribute to the BBC show, the NBC show and the amazing Tom Lehrer album "That Was The Year That Was"

That Was The Week That Was - Issue 15

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

New information this week on the number of previously uninsured purchasing on the Marketplaces, a report on financial assistance on the Marketplaces, more premium information, a look at how the US health care system stacks up and much much more...

ACA: Polls/Opposition

Big news this week from a Kaiser survey that said: Survey: Most Buying On Insurance Exchanges Weren’t Previously Covered.   This contradicts opponents of the law who said the uninsured were not being covered.  While there was a great deal of (justifiable) excitement over this announcement, it is worth noting that this survey shows much higher numbers for people on the exchanges being covered than shown by previous surveys.  The differences may be due to the way  the question was asked.  This coverage takes a look at the differences:  (Most Obamacare exchange enrollees were previously uninsured, survey finds).  Part of the question is how people categorized themselves if their previous policy was canceled as well as the issue of churn, some may have been covered for part of the previous year but not all of the previous year.  There is no question many of the people purchasing coverage on the exchanges were previously uninsured, but for now there is still some question as to exactly what the percentage is.  (You can find the full survey results here: Survey of Non-Group Health Insurance Enrollees.

A new spin out on the ongoing question, if people like most of the elements of the ACA, why does public opinion continue to be so negative?  Some think it is a reaction to the President and to false stories about the law, this piece says  " Instead, the public’s disapproval of Obamacare considered as a whole points to Americans’ broader relationship with the government, and our unwillingness to trust that it can accomplish what it sets out to do." (Americans’ Faith in Government Shapes How They Feel About Obamacare — Trust Me ) .  Sad to say the initial problems with healthcare.gov probably exacerbated those feelings.

And yet, opponents of the law continue to have problems sticking to a story.  The GOP's Latest, Embarrassing Retreat from the Obamacare Wars and This Is What It Looks Like When an Obamacare Attack Backfires.

ACA: Premiums/Costs

HHS came out with a report on premium affordability and the marketplace (primary source: PREMIUM AFFORDABILITY, COMPETITION, AND CHOICE IN THE HEALTH INSURANCE MARKETPLACE, 2014).  The report showed that Obamacare costs $82 for subsidy-eligible people and $264 for the feds on average while here in Maine, Mainers paying average of $99 in monthly premiums on exchange.  Or to put it another way, Millions of Americans are paying less for Obamacare than cable.  The importance of this report can't be overstated.  Surveys have shown that among the people who did not sign up for coverage, the most cited reason was concerns over affordability.  As we hear up for the next enrollment period (starting in November) it will be critical to spread the word on just how affordable the subsidies make health insurance.  (Of course acknowledging that this will not be the case for all, even with subsides some will find the premiums too expensive and some will not be eligible for subsidies.)

Health insurance premiums rise every year, that was a fact of life before the ACA, and it will continue to be one at least for now.  The question is, are the increases more moderate than they otherwise would have been?  Here is a look at the public filings so far:  Avalere Analysis: Average Exchange Premiums Rise Modestly in 2015 and Variation Increases.  Although it's worth noting that these look at the rates that were filed and are not final (they may be changed during the process). 

One of the factors to keep in mind is that More Insurers in Obamacare Mean Lower Premiums.  As we'll see in the next section, lots of good news this week about participation in the exchanges.

ACA: Marketplaces

It seems that Healthcare.gov's terrible rollout didn't scare away insurers.  You can find the full report by the Advisory Board here, it says: In every state so far, more insurers are asking to participate in Obamacare.

We also had a report this week from McKinsey looking at narrow networks - the reason given for creating them is that they are less expensive without giving up anything on quality.  And that's what the report found (Hospital networks: Updated national view of configurations on the exchanges ).  Although it's worth keeping in mind that this looks at the networks overall, it is possible (and probable) that there are bad narrow networks as well as good ones and in fact some states are taking a closer look: California probes Obamacare doctor networks at Anthem and Blue Shield.

The Kaiser Media Fellowship sponsored a trip to Washington State for some reporters, leading to two stories making the same important point: Obamacare struggles, even where it’s succeeding and Washington state loves Obamacare — and still has challenges making it work.  Even when all is going as well as possible, there are still challenges both in implementing the law and with certain ramifications of the law as written.

ACA: Employers

While much of the business related coverage of the law has focused on the negative, this week Forbes takes a look at Four Reasons The Affordable Care Act Is A Boon To Entrepreneurs.

ACA: Other

As we near the end of June, the Supreme Court decisions will be coming fast and furious.  Since we might get a decision any day, here is a A guide to the Supreme Court’s upcoming birth control decision.  (This is the Hobby Lobby case which will decide if a corporation can have a religious objection to a law...)

As a supporter of the law, the hardest issue to come to grips with has been the difference between policy and implementation.  The policy pieces of the law may not be perfect, but if fully implemented they would go a long way towards bringing all of us a better health care system. We all know about some of the larger implementation issues and probably have some sympathy when it comes to rolling out a mammoth computer system... but when the administration ends up Bungling the Easy Stuff it is particularly frustrating.  To date, no final rules have been issued on the simple piece of the ACA saying that those who need financially assistance have to be charged the average rate paid at the hospital - not the "chargemaster" rate.  As I said, frustrating.

And speaking of some of the frustrations, here's a (depressing) assessment on What would it cost to ‘fix’ Obamacare?

On the positive side, a study out this week that Young adults healthier after passage of Obamacare, study finds - evidence that the law is having positive effects, not only on coverage rates, but on people's health (primary source: Young adults report better health following Affordable Care Act).

To try and address some of the implementation issues, the new Secretary appears to be following earlier recommendations regarding managing the implementation as HHS’s Burwell makes management changes.

Also activity this week on getting various messages out:  First a new campaign to help enrollees get the most out of their coverage (From Coverage to Care: A roadmap for using your new coverage).  Second a campaign to let people know about special enrollment periods (New O-Care enrollment campaign targets millennials) and finally, Enroll America Pushes Ahead To Second Enrollment Period (because November will be here before you know it).

VA

On the Veteran's Administration front, an updated report shows that VA chief: More vets wait 30 days for appointment. 

Also this week the House VA bill advances and the House creates VA conference committee (including our own Congressman from Maine's second congressional district).  The conference committee will work with the Senate (who passed a bill the week before) to create a final version.  Meanwhile some info on The costs of the Senate VA bill.

But not everyone is happy, as some say: The VA Reform Legislation Is a "Trojan Horse" for Privatization: It would do more harm than good. 

One form of "privatization" has been the ARCH pilot (being tried here in Maine, in rural Virginia and a few other locations).  While most reports of the pilot have been positive, still no word on if it will be continued (Future Uncertain For VA Rural Health Pilot Program).

Medicaid

More maneuvering in Virginia with respect to Medicaid Expansion as McAuliffe to sign budget, veto Medicaid amendment.

One piece of the ACA was the temporary increase in primary care reimbursement rates for Medicaid.  Now Physicians Push for Extension of Medicaid Reimbursement Increase although if you look above at the cost fix story, getting that done is no small matter.

The Urban Institute took a look at 14 large cities, half having expanded Medicaid and half in states that have not.  Not surprisingly, These 7 major cities are losing out on a big part of Obamacare (the ones who haven't expanded).  You can see the full report here: The ACA and America's Cities: Fewer Uninsured and More Federal Dollars.

Medicare

We've talked before about "observation status" in a hospital (as opposed to being "admitted".  Here is a very useful piece to help you understand what's involved: FAQ: Hospital Observation Care Can Be Costly For Medicare Patients.

One reason hospitals may be more inclined to use observation status instead of admission is the importance of readmission statistics.  For this and other reasons, Senators Offer Bill To Ease Readmission Penalties On Some Hospitals.

Drugs

Are you tired of me reporting on Sovaldi (the Hepatitis C treatment) yet? Sorry, but the topic is not going away - this week reports on the overall impact here in the US:  $1,000-a-pill Sovaldi jolts US health care system.  The possibility that the U.K. Cost Regulator May Reject Gilead’s Sovaldi Treatment.  And an attempt to come up with a shorter (and less expensive?) course of treatment: Exclusive: A four-week hep C cure? Bristol to test drugs with Gilead's Sovaldi.

Costs

On the cost front, the former Director of the CBO and OMB and now a Vice-chair with Citigroup says Orszag: It's time for some optimism about health care spending.  The piece looks at a variety of factors leading him to conclude that "If this continues, it's massive — everything you think you know about the nation's long-term fiscal gap would be wrong."

Also on the cost front a report looking at Insurers Push Back Against Growing Cost Of Cancer Treatments.  And a reminder that Mental illness isn't just a health issue. It's an economic issue.  This second piece continues the ongoing thread reminding us that what happens in the provider's office is only one (small) piece of keeping people healthy.

System Transformation

The Commonwealth Fund released its annual comparison between the US health care system and those of other countries.  Lots of coverage so I'll provide just a small sample.  First, the primary source for those who want to read the study: Mirror, Mirror on the Wall, 2014 Update: How the U.S. Health Care System Compares Internationally.

Here is a basic overview: Once again, U.S. has most expensive, least effective health care system in survey , and here is a story that includes a look at ACA implications of the survey:  U.S. health care system ranks last among industrialized nations.  In spite of this, according to a Gallup survey out this week, Most Americans Remain Satisfied With Healthcare System. 

On the technology front, Google and Apple want to be your doctor, and that’s a good thing.  And not just them WebMD Wants to Collect Your Health Data in One Place — Just Like Everyone Else.  Aggregation of data on the consumer front has been tried before (by some of these very same players) but the hope now is that the interest is greater and technology has caught up with the aspirations.  And while some (including me) see great promise, there are those who say Apple’s HealthKit Probably Won’t Bring a New Age.

A key to the above efforts being successful would be integration with the individual's EHR.  For years we've been hearing negative stories about how all they are doing is interfering with the doctors work.  But that is not everyone's opinion:  Why this doctor loves her EHR.  And increasing use of an interim step to help doctors with the technology (Why have scribes become so pervasive in health care?).

Again, policy vs. implementation, there is no question that the switch to EHRs has not gone smoothly: Electronic health records: A 'clunky' transition.  But I continue to have hope and Embrace the age of digital medicine.  And finally, a success story: How Google Glass Automates Patient Documentation For Dignity Health.

If you watch House of Cards and bemoan those who object to safe and effective vaccinations, take a minute to watch Doctor House of Cards:  Going House of Cards on anti-vaxxers: Why we need Frank Underwood.   Think this is much ado about nothing?  This week CA announced that whooping cough had reached "epidemic proportions" (We have a vaccine for whooping cough. So why's it an epidemic in California?).

This week we'll end with a laundry list

Some concern overtreatment and inappropriate treatment:

• Maybe we don't all need annual physicals
• New Heart-Valve Procedure Sparks Doctors' Concern: Less-Invasive Treatment Is Unproven for Many Patients - "Compared with surgery, TAVR results in higher rates of some serious complications, including blood-vessel damage, stroke and the need for pacemakers after the procedure, studies have shown."
• Consumer Group Urges Hospitals To Stop Promoting Questionable Screenings

Some concern exciting new research:

• In Single Gene, a Path to Fight Heart Attacks
• The end of aging Do naked mole rats have the secret to long, healthy lives?

Some concern the triumph of rationality:

• Dr. Oz Grilled In Congress, Admits Weight Loss Products He Touts Don't Pass 'Scientific Muster'
• Fewer Women Are Having Labor Induced Early  

And last but not least a reminder that the system may be working perfectly when nothing is being done:

• Watching people die is sometimes the compassionate thing to do  (have your tissues out for this one)

Thanks for reading!

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Funded by support from the Maine Health Access Foundation

*The title is a tribute to the BBC show, the NBC show and the amazing Tom Lehrer  album "That Was The Year That Was"