Friday, March 28, 2014

That Was The Week That Was - Issue 3

Welcome to the third edition of this newsletter.   Without question, the nearing the end of the first open enrollment period is the story of the week.   Across the country, everyone is pulling out all the stops for the final push Insurers Push to Enroll People as Health Care Deadline Nears.  Although as we’ve known all along, there will be some eligible people who won’t enroll this time around Millions On The Sidelines For Big Health Care Push.

With the inevitable rush during these last few days, the Administration has let us know that if you start the processes before the deadline you don’t need to be completely done by midnight on Monday  U.S. to Extend Sign-Up Period For Insurance.  Contrary to what some would have you believe, this is not an exceptional decision.  When Medicare Part D was rolled out, the same thing occurred: Flashback to 2006: When Bush extended an enrollment deadline.  You can see the list of who can get an extension here: Here Are the 17 Ways You Can Get an Obamacare Extension.

Amidst all this activity, the Administration announced that as of Wednesday over 6 million had signed up for insurance through an exchange:  White House Says Health Care Rolls Top Goal: 6 Million.  We need to take these numbers for what they are, a preliminary indication of a broad national number, but although preliminary, they are a good sign Benefit Experts Agree With Obama That ACA Has Enough Enrolled

A tale of two cities 50 states:  Although the media may focus on the national figure, let’s remember there is no national market for insurance, due to state regulations we have fifty insurance markets that are as different as can be Obamacare's National Enrollment Looks OK, But States Matter More.  In fact, the odds of you knowing about the benefits available to you and taking action depend a great deal on where you live Deadline Near, Health Signups Show Disparity.

Even though we’ve passed the fourth anniversary of the law and nearing the end of the first open-enrollment period, the court battles continue.  This week saw the two most significant remaining challenges back in Court.

First, the Holly Hobby case in the Supreme Court; does a private company have the right to a religious exemption from the contraceptive mandate.  This week saw the oral arguments before the Court – we’ll have to wait a few months for the decision, but that didn’t stop the Court-watchers from trying to guess the outcome:  Birth control rule seems to divide Supreme Court and Supreme Court divided as it hears argument on contraceptive coverage and Hobby Lobby case: Nine justices to watch.

While I don’t want to minimize the importance of this case, even if Holly Hobby wins, the law itself will still stand.  Of possibly greater consequence to the implementation of the ACA is the case arguing that the Federal Marketplace cannot provide subsidies.  Apparently I’m not the only one with that opinion:  Forget Hobby Lobby. The Bigger Legal Threat to Obamacare Still Has Life  and The contraception case is big, but another challenge could really hurt Obamacare

While we watch the enrolment process and the courts, some are watching us – or at least asking us what we think.  There were several new polls released this week.  None of them provide any exceptional new insight but they do serve to reinforce the failure of some of the communication efforts around the law. 

To me, this quote says it all:  “I like the idea that if you have a pre-existing condition you can’t be turned down, but I don’t like the idea that if you don’t have health insurance you’ll be fined,” said Sliger. (Poll: Obama health law fails to gain support)  I can’t blame this person for not understanding that the health insurance market won’t work if you didn’t allow for pre-existing condition exclusions and you didn’t require everyone to get coverage.   I blame myself and others who have been trying to explain that to the public for years for not being able to get the message across. 

There is also a great divergence of opinion on what the impact of the law will be on health care costs – some say lowering costs is a great benefit of the law while some say impact on costs is why they don’t like it Why Americans like Obamacare (and why they don’t) — in two charts.  You can find a complete look at the Kaiser survey results here: Kaiser Health Tracking Poll: March 2014.

Also in the news this week, the Doc Fix was back.  This is the issue around Medicare payment rates to physicians; this year if a fix is not passed they will see a 24% reduction in their rates.  A few weeks ago we thought we’d finally see a permanent fix to this issue, but instead once again at the last minute we’ll see a temporary fix (for just one year) and hope that by next year this annual charade will stop House approves bill to stop cut to Medicare docs.

Four years after its passage, in addition to the continued court challenges described above, the political opposition continues to talk about repeal and replace, although they still do not seem to have figured out what they are replacing it with Four Years Into Obamacare, GOP Comes Up Short On Alternative

For the first time we saw a group of Democrats come together with some suggestions for “fixing” the law 5 Senate Dems back easing small business mandate.  Something that polls continue to indicate most people would prefer to the actual repeal of the law.  To me this is a positive sign.  Even the most ardent supporters of the law (like me) understand that it is far from perfect.  If we could get past the extreme partisanship there are changes that can be made to improve the law.

That’s it for this week – remember this is just a sample of the coverage out there.  And remember, I consider these a work in progress so please let me know what you think!

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"

Tuesday, March 25, 2014

Guest blogger over on Enroll207.com

Today you can find me over on Enroll207.com where I'm featured as a guest blogger with my post: It's About Community




Friday, March 21, 2014

That Was The Week That Was* - Issue 2

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

Welcome to the second edition of this newsletter.  You'll note that this one is a bit different - I've taken some very helpful feedback and shortened it considerably.  As much as I found all the articles in the last one interesting, not everyone has the time to plow through so much content.  So this week we take a more focused look at what went on.  Please continue to provide comments and feedback, as you see, this is still very much a work in progress.

The top story this week has to be the approaching enrollment deadline.  As I write this on Friday morning, there are a little less than 11 days to go. 

Let's start with where we are now - we saw "enrollment" hit 5 million this week: Health law enrollment hits 5 million with 2 weeks to go.  To-date I have objected to the focus on enrollment targets, but with the approaching deadline, it's inevitable that they will be reported and discussed.  So bowing to the inevitable I'll include them here.  Note that the "consensus definition" of enrollment has become those who selected a plan on a marketplace (be it Federal or State).  This does not take into account how many have gone ahead with the last step of paying their first month's premium.  Estimates vary from 75% to 90% as to how many take the final step.  We won't know the answer to that one for another couple of months.

How many of you remember Nate Sliver?  He is the blogger who came to prominence during the last presidential election by correctly predicting 49 of 50 state results (others did even better, but he is the one who got the coverage).  This open enrollment period seems to have led to a "new Nate Sliver" - and he thinks that contrary to what was being forecast at the beginning of March, not only will enrollment reach 6 million, it will blow past it to 6.2 million:  This guy knew when Obamacare enrollment would hit 5M before anyone else. Now he’s predicting 6.2M.

Regardless of the final number, it seems clear that overall the ACA will not collapse under its own weight:  Benefit Experts Agree With Obama That ACA Has Enough Enrolled.  But remember, this is really a 50 part story, while the national figures will get the attention, each state has its own insurance market and there will doubtless be a few that will have a tough time going forward.

So that's where we are, and a prediction of where we're going.  But with 11 days left, how are we going to get there?  Since March madness has begun, the only way to say it is we'll get there with a "full court press".  The Administration is using basketball in its attempts to "stuff the basket" (ok, I'll stop now):  Obamacare meets March Madness.  But not just basketball - The President was on Ellen this week talking Scandal, House of Cards and the ACA: President Obama On Ellen talks ACA (sorry, that clip is just the ACA segment).

For those looking for a handy basic introduction to enrollment, this piece is helpful: The Sign-Up Deadline Is March 31: A Consumer Guide.  And for those wondering when Ezra Klein (formerly of Wonkblog) would resurface, here is a handy explanation of the individual mandate including why it's needed provided by his new site:  Obamacare's individual mandate in two minutes.

Also under the category of momentous dates, Sunday marks the fourth anniversary of the bill's signing: Obamacare turns 4: Will anyone notice?

While it would be easy to just focus on this open-enrollment period, time marches on.  Looking forward the Administration has released new guidance regarding plans that will be offered for 2015: White House Tightens Health Plan’s Standards After Consumers Complain.  One of the big issues, both here in Maine and nationally, is the "narrow networks".  As we know, while the concept isn't new they've become much more prevalent.  The new standards begin to address them, and for further information, here is an industry based look at the concept:  Are your networks too narrow?.    When discussing networks its always worth repeating the ramifications of going outside them:  Warning: Opting Out Of Your Insurance Plan's Provider Network Is Risky.

The Administration has also said that those sub-standard plans that should have been cancelled last year but weren't can stick around another two years: Obama administration wants fewer people to get insurance cancellation notices

Of course, in addition to what the plans cover we also have to think about what they cost.  While individuals receiving financial assistance will be somewhat protected from rate increases (the percent of their income they are asked to contribute don't change, so if the plan rate goes up the subsidy will go up) long-term if the subsidies get too expensive something will have to change.  Right now, 2015 rates are anybody's guess - and everybody is guessing:  The Latest Obamacare Doom Prediction—and What to Think About It.
Looking toward next week, the Supreme Court once again here's an ACA case.  This time centered on the birth control issue for private employers: Everything You Need To Know About The Supreme Court Taking On Birth Control.

Shifting focus away from the ACA, the issue of health disparities was in the news this week.    Two excellent reviews of some of the issues involved and the scope of the problem:   Income Gap, Meet the Longevity Gap and Q&A: How States are Tackling 'Health Disparities'.  Also some thoughts on how it needs to be addressed by the provider community: Screening for poverty should be included in the medical curriculum.

We'll end with a look forward.  Maine's own Patent Centered Medical Home pilot received some focus: Our View: Pilot program focuses on health, not sick care: A team-based approach to medicine is starting to help Mainers but needs more time to develop.  This follows a few weeks of stories calling into question the efficacy of the Medical Home concept due to a recent study that failed to find the promised cost savings.  My take is that these pilots are still very much a work in progress.  The theory is sound but we haven't yet figured out how to make them work as well as they could.  It's not a simple issue, here is a helpful look at the issues involved:  Redesign the medical home to thrive in the real world.

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"


Friday, March 14, 2014

That Was The Week That Was*
A look back at the weeks health policy news with a focus on ACA implementation

Mitchell Stein
March 14, 2014
March, 14 2014

Welcome to the first edition of this newsletter.  As always seems to be the case these days, lots going on so let's dive right in.  We'll start with this release of new enrollment figures and move on from there. 

ENROLLMENT

In my initial review of the enrollment data (available at the end of this document) I noted that opponents of the law would try and make something of the drop off in enrollment between this report and the last one.  And while that's certainly happened, we've also seen some interesting analysis saying there was no drop-off:

First the numbers

Next, enrollment numbers as Rorschach test

But wait, how many days were there in February?

So the numbers didn't really show a slowing of enrollment

But realistically, going to be touch to hit 6 million by the end of March

And  finally, we need to remember that these numbers are those who have selected a plan on a marketplace, not those who've paid their first month's premium (so not really "enrollment" numbers)


CONTINUING EFFORTS

Even before the numbers were released with the March 31 deadline approaching the final press had begun.  

One of my favorites was the President heading to alternative media

Which actually seems to have helped

And of course here in Maine, naked men get people's attention


THE REGULATIONS - SOME CHANGE SOME DON'T

The biggest date that won't change is the end of open enrollment - still March 31 and given how emphatically it was stated hard to see it changing

One of the positive changes is that the cost-sharing subsidy funding will no longer be subject to the sequester cuts (the premium subsidies never were going to be)

And an understandable break on MLR for insurers increased costs due to the rollout "glitches"


THE PREVIOUS NON-PARTISAN EFFORTS ON THE DOC FIX JUST TURNED PARTISAN

The Doc-fix is the efforts to eliminate the annual problem of Medicare's physician payment system.  With health care cost inflation at historic low, now was the time to make a permanent fix.  However the House Republican's have attached the non-partisan fix to a postponement of the individual mandate for five years. Something they know won't get past the Senate and the President

Not to mention the negative impacts of delaying the mandate

So negative that the American Medical Association who has lobbied (hard) for a fix for years rejects tying the two issues together

And a reminder how important - and problematic - the mandate is


AND THAT'S NOT ALL CONGRESS IS UP TO

They passed three laws this week that span the spectrum from good to unnecessary to bad.  Note that it is unclear if any of these will make it to the Senate and then the President's desk.

The potentially good one (or at least harmless one) in the mix would allow employers to not count veterans when calculating their number of employees.  The idea is that firms would have an incentive to hire more veterans (Hire More Heroes Act, H.R. 3474).

The unnecessary one states that volunteer firefighters and emergency responders are not employees and so don't have to be offered health insurance.  The problem is they are already not considered employees per the most recent Federal guidance on the issue (Protecting Volunteer Firefighters and Emergency Responders Act, H.R. 3979).

And finally, the most troubling one would let people avoid buying health insurance under Obamacare if they could cite a religious reason.  There are many questions regarding if this is enforceable or if it would just allow anyone to say they don't want to buy health insurance.  Note there is already an exemption for those part of an established religion with objections making this bill either dangerous or redundent  (Equitable Access to Care and Health (EACH) Act, H.R. 1814).

House OKs religious exemptions to having a healthcare plan


ENROLLMENT ISSUES

As we near the end of the enrollment period, some good reminders for those who work on these issues but great reminders for the public who does not.

Yes you do need health insurance

And if you don't get it, it will cost you

Understanding what is income can be complicated

And not all enrollment issues have been solved:


POLLS

As with the enrollment numbers, poll results can also serve as a Rorschach test.

You can take good news, like a drop in the number of uninsured
Survey: Uninsured rate drops; health law cited

For those of us who support the law, we can take a realistic look at the positives and negatives
Five takeaways from Gallup’s poll on the uninsured

But don't expect everyone to take that approach
Don’t Expect Conservative Media to Cover This New Obamacare Poll

Support continues to creep up (remember, in CNN's poll the oposition to the law includes those who say it doesn't go far enough)
CNN Poll: Support for Obamacare slightly edges up

Signs of increased support come from more than one poll with this one showing 64 percent of Americans now supporting it outright or backing small changes
Americans Stick With Obamacare as Opposition Burns Bright


MEDICARE

Mostly unrelated to the ACA but of note is that proposed changes to Medicare prescription drug coverage were pulled back by the administration

While the ACA mandated changes to Medicare Advantage reimbursement continue to have an impact

For a refresher on the issue, this older item may be useful


SYSTEM REFORM

In the long run, it is reforming the overall system that will free up the resources to provide access to all.  Here is one reminder of the scope of resources that may be reclaimed

And a reminder that change is hard and we must constantly be on the lookout for those unintended consequences

NEW RESOURCE

And finally, our friends at the Robert Wood Johnson Foundation have created a new website Financial Help for Health

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"










Enrollment Recap (originally published 3/12)

To me the biggest story around the enrollment report release yesterday was that it was not a big story...   

Doing a scan at 6 AM, it did not make the CNN front page or Google News top stories.  That said, some great coverage here in Maine around all of your efforts (see below).   And of course it wasn't completely ignored by the national media - and you can be sure that the law's opponents will try and make something of the drop-off in enrollment.  

The national press takes the drop-off in February to mean the Administration won't reach the "new" goal of 6 million by the end of March.  My take is we really have no idea how busy the end of March will be.  Massachusetts saw a tremendous spike at the end of their first deadline - but I'm leery of making any predictions based on one data point.  As we all move through the final push, please remember that while aggregate numbers are important, every individual who signs up for coverage is one less person at risk - and that means a lot.

And now some numbers and links.  Note that in the detailed report released by HHS yesterday.  There was basically only one number for Maine - reflected in this chart:

Monthly Enrollment
Cumulative Total
Oct
NA
NA
Nov
1,741
1,741
Dec
11,963
13,704
Jan
6,807
20,511
Feb
4,901
25,412

Maine health officials trying to sign up immigrants, hard-to-reach populations

More than 25,000 Mainers have signed up for health care coverage through ACA


National coverage:

Obamacare enrollment drops off in February

Health Care Enrollment Falls Short of Goal, With Deadline Approaching