A look back at the week's health policy news with a
focus on ACA implementation
Before we get to this week's developments, here is a review
of 9
mind-blowing facts about the dysfunction of the American health-care system.
Stark reminders of what we're trying to fix!
In other developments a look at good implementation results
(Hispanic coverage gains) and areas for concern (tax forms and security questions).
Also court developments, marketplace developments, lots on end of life care,
and wrapping up (or in this case rapping) with the funny video of the week.
ACA: Polls/Opposition
The ACA has many moving parts, I try and discuss both what is
and isn't working each week. But some coverage doesn't even try: " It's easy
to give people a skewed impression of Obamacare without ever running a false
story. The Affordable Care Act is a huge law, and at any given moment, there
are some good things happening in it and some bad things happening in it. If
you run multiple articles every day on the problems and nothing on the broader
trends, it's easy to mislead your audience." (In
conservative media, Obamacare is a disaster. In the real world, it’s working.)
By focusing on the negatives, the GOP
finds ObamaCare opening. Focusing on GAO reports of problems (including the
security issue discussed below).
Back on the positive side, a Commonwealth Fund survey
highlights another success, showing that Latinos
Get Insured by Obamacare in Large Numbers. (Catching
Up: Latino Health Coverage Gains and Challenges Under the Affordable Care Act
Primary Source.)
ACA: Court Cases
This week a federal appeals court tossed a suit regarding
the delays in the employer mandate (Court
tosses Obamacare mandate lawsuit brought by doctors). Of note is that this
is the same argument being brought in the House of Representative's suit of the
President. Is this a foreshadowing of how that case will be resolved? Only time
will tell.
Meanwhile, Hobby Lobby is the case that keeps on giving as House
Republicans fuming over 'regurgitated' birth control mandate stating that
the revised rules introduced to address the Court's decision flies in the face
of that decision. Also, Dad
pleads: Don't let health insurance offer my daughters birth control! He
wants to not have his insurance plan cover contraceptive care lest his
daughters access the benefit without his approval.
ACA: Premiums
The New York Times takes a look at the premium hikes this
year - both in a historical context and in light of what individuals can
accomplish by switching plans: In
Context, Health Premium Increases Don’t Actually Look Like Increases.
ACA: Marketplaces
The administration this week discussed that HealthCare.gov
Is Given an Overhaul while at the same time cautioning Don't
expect 'perfection' on health care site. It seems like public expectations
are lining up with the reality as Voters,
Administration Don’t Expect Perfection on Exchanges.
Meanwhile, HHS
announced that the marketplace would have 25% more insurers (New
Report: Health Insurance Marketplace will have 25 percent more issuers in 2015
Primary Source). One of my favorite reactions to this news was from the
Washington Post: "So c’mon, conservatives — look to your free market
principles, and give Obamacare at least a little credit." (Some
good news about Obamacare that even conservatives should love) Here in Maine these statistics are reflected
by the fact that Harvard
Pilgrim joins Anthem, Maine Community Health Options in state's ACA exchange
(and don't forget to read the sidebar on the left side of the page).
A mixed message from a report looking at marketplace
security: Government
Hackers Try To Crack Healthcare.Gov "The government's own watchdogs
tried to hack into HealthCare.gov earlier this year and found what they termed
a critical vulnerability - but also came away with respect for some of the
health insurance site's security features."
And a disturbing study regarding not so much the amount
spent (although that's not great either), but the lack of controls and
reporting regarding what is being spent: Obamacare
Website Costs Exceed $2 Billion, Study Finds.
Two different looks at narrow networks - the practice as
opposed to the theory - show positive results. First, from Georgetown
University's Health Policy Institute (hardly a mouthpiece for the insurance
industry) the finding that Narrow
networks draw few complaints from consumers: study. Additionally, a look a
"natural experiment" in Massachusetts also showed positive results: Physician
Choice in Exchange Plans -"Overall, spending on health care fell by
about 35 percent. Most importantly, this fall in spending was not uniform: we
saw an increase in spending on, and utilization of, physician primary care,
with large falls in spending on specialists, hospital inpatient and outpatient
visits, and emergency room use."
On the other hand, Consumer
Group Sues 2 More Calif. Plans Over Narrow Networks. Backlash or no
backlash, some days it's hard to tell. Putting the pieces together tells me that
narrow networks can be a viable option - when introduced to consumers appropriately
and with sufficient education.
Those who work with marketplace enrollees know this, but
it's worth repeating. There is a danger when low-income enrollees select the
bronze plan instead of the silver plan. While the premiums may initially appear
lower, doing so for those earning less than 250% of the Federal Poverty Level means
they forgo extensive additional help with their cost sharing. In addition to
impacting the individual, these Underinsured
ACA enrollees strain community health centers.
ACA: Employers
The Kaiser Family Foundation takes an in-depth look at
Private Exchanges. Remember, enrollees on these exchanges ARE NOT eligible for
individual subsidies. Instead, they may face higher costs if their employers go
this route since it may go hand in hand with a switch to a defined contribution
model of health benefits (as opposed to a defined benefit model): Examining
Private Exchanges in the Employer-Sponsored Insurance Market.
Elsewhere on the employer front, in a surprise even to me,
the National Opinion Research Center at the University of Chicago found that Obamacare’s
small business exchanges offer cheaper health coverage. Due to the lack of
functionality during the first year of the SHOP's existence, there have been
questions as to its utility. This study shows that even with those functional
limitations it's worth checking out the SHOP plan premium rates.
In a follow-up to last week's story, the Debate
Grows Over Employer Plans With No Hospital Benefits. What to many of us
seems like a clear error in the spreadsheet, to some it seems like an
intentional decision on the part of CMS. As the article states, we're still
waiting from clarification from CMS on what's really going on.
ACA: Other
In multiple public appearances this week, the new Secretary
of HHS Burwell
Touts Obamacare Gains Heading to Next Enrollment while at the same time
stating that White
House reassessing Obamacare enrollment goal for 2015.
We know that sometimes mistakes are made. It's nice to see
that when that happens, there are times when they actually get fixed as CVS
cuts checks after charging women birth control co-pay.
Also this week, Tim Jost took a look at the new tax forms
that individuals receiving subsidies as well as those receiving mandate
exemptions will need to complete: Implementing
Health Reform: Complicated ACA Tax Forms Could Cause Problems. The short
version is they are not pretty. The forms are complicated, and in the case of
those receiving subsidies require those who previously were able to use the
1040 EZ to now file a more complex form. This topic was also discussed at this
week's Exchange
Advisory Committee Meeting.
Costs
Did you know you can be billed by a doctor you never met and
never asked for? Unfortunately this has
always been the case - but it seems that the practice may be getting worse. The
NY Times looks at one man's experience and the underlying trend: After
Surgery, Surprise $117,000 Medical Bill From Doctor He Didn’t Know.
As a follow-up to last week's story about the first closure
of a proton-beam center, a report detailing that Insurers
Hesitant To Cover Many Proton Beam Therapy Treatments.
One of the standard arguments of opponents of the ACA is
that you can't truly address the cost problem without "tort reform",
changes to liability for malpractice cases. However, a New
study shows that the savings from 'tort reform' are mythical.
ACOs (accountable care organizations) continue to make the
news. You can find a review of what they are here: FAQ
On ACOs: Accountable Care Organizations, Explained. Sometimes they work: A
Health Care Success Story, sometimes it's more cloudy: Medicare
gives first glimpse of ACO quality performance, sometimes they don't work: Medicare's
Pioneer program down to 19 ACOs after three more exit and finally,
sometimes they struggle to do what they set out to do (so we don't know if they
would work or not): ACOs
struggle with advanced IT, interoperability, survey shows.
At the risk of repeating myself, I note that even as some
ACOs leave the Pioneer program, some of them (and others) others are joining a
different Medicare ACO program (the Shared Savings program). This is all still
very much a work in progress. While we'd like a clear answer on what works and
what doesn't, it's only be trying these different programs that we're going to
get to the point where we know those answers.
Medicaid
A report from HHS showing the Impact
Of Insurance Expansion On Hospital Uncompensated Care Costs In 2014
(Primary Source). Basically the report shows that Affordable
Care Act Reduces Costs for Hospitals, mostly by expanding Medicaid (Hospitals
In States That Won't Expand Medicaid Left With More Unpaid Bills). In light
of this, and all the other evidence showing the financial impact of Medicaid
expansion, it's not surprising that Money
talks: Obamacare initiative makes headway in Republican states.
When some states have expanded Medicaid, they've introduced
the concept enrollees paying premiums. Unfortunately, we now know that premiums
can be an obstacle to enrollment. Add to that the fact that sometimes the
amount collected does not even cover the administrative expenses of collecting
the premiums makes it clear that often the concept is being used to discourage participation
more than anything else: Medicaid
Gives the Poor a Reason to Say No Thanks.
Medicare
As we near open-enrollment on the marketplace, we also
approach open-enrollment for Medicare and Medicare Part D (prescription drugs).
With that in mind, HHS
Warns About Medicare Part D Coupons - this practice is illegal because it
provides perverse incentives for individuals to pick what ends up being a more
expensive drug. But the practice still goes on.
On a related note, there will be Fewer
Medicare Rx plans offered for 2015 "Christine Harhaj, a senior manager
at Avalere, said the consolidations likely reflect pressure from the CMS to
eliminate products that don't offer meaningful differences in benefit design
and make choices simpler for seniors. “A lot of times the choices can be
overwhelming,” Harhaj said."
Finally, on the Medicare front, note that there is
discussion of ACOs, including Medicare ACOs, in the Cost section above.
Drugs
Every time a rule is passed, those impacted by that rule seem
to work to undermine it. In the continuing battle for increasing the appropriate
use of generic drugs, Legislation
Would Prevent Drug Makers From Thwarting Generic Rivals has been
introduced.
Under the category of hard to figure out the right balance, DEA:
Vicodin, Some Other Pain Meds Will Be Harder to Get - on the one hand we
want to keep these out of the hands of abusers while on the other hand we don't
want to keep them out of the hands of those who truly need the relief.
System Transformation
After the release of the Institute of Medicine's report last
week, more focus on end of life care. We'll start off with a disturbing look at
how the system failed this family in a big way. Note that "The records she
obtained showed that in the last year of his life, his care cost at least a
million dollars." It was not for lack of resources, it was for lack of the
ability to use those resources appropriately: A
Father’s Last Wish, and a Daughter’s Anguish - Fighting Health Care System for
Simple Request: To Die at Home
Next a look at how one doctor was able to handle things the
way the family wanted, this is how it should work: Cost-benefit
analysis: A case where conservative management wins.
Care at the end of life can bring up difficult questions,
such as: Deactivating
a pacemaker: Is it euthanasia?
And here Kaiser looks at why the system is currently biased
against doing the right thing: Too
Many People Die In Hospital Instead Of Home. Here’s Why.
And finally, speaking of doing the right thing, Congress
approves tighter scrutiny of hospices.
On the vaccination front, strange bedfellows indeed as you
find me agreeing with an opinion piece appearing in the Wall Street Journal: The
Anti-Vaccination Epidemic - Whooping cough, mumps and measles are making an
alarming comeback, thanks to seriously misguided parents.
Several other items this week I found interesting:
- The mystery of the falling teen birth rate - linked to an earlier version, has been considerably updated
- What your education says about your health " "Health care reform must be accompanied by changes in social and economic policies that are a 'win-win': creating economic opportunity for families while also saving lives (and costs) from medical illnesses," they write."
- Why climate change is a growing health threat " The effects are different across the country, the op-ed notes. Maine, for instance, had seen a tenfold increase in Lyme disease cases over the previous decade, while the Florida Keys has reported cases of a tropical disease rarely seen in the United States."
And finally, in our comic video of the week, a graphic
reminder not to use antibiotics when they're not needed: DAWN OF THE DIFF (C. DIFFICILE
RAP ANTHEM).
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"
