Friday, October 31, 2014

That Was The Week That Was - Issue 34

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

Counting - that's our theme for today.  We look forward to counting new ACA enrollments.  With open enrollment beginning in just two weeks we'll look at some new resources.  We also look forward (this time with some trepidation) to watching the count of votes on election day - and the number of lives that could be impacted by the results as states choose to either expand Medicaid for the first time or roll back their expansion.  We'll finish up this week with the count of 1, the number of Ebola cases in this country.  You would think it would be one million based on the public hysteria.  All that counting and more as we take a look at this week's developments.

ACA: Polls/Opposition
With next week's election and the probable takeover of the Senate Republicans strategize attack on Obamacare if they win the Senate.  The behind closed doors sentiment that they still won't be able to repeal the law has led to the need for McConnell reassures GOP on Obamacare opposition.  While any full repeal would be vetoed by the President, it seems there is harm that can (and will) be done around the fringes.  We'll be watching closely.

A new analysis released this week showed that Obamacare brings Democrats backlash, not benefits.  The study looked at a variety of polls over time and found that " Only 47 percent of Americans agree that it’s the government’s job to make sure everyone has health coverage, down from 69 percent in 2006, the analysis found."  It seems all the negative attacks have impacted how people approach the fundamental goal of the law.  And a new poll that was part of the study showed that "31 percent want to see Obamacare repealed, (another) 23 percent want it scaled back."  So fully half the country is not on board.

ACA: Court Cases
Remember several months ago when Speaker Boehner said that the House would be suing the President? Well Despite hype, House still hasn’t sued Obama.  In fact Boehner has hired two law firms to sue President Obama. They've both quit. Perhaps the law firms thought better of it since the suit seems to have no basis (The Congressional Research Service Finds that Boehner’s Lawsuit Has No Legal Basis).

In other court news, it has been reported that at today's conference the Supreme Court will talk about taking up the subsidy challenge: "The plaintiffs in the King case appealed to the Supreme Court. The justices are scheduled to discuss the issue Friday in conference, behind closed doors. At that point, the justices could decide to hear the case, to not hear the case, or to put off a decision until a later time, called re-listing it.  ...  The court likely will re-list the case, McElroy predicted. The Court prefers to take cases when there's a split in opinions between circuit courts, and right now there is no split because the D.C. Circuit voided the panel ruling in Halbig. Obamacare opponents have urged the high court to take the case now even without a split, hoping the conservative majority on the court will reject the premium subsidies." (Will the Supreme Court accept the Obamacare subsidy challenge Friday?)

At the same time, the five who were committee chairs at the time the law was passed have a letter in the Washington Post: Affordable Care Act opponents are cherry-picking their history "This interpretation is wrong. As members of Congress who shaped and debated the legislation, we want to set the record straight."

And of course Hobby Lobby, the case that keeps on giving as a Federal judge blocks new HHS workaround for birth-control coverage.  As you recall, the Supremes said that CMS had to rework the procedure so that objecting employers were not "complicit" in supplying birth control. According to this one Florida judge, letting the government know you're not supplying the benefit is going to far... We'll be hearing more as CMS continues to try and figure out a process the courts will allow (while they may already be there we won't know that until this decision is appealed).

ACA: Premiums/Costs
A lot is written about the ACA and of course I can't cover it all.  But now and then I read an anti-ACA piece that is just so wrong, I have to comment.  Here is this weeks: Now There Can Be No Doubt: Obamacare Has Increased Non-Group Premiums In Nearly All States - So much wrong my head may explode...  To save space (and my sanity), I'll limit my critique to two key points.  One, the plans before and after are not comparable, many non-compliant plans had lifetime limits and no out of pocket maximums (remember, this is a bad thing - almost 3/4 of personal bankruptcies included medical cost as a precipitating factor) and did not cover preventative services with no coinsurance.  Two, the ultimate goal of the ACA is to keep people healthy, but that takes time - some additional upfront costs now should reap better insurance experience later.  We'll leave it at that.

ACA: Marketplaces
Only about two weeks to go before this year's open enrollment starts (on Saturday November 15 - let's not talk about why they left it on a weekend). So in spite of the public not focusing on this, we need to. 

For those involved in the process, a new Navigator Resource Guide from the Center of Health Insurance Reforms (Georgetown University Health Policy Institute) and the Robert Wood Johnson Foundation "This guide is focused solely on the private insurance reforms of the Affordable Care Act, including the health insurance marketplaces, rating, benefit and cost structures, and premium tax credits. It is intended to supplement the Navigator training available from the U.S. Department of Health and Human Services. It is not intended to be a comprehensive, stand-alone resource for all the reforms of the Affordable Care Act. ... This resource is organized into sections that address how individuals may present themselves to Navigators, based on their insurance status and coverage options. It includes questions and answers developed in collaboration with the staff at the Center on Budget and Policy Priorities, the Georgetown University Center for Children and Families, and the Kaiser Family Foundation.”

There's no doubt it's complicated.  Some groups have more complications than others: For Families With Mixed Immigration Status, Health Insurance Can Be Puzzling and Lessons learned from LGBT Communities and the ACA.

But let's face it, most of us find selecting a health plan hard: Choosing a Health Plan Is Hard, Even for a Health Economist.  A recent study underscores that a Lack Of Understanding About Insurance Could Lead To Poor Choices "They know less than they think they know. That’s the finding of a recent study that evaluated people’s confidence about choosing and using health insurance compared with their actual knowledge and skills."

What, you don't think there is enough to deal with - how about this one: You’ve heard of HealthCare.gov. Now meet HealthCare.com  Yes, a competing site at .com instead of .gov - also selling health insurance, but without access to subsidies.  Too bad the concept of eminent domain doesn't extend to URLs...

Looking forward, some are trying to change the options available on the marketplace: 7 Democrats have a plan to make Obamacare cheaper. Here’s how.  Bottom line is they want to introduce an even cheaper plan (copper).  Given the affordability issues we've already seen with the Bronze and even Silver plans, this is not a good idea.  I'll have more to say about this next week but for now here is one taste of some of the affordability issues currently being faced: As Insurers Try to Limit Costs, Providers Hit Patients With More Separate Fees

ACA: Employers
As some of you know, I have been presenting at MeHAF's small business seminars on the ACA.  You can get information (and see videos) here: Enroll207 SHOP info.  I bring this up because of one of the points I discuss.  For some small employers, dropping coverage, so that their employees can access the individual marketplace (and subsidies), is a good decision.  It helps both the employer and the employee.  Bear that in mind as you read that  Small Firms Start to Drop Health Plans: Many View the Health Law’s Marketplace as Inviting and Affordable. 

Both the Urban Institute and the Commonwealth Fund took a look at employer sponsored coverage.  Both found little immediate impact on rates of coverage other than among the smallest employers (most of whom are not currently providing coverage anyway):
  • Monitoring the Impact of the Affordable Care Act on Employers " Taken together, these results do not suggest a massive upheaval in employer-sponsored coverage under the Affordable Care Act as some have speculated. However, there are several gaps in the literature—particularly on how the Affordable Care Act will affect health care costs—where researchers and policy analysts need additional information to better understand the potential effects of the law on employers. Monitoring the effects of the Affordable Care Act on small firms should focus on areas where the expected impacts would be largest."
  • What Will Be the Impact of the Employer Mandate on the U.S. Workforce? "Fewer than 10 percent, less than 0.03 percent of the U.S. labor force, might see reductions in employment or hours in the short run."


Also this week, At Honeywell, required biometric and medical testing prompt a lawsuit.  While wellness plans may (emphasis on may) help, they can only administered in such a way as to not harm employees.  Honeywell apparently went against those protections, prompting the Feds lawsuit.


ACA: Other
With the second open enrollment approaching, the New York Times took a deep look at the question Is the Affordable Care Act Working?  Here is a discussion of What to Look for in Judging the Affordable Care Act.

And here are some of their conclusions:  A Perfect Fit for Some, but Not Others.  And finally, Obama’s Health Law: Who Was Helped Most "The data shows that the law has done something rather unusual in the American economy this century: It has pushed back against inequality, essentially redistributing income — in the form of health insurance or insurance subsidies — to many of the groups that have fared poorly over the last few decades."

Obamacare isn't just expanding health insurance. It's reducing inequality. "But for those who live in low-income areas, Obamacare has made a world of difference. The uninsured rate for residents of poor counties fell by 9 percentage points, from 26.4 percent in 20to 17.5 percent now."

But we know it has not helped everyone.  Probably at or near the top of the list of those it has not helped is Mississippi: Mississippi, Burned: How the poorest, sickest state got left behind by Obamacare. It is a long painful read.  Painful not because of the great reporting and writing, but because of the results.

One of the benefits of ACA compliant plans is the availability of preventative services with no cost sharing.  Kaiser has issued an updated fact sheet showing what that means: Preventive Services Covered by Private Health Plans under the Affordable Care Act.

It is insurer quarterly report time and the numbers are looking good, both for insurers and for ACA enrollment: Expectations high for health insurers' Q3 results, thanks to ACA.  As the Health care overhaul doubts ease for insurers the Insurers have big plans for 2015 Obamacare enrollment "U.S. insurers planning to sell 2015 Obamacare health plans expect at least 20 percent growth in customers and in some states anticipate more than doubling sign-ups"

Medicaid
In case you haven't heard, there is an election Tuesday and contrary to the popular misconception - it matters.  The Fate of Medicaid Coverage for 2,000,000 People Could Hinge on the Outcomes of the Midterm Election  Due to the Supreme Court decision that the Medicaid expansion is a state option, what happens locally is tremendously important.  Here in Maine it will impact 70,000 Mainers (and more): Think the Midterms Don't Matter? Tell That to 70,000 Poor, Uninsured People in Maine.

But that is a two way street and the Arkansas' Medicaid expansion model could hinge on election outcomes "Under state law, the Legislature must reauthorize the expanded program annually. Because it's part of the budget, passage requires support from three quarters of the members of the House and Senate."

On a different note, there appears to be good news ahead as Coming Medicaid plan rules will set new access standards "The recent OIG investigations will lead to stronger standards for network adequacy, including guidelines for how quickly a member should be able to get a physician appointment, Golden said."

And while the ACA Primary Care rate increase for Medicaid PCPs was supposed to only be temporary, many states are continuing them: State Plans for SFY 2015 While the map shows Maine as having extended the increased reimbursement, it is not final yet.  The Maine Medical Association reports: "DHS is committed to retaining the enhanced payment as part of its initiative to promote primary care.  State funds necessary are expected to be included in the supplemental budget to cover Jan 1-June 30 then put in biennial budget."  Look for an update from them early next week.

Medicare
Theory is easy, implementation is hard.  We've seen that time and again in the first full year of the ACA, but it's not unique to the new law.  A couple of cases where Medicare had some problems this week: Another whistleblower suit alleges Medicare Advantage fraud and  Medicare bought meds for dead people.

Drugs
Drug prices continue to be a concern.  "In a letter Tuesday to key congressional committees, the National Association of Medicaid Directors said lawmakers should consider everything from outright price controls on manufacturers to federal help for states trying to pay for the new medications" (States ask Congress to intervene on drug prices)

Of course we know one of the drugs prompting the new concerns is Sovaldi - so as Sovaldi fuels triple-digit rises in Gilead revenue and profits restrictions are being put on its use: Hepatitis C Patients May Not Qualify For Pricey Drugs Unless Illness Is Advanced.

There are ways you cut your own drug bill.  For instance You can use a placebo to treat a child’s cold - that's right, a study showed that a placebo was as effective as medications for calming a child's cold - and both were better than no treatment at all.

System Transformation
We know we have to treat the whole person - what goes on in the provider's office is just one part.  It should go without saying that having a roof over your head is critical: In Focus: Using Housing to Improve Health and Reduce the Costs of Caring for the Homeless.  And here is a specific look at poverty's impact on diabetes: Poverty’s Association With Poor Health Outcomes and Health Disparities ” A recent ecological study by Carl Stevens, David Schriger, Brian Raffetto, Anna Davis, David Zingmond, and Dylan H. Roby, published in the August issue of Health Affairs, showed significant associations between neighborhood poverty and diabetes-related lower extremity amputations (LEA) in the state of California, which adds to the growing evidence that where you live (not just how you live) may directly impact your health."

We are now officially in flu season, have you gotten your flu shot yet? This week we'll appeal to your love of your grandparents:  Why even healthy people should get a flu shot: to protect your grandparents. 

Rates for vaccinations in general are falling here in Maine, so As more Maine parents reject vaccines, public health experts consider a new pitch.  And here's one story of the ramifications: I've Got Whooping Cough. Thanks a Lot, Jenny McCarthy.

A few more items for your consideration:


Ebola
One - that's the current number of Ebola cases in this country.  From the public hysteria you would think people were dropping in the streets...  (Republicans call Ebola a federal government failure. It’s exactly the opposite.)  Unfortunately, once again in this country we are reacting emotionally instead of rationally.  You can all read as much on this topic as I can, so I won't attempt to provide a thorough update on the topic - instead I'll provide some resources (from people who know what they are talking about), talk a little about what's going on here in Maine and make one point about the military policy.

I'm not a doctor, I don't even play one on TV, but I know where to find them.  If you are going to click on one link in this section, here it is, the New England Journal of Medicine on Ebola and Quarantine.  Here, a bit more distilled are 3 reasons public health experts think Ebola quarantines are a terrible idea.  And finally for those who want to dive even further into the science: Assessing the Science of Ebola Transmission: The research on how the virus spreads is not as ambiguous as some have made it seem.

As you might have heard, here in Maine we have our own celebrity health care worker, Kaci Hickox.  To me she is a hero.  She has been on the front lines  treating Ebola patients in Sierra Leone.  Now she just wants to get back to her life, but the epidemic of fear is keeping her from doing so. Although the State's position keeps shifting, essentially they want to keep her isolated for 21 days, even though she has no signs of being infected. 

In a burst of rationality, many health leaders here in Maine have sent a letter to the administration supporting her.  You can see the actual letter here: Maine Voices: To fight epidemic of fear, we must be guided by science, not emotion.  And you can see our own Gordon Smith (Executive Vice President of the Maine Medical Association) on last night's Rachel Maddow show.  She gets to Maine at about minute 8, but it's all worth watching.  A key quote from Gordon is that the policy should be "based upon science, not based upon emotion or politics": Uncowed Kaci Hickox supported by state health leaders

And as I prepare to finalize this week's post, the courts had their say: Judge requires monitoring, won’t ban Kaci Hickox from public places on Ebola fears.  So as of now Science 1: Fear 0

Fellow Mainers, I can also offer you this consolation, we are not the only state where fear is running rampant.  In Connecticut Child Barred From School After Trip to Africa; Father Sues.  The good news is that after suing the child is being allowed back in school as of today.  But before we move on, note that the family visited Nigeria - a country without an Ebola outbreak and nowhere near those countries that are currently dealing with this. 

While debate rages across the states as to what their unique policy will be (in spite of the Federal guidelines) Hagel Approves 21-Day Ebola Quarantine For Troops.  This means that Soldier or civilian, Ebola protocols not the same.  I think this sends a bad message and as with the overreactions in some states, claims to the contrary is not based on any science.  I won't scream too load since these soldiers are doing vital work (and more are on the way) but it is another unnecessary hindrance to helping those in need.

Finally, a firsthand discussion of why these unnecessary restrictions hurt: The Media's Overreaction to Ebola Is Sending a Chill Through My Coworkers at Doctors Without Borders.

I've focused on the situation here, but as we know the real emergency is in Guinea, Liberia and Sierra Leone.  If you're interested in helping consider contributing to Doctors without Borders

All comments and suggestions are welcome; please let me know what you think.  And as always, thanks for reading!
Funded by support from the Maine Health Access Foundation
*The title is a tribute to the BBC show, the NBC show and the amazing Tom Lehrer album "That Was The Year That Was"
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