A look back at the week's health policy news with a
focus on ACA implementation
As you might have heard, there was an election this
week… We'll talk about its impact on the
ACA. We'll also check in with SCOTUS to see what trouble they might be up to, and
of course with open enrollment only a week away we’ll check on the Marketplace.
Plus Ebola, Medicare rules, end of life care and more.
ACA: Elections
First the disclaimer, it will come as no surprise to anyone
that I was not pleased with Tuesday’s results. However, as I would explain to
audiences when talking about the ACA last year, we have to deal with the state
of the world as it is, not as we’d like it to be. So below I will do my best
and dispassionately (ok, maybe moderately passionately) look at what may or may
not actually happen to the ACA with a Republican controlled congress. But first
I can’t help but point out that States
Benefiting Most From Obama’s Health Law Elected Republicans.
OK, with that out of my system, I’ll start off with the
national results and then touch on the states. First, Republican leadership’s actual words;
In an editorial in the Wall Street Journal John Boehner and Mitch McConnell
laid out their game plan: Now
We Can Get Congress Going (due to paywall issues with the WSJ the link goes
to Boehner’s site which has posted a copy). We’ll go into the details of their
proposals below.
Similarly the President talked
about his approach: Obama
draws line on GOP changes to Obamacare.
While he says he is open to changes, he promised to veto certain things
including changes to the individual mandate.
As many have noted (and McConnell has admitted), it will be
impossible for Congress to repeal the law in its entirety. The Dems would
filibuster or Obama would veto (What
A Republican Senate Means For Obamacare—and What It Doesn’t). That doesn’t
mean they won’t go through the motions. Expect to see both the House and Senate
take votes early in the session on full repeal.
Once done with the showmanship, they will try to dismantle
crucial pieces hoping it will lead to the laws collapse. Here is a list of some
of what they will try along with my take on the impact/severity of the
potential success (a debt of gratitude to Vox Sentences
where I got some of the items and historical links, before making some
additions). There are two different ways of analyzing impact – on individuals
losing (or not gaining) coverage and on the ability of the change to undermine
the law as a whole.
Hire More Heroes Act
- would let companies hire veterans without having them count as full-time
employees under the ACA in order to create an incentive to hire veterans. By not
counting veterans it makes it easier to stay under the 50 (or 100 this year) threshold.
A feel good bill if there ever was one, minimal impact on the overall
implementation of the law, but may tip the balance for some threshold employers
meaning the rest of their employees may not gain coverage. Moot if ER mandate
goes away.
Definition of
full-time employee to 40 hours a week – The definition is used in two ways,
to determine if an employer is subject to the employer mandate and to determine
which of their employees they need to offer coverage to. Early in the year, the
Congressional Budget Office analyzed the impact of this change (Oops:
GOP Bill Would Strip 1 Million Workers Of Health Coverage). The headline
overstates the case as over half would most likely get coverage on the
Marketplace (potentially with subsidies). While this would definitely result in
fewer people being covered, it would not undermine the foundations of the law. Individuals
would be impacted both at firms that decided not to offer, and at those that
offer but decide to limit the offer to those working 40+ hours. If the ER
mandate goes away, could still impact individuals depending on what
requirements remain for those employers that continue to offer coverage. One
more note of caution. For those who say that the 30 hour definition caused
employers to reduce hours to 29 (sometimes called the threshold effect) who’s
to say the 40 hour definition won’t cause employers to reduce hours to 39 (Republicans
to Chip at Obamacare by Redefining Work Hours)
Repeal of Medical
Device Tax – this is one of the fees that help pay for the subsidies. If
you ask the question Why
repealing the medical device tax is a top Republican priority there is an
easy answer - In
Shift, Lobbyists Look for Bipartisan Support to Repeal a Tax (3/13) (or in
other words, money!). The Medical Device industry is not my favorite – many of
their products are introduced without any proof that they are more effective
than what came before. Plus, convoluted purchase agreements means that
competition doesn’t drive down prices, it just prevents standardization and the
ability to negotiate price with manufactures. Having said all that, if the
Republican’s decide that making the industry happy is more important than the
deficit, so be it. The danger is if they go looking for ways to pay for the tax
cut to the industry.
Risk adjustment
payments – this has been a favorite talking point of Republican’s, saying
it is a tax-payer subsidy to insurance companies (for an example of hypocrisy,
see item above). The payments are designed to be self-supporting – money taken
in should be the same as money going out – but that is not guaranteed in the
law. The Republican’s want to make sure no additional money is spent on this
program, but in the first years as the new markets settle that might not be
possible. That said, based on year 2 rates in the marketplace, the need for
these payments may have been overestimated. So this gets a big shrug in terms
of impact. It could hurt but with good enrollment numbers and experience it
could have minimal impact.
ER mandate – The
employer mandate has been delayed twice. From the beginning many supporters of
the law felt that it was not structured correctly. The point of the provision
was to insure a “level playing field”. At the time the law was passed most of
the employers in the size category impacted were already offering coverage
(although some of those were not offering it to all the employees covered by
the law). The impact of doing away with this is not as large as you would think
– partly because it is mitigated by the individual Marketplace and available
subsidies and partly because employers have other motivations than the law for
offering health coverage (the ability to attract and retain the best employees).
When the President said he would not
accept getting rid of the individual mandate, he did not mention the employer
mandate. So this could happen. (Sharing again a piece from last week: What
Will Be the Impact of the Employer Mandate on the U.S. Workforce?)
Many questions remain. There are other provisions that the
law’s opponents might target. There are also areas that the law’s supporters
would like to see changed (family glitch topping the list). Right now, how this
proceeds is anyone’s guess. While I’m not optimistic in nature, I won’t (for
now) discount the possibility of negotiations and an omnibus “fix” package for
the ACA. After the required repeal the law votes of course.
As we move forward and think about changes to the law,
remember that looming in the future is the state waiver provision. That would allow
states to opt-out of the ACA completely as long as they could show the states
own changes would have an impact as the ACA would (this is how VT is planning
on getting to single payer). Expect more talk about waivers and state
experimentation and possibly accelerating their availability (currently slated
for 2017).
On the state level it is unfortunately a simple story: The
election might keep millions of people from getting health insurance. Very simply, states where the Democrats had hoped
to pick up governorships thereby enabling Medicaid expansion did not elect
Democratic governors. So Medicaid
expansion hopes dashed. However, Secretary Burwell did have a message for
states that have not yet expanded Medicaid.
She is interested in working with them, to encourage that she said Call me!
ACA: Court Cases
Once again this week I can say that as I write this post,
the Supreme Court is discussing the subsidy cases at their weekly conference. Instead
of denying the petition they discussed last week, they relisted it resulting in
Silence,
and speculation, on health care. We’ll know more Monday when the results of
today’s conference are published.
ACA: Premiums/Costs
As we approach open enrollment, what’s really going on with
premiums for year two? Not one but two
sources of real data show that the news is for the most part, very good. First,
from McKinsey (by way of Forbes): Key
Study On Obamacare 2015 Premium Rates Is Out And You Won't Believe What's Going
To Happen And second, from the Urban
Institute (by way of RWJ): Marketplace
Insurance Premiums in Early Approval States “In 17 states plus the District
of Columbia, six states will have average premium reductions across the
carriers’ lowest cost silver plans; 10 will have small premium increases
(defined as 5% or less); and two will have increases greater than 5 percent.”
ACA: Marketplaces
November 15 is just around the corner. If you are Thinking
About Enrolling In Obamacare? Keep These 5 Tips In Mind. And if you have a
thirst for knowledge, you may drink at the fire hose of information that is the
newly updated Kaiser Family Foundation Health
Reform FAQs.
Of course open enrollment will have its share of problems as
Obamacare
users wary of new enrollment season. Although you should be careful of the
results discussed given questionnaire wording, it still signals trouble ahead. I
wonder how many of the respondents understood the need for reenrollment.
Another problem we already know about is that Obamacare
Still Has “Back-End Issues” “For consumers who switch, that can mean
getting billed for two plans, or worse, getting lost in the system.” If someone
gets two bills, who’s to say they will know which one to pay?
There is good news as well. Health
insurance brokers say Obama administration had an attitude adjustment and
are being much better to work with. Also, according to HHS:
Obamacare website is safe “These days, the site gets scanned for
vulnerabilities and threats three times a day, administration officials say:
Once by CMS, once again by HHS, and additionally by the Homeland Security
Department’s National Cybersecurity and Communications Integration Center.”
Looking forward, the Commonwealth
Fund takes a look at Marketplace sustainability. Given how much each state will
have to come up with to pay for their marketplaces, I think it’s a good
argument for a single Marketplace (with some State controls): State
Marketplace Approaches to Financing and Sustainability.
ACA: Employers
A few weeks ago we talked about the problem that the IRS definition
of benefits large employers provide did not include hospitalization (remember,
they are not subject to the EHB requirements). Looks like that will be fixed as
Feds
to require big companies to cover hospitalization.
For the gory details, we turn (as always) to Timothy Jost: Implementing
Health Reform: ‘Minimum Value’ Plans Must Have Hospital And Physician Coverage.
And here is the actual IRS notice: Group Health Plans that Fail
to Cover In-Patient Hospitalization Services (Primary Source).
What about those employers who are not impacted by the law’s
requirements but want to provide coverage?
Unfortunately, it’s still a problem: Providing
Health Insurance Still a Struggle for Small Business.
What happens as some of these small firms not providing
coverage grow? For an idea, take a look
at this story about A
Builder Swears He’ll Stay at 49 Employees to Avoid the Mandate. Unless He
Grows. A negative comment on an article led to a deeper conversation – low
and behold the employer acknowledges that yes in fact they probably will offer
coverage and the law won’t impact their expansion plans.
ACA: Other
As talk increases about changing the law, more evidence that
it is working. From HHS: Obamacare
meeting goal of extending coverage to more Americans, new report says Survey
Data On Health Insurance Coverage For 2013 And 2014 (Primary Source). And
from one provider on the front lines: Despite
its flaws, the Affordable Care Act is a step forward.
EBOLA
Here in Maine, thanks to an appropriate judicial response,
cooler heads have prevailed and Kaci
Hickox, state agree to make temporary order permanent; hearings this week
canceled. Elsewhere in the state, preparations
continued Maine
health care, emergency services prepare for Ebola although participants in
the session tried to keep things in perspective: ““You are more likely to win
the lottery without having bought a ticket [than to catch Ebola],” said Michael
Coyne, Ph.D., of St. Joseph Healthcare.”
Speaking of perspective, sometimes a picture is worth a
thousand words: Map:
The Africa without Ebola
While we’re reminded that for most of the world the
situation is under control, the same can’t be said for the three West African
nations continuing to battle the outbreak. This week Obama
Said to Seek $6.2 Billion in Emergency Ebola Funds.
About half for preparations here and half for African efforts.
Public concern continues to be disproportionate. A
thoughtful reminder from the New England Journal of Medicine that we have been
here before: Panic,
Paranoia, and Public Health — The AIDS Epidemic's Lessons for Ebola.
If it makes you feel better,
inappropriate reactions are not limited to the US.- Canada and Australia (both
of whom have governments determined to roll back progress their respective
nations have made in many areas: These
Two World Leaders Are Laughing While the Planet Burns Up: Meet earth's worst
climate villains) are busy making their own
mistakes: Canada's
Ebola visa ban is dumb, xenophobic, and illegal.
Costs
One of the foundations of our health system are home health
workers. But they are stuck between a rock and a hard place as Home
Health Workers Struggle For Better Pay And Health Insurance. Many of their agencies are reimbursed by Medicare
at set levels, making it difficult to provide better wages and benefits.
For those who had their doubts, a reminder that Yes,
we do ration health care in America “Yes, we do ration health care in
America. It’s just that those affected the most are those who have the least
income. In America, we have become oddly blasé about income inequality and its
consequences, increasingly willing to let those without simply do without.”
Medicaid
A great review of three Medicaid
fallacies that are used to denigrate the program, even though they are
baseless: Translating
research about Medicaid (and other topics).
A what-if look at Who
Would Have Health Insurance if Medicaid Expansion Weren't Optional. Even more depressing given the election results.
Here is a look at one positive that
would result from expansion: Rate
Of Premature Births Fall As Health Law Provisions Begin To Take Effect. The
report attributes some of drop to states that expanded Medicaid early.
Arkansas was the first state to use expansion money to buy
covered lives individual policies on the Marketplace. Given local election
results (and the need for the policy to be renewed every year) its continuation
is in jeopardy. For those interested in great local coverage on the issue: The
private option is not dead but it's in real jeopardy. And here is the NY
Times take: Elections
Put Future of Innovative Arkansas Medicaid Plan in Doubt.
Medicare
Last Friday night, CMS released 3,000 pages of hospital
regulations as its Halloweens treat for you (or was it a trick?): Medicare
releases slew of payment rules. In gory
detail, here is the best rundown I’ve seen of what was included: CMS
releases final 2015 payment rules for Medicare: things to know.
One item buried in there worth calling out for special
attention is that Medicare
weighs paying for end-of-life counseling.
Remember the death panels? It was this
type of counselling that led to that myth – we’ll see what happens this time.
On the Medicare Advantage front, More
scrutiny coming for Medicare Advantage, Obamacare - HHS inspector general
announces new round of fraud audits. Also What
Do We Know About Health Care Access and Quality in Medicare Advantage Versus
the Traditional Medicare Program? “At a time when enrollment in Medicare
Advantage is growing, it is disappointing that better information is not
available to inform policymaking. Our findings highlight the gaps in available
evidence and reinforce the potential value of strengthening available data and
other support for tracking and monitoring performance across Medicare Advantage
plans and traditional Medicare as each sector evolves.”
Drugs
Previously, CVS (through its Caremark subsidy) announced it
was building a tobacco free network, now one of their major PBM competitors is
considering the same as Express
Scripts Eyes Forming Alcohol and Tobacco-Free Pharmacy Networks.
And in one state, Voters
in Arizona just overwhelmingly backed a ‘Dallas Buyers Club’ law. Will it help
patients? The impact of these rules are unclear.
System Transformation
As a state and a nation we are getting older. The New Your
Times took a look at Bracing
for the Falls of an Aging Nation. At the
same time some good news as Efforts
to enable Americans to age in place are expanding.
And as we age, all things come to an end. The key is to be
prepared for that end: The
difficult conversation everyone must have. One
person who was prepared left us this week. Here is How
Brittany Maynard may change the right-to-die debate.
This month’s Health Affairs focuses on the critical issue of
Social
Services And Community Health: Health Affairs’ November Issue. As time goes on, it is becoming even clearer that only
ye looking at the totality of an individual’s situation that we are going to be
able to get them healthy and keep them that way. Here’s one example where that
is working: Hennepin
Health saves money by housing, employing patients “Hennepin Health—an
accountable care organization operated by Hennepin County, Minn.—saved more
money from fewer emergency room visits and hospitalizations among newly housed
patients than it paid for their housing.”
Part of the approach is treating the person in the most
appropriate setting. Sometimes that setting is at home. Here is One
doctor’s old-fashioned idea to cut health care spending: house calls –
House calls enabled by the ACA through Innovation grants.
Science marches on!
Two of this week’s developments worth noting. First, The
idea that milk prevents broken bones is an udder sham (with the added benefit of the best title ever). And
second, A
new study shows why cancer screening can be bad for your health. A concept that is often hard to communicate but it
is undeniable that there is such a thing as too much screening.
And finally this week, some thoughts from a recent graduate
of medical residency and a new mother on Why
company-paid egg-freezing threatens medicine and motherhood "... I
worry that using this technology for non-medical reasons has the potential to
further cement the responsibility on the female employee to make her
reproductive timeline most convenient for her employer. Instead of attempting to change the system by
creating solutions like affordable childcare and flexible hours, employers now
have a temporary stopgap to delay dealing with the ambitious woman’s womb."
Thanks for reading!
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"
