A look back at the week's health policy news with a
focus on ACA implementation
What a week: Between Gruber, subsidy case angst and
yesterday’s enrollment number revelation, you might think that this is the
worst stretch of ACA news since the botched launch of healthcare.gov last year.
However, to think that would ignore the fact that the law continues to
immeasurably improve the lives of tens of millions of people.
With that in mind, this week we’ll take a look at all of the
above, check in on open-enrollment and more. (Note that I've tweaked the section
heads again, hopefully these will allow you to better jump to the areas you’re
interested in.) Here we go…
ACA: Opposition
As open enrollment starts, several thoughtful pieces this
week on why if it’s working, opposition hasn't softened. First up, this post
showing the possibility that communication failures are not the only reason for
the ACA's unpopularity (spoiler alert – income redistribution might have
something to do with it): The
ACA is working. So why is the opposition to it so strong and persistent?
And this one saying the conflict won’t stop any time soon: Here's
Why Conservatives Will Never Give Up Their War on Obamacare. And finally,
this one putting to light the absurdity of some of the criticisms: Can
someone explain this to me? (You have to read this to believe it, and you
still won’t believe it.)
For opponents of the law, Gruber is the gift that keeps on
giving. Here is a man who apparently is a very smart economist but who has no
filter when it comes to speaking in public. Here is an excellent summary of the
“controversy”: What
Jon Gruber said was dumb, but the Gruber controversy is much dumber. Here
is a piece by a reporter who worked with him closely, providing some context: What
Jon Gruber's Quotes Really Tell Us About Obamacare—and American Politics.
Here is a thoughtful piece reminding critics that they should
be careful what they wish for – and stop objecting when they get it. Markets
are messy, remember that plans changing and people needing to shop around the
second year plans are available is simply the market working as it’s supposed
to: People
who wanted market-driven health care now have it in the Affordable Care Act.
And finally, while Uber had its own share of problems this
week, the CEO of Uber
Just Stuck a Knife in the Republican Party’s Heart “Kalanick told reporters
that Obamacare had been a crucial element in his firm’s success. “It’s huge,"
he said, according to BuzzFeed. “The democratization of those types of benefits
allow people to have more flexible ways to make a living. They don’t have to be
working for The Man.”” So maybe the law
is in fact the opposite of the “job killer” some said it would be.
This month’s Kaiser tracking poll is out and A
Quarter Of Uninsured Say They Can’t Afford To Buy Coverage. “About half of
uninsured expect to find coverage in the coming months, though another quarter
say they won't because they do not believe they can find an affordable plan.” Here
is the direct link to the full results: Kaiser
Health Tracking Poll: November 2014.
Two polls out from Gallup this week. First, continuing the
decline of recent years Majority
Say Not Gov't Duty to Provide Healthcare for All. The percent who thought
it is government’s responsibility peaked in 2006 at 69%. Interestingly, this
year the group with the lowest agreement was the oldest age group – only 39% of
55+ agree. I guess Medicare doesn’t count.
In the second poll, In
U.S., Ratings of Healthcare Coverage Generally Steady “Americans' ratings
of healthcare coverage in the U.S. have generally held steady, despite the
opening of the healthcare exchanges in 2013 and the decline in the uninsured
rate this year. Thirty-eight percent of Americans now rate healthcare coverage
in the U.S. as "excellent" or "good," within the range of
the combined”.
ACA: Court Cases
First, remember the House lawsuit of the president over
delaying the employer mandate? After two
lawyers dropped the case, The
House GOP finally found a lawyer to sue Obama. Then on Friday, the suit was
filed: House
Republicans Sue Obama Administration Over Health Law. The suit as filed not
only questions the mandate delay, but in a bit of a surprise, it also questions
the payment to insurance companies for the out-of-pocket costs subsidies. At
the time I’m writing this it is unclear if the issue is the difference between
the full out-of-pocket subsidy and the sequester cuts – which have not been implemented
to the cost sharing subsidies – or the full subsidies. Here is a post from
earlier in the year looking at the sequester issue: Does
the sequester apply to cost-sharing subsidies?
Next, in the aftermath of Hobby Lobby, another Birth
Control Challenge Rejected as “The United States Court of Appeals for the
District of Columbia Circuit rejected a claim that the accommodation imposes a
substantial burden on the groups’ expression of religion.” Or in other words, the
governments accommodation is appropriate.
And finally, the week wouldn't be complete without an update
on the subsidy case. First, from last
week a reminder that “There is simply no way to describe what the court did
last Friday as a neutral act.” (Law
in the Raw ). From Drew Altman some
numbers: How
13 Million Americans Could Lose Insurance Subsidies and a review of the
impact of a negative decision on subsidies: How
The Supreme Court Can Kill Obamacare Without Overturning It. And finally,
for those who can’t get enough Meet
Michael Cannon, the man who could bring down Obamacare.
ACA: Enrollment Numbers
As you all know, I support the ACA. But that does not mean I
support bad behavior. It was revealed yesterday that when HHS gave out
enrollment numbers, they were including stand-alone dental plans. While we all
acknowledge the importance of oral health, no one wanted those numbers mixed
together. The story was first reported by Bloomberg: Obamacare
Sign-Ups Were Inflated With Dental Plans. The administration quickly
acknowledged the problem and said it was a mistake. I am inclined to believe
them for the simple reason that if you were going to inflate the numbers, you
would do so by more than 4-5%. Remember, while the consumer facing portions of
healthcare.gov are working well (for the most part), there is still a lot of
back-end work to be completed: Health
Enrollment Counting Error Shows Where System Is Still Broken. Here in
Maine, Jackie Farwell asked the question Are
Maine’s Obamacare enrollment totals inflated too? There was some entertainment as the issue led
to this extraordinary headline: The
Affordable Care Act's Embarrassing Moment of Tooth.
ACA: Marketplaces
Amidst all the above issues, open enrollment began last
Saturday (11/15). What
a difference a year makes for the ACA. For
the most part, things got off to a good start as Some
Hiccups, but Federal Health Exchange Website Is in Good Health. On Sunday morning, Secretary Burwell announced that
there were 100K
new O-Care applications on first day.
That said, things were not perfect as Immigrants
Baffled By Healthcare.Gov Lapse (they could not easily upload their green
card information to show proof of eligibility).
Since some people think everything is better with cats, to
prepare for open enrollment, here are 9
Things You Need to Know About Obamacare and Your Health Insurance, Gif-splained
By Cats (personally I think they should have used dogs).
Here in Maine, there was a kick-off event in Portland as Maine
Obamacare advocates trumpet health insurance options. The event took place
at Becky’s Diner where the Owner
of Becky’s Diner hopes to serve up health insurance for employees. Dan Corcoran,
President of Anthem Maine wrote that Affordable
Care Act offers options aplenty under your fingertips.
ACA: Employers
While we mostly talk about open enrollment on the Marketplaces,
for many who get coverage at work, this is also the time of year when they select
their coverage for the year. Kaiser warns that with Big
Changes For 2015 Workplace Plans: Watch Out For These Six Possible Pitfalls.
Despite opponents’ talking points, Few
employers dropping health benefits, “A
year after the advent of new insurance marketplaces for individuals and small
businesses under the health-care law, just 1 percent of employers said they
have decided to stop offering health coverage for 2015, one survey said.” Although as expected, Employers
Watching Insurance Costs Closely.
ACA: Other
With the President’s address last night, it is important to
note that Obama’s
order won’t extend Obamacare to undocumented immigrants Although that’s the case, some who will now
be able to work legally may be eligible for benefits at work (Undocumented
immigrants won't get Obamacare - but Latino coverage could rise).
In an interesting turn, the NY Times highlighted that Health
Law Turns Obama and Insurers Into Allies. This
is similar to my own experiences over the past year where I have found a new communality
of interest between insurance companies and the public.
That said, while some interests coincide not all do – case in
point California
regulator knocks Anthem, Blue Shield on Obamacare networks “More than 25%
of physicians listed by Anthem Blue Cross and Blue Shield of California were
not taking Covered California patients or they were no longer at the location
listed by the companies, according to state reports released Tuesday.”
And more broadly concerning networks: Providers,
advocates seek tougher rules on network adequacy
Costs/Premiums
With the start of open enrollment, a focus on premium
changes in year two: How
Much Did Health Insurance Rates Go Up? It’s Complicated and Kaiser took a look at some of the
details: Change
in Benchmark Silver Premiums, 2014 – 2015.
In addition to the network adequacy questions asked in the section
above, a Former
HHS Official Calls For ‘Smarter’ Networks That Deliver Cost-Effective Care.
Transparency on the standards for how the networks are built would be an
important step.
A reminder that payment reform still has a long way to go as
An
Obamacare program helped poor kids and saved money. It was also doomed to fail.
The issue here is despite all the talk, we still live in a predominantly
fee-for-service world.
And in case you missed the headlines, here is How
a Canadian woman ended up with a $950,000 bill giving birth in America.
EBOLA
While pushed out of the headlines, here is Why
It's Too Early To Forget About Ebola. Although
out of site, it’s not out of mind as Americans
are more worried about Ebola than actual leading causes of death. In case you’re interested, here are the things we
should really be afraid of: What kills
us, in one chart.
And finally, a request from Kaci Hickox: Stop
calling me 'the Ebola nurse'
Medicaid
Here in Maine, Federal
appeals court rejects LePage administration attempt to trim Medicaid rolls.
The case had to do with the maintenance of effort provision in the law. In
reaction, LePage
Says Maine's Medicaid Battle Likely to go to Supreme Court. But not so
fast, If
LePage wants Medicaid case before Supreme Court, he needs a credible case.
Nationally, new numbers released this week show that Medicaid
and CHIP Enrollment Grows by over 9.1 Million People. Hand-in-hand with the
enrollment increase, U.S.
states get more, spend more on Medicaid under Obamacare.
Regarding states that have not yet expanded, some
developments: Alaska's
Medicaid future uncertain despite pro-expansion governor and in what would
be a huge shift Hospitals
seek a Texas Way to expand Medicaid (although I’m not holding my breath).
A new Commonwealth fund survey looking across 11 countries
found American
Seniors Face Health Care Gaps, Despite Medicare “Americans older than 65
are more likely to have chronic illnesses and to say they struggle to afford
health care – despite qualifying for the federal Medicare program – than are
seniors in other industrialized countries” (Primary Source: 11-Nation
Survey: Older Adults in U.S. Sickest, Most Likely to Have Problems Paying for
Care)
The ACA included provisions for testing new ways of
delivering care for dual eligible (those receiving both Medicare and Medicaid).
But change is hard as California’s
Managed Care Project For Poor Seniors Faces Backlash.
“A GAO review of health cost and quality transparency tools
available from CMS found the tools lacking in relevant and understandable
information and recommends steps for improvement. GAO identified
characteristics of effective tools, including the need for information on
specific procedures that allow consumers to compare providers based on
performance.” (Health care
transparency: Actions needed to improve cost and quality information for consumes)
Drugs
A “report” from the pharmaceutical industry this week raised
questions: $2.6
Billion to Develop a Drug? New Estimate Makes Questionable Assumptions.
Even if that figure were true (and I don’t think it is) it
would not apply to generic drugs (which have already been developed). Yet over
the last year some generic prices have soared: Soaring
generic drug prices draw Senate scrutiny “Some low-cost generic drugs that
have helped restrain health care costs for decades are seeing unexpected price
spikes of up to 8,000 percent, prompting a backlash from patients, pharmacists
and now Washington lawmakers. A Senate panel met Thursday to scrutinize the
recent, unexpected trend among generic medicines, which usually cost 30 to 80
percent less than their branded counterparts.”
A look from Kaiser at how providers are dealing with the
issue: Hospitals
And Pharmacies Grapple With Rising Drug Prices.
An unusual issue but worth a read: Payout
From Drug Raises Questions for Cystic Fibrosis Group.
And on the positive side, this week a Study
Finds Alternative to Anti-Cholesterol Drug “For the first time since
statins have been regularly used, a large study has found that another type of
cholesterol-lowering drug can protect people from heart attacks and strokes.”
System Transformation
It is taken as gospel by some that we don’t have enough
doctors in this country, but is that true?
NPR took a look: Doctor
Shortage Looming? Maybe Not
There is no doubt we do have an organ shortage, the question
arises, is there a better solution than convincing more people to donate: An organ shortage
is killing people. Are lab-grown organs the answer? While we’re not ready to “print” a whole new
organ (yet), it is astounding what we can print: PRINT THYSELF:
How 3-D printing is revolutionizing medicine.
Everyone agrees on the need for quality measures, but the
devil is in the details. What are they, who determines them, how many different
sets are needed? Amidst all the ongoing
controversies, it is refreshing to see validation of at least one set of
measures: The
Inverse Relationship Between Mortality Rates And Performance In The Hospital
Quality Alliance Measures.
As we strive for better quality care, should we as patients
be required to tell our providers how to behave? One answer: Patients
should not have to advocate for their own safety “It’s a bad turn of events when health care
quality programs need to work around physicians by asking patients to engage in
dialog with their health care providers to avoid dirty hands and unnecessary
care.”
But we do bear individual responsibility in some areas (like
vaccination). The ramifications of some decisions is disturbing as There
were more measles cases in 2014 than any year during the last two decades.
Finally, I haven’t made you cry for a while – OK, maybe I
have with continued reports of the threats to the ACA and people’s health
coverage – but not in the good way. So here you go: What does a
good death mean to you?
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"
