A look back at the week's health policy news with a
focus on ACA implementation
3.6%, 12.4%, 50,000, 765,000: Those four numbers represent
four different pieces of information released this week that shows the ACA is
working. That’s not to say healthcare is fixed and we can all go home, not by
any stretch of the imagination. There is still a lot of work to do and people
who need help. The law continues to be threatened and undermined and even if it
were working perfectly, it would not be enough. But for today, for a few
minutes, we can be thankful some things are moving in the right direction.
Oh, you want to know what those numbers represent? In order listed above they are: the rate
health spending grew in 2013 – the lowest recorded since the government started
measuring the figure in 1960 (see the Cost section below), the latest figure on
the rate of uninsured in this country – a decline of 30% from a year earlier (see the Enrollment section below), the number
of lives saved by the reduction in medical errors over the past 3 years (see
the System Transformation section below), and finally, the number of people who
have selected a plan in the first two weeks of open enrollment (see Enrollment section
below).
This week we have details on those figures, new ACO
regulations and as always, much, much more. So let’s get started.
ACA: Opposition/Support
Sometimes Democrats are their own worst enemy – last week
Sen Schumer said passing the ACA was a mistake. Here is another look at why he
is wrong: On
Obamacare, could all Democrats really be as clueless as Sen. Schumer? Since
we seem to be living in bizarro-world, this week while Democrats regretted
passing the law the former Republican Senate Majority Leader supported it saying
that Republicans should fix the ACA, not continue to hope that the courts
overturn it: Trent
Lott Encourages GOP To Make Fix To Obamacare Before Supreme Court Case
I wasn't the only person this week thinking about good news,
The Brookings Institution also asked the question: Is
Obamacare Working? Yes. Vox chimed
in: The
Obamacare paradox: the law looks terrible but is doing great as did New
York Magazine: 4
New Studies Show Obamacare Is Working Incredibly Well
ACA: Court Cases
Developments in two cases this week, the subsidy case and
the House GOP suit of the President.
Starting with the subsidy case, for those interested in the
legal arguments this is one of the best pieces I’ve seen on why the case should
fail Am
I unreasonable? And here are some additions to the legal arguments: A
couple of overlooked context clues in King and thoughts on why The
Latest Challenge to Obamacare Should Embarrass Conservative Judges.
Some think that Mitch
McConnell Just Made a Huge Tactical Mistake by Begging the Supreme Court to Gut
Obamacare personally, I don’t think it will have an impact, but it’s a nice
thought.
USA Today took a look at what would happen if the Court says
subsidies can only be offered in State Exchanges: Experts:
No easy options if court strikes down ACA. At the same time, in a review of
what states are doing to prepare for the Court’s decision, the answer was not
much: 32
States Haven't Tried To Establish an Exchange. Are They Making a Huge Mistake?
Regarding the House GOP suit of the President, focus on the
part of the suit concerning the out-of-pocket subsidies. These subsidies are
paid directly to insurance companies to lower the copays, coinsurance and/or
deductibles paid by those with income below 250% of the Federal Poverty Level. The
suit says that the Administration paying those out of the same account as the
tax credit subsidies is wrong: Obamacare
lawsuit tests 'power of the purse' and Suit
on Health Law Puts Focus on Funding Powers.
ACA: Enrollment
Unlike last year, HHS has committed to releasing weekly
enrollment reports during the open enrollment period. In the first week Healthcare.gov
signed up 462,125 customers. And while Health
law sign-ups slowed over Thanksgiving by the end of the second week Obamacare
Sign-Ups Top 765,000. Things should only get busier from here as we approach
December 15 – the deadline for anyone who wants coverage to begin on Jan 1 including
those who want to make changes to their coverage before the New Year. Although
while it’s not advised, it is possible for those who are automatically
reenrolled in their current plan to still make changes after Dec. 15 – they can
pick a new plan at any time during the open enrollment period and drop the
coverage they were reenrolled in. You can see the full release from HHS here: Open
Enrollment Week 2: November 22 – November 28, 2014
What impact did the first open enrollment have (and the
first year of coverage)? 12.4% is the
latest figure released by the Urban Institute for the percent uninsured in the
country. That represents a decline of 30% from a year earlier (Uninsured
rate keeps dropping as second open-enrollment period progresses). It’s
worth noting that there is a big discrepancy between states that expanded
Medicaid and those that did not “In non-expansion states, the uninsured rate
has dropped from 20.1% to 15.1% over the last year. In states that have adopted
Medicaid expansion, the uninsured rate dropped from 15% to 10.2% since the
exchanges were launched.” Here is the full report from the Urban Institute: Taking
Stock: Health Insurance Coverage under the ACA as of September 2014.
ACA: Marketplaces
We’ve talked about the reenrollment issue before, the need
for those who currently have coverage to review their choices before being
automatically enrolled in the same plan for next year. This week HHS issued a
report attempting to quantify the benefit of shopping around: HHS:
Switching Obamacare Insurance Plans Could Save Consumers More Than $2 Billion.
As one report from the Washington Post put it: The
administration is begging Obamacare enrollees to shop around for a better deal.
You can read the full report here: Report shows
more options and savings for consumers who shop in the Health Insurance
Marketplace in 2015.
What it comes down to is inertia – the tendency of people to
leave things as they are. NY Magazine takes a more detailed look at the problem
here: Obamacare’s
Inertia Problem
The reason to shop around is not just to check premiums. Sometimes
a plan will change certain provisions while still remaining the same plan: “But
tucked within the plans' jargon are changes that could markedly affect how much
consumers pay for health care. Generic drugs will soon be free, but the cost of
expensive specialty medications will increase. Co-payments for visits to
primary-care doctors will go down, but those for emergency room trips will be
higher.” (Big
Changes in Fine Print of Some 2015 Health Plans). How can consumers figure
out what’s going on? Propublica has an app for that! They've created a comparison tool that lets
you compare key cost-sharing provisions of any 2014 plan with any 2015 plan. It’s
definitely worth taking a look: Will My Obamacare Health
Plan Costs Go Up? Compare before you renew your health insurance plan.
Finally Kaiser took a look at Who
Is Getting ACA Insurance – And Who Isn’t.
ACA: Premiums/Affordability
One of the ways the marketplace brings costs down is by
fostering competition. In a look at the state of markets in 2013 (before the
Marketplaces opened) they found that oligopolies – market domination by just a
few large players – was the norm: Health
insurance markets dominated by oligopolies before Obamacare: report. This look from Kaiser found that More
Competition Helps Restrain Premiums In Federal Health Marketplace.
But even when everything is working as it’s supposed to, Underinsurance
Remains Big Problem Under Obama Health Law (and
a continuation by the same author Underinsurance,
ctd.). For some, even with help, the cost sharing provisions are still too
much. This Gallup survey found that Cost
Still a Barrier Between Americans and Medical Care.
In a different world, instead of continuing to fight for the laws very
existence, we would be focusing on how to improve it.
ACA: Employers
The Maine Chamber of Commerce held a business forum to help
get the word out to employers about their responsibilities (this was one I
actually did not speak at). For a group that has been a steadfast opponent of
the law, it’s nice to see them helping their members deal with reality: Maine
Businesses Gear Up for Affordable Care Act's 'Employer Mandate'.
Regarding the SHOP, HealthCare.gov’s
insurance marketplace for small businesses gets off to a slow start. The issue is that other than for the minority of
small businesses that qualify for a premium tax credit, there is no great
advantage to utilizing the online marketplace. The may change next year if employers
get excited about the ability to offer their employees a choice of plans
through the SHOP, instead of just the one option most small employers now
offer.
More evidence of something we’ve discussed before: Workplace
wellness programs don’t save money. At the
same time, the administration is challenging employers who seem to be trying to
stretch the rules with what is and is not permitted: EEOC
Takes Aim At Wellness Programs Increasingly Offered By Employers.
Given that we know they don’t really help the employers, it was
surprising to see that U.S.
CEOs threaten to pull tacit Obamacare support over 'wellness' spat. It’s
not clear to me what their continued allegiance to the concept is given the
mounting evidence of their ineffectiveness.
Costs
So much coverage, so little space. The office of the Actuary
(OACT) at the Centers for Medicare & Medicaid Services released its annual
report on health expenditures. I could fill this blog with reporting and analysis
of the report, but in the interests of not putting all of you to sleep I will
keep it short.
To start, for those interested, here is the press release: Press
release: National Health Expenditures continued slow growth in 2013 and
here are the initial results Health
Affairs Web First: National Health Spending In 2013 Continued Pattern Of Low
Growth (primary source).
The topline story is that in 2013 medical expenditures
increased only 3.6% - the lowest percentage increase since they started
measuring that statistic in 1960! (Health
costs in 2013 grew at slowest rate since 1960) While many saw Good
News Inside the Health Spending Numbers, the question persists can it
last? (America's
Medical Bill Didn't Spike Last Year: More good news, although it's hard to know
how long it will last)
Some think that the slowdown is due to the economy, and there
is no doubt that is one factor, but is more going on here? When looking more closely, this slowdown has
not mirrored behavior in previous recessions, so it seems probable that The
Health-Cost Slowdown Isn’t Just About the Economy.
For those interested in more details, Here’s
exactly how the United States spends $2.9 trillion on health care.
In other major cost news this week, CMS released new
proposed rules for Accountable Care Organizations (Press
release: CMS releases new proposal to improve Accountable Care Organizations
and Fact
sheets: Proposed Changes to the Medicare Shared Savings Program Regulations).
The new rules would make it easier for ACOs to develop without
risking their payments (Draft
Medicare ACO rules would allow more time with less risk) If you’re asking Why Medicare
won't force penalties on ACOs that don't save money, the answer is that CMS
continues to believe in the program and wants to give participating providers
time to ramp up. It is feared that if the existing penalty structure remained
in place organizations would not join the program for fear of losing money
before they figured out how to operate.
Medicaid
Medicaid expansion news in many states this week (although
alas, Maine is not one of them):
Wyoming: Wyoming
Devises Plan to Expand Medicaid Primary
Source: WYOMING’S STRATEGY FOR HEALTH, ACCESS,
RESPONSIBILITY, AND EMPLOYMENT
Utah: Gov.
Gary Herbert unveils his plan for covering Utahns in the health care “gap” Primary
Source: Healthy Utah
Florida: Yes, even Florida is considering expansion Medicaid
Expansion By Any Other Name May Fly For Florida Lawmakers
In Pennsylvania expansion proceeds but under a cloud of
confusion: Pennsylvania
launches Medicaid expansion, overhaul “Democratic Gov.-elect Tom Wolf has
said he opposes what he views as an unnecessarily complicated process and
bureaucracy being set up by Corbett, and Wolf could gradually unwind some
elements of Corbett's plan after he takes office Jan. 20. Meanwhile, the
federal government has not approved the final benefit packages proposed by the
Corbett administration for both the overhaul and expansion of Pennsylvania's
Medicaid program, injecting more uncertainty into how exactly everything will
change.”
Kaiser took a look at all the private option expansion
plans: The
ACA and Recent Section 1115 Medicaid Demonstration Waivers Note that it doesn’t
include several of the ones listed above since they have not yet received final
approval from CMS.
In CHIP news, some good signs regarding renewal of funding: “The
consensus was apparent at a subcommittee hearing of the House Energy and
Commerce panel, where Republicans and Democrats praised CHIP's benefits in
equal measure.” (Lawmakers:
Kids will lose coverage without CHIP funding) But talk is cheap and none of
the statements ruled out changes to the program when the renewed funding was
considered. With respect to timing, while it’s being talked about it is not
expected that the lame duck session will do anything (Little
action expected on CHIP funding by year-end) so stay tuned for more
developments next year.
Medicare
This week in Medicare news, many instances of misbehavior on
the part of providers, offered with minimal editorial comment:
Medicare
is doing more to police Advantage and Part D lapses, but does it matter? “Medicare Advantage plans among publicly
traded insurers usually net a profit margin between 5% and 6%.” “Critics of the program question whether the
five- and six-digit monetary penalties do enough to change behavior. “The
revenue (plans) take in from the federal government is just enormous,” said
Wendell Potter, a former PR executive at Cigna Corp. who has testified several
times to Congress about the health insurance industry. He is now an analyst at
the Center for Public Integrity. “That's not a significant fine or monetary
punishment if you ask me.””
Were
patients really sicker? Lawsuits say Medicare Advantage plans inflated
diagnoses to boost payments time once again for my favorite clip… I’m shocked! Recently I wrote about a growing convergence
of interests between insurers and the Administration (and advocates). Here is a
case where that’s not yet the case.
EBOLA
Just a few months ago, the country seemed convinced that
Ebola was going to destroy us. While it was never going to come to that, the Administration
was nonetheless criticized for not doing enough. Well it turns out, the Administration
accomplished a lot: This
Is How Much the U.S. Has Accomplished in Ebola Preparedness in Only Two Months.
With things under control here America has
stopped paying attention, but Ebola is still ravaging Sierra Leone.
Drugs
For those who doubted the worth of the Open Payments
database: ”An analysis of the new federal Open Payments database shows that
five of the 20 physicians who received the most money from Insys recently faced
legal or disciplinary action, including three who were said to have
inappropriately prescribed painkillers.”
(Using
Doctors With Troubled Pasts to Market a Painkiller)
Meanwhile, bad behavior by drug companies continues as Naloxone,
a Drug to Stop Heroin Deaths, Is More Costly, the Police Say. Just
as the laws are changing to allow first responds to carry this life saving
drug, costs are rising dramatically.
And finally, since we haven’t discussed Sovaldi in a few
weeks, here is a review of the topic – and what it says about our healthcare
system – from our friends at Vox: This drug costs
$84,000: And there’s nothing the US health-care system can do to stop it.
System Transformation
Medical errors kill thousands of people every year. While there
is still a long way to go, it is exciting news that the number of errors is
dropping. This is due in part due to changes brought about by the ACA, over a
three year period 50,000 lives were saved: Obama's plan
to reduce hospital errors is working — and it's saved 50,000 lives.
That said, if you are looking for something to worry about, this
news out of India is frightening: ‘Superbugs’
Kill India’s Babies and Pose an Overseas Threat “Indeed, researchers have
already found “superbugs” carrying a genetic code first identified in India —
NDM1 (or New Delhi metallo-beta lactamase 1) — around the world, including in
France, Japan, Oman and the United States.” In the world today, no health
problem can be restricted by boarders – we’re all in this together.
Moving back to some good news, while a bit technical, this
has the potential to make a huge difference in the utility of electronic health
records: EHR
vendors, tech-savvy providers unite around Internet-like interoperability “The hook could enable both the EHR and the
mobile app to not only read data from each other, such as lab values or care
plans, but also write data back to each other, in formats that each system
could display and compute.”
I wasn't sure if I should put this here or under the drug
section, but a great story about Prescribing
Vegetables, Not Pills. Another piece to the idea that you need to take an
individual’s situation into account when figuring out how to treat them.
And finally, for my data-geek friends out there a new
resource. “The Peterson–Kaiser Health System Tracker provides comprehensive
data on how the system is performing on critical quality and cost measures,
offering clear, up-to-date information on relevant trends, drivers and issues.
The Tracker also will illustrate how the United States is performing relative
to other countries, and how different parts of the system are performing
relative to one another. Regular in-depth insight briefs will delve into major
issues” Have fun: Peterson-Kaiser
Health System Tracker
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"
