A look back at the week's health policy news with a
focus on ACA implementation
For issue 40 (I have no idea how that happened) we have Grubergate,
CRomnibus and the problem with inertia.
With the congressional hearing this past Tuesday, we started
the week talking about Grubergate. Once the hearing ended the focus shifted to
the efforts to fund the government and what would be slipped into the spending
bill. Meanwhile, the deadline for selecting coverage (or updating coverage) for
a January 1 effective date gets closer and closer (Monday December 15) and
while new enrollment numbers look good, it seems like not enough people are
reviewing their current coverage.
We'll talk about all that, disturbing data on breast cancer
treatments, questioning payment reform efforts and much much more. Let’s get
started.
ACA: Opposition (Grubergate)/ Court Cases
To review, Gruber (Jon not Hans) is an MIT economist who developed
an economic model for pricing health reform efforts. He contributed to the
discussion that created RomneyCare and helped with the ACA. He also seems as an
individual to have no filter and has said many things where he embarrassed himself
and supporters of the law (How
Conservative Media Turned Gruber Into The Perfect Obama Villain).
On Tuesday, the House held a hearing where Gruber (and
Secretary Burwell) were questioned. During the hearing, He
squirmed. He dodged. He apologized. But Republicans barely laid a glove on him.
In his remarks he said ‘I
am embarrassed, and I am sorry’ Here are some of The
Blockbuster Moments From Today's Gruber-Gate Hearing. And in case all that’s not enough, you can read his
full written statement here: Written
Testimony of Professor Jonathan Gruber before the Committee on Oversight and
Government Reform, U.S. House of Representatives, December 9, 2014.
OK, are we done with him now? The sad answer is no, as later in the week
yet another new video appeared with more “stupid” remarks (In
a new video, Jon Gruber boasted that he “helped write” Obamacare) and, the
Committee issued a new subpoena for yet more information (Issa
Subpoenas ObamaCare Architect Jonathan Gruber).
Some have observes that 'Grubergate'
shows the sad state of debate on Obamacare “The Gruber video snippets were
dug up by opposition researchers who pushed them to cable TV producers, who
would rather smear the Affordable Care Act than report on how the law has
provided secure, affordable coverage to more than 15 million Americans and
significantly reduced the rate of increase in premiums and healthcare costs.”
Yet is can also be said that If
Obamacare's biggest problem is Jon Gruber, Obamacare is doing great.
How important is this issue?
According to a Kaiser survey, For
All the ‘Grubergate’ Talk, Few Americans May Have Listened “Preliminary
data from this month’s Kaiser Health News Index shows that just about 2 in 10
Americans say they have been following the story closely (and just 1 in 10 say
very closely), which puts Grubergate far behind major news such as the protests
that followed the Ferguson, Mo., grand jury’s decision not to indict (closely
followed by about 8 in 10) and the conflicts involving ISIS and other militant
groups (closely followed by about 7 in 10).”
Another way to think about it is that It
doesn’t matter if Congress thinks Jon Gruber is dumb. It matters if the Supreme
Court thinks he’s smart. Will his statements have an impact as SCOTUS
decides the subsidy case? Only time will
tell.
Also this week regarding the subsidy case, a very well
thought out and scary look at what happens if the decision prevents subsidies
from being paid in states with a the federal marketplace: Predicting the Fallout
from King v. Burwell — Exchanges and the ACA. The basic point is that getting
around an adverse SCOTUS decision may not be as easy as originally thought. We’ve
always known it will take action by the state – but the action is probably more
complicated than just saying the state has a marketplace and is only using
healthcare.gov for the technology. More discussion of the same concerns in the
NY Times: Many
States Will Be Unprepared if Court Weakens Health Law.
More responses this week to Senator Schumer’s remarks re the
ACA not helping the middle class. First, here are Six
Ways Health Reform Helps the Middle Class.
Next, an economist takes a look at how the subsidies helps
lower premiums for those who don’t receive them – spoiler alert, they reduce
adverse selection. But for those interested in the details, here you go, but
caution, math ahead: How
health insurance subsidies help everyone.
Looking forward to the future of the ACA and health reform
in next year’s congress; on the Democrat side of the aisle you have Health
care torch passed … to nobody - Next generation of Dems less visionary, more
wonky. Meanwhile, on the Republican side of
the aisle, Mitch
McConnell’s Obamacare gambit: Behind closed doors, Republicans are plotting one
last tilt at the Affordable Care Act.
CRomnibus
Let’s start with the basics, CRomnibus is the spending bill
passed late Thursday night by the House and to be take up Friday or Monday by
the Senate (where it is expected to pass). Why is it called CRomnibus? Because it's
a mash-up of an omnibus bill, which is how Congress funds the government when
things are working normally, and a continuing resolution (CR), which is how
Congress funds the government when it can't come to a deal. In this case, the
CR only affects the Department of Homeland Security, which, … will see its
funding expire in February.” (From
Vox) In case you’re wondering, the reason Homeland Security was singled out
has to do with Republican opposition to the President’s action on undocumented
residents. But, since this is a health policy blog, I won’t go into detail
about that or the bill in general, plenty of sites are doing that today. What I
have done below is list items highlighting some of the different pieces hidden
in the 1,600 page bill that have an impact on health policy (and ACA
implementation):
An attempt to sabotage the risk corridor program: Republicans
Dealt A Quiet Blow To O-Care In The CRomnibus and Insurers
Say Spending Bill Would Raise Obamacare Rates: The bill would cap spending on a
program Republicans call an “insurer bailout.” The program was always meant
to be revenue neutral, so it is unclear how much of an impact this will
ultimately have. It will depend on the actual claims experience plans end up
with.
In a classic bite your own nose to spite your face move, 'Cromnibus'
cuts could hamper IRS enforcement of ObamaCare. “… the funding bill's $350
million in budget cuts to the IRS will further burden the already cash-strapped
agency.” It’s been estimated that every time the IRS budget is reduced by a
dollar, we lose about $7 in tax receipts…
There is a change to the way MLR is calculated for
non-profit Blue Cross Blue Shield Plans and how their tax status is determined
(note this category does not include Anthem here in Maine). (The
CRomnibus shows Democrats, Republicans actually working together on Obamacare)
This is a “fix” that has been sought since the day after the bill was passed by
some Democrats and Republicans. For the optimists among you this can be
interpreted as a sign that there is room to clean up the law. (Given the rest
of the items on the list, I’m not so sure).
Regarding the requirement that members of Congress and their
staff use the marketplace: GOP
approves David Vitter’s Obamacare amendment. This change removes the
opportunity to classify some staff members as committee members and thus exempt
them from the requirement. Attempts to also remove the employer contribution
from Congress and their staff failed.
Looking towards the future, “Buried in the spending deal
that congressional negotiators announced on Tuesday are several nuggets that
should be of interest to hospitals, home health providers and pharmaceutical
companies. They won't have any immediate impact but could lay the groundwork
for significant policy changes.“ (Small
parts of spending deal could have long-term healthcare impact)
On a positive note, the Spending
Bill Includes Abortion Funding for Peace Corps Rape Survivors. Peace Corps
staff had been the only remaining group where Federal funds were not permitted
to be used for abortions in these extreme cases.
As I am preparing to post, an overview of the topic out from
Tim Jost looking at several of the items listed above: Implementing
Health Reform: Beneath The Hood Of The ‘Cromnibus’
ACA: Premiums/Affordability
Starting off with good news, first a reminder that Maine's
Online Marketplace Insurance Shoppers Likely to See Lower Premiums.
Also, a study showing that Many
Obamacare Plans Set Out-Of-Pocket Spending Limits Below The Cap “Seventy-four
percent of 2015 silver level plans’ out-of-pocket spending caps are below the
$6,600 spending limit allowed for individual plans and $13,200 maximum for
family plans, according to Avalere, a consulting firm. The average
out-of-pocket maximum for 2015 individual silver plans will be $5,853, says
Caroline Pearson, a vice president at Avalere. Silver was the most popular plan
type this year, selected by about two-thirds of enrollees.”
In the bad news category, a reminder of the issue of medical
debt, as a new survey shows that 42.9
MILLION AMERICANS HAVE UNPAID MEDICAL BILLS
“More than half of all debt on credit reports stems from medical
expenses.” I would suggest there is a bimodal distribution, or in other words,
we are talking about two distinct populations in the data. First are those who
experienced a catastrophic event and racked up thousands upon thousands of
dollars of medical debt that they just can’t pay. This is the group the ACA’s
out-of-pocket limit is designed to prevent (moving forward, it does nothing to
cancel existing debt).
Second, the data seems to indicate another group, those who
have more manageable levels of debt: “The report by the federal regulator
indicates that much of this trouble could be avoided. About half of consumers
who only carry medical debt have no other signs of being under financial
distress. But complaints to the CFPB indicate that consumers are routinely
baffled by medical bills. Unwieldy insurance and hospital statements leave them
uncertain as to how much money they owe, the deadline for payment, and which
organization should be paid.” Figuring
out a way to alleviate this confusion is
ACA: Marketplaces/Enrollment
In the third week of open enrollment, 618,548 people
selected a plan on healthcare.gov. So as of 12/5 there had been a total of
1,383,683 plan selections: Insurance
exchange enrollment spikes as 2015 deadline nears (Open
Enrollment Week 3: November 29 – December 5, 2014 – Primary Source). With those numbers, it looks
like Obamacare
Enrollment Poised to Blow Past 9.1 Million Projection.
While that is all good news, the numbers concerning those
who already have coverage are less encouraging. We’ve talked before about the
need for those with coverage through the marketplace to go back and update
their information and review their plan selections. The NY Times took a look at
the issue with two reports: Many
Aren’t Seeking Cheaper Health Plans as First Deadline to Switch Nears and Why
Most People Won’t Shop Again for Health Insurance “There are currently about
6.7 million people with federal or state marketplace health plans, according to
government estimates. As of Dec. 5, only 720,000 people in the 37 states using
the federal enrollment website have returned to the site to select a 2015 plan.”
With those numbers, it looks like the debate over if this
group will be able to overcome their inherent inertia is settled – inertia
continues to rule the day. With this experience, the conversations about how
open enrollment will work next year become even more important.
But while many people will not go out and check their plans,
it’s not too late so Hurry
Up! Big Obamacare Deadline Coming Monday. Let’s take a moment to review the
deadline – it’s the last chance to have coverage begin on January 1 – but it’s
not the end of open enrollment. So even if you miss this deadline you can still
sign up for coverage. You can also still change your plan if you are currently
enrolled – it just means that for January you may be reenrolled in your current
plan and your new selection won’t start until February (if you make a selection
by January 15).
As the first deadline approaches, “The Department of Health
and Human Services will promote HealthCare.gov at the bottom of some 7-Eleven
receipts in an effort to reach demographics that could be uninsured, the
department announced Thursday.” (HHS
uses 7-Eleven receipts to remind people to sign up for HealthCare.gov).
And finally, as part of the open enrollment push, the
President made an appearance on the Colbert Report. If you haven’t seen it yet,
it’s not to be missed: The President on the
ACA - as Stephen Colbert!
ACA: Employers
New information on what those covered at work are paying: “A
new Commonwealth Fund issue brief out today finds that premiums for
employer-sponsored health insurance grew 4.1 percent annually between 2010 and
2013, following passage of the Affordable Care Act, compared to 5.1 percent
between 20and 2010, before the law was passed. Deductibles also rose more
slowly. But while premiums rose 60 percent overall between 20and 2013, U.S.
workers’ incomes rose only 11 percent. The contributions employees make toward
their health plan premiums, meanwhile, increased 93 percent over this period.”
(Costs
for Employer Health Coverage Rise More Slowly But Still Claim Growing Share of
Wages)
Thoughts from Dr. Wolf regarding the ACA and small
businesses – it’s not yet providing all the help needed: Obamacare’s
pros and cons for small businesses: The jury’s still out on the benefits.
Picking up on our discussions last week regarding wellness
program costs and benefits, coverage from NPR: Wellness
At Work Often Comes With Strings Attached and Kaiser: Wellness
At Work: Popular But Unproven.
ACA: Other
In the age of smaller networks, the importance of provider
directories is amplified. In the proposed rules for next year’s open
enrollment, there are much needed requirements regarding accuracy and
availability. That said, carriers are already making excuses: Inaccurate
provider directories blamed on weak tech, network churn Although not
everyone is buying those excuses: ““These explanations are outrageous,” said
Robert Laszewski, president of consultancy Health Policy and Strategy
Associates. “Not having accurate consumer-level information about just who is
in their provider network—particularly when they are using narrow networks as
such a major part of their Obamacare offerings—is inexcusable.””
Also proposed for next year are changes to what plans people
are “reenrolled” into. There is a whole industry emerging around decision
support tools, trying to answer the question Can
technology pick the perfect health plan for you?
One of the reasons picking a plan is hard is due to
variation in plan design. That variation
is due both to state differences and plan level differences. Here is a look at
the state level differences: Health
Care Law Is Not One-Size-Fits-All, and Here’s Why and The
future of essential health benefits.
Costs
Another day, another set of cost figures. We have two to
discuss this week. On one hand, Expected
pickup in healthcare spending may be here – Note this is total
expenditures, not rate of inflation. We always knew some of this was suppressed
due to the economy, and it would rise due to newly insured. Still way too early
to know importance of different factors and how things go from here.
On the other hand, these hospital price numbers look like
things are still going well. Note these numbers are price inflation, not
expenditures: Lowest
hospital price growth in 16 years pushes down health inflation.
Confused? Join the club!
We know that some of the ways money is spent are more
impactful than others. Reports of two success stories this week: Government
anti-smoking campaign cost just $480 per quitter, study finds and Publicly
financed family planning’s return on investment ($7 for every public dollar
spent).
Lots more interesting pieces on health care costs this week.
With no real theme connecting them, we’ll punt and provide a list with brief
descriptions:
Why
I Oppose Payment Reform – a provocative editorial in Health Affairs makes
some very good points (stay tuned for Part 2 which we’ll cover next week).
Consumers
still pay bigger share for healthcare than government and businesses – with
all the talk of subsidies and employer contributions, this point is often
forgotten. Consumers continue to pay the biggest share of health care costs. (And
of course it can be argued, as I often do, that consumers are paying the
business share of costs as well through reduced wages.)
Devicemakers
explore risk contracts with hospitals “In some deals, manufacturers would
return a percentage of the device's price if it doesn't meet performance goals,
while in others, hospitals would pay more for a device that fulfills a
manufacturer's quality and economic claims.”
How
residency programs are training doctors to waste money - “Residents who
train in regions with high health care costs (that is, the places that err on
the side of more scans and specialists) continue to practice expensive medicine
decades beyond graduation — even if they move to low-cost parts of the country.”
Surgeons
see end-of-year rush for elective procedures – interesting story but no
real data. Note there was no mention of the interest in spending down their FSA
accounts (another source of year end rush). Also note the one deductible they
mention, $8,000, has to be from a grandfathered plan since it exceeds the ACA
out-of-pocket max.
Medicaid
We discussed the issue of provider directories above, but it
is relevant for Medicaid as well. A study out this week reports Half
of Doctors Listed as Serving Medicaid Patients Are Unavailable.
Also disturbing news with a study showing that Nearly
9 Percent Of Medicaid Births Delivered Early For No Medical Reason’
Medicaid programs are facing another potential problem in
2015: Obamacare
paradox: Medicaid is expanding, but doctors are facing a huge pay cut The
ACA included a provision that raised compensation for Primary Care Physicians
for 2 years (2013 and 2014). With that expiring, PCPs may experience a pay cut.
Several states are working to continue the enhanced rate with state funds. I
can report that efforts continue to retain the increased rates here in Maine but
nothing has been finalized.
Medicare
When we think of health care in this country, and all the
poor comparisons made with other countries, we like to think that at least our seniors
are taken care of through Medicare. But a new study out shows that the U.S.
Health Care Lags Worldwide for Those Over 65. Even with Medicare coverage
there are still significant coverage gaps and delivery problems.
EBOLA
This week Time magazine named their person of the year: TIME Person of
the Year: The Ebola Fighters - The ones who answered the call. A great
tribute to those who put others welfare ahead of their own. Maine’s own (OK,
she’s not a native, but I’ve adopted her) Kaci was featured in the coverage: Kaci
Hickox among Ebola fighters, survivors named ‘Person of the Year’ by Time.
She was also recognized by MTV: Nurse
Kaci Hickox named mtvU’s Woman of the Year.
Drugs
NPR did a series looking at overuse of drugs in nursing
homes. These two stories outline the problem: Old
And Overmedicated: The Real Drug Problem In Nursing Homes and Nursing
Homes Rarely Penalized For Oversedating Patients. This story takes a look at
how things can be done better: This
Nursing Home Calms Troubling Behavior Without Risky Drugs. And finally, this story
from the BDN looks at the state of things in Maine: Fewer
Maine nursing home residents treated with risky antipsychotic drugs “While
Maine was most improved under the initiative, the state ranks in the middle of
the pack, at 26th in the nation, for the total number of nursing home residents
taking antipsychotic drugs.”
This week in Sovaldi news, a new approach to try and reign
in the cost with A
new lawsuit claims $84,000 is way too much for this lifesaving drug. Not
at all clear if such a suit can be successful, but if it is there will be many
to follow.
Also
in drug cost news, another look at Avastin and Lucentis. They are two nearly
identical drugs with vastly different costs. Here is a review of the data on
drug company payments and proscribing patterns: Paid
to Promote Eye Drug, and Prescribing It Widely.
Finally, a deeply disturbing look at how much of your data
is out there: They
Know You Buy Viagra and They Want to Sell You More.
Note that all of
the data discussed in the piece is outside the scope of existing federal
privacy laws.
System Transformation
I cannot overstress the importance of this first story.
Several years after incontrovertible proof that fewer radiations treatment are
as effective as the “standard treatment”, most patients continue to receive the
old method of treatment. The story is important for several reasons: women are
undergoing unnecessary extra treatments, the system paying more for care that
is no better (and potentially worse for the patient) and for what it says about
the ability of providers to keep up with new information. Long
Radiation Treatments Called Unnecessary in Many Breast Cancer Cases and How
we treat breast cancer exposes a huge systematic issue in American health care.
Need more things to be afraid of? Superbugs
could soon kill more people than cancer. One study projected 10
million deaths by 2050 from antimicrobial resistance.
On a more mundane but equally important topic, contrary to
media reports this week, No,
The CDC Did Not Apologize And Say The Flu Vaccine Doesn’t Work. The flu
shot effectiveness varies from year to year, but that is not a reason not to
get vaccinated (How
Effective Are Flu Shots?)
It seems every day there is a headline touting the new
“superfood” or new way to prevent cancer. The sad truth is, most of these
stories are junk – which begs the question Why so
many of the health articles you read are junk. Short answer is that press releases regarding study
results can be fairly sensational and are not always written with the
researchers’ participation. So take it all with a grain of salt (but not too
much salt, that’s bad for you).
The results of the healthiest state rankings were released
this year. Unfortunately, Maine
back at its lowest point – 20th – in ‘healthiest state’ rankings - The slide
from 16th last year is blamed in part on fewer immunizations and more infant
mortality. Due to
lower vaccination rates and a surprising increase in infant mortality, Maine’s ranking
fell. While the vaccination issue has received a fair amount of attention, the
infant mortality issue was a surprise to many.
One writer take a look at Science
bashing: The latest threat to research in America. Sadly at a time when more than ever we need good
research there are those who don’t think it’s money well spent.
And finally this week, a look at one doctor’s exposure to
dying at home: “This is the first time I have visited a patient on his “death
bed” at home, even though I had done it many times in the hospital setting. And
what a difference it is! Before me is a picture of ultimate serenity — a man
completing a long journey in the comfort of his own home, surrounded by friends
and family. I contrast this with the alternative scenario — a man dying in the
chaos of an ICU, imprisoned by tubes, alarms, CPR, ventilators, and IV drips.”
(The
last house call: Turning off the defibrillator)
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"
