Everything you wanted to know about SCOTUS and the ACA subsidy cases but were afraid to ask

What Happened?

As I write this it has been forty-eight hours since the Supreme Court announced they would rule on individual ACA subsidies being available on the Federal Marketplace (healthcare.gov). Below I try and describe what happened, the background of the case, the impact of a possible decision against, and potential workarounds. In the past two days, many smart people have tackled this topic. Standing on the shoulders of giants I try and pull the pieces together for you.

Some have tied the timing of the decision to the election results. Remember technically SCOTUS is not political in nature so election results should have no impact on the Court’s ruling. That said with so many states having administrations that oppose the ACA, the election results could impact potential fixes to a ruling against subsidies, more on that below.

Two notes about some of the terminology used here. First, “Marketplace” is the current term for what was called as “Exchange” in the text of the law, they mean the same thing. Second, the case specifically accepted by the Supreme Court on Friday was King v Burwell but you may remember it under a different name, Halbig v Burwell – that is the case that appeared before the DC Circuit. The issues in both cases are the same.

On Friday afternoon, shortly after the court’s weekly conference, the announcement was made that the court would accept the case. The results of the conference are usually announced on Mondays, but it is not unprecedented that the announcement would come Friday afternoon. Why it happened in this case is still anybody’s guess.

Often (but not always) the Supreme Court would take a case because there are conflicting judgments among lower courts. As of now, there are no conflicts with the subsidy cases. So why did they take the case now? 

For one possible disturbing answer, I turn to Nicholas Bagley: “No, what’s troubling is that four justices apparently think—or at least are inclined to think—that King was wrongly decided. As I’ve said before, there’s no other reason to take King. The challengers urged the Court to intervene now in order to resolve “uncertainty” about the availability of federal tax credits. In the absence of a split, however, the only source of uncertainty is how the Supreme Court might eventually rule. After all, if it was clear that the Court would affirm in King, there would have been no need to intervene now. The Court could have stood pat, confident that it could correct any errant decisions that might someday arise.” (The Supreme Court will hear King. That’s bad news for the ACA.)

So what was once considered by many to be a laughable challenge to the law, now may very well have at least four justices supporting the reasoning.

While not yet scheduled, it seems likely that oral arguments will be heard by the court the first week in March. A ruling would then be expected near the end of the current term, in late June or early July. The DC Circuit has an “en banc” review coming on Halbig v Burwell. Given the acceptance of the case by SCOTUS, it is unclear if DC Circuit review will continue (oral arguments are currently scheduled for December 17) (Court to rule on health care subsidies).

Before we dive in, remember that with open enrollment starting in a few days nothing has changed. Subsidies will be available and even if the subsidies stop, no one will need to pay back what they’ve received (Implementing Health Reform: Supreme Court Will Review Tax Credits In Federal Exchanges). That said, it will no doubt confuse the issue just as efforts are beginning to sign additional people up for the coverage.

The Background

The argument is that due to the way the law was written, subsidies (or technically, APTCs – advanced premium tax credits) are only available on State-based Marketplaces, not on the Federal Marketplace (healthcare.gov).

Many find the legal argument against subsidies on the Federal Marketplace ridiculous: “King v. Burwell is not so much a radical legal doctrine as it is a Monty Python-esque exercise in extreme tendentiousness.“ (Supreme Court to Hear Newest, Craziest Legal Challenge to Obamacare).

But even though many continue to dismiss the legal arguments, as we saw above, it is likely that four justices are drinking the Kook-Aid and there is real concern that the case could be successful.

For more details on the arguments and further background, here is an excellent overall review of the case (along with a two- minute video explanation): Obamacare is headed back to the Supreme Court. And here is a Q&A on the case from the NY Times: Q and A: A Case of Economics and Politics.

The Impact

According to recent estimates, by 2016, 36 billion dollars in subsidies going to 7 million people would be receiving subsidies through the Federal Marketplace (Working-class Americans could lose $36 billion if the latest Obamacare challenge prevails).

Most of them would probably not be able to afford their insurance without the subsidies. Here’s one story of someone whose life was saved by the ACA: “After my year-long recovery is complete, I’m hoping to go back to work. I’ve had three careers — in higher education, in biomedical engineering sales and as a small-business owner. Because of my insurance, I’m able to contemplate my future. And I’m really frightened that the Supreme Court might cut the subsidy for me and so many others. For me, the subsidy is the difference between life and death.”  (Without Obamacare, I would have died. I’m scared the Supreme Court is going to gut the part that saved me.)

Taking a step back. Here is a list of some of the implications in those states where subsidies were not available.

The employer mandate would be nullified: This is because both penalties employers can be liable for only kick in when an employee gets a subsidy on Marketplace.

The individual mandate would apply to fewer people: Many more would now qualify for a hardship exemption due to the size of the unsubsidized premiums relative to their income.

A likely death spiral in the individual market: This would happen because a ruling against the subsidies would not remove the guaranteed issue provision of the law. With no subsidies, mostly people who really need the coverage would purchase insurance, meaning the costs of a much sicker population spread over much fewer insured lived.   This would cause rates to go up,further forcing all but the most in need of coverage out of the market (hence the spiral).

Losses for the health care industry: Insurers would lose business. Hospitals would see an increase in the number of uninsured and thus an increase in their rate of uncompensated care.

Friday already saw some immediate impact of the last point as Health insurers drop as Obamacare heads back to court “The S&P 500 healthcare sector fell more than 1%, while the main benchmark was off only a few points.” Meanwhile the major insurers fared worse: “Humana Inc. HUM, fell more than 6%, after profits missed Wall Street estimates due to increased expenses. WellPoint, Inc., WLP, -2.86% Aetna Inc., AET, -2.85% and UnitedHealth Group Inc. UNH, -2.70% were all down nearly 3%.”

For more detail on the impact: The Potential Side Effects of Halbig and The Supreme Court Decides to Hear King v. Burwell: What Are the Implications?

Possible fixes

Of course the easiest fix for the issue would be for Congress to pass an amendment to the ACA clarifying that subsidies should be available on both state based marketplaces and the federal marketplace. While you could envision scenarios where that was part of a larger deal re changes to the ACA, it is not very likely.

Alternatively, it should be possible for a state to form their own marketplace and then contract with healthcare.gov for all the services: “A state could, for example, establish an exchange and appoint a state-incorporated entity to oversee and manage it. That state-incorporated entity could then contract with Healthcare.gov to operate the exchange. On the ground, nothing would change. But tax credits would be available where they weren’t before.”  Working around Halbig (7/14)

The issue here is that it would require state action. Many of the states that currently have healthcare.gov do so because their administrations did not support the law. They did not set up their own marketplaces, and many of them did not expand Medicaid. So it’s likely that many would not want to participate in this “fix”.

That said, this situation is different in two ways. First, as Avik Roy notes, unlike Medicaid expansion no state dollars are required (after the first few years, states pay 10% of the expansion costs). Would that make a difference? (Avik Roy  https://www.youtube.com/watch?v=VbXoaqNWiGk#t=317)

Second the population who receive the subsidies is different than the one that would benefit from expansion: “The exchanges, on the other hand, reach well up into the middle class. Many of their customers are middle-income professionals who can’t afford insurance because they or a family member has a preexisting condition. Taking away their insurance would trigger a big ruckus. Conservative activists would be willing to endure the political damage, but the calculation for Republican elected officials might not be so clear-cut.” (Supreme Court to Hear Newest, Craziest Legal Challenge to Obamacare).

Are these factors enough to make a difference?  I have no idea.

Topping the list of things I have no idea about is how SCOTUS will rule on this case. Previously, I did not give this case much credence. I was encouraged by judge after judge ruling that the subsidies on healthcare.gov were OK. But logic and reason don’t always hold sway. I am concerned that the court took the case under these circumstances (no disagreement among lower courts) and that theory aside, the court has shown itself to be partisan in its rulings.

While those arguing against subsidies say they are doing so to uphold their principals, to me it is heartlessly playing politics with people’s health. So once again we find ourselves in the position of lives being at stake as we wait to hear the court’s ruling.

Stay tuned.

That Was The Week That Was - Issue 35

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.

Also this week other planning continued as US Officials Unveil Plan to Test Ebola Drugs.

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!

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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"

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:

• Doctors and Decision Fatigue - Doctors are people to, they get tired at the end of the day and that has implications
• Google working on pill that searches for illnesses - Sounds like science fiction, but it's developments like this that could be game changers
• Massachusetts town considers banning sale of tobacco products - It has to start somewhere...
• A radical cancer therapy: Don't treat " “What's unusual about [doctors],” Murray wrote, “is not how much treatment they get compared to most Americans, but how little.”"

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!

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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"

That Was The Week That Was - Issue 33

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

November will make change the lives of millions of people in this country. The results of the election on November 4 will decide if more states (including Maine) will participate in the Medicaid expansion. Then on November 15th open enrollment begins giving many access to quality affordable health care that they never had access to before.

This week we'll look at what's going on with the ACA including from new polls, open enrollment developments and ways to improve the law we'd be talking about if we lived in a world where so much energy didn't have to be spent defending the laws existence. Also data, dangerous drugs, end of life care and inevitably Ebola. Here we go.

ACA: Polls/Opposition

We'll start off with some good news. Although "health insurance" literacy is a problem for many, a recent poll found that Voters Know Insurance Basics Heading Into Open Enrollment. Among the survey's findings was that 77% of respondents could define a deductible (although the other 23% still need help).

On the other hand, this month's  Kaiser Health Tracking Poll found that Only 11 Percent of Uninsured Know About Obamacare’s Next Open Enrollment. With only three weeks before it starts, this result highlights the amount of outreach that will be needed.

On the political front, lots of drama as Gov. John Kasich’s view on Medicaid fuels two-day spat with AP. Basically, he said that the ACA wasn't going anywhere because it was helping people - he then rapidly walked back his comments (Ohio's GOP governor says Obamacare is helping people, then rapidly retreats). Nonetheless, in some respects This Republican Just Made the Best Obamacare Pitch of Any Politician. The key sentence: "The opposition to it was really either political or ideological. I don't think that holds water against real flesh and blood, and real improvements in people's lives."

ACA: Marketplaces

Secretary Burwell spoke to the American Academy of Family Physicians this week and told them: “We're going to need your help and your support just as much as we did last year, if not more”  (HHS chief rallies docs to boost ObamaCare enrollment).

We learned this week that Healthcare.gov's Ez Form Not For Legal Immigrants. Specifically, they will not be able to use the new 16 screen form and instead must use the old 76 screen one because they will automatically be classified as "complex cases". This issue joins the long list of things that could be addressed if more people were concerned about making the law work well instead of just criticizing it and trying to get rid of it (another example of this leads of the cost section below).

The Commonwealth Fund shared its thoughts on reenrollment with a useful overview: Keeping Covered: The Affordable Care Act’s First Reenrollment Period for Marketplace Plans.

Two reports were released drawing lessons from history to help with open enrollment. The first: Open Enrollment: Insights from Medicare for Health Insurance Marketplaces presents a cautionary note that while reviewing one's current marketplace plan during open enrollment is the smart thing to do, Medicare Part D experience says it's an uphill climb to get people to do so. The second: Report from the First Year of Navigator Technical Assistance Project: Lessons Learned and Recommendations for the Next Year of Enrollment is a new report from Georgetown and RWJ drawing lessons from last year's experience.

ACA: Employers

The Wall Street Journal takes a look at how some businesses are reacting to the law: Restaurant Owners Look for Creative Ways to Escape Health-Law Penalties (no subscription required for this article, don't ask me why, when the Journal enforces its pay-wall remains one of life's great mysteries). Unfortunately, instead of accepting the law as a cost of doing business some look for creative ways around it.

Also this week, Sam’s Club to launch a private health insurance exchange. Private exchanges have been around (and growing) for large firms, but this is specifically geared to small employers. Remember, private exchange participants are not eligible for any subsidies (for either individuals or the small business). What they do offer is a way for employers to switch from a defined benefit health plan to a defined contribution plan - they just designate a sum of money for each employee - what they buy with it is up to them (and there are no guarantees there will be something affordable for that sum of money).

On the public exchange front, Obamacare’s small-business exchanges to see major changes in the coming months. This article looks at some state specific small business marketplaces as well as the federal one.

ACA: Court Cases

The Rand Corporation produced a rather sensationalist report this week reacting to the Halbig case: Assessing Alternative Modifications to the Affordable Care Act Impact on Individual Market Premiums and Insurance Coverage (Primary Source). The report evaluates what would happen to the Marketplace if the subsidies went away. However it assumes they go away in every state and ignores the real possibility that even if the suit was ultimately successful before the Supreme Court, there are ways to still use the federal IT platform and call it a state exchange (marketplace). Here is a review of the report from the Washington Post: How the Supreme Court could still wreak havoc on Obamacare

Also from our friends at the Washington Post: The ongoing Hobby Lobby battle: Who else can get an exemption? The easiest way to describe where things stand with respect to the Hobby Lobby battle is with a one word summary: "confused".

ACA: Other

More guidance out this week from CMS with respect to the Basic Health Program. This is an option open to states as an alternative way to cover those earning between 133% and 200% of FPL. You can read the CNS fact sheet here: Fact sheets: Basic Health Program Funding Methodology Proposed Notice. Maine's Health Exchange Advisory committee discussed the concept and heard a presentation on the plan and alternatives. The September 22 Meeting Materials  include the presentation (towards the end).

Other technical guidance has been released recently, for a review we turn to Tim Jost's Health Affairs Blog: Implementing Health Reform: The Qualified Health Plan Federal Exchange Participation Agreement And More (fairly technical but of interest to some of us).

RWJ released a report: Essential Health Benefits: 50-State Variations on a Theme. This will be extremely important information in 2015. Remember, originally, there was going to be one national definition of essential health benefits. Instead, each state has their own definition, but that is only for the first two years (2014 and 2015) of implementation - anytime now we'll hear what the plan is for 2016. Regardless of what the plan is, expect fireworks after the announcement.

"With an estimated 25 million new people becoming insured over the next few years, a coalition of family physicians has a message for the country: Don't forget about us.  ... The timing is right for the group, which on Thursday announced a five-year, $20 million campaign aimed at promoting the importance of primary care. The flood of newly insured patients presents a big opportunity for primary care doctors, when you consider this: just one-third of uninsured adults said they have a regular doctor, about half the rate of the insured population, according to a 2013 Kaiser Family Foundation survey." (Primary care doctors to patients: Don’t forget about us).

Costs

On top of that list of issues to address to improve the law is the issue of affordability. From the "family glitch" to high deductibles, we know there are people who are not able to get the full benefit of health coverage given current circumstances. This was highlighted in the NY Times piece: Unable to Meet the Deductible or the Doctor. I will note that the piece looks at cases that fall into two broad categories. First there are those who may have been better served making a different choice on the marketplace such as a silver plan where they may have been eligible for cost sharing subsidies or even a more expensive gold plan. The focus on premium as opposed to overall cost during the year can lead to these types of problems. Second is the group that did everything right but nonetheless end up with greater costs than they can afford. Unfortunately in our system focused on health coverage instead of health care, these circumstances will inevitable arise.

This week HHS Secretary announces $840 million initiative to improve patient care and lower costs “The administration is partnering with clinicians to find better ways to deliver care, pay providers and distribute information to improve the quality of care we receive and spend our nation’s dollars more wisely,” said Secretary Burwell. “We all have a stake in achieving these goals and delivering for patients, providers and taxpayers alike.”  And more info here: Transforming Clinical Practices Initiative

Also on the cost front, reference pricing is back in the news. A review from Kaiser: More Plans Setting Spending Limits For Some Medical Services and a study published on the potential extent of savings: The incredible cost savings that are possible when patients can actually shop around. I do take issue with the headline (as I often do). While the savings are real, they won't fix the system (we've discussed other studies previously that looked at total savings possible). There is also this caution about the strategy: "Health care economist Uwe Reinhardt, writing in a separate JAMA editorial, says the early results seem to support expectations that transparency in health care can lower spending. But it only works, he cautions, if there's enough provider competition. "It is a point that is sometimes overlooked but is an essential ingredient for patients to benefit from knowing the price and quality of the health care services they purchase," he writes."

And speaking of competition (or lack thereof due to consolidation): Study: Medical costs up to 20% higher with hospital-owned physician groups "" Total spending per patient was 10.3% higher for hospital-owned physician offices compared with  doctor-owned organizations, according to the study. ... Costs were even higher when large health systems running multiple hospitals owned medical groups. Their per-patient spending was 19.8% higher compared with independent physician groups."

Much has been made of the Medicare cost slowdown. Upon further analysis it appears You may want to thank George W. Bush — not Obamacare — for the remarkable Medicare cost slowdown. It seems that Medicare Part D is a big part of what's happening: " In a recent analysis of the Part D slowdown, the CBO concluded that it can be almost entirely explained "by broader national trends in per-capita drug spending that occurred as a result of the pharmaceutical technological slowdown" -- as well as lower-than-expected enrollment in the prescription drug program. ... "The decrease in Medicare spending growth has already been a remarkable shift, and prolonging the slowdown in Parts A and B would be a tremendously important contribution," the pair write. "Unfortunately, though, the outsized role that Part D has played in the Medicare slowdown is bad budget news because it may prove fleeting.""

Medicaid

There may have been news out of Utah this week but we're not sure. Gov. Herbert: Deal is done with Obama administration on Medicaid alternative. There were no details released: "The governor expects to share details of his plan with legislators in mid-November, and there will be a 30-day comment period for the public as well." Additionally, we're not even sure if the deal is final: "David Patton, executive director of the Utah Department of Health, however, told lawmakers Thursday that negotiations continue on a few details, specifically a table of co-payments that low-income Utahans would make for medical services under Healthy Utah."

Drugs

Apparently, CVS wasn't satisfied to stop selling tobacco products in their stores, they want all pharmacies to do so. To achieve that, CVS has a plan to strong-arm other pharmacies out of selling cigarettes. They are planning to impose an additional copay through its Caremark pharmacy benefits manager business for drugs purchased in pharmacies that sell tobacco products. Expect to hear more about this. While the goal may be admirable it has the potential to end up costing consumers more money due to factors they have no control over. (Plus it sounds a little like using their PBM power to force customers to their retail pharmacies...)  Stay tuned!

Meanwhile, here are three stories where we know for sure consumers are being harmed:

• Dangerous Dietary Supplements Return to Store Shelves "The study found that two-thirds of the 27 supplements analyzed contained at least one unlisted anabolic steroid, prescription drug or banned substance. A majority contained the same drug or illicit ingredient that led to them being recalled by the agency."
• On an Antibiotic? You May Be Getting Only a False Sense of Security
• Warning: This Parkinson's drug can make you addicted to gambling, sex, or food

System Transformation

How do we know if a treatment is appropriate?  Is there some number that could be told to patients (and providers) to help them decide if a treatment is appropriate? "That number exists, and it’s called the number needed to treat. Developed by a trio of epidemiologists back in the ’80s, the NNT describes how many people would need to take a drug for one person to benefit. (The NNT for antibiotics in a case of acute bronchitis is effectively infinity, because the medicine is no better at curing the illness than a placebo.)"  A potentially crucial part of the movement towards evidence based case, you can read more about NNT here: This Man’s Simple System Could Transform American Medicine.

Atul Gaawande's new book on end of life care is now out. First a book review from Janet Maslin from the NY Times: A Prescription for Life’s Final Stretch (remember when Janet Maslin was their film critic? I miss her film reviews). And from our friend Ezra Klein, here are 9 lessons Atul Gawande taught me about dying. Meanwhile, on the same topic here in Maine, the most recent entry in the continuing series: Someone to watch over THE JOURNEY’S END.

Some focus this week on organ transplants and the organ shortage that exists: An organ shortage kills 30 Americans every day. Is it time to pay donors? and America's Organ Transplant Law Is Criminally Unfair to Donors.

One physician take a fresh look at EHRs and how they are doing: The EHR report card 2014: Has it gotten better? "While the software is not evolving as quickly as I would like, the ways that I interact with it are changing more rapidly. I’m always finding new (usually better and faster) ways of doing things."  He reaffirms that yes it has been slow going, but there is value to be had (unlike some who are ready to get rid of them all).

On the quality front, people in Maine had reason to be proud this week as the Washington Post said: Best state in America: Maine, for its hospitals. It's a nice headline, and it's true that a greater percentage of Maine hospitals got an A rating from Leapfrog than any other state, but that doesn't mean we're done. We have a lot to be proud of here in Maine but there is still a long way to go.

If you need a reminder that health care itself needs improving, here you are: Mistakes in Treating Childhood Fractures  "A pediatric orthopedic team at the University of Maryland School of Medicine examined the splinting technique used in 275 young patients, who averaged 8 years old. In 93 percent of the cases, the injury had been wrapped improperly, according to a study presented this month at the American Academy of Pediatrics conference in San Diego."

Ebola

And finally, inevitably, we'll talk a little about Ebola. Today (Friday 10/24) the number of cases in this country reams constant  - but that represents a swap of a new case in New York for a cured case (one of the Dallas nurses).

Ebola is a huge problem, but not here in the US. Here's a reminder of what real tragedy looks like: Video: Inside the Ebola Ward

Most of the coverage remains sensational, but so far policy remains restrained in that the Feds have not succumbed to pressure to institute a travel ban. Why not you ask?  The evidence on travel bans for diseases like Ebola is clear: they don't work. Instead we have The CDC's New Ebola Plan Is Better Than a Travel Ban. And while some argue Why new post-entry screening in the US is unlikely to catch Ebola, even this author ends up saying "it should avoid a travel ban, which is a good thing".

And while the Maine CDC creates its own resource page Ebola: Information for the Public the Bangor Daily News appropriately says: Worried about Ebola? Grab a bar of soap.

I took a long time deciding if I was going to include the next link or not - it's a song parody about Ebola - but I finally decided to share it along with the introduction provided by its creator:

"Ebola is NOT funny... ...but the absurd US media hysteria about the virus is ripe for some ZDogg ridicule!  So ZDoggMD Industries has once again teamed up with musical legend Devin Moore from the band Rabbit! to pull the plug on Ebola...or at least perform Ebola unplugged.  And as you watch, please send your thoughts (and hopefully some aid) to those suffering from this massive humanitarian tragedy in Africa, and our affected healthcare workers here at home."

EBOLA (A LOLA PARODY)

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!

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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"