Tuesday, December 31, 2013

Health Care Reform Articles - December 31, 2013

India’s Efforts to Aid Poor Worry Drug Makers

NEW DELHI — Alka Kudesia needs an expensive drug to treat her breast cancer, but refuses to tell her children for fear they will take out loans to buy the medicine and spend the rest of their lives in debt.
“We’re barely able to afford the treatment I’m already getting,” Ms. Kudesia, 48, said with quiet defiance. “My kids are just starting out in life. There is no way I’m going to be a burden to them.”
The drug, Herceptin, is one of the most effective treatments for an aggressive form of breast cancer. But in India, at a cost of at least $18,000 for one course of treatment, only a small fraction of the women who need it get it.
The Indian government last year threatened to allow production of less costly, generic versions of Herceptin. Its maker, Roche Holdings of Switzerland, initially resisted, but surrendered its patent rights this year in large measure because it concluded that it would lose a legal contest in Indian courts.
The skirmishing over Herceptin and other cancer medicines is part of a new and critical phase in a struggle to make drugs affordable to the world’s poorest people, one that began in earnest more than a decade ago when advocates campaigned successfully to make AIDS medicines accessible to millions of Africans.
“Cancer is the next H.I.V./AIDS issue, and the fight has only begun,” said Shamnad Basheer, a professor of law at West Bengal National University of Juridical Sciences in Kolkata.
American trade officials have voiced concerns about India’s treatment of drug patents, including its reasons for sometimes overriding them. President Obama discussed the issue this year with Prime Minister Manmohan Singh of India in the Oval Office, administration officials said.
Executives in the international pharmaceutical industry, increasingly dependent on drug sales in emerging markets like India, China and Brazil, contend that India’s efforts to cancel patents threaten the global system for discovering cures while doing little to resolve the health challenges most patients here face.
“We are open to discussing what the best way is to bring innovative medicines to patients,” said Daniel Grotzky, a spokesman for Roche, which has a large portfolio of cancer medicines. “But a society that wants to develop new medicines and technology must reward innovation through a solid protection of intellectual property.”

Breast Cancer Screenings: What We Still Don’t Know

HANOVER, N.H. — A COUPLE of months ago, JAMA Internal Medicine, a journal of the American Medical Association, published the findings of a brief online survey of middle-aged Americans.Most had previously been screened for either breast or prostate cancer. But the study found that about half said they would not choose to start screening if the test resulted in more than one overtreated person per one cancer death averted.
Wow. That implies that millions of Americans might choose not to be screened if they knew the whole story — that overtreatment is typically more common than avoiding a cancer death.
Is the survey right? Honestly, I have no idea. Different surveys get different answers. According to surveys, most of us hate Obamacare. But a number of us like the Affordable Care Act (another name for the same thing). And most of us like the bulk of the individual components of the law. How you ask the question matters.
Similarly, how Americans feel about screening is obviously related to what they are told about screening. Most of the time they get a simple message: It’s the most important thing they can do to stay healthy. Occasionally, they may hear just the opposite: It’s dangerous. The truth is, it’s neither.
Instead, it’s a close call. Different people in the same situation can rationally make different choices. But first, patients need some quantification of the benefits and harms.
In a study to be published Monday, Dec. 30 in JAMA Internal Medicine, a colleague and I attempt to provide that data for women making the choice about screening mammography. Let’s be clear at the outset: There is a lot of uncertainty — and professional disagreement — about what the data are. So we provide a range of estimates, from optimistic to pessimistic.

A.D.H.D. Experts Re-evaluate Study’s Zeal for Drugs

Twenty years ago, more than a dozen leaders in child psychiatry received $11 million from the National Institute of Mental Health to study an important question facing families with children with attention deficit hyperactivity disorder: Is the best long-term treatment medication, behavioral therapy or both?
The widely publicized result was not only that medication like Ritalin or Adderall trounced behavioral therapy, but also that combining the two did little beyond what medication could do alone. The finding has become a pillar of pharmaceutical companies’ campaigns to market A.D.H.D. drugs, and is used by insurance companies and school systems to argue against therapies that are usually more expensive than pills.
But in retrospect, even some authors of the study — widely considered the most influential study ever on A.D.H.D. — worry that the results oversold the benefits of drugs, discouraging important home- and school-focused therapy and ultimately distorting the debate over the most effective (and cost-effective) treatments.
The study was structured to emphasize the reduction of impulsivity and inattention symptoms, for which medication is designed to deliver quick results, several of the researchers said in recent interviews. Less emphasis was placed on improving children’s longer-term academic and social skills, which behavioral therapy addresses by teaching children, parents and teachers to create less distracting and more organized learning environments.
Recent papers have also cast doubt on whether medication’s benefits last as long as those from therapy.
“There was lost opportunity to give kids the advantage of both and develop more resources in schools to support the child — that value was dismissed,” said Dr. Gene Arnold, a child psychiatrist and professor at Ohio State University and one of the principal researchers on the study, known as the Multimodal Treatment Study of Children With A.D.H.D.
Another co-author, Dr. Lily Hechtman of McGill University in Montreal, added: “I hope it didn’t do irreparable damage. The people who pay the price in the end is the kids. That’s the biggest tragedy in all of this.”

Obama's healthcare law takes full effect this week

The total of those who have signed up appears to be about 2 million, short of the goal but a recovery from the enrollment system's disastrous debut.

By Noam N. Levey and Chad Terhune
9:21 PM PST, December 29, 2013

WASHINGTON — Nearly four years after it was signed and after months of scrambling and uncertainty, President Obama's landmark bid to guarantee Americans health security takes full effect Wednesday as the Affordable Care Act begins delivering healthcare coverage to millions nationwide.
Administration officials reported Sunday that about 1.1 million people had enrolled in health plans using the federal website,, the main entry point for coverage in 36 states. Nearly all the enrollments came in the last couple of weeks as the deadline approached for coverage that would take effect Jan. 1.
Several hundred thousand people have enrolled on separate sites run by 14 states and the District of Columbia, with the largest figure coming from California, where more than 400,000 have signed up.
An exact count nationwide is not yet available because not all states have tallied their figures, but the total appears to be about 2 million. That remains short of the administration's original goal of 3 million by this point, but marks a significant recovery from the system's disastrous debut in October.
More than 4 million additional people have been found eligible for coverage under the law's expansion of Medicaid and the Children's Health Insurance Program.
How the law will ultimately work and whether it can endure remain unclear, though the fact that coverage will now be real for several million people will almost certainly change the debate over Republican efforts to repeal it.
While that broader political fight plays out, doctors, hospitals and pharmacies across the country are bracing for more confusion as patients struggle to understand their new coverage.
Some may show up at physicians' offices without insurance cards, victims of the error-plagued enrollment process that bedeviled the initial rollout.
Others may discover that although they're properly enrolled in a health plan, the doctor or hospital they visit or the prescription they want to fill won't be covered by the plan they have selected.
Still other patients, including many who have never had insurance before, may be shocked to learn they have to pay thousands of dollars out of pocket before their coverage kicks in. Like employer-provided health plans, many insurance plans set up under the health law come with low premiums and high deductibles.
Surveys indicate that many Americans have little understanding of basic insurance concepts such as co-pays and deductibles.
"We still have a lot of education to do for the average man on the street who doesn't really understand the Affordable Care Act," said J. Mario Molina, chief executive of Molina Healthcare Inc., a California-based insurer that is selling policies in nine states.,0,2110955,print.story

As critics gain, ALEC gives ground
By: Tal Kopan
December 27, 2013 04:56 PM EST
ALEC is putting 2013 in its rearview mirror.
The American Legislative Exchange Council, a conservative group of state lawmakers and corporations that, among other things, drafts model legislation, saw an exodus of members and a sharp decline in fundraising after it was tied to controversial “stand your ground laws” like the one made infamous following the shooting death of Florida teen Trayvon Martin.
ALEC has denied being the source of Florida’s law and says it has no model policy today bearing resemblance to it. But the group says its practice of keeping draft bills secret has allowed opponents to pin the organization unfairly to such measures.
So now, ALEC’s leaders say they are putting in place a key change that will make sure that never happens again. As part of what it calls a move toward more transparency, the group has decided to post online all the “model legislation” it develops so that lawmakers, the public and the press will be able to see exactly where ALEC stands.
“We all acknowledge there were challenges in our past, but challenge oftentimes gives you the opportunity to be introspective and see what you can do differently, what you can do better, how you can better serve your constituents and your community,” said Bill Meierling, senior director of communications and public affairs.
It’s the draft bills where the group has run into the most trouble. Opponents charge that the model legislation is written in secret, then translated into real bills — sometimes word for word — and passed by lawmakers as if it were their own work and with scant understanding of the implications.
The move toward greater openness comes in the wake of dozens of corporate members pulling out earlier this year after ALEC was drawn into the Martin case. By some estimates, as many as 400 lawmakers and 60 companies, including brand names like Coca-Cola, Pepsi and McDonald’s, bolted.
But critics say the transparency effort is a smokescreen, and they charge that ALEC remains the same corporate-driven “bill mill” designed to push right-wing business interests in statehouses with as little notice as possible. Enrolls 1.1 Million by Year-End––Cause For Celebration or Worry?

After the disastrous launch of Obamacare the enrollment of 1.1 million people in the 36 state exchanges run by the feds is a major accomplishment. It is likely that the enrollment in the 14 state-run exchanges will take total Obamacare's private insurance enrollment to near 2 million for the year.

Does this mean that Obamacare is finally on track and moving toward success?

At least the front-end of is now clearly working.

I will suggest there are still some very important questions for Obamacare that need to be answered.

First, how many of these new enrollments are people whose policies have been cancelled under Obamacare?
As I have said on this blog before, I expect at least 80% of those in the existing individual health insurance market to lose their coverage by the end of 2014. Half of the market bought their coverage after March 2010 and therefore cannot continue while most of the other half of the market will not qualify under the Obama administration's stringent grandfather rules.

What we don't know is just how many of these people had to buy new coverage on January 1 given the widespread offers by carriers to "early renew" their coverage into late 2014. Then the President asked insurers and states to allow people to keep their coverage another year. It appears about two-thirds of the states went along with that request. Then many of the cancellations won't occur until they renew throughout calendar year 2014.

We do know that California did not allow insurers to continue coverage for another year leading to 800,000 cancellations on January 1 and 200,000 cancellations by March. The state exchange has said that 300,000 of these are subsidy eligible and they can only get a subsidized policy on the exchange.

California will likely announce they have signed-up about 600,000 people this year. But given the cancellations that are occurring by January 1, is this a big accomplishment?

Washington State cancelled 260,000 policies and also did not allow the cancelled policies to continue past January 1. Half of these polices are subsidy eligible and can only get a subsidized policy in the state insurance exchange. Washington State might report 100,000 private plan enrollments by year-end. But if they cancelled 130,000 people who can only get a subsidized policy in their exchange, is this a big accomplishment?

The good news is that Obamacare will likely enroll almost 2 million people in 2013.

Even if we ignore that fact that many of these people were previously insured and had to replace cancelled policies (there were more than 400,000 subsidy eligible cancellations in California and Washington alone), 2 million people are only 10% of the 20 million uninsured in the U.S. who are eligible to buy coverage in the health insurance exchanges.

Second Official to Leave After Health Site Trouble

WASHINGTON — The No. 2 official at the Centers for Medicare and Medicaid Services, who supervised the troubled rollout of President Obama’s health care law, is retiring, administration officials said Monday.
The official, Michelle Snyder, is the agency’s chief operating officer. She is the second administration official to depart since problems at the website,, frustrated millions of people trying to buy insurance and caused political embarrassment to President Obama.
Ms. Snyder is in charge of the Medicare agency’s day-to-day activities and the allocation of resources, including budget and personnel. Technology experts who built the website for the federal insurance exchange reported to her, and she has been actively involved in the effort to fix the site’s problems.
Ms. Snyder’s departure follows that of the agency’s chief information officer, Tony Trenkle, who stepped down in November to take a job in the private sector.
A former agency official who had predicted Ms. Snyder’s departure said Monday: “She had to go. She was responsible for the implementation of Obamacare. She controlled all the resources to get it done. She was in charge of information technology. She controlled personnel and budget.”
Asked about Ms. Snyder’s plans, an agency official said Monday: “It’s her personal decision to retire now.”
Ms. Snyder could not be reached for comment.
The move comes after a series of congressional oversight hearings at which Republicans and Democrats sought to determine who should be held accountable for the health law’s disastrous rollout. At one such hearing on Oct. 30, Kathleen Sebelius, the secretary of health and human services, was asked who was responsible for developing the federal website, and she named Ms. Snyder. But Ms. Sebelius quickly added: “Michelle Snyder is not responsible for those debacles. Hold me accountable for the debacle. I’m responsible.”

Sign-Ups Surge in New York State’s Health Exchange

After a rush of 11th-hour interest, 230,624 people had enrolled in either private or public insurance through New York State’s health insurance exchange by the Dec. 24 deadline, qualifying them for coverage on the first day of the new year, state officials said on Monday.
The burst of interest in New York continued even after the deadline, with enrollments rising to 241,522 as of Monday, officials said.
Of those enrollments, 175,146 are in private commercial insurance plans, and 66,376 are in Medicaid, the government insurance program for the poor, which has spurred enrollment by raising its income limit.
Enrollment in the exchanges remains open through March 31. According to federal rules, individuals who apply by the 15th of the month will have insurance coverage on the first day of the following month, but the original Dec. 15 deadline for Jan. 1 coverage was extended because of early troubles on the website of the federal health exchange.
About 75 percent of those enrolling in individual plans on the New York exchange qualify for a subsidy to reduce the cost of coverage.
New York has surpassed the goal set by the federal government of 102,500 sign-ups by Dec. 31.
The federal goal for the March 31 enrollment deadline is 218,000 sign-ups for private insurance, as set forward in a September memo from the Centers for Medicaid andMedicare.
The state set a goal of 1.1 million enrollments by the end of 2016, and said it is on track to meet that goal.

Three health care changes that kick in on Jan. 1

Posted Dec. 28, 2013, at 6:28 p.m.
Last modified Dec. 29, 2013, at 5:59 a.m.
WASHINGTON — While the expansion of health insurance starting on Jan. 1 is the focus of much attention, there are plenty of other changes to the health care system sprinkled throughout the Affordable Care Act’s many, many pages. Here’s a look at some of the less-known health law provisions coming into effect with the start of the new year.
1) Wellness programs can grow. A lot. Beginning in January, the healthcare law allows employers to tether as much as 50 percent of workers’ insurance costs to their participation in wellness programs. These can range, for example, from a reduced deductible for taking a health assessment to rewards for meeting a certain target weight or cholesterol level.
Right now, the federal government limits the amount of cost-sharing that can ride on wellness programs to 20 percent. In 2014, that number will rise to 30 percent for general wellness programs — and 50 percent for participation in programs that aim to reduce tobacco use.

After troubled rollout, Obamacare’s new test starts on New Year’s Day

Posted Dec. 30, 2013, at 6:20 a.m.
New Year’s Day will bring a fresh test for President Barack Obama’s health care overhaul, as hundreds of thousands of Americans will begin to use the program’s new medical coverage for the first time.
For the nation’s health care system as well as its politics, the stakes are huge in Wednesday’s launch of the program known as Obamacare.
For anxious Democrats with an eye on the 2014 congressional elections, it is a chance for the Obama administration to rebound from the disastrous rollout of the website that enrolls people in private coverage through the program — and show that the White House’s effort to help millions of uninsured and underinsured Americans is finally gaining its footing.
Or, as Republican congressman Fred Upton and other critics of Obamacare warned in recent days, Wednesday could represent the beginning of another debacle that fuels Republicans’ push to make dissatisfaction with Obamacare the chief issue in the November elections.
More immediately, the question is whether the program will work as advertised on Jan. 1, after a chaotic enrollment period in which problems with the website led to a series of deadline extensions and undermined public support for Obamacare and the president.
The White House said early Sunday that about 1.1 million people have enrolled in coverage plans through the federally run, which covers 36 states. That figure does not include the latest enrollment data from 14 states that run their own health care enrollment sites — including California, Connecticut, Kentucky, New York and Connecticut — and where response to Obamacare has been enthusiastic, so the total enrollment nationally is likely more than 1.5 million.

Exclusive: U.S. government urged to name CEO to run Obamacare market


Sunday, December 29, 2013

Health Care Reform Articles - December

Medicare to Cover More Mental Health Costs

For decades, older adults with depression, anxiety and other psychological conditions have received unequal treatment under Medicare. The program paid a smaller share of the bill for therapy from psychiatrists, psychologists or clinical social workers than it did for medical services. And Medicare imposed strict lifetime limits on stays in psychiatric hospitals, although no such limits applied to medical care received in inpatient facilities.
There was never a good rationale for this disparity, and in 2008 Congress passed the Medicare Improvements for Patients and Providers Act. The law required Medicare to begin covering a larger share of the cost of outpatient mental health services in 2010 and to phase in additional increases over time.
On Jan. 1, that process will be complete, and for the first time since Medicare’s creation seniors who seek psychological therapy will be responsible for 20 percent of the bill while Medicare will pay 80 percent, the same percentage it covers for most medical services. (Payment kicks in once someone exhausts an annual deductible — $147 next year.)
In 2008, Medicare covered 50 percent of the cost of psychological treatment. Last year, it covered 65 percent.
The Medicare change follows new regulations issued last month by the administration for the Mental Health Parity and Addiction Equity Act, which expanded the principle of equal treatment for psychological illnesses to all forms health insurance. But that law does not apply to Medicare.
“Hopefully, older adults who previously were unable to afford to see a therapist will now be more likely to do so,” said Andrea Callow, a policy lawyer with the Center for Medicare Advocacy.
But parity under Medicare remains incomplete, and hurdles still stand in the way of older adults receiving services. A 190-day lifetime limit on inpatient services at psychiatric hospitals is the most notable example. There is no similar cap on any other inpatient medical services provided through Medicare.
“It’s just an arbitrary cap that targets people with serious mental illnesses who need care,” Ms. Callow said.

Placing Odds on Your Health (and Its Cost)

What is the chance that you will rack up big health care bills in 2014?
For the typical American adult under 65 who does not have health insurance, the total of all health care bills would be $2,700. That’s according to calculations by Milliman, an actuarial firm.
The obvious problem is that you can’t know in advance if your costs for the year will be typical. If you are unfortunate enough to have a costly medical problem, you could end up with far higher bills. Milliman calculated that 5 percent of the population will incur bills, absent insurance, exceeding $47,300.
Milliman estimated what patients will be billed without insurance, not what is paid to providers. According to Milliman, uninsured patients, who don’t have the benefit of insurance negotiators, are billed about 30 percent more than insured patients. The Affordable Care Act requires individuals to purchase insurance, but at what coverage level? If half of Americans without insurance will be billed less than $2,700, as Milliman projects, a healthy person, might do better under a plan with lower premiums but with high deductibles. (They can generally run as high as $5,000 for an individual and $10,000 for a couple.)
Of course, Milliman doesn’t know whether you are likely to become sick and to be among the top 5 percent or even the top 20 percent (who are billed more than $13,300). When choosing insurance, consumers need to consider their personal situations — and their stomach for risk.

Seeing the positive changes brought by the federal health law

Despite a troubled rollout, as many as 20 million people have gained access to coverage. But GOP lawmakers have blocked wider access to Medicaid, and House Republicans' hostility is making it impossible to fix flaws.

Michael Hiltzik
5:00 AM PST, December 29, 2013

This was the year that millions of Americans learned that health insurance is complicated. The landscape they discovered is ugly.
Paying a premium doesn't mean your costs are over. Lower premiums mean higher deductibles, higher fees at the doctor's office, higher prescription costs. You may have to pay more to see a certain doctor or go to a certain hospital.
After New Year's Day 2014, the discoveries will keep coming, when many of the newly insured use their policies for the first time. They may wonder, Why am I getting a bill? And, Why is it still so high?
And many may blame this curious, largely mythical beast called Obamacare, even though these features have been baked into the American healthcare system for years, even decades.
What they will be discovering is that the American way of health coverage is close to the worst and costliest in the developed world. The Affordable Care Act puts a dent in both those features, but doesn't eliminate them. During 2014, the country will finally start coming to grips with what to do about the features of American healthcare that haven't been measurably improved by the new law. And at the same time, the process of fixing the act's existing flaws will begin — or rather, continue.
"It's important that people realize this is a multi-year process," says Timothy S. Jost, a healthcare expert at Washington and Lee University. "I feel we're bottoming out this year in terms of the disruption of change." The hard work, he says, still lies ahead.
It's crucial that Americans don't allow the disruptions to obscure the positive changes already wrought by the Affordable Care Act, including access to insurance for as many as 20 million people previously locked out of the system by high costs and medical conditions.
Last month, Harold Pollack of the University of Chicago tried to tote up the number of people with a stake in the success of healthcare reform, using statistics from the U.S. Centers for Disease Control and Prevention. He counted 1.8 million uninsureds who had received a cancer diagnosis, 2.8 million suffering from diabetes, another million or more diagnoses with stroke, emphysema, heart disease or another serious chronic condition.
Throw in an additional 4.6 million with asthma or other pulmonary condition or liver and thyroid disease, and you've got 10.3 million uninsured Americans with "significant physical health issues." Prior to Obamacare, a huge percentage of these people, perhaps almost all of them, would have been unable to find affordable coverage at all. Now none of them can be excluded or socked with inflated premiums.
That's a population that easily swamps the number of those who are made worse off by the act. That latter figure, moreover, has been systematically overstated, due in part to confusion by customers and lazy news reporting.,0,3488407,print.column

Goodbye, Dirigo Health: What Maine’s program accomplished over 10 years

Posted Dec. 27, 2013, at 1:07 p.m.
As full implementation of the Affordable Care Act unfolds, it’s hard not to reflect upon Maine’s experiences with health reform.
Certainly Maine’s Dirigo Health reform is a microcosm in this sea of change, but a full decade after its enactment the similarities are striking. Both reforms created subsidized, private health insurance, negotiated by an inde­pendent entity; both expanded Medicaid and included strategies to improve quality and lower cost; and both met with strong, well-organized conservative opposition.
States have long experimented with health reform, and in 2003 Maine led the next wave, enacting Dirigo Health Reform. A campaign promise in John Baldacci’s race for governor, it became law his first year in office, after considerable work and compromise that won strong bipartisan support but only by changing the under­pinnings of the program.
Always controversial, Dirigo survived numerous assaults. Gov. Paul LePage campaigned to end the program, but instead the program continued and accepted new enrollees, albeit with reduced funding.
And, just as Baldacci’s bipartisan advisory group recommended, Dirigo will sunset on Dec. 31, 2014, as enrollees transition to the ACA’s health exchange.
A quick review of Dirigo’s accom­plishments:
• Covered 40,498 people and 994 businesses with affordable commer­cial insurance and annually funded MaineCare coverage for about 6,500 low-income parents.
• Established an independent agency, like Massachusetts and the ACA that followed, that negotiated with insurers and bargained on behalf of members for more affordable and quality products.
• Brought new competition to the market. The nonprofit Harvard Pilgrim Health Plan, routinely ranked best health plan by the National Committee for Quality Assurance, became the Dirigo insurance carrier.
• Responded to the market, helping low-wage, part-time workers buy their companies’ insurance. Unlike Massachusetts or the ACA, Dirigo subsidized workers in small businesses, not just indi­viduals and families.
• Covered preventive services with no co-pays required, a provision now part of the ACA.
• Bucked national trends by reducing the number of uninsured in Maine, despite the deepest reces­sion since the Great Depression, when employer-sponsored health insurance was waning. In 2003, America’s Health Rankings listed Maine 18th among the states lacking health insurance; in 2011, Maine was sixth best in the country.
• Linked access to health coverage with efforts to limit costs and spur quality. Dirigo established volun­tary targets that limited hospital costs to a 3 percent growth rate; created a state health plan to guide decisions about the health system; and launched the Maine Quality Forum, advocating for high-quality health care and helping consumers make informed health care choices. The ACA establishes a new Patient Centered Outcomes Research Center to improve quality of care nationally.

Medicaid expansion through private insurance? Not if we want lower health spending

Posted Dec. 27, 2013, at 1:17 p.m.
As the Legislature returns to Augusta this winter, some might suggest an arrangement under which Maine uses federal funds meant to expand Medicaid to instead purchase private insurance for low-income residents.
It’s an approach that’s proved more politically palatable to Republicans across the country than a direct Medicaid expansion. Arkansas, with a Democratic governor and Republican legislature, blazed the trail for the arrangement, securing the federal government’s approval to try it out. In Iowa, Republican Gov. Terry Branstad has followed suit. A number of other Republican governors are also interested. Maine Gov. Paul LePage is paying attention to those developments while he remains opposed to an expansion, his spokeswoman has said.
But is expanding coverage by having the state pay for private insurance for some of its poorest residents a good idea?
Arkansas Gov. Mike Beebe is out to prove it is. In applying for federal approval for the Medicaid expansion alternative, Arkansas said it would seek to prove those who receive private insurance rather than Medicaid will have access to more care providers than their Medicaid counterparts, will use the emergency room less and will “churn” in and out of health plans less frequently as their incomes and eligibility for services change. The idea is they would be able to stick with a private plan even if they no longer qualified for Medicaid.
In addition, Arkansas said it would get those results at a comparable cost to traditional Medicaid.
We’re eager for the results on those first three points, and we think there’s a good chance Arkansas will be proved right. On the last point, cost, we have our doubts.
There’s a reason people with low incomes don’t enroll in private insurance: They can’t afford it. Indeed, it might be unwise to read too deeply into early Obamacare enrollment numbers, but just 41 percent of those who qualified by the end of November to enroll in private insurance through the law’s exchanges had incomes low enough to receive federal subsidies meant to defray the cost. To qualify for those subsidies, someone has to make between 100 percent and 400 percent of the federal poverty level — between $26,951 and $78,120 for a three-person family.
The new participants in Arkansas’ alternative Medicaid model won’t have to pay monthly premiums, but many of them will ultimately be responsible for cost sharing — including deductibles and copayments. Even with the Affordable Care Act’s annual caps on the amount someone can spend out of pocket on medical expenses, a three-member family participating in Arkansas’ Medicaid expansion making less than $27,000 could still end up paying more than $4,200 out of pocket on medical expenses. That’s nearly 16 percent of annual income for a family that’s unlikely to have much money to spare.

Commentary: New day in health care dawns Jan. 1

Millions of Americans, in Maine and nationwide, are learning what a bargain quality health coverage can be under the Affordable Care Act.

By Kathleen Sebelius
Kathleen Sebelius is secretary of the U.S. Department of Health and Human Services.
This Wednesday, Jan. 1, will mark a new day in health care for millions of families and individuals throughout Maine.
Starting Wednesday, it will be against the law for insurance companies to deny you coverage or charge you more because of a pre-existing medical condition like diabetes, high blood pressure or asthma. And they will no longer be able to drop you from coverage just because you get sick or get into an accident.
What’s more, insurance companies will no longer impose an annual cap on your health benefits. They won’t be able to deny you coverage simply because you made a mistake on your paperwork. Most plans must cover preventive services like cholesterol and cancer screenings, at no out-of-pocket cost. And being a woman will no longer be a pre-existing condition.
It’s all thanks to the health care law: the Affordable Care Act.
If you do not have health insurance through your job, you have an opportunity to obtain quality, affordable coverage through In fact, you may even qualify for financial assistance to help lower the cost of your premiums.
The Health Insurance Marketplace has brought choice and competition to Maine that were previously unavailable: In the Portland area, you can choose from 17 qualified health plans.
As millions of Americans learn about their new options, they’re finding just how affordable health coverage can be under the new law. A family of four in Portland earning $50,000 per year can obtain affordable coverage for as little as $103 per month (with premium tax credits).
Nationwide, six in 10 uninsured Americans can obtain coverage for as little as $100 a month or less.
And make no mistake: The plans offered on the marketplace are actual, honest-to-goodness health insurance. By law, they must cover a set of essential benefits, including visits with doctors, prescription medications, hospital stays, ambulatory care, maternity and newborn care and preventive services.
You still have three more months to enroll in affordable coverage – the deadline is March 31.
If you want your health insurance to begin Feb. 1, you’ll need to sign up by Jan. 15.

'Sticker shock' over Obamacare bolsters single-payer argument

New reporting by AP underscores systemic problems with healthcare system based on for-profit insurance model

By Jon Queally
Common Dreams, Dec. 23, 2013
As the political uproar surrounding the Affordable Care Act has played out over recent months, one single fact remains: the private insurance model—on which the law widely known as Obamacare is based—is more complicated, more expensive, and provides less coverage than a simple, "everybody in/nobody out," single-payer model that almost every other advanced country in the world enjoys.
And even within the debate about whether or not Obamacare is a "step forward" or a "step back" for healthcare delivery in the U.S., what's become increasingly clear—as was predicted by progressive critics of the Obamacare model—is that though portions of the law undoubtedly improve the kinds of coverage that some people receive, others are still excluded from the system entirely and among those who are now purchasing insurance for the first time in their lives many will face "sticker shock" at the high premiums or out-sized deductibles.
As new reporting by The Associated Press highlights:
"As a key enrollment deadline hits Monday, many people without health insurance have been sizing up policies on the new government health care marketplace and making what seems like a logical choice: They're picking the cheapest one.
"Increasingly, experts in health insurance are becoming concerned that many of these first-time buyers will be in for a shock when they get medical care next year and discover they're on the hook for most of the initial cost.
"The prospect of sticker shock after Jan. 1, when those who sign up for policies now can begin getting coverage, is seen as a looming problem for a new national system that has been plagued by trouble since the new marketplaces went online in the states in October."
What the AP goes on to describe is how the economic hardships that most middle- and low-income Americans experience on a daily basis compel them to choose insurance policies with the lowest monthly premium, but don't realize that the huge deductibles attached to those plans mean that they may have huge medical bills to pay before their coverage kicks in.

Simple solution — single payer

By Rochelle Dworet, M.D.
Health Policy Solutions (Denver, Colo.), Dec. 23, 2013
So the Affordable Care Act is finally being implemented, even online.  Our state has its own exchange, which seems to run better than the national model.  The people in the states that implemented their own exchanges are all busy heaping accolades on each other. However, the real question is, “Where is the single-payer solution that would save hundreds of millions of dollars and lives?”
Our fiscally prudent cohorts should want a system of private care or whatever the provider fancies with a low overhead to administer, and one that covers everyone — namely single payer.  After all, let’s remember that Medicare was implemented within six months of passage using one’s Social Security number and all the relevant information documented on index cards.  No fancy computer system was required with exorbitant expenditures to make it work. Now seniors love their Medicare, as witnessed by the signs, “Government, hands off my Medicare.”
Unfortunately, the big PR firms, lobbyists and corporate giants that control the medical empire make way too much in salaries and bonuses to care about what is good for people.
We recently mourned the loss of one of the greatest civil and human rights activists ever, Nelson Mandela.  Yet, we forget that the United Nations decreed that health care is a human right.  We, as a civil society, have an obligation to all our brothers and sisters to afford them health care regardless of financial means.
But no, as Steven Brill pointed out in “The Bitter Pill,” his Time Magazine article last March,  hospitals and clinics charge as much as they can get away with based on some medical fiction called the “Chargemaster,” a system more suited to a Star Wars movie than to humanity.  Is it any wonder that we are the only developed nation with a 62 percent bankruptcy rate due to medical debt, and two-thirds of those people had insurance!
As a physician, I know that medicine does not fit a business model.  Each time a patient enters into a discussion and examination for care, she breaks the mold of another algorithm and diagnostic code.  Providers need to use their skills to fullest capacity and be compensated fairly whether they are in primary care or a narrower specialty.  It is a team approach that creates success at wellness.

Friday, December 27, 2013

Health Care Reform Articles - December 27, 2013

Op-Ed: Our Profit-Centered Private Medical Industry Is Cutting Back on Hospital Care 

With all the clamor over the website woes of the rollout of the Affordable Care Act finally ebbing, let's hope the media can begin to notice some changes in the delivery of health care that will have more far-reaching consequences for health care quality and access long after the sign-up problems are a distant memory.
Despite the hysteria on the right, some components of the ACA are clearly welcome, especially the Medicaid expansion in those states where the governors are not standing with pitchforks in the door to block health coverage for the working poor.
Yet there's plenty of trouble ahead, most evident with the cost shifting from insurers and providers to workers and families.
Many are now aware that the insurance plans offered through the exchanges are chock full of added out-of-pocket costs.
The cost problem extends well into the provider setting, as is now just being gleaned through some reporting on price gouging [3] by many big hospitals which jack up costs to patients through steeper co-pays, requiring cash up front before administering care, Medical Credit Scoring to determine if patients are a payment risk, and hounding patients for payment afterwards.
Less reported are the escalating problems on the care delivery side.
Let's start with a new survey [4] out from Citi Research, via Reuters, which reports that "hospital inpatient admissions in November fell to their weakest level in more than a decade."
Two big chains illustrate the trend. Henry Ford Health System in Detroit had a 6 percent drop the first seven months of this year, Modern Healthcare reported in August. California-based Kaiser Permanente has reduced its average daily census by 11 percent the past four years.
No one, of course, wants to be hospitalized. Sometimes you must be. A hospital is where you receive 24-hour nursing care, where they have the ability to quickly shift you to an operating room or intensive care floor if your condition suddenly deteriorates, and where they have the most specialized equipment.
But the hospital industry, increasingly dominated by giant corporations, either for-profit or acting like for-profits, are making higher profits elsewhere - in outpatient settings, especially surgery centers and boutique care centers, and investments, for example.

The painful path to Obamacare deadline

WASHINGTON (Reuters) - Tuesday is a moment of truth for Obamacare.
It marks the final deadline for most Americans to sign up for health insurance under President Barack Obama's 2010 Affordable Care Act, popularly known as Obamacare, if they want coverage starting on January 1.
If enough people - and the right mix of young and old - do not enroll, the ambitious program designed to provide health benefits to millions of uninsured and under-insured Americans risks eventually unraveling.
The deadline caps a turbulent roll-out this year for Obamacare and the website that is key to enrolling millions of people in the initiative. The website crashed upon its launch on October 1, frustrating users trying to shop for insurance plans. It now is functioning much better, but is still not at 100 percent.
Despite the continuing problems, the administration is expressing confidence that Obamacare is getting back on track after enrollment accelerated in December, with more than 1 million people signing up for private insurance.
Here is a look at some notable moments in the months leading up to Obamacare's troubled launch.

Bridging the care gap

Hospital miscues have decreased, but what about after discharge?