Tuesday, April 28, 2015

Health Care Reform Articles - April 28, 2015

Britain’s National Health Service, Creaking but Revered, Looms Over Elections

The Demise of Vermont's Single-Payer Plan

John E. McDonough, Dr.P.H., M.P.A.
On December 17, 2014, Vermont Governor Peter Shumlin publicly ended his administration's 4-year initiative to develop, enact, and implement a single-payer health care system in his state. The effort would have established a government-financed system, called Green Mountain Care, to provide universal coverage, replacing most private health insurance in Vermont. For Americans who prefer more ambitious health care reform than that offered by the Affordable Care Act (ACA), Shumlin's announcement was a major disappointment. Was his decision based on economic or political considerations? Will it damage the viability of a single-payer approach in other states or at the federal level?
Shumlin's exploration of a single-payer health care system, which included three assessments by different expert groups, was among the most exhaustive ever conducted in the United States. A 2011 study led by Harvard health economist William Hsiao provided optimistic projections: immediate systemwide savings of 8 to 12% and an additional 12 to 14% over time, or more than $2 billion over 10 years, and requirements for new payroll taxes of 9.4% for employers and new income taxes of 3.1% for individuals to replace health insurance premiums 
Two years later, a study by the University of Massachusetts Medical School and Wakely Consulting projected savings of just 1.5% over 3 years.Finally, a 2014 study by Shumlin's staff and consultants predicted 1.6% savings over 5 years and foresaw required new taxes of 11.5% for employers and up to 9.5% for individuals. The governor cited these last projections in withdrawing his plan: “I have learned that the limitations of state-based financing, the limitations of federal law, the limitations of our tax capacity, and the sensitivity of our economy make that unwise and untenable at this time . . . . The risk of economic shock is too high,” Shumlin concluded.
Two factors explain most of the decline in the plan's financial prospects. First, the anticipated federal revenues from Medicaid and the ACA declined dramatically. Second, Shumlin's policy choices significantly increased the total projected cost of Green Mountain Care: raising the actuarial value of coverage — the expected portion of medical costs covered by a plan rather than by out-of-pocket spending — from 87% to 94%, providing coverage to nonresidents working in Vermont, and eliminating current state taxes on medical providers. Still, even Shumlin's projections indicated that the plan would reduce Vermont's overall health spending and lower costs for the 90% of Vermont families with household incomes under $150,000. Despite differing projections, all three studies showed that single payer was economically feasible.
In reality, the Vermont plan was abandoned because of legitimate political considerations. Shumlin was first elected governor in 2010 promising a single-payer system. But in the 2014 election, his Republican opponent campaigned against single payer. Shumlin won the popular vote by a single-percentage-point margin, 46% to 45%, which sent the election to the Democratic-controlled House of Representatives; though the House reelected him easily in January, a clear public mandate for his health care agenda was nowhere in evidence.
Public disagreement over single payer was clear in an April 2014 survey showing 40% public support, 39% opposition, and 21% undecided. Though Shumlin's team had worked hard on policy development between 2011 and 2014, they had neglected to launch a serious and sustained effort to educate the public — a crucial missed opportunity. Indecision was evident in the Vermont legislature, where strong support for single payer was hard to find. Also, the administration's disastrous launch of its ACA health insurance exchange website, Vermont Health Connect, created doubts about the state's capacity to assume management and administrative responsibilities for the entire health care system.
Asking the legislature to approve a new 11.5% payroll tax on employers and income taxes on households as high as 9.5% to finance Green Mountain Care would have increased the size of Vermont's 2015 state budget, set at $5.6 billion, by 45%. Even though the taxes would have replaced private insurance premiums that employers and individuals currently pay, and even though the Internal Revenue Service had agreed that the taxes would be federally deductible, in political terms it would have been a mammoth increase that would have been glaringly evident on every Vermonter's tax bill, unlike employer-based health insurance premiums, which most workers fail to notice. According to research in behavioral economics, people pay more attention to hypothetical losses than to hypothetical gains. The political furor that would certainly have erupted over Shumlin's tax plan — as foreshadowed by the political uproar over the ACA — would have left most Vermonters believing they would be losers. Shumlin's decision to withdraw the plan represented a failure of political will — but sometimes making decisions because of likely political consequences is the necessary, albeit regrettable, thing to do.
In many states, legislators continue filing bills to establish state single-payer systems. Because of Vermont's failure, their path is both clearer and more difficult. Any other state considering this path will find obstacles similar to Vermont's.
For example, Section 1332 of the ACA permits state governments, beginning in 2017, to obtain federal waivers to develop alternative health coverage systems and to claim federal revenues that would otherwise flow into the state under the ACA. The three reports on Vermont's single-payer plan offered widely varying and rapidly descending revenue estimates: $420 million in the 2011 report, $267 million in 2013, and $106 million in 2014.
In the early 1990s, I served as a Massachusetts legislator who took a turn as the state's leading single-payer advocate. After years of failure, I reluctantly concluded that single payer is too heavy a political lift for a state. Though the economic case is compelling, our body politic cares about more than just economics. In 2011, many observers thought that Vermont, a small and progressive state, was the ideal locale in which to try single payer. No more. Even in deeply blue Massachusetts, Donald Berwick, former acting administrator of the Centers for Medicare and Medicaid Services, came in last in the 2014 Democratic gubernatorial primary in a campaign where his single-payer platform represented a compelling difference between him and his two opponents.
At some point, perhaps 5 to 15 years from now, as the size and scope of Medicare, Medicaid, and the ACA subsidy structure balloon far beyond today's larger-than-life levels, our political leaders may discover the inanity of running multiple complex systems to insure different classes of Americans. If advanced by the right leaders at the right time, the logic of consolidation may become glaringly evident and launch us on a new path. If such consolidation is to occur, like it or not, I believe it will happen federally and not in the states — and no time soon.

UNE official: Better teamwork could reduce medical errors

Democratic lawmakers reject switching their health coverage to Obamacare

Democratic state lawmakers on Thursday shot down a proposal that would have required all California state legislators to get their health insurance from Covered California, the benefits exchange set up to implement Obamacare in the state.
The Assembly Rules Committee split along party lines, with seven Democrats opposing AB 1109 and three Republicans in support of the bill by Assemblyman Scott Wilk (R-Santa Clarita). The measure would have forced lawmakers to give up the taxpayer-subsidized health plans provided by the Legislature and individually sign up for Covered California.
Wilk introduced the measure after hearing complaints from several constituents about difficulties in signing up on the Covered California website and limitations on what is covered.
“I believe the Legislature would be more pro-active in addressing these concerns if we were enrolled in the program,” Wilk said.
However, some Assembly members said the legislation violates a provision of the federal Affordable Care Act (ACA) that prohibits large employers from shifting their workers to Obamacare.
Wilk does not believe the ACA provision on large employers would prevent lawmakers from switching to Covered California, according to his spokeswoman, Lisa Johnson.
“Legislators are not employees of the Assembly in any traditional sense,” she said. “They aren’t hired or fired by the Assembly.  They have immunity from many things.  Legislators are representatives to their respective districts and are elected by the people. If anything, they are employees of those voters and individual districts.”

18,000 Californians use extended Obamacare sign-up to avoid tax penalty

California officials said about 18,000 people have taken advantage of an extended Obamacare enrollment period that was created as a final opportunity to escape the health law's tax penalties.
The special enrollment window runs until April 30 for people who claim they were unaware of the Affordable Care Act's financial penalties for being uninsured.
Peter Lee, executive director of the Covered California exchange, said Tuesday that since Feb. 23 more than 18,000 people have signed up for a private health plan and cited that reason for enrolling during the extended period.
Normally, obtaining a policy outside regular open enrollment, which closed Feb. 20, is reserved for people who experience a qualifying event such as divorce, having a child or losing employer coverage. That type of special enrollment is available year round.
Overall, 1.4 million Californians get their health coverage through the state marketplace.
Uninsured people can't avoid a health-law penalty for lacking coverage in 2014. But there's still time to do something for the 2015 tax year.

Decades-long Franklin County health initiative praised in national medical journal

Posted Jan. 14, 2015, at 1:07 p.m.
FARMINGTON, Maine — Forty years ago, the concept that the health of an entire community could be improved if everyone worked together for their shared benefit was launched by a handful of doctors and nurses at Franklin Memorial Hospital.
That concept is earning high praise from the Journal of the American Medical Association, along with the Journal of the American Medical Association’s recommendation that the accomplishments in Franklin County deserve international study.
In the 1970s, recognizing that low-income residents were not getting the health care they needed, Dr. Burgess Record and his wife, Sandra Record, R.N., solicited the help of co-workers and volunteers who teamed up and went to churches, town halls, schools and businesses to talk to people about high blood pressure and do health screenings, combining social outreach and individual medical care.
At the suggestion of Dr. David Dixon of Franklin Memorial Hospital, they tracked their efforts and patient outcomes and have since proven this community-based health care model works to help prevent chronic disease.
According to their data, this team approach reduces hospitalizations, reduces deaths, increases quit-smoking rates, improves the lives of people suffering from chronic diseases and increases workplace productivity.
The community-based health care model — The Franklin Model — is the subject of what is being called a tremendously important Journal of the American Medical Association study titled “ Community-Wide Cardiovascular Disease Prevention Programs and Health Outcomes in a Rural County 1970-2010.”
The study was released Tuesday.
Included in the Journal of the American Medical Association report is an editorial recommending the Franklin approach be studied for possible replication in rural areas of the United States and other parts of the world.
In fact, Franklin Memorial Hospital Chief Operating Officer Gerald Cayer, one of 10 study co-authors, said the proof of improved health under the Franklin approach is so clear and the process so well-documented in the Journal of the American Medical Association study that it supports the idea “that this approach is replicable and may be a piece of the surprising solution for fixing our health care system.”
At a news conference announcing details of the Journal of the American Medical Association study Tuesday at Franklin Memorial Hospital, Dixon said the idea of teams reaching out to their neighbors to improve health care seemed straightforward and attainable in the 1970s, but “it was a deceptively difficult task” to document the work and prove that their approach works. And in the early years, not everyone in the county supported their efforts.
Less comprehensive efforts in other communities failed, including in Minnesota and Rhode Island, but Dixon attributes the success in Franklin County to its community base.
Dr. Daniel Onion of the Maine-Dartmouth Family Medicine Residency and another co-author of the Journal of the American Medical Association study said he moved to Franklin County “in the 1970s with a 1960s zeal to help the community.”
That zeal propelled, Dixon, Onion, the Records, Dr. Roderick Prior and Fenwick Fowler of Western Maine Community Action, among others, to come up with a plan to improve access and document patient outcomes. They describe it as a frugal, efficient and effective plan.
Due in great part to a federal grant, Franklin Memorial Hospital increased staff and established three satellite clinics, creating a nurse-directed communitywide effort to reach people where they shopped, worked, worshipped and their children attended school.
After years of continued outreach, including finding and reaching out to patients who didn’t attend appointments, Prior said the result was that Franklin County started to produce good health statistics, better than elsewhere in Maine. That is despite its low-income population, which is generally a statistical indicator of poor health.
In time, and after then-Gov. Angus King and then-Public Health Director Dr. Dora Anne Mills designated tobacco settlement funds for quit-smoking programs, the quit-smoking rate in Franklin County was higher than anywhere in Maine and higher than the U.S. average. The hospitalization and mortality rates for those living in Franklin County were lower than in Maine and elsewhere in the country, and those successes have since continued.
According to Onion, health care workers and volunteers “created peer support for a community culture change,” demonstrating that, by working together, “low-income counties may not be doomed to low health outcomes.”
Angus King, a U.S. senator, joined the news conference by video and said the Journal of the American Medical Association study “is a big deal. This is a big national deal. It verifies what some of us have known for years,” and that is “community health can be improved.”
King’s wife, Mary Herman, joined him in the videoconference. A nurse, she praised the study participants for their work and said her favorite part of the Franklin story was how volunteers worked in the community among their friends and neighbors “to bring about behavioral changes.”
King, who said he hoped other communities will look to the Franklin model to improve their health, said he has faith it can be done if people remain committed.
“This is a national model that can be replicated and can save money,” King said, a combination “that is a good thing for Maine, for Franklin County, but really for the entire United States.”
He called the Franklin results “an important direction for health care.”
Franklin’s success, according to Sandra Record, was to go where people are rather than expect everyone, particularly those who don’t have insurance or can’t pay for health care, to seek medical attention.
“We go to where the people are, was our motto,” she said, including outreach at the University of Maine at Farmington, five school districts and 60 community and civic groups across Franklin County. And in an effort to lead by example, Franklin Memorial Hospital became the first smoke-free hospital in Maine.
Dr. Thomas Pearson, executive vice president for research and education at the University of Florida Health Services Center and a co-author of the Journal of the American Medical Association study, called the 40-year commitment in Franklin County “just amazing.” He described it as a group of people “who decided to do the right thing and then stuck with it.”

Former Rep. Allyson Schwartz's new group, The Better Medicare Alliance, is not what it appears

Commentary: Fronting for a phony front group




Admitted to Your Bedroom: Some Hospitals Try Treating Patients at Home

When Martin Fernandez came into Mount Sinai Hospital’s emergency room one recent afternoon, with high fever and excruciating abdominal pain, he and his family were asked an unexpected question.
Mr. Fernandez, 82, would have to be officially admitted to receive intravenous antibiotics for his urinary tract infection. But he could stay at Mount Sinai, or he could receive treatment at home.
If he chose to be hospitalized at home, doctors and nurses would visit daily. He would receive lab draws and intravenous medications, even X-rays or ultrasound scans if he needed them. The costs to him would be no greater than if he were physically in the hospital. In three or four days, he would be discharged — and he would not have to go anywhere.
For Mr. Fernandez, a retired house painter from Venezuela who lives with his wife on Manhattan’s Upper West Side, the choice was clear. He was hospitalized at his daughter’s apartment, just a couple blocks away, a few hours later.
He had a urinary catheter, but Mr. Fernandez could still wear his own clothes during the day and his pajamas at night. His wife and his daughter cooked him meals of arepas, vegetables and black beans, and served them to him in bed.
“Hospitals help you, but there’s so much noise that you can’t sleep and you’re lonely,” said Mr. Fernandez’s daughter, Ana Vanessa Fernandez. “Here, there was no timing for visitors. There was no curfew. It’s like being at home, but the hospital is home with you.”

Health Care Policy and Marketplace Review

A Health Care Reform Blog––Bob Laszewski's review of the latest developments in federal health policy, health care reform, and marketplace activities in the health care financing business.
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The Republicans should offer an unconditional subsidy extension if the Supreme Court strikes them down

Wisconsin Senator Ron Johnson (R) has offered a plan to extend the Obamacare state exchange subsidies into 2017 if the Supreme Court strikes them down this summer. The Republican Senate leadership is supporting his bill.

But Johnson has some pretty big conditions:
  • Existing subsidies in the federally run exchanges would continue until September 1, 2017. 
  • The individual mandate would be struck down.
  • The employer mandate would also be repealed.
  • Obamacare's benefit mandates––the essential health package requirements––would be struck down enabling insurance companies to market any health insurance plans that complied under state law. 
  • Consumers could keep any pre-Obamacare policies still in effect. 
  • The subsidy extension would not apply to new enrollees––just those individuals and families getting subsidies at the time the Senator's bill became law. 
On the face of it, Republicans are smart to demand the most unpopular parts of Obamacare should be immediately scrapped.

But, Democrats just aren't going to go for this. They will point out that while the individual mandate was being struck down the guarantee issue provisions of Obamacare would still be intact leading to significant anti-selection and problems for the health insurance markets without at least a viable alternative to the individual mandate.

They will also point out that all subsidized enrollments in the federally-run states would be frozen resulting in people who would otherwise be eligible for coverage being prohibited from signing up for subsidized Obamacare insurance, including during the scheduled open-enrollments starting in late 2015 and late 2016. 

In other words, this Republican strategy just takes us into another partisan pissing contest while regular people worry about the status of the insurance subsidies.

Vermont Activists Battle Democratic Governor for Single-Payer Health Care 

April 27, 2015
Liz Nikazmerad is a rarity in American labor: a local union president under the age of 30, displaying both youth and militancy. For the last two year years, she has led the 180-member Local 203 of the United Electrical Workers (UE), while working in the produce department of City Market in Burlington, Vermont. Thanks to their contract bargaining, full-time and part-time employees of this bustling community-owned food cooperative currently enjoy good medical benefits.
But that wasn’t always the case in Nikazmerad’s past non-union jobs, nor is it any assurance that UE members won’t be forced to pay more for their health care in the future. To curb medical cost inflation and related cost-shifting to workers, the UE has long advocated that private insurance plans be replaced with publicly funded universal coverage.
Four years ago, a newly elected Vermont governor, Peter Shumlin, took a promising first step in that direction at the state level. His Democrat-dominated legislature passed Act 48, which laid the groundwork for creating a comprehensive public insurance plan called Green Mountain Care (GMC).
Not all activists deemed GMC to be truly “single-payer,” because of potential legal or political obstacles to the inclusion of Vermonters currently covered through Medicare, the Veterans’ Administration, and even some “self-insured” plans offered by local employers. However, Act 48’s blueprint for getting everyone else into a more rational, cost-effective healthcare system, financed by taxes, was generally hailed as a great breakthrough.
Unfortunately, the Affordable Care Act (ACA) first required Vermont to operate a private insurance exchange until 2017, when a federal waiver permitting further experimentation might be granted. Despite this delay, Shumlin was still reassuring Vermonters, as recently as last fall, that a brighter health care future lay just a few years ahead.
By January 8, when the governor began his third term, that promise had dimmed so much that Liz Nikazmerad and several hundred others weren’t there to applaud his inauguration in Montpelier. Instead, frustrated advocates of health care reform staged a sit-in at the state capitol, chanting and singing, unfurling banners and refused to leave in protest against the governor’s abrupt abandonment of universal health care six weeks after his re-election.
“People had fought for this a long time,” Nikazmerad says. “It was a huge win and to have the rug yanked out like that was very upsetting. People were very emotional about it.”

Thursday, April 23, 2015

Health Care Reform Articles - April 23, 2015

Obamacare, Hands Off My Medicare

A number of factors underpin the anti-redistributionist shift in public opinion that I wrote about last week.
First, and perhaps most important, is the emergence of significant resistance to downward redistribution among the elderly, a major voting bloc.
The views of older voters deserve scrutiny. They “worry that redistribution will come at their expense, in particular via cuts to Medicare,” Vivekinan Ashok, a Ph.D. candidate in political science at Yale; Ilyana Kuziemko, a professor of economics at Princeton; and Ebonya Washington, a professor of economics at Yale, write in a March 2015 Brookings Institution essay, “Support for Redistribution in an Age of Rising Inequality”— an essay my Times colleague Neil Irwin also discussed in a recent column that asked why Americans don’t want to soak the rich.
In the end, Ashok, Kuziemko and Washington conclude that
the elderly have grown increasingly opposed to government provision of health insurance and that controlling for this tendency explains roughly half of their declining relative support of redistribution.

What the Brookings essay neglects to explore are the material circumstances of over-65 voters that might affect their views on redistribution. Over a third of retirees depend on Social Security for 90 percent or more of their annual income, according to the Social Security Administration. In the zero-sum competition for federal dollars, the cost of major spending programs like the Affordable Care Act has to be made up by spending cuts elsewhere.

It’s time for Maine to reconsider Medicaid expansion

Gov. Paul LePage and his administration have claimed repeatedly over the past few years that Maine can’t afford to expand Medicaid to about 70,000 low-income parents and adults without children.
But policymakers in Maine can now inform their decisions with the experience so far of states where Medicaid coverage expanded on Jan. 1, 2014. Drawing on that experience, a new analysis of Medicaid expansion’s potential impact on Maine’s state budget complicates the narrative that extending health coverage would be prohibitively expensive.
The analysis, released Wednesday by the Maine Health Access Foundation, projects a $26.7 million budget benefit in 2016 if Maine expands Medicaid due to a combination of savings from shifting expenses elsewhere in the state budget to Medicaid and new revenues the state would take in from hospitals treating newly covered patients. Those $43.9 million in projected savings and new revenues for 2016 would more than offset the $17.2 million projected in new costs.
The organization that conducted the analysis, Manatt Health Solutions, drew on its examination of the expansion-related costs and savings experienced by eight states that extended Medicaid coverage. Those states all faced costs due to the expansion — to be sure, Maine would see higher initial costs than many — but the savings more than offset them.
Those savings came in part from enrolling newly eligible residents in Medicaid who would otherwise qualify for services funded entirely or mostly with state funds. By shifting state spending for mental health services, breast and cervical cancer screening, and prescription drug assistance for older residents to Medicaid, the federal government effectively takes over the responsibility of paying for them.

What It Means For Your Health When Your State Refuses to Expand Medicaid

Nearly 60 percent of African Americans and 40 percent of Latinos live in states that have not expanded the program.

Even though the Affordable Care Act (ACA) has helped millions of people get health insurance, quality health care is still out of reach for a large number of people of color, low-income families and those with language barriers. The high cost of insurance premiums and co-pays was the main reason cited for those who remain uninsured. The complexity of the enrollment process was also a deterrent.