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Wednesday, December 10, 2014

Health Care Reform Articles - December 10, 2014

ObamaCare author: Health law is 'really complicated'


Sen. Tom Harkin, one of the co-authors of the Affordable Care Act, now thinks Democrats may have been better off not passing it at all and holding out for a better bill.
The Iowa Democrat who chairs the Senate Health, Education, Labor and Pensions Committee, laments the complexity of legislation the Senate passed five years ago.
He wonders in hindsight whether the law was made overly complicated to satisfy the political concerns of a few Democratic centrists who have since left Congress. 
“We had the power to do it in a way that would have simplified healthcare, made it more efficient and made it less costly and we didn’t do it,” Harkin told The Hill. “So I look back and say we should have either done it the correct way or not done anything at all.
“What we did is we muddled through and we got a system that is complex, convoluted, needs probably some corrections and still rewards the insurance companies extensively,” he added.
Harkin said the sweeping healthcare reform bill included important reforms such as preventing insurance companies from discriminating against people with pre-existing conditions and keeping young adults on their parents’ health insurance plans until age 26.
He also lauded the law’s focus on preventing disease by encouraging healthy habits, something he contributed to by drafting the Healthier Lifestyles and Prevention America Act, which informed ObamaCare.
But he believes the nation might have been better off if Democrats didn’t bow to political pressure and settle for a policy solution he views as inferior to government-provided health insurance.
“All that’s good. All the prevention stuff is good but it’s just really complicated. It doesn’t have to be that complicated,” he said of the Affordable Care Act.  
Harkin, who is retiring at the end of this Congress, says in retrospect the Democratic-controlled Senate and House should have enacted a single-payer healthcare system or a public option to give the uninsured access to government-run health plans that compete with private insurance companies.
“We had the votes in ’09. We had a huge majority in the House, we had 60 votes in the Senate,” he said.
He believes Congress should have enacted “single-payer right from the get-go or at least put a public option would have simplified a lot.”
“We had the votes to do that and we blew it,” he said.

If Slow Is Good For Food, Why Not Medicine?

Maria Fabrizio for NPR

Maybe you've heard about the slow food movement. Maybe you're a devotee.
The idea is that cooking, nutrition and eating should be intentional, mindful and substantive. Avoid fast food and highly processed grub. For the slow food set, the process is as important as the product.
Now I'm seeing a medical version of slow food. The concept is bubbling up in response to industrialized, hypertechnological and often unnecessary medical care that drives up costs and leaves both doctors and patients frazzled.
As a teacher of medical students and residents, I find myself pulled between two contradictory poles. I want new doctors to be efficient so that they can survive in the real world of medical practice, which breaks our time into eight-minute increments. But I also want them to take the time to think through their actions and consider potential consequences.
Slow medicine adherents will be quick to tell you that the vast majority of CT scans ordered in emergency departments are of little value, most of the time adding only unnecessary cost and radiation risks for patients. Antibiotics for colds are another example of harmful waste. They don't work for viruses, and patients who take antibiotics are more likely to develop resistant bacteria, diarrhea and other symptoms that lead to avoidable office visits and hospitalizations.
As I've learned more about slow medicine, I've found it comes in many flavors.
One variety geared to geriatrics is exemplified by family doctor and author Dennis McCullough. He argues that in caring for the elderly, we doctors need to slow down and think twice about treatments we might reflexively offer younger folks, like medication for blood pressure, which can cause older patients to faint. Doctors also have to take extra care to avoid sending the frail into a medical-industrial complex that frequently causes unintended harm — think bedsores, falls and hospital-acquired infections.
Another vision of slow medicine is advocated by Victoria Sweet, whose two decades spent working at a hospital outside San Francisco taught her the value of low-tech, high-touch medical care for society's poorest patients. For Sweet, slow medicine incorporates the medieval view of the human body as a garden to be tended rather than a machine to be fixed.

Health care premiums on track to skyrocket
By Stephen T. Parente
POSTED: 01:30 a.m. HST, Dec 07, 2014
Hawaii residents are now knee deep in the Affordable Care Act's second open enrollment period, which began on Nov. 15.
Many are finding what appears to be a pleasant surprise: over 70 percent of plans will have lower premiums than 2014. The Affordable Care Act's naysayers predicted double-digit spikes, or worse.
Those naysayers should have read the law more carefully. In Hawaii, as elsewhere, average health care premiums are likely to modestly increase (and possibly decrease) both in 2015 and 2016. The real premium spikes won't occur until January 2017 — conveniently after the next presidential election.
The Medical Industry Leadership Institute, where I am director, recently released an analysis predicting how the ACA will affect prices over the next few years. Using data provided by the Department of Health and Human Services, we estimated that single and family-plan premiums in Hawaii could increase by low single digits for 2015 — a prediction that has been largely borne out by the recently announced rates. As for 2016, we estimate that family and individual bronze plan premiums could change by 2 percent and 1 percent, respectively.
Up until that point, the Affordable Care Act will look little different than the system it replaced — a few percentage point increases every year. True, it has not led to the dramatic cost savings that its authors promised, but neither has it made health care essentially unaffordable.
2017 will be the real test. The law contains two programs that will expire at the end of that year: "risk corridors" and "re-insurance." Both programs conceal health insurance's true costs — costs that truly have skyrocketed, thanks to the ACA's mandates and regulations.
Risk corridors and re-insurance operate in similar fashions: They subsidize insurance companies with taxpayer money. Risk corridors give insurance companies money if their custom- ers spend more on health care than the insurer estimated; reinsurance allows insurance companies to bill the federal government for particularly expensive patients.
Both programs ultimate-ly allow insurance companies to list artificially low premiums for their health care plans.
The Affordable Care Act's authors created these two programs for a specific reason: They would ease the transition from the pre- to the post-ACA health care system.
In the post-ACA world, health care is more expensive — a fact borne out by 2014's average 41 percent spike in base premiums. Reinsurance and risk corridors have largely hidden these price increases from consumers for the past year; they will continue to do so until Jan. 1, 2017.
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Premiums will likely skyrocket come that date. The Medical Industry Leadership Institute's study estimates
that once the two subsidies expire, premiums for a cheap bronze plan in Hawaii could increase by a staggering 96 percent for individuals and by 46 percent for families.
It appears that the law's authors didn't initially think this would be problematic; they assumed that the ACA would be so popular, or at least engrained in the national psyche, that such changes would be taken in stride. Instead, recent polls show that the Affordable Care Act is more unpopular than ever. 

Paid to Promote Eye Drug, and Prescribing It Widely

By  and 
When the drug maker Genentechintroduced a major product in 2006, it found itself in an awkward position: persuading eye doctors to start using its new more expensive drug instead of a popular cheaper version that the company already sold.
Ophthalmologists had been enthusiastically using the company’s cancer drug Avastin, which cost about $50 a dose, to treat a common eye disease in the elderly, wet macular degeneration. Then Genentechintroduced Lucentis, a nearly equivalent drug that cost $2,000 a dose and was approved specifically to treat the disease.
Use of Lucentis took off, and it has become one of Medicare’s most expensive treatments — costing the federal government about $1 billion a year — even though several studies have concluded Lucentis has no significant advantage over its cheaper alternative.
Now, a new federal database shows that many of the doctors who were the top billers for Lucentis were also among the highest-paid consultants for Genentech, earning thousands of dollars to help promote the drug. The data raises questions about whether financial relationships between doctors and drug companies influence treatment decisions, even though physicians maintain they cannot be swayed.


Health Care Law Is Not One-Size-Fits-All, and Here’s Why

One criticism of the Affordable Care Act is that it imposes a costly, one-size-fits-all standard, drastically increasing premiums by requiring everyone to buy health insurance that covers the same mandated benefits. This is not so.
It’s true that the health reform law imposes some requirements — “essential health benefits” — on what individual market and small business plans offer. But the statute left a lot of discretion to federal regulators, who, in turn, passed much of it on to states, each of which interpreted the requirements differently. And, because most plans already covered these so-called essential health benefits, the additional cost of the regulation is small.
The mistaken notion that the Affordable Care Act imposes a nationally uniform set of required benefits comes, perhaps, from language in the statute itself. It lists 10 broad areas of essential health benefits plans must cover, including hospital, outpatient and emergency services, along with related laboratory services; maternity, newborn and pediatric care; prescription drugs; rehabilitative and habilitative services and devices; mental health and substance abuse treatment; and wellness and chronic disease management.
Though that’s a fairly comprehensive list, including areas of care one would typically expect of a health insurance plan, it’s not specific. What does it mean, for instance, to cover “prescription drugs”? Must all drugs be covered? If not, which ones?
How regulators addressed these questions is what gave rise to state variation.
The law delegates authority to the secretary of Health and Human Services to flesh out which benefits plans must cover. As my colleague Nicholas Bagley wrote with his co-author, Helen Levy, this presented the secretary with a dilemma. Defining essential health benefits narrowly would lead to lower-cost plans but would also leave more care uncovered, rendering that care unaffordable for some patients. A broader definition would increase premiums, potentially making health insurance too costly for some people the health law was designed to help.


Single Payer Advocates Voice Concerns About Leaked, Unconfirmed Financing Plans

Single payer advocates called a news conference Monday to decry what may or may not be some or all of a plan that Gov. Peter Shumlin has said will be released by the end of the month.
The conference came after a VTDigger story last week, citing unnamed sources and with no official response from Gov. Peter Shumlin or his administration, said that in Shumlin’s latest proposal to fund single payer, “employer-funded payroll tax was pegged at 8 percent.”
The Health Care Is a Human Right campaign called for an “equitable” funding system supported by a progressive tax.
“Green Mountain Care must be funded publicly through a tax system,” said James Haslam of the Vermont Workers Center. “Individuals and businesses should contribute according to their ability to pay, in line with the principle of equity. This requires progressive taxes. Green Mountain Care should be funded by a mix of income taxes on earned and unearned income, wealth taxes and a graduated payroll tax for businesses with exemptions for the smallest of businesses.”
Another aspect of the new health care system that members of the Health Care Is a Human right campaign called for is the end of co-pays or any other costs associated with a doctor visit.
“When you ask people to pay at the point of service – and certainly when you’re asking big chunks of money to be paid in forms of so-called cost-sharing – you’re basically asking people who are accessing health care, people who are sick or injured or need health care services, to pay a larger share of the health care system,” Haslam said. “We think we all need the system, we think we should all pay for it in a fair and equitable way.”
The press conference belied high anxiety among single payer advocates who applauded Gov. Peter Shumlin’s signing of Act 48 in 2011, putting Vermont on the path to launch a single payer system in 2017.



The Battle Over Douglas Elmendorf — and the Inability to See Good News


Many Senate hearings are mere theater, but one that took place on July 16, 2009, mattered. With Congress in the midst of writing the bill that became Obamacare, senators asked Douglas Elmendorf, the director of the Congressional Budget Office, to evaluate their efforts.
In the hearing’s pivotal moment, Senator Kent Conrad – the North Dakota Democrat who was then the Budget Committee chairman – asked Mr. Elmendorf whether the legislation was likely to curb the growth in health costs, as its advocates asserted.
“From what you have seen,” Mr. Conrad asked, “do you see a successful effort being mounted to bend the long-term cost curve?”
Mr. Elmendorf’s answer was clear. “No, Mr. Chairman,” he said. “We do not see the sort of fundamental changes that would be necessary to reduce the trajectory of federal health spending by a significant amount. And on the contrary, the legislation significantly expands the federal responsibility for health care costs.”
For anyone who remembered health care history, the moment was ominous. It recalled the role that the budget office – Congress’s official scorekeeper – played in scuttling President Bill Clinton’s efforts to pass a health care bill. (Mr. Elmendorf, as it happens, was an obscure staff member on the C.B.O. team evaluating the Clinton bill.)
ABC News called the July 2009 hearing “a blow to President Obama and Democrats pressing health care reform.” The Washington Examiner, a conservative publication, later wrote that Mr. Elmendorf had “helped fuel the cross-country uprising against the health plan.” Liberals, meanwhile, tried to fight back by citing other experts who seemed more upbeat than Mr. Elmendorf.
But congressional Democrats knew that the budget office had the loudest voice, and their staff members got to work (which may have been Mr. Conrad’s purpose in asking the question). They added provisions to nudge the health care system away from paying for the quantity of medical care rather than the quality.
Ultimately, the C.B.O. judged those provisions to be substantive. The Affordable Care Act would reduce the deficit in the long run, the budget office forecast, because its new taxes and its cost-cutting would exceed the new spending on health coverage for the uninsured.

Half of Doctors Listed as Serving Medicaid Patients Are Unavailable, Investigation Finds

By 
WASHINGTON — Large numbers of doctors who are listed as serving Medicaid patients are not available to treat them, federal investigators said in a new report.
“Half of providers could not offer appointments to enrollees,” the investigators said in the report, which will be issued on Tuesday.
Many of the doctors were not accepting new Medicaid patients or could not be found at their last known addresses, according to the report from the inspector general of the Department of Health and Human Services. The study raises questions about access to care for people gaining Medicaid coverage under the Affordable Care Act.
The health law is fueling rapid growth in Medicaid, with enrollment up by nine million people, or 16 percent, in the last year, the department said. Most of the new beneficiaries are enrolled in private health plans that use a network of doctors to manage their care.
Patients select doctors from a list of providers affiliated with each Medicaid health plan. The investigators, led by the inspector general, Daniel R. Levinson, called doctors’ offices and found that in many cases the doctors were unavailable or unable to make appointments.
More than one-third of providers could not be found at the location listed by a Medicaid managed-care plan.
“In these cases,” Mr. Levinson said, “callers were sometimes told that the practice had never heard of the provider, or that the provider had practiced at the location in the past but had retired or left the practice. Some providers had left months or even years before the time of the call.”

Hospitals and Health Law

To the Editor:
Re “The Piecemeal Assault on Health Care” (editorial, Nov. 23):
The American people aren’t the only ones who will suffer from the systematic dismantling of the Affordable Care Act. It’s also bad news for America’s hospitals.
The health law’s hospital cuts — a staggering $245 billion over the first 14 years — include enormous cuts to the special Medicare and Medicaid payments hospitals receive for caring for uninsured and low-income patients. These “disproportionate share” funds were cut on the theory that insurance expansion would reduce the need for hospitals to provide uncompensated care.
That theory was strained at best, and never included the undocumented, uninsured immigrants who will continue to flood hospital emergency rooms for their care — and they won’t be turned away.
Despite these flaws, the hospital community continues to support the law’s promise of extending health insurance to tens of millions of uninsured Americans. That’s why the very real threat of the law’s unraveling is so troubling.
Not only could millions of newly insured Americans lose their coverage, but hospitals — the indispensable safety net for the country’s poor and uninsured — would also still be on the hook for hundreds of billions in funding cuts. That’s a lose-lose situation.
KENNETH E. RASKE
President, Greater New York
Hospital Association
New York, Nov. 24, 2014
http://www.nytimes.com/2014/12/08/opinion/hospitals-and-health-law.html?src=relcon&action=click&contentCollection=Politics&region=Footer&module=MoreInSection&pgtype=article

One year into Obamacare: where is it now?

By Jeanne Lenzer
BMJ, Dec. 5, 2014
[Excerpts]
About one year since the launch of the Patient Protection and Affordable Care Act’s insurance exchange program, the overwhelming majority of the 48 million people who were uninsured in 2012, remain uninsured — a problem that will persist for the next 10 years, according to government projections. The Congressional Budget Office estimates that 37 million people will not have health insurance in 2015 and 31 million will be uninsured in 2024.
About 6.7 million (corrected from an earlier estimate of 7.3 million) were newly insured under the act known as Obamacare during 2014.
Access to insurance has been liberalized in several ways: insurers may no longer deny coverage to individuals with pre-existing illnesses; young adults under age 26 may remain on their parents’ policy; and Medicaid has been extended to include some poor single adults and adults without children. …
According to a study by the Kaiser Family Foundation, “The ACA [Affordable Care Act] establishes an affordability standard for health insurance premiums, but not for out-of-pocket medical expenses. Even with limits on cost-sharing established under the ACA, deductibles and other cost-sharing will continue at a level above what many people could afford if a significant illness or injury strikes.”
It was hoped that reducing the number of uninsured people would also reduce the number of people putting off medical care because of costs. However, according to a Gallup poll conducted in early November 2014, the proportion of families who put off medical treatment rose from 30 percent in 2013 to 33 percent in 2014. The proportion of people with serious medical problems who put off treatment increased from 19 percent to 22 percent. ...
Progressive challenges to Obamacare include a bill introduced in Congress (HR 676) to establish a universal single payer healthcare system. Physicians for a National Health Program supports the bill, which it says could slash administrative costs by more than $400bn annually and solve many of the problems of the act — including providing care for the estimated 31 million people who will still be uninsured in 2024 under Obamacare.

I’m an Obama supporter. But Obamacare has hurt my family.

Obamacare has been far more frustrating than I’d ever dreamed.

At the moment President-elect Barack Obama proclaimed that “change has come to America,” I stood at the foot of my husband’s bed in the cardiac ICU of Mission Hospital in Mission Viejo. I was praying. Jim lay, with a ventilator tube down his throat, recovering from open-heart surgery to replace a congenitally defective aortic valve.
I was elated — for Jim’s survival and for Obama’s victory. I looked forward to one of Obama’s major campaign promises: to provide national healthcare reform so Americans with a pre-existing condition could get insurance. Since his heart diagnosis in 2005, Jim, who probably couldn’t have found a policy as an individual because of his condition, had been covered by small-business group insurance — because his self-storage business in Banning had one other employee. But his work, and his coverage, were always subject to change.
I remained vulnerable as a freelance writer and part-time university professor who had to pay for her own health insurance. I also had had a few health hiccups, including surgery to repair a herniated disk from spinal degeneration, and so I lived with the daily realization that one bit of bad health news could cause my policy to be canceled.
As it happened, the 2008 election was the first time Jim and I were bitterly divided on candidates. Jim foresaw healthcare reform as an addition to the federal deficit more worrisome than any health benefit. When I told him about Obama’s victory, he grumbled, “I guess I can’t blame Obama for breaking my heart.” But, he worried that he would eventually be able to blame the president “for keeping me from getting better.”
The transition to Obamacare – at least for a 59-year-old man and a 56-year-old woman in south Orange County – wouldn’t be quite that bad. But it would be, in three big ways, far rougher and more frustrating than I’d ever dreamed.
1) Obamacare brought us new health insurance options, but cost us our more affordable plans.
“If you’re one of the more than 250 million Americans who already have health insurance, you will keep your health insurance — this law will only make it more secure and more affordable,” President Obama promised in 2012.
The fact that this wasn’t true would be our biggest disappointment. In November 2013, Jim learned his small-business policy would be canceled because it didn’t comply with the new mandate to cover pediatric dentistry and maternity care. So Jim went to Covered California, the state’s health insurance exchange, to look for coverage for his employee and himself.

Blue Shield moves into Medicaid with Care1st deal
Seizing on the massive expansion in Medicaid, Blue Shield of California has agreed to acquire Care1st, a Monterey Park-based health plan with more than 500,000 patients.
Until now, insurance giant Blue Shield hasn't participated in Medi-Cal, the state's Medicaid program for low-income people. As a result, it has missed out on the program's growth to 11.3 million Californians as part of the federal health law expansion.
Major insurers across the country such as Anthem Inc. and Aetna Inc. have made similar deals to grab more of the Medicaid expansion. Anthem, formerly WellPoint Inc., acquired Medicaid insurer Amerigroup for $4.9 billion in 2012.
The Care1st deal, if approved by regulators, would give the San Francisco nonprofit a total of 473,000 people in Medicaid managed-care plans as well as 46,000 Medicare patients. The large majority of Care1st members are in Los Angeles and San Diego counties, but it also has patients in Arizona and Texas.
Blue Shield Chief Executive Paul Markovich said his company has been looking for a way to break into Medicaid for some time and Care1st was an ideal fit.
"One in three Californians are getting their health insurance through Medicaid," Markovich said in an interview. "It's really a big gap to not be in that line of business at all."
Neither company disclosed the acquisition price or other terms of the deal. Blue Shield said it is drawing on some of its $4 billion in reserves for the all-cash transaction.
Blue Shield is playing catch-up in this fast-growing segment of government healthcare.


Obamacare sign-ups near half a million in first week of enrollment
About half a million people selected a health insurance plan in the first week of the 2015 enrollment period under the Affordable Care Act, according to a new federal report that underscores huge progress since last year, when website problems made signing up for coverage nearly impossible.
From Nov. 15 to Nov. 21, the Department of Health and Human Services announced, 462,125 people signed up for a plan through HealthCare.gov, the federally run insurance marketplace that serves 37 states nationwide.
Tens of thousands of additional people signed up for coverage on state-run marketplaces in the remaining 13 states, including California, Maryland and Connecticut, and the District of Columbia.
California reported last week that more than 11,000 people had selected plans in the first four days of open enrollment.
The HealthCare.gov total — which is split roughly evenly between new enrollees and people renewing coverage they had in 2014 — is a major advance from last year, when the website did not work for more than a month.
Just 106,000 people signed up for coverage in the first month of open enrollment last year.
This year, it appears that the site is working far better. Administration officials said Wednesday it had not crashed since it opened, though it had twice directed users to an online “waiting room” that is deployed when there is high volume or other technical issues with the site.
In total, more than 3.7 million users visited HealthCare.gov in the first week of the new enrollment period, according to the health agency.

Out-of-pocket costs put care out of reach

By Anne Scheetz, M.D.
Chicago Tribune, Letters, Dec. 6, 2014
Some of the newly insured have joined the ranks of those who can't afford to use their health coverage because their out-of-pocket costs are so high. This is an inevitable problem in a system in which people's total costs -- premiums plus deductibles, co-pays, co-insurance and non-covered expenses -- are related poorly if at all to what they have left after paying for food, housing, utilities, transportation and other necessities. It is an inevitable problem in a system in which those who have the greatest health care needs -- because they are women, or sick, or have disabilities -- have the highest health care costs.
Yet there is a simple solution that would save money for almost everyone -- for the country as a whole, for governments at all levels and for 95 percent of U.S. households. If we get rid of the enormous administrative waste created by our complex system of financing and implement instead single-payer Medicare for all, we can provide high-quality health care for everyone with no financial barriers or burdens. It's the common-sense solution, and it's the solution that would show us to be truly a nation united.
Dr. Anne Scheetz resides in Chicago. This letter was originally titled "Insurance costs."
http://www.pnhp.org/print/news/2014/december/out-of-pocket-costs-put-care-out-of-reach


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