Health Care Reform Articles - February 26, 2015

When the System Fails

By SONDRA S. CROSBY

I PURCHASED a purple “My Little Pony” at Walmart. I told myself it was to bring a brief smile to a sad little girl’s face. In reality, it was for me. In the overwhelming apparatus that medicine has become, sometimes the patient gets lost. So does the doctor. As the major safety net hospital in our region, my own hospital is arguably better equipped than most to effectively handle the human side of medical care. But even the most experienced institutions face an increasingly uphill battle against the systemic shortfalls of American medicine.

The patient, whom I’ll call Mohammed, was an American citizen, fully employed with health insurance, although with limited English language skills and health literacy. I had been his primary care doctor for seven years, and he came to me about two years ago with a lesion on his scalp after hitting his head on the door. I didn’t know exactly what it was, although my best guess was some sort of post-traumatic injury. I sent him to surgery for another opinion. The surgeon concurred with my diagnosis, but scheduled a biopsy. What I didn’t know was that Mohammed didn’t return for the planned procedure. He was struggling as a new single parent to his two young children who had just arrived from a war-torn African country, while his wife was left behind, her visa delayed by bureaucratic obstacles. He had deferred the biopsy because of his life circumstances without understanding the significance, and without catching anyone’s attention. The ball was dropped, and he fell through the cracks in the mighty apparatus.

http://opinionator.blogs.nytimes.com/author/sondra-s-crosby/

Health Secretary Says There’s No Backup Plan if Supreme Court Rules Against Law

FEB. 24, 2015

Margot Sanger-Katz

Next week, the Supreme Court hears arguments in a case that could upend Obamacare insurance coverage for millions of people. Tuesday, the Secretary of Health and Human Services said there was little the administration could doto limit the impact of such a ruling.

“We know of no administrative actions that could, and therefore we have no plans that would, undo the massive damage to our health care system that would be caused by an adverse decision,” wrote Sylvia Mathews Burwell in a series of identical letters to Republican leaders in Congress.

The message represented a shift in tone from Ms. Burwell, who has been asked repeatedly by reporters and members of Congress what the administration would do in the aftermath of such a decision. In the past, her strategy has been to change the subject. We’re confident we’ll win the case, she’s said, and we’re focused on signing people up for insurance, not planning for a possible loss.

The new message is consistent with her previous stance, but considerably more alarmist in tone. The letter describes the consequences of a court ruling for the case’s plaintiffs: the loss of insurance subsidies for millions of people in a majority of the states, followed by increases in the number of uninsured Americans and instability in insurance markets.

http://www.nytimes.com/2015/02/25/upshot/health-secretary-says-theres-no-backup-plan-if-court-rules-against-health-law.html?hpw&rref=upshot&action=click&pgtype=Homepage&module=well-region&region=bottom-well&WT.nav=bottom-well&abt=0002&abg=0

PRESS RELEASE: Study Urges Greater Financial Disclosure by Nonprofit Integrated Health Systems

Little Evidence Backs Up Claims of Cost, Quality Advantages

For Immediate Release: February 25, 2015

Contact: Jill Braunstein at (202) 243-7009

WASHINGTON, D.C.—Based on publicly available information, there is scant evidence to back up claims by large, nonprofit integrated health systems that they deliver higher quality care more efficiently, according to a new study released today from the nonpartisan National Academy of Social Insurance (NASI). The report will be discussed at a 2pm panel on trends in provider consolidation during a Federal Trade Commission / Department of Justice live webcasted workshop on “Examining Health Care Competition.”

Along with a comprehensive review of the academic literature, the study included an analysis of publicly available quality and financial information from 15 of the largest nonprofit integrated delivery networks (IDNs) across the country, including Henry Ford Health System in Detroit; North Shore-LIJ Health System in suburban New York; Intermountain Healthcare in Utah/Idaho; Sutter Health in Northern California; BayCare Health System in Tampa/St. Petersburg; and Geisinger Health System in Central Pennsylvania.

The study defined IDNs as vertically integrated health services networks that include hospitals, physicians, post-acute services and sometimes health plans with a stated purpose to coordinate care across the continuum of health services and to manage population health; or fully integrated provider systems inside a health plan (e.g. with no other source of income than premiums).

"Some of the nation’s finest hospitals and clinical staffs can be found in this fifteen IDN sample.　This analysis was not intended to denigrate these fine institutions or their managements," said Jeff Goldsmith, the study’s lead author, President of Health Futures, Inc., and Associate Professor of Public Health Sciences at the University of Virginia. "Rather, it is intended to address whether the way they have organized care creates measureable benefits to society, or for that matter, to the institutions themselves. If these benefits exist, we could not find evidence of them in their public disclosures, beyond the claimed ‘community benefit’ common to all non-profits."

According to the study, IDNs have "operated under a halo of presumed societal benefits (quality, efficiency, care integration, etc.) for the better part of four decades with remarkably little evidence that these benefits in fact exist. It is still possible that these societal benefits of IDNs exist. But if they do, given the opacity of present IDN disclosure of key operating information, they eluded us in this preliminary investigation. If public policy is to continue fostering IDN growth and development, a more solid evidentiary foundation for this form of medical care organization seems essential. The mere presumption of societal benefits of IDN formation or operations is no longer tenable as a policy principle."

http://www.nasi.org/press/releases/2015/02/press-release-study-urges-greater-financial-disclosure-no

Judge overturns Maine law allowing prescription drug imports

by Jackie Farwell

A federal judge has overturned Maine’s first-in-the-nation law allowing residents to purchase medication by mail from other countries. 

U.S. Chief District Judge Nancy Torresen’s ruling Monday comes more than a year after several Maine pharmacy groups filed suit against the state over the 2013 law, arguing it jeopardizes the safety of the nation’s prescription drug supply and opens the door to counterfeit and tainted medications.

Federal law strictly limits the importing of prescription drugs from foreign countries for personal use. Torresen ruled that Maine infringed on the federal government’s established regulatory authority by allowing drug importation at the state level. Her decision nullifies the law, though the state could potentially appeal.

The law allowed Maine residents to buy prescription drugs from Internet pharmacies in Canada, the U.K., Australia and New Zealand, which the U.S. government deems to have equivalent or greater drug safety and licensing regulations. Those countries, among others, can sell prescription drugs more cheaply because their governments cap prices or negotiate prices with drug makers.

Torresen wrote in her decision that Maine’s “singling out of certain countries from which pharmaceuticals may be imported compromises the tightly regulated structure” set up under federal law and “compromises federal government’s ability to ‘speak with one voice’ when it regulates foreign commerce.”

The three pharmacy groups argued Maine’s law sidestepped the U.S. Food and Drug Administration’s oversight, designed to protect consumers from unsafe medications. Their suit, filed in September 2013, names as defendants Maine Attorney General Janet Mills and Richard Rosen, who has since been named the state’s finance commissioner.

“Maine pharmacists are relieved that Judge Torresen’s ruling ensures the safety of prescription drugs for Mainers by upholding federal laws that are designed to prevent unapproved and substandard drugs from coming into the United States,” said Kenneth McCall, immediate past president of the Maine Pharmacy Association, one of the plaintiffs in the case.

His group was joined by the Maine Society of Health System Pharmacists and the Retail Association of Maine. The drug industry’s largest lobbying group, the Pharmaceutical Research and Manufacturers of America, also sued the state, but Torreson dismissed the organization as a plaintiff in June 2014.

“Maine people can be assured that the prescriptions that are filled by Maine pharmacists are approved medications,” said Curtis Picard of the Retail Association of Maine. “We expect foreign companies to abide by this ruling and federal law and to cease illegally importing drugs into Maine.”

Mills said the issue of drug importation needs further scrutiny, but she did not indicate whether she plans to appeal Monday’s decision.

http://bangordailynews.com/2015/02/24/health/judge-overturns-maine-law-allowing-prescription-drug-imports/print/

 As Maine’s uninsured rate drops, Lewiston co-op again woos most Obamacare enrollees

by Lindsay Tice

LEWISTON — Over 66,000 Mainers have signed up for health insurance with Maine Community Health Options, an increase of 65 percent for the state’s only health insurance co-op. 

Of those people, 57,600 got insurance through the federal marketplace established by the Affordable Care Act, also known as “Obamacare.” That means for the second year in a row, MCHO will insure the majority of Mainers on the marketplace.

“(The overall numbers) are right in line with what we had been working towards and what we were projecting, so it’s great to see coming into focus this way,” said CEO Kevin Lewis. 

Co-ops are health insurance companies run by members for members. They were created through the 2010 Affordable Care Act to increase competition among health insurers and to provide consumers with greater choice in the marketplace.

There are 23 co-ops throughout the country. Rating company A.M. Best has said that, as of last fall, Lewiston-based MCHO is the only one making money.

As of Feb. 18, nearly 75,000 Mainers had signed up for insurance through the marketplace, according to the Centers for Medicare and Medicaid Services. About 57,600 of those Mainers chose one of MCHO’s insurance plans, according to preliminary numbers released by the co-op Tuesday. However, MCHO’s figures include only people who have paid their first bill.

With several days left for consumers to pay for March 1 coverage, Lewis expects that MCHO will ultimately be responsible for about 80 percent of the marketplace.

Last year, MCHO had about 83 percent of the marketplace. At that time only two insurance companies shared the marketplace — MCHO and Anthem Blue Cross and Blue Shield. This year, a third insurer, Harvard Pilgrim Health Care, has joined the marketplace.

http://bangordailynews.com/2015/02/24/health/lewiston-health-insurer-again-woos-most-of-maine-obamacare-enrollees/

H&R Block: Taxpayers Following ACA Rules, Refunds Take a Hit

February 24, 2015

So far taxpayers seem to be indicating true insurance status as refunds dip 17 percent

So far in the 2015 tax season, H&R Block (NYSE: HRB), the world’s largest consumer tax services provider, is seeing a majority (52 percent) who enrolled in insurance via the state or federal Marketplaces paying back a portion of the Advance Premium Tax Credit (APTC). The average amount paid back is $530, decreasing the tax refund on average by 17 percent, according to analysis almost six weeks into the 2015 tax season. In addition, it seems taxpayers are accurately indicating their insurance coverage status as the number of those selecting a penalty and/or qualifying for an exemption is in line with preseason projections.

The analysis by H&R Block, uniquely positioned in the industry as the largest provider offering both assisted and do-it-yourself tax preparation, indicates the data of returns filed to date is in line with three primary preseason expectations:

• A majority of year-end Marketplace enrolled clients who reconciled using Form 8962 underestimated their household income and therefore must repay a portion of the APTC.
• The average tax penalty for not having insurance was $172, an indication that most taxpayers are paying more than the flat-fee of $95 per uncovered adult penalty many consumers anticipated.
• Taxpayers appear to be foregoing hunting down Marketplace hardship exemptions and instead claiming tax return exemptions, especially those which are income based.

“Our data suggests that most taxpayers are accurately indicating their household insurance coverage status,” said Mark Ciaramitaro, vice president of H&R Block health care and tax services. Ciaramitaro said clients “appear to be answering truthfully by paying the tax penalty for being uninsured. We don’t think they are just checking the box that they are covered when they’re not.”

Average refund reduced 17 percentWith many clients relying on 2012 income as a baseline to estimate their 2014 income at the time of the first open enrollment, H&R Block expected that most filers would not accurately estimate their 2014 household income. This income underreporting has led to a majority of Marketplace-enrolled taxpayers paying back a portion of the tax credit. The average tax refund for these taxpayers was almost $3,100 but it was reduced by $530 due to the tax credit reconciliation process.

“The level of payback of the Advance Premium Tax Credit is significant in that it’s costing taxpayers a large percentage of their refund – a refund many of them count on to pay household expenses,” Ciaramitaro said.

Conversely, the analysis also showed roughly one-third of Marketplace enrollees overestimated their 2014 household income, and therefore received an additional premium tax credit of close to $365 on average, which was an additional 11 percent increase resulting in an average $3,816 refund.

H&R Block is assisting clients in its offices by conducting a detailed ACA tax impact analysis to help them understand their personal situation and apply for Marketplace insurance plans with a more accurate household income figure going forward.

http://newsroom.hrblock.com/hr-block-taxpayers-following-aca-rules-refunds-take-hit/

Worries about health care law leads tax filers to seek professional health

By Deirdre FernandesGLOBE STAFF  FEBRUARY 26, 2015

Worries about how the Affordable Care Act may affect 2014 returns could drive more filers to spend hundreds of dollars to get professional help from accountants and preparation services, tax specialists said.

The tax code changes tied to the federal health care law take effect this year. That has triggered television, radio, and newspaper ads suggesting that filers need to brace for complications and may need specialized tax help.

“For millions of Americans, the Affordable Care Act is no longer some distant conversation,” H&R Block president Bill Cobb, wrote in USA Today op-ed in January. “It’s real. It’s here. And it’s going to affect them at tax time.”

The law essentially requires individuals to carry health insurance or face penalties and to report it on their tax returns. But the vast majority of filers should be able to handle the new requirements without hiring extra help, tax specialists said. Most Americans are insured through their work, and all they need do is check a box stating they had employer-provided coverage in the last year.

The situation becomes more complicated for those who bought insurance through a government sponsored exchange, received subsidies for it, or remain uninsured. They may have to fill out additional forms (move over 1040s, the 1095-As and 8962s are here) and do additional calculations.

For Massachusetts residents, however, these changes are less problematic since the state has mandated medical coverage since 2006, said Angelina Camacho, who leads the Volunteer Income Tax Assistance program at the Action for Boston Community Development, a nonprofit agency.

Less than 1 percent of the state’s residents are uninsured, according to the Massachusetts Center for Health Information and Analysis. About 4 percent buy health insurance through exchanges.

http://www.bostonglobe.com/business/2015/02/26/worries-about-health-care-law-leads-tax-filers-seek-professional-health/64wNq05LqkFEZqTj58WpFK/story.html

For Many Middle-Class Taxpayers On Obamacare, It’s Payback Time

By Anna Gorman February 26, 2015

Roberta and Curtis Campbell typically look forward to tax time. Most years, they receive a refund – a little extra cash to pay off credit card bills.

But this year the California couple got a shock:  According to their tax preparer, they owe the IRS more than $6,000.

That’s the money the Campbells received from the federal government last year to make their Obamacare health coverage more affordable. Roberta, unemployed when she signed up for the plan, got a job halfway through the year and Curtis found full-time work. The couple’s total yearly income became too high to qualify for federal subsidies. Now they have to pay all the money all back.

“Oh my goodness, this is just not right,” said Roberta Campbell, who lives in the Sacramento suburb of Roseville. “This is supposed to be a safety net health care and I am getting burned left and right by having used it.”

As tax day approaches, hundreds of thousands of families who enrolled in plans through the insurance marketplaces could be stuck with unexpected tax bills, according to researchers. Those payments could be as high as $11,000, although most would be several hundred dollars, one study found.

The result is frustration and confusion among some working and middle-class taxpayers, whom the Affordable Care Act was specifically intended to help. The repayment obligations could dissuade people from re-enrolling and provide more fuel to Republicans’ continuing push for a repeal of the law.

The problem is that many consumers didn’t realize that the subsidies were based on their total year-end income and couldn’t reliably project what would happen over the course of the year, said Alyene Senger, research associate at The Heritage Foundation, a conservative think tank.

“How do you know if you are going to get that promotion?” she said. “How do you know what your Christmas bonus is going to be?”

In addition, Senger said the government didn’t go out of its way to publicize the tax consequences of receiving too much in federal subsidies. “It isn’t really something the administration focused on heavily,” she said. “It’s not exactly popular.”  

The system was intended to ensure that people received the right amount in subsidies, no more or less than needed. But the means the government chose to reconcile the numbers was the tax system — notorious for its complexity well before the Affordable Care Act passed.

Enrollees who enrolled in Obamacare now are realizing that certain positive life changes – a pay raise, a marriage, a spouse’s new job – can turn out to be a liability at tax time. “We are definitely seeing some pain,” said Jackie Perlman, a principal tax research analyst at H&R Block.

H&R Block released a report Tuesday saying that 52 percent of customers who received health coverage through the insurance marketplaces last year underestimated their income and now owe the government. They estimate that the average subsidy repayment amount is $530.

http://kaiserhealthnews.org/news/for-many-middle-class-taxpayers-on-obamacare-its-payback-time/

A Mission of Mercy

By SEEMA JILANI

 FEBRUARY 26, 2015 3:30 AM

I wasn’t worried about whether the baby would die. I knew he would. My fear was that I couldn’t keep him alive long enough so he could take his last breath in his mother’s arms.

His mother was still in McAllen, a town 10 miles from the Texas-Mexico border — but hundreds of miles and more than an hour’s flight from where her son was, with me, in Houston. She had slogged through coyote-plagued deserts, her seven-months-pregnant belly buoyant in the muddy waters of the Rio Grande. She carried her 4-year-old daughter on her hip as the waters lapped against her, mindful of the copperhead snakes, trudging her way to the promised land: “Tejas.”

She had fled, she told me, an abusive husband and vicious gangs, both of whom had vowed to rape and murder her and her children. Against all odds, she escaped the drug lords, the arms traffickers and that wasteland.

And so her baby had been born on the “right” side of the border. Shortly after birth, however, he was found to have hypoplastic left heart syndrome, which holds a bleak prognosis. Our flight medical evacuation team brought him to our world-renowned hospital in Houston for evaluation.

An extensive work-up revealed that he had a minimal chance of survival. He would require at least three major cardiac surgeries, and those would be only temporary measures. If he survived them, he would still need a pediatric heart transplant.

In the meantime, he would be a frequent flier in the intensive care unit, with various complications. He’d be on a ventilator for long periods, perhaps need a feeding tube for growth, and probably have some developmental delay. 

Still, we were willing to do it all at our hospital — on the condition that his mother would be alongside him, learning how to care for his illness. But his mother decided not to come.

Usually, my job as a flight medical evacuation physician involves my going to pick up a critically ill child from Nowheresville, Middle America or Central America or elsewhere around the globe and flying him or her back for life-saving procedures. Tonight, my pager went off to tell me that I was doing the reverse: taking a child back to his mother, to his inevitable death. My job was merely to prolong what little life he had left until they were reunited.

“Why doesn’t she come and take care of her baby? What kind of woman is this?” I thought. My judgmental tone had been razor sharp by the end of my residency. Now, as an attending, I was used to being on call for more than 30 hours at a time, and sometimes that bitterness seeped in. Yes, she was still recovering from labor, and she had her daughter to look after, but to turn down her son’s chance of the only treatment that might save his life — why?

The answer was that the baby’s mother was petrified to come to Houston. Although she was technically within United States borders, she would still have to navigate an intricate web of checkpoints for safe passage to Houston. She would risk deportation and separation from her children.

HTTP://OPINIONATOR.BLOGS.NYTIMES.COM/2015/02/26/A-MISSION-OF-MERCY/?ACTION=CLICK&PGTYPE=HOMEPAGE&VERSION=MOTH-VISIBLE&MODULE=INSIDE-NYT-REGION&REGION=INSIDE-NYT-REGION&WT.NAV=INSIDE-NYT-REGION