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Tuesday, November 3, 2015

Health Care Reform Articles - November 3, 2015

Many Need to Shop Around on HealthCare.gov as Prices Jump, U.S. Says

By  and 
WASHINGTON — In Tennessee, the state insurance commissioner approved a 36 percent rate increase for the largest health insurer in the state’s individual marketplace. In Iowa, the commissioner approved rate increases averaging 29 percent for the state’s dominant insurer.
Health insurance consumers logging into HealthCare.gov on Sunday for the first day of the Affordable Care Act’s third open enrollment season may be in for sticker shock, unless they are willing to shop around. Federal officials acknowledged on Friday that many people would need to pick new plans to avoid substantial increases in premiums.
But, they said, even with a number of companies leaving the marketplace for health insurance under President Obama’s signature health care law, most people around the country will still be able to choose from three or more insurers in 2016.
“Shopping can save you money,” said Richard G. Frank, an assistant secretary of health and human services, who unveiled a huge collection of data on health plans that will go on sale on Sunday in the 38 states served by HealthCare.gov.
Consumers have until Jan. 31 to sign up, but must do so by Dec. 15 to obtain coverage starting on Jan. 1.
Mr. Frank, on leave from his position as a professor of health economics at Harvard, described the data in a positive light. “The Affordable Care Act has created a dynamic, competitive marketplace, with considerable choice and affordable premiums in 2016,” he said.
Consumers are not so sure.
“It really shocks me to see these plans with $5,000 deductibles,” Belinda Greb, 56, of Vida, Ore., said in an interview. “It becomes an area of stress as opposed to making me feel secure.”
Federal subsidies for low- and moderate-income consumers will keep pace with premiums for a benchmark plan, the second-lowest-cost “silver” plan, Mr. Frank said, and consumers who choose that plan can protect themselves and their wallets.
“The vast majority of marketplace consumers receive tax credits that insulate them from premium increases,” Mr. Frank said.

Health Care Companies in Merger Frenzy

By 
In a fast-paced financial version of musical chairs, health care companies of all kinds — drug makers, hospital groups and insurers — have been frantically circling to be sure they are not left out of the latest frenzy of deal making. Mergers and acquisitions worth about $270 billion have been announced in the first nine months of 2015 in the United States, easily outpacing the activity in recent years, according to a tally by Mergermarket.
On Thursday, Allergan, itself the product of a recent merger, said it was in talks to be bought by Pfizer in a deal that could easily become the year’s biggest deal. Allergan’s current market value is $113 billion.
But the quest for size goes beyond the drug industry. The year’s biggest deals included mergers among the nation’s five largest health insurance companies, which pursued one another until only three may remain. Anthem is trying to buy Cigna for nearly $50 billion, and Aetna is pursuing Humana. Only UnitedHealth Group remains without a partner.
But UnitedHealth, which has created a portfolio of health care businesses, fortified its pharmacy benefit manager, known as OptumRx, by buying Catamaran Corporation a fast-growing competitor, this year. The combined entity, which is expected to process more than one billion prescriptions in 2015, is better equipped to compete with the industry giants Express Scripts and CVS Health, which operates CVS/caremark in addition to drugstores. CVS, in turn, acquired Omnicare to broaden its reach into nursing homes and bought 1,700 pharmacies from Target.
Not to be outdone, earlier this week, Walgreens Boots Alliance, the giant drugstore chain, said it planned to buy Rite Aid, a competitor.
The activity has been dizzying among pharmaceutical companies, always in the market for a promising new drug or pipeline. Last November, Actavis bought Allergan, the Botox maker, and took its name. The combined company then decided to sell its generic business to Teva Pharmaceuticals for around $40 billion. Allergan says its talks with Pfizer do not affect that deal.
Then there were the mergers that weren’t: AbbVie, a drug maker, dropped its deal with Shire of Ireland, at least temporarily ending the flurry of “tax inversion” mergers that had occurred as a way to cut tax obligations by merging with an overseas company. AbbVie cited new federal rules that made such deals less attractive. But then the company set its sights on an easier target: Pharmacyclics, which offers an attractive cancer drug.
Pfizer’s flirtation with Allergan, which may not come to fruition, could represent a return to American drug makers’ strategy of finding a base overseas. Allergan’s headquarters are technically in Dublin, and Pfizer had made an earlier run at AstraZeneca in London.

Why the Urge to Merge?

Low interest rates and cheap capital are fueling merger activity across many industries, but health care is especially devoted to the mantra that bigger is always better. And there are both the short-term goal of increasing revenue and the longer-term need to restructure in response to changes in the health care landscape under the Affordable Care Act. Unlike other areas, like telecommunications, where a tremendous amount of consolidation has already occurred, health care has been fragmented, with many smaller players.


Why the so-called 'Cadillac tax' might not be a bad thing

 Updated 
If you listen to politicians and morning talk show hosts, you might think the so-called "Cadillac tax" is intended to take away your health care benefits.
But the reasoning behind the 40 percent tax on health care benefits exceeding a certain dollar threshold is more nuanced, and the Robert Wood Johnson Foundationhas undertaken an analysis of the tax and some potential alternatives.
With 30 percent of the American public voting that repeal of the tax is their top priority, and with a 12 percent of small businesses slated to be affected(more than 16,000 businesses in Massachusetts, according to census data) and 19 percent of large businesses (almost 1,200 businesses in Massachusetts) when the tax goes into effect in 2018, Katherine Hempstead with the Robert Wood Johnson Foundation chatted with the BBJ on what the tax is, why it was enacted, and where we go from here:
So first of all, what is ‘Cadillac tax’?
It’s a tax on health insurance expenditures that go above a certain amount. As you might know, right now employers get a tax exclusion for paying for worker’s health insurance, which is why historically they have done it. One of the things people are concerned about is employers are incentivised to put more of people’s compensation into health insurance rather than wages. People have generous health plans and aren’t incentivized to think about if consuming health care is of value to them…
The idea then is benefit plans distort things, they get more generous than they would otherwise. That’s the wrap on the tax exclusion. For a long time people said there should be a limit on the exclusion, some say we should get rid of it. The Cadillac tax is part of the ACA and what it is designed to do is raise revenues, but its also an important way to contain health care costs, to reduce this distortion.
Then what’s the complaint?
It’s the kind of thing that people agree in the abstract that it’s a good idea, but it will have a big impact if people don’t make good changes. People will say, ‘That’s the idea,’ but for a corporation that has been used to doing things in a certain way, they don’t want to make these changes. Mostly everyone says we won’t pay the tax. They are hoping it gets repealed. A lot of people say they want to repeal it. That’s possible.
But what people are really trying to do is think about how to eliminate or minimize what their liability would be. What that means is shifting the health benefits to workers by higher deductibles, more cost sharing and reducing some of the generosity of the benefits. It includes flexible spending accounts and health savings accounts. Those are some things that would be on the chopping block if they are looking to reduce their liability, finding ways to make health benefits cost less, narrower networkers, lower providers. Those would happen more.
Another thing people think about is using a private exchange. When an employer gives an employee a lump sump, a defined contribution, and you go onto the exchange and you add money on your own and there is a range of plans and you pick the one you want. That’s another option people will be looking at.
Describe what your analysis has found and what you have recommended.
What we’re doing is saying everyone is against the Cadillac tax, but the same people that criticized it have been supporters on the tax exclusion, which is pretty similar.
The tax says when your benefits go over ($10,200 in 2018 for a single person plan, and $27,500 for other plans), we’ll tax you at 40 percent. (The tax exclusion cap) approach would say there’s a limit to how much you can exclude from taxes and here it is.
What this analysis is doing is there is this opposition, but it’s similar to having a cap on tax exclusions that people have supported for a long time, and the effects are pretty much the same…it’s reminding people that there is broad bipartisan support for this approach for some time. Now that it’s time to do it, let’s not forget this … and you are going to repeal the Cadillac tax, you’d replace it with something similar.
It’s not a defense, but it’s saying this is something that has had broad support for some time. Now that we’re about to do it, there is opposition that doesn’t acknowledge that people thought this was a good idea for a long time.


Book Review: ‘Ending Medical Reversal’ Laments Flip-Flopping

By  ABIGAIL ZUGER, M.D
“Ending Medical Reversal” is a subtly subversive book in need of a considerably snappier title. “OOPS!” perhaps, or “Are You Kidding Me?”
This last was the reaction of a diabetic patient described by the authors who, after years spent dutifully following the most spartan of diets in order to keep his blood sugar in check, just learned he needn’t have bothered. The goal his doctor (and doctors everywhere) were routinely setting for their patients had just been proven by a new study to be far too stringent.
All that broiled fish, all those unbuttered green beans, all that willpower, all for nothing. Oops. (Read an excerpt.)
This kind of medical whiplash is increasingly common and every bit as scary and damaging as the physical kind. What was good for you yesterday is useless or even bad for you today (and may be good for you again tomorrow; who knows). Medical gospel is rewritten daily on the evening news.

The incremental progress of ordinary science is one thing, as individual treatments are progressively replaced by better variants. We all happily accept that kind of revision. But medical reversal, the authors’ sober term for sudden flip-flops in standards of care, unnerves and demoralizes everyone, doctors no less than their patients.
Dr. Vinayak K. Prasad and Dr. Adam S. Cifu, of Oregon Health & Science University and the University of Chicago, have set themselves the task of figuring out how often modern medicine reverses itself, analyzing why it happens, and suggesting ways to make it stop. If this short list of objectives explodes into a breathless and somewhat unwieldy critique of all of Western medicine, you still have to appreciate both their ambition and their argument.
An old saw has long held that 50 percent of everything a student learns in medical school is wrong. Actual calculations suggest that number is not too far off base — Dr. Prasad and Dr. Cifu extrapolate from past reversals to conclude that about 40 percent of what we consider state-of-the-art health care is likely to turn out to be unhelpful or actually harmful.
Recent official flip-flops include habits of treating everything from lead poisoning to blood clots, from kidney stones to heart attacks. One reversal concerned an extremely common orthopedic procedure, the surgical repair of the meniscus in the knee, which turns out to be no more effective than physical therapy alone. The interested reader can plow through almost 150 disproved treatments in the book’s appendix.

Death Rates Rising for Middle-Aged White Americans, Study Finds

By 

Something startling is happening to middle-aged white Americans. Unlike every other age group, unlike every other racial and ethnic group, unlike their counterparts in other rich countries, death rates in this group have been rising, not falling.
That finding was reported Monday by two Princeton economists, Angus Deaton, who last month won the 2015 Nobel Memorial Prize in Economic Science, and Anne Case. Analyzing health and mortality data from the Centers for Disease Control and Prevention and from other sources, they concluded that rising annual death rates among this group are being driven not by the big killers like heart disease and diabetes but by an epidemic of suicides and afflictions stemming from substance abuse: alcoholic liver disease and overdoses of heroin and prescription opioids.
The analysis by Dr. Deaton and Dr. Case may offer the most rigorous evidence to date of both the causes and implications of a development that has been puzzling demographers in recent years: the declining health and fortunes of poorly educated American whites. In middle age, they are dying at such a high rate that they are increasing the death rate for the entire group of middle-aged white Americans, Dr. Deaton and Dr. Case found.
The mortality rate for whites 45 to 54 years old with no more than a high school education increased by 134 deaths per 100,000 people from 1999 to 2014.
“It is difficult to find modern settings with survival losses of this magnitude,” wrote two Dartmouth economists, Ellen Meara and Jonathan S. Skinner, in a commentary to the Deaton-Case analysis to be published in Proceedings of the National Academy of Sciences.
“Wow,” said Samuel Preston, a professor of sociology at the University of Pennsylvania and an expert on mortality trends and the health of populations, who was not involved in the research. “This is a vivid indication that something is awry in these American households.”
Dr. Deaton had but one parallel. “Only H.I.V./AIDS in contemporary times has done anything like this,” he said.

Know Your Risks, but Meat Still Isn’t the Enemy



Smoking tobacco causes cancer. So does eating salted fish, drinking alcohol, breathing polluted air and being exposed to the sun. All of these things are classified as cancer-causing by the World Health Organization.
This week, processed meat has been added to that list, meaning that the world’s attention has been focused on whether everyone should stop eating bacon, sausage or various charcuterie.
The short answer is no, you’re probably fine. As with many pronouncements about food, this one is being overhyped by some news media outlets, and potentially over-interpreted by scientists.
I wrote about red meat here at The Upshot back in March, focusing mostly on the cardiovascular risks, rather than the cancer risks. But I still highlighted and discussed some key studies, including one that found that eating meat, especially processed meat, was associated with increased cancer and mortality in people age 50-65. As I said, it also found that the opposite was true in people over 65 years, but that gets mostly ignored.

Based on epidemiologic data like these, 700 studies on red meat and cancer and 400 more on processed meat, the International Agency for Research on Cancer felt comfortable making the declaration that processed meat causes cancer and that red meat probably causes cancer. The specific meta-analysis of cohort studies they cited for their relative risk point estimate of 1.18 was published in PLOS One in June 2011.
As Geoffrey Kabat pointed out, it’s worth noting that 25 years ago, the I.A.R.C. ruled that coffee was “possibly carcinogenic.” Despite the huge amount of evidence to the contrary that has been published since, the agency has not changed its position. In fact, of the 985 substances the I.A.R.C. has classified, only one has been labeled“probably not carcinogenic to humans.”
I’ve written before about the dangers of making assumptions about causes from observational studies. My review of the literature and that of the experts at the I.A.R.C. use the same data. We just reach different conclusions. I also find it hard to ignore the fact that randomized controlled trials do exist. The Polyp Prevention Trialfailed to show any effect of a low-fat, high-fiber, fruit-and-vegetable diet on tumor recurrence even after eight years of follow-up tests. The Women’s Health Initiative, which involved almost 50,000 women, also could not show that a change in diet reduced the risk of colorectal cancer after more than eight years.


We Mapped the Uninsured. You'll Notice a Pattern.
By QUOCTRUNG BUI and 

Two years into Obamacare, clear regional patterns are emerging about who has health insurance in America and who still doesn’t.
The remaining uninsured are primarily in the South and the Southwest. They tend to be poor. They tend to live in Republican-leaning states. The rates of people without insurance in the Northeast and the upper Midwest have fallen into the single digits since the Affordable Care Act’s main provisions kicked in. But in many parts of the country, obtaining health insurance is still a problem for many Americans.
These trends emerged in an analysis we undertook with the help of two organizations that are closely monitoring the progress of the health law. Last year, we used similar data to show the the substantial effects Obamacare had on reducing the number of Americans without health insurance. This year, the same groups updated their estimates of where America’s uninsured live, and the change is a lot less drastic. States that were late to expand Medicaid, including Pennsylvania and Indiana, showed substantial reductions in their uninsured residents compared with last year. In other places, the changes have been more modest. In a few — like Mississippi — things appear to have gotten worse, with fewer people having health insurance this year than last.
“This year it’s more of a state-specific story,” said Ed Coleman, the director of data and analytics at Enroll America, an organization devoted to finding uninsured people and signing them up for insurance. Enroll worked with the data firm Civis Analyticsto produce the numbers in our map. “There was a pronounced drop pretty much everywhere last year, and we don’t see that pattern again this time around.”
The incremental changes in our map are consistent with other data. Fewer people signed up for insurance this year using the new state marketplaces than some analysts had expected. Medicaid enrollment leveled off. And many of the people who lack insurance in states with a lot of uninsured people are effectively unable to benefit from Obamacare programs because of their low incomes and local politicians’ decisions to forgo Medicaid expansion. More than three million people in 19 states remain stuck in a “Medicaid gap,” too poor to qualify for subsidies in the new marketplaces, but unable to get into a government program.
Medicaid expansion continues to be a huge predictor of how many people remain uninsured in a given state. We’ve outlined the states that expanded Medicaid in black to make them easy to see. But we almost don’t have to, because many of the state lines are so clear from the uninsured rates alone. Look at the difference between Missouri and Illinois, for example.

Our View: Medicaid stance puts Maine in dubious alliance

Portland Press-Herald Editorial Board

Maine’s Washington County has the dubious distinction of being the northernmost outpost of the Confederacy.
At least it looks that way on a map created by The New York Times that shows the percentage of residents without health insurance in all of the 50 states.
Washington County has the highest rate of uninsured residents in Maine – 14 percent – as opposed to 9 percent in Cumberland County and 8 percent in York County. In fact, no other county in New England has such a high rate of people without health insurance. Neither does any county in New York state or Pennsylvania. In fact, you would have to go all the way to the southern tip of West Virginia before you can find such a high rate.
The map changes dramatically, however, when you get into the states of the old Confederacy. North Carolina, South Carolina, Georgia, Alabama, Mississippi, Tennessee, Florida and Texas all average rates of uninsurance at or above Washington County’s levels. This is not just a quirk of history or geography. This is the result of policy choices made in Republican-controlled states of the Old South that rejected Medicaid expansion under the Affordable Care Act, and as a result have chosen to put their citizens’ lives at risk.
Since Maine is the only state in the Northeast to have made that choice, its poor are suffering along with the people in the Old South.
The Affordable Care Act has succeeded in reducing the number of people without health insurance, but the data show the improvement hasn’t been equally distributed. The optional Medicaid expansion helps people with incomes below 138 percent of the federal poverty line (or about $16,000 a year for an individual), who rarely work in jobs that provide health benefits. In Maine, an estimated 70,000 people would have been able to obtain affordable care if the state had accepted the federal funds.
It’s important to remember that this is not just about insurance, it’s also about health.
People without insurance are less healthy than people with coverage. Thousands of avoidable deaths every year result from undetected cancers, mismanaged chronic conditions and lack of access to life-saving medical procedures. Millions of dollars are wasted in lost productivity, charity care and bad debt.
The rejection of the almost entirely federally funded Medicaid expansion results from a hatred of federal authority that has festered in the South since it was invaded and occupied by a victorious federal army a century and a half ago. Given Maine’s history as a part of that force, its ideological alliance with the Southern states makes as little sense from a historical perspective as it does from an economic and humanitarian one.
Maine should not fight this common-sense medical reform any longer. It’s time to rejoin the Union, and expand Medicaid.

Editorial: End of Arches points to single-payer

First Published   
The collapse of Utah's cooperative insurance provider, the Arches Health Plan, was not unforeseen, either by those who favor the Affordable Care Act or those who have always hated it.
Count Utah's Sen. Orrin Hatch among the latter. Hearing that the health insurance co-op had been declared insolvent and put into receivership by the Utah Insurance Department, Hatch pressed control-F7 on his computer and spewed forth another Obamacare-will-never-work press release.
Hatch's preferred alternative, the Patient CARE Act, has the advantage of not being Obamacare. But it is at least as complex as the ACA, shifts more costs onto consumers and more work onto states. Worst of all, passing it would force millions of Americans who have finally found health care under the current law back to square one.
Which is what just happened to 63,000 Utahns who will have to find new coverage now that Arches has tanked.
All of this fiddling with rival steampunk assemblages of subsidies, mandates, taxes, exchanges and co-ops continues to burden Americans because Republicans have never accepted, and Democrats have never fully sold, the realization that a country where millions of people do not have access to affordable health care is the skunk in the garden party of First World nations. No truly civilized society would tolerate such a condition.
The establishment of non-profit co-ops was one of many unsatisfying compromises between those who wanted a single-payer, Medicare-for-all design — or, at the least, a government-run public option — and those who irrationally trusted the private sector to provide what it simply is not willing or able to provide, now or ever, affordable health care for all.
The original ACA had funds to back the co-ops if — when — they ran out of money. But the Republican-controlled Congress, frustrated by many failed attempts to repeal Obamacare outright, cut back on the guarantees. So at least 10 such organizations around the country have now failed.
Meanwhile, premiums continue to rise and the private insurance sector is consolidating as big firms are bought by bigger ones. There is less and less of the competition that reformers of all ideological stripes were hoping, some with more faith than others, would keep costs down.
What Obamacare opponents do not seem to grasp is that, if it doesn't work, if the co-ops fail and the exchanges don't meet the needs of working families, going back to a pre-ACA jungle will not be a workable or ethical option.
It'll be single-payer, or at least a robust public option. As it should have been from the beginning.



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