Health Care Policy Briefs: Early Retirement, The Two Americas, Sabotaging Obamacare, Marijuana Not A Gateway Drug, And The Pentagon’s Plan For The Zombie Apocalypse

zombies_01

Five  health care policy items today:

Goldman issued a report on how availability of health insurance allows people the option of retiring early (or as Republicans would put it, become takers) as opposed to waiting until they qualify for Medicare. The found that “the annual probability of retirement–i.e., what share of workers of a given age will retire within the next year–is on average between 2% and 8% higher when retiree health insurance is available.” Early retirement is seen more between the ages of 60 to 64, than in those who are age 55-59.

With Republicans blocking Medicaid expansion in twenty-four states, The Commonwealth Club looked at the healthcare differences in the two Americas:

The Commonwealth Fund’s recently released Scorecard on State Health System Performance, 2014, finds big differences between states on measures of health care access, quality, costs, and outcomes. What’s more, its authors warn that these differences could very well widen in the future. Many of the lowest-performing states are choosing not to expand their Medicaid programs under the Affordable Care Act (ACA). Some also are discouraging eligible uninsured citizens from purchasing subsidized coverage through new ACA marketplaces, though some uninsured are signing up nonetheless.

The fact that so many low-performing states are spurning the ACA’s benefits, while high-performing states are rushing to embrace them, raises profound questions for the future of our country. What would it mean if different parts of the United States find themselves on radically different health care trajectories, with some enjoying progressively better health and health care and others falling further and further behind? In other words, what would it mean if the two health care Americas grow further and further apart over time?

This is unexplored territory for health care researchers and policymakers, but we know enough to point to some possibilities.

To begin with, we know that when people have health coverage they live longer, healthier lives. Widening gaps in rates of insurance coverage between low- and high-performing states will almost certainly lead to growing differences in life expectancy and health status. This is worrisome and regrettable, but probably only part of the story.

An equally important—but much less explored—question is whether differing health care trajectories also will lead to differing economic and social trajectories. All else equal (of course, it never precisely is), will regions with poorer health care and health status suffer economically and socially as well? Will they have less productive workforces, less productive economies, and, as result, lower quality of life overall? Will they become less attractive places to live, work, and do business?

Several lines of evidence suggest that diverging regional health care systems could lead to diverging general welfare. First, untreated physical and mental health problems increase workers’ time off from work, reduce performance while at work, and lower rates of employment. In the early 20th century, infections such as yellow fever, malaria, and hookworm greatly hindered the economy of the American South. In his memoir, Jimmy Carter recalls that, while growing up in rural Georgia, “almost everyone was afflicted from time to time with hookworm,” a parasite that causes anemia, malaise, and fatigue. Eventually, public health measures and improved living conditions brought this and other health problems under control, contributing to a burst of economic growth.

A century later, chronic illness is the equivalent of the infectious illness that once disproportionately taxed the economy of the American South. In the United States, annual productivity losses from diabetes and depression alone exceed $100 billion nationally. And we know this burden can be lightened through good primary and preventive care that will be less available in regions with large uninsured populations.

Second, health insurance boosts economies by protecting people against catastrophic out-of-pocket health care expenses. These costs can lead to bankruptcy, which raises the cost of borrowing for the rest of society as lenders take into account the risk that they will not be repaid. Those avoiding bankruptcy often incur substantial medical debt, with far-reaching consequences. A 2012 Commonwealth Fund survey found that 61 percent of uninsured adults ages 19 to 64 reported problems paying their medical bills or said they were paying off medical debt over time. Among these individuals, more than half said they received a lower credit rating as a result of unpaid medical bills, 43 percent used all of their savings to pay their bills, and 29 percent delayed education or career plans. The 2006 Massachusetts health reform, which has led to nearly universal health coverage, has also led to fewer personal bankruptcies and bills past due and improved credit scores, particularly for those with limited access to credit before the reform…

The report continued to discuss further differences resulting from differing access to health insurance.

Besides blocking Medicaid expansion, conservatives are reducing the number of insured with misinformation campaigns and campaigns to outright dissuade people from obtaining coverage in the exchanges. This has led many uninsured people to fail to obtain coverage through the exchanges to based upon misconceptions spread by conservatives, such as that the cost would be much higher than it actually is. Jonathan Cohn wrote:

About half of the people who McKinsey surveyed did not end up buying insuranceeither because they shopped and found nothing they liked, or because they didn’t shop at all. When asked to explain these decisions, the majority of these people said they thought coverage would cost too much. But two-thirds of these people said they didn’t know they could get financial assistance. In other words, they assumed they would have to pay the sticker price for coverage, even though federal tax credits would have lowered the price by hundreds or thousands of dollars a year.

With a little education and outreach, many of these people will discover that insurance costs less than they thought. When next year’s open enrollment period begins, they are more likely to get coverage. But the idea was to help more of those people this year. And if the administration deserves some blame for this shortfall, its adversaries deserve more. Republicans and their allies did their best to taint the lawand, where possible, to undermine efforts to promote it. Without such obstruction, even more uninsured people would probably be getting coverage right now. As Sprung quipped in his post, “Those who deliberately spread disinformation about the ACA and actively encouraged the uninsured to remain in that blessed state of freedom can be really proud of themselves.”

Or as I put it in a recent post: Fox Lied, People Die.

The National Bureau of Economic Research looked at the effects of legalization of medical marijuana on drug use:

21 states and the District of Columbia currently have laws that permit marijuana use for medical purposes, often termed medical marijuana laws (MMLs). We tested the effects of MMLs adopted in seven states between 2004 and 2011 on adolescent and adult marijuana, alcohol, and hard drug use. We employed a restricted-access version of the National Survey on Drug Use and Health (NSDUH) micro-level data with geographic identifiers. For those 21 and older, we found that MMLs led to a relative increase in the probability of marijuana use of 16 percent, an increase in marijuana use frequency of 12-17 percent, and an increase in the probability of marijuana abuse/dependence of 15-27 percent. For those 12-20 years old, we found a relative increase in marijuana use initiation of 5-6 percent. Among those aged 21 or above, MMLs increased the frequency of binge drinking by 6-9 percent, but MMLs did not affect drinking behavior among those 12-20 years old. MMLs had no discernible impact on hard drug use in either age group. Taken together, MML implementation increases marijuana use mainly among those over 21, where there is also a spillover effect of increased binge drinking, but there is no evidence of spillovers to other substance use.

If marijuana turns out not to be a gateway drug, this would be another reason to reevaluate current marijuana laws. Further discussion at Vox.

The Pentagon has contingency plans for any emergency, including the Zombie Apocalypse. It isn’t as ridiculous as it sounds as it is actually a model plan using a fictional situation, as reported by Foreign Policy:

“This plan fulfills fictional contingency planning guidance tasking for U.S. Strategic Command to develop a comprehensive [plan] to undertake military operations to preserve ‘non-zombie’ humans from the threats posed by a zombie horde,” CONOP 8888′s plan summary reads. “Because zombies pose a threat to all non-zombie human life, [Strategic Command] will be prepared to preserve the sanctity of human life and conduct operations in support of any human population — including traditional adversaries.”

CONOP 8888, otherwise known as “Counter-Zombie Dominance” and dated April 30, 2011, is no laughing matter, and yet of course it is. As its authors note in the document’s “disclaimer section,” “this plan was not actually designed as a joke.”

Military planners assigned to the U.S. Strategic Command in Omaha, Nebraska during 2009 and 2010 looked for a creative way to devise a planning document to protect citizens in the event of an attack of any kind. The officers used zombies as their muse. “Planners … realized that training examples for plans must accommodate the political fallout that occurs if the general public mistakenly believes that a fictional training scenario is actually a real plan,” the authors wrote, adding: “Rather than risk such an outcome by teaching our augmentees using the fictional ‘Tunisia’ or ‘Nigeria’ scenarios used at [Joint Combined Warfighting School], we elected to use a completely-impossible scenario that could never be mistaken for a real plan.”

But do they have plans in case of a Dalek invasion?

Please Share

Insurance Companies Plan To Increase Policies Offered On Exchanges Following 2014 Success, And Other Health Care News

The first year of enrollment for insurance under the exchanges is largely for first getting our feet wet, with more people projected to sign up in the future. It certainly exposed problems in the computer system and allowed for them to be fixed (although further testing before October was clearly needed). Insurance companies got to see whether this was a profitable market they would want to enter. In the past one or two insurance companies dominated in most areas on the individual market. One of the benefits of selling coverage through the exchanges was the hope that multiple companies would now begin to offer coverage.

Even conservatives who oppose the Affordable Care Act should agree with the benefits of having more companies offer insurance, including the likelihood of competition leading to lower prices. Actually exchanges, along with mandates, were originally supported by Republicans until they opposed the plan when supported by Barack Obama.

So far we are receiving good news following the initial IT problems. The Affordable Care Act now looks like a good policy which just got off to a rocky start. Enrollment is estimated at 7.5 million, exceeding predictions made even before they were adjusted downward with the early computer problems, with more healthy young people signing up at the last minute. Politico reports that insurance companies are happy with what they are seeing and want to get in:

Health insurers got their first taste of Obamacare this year. And they want seconds.

Insurers saw disaster in the fall when Obamacare’s rollout flopped and HealthCare.gov was a mess. But a strong March enrollment surge, along with indications that younger and healthier people had begun signing up, has changed their attitude. Around the country, insurers are considering expanding their stake in the Obamacare exchanges next year, bringing their business to more states and counties. Some health plans that skipped the new marketplaces altogether this year are ready to dive in next year.

At least two major national insurers intend to expand their offerings, although a handful of big players like Aetna, Humana and Cigna, are keeping their cards close for now. None of the big-name insurers have signaled plans to shrink their presence or bail altogether after the first rocky year. And a slew of smaller health plans are already making moves to join more states or get into the Obamacare business for the first time.

“[W]e see 2014 as just the beginning for exchanges,” said Tyler Mason, a spokesman for UnitedHealth Group, one of the nations’ largest insurers. “As the economics, sustainability and dynamics of exchanges continue to become clearer, we believe exchanges have the potential to be a growth market with much to offer UnitedHealthcare and other insurers and consumers.”

Nurturing this growth and health plan participation will be one of the first tasks of Sylvia Mathews Burwell, assuming she is confirmed to succeed Kathleen Sebelius as secretary of Health and Human Services.

The article reviewed plans by many of the larger insurance companies and also noted that several smaller companies now want to start selling insurance. Being able to offer their plans on the same computer site as the larger companies will allow small companies to compete for sales more easily than in the past, further increasing choice for consumers.

It is not only insurance companies which see the Affordable Care Act as succeeding. The latest Reuters/Ipsos poll shows the number of people who prefer Democrats over Republicans on health care has increased:

Americans increasingly think Democrats have a better plan for healthcare than Republicans, according to a Reuters/Ipsos poll conducted after the White House announced that more people than expected had signed up for the “Obamacare” health plan.

Nearly one-third of respondents in the online survey released on Tuesday said they prefer Democrats’ plan, policy or approach to healthcare, compared to just 18 percent for Republicans. This marks both an uptick in support for Democrats and a slide for Republicans since a similar poll in February.

Not surprisingly, Gallup has found a greater decrease in the uninsured in states which have embraced the Affordable Care Act, such as by setting up their own exchanges and taking advantage of the expanded Medicaid program.

Having Gallup survey the number of uninsured is of value as the Census Bureau is changing how it is surveying the uninsured, with Gallup providing a second set of numbers for comparison. Many Republicans see a conspiracy to make Obamacare look good. Actually this looks like a change to get more accurate results, which might actually show a greater number of uninsured. The changes also started with 2013 so we will still be able to compare the year prior to the exchanges to subsequent years. Sarah Kliff explained further at Vox.

Cross posted at The Moderate Voice

Please Share

Fact Checking Valuable, But Not Always Right

Pinoccio

The Moderate Voice has a post yesterday on the increase in fact-checking in journalism. Fact-checking is preferable to the standard media practice of quoting both sides as if they are equally valid, generally with an implied assumption that the truth is somewhere in the middle. This leads to erroneous reporting when one side is intentionally using misinformation and lying far more than the other. However labeling something fact checking doesn’t necessarily mean it is immune from journalistic problems. Paul Krugman pointed out one problem:

“The people at PolitiFact are terrified of being considered partisan if they acknowledge the clear fact that there’s a lot more lying on one side of the political divide than on the other,” Krugman wrote in 2011.

“So they’ve bent over backwards to appear ‘balanced’ — and in the process made themselves useless and irrelevant.”

As Krugman pointed out, there are fact checkers which label an equal number of statements from Democrats and Republicans as being wrong in order to give the appearance of being impartial. That typically means that outrageous lies from Republicans are called lies but to provide a sense of balance,  statements from Democrats which are generally true but in which there is an exception are also called lies.

The entire idea of calling something true or a lie is often a poor way to handle complex issues which are stated by politicians in brief statements. Sometimes politicians are trying to be truthful, but boiling down a complex issue into a brief statement, or commercial, will result in exceptions where the statement is false. Often it is preferable to look at what is true in what is being said and where it isn’t entirely true and explain the issue rather than just calling it truth or a lie.

While Republicans have been hit far more with big lies on health care, Democrats have been harmed by the problems in how some fact checkers declare something either true or a lie (being a lie if not 100% true in every case). There have been two big examples of this. The first is Democrats saying that the Medicare proposals in the Ryan budget would destroy Medicare. Technically this is untrue as Ryan would replace Medicare with something named Medicare. On the other hand, it is true because the Republican proposals would change Medicare into something fundamentally different with far less protection for seniors. Rather than just calling it a lie, fact checkers would have done more good by explaining why Democrats consider these changes to be destroying Medicare.

The other is the greatly exaggerated “lie of the year” when Obama said people could keep their own doctor under the Affordable Care Act. This was an absurd statement on one level because every year insurance companies and doctors make decisions which can affect this which the government has no  power over. On the other hand, Obama was right in the context where he was speaking, even if worded poorly. Republicans were lying when they claimed that Obamacare would make people join some sort of government run program which would tell them which doctors they can see. The Affordable Care Act actually makes it more likely that people could have insurance which would allow them to keep their doctor than had been the case in the past and does nothing to force people to lose their doctor. People have a better chance of keeping their doctor when protected from losing their insurance. Frequently people are forced to change doctors because of employers changing insurance plans. Employees have a better chance of keeping their own doctor when provided more choice in plans, as under the Affordable Care Act.  Where Obama got it wrong was that the same forces already present which lead to people having to change doctors, while diminished, would still exist. It would be far better to explain this complex issue, where Obama was mostly right, than to just declare it a lie because it is not true one hundred percent of the time.

Cross posted at The Moderate Voice

Please Share

Obama Administration Announces Increase In Payments To Medicare Advantage Plans

Presumably in response to Republican scare stories about Medicare cuts to Medicare Advantage plans and insurance company lobbying, CMS has announced an increase in payments of  0.4% in 2015, in place of the expected 1.9% rate cut as of February. This negates a distorted Republican attack that Obama is cutting payments to Medicare.

The proposed cuts were to what is essentially corporate welfare for insurance companies running  Medicare Advantage plans. The plans increased payment compared to what it costs to care for similar patients in the government Medicare plan. Republicans have included the same cuts which were previously proposed by the Obama administration in their proposed budgets despite faux attacks against Democrats for cutting Medicare.

Update: Full Text of Press Release from CMS

CMS Ensures Higher Value and Quality for Medicare Health and Drug Plans

Rate Announcement Details Plan Payments and Other Program Updates for 2015

Today, the Centers for Medicare & Medicaid Services (CMS) issued the 2015 rate announcement and final call letter for Medicare Advantage and prescription drug benefit (Part D) programs. The announcement sets a stable path for Medicare Advantage and implements a number of policies that ensure beneficiaries will continue to have access to a wide array of high quality, high value, and low cost options while making certain that plans are providing value to Medicare and taxpayers.

Since the Affordable Care Act was passed in 2010, Medicare Advantage premiums have fallen by 10 percent and enrollment has increased by 38 percent to an all-time high of more than 15 million beneficiaries. Today, nearly 30 percent of Medicare beneficiaries are enrolled in a Medicare Advantage plan. Furthermore, enrollees are benefiting from greater quality as over half of enrollees are now in plans with 4 or more stars, a significant increase from 37 percent of enrollees in such plans in 2013.

 “The policies announced today will provide improved benefits in Medicare Advantage and the Prescription Drug Plans while keeping costs low for Medicare beneficiaries,” said Jonathan Blum, CMS principal deputy administrator. “We believe that plans will continue their strong participation in the Medicare Advantage program in 2015 and beneficiaries will continue to have access to a wide array of high quality and affordable Medicare health and drug plans.”

After careful consideration of public comments, key changes and updates finalized in the Rate Announcement and final Call Letter include:

Lower Out-of-Pocket Drug Spending: Beneficiaries in the Part D prescription drug coverage gap, or “donut hole,” will benefit from greater savings on prescription drugs. As a result of the Affordable Care Act, in 2015, enrollees who reach the donut hole will receive coverage and discounts of 55 percent on covered brand name drugs and 35 percent on covered generic drugs, an increase from 52.5 percent and 28 percent, respectively, in 2014. The Affordable Care Act’s Coverage Gap Discount Program has provided discounts to more than 7.9 million Medicare beneficiaries, saving $9.9 billion on prescription drugs, or an average of $1,265 per beneficiary.

Greater Protection for Beneficiaries: CMS intends to again use its authority, provided by the health care law, to protect Medicare Advantage enrollees from significant increases in costs or cuts in benefits, and, for the 2015 contract year, finalizing the permissible amount of increase in total beneficiary cost to $32 per member per month (down from $34 per member per month for the 2014 contract year). CMS also continues to require plans to refine their offerings so that beneficiaries can easily identify the differences between their options.

Increased Protections for Beneficiaries Affected by Changes in Medicare Advantage Plan Networks: The final Call Letter strengthens tools used to ensure compliance with established provider access requirements and establishes best practices for Medicare Advantage Organizations to follow when they make significant changes to their provider networks.

Payments to Medicare Advantage Plans:

  • CMS estimates that the overall net change to plan payments between 2014 and 2015 to be +0.4 percent, compared to the estimated overall net change to plan payments of -1.9 percent for the proposals in the Advance Notice   Individual plan payments will vary by plan based on, but not limited to, its location and star rating.
  • Before the Affordable Care Act, Medicare Advantage plans were paid more than 10 percent compared to traditional Medicare, costing the program more than $1,000 per person each year, while quality and health outcomes were similar to those enrolled in traditional Medicare. The changes underway reduce excessive payments to Medicare Advantage plans, while incentivizing quality improvements by basing part of Medicare Advantage payment on plan quality performance.
  • To provide for continued stability in the Medicare Advantage program, CMS will implement a new phase-in schedule for the Part C risk adjustment model introduced in 2014. In addition, to improve payment accuracy, CMS has refined its risk adjustment methodology to account for the impact of the influx of baby boomers. In addition, for 2015, CMS will not finalize the proposal to exclude diagnoses from enrollee risk assessments.

Other policies that are not being finalized as proposed include:

Delayed implementation of new Part D Risk Adjustment Model.

Not implementing some proposed changes to the Star Ratings.

Not implementing the proposal to require additional coverage in the gap for generic and brand drugs in Enhanced Alternative plans.

To view a fact sheet on the 2015 Rate Announcement and final Call Letter, please visit: http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2014-Fact-sheets-items/2014-04-07.html

The 2015 Rate Announcement and final Call Letter may be viewed later today through: http://www.cms.hhs.gov/MedicareAdvtgSpecRateStats/ and selecting “Announcements and Documents.”

Update II: The mainstream media is starting to pick up the news. Here are reports from AP and from The Hill.

Cross posted at The Moderate Voice
Please Share

Republicans Had To Hide Support For Fix To Affordable Care Act To Limit Attacks From The Right

The “doc fix”  has become a strange legislative tradition as Congress regularly votes to stop the automatic  cuts in physician payment called for under the flawed Sustainable Growth Rate formula. As I discussed in March, this time there were a couple of new twists which were known, but in addition it turns out that another item hidden in the bill reveals a lot about the Republican Party.

First I’ll recap what we had already known. The “doc fix” proposed to block the cuts which would have taken effect in April was for one year and included multiple other measures, including a delay in implementing change to ICD-10 diagnosis codes until at least October 2015. Physician groups actually opposed this bill because a permanent fix was also under consideration and it was feared that passing yet another temporary fix would lead to abandonment of the permanent fix (which does now appear dead).

The “doc fix” regularly passes with bipartisan support because Congress is not going to risk the backlash which would be created if many Medicare patients could no longer find physicians willing to accept them. This time the House passed the “doc fix” on a voice vote, which allows individual members to avoid being held accountable for the vote.

Over the weekend we learned why House Republicans wanted to pass this on a voice vote. Another item in the bill made some changes in the Affordable Care Act which was desired by small business and which Democrats were willing to make:

At the prodding of business organizations, House Republicans quietly secured a recent change in President Barack Obama’s health law to expand coverage choices, a striking, one-of-a-kind departure from dozens of high-decibel attempts to repeal or dismember it.

Democrats describe the change involving small-business coverage options as a straightforward improvement of the type they are eager to make, and Obama signed it into law. Republicans are loath to agree, given the strong sentiment among the rank and file that the only fix the law deserves is a burial.

“Maybe you say it helps (Obamacare), but it really helps the small businessman,” said Rep. Phil Roe, R-Tenn., one of several physician-lawmakers among Republicans and an advocate of repeal.

No member of the House GOP leadership has publicly hailed the fix, which was tucked, at Republicans’ request, into legislation preventing a cut in payments to doctors who treat Medicare patients.

It is unclear how many members of the House rank and file knew of it because the legislation was passed by a highly unusual voice vote without debate.

This shows how dysfunctional Congress has become. Normally both parties would see it as a victory for the system that they passed a measure to make requested changes in the Affordable Care Act. However, Republicans felt compelled to hide this vote because it contradicts their public policy of only supporting repeal (having voted for repeal over fifty times). Since this became public, the Republicans have faced criticism from the right, probably making it even harder for them to vote on improvements in the Affordable Care Act in the future.

The fix which passed allows small businesses to offer policies with higher deductibles. This allows for lower premiums, and the higher deductibles are often handled separately with Medical Savings Accounts. There are also added protections in new insurance policies under the Affordable Care Act such as annual limits on out of pocket expenses and the elimination of annual and lifetime caps on coverage which help offset the problems created by higher deductibles.

If Republicans should attack the Affordable Care Act based upon including high deductible plans, keep in mind that this is exactly the type of plan which Republicans frequently advocate, and that the Republicans voted to increase the allowable deductible levels in response to requests from small business.  Democrats had no objection to the change as the limit on deductions was originally placed in the bill because it was supported by Republican Senator Olympia Snowe. In response to this addition, Snowe voted for the Affordable Care Act when in the Senate Finance Committee but ultimately voted against the bill on the Senate floor, along with every other Republican Senator.

Cross posted at The Moderate Voice

Please Share

Good News On Obamacare Enrollment Leading To More Favorable Coverage

Democrats have suffered damage from the Affordable Care Act far more from negative press than actual negative results. Of course they make the problem far worse by running away as opposed to standing up for the successes of the Affordable Care Act. Two stories last fall did the most harm–the failed roll out and news of people receiving cancellation letters. The computer problems were IT issues which have nothing to do with the benefits of the Affordable Care Act as policy. Now that we have some data on enrollment, we know that the initial IT problems did not decrease enrollment at all from initial projections. We also now know that most of the people who received cancellation letters received alternate coverage, frequently from the same company, with better coverage at a lower price.

Bad news tends to lead to more bad news but good news often leads to more good news, and hopefully the Democrats will show the ability to capitalize on it. Republicans who made claims of Obamacare leading to fewer people having coverage or failing to meet projections look as foolish as the Republicans who ignored the polls and projected a Romney victory in 2012. Instead of negative stories, we are seeing stories such as this from Politico: Obamacare critics: Homina, homina, homina:

Back in the fall, conservatives seized on the flubbed Obamacare rollout as proof that President Barack Obama’s brand of liberalism doesn’t work.

Now, the law’s opponents aren’t about to say that critique was wrong — but they’ve lost the best evidence they had.

On Tuesday, Obamacare sign-ups passed 7 million, six months after the launch of a federal website that could barely sign up anybody. There are still a lot of questions about how solid that figure is, but the idea that the law could even come close to the original goal after such a disastrous start would have been laughable even a few weeks ago.

It was also a wake-up call for Republicans and conservatives, and even the occasional liberal, who pushed the argument that the failed website challenges the idea at the heart of Obama’s agenda — that government can still solve big social problems.

Of course Fox and other right wing outlets are still running negative headlines, but otherwise success is leading to the rest of the media being more positive. While conservatives spread false stories of Obamacare nightmares, there are more stories on those who benefit under the Affordable Care Act. The New York Times has pointed out that many people have purchased insurance directly from insurance companies in addition to the over seven million purchasing through the exchanges:

Millions of newly insured people are hiding in plain sight.

They are the people who have bought new health insurance since the start of this year but have chosen for one reason or another to bypass the state and federal exchanges that opened last year under the Affordable Care Act. While the exact number is unknown, some health care experts estimate that it may be in the millions.

Politicians and policy makers have focused on the number of people who signed up through the exchanges — at nearly seven million and counting a day after the March 31 deadline — but they have largely overlooked the group that did not use the exchanges, even though it could have a major impact on the program’s financial success in the years ahead…

All individual health insurance plans offered after Jan. 1 must adhere to several new requirements, regardless of whether they are bought through the marketplaces. Insurers must offer more comprehensive coverage and charge healthy and sick people the same rates. And they can no longer turn people away if they have existing medical conditions.

It makes little difference to insurers how the new customers arrive at their door: What matters most is that they get there. Insurers must bring in enough new customers, including a significant number of healthy ones, to offset the higher costs of complying with the law.

Aaron Billger, a spokesman for Highmark, an insurer that offers plans in Delaware, Pennsylvania and West Virginia, said about 30 percent of the approximately 133,000 members that Highmark had enrolled as of mid-March had signed up outside the marketplaces. The large insurer WellPoint, which has said it expects to enroll about one million customers nationwide in new plans, has reported that about 20 percent of its sign-ups have occurred off the exchanges.

Some people are saving money by purchasing insurance from co-ops which are being set up in some states thanks to the Affordable Care Act as an alternative to the large insurance companies. It is too soon to tell whether they will really lower costs, but they do sound like a promising alternative:

The names of the big health insurance companies are familiar – Blue Cross, Aetna, United Healthcare. But what about CoOportunity Health, or Health Republic Insurance of New York?  These are among 23 new health insurance companies that started under the Affordable Care Act.  They’re all nonprofit, member-owned cooperatives, and the aim is to create more competition and drive prices down…

“In some states, co-ops are dominating the marketplace, with 80 percent of the enrollees going to the co-op,” he says.

That’s in Maine. Morrison says most co-ops are very happy with their enrollment numbers. Their rates are often the lowest available through an exchange.

“The co-op states have 8.4 percent lower premiums on average than the non-co-op states, across the marketplace,” says Morrison. “So co-ops are creating that competition. They’re keeping rates down in the states they’re operating in.”

The Los Angeles Times told the story of a cancer patient who benefited from Obamacare:

Robertson wrote a passionate account of his cancer and posted it on the White House website to illustrate how important insurance is even for younger people. Noting that he had paid just 1% of the $900,000 cost for five surgeries, radiation and chemo, he wrote, “Without that, I would have bankrupted my family just to stay alive.”

And without Obamacare’s guarantee that he could buy affordable insurance despite his preexisting medical condition, he wrote, “there’s no telling what life would have been like for us moving forward.”

A major benefit of the Affordable Care Act is to enable people to obtain coverage on the individual market who had difficulty obtaining coverage in the past, when most coverage outside of government programs came from large businesses. There have already been stories on some of the winnersPolitico reported on how Obamacare has helped self-employed artists and actors:

Abromaitis is among the hundreds of thousands of artists, musicians, dancers, actors and filmmakers around the country who especially stand to gain under Obamacare, either through the plans and premium subsidies available on its new insurance exchanges or from the plans employers must start offering.Typically a well-educated but lower-earning demographic — whose members are self-employed more often than not — these Americans have frequently struggled to buy insurance on their own. Some were able to afford union plans, but others paid for costly coverage on the individual market or went without it despite the risk.

A survey last year by The Actors Fund found that 43 percent of individuals working in the visual and performing arts lacked coverage, more than double the national uninsured rate. More than a third of those who had coverage said they got it on the individual market, compared with the 6 percent of Americans generally who turn there for health insurance.

Many are now flocking to Obamacare’s federal- and state-run exchanges, hoping for a way to get covered without breaking the bank. They’re finding both good and bad: more affordable plans but sometimes narrow provider networks and high deductibles.

The narrow provider networks and high deductibles did come as a surprise to some but this has actually been a characteristic of insurance sold through the individual market for a long time. When I purchased new coverage (directly from the insurance company, bypassing healthcare.gov), there was a choice of policies with more restrictive networks with a lower premium, along with choices without restrictive networks but with a higher premium. Most people who wind up in plans with the most restrictive network did so out of a choice to save money. The choices I saw were no different from the choices offered prior to the Affordable Care Act. The difference was that the coverage was far more comprehensive, had new limits on out of pocket expenses, and could never be canceled due to medical problems.

There is far  more good news this week on the Affordable Care Act. Hopefully the Democrats will finally stop being scared of negative and false attacks from Republicans and go on the offensive and develop a new message to take political advantage of the law they passed.

Cross posted at The Moderate Voice

Please Share

Bill Calls For Adding ICD-10 Delay To Latest “Doc Fix”

I recently pointed out that the Republicans killed a recent attempt to repeal the Sustainable Growth Rate formula by attaching a measure to end the individual mandate in the Affordable Care Act. With failing to repeal the Sustainable Growth Rate it becomes necessary for Congress to pass yet another temporary “doc fix” to prevent Medicare reimbursement from automatically falling so low that doctors will not be able to afford to see Medicare patients.

Medical Economics reports that a proposal to delay the transition from ICD-9 to ICD-10 diagnoses codes from October 2013 to October 2014. The transition was originally passed under the Bush administration, so ignore the Republican claims which are out there which blame Obamacare for the change. While there are benefits to the newer system which is used by the rest of the world, the change would be very expensive for medical practices. Changes such as this also take up a lot of physician time, reducing the number of patients which can be seen each day.

Such decreases in productivity would come at a poor time in 2013 when millions of new people will receive health insurance due to the Affordable Care Act and will need to find physicians who are accepting new patients. In addition, the second phase of requirements for electronic medical records (EMR’s) also kicks in for many physicians this October and having two sets of major changes will further reduce physician productivity, making it more difficult to accept new patients. Personally I had to greatly restrict accepting new patients for several months after the first phase of requirements went into effect, and anticipate again having to limit accepting new patients this fall if both the new EMR requirements and change to ICD-10 take effect simultaneously.

The AMA and many other physician groups have been lobbying for a further delay in ICD-10 implementation, which has already been delayed in the past. Medical Economics reports:

The ICD-10 transition has been a major point of concern for physicians due to its scope and cost to implement. In recent months the American Medical Association (AMA) ramped up opposition to the ICD-10 transition, and petitioned CMS for a delay to the implementation of ICD-10.

According to the AMA, small practices can expect staggering costs ranging from $56,639 to $226,105 to implement the new code set. According to a February survey by the Medical Management Group Association, 79% of physicians report that they haven’t begun ICD-10 implementation, or were only “somewhat ready.”

Molly Cooke, MD, FACP, president of the American College of Physicians, said the college favors the delay. “The college has expressed concern at every opportunity about the implementation of ICD-10. I’m not sure the healthcare system loses a lot if we delay implementation for another year, and it certainly would give our members a bit of a breather.”Earlier this month, the Republican-led House passed a bill to repeal SGR and replace it with a formula that would calculate payments based on quality metrics. But the bill received widespread opposition from Democrats because it was paid for by a five-year delay in the individual mandate in the Affordable Care Act (ACA).

Cross posted at The Moderate Voice

Please Share

Republican House Plays Politics, Screwing Both Doctors And Medicare Patients

After several years a deal had been reached to permanently repeal the flawed Sustainable Growth Formula but the House Republicans chose to play politics with it. The House Republicans showed a disregard for both physicians and  Medicare beneficiaries. They attached the fix to a five year delay on the individual mandate, knowing that this would be dead in the Senate.

The Sustainable Growth Formula was initially devised to give doctors increased Medicare reimbursement if medical costs go down and decrease reimbursement if costs rise. The formula was quickly found to be flawed. Individual physicians cannot control the overall trajectory of Medicare expenses regardless of the financial rewards or penalties. The formula failed to take into account overall increases in costs we have experienced over the past decade as a result of an aging population and new medical technology. As a result, the formula would reduce Medicare payments to physicians to a level below what doctors could afford to see Medicare patients for. Reimbursement from Tricare, which covers military families, is also tied to Medicare reimbursement. Congress has realized that the cuts were not tolerable and has repeatedly voted for a “doc fix” to circumvent the automatic cuts called for under the Sustainable Growth Formula.

The persistence of this problem over the past decade has eroded confidence in the federal government and the Medicare program, leading some physicians to stop accepting Medicare patients. Even Congress finally realized that something had to be done and an agreement was reached in principle between the federal government and physician organizations for a new payment structure to replace the Sustainable Growth Formula. The House had the opportunity to pass this as a clean bill today, but instead played politics by attaching it to a delay to the individual mandate.

It is getting difficult to keep count but I believe this is now the fifty-first vote to either repeal or greatly interfere with the implementation of the Affordable Care Act.

The individual mandate is a necessary component of the Affordable Care Act as currently structured. If insurance companies are required to provide coverage to everyone applying, they need protection against the problem of people not buying insurance until they become ill. In order for the system to function, insurance companies need the premiums from healthy people coming into the system every year to cover the expenses of those who are ill.

There are potentially other ways to solve the free rider problem but it is not possible to simply eliminate the individual mandate without implementing alternative measures to provide strong incentives for people to purchase insurance coverage while still healthy. While I had preferred using other measures instead of the mandate when health care reform was being considered, unlike the House Republicans I recognize when an issue has been settled and see no sense in continuing to fight the same battle. The Affordable Care Act is established law which has been upheld by the Supreme Court. Congress should be concentrating on making some necessary fixes (as any law of this complexity would require) to smooth its implementation as opposed to trying to sabotage it.

Twelve Democrats voted with the Republicans out of political fears. The Affordable Care Act is turning into a major success, providing millions with health insurance coverage and ending the ability of insurance companies to abuse the system by finding ways to sell policies and then avoid paying out. In addition,  Obamacare frees people from the “insurance trap” which forced people who otherwise do not need to work to continue working for insurance coverage, along with other overall benefits to the economy. The Congressional Budget Office Report, frequently distorted by Republicans, showed that the Affordable Care Act will reduce unemployment, help decrease the deficit, and allow more people to leave large corporations to start small businesses, further stimulating the economy.

Despite all of these benefits, Democrats remain on the defensive politically. While granted the Republicans have a strong propaganda machine delivering their misinformation, and a media willing to repeat Republican lies as if they are equally valid as statements of fact, Democrats should be able to do a better job of gaining support when the facts are so firmly on their side. The same is true of health care issues in general, as Republicans have managed to put Democrats on the defensive over bogus claims of Medicare cuts while the Republicans seek to turn Medicare into a voucher system which would destroy the program as we know it.

Democrats need to follow the advice of Paul BegalaStop being so damn defensive about the law and show people it’s worth fighting for, already.

Begala thinks Dems can address it with a simple flipping of the script. Dems now debating how to talk about Obamacare seem to be leading defensively with their willingness to fix the law. Instead, Begala says, they should lead with an attack on Republicans that is framed as a medical rights issue – before pivoting to fixing the law — and then wrap it all up in a larger message about how Republicans have no answers to people’s health care or economic problems.

“We should open by saying, ‘my opponent wants to repeal your rights,’” Begala said. “He wants to take away your right to be protected against discrimination because you have a preexisting condition. He wants to take away your right to be protected against discrimination for being older or being a woman. He wants to take away the closing of the Medicare donut hole for seniors.”

“That’s point one,” he continued. “Then you say, ‘look, I’m open to working with everybody to fix the law. But I’ll never let them go back to the days where insurance companies could send letters saying your coverage has been canceled because you have a preexisting condition.’”

And then from there to an economic message: “Repeal is their whole agenda. They have no ideas for giving you a pay raise. No ideas for raising the minimum wage. No ideas about how to create jobs. No ideas about how to get your kid into pre-K. Their entire agenda as a party is repeal — to take away rights that you have won. I’m not going to let them do that.”

All Democrats should have also stood up for both physicians and Medicare patients today and demanded a clean vote on the repeal of the Sustainable Growth Formula as opposed to tying it to yet another attempt to thwart Obamacare. If Democrats did something as silly as vote over fifty times to repeal the same thing while otherwise failing to legislate, imagine how the right wing noise machine would be mocking them.

Cross Posted at The Moderate Voice

Please Share

Predictions As To The Demise Of The Health Insurance Industry

Ezekiel-Emanuel

I’ve been seeing a prediction from Ezekiel Emanual recently that insurance companies will be replaced by Accountable Care Organizations and hospital systems in various medical publications recently and now that The New Republic has picked up on this it is starting to be discussed in the blogosphere. Accountable Care Organizations are basically organizations of hospitals and physicians which form a network to provide care to Medicare patients, receiving financial rewards if able to provide the care more economically.

Conservatives are reacting with their usual knee jerk panic and ignorance. The Gateway Pundit, for example, writes, “Despite all of the accumulating evidence that government will be unable to manage the health care system in America, Emanuel is sticking to his guns and hoping for demise of insurance companies.” This evaluation is wrong on so many levels. First of all, the organizations which Emanual foresees as replacing insurance companies are private organizations, not government. Secondly, historical information has shown that government programs such as Medicare have been more efficient than insurance companies in managing health care in America. Thirdly, assuming that the blogger is referring to the problems with the roll out of the Affordable Care Act, the problems have been due to the use of private insurance companies to continue to provide insurance coverage. One lesson from the events of the past few months has been to verify that a single payer system would be far more efficient and easier to establish, regardless of whether this is the desired model.

Conservative blogs have also been quick to claim high rates of happiness with insurance companies prior to Obamacare but that is misleading as most people did not realize how vulnerable they were to problems such as insurance policies being revoked when people became ill and to caps on insurance coverage. Regardless, these problems have been eliminated under the Affordable Care Act and therefore are no longer an issue with regards to whether it is desirable to see insurance companies be replaced.

It is certainly possible that Emanual’s prediction will take place but personally I wouldn’t be so quick to predict the demise of the health insurance industry. I’ve seen a lot of changes in health care during my career. Lots of fads come and go. The insurance companies always seem to remain around. I’m not as certain as today’s fads such as Medical Homes and Accountable Care Organizations. ACO’s have not been around long enough to say for certain what will become of them, but so far the outcomes have not been what would be expected of an idea successful enough to begin to replace health insurance companies.

There are two different ACO models which vary in terms of how much risk they accept. The more they are willing to risk being out money if costs remain high, the higher their potential rewards. Many ACO’s which started out in the high risk model converted to the lower risk model after they were initially formed. Neither model has shown much success yet. While I receive lots of bonuses from various plans which are adopting pay for performance models, I have yet to see a dime from the ACO I belong to, and neither are many other physicians. Again it is still early, but this does not make me see a strong future for ACO’s at this time.

Hospital systems offering their own insurance policies isn’t a new idea. They have been doing it for a while, and I am seeing an increase in this. Success has been variable. They still have to compete with insurance companies, which have many more years experience in developing insurance products and marketing them. I suspect that plans marketed directly by hospital systems to both business and to individuals (through the exchanges) will grow over the next couple of years but I’m skeptical as to whether they will replace insurance companies. I also wouldn’t be surprised to see insurance companies profit from this trend, offering their services to assist hospital systems and ACO’s which desire to put out a plan under their name.

Again, maybe Emanual is right. If I had to bet on one or the other, my bet is that insurance companies will be around longer than Accountable Care Organizations.

Cross posted at The Moderate Voice

Please Share

Rand Paul Blocks Surgeon General Nomination For Calling Guns A Health Threat

Rand Paul has placed a hold on Dr. Vivek Murthy, Obama’s nominee for Surgeon General, because of calling guns a significant public health threat. Paul stated, “As a physician, I am deeply concerned that he has advocated that doctors use their position of trust to ask patients, including minors, details about gun ownership in the home.”

As I have discussed before, this position is based upon recommendations of medical organizations which are justifiably concerned about the health risks of gun violence in this country. Following the Newton shootings fifty-two medical organizations including the American Medical Association, American Psychiatric Association, American College of Physicians, American College of Surgeons, American Academy of Family Physicians and American Academy of Pediatrics sent a letter to President Obama requesting such intervention.

The text of the letter (pdf here) follows (emphasis mine):

The undersigned medical organizations, together representing the vast majority of practicing physicians and medical students in the United States, share the nation’s grief and sadness over the recent tragic school shootings in Connecticut. As physicians, we see first-hand the devastating consequences of gun violence to victims and their families. We offer our experience and expertise in finding workable, common sense solutions to reduce the epidemic of gun violence—indeed the overall culture of violence—in America. We also urge the nation to strengthen its commitment and resources to comprehensive access to mental health services, including screening, prevention, and treatment.

The investigation into the Connecticut shootings is still continuing, and the issues surrounding such violence are often complex and can vary significantly from case to case. Strategies for preventing gun-related tragedies must also be complex and carefully considered. The relatively easy access to the increased firepower of assault weapons, semi-automatic firearms, high-capacity magazines, and high-velocity ammunition heightens the risk of multiple gunshot wounds and severe penetrating trauma, resulting in more critical injuries and deaths. Even for those who manage to survive gun violence involving these weapons, the severity and lasting impact of their wounds, disabilities and treatment leads to devastating consequences for families affected and society, and contributes to high medical costs for treatment and recovery. Renewing and strengthening the assault weapons ban, including banning high-capacity magazines, would be a step in the right direction.

Many of the deaths and injuries resulting from firearms are preventable. More resources are needed for safety education programs that promote more responsible use and storage of firearms. Physicians need to be able to have frank discussions with their patients and parents of patients about firearm safety issues and risks to help them safeguard their families from accidents. While the overwhelming majority of patients with mental illness are not violent, physicians and other health professionals must be trained to respond to those who have a mental illness that might make them more prone to commit violence. Funding needs to be available for increased research on violence prevention in general, and on the epidemiology of gun-related injuries and deaths in particular, as well as to implement available evidence-based interventions. Of equal importance is providing sufficient access to mental health services. While we strongly supported the passage of the Mental Health Parity Act of 2008, unfortunately, the promise of better access top psychiatric treatment will not be a reality absent requisite federal and state funding. This effort should be combined with an education campaign that reduces the stigma of seeking mental health services.

Newtown, Connecticut has now been added to the sad litany of recent mass shootings, including Columbine, Virginia Tech, Fort Hood, Arizona, and Aurora. As we come together as a nation to mourn the most recent victims of senseless gun violence, we must make a real and lasting commitment to work together on meaningful solutions to prevent future tragedies. We stand ready to work with Congress and the Administration to make progress in protecting our communities, especially our children, from this epidemic of violence.

We would expect that a nominee for Surgeon General would support the recommendations of these medical organizations. Discussing the presence of guns in the home does not mean these medical organizations are advocating banning guns. Medical organizations recommend that physicians ask about a wide variety of potential risks. When we ask patients about use of seat belts we are not seeking to ban automobiles. When we ask elderly patients about electrical cords which could present a risk for falls we are not seeking to ban electric lights. When we discuss keeping medications safe and out of the hands of children we are not seeking to ban medications.

Think Progress has more on how Rand Paul’s view is out of step with that of the medical profession:

The idea that gun violence is a danger to public health is utterly uncontroversial among doctors’ groups, academic institutions that focus on public health, and children’s safety advocates. Although Paul criticizes Murthy’s position that physicians and pediatricians should ask patients about the presence of guns in their households, the American Medical Association (AMA) adopted a resolution in 2011 officially opposing any law that bars doctors from having open conversations about gun safety and the risks of having firearms in a household with their patients.

In fact, just yesterday, the American Academy of Pediatrics (AAP) issued new guidelines recommending that households with children who are diagnosed with depression should remove guns and ammunition from their homes entirely.

Not only would Obama’s nominee for Surgeon General be making recommendations in the mainstream of medicine today, Murthy’s views are consistent with those of Reagan-appointee for Surgeon General C. Everett Koop who has written about the dangers of gun violence.

Cross posted at The Moderate Voice

Please Share