HWR on ACA

The real experts opine on what’s going to happen with ACA – all collected in one place for your reading enjoyment.

Kudos to David Williams for hosting this fortnight’s edition; among the posts worth your consideration are:

As Julie would say, “Quelle Surprise!”

HealthWonkReview’s Inauguration Edition

Through election after election, HealthWonkReview has been your go-to source for the real impact on healthcare, health policy, access, coverage, and the rest of the story about the industry that accounts for one-sixth of our nation’s economy.

In preparing this edition, I was struck by how much better these blog posts were than pretty much any articles in the mass media (with a couple notable exceptions.).

The depth, understanding of core issues, knowledge of how various parts of ACA interact, and ability of the authors to explain all this in words everyone can understand is impressive indeed.

Louise Norris, Roy Poses, Andrew Sprung, David Harlow, David Williams – these are the folks you need to be following.

Repeal…

Andrew Sprung’s contribution is a welcome list of 7 ways the GOP could blow up ACA gains.  Or maybe not.

Andrew describes various paths to repeal and replace, dissects the problems, perils and promise of each, and handicaps the odds.  It’s a very, very insightful read.

Tick, tock…Louise Norris just keeps getting better and better; as a small-business insurance broker she is on the front lines AND understands the core issues affecting ACA and health policy.  Her entry this month discusses the Republicans’ plan to have legislation ready tomorrow – yes, January 27 – to begin the repeal process. 

A bit of background on the trump Executive Order that required the January 27 legislation comes from the estimable David Harlow.  A quick read, and a valuable one.

Friend and colleague Bob Laszewski’s wondering if the trump administration is prepping for it’s own “if you like your insurance you can keep it” fiasco.  In a great companion piece to the Norris and Harlow reportage, Bob asks a question the current administration likely didn’t:

if you take this new executive order to its logical conclusion, doing things like killing or easing the individual mandate or allowing for cheaper medically underwritten plans can’t have any effect other than making an already fragile Obamacare risk pool worse. Making the pool worse can only lead to fewer consumer choices, or no choices, or higher rates and bigger out-of-pocket expenses for those who remain in the Obamacare risk pool.

My entry this month compares the Republican position on repeal and replace to Wile E Coyote’s headlong charge off the cliff.  Beyond repeal and into replace, things could get pretty interesting – as Mr Coyote learns every episode, it’s not the fall that hurts, it’s the reality of the landing.

As I see it there are two main issues:

  1. Repeal without replacement is a budgetary and political minefield.
  2. Congressional Republicans aren’t even close to agreeing on what a replacement bill would look like

One of the big changes might be block grants for Medicaid – where the Feds just give each state a chunk of money and the state gets more flexibility in how they spend it.  There’s a LOT of detail around this, but at least in Massachusetts, it may not be much of an issue.  David Williams posits that MA is in a pretty different place than most states, one where a full-on total repeal of ACA wouldn’t be a big deal.  That’s because Mass has been in the forefront of these changes, and things are working pretty well.

Federal changes…

OSHA is going to be a different animal altogether in the new administration; perhaps more akin to a cuddly panda than a persistent bloodhound. Julie Ferguson details how the agency is already shifting to a more “employer-friendly” mode.

Julie’s post also digs into the administration’s claim of a “dramatic expansion of the federal workforce in recent years.” and resulting hiring freeze and consequences thereof; quoting a source that finds there has been no federal workforce expansion and that “employment by the federal government as share of all US employment is relatively low compared to most of the last 70 years.”

That’s a fact, not an “alternative fact”, or what we would call a “lie”.

Peter Thiel is the focus of Roy Poses’ ire this month, and that ire is well-placed.  The trump advisor supported one “Jim O’Neill, one of Mr Theil’s business associates, for this position [of head of the FDA], despite Mr O’Neill’s apparent complete lack of experience or training in medicine, health care, public health, or biomedical research, and Mr O’Neill’s obvious conflicts of interest.”

Other news of note

Brad Flansbaum’s penned a piece on healthcare CFO and CEO ratings at The Hospital Leader. Interesting take on how administrators – who currently are not being “rated” – perhaps should be. Brad provides his views on a few evaluation standards; good to see the proverbial shoe being placed on another foot!

And the ever-wonderful Hank Stern informs us that healthcare inflation is not limited to this side of either pond; costs are going up in other countries too – driven there by a demand for private care.

The election’s impact on health care – experts opine

This is a special post-election edition of Health Wonk Review – we asked our contributors to share their thoughts about how the GOP’s sweep will affect health care, health reform, and the health care system.

I’d like to profusely thank our contributors.  For most, this was a totally unexpected result that no one i know (except Michael Moore, who I don’t “know”) predicted or even considered possible.  Our contributors have focused, dug in, and come up with some terrific insights into implications for health care.

Before we jump in, a couple key data points.

  1. Health care accounts for one-sixth of our GDP.  This is a HUGE, incredibly complex, deeply entrenched business.
  2. Unlike any other part of our economy, health care is unique because it profoundly affects us as individuals.
  3. ACA is MUCH bigger than the Exchanges; only 1 American out of 19 is covered via the Exchanges.

More on what ACA is and is not, and how it has been portrayed in the media from Daniel Dawes at healthinsurance.org.  If you’re up for more fact-checking, Daniel’s got you covered.

David Williams encourages Democrats to go ahead and allow Republicans to repeal ACA. Filibustering such a move, while possible, would delay the death by a thousand cuts from executive action and the budget reconciliation process. That being the case, let ’em at it.

David correctly notes that the GOP’s positions are often directly contradicted by (some of) Trump’s positions, and health care is no exception. He also breaks down the key “policy initiatives”, most of which won’t do anything to bend the cost curve. David concludes that once Trump figures out these initiatives aren’t going to solve the problem, he may well decide to go back to his earlier plans to adopt a Canadian-style system.

We welcome Matthew Holt back to HWR!  Somehow able to write a cogent post while watching election returns (when I was hiding under the covers), Matthew wonders how Trump is going to A) repeal “Obamacare” while ensuring everyone has access to high quality, affordable health care. The middle-aged white folks who supported him expecting he’d “fix” health care are going to be disappointed if he doesn’t deliver…

That, plus the fact that the entire health care system – payers, providers, IT, pharma – have spent six years working to adapt to ACA and there will be an awful mess if there’s a hard stop on Inauguration Day.

Bob Laszewski tells us the GOP does have a written plan, and it’s ready to go.  He also believes the Dems will work with the GOP to replace ACA because there are a lot of Democratic Senators up for election in 2018.

Thanks to Peggy Salvatore for her contribution; she notes that for many voters “Obamacare” may well have been a big reason they pulled the lever for “anyone else”. She also hopes Trump will assemble a team of experts to plan the new health care laws.

Brad Wright notes that while most may think ACA will be repealed, most also thought Clinton would be our next President.  The real question is what will happen to the 20 million + who have coverage due to ACA.

Tim Jost of Health Affairs reminds us that the simplistic statement “repeal Obamacare” is not going to happen.  Most Americans equate the Exchanges with “Obamacare”; ACA is much more than that.  An outright repeal would impact everything from pharmaceutical pricing to biosimilars to Medicare reimbursement to hospital financing; the entire system will grind to a halt if the “replacement” plan isn’t carefully thought out and well planned. 

Given Trump’s wildly inconsistent stances on health care and the low likelihood that the Ryan plan’s policies will do anything to bend the cost curve, I don’t see a solution coming that will make Trump voters happy. 

Thanks to Roy Poses for his post on how the current system is “rigged” to enable companies to sell useless stuff.  The FDA finally caught up with a company shilling its “beads” as a drug delivery tool, when it had been explicitly prohibited from doing just that. Perhaps we need MORE regulatory enforcement, not less.

Pre-election pundit ponderings!

With just a couple Health Wonk Review publication dates between now and the election, we decided to jump into this with both feet.  Which is decidedly different from anything we’re hearing from the Presidential candidates, and pretty much everyone running for elective office.

Not that a little silence wouldn’t be welcome right about now, especially in those hotly-contested toss-up states (we’re talking about FL OH PA NC AZ NV…)

First up is a fact-filled briefing on why insurers are leaving the Exchanges from the keyboard of Louise Norris.  Louise notes that, despite losses in the individual market/Exchanges, insurers are doing fine.  That’s because only 6 percent of Americans get their insurance via individual plans in 2014.

InsureBlog’s got a view on the Exchanges, courtesy of Mike Feehan.   Mike opines: “The collapse of most Obamacare exchanges has captured the attention of the media in recent months” While I’d encourage Mike to not get his shovel ready just yet, in his view private exchanges may – emphasize may – work, but it’s too early to tell.

(HWR Hero Hank Stern is participating in the Strides Against Breast Cancer event next week; you can help him out here.)

healthinsurance.org is wondering if the GOP  would get behind a Medicare expansion that focused on Medicare Advantage plans offered by commercial insurers, these plans are favorites of the Republican establishment.

All you need to know on “Clinton & Trump on workplace issues“, a service provided by the talented and ever-entertaining Julie Ferguson.  Parental leave? Health reform? Drug pricing? Zika?  It’s all there!

Brad Wright offers a trenchant piece on the actual results of ACA to date; Brad notes that most of the folks who gained coverage got it via Medicaid, with significant increases even in non-Medicaid expansion states.  About a third of the growth in coverage came from private insurance bought on the Exchanges.  Not only did Brad report on the data, he got additional insights from one of the study’s principal authors…

Peggy Salvatore is peering into the future of health insurance, and what she sees is pretty darn intriguing.  Peggy’s review of the “demonetization” of health insurance and potential use of real-time data capture and analysis by “health insurers” makes for compelling reading.  Lest you think it too far-fetched, a decade ago you couldn’t read this on your phone…

A BIG issue this election has been pharma costs, with the EpiPen the proverbial poster child.  David Williams thinks that there’s been a bit too much grandstanding and hyperbole here; check out his perspective at Health Business Blog here.

Acronym soup! My contribution is a primer on physician reimbursement changes from CMS. MACRA. MIPS, APM, RBRVS, SGR, along with a discussion of implications for workers’ comp is ready for viewing.

Our good friends at Health Affairs provide welcome insight into maternity care, and why less is more; less care = better outcomes for moms and babies.  That being the case, why is “more” so common? Some thoughts on that, too.

Meanwhile on the hospital front, things aren’t as rosy – unless rosy describes the color of the ink on the financial reports.

Assumptions About Your Hospital Remaining In The Black Are Wrong. And You Better Listen To Who Is Saying So.

Insight into how private equity’s involvement can end up in a heads-they-win, tails-you-lose result comes from Roy Poses MD.  The most persistent and insightful “investigative blogger” I know, Roy’s decade-long focus on the often ugly intersection of capitalism and health care makes for disturbingly necessary reading.  Today he takes on Cerberus’ involvement with Steward Health.  His reporting will NOT make you feel good about our “system”.

There’s a new blog in the blog-o-sphere; GoodNewsWorkComp is up and running, It’s the place for industry folk to meet, greet, and share their stories.  Read Ronnie’s Story for a perspective you won’t get from the “work comp is evil” set.

Meanwhile, Jaan Sidorov is pondering why Apple and insurance companies are working to put Apple watches on members’ wrists. Hint – it’s kinda-sorta big brother, but there’s a win in it for you!

Thanks for reading this far, clicking thru, and sharing with friends, family, and frenemies.

HWR reports on what’s REALLY happening in health care

Thanks to Louise and Jay Norris, HWR is up and ready for your enlightenment.

One of the great things about HWR is the information on stuff the regular media ignores, written by people who actually really understand health care.

Whether it’s reporting on the impact of ACA on poor and sick folks, the exploitation of immigrant workers, or a deep dive into pharmaceutical pricing, there’s way more insight here than you’ll get anywhere else!

And congratulations to Louise and Jay on their tenth year publishing Colorado Health Insurance Insider!

Steve Anderson’s Health Wonk Review

Steve Anderson’s edition of Health Wonk Review somehow manages to find new news from last week’s Republican convention.

That would be impressive enough, but wait, there’s more!

David Williams’ deep dive into dialysis – an industry that exemplifies the conflicts and adverse motivations inherent in our health care system.

A revealing look at healthcare “ministries”; a business which, at the very least, requires a leap of faith across a very deep chasm.

And a critical de-construction of President Obama’s JAMA article about ACA.

A great way to start your week!

 

Clinton health 2.0

Medicare for more, caps on premiums and out-of-pocket spending,

Presumptive Democratic nominee Hillary Clinton’s health plan builds on ACA in several key ways, with an over-arching goals of providing more consumer choice and reduce the financial burden on consumers.

  • a tax credit of up to $5,000 per family to offset a portion of excessive out-of-pocket and premium costs above 5% of their income.
  • incease financial incentives for states to expand Medicaid
  • allow younger seniors to “buy-in” to Medicare

Let’s take these in order.

Tax credit

The Clinton plan’s tax credit is intended to address a growing concern; while premium costs aren’t zooming up (altho 2017 premiums look to be increasing at near-double-digit rates) deductibles, co-pays and coinsurance are becoming increasingly problematic.  The $5,000 tax credit is intended to offset some of these increases, and is coupled with a limit on total insurance and related expenses of 8.5% of family income and a mechanism intended to reduce costs for those earning more than 400% of the federal poverty level. (this last can make a huge difference, as costs for those just under 400% can be a fraction of what those earning just above 400% pay).

The subsidy isn’t limited to lower-income folks, and will certainly increase costs and concerns about affordability. However, indications are that take-up among the more affluent would likely be fairly low – and the subsidy pales in comparison to the favorable tax treatment currently enjoyed by those with employer-based insurance. Notably, there’s effectively a “fade-out” of the impact of the 8.5% cap for the truly affluent just because that 8.5% represents a pretty high figure for those with a lot of income.

Medicaid

Clinton proposes federal payment of 100% of the cost for any state that expands Medicaid for three years (declining to 90% thereafter).  Her plan also includes increased funding for education and enrollment activities for Medicaid-eligibles.

Medicare buy-in

The yet-to-be-finalized plan would allow seniors as young as 50 to buy in to Medicare. If enough seniors chose Medicare, rates for “regular” insurance on the Exchanges would likely decrease as the average age of members would decrease, thereby decreasing expected costs. And, insurance premiums for those seniors buying in would almost certainly be several thousand dollars lower than they can currently get via the Exchange. Clinton contends, with some justification, that adding more consumers to Medicare would reduce overall health care costs.

Medicare’s buying power and regulatory authority gives it much more control over health care price and utilization.  That, plus the sheer number of Medicare recipients, makes it the dominant force in the marketplace.  While providers may balk, many will find it necessary to go along – or lose a substantial chunk of their patient base.

However…Medicare is a mash-up of four separate and distinct parts, with different deductibles, treatment requirements, cost sharing, and treatment limits.  While it is well understood by practitioners, that’s only because it is THE dominant health insurer in every market.  Streamlining and rationalizing the benefit plan would make it much more palatable to under-65s.

Clinton has yet to dive into the details, but given the attention span and appetite for same among the eligible-voter population, those details are going to get attention from a very limited group of health care geeks (your faithful author included).

What does this mean for you?

Depends on whether a) Sec. Clinton is elected; b) the Dems take over the Senate; and c) the Dems make significant inroads in the House.