Tinker Ready hosts the most recent Health Wonk Review. She keeps the non-edition edition alive with a roundup of excellent but diverse submissions from the last two weeks. Read it here.
For a long time, it seemed like the lead story on the Today show was the weather. More recently, it has been politics, and this week, things got even more interesting (if that was possible). On Tuesday, Bernie Sanders pulled off a surprise victory over Hillary Clinton in Indiana extending the Democratic primary season a while longer (although Clinton’s camp is quick to point out she leads by about 3 million votes), while Donald Trump won Indiana by double digits and became the presumptive nominee as Ted Cruz and John Kasich both suspended their campaigns. In short, it’s looking more and more like the country faces a choice between Clinton and Trump as our next president. Now, all the talking heads are pontificating about what we can expect from both candidates as they pivot towards the general election, which is wonkspeak for making an appeal to more moderate voters than they courted during the primaries. As I looked over the submissions for this edition of the Health Wonk Review, I was struck by the tremendous amount of variety being presented. Sure, there was some focused attention on a couple of prominent developments, but overall, it felt like a miscellany of health policy writing. There is something in here for everyone. It appeals to the middle. A month ago, Jaan Sidorov gave us a politics-free edition, and two weeks ago Peggy Salvatore went with a theme based on the order in which things hit her email inbox. So, why don’t we just tell it like it is? The Health Wonk Review is moving away from the extreme themes and pivoting towards the general edition.
Like a good politician, let me contradict myself about this being a general edition right out of the gate with a bunch of posts about the exit of UnitedHealthcare from the ACA marketplaces. On this topic, we have Andrew Sprung at the healthinsurance.org blog asking why some carriers appear to be thriving in the ACA’s marketplaces and why some – like UnitedHealthcare – are taking a dive. You can read what he proposes are the elements of marketplace success for an insurer here. At HealthReformExplained.com, Sean McGuire also takes a look at “the big insurer marketplace exodus” and examines what this will mean for people’s ability to obtain coverage and the costs of that coverage. David Williams of the Health Business Blog places the blame on UnitedHealthcare. As he puts it, United exiting the marketplace says more about United’s shortcomings than it says about problems with the marketplace. Read more here.
In other marketplace related news, Louise of the Colorado Health Insurance Insider discusses the passage of SB2 by the Colorado Senate, which she says is a waste of time. According to her, “if Connect for Health Colorado couldn’t gain access to the funding needed to be sustainable, the worst case scenario would be the dissolution of the exchange, and a switch to Healthcare.gov. And the federally-run exchange would charge 3.5% of premiums – the same as Connect for Health Colorado’s administrative fee that triggered SB2. And under ACA guidelines, every carrier that sells plans both on and off the exchange would have to spread their total exchange fees across their full book of business…which is the exact problem that SB2 is attempting to address.”
The other topic with multiple submissions is MACRA–the Medicare Access and CHIP Reauthorization Act of 2015. CMS just released their proposed MACRA regulations, and as you could expect, according to Brad Flansbaum of the Hospital Medicine blog, every specialty society and interested party dug in and found something to critique. Yet, Flansbaum writes, the AMA is unbeloved and overvilified in the whole MACRA process. And, according to Peggy Salvatore of Health System Ed, it’s time to prepare for legal challenges. Without the solid data, clear benchmarking and reasonable outcomes that account for the reality of caregiving in widely diverse regions with wildly diverse patient populations, quality- and outcomes-based payment just isn’t ready for prime time.
What has been happening with the job market thanks to the ACA? Joe Paduda of Managed Care Matters writes, “There’s been a lot of blather about the impact of ACA on employers’ decisions on work hours – most of it anecdotal at best, and lots ideologically driven.” Joe’s latest post is here to tell you what is really happening, and why it’s too early to tell much.
Before we shift gears from the political, Anthony Wright of Health Access California offers a suggestion for moving the country towards single payer. He writes, “The great primary debate on health reform had some missed opportunities, but as Senator Sanders seeks to influence the party platform, he could spell out concrete steps—some that California has implemented or is considering–that would improve the health system and bring us closer to the Medicare for All system he advocates.”
As usual, Roy Poses is on the hunt for a scandal of unethical proportions. In his latest post at Health Care Renewal, he examines comments from Fox commentator John Stossel who lamented his recent experience at New York Presbyterian Hospital–an unpleasant stay he chalked up to the hospital’s “socialist bureaucracy.” Poses wonders how, exactly, this private non-profit hospital with a board of trustees dominated by corporate CEOs of large financial firms like AIG, Merrill Lynch, and Citigroup, warrants a socialist label. He has a good point! By contrast, Hank Stern of the InsureBlog underscores that there was a great deal of truth to some of Stossel’s other comments about his experience, which are reflective of issues throughout the U.S. healthcare system. And speaking of hospital boards, Dr. Jaan Sidorov of the Population Health Blog reviews a recent JAMA article on how hospital boards should provide governance oversight of population health programs.
While recent news reports find that medical errors are now the 3rd leading cause of death, Julie Ferguson of the Workers Comp Insider shares a post about the opioid crisis and the fentanyl factor, at a time when prescription drug overdoses have outpaced auto crashes and gunshots in annual fatalities.
Putting the health in health policy, we have a trio of posts from the Medical Care Blog, the Health Affairs Blog, and the Healthcare Economist. At the Medical Care Blog, Lisa Lines suggests that death is not always an adverse event. She writes, “In a high-quality health care system, a patient’s preferences for less intensive end-of-life care must be respected. In those cases, the predictable end result of less intensive end-of-life care – mortality – must also be accepted as the preferred outcome and not count against a healthcare provider’s quality record.” Very true. What about readmissions? The Healthcare Economist, Jason Shafrin, investigates whether Medicare managed care decreases hospital readmissions. I’m not going to tell you the answer. You need to go here to find out.
And then there’s the Zika virus. On the Health Affairs Blog, Alexandra Phelan and Lawrence O. Gostin examine the implications of a potential Zika virus outbreak this summer and whether the U.S. is prepared to handle it. With alarming imagery, the authors write: “It is one thing to fail to prepare for an emerging infectious disease if the risks are uncertain. But it is quite another to fail to act when the facts are clear: we know that Zika is coming to the US, that it harms newborns, and will disproportionately affect poor women and their children. Failure to prepare for a storm that is spreading rapidly in our region, heading for our shores, and which could affect the next generation is unconscionable. It is also a major political mistake. Imagine if nine months following a Zika virus outbreak this summer babies are born with severe birth defects, and poor women testify in Congress holding their babies. It would, and should, result in a public moral outrage.” The authors specifically discuss the Obama Administration’s supplemental funding request of $1.86 billion to Congress to respond to the Zika virus domestically and internationally.
Finally, David Harlow of the HealthBlawg reports back from the MIT Hacking Medicine Grand Hack 2016. The final presentations gave him a terrific glimpse of digital health innovation at the bleeding edge. Read his take here.
Well, that’s it for this edition of the Health Wonk Review. By the time I host again, the election should be close to over. Hopefully, you can take some solace in that.
Peggy Salvatore hosts the most recent Health Wonk Review at the Health System Ed Blog. It’s entitled: The Early Bird Catches the Worm Spring Edition. It hasn’t been an especially cold winter in Iowa this year, but I’m still happy to have longer days, chirping birds, and flowering trees, and I’ll bet you are too. But just stay inside a few minutes and read all the good stuff she’s pulled together from the wonk crowd.
Hosted by David Williams at the Health Business Blog, the latest edition of the Health Wonk Review provides a nice escape from the cesspool that is the presidential election primary season. Oh, well, except for all those references to America’s favorite orange candidate for the republican nomination. Read it here.
Well, it’s official. The Centers for Medicare and Medicaid Services (CMS) has approved Iowa’s plans to “modernize” Medicaid by moving everyone into managed care. A guest post from April 2015 laid out the details of what was being proposed, and now it’s soon to be upon us. CMS has given the thumbs up for an April 1st start to the process, which is actually already well underway. In fact, the state originally planned for modernization to occur on January 1st. But, thanks to some serious opposition from key stakeholders and members of the public, CMS put the brakes on things for a while and required the state to at least give the appearance of addressing some concerns. The state then said things would roll out March 1–today–but CMS still wasn’t convinced that the state was ready, so the final date was set for April 1, 2016.
People are concerned that the state’s attempt to control costs will come at the expense of some of the most vulnerable Iowans and, as this recent report from KCRG-TV9 out of Cedar Rapids highlights, if the results of similar efforts in Kansas are any indication of what to expect, those concerns are more than legitimate. There’s little question that things are going to be disruptive during the transition. The biggest open-ended questions that remain are how effective oversight of the program will be, to what extent the private managed care organizations will provide the state (and health services researchers) with individual-level (rather than aggregated) claims data, and what actually happens in terms of utilization and spending.
Evaluating those outcomes may play a key role in shaping the future politics of the state. Iowa Governor Terry Branstad, already the longest serving governor in American history, is now contemplating running for a 7th term, and the move to Medicaid managed care in Iowa has taken a central place in the political narrative between Branstad and his possible challenger former Governor Chet Culver. So says this column in The Des Moines Register by Kathie Obradovich. It might actually be nice if Iowans elected a new governor. Someone who hadn’t ever held the office before. Ironically, it seems the more things change for the worse in Medicaid, the more they stay the same in Des Moines. It all feels a little bit like a nightmare. The kind of thing someone says to you on April 1st to get a reaction out of you before exclaiming “April Fool’s!” Only this time, it’s not a joke, and try as they might, I don’t think that the state or the managed care organizations are fooling anyone.
I’m proud to say that I filed my federal and state taxes over the weekend. It wasn’t fun, but Turbotax made it painless. The hardest part was gathering all of the various documents I needed to fill in the boxes as the software walked me through everything. You know, the W-2s from employers, the various 1099 forms for miscellaneous income, dividends, and interest, and the statements from various non-profit organizations with records of charitable contributions. These are the standard things most people have. But this year there was a new form. A 1095 form with information about my health insurance coverage. Mine was a 1095-C, because I happen to work for a large employer, but there also 1095-A and 1095-B forms. So, what are these forms about?
The first thing you’re probably thinking, if you’re like some of the anti-ObamaCare (and, well, just plain anti-Obama) folks I know is that this means you’re going to have pay taxes on your health insurance. Let me stop you right there. That’s NOT what any of these forms, be they A, B, or C, are about. However, there IS a chance that you’ll have to pay more taxes depending on what the forms say, so now is the time to pay close attention: The forms are simply documentation of your (and your family’s) health insurance coverage for 2015.
Form 1095-A has actually been around for a year, corresponding with the roll out of the health insurance Marketplace established nationwide by ObamaCare. So, if you had coverage through either the Marketplace operated in your state, this year is likely the second year you’ve seen this “new” form. Forms 1095-B and 1095-C are new this year though. They are sent to individuals with employer-sponsored health insurance. The B forms go to employees of small employers, while, as I mentioned already, the C forms go to employees of large employers.
And you’re not the only one who receives a copy of the form. A copy is also furnished to the IRS. However, you don’t have to submit the form with your taxes. Just keep a copy for your records in case you get audited. If you had insurance in 2015, you check a box on your tax return that attests to that, and you’re done. No taxes on your health insurance coverage and nothing else to do.
On the other hand, if you DIDN’T have health insurance in 2015, you’re going to have to ante up. Remember the individual mandate? Yeah, that one. If you have affordable insurance options available to you and you do not obtain coverage, you are subject to paying a penalty. The penalty was in effect last year, too, so this isn’t necessarily news. What may be news to those who haven’t been paying close attention is that the penalty is getting steeper. This was done by design–phased in to soften the blow for folks as they got accustomed to the requirements of the new law. If you (or your family) didn’t have insurance in 2015, you’ll pay the higher of 2.5% of household income or $695 per adult and $347.50 per child up to a maximum household cap of $2,085. That’s more than double the penalties from last year in some cases, and that’s the idea. Uncle Sam assumes that maybe if it stings enough, you’ll give in and decide to get covered.
And there’s one more thing: If you didn’t have health insurance coverage for some or all of 2015, you may still qualify for an exemption from the penalty. Healthcare.gov has a nifty little tool that can show you any exemptions for which you qualify. Access it here.
Update: You’ve probably noticed that Wright on Health posts have been few and far between lately. The simple explanation is that academic life pre-tenure is time consuming–especially when you try to be attentive to other even more important things like being a husband and father–and writing a blog, as important and personally fulfilling as it is, doesn’t “count” towards my success in those areas. And I’m not paid to write this blog, so it necessarily takes a back seat to everything else. In fact, several times, I’ve considered hanging up the blog altogether. But I maintain hope that I will one day find the time to blog more regularly once again. At any rate, if you’re reading this, I thought you deserved an explanation for my absence, and I couldn’t just write you this update without an accompanying post, so here you go…..
Yesterday, the Congressional Budget Office released new projections on the number of Americans expected to sign up for health insurance through the ACA/Obamacare Marketplace in 2016. If you’re the kind of person who likes to see things for yourself, take a look at page 69 of this report. You have to go digging around in the footnotes, but there you’ll find that CBO originally projected 21 million Americans to purchase coverage through the Marketplace in 2016, a number they’ve now revised downward to just 13 million. As is being widely reported this morning from outlets like The Hill, that’s a 40% reduction. There are two ways you’re likely to respond to that information, assuming you pay it any mind at all.
The first is to think: “Wow. The government really got it wrong. They missed the mark on that one.” And that’s absolutely right. Now, how you spin that is a matter of your pre-existing political beliefs. If you’re more progressive, you’re probably inclined to discount that failure. “No one has a crystal ball,” you might say. “Of course their numbers are going to be off sometimes,” your buddy will chime in. Conversely, if you’re more conservative, you’ll jump to the obvious conclusion that this is simply more evidence of government ineptitude. “They can’t ever get anything right,” you might say. “Yeah, tell me about it. Thanks, Obama!” your buddy will reply sarcastically. While it might seem, given their diametrical opposition, that one of these perspectives must be true and the other false, let me suggest that other from the obvious fact that the CBO’s projection was off target, they’re both wrong in their interpretation of that.
The second, and I would submit more accurate, way to think about this is to dig a little deeper and ask what it truly means. Although they can be interpreted at will, the numbers don’t lie. The CBO estimate was off target. This mistaken projection should neither be written off by the progressive, nor given undo importance as evidence of government’s incompetence by the conservative. The truth is that, to the extent that Obamacare’s major goal was to reduce the number of uninsured Americans, it has been a success. The rate of uninsured Americans is the lowest it has ever been since we started tracking that data more than 50 years ago. At the same time, the country still has a long way to go if the goal is to ensure that every American has some form of health insurance coverage. In that respect, Obamacare has underperformed. The CBO projections have proven to be overly optimistic. The reduction in the number of uninsured seems to be leveling off. In short, we’re approaching a floor. Now, on the other side of that floor, there are people who qualify for benefits under the ACA as originally enacted. The question we face now is how to improve implementation and outreach efforts. First off, there are the 20 states that have still refused to expand their Medicaid programs, denying insurance coverage to their most vulnerable residents. Unfortunately, there’s not much the Obama administration can do about that. But then there are the Marketplaces and it’s imperative that we do more to make sure that people are knowledgeable about how they work, how to find out if they are eligible for subsidies, and how to get and keep coverage. An alarming number of people signed up for coverage and then never sent in their first premium payment, so their policies were never in force. There are certified application counselors and the like out there, but we also need to better understand the barriers people face in navigating our complex healthcare system. This is public policy and community outreach. This is health services research and implementation science. The point is, it’s going to take a real concerted and ongoing push from many fronts to break through the floor. Millions of Americans would benefit. It is up to us to help them.