The latest edition of the Health Wonk Review is up on the Managed Care Matters blog. Thanks to Joe Paduda for hosting. Go check it out!
Tonight, an anticipated audience of 100 million will all be tuned in to watch the first presidential debate between democratic nominee Hillary Clinton and republican nominee Donald Trump. A big part of the draw is the expectation of being entertained by a real estate developer turned brand curator turned reality TV star turned candidate for leader of the free world, who is undoubtedly entertaining. As has been stated repeatedly by many on both the left and the right, Donald Trump has said numerous things during his campaign that would have historically disqualified any other candidate. At the same time, there is a strong narrative that has circulated for decades that Hillary Clinton is not trustworthy–even when it can be independently verified that she is telling the truth. When it comes to politics, people are inherently irrational, but we seem to be taking that lack of thought to another level. The LA Times just reported that the “scope of Trump’s falsehoods [is] unprecedented for a modern presidential candidate.” Yet Clinton is the one with a website devoted to her called–and I am not making this up–LyingCrookedHillary.Com. And the articles emerging on Trump’s lying were all coordinated by the Clinton campaign, according to the folks behind a website appropriately titled “Hot Air.” Some have complained that the media is going too easy on Trump while the Trump campaign has called the media out for going too easy on Clinton. At the same time, both the Trump and Clinton campaigns have claimed the media is being too tough on them. But what about the facts? Although Trump has said that the media should not be engaged in fact-checking, there are many who are hoping that there will be real-time fact-checking at tonight’s debate, so that neither candidate is allowed to get away with lying to the American people. Fortunately, sources such as the Pulitzer Prize winning PolitiFact, and Bloomberg TV, will be doing just that.
Still, in advance of tonight’s debate, I feel compelled to engage in a little bit of preemptive fact-checking on a topic I care deeply about: U.S. healthcare. With only 90 minutes to debate, and with such vague topics as “America’s Direction” and “Achieving Prosperity,” it is unclear whether and to what extent healthcare will be discussed by either candidate. If the issue is raised, however, you can bet that Trump will do his best to throw Obamacare under the bus, while Clinton aims to defend it and stress the need to improve it. If you hate Obamacare, you’ll love what Trump says, and if you love Obamacare, you’ll love what Clinton says, but that’s still based on biases, emotion, and gut instinct. What about facts? Well, the facts are that only 9% of Americans are uninsured today–the lowest that number has been since it began being tracked. Obamacare has clearly succeeded in providing health insurance to approximately 20 million Americans. Still, that is just a single measure, and both opponents and proponents of Obamacare have other criticisms of the law. If only there were more facts.
Fortunately, thanks to the work of Molly Frean, Jonathan Gruber, and Benjamin Sommers, we know quite a bit about the success of Obamacare in providing insurance coverage. In last week’s New England Journal of Medicine the three co-authored a piece entitled “Disentangling the ACA’s Coverage Effects–Lessons for Policymakers” which outlines where the gains in insurance coverage occurred. They found that 63% of the gains in insurance coverage in 2014 were attributable to Medicaid, while 37% were attributable to private insurance purchased on the federally-subsidized Marketplace. Interestingly, the Medicaid expansion–in which 31 states and the District of Columbia are participating following the Supreme Court ruling that made it optional–is having an effect, but so too is the “woodwork” or “welcome mat” effect that results when policies cause previously eligible persons to enroll for the first time. Examples of these policy changes enacted by Obamacare might include the individual mandate to have insurance coverage, as well as the streamlined enrollment process through Healthcare.gov.
I reached out to Dr. Sommers, who is an Assistant Professor of Health Policy and Economics at Harvard’s T.H. Chan School of Public Health for his comments on the study, and this is what he had to say: “One of the key findings here is that despite all the recent attention on the Marketplaces in terms of premiums and several large insurers cutting back their presence, Medicaid remains the workhorse of the ACA’s coverage expansion.” Sommers is referring to the collapse of co-ops nationwide, the high-profile exit of insurers like Aetna, Humana, and UnitedHealthcare from the Marketplaces, and the proposed double-digit increases in health insurance premiums in many markets. It’s not that those issues aren’t cause for concern–they are–but it’s striking to see that Medicaid is accomplishing so much in its own right, even as just under half of states have not expanded the program.
“Another notable finding is that we found no evidence that the law was leading a loss of employer provided coverage, which had been one of the predictions offered by opponents of the law,” said Sommers. You might remember Congressional Republicans referring to the “Job-Killing Healthcare Law” during their numerous efforts to repeal Obamacare. The notion here was that larger employers who were mandated to provide insurance coverage to their employees might downsize their workforce to control their insurance costs. A related concern is what is known as “crowd out”–namely that when Uncle Sam offers subsidized insurance, many smaller employers–who were not mandated to provide coverage–would decide to stop offering insurance to their employees and let the government foot their share of the costs. Fortunately, that doesn’t appear to be happening.
Finally, according to Sommers, “We find that state policies have a big impact – not just the obvious question of Medicaid expansion, but also whether states started expanding Medicaid before 2014 (which led to bigger coverage gains) and whether they ran their own state Marketplaces (which made the premium subsidies more effective at enrolling people). It’s a federal law, but the states have a lot of discretion in how they implement it.” The fact is, Obamacare is working, but it works better in some states than others. More importantly, circling back to tonight’s debate and the presidential election, the law is imperfect. The outcome of this election will have much to say about its fate. If Trump wins, it is unlikely that the law will be repealed, but it is likely that nothing will be done to improve it and build upon this early success, and there is reason to be concerned about the long-term stability of Obamacare with adverse developments in the health insurance Marketplaces. Conversely, if Clinton wins, the law will certainly not be repealed. The extent to which it is strengthened will depend upon control of both houses of Congress, and the degree of policymaking that can occur through the executive branch and its federal rulemaking process. The fact is that 20 million uninsured Americans have gained health insurance since 2010. That’s more than the entire population of New York or Florida. What happens going forward depends on you and your vote. So, watch the debate tonight, check the facts, and vote in November.
I know, I know. I haven’t written a blog post in forever. Life’s been tied up with writing grant proposals and sending manuscripts out for peer-review. You know, the things people actually pay me to do. But every once in a while, something pretty big happens in the world of healthcare, and I feel compelled to dust off my keyboard and draft a quick post. After all, what would a few dozen of you do without my thoughts on the matter?
The event in question is Aetna’s announcement that it will no longer be participating in 11 of the 15 state insurance exchanges it currently serves come next year. And Aetna’s not the only one–just the most recent. UnitedHealth and Humana have also announced plans to pull back substantially. In fact, right now Anthem is the only one of the four largest insurers in the country that hasn’t said it will be exiting the exchanges. From the insurers’ point of view, the logic is straightforward: They’re losing a lot of money on the exchanges–hundreds of millions of dollars each–even as they continue to make billions of dollars in profits overall as this Bloomberg article reports.
Why are they losing money? The short answer is that the people who are signing up for insurance coverage are sicker than expected, while healthier individuals have opted to forego coverage or have obtained it outside of the exchanges. In response, the insurers have raised the cost of their products, and that has further served to keep the sickest individuals enrolled, while healthier individuals seek other options or drop their coverage. It is what health economists call a “death spiral.”
Whoa. A death spiral?! Sounds serious. Yeah, it is. Potentially. While a recent editorial from The New York Times expressed confidence that Obamacare will be just fine, that’s only true if somebody does something to fix this. Otherwise, the price of insurance on the exchange will continue to climb until it reaches a point that it becomes unsustainable for the people purchasing it or the government subsidizing it, and the insurance market will collapse.
So how can we fix it? Well, first, that assumes you want to fix it. If you’re the GOP, you hope that this doom and gloom culminates in Trump winning the White House, and Republicans keeping control of Congress, leading to repeal of the ACA. However, if you’re more interested to practical solutions to problems, there are a few things that can be done. One is to increase the penalties for not having insurance, making that a much less palatable choice for healthy individuals to make. Similarly, the federal government can increase the size of exchange subsidies. Together, these two steps would probably go a long way in getting healthier individuals to sign up for an exchange-based insurance plan, which would even out the risk pool and steady the market. Alternatively, the government could provide some sort of stop-loss or reinsurance to insurers offering plans on the exchanges who encounter higher-than-expected utilization among their beneficiaries. Finally, there’s the notion of reintroducing the public option. Yeah, you remember, that thing that Joe Lieberman pretty much singlehandedly removed from the ACA? Proponents suggest that a public option plan would work by creating more competition in the exchanges, which could keep costs down and encourage healthier individuals to sign up. I’m not terribly optimistic here, because as much as I love the notion of the public option and competition, there is a very real sense in which the public option would have the ability to artificially lower prices, meaning insurers would still be hemorrhaging cash and would likely exit the exchanges anyway. Besides, I’m not at all convinced that the political will exists to enact the public option. That said, if we had a public option and insurers still wanted to exit the exchanges, we’d be much closer to the possibility of a single-payer system than we are today.
Of course, this may all be a bit overblown. Sure, Aetna and others are losing money on the exchanges, but they can afford to. They’re still making billions of dollars every year. And Jonathan Cohn and Jeffrey Young did some sleuthing to discover that Aetna’s withdrawal from the exchanges may have less to do with losing a few hundred million dollars, and more to do with trying to manipulate the federal government. In a letter to the Department of Justice, the CEO of Aetna essentially said “Approve our merger with Humana, or we’ll leave the exchanges.” The DOJ didn’t approve the merger, calling Aetna’s bluff, and Aetna proved it wasn’t bluffing. If that’s the case, it tells you an awful lot about the motives of private insurers in the United States. But sure, if it makes you feel better, go ahead and blame Obamacare. Meanwhile, I just hope our policymakers have enough common sense to take action when it is so clearly warranted.
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.