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October 17, 2013: For-Profit Insurers Seek 2-Year Delay in the Fees They Pay Under Obamacare, Despite All the Business the Law Brings to Them

The greedy for-profit health insurance industry which is already bleeding off 25-30% of the nation's health care dollar in "profits" and administrative overhead expenses now wants to delay for two years the fees they agreed to pay under the Patient Protection and Affordable Care Act.  The head of the nation's largest health insurance lobby recently said that she'll push lawmakers to include a two-year implementation delay of the new health law insurance tfee in the budget agreement that they must negotiate by December 13 under the measure Congress passed to reopen the federal government and suspend the debt ceiling limit.

Part of the industry fees charged under the health law to pay for wider health coverage, the taxes would start in 2016 rather than 2014, said Karen Ignagni, president of America's Health Insurance Plans. Ignagni spoke to an industry conference in suburban Virginia and to reporters afterward.

Ignagni said the fees are driving up premium charges to individuals, small businesses and enrollees in Medicare Advantage, the GOP-promoted "privately-run" Medicare program that was supposed to "save" Medicare money by infusing more compewtition into the market, but which has according to the Congrssional Budget Office cost Medicare on average 14-19% more ever since it was enacted in 2003, more than $200 billion and counting.  Delaying them by two years would require offsets totaling $15 billion in order to avoid adding to deficit spending, she said.

A nearly successful campaign by the medical device industry to get out from under fees they must pay under the health law has energized attempts by other industry lobbies to lessen fees and payment cuts. The Federation of American Hospitals recently called for relief from health law cuts as a matter of parity if lawmakers were going to eliminate the $29 billion in fees device makers must pay over 10 years. [Jeanne's Note: All of these fees were originally agreed to by the various industries when Obamacare was enacted in 2010. All the new business that the law would bring them was supposed to make the fees a win-win situation for them and for the public. Now these industries want their to keep their "wins" but turn the public's side of the deal into a loss.]

The scramble to lessen health law burdens raises questions about whether financing of the health law that keeps it budget neutral is beginning to unravel. The latest tactic is to press for delays rather than outright elimination of the fees. Given the kick-the-can-down-the-road propensities of lawmakers, not to mention the millions in lobbying dollars they are spending (to save billions in fees), these delays have a way of turning into the same thing.

Under the law that resolved the budget impasse, Senatecritter Patty Murray, D-Wash., and Housecritter Paul D. Ryan, R-Wisc., the chairs of the budget committees in their respective chambers, must negotiate a budget accord by December 13. "We don't know the scale and scope of that," Ignagni said. But she noted that lawmakers are preoccupied with the cost of insurance premiums. "More and more members of Congress are focusing on this issue and asking for solutions and to the extent we can point to things that impede affordability and solve that problem that would be a very good thing," she said. The insurance fee adds 2.3 percent to premium changes in 2014, said Ignagni, or $300 per family. Over time the fees increase so they will add 5 percent to premium charges, she said.

[Jeanne's End Note: These fees were always considered just that a "fee" paid by the impacted industry (be that the for-profit insurers reaping profits from 25-40 million newly insured under the law; the medical device industry, again from the same new markets, or the pharmaceutical industry who had already been reaping enormous profits from the unfunded Medicare Part D passed by Republicans in 2003, and who would be gaining even more under Obamacare) ... it was not understood that these fees would be passed along as higher premiums. But then the "free" market is never all that free.]


October 15, 2013: Fixing Obamacare ... A Better Solution

Obamacare has gotten off to a ocky start. Federal and state online health insurance exchanges, which opened for business at the beginning of the month, have been bedeviled by technical snags. And opposition to the law from some House Republicans blocked funding for the entire federal government, leading to its partial shutdown.

In fact, with all the conflict and vituperation over Obamacare, it sometimes seems that one of the few things Democrats and Republicans agree on is that the law is imperfect at best. And they also agree that it could be improved. Even if a bipartisan deal to create a better health care system seems far off today, it's not too soon to start imagining what a future bargain might look like.

Just to get started, ... and because I am an incorrigible optimist ....let's assume that, at some point, Democrats will be willing to acknowledge that not everything has worked out as planned with the legislation, and that they would consider a rewrite that would expand coverage. We might also assume, hope against hope, that Republicans will acknowledge that a feasible rewrite of the bill cannot give the Democrats nothing. And Republicans will need to recognize that repeal of Obamacare should not be their obsession, because they would then be leaving the nation with a dysfunctional yet still highly government-oriented health care system, not some lost conservative paradise. Both sides have a lot to gain, and, at some point, they should realize it.

Let's look at some of the current problems in the health care system and see whether they might be patched up.

Even under Obamacare, many people will not have health insurance coverage, including two-thirds of poor blacks and single mothers and more than half the low-wage workers who lacked coverage before the law was enacted. That is largely because of the unwillingness of 26 governors to expand Medicaid coverage as the original bill had intended. The Supreme Court struck down that portion of the Patient Protection and  Affordable Care Act, however, giving states a choice.

Will many red-state governors eventually accept the act's Medicaid extension, which is sometimes portrayed as a financial free lunch, since federal aid covers most of the coverage expansion? It's not clear that they will. If the Republicans win the White House in 2016 and perhaps the House and Senate as well, they may cut off federal funds for that Medicaid expansion. In the meantime, many states don't want to extend their Medicaid rolls, because such benefits are hard to withdraw once granted.

There is a deeper problem with relying heavily on Medicaid as the backbone of health care for the poor. The fact that so many governors have found political gain in opposing a nearly fully-funded Medicaid expansion suggests that long-term support for Medicaid is weaker than it appeared just a few years ago. Furthermore, in cyclical downturns, the increase in Medicaid coverage after a climb in unemployment puts much strain on state budgets. Finally, both sides need to recognize in the war over he use of the word "entitlement" ... that Medicaid is NOT an entitlement! Medicaid is a welfare program, pure and simple. No one is entitled to welfare ... but Americans are a kind and generous people and we have long opened our public hearts (as distinguished from our private ethical hearts) to address poverty, disease and need. In "fatter" times, when sense that our purses are full, our largesse toward those in need is unequaled anywhere in human history, But when things are tighter, our purses slam closed and welfare programs are quickly curtailed, see: current history.

A separate issue concerns employers who are shedding insurance coverage, whether by dropping retirees, moving more workers to part-time status, withholding coverage and paying fines mandated by law, or simply not hiring more workers in the first place. The magnitude of these effects is not yet clear, but over time we can expect that new businesses and new hiring will be structured to minimize costly insurance obligations. It's no accident that the Obama administration handed out more than 1,000 exemptions from the employer coverage mandate, and postponed the employer mandate until 2015: both actions reflected underlying problems in the legislation. Ideally, the health care law should minimize what is essentially an implicit tax on hiring.

One way forward would look like this: Federalize acute care Medicaid, remove its obligations from state budgets altogether and gradually shift people from Medicaid into the health care exchanges and the network of federal insurance subsidies. The Obama administration has already done at least part of this for the expanded Medicaid program in Arkansas.  One benefit would be that private insurance coverage brings better care access than Medicaid, which many doctors are reluctant to accept.

To help pay for such a major shift, the federal government would cut back on revenue sharing with the states. The states should be able to afford these changes because a big financial obligation would be removed from their budgets... and besides, why should the federal government be "subsidizing" states for services they were no longer resposnible for?

By moving people from Medicaid to Obamacare, the Democrats could claim a major coverage expansion, an improvement in the quality of care and access for the poor, and a stabilization of President Obama's legacy -- even if the result isn't exactly the Affordable Care Act as it was enacted. The Republicans could claim that they did away with Medicaid and expanded the private insurance market.

At the same time, I'd recommend narrowing the scope of required insurance to focus on catastrophic expenses. If insurance picks up too many small expenses, it encourages abuse and overuse of scarce resources.

In sum, poorer Americans would get a guarantee of coverage and, with private but federally subsidized insurance, gain better access to quality care for significant expenses than they have now with Medicaid. Private insurance pays more and is accepted by many more doctors. But on the downside, the insured care would be less comprehensive than under current definitions of Obamacare's mandate.

With a cheaper and more modest insurance package mandated under a retooled law, employers would be less intent on dropping coverage. That would help in job creation. It also would lower the federal cost of the subsidies through the exchanges, both because employers would cover more workers and because the insurance policies would be cheaper.

This wouldn't be an ideal health care system, but it may be the best we can do, considering where we stand today


October 11, 2013: Red State or Blue, Obamacare Pricing Seems Apolitical

For Americans who are able to check out new insurance plans launched under President Barack Obama's healthcare reform, the price differences from state to state may be surprising.

Residents of Minnesota, a Democratic-led state, are likely to pay the lowest monthly premiums in the country. Just two states away, some residents of Republican-dominated Wyoming might be surprised to find they will pay among the highest.

But the ideological debate between Obamacare's supporters and opponents seems to have had little relevance when it comes to the affordability of care, the main goal of the Democratic president's signature program, health economists and actuaries say.

Instead, they point to regional differences in medical costs, the relative health and age of local populations and competition among insurers as having greater influence over the monthly premiums. Those differences lead to a wide variance in prices between states, and even within states.

Of the 24 states that fall below a national average of $328 in monthly premiums, laid out in a U.S. Department of Health and Human Services analysis last month, at least half are dominated by Republican state governments.

The affordability of the plans will likely determine whether enough uninsured Americans, particularly young and healthy ones, sign up to make the program successful.

The new insurance plans became available for enrollment nationwide on Oct. 1. But technical problems with the federal government's Healthcare.gov website serving 36 states have blocked millions of people from accessing the information.

In Wyoming, the cheapest mid-tier plan, or "silver" plan, costs $307 for a 27-year old in Laramie County, one of the state's only two counties considered "urban" and where the state capital Cheyenne is located. It has 60,000 residents with an average age of 37 years old. Venture outside those two counties and prices rise by $25. Change to the one other insurer offering a plan, and prices climb $100.

In Minnesota, a 27-year old in Minneapolis could pay $126 for a silver plan. Its population is 393,000, and the median age is 34. Go out to Traverse County, with the oldest population in the state, and that starting price rises to $153. In Minnesota, residents can choose from four insurers.

"It seems that basically the eligible populations in those areas, and the relative negotiating power of providers and insurance plans seem to really be the driver" of prices, said Matthew Buettgens, a mathematician at the Urban Institute, a social and economic research, "not necessarily politics."

Maryland, a staunchly Democratic state with an active insurance department, emphasized its ability to reduce premium rates by about 30 percent overall on the new products. But the average price on its mid-tier "silver" insurance plan is $299, only $6 less than in Republican-led Texas, whose leaders have been at the forefront of an effort to kill the healthcare law, culminating in a federal government shutdown.

Even within a state, there are variations. In Georgia, a 100-mile difference can mean hundreds of dollars in the monthly cost. Monthly premiums in rural regions cost much more than in more populated areas.

According to the data on the federal Healthcare.gov website, the cheapest "silver" plans in the state are in the counties surrounding Atlanta - about $185 a month - where five insurers sell plans. The most expensive are in Georgia's southwest corner, where only Anthem Blue Cross Blue Shield (part of WellPoint Inc ) sells Obamacare plans at a minimum of $200 a month higher for a comparable plan.


To be sure, politics historically has played a role in how states regulate insurance. Many of the Republican "red" states have had a laissez-faire attitude towards regulation compared with activist Democratic, or "blue," states.

And to a lesser degree, that regulation did affect Obamacare prices. Many Republican states have deferred to the federal government to run their exchanges, while Democratic states that support Obamacare have taken an active role in running their own exchanges. For a graphic, see: http://link.reuters.com/gug63v

Leaders in Texas and Florida also blamed Obamacare for skyrocketing health insurance costs, arguing that the new plans will take a toll on individuals and businesses.

In Florida, the Republican-led legislature and governor suspended the state insurance department's rate review authority for 2014 and 2015, saying they didn't want the state to participate in the overhaul.

But even without official authority, Florida still conducted "informational" reviews of rates for 2014 insurance products, and the federal government examined premiums there.

A Reuters review of insurance filings in both states showed their insurance departments played an active role in examining the plans proposed by insurance companies before they were submitted to the federal government. In at least one instance in Texas, the review led an insurer to lower prices for their plan, the insurer said.

In Florida, the average monthly premium matches the national average at $328. In Texas, it is lower at $305. A check of the benchmark mid-tier, or "silver," plans shows Texas is among the least expensive, costing $108 to insure a 27-year-old.

Florida's silver plans start more than $100 below the national average price, with prices at around $200 for a 27-year-old available in much of the state. The figures are before government subsidies for people earning less than 400 percent of the federal poverty level, or $94,200 for a family of four.


Obamacare requires all insurance policies for individuals to cover 10 standard health benefits, including maternity and emergency services, making the estimated cost of covering an individual the single biggest factor in premium rate. Regional differences play a role in making those estimates, experts explain.

"Colorado is purportedly a very healthy state and knowing people who live there, I understand why. They are always out there climbing mountains," said Jim O'Connor, a principal at actuary firm Milliman in Chicago.

Spending also varies by the price of medical services rendered in each region - the cost of an X-ray in Topeka versus Miami, for example. A third factor is how often someone living in the region typically goes to the doctor when they are sick, which can be heavily influenced by social norms.

Other wild cards involved in setting premiums include how many of the very sick people in their state will buy a particular insurer's plan, and how many of the previously uninsured population will come in with pent-up demand for doctor visits and new treatments - one of the true tests of Obamacare.

"That is one of the big unknowns," O'Connor said.





October 7, 2013: Malpractice Insurance Premiums Fall Again in 2013: Are Medical Malpractice Costs Really a Problem?

Judging by 3 representative specialties, physicians in 2013 are once again experiencing relief on malpractice insurance premiums.

Collective rates for obstetrician-gynecologists, internists, and general surgeons fell on average for the sixth straight year in 2013, according to an annual premium survey released this week by Medical Liability Monitor (MLM).

The decrease is only 1.9%, a tad more than the 1.7% decline in 2012. However, one group views the ongoing premium shrinkage as more evidence that organized medicine's push for tough medical-liability tort reform, such as limits to noneconomic damages, is much ado about very little.

"It makes sense that premiums are going down because malpractice litigation is going down," said Taylor Lincoln, a research director for the consumer watchdog Public Citizen. Lincoln's organization announced in August that the number of malpractice payments on behalf of physicians as reported to the National Practitioner Data Bank fell for the ninth consecutive year in 2012. Public Citizen maintains that malpractice litigation cannot be blamed for runaway health care costs.

Asked to comment on the numbers from MLM, the American Medical Association (AMA) issued a statement from its president, Ardis Dee Hoven, MD.

"Although the 2013 Medical Liability Monitor [survey] suggests decreases in premiums have become more common than premium increases, they pale in comparison to the magnitude of the increases experienced during the most recent liability crisis," said Dr. Hoven. "We are committed to testing alternative reforms, such as safe harbors for the practice of evidence-based medicine, to determine if these innovations can improve patient care and reduce costs."

The AMA, she said, "continues to work for proven reforms to rein in the broken medical liability system, reduce the growth of healthcare costs, and preserve patients' access to medical care."

Chad Karls, an actuary who summarized premium trends in an article for MLM, sees both sides of the argument.

For proponents of tort reform, "the wind has been taken out of their sails a little bit," said Karls, a principal and consulting actuary for Milliman. "Premium costs are lower than what they were a decade ago. However, it doesn't necessarily mean that they shouldn't be lower."

Falling premiums, Karls , reflect a roughly 50% drop in malpractice claims per physician since the liability crisis in the early 2000s that the AMA references. In both 2003 and 2004, premiums shot up roughly 20%, according to MLM. State-level tort reform accounts for some of the decrease in malpractice claims, Karls said. However, claims frequency also has declined in states that lack such laws.

The 1.7% drop in premium rates this year for the combined specialties of obstetrics-gynecology, general surgery, and internal medicine, Karls noted, applies more or less to each individual specialty as well. In other words, it isn't as if decreases for 2 specialties erased an increase for the third.

86% of Rates Decreased or Did Not Change

The MLM survey analyzes malpractice insurance rates charged by carriers in markets that range from entire states to single counties. The publication asks insurers to quote their standard rates for policies with limits of $1 million for an individual claim and $3 million in any given year for all claims. Rates published by MLM, effective as of July 1, are not necessarily what physicians pay, because insurers apply a variety of credits, debits, and other factors that raise or lower the dollar amount.

Insurers lately have been liberal with credits, reducing rates for physicians who take a risk-management seminar or use an electronic health record system, said Karls. Such credits probably have lowered rates by an additional 2 or 3 percentage points in 2013.

MLM collected hundreds of premium quotes that represent 65% to 75% of the medical liability insurance market. In a virtual replay of 2012, 57.6% of the 2013 quotes remained the same from the year before, 28.8% decreased, and 13.7% increased, usually by less than 10%.

The survey includes rate information for 7 states with patient compensation funds designed to lower the cost of malpractice coverage. Every physician in the state pays a surcharge into the fund in addition to buying minimal coverage from a private insurer, said MLM editor Michael Matray. Acting essentially as a reinsurer, the compensation fund boosts the coverage -- in some states to the $1 million/$3 million level. The rates that MLM reports for these states are the sum of physician surcharges and premiums.

"Hot and Cold" -- Rates for Internists Range From $3375 to $47,707

As in previous years, the MLM report reveals where malpractice litigation is red hot and where it is blue-green cool. Premium rates, after all, are based on an insurer's claims experience in a given locale.

The most expensive premiums for a $1 million/$3 million policy for internists once again turned up in Miami-Dade County, Florida. There, the Doctors' Company quoted a rate of $47,707. The nation's lowest rate for internists was $3375, quoted by ProAssurance Wisconsin Insurance for the entire state of Minnesota.

The New York counties of Nassau and Suffolk on Long Island are home to the highest rates for obstetrician-gynecologists -- $227,899 from Physicians' Reciprocal Insurers. On the low end is a quote of $16,240 from Cooperative of American Physicians (CAP) for ob/gyns in mid-California. The quote is on top of CAP membership dues of $440 each year.

For general surgeons, quoted rates range from $190,829 from the Doctors' Company for Miami-Dade County to $10,868 from MMIC Group for Wisconsin.



October 4, 2013: Physician Quality Reporting (With a 1.5% Penalty vs a .5% Bonus) Deadline Looms ... October 15

Physicians have until October 15 to take advantage of the easiest way to avoid a 1.5% Medicare penalty in 2015 for not participating in the Physician Quality Reporting System (PQRS) this year.

PQRS, formerly known as the Physicians Quality Reporting Initiative, calls on individual physicians and group practices to tell Medicare how they are performing on measures of clinical quality. They can pick from a long list of yardsticks that include everything from the percentage of adult patients with diabetes whose most recent hemoglobin A1c reading exceeds 9% to the percentage of patients aged 50 through 75 years who received the appropriate colorectal cancer screening.  The program used to be voluntary, and physicians and group practices that successfully reported their quality scores -- as opposed to meeting a certain threshold -- received a small bonus. However, participating in PQRS became mandatory in 2013 on pains of a 1.5% reduction in Medicare reimbursement in 2015. The penalty -- labeled a "payment adjustment" by the government -- increases to 2% in 2016 and beyond.

Physicians can dodge the penalty in 2015 by qualifying in 2013 for a PQRS bonus of 0.5%. Individual physicians can do this by reporting performance data on several quality measures either through Medicare claims, their electronic health record (EHR) system, or a patient registry, an outside system for capturing and storing patient information. The deadline for submitting performance data is February 28, 2014, via claims and EHR, and "in the first quarter of 2014" via registry, according to the Centers for Medicare & Medicaid Services (CM2) Web site.

CM2 created 2 other escape routes from the penalty that require less work. One way is to submit 2013 performance data early next year for at least 1 quality measure or group of measures through the various reporting channels. This option will not earn anyone a bonus, however.

The easiest way for physicians to avoid a PQRS pay cut in 2015, however, is to ask CM2 to calculate their quality grade based on the claims they submitted in 2013. Again, there's no bonus upside. The deadline for requesting this option is October 15. Information on how to request it is available on the CM2 Web site.

Group practices have the same deadlines and roughly the same choices for earning a collective bonus based on their 2013 performance and avoiding a penalty in 2015. Groups that want CM2 to calculate their quality score based on Medicare claims to avoid the 1.5% pay cut can visit another page on the CM2 Web site to find how to select this option.

Taking this step is especially important for groups with 100 or more physicians and other eligible clinicians. Groups this big face an additional 1% reduction in their Medicare pay in 2015 under the Value-Based Payment Modifier (VBPM) program if they fail to participate in PQRS at some level this year. Requesting the CM2 quality calculation gets them off the hook.


October 3, 2013: Government Shutdown Impacts Public Health ... And "Fixing the SGR"

The partial government shutdown of 2013, now in its third day, has not yet affected the everyday practice of medicine, but it has begun to gnaw away at the nation's public health infrastructure, and that's worrisome, say leaders of organized medicine.

Case in point: Right at the onset of the 2013-2014 influenza season, the shutdown caused the Centers for Disease Control and Prevention (CDC) to furlough employees who run its seasonal flu program, which detects outbreaks, identifies virus strains, and tracks flu-related illness and mortality. As a result, physicians will battle influenza without the program's intelligence, at least for now.

"It's a shame," said Charles Cutler, MD, who chairs the Board of Regents of the American College of Physicians (ACP). "It's worse than a shame. It's a disgrace.  This is the public health of the country. We need to know where the outbreaks are, what it's doing in our community."

These concerns appear to be lost in the din of political acrimony as a new fiscal year for the federal government arrived on October 1 without any cash. The Republican-controlled House has repeatedly passed appropriation bills with crippling provisions for the Patient Protection and Affordable Care Act (ACA) only to meet granite resistance from the Democrat-controlled Senate and President Barack Obama, who say government funding should not be held hostage to ACA animus. Congressional leaders met with Obama last night to discuss how to break the stalemate, but nobody budged.

"There's such partisanship," said a frustrated Reid Blackwelder, MD, president of the American Academy of Family Physicians (AAFP) in an interview with Medscape Medical News. "I don't know what happens to the art of compromise."

Skeleton Crews Protecting the Nation's Health

In the meantime, the federal government is executing its playbook for a partial shutdown. It has spared what are deemed essential services, such as mail delivery and Social Security and Medicare benefits -- Medicare reimbursement for physicians, too -- while closing national parks, halting routine Environmental Protection Agency inspections of drinking water systems, and holding up permits for transportation projects.

Ironically, one part of the federal government that continues to operate unscathed is the collection of state-by-state online marketplaces, or exchanges, where Americans can buy subsidized health insurance under Obamacare. Those exchanges debuted October 1 only to malfunction frequently owing to high traffic and software glitches. Obama promises that with some fine-tuning, the exchanges will work better in the future.

Obamacare, the government's healthcare operations took a big hit on Tuesday. The Department of Health and Human Services (HHS) furloughed almost 41,000 employees -- 52% of its workforce -- with far-reaching consequences for a panoply of agencies, as explained in the department's shutdown plan:

National Institutes of Health (NIH): Patients enrolled in existing NIH clinical trials will continue to receive care, but NIH will not admit new patients, initiate new trials, or act on grant applications or awards. The American Society of Clinical Oncology (ASCO) is alarmed about what this means to patients with cancer looking for a cure. "We are deeply concerned that as a result of the government shutdown, roughly 200 patients with cancer per week, including children, will not be able to participate in clinical trials at the National Institutes of Health Clinical Center in Bethesda, MD," said ASCO president Clifford Hudis, MD, in a news release.

House Republicans passed a measure yesterday that would restore NIH funding, but Senate Democrats today blocked it, objecting to what they call a piecemeal approach to funding the government. The White House took the same position.

Food and Drug Administration (FDA): The agency is staffed for emergencies and "high-risk recalls," but not for most of its food safety, nutrition, and cosmetics activities, or the majority of its laboratory research. The AAFP's Dr. Blackwelder wonders whether a skeleton-crew FDA can adequately respond to a crisis, such as last year's outbreak of fungal meningitis that was traced back to contaminated steroid injections from a Massachusetts compounding pharmacy.

"Who's to say something like this won't happen during the shutdown?" Dr. Blackwelder told Medscape Medical News.

Children's Hospitals Threatened: Health Resources and Services Administration (HRSA): The sprawling agency has halted payments to residency programs at children's hospitals. Thomas McInerney, MD, president of the American Academy of Pediatrics, said in a news release that this and other healthcare cutbacks put kids and families at risk. "Our children deserve better than this," Dr. McInerney said.

HRSA will continue to operate the National Practitioner Data Bank, which collects information on jury awards and settlements in malpractice cases.

Physician EHR "Bonuses" Jeopardized:  The Office of the National Coordinator for Health Information Technology (ONC): Furloughs here could jeopardize physicians qualifying for bonuses or avoiding penalties in an HHS program that promotes "meaningful use" of electronic health record (EHR) systems. To satisfying meaningful-use requirements, physicians must deploy an EHR system certified by ONC. That vetting has been suspended at a time when vendors are trying to get their products approved for a second stage of meaningful-use requirements that takes effect next year.

CDC: The effects of the shutdown on this healthcare watchdog perhaps are the most unsettling to clinicians -- after all, viruses and bacteria do not belong to political parties. According to the HHS shutdown plan, the CDC will have "significantly reduced capacity to respond to outbreak investigations, processing of lab samples, and maintaining the agency's 24/7 operations center."

The suspension of the seasonal influenza program exemplifies this retrenchment. The CDC was scheduled to post its first weekly "FluView" report about the 2013-2014 influenza season on its Web site on October 11. However, agency spokesperson Barbara Reynolds, PhD, says that FluView data aren't being compiled as a result of furloughs.

"Expect delays," said Dr. Reynolds. "So sorry to have to tell you that."

Dr. Blackwelder said that physicians depend on FluView reports to guide patient care and make a more compelling case to get vaccinated. He pointed to his own practice in Kingsport, Tennessee, in the eastern part of the state.

"It's one thing to say, 'Did you get your flu shot?' It's another to say, 'We're noticing that in Tennessee, the western part of the state has already started seeing a dramatic increase [in flu-related illness]. It means we're likely to see it soon. Now is the time to get your flu shot.' "

Will the Doc Fix Go Off the Radar of Congress?

While the behind-the-scenes work of the CDC and other agencies suffers, the shutdown has caused nary a ripple so far for the average physician, by all accounts.

"I'm unaware of any problems," said Dr. Cutler. "Doctors are seeing their patients."

Practice management consultant Judy Capko in San Francisco, California, told Medscape Medical News that she was at an orthopedic practice yesterday, and "they were totally unfazed."

"We're not hearing anything from our members except anxiety," said Dr. Blackwelder at the AAFP.

The anxiety, he said, has been first and foremost about getting paid by Medicare and Medicaid. His medical association has attempted to reassure members with the facts.

Medicaid is safe. Jointly funded by the federal government and states and administered on the state level, it will keep chugging along during the shutdown. State Medicaid programs received their federal payments for the new fiscal year before October 1, according to HHS.

And Medicare continues to cut checks to physicians, just as it did during the last government shutdown in December 1995 and January 1996. The Centers for Medicare & Medicaid Services (CM2) doesn't depend on Congress to appropriate money to reimburse providers because those funds come from Medicare trust funds.

In contrast, the private companies called Medicare administrative contractors (MACs) that process and pay claims on behalf of CM2 are paid from the agency's operational budget, which Congress controls. Interrupted cash flow for MACs in the last shutdown did not keep physicians from getting paid, however, because the companies did their work on a credit basis for CM2, expecting the agency to catch up later.

Perhaps not surprisingly, CM2 announced on Tuesday that the MACs would continue processing and paying claims during the duration of the current shutdown.

That announcement provided short-term comfort, but organized medicine is worried about the shutdown's long-term impact on Medicare reimbursement. After all, physicians face a 24.7% pay cut on January 1 dictated by the program's sustainable growth rate (SGR) formula unless Congress acts to avert it. Similar cuts in the past have been merely postponed. A bill with rare bipartisan support in the House would repeal the 16-year-old SGR formula, provide 0.5% annual raises from 2014 to 2018, and then introduce pay-for-performance requirements.

Physicians have high hopes for Congress to enact this "doc fix," but Dr. Cutler and Dr. Blackwelder both warn that the legislation could languish from inattention, not only during the shutdown crisis but also because of the expected battle over raising the federal debt ceiling later this month. The result could be just another 1-year delay of a massive Medicare rate reduction, and more angst for physicians.

"We're now extremely concerned," said Dr. Blackwelder. "Discussions have been diverted from that critical issue. All of a sudden, the SGR fix as a repeal-and-replace option is much less likely." The odds decrease, he said, as the congressional civil war continues.

Dr. Cutler agrees. "The last few days have jeopardized a solution to the SGR impasse," he said. "The longer the shutdown goes on, the less focused Congress is in solving the problem."


September 27, 2013: Digging Through the Obamacare Data Dump

Until now we've seen information on subsidized policies to be sold through online marketplaces released in trickles by states that are creating their own online portals, mostly Blue states with progressive-thinking giovernors and state legislatures.  The new federal data covers states that dumped all or part of the work of building the marketplaces on the feds, mostly Red states with reactionary governors and Tea Party-controlled legislatures.  It's the biggest chunk of information so far available, even though many critical pieces -- the identity of the insurers, the structure of the benefits, the networks of the hospitals and doctors -- won't be known until next week. That's when the online portals in every state are scheduled to start selling subsidized insurance made availableunder Obamacare to those who aren't otherwise covered.

The Obama administration boasted that the average premiums came out lower than projected by the Congressional Budget Office. Opponents of the PPACA countered that many people buying through the exchanges, especially younger, healthier consumers, may pay substantially more than what they pay now.

But those were only the headlines. Here's what else the data show:

-- Competition equals lower prices. In regions with only one insurance company selling through the subsidized exchange, the average monthly premium for a 21-year-old buying the lowest cost bronze policy is $186, before any subsidies are applied. In regions with 10 or more rival carriers, the average cost is $132 or less.  In the exchanges' metal rating system, bronze plans are the least expensive category, covering 60 percent of medical costs on average after you pay the premium.

-- The number of insurance companies selling through the subsidized marketplace varies hugely from one area to another. In many parts of West Virginia, Arkansas and Alabama, only one company is selling policies to individuals and families through the subsidized exchange. (Insurers may also offer policies outside the exchange.) In New Hampshire only one insurer will sell through the exchange in the entire state. In the Detroit region, on the other hand, 11 carriers will sell subsidized policies. In Phoenix, 10 will.

-- The number of available plans, another indicator of choice, also varies. Residents of Oviedo, in eastern Florida, will have 181 polices offered by six insurers to pick from. In Oshkosh, Wis., consumers can choose from 181 plans sold by eight companies. But only seven policies from one insurer will be available in most parts of Alabama. St. Louis residents can pick from 23 policies offered by two insurers.

-- There is a paucity of platinum plans. Under the metal ratings, platinum policies are the most expensive. They cover 90 percent of average medical expenses after you pay the premium. Policymakers predicted lower-level bronze and silver plans would prove more popular than gold and platinum, and it looks like insurance companies think so, too. While in parts of Florida and Wisconsin you can choose from more than a dozen platinum plans, in 40 percent the regions included in the federal database there are no platinum policies. Insurers are putting their energy into plans with lower premiums and higher deductibles and other out-of-pocket costs.

-- There are wide variations in prices, even for similar policies sold in the same state. In Tucson, Arizona, the lowest-cost bronze plan for a 21-year-old is $114 a month. But in several rural Arizona counties a bronze plan costs $164. In Missouri bronze plans for a 21-year-old range from $140 a month to $219.

-- Other things being equal, you'd rather be an uninsured oil hand in Oklahoma than an uninsured cheese maker in Wisconsin. In western Wisconsin areas bordering St. Paul, Minn., the cheapest bronze policy for a 21-year-old is $301 a month. That's the highest in the federal database. In Comanche County, Oklahoma, (Fort Sill), a similar plan costs $96. That's the lowest.



September 26, 2013: Exchange Plans are Costing Far Less (on Average) Then Predicted

Just days before new online health insurance markets are set to open, the Obama administration Wednesday released a look at average premiums, saying rates in most states are lower than earlier projected -- and that 95 percent of consumers will have at least two insurers to choose from. The report -- released the same day that President Barack Obama and former President Bill Clinton touted the law's benefits -- comes as part of a stepped-up administration effort to explain and defend the health law as congressional Republicans target it for defunding.

Until this week's report, little information was available about insurance rates in most of the 36 states whose online marketplaces will be overseen entirely or partially by the federal government because state leaders opted out of running their own.

The analysis showed huge variations among states: A family of four making $50,000 in Wyoming, for instance, would pay $1,237 a month on average for a mid-level plan before subsidies, compared to $584 a month on average in Tennessee. After subsidies are added in, however, the cost to both families would be $282 because the amount they pay is linked to their income, not to the cost of coverage.

While experts say premiums vary across the states and even within states, the analysis pegged the national average for an individual at $328 a month for a midlevel policy called a silver plan, before subsidies are factored in. Thats less than the average $392 projection drawn from earlier data released by the nonpartisan Congressional Budget Office, which will mean savings to families as well as to the federal government for tax credits.

"For millions, these new options will make health insurance work in their budgets," said Health and Human Services Secretary Kathleen Sebelius.

No Clear Political Pattern

One of the report's most striking findings is that states like Texas and Florida, where the law has faced fierce opposition despite high rates of uninsured residents, will see rates at or below the national average.  "sThere is no clear political pattern to these premiums," said Larry Levitt, a senior vice president at the Kaiser Family Foundation, a nonpartisan research organization. "Some conservative, anti-Obamacare states have lower-than-average premiums, and some pro-Obamacare states have higher-than-average premiums."

Premium prices are influenced by many factors, including what insurers guess their costs will be, a region's labor costs and how much hospitals and other facilities charge. Competition between insurers is also a significant factor, and in several states the decision by large for-profit insurers NOT to enter the market has reduced competition and skewed prices. ... Not that anyone might want to accuse them of "playing politics" in undermining that state's Exchange, whether operated by the Feds or not.

Some rural states, such as Wyoming or Alaska, have fewer insurers and therefore, less competition, which could partially account for the higher prices there. Other states with high rates include Mississippi, Indiana, Vermont and Connecticut.

Under the law, insurers can vary rates based on age and are allowed to charge older people up to three times more than younger ones, starting January 1. But insurers cannot charge the sick more than the healthy or reject applicants for coverage if they have a medical condition.

While the administration said the rates show that the new plans will offer consumers affordable coverage, there are caveats. The study used weighted averages, for example, which do not reflect what any one consumer might pay. In addition, many of the highlighted rates in the report are for 27-year-olds, who are on the lower end of the premium cost scale.


7 Million Expected To Enroll

The insurance marketplaces, which can be used by individuals and small businesses, are expected to enroll 7 million people next year, according to the CBO. Of those, 6 million are expected to qualify for subsidies because they do not have affordable job-based coverage and their incomes are between 100 percent and 400 percent of the federal poverty level. That's between $11,500 to $46,000 a year for an individual, or up to $94,000 for a family of four. Those who get subsidies must pay between 2 percent and 9.5 percent of their income -- on a sliding scale -- toward the premium.

While the administration said consumers will have "significant choice" in the subsidized exchanges, data show that in some places only a few insurers are offering plans. In Alabama, for example, only one carrier is selling through the exchange in most parts of the state. In Missouri only two insurers are offering plans. North Carolina has only two and in some sections, one. In some rural sections of Florida as well as Panama City and the capital of Tallahassee only one insurer is selling exchange policies.

On the other hand, in New Mexico five companies will sell plans throughout the state. In some parts of Ohio as many as seven insurers will compete for exchange customers. In parts of central Pennsylvania as many as 10 will offer plans.

Texas Rates 'A Surprise'

The rates in Texas have "surprised" analysts ... especially since noting that state( which has the highest rate of uninsured residents) has put up roadblock after roadblock to implementation, the premiums are coming in below average.

For instance, a 27-year-old in Dallas, who makes $25,000 a year and thus qualifies for subsidies, could pay $74 a month for the lowest-cost bronze plan, the least expensive type of plan, or $139 for the lowest-cost silver plan, after taking into account the subsidies.   In Dallas, a family of four with a household income of $50,000 could get the lowest cost bronze plan for as low as $26 a month after subsidies. ... an absolutely amazing price which may still end up being missed by many because of the state's roadblocks to understanding the Exchanges and enrolling in them.

The premiums in Florida, meanwhile, were in the middle of the pack. While the prices are comparable, the provider networks will be much smaller than on today's market which could deter enrollment.  Some young people, especially those who qualify for less of a subsidy, may choose the penalty rather than buying coverage.

Premiums Not The Only Consideration

While some of the lowest cost plans are in the "bronze" tier of coverage, such plans generally have higher annual deductibles and co-payments than a silver plan. Also, the silver plans reduce some costs for subsidy-eligible consumers, which could reduce their exposure to big bills if they fell seriously ill.

"The most important point for consumers is that report does not account for cost sharing," said one analyst. Greg Mellowe of the consumer advocacy group, Florida CHAIN, offered similar advice. "Although premiums are generally the first and last thing discussed when comparing plans, out-of-pocket costs may be an equally or even more important consideration, particularly for those with significant health care needs."



September 25, 2013: OBAMACARE FAQS: Some Employers Using Obamacare as an Excuse to Change Employee Health Plans

United Parcel Service got attention by dropping some working spouses from its health plan and partly blaming Obamacare. But UPS's move is only one among many changes in employer health insurance, most of them having little to do with the health law.

Employers are raising deductibles, giving workers health savings accounts that look like 401(k) plans, mimicking the health law's online insurance marketplaces and nudging patients to compare prices and shop around for treatments. Together the moves could eventually affect far more consumers than the law's Medicaid expansion or health exchanges aimed at the uninsured and scheduled to open October 1. Here's a rundown.

Q. The Patient Protection and Affordable Care Act required fewer changes in employer coverage than in plans sold directly to consumers. Why are employers overhauling their benefits?

A. They cite rising costs. Although overall medical expenses are rising at the slowest pace in decades, they're still going up at twice the rate of inflation. The important point is that since Obamacare was enacted, the rate of increase has actually been declining. During the late 1980's and until 2008, they were going up at an average of 8%-12% a year. The only time they went down was the period 1994-96, when for profit health insurers launched an all-out offensive against "Hillarycare" (the Clinton health care reform proposal ... remember "Harry and Louise") and saw some rates actually decline. As soon as Hillarycare was killed and the GOP took over control of Congress, the rates skyrocketed back up again.  The Power Point slide below is the one I used in the early 2000's (long before Obamacare) to illustrate this trend of rising premiums and the "Hillarycare dive."

Currently, some employers argue that Obamacare's requirements such as covering dependents to age 26 and banning annual and lifetime limits on benefit payouts also increase their costs. However, most health care underwriters and actuaries portray what's going on as part a long-term trend of employer benefit redesign that has little to do with the health law.

Q. What are employers doing?

A. There are two themes. In trying to control their own spending, employers often are shifting health costs to employees. So the average annual deductible for an individual -- what consumers pay before insurance kicks in -- nearly doubled in the past seven years, from $584 in 2006 to $1,135 this year, according to the Kaiser Family Foundation. This is really just an extension of the same trend that has been taking place for almost 30 years,

But employers aren't just making workers pay more. They're trying to make them think more about health-related expenses and behavior.

Companies such as grocer Kroger Co. pay only a fixed amount for particular drugs or procedures, giving patients incentive to shop around for the best price. IBM started giving rebates to workers who adopt healthy lifestyles. Penalizing smokers with surcharges is one of the few discriminatory measures the health act allows.

Q. All that will save employers money. Will it keep workers healthy?

A. The law requires insurance to pay for recommended preventive services without cost sharing. Even so, some worry that the increasing number of plans with high deductibles will cause consumers to avoid seeking treatment when they might need it. Many patients don’t realize the deductible doesn't apply to preventive care.

At the same time, critics say the veil around the health industry's costs and prices makes smart shopping all but impossible. Companies such as Castlight are trying to change this by listing prices and information on quality in accessible ways, such as through smartphone apps and easily searchable web sites.

Q. How can workers afford the extra costs of higher deductibles?

A. Proponents of making patients share more costs and shopping -- it's been dubbed "consumer-directed insurance" -- say it's the best way to control the soaring medical spending that strains not just household budgets but corporate and government accounts, too. But many patients with high-deductible plans have trouble paying the bills when they seek care ... these plans look good on paper but many collapse when the actual need arises and the covered employee actually has to pony up the enormous deductibles and co-pays.

Q. If having employees shop for doctors and hospitals makes sense, why not give them more power to shop for health insurance, too?

A. That's the idea behind "private exchanges," so called to distinguish them from Obamacare's public exchanges that will sell subsidized coverage directly to individuals starting October 1.  In both cases the consumer gets what’s basically a voucher to buy coverage. With the public exchanges it's an instantly spendable tax credit. With private exchanges it's employer dollars.

Software guides the consumer through a menu of comparable plans and helps pick the best one for her. Companies steering workers to private exchanges include Darden Restaurants and Sears. IBM and other corporations are putting retirees into private exchanges. Private and public exchanges are likely to have something else in common: plans with closed, narrow networks of doctors and hospitals that promise lower costs through discounts and better control of care.

Some see private exchanges and HSAs nudging aside traditional health insurance much as 401(k) plans replaced traditional pensions. Whereas employers used to promise health care and retirement income no matter the cost, increasingly they cap contributions for both benefits and let workers bear the risk.

Q. I heard Washington delayed the requirement for large employers to offer health insurance. How is that affecting coverage?

A. The delay is for one year, and most employers already offer coverage. The requirement applies to employers with at least 50 workers. Stores and restaurants, less likely to offer health insurance in the past, may be most affected. The coverage mandate doesn't affect workers who put in less than 30 hours a week, and some employers have talked about cutting hours.

Q. Are other companies following UPS in how they handle spouses and dependents?

A. UPS decided to stop covering working spouses if they have access to coverage at their own jobs. The health law does not require employers to cover spouses, but surveys show that only a minority of companies have implemented a UPS-style "spousal exclusion."  However, employers increasingly offer incentives to get spouses off their plans. They may charge workers extra if a covered spouse has access to other insurance, or they may pay bonuses when spouses are not on the company policy.

The health law does require large employers to offer coverage to dependent children as well as employees or pay a penalty.

Q. What are small employers doing?

A. The Patient Protection and Affordable Care Act does not require companies with fewer than 50 workers to offer coverage. It does create online marketplaces, scheduled to open in October, for small employers to buy insurance similar to policies offered there for individuals. But the ability for small-business workers to choose from multiple plans will be delayed in most states until 2015.


September 24, 2013: OBAMACARE FAQs: Scaring the Young

A Koch-brothers funded conservative group, Generation Opportunity, is out with a wildly misleading, pernicious set of ads aimed at sabotaging the Patient Protection and Affordable Care Act by discouraging young people from signing up for health insurance exchanges.

One targets young men, the other young women. In the "for him" version, a young man tells his doctor that he saw an ad for Obamacare and "figured, why not?" The doctor tells him to take his pants off, "hop up here, lay down and bend your knees to your chest." He leaves the room. Then a man wearing an Uncle Sam mask snaps on a blue glove. As if the message weren't perfectly clear, the ad states: "Don't let government play doctor."

The "for her" version is much the same, except in that case Uncle Sam's performing a gynecological exam.

The ads are as offensive as they are derivative.

During the 2012 campaign, the reproductive rights site Lady Parts Justice released a web video attacking laws requiring women to undergo medically unnecessary ultrasounds before receiving abortions. In that spot, a woman with her feet in stirrups explains that she wants an abortion because she's "just not emotionally or financially ready to have kids right now." The doctor, sitting between her legs, responds, "OK, well, just so you know, the law says that before I can do that, I need to do some things to you that you need to pay extra for. You know, just some things that will help you better understand what it is you really want." These "things" include inserting a camera into her vagina and looking at pictures of what's inside her uterus.

But that video made sense -- states actually did pass laws interfering with the doctor-patient relationship -- whereas the Generation Opportunity ads perpetuate outright lies. Young people who sign up for exchanges won't be getting access to government-run healthcare (if only they were!), but to privately run insurance. Nor does the PPACA force doctors to ask patients about their sex lives or perform unwanted exams -- as Politifact explained recently. Under the PPACA., government doesn't "play doctor," it merely enables access to doctors who then decide, using their professional judgment, the best course of action.

Signing up for an exchange isn't an act of political (or sexual) submission. It's just a way to get insurance if you don't have a job or your employer doesn't provide it. The Generation Opportunity crowd surely knows that and obviously doesn't care because its priority now, as ever, is bringing down President Obama's signature domestic accomplishment. The group also doesn't care about the possibility that some number of young people, scared by its ads, will forgo access to affordable care, get sick, and go bankrupt paying their medical bills.

September 23, 2013: MORE OBAMACARE FAQs on Medicare

Nearly 50 million Americans are enrolled in Medicare, the federal health insurance program for the elderly and disabled. The 2010 health care law, known as the Patient Protection and Affordable Care Act, will make some changes to the program. Here are some answers to frequently asked questions about Medicare and the health law.

Q: The health law creates something called a health insurance marketplace. What is that and can I apply for coverage on an exchange?

A: There is no need for a Medicare beneficiary to enroll in the health law's exchanges. It's an online marketplace where individuals and small employers without group coverage will be able to shop for insurance coverage. Enrollment begins Oct. 1 for policies that will go into effect on January 1. Medicare is not part of the health insurance exchanges. Seniors will still get health coverage through Medicare's traditional fee-for-service program or Medicare Advantage plans, private health insurance plans that are approved by Medicare. Those who are enrolled in Medicare Part A, which covers hospital care, or the Advantage plans will meet the health law's mandate for individuals to have insurance.

Q: Does the health care law offer any new benefits for Medicare beneficiaries?

A: Beneficiaries receive more preventative care services -- including a yearly "wellness" visit, mammograms, colorectal screening, and more savings on prescription drug coverage. By 2020, the law will close the Medicare gap in prescription drug coverage, known as the "doughnut hole." Seniors will still be responsible for 25 percent of their prescription drug costs.

Q: Does the law cut spending on Medicare?

A: Medicare spending will continue to expand as increasing numbers of baby boomers reach 65. However, the law does cut the expected growth of Medicare spending by about $716 billion over the next decade.

Those cuts are made by lowering reimbursements to nursing homes, hospitals, home health agencies and other providers. It also cuts payments to Medicare Advantage plans (which currently are being paid as much as 15 MORE than traditional Medicare) to bring those payments closer to what Medicare pays for care for beneficiaries enrolled in the traditional fee-for-service plan. Medicare officials stress that the spending changes will not reduce Medicare benefits.

Q: Does the health law require higher-income Medicare beneficiaries to pay more for their Medicare prescription drug coverage?

A: It does. Currently, Medicare beneficiaries who earn more than $85,000 ($170,000 for a couple) pay more for their Medicare Part B premiums, which cover physician and outpatient services. The health law brought that same sliding-scale approach to beneficiaries' prescription drug coverage in Medicare Part D for those with incomes of more than $85,000 ($170,000 for a couple). Those income thresholds will be frozen through 2019. (As noted below, this "means test" for certain Medicare beneficiaries was first initiated by Republicans in 2003, with passage of the Medicare Modernization Act ... and has now been extended under the Patient Protection and Affordable Care Act.

Q: What is the Medicare "doc fix?"  What is that and does the health law fix it?

A: The "doc fix" refers to the sustainable growth rate, or SGR, which is the payment formula based on economic growth that Medicare has used to pay physicians since the passage by a Republican-controlled Congress in 1997 of the "Balanced Budget  Act. Over the past decade, the formula would have cut Medicare physician payments but Congress has stopped the cuts. For example, it calls for a 25 percent drop next January 1. Doctors warn that if the pay reductions were to take effect, fewer physicians will treat Medicare patients.

The health law does not change that formula, but there is bipartisan legislation pending on Capitol Hill that would. The House Energy and Commerce Committee passed a measure in July to repeal the SGR but the bill does not specify how to finance a fix. The House Ways and Means Committee and the Senate Finance Committee are working on legislation as well. ... But given the constant squabbling and insistence upon defunding Obamacare by Congressional Tea Party Republicans, we can expect them to attribute thr "blame" for this on Obamacare, despite the fact that the problem predates Obamacare by more than 12 years and was created by a poorly-drafted and thought out Republican-pushed law.



September 22, 2013: OBAMACARE FAQs: Will Obamacare Destroy Medicare? (And Other Distortions and Lies)

When pollsters ask Americans what they know about the Patient Protection and Affordable Care Act (PPACA), the typical response is a quizzical shrug. The PPACA, also known as Obamacare, remains a great mystery to many people, even though it was signed into law in 2010.

When AARP holds town hall meetings, officials have found that the public is equally unclear about Medicare, the government health insurance program for Americans with certain disabilities or who are more than 65 years old, and whether it will change under the PPACA.

Until now, the country's 49.5 million seniors on Medicare have mostly felt the impact of health care reform in their doctors' offices, where preventative services such as annual wellness checkups, immunizations and tests for cancer, cholesterol and diabetes are now covered without co-payments. But with full implementation of the law on the horizon, questions about how one will affect the other abound.

"There always has been confusion about Medicare," says Dr. Gail Wilensky, a policy analyst who directed Medicare and Medicaid from 1990 to 1992 and served as a senior health and welfare adviser to President George H.W. Bush. "Now there's more confusion than usual because of the focus on the [Patient Protection and] Affordable Care Act and how it does or does not relate."

Here are five myths and facts surrounding Medicare and the [PP]ACA.

Medicare is ending. False. Obamacare is not replacing Medicare. In fact, AARP representatives say that Medicare will become stronger once the [PP]ACA is fully in effect. "Medicare's guaranteed benefits are protected in ways they hadn't been protected in the past," says Nicole Duritz, AARP's vice president for Health Education and Outreach.

Seniors on Medicare must buy more health insurance to comply with Obamacare. False. This stems from misunderstandings about the individual mandate, a key [PP]ACA provision requiring people who are currently uninsured to buy coverage or pay a penalty. Medicare is health insurance, so beneficiaries do not need to buy anything during the Obamacare enrollment period that starts on October 1, when the state-run health insurance marketplaces open for business. Seniors on Medicare can change their plans and prescription drug coverage during the Medicare open enrollment period, which is October 15 through December 7. Medicare beneficiaries who are satisfied with their current plans don't have to do anything.

Medicare beneficiaries will pay more for their medications under Obamacare. Mostly False. Under the [PP]ACA, higher-income Medicare beneficiaries -- those who earn more than $85,000 per person or $170,000 per couple -- pay slightly more for their prescription drug coverage, or Medicare Part D. But this only affects about 5 percent of beneficiaries, AARP's Duritz points out. The vast majority of seniors on Medicare will see their drug costs go down as the ACA begins to close the "donut hole," a coverage gap that forces Medicare beneficiaries to pay 100 percent of their prescription drug costs up to a certain amount. This gap is expected to be fully closed by 2020, but those who fall into the gap this year will get a 47.5 percent discount on certain brand-name drugs and a 21 percent discount on generic drugs until they reach the out-of-pocket limit. In 2012, roughly 3.5 million Medicare beneficiaries saved an average of $706 each, the federal Department of Health and Human Services reported in March. As the donut hole closes, the savings will increase.

Medicare beneficiaries won't be able to see their current doctors. False.

Nothing in Obamacare expressly changes which doctors Medicare patients can see. Hospitals, physicians, pharmacies and other health care providers make routine business decisions and may choose to withdraw from the Medicare program, but no master switch is flipping on January 1 requiring seniors on Medicare to leave their current doctors and choose new providers.

Medicare premiums are rising. Misleadingly True.

Medicare premiums are calculated by a complicated formula established long before the [PP]ACA, dating in fact, all te way back to the initial passage of Medicare in 1965, and those premiums rise annually. "Medicare premiums are rising because health care costs rise each year, but less rapidly than premiums for private health insurance, and less rapidly than previously projected," explains Paul Van de Water, senior fellow at the Center on Budget and Policy Priorities. Those who earn more than $85,000 per person or $170,000 per couple will continue to pay more for their Medicare Part B coverage, as they have since 2004 -- that increased cost is not related to Obamacare, but was added as part of the Medicare Modernization Act of 2003, a law passed by a Republican-controlled Congress, without a single Democratic vote, and signed by George W. Bush.

Amid rhetoric of an impending Medicare train wreck caused by Obamacare, Van de Water emphasizes: "Medicare faces financial challenges, but it is not on the verge of 'bankruptcy' or ceasing to operate."

Dr. Mark Pauly, a professor of health care management at the University of Pennsylvania's Wharton School, affirms that "there will always be a subsidized insurance program for the elderly," but explains that it is a malleable policy subject to political will. "What it will pay for and how much of it will be paid by non-poor seniors is, however, highly uncertain and will depend on politics as much as economics," he says.



September 21, 2013: NIH Director: Next 'Cure for Cancer' Lost to Sequester

Billions of dollars in research funding and thousands of health-related jobs have been lost to the sequester, putting the nation's healthcare system at risk, said panelists speaking at a health forum last week.  National Institutes of Health Director Francis Collins, MD, said his institute has lost $1.7 billion in federal funding since the start of sequestration and stands to lose another $600 million on October 1.

"People are demoralized," said Dr. Collins, speaking at the 2013 National Health Research Forum held at the Newseum last week in Washington, DC. "That is research that could have been the next cure for cancer or the next Nobel Prize. But we'll never know."

Last Thursday's forum, titled "Straight Talk About the Future of Medical and Health Research," was hosted by Research!America and featured 3 panel discussions that included representatives from government, industry, research, and academia.  Although some of the discussion focused on new and innovative ways that government, academia, and the private sector could partner on research, much of the conversation was devoted to public sector cuts in research funding, many of which stem from the sequester.

"Are we ready to speak forcefully and candidly to our officials about the problems they've created through their inaction?" asked Research!America Chair John Edward Porter, JD, a former US congressman from Illinois, during his opening remarks.  "Are we ready to talk to them about the research that's not being conducted and the number of scientists leaving the profession, the missed opportunities, the lost jobs, the threat to our global competitiveness?"

Porter said Research!America's polling shows that the majority of Americans support research as a means to lower healthcare costs, and half are willing to pay more taxes if the money is used to support medical research. He added that Congress can no longer "kick the can down the road" when it comes to medical research. "They either have to get the job done or they have to get out of the way."

Other speakers expressed similar concerns.

"Outbreaks Won't Be Detected..."

Centers for Disease Control and Prevention Director Thomas Frieden, MD, MPH, said tens of thousands of federal, state, and local health care jobs have been or will be cut because of ongoing budgetary restraints. He said the results could be devastating.

"Outbreaks won't be detected, vaccines won't happen," he said, adding that there "will be costs in terms of human suffering."

Bart Peterson, JD, senior vice president of corporate affairs and communications at drug maker Lilly, the conference's lead sponsor, said the United States has become the global leader in health innovation during the past 30 years through "sound public policy," but that status is at risk. 
"Public funding for research, which is so threatened today, is absolutely critical to the future, and we care about that in the private sector as much as anybody else," said Peterson, a former mayor of Indianapolis. "The stakes are very, very high. We need new medicines, and we need new technologies in medicine."

On the regulatory side of medicine, FDA Commissioner Margaret Hamburg, MD, said the sequester has reduced and strained resources to her agency as well. "Investment in research is key," she said. "We have to look at economic policies, we have to look at reimbursement policies, and we have to look at regulatory policies and pathways. Advancing innovation and protecting the patients that use our healthcare system go hand and hand."  Dr. Hamburg added that she and others at the agency worry further cuts may make it difficult for the FDA to retain the "very best people" to oversee the drug and device review process.


September 20, 2013: OBAMACARE FAQs: Coverage of Immigrants, Legal and Illegal

The U.S. is home to more than 21 million immigrants who are not citizens, and for many of them, health coverage is a concern. That is partly because so many of them -- both those who came here legally and those who do not have permission to live in the United States -- work in low wage jobs that don't include health coverage.   As a result, non-citizens are three times more likely to be uninsured than U.S.-born residents, although they represent only 20 percent of the total uninsured.

The health law will help some gain coverage, although those in the country illegally will not get access to federal subsidies or to insurance sold through new state-based exchanges. That decision by the Obama administration brought complaints from immigration advocates. Hispanic groups complained about the Obama administration's decision in 2012 to not extend the health law's coverage to young adults who are accepted into a new program granting temporary amnesty to some who were brought to the U.S. as children.

But for those who are not exempt, the health law is expected to boost coverage, either through private insurers or in Medicaid, the state-federal health program for low-income residents. Here are five questions about the health law, immigrants and the medical providers who care for them.


Q. How does the health law affect immigrants who are not citizens and are living in the U.S. legally?

A. Many of the 10 million non-citizens in the U.S. legally are expected to gain health insurance.

Immigrants here legally who don't get coverage through their jobs will be able to purchase health coverage through new state-based marketplaces called exchanges that open October 1. Since many are in low-paying jobs, they may also qualify for Medicaid, although most are not eligible for that coverage until they have been in the country for at least five years. Immigrants who have refugee status can qualify for Medicaid without the five-year waiting period. The federal law expands Medicaid eligibility in all states to people earning up to 138 percent of the federal poverty level, about $15,800 for an individual and $33,000 for a family of four. An estimated 57 percent of uninsured non-citizens meet that income requirement. However, about half the states have opted not to accept that expansion because the Supreme Cohttp://www.politifact.com/florida/statements/2013/jul/09/chain-email/illegal-immigrants-are-covered-under-health-care-l/urt ruled that the federal government cannot penalize states that choose not to expand eligibility.

Legal immigrants earning more than the Medicaid limit could qualify for a federal subsidy aimed at helping people earning up to four times the poverty level -- about $46,000 for an individual -- purchase coverage through the exchanges. Also, legal immigrants who are not eligible for Medicaid because they haven't been in the country for five years -- will be eligible for subsidies through the new marketplaces.


Q. Does the health law give coverage or subsidies to immigrants in the country illegally?

A. No. The estimated 11 million immigrants living in the U.S. illegally are not eligible for Medicaid, nor can they qualify for federal subsidies to purchase insurance.

These individuals are also barred from using their own money to purchase insurance coverage through the state exchanges. The Congressional Budget Office estimates that about 30 million people will remain uninsured in 2016. According to a report funded by the Robert Wood Johnson Foundation, about a quarter of those uninsured would be illegal immigrants.   But, they also are not subject to the law's mandate that nearly all residents carry insurance.

A viral e-mail continues to circulate perpetuating the lie that Obamacare will cover illegal immigrants. Not so:  There are no graveyards for ridiculous, oft-debunked chain emails. Hatred for Obama surpasses all logical thinking and facts.


Q. Where are non-citizens -- both those here legally and illegally -- currently get medical care, particularly if they are uninsured?

A. While insured residents generally get coverage through networks of doctors, hospitals and other medical professionals provided by their insurers, uninsured immigrants have fewer choices, particularly for ongoing medical needs. One option is the nation's 8,500 community health centers, which serve about 22 million people. About 40 percent of their patients are uninsured, while an additional 38 percent have Medicaid coverage. The centers do not ask about immigration status.

Under federal law (EMTALA), hospitals are required to provide emergency room care to everyone, regardless of ability to pay or immigration status. But that care is limited. Generally, emergency rooms provide treatment to stabilize a patient but are not responsible for ongoing needs, such as chemotherapy for cancer, physical therapy for accident victims or prescription medication for chronic illnesses such as diabetes. Some people are able to get those services through individual physicians, safety-net hospitals, community health centers or other charitable organizations.


Q. How does the health law's treatment of immigrants affect hospitals and community health centers?

A. Recognizing that more health centers would be needed to help care for the estimated 30 million newly insured, Congress included in the health law $11 billion over five years for community health centers. However, Congress in 2011 cut $600 million from health center funding. Unless Congress restores that money, the cuts will continue and over five years will trim $3 billion off the $11 billion.

Federal payments to hospitals are also going to be reduced. Because they expected to see fewer uninsured patients as a result of the health law, hospitals agreed to cuts in federal funding to reimburse facilities caring for the uninsured. Called disproportionate share payments, the money is scheduled to be scaled back by about $18 billion from 2014 to 2020. The law also boosted funding for the National Health Service Corps, who help bring primary care services to underserved populations.

Q. How does the ongoing debate in many states over whether to expand Medicaid under the health law affect medical providers?

A. About half of the people expected to gain insurance through the law will do so by enrolling in the expanded Medicaid programs. The federal government picks up the full tab for the expansion in the first three years, but states will ultimately pay 10 percent of the cost for the new enrollees. While many states are expected to expand Medicaid eligibility, some are balking, citing the cost. In states that opt not to expand their Medicaid programs, hospitals fear they will face a reduction in their federal disproportionate share payments while not getting the increase in the number of insured patients they had expected and have been pressing state and federal officials to restore funding.


September 19, 2013: Is Obamacare Really to Blame for Hospital (and Other Business) Lay-offs (Or is it Just a Convenient Excuse for Actions That Have Been in Progress for Years)

THE QUOTE NOT REPORTED BY RIGHT WING MEDIA: "We're not blaming health care reform. We think it is very necessary,"  (Eileen Sheil, executive director of corporate communications for the Cleveland Clinic)

Cleveland Clinic officials announced this week that they would be offering 3,000 buyouts in an effort to cuts costs, citing financial pressures from health care reform as just one of the reasons for their decision. More than a dozen hospitals across the country are taking similar measures, due in part to health care reform requirements, but mainly because of the $9.9 billion in government sequester cuts to Medicare, hospital debt and states' refusal to expand Medicaid, the government's health insurance program for the poor.

"For hospitals in general this is kind of the new normal," says Eileen Sheil, executive director of corporate communications for the Cleveland Clinic. According to most recent estimates from the Bureau of Labor Statistics, the hospital sector lost about 4,400 jobs in July. In May, hospitals shed 9,000 jobs, the worst month for the industry in a decade.

Ron Stiver, senior vice president of engagement and public affairs for Indiana University Health, which plans to cut 800 employees, says the assertion that health care reform is the reason behind hospital cuts is "overly simplified." IU Health is making cuts partially because of the health law, he says, but also because the state has not expanded Medicaid, the hospital system has fewer inpatient volumes, and payment rates for its services have been declining.

Vanderbilt University Medical Center in Nashville, Tenn., plans to cut 1,000 positions, citing an aging population, lower reimbursement rates, a reduction in National Institutes of Health grant funding and a lack of Medicaid expansion in Tennessee.

In 2012 the Supreme Court ruled that state legislatures could opt out of increasing the number of people who are eligible for Medicaid, and North Carolina is one of 22 states that has done so, a decision that resulted in Vidant Pungo Hospital in Belhaven, N.C., closing down, according to hospital officials.

Democratic Congressman Charles Rangel from New York, the main sponsor of the health reform bill, says organizations have several other tools they could use to reduce costs, and that many businesses are blaming health reform for actions for which they don't want to take responsibility. "U.S. health costs have been the highest in the world, yet our quality measures were middling at best," he says. "While there is no doubt that [health reform] has helped slow health care cost growth, which is beneficial to both national and household budgets, there is nothing in the law that tells hospitals to reduce staff. The fact is that patients are paying less, not more, as a result of the [health law]."

The Office of the Actuary for the Centers for Medicare & Medicaid Services predicted that decreases like these would occur, stating in a 2010 memo that by 2019 it expected hospitals, skilled nursing facilities and home health agencies would undergo a 15 percent reduction.

For a sector that employs more than 5.5 million people, according to the American Hospital Association, the numbers are likely to get worse. The pattern of layoffs and buyouts has already begun. SouthCoast Hospital Group in Florida cited federal health reform when it laid off 100 employees in mid-September. John Muir Health in California is offering staff voluntary buyouts. NorthShore University HealthSystem in Illinois will lay off 1 percent of its workforce, and Covenant Health in Texas laid off 49 employees.

The requirements that hospitals must meet in order to receive full Medicare reimbursements are having a large impact. Hospitals once were able to bill insurance companies and the federal government for services rendered, but now they have to demonstrate that those services help keep patients healthy.

The government is capping reimbursement rates for specific diagnoses and having hospitals pay to fix their own medical errors, including hospital-acquired infections. The plan is to lower inefficiencies, thereby lowering costs. "We want hospitals to do things more efficiently," says Dr. Ross Koppel, professor of sociology and affiliate professor of medicine at the University of Pennsylvania. "We don't want to redo tests or subject people to hideous radiation because exam records have been lost, for example. There may be some inefficient practices that were money makers, but with a more efficient system hospitals can't get away with them."

Hospitals with excessive numbers of readmissions for Medicare patients will face large penalties, and hospitals that serve the poor will be particularly vulnerable.

Sheil said hospitals will be getting paid less and still have to do more. "Nobody is immune to that, not even Cleveland Clinic," she says.

The news appeared to be particularly devastating to a hospital system that President Barack Obama applauded only four years before for delivering exceptional care at costs well below the national norm. Still, Cleveland Clinic officials were attributing its most-recent cuts to a number of factors, and pointed out that it was continuously developing ways to be more efficient. "There are many factors, and any one isn't going to tip us over," Sheil says. "We're not blaming health care reform. We think it is very necessary," she adds. "Something had to give because costs are going to continue to rise and it's unsustainable."


September 16, 2013: Still 48 Million of Our Fellow Americans Uninsured, American Disgrace Among Industrialized Nations

The rate of uninsured Americans dropped slightly for the second consecutive year in 2012, from 15.7 percent to 15.4 percent, largely a result of more people enrolling in Medicare and Medicaid, the U.S. Census Bureau reported Tuesday.

The closely-watched report found that about 48 million Americans were uninsured in 2012, down from 48.6 million in 2011, a change the agency said is not statistically significant. The report is the last look at the uninsured before the major coverage expansions of President Barack Obama's health law take effect in January.  "It is encouraging that fewer people were uninsured in 2012 than in the previous year, but the huge number of Americans still without health insurance is a stark reminder of the important work that lies ahead," Ron Pollack, executive director of Families USA, a consumer advocacy group, said in a statement.

One of the most significant changes was a decline in the rate of uninsured children, from 9.4 percent in 2011 to 8.9 percent, largely related to government efforts to make it easier for children to get coverage and keep it.

"Uninsurance is already low for children, and the fact that it still appears to be declining is an encouraging sign," said Genevieve Kenney, a senior fellow at the Urban Institute. "It shows when there is a concerted public policy focus on a problem, it can pay off."

The uninsured rates for all other age groups showed no statistically significant change, the bureau reported.  The census data did not show any sign that employers were moving to drop coverage as a result of the federal health law.  The number of people with private health insurance increased slightly in 2012 to 198.8 million, up from 197.3 million in 2011. Those with employment based coverage rose slightly from 170.1 million to 170.9 million.

Employer-sponsored coverage rose from 58.3 percent to 58.4 percent -- the first increase since 2000. This belies the allegations that Obamacare has been causing employers to drop coverage. The trend of employers dropping employee health coverage has been been ongoing for nearly three decades, falling to its current percentage from over 70% in 1985. The trend was particularly accelerated during the George W. Bush years, ending in 2008. While the trend has continued under Obama who has been struggling with the Bush economy he inherited and a cantankerous GOP-controlled House that has done nothing to help employees and the job situation, this year's report reflects an upbeat, albeit very small, and this in the face of allegations that Obamacare is driving employers away from covering their employees.  Opponents of Obamacare have tried to convince the public to ignore the trend line over the past decades, BEFORE Obamacare was enacted, and cast the blame for employers dropping coverage on Obamacare. NOT TRUE!

While the percentage of those enrolled in Medicaid, the state-federal program for the poor, remained about the same, the percentage of those covered by Medicare rose from 15.2 percent in 2011 to 15.7 percent in 2012.  A total of 101 million Americans, nearly a third of the U.S. population, are now in one of those government programs.

The nation's uninsured rate reached a peak of 16.3 percent in 2010, when about 50 million people lacked health coverage. That same year, Obama signed the Patient Protection and Affordable Care Act into law.



September 15, 2013: Obamacare FAQs: Why are Some Labor Unions Publicly Protesting and Opposing Obamacare?

According to Jeanne:

Unions are opposed to two provisions in Obamacare ... (1) the "Cadillac tax" on union-negotiated employer plans costing more than $10,500/yr for individuals, $27,5000/family ... payments above that are taxable income to the beneficiary (this hits many union-negotiated health plans) ... and (2) provisions not allowing union-run health plans from participating in the health exchanges ... which effectively means that individuals covered under one of these plans are not eligible for the tax subsidies based on income that are available to others.

Union-negotiated plans are plans provided by the employer to union employees. In some industries, unions have negotiated plans where the costs exceed the statutory thresholds (which are supposed to be inflation-adjusted each year) ... there are exceptions for dangerous jobs, police, fire and mining ... but other union jobs will be impacted. Personally, I don't feel too sorry for most of those who might be impacted. The Cadillac tax will mostly hit corporate executive health plans ... many Fortune 500-type companies have plans for their executives costing $100,000 a year or more. These will be taxed heavily.

Union-run plans are different. Many craft unions (electricians, carpenters, plumbers) operate their own plans and contractors employing union members pay into the plan for every union member hired or being used on  a job project ... many of these arrangements are short-lived with the union member being out of a job when the project for which they were hired is completed ... but since their health insurance is through the union and not the job's contractor/employer, they usually have continuous health plan coverage.  Many of these individual union members would be eligible for a tax subsidy through the exchanges under Obamacare ... but their union-run plans are not eligible to participate in the exchange, therefore no subsidy. This was either a drafting error in the law, an oversight (most likely), or a deliberate loop-hole put in by opponents ... attempts to close this loop-hole have been stymied in the House (what else is new).  Unions opposing the whole Obamacare law over this are biting off their own noses to spite themselves in my opinion.


September 12, 2013: Obamacare Saved America Over $1.2 BILLION in 2012

Insurers were less likely to seek health premium increases greater than 10 percent in 2012 because of the provision in Obamacare that requires them to justify such requests, explanations that are then publicly posted for consumers to see, according to a recently released federal report.

The second annual rate review report from the Department of Health and Human Services (HHS) says that 6.8 million consumers with insurance in the individual and small group markets saved an estimated $1.2 billion on health insurance premiums in 2012 because of the Obamacare's rate review provision. The health law (PL 111-0148, PL 111-152) also provides for $250 million in grants to state insurance departments for fiscal years 2010 through 2014 to help them beef up their rate review activities.

According to the report, the average rate request increase in the individual market dropped by 12 percent (from 8.1 percent to 7.1 percent) after rate review, saving consumers an estimated $311 million. And in the small group market, the average rate increase request declined by 19 percent (from 5.8 percent to 4.7 percent), saving consumers an estimated $866 million after rate review.

In 2012, 26 percent of requests for rate increases in the individual market were for an increase of 10 percent or more, significantly lower than the 43 percent requested in 2011, the report said.

Because insurance regulation is vested in the states, it varies from state to state whether insurance commissioners have the power to stop an insurer from increasing their premiums. But the theory behind the rate review provision was that insurers would be deterred from filing huge rate increases if they had to explain why they were planning rate increases above 10 percent and if state insurance regulators also would post an online notation when they believed an increase was unreasonable


September 9, 2013: Health Care in Two Americas ... Even When They Have Some Coverage, Most Poorer Americans Have Less ... But States Could Do Better for All, Richer and Poorer

Ensuring that all people have equal access to high-quality health care to help them live healthy and productive lives is a core goal of a high performance health system. In the United States, however, where you live matters, particularly if you have low income. In many states, there is a wide gulf in access to and quality of care between those with below-average income and the rest of society.

Recognizing the importance of families' economic status for affordable access to care and health status, The Commonwealth Fund’s Scorecard on State Health System Performance for Low-Income Populations, 2013, aims to identify opportunities for states to improve how their health system serves their low-income populations and to provide benchmarks of achievement tied to the top-performing states. Based on its assessment of 30 indicators of access, prevention and quality, potentially avoidable hospital use, and health outcomes, the Scorecard documents sharp disparities among states in each of these areas.

The analysis finds that raising state health system performance to the top benchmark levels would make a critical difference for low-income populations. Between the leading and lagging states, there is often up to a fourfold disparity in performance on indicators of timely access to care, risk for potentially preventable medical complications, lower-quality health care, and premature death, affecting millions of Americans.

If all states could reach the benchmarks set by leading states for more advantaged populations, an estimated 86,000 fewer people would die prematurely, with potential gains of 6.8 million years of life; 750,000 fewer low-income Medicare beneficiaries would be unnecessarily prescribed high-risk medications; and tens of millions of adults and children would receive timely preventive care necessary to lessen the impact of chronic disease and help avoid the need for hospitalization.

Notably, the Scorecard finds that having low income does not have to mean below-average access, quality, or health outcomes. In fact, in the top states, many of the health care benchmarks for low-income populations were better than average and better than those for higher-income or more-educated individuals in the lagging states. With new nationally funded expansions of health insurance and an array of new resources and tools, all states will have a historic opportunity to greatly improve health and health care for vulnerable populations across the country.



September 4, 2013: Bill Clinton, "Explainer-in-Chief"

Bill Clinton last week took over the apologia for Obamacare, attempting to do what so far the Obama administration has been unable ... explain to the American people that the Patient Protection and Affordable Care Act (affectionately known by one and all as "Obamacare") is the best thing to come down the pike since sliced bread ... or at least since Medicare went into effect in 1966. By cutting through the political noise and change the perception of a law much of the public doesn't like or understand, his speech at Clinton's presidential library in Arkansas last week was a continuation of the relationship that benefited the former and current president in the 2012 campaign. It's a role Clinton has played before on behalf of Obamacare, which is rooted in the failed effort by he and his wife, Hillary Clinton, to pass comprehensive health care reform two decades ago.

Clinton gave the speech at the request of the White House, but the choice of venue was his, and one that seemed natural to him, according to his aides. "For a variety of reasons, including having hundreds of millions of dollars in negative ads run against the law, the administration has had a hard time communicating the law’s benefits and knocking down the false attacks," said Democratic strategist Stephanie Cutter, who was deeply involved in the health reform effort when she was an adviser to President Barack Obama.

"There's no one better to lay it all out for the American people than President Clinton," she added. "He'll cut through the rhetoric and get to the heart of the issue ... 'How does the law impact me and my family, and how much will my health care cost?' Ultimately, that's all the American people care about, and President Clinton knows how to put it in their terms."

The aim of the speech may have been broader than a continuation of Clinton's well-received defense of the law last year at the Democratic National Convention in Charlotte, N.C., where he laid out the intricate legislation in a way people could understand.

The venue is Bill Clinton's home turf -- his native Arkansas -- and speaking in one of the poorest states in the nation could help him to highlight what the White House sees as the benefits of the bill. The speech suggests that the relationship between Clinton and the White House will continue as long as there is a need in the final three years of Obama's presidency -- the period, of course, during which Hillary Clinton will decide whether to run again in 2016. "He will lay down the facts about what is working and what is to come," said a White House official of the speech.

The September 4th speech will be the first of a number of high-profile events and speeches by administration officials and allies throughout the fall aimed at raising awareness about the law. In addition to his remarks in Little Rock, President Clinton is also expected to continue to raise public awareness around the law during the critical months for open enrollment.

Officials on both sides have tended to downplay the breathlessness with which every Clinton utterance related to Obama gets covered. Clinton's usefulness goes only so far for Obama, but there is a recognition that he is seen as less polarizing than the president on certain topics.

And Clinton supporters argue that he has given many speeches that are similar to the one he delivered week, but they don't all get written about. Still, health care is an issue that both Clintons care deeply about. And as Clinton attempts to highlight that Republicans have offered no alternative to the bill that the U.S. Supreme Court has upheld, his speech serves as a tacit reminder of how much work he and his wife put into health care early in his presidency. Clinton has emerged as a big Obamacare booster over the past couple of years, working to calm a Democratic base that's been either upset the law isn't liberal enough or anxious about what could be a bumpy beginning.

The stakes are high: In less than a month, millions will be able to start signing up for Obamacare coverage. But new polling shows about 40 percent of the public remains confused about whether Obamacare is still the law -- let alone what's actually in it. Clinton's Obamacare history most notably includes a dissertation on its benefits during his prime-time address at the convention, where President Barack Obama barely touched on his own signature law.

"Are we all better off because President Obama fought for health care reform? You bet we are," Clinton said in Charlotte almost a year ago. He also slipped an Obamacare mention into his Wednesday speech marking the 50th anniversary of Martin Luther King Jr.'s "I Have a Dream" speech. "We cannot relax in our efforts to implement health care reform," Clinton said from the steps of the Lincoln Memorial.

In February, Clinton urged House Democrats nervous about the law's rollout to focus on smooth implementation, also reassuring them that the party got the strongest health care bill through Congress that it could. "It was the best bill you could have passed in the Congress given the filibuster circumstances," Clinton said at the Democrats' retreat. "It really matters how it's implemented."

While Clinton has acknowledged the massive health overhaul will require future fixes, he's also cautioned against rushing to judgment on Obamacare's ultimate impact -- though Democrats and Republicans will be eager to diagnose the law's success or failure early on.

"We really need about five years to see whether the drivers in the health care law, which clearly are trying to give incentives for people to be healthier and incentives for the system to give health care where you pay for results rather than procedure, to see if that works," Clinton said at the Peterson Foundation Fiscal Summit in May.

Clinton's emphatic Obamacare support has erased a once-bitter divide between Obama and the Clinton camp over health care, specifically the law's controversial requirement requiring individuals to carry insurance. Obama slammed Hillary Clinton's support for the so-called individual mandate during the 2008 Democratic primary before eventually embracing it as the linchpin for his own health care law.


August 18, 2013:

As supporters and opponents of the Patient Protection and Affordable Care Act (affectionately known by one and all as "Obamacare") debate the best way to overhaul a clearly broken health care system, it's perhaps helpful to put American medicine in a global perspective. The infographic below is based on a recent Bloomberg ranking of the most efficient countries for health care, and highlights enormous gap between the soaring cost of treatment in the U.S. and its quality and effectiveness. To paraphrase Ricky Ricardo, the American health care system has a lot of 'splainin' to do.



It's remarkable how low America places in health care efficiency: among the 48 countries included in the Bloomberg study, the U.S. ranks 46th, outpacing just Serbia and Brazil. Once that sinks in, try this one on for size: the U.S. ranks worse than China, Algeria, and Iran. But the sheer numbers are really what's humbling about this list: the U.S. ranks second in health care cost per capita ($8,608), only to be outspent by Switzerland ($9,121) -- which, for the record, boasts a top-10 health care system in terms of efficiency. Furthermore, the U.S. is tops in terms of health care cost relative to GDP, with 17.2 percent of the country's wealth spent on medical care for every American.

In other words, the world's richest country spends more of its money on health care while getting less than almost every other nation in return. It's important to note that this data doesn't necessarily reflect the best health care in the world; it is simply a measure of overall quality as a function of cost. Bloomberg explains its methodology as such:

Each country was ranked on three criteria: life expectancy (weighted 60%), relative per capita cost of health care (30%); and absolute per capita cost of health care (10%). Countries were scored on each criterion and the scores were weighted and summed to obtain their efficiency scores. Relative cost is health cost per capita as a percentage of GDP per capita. Absolute cost is total health expenditure, which covers preventive and curative health services, family planning, nutrition activities and emergency aid. Included were countries with populations of at least five million, GDP per capita of at least $5,000 and life expectancy of at least 70 years.

So what can the U.S. learn from the many countries that get more bang for their health care buck? Unsurprisingly, there is no one formula for success when it comes to efficient medical care. The systems that rank highly on Bloomberg's list are as diverse as the nations to which they belong. The unifying factor seems to be tight government control over a universal system, which may take many shapes and forms -- a fact evident in the top-three most efficient health care systems in the world: Hong Kong, Singapore, and Japan.


Ranking third on Bloomberg's list, the Japanese system involves universal health care with mandatory participation funded by payroll taxes paid by both employer and employee, or income-based premiums by the self-employed. Long-term care insurance is also required for those older than 40. As Dr. John W. Traphagan notes in The Diplomat, Japan controls costs by setting flat rates for everything from medications to procedures, thus eliminating competition among insurance providers. While most of the country's hospitals are privately owned and operated, the government implements smart regulations to ensure that the system remains universal and egalitarian.

Meanwhile, Singapore's health care system is largely funded by individual contributions, and is often hailed by conservatives as a beacon of personal responsibility. But as conservative David Frum notes, the system is actually fueled by the invisible hand of the public sector: individuals are required to contribute a percentage of their monthly salary based on age to a personal fund to pay for treatments and hospital expenditures. In addition, the government provides a safety net to cover expenses for which these personal savings are inadequate. Private health care still plays a role in Singapore's system, but takes a backseat to public offerings, which boast the majority of doctors, nurses, and procedures performed.

Despite being considered by some as having the freest economy in the worldHong Kong's universal health care system involves heavy government participation; its own health secretary calls public medicine the "cornerstone" of the system. Public hospitals account for 90 percent of in-patient procedures, while the numerous private options are mostly used by the wealthy.

All this government care isn't taking much of a bite out of the state's bustling economy: According to Bloomberg, Hong Kong spends just 3.8 percent of GDP on health care per capita, tied for the third-lowest among nations surveyed and good for the most efficient health care system in the world.



August 15, 2013: Memorializing Our Friend Sandy

Or next door neighbor Sandy Crist passed away on Monday and today he will be memorialized at the mortuary chapel.  His widow asked my husband Bob to officiate and to preach a homily.  Bob's homily is re-printed here:

As an ordained minister, 54 years ago, in the United Methodist Church and after years of service as a chaplain in the United States Air Force, I have been privileged to officiate at countless funerals ... several were extremely sad occasions, remembering lives cut short ... but many more were really celebrations of lives lived well and long ... today we gather for one of those celebrations.

But unlike almost all of those other funerals, this one today ... a celebration for Sandy Crist ... is very special ... I am here to officiate at the celebration of a friend.  James Sanford Crist was my friend ... my next door neighbor ... the guardian of my home while I was a way ... a watchman over the elderly mother and father of my wife Jeanne before we came to live full time in Arizona ... a friendly face who greeted us most days as we went about our daily activities ... a good and loving partner to LuAnn and someone who we knew and trusted. He built his home here ... he shared it with LuAnn and in a variety of ways with my wife Jeanne and myself. The Apostle Paul says that our home is in heaven. We build houses for ourselves. We decorate them. We become settled in life. Very few people like moving around from one place to another. And yet despite the fact that we are so settled where we are, Paul says, that is still not home. 'For us, our homeland is in heaven.' We might think we are at home here, but if we have faith we can see beyond the surface of life and we know that we have been created to know, love and serve God.

Just two weeks ago, as Sandy had becomes increasingly ill and his earthly body was being ravaged by the cancer that would so soon take his life, I had the honor and the privilege to officiate at another ceremony ... the marriage of Sandy and LuAnn at his bedside in Mountain Vista Hospital ... actually we did it twice ... the first day in the eyes of God ... the second to make it all legal in the eyes of the State of Arizona.

That wedding and today's memorial celebration are evidence that Sandy's life ... and indeed, each of our lives ... is but a step in the journey we are all undertaking in life ... Life is a journey, a journey from birth to death. The greatest journey in the Old Testament was the journey from Egypt to the promised land of Canaan. For us our promised land is not on this earth, our promised land where milk and honey flow is heaven. The journey to the promised land in the Old Testament is a symbol of the journey each of us makes to God as we go through this life. Between our birth and our death we are pilgrims on the road to God. We are but travelers on a journey, pilgrims on a pilgrimage to God.

For that reason, Paul describes life as a tent in which we live. If somebody lives in a tent it is because they are traveling and intend to move from place to place and a tent is only a temporary dwelling. It was a good description by Paul for the fact that we are only pilgrims in this world, on a journey to God.

Because we are but travelers, only pilgrims on our journey through life, knowing that our final destiny is with God, we keep our sight always fixed not just on the appearance of this life, but on the fact that we were created by God, that we cannot be truly happy unless we live as God wishes us to live, and of course God wants only what is good for us, we keep our eyes fixed on the fact that our destiny is eternal life and not just death.

And so as we honor Sandy today, it is true to say we honor one of us, no matter how big or small the funeral is. We are gathered today next to cemetery where people of different faiths are interred ... a further reminder to us that it is we who create differences, not God because there is only one heaven surely.

I have never yet heard anybody say there is a different heaven for each faith. The fact that we all die is yet another reminder to us that we are all the same before God. No matter how much we owned or possessed, when it comes to the end we are all the same. I have heard from a missionary that in a part of Africa the dead are buried naked. That is to symbolize the fact that we are really all the same before God and as we say, we take nothing with us when we die, we leave it all behind. Here in America we have a very beautiful way of saying that. We say we are only passing through. So as we mourn but honor Sandy, we mourn but honor one of ourselves.


August 12, 2013: Oops, Obama, Bending to the For-Profit Insurance Lobby Again, Delays Another Critical Provision in PPACA

In another setback for President Obama's health care initiative, the administration has delayed until 2015 a significant consumer protection in the law that limits how much people may have to spend on their own health care. The limit on out-of-pocket costs, including deductibles and co-payments, was not supposed to exceed $6,350 for an individual and $12,700 for a family. But under a little-noticed ruling, federal officials have granted a one-year grace period to some insurers, allowing them to set higher limits, or no limit at all on some costs, in 2014.

The grace period has been outlined on the Labor Department's Web site since February, but was obscured in a maze of legal and bureaucratic language that went largely unnoticed. When asked in recent days about the language -- which appeared as an answer to one of 137 "frequently asked questions about Affordable Care Act implementation" -- department officials confirmed the policy.

The discovery is likely to fuel continuing Republican efforts this fall to discredit the president’s health care law.

Under the policy, many group health plans will be able to maintain separate out-of-pocket limits for benefits in 2014. As a result, a consumer may be required to pay $6,350 for doctors’ services and hospital care, and an additional $6,350 for prescription drugs under a plan administered by a pharmacy benefit manager.

Some consumers may have to pay even more, as some group health plans will not be required to impose any limit on a patient's out-of-pocket costs for drugs next year. If a drug plan does not currently have a limit on out-of-pocket costs, it will not have to impose one for 2014.

The health law, signed more than three years ago by Mr. Obama, clearly established a single overall limit on out-of-pocket costs for each individual or family. But federal officials said that many insurers and employers needed more time to comply because they used separate companies to help administer major medical coverage and drug benefits, with separate limits on out-of-pocket costs. In many cases, the companies have separate computer systems that cannot communicate with one another.

A senior administration official, speaking on condition of anonymity to discuss internal deliberations, said: "We knew this was an important issue. We had to balance the interests of consumers with the concerns of health plan sponsors and carriers, which told us that their computer systems were not set up to aggregate all of a person's out-of-pocket costs. They asked for more time to comply." [Jeanne translates" "they threw campaign money at members of Congress, who in turn lobbied the White House to cave in."]

Health plans are free to set out-of-pocket limits lower than the levels allowed by the administration. But many employers and health plans sought the grace period, saying they needed time to upgrade their computer systems. "Benefit managers using different computer systems often cannot keep track of all the out-of-pocket costs incurred by a particular individual," said Kathryn Wilber, a lawyer at the American Benefits Council, which represents many Fortune 500 companies that provide coverage to employees.

Last month the White House announced a one-year delay in enforcement of another major provision of the law, which requires larger employers to offer health coverage to full-time employees. Valerie Jarrett, Mr. Obama's senior adviser, said that the delay of the employer mandate showed "we are listening" to businesses, which had complained about the complexity of federal reporting requirements.

Although the two delays are unrelated, together they underscore the difficulties the Obama administration is facing as it rolls out the health care law.

Advocates for people with chronic illnesses said they were dismayed by the policy decision on out-of-pocket costs.

"The government's unexpected interpretation of the law will disproportionately harm people with complex chronic conditions and disabilities," said Myrl Weinberg, the chief executive of the National Health Council, which speaks for more than 50 groups representing patients.

For people with serious illnesses like cancer and multiple sclerosis, Ms. Weinberg said, out-of-pocket costs can total tens of thousands of dollars a year.

Despite the delay, consumers in 2014 will still have many new protections. They cannot be denied health insurance or charged higher premiums because of pre-existing conditions, and many will qualify for subsidies intended to lower their costs.

In promoting his health care plan in 2009, Mr. Obama cited the limit on out-of-pocket costs as one of its chief virtues. "We will place a limit on how much you can be charged for out-of-pocket expenses, because in the United States of America, no one should go broke because they get sick," Mr. Obama told a joint session of Congress in September 2009.

Advocates for patients said the promise of the law was being deferred. "We have wonderful new drugs, the biologics, to treat rheumatoid arthritis, but they are extremely expensive," said Dr. Patience H. White, a vice president of the Arthritis Foundation. "In the past, patients had to live in constant pain, often became disabled and had to leave their jobs. The new drugs can make a huge difference, and we were hoping that the cap on out-of-pocket costs would make them affordable. But now many patients will have to wait another year."

The American Cancer Society shares the concern and noted that some new cancer drugs cost $100,000 a year or more.


August 5, 2013: Anti-Obamacare Conspiracy Theories: As the Deadline Approaches. The Koch Brothers and Their Allies on the Extreme Right Fringe are Counting on American Stupidity and Fox News to Carry the Day

Obamacare is going to implant you with a microchip. Obamacare is going to tax your golf club. Obamacare is going to create a massive unprecedented federal database to hold all of your "intimate ... secrets."

One of the largest components of the Patient Protection and Affordable Care Act -- the health exchanges from which Americans can buy discount health coverage -- will go into effect on October 1. And that has right-wingers in conspiracy theory high gear. Here are seven conspiracy theories about the health care law, along with debunkings from the fact-check websites PolitiFact and Snopes:

1. Obamacare Will Tax Your Outboard Motor

The Claim: A chain email making the rounds this summer claims that a "hidden" provision of Obamacare taxes sporting goods as medical devices, including "Sport fishing equipment; Fishing rods and fishing poles; Electric outboard motors; Fishing tackle boxes; Bows, quivers, broadheads and points; Arrow shafts; Coal; Taxable tires; Gas guzzler automobiles." Yikes!

The Reality: Obamacare does impose a 2.3 percent tax on some medical devices to offset the added costs of expanding health coverage to the uninsured (and to recoup a small portion of the windfall profits durable medical equipment mnufacturers will gain from the expanded coverage) which went into effect at the beginning of the year. But, as PolitiFact  points out, none of the items listed in the chain email is labeled as a medical device by the federal Food, Drug and Cosmetic Act, which defines the types of devices that can be taxed. No, Obamacare won't be taxing your golf club after all.

2. Obamacare Will Kill Your Grandma

The Claim: Another zombie chain email warns that Obamacare will deny old people cancer treatment: "Please for the sake of many good people, please ... pass this on. We all need to be informed. YOU ARE NOT GOING TO LIKE THIS ... At age 76 when you most need it, you are not eligible for cancer treatment."

The Reality: This particular email has been making the rounds for a good four years, according to Snopes, and is based on an old version of the law that didn't pass. But even that version of the legislation did not ration cancer care; in fact, the American Nurses Association says the cancer treatment section of that law would implement "the opposite of rationing. The section allows Medicare to pay cancer hospitals more if they are incurring higher costs." Similarly, there is no cut-off age for cancer treatment under the law that passed, known as Obamacare. "The claim is based on an inaccurate reading of a bill that went nowhere," PolitiFact concludes.

3. Obamacare Comes With Microchips

The Claim: Beware, Obamacare is going to implant a microchip in you, cautions yet another chain email batting around the internet: "This new Health Care (Obamacare) law requires and RFID [radio frequency identification] chip implanted in all of us. This chip will not only contain your personal information with tracking capability but it will also be linked to your bank account."

The Reality: As Snopes points out, "[C]laims that health care reform legislation will require such implantations date to the Clinton administration" and are "often linked to the 'mark of the beast' referenced in Revelations." The sections of legislation referenced in the email and others like it pertain to a passage in a previous version of the health care law that called for the creation of a registry that would allow the federal Department of Health and Human Services (HHS) to collect data about medical devices "used in or on a patient" -- such as pacemakers or hip replacements -- in order to track their effectiveness. Nothing in the Patient Protection and Affordable Care Act calls for the government to stick a microchip in your wrist.

4. Illegal Immigrants Are Eligible for Obamacare

The Claim: Illegal immigrants will get health coverage under Obamacare, warns one widely circulated, oft-debunked, and still undead chain email.

The Reality: The health care law requires Americans (Americans) to purchase health insurance. Undocumented immigrants "don't have to follow the mandate because they shouldn't be here," PolitiFact reiterates. "They [also] remain ineligible for regular Medicaid coverage, just as they are ineligible for food stamps."

5. Thomas Jefferson Warned Us About Obamacare

The Claim: Thomas Jefferson warned of the dangers of government interference in health care. Here is the purported quote from our founding father, via a chain email: "If the people let the government decide what foods they eat and what medicines they take, their bodies will soon be in a sorry a state as are the souls of those who live under tyranny."

The Reality: Jefferson did write something similar in a book published in 1785 called Notes on the State of Virginia: "Was the government to prescribe to us our medicine and diet," he wrote, "our bodies would be in such keeping as our souls are now." The latter quote was transformed into the former in the 1990s, Snopes explains, and has been trotted out repeatedly as a caution against government meddling in private medical practice. But that wasn't Jefferson's argument; he was suggesting that legislating morality was as useless as legislating what a person eats.

6. Almost Everyone Who Works for a Small Business Is Getting Fired

The Claim: In late July, Senatecritter Marco Rubio (T/R-Fla.), citing a study by the Chamber of Commerce, asserted that three-quarters of all small businesses have said they're going to fire workers or cut hours. Rubio said this is due to the provision in the law that requires businesses with 50 or more full-time employees to offer affordable health coverage or face a penalty.

The Reality: The Chamber study involved 1,300 small business executives, but PolitiFact did some digging and found out that the Chamber did not actually survey the entire group on whether they'd fire employees because of the law. Only 17 percent of survey members said they would be impacted by the law's so-called employer mandate. Out of that 17 percent of small businessmen and women, the study purportedly found that 75 percent of them said they would cut hours or replace workers, but Politico found that even that number was fudged by lumping survey questions together. Math shows that out of all small business execs in the study, only 5 to 9 percent actually said they would cut back hours or replace full-time workers in response to the health care law.

7. The Giant Obamacare Database

The Claim: In May, Housecritter Michele Bachmann (T/R-Minn.) warned of a "huge national database" created by the health care law that will collect Americans' "personal, intimate, most close-to-the-vest-secrets." The claim has been widely discredited, but fringy conservative email chains continue to perpetuate the falsehood.

The Reality: The government is not constructing a database that collects, centralizes, and stores data. The health care law does create something called a Federal Data Hub which will allow HHS to extract data -- such as whether a person already has health insurance -- from already existing databases at other state and federal agencies. The hub will be used to verify consumer information when they are purchasing health insurance on the exchanges. The hub also has the ability to access income data and Social Security numbers, but that information already exists in other federal databases, "so the hub wouldn't represent an expansion of federal data collection," according to PolitiFact. Brian Cook, a spokesman for HHS, told the fact-checking organization that the hub will have "strict privacy controls to safeguard personal information."


August 2, 2013: NYT: Once Again Into the Muck ....

Republicans Refuel Effort to Cripple Health Care Law

WASHINGTON -- With the House poised to vote today on yet another bill to cripple President Obama's health care law, the question arises: Why do Republicans persist in their so-far futile efforts? Democrats have many theories. Republicans, they suggest, care little about the uninsured. Many, they say, dislike Mr. Obama and want him to fail

"The health care law has become the Republicans' great white whale," Representative Henry A. Waxman, Democrat of California, said Thursday. "They will stop at nothing to kill it."

Republicans say they persist because the law is an example of government overreach and is proving unworkable. For many elected in the 2010 Republican wave, their opposition to the law is the reason they are in Congress. And, they say, voting to repeal the law is good politics, as it remains extremely unpopular among Republican voters.

Republicans and some business owners also say they resent the way in which the law was written and passed by Democrats in 2009-10. Jeffrey S. Kelly, the chief executive of Hamill Manufacturing, a small Pennsylvania company that produces metal parts for Navy ships, made that point at a recent hearing to examine the effects of the law on businesses.

"Haven't you really reaped what you've sown?" Mr. Kelly asked House Democrats. "Look at the history of this law. It was passed without any support on the Republican side."

Though the White House and Congressional Democrats say they sought bipartisan support for the bill, Congressional Republicans argue that they were shut out of the legislative process.

"We offered 30 amendments when we were in the minority that were swatted away by the majority late into the night, not considered, not adopted,'" said Representative Peter Roskam, an Illinois Republican on the Ways and Means Committee.

Representative Michael C. Burgess, Republican of Texas, said: "No governor of either party was involved in the development of this law, even though the administration now says, 'We want the states to be involved and to be leaders in carrying it out.'"

With the battle over health care still raging, some lawmakers say they now understand what Thomas Jefferson meant when he said, in 1808, that "great innovations should not be forced on slender majorities," or enacted without broad support.

When Congress created Social Security in 1935 and Medicare in 1965, the majorities in both chambers were larger and more bipartisan than the ones that passed the [Patient Protection and] Affordable Care Act in 2010.

[Jeanne Interrupts Bob Pear's account with an Historical Note: Of course, left out of this argument is the history surrounding the passage of the "Medicare Modernization Act of 2003" ... the law that gave us Medicare Part D, a drug benefit that assured the pharmaceutical industry of massive profits (drug prices have more than doubled and for some commonly ordered Medicare drugs, have quintupled since then) but prohibited the Medicare program from negotiating the price ... but even more importantly, the MMA created a new Medicare Part C ... a for-profit alternative plan that was supposed to lead to "competition" among insurers but instead has led to companies like Humana reaping 85% of their profits from Medicare and costing the program on average 14% more per year than coverage under traditional Medicare. (This law is the "model" for Rep. Paul's Ryan's proposal, which has passed the House, to dismantle traditional Medicare and replace it with a "profit-driven" privatization plan, that would raise out-of-pocket expenses for middle-income Medicare beneficiaries by $8,000 or more per year by 2022, while lining the pockets of the for-profit health insurance industry ... no wonder these companies contribute so much via their political action committees to Republican candidates.)  The 2003 MMA was passed without a single Democratic vote in the middle of the night after holding the bill open on the House floor for over 9 hours (the usual time is 15 minutes) while GOP whips gathered enough votes to pass the bill without Democratic support ... and passing the bill in the Senate over a possible Democratic filibuster using a little known legislative process known as "reconciliation." Sound familiar? PPACA was passed in the same way by the Democrats in 2010 ... but now the GOP cries FOUL!]

The bill coming up in the House on Friday would prohibit enforcement of the health law by the Internal Revenue Service, the agency responsible for imposing penalties on individuals who go without insurance and on employers that fail to offer coverage.

Representative Jim McDermott, Democrat of Washington, said one reason Republicans kept voting to repeal or gut the health care law was that they feared it would succeed.

"What we are hearing right now is the sound of Republican heart rates going up," Mr. McDermott said. "It's a frenetic expression of Republican anxiety over the president's signature legislation working. Washington, Oregon and California are already reporting lower rates for 2014. New York premiums were cut by 50 percent. Sick children are getting covered. The promise we made Americans is being fulfilled, and Republicans see a giant election map slowly losing red blocks."

Republicans say that public opinion is on their side. In 2011-12, the House voted more than 30 times to roll back some or all of the law, but Speaker John A. Boehner said that more votes were needed this year because freshman Republicans wanted a chance to go on the record.

Republicans were encouraged to see some Democrats voting with them last month. Twenty-two House Democrats joined them in voting to delay a crucial part of the law that requires most people to have insurance, and 35 voted to postpone a requirement that large employers offer coverage to full-time employees.

Moreover, Republicans cite concerns about the law expressed by labor unions, including the Teamsters. In a letter last month to the top Democrats in Congress, James P. Hoffa, president of the Teamsters, and two other union presidents said that perverse incentives in the Affordable Care Act were "already creating nightmare scenarios." They said that "numerous employers have begun to cut workers' hours" to avoid the cost of providing them health benefits.

Marilyn B. Tavenner, the administrator of the Centers for Medicare and Medicaid Services, told Congress on Thursday that she had heard of only "isolated incidents" in which employers tried to cut back hours. Representative Steve Scalise, Republican of Louisiana, told her that she must be "living in some cocoon" because he heard of such actions almost every day.

Votes to repeal the law are also a way to unite Republicans who cannot agree on other aspects of health policy.

"Republicans have never, never, never had a comprehensive health care reform plan," said Representative Sander M. Levin of Michigan, the senior Democrat on the Ways and Means Committee.

Republicans are sparring among themselves over whether they should try to block all legislation that includes money to carry out the health care law. Some of the most conservative Republicans in Congress say they are prepared to force the issue in debate over a stopgap spending bill, needed to keep the government in operation beyond Sept. 30.

"Under no circumstances will we support a continuing resolution that funds one penny of Obamacare," said Senator Ted Cruz, Republican of Texas.

More experienced Republicans, including Senators John McCain of Arizona and Roy Blunt of Missouri, agree with the goal, but oppose the tactic, fearing that Republicans would be blamed for any government shutdown, as they were in 1995-96.

Whatever the reasons for Republicans' opposition to the law, it is unlikely that Friday's votes will be their last on the issue


August 1, 2013: Jeanne's Update on Obamacare Implementation: Marketplaces (Exchanges); Medicaid Expansion, and New Rules and Developments

Insurance Marketplace Updates

Beginning on October 1, 2013, Americans who do not have affordable health benefits through a job will be able to go to a new health insurance marketplace in their state and enroll in a private health plan. Adults with annual incomes up to 400 percent of the federal poverty level ($45,960 for an individual and $94,200 for a family of four) will be eligible for premium tax credits to help reduce the cost of coverage. In most states, companies with 50 or fewer employees will also be able to select plans through their state's small-business marketplaces.

Currently, 16 states and the District of Columbia intend to operate a state-based marketplace, while the remaining 34 states will have a federally facilitated marketplace. Seven of these 34 states will conduct plan management activities and/or consumer assistance and outreach functions in a state -- federal partnership model. Another seven of the 34 will conduct plan management activities only, and one, Utah, will operate the small-business marketplace while the federal government operates the individual marketplace


Here is a list of recent state and federal activity.

Action on state-based marketplaces


An audit of California's marketplace, Covered California, found it is on track for open enrollment to begin this fall. 

California's exchange has approved six insurers to sell plans on the small business marketplace. They are Blue Shield of Califronia, Chinese Community Health Plan, HealthNet, Kaiser Permanente, Sharp Health Plan, and Western Health Advantage. 

Anthem BCBS will not be selling plans in California's small-employer "SHOP" marketplace.

California may spend more than $300 million to support enrollment outreach and education. About $174 million will come from federal funds and about $130 will come from the California Endowment. 

Covered California announced $3 million in grant funds for education outreach

Covered California, in partnership with the private Sierra Health Foundation, has granted $1.5 million to three organizations to promote consumer outreach. The recipients are: California Family Resource Association, Healthy Community Forum for the Greater Sacramento Region, and Women's Health Specialists. 


Four insurers have submitted plans for approval to be sold in Connecticut's individual marketplace. After reviewing new data suggesting enrollees will be healthier than originally thought, HealthyCT, a new plan, recently resubmitted its proposal with lower rates, with the average single plan costing $271 per month. These rates are not yet final and are still under review. The three other insurers that will submit plans are: Aetna, Anthem Blue Cross Blue Shield (BCBS), and ConnectiCare. HealthyCT, Anthem BCBS, and United Healthcare have submitted plans for review to be sold in the small-group exchange.

ConnectiCare originally submitted plans to be sold in the small-group exchange as well, but has since withdrawn the submission, although it may sell in the small-group exchange in the future. 

District of Columbia

Washington, D.C., awarded a contract to MAXIMUS to run a call center for its marketplace.

Three insurers, Aetna, CareFirst, Kaiser, and United, have been approved to sell plan on D.C.'s individual marketplace. The average silver plan premium for a 40-year-old ranges from $247-$312 per month. 

Following United HealthCare and Aetna, Kaiser is the third insurer to drop premium rates for small-business plans sold through D.C.'s marketplace


Maryland released approved 2014 rates for its individual marketplace. According to the press release, some rates have dropped by as much as one-third. Nine insurers have been approved to sell on the exchange: Aetna, All Savers, BlueChoice, Care First of Maryland, Inc., Coventry Health and Life Insurance, Coventry Health Care of Delaware, Evergreen, Group Hospitalization and Medical Services, and Kaiser Foundation Health Plan of the Mid-Atlantic.

The rates can be found here.

The press release.


Massachusetts awarded $1.14 million in navigator grants to 11 organizations. 


In Detroit, Michigan, city officials are considering moving pre-Medicare retirees into the marketplace to save money.


In Nevada, four insurers, Health Plan of Nevada, Anthem, Saint Mary's, and Nevada Health CO-OP, have submitted plans to be sold through the marketplace. Proposed rates, which are currently under review, vary by geographic region, as in other states.


Organizations in Oregon have until August 9 to apply for $750,000 in grants to educate small businesses about the exchange and enrollment. 


Vermont's governor plans to have a financing plan for Green Mountain Care, a single-payer system, in front of the state legislature by January 2015. 


Four insurers have been approved to sell plan's on Washington's individual marketplace. They are: Bridgespan, Group Health Cooperative, Lifewise, and Premera BlueCross. 


Action on federally facilitated and partnership marketplaces:

The online broker eHealthInsurance will be allowed to enroll individuals in federally facilitated marketplaces.


In Alabama, BCBS and UnitedHealthcare have applied to sell plans on the federally facilitated exchange in all counties in the state. Humana has applied to sell plans in 50 of the 67 counties. 


Delaware has contracted with four community organizations, Brandywine Women's Health Associates, Christiana Care, Delmarva Foundation, and Westside Family Healthcare, to support outreach and enrollment activities

Delaware launched a new website for consumers


In Florida, 11 insurers have applied to sell plans in the individual marketplace and five have applied to sell plans in the small-business marketplace. Cigna and Florida Blue are two of the plans applying to sell in the individual marketplace.

Read a breakdown of insurers that have applied to sell individual and small-group plans in Florida, both on and off the marketplace. 

Read a breakdown of the number of insurers offering plans approved by the Florida insurance department, by county. 


See a list of awards granted to 44 in-person counselor programs in Illinois. 


Sarah Kliff explains how an average premium price quoted by Indiana for plans sold through the marketplace in 2014 may not be illustrative of what consumers can expect to pay

Anthem BCBS and Maine Community Health Options (CO-OP) have been approved by Maine to sell plans on the state's marketplace. Anthem recently formed a partnership with the Maine Health Network (a network of hospitals and providers) that was approved by the insurance department. 

Maine Community Health Options has applied to sell seven plans on the individual marketplace and five on the small-business exchange. Anthem has applied to sell 20 on the individual marketplace; information about plans to be sold on the small-business exchange has not been released. 


Humana became the first company to offer individual plans in 36 counties in Mississippi though the federally facilitated marketplace. 


Unitedhealthcare, Cigna, and Assurant Health have declined to sell plans in Missouri's federally facilitated marketplace in 2014. 


North Carolina has approved three insurers, Blue Cross and Blue Shield of North Carolina, Coventry Health Care of the Carolinas, and FirstCarolinaCare, to sell in the federally facilitated marketplace. BCBS of North Carolina has also applied to sell in the small-business exchange. 


South Dakota has approved three insurers, Avera Health Plans, Sanford Health Plan, and DAKOTACARE, to sell plans in the individual marketplace and federally facilitated small-business marketplace


The New York Times reports on what community organizations in Texas are doing to educate Texans about the federally facilitated marketplace. 



The Patient Protection and Affordable Care Act set a new income eligibility floor for Medicaid, expanding the program to cover all legal U.S. residents beginning in 2014 with incomes up to 138 percent of the federal poverty level ($15,856 for an individual and $32,499 for a family of four).

In June 2012 the Supreme Court ruled that states' participation in the Medicaid expansion was optional. A state may choose not to participate, forgoing the influx of new federal funds, but still maintain its traditional Medicaid program.

As of August 2, 2013, 22 states and the District of Columbia have indicated that they intend to expand Medicaid as it was written in the law; three states are pursuing or expressed an interest in a variation on the expansion; 21 states have indicated they will not participate; and four states remain undecided.

These updates highlight recent state-level action.


Idaho's Health and Welfare office is trying to prepare for a Medicaid expansion should one pass through the legislature, talking with private insurers about plans that they might offer a Medicaid-eligible population. 


The governor of Illinois signed the Medicaid expansion bill into law


The Iowa Health and Wellness Plan, which expands Medicaid and uses some federal funds to pay for premiums for some people in the state exchange, will be submitted for official approval by the federal government by August 20. 


An op-ed by Louisiana's governor lays out his opposition to Medicaid expansion. 


In Michigan, a Senate workgroup builds on the Medicaid expansion legislation passed by the House, adding additional reforms to the expansion. 


New Hampshire is awaiting recommendations from a commission, due in October, on whether to expand Medicaid

The commission is also looking into moving some newly eligible people to the marketplace



U.S. Government Accountability Office report: Private Health Insurance: The Range of Base Premiums in the Individual Market by State in January 2013

The Congressional Budget Office (CBO) estimates that the employer mandate delay will result in 1 million fewer people with employer coverage than was estimated by CBO in May 2013, and the cost to the federal government from 2014-2023 would be $12 billion.  

Request for Information on Nondiscrimination in Certain Health Programs or Activities Rule



July 31, 2013: Two States Reflect the Great Divide Between Red States and Blue

Missouri Citizens Face Obstacles to Coverage

Just when you thought that the voters in North Carolina may have broken all records for group insanity in turning their state over to TeaParty-Republicans last November, Missouri gives us a reminder of George Carlin's old adage: "Never underestimate the power of stupid people in large groups."

 JEFFERSON CITY, Mo. -- Looking for the new health insurance marketplace, set to open in Missouri in two months, is like searching for a unicorn.

The marketplace, or exchange, being established by the federal government under President Obama's health care law has no visible presence here, no local office, no official voice in the state and no board of local advisers. It is being run like a covert operation, with no marketing or detailed information about its products or their prices. While states like Colorado, Connecticut and California race to offer subsidized insurance to their citizens, Missouri stands out among the states that have put up significant obstacles. It has refused to create an insurance exchange, leaving the job to the federal government. It has forbidden state and local government officials to cooperate with the federal exchange.

It has required insurance counselors to get state licenses before they can help consumers navigate the new insurance market. And, like many states, it has refused to expand Medicaid.

"It's like running an obstacle course every day of the week, but the course changes from day to day," said Herb B. Kuhn, president of the Missouri Hospital Association, a strong advocate of expanded coverage.

Over 850,000 Missouri residents, including low-income people in St. Louis and Kansas City, family farmers and small-business employees, are uninsured. Many could qualify for coverage through the exchange, which encourages competition and offers subsidies to reduce costs.

People in Missouri have not seen any evidence of the federal exchange -- how it will be run, how it will be structured in Missouri. Will it be run from Jefferson City? Will it be run from Washington? Who will watch over it? No clue.

Missourians want to know: "Where do we go to purchase health care coverage? How much will it cost us? If we can't afford it, what then?"

Private foundations and community groups have stepped into the vacuum. Ryan Barker, vice president of the Missouri Foundation for Health, said his organization planned to spend $8 million this year on a campaign to secure coverage for 200,000 of the uninsured. "The state government is not doing a whole lot, its hands are tied, so we are taking on a bigger role," he said.

Jennifer G. Bersdale, executive director of Missouri Health Care for All, a grass-roots organization, has been educating thousands of people about what she sees as an exhilarating prospect. "People who have been shut out of the market for years will soon be able to get good insurance, cannot be denied because of pre-existing conditions and can get financial assistance to afford it," she said.

Missouri is one of a handful of states where the federal government directly enforces the consumer protections of the Patient Protection and Affordable Care Act (affectionately known as "Obamacare") because the state lacks the authority to do so. In 2010, Missouri voters overwhelmingly approved a ballot measure expressing opposition to the federal requirement for most Americans to have health insurance. In November 2012, voters approved a ballot measure that prohibits the governor and other state officials from establishing or operating a state-based insurance exchange unless authorized by a vote of the people or by the state legislature. The measure says state and local officials cannot provide "assistance or resources of any kind" to a federal exchange unless such assistance is specifically required by federal law. It authorizes taxpayers and state legislators to sue state and local officials who flout its restrictions. The threat of such lawsuits has made local officials cautious.

Gov. Jay Nixon, although a Democrat, said debate on the ballot measures had been highly political. He has held dozens of events to promote the expansion of Medicaid, stressing its economic benefits for the state. But Republicans hold two-thirds of the seats in each house of the legislature.

"A core principle of public health is to increase access to health care," said Josephine P. Waltman, the health officer for Phelps County. But, she said, the ballot measure limits what local officials can do and is forcing them to consult lawyers. As a result, Ms. Waltman said she and her staff would distribute general information about the insurance exchange, but would not sit down with people at computers to help them choose health plans and see if they qualify for subsidies. "I would love to do that," she said.

But on the flip side ...in a state with a rising progressive attitude (not to mention far less incipient anti-Obama racism that still holds so much sway, blinding Missourians to vote against their won best interests in southern Missouri and other rural areas) ... there is Colorado.


Colorado Presses for Uninsured to Enroll

DENVER --Television commercials have already run suggesting that buying health coverage through the state’s new insurance market, Connect for Health Colorado, will feel like winning the World Series.

The market's employees are traveling the state to explain how it will work, often in electric yellow T-shirts with the message, "Got Insurance?" In the coming weeks, 400 guides will be trained to help the uninsured sign up for coverage, with some targeting groups like Hispanics, gay and lesbian citizens, and even truckers.

This is Colorado, five months before the central provisions of President Obama's health care law take effect: a hive of preparation, with a homegrown insurance market working closely with state agencies and lawmakers to help ensure the law’s success. Gov. John W. Hickenlooper, a Democrat, is a firm supporter, and the state legislature, controlled by Democrats, has not thrown up any obstacles.

When the legislature voted to allow a state-based insurance market in 2011, Republicans controlled the House of Representatives, but many supported the bill, contending that it would give Colorado more control over how the health care law played out here. This spring, state lawmakers voted along party lines to approve an expansion of Medicaid, which is encouraged but not required under the law.

The law does have opponents in Colorado, but they can do little to stop the Democrats from carrying it out. In February, Republicans even helped kill a bill that would have repealed the law allowing the insurance market.

"There's politics everywhere these days," Mr. Hickenlooper said in an interview, "but for the most part, we've really been focused on how to do this right, and trying to make sure that people have affordable health care."

Connect for Health has received about $180 million in federal money to be up and running by October 1 and to cover the first year's operating costs.

Much of the work involves building the Web portal through which people who do not get insurance through their job can buy coverage. Colorado residents will be able to shop for insurance plans and compare them on www.connectforhealthco.com, and determine whether they qualify for federal subsidies to help with the cost. The portal has to be able to exchange information in real time with insurance companies, state agencies and the federal government, which is building a "data hub" through which it can verify income and citizenship.

Contractors have almost completed work on the portal, said Patty Fontneau, executive director of Connect for Health. Testing is under way to make sure it will function properly when it opens for business in just two months. "Will it be perfect?" Ms. Fontneau said. "Unlikely, but we have the right team in place to ensure that we're going to be open and running, and as close to perfect as could be, on October 1."

Connect for Health has announced which insurers want to sell plans through the market -- more than a dozen companies, including most of the state's biggest insurers -- and their proposed rates. Colorado's Division of Insurance will announce the final rates this month.

The biggest remaining task is letting roughly 760,000 uninsured Coloradans know the new marketplace exists, and persuading those who qualify to buy coverage through it. That is what the ads are for, and what people like Jessica Dunbar are spending most of their time trying to do. She is the individual market manager at Connect for Health, and her job is getting the word out.

Ms. Dunbar spent one evening explaining the law's basics and how the market will work, to a small group at the Central Park Recreation Center in Denver.

"We're trying to connect people to a healthier way of life through secure health insurance coverage," she said, encouraging her audience to share stories of why insurance matters to them. She told them about Connect for Health's Web site and explained how to use a calculator on the site to find out how big a subsidy they might qualify for.

Connect for Health needs Obamacare enthusiasm to spread, and fast. At a brainstorming session, members of an outreach advisory group suggested contests for designing T-shirts and posters to advertise the marketplace, and apps to explain how it works. State officials were among those tossing out ideas: Vincent Plymell, a spokesman for the Division of Insurance, suggested having games for children at promotional events so that parents could focus on learning about Connect for Health.

Mr. Hickenlooper said he would lend his voice to the publicity campaign if people thought it would help, adding that he was "nervous as a cat" about making sure the marketplace succeeded. "We'll do whatever it takes," he said. "I'll ride around the state on a bicycle if I have to."



July 1, 2013:

Jeanne's Weakly Lawyer Jokes for the Week of July 1, 2013

Lawyer versus Lawyer (part 2)

The two partners in a law firm were having lunch when suddenly one of them jumped up and said, "I have to go back to the office -- I forgot to lock the safe!"  The other partner replied, "What are you worried about?  We're both here."

... for the rest go to: http://www.health-politics.com/humor.html#07-01-13



June 30 2013: Red States Committing Fiscal Suicide (and actually killing many of their citizens) in the Name of Fighting Obamacare

On the one-year anniversary of the Supreme Court ruling that says states would not lose their entire Medicaid funding if they decided not to expand the program, the nation is closely divided. With the fiscal year beginning in most states on July 1, many have decided whether or not to expand eligibility for adults starting on Jan. 1, 2014, as allowed by the health care law. So far, only 23 states and the District of Columbia have announced they will expand eligibility. Another 22 have either said they will not expand or appear unlikely to expand on Jan. 1, while a handful remain unsettled.

Because there is no deadline to expand, state officials could change their minds later this year or decide next year to start offering expanded coverage in 2014 or 2015. And there is nothing to prevent states from starting their Medicaid expansion programs on another date -- say, a year from no -- as some new fiscal years start on July 1, 2014, not January 1. But states that expand later will lose some of the benefits of federal financing. The Centers for Medicare and Medicaid Services (CM2) will cover all of the costs for newly eligible adults for the first three years, but that phases down afterwards. In 2020, the federal matching rate will decline to 90 percent, where it is supposed to remain. Obamacare (PL 111-148, PL 111-152) allows states to expand Medicaid for people with annual incomes of up to 138 percent of the federal poverty level.

The year has brought surprises, such as the announcement by nine GOP governors that they would support expansion. Arizona TeaPartyGOP Gov. Jan Brewer, who had been considered a favorite by conservatives until she backed expansion, went so far as to veto unrelated bills and call a special session until she got her way.

Expansion Advocates Still Pushing

Advocates for the expansion are still hoping the issue can succeed, one way or another. In Montana, a state where the level of support for expansion was very close in the state Legislature and Democratic Gov. Steve Bullock backed it, a coalition of advocates is trying to get the issue on the 2014 ballot. In Maine, the Legislature has passed an expansion, but Republican Gov. Paul R. LePage vetoed the legislation, and the Legislature does not have the votes to override it.

Among the states that are left, Ohio seems to have the strongest chances for passing an expansion. State officials have warned that implementation could take up to six months there, but supporters say they believe the state potentially could still be ready on January 1.  "I'm feeling pretty good about Ohio, that it'll get done in time for a January 1 implementation," said Georgetown University Center for Children and Families Senior Fellow Tricia Brooks, who visited the state last week. "Is it ideal to have six months to plan?," she added. "Once the legislature has signed on, you can do expedited administrative rules," she said, noting that IT systems for Medicaid are already being updated nationwide. "Would it be challenging? Yeah. ... I think you could do it in three to four months, if you really wanted to make it happen."

One thing that could make expansion more complex in Ohio is that Gov. John R. Kasich is interested in using Medicaid dollars to buy coverage in the exchange for at least some beneficiaries. Arkansas also has pursued a similar approach and released a copy of its proposal recently. CM2 officials are reviewing it and previously indicated that they did not have major problems with the concept. Other states, such as Michigan, could end up looking to that type of plan as a way to expand eligibility.

Here is a state-by-state guide of some states to watch

-- Florida: The state's hospitals are planning a major lobbying push to try to persuade Republican Gov. Rick Scott, who announced in February that he supports the expansion, to call a special legislative session this fall and to persuade lawmakers to accept expansion. Florida's regular session ended in May without an authorization for expansion.  The state Senate had supported legislation that would allow the more than 1 million Floridians who would qualify for coverage to use Medicaid dollars for private coverage through a program called "Healthy Florida."  But the House did not approve it.  Advocates for expansion see a chance that Scott could call a special session in September, when lawmakers will be back in Tallahassee for committee meetings. So far, Scott has not indicated that he will schedule a special session. The governor told reporters in Florida last month that "unless the House is going to make a change in their decisions, it wouldn't make sense to have a special session."

-- Indiana: Republican Gov. Mike Pence is open to expansion if it can be operated much like the current Medicaid program, Healthy Indiana. That program, which was approved through a waiver and is expiring at the end of the year, offers beneficiaries a set amount of coverage, like a health savings account.  Policy experts doubt CM2 officials would allow the newly eligible group to be covered in that way. "The administration is not real keen on that," said Matt Salo, executive director of the National Association of Medicaid Directors. "They certainly have not signaled any interest in doing the Indiana version. If that's what Indiana is going to hang its hat on, they may be waiting a long time."

-- Michigan: Republican Gov. Rick Snyder, who supports expansion, has been touring the state to put pressure on the Senate to approve authorization of the Medicaid expansion, which the House passed earlier this month. Snyder called on the state Senate to "take a vote, not a vacation." The legislature meets year-round and will come back after a break. Meanwhile, a half-dozen GOP senators said they will meet over the summer to try to work out a solution.

-- New Hampshire: Democratic Gov. Maggie Hassan still hopes the legislature will pass an expansion this fall. The House supported it. But the legislature recently approved a state budget, which Hassan supported, that puts off the Medicaid decision by creating a commission that is supposed to study the issue, with a report due by October 15.  "I am confident that once the study is complete the legislature will seek to move quickly to implement expansion through a special session in order to improve the health and financial wellbeing of our citizens," Hassan said in a June 26 statement about the budget and the Medicaid legislation. Spokesman Marc Goldberg said the governor believes that the expansion could be implemented within a few months. The vote in the legislature is "really close, and it's a little hard to judge exactly who they might be able to move," said Georgetown's Brooks, who is a New Hampshire resident. "I still think there's hope in New Hampshire, and in time for Jan. 1. But I'm not sure I'd put as much money on it as I would in Ohio."

-- Ohio: Republican Gov. John Kasich is pushing hard for an expansion. He is backed by a large coalition of health industry officials, employers, and religious groups. Republican legislators have been reluctant so far, and stripped Kasich's plan to expand Medicaid from the two-year state budget. But the legislature meets throughout the year. In recent weeks, Kasich has been making a moral argument, according to The Columbus Dispatch, which recounted a conversation that Kasich said he had with a legislator. Kasich is quoted as telling the lawmaker, "I respect the fact that you believe in small government. I do, too. I also know that you're a person of faith. Now, when you die and get to the meeting with St. Peter, he's probably not going to ask you much about what you did about keeping government small. But he is going to ask you what you did for the poor."

-- Pennsylvania: The Pennsylvania legislature, which is controlled by Republicans but closely divided, meets throughout the year, and backers of expansion hope that Republican Gov. Tom Corbett will come around to the idea of supporting an expansion.  Corbett initially resisted expansion in Pennsylvania. But after Secretary of Public Welfare Gary Alexander, a critic of expansion, left his post several months ago, Corbett's administration has been holding talks with CM2 officials. Advocates, including hospital groups and the seniors group AARP, are pushing state officials to support expansion.

-- Tennessee: Some policy experts are watching to see if action emerges in Tennessee, but the state looks like a long shot to expand Medicaid by January 1. The legislature is out of session. Republican Gov. Bill Haslam has expressed some support for the idea of using Medicaid dollars for private health insurance. Salo said that what Tennessee officials really want is permission to expand Medicaid for part of the newly eligible population -- an idea that CM2 officials have clearly rejected. "What Tennessee is saying ... is, are we going to do an expansion this way, with partial expansion, or nothing? Wouldn't you rather have people covered?" said Salo, outlining the state's position to CM2 officials. "Tennessee is holding out hope that this argument is strong enough to give them what they want. Will it be? If I'm a betting man, I'd say no, but that's way above my pay grade."


June 27, 2013: "Killing Granny" Through Comparative Effectiveness

You remember "comparative effectiveness" ... the provision in Obamacare (copied from the 2003 Medicare Modernization Act" and extended to all health care ... the provision that so exorcised Sarah Palin and others to declare Obamacare would "kill granny" by rationing her care and send her to appear before a "death panel?" Of course you do, it is one of the most blatant and virulent of Obamacare lies ... and one that refuses to die ... never mind the fact that it was first proposed by Republicans and embraced by George W. Bush and John McCain during his 2008 presidential run. These slides are from my 2010-2011 presentations:









Just another good Republican idea gone bad because Obamacare embraced it.  ISPOR, majority funded by the American for-profit health insurance industry, has been pushing for "comparative effectiveness" and "outcomes research" for over a decade now. It is the future of American, indeed worldwide, health care and everyone needs to understand exactly what it means for all of us.



June 26, 2013: EHR: More Dangerous? More Difficult? More Error-Prone? Too Expensive

I spent the morning today at the office of my pulmonologist (as an Arizonan, I have had coccidioidomycosis ... affectionately known by southwestern desert denizens as "Valley Fever") and because he knows almost all (but not all) the terrible things I have done in my life, like being one of the principle lobbyists who drafted and pushed through to enactment a little law ... the Health Insurance Portability and Accountability Act of 1997, otherwise known as "HIPAA," I spent at least 20 minutes of the half hour he shared with me, hearing his litany of complaints about the requirements imposed on his practice by the law ... electronic medical records. Among his many complaints: the cost, where, despite installing a whole new EHR system with some financial support from the 2009 "stimulus" bill, his group's system today cannot "communicate" with the cardiology practice one floor down in the medical office building they occupy in Mesa. And neither his practice or the cardiology group downstairs is prepared to incur the costs to make the two system interoperable. His second complaint, the difficulty of using the system ... changing his modus operandi in practice ... the complexity of entering and cross-checking data, identifying and correcting entry errors ... the time he has to spend in the process.  He did NOT order a hysterectomy for the 72-year old male patient he saw last week. He said that his group is actually considering "paying the penalty" for not adopting the new Obamacare requirements ... the penalty being a reduction of around 2% in Medicare reimbursement, as simply being less expensive and less time-consuming than compliance.

Electronic health records are supposed to improve medical care by providing physicians quick and easy access to a patient's history, prescriptions, lab results and other vital data. While the new computerized systems have decreased some kinds of errors, such as those caused by doctors' illegible prescriptions, the shift away from paper has also created new problems, with sometimes dire consequences.

Drug Doses

Dangerous doses of drugs have been given because of confusing drop-down menus; patients have undergone unnecessary surgeries because their electronic records displayed incorrect information; and computer-network delays in sending medical images have resulted in serious injury or death, according to a study published in 2011 based on reports submitted to the U.S. Food and Drug Administration. According to a study published in December by the Pennsylvania Patient Safety Authority, the number of reports about medical errors associated with electronic records is growing. Of 3,099 incidents reported over an eight-year period, 1,142 were filed in 2011, more than double the number in 2010.

Digital medical records, a cornerstone of U.S. President Barack Obama's push to modernize the nation's health-care system, are increasingly common at the doctor's office. About 69 percent of U.S. physicians said they used these electronic records in 2012. That number is likely to grow as the government dangles bonuses for early adopters and imposes penalties starting in 2015 for those who don't upgrade.

$24 Billion Market

The electronic-medical-records market generated an estimated $24.2 billion in revenue globally last year and will grow an average of almost 10 percent a year through 2015, according to Accenture Research. The biggest providers of these systems are Epic Systems Corp., McKesson Corp., Cerner Corp., Allscripts Healthcare Solutions Inc. and Siemens AG. [Jeanne's Moment of Truth: I have done consider legal work over the years for McKesson and Siemens, but am no longer affiliated with eithher company.] Digital records have dramatically reduced some common medical errors. More than 17 million medication mistakes are now avoided in the U.S. each year because of hospitals' use of computerized prescription-ordering systems, according to a study published in February in the Journal of the American Medical Informatics Association. In such systems, sloppy handwriting is irrelevant, and doctors get pop-up alerts when attempting to prescribe dangerous drug combinations. "I would never go back to paper charts -- clearly electronic records are better," said Leora Horwitz, a doctor and assistant professor of medicine at Yale University School of Medicine. "But while they're good, they're so far from great it's astonishing."

Nurses Complain

Last month, nurses at Marin General Hospital in California complained about an electronic medical-record system made by McKesson that they said was causing medications to be ordered for the wrong patients. Jamie Maites, a spokeswoman at Marin General, said the hospital has made "significant progress" in dealing with the issues. The rollout has been "challenging," yet "has resulted in a safer hospital for our patients," she wrote in an e-mail. Kris Fortner, a spokesman for McKesson, said the company is working with Marin General to address the concerns. "Aside from some initial issues related to changes in nursing workflow, feedback from Marin's leadership to McKesson about the implementation has been positive," Fortner wrote in an e-mail. 

Epic Systems was the target of criticism last year by nurses working in Contra Costa County, near San Francisco. They complained that glitches in the county's $45 million system, such as medications disappearing from electronic files, were endangering patients' lives.

My pulmonologist echoed these complaints and added his own ... current systems do not always recognize potential conflicts in drug or physician orders ... in the past, he said, he might get a call from a nurse, saying "Doctor, do you really want to order this?" or "Dr. Jones is ordering something, do the two of you need to get together and decide if this is O.K.?"  Today, the nurses don't see the whole electronic record as they used to see all the physician's handwritten orders ... and  the potential problem some times goes undetected.

Human Error

In one month, 129 complaints were filed by nurses at county detention facilities, where the problems were most acute, according to Jerry Fillingim, labor representative at National Nurses United. Some problems in Contra Costa arose because of human error -- medications were entered incorrectly into the Epic system when it went live, said Rajiv Pramanik, chief medical information officer for the county. There has been "dramatic improvement" among staff members in using the technology and the system's "strengths are tremendous," he said.

Records Exempted

Unlike U.S. medical-device makers, which must report all malfunctions, serious injuries and deaths involving their products to the FDA, software companies that make electronic medical records are under no such requirement. As a result, little is known about the risks of their systems, since there is no central database of error reports and makers of electronic records often prohibit customers from discussing unsafe processes. That practice creates "unacceptable risks to safety," according to a 2011 report from the Institute of Medicine of the National Academies.

One of the most comprehensive studies on the topic examined adverse-event reports submitted to the FDA from January 2008 to July 2010. Of 899,768 reports, 436 unique events involved health information technology, including electronic records, and 46 were associated with patient harm, including four deaths, according to the study, entitled "Patient Safety Problems Associated With Healthcare Information Technology."  "People are still in fantasy mode that just by putting technology into health care it will make it better -- and that's not real," said Enrico Coiera, professor at the University of New South Wales in Sydney and co-author of the study.

Voluntary System

Much of what is known is through voluntary reports. "The emphasis on doctors self-reporting errors is ludicrous," said Ross Koppel, adjunct professor of sociology at the University of Pennsylvania and co-author of a 2005 study that found a widely used electronic prescription-ordering system contributed to 22 types of medication errors. "When a locomotive crashes into two apartment buildings, we know about it," he said. "When a patient gets the wrong med, we seldom know about it." Cerner, one of the industry's big players, voluntarily reports problems with its technologies to the FDA even for unregulated products such as electronic records, said Megan Moriarty, a spokeswoman at the company. Customers are permitted to disclose safety issues to "appropriate entities" or in "professionally appropriate venues," she wrote.

Government Oversight

Siemens, based in Munich, submits required adverse-event information to the FDA and doesn't prohibit customers from disclosing problems, Matthias Kraemer, a spokesman, tells us. The company is assessing how to appropriately submit voluntary reports to the FDA and already has a "mature" system in place for customers to report problems with its regulated and unregulated technologies, Kraemer said.

While the FDA doesn't regulate the electronic records, the Office of the National Coordinator for Health Information Technology, part of the U.S. Department of Health and Human Services, is overseeing the rollout of the systems and sets the safety standards. "So far, the evidence we have doesn't suggest that health information technology is a significant factor in safety events," said Jodi Daniel, director of ONC's office of policy and planning. "That said, we're very interested in understanding where there may be a correlation and how to mitigate risks that do occur."



June 25, 2013: Sebelius: O.K. Red States, Under Obamacare's Directly Run Federal Exchanges "We Will Negotiate the Rates"

Hoping to get consumers the best prices, the Obama administration is negotiating with insurers looking to sell policies in online health insurance marketplaces this fall, Health and Human Services Secretary Kathleen Sebelius said Monday. "Negotiations are underway and we will be negotiating rates across the country," Sebelius said at a news briefing. HHS officials said last year they would not operate the federally-run exchanges using the "active purchaser" model -- meaning they would not bar insurers that offered rates they deemed uncompetitive. HHS is operating exchanges in about 35, mostly red states. states starting October 1. Congress gave federal and state regulators the option to work as "active purchasers," and California and five other mostly blue states chose that model.

Consumer advocates prefer an "active purchaser" approach because they believe it will increase competition and lower prices among plans. But the Obama administration -- in yet another example of Obama's "capitulation" to right-wing business groups and pressure (proving just how bad a "socialist" he is) -- opted against that after being lobbied by insurers and business groups who said they prefer the "open market" model because it ensures greater competition.

HHS last year said it would take all insurers that apply to sell policies in the federally run exchanges for at least the first year of open enrollment that runs from October through March. Negotiating with insurers is a more subtle approach, said a senior health official speaking on background. He said insurers are being told by HHS if their rates are "outliers" as compared to others'. When that occurs, he said, the federal government is asking insurers if they have submitted the correct rates. "The process is really to make sure the information is accurate and we will be providing plans an opportunity to see what is posted before they become public," the health official said. [Just another example of the heavy-handed Obamacare socialism at work.]

Joel Ario, a fomer Obama administration who is now managing director of consulting firm Manatt Health Solutions, said negotiations between HHS and the carriers could be a win for both consumers and insurers "In a marketplace where some insurers know they priced at the high end of their actuarial range, feedback from regulators that allows them to reconsider their pricing might be a welcome opportunity," he said.  Sabrina Corlette, project director at the Health Policy Institute at Georgetown University in Washington, pointed out the Obama administration may be limited in such efforts by the fact that many states have only one or two carriers in their individual or small group insurance markets. "States like Mississippi are struggling to get more than one insurer to participate in the exchange," she said. But in other states where there are four or five insurers, she said, HHS will have more leverage.


June 24, 2013: The Blues to the Rescue: Blue Plans Will Dominate in the Obamacare Exchanges; United, CIGNA, Aetna, Not-So-Much

At a closed White House meeting in April, President Barack Obama told corporate insurance bosses "we're all in this together" on implementing his signature health law. But some insurance companies seem to be more in than others. At least five Blue Cross and Blue Shield executives sat at the table of about a dozen CEOs with the president, according to those knowledgeable about the session. Just as significant is who wasn't there: chiefs of the country's biggest and third-biggest health insurers, UnitedHealth Group and Aetna.

Those two and most other non-Blue insurers "seem to be proceeding cautiously" in the online marketplaces expected to cover to millions, said David Windley, who follows the industry for Jefferies & Co., an investment firm. "They are evaluating markets state by state and in some cases region by region within the state to assess the viability of all the different pieces."

But Not the Blues. They're expected to offer health-exchange plans nearly everywhere, ensuring at least a minimum choice for individuals seeking subsidized coverage when the marketplaces open October 1. It also makes them an undeclared Obama ally in implementing the health law. "The Blues will definitely participate," said Ana Gupte, an insurance stock analyst for Dowling & Partners. "If there is an exchange I'm sure there will be the Blues."

The exchanges are online marketplaces that will operate in all 50 states, offering insurance plans for individuals and small businesses. The individual market has long been a high-risk, unstable business that some insurers never sought. The health law -- with its mandate that could bring younger, healthier people into the pool and its subsidies -- seeks to stabilize the individual market. But if few other insurers follow the Blues into those markets, consumers in those states may not see the same kind of competitive pricing of premiums that states like California, Oregon and Maryland.

Still, it's not just that Blues will offer coverage in places other carriers may avoid. In states where Republican governors oppose the health law, Blues may be the single biggest factor in educating consumers and recruiting them into Obamacare. In Louisiana, where Gov. Bobby Jindal has flatly said "we are not implementing the exchange," the local Blues plan has organized community nonprofits, churches, chambers of commerce and food banks to get out the word on what will be a federally run marketplace there.

BlueCross BlueShield of Louisiana "is the driving force" behind the Louisiana Healthcare Education Coalition, launched in March, said Nebeyou Abebe, who works on consumer engagement at the Louisiana Public Health Institute. "I can't think of any other entity in Louisiana that’s developing a massive campaign to educate people."

The Concerns Of Insurers

The Patient Protection and Affordable Care Act (affectionately known by one and all as "Obamacare") requires exchange plans to cover anybody, no matter how sick, at regulated prices and often with large government subsidies.

Despite the prospect of millions of new customers and measures to cushion insurers with disproportionately high claims in the early years, carriers worry that the sick will be first to sign up while the healthy stay away. Fears grew after claims came in far higher than expected for temporary "high risk pools" that had been established by the law to cover the chronically ill until the full law took effect in 2014. The shortfall prompted the plans to close enrollment early. "Insurance companies, very suddenly in my estimation, are getting very conservative and hesitant about being in the exchanges," said Robert Laszewski, a Virginia-based consultant and former insurance executive. "All along everybody, including the companies, assumed they would be in a lot of exchanges."

UnitedHealth Group's recent disclosure that it would offer plans in only a dozen state exchanges marked new disappointment for those hoping the exchanges will generate vigorous competition and new insurance for millions. UnitedHealth Group CEO Stephen Hemsley earns upwards of $15 million a year and he doesn't want to risk losing that money-train.  Previously United had said it would sell on as many as 25 exchanges. The company will "watch and see" how exchanges work, "approaching them with some degree of caution," Hemsley told analysts last month.

Aetna plans to offer individual exchange policies in just 14 states and may reduce that if some states look unprofitable or unprepared, CEO Mark Bertolini, whose salary and bonuses tripled last year to more than $36 million,  said on a conference call in late April. On June 17 Aetna disclosed it would stop selling individual insurance in California, the most populous state.

For its part, CIGNA, whose CEO earned $12.5 million last year, will focus on making exchange plans work well in just five states rather than spreading efforts more thinly, said Ray Smithberger, who's in charge of the company's individual business. "What you see in the general market is just a hesitancy" over whether states will be technologically ready, he said in an interview. "With condensed time frames, it's important that we provide the right connectivity to ensure we're providing the best experience for the customer." (Translated this means the company is not sure it can reap sufficient profits and meet its investor profitability goals.)

Although not every state has announced online marketplace participants, the Blues characterize their approach very differently. "We expect Blue Cross Blue Shield plans will have a strong, reliable presence in the new exchanges," said Alissa Fox, a senior vice president at the Blue Cross and Blue Shield Association. "We've been in this market for more than 80 years and we've been providing coverage in every zip code to everybody. We imagine we will continue to do that." Five Blues executives attended the meeting with Obama on April 12 to coordinate exchange implementation: Scott Serota, CEO of the Blue Cross and Blue Shield Association; Florida Blue CEO Patrick Geraghty; Chet Burrell, CEO of CareFirst BlueCross BlueShield, with plans in Maryland and D.C.; Patricia Hemingway Hall, CEO of Health Care Service Corp., with Blues plans in four states; and WellPoint CEO Joseph Swedish. WellPoint is the No. 2 health insurer and operates Blues plans in 14 states.

The White House declined to release the full list of attendees. Nor does it comment "on the role of one company or provider" in implementing the health act, a spokeswoman said.

Protecting Their Business

Blues aren't the only alternative to national commercial insurers. In many states there are regional nonprofits such as Group Health Cooperative in the Northwest or Presbyterian Health Plan in New Mexico, And the drive to build new "health CO-Ops" is growing in several states. But for health coverage sold directly to consumers -- the kind that will be offered on the exchanges -- Blues have the most members in a large majority of states.

Protecting that business is why Blues have little choice but to offer plans in the online marketplaces, analysts said. If they abstain, they risk losing those members. Once in the game, they need to recruit as many customers as possible to avoid signing a disproportionate share of the sick.

Florida Blue, which owns about half the market in that state for individual insurance, intends to use its 11 recently opened retail centers to get out the word and will rent temporary storefronts in key neighborhoods, said Jon Urbanek, senior vice president of commercial markets for the company. Florida Blue will double the size of its call center to 200 employees as October approaches, he said. "In campaign terms, it's a get-out-the-vote type of approach," said Michelle Riddell, vice president of community investment for BlueCross BlueShield of Texas.

Like the Louisiana Blues, the Texas Blues are educating and recruiting exchange customers with little cooperation from the state. Texas and Louisiana are among 33 states leaving exchange implementation to the federal government amid questions about whether it has the resources to educate a broadly ignorant public. The Texas insurer's Be Covered Texas team includes Habitat for Humanity, diabetes groups, churches, social services nonprofits, the NAACP and community clinics -- all putting out the Obamacare word in the state with the highest percentage of uninsured people in the country.

The campaign includes a Web site, a texting campaign and community events planned through the rest of the year. A Blues official recently spoke to the Houston congregation of Windsor Village United Methodist Church, which has more than 16,000 members. Food bank grocery bags bear printed information about health insurance. Barber shops are seen as health information hubs. Be Covered Texas doesn't mention Blue Cross, presenting itself as a grass-roots program. Health Care Services Corp., the parent of the Texas Blues, hasn't disclosed how much it is spending on the Texas effort and similar outreach by its Blues plans in New Mexico, Illinois and Oklahoma.

"I view this as a three-year project," said Bert Marshall, president of BlueCross BlueShield of Texas. "I think the education piece is going to last well beyond this enrollment and well beyond the next." With his company holding more than half of the Texas individual insurance market, Marshall believes an early and extended campaign is a good investment. His competitors seem to have a different view.

"The Blue Cross plans ... are going to be in the exchanges because it's part of their DNA," said Laszewski. "But the rest of the marketplace, if you go look at their block of individual business, it's small, and it's probably losing money."


Jeanne's Weakly Lawyer Jokes for the Week of June 24, 2013

Lawyer versus Lawyer

Pete and Jerry had been law partners for many years.  One day, Pete fell ill, and grew progressively worse.  Medical specialists were called in from the world over, but no one could diagnose Pete's illness.  The only thing that seemed certain was that Pete's death was imminent.  As Pete lay in his last hours, he felt obligated to reveal a few secrets to Jerry.  "You know that million dollar settlement we got from Morgan last year?  I never told you this, but it was really three million.  I kept the other two million, and eventually gambled it away.  Can you forgive me?" ...

for more go to: http://www.health-politics.com/humor.html#06-24-13


In case you haven't noticed, the question of "reforming US health care" has been the dominant issue in my professional career over many years. After all, I spent 9 years working for the nuns at the Catholic Hospital Association ("CHA") ... and those gals were all communists.  Indeed, my old electronic newsletter, the humbly-named "theJeanneScottletter" had been subtitled: "Implementing Health Care Reform" from its first issue almost 19 years ago. The questions of "US health care reform" and "universal health care coverage" have ebbed and flowed over these many years on the political spectrum. Today, the issues of "Medicare insolvency," repealing Obamacare, and/or enacting "Vouchercare," rank in the top 5 on that spectrum, trailing only "jobs" and the economy.   Underlining these debates has always been the sometimes subtle, sometimes overt issue of "health care rationing." Sarah Palin rose to the top of the political right-wing wacko scale with her cries that the new Patient Protection and Affordable Care Act" (PPACA, or jas it is affectionately known by one and all. "Obamacare") would end up "killing granny" by rationing health care services to the elderly. 

TeaParty/Republicans now control the U.S. House of Representatives and are only 4 votes shy of taking over the Senate as well. And they have a plan: VOUCHERCARE.  House Majority Whip Eric Cantor (T/R-Va.) has now, in essence, admitted to the whole world that the House-passed and Senate-blocked (by those very same 4 votes) plan to unravel Medicare and replace it with Vouchercare, which will, in essence, promote rationing that would mean some seniors would die for lack of treatment.

Cantor admitted that treatment would be based on the ability to afford different levels of coverage. It was a rather shocking admission - considering that Ryan is still implausibly claiming that his voucher (coupon) approach to Medicare will not cut back on access for seniors. Yet, Cantor's rare candor went all but unnoticed by the corporate mainstream press. The reality is that the TeaParty/Republicans have created the illusion that private medical insurance is universally generous and all-encompassing in its coverage. Nothing, however, could be further from the truth.

Private insurance is as varied as a used car warranty, and most Americans cannot afford medical insurance that is all-encompassing. Private insurance, except for top executives and the wealthiest, is trending toward higher deductibles, more restricted coverage and more vigorous challenge to claims. For most people, even with private, for-profit insurance, health care is rationed right now.

Even for Medicare as we know it, there are restrictions, premiums, deductibles, co-pays, supplemental policies etc. Many seniors, under Medicare, cannot afford prohibitively priced life-saving drugs.

In short, there is no medical insurance in the United States that does not ration care, and Medicare, in fact, is the fairest, regardless of income. As I have noted repeatedly in my presentations, particularly over the past 6-7 years, Medicare is far cheaper to run than private health insurance. True Medicare faces a near term insolvency, around 10 years, but that is because the effective rates that Medicare can charge seniors (both in the FICA/Medicare tax rate that is supposed to pay for Medicare Part A, and in the premiums seniors are charged for Medicare Parts B and D) have been frozen or capped in the low single digits.  Private insurance companies, on the other hand, are making record profits in part by raising annually the premium rates they charge employers and individuals, by double-digits.  If Medicare could raise it rates by the same factors, Medicare would be solvent and maybe even returning a profit to the federal government just as these private insurers are making today. But  for most middle-income Americans, that's not what we want from our health care system.

Cantor and Ryan believe that the wealthy are entitled to more extensive, life-saving and routine health care, because they have earned it. But the health of a nation is dependent upon the health of its people, and not just its largest income earners.



June 20, 2013: Medicare Moves to Stage 2 of "Competitive Bidding" ... and the Private Sector Bitches That the Government Using a Free Market Bidding Process Sucks ...

A major change in US Medicare reimbursement rules beginning July 1 will save money but will drastically limit the number of vendors from which beneficiaries with diabetes can obtain glucose-testing supplies. There are fears in some quarters that this disruption may lead to people not accessing the supplies they need, resulting in a decline in self-monitoring of glucose and subsequent adverse outcomes. However, others stress that diabetics receiving Medicare will gain financially, as their co-pays for their supplies will drop. Independent retail pharmacies are also concerned: they believe the price cuts will mean many of them will drop out of providing these services, with the resulting loss of face-to-face interactions between pharmacists and patients, which can be of immeasurable benefit, they say. And patients may be forced to switch to lower-quality products, they charge.

But proponents of the changes stress that the new rules do not force beneficiaries to switch brands, although they acknowledge that not all suppliers will carry all the brands. The American Diabetes Association (ADA), US Centers for Medicare and Medicaid Services (CM2), and Diabetes Care Club (DCC) have all posted information on their websites to help beneficiaries and physicians understand and negotiate the new program.

ADA: Ensure Glucose Self-Monitoring Not Disrupted

Part of the new plan -- the nationwide Medicare National Mail Order Program -- will mean that diabetic beneficiaries who receive their glucose-testing supplies delivered to their homes will need to obtain them from 1 of 18 contract suppliers chosen by Medicare via a competitive bidding process. People who prefer to buy their supplies at retail stores can still do so, but they need to make sure that the store accepts Medicare "assignment" to avoid higher charges for the supplies. The program applies only to enrollees in "old Medicare" and not to private Medicare Advantage plans.

Testing supplies affected by the new plan are glucose strips, lancets, lancet devices, batteries, and control solution, but not the meters themselves. However, because the strips are designed to work with specific meters, the new plan could result in a change of meter for many seniors as well. The ADA is monitoring the landscape as the program's launch nears. According to Claire Borelli, associate director of public policy at the ADA.  "If beneficiaries want to continue using their current monitor, they may need to shop around to find a mail-order contract supplier or a local store that can provide them with the supplies they need," she said. "Our overarching concern with the national mail-order competitive bidding program is that beneficiaries with diabetes can access the testing supplies they need to manage their condition and that self-monitoring of blood glucose is not disrupted," she stressed.

New Program Intended as a Cost-Saving Measure

The program starting July 1 is "round 2" of Medicare's recent competitive bidding initiative for vendors of durable medical equipment, aimed at cost saving. "Round 1" began in January 2011 in 9 areas of the country and included high-cost, high-volume product categories such as wheelchairs, hospital beds, and portable oxygen tanks in addition to glucose-testing supplies. Round 1 ended on January 1, 2013. Now, in round 2, beginning July 1, this process will expand to 91 regions of the country. The national mail-order program for glucose testing supplies, now a separate program, will expand to all 50 states, the District of Columbia,
and US territories. In all, Medicare is reducing reimbursement for glucose-testing equipment by 72%, with a projected saving to Medicare of $25.8 billion over the next 10 years and a saving to beneficiaries of $17.2 billion in co-pays.

Indeed, notes Mike Iskra, the current chief operating officer and incoming chief executive officer of Diabetes Care Club (DCC), the 72% drop in reimbursement means that Medicare will now reimburse just $10.41 for a box of 50 test strips, compared with $34 previously. The beneficiaries' 20% co-pay, therefore, will also be reduced proportionately. "It's a huge cost-saving measure," said Mr. Iskra, whose company is 1 of the 18 CM2-selected contract suppliers and the largest among them devoted solely to diabetes-related products.

Potential Downsides for Independent Retail Pharmacies

While the savings of the new program may benefit Medicare and patients, it's a huge loss to many retail pharmacies, especially the smaller ones. As part of the Taxpayer Relief Act that Congress enacted into law in 2012, retail pharmacies can no longer charge more than do mail-order pharmacies for the same product. Those that contract with Medicare must accept Medicare's reimbursement as payment in full and cannot charge the beneficiary more than the 20% copay and any unmet Medicare Part B deductible for the year. So, while most of the "big-box" drug stores are expected to be able to continue to accept Medicare reimbursement, many of the smaller independent pharmacies are expected to drop out of the program, says Kevin Schweers, of the National Community Pharmacists Association (NCPA). "Not only is this an enormous inconvenience, but the loss of face-to-face consultation that pharmacists provide will not ensure these blood glucose monitoring tools are being used correctly and the results are being interpreted correctly," he observed.

The new plan will also effectively prohibit independent community pharmacies from providing same-day, home delivery of diabetes testing supplies to homebound seniors. "The banning of the delivery of [diabetic testing supplies] to homebound seniors is shortsighted. If everyone is being reimbursed at the same rate, why prevent independent community pharmacies from providing this service to vulnerable seniors in assisted-living facilities and other places?" Mr. Schweers commented.

In May, 43 members of Congress agreed with the NCPA that this might cause difficulties and sent a letter to the CM2, asking the agency to reconsider this part of the program. "When all of the changes to Medicare Part B diabetes testing supplies are enacted, independent community pharmacies will have a difficult time participating in the program," Mr. Schweers stressed.

Beneficiaries Will Not Be Forced to Switch Testing Products

Mr. Schweers also expressed a concern voiced by some in the diabetes community that the national mail-order program could result in beneficiaries being forced to switch to lower-quality testing products. But Mr. Iskra of the DCC says that is not likely because of 2 of the program's rules. One, dubbed the "50% rule,"
says that each of the 18 contract suppliers must carry at least half of all the available testing supply brands on the market. His company will offer 22 models of blood glucose monitors and test strips from 13 companies. "After July 1, we will actually offer more product choice than we had before," he said. He acknowledged, however, that "we predominantly will make our formulary of a large number of lower-cost products [but] we will still have well-known brand-name companies."


Many of the companies that make lower-cost testing supplies have more significant presence in other parts of the world, he added, noting: "The US is dominated by the big companies." And "quite frankly, many of these new products on the market are as good as some of the existing products, but the companies just haven't yet built the tremendous marketing infrastructures and have realized that this whole category is moving toward a more cost-sensitive approach."

The other rule, known as the "antiswitching rule," prohibits the contract suppliers from influencing or providing incentives to beneficiaries to switch their current glucose monitor and testing supplies to a lower-cost brand. If the contract supplier does not carry the strips that work with the beneficiary's brand of meter, the beneficiary can ask the supplier about other brands and the supplier can respond. But the supplier cannot initiate the conversation. And if the physician prescribes a particular brand of testing supplies -- and documents why it is necessary to avoid an "adverse medical outcome" -- the contract supplier has 3 options: furnish the specific brand as prescribed; consult with the physician to find another appropriate brand and then obtain a new prescription; or assist the beneficiary in locating another contract supplier that can provide that specific brand.

Ms. Borelli said that she had heard anecdotally that with round 1, CM2 had heard from beneficiaries who were confused about the diabetes testing supply part of the program. "We are trying to help educate the diabetes community about these upcoming changes. We're going to closely monitor as best we can how this program rolls out. It's just not entirely clear how it's all going to play out at this time," she concluded.


June 18, 2013: Better Use of Rx Could Save LITERALLY Billions ... But Americans Wants All Those D-T-C Advertised Drugs

The U.S. spends $200 billion each year -- about 8 percent of the nation's health care tab -- on medical care stemming from improper or unnecessary use of prescription drugs, a new report out Wednesday says. [Jeanne's Note: Ever since a Republican-controlled Congress first ordered the Food and Drug Administration to allow drug companies to advertise their products on television in 1997 (remember "Newt Gingrich's 'Contract on America'"), health policy analysts and public health health specialists have worried about the impact on actual patient care delivery ... to date, only two countries, New Zealand and the United States allow "direct-to-consumer" (D-T-C) advertising ... and in the U.S., D-T-C impact is just now starting to be researched and understood. Early studies are not good from BOTH a care and a cost standpoint. Bad care at higher cost.]

Much of those costs result from unneeded hospitalizations or doctor visits, according to the study by the IMS Health's Institute for Healthcare Informatics, which provides data and other consulting services to the health care industry. Medical costs are driven up by patients who don't get the right medications or fail to take their drugs, the misuse of antibiotics, medication errors and inadequate oversight when patients take multiple drugs.

Even though the use of lower cost generic drugs is high, further increases could shave $10 billion in costs, the report says. Some private and government pilot programs aiming to better coordinate patient care have helped reduce the problems, the report said. Some provisions in the federal health law that create financial incentives to better coordinate care and to reduce hospital readmissions may further that progress, said author Murray Aitken, executive director of the IMS Institute for Healthcare Informatics.

The report notes "that even though avoidable costs are significant, encouraging progress is being made in addressing some of the challenges that drive wasteful spending in many parts of the healthcare system. Medication adherence among large populations of patients with three of the most prevalent chronic diseases -- hypertension, (high cholesterol) and diabetes -- has improved since 2009 by about 3%. The proportion of patients diagnosed with a cold or the flu -- both viral infections that do not respond to antibiotics -- who inappropriately received antibiotic prescriptions has fallen from 20% to 6% since 2007. And, for diseases where lower-cost generic medications are available, use of generics reached 95% in 2012."

[Jeanne's End Note: The United States spends almost twice as much per capita on health care than any other industrialized nation in the world ... but our virtually blind (clinically, I believe) acquiescence and seriously misguided (fueled by too much Fox News) expectations of the impact the alleged "free market" will have on heath care, are perpetuating the end result ... U.S. health care is sadly lagging the industrialized world in quality and effectiveness. Too many of our country's health care dollars are ending up in the pockets of too many for-profit managers, in the drug industry and in the health insurance business, who have fine-tuned the process of manipulating our laws and regulations to their (not the public's) advantage.]


June 17, 2013: Availability of Health Plans Under Obamacare Exchanges Will Vary Widely (and Wildly) ... and maybe a backdoor to true health care delivery payment reform without the profit motivation

When a typical 40-year-old uninsured woman in Maine (with a very conservative Republican governor) goes to the new state exchange to buy health insurance this fall, she may have just two companies to choose from: the one that already sells most individual policies in the state, and a complete unknown -- a nonprofit start-up. Her counterpart in California, however, will have a much wider variety of choices: 13 insurers are likely to offer plans, including the state's largest and best-known carriers. With only a few months remaining before Americans will start buying coverage through the new state insurance exchanges under President Obama's health care law, it is becoming clear that the millions of people purchasing policies in the exchanges will find that their choices vary sharply, depending on where they live.

States like California, Colorado and Maryland have attracted an array of insurers. But options for people in other states may be limited to an already dominant local Blue Cross plan and a few newcomers with little or no track record in providing individual coverage, including the two dozen new carriers across the country created under the Patient Protection and  Affordable Care Act. Maine residents, for example, will not see an influx of new insurers. The state has an older population and strict rules that already have discouraged many insurers from selling policies, so choices will probably be limited to the state's dominant carrier, Anthem Blue Cross, and Maine Community Health Options. "What we're seeing is a reflection of the market that already exists," said Timothy Jost, a law professor at Washington and Lee University in Virginia who is also closely following Obamacare.

Obama administration officials estimate that most Americans will have a choice of at least five carriers when open enrollment begins in October. There are signs of increased competition, with new insurers and existing providers working harder to design more affordable and innovative plans. In 31 states, officials say there will be insurers that offer plans across state lines. The exchanges will be open to the millions of Americans who are uninsured or already buying individual coverage. Many will be eligible for federal subsidies.

But the insurance landscape will be highly varied, with some of the states that have been slow to embrace the law potentially offering the fewest options (i.e., "red states" dominated by TeaParty-supported ultra right wing politicians) -- and plans with the highest premiums -- in the first year. People in certain parts of the country may not have the robust choice of insurers that the law sought as a way to keep premiums lower and customer responsiveness high. These people are likely to have few brand-name options to choose from, and they will be gambling on plans offered by insurers new to the individual market as well as brand-new carriers. The choice of providers and costs could also vary as a result.  As people become aware of the differences among the exchanges, "some of the laggard states are going to end up changing," said Ron Pollack, the executive director for Families USA, a consumer advocacy group that supports the law.

Whether the law ultimately accomplishes its aim of making the insurance markets nationwide more competitive -- and plans more affordable -- will only become clear over time. Experts expect some insurers to drop out after a year or so, while some other companies may decide to enter, depending on how the markets evolve. Insurers will have to figure out how to offer plans that most people can afford but still provide coverage to those with expensive medical conditions -- and, for investor-owned plans, how to make a profit in the meantime. [Jeanne's Question: Is a system based on "maximizing corporate profits" the kind of health care system we should be building?]

"A rush to judgment will be just that," said Dan Mendelson, the chief executive of Avalere Health, a consulting group. "It's not going to be possible in 2014 to make a strong valid judgment of whether the exchanges are working or not."

Insurers already active in the market are the most likely to show up on the exchanges. Blue Cross plans, for example, have already established relationships with local hospitals and physician groups, as well as state regulators. "We don't have to recreate the wheel because the Blue plans are already there," said Daniel J. Hilferty, the chief executive of Independence Blue Cross, a nonprofit headquartered in Philadelphia. In California, Anthem Blue Cross, Health Net, Kaiser Permanente and Blue Shield of California will remain big players. Most likely to be missing from any given exchange are many of the national insurers, whose business is focused mainly on providing coverage to workers through their employers -- companies liked UnitedHealth Group, Aetna and Cigna.

 WellPoint, which operates Blue Cross plans (as for-profits) in 14 states and is the nation's largest provider of individual and small business policies, has little choice but to compete because many of its customers will be buying insurance on the exchanges. But the other companies may delay entering any given exchange until they see a real chance to gain customers. Given the uncertainty over how well the exchanges will function, and whether enough healthy people will enroll, insurers are likely to enter only those markets where they already have a sizable number of existing customers. "If you're not going to protect your position, you would more likely take a cautious, wait-and-see-stand," Ana Gupte, a health insurance analyst for Dowling & Partners Securities.

Once the market becomes more established, some of those companies may start offering plans, Mr. Jost said. "As soon as they see there's money to be made there, they will jump right in," he said. The law has clearly encouraged the entry of new competitors. As many as a quarter of the companies vying to offer plans on the 19 exchanges run by the federal government are new to the market, federal officials said in a memo released last month.

If the experience in Massachusetts is any guide, the fact that a plan is new and unknown might not keep it from becoming popular quickly. In that state, a relatively unknown insurer, Neighborhood Health Plan, captured a large market share. Obamacare "represents disruption," said Kevin J. Counihan, who spent several years in Massachusetts helping to run its marketplace before coming to Connecticut to head its exchange.

On the flip side, though, one of the potential new entrants in Vermont, the Vermont Health Co-op, has not been able to win licensing approval from state regulators. Insurers also say they plan to compete aggressively on price. The new law places strict limits on how much of every dollar of premium can go to anything other than medical expenses, and the insurers say success will depend on enrolling as many customers as possible rather than figuring out how high a premium they can charge to raise profits. "It's more a volume game," said Wayne S. DeVeydt, an executive vice president at WellPoint, which expects to spend about $100 million in marketing for plans offered on the exchanges.

To compete, insurers will have to find ways to offer inexpensive plans, he said. In California, for example, WellPoint's Anthem Blue Cross wants to offer a plan in southern Los Angeles for as little as $259 a month for a 40-year-old. In Maine, WellPoint has asked regulators to approve plans in which it will partner with selected health systems to offer less expensive coverage for people willing to go to a specific network of doctors and hospitals.

The consumer-operated plans, known as co-ops, are also expected to put pressure on other insurers to hold down prices. "We don't have to return money to stockholders on Wall Street, like for-profit insurers," said Jerry Burgess, the chief executive of Consumers' Choice Health Plan, the co-op established in South Carolina. He says the insurer expects to charge little more than the actual costs of its medical care and will lower its premiums if possible. "We would see an opportunity to gain market share by lowering our price," Mr. Burgess said. "That's exactly what health reform hopes will happen.  [Jeanne's Aside: Are these non-profit co-ops Obamacare's not so secret weapn in changing the U.S. health care system to a more rational, traditional system in which true not-for-profits predominate? Has the right-wing opposition actually backfired and opened a door to true reform?]

The plans offered by insurers like Molina Health Care that specialize in Medicaid, the government program for low-income individuals, may also prove to be formidable competitors because of their focus on serving that population. "These are players who are going to be aggressive," said Jaime Estupinan, a vice president at Booz & Company. Experts say large health systems are also expected to compete. Kaiser and Sharp Healthcare, a San Diego hospital group that also offers insurance, are expected to participate in California, and hospital groups and insurers are increasingly working together to offer new plans. Insurance "executives concede that it may take years for the new market to take shape. "We're looking at three to five years," said Joel Farran, an executive for the Health Care Service Corporation, which operates nonprofit Blue Cross plans in four states.

Jeanne's Weakly Lawyer Jokes for the Week of June 17, 2013

A Taste of Lawyer

OK, it's another Monday ... to all my lawyer-joke followers ... lawyers taste like chicken ...

... for more ... go to http://www.health-politics.com/humor.html#06-17-13


June 15, 2013: MedPAC's June Report to Congress, the Secretary and the Nation (... as if anyone pays attention to these things)

This year's version of the Medicare Payment Advisory Committee's June report to Congress, released last week, addresses a variety of problems in the program ranging from overall spending growth to wildly varying levels of outpatient therapy spending in different parts of the country. It's far from the mother lode of potential payment offsets that more often is found in MedPAC's other major report to Congress each March. But it reflects effort in a variety of areas to identify and eliminate inefficient spending in the program.

Among the topics is one that would have gotten far more attention had Mitt Romney been elected president: premium support, which Republicans advocated to trim overall Medicare spending growth. MedPAC doesn't call it that, using instead the term "competitively determined plan contributions," or CPC.  It's used to describe "a federal contribution toward the coverage of the Medicare benefit, based on the cost of competing options for the coverage, including those offered by private plans and by the traditional Medicare fee for service program," the report states. Such a system is no simple way to produce savings, MedPAC says. "Competing private plans ... do not necessarily lower cost to the Medicare program if the rules defining how they compete and how they are paid do not encourage them to do so," according to the report.  "Whether a CPC approach can lower overall Medicare spending will depend on the characteristics of each market, the specific design of the model, and how different components of the model interact," the report says.

Use Most Cost-Effective Setting

A big focus of MedPAC's work is "site-neutral payment." Medicare's payment rates often vary for the same or similar ambulatory services provided to similar patients in different settings, such as physicians' offices and hospital outpatient departments, it notes. "Such variations raise questions about how Medicare should pay for the same service when it is delivered in different settings," it adds. If the same service can be safely provided in different settings, a prudent purchaser should not pay more for that service in one setting than in another, commissioners say. "Payment variations across settings may encourage arrangements among providers that result in care being provided in higher paid settings, thereby increasing total Medicare spending and beneficiary cost sharing."  In general, the panel advises Medicare to base its payment rates on the resources needed to treat patients in the most efficient setting while adjusting for differences in how sick the patients are that are taken care of in different settings.

In its March report, MedPAC recommended that Medicare payment rates should be equal whether a doctor evaluates or manages a patient's condition in an outpatient department or in a freestanding office. In the new June report, the commission identifies 66 groups of services provided in outpatient departments that are also frequently performed in physician's offices. "Changing OPD payment rates for these services to reduce payment differences between settings would reduce program spending and beneficiary cost sharing by $900 million in one year," the report says. "We also identified 12 groups of services that are commonly performed in ambulatory surgical centers for which the OPD payment rates could be reduced to the ASC level. This policy would reduce Medicare program spending and beneficiary cost sharing by about $600 million per year," the commission counsels.

But the panel expressed worry about the impact of these policies on hospitals that treat many poor patients. Those patients are more likely to use a hospital outpatient department as their usual source of care. Because large reductions in Medicare revenue for the facilities could cut access to physician services for these patients, the report suggests a possible "stop-loss policy" that would limit the hospitals' loss of Medicare revenue.

But are Americans willing to change the delivery setting in order to save costs ???


Bundling Could Save Money

The report notes that Medicare rates vary widely for the care beneficiaries can receive following a hospital stay in the four post-acute care settings: skilled nursing facilities, home health care, inpatient rehabilitation hospitals, and long-term care hospitals. "Nationwide, use rates for post acute services vary widely for reasons not explained by differences in beneficiaries' health status." As a possible remedy, reimbursement for a number of services could be bundled into one payment. The approach would entail having hospitals and post-acute care providers coordinating the treatment of patients. That way, the panel says, "providers would have an incentive to coordinate care and provide only clinically necessary services rather than furnishing more services to generate revenue." The report illustrates a bundled payment approach for post-acute care in which CM2 would compare "actual average spending for a condition with a benchmark, return some portion of payments if average spending is below the benchmark, and put providers at some risk for spending above the benchmark."

The report also discusses possible refinements to Medicare's hospital readmissions policy. Congress enacted a readmissions reduction program in 2010. It includes a penalty that reduces Medicare payments in 2013 to hospitals that had above-average readmission rates from July 2008 through June 2011. One problem with the policy is that hospitals that treat many poor patients are more likely to have readmissions and see payments cut as a result. A possible refinement, the report says, would be to "evaluate a hospital's readmission rate against rates for a group of peer hospitals with a similar share of poor Medicare beneficiaries as a way to adjust readmission penalties for socioeconomic status."

The report also discusses possible adjustments to hospice payments, outpatient therapy reimbursement, and payments for ambulance services. "Given the magnitude of hospice spending on long-stay patients, who are more profitable under the current payment system than other patients, it is important that an initial step toward payment reform be taken as soon as possible," the panel advises.

Therapy Changes Recommended

The report says that Medicare spending on outpatient therapy in the highest spending areas of the country "is five times more than that in the lowest spending areas of the country, even after controlling for differences in patients' health status." It makes several recommendations to decrease inappropriate use of outpatient therapy services. It also makes recommendations to assure that Medicare pays for "clinically appropriate" use of ambulances and calls for ending a floor on a payment adjustment.

The report endorses a geographic adjustment to physician payments. The "cost of living varies geographically," and Medicare payments to doctors should reflect that, it says. But the current system is flawed because of a lack of quality data on the earnings of physicians and other professions, the report says. "The adjustment should reflect geographic differences in labor costs per unit of output across markets for physicians and other health professionals," it says. It also calls for ending a floor on such geographic adjustments for payments that keep them from going below a certain level.



June 14, 2013: CM2 Issues Call for EHR Tests

As part of meaningful use Stage 2's transition of care objective, measure #3 requires eligible professionals (EPs) and eligible hospitals/critical access hospitals (CAHs) to either:

* Conduct one or more successful electronic exchanges of a summary of care document, with a recipient who has Electronic Health Record (EHR) technology designed by a different EHR technology developer than the sender's.

* Conduct one or more successful tests with the Centers for Medicare and Medicaid Services (CM2) designated test EHR during the EHR reporting period 

CM2 seeks to designate multiple "test EHRs" for EPs, eligible hospitals and CAHs to use if they elect to pursue the second approach to meet measure #3 of Stage 2's transitions of care objective.  CM2 and the Office of the National Coordinator (ONC) have worked together to identify a minimum set of technical capabilities that need to be in place in order to be designated.  Designated test EHRs will be registered on a software system hosted by the National Institute of Standards and Technology (NIST). The NIST- hosted software system will randomly match an EP, eligible hospital, or CAH with a designated test EHR that is designed by a different EHR technology developer than theirs.

CM2 and ONC strongly encourage the EHR technology developer community to participate in the program to become a CM2 designated test EHR.

To find out more about becoming a CM2 designated test EHR, please contact Nora Super (Nora.Super@hhs.gov)


June 13, 2013: Medicare Doctors Choose Brand Name Over Generic Too Often for Patients

A new study suggests that cash-strapped Medicare missed an opportunity to save more than $1 billion by not addressing the varying costs and use of prescription drugs.  Comparing Medicare enrollees and those on the U.S. Department of Veterans Affairs (VA) health plan, researchers found that Medicare beneficiaries were up to three times more likely than VA patients to choose higher-cost brand name drugs over generic brands, according to the Annals of Internal Medicine report.

"The main issue, and the only way to fix this, is to change what physicians are doing," said Dr. Walid Gellad, a lead author and internist with the VA Pittsburgh Healthcare System and the University of Pittsburgh.

Physicians in the VA system follow an approval process that requires them to try the generic drug before they prescribe a patient the brand-named version. The system also limits their providers’ interactions with pharmaceutical representatives, which Gellad said can alter the way a doctor chooses to prescribe certain drugs.

Researchers compared diabetic patients of similar ages -- about 75 years old -- and health outcomes. They calculated that if Medicare Part D followed the VA system, drug spending would have been $1.4 billion less in 2008. If the VA had adopted Medicare practices, on the other hand, its spending would increase by $108 million.  The findings echo a larger conversation among policymakers about pharmaceutical costs, since brand-named versions can cost significantly more than their generic counterpart. Both nonprofit patient assistance programs, like NeedyMeds, and government legislation, like the Physician Payment Sunshine Act, have sought to tackle the high costs of prescription drugs and physicians' prescribing practices.

"There is not too much transparency when it comes to drug pricing," said David Lipschutz, an attorney at the Center for Medicare Advocacy. "People focus on out-of-pocket expenses."

He pointed out that lawmakers have offered many proposals to deal with prescription drugs, with different methods to control the costs through both market competition and changes in the patient's copay. Lipschutz said the new study would help inform a debate, even if data was culled from two "very different systems with big structural differences."

Meanwhile, Gellad called the results of his study "startling" and said he hopes it will spur action as lawmakers seek ways to slow Medicare spending. "It's an easy solution," he said. "You don't have to change a law or do anything special to decrease costs --  you just have to change the kind of drugs people are using."



June 11, 2013: Democrats Hit the Road to Tout (and Support) Obamacare

Three years after it passed, President Barack Obama and fellow Democrats are still trying to sell the federal health care law to a skeptical nation. Chastened by their defeats in the 2010 Congressional elections, when they were overly defensive rather than actively positive about the law now most commonly known as "Obamacare," Democratic lawmakers, armed with tool kits and fact sheets, are fanning out across the nation to tout the law's benefits. Those charged with implementing its changes, starting with Health and Human Services Secretary Kathleen Sebelius, are pushing companies to donate money to a private group that's working to get the program up and running. Supporters are organizing armies of volunteers to go door to door to try to sign up millions of uninsured Americans.

Obama, too, is touring the nation to talk up the benefits. His most recent speech -- Friday in San Jose, California (see below). -- focused on the promise of lower premiums in the state that has the largest insurance market, as well as on the Republicans who've been relentless in criticizing the law.

"It's basic trench warfare," said Stuart Altman, an economist at Brandeis University who specializes in health care policy. "It's symbolic of the split in the country."

Ever since the creation of Social Security in the 1930s, the government often has had to explain or sell new social programs to the country. But the campaign to sell this law is far greater than any other in recent history, including the Medicare prescription-drug benefit enacted in 2006, political and health care experts said.

As ever, politics drives the debate.

Democrats say they have no choice but to sell the law to the public because Republicans and their allies are aggressively spreading misinformation, discouraging people from enrolling and refusing the additional money the administration says is needed to implement the changes. The law included $1 billion for implementation, but the nonpartisan Congressional Budget Office says it will take $5 billion to $10 billion, and Congress won't appropriate any more. Also, some GOP governors are rebuffing efforts to expand Medicaid, the government-run health program for the poor and a key part of the law.

"The Republicans in Congress are hell bent on doing whatever they can to help this fail," said Mo Elleithee, a veteran Democratic political consultant.

A Democratic-controlled Congress passed the Patient Protection and Affordable Care Act,  first dubbed Obamacare, in March 2007. The Supreme Court upheld the constitutionality of the law last year. Republicans haven't given up, working to eliminate, defund or minimize the law. The House of Representatives, now run by Republicans, has voted 37 times to repeal it, symbolic votes that die in the Democratic-led Senate. "The president has shown over and over again that he is good at campaigning, but not so good at governing," said Senate Minority Leader Mitch McConnell, T/R-Ky. "All of the campaign-style events in the world won't mask the fact that Obamacare costs too much: too much for families, too much for businesses and too much for taxpayers." Whatever the reason, Americans are skeptical. A new Wall Street Journal/NBC poll released last week found that 49 percent of Americans think the law is a bad idea. although 13% of those listed as "opposed" actually say it is because the law doesn't go far enough and should be expanded.

That may be part of the reason the Obama administration is working to arm its allies. Two weeks ago, for example, the White House, the Health and Human Services Department and the Small Business Administration held a series of sessions for lawmakers, chiefs of staff, legislative assistants and press secretaries on the implementation of the law and how to talk about it. In the House, Democratic members were issued a tool kit: a binder of information about the law, including responses to Republican "myths." [See also: http://www.health-politics.com/issue.html#lieslies] There's also the public relations pitch financed in part by the private sector -- with a push from the government. Under questioning by Congress, Sebelius testified last week that she'd been forced to ask companies and organizations -- even some that her department regulates -- to help a nonprofit group promoting the health care law because Republican lawmakers refused to provide the millions of dollars necessary to implement it.

She said she called five companies -- Johnson & Johnson, the drug maker; Ascension Health, the large Roman Catholic health care system; Kaiser Permanente, the health insurance plan; H&R Block, the tax preparation service, which is helping low- and middle-income people apply for tax credits that can be used to buy private health insurance; and the Robert Wood Johnson Foundation, which works in public health. Sebelius said the Public Health Service Act granted her the authority to urge groups to get involved and that her actions were similar to those in Bill Clinton's administration to encourage enrollment in the Children's Health Insurance Program and George W. Bush’s administration to help Medicare beneficiaries sign up for prescription drug coverage. The nonprofit group that's helping to implement the health care law, Enroll America, is led by and supported by former Obama aides. Recent reports say that President Anne Filipic, a former deputy director of the Office of Public Engagement, will send volunteers door to door to enroll uninsured Americans while another former White House staffer, Nancy-Ann DeParle, is raising money for the group.

In his speeches, Obama has avoided the controversies and focused on facts to make his case (here's one: 25 million uninsured Americans will gain coverage by 2023, according to the Congressional Budget Office) while treating the events like campaign rallies, complete with supporters and Republican jabs. "This is working the way it's supposed to," the president said last week in San Jose. "So the bottom line is you can listen to a bunch of political talk out there -- negative ads and fear mongering geared towards the next election -- or alternatively you can actually look at what's happening."



June 11, 2013: Maximum Out-of-Pocket Spending Limits May Not Be the Maximum for Some Grandfathered Plans

Starting next year, Obamacare sets maximum limits on how much consumers can be required to pay out-of-pocket annually for their medical care. But some people with high drug costs may find the limits don't protect them yet. That's because the federal government is giving some health plans extra time to comply with the rules.

Under the law, the maximum amount a consumer with single coverage will pay out-of-pocket in 2014 will generally be $6,350 while a family could pay up to $12,700. Those totals include copayments and deductibles, but not premiums, and they apply only to plans that are not grandfathered under the law.

Here's the catch. Although all non-grandfathered plans will have to cap the amount that consumers pay out-of-pocket for major medical expenses, if health plans use more than one company to administer their benefits -- as many do for major medical and pharmacy benefits, for example -- consumers may face separate caps next year, or no cap on their pharmacy spending at all.

According to guidance from the federal government issued in February, health plans with more than one benefits administrator don't have to combine their tallies of members' out of pocket spending into one total until 2015. So a plan with a separate cap on pharmacy benefits can keep it as long as the limits don't exceed the new maximum. Plans with no drug spending limit -- the norm, according to experts -- don't have to cap members' out-of-pocket spending at all.

What is a grandfathered plan?

Most health insurance plans that existed on March 23, 2010 are eligible for grandfathered status and therefore do not have to meet all the requirements of the health care law.  But if an insurer or employer makes significant changes to a plan's benefits or how much members pay through premiums, copays or deductibles, then the plan loses that status.  The government's regulations spell out how much plans can change the amount paid by workers or employers before losing their status.  Both individual plans, the kind you buy on your own, and group plans, the kind you receive through an employer, can be grandfathered. If you get coverage through an employer, you can join a grandfathered plan even if you weren't enrolled on March 23, 2010. 

What rules does a grandfathered plan have to follow?

A grandfathered plan has to follow some of the same rules other plans do under PPACA.  For example, the plans cannot impose lifetime limits on how much health care coverage people may receive, and they must offer dependent coverage for young adults until age 26 (although until 2014, a grandfathered group plan does not have to offer such coverage if a young adult is eligible for coverage elsewhere). They also cannot retroactively cancel your coverage because of a mistake you made when applying, a practice known as a rescission. However, there are many rules grandfathered plans do not have to follow. For example, they are not required to provide preventive care without cost-sharing.  In addition, they do not have to offer a package of "essential health benefits" that individual and small group plans must offer beginning in 2014.  (Large employer plans are not required to offer the essential benefits package even if they are not grandfathered.) Furthermore, grandfathered individual plans -- the policies you purchase yourself, rather than through work -- can still impose annual dollar limits, such as capping key benefits at $750,000 in a given year. Grandfathered individual policies also can still lock out children under 19 if they have a pre-existing conditions. 


June 10, 2013: Obama Launches High-Profile, High-Stakes Campaign to Sell Health Law

Marking the opening round of what's likely to be steel-cage political combat over the impact of the health care law on insurance rates, President Barack Obama said last week in a speech in California that the overhaul is ushering in a new era of vigorous competition among plans in the state and elsewhere, resulting in reliable, affordable coverage.  Appearing in San Jose with local government, media, and philanthropic officials, Obama touted the state's new insurance exchange as a model. "If you're one of nearly 6 million Californians or tens of millions of Americans who don't currently have health insurance, you'll soon be able to buy quality, affordable care just like everybody else," Obama said. Thanks to new online insurance marketplaces opening in the fall, health plans will actually have to compete, he said, "and that means new choices."

While in many states Americans now only have a choice of one or two plans, based on early reports about 9 in ten Americans expected to enroll in the new marketplaces live in states where they'll be able to choose between five or more different insurers, he said. Contrary to "doom and gloom" forecasts, Obama said that in states that are properly implementing the overhaul, "competition and choice are pushing down costs in the individual market just like the law was designed to do." Premiums in California's exchange "were lower than anybody expected," he said. And about 2.6 million Californians, nearly half of whom are Latinos, "will qualify for tax credits that will in some cases lower their premiums a significant amount."

Republicans Starting to Push Back

Health law supporters say Obama's salesmanship is long overdue and sorely needed if the administration is to meet its goal next year of enrolling 7 million uninsured people in the new insurance exchanges. While Obama's appearance was good news for them, Republicans are gearing up to make counter claims. The right-leaning American Action Forum issued a statement last week saying coverage on the California exchange will limit enrollees' choice of providers. "What you will not hear from [Obama] is that if you live in California you could be losing 64 percent of your provider network," said Forum spokeswoman Emily Egan.  And in Ohio, Lieutenant Gov. Mary Taylor, a Republican, said the state insurance department's initial analysis shows "consumers will have fewer choices and pay much higher premiums" for plans to be offered by the federal exchange serving the state. Monthly premiums in the individual market now average $223, Taylor said, citing an estimate by the Society of Actuaries. But proposed rates show that average climbing 88 percent to $420, she added in a recent news release.

Late last week, five Senate Health, Education, Labor and Pensions Committee Republicans wrote to Health and Human Services Secretary Kathleen Sebelius asking her to follow up on a May 9 Associated Press story saying that a California law gave the state's exchange the power to keep secret certain spending details for the contractors that will perform most of the marketplace's functions.

The White House made clear in focusing on California that coverage of the uninsured Latino population is going to be a key part of making the health care law a success -- not only in California, but nationally. Not only will that score the administration political points with a pivotal voting bloc in the 2012 elections, it could sharply reduce the number of Americans without coverage. California has a big chunk of the nation's uninsured population, and nearly two-thirds of it are Latino, says the California Endowment, a health care philanthropy.

White House officials said in a background briefing that California provides a good model for the success of enrollment efforts going forward, Three powerful Spanish-language media companies have agreed to be part of the California outreach effort, officials noted, and will hit nearly 100 percent of the target Hispanic communities in the state, they added. The three -- Univision, Telemundo, and impreMedia -- are beginning a three-phase campaign that could be copied in other states, officials said. The opening "awareness" phase will tell people what Obamacare does and that the enrollment period is fast approaching. The next is the "education" phase -- which will start closer to the fall. That will let people know where to get more information and to find out what their coverage options are. The third phase is the actual enrollment period that will run from October 1 through March.

Particularly critical to the success of the law is enrolling young and healthy people whose relatively low health costs would make it possible to keep premiums affordable for older, sicker Americans. Of the target population of 7 million covered in exchanges next year, administration officials say it's important that 2.6 million or 2.7 million are young and healthy. When you drill down and think about who these folks are, about one in three live in California, Florida and Texas, one official said. Obama emphasized the importance of people stepping forward and signing up for coverage. But the key to that will be whether rates in exchanges across the country are affordable -- or perhaps more importantly, are viewed as affordable.

Politics and Rates

States with Democratic governors are more likely to cast exchange rates in a favorable light and those run by Republican governors in a negative light. Kaiser Family Foundation Senior Vice President Larry Leavitt said in an interview that his review of the Ohio rates shows that they are actually about the same as those in California. In California, officials helped to create a favorable impression of the rates in the individual insurance market next year by noting they would be about the same or lower as the rates in 2013 for small employer plans. Individual rates would range from 2 percent above to 29 percent below the 2013 average premium for small employer plans, officials said. Comparing premiums to those in the small group market is "a way of testing the reasonableness" of individual plan premiums, Leavitt said. That's because the benefits individual plans must provide next year will be comparable to those that exist in the small group market, he said. Had insurers come in with 2014 rates for the individual market that were sharply higher than those in the small group market, it would have been a sign of insurer price gouging under the health law, something he said supporters of the measure feared insurers would do after the law took effect.

In Ohio, officials instead chose to focus on year-to-year comparisons of individual plans. The 2013 rates they used to calculate the 88 percent increase were based on much skimpier coverage than the plans will have next year, analysts said. Kaiser analyst Karen Pollitz said that in some instances, plans now sold on Ohio's individual market barely qualify as health insurance and someone buying such policies risk bankruptcy if serious illness strikes. But individual coverage next year in Ohio will be more comprehensive and "heavily subsidized for 80 to 90 percent of newly insured Ohioans," she said. The rates cited by Ohio officials are proposed and could be lower following rate review in the state.

California officials had only limited data comparing individual plan premiums in 2013 versus 2014. Blue Shield of California suggested enrollees in its individual plan would be paying 13 percent more next year.


Jeanne's Weakly Lawyer Jokes for the Week of Week of June 10, 2013


(Both Sides, win a few, lose  a few)



... for more go to: http://www.health-politics.com/humor.html#06-10-13



June 8, 2013: "Patient-Centered Medical Home" ... An Experiment That Seems to Be Working

The nation's largest experiment in delivering medical care in an innovative way has reduced costs and improved the quality of care even more in its second year than in its first, according to the insurance company behind it.  The nonprofit CareFirst BlueCross-BlueShield launched its "Patient-Centered Medical Home" program in January 2011 among primary-care providers serving about one-third of its 3.4 million members in Maryland, Washington, D.C., and northern Virginia.

Like other "accountable care organizations" (ACOs), which are centerpieces of President Barack Obama's health care reform, the medical home program ties insurance payments to health care providers to the quality of care they deliver.

On Thursday, CareFirst reported cost savings of $98 million for the medical home program in 2012, compared with $38 million the year before. Proponents of the model say it shows that "bending the cost curve downward," as Obama described one of the goals of his 2010 health care law, is achievable. If innovative models like CareFirst's deliver as promised, it will ease the financial pressures on Medicare, the government health insurance program for the elderly and disabled, and help make Obamacare more likely to succeed.

"This is a very important finding, that a major health plan is able to achieve savings" of this magnitude, said Dr Elliott Fisher, a health policy expert at the Dartmouth Institute for Health Policy and Clinical Practice and an architect of accountable care organizations.

Medical homes, like other ACOs, induce physicians to coordinate care to make sure patients' prescriptions don't interact adversely, for instance, and to think twice before ordering unnecessary tests. Physicians who reduce costs while hitting quality metrics such as regularly checking a diabetic's eyesight receive awards in the form of higher payments. In CareFirst's program, that incentive is substantial: a 29 percent bump in physician reimbursement rates. The insurer can afford to be so generous because improving primary care, which accounts for only 6 percent of medical spending, reduces far pricier hospitalizations and specialist visits.

CareFirst's success is likely to accelerate other efforts to move from a traditional fee-for-service model, where the more tests and treatments physicians and hospitals do the more they make, to one that rewards efficiency and quality. Twenty-nine U.S. states now let primary-care providers act as patient-centered medical homes for residents on the Medicaid program for the poor, for instance. Major insurers including UnitedHealth Group, WellPoint, Aetna, Humana and Cigna are also contracting with physicians to operate under an accountable care model.


Skeptics have warned that any savings in programs like medical homes would peter out after their first year, as physicians eliminated the most obvious and easiest-to-cut waste, and that further reductions woul:d cut necessary care.  CareFirst has found otherwise.

One million of its members (almost all employed, with an average age of 42) were in medical homes in 2012, the company reported, and 80 percent of the primary-care providers in CareFirst's network participate in the program. These members' health care costs were $98 million (2.7 percent) less than CareFirst projected. In 2011, the savings were 1.5 percent. Most of the savings came from reduced hospital admissions, less use of emergency rooms and lower spending on drugs, said CareFirst Chief Executive Officer Chet Burrell.

Two-thirds of the 3,600 physicians and nurse practitioners participating in the medical home program earned higher reimbursements from CareFirst in 2012, based on a combination of cost savings (which averaged 4.7 percent) and quality measures. Measuring quality - which also includes having extended office hours and using electronic medical records - keeps doctors from trying to save money by skimping on needed care.

"This is a measurable and meaningful step in the right direction of slowing the rise of health care costs," said Burrell.

At primary-care practices that did not earn an incentive award, costs averaged 3.6 percent higher than expected. Their quality scores were also worse, suggesting that wasteful care often goes hand in hand with poor care.

CareFirst's savings are in line with those reported by 10 physician groups across the United States that treated Medicare patients under an accountable care model. Annual savings averaged $114 per patient, researchers led by Fisher reported in the Journal of the American Medical Association last year. But savings reached $532, or 5 percent, for patients eligible for both Medicare and Medicaid.

CareFirst received a grant from the federal Centers for Medicare and Medicaid Services to expand the medical home model to Medicare patients starting July 1. These older Americans "frequently have complex health needs and multiple chronic health conditions," said Burrell, and so "could benefit greatly from the coordinated model of care" in medical homes


June 7, 2013: Non-Profit Hospital Chain CEOs Gorging at the Hog Trough Too

Trimming medical costs is the latest mantra among hospital executives, government bureaucrats, insurers and benefit managers as they grapple for ways to contain U.S. health care spending. But executive compensation in the health care industry shows few signs of hitting a ceiling. One sure bet: The salaries and benefits for hospital administrators will continue to rise. A recent survey by Equilar, an executive compensation data firm based in Redwood City, California, found that -- for the fourth time in five years -- health care chief executives commanded the highest pay packages last year among publicly traded companies. On average, Equilar found, health care CEOs were paid more than their counterparts in six other industry sectors, including technology, financial services and industrial goods.

The value of executive pay at large, for-profit health companies tends to be higher than nonprofit organizations, but the gap appears to be narrowing. In recent years, executives at nonprofit health organizations have seen annual double-digit increases of as much as 40 percent in their total compensation packages, which typically include salaries, bonuses, pensions and health benefits. Such pay hikes occurred as these nonprofit organizations enjoyed their largest operating margins in years, and also at a time when health providers speak of a new era of transparency in pricing, improved quality of care, and personalized medicine.

"Health care is a remarkably complex business, so in some ways, you might say they deserve higher pay," said Professor Harold Miller, executive director of Center for Healthcare Quality Payment and Reform at Carnegie Mellon University in Pittsburgh. "And the salary that goes to the CEO is still a small piece of health care costs. ... But if a health care executive's pay is based on the amount of revenue they generate, the problem is in the incentive,"  he said. "Basically, hospitals get rewarded by putting more heads in beds. It works against the goal of affordable health care. We need to start paying these executives to keep people healthy."

Catalyzed by the Patient Care and Affordable Care Act, a growing number of health executives talk of transforming a broken health care system by focusing on preventive medicine and primary care, reducing unnecessary tests and surgeries, and eliminating excessive costs. Thomas Getzen, executive director of the International Health Economics Association and a professor at Temple University, said that "an argument can be made that an innovative health care CEO is as valuable as a college basketball coach." But, he added, "for me the big problem, whether it's a for-profit or nonprofit, is when executives start chasing their own compensation rather than the good of the company. We've seen that in banking, and that can happen in health care."


Non-profit hospital administrators say they have their organizations' best interests at heart. "I'm not in this job because of the salary," said William Thompson, chief executive of Missouri-based SSM Health Care, a Roman Catholic hospital chain, which operates 18 hospitals in four states. He received total compensation of $2.3 million in 2011 -- a 26 percent increase over 2010. Some of that pay hike was attributable to a change in jobs. Thompson, SSM's former chief operating officer, assumed the role of chief executive in August 2011. In 2010, his pay increased 95 percent from $918,229 to $1.8 million. "I've been (at SSM) for 33 years, and for a lot of those years I wasn't paid nearly the salary I'm paid now," Thompson said. "If you look at the revenue, I don't think I'm over- or underpaid."

Health administrators often justify their salaries by noting the challenge of running multibillion-dollar systems on thin operating margins and overseeing hospitals that demand high safety standards.  Health administrators also stress that their pay packages are determined by independent committees of their boards of directors. Those panels rely on market surveys and "benchmarking data" that examine compensation levels at similar-size health institutions. Any bonuses and incentive pay are calculated using formulas based on performance objectives.


Walter Kopp, a health care consultant based in San Anselmo, California, said that executives who run nonprofit health systems "are generally making a fraction of what their counterparts in for-profits are making." One case in point: Tenet Healthcare Corp. The nation's third-largest for-profit hospital chain operates 49 hospitals in 10 states. The company's net revenue exceeds $9 billion, but its net income is slim: $141 million in 2012, and $58 million in 2011. Dallas-based Tenet's chief executive and president, Trevor Fetter, received total compensation in 2012 of $11.2 million -- up nearly 5 percent from 2011, according to Tenet's annual proxy statement. In contrast, the CEO of nonprofit Ascension Health Alliance -- whose organization generates more than 180 percent of Tenet’s revenue -- received only 36 percent of Fetter's compensation package last year.


Defenders of generous health care salaries and benefits speak of hospital executives' depth of knowledge, leadership skills and responsibility for tens of thousands of employees as well as patients. Some public officials bear responsibility for even larger organizations, but the compensation of public officials is much smaller than the pay packages of nonprofit health executives. Kathleen Sebelius, secretary of the U.S. Department of Health and Human Services, receives a salary of $199,700 a year, plus retirement and health benefits. Her agency has an $874 billion budget and 74,193 employees. Margaret Donnelly, former director of Missouri's Department of Health and Senior Services, received a salary and benefits last year totaling $151,708. The agency's budget is about $1 billion.


Labor -- including salaries, wages and benefits -- is often the leading expense for large health systems, followed by supplies and professional fees. It's not uncommon for labor to exceed 50 percent of a health system's budget. But most hospital workers do not see double-digit increases in their pay. Ascension Health -- a subsidiary of Ascension Health Alliance -- is the nation's largest Catholic and nonprofit health system. Ascension operates about 80 hospitals in 20 states and the District of Columbia, with operating revenue of $16.6 billion in 2012, according to its annual report. Anthony Tersigni, chief executive of Ascension Health Alliance, received total compensation in fiscal year 2012 of $4 million -- a 12 percent increase over the previous year. He declined to comment.

"When we look for leadership of our ministry, we need to draw from the best and brightest to serve those who are poor and vulnerable," said Jon Glaudemans, chief advocacy and communications officer for Ascension. "We are required to be competitive, but we also have a mission to care for those who are poor and vulnerable. Candidly, many of our executives could do better for themselves working in other environments." Glaudemans said that Ascension is seeking "to remain competitive in a market that is increasingly complex and characterized by challenging regulatory circumstances, including implementation of the Affordable Care Act."

Nine executives at Ascension's headquarters received total compensation in fiscal year 2012 exceeding $1 million. Ascension's labor costs accounted for 48 percent of its annual expenses. It's employees -- which include a spectrum of jobs from administrators, physicians and nurses to medical technicians, office workers and supply clerks -- earn annual salaries and benefits on average totaling about $55,000. Ascension’s CEO's pay package of $4 million for 2013 was nearly 73 times greater than the average Ascension employee’s compensation.



June 6, 2013: They Don't Call the State "Tex-ASS" for Nothing; Texas Stands to Lose Billions

By opting not to expand Medicaid, Texas is passing up an estimated $6 billion in federal funds over the coming decade, leaving its health care providers, especially hospitals, in a tough financial spot. Rural care facilities are especially vulnerable. The Medicaid enrollment expansions that take effect on January 1, 2014 under the Patient Protection and Affordable Care Act (Obamacare) are expected to extend health insurance coverage to as many as 17 million Americans, depending upon who's doing the calculations and how many states eventually sign on.

For health care providers in most states, the expansion represents a windfall of billions of dollars. The federal government will pay for the entire cost of the expansion through 2016. After that, the cost will gradually shift toward the states, but the feds will still pay 90% of the cost after 2020. The expansion offers coverage to people who earn as much as 138% of the federal poverty level, which is $15,400 for one person and $31,800 for a family of four.  

Given that hospitals and health care are huge economic drivers, those new Medicaid dollars could prove to be as valuable for economic activity and job growth as they are for improving population health. The Medicaid money will also free up local property and sales taxes that would otherwise be used to prop up charity care.

Under such circumstances, expanding the Medicaid rolls would seem like a no brainer. After all, the need is already there. People are going to get sick and need medical care regardless of whether or not they are insured. That care is going to cost money. Of course, these states could also adopt the policy shouted from the audience during the Republican president nominee debates last year; "Let 'em die!" If they have no health insurance it must be their own fault, just let them die ... or go to a hospital emergency room under the law signed by Ronald Reagan, EMTALA.  Medicaid expansion simply answers the question of who is going to pay for it.  The insurance ratepayer and the county taxpayer gets hit one way or another

However, as we have seen over the last three years, the politics of Obamacare are so toxic that at least 14 states have said they will not expand coverage. "If the discussion is purely about money, it's hard to just walk away," says Matt Salo, executive director of the National Association of Medicaid Directors. "But this is not just about money. This is very much about politics and ideology."

More than any other state, Texas has come to represent "not just 'no' but 'hell no'" opposition to Obamacare, even though the Lone Star State has the highest percentage of uninsured citizens in the United States. It has been estimated that as many as 1.7 million Texans could gain coverage with the expansion, which would also funnel about $90 billion in federal dollars into the state over the next decade.  

Governor Rick Perry and other key Republican leaders, however, have led the opposition, with Perry calling the expansion plan "a misguided, and ultimately doomed, attempt to mask the shortcomings of Obamacare. It would benefit no one in our state to see their taxes skyrocket and our economy crushed as our budget crumbled under the weight of oppressive Medicaid costs.  Instead of another federal mandate, Perry has called for "the flexibility to care for our own in a manner that makes sense both effectively and financially."

The problem is that the Texas legislature, which meets once every two years, adjourned this spring without taking any action on an alternative to the federal expansion plan. They could call a special legislative session to address the expansion, or it could be done administratively through the Perry administration, but those options appear unlikely right now.

As a result, when January 1, 2014 rolls up, "the poorest Texans will be left out," says Anne Dunkelberg, associate director of the nonprofit Center for Public Policy Priorities.

"If they live in a big city they might be able to get some help from their local hospital district and what group gets served depends on what city they live in. That is going to be funded by 100% local property tax dollars instead of 100% federal funds. And if they live in a more rural county they may have no options. There may be no public program that is going to help them."

Dunkelberg says various studies have estimated that Texas will lose about $6 billion [PDF] a year over the next decade and beyond in federal subsidies because it won't expand the Medicaid rolls. "The funds would have created hundreds of thousands of jobs, the estimates ranged from between 215,000 to 300,000 jobs a year," Dunkelberg says.  

"The amounts of money that are potentially going through communities -- urban and rural -- are fairly staggering and potentially having a big boost in terms of economic development in some parts of the state and certainly offsetting large amounts of uncompensated care that is currently funded with local property tax dollars. We are leaving that money on the table."  

Left holding the bag, of course, will be health care providers, especially hospitals. They get the worst of both ends. They don't reap the benefit of seeing more insured patients, and their reimbursements for Medicare and Medicaid are being cut through the federal budget process and sequestration mandates.   "It's a difficult financial model," says John Hawkins, senior vice president for government relations at the Texas Hospital Association. "Trying to balance those cuts without being able to expand coverage is going to be difficult going forward."

In all likelihood, dwindling funding could mean that some smaller or financially strained hospitals will close. "For rural hospitals that is probably more the reality. In other areas you will see hospitals limit services which can be equally as challenging for their communities," Hawkins says.  

"You are going to have worse health outcomes, particularly in areas where facilities have to limit services. Folks will have to drive farther. Your workforce isn't going to be as productive because of lack of coverage. The bigger impact will be poorer health outcomes and less-productive state."

It's not just the usual public advocacy groups who are calling for expanding the Medicaid rolls. Leading business groups in Texas have called for some sort of action. Hawkins says there has been a "continued drum beat" for expanding the rolls from a wide swath of special interest groups that recognize what is at stake.  

"Certainly folks are concerned about the level of uninsured. They are concerned about the cost of health care. They understand the cost shift to taxpayers and the private market. There is a lot of discussion about it, but the general political headwind in this state against Obamacare is difficult to overcome," he says.

Perhaps the best hope for states that are ideological entrenched against Obamacare lies with the so-called Arkansas Medicaid Model, which would use Medicaid expansion money to subsidize premiums for commercial plans purchased through health insurance exchanges. That proposal is still being vetted by the Centers for Medicare & Medicaid Services.

It's not clear if Texas would adopt a similar plan. Even if it did it's not clear if the state could expand its rolls by January 1, 2014 deadline.  

Hawkins remains optimistic that some sort of solution will be reached.

"Actually, in retrospect, we are pleased the debate got as far as it did where we were actually talking about alternatives because early on it looked like folks were being reticent even to have that discussion given the will of the leadership," he says. "But we did advance the discussion even to the point where if things in other states continue to move forward we may have a chance to revisit this administratively."  


June 5, 2013: Nurse Practitioners to the Rescue ... Again

The U.S. physician workforce is struggling to keep pace with the demand for health care services, a situation that may worsen without efforts to enhance team-based care. More than half of family physicians work with nurse practitioners, physician assistants, or certified nurse midwives, and doing so helps ensure access to health care services, particularly in rural areas.

As more people become insured with the implementation of the Patient Protection and Affordable Care Act, an increase in demand for primary care services may not be sufficiently met by the physician workforce. NPs, PAs, and CNMs already augment the physician workforce. Between 1999 and 2009 the number of physician offices whose teams included at least one of these clinicians increased from 25% to nearly 50%. Better understanding of this trend is important to health workforce planning in response to increased access needs. Identifying these relationships is also important when studying their association with health outcomes.

The American Board of Family Medicine (ABFM) conducted a survey in September and October of 2011. During the survey, any physician accessing their online physician portfolio on the ABFM website had to complete a brief survey. They used a question asking, "Do you routinely work with nurse practitioners, physician assistants, or certified nurse midwives?" to gauge family physician collaboration with these clinicians. In this 2-week period, 5818 family physicians residing in the 50 United States completed the survey. Compared with other family physicians in the ABFM database, those in the sample were slightly younger, more likely to be women, and more likely to be currently board certified and to have completed more Maintenance of Certification activities than those not in the sample. Nearly 60% of respondents reported routinely working with NPs, PAs, or CNMs. Physicians more likely to work with these clinicians were younger and live in rural areas.

These data suggest that the number of family physicians routinely working with NPs, PAs, and CNMs is continuing to increase. As in previous studies, physicians working in rural areas were more likely to work with these clinicians. Teams of family physicians and NPs, PAs, and CNMs working together within the patient-centered medical home model are likely essential to meeting the future health care needs of all Americans. Such teams may help alleviate patient access to health care issues due to the projected shortage of primary care physicians.



June 4, 2013: Red States Losing Billions By NOT Expanding Medicaid

States would save money by accepting the Medicaid expansion in President Obama's health care law, according to a new study. The research, published in the journal Health Affairs, said states that reject the Medicaid expansion will end up paying more for health care coverage than states that participate -- and covering far fewer people.

Together, 14 states that have rejected the expansion will spend $1 billion more on uncompensated care than they would under the expansion, and they'll lose out on $8.4 billion in federal payments, researchers from the Rand Corporation said.

"Our analysis shows it's in the best economic interests of states to expand Medicaid under the terms of the federal Affordable Care Act," said Carter Price, the study's lead author. The 14 states included in the Rand analysis are also passing up a chance to cover 3.6 million uninsured people, the study said.

Several Republicans governors have embraced the Medicaid expansion, but others have staunchly refused to implement any part of a health care law they strongly oppose.

Governors rejecting the Medicaid expansion often cite the costs to the state, but the Rand analysis said rejecting the expansion will actually raise those states' health care costs without covering the uninsured.

"State policymakers should be aware that if they do not expand Medicaid, fewer people will have health insurance, and that will trigger higher state and local spending for uncompensated medical care," Price said. "Choosing to not expand Medicaid may turn out to be the more-costly path for state and local governments."

The federal government initially pays the entire cost of the expansion, dropping to a 90 percent share by 2020. 


June 4, 2013: Medicare Data Show Wide Divide In What Hospitals Bill For Outpatient Services

Medicare released average bill charges for 30 hospital outpatient procedures yesterday, showing big differences from hospital to hospital in how much they bill patients for the same service. The data come a month after the Centers for Medicare & Medicaid Services garnered front-page attention for its release of similar information about 100 common hospital inpatient procedures.

The value of hospital charge data is hotly disputed, because few people actually end up paying the amounts listed. Insurers negotiate their own rates and the uninsured often get steep discounts. However, others believe the extremely high amounts that hospitals bill, and the lack of any logical connection to procedures’ actual costs, is an illustration of the dysfunctional health care market.

The new data show that hospitals' initial charges are many times the amount that Medicare pays using its own method to calculate costs. Hospitals billed an average of $148 for a Level 2 hospital clinic visit, which was nearly double the $76 that Medicare reimbursed on average. Hospitals billed for more than 8 million of these visits in 2011, more than for any other service in the CM2 database.

The discrepancies were even higher for other popular services. Hospitals charged $2,587 for magnetic resonance imaging and magnetic resonance angiography without dye. That was more than seven times the $346 that Medicare ultimately paid. In the aggregate, those were big differences for Medicare's budget: instead of paying $1.2 billion, Medicare paid $397 million.

The differences between charges from one hospital to another were substantial. For a level 3 diagnostic and screening ultrasound, St. Joseph's Medical Center in Stockton, Calif., charged an average of $7,566 -- 40 times the $186 that Medicare reimbursed on average. But in Hamilton, N.Y., Community Memorial Hospital billed $157 on average for the same service, and Medicare reimbursed $152. (Medicare's payments vary for the same service because of a host of factors, such as the labor costs in the area.)

For a level 2 echocardiogram without dye, Crozer Chester Medical Center in Upland, Pa., charged an average of $11,451, which was 27 times the $417 Medicare paid. Morton County Hospital in Elkhart, Kan., charged $410 and was reimbursed $379.

Medicare has posted the outpatient billing data here.


June 3, 2013: Things are Already Ugly and About to Get Even Uglier

In what may be the epic battle of the summer, the White House and Republicans are assembling their armies and sharpening their bayonets for a political fight over the selling of Obamacare. On one side is the Obama administration, which is preparing to carry out the president's landmark health care reform law. It sees success directly linked to his legacy. On the other side are House Republicans, conservative groups, GOP governors and tea party affiliates. They are reading the latest polls and are determined to make the repeal or severe crippling of the Patient Protection and Affordable Care Act their top priority before the 2014 midterms.

"It's a very important battle and both sides are trying to come out on top," said Julian Zelizer, a Princeton University historian. "The first stage was about whether this passes or not. ... Now the battle is over implementing it and there are all sorts of ways Republicans are trying to cause problems." Zelizer said Republicans have been aggressively promoting the program's problems in the past few weeks. "And the administration feels the pressure," he said.

The next phase of the fight for the White House, according to administration officials, is a series of initiatives aimed at using social media, websites, on-the-ground efforts and targeting Spanish speakers and young people in particular to convince as many uninsured as possible to buy insurance when it becomes available on October 1.

"We've got to make sure everybody has good health in this country," President Barack Obama told Morehouse College's commencement ceremonies recently. "It's not just good for you, it's good for this country. So you're going to have to spread the word to your fellow young people."

Meanwhile, Republicans are continuing to whittle away at the law's impact and are hoping that Obamacare's failure could become a rallying cry. "It's going to be an issue in the 2014 midterm elections," said Sally Pipes, president and CEO of Pacific Research Institute, a conservative-leaning think tank and author of "The Truth about Obamacare." "When 2014 comes and the percentage of Americans that have employer-based insurance find out they could lose their insurance and be dumped into an exchange there will be an uproar," Pipes said.

Here's a glimpse into each side's playbook and the tactics they hope will win:

What the administration wants to do 
This summer, the administration will launch several initiatives in its goal to sign up as many as seven million Americans over the next year.

They will hit the Internet. They plan to roll out www.healthcare.gov as the go-to site for those signing up for insurance under the law, leading up to open enrollment starting on October 1.

They will take it to TV.  Health and Human Services will soon unleash a campaign to saturate the airwaves with ads pushing people to begin shopping for health care plans.

They are making it easier to sign up. To make it easier for consumers to apply for coverage from private insurers under the Obamacare rules, the administration is touting a simplified online form that takes 21 pages and boils it down to three.

They will target minorities and young people. These groups are some of those most affected by a lack of insurance. This strategy will leverage Spanish language ads, public education and outreach campaigns targeting recent college graduates, young and diverse faces on its website and a heavy emphasis on digital media.

They are claiming it will be cheaper. The White House is pushing a recent surprise in California, where the cost of buying health insurance through the state's exchanges -- as required by the Patient Protection and Affordable Care Act -- are coming in as much as half the price of what was initially expected. For instance, the state will charge an average of $304 a month for the cheapest silver-level plan in state-based exchanges next year.

What Republicans want to do 
The GOP will continue to beat the drum on just how bad Obamacare is for the country.

They continue to keep it in the headlines. House Republicans have voted 37 times to repeal the law and some critics have suggested it's a waste of time.

"Well, while our goal is to repeal all of Obamacare, I would remind you that the president has signed into law seven different bills that repealed or defunded parts of that law. Is it enough? No. A full repeal is needed to keep this law from doing more damage to our economy and raising health care costs," House Speaker John Boehner, T/R-Ohio, said at a recent press conference.

They are linking Obamacare to the IRS scandal. Leading Republicans, such as Senate Minority Leader Mitch McConnell, T/R-Kentucky, have also suggested suspending implementation of Obamacare until an investigation in completed into the Internal Revenue Service's targeting of conservative groups.

They are challenging it in the states. Several states with Republican governors and legislatures have threatened not to establish the required insurance exchanges -- and giving up millions in federal subsidies in the process -- in an effort to derail Obamacare.

Still, things are starting to get ugly.

Repeated requests by HHS for more money from Congress to implement the law have been denied. Ranking Republicans are now calling the agency's inspector general to investigate whether Health Kathleen Sebelius violated appropriations and ethics rules when she reportedly tried to raise funds for Enroll America, an organization that is working to help put Obamacare in place. Those actions are now also under investigation by two House congressional committees. The agency maintains she made "no fundraising requests to entities regulated by HHS."

Public has questions

Caught in the middle is the American public. A Kaiser Family Foundation poll in April showed 49% of those surveyed didn't know how Obamacare would affect them and roughly 40 percent were unaware that the law was being carried out. "In our research looking at barriers faced by families accessing available public insurance for their kids we found that families were often very confused about the requirements and the processes for enrollment," said Jennifer Devoe, a family physician, and professor at Oregon Health and Science University of such programs as Medicaid and the Children's Health Insurance Program. "We also found confusion among families who believed their child to be covered when the child was actually uninsured, and vice versa."

A majority of Americans said they opposed the nation's new health care measure, three years after it became law, according to a CNN/ORC International poll released last Monday. But looking deeper, the poll also indicated that more than a quarter of those who oppose the law said they didn't support it because it didn't go far enough. Further, when broken down by major sections, individual portions of Obamacare are proving to be very popular ...


Jeanne's Weakly Lawyer Jokes for the Week of June 3, 2013


Funkhouser's Law of the Media: The quality of legislation passed to deal with a problem is inversely proportional to the volume of media clamor that brought it about.

... for more, go to ... http://www.health-politics.com/humor.html#06-03-13



May 31, 2013: House GOP Inches Toward Resolving SGR "Problem"

Republican leaders of the House continue to inch toward a replacement of Medicare's notorious sustainable growth rate (SGR) formula for setting physician reimbursement, releasing draft legislation yesterday that gives organized medicine a big role in determining how its members are paid.  By repealing the SGR formula, the draft legislation would avert a 24.4% Medicare pay cut that is scheduled for January 1, 2014. Medicare reimbursement would slowly shift to a mix of fee-for-service (FFS) and pay-for-performance, with medical societies designing the yardsticks for measuring performance. In addition, physicians could choose from a menu of payment options(Jeanne's Note: It was a GOP-controlled Congress bent on "balancing the budget" that enacted the SGR in 1997 as part of the so-called "Balanced Budget Act.")

The draft legislation, issued by GOP leaders of the House Energy and Commerce Committee, closely hews to an SGR "doc fix" that these Republicans and their counterparts on the House Ways and Means Committee first unveiled in February. The latest version comes after extensive consultation with organized medicine, which has long lobbied for repealing the SGR formula. The health subcommittee of the Energy and Commerce Committee has scheduled a hearing on the draft legislation for June 5.

The House GOP "doc fix" taking shape for the Medicare reimbursement crisis competes with bipartisan SGR repeal legislation introduced in February by  Housecritters Allyson Schwartz (D-PA) and Joe Heck, DO (R-NV). Their bill also takes a gradual turn toward pay-for-performance, but unlike the bill from the House GOP leadership, it eventually phases out FFS reimbursement as opposed to preserving it in a modified form.

In addition, budget proposals from Senate Democrats and President Barack Obama assume the demise of the SGR formula, enacted by Congress in 1997 to control Medicare spending on physician services. Although Republicans and Democrats alike have talked about repealing the formula for years, lawmakers say 2013 could be the year when talk turns to action, given a fiscal opportunity that has fallen into their lap.

Every year since 2002, the formula has called for a cut in physician reimbursement, but with the exception of 2002, Congress has postponed each cut. "Kicking the can down the road," as Capitol Hill likes to call it, has caused the cuts to accumulate to their current level. In an age of deficit-anxiety, lawmakers have been loath to repeal the SGR formula and its massive pay cut outright on account of the price tag. In January 2012, the Congressional Budget Office (CBO) put the cost of repeal -- together with a 10-year freeze of Medicare rates -- at $316 billion. However, given a recent slowdown in Medicare spending on physician services, the CBO revised the cost downward to $139 billion a few months ago. Now a doc fix looks much more affordable.

Bonuses for Quality and Efficiency

Under the plan laid out yesterday by Republican leaders of the House Energy and Commerce Committee, 2014 would usher in several years of Medicare payment stability, created by predictable, statutorily defined FFS rates. In the next phase, Medicare would adjust FFS rates upward or downward based on quality measures and "clinical improvement activities," such as reporting clinical data to a registry that medical societies would develop and endorse.

Medicare also would take into account how physicians rank within their specialty on a risk-adjusted basis, as well as how their scores change over time, according to an overview of the plan released by House Republicans.

Physicians would be given timely access to their performance scores. That provision jumps off the page in light of long lag times in the past between performance and report cards in Medicare's Physician Quality Reporting System, a source of consternation to organized medicine. In other nods to medical societies, House Republicans say their plan will "reduce the reporting burden on physician practices" and "override the current ineffective CMS quality measurement programs."

Republicans add that they will "align Medicare payment initiatives with private payer initiatives." At the same time, physicians participating in accountable care organizations, medical homes, and other Medicare experiments in alternative reimbursement can stay where they are.

In the third phase of the new Medicare payment system, physicians who earn bonuses for their quality of care will have a chance to earn additional bonuses for being efficient. Again, all this comes on top of FFS reimbursement. Physicians retain their right to receive their Medicare dollars under alternative arrangements.

The draft legislation requires the Department of Health and Human Services to regularly assess both the modified FFS system and alternative Medicare and private payer reimbursement methods with an eye to continual improvement. The goal is to provide "reimbursement options -- instead of the current one-size-fits-all approach -- that enables physicians to select the Medicare payment system that best fits their practice."



May 31, 2013: For Profit Health Insurers, Ripping Off Ratepayers

For profit health insurers, already ripping off ratepayers for their exorbitant CEO and executive salaries, bonuses and perks spent an average of less than 1 percent of the premiums they collected from policyholders in 2011 on activities directly supporting improvement of health care quality, according to the Commonwealth Fund study released earlier this year.

The new looks at differences in medical loss ratios, consumer rebates, and quality improvement expenses, based on insurers' corporate structure and ownership. The study finds that insurance companies spent a combined $2.3 billion on direct quality improvement activities ... an average of $29 per subscriber.


Obamacare's medical loss ratio rule requires large insurers to spend at least 85 percent of premiums on medical claims and quality improvement activities ... those likely to improve health outcomes, prevent hospital readmissions, improve patient safety, and increase wellness and health promotion ... or else pay rebates to consumers.


May 30, 2013: For Medicare, Immigrants Offer Surplus, Study Finds

Immigrants have contributed billions of dollars more to Medicare in recent years than the program has paid out on their behalf, according to a new study, a pattern that goes against the notion that immigrants are a drain on federal health care spending. The study, led by researchers at Harvard Medical School, measured immigrants' contributions to the part of Medicare that pays for hospital care, a trust fund that accounts for nearly half of the federal program's revenue. It found that immigrants generated surpluses totaling $115 billion from 2002 to 2009. In comparison, the American-born population incurred a deficit of $28 billion over the same period.

The findings shed light on what demographers have long known: Immigrants are crucial in balancing the age structure of American society, providing an infusion of young, working-age adults who support the country’s aging population and help cover the costs of Medicare and Social Security. And with the largest generation in the United States, the baby boomers, now starting to retire, the financial help from immigrants has never been more needed, experts said.

Individual immigrant contributions were roughly the same as those of American citizens, the study found, but immigrants as a group received less than they paid in, largely because they were younger on average than the American-born population and fewer of them were old enough to be eligible for benefits. The median age of Hispanics, whose foreign-born contingent is by far the largest immigrant group, is 27, according to the Brookings Institution. The median age of non-Hispanic whites in the United States is 42.

The study drew on two nationally representative federal surveys, from the Census Bureau and the Department of Health and Human Services. Researchers included the contributions from three groups (1) legal residents who were not citizens, a group that is eligible for Medicare if certain requirements are met; (2) unauthorized (illegal) immigrants; and (3) citizens who were born abroad. It was not clear how much of the surplus was made up of earnings by immigrants in the country illegally, who are ineligible for most government programs.

The Census Bureau, whose data was used for the contributions portion of the study, says it attempts to count all immigrants, including those in the country illegally.

The finding "pokes a hole in the widespread assumption that immigrants drain U.S. health care spending dollars," said Leah Zallman, an instructor of medicine at Harvard Medical School and the lead author of the study.

The study, which was published on the Web site of the journal Health Affairs on Wednesday, comes as Congress considers legislation that would eventually give legal status to the country's 11 million unauthorized immigrants. The legislation has sparked a vigorous debate about whether immigrants ultimately contribute more than they receive from the federal budget. One of the sticking points has been whether immigrants should be eligible for government programs, including health benefits, before they qualify for citizenship, but while they are on the path to getting it.

The study was concerned only with Medicare, the federal program that accounts for about a fifth of all American health care expenditures. Experts said that the study's findings served as a useful reminder that immigrants, at least for now, are extending the life of the beleaguered program, not hastening its demise.

"There's this strong belief that immigrants are takers," said Leighton Ku, the director of the Center for Health Policy Research at George Washington University. "This shows they are contributing hugely. Without immigrants, the Medicare trust fund would be in trouble sooner." The belief prevails, for example, among some opponents of immigration reform.

Similar calculations have been made for Social Security. The chief actuary of the Social Security Administration, Stephen C. Goss, estimated that immigrants in the country illegally, some of whom assume fake Social Security numbers to provide cover for employers and themselves, among other reasons, generated a surplus of about $12 billion for the Social Security Trust Fund in 2010.

Federal coffers tend to benefit from immigrants in the country illegally, with contributions to programs like Social Security and Medicare that those immigrants cannot draw on later. But state and local governments, on the other hand, have to absorb more of the costs, like education for their children and emergency room visits.

Immigrants tend to be healthier than American-born citizens, and have lower mortality rates, research has found. For example, immigrants' medical costs average 14 percent to 20 percent less than those of native-born Americans, even after controlling for other factors like emergency room visits and insurance coverage, which fewer immigrants have.

The Harvard study found that average costs to Medicare for immigrant enrollees in 2009 were $3,923, lower than the average $5,388 expenditure for the American-born.


May 29, 2013: TeaParty/Republicans Will Not Cooperate in Helping Make PPACA Work

From a report in this this morning's New York Times on implementing Obamacare: "Republicans simply want to see the entire law go away and will not take part in adjusting it. Democrats are petrified of reopening a politically charged law that threatens to derail careers as the Republicans once again seize on it before an election year. ... As a result, a landmark law that almost everyone agrees has flaws is likely to take effect unchanged."

Unlike their counterparts 48 years ago when Medicare was enacted, Republicans today are blocking all attempts to improve the Patient Protection and Affordable Care Act ...
back in 1965-66 Republicans worked with Democrats to make Medicare work. Romneycare is working in Massachusetts 7 years after it started, because Republicans there have worked with Democrats to fill in the gaps and correct the errors and problematic areas ... Obamacare can and should work for ALL Americans but Tea-publicans today work only for the 1%, for the for-profit health insurance industry and for the drug company lobbyists


May 28, 2013: Paying I.T. Bonuses to Providers Who Won't (or Can't) Share Information

More than half of all doctors now get Medicare or Medicaid incentive payments for using electronic health records, according to a report federal officials released last week. But Republicans say medical professionals should not just use the records in their own offices but also should exchange them with other providers. Republican lawmakers, backed by a business and insurance company alliance known as the Health IT Now Coalition, have been pushing the Department of Health and Human Services (HHS) in recent months to end Medicare and Medicaid IT bonus payments for providers who do not share electronic medical data with other providers.

[Jeanne: WHOA! Wait a minute here, is this a really good idea from Republicans ??? Well, expanding health care I.T.  was their original idea after all. WEDi was established by George Herbert Walker Bush in 1991; HIPAA was passed by a Republican-controlled Congress in 1996; and the Office of the National Coordinator for Health Information Technology (ONC) was created under Junior Bush in 2004. Obama is a johnny-come-lately to the issue. And if its going work, providers, patients and insurers will to TALK WITH ONE ANOTHER!  It doesn't really much if all they do is talk to themselves. The key is "interoperability" ... the sharing of patient health care information and insurance data, saves paperwork, reduces overhead, avoids duplication and redundancy, increases efficiency and effectiveness, improves patient care and saves money. Or at least that is what we claimed when the whole health care I.T. movement started in 1989 with the drafting of the "Bond Bill" (named after then Missouri GOP-Senatecritter Christopher "Kit" Bond ... the forerunner of 1996's HIPAA law.  Paying "bonuses to providers who do not share their information seems wasteful, albeit I can see why HHS says the infrastructure/capability must be built first. The health care industry has been very slow in adopting I.T. capabilities, having to be coerced, dragged and kicked into at least the late 20th century (we'll worry about getting it into the 21st later) ... but as Secretary Sebelius says, we may now have reached the tipping point. Did I hear someone say "Meaningful Use?"]

The response from HHS officials has been to point to the progress that has been made since the Medicare and Medicaid incentive payments for providers that adopt electronic records was included in the 2009 stimulus law (PL 111-5).The recent report noted that HHS has exceeded its goal of having half of physicians' offices and 80 percent of eligible hospitals using electronic health records by the end of 2013.

HHS officials showed charts indicating how the use of medical records has grown: The percentage of physicians and other medical professionals using an electronic health system was 17 percent in 2008 and is currently about 55 percent. For hospitals, about 9 percent used electronic records in 2008, but more than 80 percent have established and used electronic records. As a result, more than 291,000 eligible professionals and more than 3,800 eligible hospitals have gotten incentive payments from Medicare and Medicaid. Doctors have received a total of nearly $6 billion, while hospitals have received almost $9 billion.

But Republicans say that some of that money may have been wasted or unnecessary. Six senators produced a 27-page report criticizing the program and demanding more oversight. Those senators are John Thune of South Dakota, Lamar Alexander of Tennessee, Pat Roberts of Kansas, Richard M. Burr of North Carolina, Tom Coburn of Oklahoma and Michael B. Enzi of Wyoming.

Sharing Information Changes an EMR to an EHR

DHHS News Release

                                       For immediate release:                                                                                                                                                                       Contact HHS Press Office:

                                       May 22, 2013                                                                                                                                                                                         (202) 690-6343

Since the Obama administration started encouraging providers to adopt EHRs, usage has increased dramatically. According to the Centers for Disease Control and Prevention survey in 2012, the percent of physicians using an advanced EHR system was just 17 percent in 2008. Today, more than 50 percent of eligible professionals (mostly physicians) have demonstrated meaningful use and received an incentive payment. For hospitals, just nine percent had adopted EHRs in 2008, but today, more than 80 percent have demonstrated meaningful use of EHRs.

"We have reached a tipping point in adoption of electronic health records," said Secretary Sebelius. "More than half of eligible professionals and 80 percent of eligible hospitals have adopted these systems, which are critical to modernizing our health care system. Health IT helps providers better coordinate care, which can improve patient's health and save money at the same time."

The Obama administration has encouraged the adoption of health IT starting with the passage of the Recovery Act in 2009 because it is an integral element of health care quality and efficiency improvements. Doctors, hospitals, and other eligible providers that adopt and meaningfully use certified electronic health records receive incentive payments through the Medicare and Medicaid EHR Incentive Programs. Part of the Recovery Act, these programs began in 2011 and are administered by the Centers for Medicare & Medicaid Services and the Office of the National Coordinator of Health Information Technology.

Adoption of EHRs is also critical to the broader health care improvement efforts that have started as a result of the Affordable Care Act. These efforts -- improving care coordination, reducing duplicative tests and procedures, and rewarding hospitals for keeping patients healthier -- all made possible by widespread use of EHRs. Health IT systems give doctors, hospitals, and other providers the ability to better coordinate care and reduce errors and readmissions that can cost more money and leave patients less healthy. In turn, efforts to improve care coordination and efficiency create further incentive for providers to adopt health IT.


More from Jeanne:


(without it, this has all been for naught)


Meaningful Use Defined


Meaningful use is using certified electronic health record (EHR) technology to:

- Improve quality, safety, efficiency and reduce health disparities

- Engage patients and families

- Improve care coordination, and population and public health

- Maintain privacy and protection of patient health information

Ultimately, it is hoped that the meaningful use compliance will result in:

- Better clinical outcomes

- Improved population health outcomes

- Increased transparency and efficiency

- Empowered patients

- More robust research data on health systems

Meaningful use sets specific objectives that eligible professionals (EPs) and hospitals must achieve to qualify for Centers for Medicare & Medicaid Services (CM2) Incentive Programs.


Stages of Meaningful Use

These objectives will evolve in three stages over five years:



Stage 1

Data Capture and Sharing



Stage 2

Advance Clinical Processes



Stage 3

Improved Outcomes


In theory at least, the HHS "bonuses" being paid to hospitals and doctors to implement health care I.T. are ONLY supposed to be paid to those providers meeting these goals, so if they are trully not talking to one another and sharing information, they should not be getting the bonus payments. Whether or not  the Sebelius HHS is paying just to incentify the building of the infrastructure, so that providers might actually have someone to share information with in a meaningful way, it may be time to pay a bonus ONLY to those actually moving NOW from the later phasen of Stage 1 into Stage 2.  If they haven't advanced that far by now, they do not deserve the extra payments. After all, this is NOT the V.A.



Jeanne's Weakly Lawyer Jokes for the Week of May 27, 2013



A big shot Wall Street lawyer phoned home to his Long Island mansion one morning, and a woman with a strange voice answered.

"Are you the new maid?" he asks.

"Yes, I am," the woman replies

... for the punch line and more go to ... http://www.health-politics.com/humor.html#05-27-13


May 26, 2013: The Obamacare Shock

The [Patient Protection and] Affordable Care Act, a k a Obamacare, goes fully into effect at the beginning of next year, and predictions of disaster are being heard far and wide. There will be an administrative "train wreck," we're told; consumers will face a terrible shock. Republicans, one hears, are already counting on the law's troubles to give them a big electoral advantage.

No doubt there will be problems, as there are with any large new government initiative, and in this case, we have the added complication that many Republican governors and legislators are doing all they can to sabotage reform. Yet important new evidence -- especially from California, the law's most important test case -- suggests that the real Obamacare shock will be one of unexpected success.

Before I can explain what the news means, I need to make a crucial point: Obamacare is a deeply conservative reform, not in a political sense (although it was originally a Republican proposal) but in terms of leaving most people's health care unaffected. Americans who receive health insurance from their employers, Medicare or Medicaid -- which is to say, the vast majority of those who have any kind of health insurance at all -- will see almost no changes when the law goes into effect.

There are, however, millions of Americans who don't receive insurance either from their employers or from government programs. They can get insurance only by buying it on their own, and many of them are effectively shut out of that market. In some states, like California, insurers reject applicants with past medical problems. In others, like New York, insurers can't reject applicants, and must offer similar coverage regardless of personal medical history ("community rating"); unfortunately, this leads to a situation in which premiums are very high because only those with current health problems sign up, while healthy people take the risk of going uninsured.

Obamacare closes this gap with a three-part approach. First, community rating everywhere -- no more exclusion based on pre-existing conditions. Second, the "mandate" -- you must buy insurance even if you're currently healthy. Third, subsidies to make insurance affordable for those with lower incomes.

Massachusetts has had essentially this system since 2006; as a result, nearly all residents have health insurance, and the program remains very popular. So we know that Obamacare -- or, as some of us call it, ObamaRomneyCare -- can work.

Skeptics argued, however, that Massachusetts was special: it had relatively few uninsured residents even before the reform, and it already had community rating. What would happen elsewhere? In particular, what would happen in California, where more than a fifth of the nonelderly population is uninsured, and the individual insurance market is largely unregulated? Would there be "sticker shock" as the price of individual policies soared?

Well, the California bids are in -- that is, insurers have submitted the prices at which they are willing to offer coverage on the state's newly created Obamacare exchange. And the prices, it turns out, are surprisingly low. A handful of healthy people may find themselves paying more for coverage, but it looks as if Obamacare’s first year in California is going to be an overwhelmingly positive experience.

What can still go wrong? Well, Obamacare is a complicated program, basically because simpler options, like Medicare for all, weren't considered politically feasible. So there will probably be a lot of administrative confusion as the law goes into effect, again especially in states where Republicans have been doing their best to sabotage the process.

Also, some people are too poor to afford coverage even with the subsidies. These Americans were supposed to be covered by a federally financed expansion of Medicaid, but in states where Republicans have blocked Medicaid expansion, such unfortunates will be left out in the cold.

Still, here's what it seems is about to happen: millions of Americans will suddenly gain health coverage, and millions more will feel much more secure knowing that such coverage is available if they lose their jobs or suffer other misfortunes. Only a relative handful of people will be hurt at all. And as contrasts emerge between the experience of states like California that are making the most of the new policy and that of states like Texas whose politicians are doing their best to undermine it, the sheer meanspiritedness of the Obamacare opponents will become ever more obvious.

So yes, it does look as if there's an Obamacare shock coming: the shock of learning that a public program designed to help a lot of people can, strange to say, end up helping a lot of people -- especially when government officials actually try to make it work.


May 24, 2013: Lying About or Misrepresenting Obamacare is Endemic in the TeaParty/Republican DNA.

From politifact.com

Mitch McConnell says HHS put a gag order on insurers about impact of Obamacare

Controversy is swirling around the White House, with inquiries into the consulate attack in Benghazi, the IRS' targeting of conservative groups and the Justice Department's probe of journalists' phone records.

Some Republicans say these issues are emblematic of the how the Obama White House operates.

"There is a culture of intimidation throughout the administration. The IRS is just the most recent example," Sen. Mitch McConnell, R-Ky., said on Meet the Press on May 19, 2013. "... Over at HHS back during the Obamacare debate, Secretary (Kathleen) Sebelius sent out a directive to help insurance companies telling them they couldn't inform their policyholders of what they thought the impact of Obamacare would be on them."

McConnell named off a few more examples, but we zeroed in on his Obamacare claim. The letters he mentioned, written in 2009, didn't actually come from Sebelius but from the acting director of the Medicare Drug and Health Plan Contract Administration Group, which falls within Sebelius' Department of Health and Human Services.

We decided to check whether the letters prohibited insurance companies from communicating with their policyholders about the effect of Obamacare, which had not yet become law.

What the letters said

In the fall of 2009, during the fevered debate over Obama's proposed health care overhaul, the Centers for Medicare and Medicaid Services announced it was looking into mailings that Humana sent to its nearly 1 million Medicare Advantage and Part D patients. CMS (CM2, in my usage), as it's known, is the federal agency that runs Medicare.

"CMS has learned that Humana has been contacting enrollees in one or more of its plans and alleging that current health care reform legislation affecting Medicare could hurt millions of seniors and disabled individuals (who) could lose many of the important benefits and services that make Medicare advantage health plans so valuable," the agency wrote to two Humana executives.

The letter said CMS was concerned that "this information is misleading and confusing to beneficiaries, represents information to beneficiaries as official communications about the Medicare Advantage program, and is potentially contrary to federal regulations and guidance."

The letter had a narrow scope: It dealt with Humana, as a government contractor, and the information it was giving Medicare beneficiaries.

But the Humana mailing prompted CMS to send a memo to all other Medicare Advantage and Part D contractors, warning them "to suspend potentially misleading mailings to beneficiaries about health care and insurance reform."

"We are concerned that the materials Humana sent to our beneficiaries may violate Medicare rules by appearing to contain Medicare Advantage and prescription drug benefit information, which must be submitted to CMS for review," CMS official Jonathan Blum said in a press release. "We also are asking that no other plan sponsors are mailing similar materials while we investigate whether a potential violation has occurred."

What the letters didn't say

McConnell's comment was much more sweeping. He said the Obama administration was restricting what insurance companies could say to their policyholders, which wasn't the case. The letters only applied to government-contracted Medicare Advantage providers.

"Insurance companies certainly have not been prevented from communicating their views," CMS spokesman Brian Cook told PolitiFact. "In this instance, Humana was conducting political advocacy work using government funds via 'official Medicare notices' sent to beneficiaries who have not opted in."

It's worth noting that after the CMS letter to Humana triggered some backlash from conservatives including McConnell, the Obama administration clarified its rules.

The new guidelines said Medicare Advantage contractors could communicate with Medicare beneficiaries about pending legislation as long as they did not use federal money to do so. Insurers also were required to get permission from beneficiaries before sending them information about legislation or asking them to join advocacy efforts. At the same time, Humana was cited for violating Medicare rules by sending misleading information to beneficiaries. The company was issued an official "notice of noncompliance" -- the lowest level of citation which carries no penalty.

In addition, a 2010 Government Accountability Office review of the letters found that in general, CMS "appeared to adhere to the agency's policies and procedures."

Our ruling

McConnell said that in 2009 the Obama administration sent letters telling insurance companies "they couldn't inform their policyholders of what they thought the impact of Obamacare would be on them."

But that's an inaccurate characterization. The administration did not issue such a sweeping prohibition on insurance companies.

The letters McConnell referred to went first to Humana about the information it sent to beneficiaries of the federal Medicare program. That was followed by another memo to other Medicare Advantage companies, warning them not to spread misleading information about health reform.

But as long as they weren't Medicare providers using federal dollars to communicate with Medicare beneficiaries, insurance companies have always been free to communicate with their policyholders.

We rate the statement Mostly False.

[Jeanne's End Note: McConnell and his TeaParty cohorts have tried to conflate the IRS, which was simply trying to enforce the clear letter of the law (stop big contributors from avoiding taxes by giving to politically-active groups not acting "exclusively" for social welfare purposes) and DHHS, trying to tell health insurers that could not "lobby on the taxpayers dime" (using Medicare administrative funds to pay for mailings to beneficiaries opposing certain provisions in Obamacare ... BTW, these insurers love Obamacare which will give them millions of new paying customers and fattening their profits, they just oppose the sections that suggest they might have to be more accountable for the payments they receive and be subject to some regulation and scrutiny.) Since when has opposing corporate influence on public policy decisions, using public funds or tax avoided dollars become unpatriotic

Perhaps this graphic above reproduced from that "ultra-socialist" magazine Forbes, Humana, a heavy-hitting lobbyist-driven insurer, earns upwards of 50% of its profits marketing Medicare Advantage plans, spending millions on advertising promotions, television ads and executive bonuses in the process.  Medicare Advantage (cuts in which Obamacare is making) was "sold" in 2003 to a then Republican-controlled Congress, as a mechanism to hold Medicare costs down, but by the for-profit health insurance industry's own admission, it is costing U.S. taxpayers at least $200 billion more ... (and probably a lot more than that) ... than traditional old-fashioned Medicare.  So what if, in the near future, affluent seniors in white glove retirement communities won't get their health club memberships paid for by Medicare. This is a program cut that can help preserve the basic Medicare program and assure benefits for ALL Americans.


May 23, 2013: The Real IRS Scandal

Allowing so many 'social welfare' groups to enjoy tax-exempt status while participating in politics must stop. The IRS is obligated to scrutinize applicants, 'tea party' or no.   It's strange how "scandal" gets defined these days in Washington. At the moment, everyone is screaming about the "scandal" of the Internal Revenue Service scrutinizing conservative nonprofits before granting them tax-exempt status.

Here are the genuine scandals in this affair: Political organizations are being allowed to masquerade as charities to avoid taxes and keep their donors secret, and the IRS has allowed them to do this for years.

The bottom line first: The IRS hasn't done nearly enough over the years to rein in the subversion of the tax law by political groups claiming a tax exemption that is not legally permitted for campaign activity. Nor has it enforced rules requiring that donors to those groups pay gift tax on their donations.  (Aaah, there is the real "tax avoidance" issue.)

The organizations at issue are known as 501(c)4 groups (call them C4s for short) after the section of the tax code that applies to them. They're nonprofit "social welfare" organizations that by the actual statutory language must be devoted exclusively to programs broadly serving their communities, not private groups. IRS forms reveal what the agency considers to be mainstream C4s: religious groups; cultural, educational and veterans organizations, homeowners associations, volunteer fire departments. In recent years, however, overtly political groups have been claiming C4 status, which allows them to keep their donor lists secret and to avoid paying taxes on certain income.

At issue is the word "EXCLUSIVELY" ... the word used in the actual statutory law. Sometime along the line, with the date blurred by history and politics, the term "exclusively" was deemed by the IRS in its internal regulations to be met if:

"that an organization is operated exclusively for the promotion of social welfare if it is primarily engaged in promoting in some way the common good and general welfare of the people of the community, i.e., primarily for the purpose of bringing about civic betterment and social improvements. Whether an organization is "primarily" engaged in promoting social welfare is a 'facts and circumstances' test." IRS Reg. 1.501(c)(4)-1(a)(2)(i).  The agency (the IRS) changed the law without Congressional action.

Our lunatic campaign finance system is what turned the typical C4 from a volunteer fire department into a conduit of anonymous political cash. Big donors were given the green light to spend freely on elections by the Supreme Court's 2010 Citizens United decision. That wasn't good enough for some; they wanted to distribute their largess secretly.

C4s were there for the exploitation, and the result has been a wholesale decline of donor disclosure on the national level: As recently as 1998, nearly 100% of all donors to federal campaigns were publicly identified, according to the Center for Responsive Politics, a campaign finance watchdog group. By the 2012 presidential election, that was down to 40%.

The beneficiaries of the C4 tax break, understandably, will employ any subterfuge to keep it. That's what's behind the current firestorm over disclosures that in 2010 and 2011, IRS personnel screened requests for C4 status by applicant organizations with "tea party," "patriot" or "9/12" in their names. Those weren't the only groups whose applications were selected for extra scrutiny on the reasoning that they might be devoted to more than "social welfare." According to an IRS Inspector General report made public this week, they represented only about a third of the 298 applications selected. That was certainly too coarse a screen, and by January 2012 the IRS had scrapped those definitions. It had substituted a screen designed to capture "political action type organizations involved in limiting/expanding government, educating on the constitution and bill of rights, [and] social  economic reform/movement."

Conservatives contend that this is still an anti-conservative screen. It sounds perfectly neutral to me, unless someone knows of a conservative organization devoted to "expanding government," or unless right-wing groups are supposed to have a monopoly on "social economic reform." In any case, the inspector general found that most of the 298 selected applications indeed showed indications of "significant" political activity that might have made them ineligible for the tax exemption.

It's about time the IRS subjected all of these outfits to scrutiny ... all of them, right and left. The agency's inaction has served the purposes of donors and political organizations on both sides of the aisle, and contributed to the explosive infection of the electoral process by big money from individuals and corporations. The law should apply equally to these politically-motivated organizations on both the left AND the right -- and none of them should be eligible for C4 designation.

Nor is Congress innocent. The lawmakers have dodged their responsibility to make the rules crystal clear. On the rare occasions when the IRS has tried gingerly to impose regulatory order, members of Congress have forced the agency to back off. There should be a rule in Washington that if you give regulators deliberately vague guidelines, you're not allowed to protest when they try to figure out where the lines are.

Thanks to ambiguity about what it means to be "primarily" concerned with "social welfare," political activists have reaped a bonanza for years while the IRS ignored their chicanery. And once again, now that the agency has tried to regulate, the regulated parties have blown its efforts up into a "scandal." It's amusing to reflect that some politicians making hay over this are the same people who contend that we don't need more regulations, we just need to enforce the ones we have. (Examples: gun control and banking regulation.) Here's a case where the IRS is trying to enforce regulations that Congress enacted, and it's still somehow doing the wrong thing.

Keep that in mind when you hear politicians -- and they're not exclusively Republicans -- grandstanding about how the IRS actions are "chilling" or "un-American." It turns out that none of the "targeted" groups actually was denied C4 status. Nevertheless, says Sheila Krumholz, director of the Center for Responsive Politics. "There's a sense of discomfort that the IRS was doing much of anything."

C4s are curious creatures in the tax code. They're allowed to engage in lobbying, but not ("primarily") in campaign activity. Their donors don't get a tax deduction, but the organizations are tax-exempt. For example, they don't have to pay taxes on income they earn by investing donated funds. But what makes C4s especially attractive to people who want to funnel money into politics is this: They don't have to identify their donors.

Remember the mysterious $11-million donation to the campaign for California's anti-union Proposition 32 last November? When the state Fair Political Practices Commission punctured its anonymity, it found not one, but two 501(c)4 organizations behind it. The FPPC, which is still investigating, has already called this a case of "campaign money laundering."

As of September last year, the center found, some $254 million, or 20%, of all outside spending came through C4s. The biggest C4 in the electoral arena was Crossroads GPS, an affiliate of American Crossroads, a campaign organization founded by Rove. The Obama camp's C4 was known as Priorities USA.

The IRS was swamped by the wave. The number of groups seeking C4 status from the agency rose from 1,500 in 2010 to 3,400 last year. Meanwhile, the agency was being pulled in two directions. In February last year, seven Democratic senators complained that the IRS was too "permissive" with its rules, which judged a C4 not to be engaged "primarily" in electioneering as long as no more than 49% of its spending went to such activities. In August, 10 GOP senators warned the agency to deep-six any efforts to tighten the rules on C4s.

Already in 2011, an IRS disclosure that it was auditing five big donors to determine whether they owed gift taxes for donations to C4s had caused a political uproar. (The gift tax can be up to 35% of a donation in excess of $14,000 per recipient and a $5.25-million lifetime exemption, paid by the donor.) GOP lawmakers accused the IRS of "targeting constitutionally protected political speech." As Ellen Aprill, a tax law expert at Loyola Law School, observed later that year, "at that point, the IRS threw in the towel" -- even though there was little doubt that the tax levy was proper ands plainly constitutional.

The danger inherent in the latest faux controversy is that the IRS will have its wings clipped before its investigation of C4s is fully fledged. Politicos and pundits are in a lather over the questions the agency put to targeted organizations to determine their social welfare bona fides -- things like the identity of their board members and the amount of time and money spent on "electoral issues," and endorsements of candidates. These facts would be pretty fundamental to determining whether an organization is political, wouldn't you say?

The IRS also asked some groups for the identity of their donors. The inspector general contends that request was inappropriate. Still, if the IRS discovered that a major donor to a C4 was, say, the politically active billionaire Sheldon Adelson, wouldn't that suggest that the group might not be a plain vanilla "homeowners association"" By the same token, when the pro-Obama C4 Priorities USA disclosed that it had five anonymous donors, one of whom contributed $1.9 million, or 84% of the total, wouldn't it help an investigator to know who that person is?

Let's remember that a tax exemption handed over to any group costs all of us money. It's proper for the IRS to scrutinize applicants. The biggest laugh line uttered in this affair is that the IRS is somehow "harassing" these public-spirited organizations by asking them to justify their status. Here's a good rule of thumb: You don't want to get harassed by the IRS? Then don't claim a tax exemption you may not deserve.


May 22, 2013: Republicans Jump on IRS "Scandal" to Attack Obamacare

Listening to recent statements from some congressional Republicans, you might think that the 2010 health law allows the Internal Revenue Service to have access to your medical records. Not so, says the Department of Health and Human Services. "The [Patient Protection and] Affordable Care Act maintains strict privacy controls to safeguard personal information.  The IRS will not have access to personal health information," said agency spokeswoman Erin Shields Britt.

Republicans have pounced on news reports that the IRS unfairly targeted conservative groups for greater scrutiny when the groups sought tax-exempt status. Housecritter Michele Bachmann, T/R-Minn., said the health law "will allow bureaucrats access to our most intimate, personal health care information."  Senatecritter Rand Paul, T/R-Ky., a physician, said he was "quite worried about the privacy of medical records. I'm quite worried now that your medical records will be evaluated by the IRS."

The IRS does play a key role in implementing the 2010 health care law. Those duties include enforcing the law's requirement that most individuals have health insurance or pay a fine and helping determine whether individuals are eligible for a tax credit to help afford health insurance premiums.

During a House Ways and Means Committee hearing Friday into the IRS scandal, Housecritter. Jim McDermott, D-Wash., also a physician, asked Steven Miller, who recently resigned from his post as acting IRS commissioner, if the agency had access to individuals' medical information. Here are the key points:

McDermott: "We need to find some truth here ... And I've heard members of this committee now talk about it. The IRS can't access your medical files. Is that true, Mr. Miller?"

Miller: "Correct, sir."

McDermott: "They cannot find out your private medical information?"

Miller: "That's correct, sir."

McDermott: "Their job in Obamacare is simply to collect financial information on which a determination is made as to whether somebody can get a subsidy for their premium. Is that correct?"

Miller: "Were you covered and over what period is what we would be getting."

For the record, as an attorney and as a 40-year veteran of health care policy and politics, "Under Obamacare the IRS will not have access to an individual's medical record, but they will have access to an individual's coverage status."




And here is what FactCheck.org had to say about Rand Paul's statements:

Paul's Unfounded Speculation

In an appearance on CNN's "State of the Union" on May 19, Sen. Rand Paul also tied the IRS controversy to the health care law, which he referred to as Obamacare.

Paul, May 19: There's rumors that who wrote the [IRS] policy [to scrutinize tea party and other conservative groups] is the person running Obamacare, which doesn't give us a lot of confidence about Obamacare.

He's referring to Sarah Hall Ingram, who served as the IRS' commissioner for the Tax Exempt and Government Entities Division for a portion of the period under the IG's review. Ingram is now the director of the IRS' Affordable Care Act office (so not "running" Obamacare, just overseeing the IRS end).

More importantly, the Treasury Inspector General for Tax Administration's report makes no suggestion that Ingram "wrote the policy" that resulted in the IRS targeting conservative groups seeking tax exempt status.

The IG's report concluded the policy, or directive, wasn't written by administrators in Washington, D.C., but rather, "The Determinations Unit [in Cincinnati] developed and implemented inappropriate criteria in part due to insufficient oversight provided by management. Specifically, only first-line management approved references to the Tea Party in the BOLO [be on the lookout] listing criteria before it was implemented."

According to the report, Lois Lerner, the IRS's director of the exempt organizations division -- a position under Ingram -- "immediately directed that the criteria be changed" once she learned about it in June 2011.

At worst, the report suggests that perhaps Ingram can be criticized for failing to provide management guidance, but not for writing the policy, as Paul suggested.

Further scrutiny of the IRS is coming, but on "Fox News Sunday," Obama senior adviser Dan Pfeiffer warned that people ought not to jump the gun on Ingram until all the facts are in. The report does not name anyone; only titles were used and her title rarely appears in the 48-page report.

Pfeiffer, May 19: Well, I think first it's important to note this individual [Ingram] was not named in the inspector-general's report. No one has suggested she's done anything wrong yet ... The acting commissioner is going to do a 30-day review. And everyone who did anything wrong is going be held accountable. But I think before everyone in this town convicts this person in a court of public opinion with no evidence, let's actually get the facts and make decisions after that.

Unless or until further investigation proves otherwise, Paul's speculation runs contrary to the findings of the IG report.


  Andy Borowitz: "When Congress grills the IRS, it's impossible to root for anything but a roof collapse."

  Andy Borowitz: "Congress, IRS Face Off for Title of Most Hated People in America."


May 21, 2013: Four In Ten Unaware Obamacare Is Still Law; Kaiser Poll

Unbelievable, four out very ten Americans are either unaware that Obamacare is the law of the land, or believe that it has been repealed. FOUR OUT OF EVERY TEN are  unaware that the law is being implemented and that the deadline for many of them to meet the law's requirements is December 31. 2013. This ignorance is even higher among certain populations that the law was specifically designed to help; for example, six in ten of those in households making less than $30,000 a year are unable to say the law is still in force, as are half of younger Americans.  This a testament to one of several things (1) Obama has done a piss poor job of using his bully pulpit to reach out to the nation to publicize and explain the new law; (2) TeaParty/Republican recalcitrance and misrepresentations about the law have taken their toll on the American psyche; (3) America's educational system has completely failed to prepare vast numbers of its citizens to function in a modern world of information assimilation, processing and understanding; and/or (4) Americans watch entirely too much Fox News. Probably, its a combination of all four. <sigh>


As you may know, a health care bill was signed into law in March 2010. As far as you know, which comes closest to describing the current status of the health care law? All Ages
Annual household income less than $30,000
It is still the law of the law and is being implemented (aware of Obamacare's status) 59% 49% 42%
Unaware of Obamacare status (NET) 42 51 59
It has been overturned by the Supreme Court and is no
longer law
7 8 14
It has been repealed by Congress and is no longer law 12 21 16
Don't know/Refused 23 22 29
Note: Percentages may not add to 100% due to rounding.

Not surprisingly, then, about half the public (49 percent) says they do not have enough information about the health reform law to understand how it will impact their own family, a proportion which rises to 56 percent among those non-elderly living in low-income households, and 58 percent among the uninsured. Also notable: Hispanics are more likely than whites or blacks to report they do not yet have enough information about the law to understand how the ACA will affect their families (65 percent of Hispanics say so, compared to 48 percent of blacks and 45 percent of whites).

See the full April 2013 Kaiser Tracking Poll:  http://kff.org/health-reform/poll-finding/kaiser-health-tracking-poll-april-2013/


May 21, 2013: Market Forces Simply Do NOT Work in the For-Profit Health Care Insurance World



May 20, 2012: Obama Administration Eases Requirements for Medicaid Enrollment

The Obama administration is making it easier for states to sign up the poor for health coverage -- and to help those people stay covered. On Friday, it informed state officials that they could simplify enrollment in Medicaid, the federal-state program for the poor, to handle the onslaught of millions of anticipated enrollees next year when the health care law expands coverage.  The administration said the changes are geared to states that are expanding their programs, but they may also be adopted by others.  At least 22 states have committed to expanding Medicaid, one of the chief ways the law extends coverage to the uninsured, and several more are undecided. [see below] The Supreme Court made expansion of Medicaid optional, and most Republican-controlled states have opted against it

In a letter to state officials, federal Medicaid Director Cindy Mann laid out several ways states might streamline enrollment for adults, including using data people have already submitted to qualify for foods stamps -- a practice that a few states permit for children.  States may also allow adults to stay enrolled in the program for up to a year, even if their income changes, she said. Allowing adults to stay in the program when their income changes is a "big deal," said Alan Weil, executive director for the National Academy for State Health Policy.  He said it was likely to reduce the large number of people churning in and out of the program, which interferes with their ability to get care. Thirty-two states now use this option for children.

In states moving forward with the expansion, residents with incomes up to 138 percent of the federal poverty level -- or about $33,000 for a family of four -- will be eligible for coverage. About 13 million people are expected to enroll in Medicaid starting next year, according to the Congressional Budget Office. Mann's letter outlines several options state can use to streamline enrollment and retention. "Enrollment strategies that target individuals likely to be eligible for Medicaid, and for whom eligibility information is already in the state's files, provide important advantages both for uninsured individuals and for states," she wrote.

To help states deal with the demands of increased enrollment, they will have the option in the first three months of next year to extend the Medicaid renewal period by up to 90 days. That means that if an individual on Medicaid comes up for renewal on February1, their eligibility could be extended to May. "This is part of our longstanding ongoing effort to continue to simplify and streamline enrollment and renewal in Medicaid," said Donna Cohen Ross, a senior policy adviser at the Centers for Medicare & Medicaid Services (CM2).  Cohen Ross said the administration is employing lessons learned from enrolling children in Medicaid. Red states, like Louisiana and South Carolina, for instance, have used the food stamp strategy to help sign up thousands of children, but states have not previously had the option for adults.  Similarly, CM2 said states can use existing government data to sign up parents whose children were already enrolled in Medicaid.



May 20, 2012: Where Do We Stand on State Medicaid Expansion?

Under the Patient Protection and Affordable Care Act (affectionately known by one and all as Obamacare), individuals making less than $14,856, 2-person households making less than $20,123, 3-person households making less than $25,390, 4-person households making less than $30,657, 5-person households making less than $35,923, and 6-person households making less than $41,190 per year will receive mostly low cost and no cost health care coverage (Medicaid) if they live in one of the blue states on this map. If you live in a red state and qualify, you will not receive this health care coverage, but you will be exempt from having to purchase health insurance if you don't already have it.



Visit the Obamacare Information Desk, for more information and updates.



Arizona senators moved Medicaid expansion one step closer to reality in that state this week while the effort fell short in Michigan. Both states are led by Republican governors who announced earlier this year that they support expansion.

In Arizona, the Republican-led Senate voted last week to include provisions in the state's $8.8 billion budget that put in place GOP Governor. Jan Brewer's proposal to expand Medicaid coverage to people with income up to 138 percent of the federal poverty level, as called for in the health care law. The issue now goes to the Arizona House, where the prospects are less clear. Arizona's fiscal year starts July 1.

"When I announced my health care plan in January, I knew this would be a long and difficult road," Brewer said in a statement. But she added that public polls show "strong support for my Medicaid Restoration Plan across party lines and among residents from every corner of our state." If the state legislature chooses to broaden the program, Brewer said, "We can keep Arizona tax dollars in Arizona. We can use these resources to provide cost-effective health care to Arizona's working poor. We can protect our critical rural and safety-net hospitals. We can create thousands of jobs and improve Arizona's economic competitiveness."

The situation is more complicated in Michigan. The Republican-led Senate on last week narrowly approved a budget bill that doesn't broaden Medicaid eligibility. The House has already passed a budget measure without the expansion. Some Medicaid advocates hope that it could re-emerge in legislation separate from the budget process, which will wrap up in the next few weeks. The fiscal year in Michigan starts October 1. Some Michigan House Republicans are considering a bill that would expand Medicaid but it includes limits on the numbers of years that people could receive Medicaid, something the Obama administration is not likely to approve.

Similar ideas have been floated in Ohio, another state in which a GOP governor supports the expansion but the legislature has not acted. In that state, one idea that some Republicans are pushing is the notion of time limits. Others like the idea of spending Medicaid dollars to pay for coverage in the new marketplaces that will start enrollment in October, in a manner similar to what Arkansas has proposed. Republican governors have been influenced by lobbying from local employers and health industry officials, such as hospital administrators. They also like the fact that the federal government will pick up the full tab for the first three years, although the federal contributions scale down to 90 percent in 2020.

However, many GOP legislators see the vote on Medicaid expansion as their last chance to vote against a part of the health care overhaul for philosophical and political reasons, politics uber alles, no matter that it hurts their state's payers and harms the health of their citizens. They must make Obama look bad..



Jeanne's Weakly Lawyer Jokes for the Week of May 20, 2013

Lawyer/Legal Proverbs (10)

Home is home, as the devil said when he found himself in the Court of Session.


(My subtitle: "One Third of Every Dollar the U.S. Taxpayers Pay for Health Care is Being Sucked Up by Those Who Profit From the Current System Without Contributing to it -- i.e., blood-sucking for-profit health insurers, con-artist providers and the lobbyists and Congresscritters they have bought off to keep their gravy train rolling.")

The IOM report includes a wonderful infographic that I have broken down into several separate charts. (Which, of course, I have modified with my own comments and which I will steal to be used in future presentations <smile>) ...


These charts tell us a lot  ... (1) they show the improvement in computer graphic design capabilities since 1993, but (2) how slowly, if not at all, U.S. health care delivery and financing capabilities have changed over the last 20+ years despite repeated calls for change ... Take a look at that last chart above, 1/3rd of all U.S. health care spending (not just Medicare) ... ALL spending ... one out of every three dollars in U.S. health care spending is not actually going toward needed and effective health care, rather it is wasted on unnecessary overhead, duplication and inefficient delivery of care much of which is itself ineffective and unnecessary. <sigh>.

Now compare this to  a 6'x3' blow-up chart used by then President Clinton on September 22, 1993 when he went on national television to explain to an eagerly awaiting American nation his plans to reform US health care and offer universal coverage to all Americans ... a system its opponents successfully beat back ... Hillarycare ... (This graphic is from a PowerPoint presentation I used for almost 10 years after the defeat of Hillarycare in 1994.) President Clinton's chart was based on a study by the UCLA Medical Center in 1992-93 and widely reported at the time.  Guess what the study in 1993 showed? 33 1/3% of all US health care spending was wasteful, duplicative and/or fraudulent We've come along way ... NOT

So ask yourself the next time you hear Mitt Romney attacking the President for "stealing" $716 billion from Medicare to fund Obamacare. Obama is simply saying we can and we will begin to cut into all that waste in health care spending. If we can save, over 10 years, $716 Billion, just on Medicare (while adding additional benefits for seniors and extending the solvency of the program by at least 8 years) think how much more can be saved out of ALL U.S. health care by improving systems and cutting out the middlemen in the financing and delivery of health care. And remember, the $716 billion Obama says can be saved in Medicare is actually be used to save Medicare ... unlike the identical $716 billion Romney's running mate, House Budget Committee Chair, Paul Ryan, would cut out of Medicare but would then use to cover tax cuts to millionaires while leaving Medicare on an early path to insolvency.


May 15, 2013: Most Doctors Still Waiting On Medicaid Pay Raise   

Five months after primary care doctors who treat Medicaid patients were supposed get a big pay raise, most physicians have yet to see it. Only three states have implemented the pay raise -- Nevada, Michigan and Massachusetts, according to the American Academy of Family Physicians. 

The two-year pay hike is intended to entice more doctors to treat the millions of residents expected to enroll in Medicaid in 2014 when the federal health law expands eligibility. Critics have said the expansion of the federal-state program for the poor would accelerate the shortage of doctors who treat them.  Most states have not started offering the higher pay rates because the Obama administration did not issue the rules until November, and state officials said they didn't have time to carry out the change and have the federal government approve the new rates.  All states have applied with the federal government to start offering the higher rates, but the Centers for Medicare & Medicaid Services has approved only seven.

"CMS remains confident that the higher payment rates ultimately will help increase access to care for Medicaid beneficiaries," said a CM2 statement.

While Medicaid fees vary by state, they are generally far below those paid by Medicare and private plans. The change means an average 73 percent pay increase nationally, according to a 2012 study by the Kaiser Family Foundation. Earlier this year, CM2 said doctors will be able to get the higher fees retroactively to January 1, when states do implement the provision. But many states have set deadlines for April and May for doctors to self-attest that they are primary care physicians in order to get the retroactive pay. Those that miss the deadline will only receive the pay raise once they fill out a form showing they are licensed as a family doctor, pediatrician or internist.

Several major physician groups, including the American Medical Association, American Academy of Pediatrics and the American Academy of Family Physicians, wrote to CM2 earlier this month about their frustration with the delays. "Our organizations have grown increasingly concerned that the brief time frame which states had to implement this provision has resulted in confusion both by state employees responsible for administering the program and the physician community," stated the letter to Cindy Mann, who runs the Medicaid program. "One overarching concern shared by our organizations is the lack of a coordinated plan to educate and communicate to eligible providers about the payment increase and steps physicians must take to participate.

Stephen Zuckerman, senior fellow at the Urban Institute, said doctors were hesitant to sign on as a result of the pay raise given that it expires at the end of 2014, and the implementation problems won't help.  "Because of the temporary nature of the pay raise, it was always questionable how many doctors would jump at treating Medicaid patients if they had not done in the past," he said. "If doctors were tentative before, they still have a reason to be."

Jeanne's End Note: The issue of provider reimbursement for Medicaid has been a thorny issue from the git-go in the program's history. At the start in 1966, states were expected to reimburse hospitals and doctors at or near their standard rates, but that quickly bogged down. Promises  that "Poor people would be able to show up at a doctor's office with their heads held high, presenting their Medicaid cards and getting the same coverage (and presumably respect) as every other insured patient." (LBJ's promise in 1965 when he signed the Medicare-Medicaid law) vanished almost immediately.  It will be interesting to see whether the so-called "Arkansas model" for states expanding their Medicaid program can get off the ground. It could be the best, albeit potentially the most expensive, solution to the problem.



May 15, 2013: Could U.S. Health Care Spending Really Be Going Down?   

The current health spending slowdown may persist after the U.S. economy rebounds, with a potentially dramatic impact on deficit reduction efforts, three leading policy analysts concluded in separate studies released this week. A host of fundamental changes in the health care system, such as slower-paced innovation in the pharmaceutical and medical imaging spheres, increased cost-sharing by patients, and greater provider efficiency account for most of the recent slowdown -- not the recession -- said the author of one of the studies, David Cutler. The Harvard University economist spoke at a Washington, D.C., forum sponsored by Health Affairs, which featured his study in its May issue.

"The 2007-09 recession, a one-time event, accounted for 37 percent of the slowdown between 2003 and 2012," Cutler and coauthor Nikhil Sahni wrote in study. Sahni is a senior researcher in the economics department at Harvard. "The evidence thus suggests at least as strong a case for structural changes as for cyclical factors" relating to the economy, they said. One of the structural changes relates to a growth in high deductible health plans. "These deductibles are now greater than most families have in the bank," Cutler told the forum. "I say this is unrelated to the recession because nobody that I know of when they are making a forecast about the future thinks that if economic growth returns very rapidly, cost sharing is going to come down," he added.

"If these trends continue during 2013-22, public sector health care spending will be as much as $770 billion less than predicted," the authors said in the study. "Such lower levels of spending would have an enormous impact on the U.S. economy and household finances." By 2021, they would wipe out 20 percent of the expected budget deficit in the year 2021, "the equivalent of doing a massive deficit reduction effort," Cutler said.

The findings were released on the same day the Congressional Budget Office estimated that deficit spending is $231 billion lower so far in fiscal 2013 than in the same period in fiscal 2012.

While more analysts seem to think the slowdown doesn't just stem from people having less money to spend because of joblessness or shrinking incomes, some warn that the current wave of optimism may be overblown. Speculation that the nation's health spending problem has somehow been solved or cut down to size is unrealistic, said a Kaiser Family Foundation study released April 22, which concluded that 77 percent of the slowdown stems from the weak economy. It would be a mistake to think deficit reduction is fading as a political issue even if some recent trends and studies are creating some cautious optimism.

But the idea that the spending slowdown isn't going away soon got backing in two other studies released this week.

Harvard health policy professor Michael Chernew, vice chairman of the Medicare Payment Advisory Commission, said in a study conducted with other Harvard researchers that from 2009 to 2011, per capita national health spending grew about 3 percent a year compared to an average of 5.9 percent annual growth during the previous ten years. Their study examined two factors that might account for the slowdown: job loss and benefit changes that shifted more costs to insured people. "We conclude that such benefit changes accounted for about one-fifth of the observed decrease in the rate of growth," they said.

The researchers tried to find a group that was not as affected by the recession in their study. So they looked at spending patterns among workers who did not lose their health coverage. They found that "spending growth slowed even for this population," Chernew told the forum. So the slowdown had to involve factors other than the direct effects of job loss, he said. That suggests "other factors, such as a reduction in the rate of introduction of new technology," were also at work.

"Our findings suggest cautious optimism that the slowdown in the growth of health spending may persist -- a change that, if borne out, could have a major impact on U.S. health spending projections and fiscal challenges facing the country," the study said.

Chernew said "I share David's [Cutler] sense of good news. This is a really big deal." But simply because spending growth is slow does not mean policymakers should stop efforts to make spending more efficient, he warned.

"There's more going on than just the recession," added John Holohan of the Urban Institute, who led a third study. In reviewing health spending growth over the last decade, Holohan and fellow Urban analyst Stacey McMorrow found that that growth began to slow well before the most recent recession. Medicare spending growth began to slow in 2004, he said. "A variety of payment policies for imaging, home health, durable medical equipment and Medicare Advantage have contributed to slower Medicare spending growth," according to the Institute's study.

"State Medicaid programs have also tightened payment policies, expanded managed care, and increased community-based long-term care alternatives under intense budgetary pressures. Moreover, slower growth in prescription drug spending has affected all payers due to the development of fewer blockbuster drugs, the adoption of tiered formularies, and increased substitution of generics for brand-name drugs," the study added.

The analysts at the Urban Institute were more skeptical that changes such as medical homes and accountable care organizations are driving the slowdown. Their study instead pointed to trends over the past decade such as "declines in real incomes and a shift towards less generous insurance arrangements," that have "slowed the growth in provider revenues and forced cost-containment efforts. Some of the more recent payment and delivery system reforms may help to sustain this slow growth, but this remains to be seen.

Jeanne's End Note: Nowhere in the discussions reported from this Health Affairs conference was there mention of the longer term impact of this apparent reduction in health care utilization (note: costs per service have NOT gone down, rather fewer services are being provided).  The USA already lags most of the industrialized nations with which it is competing economically in health care outcomes, life expectancy, infant mortality, and even quality of life. Yet we continue to spend almost twice as much per capita than these other nations ... assuming less health care utilization is our goal, would not our outcomes worsen over time? And what would be the longer term impact on this country's competitiveness and economic well-being?


May 14, 2013: Will Enough "Healthy" People Enroll in the Exchanges or Will They Be Stuck With Just the Sick?  

The Obama administration has identified specific groups of people it would like to focus on as it promotes enrollment in the state health insurance exchanges this fall. The administration plans a localized approach to reach 2.7 million healthy people who are 18 to 35 years old and without health insurance. Enrolling that population group is crucial to stabilizing the marketplace, because the healthier people will balance out the costs of covering enrollees who are older and sicker. The ratio of healthy people to sicker people who participate in the exchanges will affect the premium rates in the second year.

The Congressional Budget Office (CBO) expects 7 million people to enroll in the insurance exchanges in the first year, and the administration expects that nearly 5 million will be those with pre-existing conditions or those who already buy insurance on the individual marketplace. Of the 2.7 million young people being pursued, 96 percent have no chronic conditions, 57 percent are female, and 52 percent are non-white, according to senior administration officials. In addition, one-third of the population lives in one of three states: California, Florida and Texas.

The administration's focus now is on consumer outreach and assistance, as nearly all of the guidances and rules for Obamacare's (PL 111-148, PL 111-152) marketplaces are complete, the officials said.

Speaking at a recent White House event, President Barack Obama touted the law's benefits and tried to assure people who are anxious about the law. "I am 110 percent committed to getting it done right," he said. "It's not an easy undertaking. If it were easy, it would have already been done a long time ago. Undoubtedly there will be some mistakes and hiccups as the thing gets started up, but we're learning already from them."

The administration's enrollment outreach will be tailored to each specific group, and the plan is to appeal to young people with a simple insurance application, providing new benefits, and tax credits to help buy insurance. For example, in California, 54 percent of the goal population is eligible for tax credits, and 50 percent is Hispanic.

Administration officials also said they planned on reaching out to mothers specifically, because they can encourage their children to buy insurance.

Assisting in the outreach efforts will be community health centers, which recently received $150 million from the law to help enroll the uninsured. Churches and other community organizations can also help with enrollment, the administration officials said. They noted that lessons learned from the 2012 presidential campaign have informed their outreach plan.

Open enrollment for the insurance exchanges begins October 1 and lasts for six months, with coverage beginning January 1, 2014. That gives the eligible population an extended period to sign up, so the outreach efforts can ramp up over time, the officials said. The officials noted that they recently completed the paper application for insurance in the exchanges for single adults, which is three pages long. They are now translating that into an online application.

The administration said that once people enroll in the exchanges and begin receiving insurance benefits, the politics of the law could change. The GOP message of stopping the law will mean taking away real benefits, not something abstract, they said, noting that the House plans to vote on a bill (HR 45) to repeal the law next week.

Republican leaders criticized Obama's speech and promoted the upcoming repeal vote.

"The president's health care law is a train wreck for men and women alike, and that's why a majority of Americans support Republican efforts to repeal it to protect their health care -- and their jobs," Speaker John A. Boehner, T/R-Ohio, said in a statement. "The entire law should be repealed so we can enact a step-by-step, common-sense approach to health care that starts with lowering costs and protecting American jobs."

Obama dismissed the "political bickering" over the law and told people to get informed about how the law would affect them personally. "Precisely because there's been so much misinformation, sometimes people might not have a sense of what the law actually does. And that misinformation will continue at least through the next Election Day," he said. "This is too important for political games. You stand to benefit, if you're not already benefiting from this thing," Obama added. "Don't let people confuse you. Don't let 'em run the okey-doke on you. Don't be bamboozled."

Jeanne's End Note: One of the aims of the for-profit health insurance lobby is assure that most of the "sick" people (i.e., those with pre-existing conditions, diabetes, who are obese, or who have other socio-economic problems that might adversely impact their health status now or in the future) don't end up enrolled under one of their policies. Why? Simply, the less they have to pay out, the more money they can make for their stockholders and to fund the 7 and 8 digit bonuses paid to their corporate executives. Since the partial privatization of Medicare in 2003 under the so-called "Medicare Modernization Act," for-profit insurers have honed their skills at minimizing the accidental enrollment of less healthy seniors, with result that companies like Humana now earn upwards of 80% of their profits, amounting to billions of dollars, from Medicare. Now, under Obamacare, these for-profit insurers are salivating at the opportunity of doing the same in "cherry-picking" only the healthiest of the 30-40 million people who will now be signing up for the first time to get health insurance. If these marketplaces under Obamacare cannot enroll a manageable mix of healthy and less healthy insured, they are doomed to failure ... something that has probably been on the GOP agenda all along.


May 13, 2013: Transparency in Hospital Charges versus Actual Hospital Payments

Following up on last week's report on the widely (and wildly) varying charges of hospitals for the same identical services, even in the same metropolitan area, it should be noted that WHAT A HOSPITAL CHARGES MEDICARE IS NOT WHAT MEDICARE PAYS THE HOSPITAL. Hospital charges are almost always discounted, in many cases, significantly.  The correlation between charges and payments has always been a mystery to me, so much so, that I used to have a presentation on my speaking circuit entitled: "Hospital Accounting is to Accounting as Military Music is to Music." They are virtually unrelated. Never has this dichotomy been made more (hopefully) understandable to the general public (who often complain bitterly about $10 aspirins) than in reading through the spread sheets from last week's CM2 report.

For example, Alaska Regional, in Anchorage, charges Medicare $46,252 for a patient with heart failure and a major complication. Alaska Native Medical Center, also in Anchorage, charges $20,839. In both cases, Medicare doesn't pay anywhere close to the full charge. The government reimburses Regional $13,950 and Alaska Native, $12,935.

[Please note this kind of "discounting" from charges to payment is not limited to Medicare. Private fee-for-service insurance plans usually pay more than Medicare, but they also usually have negotiated the amount down significantly from charges. Private managed care plans (HMOs, PPOs) in many cases pay less than Medicare.]

The system doesn't make much sense, but Rick Davis, the CEO of Central Peninsula General Hospital in Soldotna, Alaska says more transparency will help: "For there to be pressure on pricing on the consumer side, the consumer has to understand what it's going to cost them. And so, I think this is a good report. I think it's going to force hospitals to address their pricing." Davis says the data show the prices at his own hospital, Central Peninsula, are fair. And he doesn't expect to make any adjustments.

But Bruce Lamoureux, CEO of the Providence health system, says his hospital will consider changing some prices, down or even up, based on the report: "There are some instances where our charges for a particular procedure are, in one case, half of a different provider's, and in a different case, twice a different provider." Lamoureux thinks the information actually gives consumers some negotiating power when it comes to health care costs, something they've never had before. He says the system of hospital pricing and reimbursement is badly broken and this step toward more transparency is long overdue.

But a hospital bill is only one part of the overall health care cost picture.

"That's kind of like a rack rate in the hotel room," says Karen Perdue, president of the Alaska State Hospital & Nursing Home Association. "Most people aren't paying that one rate in the hotel. Different payers are demanding different deals at the hospital, so I think what consumers need is not only a more accurate way to determine what their costs are going to be, but also what the full cost will be, not just the hospital cost."

Data like the charges from doctors and anesthesiologists, which aren't included on a hospital bill. Perdue says her board is looking at ways to make hospital cost data easily available to consumers. But health care is a complicated industry and it's not an easy task.

"Transparency, for us, feels like the future and where we should be going, and where we should be putting our effort," she says. "How we should do that in a way that is meaningful to the consumer is the challenge ahead of us."


Jeanne's End Note: Charts like these above can be duplicated for every state and every metropolitan region.  But will patients (consumers) actually use them, or will they blindly follow their doctor's orders (even if in some cases, the physician may have a financial stake in the hospital)? For the Providence system's Karen Perdue, I have this to say, "Oh Karen, transparency was a major goal of the Bush administration too, but it was stymied at almost every turn by organized physician groups who didn't want the public to compare Dr. Smith to Dr. Jones." The AMA and other physician groups have fought tooth and nail against almost any kind of physician-to-physician comparison whether it be on prices or, heavens forbid, quality, i.e., results. The hospital industry had to finally relent as part of Obamacare's quality care initiative and future reports will compare not only hospital prices, but also hospital outcomes, with patient reviews and "consumer reports."

For the doc, on the other hand the battle continues. A few of the medical groups, associations and societies have agreed to reveal pricing and we should see new comparison reports in this area. But a word of caution, remember back to 1966 when Medicare Part B began and physicians were to be paid their "usual and customary fees" ... the net result of that LBJ give-away was that every doctor below the highest UCF in the area, quickly moved his or her fee schedule up to what was then the new standard. Physician simply leapfrogged on that scale. Of course that was remedied (somewhat) in 1983 when the UCF was replaced by "resourced-based relative value scales" (RB-RVS). Physicians now reporting their fees may simply be encouraging their medical brethren to move their prices to the highest quartile. And for the time being, reporting on quality is not in the works for docs ... BUT hospitals facing penalties and lost revenues for poor outcomes can be expected to step in and demand more and more accountability from their docs ... welcome to the brave new world of ACCOUNTABLE CARE ... being brought to you by Obamacare.

Jeanne's Weakly Lawyer Jokes for the Week of May 13, 2013

But First There is Law School

Law School Admission Form

Sue U. University


Law School for the Ethically Disadvantaged

666 Ambulance Chase

Sue Sainte Marie, Michigan

... for more law school jokes go to: http://www.health-politics.com/humor.html#05-13-13



May 10, 2013: Boehner Says NO to Any GOP Nominations to PPACA Board (What Else is New?)

Note to the Obama administration: Don't wait by the phone for those GOP nominations to the Independent Payment Advisory Board, a panel created in the health law to make recommendations to Congress on how to control Medicare costs.

House Speaker John Boehner, T/R-Ohio, made it clear yesterday that neither he nor Senate Minority Leader Mitch McConnell, T/R-Ky., would be sending in any names for consideration. "This is the 15 unelected, unaccountable individuals who have the authority to deny seniors' access to care," Boehner told reporters. "The American people don't want the federal government making decisions that doctors and patients should be making." [No Bonehead, we should continue to allow unelected, unaccountable corporate lackeys seeking to maximize profits to continue to make those decisions behind corporate veils of secrecy and without oversight or appeal, as they have doing all along.]

Known as IPAB, the panel is charged with making proposals to reduce Medicare spending if government funding of the program grows beyond a target rate. Congress can pass alternative changes of the same size instead, but if it fails to act, the IPAB plans would become law. But recent slowdowns in the growth of Medicare spending means there's no immediate pressure for the panel, which has not yet been assembled, to make spending recommendations to Congress.

[By the way, be sure to call the White House and put my name in nomination to serve on the IPAB, I'd be a great addition <smile>]


May 10, 2013: Red States Get Obamacare Jobs

Four states that have snubbed the federal health law by defaulting to the federal government to build new online insurance marketplaces and not agreeing to expand Medicaid are getting new jobs at call centers that will help consumers understand their new coverage options this fall. Up to 9,000 jobs are expected to be created at call centers to support the new federally run marketplaces. A Department of Health and Human Services spokeswoman said some of them will be added to existing Medicare call centers in Phoenix, Chester, Va., Lawrence, Kan., and Tampa -- all states with Republican leaders who oppose the law. A fifth center in Coralville, Iowa and a sixth in Corbin, Ky., will also be expanded, she said. Plans are still being finalized for other locations, she said. Of those states, only Kentucky is setting up its own online insurance marketplace that will help people shop for individual or small employer coverage. Iowa, will run its exchange in partnership with the federal government.  The other states are relying entirely on the federal government.

Of the six states getting call centers, only Kentucky has committed to expanding Medicaid in 2014, even though governors in Florida and Arizona say they support it. So far, 22 states have agreed to expand Medicaid.

The jobs are through Vangent, a General Dynamics Information Technology subsidiary, which was awarded a $530 million one-year contract  by the federal government to set up call centers to answer inquiries related to the insurance marketplaces in 34 states where they will be run in whole or part by the federal government. The government estimates that next October, when the marketplaces go live, the call centers will be open seven days of the week, 24 hours a day, handling 6.1 million phone calls and 23,000 e-mails. The contract could be renewed for up to nine more years, making it potentially worth more than $5 billion. States running their own marketplaces will have their own call centers. The marketplaces are expected to expand health coverage to about 27 million people by 2016. Under the federal contract awarded to Fairfax, Va.-based Vangent, the company will also field inquiries about Medicare, Medicare Advantage and "other relevant programs," the award announcement stated.

Jeanne's Comment: Apparently for blue states, no good deed goes unpunished by the Obama administration.


May 8, 2013: NEW GOVERNMENT REPORT: Hospital Charges Vary Dramatically, Even in the Same City


Consumers on Wednesday will finally get some answers about one of modern life's most persistent mysteries: how much medical care actually costs. For the first time, the federal government will release the prices that hospitals charge for the 100 most common inpatient procedures. Until now, these charges have been closely held by facilities that see a competitive advantage in shielding their fees from competitors. What the numbers reveal is a health-care system with tremendous, seemingly random variation in the costs of services

As part of the Obama administration's work to make our health care system more affordable and accountable through transparency, data are being released that show significant variation across the country and within communities in what hospitals charge for common inpatient services. The data provided today include hospital-specific charges for the more than 3,000 U.S. hospitals that receive Medicare Inpatient Prospective Payment System (IPPS) payments for the top 100 most frequently billed discharges, paid under Medicare based on a rate per discharge using the Medicare Severity Diagnosis Related Group (MS-DRG) for Fiscal Year (FY) 2011.

These DRGs represent almost 7 million discharges or 60 percent of total Medicare IPPS discharges. Hospitals determine what they will charge for items and services provided to patients and these charges are the amount the hospital bills for an item or service. The Total Payment amount includes the MS-DRG amount, bill total per diem, beneficiary primary payer claim payment amount, beneficiary Part A coinsurance amount, beneficiary deductible amount, beneficiary blood deducible amount and DRG outlier amount. For these DRGs, average charges and average Medicare payments are calculated at the individual hospital level. Users will be able to make comparisons between the amount charged by individual hospitals within local markets, and nationwide, for services that might be furnished in connection with a particular inpatient stay.

Inpatient Charge Data, FY2011, Microsoft Excel version
Inpatient Charge Data, FY2011, Comma Separated Values (CSV) version

The New York Times has an interactive map -- http://www.nytimes.com/interactive/2013/05/08/business/how-much-hospitals-charge.html?ref=business

May 8, 2013: NEW STUDY: Medicare Advantage Plans are Costing Far More and Saving Little

Health plans participating in Medicare Advantage (MA), the private mostly for-profit  insurance option for Medicare beneficiaries, have long been paid considerably more to provide coverage of hospital and physician services than what the government spends to deliver the same benefits to enrollees in traditional Medicare.

Unveiled as part of a Republican-driven "privatization plan" for Medicare as part of the Medicare Modernization Act of 2003 (passed without a single Democratic vote, at 3:30am in the morning after holding the House floor vote open for nearly 6 hours while GOP whips rounded up the needed votes -- the normal time limit is 15 minutes -- and signed by President George W. Bush on December 3, 2003) these private, mostly for-profit plans now enroll almost a quarter of all Medicare beneficiaries.

Republicans originally argued that competition among these plans would hold down Medicare cost growth. Instead, they have consistently cost far more than traditional Medicare. Under the Patient Protection and Affordable Care Act, affectionately known by many as "Obamacare," overpayments to these plans are gradually being pared back. But will these private Medicare plans be able to cope with the reduced payments?

Using newly available information on 2009 MA plan costs, analysts have compared  MA plans’ estimates of per capita costs for providing Parts A and B benefits to their enrollees, on a risk-adjusted basis, against what government data show to be the same costs for traditional Medicare program beneficiaries residing in the same county. In doing so, analysts have found that on average, risk-adjusted MA plan costs were 4 percent higher than traditional Medicare costs (104%). Among plan types, only HMOs had lower average costs than traditional Medicare. Among local PPOs and private fee-for service plans, over 75 percent had costs exceeding those in traditional Medicare. The wide variation seen in MA plan costs relative to traditional Medicare suggests there is room for greater efficiency in care delivery.


May 8, 2013: Tackling Medicare, The Rand Corporation Looks at Three Options.

Lawmakers are looking for ways to tackle the growth of Medicare spending, which the Congressional Budget Office estimates will account for 24 percent of the federal budget by 2037. But some strategies to cut program costs could leave millions of beneficiaries without coverage.

A study from the Rand Corporation, a nonprofit research organization, compared the impact of three proposals that have been discussed by Congress or the White House to  curb the costs of the government health care program for seniors and the disabled. The study is published in the May issue of Health Affairs.

Here are the three policy changes the study modeled:

Means-Testing Part A: Medicare Part A includes coverage of care in hospitals and nursing homes, and unlike Part B (which covers doctor visits, labs and equipment), the Part A premium is the same no matter how much a beneficiary earns. The idea of making wealthier seniors pay more for Part A has been around for a long time: It was suggested by the bipartisan Kerrey-Danforth commission back in the mid-1990s.

Premium Support: Premium support would give seniors a set amount of money to purchase a private or Medicare-like health insurance plan. It's a proposal similar to the one championed by House Budget Committee Chairman Paul Ryan (R-Wis.).

Raising the Eligibility Age: If Medicare mirrored Social Security, the eligibility age would be 67. This proposal has been floated by both parties and has stoked heated debate. Medicare's age requirement has not changed since the program's inception in 1965, though life expectancy has increased by eight years in that time.

"The magnitude of savings can vary quite substantially," said author Christine Eibner, a senior economist at RAND, about the results of the comparative study.

The researchers found that premium support and raising the eligibility age were the most effective changes to curb costs. Increasing the eligibility age, for example, reduced federal spending by 7.2 percent through 2036, compared to 2.4 percent if a premium for Part A was added. And the premium support plan resulted in the most savings after 2019 of all three options.

The savings from raising the eligibility age in the RAND study was different from earlier Congressional Budget Office estimates because the Rand authors modeled the outcome with the idea of raising the age in 2014. The government office instead assumed the age would gradually be raised and not be in full effect until 2027.

But all three scenarios had downsides and the two scenarios that produced the greatest potential savings also produced the greatest possible burden for Medicare enrollees both financially and in terms of access to health care.

In the means-tested strategy, somewhere between 2 and 20 percent of eligible beneficiaries may choose not to enroll in Medicare Part A, researchers found. For the premium support plan, the authors estimate 13 percent of seniors would forgo coverage. And raising the eligibility age to 67 also would reduce enrollment by approximately 13 percent, according to the study.

Jeanne's End Note:  "Premium support," AKA the end of Medicare as we know it. doesn't reduce costs, it merely transfers costs from the Medicare system to some of the most financially challenged citizens.


May 7, 2013: Most Veterans Will Get More Under Obamacare ... But ...

Military veterans will have more health insurance options under the Patient Protection and Affordable Care Act, but some vets, like many Americans, may still struggle to find affordable, accessible care that meets their needs. Roughly 40 percent of the 22.3 million military veterans receive health-care services from the Veterans Health Administration, which operates a nationwide network of medical centers, hospitals and clinics. Many veterans are eligible for both VA health care and Medicare, Medicaid or Tricare. About half of veterans have private insurance; approximately one in 10 veterans younger than 65 are uninsured.

Veterans who were honorably discharged after being on active duty for at least two years may qualify for VA health services. Since funding for the VA health program is limited, however, priority is given to veterans who have service-related disabilities or low incomes. Although there are no premiums for VA health care, some veterans may owe co-payments for services. Veterans who return from active military duty are typically eligible for free VA health care for five years.

Under Obamacare, most people will have to have health insurance starting in January or pay a penalty. Veterans who are enrolled in VA health care won't have to buy additional coverage, although they can supplement their coverage if they want to.

Example: Mike Sage, 64, a Vietnam War combat veteran, pays $15 per visit for primary-care services and $50 for specialist care at the VA clinic near his home in Monmouth, Ill. Prescription drugs are $8 for a 30-day supply. But his wife, Kay, like many veterans' spouses, doesn't qualify for VA health care. They plan to check out the policies offered on the Illinois health insurance exchange this fall to see if there's a better option than the catastrophic-coverage plan with a $5,000 deductible that she currently carries. Sage was relieved to learn that his VA health care counts as coverage under the PPACA. "As long as I'm not subject to a penalty [for not having insurance], we'll do some comparative shopping for her," he says. Kay Sage might qualify for a premium tax credit for coverage on the exchange if the couple's household income is between 100 percent and 400 percent of the federal poverty level ($15,510 to $62,040 for a family of two in 2013), according to the Treasury Department.

The expansion of Medicaid under the Patient Protection and Affordable Care Act -- which "red" states are currently wrestling over whether to implement -- could also affect veterans' health care. The law allows the expansion of the federal-state program for low-income people to include adults with incomes up to 138 percent of the federal poverty level ($15,856 in 2013).

According to an analysis published by the Urban Institute last month, four in 10 uninsured veterans have incomes below 138 percent of the federal poverty level, potentially enabling them to qualify for Medicaid if their states expand the program. Most of those veterans have incomes below 100 percent of the poverty level. "For these veterans, it's critical that their state expand Medicaid," says Jennifer Haley, a research associate at the Urban Institute who co-authored the report.

In states that don't expand their programs, veterans whose income falls below 100 percent of the poverty level will generally not qualify for Medicaid, nor for subsidized coverage on the exchanges. Even though a non-disabled veteran may meet the income threshold for VA health care -- nationally, about $34,000, further adjusted by geographic location -- he or she may not live near VA facilities or know that VA care is available, according to the report.

At a hearing last month before the House Committee on Veterans' Affairs, VA officials said they expect a net increase of 66,000 veterans seeking health care through VA facilities when the mandate to have health insurance kicks in next year.  Some veterans will come into the VA system but others will leave to seek coverage on the exchanges or through Medicaid, they said. Those who are eligible for more than one health program may pick and choose, using one program for cheaper prescription drugs, for example, and another for specialist care.


May 6, 2013: Spending to Promote Obamacare Exchanges Varies Dramatically in Red States versus Blue

Florida (whose state legislature adjourned this weekend WITHOUT adopting Governor Scott's plan to expand its Medicaid program)  is on course to spend $6 million to reach out to nearly 4 million uninsured people and help them sign up for coverage in the federal health law's online marketplace this fall.  Maryland will spend more than four times as much, or about $24.8 million, to help about 730,000 uninsuredThe District of Columbia expects to spend about $9 million assisting 42,000 uninsured. 

The wide variation in spending to hire and train people to provide consumer assistance in the first year of the new marketplaces could have a major impact on how many people actually get coverage under Obamacare, experts say.

Yet states with some of the nation's highest uninsured rates, such as Florida and Texas, are getting far less federal money per uninsured resident than states with low rates, such as Maryland, Vermont and Rhode Island. That's because states relying on the federal government to run their marketplaces are getting far less money than states setting them up themselves because of how the health law was written. In addition, some states such as Maryland that are running their own operations are supplementing the federal dollars with states funds. That's widening the gap.

"The spending difference could have a huge impact," said Jon Kingsdale, a consultant who helped launch the successful Massachusetts health insurance exchange in 2006 ("Romneycare").

Consumer assistance is considered key to enrolling the uninsured for several reasons. Polls show most people are unfamiliar with the law's benefits, including new government subsidies that take effect next year. For example, those subsidies will apply to a family of four with an income as high as $94,000.

The online marketplaces, which open for enrollment October 1, were envisioned to be as easy to use as travel websites like Expedia, but experts say that many people will need help figuring out which plan is best for them and what information they might need to sign up for coverage. Some have never applied for health insurance coverage before and may need assistance even to navigate the website.

The marketplaces, also known as exchanges, are the key way the law expands health coverage to about 27 million people by 2016. That's where people will shop for and enroll in private coverage and determine if they are eligible for premium discounts, or for Medicaid, the state-federal health insurance program for the poor. While many customers will be uninsured, others with coverage will use them to take advantage of government subsidies.

"It's a shame that we see states with lower rates of uninsured putting more money into education and outreach than states with higher rates of uninsured," said Deborah Bachrach, a former New York State Medicaid director.

To be sure, consumer assistance is only one way that potential enrollees may learn of new insurance options and how to sign up for them. Additional federal dollars will go to advertising on radio, television and billboards. And insurers, hospitals and nonprofit groups may supplement public education efforts in many states.

The biggest reason for the uneven spending on consumer assistance is that when Congress passed the health law in 2010, it assumed most states would run the online marketplaces, and it authorized broad funding for that. As it turned out, only 16 states and the District of Columbia agreed to do so. The law did not set aside money for the federal government to operate the marketplaces, either alone or in partnership with the states, as it is doing in at least 34 states. To remedy that, the Obama administration recently moved $54 million from the law's prevention fund to provide money to hire and train people to assist consumers in those states, based on their number of uninsured.  That money will be awarded directly to organizations that agree to hire and train people to assist consumers. Those eligible include church groups, local health agencies, community health centers, chambers of commerce.

Laura Goodhue, executive director of Florida CHAIN, a consumer advocacy group estimates about 1.7 million people in Florida could benefit from subsidized coverage in the marketplace run by the federal government, but few know it will exist. "We are equally concerned about a lack of consumer assistance or any type of consumer advocacy at the state level to help resolve issues related to enrollment and eligibility," she said.

Texas, with the nation's highest uninsured rate of about 24 percent, will get as much as $8 million to enroll about 5 million uninsured in a federally run marketplace. That's less than $2 per uninsured resident -- compared to about $31 per person in Maryland. Virginia, with 845,000 uninsured, is getting $1.4 million for consumer assistance to help people sign up for its federally run marketplace.

Several states with high rates of uninsured are running their own marketplaces, and as a result, have more money for consumer assistance. New York, for instance, expects to spend up to $32 million on consumer assistance. Washington state has budgeted $6 million; Nevada, $2.3 million through 2014; California has budgeted $49 million through 2014.

Small states running their own marketplaces also have relatively big budgets to hire and train people to assist consumers. Rhode Island, which has 116,000 uninsured residents, plans to spend nearly $2 million over 18 months. A handful of states, including Maryland and Vermont, are also spending state taxpayer money to supplement their federal grants. Maryland has put up $8.6 million on top of $16 million it got from the federal government. Vermont, which has about 55,000 uninsured, has put up $400,000, for a total of $2 million.

While the amount of money channeled toward consumer assistance is important, other factors also will have an impact. For example, states can streamline enrollment in Medicaid and make other efforts to make the process as consumer friendly as possible.

A number of states are also counting on help from private organizations. The California Endowment, a large health foundation has offered about $29 million to help California's already well-financed outreach effort -- mostly to help find and enroll people in Medicaid.

Health advocacy groups in Maryland, meanwhile, are giddy at the $24 million that state is putting toward getting people signed up for insurance. The money will pay for 300 consumer assistance jobs created by six groups, including county health agencies and nonprofits.  Asked about how Baltimore will have more money for consumer assistance than the entire state of Florida, HCAM CEO Kathleen Westcoat laughed. "Maryland is putting its money where its mouth is," she said.


Jeanne's Weakly Lawyer Jokes for the Week of May 6, 2013

A More Feminine Practice of Law

... for more go to http://www.health-politics.com/humor.html#05-06-13


May 2, 2013: Finish Line Fast Approaching on Medicaid Expansion

Ever since the U.S. Supreme Court ruled last summer that expanding Medicaid to more low-income people was optional for the states, the focus has turned to what Republican governors and GOP-controlled legislatures would do.  Would they forego tens of millions of dollars in federal aid that would extend health insurance to many more people and, proponents argue, would provide a major boost to state economies? Or would these governors, many of whom vowed not to expand, stand their ground and insist the federal government will not be able to afford the expansion?

As of May 1, 16 states plus the District of Columbia have approved the expansion or are headed in that direction, 27 have rejected it or are about to and seven states could still go either way.

Some Republican governors, including Arizona's Jan Brewer and Florida's Rick Scott, have broken ranks, which in some cases has pitted them against GOP majorities in their legislatures. The other major development has been the proposal (see below) by Arkansas Democratic Gov. Mike Beebe, who received tentative permission from the Obama Administration to use federal Medicaid dollars to buy health insurance on the private market. And Republican legislators in some states, such as Texas and Louisiana, are interested in exploring similar plans, even as their GOP governors remain fiercely opposed.

With uncertainty about those plans and legislative battles still unfolding in a number of states, it's not yet known how many states will expand their Medicaid programs come January. 1, when the Patient Protection and Affordable Care Act (Obamacare) is set to take effect. Below is an up-to-date look at where each state and the District of Columbia stand at the moment.

Stay tuned. Much can happen before January.


May 2, 2013: The Arkansas Medicaid Model: What You Need To Know About The "Private Option"

The Obama administration wanted Republican states to accept the health law's Medicaid expansion pretty much as is. Republicans wanted Medicaid money in no-strings block grants. Arkansas has broached what could be a deal-making compromise, giving Washington the increased coverage for the poor it wants and Republicans something that looks less like government and more like business. Florida, Nebraska and other Republican-heavy states have taken a look. Some think the Arkansas model, passed by a Republican legislature and signed by Democratic Gov. Mike Beebe last week, could erode resistance in some 30 red states and eventually prompt similar programs elsewhere. And because the federal government has put no deadlines on Medicaid expansion, other states will be able to watch what happens in Arkansas and see if they want to adopt a similar idea.

While the plan brings what many see as advantages for patients, it also raises difficult questions of cost and implementation, not the least of which is the high overhead generally required by for-profit private insurers seeking to satisfy their investors and the stock markets. Government-run Medicare and Medicaid programs operate with much smaller margins and lower operating costs. Republicans insist that the "efficiencies" of the for-profit business model and market competition will reduce costs even more than "inefficient" government managers. Government bureaucracies are worse than private sector bureaucracies they argue. Democrats, who have long argued for a single-payer government plan point to the success of the government run Medicare program which operates at less than half the overhead expense of the for-profit alternatives under Medicare Advantage, without the 14% "kicker" these MA plans receive and without the "pressure" to increase profits that have led to so many consumer complaints in the private sector about claim denials and paperwork requirements.

How Does the Arkansas Plan Work?

In upholding the Patient Protection and Affordable Care Act last June, the Supreme Court did reject one critical element of Obama’s plan: mandatory requirements that states expand their Medicaid programs to at least 133% of the poverty level. That  Supreme Court decision making Medicaid expansion optional, combined with red-state reluctance, reduced the chances of reaching Obamacare's original coverage targets and undermining its universality. Arkansas would let newly eligible Medicaid beneficiaries shop for insurance policies along with other consumers in the online marketplaces, also known as exchanges, created by Obamacare. Arkansas House Speaker Davy Carter, a Republican, called the idea "a conservative alternative to the policy forced upon us by the federal government."

How is the Arkansas Proposal Different From Traditional Medicaid?

Medicaid is a combined federal and state program for low-income and disabled people that for many years paid health care providers for each procedure as well as each doctor and hospital visit. Recently most Medicaid treatment has shifted to managed-care plans run by private insurance companies with incentives to keep costs down. Arkansas takes the privatization idea a step further by letting many Medicaid consumers shop for the same commercial insurance available to those who aren't eligible for the program. "The menu of options is going to look the same" for eligible Medicaid consumers as for anybody else buying through the online marketplaces, said Matt Salo, executive director of the National Association of Medicaid Directors. "Access to physicians is going to look the same."

[Jeanne's Historical Memory Aside: My first job working in the health care industry, while going to law school, was as a claims examiner for a Blue Cross-Blue Shield plan. The year was 1965 when on July 2, President Lyndon B. Johnson signed the new Medicare (and Medicaid) law. While Medicare drew the most public attention and controversy, there was this Medicaid program coming along almost as an afterthought.  I remember how the argument in support of it went: "Poor people would be able to show up at a doctor's office with their heads held high, presenting their Medicaid cards and getting the same coverage (and presumably respect) as every other insured patient." Well history has shown us different as the costs of Medicaid ... and the states willingness to fund and support it ... has ebbed and flowed with the economy, the politics and the medical profession's acceptance. Now Arkansas Republicans seem to be making the same argument that LBJ made in 1965, Medicaid patients will be on a par with everyone else. Time will tell.]

What are the Advantages?

Commercial insurers' doctor networks are generally wider than Medicaid networks. Enrollment for Medicaid patients could improve access to care and prevent minor illnesses from spiraling into expensive hospitalizations. It could also reduce care disruptions for those whose incomes fluctuate, shifting them between Medicaid and the subsidized exchanges. At the same time, adding thousands of Medicaid members to the exchanges could reduce the risk that a few chronically ill patients would sharply drive up exchange premiums. With proper software, exchanges could determine people's eligibility for Medicaid and pay federal and state Medicaid dollars directly to their insurance plans.

What are the Disadvantages?

Cost might be a big one. Medicaid typically pays hospitals and doctors much less than average. A beneficiary costing the government $6,000 a year for Medicaid would cost $9,000 on a private plan on the exchange, the Congressional Budget Office has estimated. On the other hand, Arkansas officials have suggested that competition among insurers and providers for Medicaid patients could keep the cost from being prohibitive or even save money eventually. There would also be challenges to harmonizing Medicaid plan designs with those of policies sold on the exchanges. Private coverage on the exchanges is expected to come with large deductibles and co-payments for consumers, but Medicaid strictly limits such cost sharing. For a Medicaid patient, "if you're going to go to the pharmacy counter and pick up your prescription, are you going to have to come up with this 15 or 20 percent copay out of your pocket?" said MaryBeth Musumeci, a senior analyst at the Kaiser Family Foundation's Commission on Medicaid and the Uninsured.

Finally, the law would keep most of Arkansas' existing Medicaid beneficiaries -- mainly children -- in the state's regular Medicaid program. To avoid potential cost shocks to the exchanges, the very sickest of patients in the Medicaid expansion would also be placed in traditional Medicaid.



May 1, 2013: Aetna, We Aren't Sure We're Glad to Meet Ya. Slowing the Obamacare Exchange System, While Reaping Huge Profits

In a new sign that implementing the health law could take longer than expected, insurer Aetna said Tuesday it lowered the number of medical policies it expects to sell through online marketplaces that open for business in October.

"This is going to be a slow uptake," Aetna CEO Mark Bertolini told investment analysts on a call to discuss financial results. [Jeanne: Aetna reported profits of almost $500 million for the quarter, on a pace to earn nearly $2 billion for the year ... profits, not just revenues, money going for huge executive bonuses, money that should be spent on actual health care.]  "The process required to sign up, to get the subsidies, is going to take some time. And I think this is a two-year ramp to get the individual exchanges up to a level where customers are going to feel appropriate signing up. And so our estimates of what we believe ... enrollment [will be] are dropping for the first year."

He didn't give a number, and insurers rarely disclose projections for specific business lines. But Aetna offered nothing to challenge perceptions that it will approach Obamacare's  subsidized marketplaces, also known as exchanges, with great deliberation.

Without naming specific states, the company cut from 15 to 14 the number of states in which it might sell exchange plans to individuals. Aetna might even withdraw at the last minute if exchanges aren't ready or look unprofitable, Bertolini said. Under the PPACA's requirement that everybody buy health insurance or pay penalties, consumers without coverage from employers or government programs such as Medicare are supposed to start shopping for exchange plans on October 1.

"We're not going to go in for a land grab," Bertolini said. "Obviously at the end of all this we have an opportunity to pull out in September. And we continue to hold that as an option should the exchanges not develop favorably or they ask for unreasonable rates."

The caution of No. 3 health insurer Aetna echoes that of No. 1 UnitedHealthcare, which has said it will be "very selective" in selling exchange plans.

Aetna itself is helping hold down exchange enrollment by offering to renew policies of existing customers before the end of this year, thus delaying potential price increases associated with the health law. Rating rules expected to raise premiums for younger, healthier customers kick in January 1, but only for plans starting a new policy year. Approving a one-year renewal before the calendar turns over could delay the price hike for most of 2014 and prove to be more attractive for some clients than buying an exchange policy.

"We are going to offer that opportunity as part of our renewal strategy with accounts," said Bertolini.

Like other insurers, Aetna is attempting to compete on exchanges with narrower networks of hospitals and doctors who agree to lower prices in return for more new customers. The insurer has signed deals with two-thirds of the care providers it hopes to include, Bertolini said, adding that Aetna's exchange networks are a fourth to half the size of its regular provider organizations. The narrower the network, the closer Aetna's costs will be to lower rates paid by Medicare rather than higher commercial reimbursement, he said.

Challenges to opening the health marketplaces include building complex computer systems; persuading insurers to participate; running federally managed exchanges in hostile Republican states; relying on limited budgets to educate largely ignorant consumers; and enrolling young, healthy members to finance the expenses of those with pre-existing illness who will be first in line to join. Health and Human Services Secretary Kathleen Sebelius says the exchanges will be ready.


May 1, 2013: LAW DAY, 2013

May 1, is Law Day in the United States, and although it started out as a Eisenhower era "cold war stunt" to counter the "May Day" celebrations in many Communist and western European nations, it has taken on a force of its own, albeit if little recognized by the American public.
Law Day was originally the idea of Charles S. Rhyne, Eisenhower's legal counsel for a time, who was serving in 1957-1958 as the president of the American Bar Association. To dissuade citizens from being inspired by the populist tones of May Day, Eisenhower proclaimed May 1 to be Law Day, U.S.A. in 1958. Its observance was later codified into law by Public Law 87-20 on April 7, 1961.
On February 5, 1958, President Eisenhower recognized the first Law Day when he proclaimed that henceforth May 1 of each year would be Law Day. He stated "In a very real sense, the world no longer has a choice between force and law. If civilization is to survive it must choose the rule of law."
Law Day is not a government holiday. In fact, few outside the legal community in the United States are even aware of the existence of Law Day. To celebrate Law Day, many local bar associations hold a luncheon, featuring speakers who discuss topics such as justice or the liberties provided for by the United States Constitution.  This year the theme of Law Day, set by the American Bar Association, is "Realizing the Dream: Equality for All" ... Ten states have recognized the rights of their gay, lesbian and transgendered citizens, 40 others have not ... it remains but a dream in most of the country.


April 30, 2013: Doctors Warned About Using "Social Media"

A new social media policy urges doctors to "pause before posting" and to not "friend" patients online. The position paper, issued by the American College of Physicians (ACP) and the Federation of State Medical Boards, was released at ACP Internal Medicine 2013 in San Francisco, California, and was simultaneously published online April 11 in the Annals of Internal Medicine.

It addresses the benefits and drawbacks of a number of online interactions, and proposes safeguards. A recent survey of state medical boards showed that 92% reported at least 1 online violation of professionalism that led to a major action, such as license revocation (JAMA. 2012;307:1141-1142). Those researchers were surprised to find that problems ranged across every age group and demographic.

"We decided to work with the ACP to get this information out to all physicians," Humayun Chaudhry, DO, president and CEO of the Federation of State Medical Boards and one of the authors of the position paper, said at a news conference. The resulting position paper "is valuable to every physician across the country," Dr. Chaudhry added.

There are legitimate ways that physicians can engage in social media with patients.

"It's really the beginning of a conversation. The online media world is constantly changing. There are legitimate ways that physicians can engage in social media with patients," added Dr. Chaudhry. Email and electronic communication should be restricted to individuals with whom the physician has an established physician–patient relationship. "This has happened to me and to many of my colleagues: A patient sends an email out of the blue. It may be someone we have an established relationship, but not a healing relationship, with. They may ask very poignant questions about themselves or a loved one. We need to be very careful about the type of information that we provide. It places us at a professional and ethical risk," said David Fleming, MD, chair of ACP Ethics,

Professionalism, and Human Rights Committee.

One challenge is ensuring confidentiality. Posts on Facebook, Twitter, and other social media sites can be widely read, and even emails can be forwarded. "We have to assume that any time we send electronic communication, it's not just the patient that's going to see it.... So we have to be careful about the kind of information we provide, particularly private and confidential information that the patient may not want shared," said Dr. Fleming.

Many institutions have set up portals for confidential interactions with patients. The position paper urges physicians to use such options rather than standard social media or personal Web sites. "A post can be taken out of context and go viral...and will last in perpetuity. I don't think every physician is aware of that," Dr. Chaudhry explained.

Social media enables communication with "a larger audience than you might be able to in a practice," which can be helpful when disseminating information on issues such as public health reform or vaccines. However, "you have to realize that any comment you make...can have a life of its own and might spread in a fashion you hadn't intended.

"Our advice is to pause before posting," said Dr. Chaudhry. Posts can be objective, such as referenced health information, or subjective, such as opinions on matters of public

Professional and Personal Personas

Finally, the position paper provides specific recommendations for users of social media.

First, physicians should keep their professional and personal personas separate; they should not "friend" or contact patients through personal social media. Establishing a professional profile so that it "appears" first during a search can provide some measure of control that the information patients read is accurate. Email and other electronic communications should only be used by physicians within an established patient–physician relationship and with patient consent. When a physician is approached through electronic means for clinical advice in the absence of a patient-physician relationship, the individual should be encouraged to schedule an office visit or go to the nearest emergency department.

Text messaging should never be used for medical interactions, even with an established patient, except with extreme caution and consent from the patient. It should be remembered that trainees can inadvertently harm their future careers by not posting responsibly or actively policing their online content. Educational programs that stress a proactive approach to maintaining an online reputation are good forums to introduce potential repercussions.


April 29, 2013: Hospital "Cost-of-Living" for F/Y 2014 Negligible; Quality Bonuses and Penalties Announced

Hospitals would get a fairly skimpy net rate increase of 0.8 percent in fiscal 2014, under a rule that the Centers for Medicare and Medicaid Services (CM2) posted late last week.  In addition, that large of an increase would go only to hospitals that successfully participate in a quality reporting program developed by CM2, according to documents released by the agency. Those hospitals that are not successful would get slapped with a penalty equal to a 2-percentage-point reduction in that proposed payment increase.  In addition, the proposal reveals how CM2 plans to administer a new patient safety program that's part of Obamacare and will be launched in fiscal 2015.

These quality-focused provisions and others continue the Obama administration's stress on trying to more closely link hospital payments to how well institutions perform, rather than simply the number of patients they treat. "The new policies in this proposed rule support hospitals' important work and the people with Medicare who depend on them by promoting safety and care improvement," said Marilyn Tavenner, acting CM2 administrator, in a statement.

Compared with fiscal 2013, total inpatient hospital payments for both operating and capital payments in fiscal 2014 are projected to increase by $27 billion. The proposal would apply to about 3,400 acute-care hospitals as well as 440 long-term-care hospitals and would be effective for discharges on or after October 1. Long-term-care hospitals would receive a payment increase of 1.1 percent under the proposal, or about $62 million in all.

The proposed 1,424-page rule will be published in the Federal Register on May 10.

CM2 sets rates in advance for hospitals based on patients' diagnoses and the severity of their illnesses. Overall, the increase would be 0.8 percent. That is computed by starting with a 2.5 percent increase to account for increases in the costs of goods and services used by hospitals. But that's then decreased after CM2 takes into account various adjustments, including reductions required under the health care law and for earlier overpayments due to documentation and coding changes. Those overpayments of $11 billion are to be recovered during the next three years as well.

Obamacare leaves a big imprint on the proposal. For example, more money is being tied to how well hospitals perform on quality measures. This is part of what's called the Value Based Purchasing program. The proposal increases to $1.1 billion the pool of money from which payments are taken to pay facilities that perform well on quality scores. The proposal creates that pool by reducing Medicare inpatient hospital payments to all facilities initially by 1.25 percent. Facilities that perform well get all that back and more and would end up with a net increase of 0.8 percentage points.

Another big change relates to provisions of the overhaul that lower payments if patients in a hospital acquire an infection or the facility performs poorly on other patient safety measures. Infections and unsafe forms of care fall under the rubric of "hospital-acquired conditions." The proposal outlines a framework for starting these payment changes in fiscal 2015. "Under this program, hospitals that rank in the lowest-performing quartile of hospital acquired conditions would be paid 99 percent of what they would otherwise would be paid" in fiscal 2015, the proposed rule says.

Two sets of measurements would be applied. One consists of six patient safety measures. These include the incidence of pressure ulcers, or bed sores; the "volume of foreign objects left in the body; "the rate of "accidental puncture and laceration"; and post-operative pulmonary embolism, among others. The second set of measures relates to infections. They include catheter associated urinary tract infections and blood stream infections associated with the "central line" used to stream medications into the patient through insertion in the neck or chest.

The proposal also increases penalties in fiscal 2014 for certain preventable hospital readmissions. The maximum reduction under this program was 1 percent of payments in fiscal 2013. In fiscal 2014, the proposal increases that to 2 percent. The readmission penalties currently relate to heart attack, heart failure, and pneumonia. CM2 is proposing to add two new readmission measures in fiscal 2014 that would be used to dock payments in fiscal 2015. They are readmissions for chronic obstructive pulmonary disease and for hip/knee arthroplasty.


April 29, 2013: More on Medscape's Annual Physician Income Survey

Physician Compensation by Geographical Area

Where you practice affects your income. This year, as in Medscape's previous two Compensation Reports, physicians in the North Central region earn the most ($259,000). The region comprises Iowa, Missouri, Kansas, Nebraska, South Dakota, and North Dakota. Also similar to prior years, physicians in the Northeast Region earn the least ($228,000).There's less managed care in the North Central region, fewer doctors, and a lower cost of doing business. The opposite is true in the Northeast.

This leads naturally to a couple of questions: Does this mean that "managed care" actually does hold costs down? Does having more physicians per capita (as in many other 1st world countries) lead to more competition and lower prices? Or is this simply the result of lower operating costs and thus higher profit margins? In my opinion, all three questions need more analysis, especially the number of physicians per capita as that would lead to a serious discussion as to why the USA has relatively speaking so few physicians per 10,000 and whether the medical profession is engaged in antitrust deliberately holding down the number of physicians to keep competition down and prices up.


Physician Compensation by Practice Setting

Physicians in group practices -- both single-specialty ($265,000) and multispecialty ($260,000) -- were among the top earners, which was similar to last year's survey results. Hospitals moved up as high payers; this year, physicians working in hospitals earned a mean of $260,000, compared with $225,000 in last year's report.

One change worth noting: In last year's report, physicians in solo practice earned more ($220,000) than did employed physicians ($194,000). Not so in this year's report: The income of solo practitioners ($216,000) has declined and is lower than that of employed physicians, who experienced an increase in income ($220,000).

All of this leads to some more questions: What does this sharp increase in employed physician salaries foretell for the many new Accountable Care Organizations being established as part of Obamacare? As hospitals compete for physicians, particularly in larger metropolitan areas, will these sharp salary increases continue? And finally, what might be the ultimate impact of the trend by 3rd party payers, including Medicare, to bundle payments to all the providers treating a patient for a condition, hospital, lab, physician, et al?


Participation in Various Payment Models

There's a dramatic change in the number of physicians who are becoming involved in Accountable Care Organizations (ACOs). The focus on ACOs as a care-delivery and cost-containment method is making an impact.

But whether that impact on costs is positive or negative remains to be seen.  

In Medscape's 2012 report, only 8% of physicians were either in an ACO or planned to be in an ACO within a year. However, in 2013, 24% of respondents were either in an ACO or plan to be in one in the coming year.

The percentage of physicians in a concierge or cash-only practice increased very slightly from the previous year, from 4% to 6%.  A better question Medscape needs to survey next year is how many physicians moved to concierge care and/or and cash only and whether they have continued such practice exclusively, or whether they have resumed taking  some insurances and/or have gone back to a more traditional practice to  maintain their income? For a discussion of doctor incomes and concierge medicine confronting average American family incomes go to a conversation I created between myself and Prof. Uwe Reinhardt of Princeton University.


Do Physicians Feel Fairly Compensated?

And for all of this, earning over 5 times the average American income, a slight majority of the greedy ba$$rds  think they are underpaid.


Jeanne's Weakly Lawyer Jokes for the Week of April 29, 2013

I've posted my "weakly" lawyer jokes for the week of April 29, 2013 on my humor page ... a story about the origins of LEGALESE and whether this is a separate and distinct language from English ... along with a few cartoons ... http://www.health-politics.com/humor.html#04-29-13


April 26, 2013: Medscape's Annual Physician Income Survey

Physician Compensation in 2012

By and large, physicians are still doing well and income is on the rise overall. About one third (8) of the specialties surveyed each earned a mean of over $300,000 annually. This year's 3 top-earning specialties -- orthopedics, cardiology, and radiology -- were the same as in Medscape's 2012 Compensation Report, although last year radiology and orthopedics tied for the number-one spot.

On the other side of the scale, HIV/ID dropped to bottom position this year, which was last year occupied by pediatrics.

For employed physicians, compensation includes salary, bonus, and profit-sharing contributions. For partners, compensation includes earnings after tax-deductible business expenses but before income tax. Compensation excludes non-patient-related activities (eg, expert witness fees, speaking engagements, and product sales).

Who's Up, Who's Down Since 2011?

Most specialties reported income increases ranging from modest to significant. Orthopedic surgeons showed the highest increase, while endocrinologists and oncologists noted a slight decline.

"As the economy has gotten somewhat stronger, many people who have been putting off elective procedures are now getting them," says Tommy Bohannon, a vice president at Merritt Hawkins, a physician recruiting company in Irving, Texas. "As the population ages, more knees and hips are giving out and need to be fixed." As far as the 9% increase for internists and 5% increase for family medicine, "there's an intense doctor shortage, and health care reform is giving them a bit of a boost for Medicare patients," says Bohannon.

Do Men or Women Earn More?

There's still a large gap between male and female physicians, although that gap is narrower in primary care. Overall, male physicians earn 30% more than women; in primary care that gap is 17%.

One contributing factor involves choice of specialties. There are fewer women in some of the higher-paying specialties. For example, in orthopedics, only 9% of the survey respondents were women, whereas in pediatrics, 53% of survey respondents were women.

"As more doctors start working regular set hours for large health systems, there's little variance in income based on sex," Judy Aburmishan, partner in FGMK, LLC, a Chicago firm that represents physicians and other providers

The United States Compared to Other 1st World Countries

Doing a direct comparison of remuneration across different countries is tricky because the same salary may allow for different standards of living in different places.

But here are two possible ways to think about these comparisons, taken from a 2007 Congressional Research Service report entitled "U.S. Health Care Spending: Comparison with Other OECD Countries".

One way to compare cross-country data is to adjust the salaries for purchasing-power parity -- that is, adjusting the numbers so that $1,000 of salary buys the same amount of goods and services in every country, providing a general sense of a physician's standard of living in each nation. Another way is to look at how a doctor's salary compares to the average national in that doctor's country -- that is gross domestic product per capita.


April 24, 2013: The Public Option is Dead. Long Live CO-OPs!

Everything you ever wanted to know about CO-OPs can be found in this report from Politico. What? You didn't even know there was such a thing as a CO-OP? And, BTW, what does the acronym CO-OP stand for? Well, remember way, way back to 2009 when the legislation that became Obamacare was first being introduced, advocates on the left argued strongly for a public option ... that is a program run entirely by the government -- in effect Medicare for all! Support for any such provision was not strong enough to overcome threats of GOP filibusters, especially since there were 8-10 Democratic senatecritters who weren't ready to jump on that bandwagon. In the real politik negotiations that then took place (politics being defined as the "art of the possible") the public option option was dropped, but in its place as a poor distant cousin was something called Consumer Operated and Oriented Plans ... and in the report below, Politico explains it all to you, interrupted only now and then by my own comments, a little sarcasm and a couple of cartoons.

The public option is dead. Long live CO-OPs!

That's the chant from mostly grass-roots health reformers in 24 states, backed by billions of dollars in government loans, who are gearing up to offer alternatives to commercial insurance plans on the exchanges next fall.

And those who are starting up these Consumer Operated and Oriented Plans speak earnestly about a CO-OP "movement" that's ready to break out onto the scene.

"[W]hat a historic opportunity it is to inject into the marketplace a member-governed, nonprofit health carrier that is building from the ground up, writing from a blank slate," said John Morrison, a former Montana insurance commissioner and president of the National Alliance of State Health CO-OPs. "It's exciting."

Historic but challenging. To succeed, CO-OPs will have to compete with large established insurers that are also hungry for the new exchange business under the health law. Those insurers have provider networks in place, established reputations and large marketing budgets. Most CO-OPs have had less than a year and limited resources to mount their challenge.

"It remains to be seen whether CO-OPs can effectively market their policies and services to become self-sustaining," a recent brief from the Robert Wood Johnson Foundation states.

"This is a flabbergastingly enormous task," said Jan VanRiper, executive director of NASHCO. "The oldest [CO-OP] has been around for one year."

The liberals' dream of a government public plan to compete with private insurance under the federal health law was sacrificed during negotiations, but what was widely considered a watered-down backup option to fund these consumer-run plans has survived -- albeit bloodied and diminished.

While it's clear CO-OPs will be up and running in nearly half of the states this fall, they would have had a much broader presence save for a provision in the fiscal cliff deal that forbade the feds from contracting with any CO-OPs that hadn't already signed loan agreements with the government. The burgeoning "movement" reeled at the cliff deal, which came just one day after the Centers for Medicare & Medicaid Services' Dec. 31 application deadline. More than 40 additional applications were pending, some from organizations in major states like Florida, Texas and California.

"This was a deal that was done quickly and quietly in the dark for reasons other than saving money," Morrison said at the time. The cut, in his view, was "about the health insurance giants attempting to eliminate competition at the expense of millions of Americans who will pay higher premiums because of a lack of competition."

Funded initially by $6 billion in the [Patient Protection and] Affordable Care Act, the CO-OP effort already had been cut to $3.4 billion even before the fiscal cliff deal swept most of the remaining money off the table. But CM2 had already contracted with the 24 CO-OPs for about $2 billion in loans, which are unaffected, and was left with 10 percent of remaining funds to administer the program.

The fiscal cliff deal doesn't necessarily mean the program will be forever confined to 24 states, CM2 has said. Some of the approved CO-OPs want to expand to other states -- and CM2 can give them loans to do so. So far, 13 CO-OPs have licenses to sell insurance in 13 states, and most of the rest expect final approval in the next few weeks. They have designed health plans, most have contracted with provider networks and claims processors and are developing public outreach campaigns.

The [PP]ACA blocks CO-OPs from using loan funds for marketing but not educational efforts. The government faces challenges in explaining the exchanges and encouraging enrollment; the CO-OPs will also have to explain what these new consumer-owned insurance offerings are and how they differ from the other exchange options.

Linn Baker, CEO of the Arches Health Plan, a CO-OP in Utah, plans to market to the "young immortals" -- healthy young adults who are often uninsured. Health plans want to get them into the market. Baker plans to offer a low-deductible, catastrophic "Wellth Plan," a more comprehensive "No Worries" policy and a "Healthy Lifestyles" option that will offer first-dollar accident benefits and no copays for some office visits.

CO-OPs also hope the appeal of a nonprofit insurer that will use any extra revenues to lower premiums or improve benefits will appeal to consumers used to thinking about insurance companies as antagonists. "We're here to reach out to the uninsured," Baker said. "We are coming back to centering it on the patient."

Whether they will succeed in capturing a significant piece of the new market from traditional insurers is an open question. The barriers are considerable. Ken Lalime, CEO of the Connecticut CO-OP HealthyCT, said his state hasn't licensed a new insurance company in about 30 years. Lalime has contracted with a network of 7,000 physicians in the state and plans to compete aggressively for individuals and small businesses on and off the exchanges, but he doesn't expect to have the big-ticket business with self-insured employers right away.

"For a small organization -- a startup -- to walk out the door and say I'm going head to head with Aetna, probably isn't the smartest strategic move," he said. But small businesses that have been underserved in the past may be easier to reach.

[The Real Politik According to Jeanne: The for-profit health insurance industry led the charge to delete any public option from the final version of Obamacare, after all at stake for them were the billions in profits they hoped to garner from having 30-40 million more Americans insured in their plans. How would they be able to pay their senior executives the multi-million dollar bonuses to which they had become so addicted? These obscene salaries and perks, corporate jets and near billion dollar stock options might have to give way if they had to compete with a government plan that held overhead costs down to the same 4-6% that has been the average for Medicare, instead of the 18-24% overhead costs standard in the for-profit sector. Even these new watered-down CO-OPs might also be a problem if they actually succeed, keeping administrative overhead including stock pay-outs and executive pay in check through meaningful competition. The private for-profit health insurance industry has no incentive to cut costs as long as they have been able to raise premiums at near double-digit rates year after year after year and is lobbying its friends in Congress to keep the gravy train rolling.]

Martin Hickey, CEO of New Mexico Health Connections, says that 97 percent of employers in his state are small businesses that would qualify for tax credits in the health law if they provide coverage to employees. Most do not now, he said, in a state that has among the highest uninsured rates in the country -- 23 percent. "That's an opportunity," he said.

In addition to the challenge of competing with large, established insurers, CO-OPs are also still contending with skeptical lawmakers on the Hill. Some Republicans have criticized CO-OPs as Solyndra-like giveaways to Obama administration allies, in particular the Freelancers Union, headed by Sara Horowitz, which is sponsoring CO-OPs in three states.

And the House Oversight and Government Reform Committee, chaired by Housecritter Darrell Issa (T/R-Calif.), has asked 12 CO-OPs for a detailed accounting of how they have spent their federal loans so far. He cites an Obama administration estimate that taxpayers could lose up to 43 percent of money given out in loans. He has also asked CM2 for documents relating to how it approved CO-OPs, saying the agency has been opaque in administering the program. Asked for comment on the investigation, a spokesperson said only that the committee had received some documents and was considering how to proceed.

Morrison, the NASHCO president, says some policymakers misunderstand the funding. The majority of the funding comes in 15-year, low-interest loans meant to ensure that the upstart insurance plans can meet the financial solvency requirements of state regulators and to guarantee they can pay any claims newly covered patients may incur. "Many policymakers and policy analysts think this money is being spent, but it isn't being spent," he said. "In order to be an insurance company, you have to keep the gas in the tank."

Congressional scrutiny and competition aside, many of the CO-OP developers are "people who have hit their head against the wall with the system for 20 or 30 years," said Richard Miltenberger, a board member of the Montana CO-OP who runs a benefits management consulting firm. And they're jumping at the opportunity to do something new, something the big insurers with legacy computer systems and contracts aren't nimble enough to do, he said. "You're going to see a lot of innovation."


April 22, 2013: Health Insurance Exchanges In Switzerland and The Netherlands Offer Five Key Lessons For The Operations Of US Exchanges

Since the 1990s some European countries have had regulated health insurance exchanges or have incorporated elements of exchange markets into their health systems. Health reforms in Switzerland and the Netherlands in 1996 and 2006, respectively, created managed competition in the countries' health insurance markets, which are somewhat analogous to the US state and federally operated health insurance exchanges scheduled to begin operations in 2013 under Obamacare. Looking at the Swiss and Dutch experience with their exchanges offers specific lessons for the US in running the Obamacare market places.

(1) Risk-Adjustment Mechanisms -- which provide premium adjustments intended to compensate health plans for enrolling people expected to have high medical costs -- need to be sophisticated and continually updated. One of the issues that led to the downfall of the "Hillarycare" initiative by the Clinton Administration in 1993-94, was effort to limit "cherry-picking" particularly by very sophisticated for-profit insurers who sought to enroll only healthy people in their plans leaving expensive care to non-profits and the government, maximizing their profits in the process. The Clintons spent about 800 pages in their 1100 page law addressing just this issue with overly complex formulas for adjustment. Obamacare's exchanges must be less complex and more manageable.

(2) Enrolling Most Eligibles -- it is important to determine why people eligible for coverage don't enroll and to craft responses that will overcome enrollment barriers. Trust me on this, I am a lawyer after all, red state governors and state legislatures are not anxious to do anything to help Obamacare get off to a good start. If roadblocks can be thrown in front of those eligible to sign-up through one of the federally-operated exchanges, they will lie down in the roadway to block passage if they can.

(3) Simplify the Process -- particularly the process for applying for subsidies must be as simple as possible for low income, under-educated people and families to understand and accept. No more governmentese ... use small, easily understood words, save paper (and trees).

(4) Balancing the Bargaining Power -- insurers will need bargaining power similar to that of providers, and vice-versa to create a level playing field for negotiating about prices and quality of services, and interim cost containment measures may be necessary.

(5) Transparency and Information -- insurers and consumers alike will need meaningful information about providers' costs and quality of care so they can become prudent purchasers of health services, since managed competition among health plans by itself will not substantially drive down health costs.




United States

Life Expectancy at birth (m/f):




Infant Mortality:




Doctors per 10,000 people




Health spending as a percentage of GDP




Total Expenditure on health per capita





Jeanne's Weakly Lawyer Jokes for the Week of April 22, 2013

Tales of the Court ... a Few Judge Jokes

A lawyer went to Heaven after he dies, and was warmly welcomed by St. Peter. "We get so few of you around here, and each honest advocate is a pleasure." The lawyer, who had maintained a reputation for effectiveness as a plaintiff's lawyer before the Federal bar, was pleased, but still somewhat concerned.

see more at: http://www.health-politics.com/humor.html#04-22-13


April 21, 2013: Study of Massachusetts Connector Exchange Raises Issues of Obamacare's Cost to Lower Income Families

In six months, open enrollment for the Patient Protection and Affordable Care Act's health insurance marketplaces will begin around the country. Massachusetts' experience has proven to be instructive. In 2006, the state created an insurance exchange, called the Commonwealth Health Insurance Connector Authority. The Connector, which began offering unsubsidized commercial insurance products in 2007, now provides an array of options for consumers, including subsidized coverage to people with incomes below 300 percent of the poverty level.

A new study, released April 17 by Health Affairs, surveyed 393 families in unsubsidized Connector plans. It found that 38 percent of surveyed families reported financial burden associated with their health care and 45 percent reported higher-than-expected out-of-pocket costs. This study is one of the first to evaluate the prevalence of and risk factors for financial burden and unexpected costs among families in unsubsidized health insurance exchange plans.

To obtain their data, the authors conducted a cross-sectional survey of families enrolled through the Massachusetts Connector in unsubsidized Commonwealth Choice plans from Harvard Pilgrim Health Care, a large nonprofit insurer that has one of the largest market shares among commercial carriers in the Connector. Between April and October 2010 the authors conducted a survey by mail then followed up by phone, studying families both with and without children.

Although exchanges may expand access to coverage, "those with lower incomes, increased health care needs, and more children will be at particular risk after they obtain coverage through exchanges in 2014," the authors conclude. "Given the complexity of health insurance choices and consumers' limited understanding of health insurance benefits, policy makers need to reach out and simplify information to promote optimal plan choices for the people."

The study is available to Health Affairs subscribers at http://content.healthaffairs.org/content/early/2013/04/15/hlthaff.2012.0864 

The abstract of the study states: "Health insurance exchanges created under the Affordable Care Act will offer coverage to people who lack employer-sponsored insurance or have incomes too high to qualify for Medicaid. However, plans offered through an exchange may include high levels of cost sharing. We surveyed families participating in unsubsidized plans offered in the Massachusetts Commonwealth Health Insurance Connector Authority, an exchange created prior to the 2010 national health reform law, and found high levels of financial burden and higher-than-expected costs among some enrollees. The financial burden and unexpected costs were even more pronounced for families with greater numbers of children and for families with incomes below 400 percent of the federal poverty level. We conclude that those with lower incomes, increased health care needs, and more children will be at particular risk after they obtain coverage through exchanges in 2014. Policy makers should develop strategies to further mitigate the financial burden for enrollees who are most susceptible to encountering higher-than-expected out-of-pocket costs, such as providing cost calculators or price transparency tools."


April 18, 2013: Society of Actuaries "Rate Shock" Study -- Biased, Self-Serving and Error-Filled ???

Few aspects of the Patient Protection and Affordable Care Act are more critical to its success than affordability, but in recent weeks experts have predicted costs for some health plans could soar next year. Now health law supporters are pushing back, noting close ties between the actuaries making the forecasts and an insurance industry that has been complaining about taxes and other factors it says will lead to rate shock for consumers.      (I have posted numerous FAQ about this report, see: http://www.health-politics.com/issue.html#SOAFAQs.)

"Most actuaries in this country -- what percentage are employed by insurance companies?" Senatecritter Al Franken, a Minnesota Democrat, asked an actuary last week at a hearing of the Committee on Health, Education, Labor and Pensions. The committee was discussing a study published last month by the Society of Actuaries (SOA) predicting that, thanks to sicker patients joining the coverage pool, medical claims per member will rise 32 percent in the individual plans expected to dominate the Obamacare exchanges next year. In some states costs will rise as much as 80 percent, the report said.

The witness was unable to answer Franken's question, but the senatecritter made his point. Insurance is why actuaries exist. The industry and the profession are hard to separate.  Using predictive math, actuaries try to make sure insurers of all kinds don't run out of money to pay claims. Many actuaries also work for consultants whose clients include insurance companies. Undisclosed in the SOA report was the fact that about half the people who oversaw it work for the health insurance industry that is warning about rate shock. The chairman of society committee supervising the project was Kenny Kan, chief actuary at Maryland-based CareFirst BlueCross BlueShield.

Others on the committee work for firms with insurer clients. The report included committee members' names but not their affiliations.

The SOA "portray themselves as this nonpartisan think tank when in fact everything about the study is by people who have a vested interest in the outcome of the study," said Birny Birnbaum, executive director of the Center for Economic Justice, a Texas group that advocates on behalf of financial and utility consumers.

To perform the research, the society hired Optum, sister company of UnitedHealthcare, the country's biggest private health insurer, and an insurer that has a long history of "troubles" when it comes to how it has maximized its profits, paid its executives enormous bonuses, and abused the public trust in covering or not-covering health insurance claims and reimbursing providers. Society spokeswoman Kim McKeown said the project was overseen by credentialed actuaries "from a cross-section of industry organizations" and was "exposed for review and comment to the broad health care actuarial community."

Even supporters of the health act worry about premium increases next year, when many of its provisions take effect. But the debate fits into a larger discussion about actuaries' public role. Actuaries are self-regulated, which some say makes them unaccountable. Their associations set conduct standards and investigate malpractice in confidential proceedings. During the previous two decades the Actuarial Board for Counseling and Discipline, which works with the Society of Actuaries, has recommended public disciplinary measures for fewer than two people a year, according to its annual report. Other professions, including those for health professionals, lawyers, and even beauticians and morticians are subject to much more publicly scrutinized reviews and, on a percentage basis, report far more disciplinary actions than do actuaries. One either has to assume that actuaries are intrinsically more honest than other professionals, or that their profession looks the other way in an effort to protect itself and its members from criticism or question.

Yet actuaries play many public roles. By calculating the adequacy of employer pension contributions they affect the retirement of millions. And they'll act as virtual referees for important aspects of implementing the health act.  "I have a great deal of respect for actuaries," said Timothy Jost, a law professor at Washington and Lee University and health law expert. "But I do think they often end up in ... situations where the interests of the public and of their employers might be in conflict."

While the Obama administration has developed a calculator plans must use for determining whether insurance plans meet the health act's standards for benefits and value, recently finalized regulations give insurer-employed actuaries the power to override it by substituting one benefit for another.

Insurance company actuaries calculate rates when plans file with states, which act as the industry's primary regulators. Charged with making sure the prices are justified, state insurance departments often have far less actuarial expertise at their disposal than the insurers. For example, the Vermont Department of Financial regulation "does not have actuaries on staff," a spokeswoman said. "We outsource our review of rate filings." The situation in 2011 was the same in a dozen other states, according to information compiled by the National Association of Insurance Commissioners.

Health-act supporters complained that that the actuary society's study predicting a 32 percent increase in claims didn't account for key factors, including the potential for competition to lower prices, the subsidies people will receive to buy the coverage and the fact that next year’s plans will be more generous than this year's.

Often actuaries' predictions are not significantly better than, say, those of the Weather Channel. Recent premium increases of 50 percent and higher for nursing home insurance reflect a previous under-calculation of costs by actuaries. Actuarial models didn't work especially well at calculating subprime mortgage risk a few years ago, either A settlement in New York last month revealed cases in which actuaries overestimated liabilities and a mortgage insurer paid out as little as 20 percent of collected premiums in claims.

Jost and Birnbaum want representatives of consumers and state insurance departments to be included on the actuaries' discipline board. In proceedings at the insurance commissioners' group, consumer advocates also want the board to state that actuaries' first duty is to the public whenever they furnish calculations to state or federal regulators and to tighten conflict-of-interest standards for firms producing work relied on by both insurers and regulators.

"There is always room for improvement in everything," said Karen Terry, an actuary for State Farm and the vice president of professionalism at the American Academy of Actuaries, an umbrella group that works with the discipline board and groups such as the SOA that represent professional subspecialties such as health or pension actuaries. "We're open to that dialogue."


April 15, 2013: Red States and TeaParty Republicans Block Obamacare Implementation and Funding

Frustrated by red state governors and legislatures refusing to implement major parts of the new health care reform legislation and with Tea Party House Republicans and filibuster-loving Tea Party Senators continuing to block the funding for the program, federal officials have been forced to scramble to cobble together necessary monies to continue preparing for next January’s roll-out of major provisions in the law. Last week the Obama administration revealed long-withheld details about how they are funding the creation of the insurance marketplace "exchanges" so critical to the success of the health care law and its coverage expansion provisions. Health and Human Services (HHS) Department officials said they expect to spend some $1.5 billion in fiscal 2013 on the federal exchange.

They are piecing together funding from sources such as a Public Health and Prevention Fund created under the law (PL 111-148, PL 111-152), a "non-recurring expenditures" account and other sources. These newly revealed details about where HHS is finding the money could spark attempts by Republicans to shut off those financing sources in fiscal 2014, which starts October 1, just as the operations of the exchange are scheduled to start. Tea Party Republicans including Senatecritters Orrin G. Hatch of Utah have repeatedly asked for such details. Hatch criticized Marilyn Tavenner, the acting administrator of the Centers for Medicare and Medicaid Services, for not providing the information at her confirmation hearing last week.

HHS hopes that Congress will give it the $1.5 billion for fiscal 2014 and that it won't have to keep cobbling together money from other sources. Both are extremely iffy propositions given the continued obstinacy and procrastination of the Tea Party Republicans who vowed to use every tool at their disposal to stop Obamacare in its tracks. HHS officials said at a recent budget briefing that they need a total of $2 billion next year to operate the federal marketplace -- to be called the "federally facilitated exchange" -- including the $1.5 billion from Congress. HHS will receive an estimated $450 million in fees on insurers that already have been promulgated under the law.

"We need to get that $1.5 [billion] in budget authority from the Congress," said Ellen Murray, assistant HHS secretary for financial resources, at a press briefing on the administration's fiscal 2014 HHS budget proposal. Asked about the chances of getting such implementation funding from lawmakers, HHS Secretary Kathleen Sebelius said: "This is an ongoing conversation with Congress. ... As this act is fully implemented and Americans begin to take advantage of the benefits, I'm hopeful that Congress will see that this is the law of the land, the Supreme Court has ruled, we intend to implement the law, and millions and millions of Americans are looking forward to full implementation," she said.

Murray said the $1.5 billion this fiscal year has come from these sources: what remains from $1 billion that was allotted under the law for its implementation; "frugal" use of the CM2 administrative budget; the "non-recurring expenses fund, which is authority we have to use past-year dollars for IT investments"; and "the secretary's authority to transfer limited sums of money." Specifically, Murray said, $235 million is coming from the original $1 billion in implementation money, $450 million from the non-recurring expense fund and $116 million from the secretary's authority to transfer funds. "We're still finalizing the final dollars," she said. Asked to elaborate on the nature of the non-recurring expenses fund, Murray said it is "a fund which was set up by the appropriators in 2008. Social Security, many other agencies have such a fund, which enables an agency to use dollars from prior years that are no longer available for obligation, for one-time IT and real estate investments." Asked whether HHS would have access to that fund in fiscal 2014, Murray said: "We are using the fund for the first time because authority began in 2008, and as many of you may know, funds are available often for five years, so most of the money that we know is definitely available [will] come, we don't have projections yet for what might be available next year."

Murray also said that an undisclosed amount is coming this fiscal year from the Public Health and Prevention Fund. Senatecritter Tom Harkin, D-Iowa, who secured that funding in the health care law, recently was adamant in saying that money for the fund would not be used for exchanges in fiscal 2014. However, Murray served for many years as an aide to Harkin in his capacity as chairman of the Senate Labor-HHS-Education Appropriations Subcommittee. The federal exchange is the mechanism established by the law to expand coverage of the uninsured in states that refuse to create their own such marketplaces -- and there are many. Twenty-six states have declined to play any role in creating their own exchanges, which means their uninsured residents must rely on the federal exchange. An additional seven states will rely at least partially on the federally operated marketplace under agreements with HHS to open "partnership" exchanges.

The upshot is that in much of the country, make-or-break functions of the health law will have to be performed by the federal exchange -- assuming it will have the money to do them. These include determining eligibility for coverage, establishing individual income levels for purposes of setting subsidy amounts, steering the uninsured to Medicaid coverage and enrolling people in plans.


April 15, 2013: Five Things the Obama-Proposed Budget Would Do to Medicare

(1) Higher Cost Sharing for New Medicare Beneficiaries: In 2017, 2019 and again in 2021, new Medicare beneficiaries would have to pay an additional $25 for their Part B deductible, for a three-year total of $75 to be added on to the cost of the Part B premium, which in 2013 is $147. The administration says the change would "strengthen program financing and encourage beneficiaries to seek high-value health care services." Seniors advocates say it's an additional cost to people already struggling on fixed incomes. In 2012, nearly half of Medicare beneficiaries had annual incomes of below $22,500.

Also starting in 2017, Obama's plan would require new Medicare beneficiaries to pay $100 for five or more home health care visits that are not preceded by a stay in the hospital or another medical facility, such as a nursing home or a rehabilitation hospital. Home health care is one of the few areas in Medicare that does not have cost sharing, and its rapid growth in recent years has led panels like the Medicare Payment Advisory Commission (MedPAC) to recommend beneficiary cost sharing. 

Beginning in 2017, new beneficiaries who purchase supplemental insurance, known as Medigap, with particularly low cost-sharing requirements -- such as "first-dollar" coverage -- will face a surcharge equivalent to approximately 15 percent of the average Medigap premium. The thought is that more generous Medigap plans encourage overuse of services, but seniors rely on these generous plans to shield them from unanticipated costs.

Joe Baker, president of the Medicare Rights Center, said that Medicare proposals that "increase deductibles and co-pays, and tax Medigap plans that ensure financial security, must be rejected."

(2) Wealthier Beneficiaries Pay More: Current law (enacted by Republicans as part of the Medicare Modernization Act of 2003) already requires individual beneficiaries whose incomes are $85,000 and above ($170,000 and above for couples) to pay a larger share of Medicare Part B (outpatient services like doctor visits and laboratory services) and Part D (prescription drugs) premiums. While most beneficiaries pay 25 percent of their Part B premiums, higher-income beneficiaries pay between 35 to 80 percent, depending on their income.

Obama's plan would increase the lowest income-related premium to 40 percent and cap it at 90 percent.  His plan would also maintain the current income thresholds until a quarter of Part B and Part D beneficiaries are paying the higher income-related premiums. 

In a 2012 analysis, the Kaiser Family Foundation found that if the proposal to have a quarter of all beneficiaries pay the higher premiums were implemented last year, beneficiaries with incomes at or above $47,000 for individuals and $94,000 for couples would be paying higher income-related Medicare premiums.

The Obama administration says the proposal would help improve Medicare's financial stability by reducing how much the government spends on Medicare for beneficiaries who can afford to pay more. But the Center for Medicare Advocacy fears asking higher income people to pay a greater share of premiums "might lead to more people choosing not to participate in Medicare. Fewer participants in [Medicare] B and D would result in increased costs for the remaining participants."

(3) Doughnut Hole Closing Faster, Higher Drug Rebates for Low-Income Beneficiaries: Obama's budget plan would close by 2015 --  instead of 2020 as mandated by the health law --  the "doughnut hole," that gap in Medicare prescription drug coverage where seniors pay the full cost of prescriptions until they hit a catastrophic cap. This acceleration would be financed by increasing the current 50 percent discount that the drug makers give to beneficiaries in the "doughnut hole" to 75 percent starting in 2015. Beneficiaries would be responsible for the remaining 25 percent of drug costs. Drug makers oppose raising the discount amount.

The president's proposal also alters drug costs for the nine million low-income Medicare beneficiaries who qualify for both Medicare and Medicaid. These people, known as "dual eligibles," used to get their drug coverage from Medicaid, the shared federal-state health insurance program for the poor and disabled. And drug makers returned back to Medicaid in the form of rebates part of the cost of drugs for those beneficiaries, just they do now for current Medicaid beneficiaries.

As part of the creation of the unfunded Medicare Part D prescription drug program (established under a Republican-controlled Congress in 2003), the drug coverage for "duals" shifted to Medicare. But the rebates that Medicare Part D plans negotiate are not as generous as those that drug makers previously paid to Medicaid, the administration says. Part D plans also pay higher prices for drugs than Medicaid does. The administration's proposal would require drug makers to pay the difference between rebate levels they now provide to Part D plans and the Medicaid rebate levels.

In a statement the Pharmaceutical Research and Manufacturers of America, said the rebate proposal would increase beneficiary premiums and copays. 

(4) Provider Cuts: Hospitals are none too happy about Obama's plans to cut their Medicare payments for bad debt and graduate medical education over the next decade. Medicare now pays hospitals 65 percent of debts resulting from beneficiaries' non-payment of deductibles and co-insurance after providers have made reasonable efforts to collect the money. Starting in 2014, the president's plan would decrease that amount to 25 percent over three years, which the administration says would be closer to private payers that typically pay nothing on bad debt. The reductions would be in addition to those hospitals and other providers face as part of the 2010 health law.

Beginning in 2014, the Obama plan also would cut by 10 percent "add-on" payments to teaching hospitals for graduate medical education. In its budget document, the Department of Health and Human Services cites a MedPAC finding that these additional payments "significantly exceed the actual added patient care costs these hospitals incur."

Hospital groups, however, maintain that the cuts to bad debt reimbursement and medical education payments would weaken hospitals' ability to provide care and to train physicians, nurses and other health professionals.

Concerning payments to physicians, Obama's budget assumes that Congress will once again pass a "doc fix" to avert a scheduled 25 percent payment cut in 2014. Administration officials say they want to work with Congress to find a long-range solution to avert the annual crisis over Medicare physician payments.

(5) What Obama Left Out: The president did not propose an increase in the Medicare eligibility age from 65 to 67, a savings mechanism favored by the GOP but assailed by some key Democrats.

Nor did Obama propose combining the premiums beneficiaries pay for hospital care (Part A) and outpatient services (Part B). Taking that step, which has the support of Republican leaders like House Majority Leader Eric Cantor, T/R-Va., would reduce Medicare expenditures and lower beneficiaries' costs for hospital care. But seniors who mostly use Part B and don't go to the hospital often would pay more.

Some analysts wonder if these and other Medicare overhaul ideas could resurface as part of a larger discussion that includes overhauling the tax code and entitlements.  "This is the first time in this presidency that I have seen a chance at a bipartisan budget agreement, so I am cautiously optimistic about that," House Budget Committee Chairman Paul Ryan, T/R-Wis., told National Public Radio.

House Ways and Means Committee Chairman Dave Camp, T/R-Mich., has said his panel will hold a series of hearings to evaluate ideas including those advanced by Obama and by his fiscal overhaul commission. "Given the bipartisan support for various reforms to these programs, there is no reason we cannot roll up our sleeves and get this done," Camp said in a statement.

But the GOP and Obama have widely different views. House Republicans' fiscal 2014 budget plan, for instance, would eventually turn Medicare into a "premium support" plan that would give beneficiaries a set amount for their coverage, which Democrats oppose. Meanwhile, Obama has said he'll agree to entitlement changes only if Republicans agreed to higher revenues, which they steadfastly oppose.


Jeanne's Weakly Lawyer Jokes for the Week of of April 15, 2013

... a few Tax Lawyer Jokes