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
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:
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
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
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
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
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
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
"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
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.
FLORIDA AND TEXAS RATES
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,
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
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
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
"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
"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
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
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)
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.
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
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
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
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
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
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
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
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
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
-- 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
before new online health insurance markets are set to open, the Obama
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
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
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
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
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'
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
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
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
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
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
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
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
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
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
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
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
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
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
Medicare beneficiaries won't be able to see their current doctors.
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.
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
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
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
"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
"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
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
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
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.
A. Many of the 10 million non-citizens in the U.S.
legally are expected to gain health
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
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
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
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
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
Q. How does the ongoing debate in many states
over whether to expand Medicaid under the health law affect medical
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
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
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
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
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
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
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
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
September 15, 2013:
Obamacare FAQs: Why are Some Labor Unions Publicly Protesting and
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
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
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.
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
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"
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.
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.
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."
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.
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.
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.
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.
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.
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.
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."
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.
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
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.
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 world, Hong
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
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.
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.
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.
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.
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.
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.
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.
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
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
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
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.
government's unexpected interpretation of the law will
disproportionately harm people with complex chronic conditions and
said Myrl Weinberg, the chief executive of the National Health
Council, which speaks for more than 50 groups representing patients.
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.
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."
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 ...
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:
Obamacare Will Tax Your Outboard Motor
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!
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
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
Obamacare Will Kill Your Grandma
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."
This particular email has been making the rounds for a good four
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,"
Obamacare Comes With Microchips
Obamacare is going to
implant a microchip in you,
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."
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.
Illegal Immigrants Are Eligible for Obamacare
immigrants will get health coverage under Obamacare, warns one widely
circulated, oft-debunked, and
still undead chain email.
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."
Thomas Jefferson Warned Us About Obamacare
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."
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,
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.
Almost Everyone Who Works for a Small Business Is Getting Fired
July, Senatecritter Marco Rubio (T/R-Fla.),
citing a study by the Chamber of Commerce,
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
The Chamber study involved 1,300 small business executives, but
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.
The Giant Obamacare Database
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
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,"
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 ....
Effort to Cripple Health Care Law
WASHINGTON -- With the House poised to vote today on yet another bill
to cripple President
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
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
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
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."
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.
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.'"
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.
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.
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!]
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
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.
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.
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.
to repeal the law are also a way to unite Republicans who cannot agree
on other aspects of health policy.
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.
no circumstances will we support a continuing resolution that funds
one penny of Obamacare," said Senator Ted Cruz, Republican of Texas.
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
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.
states and the District of Columbia intend to operate a state-based
marketplace, while the remaining 34 states will have a federally
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
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
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
Anthem BCBS will not be selling plans in California's small-employer "SHOP"
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
Covered California announced $3 million in grant funds for education
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
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
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
The rates can be found
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
broker eHealthInsurance will be allowed to enroll individuals in
federally facilitated marketplaces.
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
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
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
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
a partnership with the Maine Health Network (a network of
hospitals and providers) that was approved by the insurance
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
The New York Times reports on what community organizations
in Texas are doing to educate
Texans about the federally facilitated marketplace.
MEDICAID EXPANSION UPDATES
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
These updates highlight recent state-level action.
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
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
The commission is
also looking into moving some newly eligible people to the
LATEST FEDERAL RULES, NOTICES, AND GUIDANCE ON AFFORDABLE CARE ACT
U.S. Government Accountability Office report: Private
Health Insurance: The Range of Base Premiums in the Individual Market
by State in January 2013
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
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:
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.
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.
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.
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.
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.
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?"
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.
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.
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.
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
--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.
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.
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.
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.
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
politics everywhere these days,"
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."
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
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
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.
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."
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.
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.
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
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.
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.
do whatever it takes,"
he said. "I'll ride around the
state on a bicycle if I have to."
Weakly Lawyer Jokes for the Week of July 1, 2013
Lawyer versus Lawyer
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
... for the rest
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.
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
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
Here is a state-by-state guide of some states to
-- 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
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
-- 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
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
-- 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
"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."
"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
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.
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
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.
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.
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 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
in dealing with the issues. The rollout has been
"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.
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,"
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
"unacceptable risks to safety,"
according to a 2011 report from the Institute of Medicine of the
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
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,"
"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"
"professionally appropriate venues,"
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
"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."
Sebelius: O.K. Red States, Under Obamacare's Directly Run Federal
Exchanges "We Will Negotiate the Rates"
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
The Blues to the Rescue: Blue Plans Will Dominate in the Obamacare
Exchanges; United, CIGNA, Aetna, Not-So-Much
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.
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."
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."
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.
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."
Concerns Of Insurers
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."
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
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.
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
Protecting Their Business
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
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.
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
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.
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.
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."
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
for more go to:
June 22, 2013:
Deep Dark Secret: Private Health Insurance By Definition "Rations"
Health Care Based on Income
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
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
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.
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.
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
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.
Medicare Moves to Stage 2 of "Competitive Bidding" ... and the Private
Sector Bitches That the Government Using a Free Market Bidding Process
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,
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
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
program starting July 1 is "round 2"
of Medicare's recent competitive bidding initiative for vendors
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
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.
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
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
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.
Better Use of Rx Could Save LITERALLY Billions ... But Americans Wants
All Those D-T-C Advertised Drugs
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.]
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
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
"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.
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
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
a memo released last
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
said Kevin J. Counihan, who spent several years in Massachusetts
helping to run its marketplace before coming to Connecticut to head
the flip side, though, one of the potential new entrants in 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
"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.
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
another Monday ... to all my lawyer-joke
followers ... lawyers taste like chicken ...
... for more ... go to
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
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
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
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
use of ambulances and calls for ending a floor on a payment
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.
CM2 Issues Call for EHR Tests
As part of meaningful
2's transition of care objective, measure #3 requires eligible
professionals (EPs) and eligible hospitals/critical access hospitals (CAHs)
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
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
and ONC strongly encourage the EHR technology developer community to
participate in the program to become a CM2
designated test EHR.
find out more about becoming a CM2
designated test EHR, please contact Nora Super (Nora.Super@hhs.gov)
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.
main issue, and the only way to fix this, is to change what physicians
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
The system also limits their providers’
interactions with pharmaceutical representatives, which
Gellad said can alter the way a doctor chooses to prescribe certain
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.
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
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."
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
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.
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.
Democratic-controlled Congress passed the Patient Protection and
Affordable Care Act,
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:
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."
Maximum Out-of-Pocket Spending Limits May Not Be the Maximum for Some
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.
the law, the maximum amount a consumer with
single coverage will pay out-of-pocket in 2014 will generally
$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.
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
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
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
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
For example, they are not required to provide preventive care without
cost-sharing. In addition, they do not have to offer a package
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
June 10, 2013:
Obama Launches High-Profile, High-Stakes Campaign to Sell Health Law
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
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.
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
Weakly Lawyer Jokes for the Week of Week of June 10, 2013
A WHOLE BUNCH MORE DOCTOR vs. LAWYER COMMENTS
(Both Sides, win a few, lose a few)
... for more go to:
June 8, 2013:
"Patient-Centered Medical Home" ... An Experiment That Seems to Be
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
other "accountable care organizations"
(ACOs), which are centerpieces of President Barack
care reform, the medical home program ties insurance payments to
health care providers to the quality of care they deliver.
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.
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.
BUILDING UP SAVINGS
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
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
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,"
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
CareFirst received a grant from the federal Centers for Medicare and
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
June 7, 2013:
Non-Profit Hospital Chain CEOs Gorging at the Hog Trough Too
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
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
The value of executive pay at large, for-profit health companies tends
to be higher than nonprofit organizations, but the gap appears to be
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
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.
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
"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,"
"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
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
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
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."
FOR SERVICES RENDERED
administrators say they have their organizations' best interests at
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.
been (at SSM) for 33 years, and for a lot of those years I wasn't paid
nearly the salary I'm paid now,"
"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
that examine compensation levels at similar-size health institutions.
Any bonuses and incentive pay are calculated using formulas based on
FOR-PROFIT AND PUBLIC SECTORS
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.
NONPROFIT HEALTH SYSTEMS
Labor -- including salaries, wages and benefits -- is often the
leading expense for large health systems, followed by supplies and professional
It's not uncommon for labor to exceed 50 percent of a health system's
But most hospital workers do not see double-digit increases in their
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
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.
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.
They Don't Call the State "Tex-ASS" for Nothing; Texas Stands to Lose
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.
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.
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.
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."
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."
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.
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
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.
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
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."
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.
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
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,"
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
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.
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
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
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
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
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
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,
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
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
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
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.
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.
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
Republicans governors have embraced the Medicaid expansion, but others
have staunchly refused to implement any part of a health care law they
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.
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
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
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.
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.
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.
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.)
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.
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.
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
"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
Meanwhile, Republicans are continuing to whittle away at the law's
impact and are hoping that Obamacare's failure could become a rallying
"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,"
Here's a glimpse into each side's playbook and the tactics they hope
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
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
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
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
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
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.
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 ...
Weakly Lawyer Jokes for the Week of June 3, 2013
LAWS ON LAWS
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 ...
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,
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.")
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
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
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
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
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
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
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
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.
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
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
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.
"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
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.
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
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
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
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
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
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
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.
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
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
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
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
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
More from Jeanne:
MEANINGFUL USE ... the KEY TO HEALTH CARE
INFORMATION TECHNOLOGY'S VALUE and EFFECTIVENESS
(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
- Engage patients and families
- Improve care coordination, and population and
- Maintain privacy and protection of patient
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
(CM2) Incentive Programs.
Stages of Meaningful Use
These objectives will evolve in three stages
over five years:
Data Capture and Sharing
Advance Clinical Processes
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
shot Wall Street lawyer phoned home to
his Long Island mansion one morning, and a woman with a strange voice
you the new maid?" he asks.
I am," the woman replies
... for the punch line and more go to ...
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.
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
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
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
Obamacare closes this gap with a
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
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
states where Republicans have been doing their best to sabotage the
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.
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
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."
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
What the letters said
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.
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."
had a narrow scope: It dealt with Humana,
as a government contractor, and the information it was giving
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
"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."
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
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."
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."
an inaccurate characterization. The
administration did not issue such a sweeping prohibition on
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.
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
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
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
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
'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.
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.
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
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.
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:
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
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.
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
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
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.
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
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."
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."
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
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.
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.
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?
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.
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
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
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."
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.
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?"
McDermott: "They cannot find out your
private medical information?"
"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
"Were you covered and over what period is
what we would be getting."
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.
referring to Sarah Hall Ingram, who served as
the IRS' commissioner
for the Tax Exempt and Government Entities
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
More importantly, the Treasury
Inspector General for Tax Administration's
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,
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
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
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."
"Congress, IRS Face Off for Title of Most Hated
People in America."
May 21, 2013:
Four In Ten Unaware Obamacare Is Still Law;
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>
It is still the law of the law and is being implemented
(aware of Obamacare's status)
Unaware of Obamacare status (NET)
It has been overturned by the Supreme Court and is no
It has been repealed by Congress and is no longer law
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
See the full April 2013 Kaiser Tracking Poll:
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
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
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
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
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
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
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
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
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
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.
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
Home is home, as the devil said when he found
himself in the Court of Session.
For the rest, go to
May 17, 2012:
Times the Tea Party-Controlled House Has Voted to Repeal Obamacare ...
37 Times! But no jobs bill, no budget, nor anything to help the
May 17, 2012:
The Role of Medicaid and Medicare in Women's Health Care
May 16, 2012:
National Institute of Medicine Report: American Health Care System
Wastes One-Third of Every Dollar
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.")
Preamble: America's health care system
has become far too complex and costly to continue business as usual.
Pervasive inefficiencies, an inability to manage a rapidly deepening
clinical knowledge base, and a reward system poorly focused on key
patient needs, all hinder improvements in the safety and quality of
care and threaten the nation's economic stability and global
competitiveness. In the face of these realities, the IOM convened the
Committee on the Learning Health Care System in America to explore
these central challenges to health care today. The product of the
committee's deliberations, Best Care at Lower Cost,
points out that emerging tools like computing power, connectivity,
team-based care, and systems engineering techniques ... tools that
were previously unavailable ... make the present opportunities for
better health care in America. Applying these new strategies can
support the transition to a continuously learning health system, one
that aligns science and informatics, patient-clinician partnerships,
incentives, and a culture of continuous improvement to produce the
best care at lower cost. The report's recommendations speak to the
many stakeholders in the health care system and outline the concerted
actions necessary across all sectors to achieve the needed
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
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.
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.
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 &
Services has approved only
remains confident that the higher payment rates
ultimately will help increase access to care for
said a CM2 statement.
While Medicaid fees vary by state, they are
generally far below those paid by Medicare and
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
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.
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
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.
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
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
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
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.
2007-09 recession, a one-time event, accounted
for 37 percent of the slowdown between 2003 and
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.
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.
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,"
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.
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.
idea that the spending slowdown isn't going away soon got backing in
two other studies released this week.
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.
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.
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
the study said.
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.
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
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.
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
Will Enough "Healthy" People Enroll in the Exchanges or Will They Be
Stuck With Just the Sick?
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.
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
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.
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."
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
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.
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
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
Speaker John A. Boehner, T/R-Ohio, said in a
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."
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."
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
May 13, 2013:
Transparency in Hospital Charges versus Actual
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
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.
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.
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.]
system doesn't make much sense, but Rick Davis, the CEO of Central
Peninsula General Hospital in Soldotna, Alaska
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.
Bruce Lamoureux, CEO of the Providence health system, says his
hospital will consider changing some prices, down or even up, based on
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.
hospital bill is only one part of the overall health care cost
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."
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.
for us, feels like the future and where we
should be going, and where we should be putting
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
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
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
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"
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
But First There is Law School
School Admission Form
Sue U. University
School for the Ethically Disadvantaged
Sainte Marie, Michigan
... for more law school jokes go to:
May 10, 2013:
Boehner Says NO to Any GOP Nominations to PPACA
Board (What Else is New?)
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
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.
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.]
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
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.
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
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.
Apparently for blue states, no good deed goes unpunished by the Obama
May 8, 2013:
NEW GOVERNMENT REPORT: Hospital Charges Vary
Dramatically, Even in the Same City
Wednesday will finally get some answers about one of modern life's
most persistent mysteries:
how much medical care
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 --
May 8, 2013:
NEW STUDY: Medicare Advantage Plans are Costing Far More and Saving
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.
Tackling Medicare, The Rand Corporation Looks at Three Options.
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
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.
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
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.
magnitude of savings can vary quite
said author Christine Eibner, a senior
economist at RAND, about the results of the
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 ...
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
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
poverty level ($15,510 to $62,040 for a family of two in
2013), according to the Treasury Department.
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
According to an
analysis published by the Urban Institute last month,
four in 10 uninsured veterans have incomes
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.
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.
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.
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
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 uninsured. The District
of Columbia expects to spend about $9 million assisting 42,000
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
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.
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
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
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.
a shame that we see states with lower rates of
uninsured putting more money into education and
outreach than states with higher rates of
said Deborah Bachrach, a former New York State
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.
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.
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.
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.
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.
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.
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.
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.
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.
is putting its money where its mouth is,"
Jeanne's Weakly Lawyer Jokes for the Week of May
Feminine Practice of Law
... for more go to
May 2, 2013:
Finish Line Fast Approaching on Medicaid
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
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
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
(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
Stay tuned. Much can happen before January.
May 2, 2013:
The Arkansas Medicaid Model: What You Need To
Know About The "Private Option"
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.
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
Does the Arkansas Plan Work?
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
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
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
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
are the Disadvantages?
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
May 1, 2013:
Aetna, We Aren't Sure We're Glad to Meet Ya.
Slowing the Obamacare Exchange System, While
Reaping Huge Profits
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.
is going to be a slow uptake,"
Aetna CEO Mark Bertolini told investment analysts on a call to discuss
[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
money that should be spent on actual health care.]
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."
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.
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.
not going to go in for a land grab,"
"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
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.
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
are going to offer that opportunity as part of
our renewal strategy with accounts,"
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
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
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
It addresses the
benefits and drawbacks of a number of online interactions, and
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.
are legitimate ways that physicians can engage in social media with
"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
"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
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.
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
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.
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
April 29, 2013:
Hospital "Cost-of-Living" for F/Y 2014
Negligible; Quality Bonuses and Penalties
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
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
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.
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
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
Physician Compensation by
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
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
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
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
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
The percentage of physicians in a concierge or cash-only practice
increased very slightly from the previous year, from 4% to 6%.
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
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 ...
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
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
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
"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
"there's an intense doctor shortage, and health
care reform is giving them a bit of a boost for
Medicare patients," says
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
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
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
One way to compare cross-country data is to
adjust the salaries for purchasing-power
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!
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,
the left argued strongly for a public option ... that is a program run
entirely by the government -- in effect Medicare for all!
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")
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!
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.
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
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.
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.
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
is a flabbergastingly enormous task,"
said Jan VanRiper, executive director of
"The oldest [CO-OP] has
been around for one year."
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.
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
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
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,
"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."
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.
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
blocks CO-OPs from using loan funds for marketing but not educational
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.
Baker, CEO of the Arches Health
Plan, a CO-OP in Utah, plans to market to the "young
young adults who are often uninsured. Health plans want to get them
into the market. Baker plans to offer a low-deductible, catastrophic
policy and a "Healthy
option that will offer first-dollar accident benefits and no copays
for some office visits.
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
here to reach out to the uninsured,"
"We are coming back to centering it on the
will succeed in capturing a significant piece of the new market from
traditional insurers is an open question.
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.
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
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.
would they be able to pay their senior
executives the multi-million dollar bonuses to
which they had become so addicted?
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.]
Hickey, CEO of New Mexico Health Connections, says that
97 percent of
employers in his state are small businesses that would qualify for tax
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
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
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.
the NASHCO president, says
policymakers misunderstand the funding.
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,"
"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
"people who have hit their head against the wall with the system for
20 or 30 years,"
Miltenberger, a board member of the Montana CO-OP who runs a benefits
management consulting firm.
jumping at the opportunity to do something new, something the big
insurers with legacy computer systems and contracts aren't nimble
enough to do,
"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.
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
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
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.
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).
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.
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.
Expectancy at birth (m/f):
Doctors per 10,000 people
Health spending as a percentage of GDP
Expenditure on health per capita
Weakly Lawyer Jokes for the Week of April 22, 2013
Tales of the Court ... a Few Judge
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.
Study of Massachusetts Connector Exchange Raises Issues of Obamacare's
Cost to Lower Income Families
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
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
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."
study is available to Health Affairs subscribers at
The abstract of the study
"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:
actuaries in this country -- what percentage are employed by insurance
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
Others on the committee work for firms with insurer clients.
The report included committee members' names but not their
"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
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
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.
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."
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.
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
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.
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
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
"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
"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
-- 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
"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;
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.
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
Asked whether HHS would have access to that fund in fiscal 2014,
"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
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
April 15, 2013:
Five Things the Obama-Proposed Budget Would Do to
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
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
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.
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
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
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.
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."
Doughnut Hole Closing Faster, Higher Drug Rebates for Low-Income
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.
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
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.
statement the Pharmaceutical Research and Manufacturers of America,
said the rebate proposal would increase beneficiary premiums and
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
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
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.
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
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.
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,
National Public Radio.
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.
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.