Friday, May 26, 2017

AHIP puts Medicaid first in "do no harm" plea to Republicans

Early this week, in a letter to Senate Finance Committee Chair Orrin Hatch, the America's Health Insurance Plans (AHIP), the largest association of private health insurers, basically begged Republicans to stop threatening to uninsure tens of millions in the name of reform. 

AHIP voiced support for community rating, guaranteed issue, income- and age-based subsidies, and an enforcement measure sufficient to induce people to buy insurance. In other words, for preserving the ACA marketplace with a few regulatory teaks  -- and with the AHCA's $138 billion in federal funding for state reinsurance or other "stability" measures tossed in.

Striking on its face though the health insurance industry's renunciation of medical underwriting may be, the most remarkable part of the letter comes early, in its reframing of what healthcare "reform," Republican-style, is all about. AHCA opponents have been screaming for months that at the bill's core is a $900 billion tax cut* paid for by an $800+ billion Medicaid cut. It's been hard to break through the noise with that core equation, given the AHCA drafters' high-strung debates about various proposed malformations of the individual market. AHIP puts the pieces in perspective:

Thursday, May 25, 2017

CBO: Some states will kill protections for those with pre-existing conditions -- and oh yes, the AHCA still eviscerates Medicaid

In late April, Matthew Fiedler explained in a Brookings brief that the MacArthur amendment to the AHCA, which allowed states to subject people who fail to maintain continuous coverage to medical underwriting, would not just affect those who fail to maintain continuous coverage. Fiedler's summary:
...the framework created by the waiver would allow states to effectively eliminate community rating protections for all people seeking individual market coverage, including people who had maintained continuous coverage.

In brief, healthy people would have a strong incentive to “opt out” of the community-rated pool and instead pay a premium based on health status. With healthy enrollees opting out of the community-rated pool, community-rated premiums would need to be extremely high, forcing sicker individuals—including those with continuous coverage—to choose between paying the extremely high community-rated premium or being underwritten themselves. Either way, people with serious health conditions would face prohibitively high premiums. As a result, community rating would be eviscerated—and with it any meaningful guarantee that seriously ill people can access coverage.
The CBO analysis of the amended AHCA released yesterday reproduces this argument:

Wednesday, May 24, 2017

Medical Billing: The Ten Do-well Commandments (after Elisabeth Rosenthal)

Elisabeth Rosenthal, reporter of the monumental Paying Till it Hurts series in the New York Times and author of  An American Sickness: How Healthcare Became Big Business and How You Can Take it Back, has been out front with the "Ten Economic Rules of the Dysfunctional Medical Market" with which the book leads off -- e.g., on Twitter and on Medium.

To those of us who have saturated themselves in Lin-Manuel Miranda's Hamilton (which already feels like a relic of a bygone era), "10 rules"  inescapably conjure up The Ten Duel Commandments. So I have set them to imagined music below. At bottom, the rules as Rosenthal worded them.

A disclaimer: While the rules in isolation may seem excessively cynical, I don't think Rosenthal's point is that all providers follow them all the time, but that the incentives in our dysfunctional system pull them this way.  Another disclaimer: I haven't read the book yet. Too much current bad news to absorb. But I'll get there.

The Ten Billing Commandments

1. The treatment. More is always better.
Feed the bottom line, be a real go-getter.

2. Keep 'em coming. More is always more.
A lifetime of treatment trumps a simple cure.

3. Amenities and marketing are the way it's done.
Look like Cedars-Sinai and the battle is won.

Tuesday, May 23, 2017

Single Payer in CA? The impediments are mountainous

The widely reported topline of the analysis of California's single payer bill released by the state Senate Appropriations Committee is a highly uncertain forecast that the state would need to roughly double its revenue to pay for the benefit. That is, the total cost of care could run to $400 billion per year,  offset by up to  $200 billion in existing federal funding for Medicaid and Medicare -- if  HHS granted basically every waiver sought to transfer that funding from multiple programs. The spending would also replace an estimated $100-150 billion in employer-sponsored insurance. Funding it would require an estimated 15% payroll tax or equivalent revenue.

That level of spending, and cost-shifting from the private to the public sector, could be defensible, in the abstract. But the report, released under the name of committee chair Ricardo Lara and consultant Brendan McCarthy, asserts a host of practical impediments to implementation, including:

1. No cost control: The Healthy California Act imposes no premiums, no deductibles and no copays on enrollees (who include every resident in the state) and mandates no gatekeeping functions -- any enrollee can contract with any accredited provider and get 100% coverage for service.  Payment is essentially on a fee-for-service basis:
While the bill would allow for other forms of payment, the basic requirement in the bill that payments be cost-based and requirements in the bill that patients are able to see any willing provider of services would make it difficult for the Board to create capitated payment systems that would work under those constraints.
Consequently, and given the participation of every provider in the state, "the analysis assumes a 10% in health care service utilization over fee-for-service Medi-Cal...likely a conservative assumption."

Saturday, May 20, 2017

My letter to the Senate Finance Committee about ACA repeal legislaton

Topher Spiro, veep for health policy at the Center for American Progress and a forceful ACA advocate on Twitter (@topherspiro), got hold of a letter from Senate Finance Committee Chair Orrin Hatch to healthcare "stakeholders," inviting their input by May 23 on Republican senators' efforts to write an ACA repeal bill. Hatch asked that letters be sent to HealthReform@Finance.Senate.gov.

Since the Republican senators' bill-writing process is as secretive and rushed as the House's, Spiro seized the opportunity to encourage non-privileged "stakeholders" -- all of us -- to send their two cents to the email address provided. He has offered to tweet any letters tweeted at him, with a screenshot.

Here's mine:

Dear Members of the Senate Finance Committee:

As a constituent, husband and father of two adult children, son and son-in-law of four aged parents, member of a community and citizen of a nation with many people who lack affordable, reliable access to health insurance or are at risk of losing newly obtained insurance, I urge you
  • not to eviscerate Medicaid by imposing per capita caps on federal funding or imposing a block grant formula; 
  • not to phase out the ACA Medicaid expansion or reduce the enhanced federal funding that enables it;
  • not to end income-based subsidies for premiums and out-of-pocket medical expenses that render individual market coverage and actual healthcare affordable to millions of low-and moderate-income Americans; 
  • not to compromise the ACA's ban on medical underwriting or mandating of guaranteed issue or requirement that health plans provide Essential Health Benefits; and 
  • not to repeal the ACA taxes that have enabled some 20 million Americans thus far to gain insurance coverage.

Friday, May 19, 2017

CMS's warmup for AHCA-world: Guidance on ACA innovation waivers

CMS recently issued guidance to states seeking ACA Section 1332 "innovation waivers," by which states can apply to alter or even thoroughly redesign their ACA marketplaces.

The checklist offers explicit encouragement to states to seek federal funding for reinsurance programs or high risk pools:
In particular we welcome the opportunity to work with states to pursue Section 1332 waivers incorporating a high-risk pool/state-operated reinsurance program. State-operated reinsurance programs have a demonstrated ability to help lower premiums, and if the state shows a reduction in federal spending on premium tax credits a state could receive Federal pass-through funding to help fund the state’s reinsurance program. 
Encouragement to states to implement a reinsurance program is good news, as reinsurance does keep down premiums, and the expiration of the ACA's federal reinsurance program after 2016 contributed to the 2017 premium spike. Including the high risk pool (HRP) option is a bit of a mystery, since 1332 waivers cannot be used to waive the ACA's ban on medical underwriting or guaranteed issue. (The waivers can be used to alter the ACA's Essential Health Benefits required of all qualified health plans, as well as subsidy formulas and the individual and employer mandates.)

Thursday, May 18, 2017

A Sparer means to universal health insurance

Last November Michael Sparer, chair of Columbia's Mailman School of Public Health, proposed that managed Medicaid programs be used as a fallback for regions of the country in which no insurer was participating in the ACA marketplace.  Today Sparer went one better and proposed, in a NYT op-ed, that managed Medicaid replace the ACA marketplace:
Some liberals have proposed using Medicare, the federal health care program for the elderly and disabled, as the basis for providing universal health insurance. But Medicaid is the better fit. It has a more generous benefits package, is less costly and is developing more innovative care-management strategies. Moreover, the integration of the Obamacare exchanges into Medicaid would be relatively seamless: Many health plans are already in both markets...

Moderates in both parties recognize that the chance of success for an insurance marketplace that serves only the self-employed, part-time workers and small businesses, as Obamacare does now, is small. So why not eliminate the insurance exchanges — enabling Mr. Trump to claim he “repealed” Obamacare — while allowing exchange beneficiaries to buy into Medicaid, using tax credits to pay the premiums. Recent surveys showing that Medicaid beneficiaries are generally satisfied with their coverage, more so than their exchange counterparts, makes the case even more persuasive.
Of course this excites me, since so far as I can tell the only person who has consistently suggested that managed Medicaid, or something close to it, is the best way to serve those currently dependent on the individual market is...me. I have argued that using a solo public option to push private insurers' costs down is pushing on a string; that marketplace enrollees have given ample testimony to Medicaid envy; that insurers are happier in markets in which government effectively sets rates (happier than in the individual market, at any rate); and that managed Medicaid is the only path to fulfilling Trump's healthcare promises (not that those promises are worth anything).

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