Posts Tagged ‘Supreme Court’

ACOs Double in Size

Tuesday, July 17th, 2012

While the fate of Obama Care hung in the balance, the ACO became the voluntary dance that nobody wanted to show up to too early. Defined by the Centers for Medicare and Medicaid Services (CMS) as “an organization of health care providers that agrees to be accountable for the quality, cost, and overall care of Medicare beneficiaries who are enrolled in the traditional fee-for-service program who are assigned to it,” ACOs (Accountable Care Organizations) were promoted as a bigger, better model that allowed providers to get paid in a number of ways (capitation, fee-for-service, shared savings) in return for managing health at the population level across a broader swathe of the healthcare spectrum. But ACOs were tough, requiring greater accountability with providers having to report on 33 different performance measures to ensure they’re not skimping on care.  And then there was the little issue of whether reform would be repealed and make it all null and void. Well, a mere week and a half after John Roberts cast the tiebreaker to make the individual mandate — and essentially, Obama Care — a reality, the ACO program has doubled in size.  Eighty-nine participants joined 27 existing ACOs in the program. “The Medicare ACO program opened for business in January, and already, more than 2.4 million beneficiaries are receiving care from providers participating in these important initiatives,” acting CMS Administrator Marilyn Tavenner said in a statement.

According to the CMS, the selected ACO programs operate in a range of areas nationwide and nearly half are physician-led organizations that serve fewer than 10,000 beneficiaries, which indicates smaller organizations are interested in participating. Four hundred more organizations have already submitted a notice of intent to apply next month, according to the CMS. The application period is Aug. 1-Sept. 6, 2012 for organizations that want to participate in the Medicare shared-savings program starting in January 2013.

Now that reform has the imprimatur of the Supreme Court judges, the next court that the Administration will have to focus its efforts on is the court of provider and public opinion. According to a survey of 24,000 U.S. physicians by Medscape, WebMD’s flagship site for medical professionals, only about 3% of physicians participate with ACOs ; only another 5% say that they plan to become involved in the coming year.  52% percent of physicians believe that ACOs will cause a decline in income, while 12% say they will have little or no effect.  Overcoming that natural resistance to change may be the toughest part of putting the ACO in place.

HHS Sets November 16 Deadline for Healthcare Marketplace Details

Wednesday, July 11th, 2012

States must give detailed information to the federal government by November 16 – just 10 days after the 2012 presidential election – on how they intend to run their online insurance marketplaces, according to Kaiser Health News.  States that miss the deadline — or can’t operate their own marketplaces – will have it done for them by the federal government, starting in January 2014.

The marketplaces, which are mandated by the Patient Protection and Affordable Care Act (ACA), are designed to increase competition among insurers and make coverage more affordable.  States can opt to run the exchanges, perform limited services, or yield control to the federal government.  The Department of Health & Human Services (HHS) “will seek to harmonize…policies with existing state programs and laws wherever possible.”  Although the guidance does not state whether there will be a governing board overseeing the federal exchanges, it does say the federally-overseen marketplaces will accept any insurer that meets the basic requirements.  Consumer groups, such as the American Cancer Society Cancer Action Network, wanted the federal government to be more selective, in hopes that it would make insurers compete more on pricing and quality measures.

Steve Larsen, the federal official overseeing the federal exchange creation, said the initial approach will be an open marketplace, although in the future, other options may be explored.  States that operate their own exchanges are free to choose whichever model they prefer.  While many states are moving forward – 34 have received federal grants to fund planning efforts – others are moving slowly or not at all.  Six states — Illinois, Nevada, Oregon, South Dakota, Tennessee and Washington – recently received additional grants totaling more than $181 million.

Officials in some state say they are holding back pending the Supreme Court’s decision on the constitutionality of the ACA.  The court could uphold the entire law, strike it down entirely or eliminate some parts of it.  Other state lawmakers have said they want to hold off on creating marketplaces until after the November election.  Larsen reiterated the government’s stance that the court will uphold the law and that President Obama will be re-elected, noting that “states should turn their attention to moving forward.”

The ACA requires states to establish exchanges that offer federally subsidized health coverage to an estimated 16 million people who currently lack healthcare insurance.  The exchanges let consumers purchase their insurance from an easily readable menu of competing plans, at premiums set on a sliding scale according to the buyer’s income.

“What this shows is that states are making real progress in delivering quality, affordable health coverage to their residents and they want to be up and running by January 2014,” said Kathleen Sebelius, HHS Secretary.  She said that 34 states — including some that want the ACA overturned — and the District of Columbia have accepted federal grant money to help establish the insurance exchanges.  Approximately 15 states have moved to establish exchanges, either through legislation or executive order.

HHS also released guidelines for helping states that might not be able to offer full exchange services by 2014 and for establishing federal exchanges in states that refuse to participate.  According to officials, the administration will partner with state governments in two realms: certifying health insurance providers for the exchanges and helping consumers apply for coverage and enroll in the chosen plan.

Karen Ignani, President of America’s Health Insurance Plans, is taking a wait-and-see attitude According to Ignani, “Exchanges work best when they are true marketplaces that maximize choice and competition so that individuals, families, and small businesses can purchase plans that are right for them.  States are in the best position to establish exchanges because they have the experience and local-market knowledge to meet the consumers’ needs.  If a state chooses not to establish its own exchange, any exchange that is implemented should seek to preserve consumer choice and avoid regulatory duplication that will add complexity and increase costs for consumers.  We appreciate that the Department has prioritized minimizing administrative burdens, encouraging choice, and preserving the states’ traditional role of regulating health insurance as these exchanges are developed.  Allowing all health plans that meet new quality and performance standards to offer coverage in an exchange will help ensure competition and preserve consumer choice.  Moreover, we agree that exchanges should be developed with input from all stakeholders to ensure they are able to provide individuals, families, and small businesses with the most accurate and up-to-date information about all of their coverage options.”

The Individual Mandate Passes: ObamaCare Survives Supreme Court

Monday, July 2nd, 2012

In one of the most significant rulings in recent memory (perhaps since the awarding of the Presidency to George W. Bush in 2000), the Supreme Court upheld President Obama‘s health care law  in a nuanced interpretation of Federal versus states’ rights. The historic 5-4 decision will affect the way 30 million uninsured Americans receive and pay for their personal medical care.   Chief Justice John Roberts cast the deciding vote (another surprise since most expected it to be Justice Kennedy if the law passed) and wrote the opinion. The key factor was classifying the penalty for not abiding by the individual mandate — the requirement that most Americans buy health insurance or pay a fine — as a tax and therefore constitutional. “Because the Constitution permits such a tax, it is not our role to forbid it, or to pass upon its wisdom or fairness,” wrote Roberts. The court’s four liberal justices, Stephen Breyer, Ruth Bader Ginsburg, Elena Kagan and Sonia Sotomayor, joined Roberts in the outcome; Conservative Justices Samuel Alito, Anthony Kennedy, Antonin Scalia and Clarence Thomas dissented.

The Obama Administration had taken a different approach in its argument, saying that Congress had the authority to pass the individual mandate as part of its power to regulate interstate commerce; the court struck this down, but preserved the mandate as within Congress’ constitutional taxing powers. As Roberts put it, a person who does not wish to carry health insurance is left with a “lawful choice to do or not do a certain act, so long as he is willing to pay a tax levied on that choice.”

The Republican-controlled House will vote July 11 for a full repeal of the health care law. It is a symbolic move that stands little chance of passage in the Democratic controlled Senate. Republican presidential candidate Mitt Romney and GOP congressional leaders have pledged to repeal the law if they take control of Congress and the White House in November elections. The decision may silence critics who have claimed that the Roberts Court has been one of the more partisan in recent memory, particularly with its decision in the 2010 Citizens United case which took the cap off independent political expenditures by corporations and unions. The ACA drew the Supreme Court into the election-year crossfire over the role of government and the concerns about deficit spending,

The court did find one part of the law unconstitutional, saying its expansion of the federal-state Medicaid program threatened states’ existing funding. According to the Wall Street Journal, “the court ruled that the federal government can’t put sanctions on states’ existing Medicaid funding if the states decline to go along with the Medicaid expansion.”

Some reactions:

House Budget Chairman Paul Ryan, R-Wis.: “It’s up to the American people in the next election and their representatives to determine the fate of this law.”

House Speaker John Boehner, R-Ohio: “The president’s health care law is hurting our economy by driving up health costs and making it harder for small businesses to hire. Today’s ruling underscores the urgency of repealing this harmful law in its entirety.”

Senate Minority Leader Mitch McConnell, Republican of Kentucky: “Today’s decision makes one thing clear: Congress must act to repeal this misguided law.”

The full  impact of the ruling politically remains to be seen. The Wall Street Journal reflected the uncertainty: “The court’s decision, while a relief to Democrats, could further energize voters who dislike the law to back Republicans in November. And it forces the Obama administration to continue defending the unpopular insurance mandate, which the court has now made clear is legally equivalent to a tax on those who refuse to carry health insurance. On the other hand, the court’s blessing could itself shape public opinion of the law, particularly among independents and undecided voters who view the justices as relatively free of the partisan agendas of the government’s elected branches. Polls consistently show that the public places greater confidence in the Supreme Court than either Congress or the presidency, although the justices’ approval ratings have slipped somewhat over the past year.”

6.6 MillionYoung Americans Now Have Healthcare, Thanks to the ACA

Tuesday, June 26th, 2012

More than 6.6 million young adults aged 26 and younger were enrolled in their parents’ insurance plans last year because of the Patient Protection and Affordable Care Act (ACA), the largest single-year increase in medical coverage for the age group.  The section of the law that allows young people to remain on parental plans helped boost coverage during tough economic times, said Sara Collins, vice president for affordable health insurance at the Commonwealth Fund.

The benefit for young adults is one of the most popular parts of the ACA as young adults face a labor market that makes it difficult to find a job with healthcare coverage.  Unemployment among 16- to 24-year-olds is 16.1 percent, almost double the 8.2 percent rate for the nation as a whole.  “The economy is absolutely a factor in both the large number of adults who are without health insurance and likely the number coming onto their parents’ policies,” Collins said.  The ACA “came at a really good time for young adults, in terms of the poor job market.”  Adding young adults to their parents’ coverage was one of the first provisions of the law enacted.  Approximately 71 percent of Americans polled by the Kaiser Family Foundation said they viewed that provision favorably.  The ACA in its entirety is less popular, with an approval rate of 37 percent, and an unfavorable view by 44 percent of those surveyed in May, according to Kaiser’s monthly tracking poll.

President Barack Obama’s $1 trillion, 10-year plan to overhaul the healthcare system was passed by Congress in 2010 without a single Republican vote.  Parts of the law were then challenged as unconstitutional by 26 states.  The Supreme Court is slated to rule on those objections, a decision that could overturn the law.  The head of a caucus of 21 Republican lawmakers with medical backgrounds said that no matter the outcome, he will try to preserve the coverage for young adults and for people with pre-existing medical conditions.  Representative Phil Gingrey (R-GA), an obstetrician-gynecologist, believe that the young-adult provision is “a good policy.”

Despite this, the Commonwealth Fund report found that almost 40 percent of young adults between the ages of 19 and 29 did not have health insurance in 2011.  Another finding is that more than 36 percent of young adults had medical bill problems or were in the process of paying off medical debt.  Of those young Americans, 43 percent were experiencing serious financial troubles; 32 percent had trouble making their student loans or tuition payments; 31 percent deferred education or career plans, and 28 percent couldn’t afford food, heat or rent because of medical bills.

Because of the high cost of healthcare, young Americans are not having prescriptions filled, skipping recommended tests or treatments, avoiding doctor visits and failing to get specialist care when they need it.  And, according to doctors. young adults don’t listen to medical advice once they hear how much treatment costs.

Dr. Jeffrey Hausfeld is well aware of the debt problem.  As co-owner for FMS Solutions, a collection agency that specializes in medical debt, Hausfeld has seen a 50 percent increase in the amount of debt held by young adults over the last several years.  He cited “the tremendous cost shift” to patients caused by high-deductible insurance plans, co-payments and co-insurance, said Hausfeld, an ear, nose and throat doctor who no longer practices.  “Getting sick isn’t something that a healthy 26-year-old expected to have to pay for.  They didn’t budget for it,” Hausfeld said.  “Now they’re sitting with a $10,000 hospital bill and they don’t know what to do.”

“While the Affordable Care Act has already provided a new source of coverage for millions of young adults at risk of being uninsured, more help is needed for those left behind,” Collins, said.  “The law’s major insurance provisions slated for 2014, including expanded Medicaid and subsidized private plans through state insurance exchanges, will provide nearly all young adults across the income spectrum with affordable and comprehensive health plans.”

Commonwealth Fund President Karen Davis said that the survey is a hopeful indicator at a time when millions of Americans have trouble getting access to needed healthcare.  “The new report…shows that implementation of the law has already begun to make a difference for young adults, their families and other Americans,” she said.  Allowing young adults, the majority of whom are healthy, to remain on their parents’ health plans is not as expensive as expanding coverage to populations with higher medical costs, although independent analyses estimate the expansion could boost premiums one percent to two percent.

Young Americans who had no healthcare coverage faced the greatest risk: 51 percent with a gap in coverage had a medical bill problem or medical debt.  The costs could be substantial.  One-quarter of young adults paying off medical debt owed $4,000 or more; 15 percent reported $8,000 or more in debt.  Among those who were paying off debt, 31 percent owed $4,000 or more; 21 percent had $8,000 or more; and 11 percent had $10,000 or more.

“There’s no question that young people have cut back on high-value screenings, doctor visits and therapies,” Dr. Mark Fendrick, director of the University of Michigan Center for Value-Based Insurance Design, said.  “You twist your knee playing soccer and you go to get an MRI.  But if the doctor says you have to pay 50 percent of the cost, you’re going to be less likely to go through with it,” he said.

Health Insurer OKs Reform No Matter What the Supreme Court Does

Monday, June 18th, 2012

Even if the Supreme Court declares the Patient Protection and Affordable Care Act (ACA) unconstitutional, UnitedHealth, the nation’s largest health insurer will still cover certain types of preventive care. The extensions will apply primarily to its customers who have individual policies or small-group health insurance through their employer, a minority of its 35 million total members.  The ACA, whose goal is to provide coverage for millions of uninsured people, started unfolding in 2010 after health insurers fought to block its passage.  Challenges to the law from states and other groups opposed to it wound their way to the Supreme Court.  Bob Laszewski, a consultant and former insurance executive, UnitedHealth’s move a “very smart business decision.”  The provisions are relatively inexpensive and are already factored into the coverage price.  If insurers cut these benefits, customers probably will expect a corresponding premium drop, he noted.  “It would probably be more trouble to roll these things back than go ahead with them,” Laszewski said.  “It just makes common sense to leave these things in there and not take these benefits away since they’re already priced in.”  Laszewski expects other insurers and large employers to take a similar approach.

The provisions UnitedHealth will maintain include providing coverage for dependents up to age 26 under their parents’ plan.  The company will still offer certain preventive healthcare services without requiring a co-payment.  These include yearly check-ups, screening for high-blood pressure and diabetes, and immunizations.  Additionally, UnitedHealth will continue to forgo lifetime dollar coverage limits on policies.  “The protections we are voluntarily extending are good for people’s health, promote broader access to quality care and contribute to helping control rising healthcare costs,” UnitedHealth Chief Executive Officer Stephen Hemsley said.  “These provisions make sense for the people we serve and it is important to ensure they know these provisions will continue.”

The ACA is the largest overhaul of the $2.6 trillion American healthcare system in nearly a half century.  It is designed to ultimately expand coverage to more than 30 million uninsured Americans, by setting up insurance exchanges and opening Medicaid for low-income Americans.

According to estimates, the ACA let approximately 6.6 million young adults remain on their parents’ health insurance plans last year, according to a report from The Commonwealth Fund. If the law is declared unconstitutional, Republican lawmakers may reinstate the extension of young adults dependent coverage.  Other provisions that UnitedHealth plans to maintain include providing easily understandable ways for members to appeal coverage claim decisions; and eliminating rescissions, which are considered to be retroactive policy cancellations, except in the case of fraud.  DeAnn Friedholm, director for health reform at the Consumers Union, called UnitedHealth’s actions “a positive step” and said she hopes other companies follow suit should the law be struck down.

Ronald Pollack, executive director of the consumer advocacy group Families USA and a supporter of the law, applauded UnitedHealth’s move.  “It would make a huge difference for a great number of people who would otherwise be left out in the cold in terms of getting coverage,” he said. “And hopefully, given UnitedHealthcare’s market share, this would have tremendous influence on other companies.”  Even if other large insurers follow suit, Pollack said, it would hardly make up for the loss of other provisions in the law that are set to take effect in 2014 — including subsidies to help low-income Americans buy insurance and bans against discriminating against adults with preexisting conditions.

Writing for CBS News, Stephanie Condon says that UnitedHealth’s decision “Could also alter the political fallout from the high court’s decision.  Should the Supreme Court reject President Barack Obama’s law, he could point to UnitedHealthcare’s announcement to validate his policy agenda.”

The Associated Press’ Ricardo Alonso-Zaldivar points out that dismantling the ACA could be messy.  “It sounds like a silver lining.  Even if the Supreme Court overturns President Barack Obama’s healthcare law, employers can keep offering popular coverage for the young adult children of their workers.  But here’s the catch: The parents’ taxes would go up.  That’s only one of the messy potential ripple effects when the Supreme Court delivers its verdict on the Affordable Care Act this month.  The law affects most major components of the U.S. healthcare system in its effort to extend coverage to millions of uninsured people.  Because the legislation is so complicated, an orderly unwinding would prove difficult if it were overturned entirely or in part.  Better Medicare prescription benefits, currently saving hundreds of dollars for older people with high drug costs, would be suspended.  Partially overturning the law could leave hospitals, insurers and other service providers on the hook for tax increases and spending cuts without the law’s promise of paying more to offset losses.”

Handicapping the ACA’s Fate

Wednesday, June 13th, 2012

As the nation anticipates the Supreme Court decision on the future of the Patient Protection and Affordable Care Act (ACA),  pointed questioning by justices has supporters and opponents facing the possibility that the law could be declared unconstitutional.  That would eliminate — along with the contentious mandate that people purchase health insurance — popular provisions such as letting young adults stay on their parents’ plans until age 26, making prescription drugs more affordable for seniors, and requiring insurers to cover those with pre-existing medical conditions.

Even if the court keeps most of the law intact and strikes down the individual mandate, many healthcare advocates, insurers, and legislators believe that these consumer protections will be meaningless.  “There are a series of provisions of the law which have already been enacted which have proven to be fairly popular,’’ said Andrew Dreyfus, president and CEO of Blue Cross Blue Shield of Massachusetts.  “The question nationally is will there be bipartisan consensus to maintain those provisions even if the Supreme Court overturns some aspects of the law or the whole law?’’

Congress has been disinclined to talk about contingency plans, or the possibility of compromise.  There is agreement  that nothing will be done before November’s presidential election.  “Repeal and replace is a good slogan, but what kind of replacement are we talking about?’’ asked Gail Wilensky, a healthcare economist who administered Medicare and Medicaid under George H.W. Bush.  “Is it a replacement that will substantially extend coverage for people who have been uninsured?  At the moment it’s a little hard to see that happening.’’

“It’s a standard rule of politics that people value losses more than hypothetical gains,’’ said John McDonough, director of Harvard University’s Center for Public Health Leadership and who helped the Senate write the ACA.  “If the court were to strike down significant parts of the law that are already in place, there could quite possibly be a potent public reaction against what is being taken away from people.’’

In an interview with Kaiser Health News, Jon Kingsdale, Executive Director of the Commonwealth Health Insurance Connector Authority, who is working to implement the ACA said “We’re working with about a dozen states, and they fall, I’d say, into three camps: One, working very, very hard with a real strong vision of what they want to set up, to implement by October 1, 2013 – which is less than 18 months away.  Others that are planning – they’re preparing.  They’re waiting to see, in fact, if it’s implemented after the Supreme Court decision, which is expected to be announced in June – and/or the election in November.  And then there are states, frankly, we are not working with that are pretty much waiting to see this go away.”

Kingsdale believes that the entire law will not be thrown out by the Supreme Court.  “I think their striking down the entire law is much less probable than striking down the mandate,” he said.  “I’ve begun to talk to people in insurance companies and states and vendor organizations about what happens if the entire law is struck down, and I am struck by the lack of anticipation of what that would mean.  People are aware that there are huge problems. There are many things that have been implemented already, in terms of insurance coverage and Medicare payment policies and accountable care organizations, the authorization of which would be undercut.”

David Axelrod, chief campaign strategist to President Barack Obama, is denying reports that the White House may revisit healthcare in his second term.  “Our hope and our expectation is that the Supreme Court will affirm the healthcare law,” Axelrod said.  “Now is not the time to speculate on that.  We believe that the law is constitutional.  The Affordable Care Act is also really important to the health and well-being of the American people,” Axelrod said. “It is already helping people all over this country, and has improved the position of people relative to their insurance companies, and the kind of policies they are getting and the return they are getting for the premiums they are paying.”

Which One Do You Like? Healthcare Insurance Exchanges or Marketplaces?

Wednesday, May 23rd, 2012

If a Medicare staff recommendation is okayed, health insurance exchanges may be re-named.  According to Kaiser Health News , that is because, Medicare officials say consumers understand words like “marketplace” better.  “We are recommending not using the word ‘exchange’” in enrollment materials, said Julie Bataille, director of the CMS Office of Communications.  While Bataille didn’t mention the preferred substitute, she dropped hints.  “Words like ‘marketplace’ resonate much more with the consumer and also tend to be something that is all inclusive,” Bataille said.

According to Bataille, “exchange” can have a number of different meanings to consumers, including the idea that they may have something to trade.  The Patient Protection and Affordable Care Act (ACA) requires the federal government to establish health insurance exchanges in states that refuse to create their own.  They are often described as online marketplaces similar to Travelocity.com or Amazon.com, where consumers can search for insurance policies that fit certain criteria.  Enrollment information will become available in the fall of 2013 and the exchanges — or whatever the ultimate name is – will start operating in 2014, unless the Supreme Court declares the law unconstitutional.

The word “exchange” appears 247 times in the ACA, while “marketplace” is not mentioned once, according to Kaiser Health News.  But that doesn’t mean officials are obligated to use it, said Brenda Cude, a professor of consumer economics at the University of Georgia and a consumer representative for the National Association of Insurance Commissioners.  “I don’t believe that Congress is any kind of expert on how to communicate with consumers,” she said.  But “marketplace” may not be a fool-proof alternative, Cude said.  She is concerned that comparing a health insurance exchange to a shopping website encourages the notion that the lowest price policy is the best choice.  That may be true when looking for a commodity like a cheap airfare to a single destination, but not for healthcare policies offering different benefits.

Bataille said the Medicare staff’s advice to avoid the term “exchange” is supported by external research and the agency’s focus group testing this year in Cleveland, Dallas, Miami, Philadelphia and Phoenix.  CMS “routinely” tests its materials and websites with consumers “to make sure we are serving our beneficiaries as well as possible,” Bataille said.  “So we see our work on the exchanges as an extension of that.”  According to Bataille, CMS will seek public comment on the enrollment materials before finally deciding whether to use the word “exchange” or “marketplace”.

Rest of the World Beats the U.S. on Healthcare Reform

Tuesday, May 22nd, 2012

As Americans debate whether the Patient Protection and Affordable Care Act (ACA) and its promise of guaranteed healthcare coverage should be overturned, a surprising number of less affluent nations are moving to provide medical insurance to all citizens.  Many political leaders globally have concluded that creating a system of universal healthcare is essential to remaining competitive and supporting economic growth.

After years of underfunding healthcare, China is completing a three-year, $124 billion initiative that will cover more than 90 percent of its population.  Mexico, which 10 years ago covered less than 50 percent of its population, just completed an eight-year drive for universal coverage that has noticeably expanded access to lifesaving treatments for diseases.  In Thailand, where the GDP per person is 20 percent of America’s, just one percent of the population doesn’t have health insurance.  Rwanda and Ghana — among the world’s poorest nations — are creating networks of insurance plans to cover their citizens.

“This is truly a global movement,” said Dr. Julio Frenk, a former health minister in Mexico and dean of the Harvard School of Public Health.  “As countries advance, they are realizing that creating universal health-care systems is a necessity for long-term economic development.”  Many countries are still struggling to improve the quality of their medical care.  And making health care affordable remains a challenge for most countries, as it does for the U.S., where about 15 percent of the population lacks coverage.

Today, the United States is the only one of the world’s richest nations that does not provide healthcare coverage for all citizens.  The Supreme Court is expected to hand down a ruling on a legal challenge to the ACA in June.

Some countries established public systems similar to those in Great Britain and Canada.  Others rely on a mix of government and commercial insurance, similarly to the ACA.  The Thai system, set up a decade ago, has survived years of political upheaval and a military coup.  “No party dares touch it,” said Dr. Suit Wibulpolprasert, a senior adviser to the Ministry of Public Health.

We are really an outlier,” said David de Ferranti, a former World Bank vice president who heads the Results for Development Institute, an international non-profit organization based in Washington.  That stands in sharp contrast to the United States’ leadership in education, he said.  Long before most European nations, the United States assured access to public schooling.

People are demanding responses from their governments,”  said Cristian Baeza, the World Bank’s director for health, nutrition and population.  In countries such as India, political leaders know that one of the surest ways to get votes is to promise better access to healthcare.

As Many As 112 Million May Have Pre-existing Conditions

Wednesday, May 16th, 2012

Between 36 million and 112 million Americans have pre-existing conditions, according to the Government Accountability Office (GAO).  Previously insurers have been able to deny coverage to sick people or offer policies that don’t cover their pre-existing conditions.  The Patient Protection and Affordable Care Act (ACA) prohibits insurers from charging higher prices to people with pre-existing conditions.

Americans with pre-existing conditions represent between 20 and 66 percent of the adult population, with a midpoint estimate of 32 percent.  The differences among the estimates can be attributed to the number and type of conditions included in the different lists of pre-existing conditions.

The GAO compared several recent studies that tried to determine how many adults have pre-existing conditions,  based on the prevalence of certain common conditions.  Hypertension, mental health disorders and diabetes are the most common ailments that lead insurers to deny coverage, GAO said.  The report doesn’t say how many of those people are presently uninsured, but the insurance industry said that number could be relatively low.  Most people have insurance through an employer that is available irrespective of pre-existing conditions, according to America’s Health Insurance Plans (AHIP).  The trade association stressed that requiring plans to cover everyone is closely linked to the individual mandate, which the Supreme Court could strike down this summer.  There is widespread agreement that the two policies must go hand-in-hand — the Obama administration told the Supreme Court that if it strikes down the mandate, it should also toss out the politically popular requirement to cover people with pre-existing conditions.

Adults with pre-existing conditions spend $1,504 to $4,844 more annually on healthcare, and the majority — 88 to 89 percent — live in parts of the country “without insurance protections similar to the Affordable Care Act provisions, which will become effective in 2014.”

GAO’s analysis found that nearly 33.2 million adults age 19-64 years old, or about 18 percent, reported hypertension in 2009.  People with hypertension reported average annual expenditures of $650, but expenditures reached $61,540.  Mental health disorders and diabetes were the second and third most commonly reported conditions.  Cancer was the condition with the highest average annual treatment expenditures — approximately $9,000.

Non-Profit Hospitals Will Take Financial Hit If the Individual Mandate is Struck Down

Monday, May 14th, 2012

If the Supreme Court overturns the individual mandate that requires Americans to buy healthcare insurance that is contained in the Patient Protection and Affordable Care Act (ACA), non-profit hospitals will struggle with higher costs, according to Moody’s Investors Service.  The individual mandate has become the focus for legal attacks on the healthcare law.  It “would result in a significant reduction in uncompensated care delivered by hospitals” and reduce “utilization of expensive emergency room services,” the rating agency said.

“If the Supreme Court overturns the individual mandate, the private health insurance market would likely weaken under the unbalanced weight of strict provisions to cover all those who seek insurance without the counterbalancing benefit of a new, largely healthy, population segment that would be provided under the mandate,” Moody’s said.  “This scenario could become untenable for many insurers and hospitals, as costs would rise but revenues would not.”

There are additional challenges to non-profit hospitals in the ACA, specifically cuts in reimbursement rates for Medicare and reduction of funds paid to hospitals that serve a disproportionate share of Medicaid recipients, Moody’s said.  “Removing the mandate would make the negative features of reform loom much larger.”  Moody’s said the federal government could turn to a voucher system in which individuals would receive public help for them to buy health insurance, but the results for non-profits hospitals “would be more complex and hard to foresee.”

This is bad news because by a nearly five-to-one margin, hospitals expect the ACA to shrink their revenues. The result suggests that hospital executives are having second thoughts about the deal they made with the Obama administration in exchange for supporting the healthcare overhaul will help them weather the law’s financial repercussions.

According to a recent poll, 55 percent of hospitals and health systems anticipate falling revenues as a result of the law, while 12 percent expect an increase.  Twenty-eight percent were unsure of the law’s effect on revenue, indicating continued concern in the industry over the changes wrought by healthcare reform.  Hospital executives agreed to give up $155 billion in government payments over 10 years in a deal to cap costs borne by the industry as a result of the ACA.  The agreement followed a similar agreement with pharmaceutical companies and enabled the reform.  Two crucial hospital groups — the American Hospital Association and the Federation of American Hospitals — backed the law.  “Hospitals have acknowledged that significant healthcare savings can be achieved by improving efficiencies, realigning incentives to emphasize quality care instead of quantity of procedures,” Vice President Joe Biden said at the time.  “Today’s announcement, I believe, represents the essential role hospitals play in making reform a reality.”

“Hospital and health systems’ financial health has a direct impact on the benefits offered to their employees,” said Maureen Cotter, a senior principal at HighRoads, which took the poll.   “Even though 70 percent of those surveyed stated that they are committed to providing coverage in the long term, and no organizations have plans to discontinue coverage now or in the future, the coverage provided may take a new shape,” Cotter said.

There’s even more bad news in the fact that Howard Dean, a physician who formerly was chairman of the Democratic National Committee, a 2004 presidential candidate and governor of Vermont thinks that the high court will declare the mandate unconstitutional.  Dean believes that Justice Anthony Kennedy’s swing vote will side with the conservative justices when it comes to the individual mandate.  “I do believe that it’s likely the individual mandate will be declared unconstitutional.  Kennedy will probably side with the four right-wing justices. The question is going to be, is this individual mandate question, can that be considered separately from the rest of the bill?  And I think it will be.”

Dean also said the ACA can remain in place without the mandate.  “It’s definitely not necessary for the bill to succeed,” Dean said.  “It was mainly put in by academics who built the program for Governor Romney in Massachusetts, they had did it there, and for insurance companies who will benefit from extra customers.”

According to Dean, “The number of so-called free riders — people who will refuse to get insurance until they get sick — is going to be very, very small.”  Dean noted that the actual benefit of the individual mandate is “relatively small.  Everyone is a libertarian in America, whether Democratic, Republican or independent.  They don’t like to be told what to do by government.”