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Does the Affordable Care Act Guarantee Healthcare as a Right?

Does the Affordable Care Act Guarantee Healthcare as a Right? | Healthcare and Technology news |

In his recent celebratory remarks after the Supreme Court (SCOTUS) upheld the legality of subsidies/tax credits under the Affordable Care Act (ACA), President Obama had this to say: "Five years ago, after nearly a century of talk, decades of trying, a year of bipartisan debate -- we finally declared that in America, healthcare is not a privilege for a few, but a right for all." (1)

It would be good if this were true, but it is not. Healthcare as a right has been debated over many years, but is still not in place for all Americans as this country remains an outlier among advanced industrial countries around the world. Instead, despite the ACA, we continue to have a patchwork of ever-changing programs assuring access to health care for some people some of the time.

Let's look at what we do have in this respect. In the 1960s, Congress established a broad right to health care under statutory law by enacting Medicare, Medicaid, and the Children's Health Insurance Program (CHIP) for the elderly, disabled, people living in poverty, and children. In the 1980s it passed the Emergency Medical Treatment and Active Labor Act (EMTALA) requiring all Medicare-funded hospitals with emergency departments to provide appropriate emergency and labor care. More recently, Congress passed the Mental Health Parity and Addiction Equity Act (MHPAEA) in 2013, which assures a right to equal access to care for patients with medical and mental health problems. SCOTUS has established a right to health care for prisoners and has protected some limited rights for women's reproductive care (2), but has never interpreted the Constitution as guaranteeing a right to health care for all Americans. In fact, the words "health," "health care," "medical care," and "medicine" do not appear in the Constitution. (3) 

It is disingenuous to claim that health care is a right in the U. S. when we consider these inconvenient facts:

  • 35 million uninsured, plus another similar number underinsured.
  • The first question asked of us in seeking care is "what is your insurance?"
  • 21 states have opted out of Medicaid expansion under the ACA.
  • Medicaid eligibility and coverage varies widely from one state to
  • another, in many cases falling far short of necessary care.
  • As the costs of insurance and health care continue to rise and shift
  • more to patients, a growing part of the population cannot afford either and forgo seeking care.
  • More than 40 million Americans now have an account in collection for medical debt. (4)

This situation stands in sharp contrast to elsewhere in advanced societies. Healthcare has been recognized as a right since 1948 when the General Assembly of the United Nations adopted a Universal Declaration of Human Rights including access to health care. (5) The right to health care was also later adopted by the World Health Organization (WHO) in its Declaration on the Rights of Patients. (6) As a result, most of Western Europe, Scandinavia, the United Kingdom, Canada, Taiwan, and many other countries have one or another form of national health insurance assuring access to care for their populations. Here we spend twice as much and still have no universal access to health care.

Can we ever see this country coming around to universal access to health care based on medical need, not ability to pay? The record shows that we never can, or will, as long as we permit corporate stakeholders in our medical-industrial complex to call the shots, and as long as they succeed in perpetuating our exploitive for-profit system. There is a fix -- single-payer national health insurance, as embodied in H. R. 676, Expanded and Improved Medicare for All.

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Obamacare's next 5 hurdles to clear

Obamacare's next 5 hurdles to clear | Healthcare and Technology news |

In its first five years, the Affordable Care Act has survived technical meltdowns, a presidential election, two Supreme Court challenges –including one resolved Thursday – and dozens of repeal efforts in Congress. But its long-term future still isn’t ensured. Here are five of the biggest hurdles left for the law:

  • Medicaid expansion. About 4 million more Americans would gain coverage if all states expand the state-federalMedicaid programs to cover people with incomes at or slightly above the poverty line. Twenty-one states with Republican governors or GOP-controlled legislatures, including Texas and Florida, have balked, citing ideological objections, their own budget pressures, as well as skepticism about Washington’s long-term commitment to pay for most of the costs.
  • Anemic enrollment. Eighteen million Americans who are eligible to buy insurance in federal and state marketplaces haven’t purchased it. Those marketplaces have had particular trouble enrolling Hispanics, young adults and people who object to being told to buy insurance.  Federal funding used by state marketplaces to enroll people and advertise is drying up. Many state marketplaces haven’t figured out how to be self-sustaining. Vermont, Hawaii, Colorado and Rhode Island are among those states searching for more money. The penalty for going without coverage rises next year to $695 per adult or 2.5 percent of family income—whichever is larger.
  • Market stability. Nationally, premiums haven’t gone up too much on average in the first two years of the marketplaces, but that could change. The federal government has been protecting insurers from unexpectedly high medical bills, but that cushion disappears after next year. At the same time, insurers finally have enough experience with their initial customers to figure out if their premiums are sufficient to cover medical costs. If they’re not, expect increases.
  • Affordability. People who get their insurance through their employer have mostly been spared jolts from the health law. But the federal government begins taxing expensive health plans in 2018. The “Cadillac tax,” created by the health law, will pressure employers to offer skimpier health coverage or pass the taxes’ cost on to their employees. Also, individuals buying their insurance on the health law marketplaces continue to risk large out-of-pocket costs if they need lots of care. Their maximum financial obligations for next year are $6,850 for individuals and $13,700 for families. Those who choose to go out of their insurance network may have no ceiling on how much they may have to pay.
  • Political resistance. Thursday’s ruling did little to diminish the GOP’s zeal to repeal the health law. Republicans on both sides of the Capitol pledged to continue their efforts to kill the ACA. A lawsuit filed by House Republicans last year alleges the president overstepped his authority when implementing the health law. The topic remains grist for the 2016 presidential campaign, with several Republican presidential candidates – including Sen. Lindsey Graham, R-S.C., and former Florida Gov. Jeb Bush — reiterating their desire to repeal the law. If the Republicans capture both the White House and Congress in 2016, all bets are off over whether the law survives intact.
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Mixed Effects Are Seen on an Affordable Care Act Repeal

Mixed Effects Are Seen on an Affordable Care Act Repeal | Healthcare and Technology news |

The nonpartisan Congressional Budget Office said Friday that repealing the Affordable Care Act would significantly increase federal budget deficits and the number of people who are uninsured.

But, it said, repealing the law would also raise economic output because it would create incentives for some people to work more.

The estimates came in the first major study issued by the new director of the budget office, Keith Hall. It was also the first report to use new methods of fiscal analysis, according to instructions from the Republican majority in both houses of Congress.

Repealing the law would increase federal budget deficits by $137 billion in the decade from 2016 to 2025, Mr. Hall said in the report. In addition, he said, the number of uninsured people, estimated at 35 million under current law, would increase by 24 million if the law was repealed.

Mr. Hall itemized the likely changes: Fourteen million fewer people would be enrolled in Medicaid, and 18 million fewer people would have private insurance purchased on the open market or on public exchanges established under the health law. But eight million more would have coverage through employers.

The report came as consumers, lawmakers and politicians wait anxiously for a Supreme Court ruling on health insurance subsidies paid under the health care law to millions of people in more than 30 states.

President Obama has repeatedly threatened to veto legislation repealing the health care law, his biggest legislative accomplishment as president, but Republicans keep trying and stepped up their efforts this year after taking control of both houses of Congress.

Proposals to repeal the law are included in legislation being prepared by Republicans to respond to the Supreme Court decision, which is expected within days.

The report by the budget office is sure to be cited by members of both parties as they continue fighting over health care through the 2016 elections. Democrats, defending the law they passed five years ago, can use the report to argue that repealing the law would be a bad move because it would increase the deficit. Republicans can use it to argue that the law itself is bad.

Senator Michael B. Enzi, Republican of Wyoming and the chairman of the Senate Budget Committee, said the report showed that “repealing the president’s health care law will increase economic growth.” But Representative Nancy Pelosi of California, the House minority leader, said it showed that “repeal will explode the deficit.”

The budget office said that repealing the law — with its insurance subsidies and expanded eligibility for Medicaid — would increase federal budget deficits by $353 billion in the coming decade, largely because the government would forgo big savings in Medicare and would lose revenue from new taxes and fees. But after taking account of the positive economic effects of a repeal, it said, the increase in the deficit would be $137 billion.

The law tends to “reduce the supply of labor by reducing some people’s incentives to work,” the report said. Repealing it would reverse those incentives and could increase the output of goods and services, the gross domestic product, by seven-tenths of 1 percent, the study said.

The insurance subsidies, along with expanded eligibility for Medicaid, “generally make it easier for some people to work less or to stop working without losing health insurance coverage,” the report said.

■ The government would lose $167 billion in penalty payments from large employers, who are supposed to offer insurance to full-time employees.

■ It would lose $87 billion from eliminating a new excise tax on certain employment-based health plans with relatively high premiums. Under current law, revenue from this “Cadillac tax” will grow rapidly as more health plans are affected each year, starting in 2018.

■ It would lose $346 billion in new taxes paid by high-income people, $142 billion in fees paid by insurance companies and $54 billion in fees paid by manufacturers of prescription drugs and devices, provisions of the health care law meant to help pay for it.

■ It would save $822 billion because it would no longer subsidize some private insurance bought through the exchanges.

■ It would save $824 billion in Medicaid and the Children’s Health Insurance Program.

But, the budget office said, repealing the health law would accelerate Medicare spending, which has been growing at an exceptionally slow rate.

The law throttled back the growth of Medicare payments to hospitals,nursing homes, health maintenance organizations and other providers. Repealing it would undo those savings, and as a result, Medicare spending would rise by roughly $800 billion over 10 years, the report said.

The report analyzes the economic effects of the health care law and the ways in which those effects may, in turn, influence federal spending and revenues — a technique known as dynamic scoring. Democrats fear that Republicans will use that approach to help justify tax cuts. But at least in the report on Friday, Mr. Hall was cautious in using the new technique and carefully documented the economic assumptions that led to his conclusions.

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5 Reasons The Affordable Care Act Will Be Good For Americans

5 Reasons The Affordable Care Act Will Be Good For Americans | Healthcare and Technology news |

In October, 2013, at the launch of the Affordable Care Act, I predicted that the health insurance exchanges about to go into effect would grow in popularity and  improve the health insurance marketplace, then so imperfect.

Twenty months later, the exchanges are proving effective in reducing the number of uninsured and are beginning to provide the information people need to make an informed selection about which plan is best for their needs. As a result, I’m even more convinced than I was that they will bring about major improvements – improvements not only in how health coverage is purchased, but also in lowering cost and increasing quality outcomes.

Although concerns still exist, I predict that many of the latest headlines – about the technical challenges faced in the rollout of the law, the pending Supreme Court decision on whether subsidies are being made available consistent with the letter of the law, and the continued bipartisan bickering – will be largely forgotten a decade from now.

Already, with second-year enrollment complete, the results of the exchanges are nothing short of impressive. According to Gallup, the rate of uninsured Americans has dropped from 16% to 12%.  And some 14.1 million Americans already have signed up for the public exchanges.

Here, then, are the top five improvements to American healthcare that will come directly from the exchanges.

1. They Will Transform The Health Insurance Market

The rules of engagement in the marketplace are shifting dramatically. Individuals who sign up for insurance through the exchanges are guaranteed coverage. They also gain advantages from standardized benefit design, cost transparency, and increasingly – at least in some states – data on quality.

With our limited experience on utilization and risk among enrollees, pricing has yet to settle. But in the future, as competition grows, the plans that sell insurance products through both private and public exchanges will be forced, if they want to attract new members, to lower prices and increase the value delivered.

Previously, insurance plans in the individual and small group market competed with each other mainly through product design and risk selection.

The most successful insurance companies figured out how to “slice and dice the risk pool” – selectively trying to enroll the youngest and healthiest in the individual market and thereby minimize the amount they had to pay to physicians and hospitals.

In the individual market, insurers did this by denying coverage to individuals with pre-existing conditions and creating “skinny” plans with limited benefits.

Such tactics are no longer legal under the ACA.

In addition, because competing plans in most communities used essentially the same physicians and hospitals, insurance companies had difficulty differentiating themselves from each other based on quality.

And as a result, they only invested minimally in improving the effectiveness and efficiency of care delivery.

Now we can predict that going forward, individuals will have a broader set of options with added information. And the winners will be those plans that provide high quality medical care at the lowest cost, rather than those who are best able to attract the healthiest patients or design coverage with the narrowest benefits.

2. They Will Enable Companies To Move From a Defined Benefit to a Defined Contribution  

The exchanges extend to employers the opportunity to get out from being a “middle man.” Rather than being responsible for selecting the company’s insurance plan, negotiating the coverage provided and determining the size of the deductibles required, they can provide employees a set amount of money for health insurance – a defined contribution – and increase it in subsequent years at a rate consistent with their ability to fund this benefit.

Employees can then pick among the numerous options on an exchange based on personal preference. If they select a less expensive plan, they can take home the difference. Or they can enroll in a more expensive option and contribute their own money.

Previously, to control costs, some employers forced employees to switch insurance companies and, as a result, change doctors. Others required employees to pay more out of pocket. Both of these means of controlling costs made employees unhappy with their employers.

Now employers can avoid being put in the middle, while ensuring that their company’s cost of healthcare coverage increases at a rate the company can afford.

3. They Will Help Individuals To Comparison Shop Among the Different  Plans  

With costs now transparent, and increasingly quality information being made available, enrollees will be better equipped to make informed choices about the best plan for themselves and their families.

The public exchanges offer standardized benefits and comparable pricing. Each plan, from platinum and gold to silver and bronze, varies in monthly premiums and patient cost-sharing requirements.

Previously, healthcare pricing and benefits constituted nothing less than a “black box.” Plans varied widely in what was covered and how much an individual or family needed to pay out of pocket. It took an actuary to figure out which plan had the most value.

No more.

4. They Will Motivate Changes In Behavior That Drive Down HealthCare Costs

Enrollees through the exchanges will be more active participants in controlling their healthcare costs.

The government-funded subsidies are designed to make the Silver tier the most desirable. By law, this level of coverage requires on an actuarial basis that 30% of the cost be borne by an enrollee. As a result, all include deductibles for which enrollees must pay first dollar out of pocket payments.

Knowing they will be personally responsible each year to pay for a significant amount of their care, they will be more likely to take advantage of the free preventive services offered  and deepen their personal commitment to life style changes that could minimize major medical problems in the future.

And having to pay out of pocket will fuel individuals to be financially motivated to make more cost effective choices — for example, to take time to shop to find the lowest priced CT scan and request generic rather than brand name medications.

But one risk is that higher levels of cost sharing will lead individuals to forgo needed care, and end up with increased medical problems and long-term cost. This bears watching.

5. They Will Increase Health Insurance Options And Competition Over Price

We can expect increased competition to lead to lower pricing.

The number of programs available through most public exchanges today, already quite large, is projected to increase significantly in the future.

And thanks to the pooling of risk and reduced transactional costs, participating plans should be able to further restrain their prices.

Previously, many individuals working for a small business were given only one choice. Offering more options was too expensive.

The Small Business Health Options Program (SHOP) in the ACA is an important step forward, especially the provision that enables employees to choose coverage among competing plans. Unfortunately, SHOP is being implemented slowly.

But with momentum, more businesses will move to exchanges, individuals will have more choice and plans will be forced to provide higher value if they want to attract new enrollees.”

Kiara J Stonestreet's curator insight, April 23, 1:56 AM
The affordable health care act has changed our health care system.!

No Medicaid Expansion?

No Medicaid Expansion? | Healthcare and Technology news |
Hospitals that treat many poor and uninsured patients were expected to face tough financial times in states that did not expand Medicaid under the federal law known as Obamacare.

That’s because they would get less Medicare and Medicaid funding under the Affordable Care Act, while still having to provide high levels of charity care.

But in some of the largest states that did not expand Medicaid, many safety-net hospitals fared pretty well last year — even better than in 2013 in many cases, according to their financial documents. KHN looked at the performance of about a dozen such hospitals in Florida, Texas, Georgia, Tennessee, South Carolina, Virginia and Kansas, which released their 2014 financial results.

An improving economy was the single, biggest reason shared by all of the strongly performing hospitals because it helped reduce the number of patients who couldn’t pay their bills and increased local property and sales tax revenues earmarked for publicly supported hospitals.

Another factor for some hospitals was the increase in insured patients who bought coverage through the health law’s insurance exchanges. For instance, Fort Lauderdale, Fla.-based Broward Health saw a 30 percent drop in charity care, which officials attributed to seeing more insured patients.

Still, the biggest fiscal challenges lie just ahead — with significant Medicaid funding cuts starting late next year under the Affordable Care Act. The health law’s drafters anticipated the number of uninsured Americans to decrease dramatically, in part because they expected a nationwide expansion of Medicaid. Therefore, beginning in October, 2016, the law calls for cuts to special Medicaid funding for hospitals that typically see a disproportionate share of the poor. In addition, other Medicaid funding that supports indigent care in certain states (and that predates the 2010 health law) is slated to expire in Florida in June and in Texas, next year.

“We are still very early in the Affordable Care Act, and one year does not make a trend,” cautioned Daniel Steingart, an analyst with Moody’s Investors Service. “Just because they got though this period, does not mean they do not have more financial pain to come.”
So-Called Safety-Net Hospitals Record Profits in 2014

So-called safety-net hospitals, many of which are supported by local or county taxpayers, often struggle financially because they see a high proportion of patients that are either uninsured or enrolled in Medicaid, the state-federal program that pays less money than Medicare or private insurers. The hospitals face added pressure from providing high-cost and traditionally money-losing services such as trauma and burn care. They also have the expense of training doctors.

Nonprofit hospitals need to make enough money to buy new equipment, expand programs and meet rising labor costs. The average nonprofit hospital makes about a 3 percent profit margin, Steingart said.

In the past decade, two of the nation’s largest public safety-net hospitals — Grady Memorial Hospital in Atlanta and Jackson Memorial Health System in Miami — were on the verge of financial collapse but recovered after major management changes and increased public support.

Last year, the county-owned Jackson finished its second consecutive year with about a $51 million surplus on about $1 billion in revenue, in part as a result of increased county sales-tax revenue going to the health system and tighter expense management. Jackson’s operations are supported by a sales tax in Miami-Dade County.

Grady’s profit increased to nearly $30 million through November last year, up from $17 million for the same period in 2013.

Several other safety net facilities in states that did not expand Medicaid had profits in 2014, according to financial reports, including:

— Broward Health, which runs four hospitals, saw $69 million in profit in the 2014 fiscal year that ended June 30, compared to $59 million a year earlier, on about $1 billion in revenue. That included support from local taxpayers.

— Orlando Health, a six-hospital system in central Florida, saw its profit grow to $161 million in the fiscal year that ended in September, up from $32 million the year before, on about $2 billion in revenue. Its vice president of finance, Paul Goldstein, cited the improving economy, an increase in the number of privately insured patients and the financial performance of recently purchased doctors’ groups.

— Tampa General posted a $49 million profit last year, up from $31 million the year before, on $1 billion in operating revenue. Its operating margin was 4.5 percent.

— Chattanooga, Tenn.-based Erlanger Health posted a $20 million profit for the six months that ended Dec. 31, on revenue of $336 million, after factoring in local tax support, compared to losing $1.5 million in the same period a year earlier.

— Greenville Health System in South Carolina made a $63 million profit in the fiscal year that ended Sept. 30, down slightly from $80 million the prior year. The system had about $1.8 billion in revenues.

Twenty-eight states have expanded Medicaid under the health law since the Supreme Court ruled the provision optional in 2012. Medicaid enrollment has increased nationally by almost 11 million since October 2013. Most of the drop in uninsured nationally is attributed to people gaining Medicaid coverage.

Safety-net hospitals in Florida fear what will happen after June 30 when $2 billion in federal funding expires under an agreement between the state and the federal government. Under such agreements, the federal government supplies billions of dollars in special Medicaid dollars to certain states including Florida, Texas and California to support hospitals with large number of Medicaid and uninsured patients.

“Without those dollars we have an unsound system,” said Tony Carvalho, president of the The Safety Net Hospital Alliance Of Florida.

While Miami-based Jackson Health is financially healthy now, Chief Financial Officer Mark Knight worries about the end of that federal waiver funding in June, which contributed $160 million to his budget this year. “We could not continue to serve and maintain current capacity … without that money,” he said.

In 2014, Florida safety-net hospitals also benefited from a strong tourist season and lower unemployment rates, Carvalho said.

The improved economy also helped many safety-net hospitals that are supported through local property and sales taxes, such as Broward Health and Jackson Memorial, said David Gruber, managing director of research at Alvarez & Marsal consulting firm.

A recent report by the firm predicted the nonprofits would face major financial threats as a result of health law funding cuts, particularly in states that do not expand Medicaid. “Safety-net hospitals are now operating in the untenable crosshairs of economic distress and health care reform,” the report said.

Greenville Health has kept in the black partly by finding ways to trim charity care costs, said Chief Financial Officer Terri Newsom. The South Carolina hospital has hired case managers to oversee care to some of the uninsured patients who show up regularly at its emergency department. It also launched a program to divert ambulances with patients who do not have medical emergencies to urgent care centers.

Though the hospital worked to get people signed up for Obamacare plans, it only saw a 1 percent drop in uninsured numbers last year. Nonetheless, administrators say the health system is in good shape. “We are in stable health and making the right investments,” Newsom said.
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U.S. deciding whether to extend Obamacare enrollment

U.S. deciding whether to extend Obamacare enrollment | Healthcare and Technology news |

Americans who have started enrolling for health insurance under the Affordable Care Act can still sign up, and the U.S. government is weighing whether to open a special enrollment period for those who missed Sunday's deadline, the health secretary said on Wednesday.

So far, 11.4 million Americans have enrolled in private health insurance through the health reform law known as Obamacare during the open enrollment period that ended on Sunday, according to the White House.

The Affordable Care Act requires most Americans to have health insurance or face a financial penalty. But some people may not realize they face a penalty for not having coverage until they file their tax returns in coming weeks.


HHS will decide within the next two weeks whether to allow another special enrollment period for consumers, Health and Human Services Secretary Sylvia Burwell told reporters in response to a question about those consumers amid the looming April 15 tax-filing deadline.

“We’re going to analyze it, we’re going to think about it, and we’ll be back. And we will be back quickly on it," she said at a news conference.

Separately, Burwell said fewer than 150,000 people were "in line" as of Sunday to get health insurance coverage through the marketplace set up by the Affordable Care Act. They will have until Feb. 22 to complete their application, she said.

Those applicants were in communication with the telephone call center for the federal exchange marketplace but could not complete their application before Sunday's deadline, according to HHS. They do not include people who had technical issues with the website that prevented them from completing their enrollment, the department said.

Kiara J Stonestreet's curator insight, April 23, 1:59 AM
It's 2020 and I am still not updated about that, but I'm pretty sure it ended.!

Doing More for Patients Often Does No Good

Doing More for Patients Often Does No Good | Healthcare and Technology news |

Given the remarkable advances that have been made in the last 50 or so years in pharmaceuticals, medical devices and surgical procedures, it’s not a surprise that people want more, and more invasive, care than they have had in the past. Just as it’s hard to do nothing when you’re ill, it’s sometimes hard to do less than the maximum when there are different treatments to choose from.

Unfortunately, doing more often does no good. Sometimes, it even leads to harm.

In the United States, when it appears that someone might be in trouble, emergency medical services are dispatched. Many patients die from an out-of-hospital cardiac arrest, but steps taken out in the field can make a difference. Basic life support, the kind you might be taught in a CPR class — involving the use of bag valve masks, cardiopulmonary resuscitation and automated external defibrillators — can absolutely save a life.

Advanced life support, usually requiring a trained paramedic, involves much more. Trained providers may put in endotracheal breathing tubes; start intravenous lines; deliver sophisticated cardiac drugs; and defibrillate patients manually.

We’ve assumed, for the most part, that advanced life support is better than basic life support — so much so that in most areas where both options are available, advanced life support is almost always used. But a recent study in JAMA Internal Medicine brings this assumption into question. Researchers examined Medicare patients who were billed for either advanced life support or basic life support before admission to the hospital from 2009 through most of 2011. They looked at how often patients survived to hospital discharge, and then months later.

What they found was that about 13 percent of patients who received basic life support survived and were discharged versus 9 percent of patients who received advanced life support. More patients who received basic life support lived for 90 days after discharge, too (8 percent versus 5 percent). Basic life support patients also had better neurological outcomes.

Now, of course, this is not a randomized controlled trial. It’s possible that sicker patients received advanced life support and that people who didn’t appear as sick received basic life support. But the authors called all of the state agencies, and they reported that this can’t really happen. After all, a 911 dispatcher can’t tell if it’s a “mild” or “severe” heart attack from a third party on the phone with no medical training. Dispatchers send out advanced life support if it’s available, and basic life support if it’s not.

It’s also possible that there could be differences in bystander CPR administration until help arrives. But the authors attempted to control for that, too. They conducted a number of sensitivity analyses, and in none of them did advanced life support outperform basic life support.

It would also be easier to dismiss this finding if it weren’t corroborated in many other studies. In 2004, results from the Ontario Prehospital Advanced Life Support Study were published in the New England Journal of Medicine. This was a multicenter controlled trial in 17 cities in Canada comparing advanced life support with basic life support. They found that if an instance of cardiac arrest were witnessed by a bystander, the chance of survival significantly improved. They also found that CPR administered by bystanders improved survival, and so did rapid defibrillation. These are all components of basic life support. The addition of advanced life support, however, made no difference in survival.

A 2007 study conducted in Taipei also found that advanced life support did not improve survival to discharge. Even the main components of advanced life support have failed to show results in studies. A 2008 systematic review showed no efficacy for emergency intubation. A 2010 cohort study found advanced airway methods — basically, putting in an airway tube rather than using a bag mask — to be associated with decreased survival compared with basic life support methods, as did a 2013 study in Japan.

A 2012 JAMA study found that the use of epinephrine was associated with worse outcomes, and a 2008 New England Journal of Medicine study found that adding vasopressin (another drug that, like epinephrine, constricts blood vessels to raise blood pressure) didn’t improve things. A randomized controlled trial of these drugs, published in 2009 in JAMA, found that their use didn’t improve survival either.

The evidence is compelling. Advanced life support does not seem to provide any benefits in the randomized controlled trials, and it’s often associated with worse outcomes in the cohort studies. How can this be so? Some theorize that the things that work have already been incorporated into basic life support. All that the advanced life support may be doing is slowing things down in the field, distracting people from the useful basic life support measures, and delaying the time until a patient can get to the hospital.

It’s hard not to do more if we can, though. We see this in all sorts of areas of care. A few months ago, a study was published in JAMA that examined the outcomes of women with stage 0-III unilateral breast cancer who underwent breast conserving surgery with radiation compared with those who had a unilateral mastectomy and those who had a bilateral prophylactic mastectomy. The 10-year survival differences between the groups were negligible. Breast conservation therapy is more tolerable, is much less invasive and costs less.

In fact, breast conservation therapy has become a “standard of excellence” in breast cancer care. But a study published even more recently showed that from 1998 through 2011, the odds of a woman eligible for breast conservation therapy receiving a mastectomy increased. Rates of bilateral mastectomy went up over this time period as well, from 2 percent in 1998 to 11 percent in 2011.

And based on the data from many randomized controlled trials, we know that women who have radiation therapy for early breast cancer do well with less of it. The use of “hypofractionated” whole breast irradiation, which consists of fewer treatments with higher levels of radiation, has been shown to be equally effective for women without any excess side effects. It’s cheaper, easier and just as good. Hypofractionated whole breast radiation has been endorsed by the American Society for Radiation Oncology for women who satisfy certain criteria since 2011.

But a study published a month ago that looked at the use of radiation in women with early stage breast cancer found that in 2013, only about a third of women who qualified for hypofractionated radiation therapy were getting it. The rest got more, but not better, care.

The reasons for this are varied. With respect to the radiation therapy, it’s hard not to lay some of the blame on economics. After all, in a fee-for-service system, more visits and more treatments mean more money. Research shows that twice as many women want hypofractionated radiation therapy as want conventional therapy, but only half of radiation oncologists offer it.

But it’s not all money. It’s also probably fear. Many radiation oncologists are concerned that doing fewer treatments will lead to worse outcomes. That’s most likely the concern of women who choose much more invasive surgery than necessary as well.

It’s certainly the rationale for why advanced life support is so prevalent. The Ontario Prehospital Advanced Life Support Trial was supposed to be a randomized controlled trial, but the paramedics evidently refused to do it because they felt that holding back advanced life support was unethical. This was in spite of the lack of evidence that it was effective.

More is expensive. More sometimes does no good. Sometimes, more is even harmful. When our policies and care ignore these facts, we all suffer.

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1 In 4 New Doctors Would Change Careers If They Could Start Over

1 In 4 New Doctors Would Change Careers If They Could Start Over | Healthcare and Technology news |

Even as doctors enter a medical field with more paying patients under the Affordable Care Act and unprecedented numbers of job opportunities, 25 percent of “newly trained physicians” would still choose another field if they could, according to a new analysis.

More than 60 percent of doctors-in-training who were in the final year of their medical residency last year received at least 50 job solicitations during their training, according to a survey by physician staffing firm MerrittHawkins. Another 46 percent received at least 100 job solicitations.

“There are simply not enough physicians coming out of training to fill all the available openings,” MerrittHawkins president Mark Smith said.

This comes amid a physician shortage, changing payment structures and new regulations and paying customers under the health law that are creating more opportunities yet anxiety among doctors as they enter this new order.

“The paramount thing on new doctors’ minds is: will I have a life,” said Phil Miller, vice president at MerrittHawkins, a division of AMN Healthcare (AHS). “They are running into a maelstrom and there are all sorts of changes taking place.”

Merritt executives say it shouldn’t be surprising that 25 percent would select another field of study if they had to start over with their education given the turbulent environment they face.

The 2015 survey of residents in their final year of medical residency, which tallied more than 1,200 responses last year from a sampling of 24,000, indicates young doctors are ready to enter a world of “9 to 5” employment rather than launching their own private practice. More than 90 percent said they preferred employment with a salary rather than an “independent practice income guarantee.”

The more predictable hours young doctors want comes after four years of medical school and three to five years of residency, often with long hours and an exhaustive schedule.

Here are some other survey highlights from residents in their final year:

  • 78 percent expect to make at least $176,000 in their first year of practice
  • 39 percent are unprepared to handle the business side of medicine
  • 2 percent preferred a solo setting as their first practice
  • 93 percent preferred to practice in communities of 50,000 or more people

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Think Filing Taxes Was Tough Before Obamacare? Just Wait

Think Filing Taxes Was Tough Before Obamacare? Just Wait | Healthcare and Technology news |

The Affordable Care Act, aka Obamacare, is part health law, part tax law. Some feel benefited by the law, some burdened by it. And one’s perceptions about that can change over time. Either way, you may be annoyed by the extra forms and extra tax compliance, even if your tax bill doesn’t go up. The IRS has a far more important role in the law than you might think.

This year for the first time, the Affordable Care Act has created a trickier tax season. It is more expensive too, as virtually all Americans filing tax returns will have to consider the law’s impact on them and their taxes. There is likely to be considerable confusion this first year, and probably many mistakes. Yet many expect the IRS to be lax for a time. The agency is already stretched thin, and tax season looms large, especially this year.

A major feature of the law is a mandate requiring that most Americans must carry health insurance. In its simplest, that means you must state on your tax forms whether you have coverage. You also must say whether you got tax credits to help pay for it. If you did not have coverage in 2014 as required—and you are honest and say you didn’t—there’s a fine. Yet if you fail to pay it, many in the tax filing business think you may slide by without incident.

On the other hand, if you are entitled to subsidies, your tax refund is likely to go down. In fact, your refund may go down so much that you may even owe the IRS money. The subsidy process is confused and many people who received subsidies are likely to owe the IRS. Why? Because there is estimating involved, the tax credits they received to offset their insurance premiums may have been too large.

In fact, H&R Block estimates that up to one half of the approximately 6.8 million taxpayers who got subsidies in 2014 may have to send money back to the government. Tax preparation firms are trying to gear up to provide the kind of hybrid health insurance tax law advice that consumers are needing this year. But like any new system, there are likely to be some hiccups. It will also be one more reason taxpayers may need tax professionals, even if their situations seem simple.

In that sense, this could be a pivotal tax filing season. Obamacare was enacted in 2010, eventually rolled out, and repeatedly delayed. As enacted, employers were supposed to send in to the IRS lists of employees with health coverage through their employment. After delays, though, it’s now clear that there will be more self-reporting than originally envisioned.

Given that the IRS is administering the massive health care/tax law, you might assume that there would be something like a Form W-2 or Form 1099 that would reveal key data. For now, though, the IRS says it has to trust tax filers to answer truthfully whether they had health insurance or need to pay a penalty. In some sense, it might be similar to answering the question whether you have a foreign bank account. That too is a yes or no question.

Some taxpayers are likely to just skip the question about health insurance, just as some skip the foreign bank account question. If you don’t say yes or no, the reasoning goes, how can they penalize you? Tax return preparation software may or may not default to yes or no for health insurance. Remember, though, that you must sign your tax return under penalties of perjury.

If you must pay a fine, you pay it as part of your tax bill. That will make some people unhappy. Still, the flak from people who got subsidies and then are getting smaller refunds than they thought–or even owing money–may be greater.

Finally, a major impact on many higher income taxpayers is likely to be the 3.8% net investment income tax. It was enacted in 2010 expressly to fund the health law. It first took effect in 2013, and 2014 is likely to be a big year. If you need guidance, the IRS has released these questions and answers on the net investment income tax.

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Remember That Healthcare Is About More Than The Affordable Care Act

Remember That Healthcare Is About More Than The Affordable Care Act | Healthcare and Technology news |

The midterm elections shifted the balance of power and opened the door for major policy changes in the coming months. When Congress reconvenes next year, the Affordable Care Act (ACA) will be put on the examining table once again. In a post-election article in The Wall Street Journal, Republican House and Senate leaders John Boehner and Mitch McConnell vowed to focus on jobs and the economy and “(renew) our commitment to repeal Obamacare, which is hurting the job market along with Americans’ health care.”

While modifications to the ACA seem certain (and are seen as needed by both supporters and opponents), it is critical that we acknowledge a glaring reality as we debate our next steps in healthcare reform: we have to embrace new ways of thinking to reduce runaway spending and improve health outcomes for all Americans in order to have a healthy economy and a productive workforce.

The statistics are startling. One in two adults lives with at least one chronic condition, and one in four is battling two or more. Seventy-five percent of our healthcare dollars goes to the treatment of chronic diseases, 70% of which could be avoided.

Preventable conditions, such as heart disease, diabetes and obesity, are the leading cause of death and disability in this country, and amount to an economic burden of $1.3 trillion in treatment costs and lost productivity annually.  Based on current trends, we are likely to see a 42% rise in chronic disease cases by 2023, with a cost of $4.2 trillion in treatment and productivity loss.

Chronic disease is a crippling economic and social burden. While the ACA grabs headlines, there are steps we must take beyond a single piece of legislation to make health and wellness a national priority and stem the surge of chronic disease:

1.    Change starts with vision: we need a fundamental shift of focus, within both government and society, from “sick” care to “health” care.  The U.S. “healthcare” system is a misnomer. Our approach to healthcare is as old as our nation—we treat the sick rather than prevent disease and proactively protect individual health. Patients have had little choice and a limited role in their own care, and it has cost us dearly. Our goal should be to support every American to proactively achieve and manage good health before disease develops. Once a person is sick, it’s like closing the barn door after the horse has bolted—it begins a chase with an indeterminate end and outcome. Access to health insurance is a start, but there are many other factors that contribute to wellness—education, access to nutritious foods, safe housing and transportation, and continuous, connected care are some examples. Our policies need to support these objectives for all Americans.

2.    Health care starts with the individual: we need to provide tools to consumers that allow them to control and manage their health.  At the center of a person’s health is the person. We will do a better job of protecting health and preventing disease by providing effective tools and expert support to enable individuals to make good choices for their health every day. Our focus on the annual exam (with an average 22 day wait to see the doctor) and yearly screenings as gatekeepers of health is outdated. New, more effective and personalized approaches to care delivery are being driven by advances in mobile technology and changing consumer expectations for convenience and choice. Today, an equal number of patients and doctors agree that routine health tasks should be handled by smartphones. Eighty-four percent of adults, age 18 to 34, say they prefer a smartphone consultation with their doctor. Telemedicine is no longer a solution to deliver care in rural areas—it is a tool to provide more efficient, targeted, consumer-centric care with better outcomes for everyone no matter where they are.  And yet, only 19 states and the District of Columbia require private insurers to cover telehealth services, with 43 states and D.C requiring some form of Medicaid reimbursement. We need to promote policies that enable all consumers to take advantage of these new, accessible health services.

3.    Prevention requires collaboration and transparency: we need to invest in continuous, connected care, with lower costs and better outcomes. Emerging, innovative care models use a combination of technology and human expertise to deliver ongoing care with improved health outcomes at a lower cost than traditional approaches. Companies like Doctor On Demand, Teladoc, HealthTap and my company, Vida, are developing robust health platforms and mobile apps to connect consumers, doctors and data, and drive collaboration, consumer engagement, and behavior change. Early results show this approach improves health outcomes. In the future, consumers will use mobile devices and sensors to communicate with their doctors and health teams between in-person visits and necessary tests and screenings. Consumers will shop for health providers, hospitals and insurance plans, manage chronic conditions, and optimize their health as routinely and purposefully as they pay their bills and purchase online today. We need to encourage policies that allow for interoperability between consumers, providers, hospitals, and payors (to encourage data sharing and avoid costly repeat testing), and price transparency (so consumers and employers can make smart choices).

Despite its flaws, the ACA reflects an appreciation of the starring role chronic disease plays in our nation’s failing health. It highlights preventive and wellness services and chronic disease management as “essential health benefits,” underscoring the need for more aggressive management and prevention.  It pushes a model of care that is consumer-centered with price transparency, greater choice and marketplace competition among providers. And, it incentivizes providers around positive patient outcomes rather than services delivery.

If the ACA is repealed, I think we will lose ground in our effort to achieve universal health (vs. universal healthcare) for all Americans. In the coming healthcare debate, it’s important to remember the ACA is only the start, not the end, of our battle for true health care.

Society Now's comment, March 13, 2:38 AM
housing society management system !!

As Medicaid Rolls Swell, Cuts in Payments to Doctors Threaten Access to Care

As Medicaid Rolls Swell, Cuts in Payments to Doctors Threaten Access to Care | Healthcare and Technology news |

Just as millions of people are gaining insurance through Medicaid, the program is poised to make deep cuts in payments to many doctors, prompting some physicians and consumer advocates to warn that the reductions could make it more difficult for Medicaid patients to obtain care.

The Affordable Care Act provided a big increase in Medicaid payments for primary care in 2013 and 2014. But the increase expires on Thursday — just weeks after the Obama administration told the Supreme Court that doctors and other providers had no legal right to challenge the adequacy of payments they received from Medicaid.

The impact will vary by state, but a study by the Urban Institute, a nonpartisan research organization, estimates that doctors who have been receiving the enhanced payments will see their fees for primary care cut by 43 percent, on average.

Stephen Zuckerman, a health economist at the Urban Institute and co-author of the report, said Medicaid payments for primary care services could drop by 50 percent or more in California, Florida, New York and Pennsylvania, among other states.

In his budget request in March, President Obama proposed a one-year extension of the higher Medicaid payments. Several Democratic members of Congress backed the idea, but the proposals languished, and such legislation would appear to face long odds in the new Congress, with Republicans controlling both houses.

Dr. David A. Fleming, the president of the American College of Physicians, which represents specialists in internal medicine, said some patients would have less access to care after the cuts. It would make no sense to reduce Medicaid payments “at a time when the population enrolled in Medicaid is surging,” he said.

Dr. George J. Petruncio, a family physician in Turnersville, N.J., described the cuts as a “bait and switch” move. “The government attempted to entice physicians into Medicaid with higher rates, then lowers reimbursement once the doctors are involved,” he said.

But Nicole Brossoie, a spokeswoman for the New Jersey Department of Human Services, which runs the state’s Medicaid program, said the increase was not meant to be permanent. “The enhanced rates will not be extended in New Jersey,” Ms. Brossoie said. “It was always understood to be temporary.”

The White House says Medicaid is contributing to the “largest coverage gains in four decades,” with 9.7 million people added to the Medicaid rolls since October 2013, bringing the total to 68.5 million. More than one-fifth of Americans are now covered by Medicaid.

But federal officials have not set forth a strategy to expand access to care with enrollment, and in many states Medicaid payment rates for primary care services, like routine office visits and the management of chronic illnesses, will plunge back to 2012 levels, widely seen as inadequate.

For the last two years, the federal government has required state Medicaid agencies to pay at least as much as Medicare pays for primary care services. Family doctors, internists and pediatricians have thus received Medicare-level payments for primary care, with the federal government making up the difference in costs.

The impending cuts are larger in states like California that have the widest gaps between Medicaid and Medicare rates.

A survey by the Ohio State Medical Association found that some Ohio doctors began accepting Medicaid patients because of the rate increase in 2013. Ohio doctors who were already participating in the program said they had accepted more Medicaid patients after the rate increase. And almost 40 percent of Ohio doctors indicated that they planned to accept fewer Medicaid patients when the extra payments lapsed.

Under federal law, Medicaid rates must be “sufficient to enlist enough providers” so that beneficiaries have at least as much access to care as the general population in their geographic area. In practice, doctors say, this standard is murky.

The Obama administration told the Supreme Court last month that health care providers had no legal right to enforce the “equal access” requirement in court. This section of the Medicaid law provides guidance to federal and state officials in setting Medicaid rates, but does not allow health care providers to sue state officials to enforce it, said Donald B. Verrilli Jr., the solicitor general of the United States.

The case, Armstrong v. Exceptional Child Center, was filed against Richard Armstrong, director of the Idaho Department of Health and Welfare, by five providers of residential habilitation services to children with disabilities. They argued that Idaho’s payment rates fell below federal standards, and they sued to enforce federal law, invoking the supremacy clause of the Constitution, which makes federal law “the supreme law of the land.”

The court sidestepped the issue in a similar case from California in 2012. Chief Justice John G. Roberts Jr. said then, in a dissenting opinion, that “nothing in the Medicaid Act allows providers or beneficiaries (or anyone else, for that matter) to sue to enforce” the equal-access provision.

Matt D. Salo, the executive director of the National Association of Medicaid Directors, which represents state officials, said his group had not lobbied for an extension of the Medicaid fee increase. “It has rewarded providers who were already doing the right thing, but did not bring in a flood of new providers,” Mr. Salo said.

The higher payments for primary care have been available in the traditional fee-for-service Medicaid program as well as in managed-care plans, which typically pay doctors a fixed amount per patient per month.

Joseph A. Reblando, a spokesman for Medicaid Health Plans of America, a trade group, said, “The fee increase was a good idea in concept, but it was built on an antiquated system in which doctors were paid a separate fee for each service.”

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How Doctors Improve Health Via 'Disruptive Technology'

How Doctors Improve Health Via 'Disruptive Technology' | Healthcare and Technology news |

From electronic health records and telemedicine to “internet-driven physical therapy,” Dr. Richard Rothman, founder of the Rothman Institute, says providers of medical care are embracing the promise of the digital age.

In an interview at the 2014 Forbes Healthcare Summit, Rothman talks about how a health care system with more than a half million patient visits annually is moving into the digital health space with “disruptive technology,” reducing costs by moving therapy online, conducting telehealth consults with patients and using eletronic health records to improve patient experience.

“We are very pro disruptive technology,” Rothman said in his interview, which can be seen in its entirety below.  “We are into disruptive technology that will lower costs and improve convenience for our patients.”

As insurance companies like Aetna (AET), Cigna (CI), UnitedHealth Group (UNH), Humana (HUM), and others push away from fee-for-service medicine to accountable care and bundled payments, Rothman said digital health can achieve what the insurers want in lower costs and better quality. As one example, the Rothman system is practicing “internet-driven” physical therapy that will reduce costs by 80 percent.

As the Affordable Care Act and trends in insurance payment move away from paying for quantity to reimbursement based on quality, Rothman believes health plans and government health plans will, in turn, embrace provider ideas in digital health.

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Inside 321,000 New Jobs, An Obamacare Hiring Bump

Inside 321,000 New Jobs, An Obamacare Hiring Bump | Healthcare and Technology news |

The surprisingly robust U.S. jobs report includes a boost to overall employment from a major increase in health industry jobs some credit to Americans’ ability to buy more medical care under the Affordable Care Act.

Of the 321,000 new jobs added in November, nearly 29,000 were in the health care sector. Unlike retail jobs, which typically jump now for holiday shopping, health-related employment has grown steadily all year with providers of medical care staffing up as the first year of broader coverage under the health law brought more paying customers and more states expand Medicaid coverage for poor Americans.

“Over the past 12 months, employment in health care has increased by 261,000,” the U.S. Department of Labor’s bureau of labor statistics said in its report. “Employment continued to trend up in offices of physicians (+7,000), home health care services (+5,000), outpatient care centers (+4,000), and hospitals (+4,000).”

Hospital operators like Tenet Healthcare and HCA Holdings have seen a major increase in surgeries and related hospital care, largely from pent up demand from Americans who haven’t previously had coverage. Health plans, too, like UnitedHealth Group UNH, Aetna AET, Humana (HUM) have said they have added new jobs in a variety of areas like nurse help lines and disease management.

lantis mcckelvie's curator insight, December 16, 2014 10:48 AM

Job availbilty

1 Kishan Patel's curator insight, March 11, 2015 8:29 PM

The department of labor has to do with employment, but I didn't realize that the department of labor was influenced and impacted by other event going on in our nation. Obama Care apparently helped in crease job which is good for our nation and its GDP therefore I agree with the plan, but I do believe some revision are needed because it is also causing our debt to increase. The department of labors main focus is to keep up with jobs but the other provisions are also helping them achieve that so any plan that decrease unemployment and does not raise the nations debt is a plan that I am for.

Ashley Maddox's comment, March 12, 2015 9:31 AM
5 articles and comments=100. good job!

Obamacare’s Next 5 Hurdles to Clear

Obamacare’s Next 5 Hurdles to Clear | Healthcare and Technology news |

In its first five years, the Affordable Care Act has survived technical meltdowns, a presidential election, two Supreme Court challenges — including one resolved Thursday — and dozens of repeal efforts in Congress. But its long-term future still isn’t ensured. Here are five of the biggest hurdles remaining:

Medicaid Expansion. About 4 million more Americans would gain coverage if all states expand the state-federal Medicaid programs to cover people with incomes at or slightly above the poverty line. Twenty-one states with Republican governors or GOP-controlled legislatures, including Texas and Florida, have balked, citing ideological objections, their own budget pressures, as well as skepticism about Washington’s long-term commitment to pay for most of the costs.

Anemic Enrollment. Eighteen million Americans who are eligible to buy insurance in federal and state marketplaces haven’t purchased it. Those marketplaces have had particular trouble enrolling Hispanics, young adults and people who object to being told to buy insurance.  Federal funding used by state marketplaces to enroll people and advertise is drying up. Many state marketplaces haven’t figured out how to be self-sustaining. Vermont, Hawaii, Colorado and Rhode Island are among those states searching for more money. The penalty for going without coverage rises next year to $695 per adult or 2.5 percent of family income—whichever is larger.

Market Stability. Nationally, premiums haven’t gone up too much on average in the first two years of the marketplaces, but that could change. The federal government has been protecting insurers from unexpectedly high medical bills, but that cushion disappears after next year. At the same time, insurers finally have enough experience with their initial customers to figure out if their premiums are sufficient to cover medical costs. If they’re not, expect increases.

Affordability. People who get their insurance through their employer have mostly been spared jolts from the health law. But the federal government begins taxing expensive health plans in 2018. The “Cadillac tax,” created by the health law, will pressure employers to offer skimpier health coverage or pass the taxes’ cost on to their employees. Also, individuals buying their insurance on the health law marketplaces continue to risk large out-of-pocket costs if they need lots of care. Their maximum financial obligations for next year are $6,850 for individuals and $13,700 for families. Those who choose to go out of their insurance network may have no ceiling on how much they may have to pay.

Political Resistance. Thursday’s ruling did little to diminish the GOP’s zeal to repeal the health law. Republicans on both sides of the Capitol pledged to continue their efforts to kill the ACA. A lawsuit filed by House Republicans last year alleges the president overstepped his authority when implementing the health law. The topic remains grist for the 2016 presidential campaign, with several Republican presidential candidates – including Sen. Lindsey Graham, R-S.C., and former Florida Gov. Jeb Bush — reiterating their desire to repeal the law. If the Republicans capture both the White House and Congress in 2016, all bets are off over whether the law survives intact.

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The Supreme Court's Surprise Ruling Saves Obamacare

The Supreme Court's Surprise Ruling Saves Obamacare | Healthcare and Technology news |

The Affordable Care Act survived its second major challenge at the U.S. Supreme Court on Thursday. In a 6-to-3 decision, the justices ruled that the Internal Revenue Service can continue to provide health-insurance subsidies to middle-class people living in all states.

At issue in the case, King v. Burwell, was whether the subsidies should go to residents of the roughly three dozen states that use the federal health-insurance exchange, in addition to those who live in states that run their own exchanges.

It’s a highly technical difference, but had the decision gone the other way, Obamacare might have unraveled. Individuals who receive these subsidies make less than $48,000 per year, and many would struggle to afford health-insurance plans without the government’s financial help. Health-policy analysts feared that, without the subsidies in place, healthy people would withdraw from the health-insurance exchanges in large numbers. That, in turn, would cause premiums to skyrocket, making insurance unaffordable to almost anyone who does not receive insurance coverage through their jobs.

The Affordable Care Act gave states the option to either set up their own exchanges or to rely on the federal government’s marketplace through The part of the law that describes the subsidies said they should only apply to people in the exchanges “established by the state.” The plaintiffs in the King case said that clause meant the IRS was offering subsidies to residents of federal-exchange states illegally.

In the opinion of the Court, Chief Justice John Roberts dismissed the idea that the fate of the entire Obamacare law should hinge on such a technicality.

“In petitioners’ view, Congress made the viability of the entire Affordable Care Act turn on the ultimate ancillary provision: a sub sub-sub section of the Tax Code,” he wrote. “We doubt that is what Congress meant to do.”

Many patient advocates cheered the decision. “It means that millions of people with serious health conditions such as cancer will continue to have access to essential treatment and care, and millions of others at risk for disease will be able to afford preventive screenings and tests that could save their lives,” said Chris Hansen, president of the American Cancer Society’s advocacy arm, in a statement.

Justices Antonin Scalia, Clarence Thomas, and Samuel Alito dissented, writing, “Words no longer have meaning if an Exchange that is not established by a State is ‘established by the State.’”

Roberts concludes by saying that the Court is attempting to respect what Congress hoped to accomplish in passing the law: “Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them.”

There are still a few, more minor, legal challenges to Obamacare remaining. But at least for now, the law lives to see another day.

Jannell Alino's curator insight, August 27, 2015 7:43 PM

Congress passed the Affordable Care Act and the Supreme Court ruled that the IRS will be able to continue to administer health insurance to middle class people to all in the United States. If this did not pull through Obamacare would have left thousands of people without insurance and helpless. Many who are on Obamacare make less than 48K a year and need assistance from the government. If this were to happen a large number of healthy people would withdraw from health insurances causing prices to go up and then no one would be able to afford health insurance! The Affordable Care Act gives states the option to set up their own exchanges or rely on the government. With the passing of this act people suffering from serious illness will be able to care and have access to treatment as well as others who are susceptible to illness. Some conclusions that can be drawn from this article are that by the passing of this act thousands of citizens are still able to have health insurance and do not have to pay with an arm and a leg. Yes this argument is logical because it would be irrational to take away a program that has aided so many Americans in getting the health care they need. This relates because if this act was to fail our health insurance prices would go up and going to get a simple checkup would cost a fortune! I think it is great that the congress passed this act because I would want everyone to be able to have the privilege to seek out help if they were ill. No there is no bias, it is objective to all citizens in the united states.!

Despite Obamacare, gap health insurance market explodes

Despite Obamacare, gap health insurance market explodes | Healthcare and Technology news |

Despite the promise of coverage through the U.S. Affordable Care Act (ACA), the number of people applying for non-compliant, short-term health insurance policies was up more than 100 percent in 2014, according to new data available from companies who broker these policies.

This type of health insurance is exactly the kind that the ACA, known commonly as Obamacare, was supposed to upgrade. Short-term plans provide low-cost coverage for major medical events like hospital stays, with high deductibles and out-of-pocket costs, and are subject to denial if applicants have pre-existing conditions. They do not offer the protections of Obamacare for preventive care or maternity coverage, for example.

The government does not count these gap plans as qualifying health insurance, so people who have them are subject to penalties for being uninsured.

Sign-ups at eHealth Inc to the short-term plans it offers through its website were up to 140,000 in 2014 from 60,000 in 2013, an increase of 134 percent, according to the company.

At another short-term carrier, Agile Health Insurance, a subsidiary of Health Insurance Innovations Inc, new policies were up 100 percent last year over the previous year, and are up again so far in 2015, according to Scott Lingle, the company's senior vice president of business development.

Accounting for much of the jump are individuals who somehow missed the open enrollment period for an Obamacare plan. More than 11.7 million consumers signed up for Obamacare coverage through Feb. 22, according to the government.

People missed out mostly because of poor communication between consumers, the government and insurance companies, says Nate Purpura, eHealth's director of PR and Content. Those who missed the opportunity to sign up and did not have a qualifying event now have to wait until the next open enrollment period to try again, so they need an insurance plan to bridge the gap.

Both eHealth and Agile are also seeing new signups from retirees who are looking for a low-cost plan to tide them over until Medicare kicks in at 65. At eHealth, the 55 to 64 age group is now 9 percent of the market.

"If you shop for a 50-year-old on, it is very expensive," says Agile's Lingle. "There are people who have looked at the prices and it makes more sense to buy short term."

The largest constituency is young, healthy people seeking low-cost catastrophic coverage. Those aged 18 to 34 account for 57 percent of eHealth's buyers. A typical policy could cost around $100 a month, depending on the state of residency and the features of the plan.

These customers include 19-year-old college student Kelly Thomas-Cutshaw, who had no insurance through family and her school did not offer group coverage. Thomas-Cutshaw did not qualify for a subsidy under the ACA because she did not have enough income, yet she could not get Medicaid in Oklahoma, where she goes to school, because she made too much and was not a permanent resident there.

Over the winter, Thomas-Cutshaw became ill, and now has a medical bill she says will take her four years to pay off. She decided she needed some plan in place in case she fell ill again.

When her short-term plan runs out in the fall, she is prepared to sign up for an ACA-compliant major medical plan.

"I can mostly afford to live, so that's nice," Thomas-Cutshaw said, thanks to a summer job she just landed. "It been a ridiculous and frustrating experience. I don't wish this on other people."

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ACA's Mandate To Buy Coverage May Be GOP-Friendly

ACA's Mandate To Buy Coverage May Be GOP-Friendly | Healthcare and Technology news |

Whether it’s a penalty to pick a drug plan under Medicare or the new Republican proposal to replace the Affordable Care Act or the President’s health law alone, penalties abound for being uninsured.

A new analysis by the Urban Institute said “individual responsibility” requirements akin to the controversial individual mandate included in the Affordable Care Act requiring individuals to buy coverage or face a tax penalty also exist in other health reform proposals and existing health insurance programs.

Some, like the Medicare Part D drug coverage for seniors and Medicare Part B’s physician services for the elderly, have been in place for years. Another, a new Republican proposal to replace the ACA, also has its penalties.

The so-called “Patient Choice, Affordability, Responsibility, and Empowerment Act” or PCARE, proposed by Republican Rep. Fred Upton of Michigan and GOP Sens. Orrin Hatch of Utah and Richard Burr of North Carolina would “impose strong penalties on the uninsured,” Urban Institute health policy researchers Linda Blumberg and John Holahan wrote in their analysis out this week called, “the New Bipartisan Consensus for an Individual Mandate.”

“Specifically, if individuals fail to maintain continuous coverage, they can be medically underwritten or effectively denied insurance in the nongroup market,” the Urban Institute’s authors wrote of the Hatch-Burr-Upton legislation. “Medicare Parts B and D also have provisions that penalize individuals for failing to promptly enroll in coverage for the same reason, yet this approach to an individual mandate has not been controversial.”

All of the proposals share the common thread that health insurance, particularly coverage that involves the private insurance market, need an individual responsibility component to ensure healthy people are in the insurance risk pool. Without healthy people buying coverage and paying premiums, claims submitted largely by sick policyholders would lead to soaring health care costs.

The individual responsibility provision has long been the stance of health care interests like the American Medical Association and the health insurance lobby, America’s Health Insurance Plans, which represents Aetna (AET), Cigna (CI), Humana (HUM), UnitedHealth Group (UNH) and most Blue Cross and Blue Shield plans.

“If you want to keep a private market-centered approach and prevent discrimination in insurance against those with health problems, you have to have a mechanism that brings in and holds in the healthy,” Blumberg, seniors fellow at the Urban Institute’s health policy center told Forbes in an interview. “You have to have an individual mandate to hold the healthy into the insurance risk pools.”

The GOP’s Obamacare replacement requires individuals to have insurance “continuously for 18 months to be guaranteed access to a private nongroup insurance policy,” the Institute said in a statement accompanying their analysis. Meanwhile, the ACA imposes tax penalties for those individuals who go without insurance for more than three months in any given year. And Medicare Parts B and D have penalties that are much steeper than the ACA’s for those who delay enrolling after they become eligible.

“Under both programs, penalties are assessed on those who enroll, disenroll and then enroll again,” the institute fellows wrote.

No comment yet.!

Shared Responsibility in the Affordable Care Act

Shared Responsibility in the Affordable Care Act | Healthcare and Technology news |

Recently we wrote that it was well past time to end the employer mandate in the Affordable Care Act.  In light of some commentary, we thought it best to revisit this issue in more detail.  It seems that most of the support for the employer mandate comes from a misguided understanding of why employers are currently the primary source of private health insurance.  It is explicitly not because of a sense of “responsibility” to the employee, at least not any more responsibility than they feel when they pay employee wages for their work.

Here is a basic summary of how labor markets work, based on decades of very widely accepted academic research and practical experience. Employees receive compensation from their employers in return for their work product.  In other words, employers aren’t running charities for their workers, but neither are workers volunteering their time at firms.  Each expects something from the other. Some employee compensation comes in the form of cash wages and some in the form of fringe benefits such as health insurance, pensions, free coffee, parking, etc.

Either explicitly or implicitly, employers and employees negotiate these compensation packages with employers attempting to craft the least expensive package that the employee will accept.  Firms know they can offer employees tax free income in the form of health insurance and they exploit this feature of the tax code to the benefit of both employees and employers.  And for a variety of reasons, prior to the exchanges, it was often much easier for employers to purchase insurance than it was for employees to buy it on their own.  As a result, many Americans get insurance from their employer.  As an added “benefit” of this system, the whole country likely spends more on health insurance than we otherwise would and the federal government provides more tax benefits to the rich than to the poor.

It should be clear from this point that employers are not “giving” their employees health insurance.  We know this because when health insurance gets more expensive, wages don’t grow as quickly.  This is because employers are only interested in the cost of the total compensation package, and if health costs go up, wages must go down.

Failing to understand these basic economic points leads to poor arguments and harmful policies.  For example, in a recent Viewpoint in the Journal of the American Medical Association, John McDonough and Eli Adashi make an impassioned plea in favor of keeping the Section 1513 of the ACA also known as the “Shared Responsibility for Employers.”

Congress’ decision to call the requirement of employers to provide health insurance or pay a fine as a “shared responsibility of employers” is a master stroke of propaganda to which we must tip our hats.  However, we must see through this cute turn of phrase and realize that this section of the ACA simply enshrines some of the worst aspects of our current health insurance system and actively works against many of the actual goals of the ACA.  Unfortunately, McDonough and Adashi have their blinders on.  They state, “[t]he core value undergirding the shared responsibility principle is the realization that all of the major stakeholders of the health care system must contribute something if comprehensive health care reform is to be accomplished. Stated differently, making the ACA work requires a measure of  responsibility from consumers, hospitals, physicians, insurance companies, drug makers, medical device makers, home health agencies, labor, and—because of section 1513—large employers.”  This argument amounts to a bit of a tautology.  Large employers are a stakeholder in the health care system because we mandate them to be a part of it [under section 1513] and because we mandate that they offer insurance they are a stakeholder in the health care system.  McDonough and Adashi never ask the more fundamental question:  Why should employers even be part of the health care system to begin with?  If we are trying to implement health reform, shouldn’t we be looking to end those aspects of the system the create large distortions?

They then go all in by stating that the shared responsibility is a “public good especially for employers who might otherwise be inclined to shift the cost of employer sponsored health insurance onto the federal government and thereby the taxpayers.”  Much like calling the employer mandate a “shared responsibility,” saying that this is also a public good is at best a misapplication of the term. In economics we define a public good as having two characteristics:  you cannot stop another person from using it and its value doesn’t decrease when another person does use it.  Clean air and national defense are quintessential public goods.  But health insurance?  (This is hardly the first time that JAMA has published egregiously incorrect economic arguments.  We note in passing that the American Economic Review has the good sense not to publish medical studies.)

Then there is this question of “shifting the cost” of ESI onto the government.  This notion ignores that the burden of ESI already falls on the government because these benefits are exempt from incomes taxes. According to the White House Office of Management and Budget, in 2012 this cost the federal government approximately $170 billion.  Given the progressive nature of the United States Income Tax Code, this tax break is exceptionally regressive with an estimated five sixths of the benefits of the exemption flowing to the top half of the income distribution.  If employers stop offering health insurance, the competitive market for labor will force them to increase wages.  Because health insurance costs are roughly independent of wages, the resulting wage increase will be larger, in percentage terms, for lower income workers.  At the same time, federal tax receipts will increase and, given the progressive nature of the tax code, more of this money will come from richer Americans than from poorer Americans.  And if Congress could ever get its act together on tax reform, this could be part of a grand bargain resulting in lower overall marginal income tax rates.  This is what happens when you eliminate massive inefficiencies – everyone wins.  (Well, the bloated health sector would lose, as individuals might purchase less generous health insurance.  But isn’t the point of ongoing health policy to relieve us of this bloat?)

Firms that stop offering ESI could shift costs to the federal government to the extent that lower income individuals would now qualify for subsidies on the ACA exchanges.  We find it perplexing that ending the horizontal inequity of the ACA (i.e. the individuals with similar assets, income, and family structure face meaningfully different tax liability based on whether they get insurance from an employer vs. the exchange) would be seen as a negative.  Certainly this aspect of the ACA should be seen as a bug and not a feature.

We should also note that removing the employer mandate is not the same as ending employer provided health insurance. As noted health economist Mark Pauly has said many times, employees may value the services of their employers as a knowledge broker for insurance. In addition, firms with a high percentage of relatively well compensated employees may find it is economically advantageous to give up the subsidies on the exchange in order to retain their tax free insurance (though this seems to be more of an argument in favor of ending the tax exemption).  All we are asking for by ending the mandate is allowing the exchanges to compete on a more even footing with ESI.  Even if we do not eliminate the perversions of the current tax code, ending the mandate would benefit many employees and create a thicker and healthier market for the exchanges which should improve both the options and pricing

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The Affordable Care Act: Where We Go From Here

The Affordable Care Act: Where We Go From Here | Healthcare and Technology news |

One year after we entered a new era in healthcare consumerism with the rollout of the Affordable Care Act (ACA), I want to look ahead at the critical issues and challenges the program faces in 2015 that will have a significant impact on its effectiveness and future course.

The spotlight is on the pending Supreme Court case, King v. Burwell, which will likely decide the future of a key feature of the ACA: the subsidies people receive to make their health insurance premiums more affordable. Yet a host of other issues are also on the agenda, ranging from the medical devices tax to the so-called Cadillac tax, the individual and employer mandates, and the consumer experience, to name a few.

While it’s not clear when each of these issues will be decided, what’s certain is that interest groups with entrenched positions will try to influence the outcomes. Today, it seems that everyone is a healthcare expert. Debate will be heated. The media will spin stories in many directions. But hopefully we can come together as a nation and find thoughtful, bipartisan solutions that help us reach the common goal of providing affordable, quality healthcare to all Americans.

We’re already on that road. In its first year, ACA enrolled about 6.7 million people through newly created marketplaces, or exchanges. Of that number an estimated 5 million previously had insurance in the individual market, for a net gain of 1.7 million people who were previously medically uninsured. An additional 8.7 million people received insurance as part of the ACA’s Medicaid expansion; 7.5 million people were in the 27 states and the District of Columbia that signed on to the Medicaid program (23 states did not).

Still, an estimated 29 million people remain uninsured. The reforms and revisions to ACA now under consideration will affect progress in reducing that number, with the most contentious issue being the subsidies. Subsidies played a significant role in encouraging more people to sign up in 2014: some 85 percent of new enrollees qualified for subsidies.

The King v. Burwell case narrowly focuses on the subsidies provided to enrollees in the 36 states that declined to run their own exchanges, which prompted the Federal government to step in and run them. The challengers reason that these subsidies contravene the ACA, which specifically says that subsidies should go to people who bought coverage “through an Exchange established by the State.”

I’m not a lawyer, but strictly speaking the challengers apparently have at least a definitional claim. Practically speaking, however, an exchange is an exchange, whether State or Federal authorities run it. The question is whether the court will be charitable in its interpretation of the challenger’s argument.

Regardless of what the judges decide, we should also rethink the structure of the marketplace and how subsidies are allocated for those who are not enrolled in the Medicaid program. Because the Exchanges are too small a funnel to push through the remaining 29 million uninsured, I suggest we let individuals follow their subsidies, and at the same time we unleash the power, innovation, and ingenuity of the marketplace to provide a wider variety of insurance plans.

This way, individuals can choose the plan they want from an assortment of approved and regulated insurance products – much like they do with Medicare Advantage programs – and apply their subsidies as they wish. The result will be increased access and coverage, the core objectives of the ACA.

There’s another issue concerning subsidies that must be addressed: flexibility for the states. Historically, the States have regulated insurance, not the Federal government. While it looks like the States want to block the subsidies with the Supreme Court case – and to scuttle the ACA in the process – I believe what the States really want is more flexibility to oversee parts of a program that has traditionally been their domain.

Flexibility will allow the States to devise new models that reflect not only the preferences of the party in control of the State government, but also the Administration’s overall intent with the ACA. Many States are moving in this direction: Arkansas, Iowa, Michigan, and Pennsylvania have already secured approval for their state-specific approaches, while Tennessee, New Hampshire, and Indiana have submitted waiver proposals. Meanwhile, discussions are underway in Montana, Wyoming, and Utah between the governors and the State legislatures to find a new way. The remaining States will be closely watching the outcomes of these processes to determine their own course of action.

In addition to these issues, expect the following to play a critical role in determining the effectiveness of the ACA as the program matures:

Employer Mandate/Workweek Eligibility

One of the most contentious issues under discussion is the employer mandate, which requires all employers with 50 or more full-time employees to provide health insurance, or pay a $2,000 per worker penalty. Critics say this impedes business growth, while supporters argue that it’s necessary to expand coverage. If the employer mandate is maintained, a secondary sticking point is the definition of a full-time employee: a proposal before Congress would raise the benchmark for full-time work from 30 hours per week, as currently stipulated in the ACA, to the more traditional 40 hours per week. As a result of these changes, employers would be able to offer health coverage to fewer workers.

Individual Mandate

Like the employer mandate, the individual mandate is a cornerstone of the ACA. It helps ensure that as many people as possible are covered and that healthy people don’t opt out of coverage. Yet the individual mandate, upheld by the Supreme Court, remains controversial for a simple reason: Americans don’t like being told what to do.


Medicaid expansion for low-income people was a key element of the ACA, along with higher payments to primary care physicians to encourage them to treat more Medicaid patients. However, those pay increases have now expired. Following the reimbursement rollback, the question is whether there will be adequate compensation available to attract and retain a sufficient number of primary care physicians to treat the growing ranks of Medicaid patients.

Medical Device Tax

The 2.3 percent excise tax on the sales of most medical devices sold in the U.S., like heart implants and artificial joints, is expected to raise $29 billion to help finance ACA programs over the next decade. But many in the medical devices industry argue that the tax stifles innovation and job creation and will raise health care costs.

Cadillac Tax

This 40 percent excise tax on high-cost employer health plans was aimed at raising revenue; pressuring plan sponsors – including employers and unions – to offer less expensive plans; and compelling patients to carefully select only necessary medical services. Employers, who must pay the Cadillac tax, consider it a burdensome, long-term tax increase.

Three “Rs” Stabilization Program: Risk Adjustment, Reinsurance, and Risk Corridors

This program was designed to help insulate insurers from a high level of uncertainty, unpredictability, and potential losses when setting premiums in the new marketplace. The goal was to keep premiums affordable, encourage insurers to participate in exchanges, and minimize premium fluctuations. Modifying these support mechanisms, which is expected, or perhaps eliminating them, would have a substantial impact on how insurers price premiums and the level of health plan participation at the exchanges.

The Consumer Experience

After surviving a catastrophic and disappointing launch, the State and Federal healthcare exchanges are now functioning with a fairly reasonable level of efficiency, allowing consumers to obtain information and sign up for plans. But as Americans become more engaged in the process, they will expect the same consumer-friendly and easy-to-navigate online experiences they’re used to at commercial websites, where they purchase products and services. This will require a level of investment and development that will be difficult for the Exchanges, but which is critical to creating a winning digital experience for healthcare consumers.

All of these issues will stoke heated debate as we try to find solutions to the many problems and challenges facing the Affordable Care Act. Hopefully, we won’t lose sight of the common goal along the way: achieving an affordable, high quality healthcare system for all Americans.

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More Evidence Obamacare is Good For White People | The Health Care Blog

More Evidence Obamacare is Good For White People | The Health Care Blog | Healthcare and Technology news |

The latest Gallup and Healthways poll doesn’t phrase it this way, but its findings that the Affordable Care Act “appears to be meeting its goal of reducing the percentage of Americans without health insurance” is more evidence Obamacare is good for white people.

In an interview with National Public Radio at the end of last year, President Obama was asked whether he and the Democrats had lost support among white voters. He denied it, comparing his share of the white vote favorably to that John Kerry in 2004 and pointing to the Affordable Care Act (ACA) as a program that benefited working-class white voters without many realizing it. I’d written much the same thing about Obamacare in a THCB blog post a couple of weeks before the 2012 presidential election. But as with other issues related to race, it’s a topic that the president has only reluctantly discussed, even when good policy is also good politics.

In response to NPR questions about race, Obama noted that some of the biggest beneficiaries of the ACA live in places like “Mitch McConnell’s state,” home to relatively few blacks or Hispanics. Coincidentally, a front page story in the print New York Times documented Kentucky’s experience with the law – which, the president wryly noted, Kentuckians do not call “Obamacare” – the same day the NPR interview aired.

And now Gallup, in a poll designed to mimic the national demographics on race, gender and ethnicity, has found that the national rate of uninsurance has dropped significantly. The regions with the largest decline in the rate of uninsurance were the Midwest and the South. The latter, of course, is the GOP’s stronghold region.

A large gain in the number of number of whites with health insurance was exactly what an Urban Institute analysis was predicting nearly three years ago. It suggested full implementation of the ACA would mean that 12.3 million more white people would gain health insurance.

“Based on the income levels involved, these newly insured will be working-class Americans more familiar with NASCAR than NPR, and, in rural areas, with grain elevators more than car elevators,” I wrote, drawing on several analyses. Fifty-three percent would be male. On the other hand, if Obamacare were repealed and replaced by the plan endorsed by the GOP’s Romney-Ryan ticket, I calculated nearly 25 million fewer whites would have health insurance.

So why is there a perception that minorities are the big Obamacare beneficiaries? While there are many more uninsured whites than blacks, a higher percentage of blacks and Hispanics are likely to be uninsured. On a proportional basis, then, the insurance coverage aspects of Obamacare have a larger effect on minority individuals. That, in turn, allows Obama opponents to play into the perceived victimization of whites.

The Public Religion Research Institute’s 2012 Race, Class and Culture Survey (not mentioned by Obama or NPR) found that 60 percent of non-college educated whites believe that blacks and other minorities get too good a deal from the government. A Fall, 2014 poll by the same group found that 58 percent of working-class whites believe that discrimination against whites has become as big a problem as discrimination against blacks and other minorities.

I closed my blog post in 2012 with a blunt assessment of the perception problem:

The numbers show that the [ACA] is a good deal for white folks, particularly those who are working class. But it’s also very good for many other Americans that too many of their fellow countrymen still view largely as “other” and less as “American.” The larger question is whether coloring in the facts about Obamacare will do anything to override white voter questions about the color of the man who made it possible.

As we now know, the Obama administration’s defense of all aspects of the ACA was be less than robust. Public support has slipped, according to the latest Kaiser Family Foundation poll, even as the law’s positive impact continues to grow. The new GOP majority in the Senate and swollen majority in the House will face little political blowback from the stepped-up attacks on the Obamacare bogeyman that can be expected in the weeks to come.

A newly released report by the Urban Institute updating its 2012 analysis of the racial and ethnic impact of the ACA emphasizes what Obama could have said. The ACA will narrow the uninsurance gap between whites and minorities such as Latinos and American Indians/Alaska Natives. However, since a “disproportionately large share of blacks” live in states that took advantage of the Supreme Court ruling permitting them to not expand Medicaid, the gap between black and white uninsurance rates remains.

If just five “non-expansion” states (Florida, Texas, Georgia, North Carolina and Indiana) were to expand their Medicaid program, the number of blacks with health insurance nationwide would jump by 30 percent, or 900,000 individuals. But those same five states expanding Medicaid would also cause the number of insured whites nationwide to increase by 25 percent, researchers say, or 3.3 million people. That’s more than three and a half times more whites than blacks gaining better access to care.

Although the report doesn’t mention it, three of those five states (Florida, Texas and Indiana) are home to politicians mentioned as potential 2016 GOP presidential candidates. (Florida’s GOP Sen. Marco Rubio might want to examine the breakdown among Hispanic beneficiaries of the ACA for Cuban-Americans.)

Those who oppose “give-away(s) to a selective group based on race,” as a white supremacist group Majority Whip Steve Scalise addressed in 2002 put it (he says he didn’t know their beliefs) will never be fans of the first black president. But when you color in the facts, they show today, as they did in 2012, that Obamacare is a clear win for working-class white people.

Unfortunately, unless those individuals listen to NPR or read health policy journals, most may never know it.

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Health Plan Enrollment Numbers Show Importance of Coming Supreme Court Case

Health Plan Enrollment Numbers Show Importance of Coming Supreme Court Case | Healthcare and Technology news |

A new report from the Obama administration highlights the very high stakes for a challenge to the Affordable Care Act before the Supreme Court. The subsidies that the court may eradicate are helping a large majority of customers pay for their health insurance.

The report is the first time that the Department of Health and Human Services has delivered some numbers on exactly who is signing up for health insurance for 2015, since the open enrollment period began in mid-November.

The data that was used isn’t perfect or complete — and many commentators rightly grumbled about its shortcomings — but the report is still a helpful snapshot of whom the new insurance markets are serving. It’s particularly detailed in looking at the people using the marketplaces in the 37 states that are letting the federal government manage their enrollment.

Over all, it found, customers who were using to pick insurance plans — some new customers, and some renewing customers — were overwhelmingly likely to qualify for federal subsidies to help them pay their premiums. On average, the report found that 87 percent of these customers were eligible for subsidies, with higher percentages in some states — up to a high of 95 percent in Mississippi.

Those numbers don’t include everyone in the marketplace; people who were enrolled in plans this year and simply automatically renewed them weren’t counted. But it’s reasonable to think that the proportion is representative. Last year’s number at the end of open enrollment was an average of 85 percent. A different report, also published Tuesday, said that a total of 6.5 million people in those states had selected plans or been automatically renewed into plans as of last week.

The plaintiffs in the Supreme Court case, called King v. Burwell, argue that the law does not allow the subsidies to help insurance customers in the states letting the federal government run individual insurance marketplaces. And if the court agrees, all those people would lose their subsidies, and many would be priced out of the market.

We’ve written before about the disruptions such a ruling would cause. But as more people sign up for health insurance — and more of them are relying on federal subsidies — the potential impact of the decision grows.

So far, outside of official briefs, administration officials have been quiet about any concerns about the case. Asked several times last week in a news conference about possible contingency planning, the H.H.S. secretary, Sylvia Mathews Burwell, insisted that her department was confident that the government would win in court and that it was focusing its efforts on signing up new insurance customers. But a department news release Tuesday highlighted the high rate of subsidy, suggesting that federal officials were aware of the case’s possible reach.

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Health Insurance Enrollment Strongest in Federal Marketplace

Health Insurance Enrollment Strongest in Federal Marketplace | Healthcare and Technology news |

The Obama administration on Tuesday reported a big increase in new customers signing up for health insurance in Florida, Texas and other states using the federal insurance marketplace.

But in states running their own insurance exchanges, the numbers were more modest.

All told, the administration said, in the first month of open enrollment for 2015 coverage, more than four million people signed up for the first time or re-enrolled through the federal and state insurance marketplaces. About 3.4 million of them were in the 37 states using, the website of the federal marketplace.

More than two million consumers signed up for the first time, the administration reported, and 1.8 million of them did so through the federal marketplace. States with large numbers of new customers in the federal exchange included Florida (330,000), Texas (205,000), North Carolina (110,000), Georgia (103,000) and Pennsylvania (95,000).

The report showed the importance of subsidies to people seeking coverage under the Affordable Care Act.

Officials said that 87 percent of those selecting health plans for next year in the federal exchange had qualified for subsidies that would reduce their premiums. That is larger than the proportion of people who qualified for financial assistance in the initial months of the first open enrollment period (80 percent from October to December 2013). But it is about the same as the proportion who eventually qualified for subsidies in the federal exchange: 86 percent through March 2014.

The subsidies are under attack in a Supreme Court case filed by critics of the health care law, who contend that it does not authorize such assistance in states using the federal exchange.

Larry Levitt, a senior vice president of the Kaiser Family Foundation, said, “It’s significant that the largest number of new enrollees this fall came from states like Florida and Texas, which were not the most enthusiastic supporters of the health care law.”

California, the most populous state, which led the nation with 1.4 million people insured through its state-run exchange in 2014, says it has added 144,000 new enrollees this fall, through Dec. 15.

New York, with the second-largest state-run exchange, signed up 370,500 people in the first open enrollment period and says it has enrolled nearly 83,100 new customers this fall, through Dec. 20. After snowstorms paralyzed much of western New York, the state extended the enrollment deadline to Dec. 20, for coverage starting on Jan. 1.

The demographic profile of people signing up for 2015 is similar to that of people who previously bought insurance on the exchanges. Twenty-four percent are age 18 to 34, a relatively healthy group sought by many insurers. Latinos account for 8 percent of people signing up for 2015 coverage in the federal exchange, compared with 7 percent this year.

“We see no signs that the administration has succeeded in getting significantly more young people and Hispanics,” said Caroline F. Pearson, who tracks the data as a vice president of Avalere Health, a research and consulting company.

The current enrollment period lasts three months, from Nov. 15 to Feb. 15. It is half as long as the initial open enrollment period, from October 2013 through March of this year.

The latest numbers include people who took action to renew their coverage for 2015 or changed plans, but generally do not include people who were automatically re-enrolled in their current health plans. The Obama administration repeatedly urged people to return to the marketplace, update information on their household income and shop for health plans that might offer better value. But several million people evidently failed to do so, and their coverage will be renewed in the same or similar health plans.

Mr. Levitt, from the Kaiser Family Foundation, said, “The administration appears to be well on the way to meeting its own enrollment target, but still short of projections by the Congressional Budget Office.”

Sylvia Mathews Burwell, the secretary of health and human services, has said she is aiming to have 9.1 million people insured in the federal and state exchanges next year, up from 6.7 million this year. The budget office had projected enrollment rising to 13 million in 2015 and 24 million in 2016.

Even though the federal government has awarded hundreds of millions of dollars to states to set up insurance exchanges, it has had difficulty enforcing standards for the reporting of enrollment data. The report on Tuesday was full of footnotes acknowledging gaps and inconsistencies in the data.

As a result, Ms. Pearson said, “it is very difficult to make apples-to-apples comparisons between states, between the federal and state exchanges, and between the open enrollment periods for 2014 and 2015.”

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Affordable Care Act’s Tax Effects Now Loom for Filers

Affordable Care Act’s Tax Effects Now Loom for Filers | Healthcare and Technology news |

If you decided to skip health insurance this year, consider this: Unless you can prove you have a valid excuse, you will be liable for a penalty during the coming tax season — and the time to start making your case is now.

That’s not all. People who bought subsidized insurance through one of the marketplaces may have new tax forms to complete, while paying the penalty itself may demand some serious number-crunching.

The Internal Revenue Service is gearing up to answer questions, but it warns that only half of the callers may get through — and those who succeed may have to wait a half-hour or more.

“There are quite a number of moving parts that taxpayers have not had to deal with,” said Kristin Esposito, technical tax manager for the American Institute of Certified Public Accountants.

The Obama administration’s Affordable Care Act — including its penalty provision — is in effect for the first time this year and will be reconciled through a person’s tax return.

For most taxpayers, this will simply mean checking a box on a tax return indicating they had insurance for the full year. But millions of others will have to grapple with new tax forms and calculations that may generate unexpected results.

For instance, most of the 6.7 million people who bought insurance through the exchanges received subsidies, which reduced their monthly premiums. But those subsidies were based on previous years’ income — so people whose incomes have changed will inevitably have to pay some of that money back, while others may receive fatter refunds.

Paying the penalty may also deliver some surprises. People who were uninsured for more than three consecutive months may owe something. (And since the penalty will double next year, now is the time to determine how much that might cost, before it is too late to buy a health policy through a federal or state-run marketplace for 2015.)

“This is a learning experience for everyone involved,” said Roberton Williams, a senior fellow at the Tax Policy Center, a joint venture of the Urban Institute and the Brookings Institution. “When you combine that with all of the problems with the exchanges, there will be a lot of confusion and people will be sorting it out. I am sure the I.R.S. will be inundated with calls.”

But be prepared to hit redial. John Koskinen, the Internal Revenue Service commissioner, admitted in a recent speech that because of budget constraints, the agency may be equipped to answer just over half of the phone calls it receives. Many will get a “courtesy disconnect.”

The tax filing season will also serve as yet another big test for the federal government, since it will require several government entities — the state and federal marketplaces and the I.R.S. among them — to share data and send out new tax forms with accurate information in a timely manner.

Here are some of the biggest ways the new law may affect taxpayers:

EXEMPTIONS Consumer advocates said they were concerned that some taxpayers might not realize that they needed to apply for certain exemptions, and, in some cases, substantiate their circumstances. (An estimated 23 million people will qualify for an exemption in 2016, while many others will be granted a pass because of a hardship, according to a federal analysis.)

Some exemptions must be applied for through the exchanges, while others can be claimed only on income tax returns and some can be granted through either channel. (The I.R.S. and have lists of where to apply for each). For instance, people who cannot find affordable coverage — costing 8 percent of household income or less — must claim that exemption on their tax returns.

But the most time-consuming exemptions require mailing a signed paper application to the exchanges: These are processed manually, which can take a couple of weeks. Those exemptions include several hardships, such as foreclosure, the death of a family member, unpaid medical bills and eviction, as well as religious reasons for not using insurance. “Do it now because it’s a cumbersome process,” advised Mark Steber, chief tax officer at Jackson Hewitt Tax Service.

Once an exemption is approved (and if it’s not, the applicant can appeal), a taxpayer is sent an “exemption certificate number,” which should be entered on the tax return. “We know in some cases those certificates have not come back yet,” said Cheryl Fish-Parcham, private insurance program director at Families USA, a consumer advocacy group.

TurboTax, the tax-preparation software brand, has a free exemption check tool that can determine if taxpayers qualify and help them apply.

PENALTIES Uninsured people who cannot qualify for an exemption will be required to pay a penalty, also known as the individual shared responsibility payment. Even people who went without insurance for more than three months may have to pay something.

The penalties will rise sharply over the next couple of years, so taxpayers contemplating paying the penalty instead of buying insurance for the coming year should run those calculations soon: Open enrollment on the health care exchanges runs from Nov. 15 to Feb. 15.

For the 2014 tax year, individuals pay whichever is more: $95 or 1 percent of the portion of their modified adjusted gross income that exceeds the federal income tax filing threshold: $10,150, for example, for those with single filing status. But payments are calculated on a monthly basis for each household member.

Those figures are about to double. A family of four earning $100,000 who skipped coverage in the last year would owe just shy of $800 in 2014, but it would need to pay nearly $1,650 in 2015, according to the Tax Policy Center’s calculator, which can determine how much a taxpayer might pay.

There is some question about how aggressive the I.R.S. will be in collecting the penalty in its first year. But in 2016, an estimated four million people will pay penalties, according to a federal analysis.

The agency will not be permitted to resort to its usual collection tactics, such as using levies — like wage garnishment — or liens. It cannot criminally prosecute those who do not comply, either.

But the I.R.S. can deduct the penalty from any refund due. And if a taxpayer isn’t owed a refund — and fails to pay the penalty — the amount will accrue interest and roll over into the following tax years. The I.R.S. could continue to deduct the growing amount from any refunds due for 10 years, which is how long the agency is allowed to collect payments.

RECONCILING People who bought subsidized insurance on the exchanges received what is actually an advance on a tax credit. Since the amount of help taxpayers received was based on 2012 income, it will need to be reconciled against what they actually earned in 2014 — particularly if they earned more or less and did not update their income data on the exchange.

Some people will be surprised that they must pay some of that money back, or at least have it deducted from what they would have received in a refund. Conversely, people who earned less money in 2014 — and who received subsidies that were too small — may receive money back. Changes in life circumstances — a divorce, marriage, a new child — can also affect those numbers.

“This is the part that can be very complex,” said Kathy Pickering, executive director of the Tax Institute at H&R Block. “People think of the tax credit as a discount on their premium. But realizing it can be something you repay a portion of is going to be a surprise.”

Taxpayers may be comforted that there are caps on the amount that must be paid back, though a family of four with a household income exceeding $94,200 would have to pay back the full amount if it received too much in premium subsidies.

But some taxpayers who are on the edge of losing premium subsidies may be able to reduce their incomes enough to qualify for the credits. For instance, people can contribute to a retirement account — like a 401(k), 403(b) or traditional I.R.A. (and I.R.A. contributions for 2014 can be made by April 15 for the 2014 tax year), tax experts said.

“This is the perfect time to look at their income,” Ms. Pickering added, “because they still have time to make a change.”!

Health Law Helped Adults. Now, What About Children?

Health Law Helped Adults. Now, What About Children? | Healthcare and Technology news |

With the Affordable Care Act seemingly off to a good start in its first year, increasing access to insurance coverage for adults, attention is likely to turn to an older program for children that will come to an end in 2015 if it is not reauthorized: the Children’s Health Insurance Program, or CHIP.

This program has made a huge difference in insurance coverage for children, so much so that they are not, and did not need to be, the primary beneficiaries of the A.C.A. But that does not mean that children are not a concern. A variety of factors about our national strategy for children’s health care, or our lack of one, leaves them particularly vulnerable to challenges in access and quality in the next few years.

Children have not always fared so well. From 1980 through 1984, the rates of uninsured children and non-elderly adults were almost identical. Since that time, they have diverged significantly, so that in 2012, about 15 percentage points separated the two.

This turn of events was achieved though expansions of public coverage, specifically Medicaid, in the 1984 Deficit Reduction Act, and the Children’s Health Insurance Program, in the 1997 Balanced Budget Act. In 2013, more than 41 percent of children were insured through a government program, making them more dependent on public coverage than any group except seniors.

When the Affordable Care Act was passed, Congress also reauthorized the CHIP program. As a recent Health Affairs review reports, this was done “out of an abundance of caution.” CHIP is now funded through fiscal year 2015. If it is allowed to expire after that, in some respects it might not be a calamity: Most of the children insured through CHIP would qualify for plans offered in the health insurance exchanges.

There are still many reasons to be concerned about the end of CHIP, though. CHIP plans have an actuarial value of greater than 90 percent, making them much more generous than A.C.A. silver benchmark plans, with an actuarial value of 70 percent, meaning the plan covers 70 percent of health care costs. The increased cost-sharing families might encounter by moving to private plans might leave even more children underinsured. Deductibles, co-pays, coinsurance and even premiums are usually much lower in CHIP plans than in exchange plans.

There’s also the “family glitch” to consider. The Affordable Care Act is written so that individuals who are offered adequate insurance through their jobs are not eligible for subsidies if they choose instead to buy plans from the exchanges. This is true even if the individual’s employer offers coverage only for the employee and not for the employee’s family. In that case, employees who want a family plan, or a plan for their child, must pay the full exchange price.

That could leave a significant number of children completely uninsured without the continuation of the CHIP program. Even those insured could face difficulties because of narrow networks that are part of many private exchange plans. There are fewer options for pediatric providers than adult ones, especially when it comes to specialty care, so if plans do not include children’s hospitals and networks, children can potentially be left without access to high-quality care.

Other problems exist for children beyond transitioning many of them from public to private coverage. The biggest of them lies in the way that the A.C.A. defines essential benefits. Although the A.C.A. recognizes that dental and vision care are important for children, and defines them as essential benefits even when it doesn’t do so for adults, regulations demand only that they be available as part of a plan, or as a stand-alone plan. People aren’t required to buy plans containing that coverage. Because of the increased cost for these benefits, it’s still possible that many kids won’t get them.

Another issue is in how essential benefits are put into practice in plans. The department of Health and Human Services decided not to define them as a national standard, letting states define benchmarks themselves.

This means a fairly large amount of variation as to what is required in each state. In a recent study published in Health Affairs, researchers went through states’ benchmark plans and identified differences. Only half of states explicitly covered the care of congenital defects. Even fewer explicitly covered hearing aids. About 15 explicitly covered cochlear implants, and only 10 explicitly covered cleft lip/palate repairs.

Further, some states explicitly deny coverage for certain pediatric services in benefits. Thirteen explicitly excluded services for children with learning disabilities, and 10 excluded speech therapy for developmental delays or speech issues. Some states even explicitly excluded services for intellectual disability or autism spectrum disorder.

All of these services are necessary for children with these issues to be given a chance at a normal, healthy life. And although annual and lifetime limits to coverage were banned by the law, individual limits can be placed on services covered in a year.

Part of the problem is that many assume that children are just “little adults.” This is far from the truth. Because children are growing, services aimed at fixing developmental delays and problems that might seem nonmedical to adults are essential in making sure that kids advance. Some treatments that are not curative are still needed in order to help children develop well and learn to live with disabilities. Failing to meet the social and behavioral needs of children can have lifelong effects.

There are a number of decisions to be made about children’s health in the next year. Without proper attention, we could lose many of the gains made in the last few decades with respect to children’s health insurance coverage. Without action, even those who are insured may not get the care they need. Children were not the primary beneficiaries of the Affordable Care Act, as they were already reasonably well insured, but that doesn’t mean they don’t still need our attention.

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Health Care Law Is Not One-Size-Fits-All, and Here’s Why

Health Care Law Is Not One-Size-Fits-All, and Here’s Why | Healthcare and Technology news |

One criticism of the Affordable Care Act is that it imposes a costly, one-size-fits-all standard, drastically increasing premiums by requiring everyone to buy health insurance that covers the same mandated benefits. This is not so.

It’s true that the health reform law imposes some requirements — “essential health benefits” — on what individual market and small business plans offer. But the statute left a lot of discretion to federal regulators, who, in turn, passed much of it on to states, each of which interpreted the requirements differently. And, because most plans already covered these so-called essential health benefits, the additional cost of the regulation is small.

The mistaken notion that the Affordable Care Act imposes a nationally uniform set of required benefits comes, perhaps, from language in the statute itself. It lists 10 broad areas of essential health benefits plans must cover, including hospital, outpatient and emergency services, along with related laboratory services; maternity, newborn and pediatric care; prescription drugs; rehabilitative and habilitative services and devices; mental health and substance abuse treatment; and wellness and chronic disease management.

Though that’s a fairly comprehensive list, including areas of care one would typically expect of a health insurance plan, it’s not specific. What does it mean, for instance, to cover “prescription drugs”? Must all drugs be covered? If not, which ones?

How regulators addressed these questions is what gave rise to state variation.

The law delegates authority to the secretary of Health and Human Services to flesh out which benefits plans must cover. As my colleague Nicholas Bagley wrote with his co-author, Helen Levy, this presented the secretary with a dilemma. Defining essential health benefits narrowly would lead to lower-cost plans but would also leave more care uncovered, rendering that care unaffordable for some patients. A broader definition would increase premiums, potentially making health insurance too costly for some people the health law was designed to help.

The secretary resolved this by leaning on the benefits standards already established in each state as of 2011. To fill in coverage requirements details, the secretary permitted each state to select an existing plan within its borders, from a number of options, to serve as a benefits “benchmark.” Whatever was covered in the benchmark plan would set a benefits floor. Health plans could cover additional benefits, but not fewer.

According to the Leonard Davis Institute of Health Economics at the University of Pennsylvania, which analyzed information from the Centers for Medicare & Medicaid Services, 45 states and the District of Columbia ended up with a small-group plan as their benchmark, two chose a state employee plan, and three chose the largest H.M.O. For the most part, the selected benchmark plans provided coverage in the 10 areas of essential health benefits required by the federal law, but to different degrees. And where they did not, each state was permitted to fill in with its own, additional standards.

Independent reports from The Commonwealth Fund and the Leonard Davis Institute give examples of the considerable state-to-state variation in required benefits offered to individuals and by small employers, those with 100 or fewer workers.

For example, the Leonard Davis Institute found that five states do not require coverage of chiropractic services, and half of those that do permit a range of limits on number of visits per year; only five states require acupuncture coverage; only 19 states require infertility treatment coverage; plans in 26 states must cover autism spectrum disorder; 31 must do so for temporomandibular joint (T.M.J.) disorders, which can cause jaw joint pain and dysfunction; 23 states require bariatric surgery coverage; and 12 require coverage for nutrition counseling and three for weight loss programs.

States also vary in how much coverage is required for certain services. For example, home health care requirements range from a low of 30 visits in Oklahoma to a high of 180 in Montana. Plans in Mississippi and Wyoming can limit outpatient rehabilitation to 20 visits per year, and Arizona and Nevada plans can limit them to 60.

These new requirements didn’t add a great deal of cost. Nearly all small-group plans already offered the benefits in the benchmark plan, as did most individual-market plans.

Analyses by the Congressional Budget Office and the Department of Health and Human Services both showed that benefits required by the health care law have almost no effect on premiums for small-group plans. For individual-market plans, the C.B.O. and several actuarial firms suggested that required benefits increase premiums by as little as about 3 percent, though some estimates are as high as 9 percent.

Critics have some fair points. The Affordable Care Act imposes a number of requirements on new plans, like limits on out-of-pocket costs, that do add substantially to premiums. But those requirements do not affect what benefits are covered.

Essential health benefits regulations also play a cost-limiting role. Though the federal government pays premium subsidies to low-income enrollees in exchange plans, any additional subsidy cost resulting from standards states impose beyond those in selected benchmark plans must be borne by states. This forces the states to think carefully about new benefits mandates, since they can’t pass their subsidy costs on to the federal government.

The secretary of Health and Human Services must revisit the essential health benefits periodically. Another debate about what they are and how much discretion should be left to states is not far off.

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