By David M. Walker

Oct. 1, 2013 is a focus of increasing anxiety in this country. That’s the date when enrollments begin for the federally run health insurance exchanges, created under the Affordable Care Act (ACA). No one really knows what to expect, but it could be far worse than advertised —and for a reason that has more to do with the federal deficit than health care.

What’s anticipated is unsettling enough. President Obama speaks of inevitable “glitches and bumps” in the implementation. Senate Finance Committee Chairman Max Baucus (D-Mont.) sees the possibility of “a huge train wreck” if the public isn’t adequately educated and prepared. Supporters of the ACA, especially Democrats in the Congress, are nervous about taking the blame if the exchanges don’t unfold as intended.

All these worries are legitimate. The American people, already burdened by a numbingly complex, inefficient and inequitable tax system, now wonder if an increasingly government-run health care system will follow suit. Many are concerned that some employers will dump their current health care plans and pay the relatively modest fine. There’s also worry that young people will opt out of the exchanges (preferring to pay the small penalty), leaving the exchanges with a disproportionately older and sicker pool. Then there’s the very real uncertainty surrounding the ACA’s ultimate cost — illustrated by the impact of Medicare alone, which the Office of the Chief Actuary of Medicare estimates could cost cost $10 trillion more than claimed.

Amid all these concerns and speculations, almost no attention is being paid to the opportunity that the ACA’s insurance exchanges could represent for state and local governments’ retiree health care programs. It’s time to think about it because the consequences could be far-reaching.

States in a deep hole

We already know that many state and local governments are in a financial hole that keeps getting deeper. A newly released report by the U.S. Government Accountability Office (GAO) makes clear that, absent significant reforms, the fiscal picture for most state and local governments will steadily worsen through 2060. A main cause, in addition to Medicaid, is the cost of health care for state and local government retirees. These largely unfunded obligations are similar to the pressures on the federal government to fulfill its unrealistic Medicare promises.

Continue reading “When Retiree Benefits and Obamacare Collide”

By Joanne Conroy, MD

I am old enough to remember when physicians did not advertise. It was considered a professional ethical issue. Hospital advertising consisted of institutional “We’re here” ads.  Anything aggressive by docs or hospitals was considered bad taste… but that was before health care became as competitive as any other type of business.

I have been barraged, as have many of you, by a wave of hospital advertisements as our health care marketplaces consolidate and organizations seek to brand and differentiate themselves. We are subjected to print, radio, and TV ads extolling services, expensive technology, and that fact that each institution cares more than its competitors.

Charlie Rohlfing blogged recently about the worst in hospital advertising techniques, and you will recognize them all. They usually include a Da Vinci Robot and orthopedic surgery that will “get you back in the game.” They claim to be “state-of-the-art,” “leading edge,” or “cutting edge,” with actors playing doctors and nurses in masks.

Continue reading “Can We Put the Hospital Marketing Genie Back in the Bottle?”

By J.D. KLEINKE

WASHINGTON — Oral contraceptives may be small, but they are proving to be tough pills for a vast number of Americans to swallow.

Last week, the Sunlight Foundation reported that the contraception provisions of President Obama’s health reform law garnered 147,000 comments from the public — more than on any other regulatory ruling, on any subject, in the history of the nation. Really.

The unprecedented flood of comments came from a wide range of organizations and individuals who support or oppose mandated contraception coverage as part of Obamacare.

Supporters, in general, want to extend coverage for this cornerstone of women’s health; oral contraceptives are used not just for birth control, but also for the treatment of pelvic pain, irregular periods, fibroid tumors, ovarian cysts, endometriosis, severe acne, mood disorders, and excessive menstrual bleeding that could lead to anemia. Opponents, in general, want to block this extension based on religious, moral or personal objections to women using pooled insurance resources to pay for pills that enable sex-for-fun — and that can be used, as it happens, for early termination of an unwanted pregnancy.

Continue reading “Pandora’s Pillbox”

By Nelson Lichtenstein

If it is done right, the Affordable Care Act (a.k.a. Obamacare) may well promise uninsured Americans a lot more than cheap, reliable medical care. It can also open the door to the democratic empowerment of millions of poor people, who are often alienated from much of the nation’s civic life, by strengthening the organizations that give them a voice.

This year more than 30 million uninsured Americans are to begin signing up for Obamacare, but the vast majority of those eligible for either the expanded Medicaid program, or for subsidized private health insurance through state health exchanges, have no idea how to enroll. Surveys and focus groups have found that up to three-quarters of Americans who might directly benefit from the program are skeptical that the law can provide high-quality insurance coverage at a price they can afford.

Continue reading “Obamacare’s Other Benefit”

By Robert Laszewski

As the Obama administration continues its top secret effort to build federal insurance exchanges in about 34 states while 16 states are doing it on their own, that continues to be the big question.

HHS is using IT consulting firm CGI for much of the work on the exchanges and the federal data hub. CGI has their plate full since they are not only working on the federal exchange but also doing work for the state exchanges in at least Colorado, Vermont, and Hawaii.

Earlier this month, the Senate Finance Committee held an oversight hearing. The Obama guy in charge of exchange development testified before them. I thought it was notable that it was the Democrats who expressed the greatest concern, and frustration, over senators not getting a clear idea for just where the administration is toward the goal of launching the new health insurance exchanges on October 1.

Continue reading “Six Months Out Health Plan Execs Say They Doubt Exchanges Will Be Ready”

By Robert Laszewski

So far California has received $910 million in federal grants to launch its new health insurance exchange under the Affordable Care Act (“Obamacare”).

The California exchange, “Covered California,” has so far awarded a $183 million contract to Accenture to build the website, enrollment, and eligibility system and another $174 million to operate the exchange for four years.

The state will also spend $250 million on a two-year marketing campaign. By comparison California Senator Barbara Boxer spent $28 million on her 2010 statewide reelection campaign while her challenger spent another $22 million.

The most recent installment of the $910 million in federal money was a $674 million grant. The exchange’s executive director noted that was less than the $706 million he had asked for. “The feds reduced the 2014 potential payment for outreach and enrollment by about $30 million,” he said. “But we think we have enough resources on hand to do the biggest outreach that I have ever seen.”

Continue reading “A $910 Million Price Tag For California Exchange: A Dark Omen of Things to Come”

By Ashish Jha, MD

In 2006, Governor Mitt Romney signed Chapter 58 of the Acts of 2006 entitled “An Act Providing Access to Affordable, Quality, Accountable Health Care.” It has been described by many names, including Massachusetts Healthcare Reform (MHR), Romneycare, or simply, as the template for the Affordable Care Act. The goal of the act was straightforward: to ensure near-universal access to health insurance for citizens of the Commonwealth of Massachusetts. The bill quickly led to insurance expansion: by 2010, 94.2% of adults under 65 had health insurance, an 8 percent increase over the 86.6% in 2006. By all accounts, the goals of insurance expansion were met.

But the bill has not been without controversy. There have been two main concerns: first, that the bill did too little to control rising healthcare costs. The cost crisis led to the 2012 bill that many refer to as “Mass Health Reform 2.0” – formally called Chapter 224 of the Acts of 2012. Its focus is to curtail healthcare spending, and while reasonable people have reasons for skepticism about the likelihood of success, that’s a topic for another day.

Continue reading “Did Massachusetts Health Care Reform Hurt Access To Care For the Previously Insured?”

By Michelle Snyder

Last year was a banner year for digital health, as the market saw significant growth in funding, bigger deals and new investors entering the space. So what’s in store for 2013? According to a survey of nearly 140 digital health entrepreneurs and over 50 health care information technology venture investors, conducted by my venture capital firm InterWest Partners, we are in for another exciting ride this year. In the survey, we asked which sectors will see the most love from investors in 2013; which companies (if any) will see a $1 billion valuation; where they are having trouble recruiting; and which digital health entrepreneur would win “Survivor: HCIT Island” The answers? Well, it all depends who you ask.

Continue reading “Investors Are from Mars. Entrepreneurs Are from Venus”

By MIKE MIESEN

America is only a few months away from Exchange Day—October 1, 2013—when the state and federal health exchanges open up for business. And when they do… well, I’d surprised if a whole lot happens at first; most people assume they open on January 1, 2014. But eventually there will be a flood of people streaming into the exchanges (virtually) to search for health insurance plans, including the Millennials.

Why? A variety of reasons. One is that people like being insured and prefer it to the uncertainty of being uninsured; those previously unable to purchase a policy they could afford now have subsidies to help them do so. Another is that people largely don’t have a choice—forego purchasing health insurance and get fined.

But the bottom line is this: whether compelled to do so by the safe feeling of being insured or the specter of a fine, Millennials are expected to be an enormous group of entrants into the exchanges: while we make up only 22% of the population, we account for 38% of the uninsured in America.

To compound our already-stratospheric opinion of ourselves, we know that the Millennials are a coveted market for health exchange insurers. Face it: you want us. Bad. That’s because we’re relatively healthy, loyal to brands we like that we see as having a positive impact (70% identify as being brand loyal), and we could actually be the first generation to recommend our health insurance plan to others.

So, culling from Millennial research, surveys, and conversations with fellow Millennials, here are a few morsels of unsolicited advice on how to win us over.

Continue reading “How to Win Friends and Influence Millennials: Health Exchanges Edition”

By Jeff Goldsmith

For the third year in a row, national health spending in 2011 grew less than 4 percent, according to the CMS Office of the Actuary.  However, the report said modest rebounds in pharmaceutical spending and physician visits pointed toward an acceleration of costs in 2012 and beyond.  CMS’s analysts make much of the cyclical character of health spending’s relationship to economic growth and also forecast a doubling of cost growth in 2014 to coincide with the implementation of health reform.

This non-economist respectfully disagrees and believes the pause could be more durable, even after 2014.   Something deeper and more troublesome than the recession is at work here.  As observed last year, the health spending curve actually bent downward a decade ago, four years before the economic crisis. Health cost growth has now spent three years at a pre-Medicare (indeed, a pre-Kennedy Administration) low.

More Than The Recession Is At Work

Hospital inpatient admissions have been flat for nine years, and down for the past two, despite compelling incentives for hospitals to admit more patients. Even hospital outpatient volumes flat-lined in 2010 and 2011, after, seemingly, decades of near double-digit growth.  Physician office visits peaked eight years ago, in 2005, and fell 10 percent from 2009 to 2011 before a modest rebound late in 2011 — all this despite the irresistible power of fee-for-service incentives to induce demand.

The modest rebound in pharmaceutical spending (2.9 percent growth) in 2011 appears to have been a blip.  IMS Health reports that US pharmaceutical sales actually shrank in 2012, for the first time in recorded history, and that generic drugs vaulted to the high 70s as a percent of prescriptions!

There is no question that the recession’s 7-million increase in the uninsured depressed cost growth.  But the main reason health cost growth has been slowing for ten years is the steadily growing number of Americans — insured or otherwise — that cannot afford to use the health system.  The cost of health care may have played an unscripted role in the 2008 economic collapse.  A 2011 analysis published in Health Affairs found that after accounting for increased health premium contributions, out-of-pocket spending growth and general inflation, families had a princely $95 more a month to spend on non-health items in 2009 than a decade earlier.  To maintain their living standards, families doubled their household debt in just five years (2003-2008), a debt load that proved unsustainable.  When consumers began defaulting on their mortgages, credit cards and car loans, the resultant chain reaction brought down our financial markets, and nearly resulted in a depression.

By sucking up consumers’ income since 2008, the rising cost of health benefits has weighed heavily upon the recovery.  According to the 2012 Milliman Cost Index, the cost of health coverage rose by 32.8 percent from 2008 to 2012, while family income did not grow at all in real terms.  The total cost (employer and employee contributions plus OOP spending) of a standard PPO policy for a US family of four was $20,700, almost 42 percent of the US household median income in 2012.

Continue reading “The Gold Plated Health Care System: What the New Numbers Tell Us about the State of the Economy”