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The Brave New World (of Health Insurance Exchanges)

New York Times reporter Abby Goodnough’s piece last week about the health insurance exchange in Massachusetts is instructive—especially since other states are trying to set up their own versions of these shopping bazaars where the uninsured can buy coverage if the health reform law eventually takes effect. For the last three years we have been suggesting there’s an untold story in the Bay State about how the law is working, so we were glad to see Goodnough’s reporting and offer a tip of the hat.

Goodnough gets into the subject with a success story: the tale of Peter Kim, who lost his employer-sponsored health insurance in 2005 when he opted for a career as an independent consultant. He found that shopping for insurance in the open market was a complicated affair, and that most plans were too expensive. He eventually chose coverage for catastrophic illness.

Then he discovered his state’s health insurance exchange, called the Connector. After just an hour of research, he found a plan with a monthly premium of only $1,086, a better deal than the coverage he previously had. And ideally, that’s how exchanges should work, Goodnough said.

The trouble, she reports, is that so far the Connector has not drawn enough full-paying customers like Peter Kim.

As Goodnough notes, the exchanges have drawn little journalistic scrutiny so far, despite their key place in health reform. (And, we note, despite the fact that they grew out of initiatives backed by former Massachusetts governor and current presidential candidate Mitt Romney.)

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Ozombiecare

President Obama’s push for near-universal health insurance coverage may be harder to kill than most zombies.

If the Supreme Court decides to take a metaphorical stake to Obama’s health-care overhaul law and tosses the individual mandate out on the front steps of the court, there could still be life left in that battered and bruised corpse.

Bloomberg Government senior health policy analyst Peter Gosselin took a close look at various alternatives to the individual mandate, should the court rule against it. Gosselin’s study, “A Plan to Replace the Individual Mandate If the High Court Strikes It Down,” finds that a voluntary, auto-enrollment process — similar to that used to enroll employees in corporate 401(k) retirement plans –could be an effective substitute.

Gosselin found that “even if auto-enrollment performs at a lower level of its effectiveness in retirement savings, it could offset much or all of the non-group enrollment loss of six million people expected if the mandate is overturned.”

As important as the sheer numbers of people, the study found that auto-enrollment “could largely restore the mix of young and old, healthy and unhealthy people that the mandate was intended to ensure and that’s needed to make an insurance system work well.”

Depending on how the high court rules, we may need to rename the much fought-over law to Ozombie Care.

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Safe Skyping: The Evolving Doctor-Patient Relationship


Skype and videoconferencing have surpassed the tipping point of consumer adoption. Grandparents Skype with grandchildren living far, far away. Soldiers converse daily with families from Afghanistan and Iraq war theatres. Workers streamline telecommuting by videoconferencing with colleagues in geographically distributed offices.

In the era of DIY’ing all aspects of life, more health citizens are taking to DIY’ing health — and, increasingly, looking beyond physical health for convenient access to mental and behavioral health services.

The Online Couch: Mental Health Care on the Web is my latest paper for the California HealthCare Foundation. Among a range of emerging tech-enabled mental health services is videoconferencing, for which there is a growing roster of choices for platforms that market a variety of features beyond pure communications.

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The SCOTUS Pregame Show

This post is intended for those who do not follow the Court’s work closely, but are tuning in now largely because of the ACA decision. (For avid Court watchers, this stuff is terribly obvious, so I apologize.) My goal is just to briefly explain what work is left for the Court this Term, and how it might affect the timing of when HHS v.Florida (and Florida v. HHS and NFIB v. Sebelius) are handed down.

First, the numbers. Setting aside the ACA cases, the Court essentially has twelve other decisions to hand down. (I say essentially, because Miller v. Alabama and Jackson v. Hobbsare separate cases, though they raise the same basic Eighth Amendment question. Thus, they are sure to be decided together, whether in two opinions or one, and probably with the same majority opinion author.) Those are, in the order of argument:

1.  First American Financial Corp. v. Edwards (argued November 28)
2.  Williams v. Illinois (argued December 6)
3.  Knox v. SEIU (argued January 10)
4.  FCC v. Fox Television Stations (argued January 10)
5. United States v. Alvarez (argued February 22)
6.  Southern Union Co. v. United States (argued March 19)
7.  Miller v. Alabama and Jackson v. Hobbs (argued March 20)
8.  Christopher v. SmithKine Beecham Corp. (argued April 16)
9.  Dorsey v. United States (curvelined with Hill v. United States) (argued April 17)
10.  Salazar v. Ramah Navajo Chapter (argued April 18)
11. Match-E-Be-Nash-She-Wish Band v. Patchak (curvelined with Salazar v. Patchak) (argued April 24)
12. Arizona v. United States (argued April 25)

The Court will hand down one or more opinions–almost certainly more than one–this coming Monday, June 18. The Court will then announce–probably on Monday, probably before noon–whether it will hand down any more opinions later next week. Of course, it will not announce which opinions, just whether it will hand any more down.

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Romney’s Response to ObamaCare

Mitt Romney’s entire career reflects a businesslike approach. On the one hand he has been willing to act boldly to solve problems. On the other hand he has been willing to keep what works and discard what doesn’t. The latest Romney pronouncements on health policy are consistent with that history.

As President Obama has said on many occasions, ObamaCare is based on a health reform Governor Romney spearheaded in Massachusetts. But blindly copying a health reform — while ignoring what’s really worth copying and what’s not — is hardly sensible presidential leadership.

Here is what is good about the Massachusetts health reform: (1) Governor Romney brought both parties together to achieve genuine bipartisan reform (something Barack Obama failed at miserably at the national level); (2) he cut the insurance rate in half by giving substantial tax relief to people who must purchase their own insurance, and (3) he did all this without raising taxes.

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My Initial Reaction to the Supreme Court Decision

Soon the healthcare blogosphere will be filled with reactions to the Supreme Court decision on the Affordable Care Act. Rather than see my own blog lost amidst hundreds of others, I thought it best to preempt the competition, so to speak, and offer my reactions now.

The 5-4 decision should not have surprised anyone. Many Americans will conclude (and not without reason) that most justices based their vote on whether they supported the ACA and not on whether its provisions violated the Constitution. I also have little doubt that as we move forward, many Americans will blame the court’s majority and their political allies if healthcare spending continues to rise unabated.

The justices offered thought provoking arguments on both sides of the case. While the media has focused on a couple of snarky comments written by Justice Scalia, I was particularly struck by an economic argument made by Justice Ginsberg. She notes that there is no meaningful economic difference between collecting a general tax from the entire population and then offering a rebate to individuals who purchase a specific good, and collecting a limited tax from individuals who do not purchase that good.

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Your Doctor Cares (No, Really)

Today would have been easier if I did not give a damn.  Easier if patients were clients.  Easier if medical advice was causal suggestion.  Easier if I believed that patients were solely responsible for their health.  Easier if suffering was not real.  Much easier, if I did not care.

However, despite the popular movement from “the doctor knows best” towards shared decision-making, I feel responsible for my patients.  What happens to them is very important to me.  I mean this not as an objective definition of a doctors  “job.”  I am talking about the personal love of a caregiver for his community.  Therefore, while I respect the freedom of each patient to control their own future, sometimes when they exercise that right it hurts.

First, there was my patient who received multi-agent complex chemotherapy and then vanished for three weeks.  Despite severe mouth sores, fevers, rapid weight loss, numbness of his feet and daily vomiting, he did not call.  He had attended chemo class, had received written instructions, and had at least six emergency phone numbers (and my email). Nonetheless, he did not reach out. On one occasion, one of my staff even spoke to him by phone and he did not mention the disaster.  He just suffered and deteriorated.  Now, I need to stop his treatment and can only try to salvage what remains of his frail health.

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How The Affordable Care Act Will Affect Doctors


Just over two years ago, President Barack Obama signed the Affordable Care Act (ACA), a law purported to increase access to health care and to “bend down” the health care cost curve. A great debate over the implications of that law, especially in the areas of coverage, affordability, and quality of care, has arisen. Furthermore, a series of political and legal challenges have generated uncertainty about the law’s prospects within the health industry and at the state level. Despite this, the Department of Health and Human Services (HHS) has already issued over 12,000 pages of regulations elaborating on the original 2,700-page law, leading to more uncertainty regarding how appointed and career federal officials will determine the exact shape of the law’s final requirements. All of this uncertainty raises real concerns about how the new law will impact the most crucial actors in any health care reform effort: doctors.

Doctors are demonstrably nervous about the new law and how it will affect their incomes, their access to technologies, and their professional autonomy. According to a survey by the Doctors Company, 60 percent of physicians are concerned that the new law will negatively impact patient care. Only 22 percent are optimistic about the law’s impact on patient care. Fifty-one percent feel that the law will negatively impact their relationships with patients. These statistics raise questions about how and whether doctors will participate in the new system.

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The Lethal Linkage of Medicaid Costs and Tuition

President Barack Obama has been busy recently traveling to college campuses across the country, talking about student loan debt and pitching his proposal to keep the interest rates on some federal loans at 3.4 percent for another year. His Republican rival, Mitt Romney, also supports a one-year extension.

While I agree with both that we need to make it easier for students to afford college, the president is not telling the whole story about how we got here and how we’re going to pay to fix it.

What the president needs to tell students is that his own health care policies are the principal reason that tuition and student debt are rising.

Medicaid mandates on states are soaking up dollars that would otherwise be spent on state universities and community colleges, forcing up tuition and resulting in more student loans and debt. Even worse, the federal government is trying to make a profit by overcharging students on their current loans and using part of the profit to pay for the new health care law.

According to the Congressional Budget Office, this takeover produced approximately $61 billion for the government — $8.7 billion of which went to pay for the new health care law.

The president’s new student loan proposal would, for one year, keep rates at 3.4 percent on new subsidized Stafford loans (those for which the federal government pays interest until students graduate), rather than increasing to 6.8 percent under current law. These loans account for about 40 percent of all federal student loans. According to the Congressional Research Service, the average student takes out approximately $3,600 in these new loans and will save about $7 a month in interest payments.

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Axial Makes a Deal with Mayo Clinic

Today Axial Exchange acquired mRemedy, a Mayo Clinic company. Axial specializes in creating hospital software that integrates information from different systems in order to help patients move from the hospital to the home.

With the acquisition of mRemedy, Axial adds a patient app called myTality, which helps patients plan for upcoming hospitalizations.

CEO Joanne Rohde founded Axial after working as the director of health IT strategy at open source software company Red Hat. Her company first started out with Axial Provider to help clinicians communicate patient information with each other. Axial later developed an app for patients that gives them relevant  information before an upcoming procedure.

With the Mayo deal, Axial acquires myTality’s software and customers and will add four Mayo doctors to its advisory board. For more information, read the article over at Health 2.0 News.

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