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Tag: Dan Diamond

Hospitals Lost Jobs Last Month. Should We Be Surprised?

An old data series got new life, when the Brookings Institution issued a report that compared health care jobs growth versus all other industries.

It’s “a truly astonishing graph,” according to Derek Thompson at The Atlantic. “I knew health care had been the most important driver of national employment over the last few years, but I had never seen the case made so starkly.”

Thompson wasn’t alone in his surprise. (Hopefully, readers of The Health Care Blog would be less astonished.) But lost within the reaction—and even mostly overlooked within the industry—is that not all health care jobs are growing, or at least not growing at the same pace.

Take a look at the following chart. It resembles the Brookings data, with one major change: The hospital employment curve has been separated from all other health care jobs growth.

 

Notice how hospital employment essentially flatlined across 2009—a hard year for the sector, which was still insulated compared to the rest of the economy. But many organizations pared back on staff and sought to cut non-essential services to survive the Great Recession.

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What’s Changed Since the Obamacare Verdict

Ever since its controversial passage in 2010, the Affordable Care Act has been plastered with a range of polemic labels. Critics say Obamacare is job-killing; supporters herald it as life-saving.

Here’s another, perhaps unexpected label: personally profitable.

If you were among the true believers in the law a year ago today, there was easy money to be made. Nearly 80% of bettors on InTrade expected the law to be found unconstitutional; strategically spending about $25 in favor of the ACA could’ve netted you $800, based on how InTrade’s short-selling rules worked.

Much has changed, certainly, since Chief Justice John Roberts cast the deciding vote to uphold the law. (Beyond those bettors’ account balances, and the existence of InTrade itself, which mysteriously shut down in March.)

Here’s a look at how the Supreme Court’s decision on June 28, 2012, affected five hot-button issues related to the health law.

States’ decisions on Medicaid expansion

As of June 27, 2012: Several states with progressive governors and legislatures, like California, had moved to expand Medicaid ahead of the Supreme Court’s ruling. The Golden State’s leaders also had pledged to pursue universal coverage if the ACA was ruled unconstitutional.

But most states were waiting on the resolution of the constitutionality battle.

Since June 28, 2012: After the Court’s decision that the mandate was constitutional but that the Medicaid expansion was optional for states — which “took everyone by surprise,” said Matt Salo, executive director of the National Association of Medical Directors — governors were suddenly forced to decide whether the expansion made financial, and political, sense. Within a week, about ten states had signaled they’d expand Medicaid under the ACA.

However, many wary governors chose to wait for the November elections, and the knowledge of who would hold the White House, before announcing their plans; following President Obama’s reelection, a flurry of governors clarified their Medicaid stances throughout the winter and spring.

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Could Halbig et al v. Sebelius Sink Obamacare?

Innovare may be Latin for innovate, but the values at Innovare Health Advocates are traditional: An “Old School” commitment to delivering “Healthcare the Way it Ought to Be.”

The Missouri-based health practice is run by Dr. Charles Willey, a staunch tea party conservative who’s been mentored by former Sen. Jim Talent, one of his patients. “I’ve personally, for a long time, been interested in politics,” he told a radio show in 2010, noting that he’d been leading efforts “to get doctors excited about resisting Obamacare.”

But Willey’s doing more than just resisting the health law these days — he’s become an active player in Halbig et al v. Sebelius, a lawsuit that threatens a key element in the Affordable Care Act: Whether the tax subsidies slated to help many Americans purchase coverage through many insurance exchanges are even legal under the ACA’s language.

(Innovare Health is one of the small businesses that has joined the suit.)

And the stakes are higher than most people realize, according to Michael Greve, a law professor at George Mason University.

“If the statute means what it says, Obamacare’s machinery simply doesn’t apply in half the country,” Greve contends.

“This is for all the marbles.”

Law’s Language a Sticking Point

Conservative scholars say it’s obvious in the text of the Affordable Care Act, right as rain. (Italics added by columnist.)
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Wal-Mart Could Transform Care–But Does It Want To?

“Why is Wal-Mart speaking at a health care summit?” the company’s vice president for health and wellness, Marcus Osborne, rhetorically offered up at a conference back in January.

“Wal-Mart’s in retail, we’re not in health care.”

But as analysts, researchers, and other experts who spoke with me. took care to point out, Wal-Mart is in health care, and getting further entrenched by the year. In the past six months alone, Wal-Mart launched a major contracting initiative with half-a-dozen major hospitals, and dropped hints — since retracted — that the company is exploring new services like a health insurance exchange.

Notably, Osborne teased a broader health care strategy for Wal-Mart that would include “full primary care services over the next five to seven years,” in a Q&A at that January conference captured by the Orlando Business Journal.

Wal-Mart has since denied Osborne’s comments — the second time in about 18 months that the company has had to walk back stories about its planned primary care services — and Osborne subsequently stopped talking to the press. (Wal-Mart declined to comment, and Osborne did not respond to an interview request for this story.)
But Osborne’s remarks from that January conference, and his other archived speeches, are still readily accessible. And they paint a vivid picture of a company that’s not just a potential market-mover and disruptive innovator, but an organization that could do a lot to positively reform health care.

Background: Wal-Mart’s Growing Role in U.S. Health Care System

In many ways, this isn’t a new story. Back in 2007, Princeton University’s Uwe Reinhardt suggested to NPR that Wal-Mart could be “taking aim at the entire health care system” by expanding its new discount drug program.

“I think it’s a really fascinating way to come out of the corner and really slug the system,” Reinhardt said at the time. “At the moment, the body blows don’t hurt. But they add up. I’m watching this with great fascination, and expect more from them.”

And in subsequent years, Wal-Mart did grow its health care footprint, from launching retail clinics based within its stores to advocating for national health reform. Considering its history — as recently as 2005, Wal-Mart had little involvement in the health care market and was being pilloried for skimping on its own employees’ benefits — it’s been a significant turnaround for the firm, and has positioned Wal-Mart as one of the leading disruptive innovators in health care.Continue reading…

Obamacare’s Birth Control Mandate: The Most Controversial Legislation Ever?

The war over the Affordable Care Act may be over, but one battle shows no signs of waning.

The fight over Section 2713 of the Public Health Services Act under ACA’s Section 101 — better known as the health law’s regulation on preventive services — centers on contraception.

The benefit essentially calls for health plans to cover birth control and other services with no additional cost-sharing for enrollees.

But critics quickly seized on the administration’s initial proposal in 2011, which carved out an exception for “religious employers” — such as churches — but not for “religiously affiliated” employers — such as Catholic hospitals. As a result, HHS delayed implementation for religiously affiliated employers by a year but still required them to comply with the mandate.

In February, the White House released another accommodation for religiously affiliated employers. Yet rather than lay the issue to rest, the administration’s proposed amendments drew more than 400,000 comments — the most comments on any government regulation tracked by the Sunlight Foundation.

It’s just the latest salvo in an ongoing controversy. Opponents have filed more than 60 legal challenges against the benefit. Some have called it a “war on religion.”

While the sheer volume is astounding, there’s little mystery behind the root cause.

The contraception benefit touches on a half-dozen pressure points: Politics. Religion. Sex. Federal mandates. Federal entitlements.

“Our health care system is the dumping ground for all of our worst, unresolved arguments as a society,” J.D. Kleinke writes at The Health Care Blog. And the changes at the heart of Obamacare “spark every remaining culture war,” he adds.

And a mandate related to birth control is especially fraught.

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Think NCAA Athletes Shouldn’t be Paid? What the Kevin Ware Story Says About the Risks of College Sports


In many ways, it had been an exemplary few days for the NCAA and its signature basketball tournament—a weekend that put the madness back in March.

On Friday, Michigan and star guard Trey Burke completed an epic comeback over Kansas. On Saturday, Cinderella team Wichita State crashed the Final Four.

But for many people watching the Louisville-Duke game unfold, a disturbing injury to Louisville guard Kevin Ware illustrated a different sort of madness: the continued lack of compensation for the players who make the tournament so special.

“Pray for [Ware],” columnist Dave Zirin tweeted. “There is no safety-net for the injured NCAA athlete.”

Injury worst seen on TV

Ware’s broken leg—”about the most gruesome injury I’ve seen in a basketball game,” bemoaned analyst Seth Davis—came on a routine play, as he landed awkwardly after trying to block a shot by Duke’s Tyler Thornton.

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Five Things Obamacare Got Right-and What Experts Would Fix

It was one of the most notorious quotes that emerged from the battle over the Affordable Care Act.

We have to pass the bill so you can find out what is in it. – House Speaker Nancy Pelosi, March 9, 2010.

The line was taken out-of-context, as Pelosi’s office has continued to protest. But more than three years after her quote — and nearly three years after the ACA passed Congress — Pelosi’s accidental gaffe seems pretty apropos.

The law continues to delight supporters with what they see as positive surprises; for example, some backers say Obamacare deserves credit for the unexpected slowdown in national health spending. But critics warn that the law’s perverse effects on premiums are just beginning to be felt.

And there still are “vast parts of the bill you never hear about,” notes Timothy Jost, a law professor at Washington & Lee. “I wonder if they’re [even] being implemented.”

Jost and a half-dozen other health policy experts spoke with me, ahead of Obamacare’s third birthday on Saturday, to discuss how the law’s been implemented and what lawmakers could have done better.

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The Radical Rethinking of Primary Care Starts Now

In November 2008, the New England Journal of Medicine convened a small roundtable to discuss “Redesigning Primary Care.”

U.S. primary care is in crisis, the roundtable’s description reads. As a result … [the] ranks are thinning, with practicing physicians burning out and trainees shunning primary care fields.

Nearly five years out — and dozens of reforms and pilots later — the primary care system’s condition may still be acute. But policymakers, health care leaders and other innovators are more determined than ever: After decades where primary care’s problems were largely ignored, they’re not letting this crisis go to waste.

Ongoing Shortage Forcing Decisions

The NEJM roundtable summarized the primary care problem thusly: Too few primary care doctors are trying to care for too many patients, who have a rising number of chronic conditions, and receive relatively little compensation for their efforts.

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How Many States Are Really Opting In?

Same story, different week: A governor who opposed the Affordable Care Act changes course and announces plans to opt into the Medicaid expansion.

Supporters of the ACA rejoice, conservatives grumble, and a new number gets tacked on the board — 24 states opting in, at last count.

Yet there’s more to the story than governors’ speeches. In at least eight of those states, lawmakers are warning that they may not go along with expansion plans.

Those legislative logjams — and what governors need to do to circumvent them — vary state by state , but the fights are falling out along party lines.

In Missouri, two GOP-led House committees this week voted down Medicaid expansion plans, despite Democrat Gov. Jay Nixon’s pledge to opt into the measure last year. Republican lawmakers in Arkansas, Montana and Washington have similarly been skeptical of their Democratic governors’ expansion positions. Meanwhile, four GOP governors who have backed the expansion are having difficulty corralling members of their own party.

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Why HHS Created Partnership Exchanges and Why More States Are Choosing Them

New Hampshire: We’re in.

North Carolina: We’re not.

The two states on Tuesday were the latest to announce their intentions on the Affordable Care Act’s health insurance exchanges. States have until Feb. 15 to tell HHS whether they’ll retain even some control over the exchanges, or let the Obama administration run the exchanges for them.

And while New Hampshire made clear that it wants to partner with the federal government to launch an insurance exchange, North Carolina backed out of a previous plan to do exactly that.

By Friday, we’ll know where half a dozen other states stand, too.

Background on Partnership Model
The Affordable Care Act didn’t originally spell out the partnership model; under the law, states faced a binary choice of running their own insurance exchanges or punting the responsibility to the government.

But HHS officials realized they needed to tweak the ACA’s approach, as more than 30 states — increasingly led by Republicans, who took over 11 statehouses in the 2010 election — announced they planned to opt out of the exchanges altogether. This would leave HHS officials with “an awesome task in establishing and operating exchanges in [so many] different states and coordinating those operations with state Medicaid programs and insurance departments,” before open enrollment begins in October 2013, Paul Starr writes in The American Prospect.

As a result, the agency in 2011 introduced the partnership model in hopes of shifting some of the responsibility for running exchanges back to the states.

Under the hybrid approach, the federal government takes on setting up the exchange’s website and other back-end responsibilities, while states keep functions such as approving health plans and setting up consumer assistance programs. HHS also hopes that the partnership model will be a path for states that weren’t ready to run their own exchanges to take them over eventually.

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