Tag: David Blumenthal

Reflecting on Health Reform–Narrow Networks: Boon or Bane?

Some health plans sold through the Affordable Care Act’s (ACA) health insurance marketplaces use “narrow networks” of providers: that is, they limit the doctors and hospitals their customers can use.

Go to Doctor A or Hospital A and the plan will pay all or most of the bill. Go to Doctor B or Hospital B, and you may have to pay all or most of the bill yourself.

The narrow network strategy emerged long before the ACA, during the managed care era in the 1990s, and insurance companies and large, self-insured employers have used narrow networks ever since to control health care costs.

In fact, for the first time, the ACA creates new consumer protections requiring that insurers provide a minimum level of access to local providers. A number of states have exceeded these federal standards using their discretion under the new law.

Nevertheless, some consumer advocates and ACA critics still find narrow networks objectionable. Narrow networks mean that some newly insured people are no longer covered for visits to previous providers, or, if they didn’t have a doctor before, are limited in their new choices. Not infrequently, narrow networks exclude the most expensive doctors and hospitals in a community, including some specialists and academic health centers.

More expensive doctors and hospitals are not necessarily better, but for patients with a rare or complex health problem, such restrictions can be problematic.

Welcome to the world of competition in health care, because that is what narrow networks are about. Narrow networks are used by competing plans to control health care costs, and perhaps improve quality as well. In fact, if you don’t like narrow networks, you’re saying, in effect, that you don’t like competitive solutions—as least under current market conditions—to our health system’s problems.

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They’re Not Deadlines. They’re Opportunities …

Confusion about Affordable Care Act (ACA) deadlines is rampant. That’s because there are lots of them and they keep changing. The fact is that some of them matter a lot more than others.

In my view, the BIG deadline is:

MARCH 31, 2014: Under the ACA, all Americans must have health insurance, and this is the latest date you can acquire it if you wish to avoid paying a penalty on your 2014 income tax. Some individuals will be exempt from penalties, including, as of last week, people whose policies were canceled because their plans’ benefits did not meet new ACA standards of adequacy.

Another date that has drawn attention but, in my view, doesn’t matter as much:

JANUARY 1, 2014: This is not a deadline so much as an opportunity. It is the first day, when, if you signed up in time (now December 24 for the federal website, but a few states have later deadlines)—and paid your premium in time (at the administration’s urging, many insurers are allowing a grace period through January 10 for the federally run marketplaces and some states have also moved this date)—you could enjoy the subsidized coverage available under the ACA. But if you miss these so-called deadlines, you still have until March 31 to sign up for coverage to avoid a penalty.

For the millions of Americans who are uninsured, or who could have enrolled in improved insurance through a state or federal exchange, missing these deadlines merely means you failed to make yourself better off as soon as you possibly could. BUT YOU WILL BE NO WORSE OFF THAN YOU WERE BEFORE.

There are also some dates that are consequential, but have received less attention, or have receded from the headlines:

NOVEMBER 2014: This is when the Obama administration promises online enrollment for the Small Business Health Options Program (SHOP) in the 34 states where the federal government is operating the small-business marketplaces for companies with fewer than 50 workers. For now, small businesses in these states can apply via paper application or an insurance broker or navigator.

Online access is available already in most of the 17 states and the District of Columbia that are operating their own SHOP exchanges.

JANUARY 1, 2015: The date by which employers with 50 or more employees will become liable for a tax penalty if they are not offering health insurance that meets minimum standards, and an employee becomes eligible for subsidized private coverage through the marketplaces.

The changing dates associated with the ACA are troubling to some, since they suggest confusion and even mismanagement by the Obama administration. It would obviously be reassuring if every declared date were honored and announced rules and intentions never changed.

On the other hand, I’m doing some long-delayed repairs in my home. The contractor said the work would be done by Thanksgiving, but there were unanticipated problems. We’re hoping now for Christmas.  I’ll be happy if it’s done by mid-January, but the key thing is whether, a year from now, I’m satisfied with the result.

Health insurance is obviously way more important to millions of Americans than any home repair project could ever be. But few things in life go exactly as planned, and it would be totally astonishing if the implementation of massive reforms to a sector accounting for 20 percent of our economy rolled out without a bump or a detour.  We should keep that in mind as we think about those changing ACA deadlines.

David Blumenthal, M.D., M.P.P., is president of The Commonwealth Fund, where this post originally appeared.

Resisting the Rush to Judgement On the Affordable Care Act

A full, fair reckoning of the impact of the Affordable Care Act (ACA) will take years. In an earlier blog post, we outlined some of the measures—such as reductions in rates of uninsurance and underinsurance and trends in health care costs and quality—by which the law should be judged and the time frames over which those judgments should be made.

In the mean time, however, the rush to reckoning seems irresistible. These interim conclusions could prove as faulty as the ACA websites, but they should at least be informed by the best information available. As of this writing, this is what we know about the major shortcomings and accomplishments of the ACA.


  1. Poor management of the launch of the federal website, The reasons for this failure are still emerging, but are likely multiple: management failures by the Obama administration, poor performance by its contractors, design flaws in the legislation itself, the decision by so many states not to run their own websites, a toxic political environment, and other factors.
  2. Poor messaging by the President. In retrospect, President Obama should have prepared the public better for the inevitability that some Americans would be left worse off by the law because of higher insurance prices or the need to switch health plans.
  3. Failure to prepare fully in advance for adverse impacts of the implementation of the ACA. There may have been more such preparation than meets the eye but if, for example, the administration had anticipated that private health plans might be cancelled, the policy response could have been waiting on the shelf. Instead, there was a last-minute scramble under the media spotlight.


  1. Provision of health insurance to: 7.8 million young Americans covered under a parent’s health plan who likely would not have been able to do so prior to the law’s passage, including 3 million who were previously uninsured; more than 200,000 Americans covered through state marketplaces as of November 25, 2013; and 26,794 covered through the federal marketplace as of November 2, 2013.
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The Presidential Healthcare Curse – Why Do They Even Try?

Until now, virtually every president who has dabbled with comprehensive health reform has failed spectacularly, often at huge political cost. Think of Harry Truman’s lonely campaign for national health insurance, Jimmy Carter’s devastating conflict with the late Senator Edward Kennedy over universal health care coverage, the first George Bush’s ineffectual (and little-remembered) health insurance proposal, or Bill Clinton’s damaging first-term effort to pass health reform.

Health reform is a presidential nightmare. No sane presidential consigliere would ever recommend his or her boss try it. Our health care system is so complicated and convoluted that any conceivable proposal is bound to make someone worse off. And in health care, worse off can mean real pain and suffering that creates powerful, emotional stories that echo through the news cycle. There is simply no way for presidential health care reformers to avoid grievous political harm, as the experience of President Barack Obama is now demonstrating in spades.

Which raises the question: why bother? It would have been so easy for President Obama, in the midst of the Great Recession of 2008, to kick the health care can down the road, saying that his all-consuming priority was economic revival, and that health reform could wait.

The answer provides critical context for the relentless stream of troubling news—and the cacophony of charges and counter-charges—about the implementation of the Affordable Care Act (ACA) that fill the media each day. The reason to proceed with this painful technical and political process is that there is no alternative. Before the ACA, the current health care system—and especially its private insurance market—was collapsing before our eyes, like a house tipping into a sinkhole.

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A Tale of Two IT Procurements

Recently, the President of the United States, the most powerful person on earth, the man whose finger rests on the nuclear button, struck a bold blow for . . . procurement reform?

“There are a whole range of things that we’re going to need to do once we get [the Affordable Care Act (ACA) rollout] fixed—to talk about federal procurement when it comes to IT and how that’s organized,” the president said on November 4, speaking to a group of donors and supporters.

People are clamoring for heads to roll, and the president is talking about what just could be the geekiest, most obscure topic ever to clog a federal bureaucrat’s inbox. Procurement reform? Has he gone off the deep end?

Well, not really. Among the causes of’s difficulties, the federal process for purchasing goods and services could rank right up there with toxic politics, lack of funding for ACA implementation, and management goofs. Let me explain why, from personal experience.

From 2009 to 2011, I served as National Coordinator for Health Information Technology. My job was to implement the HITECH ACT, which aims to create a nationwide, interoperable, private, and secure electronic health information system. As national coordinator I had to lead a lot of federal contracts.

This is how that went.

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HITECH in High Gear


We’ve known for years that health information technology can improve health care. But until recently, the implementation rate among providers has been low, except for a few early adopters.

In the last two years, however, there has been a significant upward inflection in the adoption rate. For primary care providers, adoption of a basic EHR increased by half from 19.8 percent in 2008 to 29.6 percent in 2010.

And with HITECH Act programs now in full swing, it looks clear that adoption and use of health information technology will go into high gear. Already, 81 percent of hospitals and 41 percent of office physicians are saying they intend to achieve meaningful use of EHRs and qualify for Medicare and Medicaid incentive payments.

A recent edition of the American Journal of Managed Care (AJMC) helps us understand why the accelerated move to EHRs is so important. This special issue devoted to health information technology presents perspectives on health IT from a wide range of stakeholders—providers, policymakers, and patients. Contributors include representatives of private companies and public agencies, managed care organizations and academic medical centers, medical educators and a medical student—confirmation that the potential of health IT is compelling for a broad spectrum of Americans.Continue reading…

Three Wishes

So I was walking down the hallway in my office, mildly distracted,
when I kicked something.  It was a USB “thumb drive.”  I picked it up
and inspected it, trying to figure out who had dropped it.  The side of
the drive had a picture that I couldn’t make out, as it was all smudged
with something.  I pulled out a tissue and rubbed it, thinking it may be
a clue as to whose drive it was.

There was a sudden rushing sound and a strong wind.  Out of the thumb drive emerged a large blue figure wearing a turban.

“Are you a genie?”  I asked

“No, I am David Blumenthal, the health IT ‘czar.’” he responded.

I hung my head down, “I guess this is about the fact that I write the word healthcare instead of health care. I was wondering how long it would be before the feds came down on me for that.

“No, that’s not my realm.  That would be the job of the Department of
Language Security, and they’ll be appearing in some creative way next
week to get on your case about the whole healthcare thing.  It has Matthew Holt and Maggie Mahar in a big tiff.”

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