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Are Smokers Really the ACA’s Biggest Losers?

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By Al Lewis & Vik Khanna

Facing thousands in extra insurance costs, smokers appear to be the Affordable Care Act’s (ACA) biggest losers.  Employers are allowed charge smokers up to 50% more for their medical coverage than nonsmokers , starting in 2014.

On November 25, Fox News put it best:  “Obamacare Policies Slam Smokers,” , noting that “smokers are the only group with a pre-existing condition that Obamacare penalizes.”   THCB itself has headlined:  Smokers Face Tough New Rules under Obamacare.

And these headlines are absolutely accurate —  meaning that, with the possible exception of the e-cigarette, ACA is the best thing that has happened to employed smokers ever.

Here is how we arrive at this conclusion.  The data is mixed on whether smokers incur much higher healthcare costs or just slightly higher healthcare costs during their working ages than non-smokers do.  None of the data shows that their costs are lower, but let’s say there is no impact on health spending.

Nonetheless, the following is incontrovertible:  smokers take smoking breaks.

Remarkably, there are no laws specifically governing smoking breaks, and like most other quantifiable human resources issues, no one has quantified them.   But we all observe these breaks, and about a fifth of us participate in them.  They reduce productivity.  By definition, if you are outside smoking, you are not inside working.

Sure, some smokers make up the time by working harder when they aren’t smoking…but (1) many non-smokers work hard too and (2) some workplaces, such as inbound call centers, don’t offer the luxury of catching up later because they operate in real time. Lacking quantification, fall back on your imagination…and imagine what you would do if you ran a company in which non-smokers spent as much time mulling around outside as smokers do.  That should give you an understanding of the impact of smoking breaks on productivity.

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I Would Rather Die at Home

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By THCBist

A THCB reader in Tennessee writes:

Thanks for listening. I am a single 55 year old male in Tennessee. I’m not offered insurance from my employer. June of 2012 I was diagnosed with Essential Thrombocytosis. A blood disease that messes up your platelets. Took every test they could think of to figure it out. In and out of hospital, adding up debt by the second, I stopped going to doctors, stopped buying meds. I drag myself to work, every day, just to survive. Under Obamacare it will be, for the worst plan, $571.00 a month, with a $ 5100.00 deductible. I can’t afford that. I would rather die in my home as it would be better than being homeless. Is this a joke?

The Presidential Healthcare Curse – Why Do They Even Try?

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By DAVID BLUMENTHAL, MD

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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Obamacare Has Failed My Family

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By TONY JEWELL

The Obamacare debacle remains … well, a debacle.

At a time when I should have my family’s insurance coverage locked up for 2014, I learned this past week that — despite previous assurances from the government’s call center — my application for coverage has not been completed or submitted to AmeriHealth.

Let’s start at November 13, when I attempted to finally enroll via healthcare.gov and over the phone.

Even though I had completed all of the necessary steps to that point, the site didn’t work that day and locked my account — allowing me to do nothing more on the healthcare.gov site. I called the call center, who couldn’t even find me in the system — despite the fact I had an account, had selected an insurer and clicked enroll.

They discovered my family in the system once they figured out healthcare.gov had determined my 8-year-old son was the head of the household. The call center operator said we couldn’t do anything until he gave me permission to access the account (he was in school, so that wasn’t happening).

Once they found me and I convinced them I wouldn’t be calling my son’s school for permission, however, they couldn’t access my account because healthcare.gov was down. She advised me to call the insurer to see if they had received my application.

The insurer helpfully said that they wouldn’t even receive the application for three to six weeks after it was submitted via healthcare.gov — which, at best, put us at early December and at worst past the deadline to have insurance on January 1.

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The Two Million Scenario: What if the Affordable Care Act enrolls a lot fewer people in the Exchanges than predicted?

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By SETH J. CHANDLER

People can be blinded by dreams in many spheres.

Many people who remain basically positive about the Affordable Care Act are viewing the enrollment statistics like the football fan whose team is 2-6 and who point out that the team could win 7 out of its 8 remaining games and still probably make the playoffs.

Yes, getting off to a really bad start doesn’t preclude a happy ending. Success may still be mathematically possible. But unless there’s good reason to think that the fundamental factors such as poor coaching,  poor game plans or unexpected injuries that have led to the bad start no longer apply, the more reasonable prediction is that things will continue more or less as they have.

It’s time to start thinking realistically about what happens if a core component of the Affordable Care Act, subsidized, non-underwritten health insurance available from private insurers, essentially fails to provide many with better access to medical care. This might not happen in every state — there might be a few whose Exchanges can be deemed “successful” — but it is looking more and more to me as if we are heading for enrollments in many states well, well short of that on which the arguments for the ACA were significantly premised.

Indeed, some supporters of the ACA have started moving the goal posts, revising history to say that the real goal of the Act wasn’t to reduce the number of uninsureds but to have an actuarially sound pool. (So the purpose of the Act was to help insurance companies stay afloat?) And it hardly helps enrollment when President Obama urges his allies to hold back enrollment efforts so the insurance marketplace does not collapse this coming week under a crush of new users even after he earlier assured the nation  healthcare.gov  was supposed to be working much better by this time.

For purposes of this blog entry, I’m going to assume that enrollment in the Exchanges ends up being about 2 million for 2014 instead of the projected 7 million.  I can’t rigorously justify that number — but, of course, neither could the pundit who is now saying 4 million. And, if I had time and space I’d prefer to do this analysis under a variety of scenarios, but, for now, the 2 million figure feels about right. And if I were betting on which side of the 2 million we will fall, it would be the lower side. What are the consequences? I can’t address all of them in a single blog entry — and trying to predict matters past 2014 gets very treacherous — but here are some.

And, for those of you who don’t want to read further, here’s the headline:

Insurance sold through Exchanges without medical underwriting — a central promise of the Affordable Care Act — is likely to implode in a significant number of states by 2015 while limping along in several others but providing little net desired decrease in the number of people without quality health insurance.  The silver lining in this failure will be that the program will likely cost less than projected due to fewer number of people receiving subsidies, although this reduction will be partly offset by higher-than-projected subsidies to the insurance industry. Expect significant pressure to grow among supporters of the Affordable Care Act to use these net savings to increase the subsidies available to people buying coverage through the Exchanges and to lure insurers in the problem states back into the Exchanges.

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The Month of Anti-Deadlines

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By Billy Wynne

As we shake off the carb-coma and make our pre-resolutions, Congress and the Administration head into a sprint to the holiday recess fraught with health policy implications. Unlike every December in recent memory, there isn’t very much Congress actually has to do. Here are the top five things you need to know to follow the fun and prepare your organization for the changes afoot. A key theme to take home is that December 2013 is a month of anti-deadlines.

  1. The Nov. 30/Dec. 1 “fix” to Healthcare.gov was set arbitrarily and has simply teed up another pivot point for opponents to pounce. We already know the wand hasn’t tapped the electro-synapses of the site yet to make the dang thing work like it should. Expect more incremental improvements through the month and enrollment numbers to come in above current rock-bottom expectations, with a healthy chunk coming from the proud, the few … the state-based exchanges.
  2. The Dec. 13 deadline for budget conferees to produce a joint resolution is similarly fictional and self-imposed. While there are some burgeoning reports that co-chairs Murray and Ryan might be able to agree to FY14 funding levels and potentially alleviate some of the sequester, the buzz-o-sphere in Washington still has deep doubts. Even if the two negotiators come to agreement, House and Senate leadership have the bigger challenge of getting a bipartisan deal through their chambers.
  3. Jan. 15 is the real deadline for a budget agreement and the real goal is writing a check to fund the government through Sept. 30. A budget resolution is helpful to give appropriators time to write actual spending policy, but it can be bypassed if the end-game is a continuing resolution that keeps current funding allocations in place. (Congress hasn’t passed an actual budget resolution since Democrats controlled both chambers.) At the end of the day, we’ll be back to the all-too-familiar roundtable of congressional leaders and Obama reps hatching a last-minute deal to avert a shutdown.

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The Purpose-Driven Doctor

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By ROB LAMBERTS, MD

My older brother is also a doctor, but not a PCP like me. He’s a specialist: a limnologist.  If you have problems with blue-green algae in your lake, he’s the man to see.  Limnology is the study of lakes, and fittingly, Bill works in the “Land of a Thousand Lakes” as a professor in fresh-water ecology.

I’m not sure he’s thinking of switching over to direct-care limnology.  I’ve been afraid to bring it up.

We do have a lot in common in our professions, as we both see a mindless assault on the things we are trying to save (patients for me, lakes for Bill).  My frustration with our health care system is matched by his anger toward those who deny global warming and the harm humans are causing on our world.

Just as he can get my blood pressure up by asking if his child will get autism from the immunizations, I simply have to suggest this week’s cold weather as proof against global warming to raise his systolic pressure.

So it was notable when I heard a rant against an unexpected target: “You know the Gaia hypothesis?” he asked.  “They think the world is a ‘living organism’ that works toward a ‘balance’ to maintain life.  They believe that humans act against nature, and so are responsible for everything that’s wrong with ‘mother earth.'”

“It’s total bullshit,” he went on to explain, not waiting to hear if I knew what he was talking about.  “Do you know that when trees appeared on the earth, they caused a mass extinction (called the Permian Extinction)!  Trees! There’s no mystical ‘balance of nature;’ it’s always in a constant state of flux, of imbalance.”

Let me make this clear: Bill is not saying that it’s OK that we are harming the earth, nor is he trying to absolve us of our responsibility for what we are doing.  His beef was with the notion that there is some kind of ‘balance’ of nature, when the evidence clearly points to the contrary.  The result of this belief is that that there is somehow an imputed moral goodness from this ‘balance’ (resulting in the idea of ‘mother earth’), and a subsequent implied immorality to any assault on our mother’s sacred ‘balance’.

This has come to mind as I have had significant changes to my thinking about giving good care my patients, especially as it applies to the area of “wellness”.  Since leaving my old practice, which was immersed in a world of ICD (problem) codes and CPT (procedure) codes, I have shifted my thinking away from a medical world where every problem demands a solution.   I have moved my thinking away from reacting to every thing that is going on at the moment, and toward the bigger picture.  I am focusing less on problems and more on risk.  I am focusing less on solutions, and more on responsibility.

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Stopping 23andMe Will Only Delay the Revolution Medicine Needs

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By Gholson Lyon

Genetic testing is a powerful tool. Two years ago, with the help of my colleagues, it was this tool that helped us identify a new disease. The disease, called Ogden Syndrome, caused the death of a four-month old child named Max. But the rules and regulations for genetic testing in the US, laid down in the CLIA (Clinical Laboratory Improvement Amendments), meant I could not share the results of the family’s genetic tests with them.

Since that time, I have advocated performing all genetic testing involving humans such that results can be returned to research participants. This I believe should extend beyond research, and some private companies, like 23andMe, are helping to do just that.

For as little as US $99, people around the world can send a sample of their saliva to 23andMe to get their DNA sequenced. Their Personal Genome Service (PGS) analyses parts of a person’s genome. This data is then compared with related scientific data and 23andMe’s own database of hundreds of thousands of individuals to spot genetic markers, which the company claims “reports on 240 health condition and traits”.

Earlier this month, however, as I had feared, the US Food and Drug Administration (FDA) has ordered 23andMe to stop marketing their service. In a warning letter, FDA said: “23andMe must immediately discontinue marketing the PGS until such time as it receives FDA marketing authorisation for the device.” By calling PGS “a device”, the FDA fears that people may self-medicate based on results they receive from 23andMe.

Somehow the US and UK governments find it acceptable to store massive amounts of data about their own citizens and that of the rest of the world. They are happy spending billions on such mass surveillance. But if the same people want to spend their own money to advance genomic medicine and possibly improve their own health in the process, they want to stop them.

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We Love to Talk About Our Lives. What About Our Deaths?

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By Alexandra Drane, Leigh Calabrese-Eck & Matthew Holt

Most of us find ourselves pretty fascinating… flipping through photos and slowing down for the ones where we’re included, tweeting our favorite tidbits of information, facebook-ing progress on this or that…

We find other people captivating as well. In fact, there’s a meme going around on facebook where people share a handful of things that most people don’t know about them – and there’s a great joy in learning these tidbits about the friends and family we think we know so well.

This Thanksgiving, we’re asking our friends and family to try this exercise, but with a twist – we want to know how they’d answer just five questions on their end-of-life preferences.

What? Are you CRAZY? Talk about how you’d want to die over Thanksgiving? Yup – that’s exactly what we’re suggesting. You know why? Because this is a conversation you absolutely want to have exactly when you DON’T need to have it… and it’s a conversation you need to have with your loved ones. Our hope for you this Thanksgiving is that you’ll have the luxury of checking both those boxes.

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Come to the Health 2.0 session at the 2013 mHealth Summit

Join Health 2.0 for an afternoon at the mHealthSummit – Dec 9th near Washington DC, at the Gaylord Convention Center!

 

First, we reveal the first ever Health 2.0 Annual Report – an insider’s guide to the 7th Annual Fall Conference, our biggest event yet. With company profiles that detail products, services, and why each presenter was selected for our stage, the Report captures all the trends and analysis you may have missed. Pre-order your copy of the report by emailing Kim Krueger. Available December 10th.

While the government is scrambling to get their exchange up and running smoothly, other tools are popping up everywhere for consumers to make smarter decisions about their insurance coverage. Jane Sarasohn-Kahn and Matthew Holt take the stage in The New Marketplace to review companies making waves in health care insurance.

Don’t miss Future of Self-Tracking and Personalized Medicine and Clinical and Population Data for Transforming Care which will cover the latest consumer quantifying tools, and how health care professionals are aggregating millions of these patient data points to streamline and provide better care.

Unmentionables is back!  Leigh Calabrese-Eck of Eliza moderates this session about life’s buffers and magnifiers.

We’ll wrap the afternoon by revealing the new Health 2.0 Database, a go-to aggregated source for all players in the industry today.

LIVE demos from:  GetInsured – WebMD – ConnectedHealth – Intuit – Ok Copay – Pokitdok – Azumio – BetterFit Technology – Withings – Aetna CarePass – Humetrix – Alere – Elation EMR – athenahealth – ManTherapy – MeQuillibrium – UT MD Anderson – Sexual Health Innovations – and more!

You can register for this session as a stand-alone or in addition to the whole event.

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