InsureBlog Hosts the Pre-Passover Edition of Health Wonk Review






Yes, it is that time again! Oh, sure, the biweekly Health Wonk Review is on your newsstand today. But also, those religious rites of spring are right around the corner. So without further ado or comment from the cheap seats here at Health System Ed, here’s Henry Stern’s pre-Passover edition of HWR. Do yourself a favor and enjoy.

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AHCA: Aye or Nay Edition of Health Wonk Review

ACA passedSeven years ago today, President Obama signed the Affordable Care Act into law, ushering in a host of reforms for the U.S. health care system. And today, House Republicans are planning to vote on the American Health Care Act (AHCA), which would repeal many of the ACA’s spending-related provisions and implement replacements for some aspects of the ACA. The bill was still undergoing changes as of last night, and it’s still unclear whether it has the votes to pass in the House. To say it’s been an eventful few week (and year) in the health wonk world would be an understatement. So welcome to the Health Wonk Review, where we make sense of all the goings-on!

We have a variety of posts this week that focus on the AHCA, but there are also several that tackle other subjects. Without further ado however, a shout out to David Williams, who has been writing at Health Business Blog for a dozen years! David’s blog turned 12 earlier this month, and David celebrated with a roundup of his favorite posts from the past year. Cheers, David, and here’s to a dozen more!

Read the whole edition here at Health Insurance Colorado. Thank you, Louise!

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A Policy Decision: Choosing Between Health Insurance and Medical Care

Those who control the language, control the debate.

The question on the table in the U.S. today is, “What is the most efficient and least costly way to provide health insurance coverage to everyone?”

Coverage is such a nice word. Uncovered is cold and uncaring. Coverage means having health insurance, but the reality is that having health insurance coverage does not automatically guarantee a person has access to medical care.

To change the discussion and find different answers, perhaps a better question is, “What is the most efficient and least costly way to provide medical care to everyone?”

In this context, let me suggest a radical overhaul of the way we think about providing medical care in the U.S. so we get more care for less money than we are spending now. It also requires re-examining the role of insurance.

As a premise, we can gauge our success by controlling the cost of healthcare as a percentage of GDP.

Historically, healthcare has risen from about 5% of national GDP in the early 1960s to nearly 18% today. More patients, new technology, higher prices and a rise in costly comorbidities all contribute to the rise. Beyond these inputs, some structural and regulatory changes also contributed to the cost increases. We have to wonder whether we are getting a commensurate rise in value for the nearly fourfold increase in investment over the last 50 years.

With some changes in basic philosophy, the government’s expenditures and policies can support working people who need to keep their money to access the care they need when they need it, and to make sure the money they spend goes directly to pay doctors and hospitals who right now have to go hat in hand to the insurance company to get paid for caring for them.

A low premium catastrophic health insurance policy coupled with a health savings account plan allows working people to put aside several thousand pretax dollars a year in an interest-bearing savings account to use for medical bills and costs such as prescriptions, eyeglasses, dental work and other health-related expenses. They retain their hard-earned money and designate it for the care they need instead of paying health insurance plans for services in a defined benefit policy that may not cover all their needs.

A Few Stories of the Uncovered Insured

Health insurance is not coverage.

One grad student and research assistant who needs to stay current on his medical care due to an ongoing medical condition is concerned about an issue but can’t afford to go to the doctor for tests because the copays for his health insurance plan are prohibitive.

Another person needs dental work…thousands of dollars of dental work. Dental work is not covered as part of her health insurance plan. She had half the work done, and is paying monthly installments until it is paid off so she can start phase 2 of the dental work. Meanwhile, she continues to pay premiums for health insurance coverage that leaves some of her most acute medical needs out in the cold.

A third self-insured, self-employed person is afraid to use his insurance for his annual exam. If something is wrong and he can’t work, he can’t pay his premiums and would therefore not be insured against medical costs any longer.

A fourth person with employer-sponsored insurance worries with every annual physical that she won’t be able to work any longer and will lose her job and health insurance, leaving her sick and uninsured. Each clean bill of health is a celebration.

The Insurance Function

Some public health insurance plans work for people who qualify for full subsidies and public assistance. For average people making working wages and buying health insurance, the system is not affordable. The government boasts that 85% of ACA enrollees are subsidized. It begs the question why there are so few buying in at full price.

Here’s the radical thought I suggested earlier: We need to revisit the function of insurance. People who are not employed do not need health insurance. They need primary medical care that is not prohibitively costly. Most doctor visits and treatments are simple. Babies with sniffles. Kids with broken arms. Moms with diabetes. Dads with high blood pressure. A doctor visit here. A generic prescription there.

After all, the function of insurance is to provide protection against loss of valuable assets. Most of our health insurance in the U.S. is provided by employers who are insuring their human resources. When people are unemployed, their wages and productivity do not need to be insured. In that case, health insurance for the indigent effectively protects providers against loss for providing medical services to those who can’t afford to pay.

Put another way, when an indigent person needs expensive medical care, it is the provider who needs to be insured against the loss of treating them if they are going to uphold their mission to treat everyone who comes through the door. The indigent person needs medical care; they do not need to be insured against any personal loss if they are judgment proof.

Finally, health insurance companies or health plans have become a clearinghouse for patient information, albeit an imperfect one. Health technology allows patient information to exist without a health plan as a hub, and the information can exist more completely and privately when held by the patient.

A Revolutionary Thought to Redefine the Debate

We need affordable and accessible medical care for everyone. Then we need to assess who and what needs to be insured against loss, and revamp the health insurance mechanism accordingly. Insurance has a valuable function; when applied properly it protects the assets of people who cannot self-insure against loss.

Right now, the government, employers and patients themselves are subsidizing the insurance industry to provide coverage for services that some members can’t afford to access and with whom providers often need to fight to get reimbursement. The insurance industry has a function but it is not functioning optimally under the current paradigm.

If you think the current way of structuring healthcare is keeping down cost, I refer you to an earlier paragraph where we see the cost of care closing in on 20% of GDP.  When we critically assess what we are getting for nearly quadrupling the country’s investment in the health of our citizens, the answers are at best uneven.

Different countries have ways of handling health care that works in the context of their histories, culture, political and economic systems and available delivery mechanisms. Given our own unique circumstances and assets, it may be time to consider stepping back from what has evolved as an expensive and uncoordinated system cobbled together to appease different political and corporate interests, and instead build one from the ground up that best utilizes our available resources and leverages our desire to provide the best care to everyone at the lowest possible cost.

The government is the largest payer of health care in the U.S. There may be ways to get a much bigger bang for a much smaller buck by reconsidering the validity of our fundamental premises regarding the role of health insurance in healthcare.

The American experiment in government requires a uniquely American experiment in universal medical care.


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The “May You Live in Interesting Times” Edition of Health Wonk Review

May You Live in Interesting Times

Just when you thought things can’t get any weirder, they do. Combine staunch opposed ideologies held by fierce political warriors, and we find ourselves under the ancient curse of living in interesting times.

It seems our nation is transitioning from a government run on compromise – remember Ronald Reagan working with Tip O’Neill or Bill Clinton reaching across the aisle to Newt Gingrich? – to one run on diametrically opposed ideologies duking it out in unceasing, heated political and legislative battles. Maybe people will pull back the throttle on the ideological thrusters and land this thing safely. For now, both clearly defined sides in this fight seem to have refined the act of demonizing the opponent to an art form. But this isn’t art. It’s life, and it’s happening in real time. Welcome to interesting times.

Now, off to the land where hyperbole and rancor take a back seat to reason.

Let’s hear from the more tempered voices of the HWR crew’s civilized, balanced and informed debate.

Kicking off the discussions this week, we turn to the Health Affairs Blog where Timothy Jost presents a detailed analysis of the Republican legislation on the table to replace the ACA. In Examining the House Republican ACA Repeal and Replace Legislation, he compares the relatively lengthy ACA draft process to the 3-week run-up to the ACHA legislation. He points out what changes (mostly Medicaid), what doesn’t (pre-existing condition protections, coverage guarantees, etc) and looks at the revenue implications.

The ACA has been an employment driver, so repeal will hurt employment. Joe Paduda breaks out the math for us here at Managed Care Matters. Making healthcare more efficient will cost jobs and reduce incomes for a large segment of the economy. Joe asks, will this affect policymakers’ priorities?

Henry Stern at InsureBlog tells us that, if measured in numbers of lives saved, patients are faring worse under ObamaCare. In fact, InsureBlog reports that the ACA’s success regarding actual lives saved is a big goose egg.  Here’s the story at The ObamaCare Success Story: Zip, nada, and zilch.

Linda Bergthold, writing for Health, provides a dictionary to help decode the meaning behind the politicians’ words, a difficult task under any circumstances. In Decoding Republicans’ Language of Repeal, she cautions readers that seemingly innocuous language such as “patient-centered”, “access to care”, “freedom” and “choice” may not deliver on those promises quite as presented. She said much of the GOP language masks “ideas that are old and tired” that are being recycled. Read more here and decide for yourself.

Over at XPostFactoid, Andrew Sprung is a man looking for a compromise and a way out that saves face for everyone, something that might include a couple of frills like, say, oh, coverage for the vulnerable. In his post, Psst, Democrats: Help Republicans Out of the Repeal Box via Cassidy-Collins, he looks at the Patient Freedom Act as an alternative to the ACA and the AHCA. Read XPostFactoid here.

Over at Health Access California, Anthony Wright pays tribute to 94-year-old health care advocate Dorothy Rice who passed away this week. Of RIP Dorothy Rice, Pioneer in Health, Anthony says, “Rice was a lead economist in the Johnson Administration who made the case for Medicare. For an encore, she had a second career as a world-renowned academic where she dealt with issues from health reform to aging to tobacco control. We were pleased to work with her on our board during the effort to pass and then implement the ACA, providing a historical perspective to remind us these policy fights are not new – although she always thought after the passage of Medicare that the next reform to cover the rest of the population would come a lot sooner than it did.” This tribute details her considerable accomplishments.

Roy Poses at Health Care Renewal questions the integrity of Trump cabinet nominee for Labor Secretary based on some of his rulings as a former U.S. Attorney regarding pharmaceutical companies that favored the corporations. Roy asks, “What sort of swamp drainage process is this?” as he explores the decisions of the cabinet nominee “who had an important role in enabling the impunity of leaders of top health care organizations…he presided over three major settlements with pharmaceutical corporations. In none of them did any individual who enabled, authorized, directed, or implemented the alleged bad behavior suffer any negative consequences. The suits were settled by payments made by the companies.” The details of these cases are in the Health Care Renewal blog here.

David Harlow at HealthBlawg recently hosted a cybersecurity webinar with government experts. To view the webinar, click on this link to view the Second Annual Cybersecurity and Health Care Panel Discussion with Government and Industry Experts. This blog post includes David’s notes from his introductory remarks as well as the 1 hour and 21 minute presentation. Grab a cup of coffee and listen to this in-depth discussion.

After taking in the webinar, you can jump over to David Williams’ Health Business Blog and click on his podcast where he interviews iCardiac Technologies CEO Alex Zapesochny about his electronic clinical outcomes assessment platform. Electronic clinical outcomes assessment platforms collect data from patients, clinicians and caregivers to make clinical trials more efficient and accurate. In this 14 minute interview, they discuss some of the trends in clinical drug development and how they impact platforms such as eCOA.

At Healthcare Economist, Jason Shafrin discusses the evolving methods for evaluating cancer care. Shafrin asks, “How do you measure the quality of care patients with cancer receive? How long they live? Avoiding side effects? Patient satisfaction? Process measures?” The Healthcare Economist investigates here.

Finally, we’ll visit an issue that has begun to cross the ideological divide. At Worker’s Comp Insider, Tom Lynch reports on a recent study on the therapeutic use of medical marijuana as a treatment for chronic pain – and the impending clash between the states and federal government stances on legality.  Read the discussion in more detail here at Who Knew? Medical Marijuana Works (at least for chronic pain).



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Our Short-Sighted and Divided Country Looks for an ACA Replacement

We have short attention spans and shorter memories. That serves politicians well but it makes bad policy.

Say, for example, you decided to run for President of the United States but you pulled a really stupid college-style prank, like plagiarizing someone else’s work, that makes you ethically ineligible for the presidency when the story gets out.  If you’re lucky, voters and even journalists who investigate the backgrounds of candidates might well forget your indiscretion a few decades later and you could end up, say, in the  White House a heartbeat away from the Oval Office.  You just never know in politics. Yesterday’s bum steer could end up today’s political sacred cow.

Take Obamacare. Please.

Way back in 2010, the public furor over the passage of the Affordable Care Act meant that some legislators were afraid to go home on break. Representatives’ offices were picketed, windows  broken, personal safety threatened. Citizens were very unhappy with the ACA’s mandatory coverage and legislated benefits packages that didn’t suit their needs and cost more than their current policies that allowed them to keep their plans and their doctors.

How unhappy were they?

As the October 2013 rollout approached, one health insurance company required training for their call center employees to teach them how to calm down member subscribers. The insurer ordered the training because it knew that it would be sending out letters terminating current policies and replacing them with more expensive, government-mandated ones. They anticipated the tears and anger, and put call center employees through sensitivity training to handle distraught customers.  That company knew well before the ACA launched that people could not keep their plans or their doctors, and that their rates would skyrocket to make up for it. The people who wrote the law, promoted it and voted for it probably knew, too. If they didn’t, they should have been fired.

Oh, wait! They were.

And here we are, in the land of Repeal and Replace.

In an administration where each new regulation requires that two are de-commissioned, we can expect a flurry of confusion from an industry that operates on auto-respond to commands from DC. While healthcare doesn’t like having to zig and zag to expensive orders from DC, providers, insurers, patients, drug and device manufacturers and even IT companies are used to reacting to dicta from federal regulatory agencies.

The most widely, publicly discussed aspects of the ACA pertain to patient coverage. The public is concerned, and understandably so, about the fate of mandatory coverage for pre-existing conditions and the 26-year-old dependent coverage clause. Everyone is required to have coverage so those who flat-out can’t afford it get subsidized. Those who flat-out can’t afford it and don’t meet the income thresholds for a subsidy pay a penalty.  Part of Repeal-and-Replace is figuring out how to address the grievances of those who haven’t fared as well under ObamaCare as they did under their former policies, and assuage those who have benefitted. It’s a job fit for a politician. Other normal humans would not want to find themselves between that particular rock and hard place.

On to the other aspects of Repeal and Replace, those aspects that affect the way the healthcare industry operates and gets paid. What happens to an industry when the regulatory bonds are loosed?

Under the ACA and other related legislation that support various facets the healthcare industry overhaul, doctors face new reimbursement models starting this year based on certain performance targets with rules so arcane that most did not even know late last year that they were subject to the new payment system called MACRA. Other laws resulted in providers and hospitals installing electronic record systems trying to catch the Meaningful Use stagecoach to reach reimbursement targets. Meanwhile, many doctors complained those same mandated electronic records systems were detracting from patient care.

On other fronts, providers are wondering what will happen to accountable care organizations, a concept best achieved with great data capture and analytics that rely on the integrity of the aforementioned electronic health record. Speculation abounds about the fate of other ACA spawn, such as bundled care payments, care coordination and value-based payment models that attempt to support population health in an effort to control costs.  

Finally, when President Trump told a joint session of Congress this week that he wants to loosen the reins on the FDA approval process, you could almost hear a little cheer go up from the pharmaceutical industry. But in the next breath, when he mentioned cutting price deals with drug companies, you got murmuring from the same quarter.

Certainly, many ACA and ACA-spawn initiatives have philosophical merit, as well as their defenders and detractors. The question before the healthcare industry now asks whether an affordable healthcare system can best be reached with less government over-reach?

The answer lies in whether initiatives that are rolled out naturally as a consequence of their merit will lower costs, improve outcomes and increase access, and can do so without adding a regulatory timeline or requiring an outlay of billions of dollars on the part of the government or the health systems that have to dance to the piper’s tune.

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The President’s Day Edition of Health Wonk Review on Your Virtual Newsstand Now

politicsDavid E. Williams is on top of the President’s Day Edition of Health Wonk Review. Click here to go to David’s Health Business Group blog for this special edition on your virtual newsstand today.

I also want to add my mea culpa that I have not been a good corporate HWR citizen and contributed lately. Writer’s Block? Actually, it’s been Writer’s Overwhelm…there is just so much I am still figuring out where to start. In the meantime, let’s all be thankful that the HWR crew remains faithfully on the job.

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Fresh Prints: An All-New, Alt-Fax Edition of Health Wonk Review


Health Wonk Review for February 9, 2017

#alternative_facts Edition

Honesty is such a lonely word. Everyone is so untrue.

– Billy Joel

The title of Billy Joel’s hit song wouldn’t have been nearly as appealing – and probably harder to pair with a melody if he had called it #Alternative_Facts.

Steve Anderson outdid himself again with this latest edition of the HWR. You will want to read the rest of this edition here.

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Health Wonk Review’s Inaugural Edition: Read It Here!

For our Health Wonk Review afficianados, here is this week’s blog aggregation in toto. Enjoy all Joe Paduda’s hard work, and those of the other contributors.

Health Wonk Review’s Inauguration Edition

by Joe Paduda of Health Care Matters

Through election after election, HealthWonkReview has been your go-to source for the real impact on healthcare, health policy, access, coverage, and the rest of the story about the industry that accounts for one-sixth of our nation’s economy.

In preparing this edition, I was struck by how much better these blog posts were than pretty much any articles in the mass media (with a couple notable exceptions.).

The depth, understanding of core issues, knowledge of how various parts of ACA interact, and ability of the authors to explain all this in words everyone can understand is impressive indeed.

Louise Norris, Roy Poses, Andrew Sprung, David Harlow, David Williams – these are the folks you need to be following.


Andrew Sprung’s contribution is a welcome list of 7 ways the GOP could blow up ACA gains.  Or maybe not.

Andrew describes various paths to repeal and replace, dissects the problems, perils and promise of each, and handicaps the odds.  It’s a very, very insightful read.

Tick, tock…Louise Norris just keeps getting better and better; as a small-business insurance broker she is on the front lines AND understands the core issues affecting ACA and health policy.  Her entry this month discusses the Republicans’ plan to have legislation ready tomorrow – yes, January 27 – to begin the repeal process. 

A bit of background on the trump Executive Order that required the January 27 legislation comes from the estimable David Harlow.  A quick read, and a valuable one.

Friend and colleague Bob Laszewski’s wondering if the trump administration is prepping for it’s own “if you like your insurance you can keep it” fiasco.  In a great companion piece to the Norris and Harlow reportage, Bob asks a question the current administration likely didn’t:

if you take this new executive order to its logical conclusion, doing things like killing or easing the individual mandate or allowing for cheaper medically underwritten plans can’t have any effect other than making an already fragile Obamacare risk pool worse. Making the pool worse can only lead to fewer consumer choices, or no choices, or higher rates and bigger out-of-pocket expenses for those who remain in the Obamacare risk pool.

My entry this month compares the Republican position on repeal and replace to Wile E Coyote’s headlong charge off the cliff.  Beyond repeal and into replace, things could get pretty interesting – as Mr Coyote learns every episode, it’s not the fall that hurts, it’s the reality of the landing.

As I see it there are two main issues:

  1. Repeal without replacement is a budgetary and political minefield.
  2. Congressional Republicans aren’t even close to agreeing on what a replacement bill would look like

One of the big changes might be block grants for Medicaid – where the Feds just give each state a chunk of money and the state gets more flexibility in how they spend it.  There’s a LOT of detail around this, but at least in Massachusetts, it may not be much of an issue.  David Williams posits that MA is in a pretty different place than most states, one where a full-on total repeal of ACA wouldn’t be a big deal.  That’s because Mass has been in the forefront of these changes, and things are working pretty well.

Federal changes…

OSHA is going to be a different animal altogether in the new administration; perhaps more akin to a cuddly panda than a persistent bloodhound. Julie Ferguson details how the agency is already shifting to a more “employer-friendly” mode.

Julie’s post also digs into the administration’s claim of a “dramatic expansion of the federal workforce in recent years.” and resulting hiring freeze and consequences thereof; quoting a source that finds there has been no federal workforce expansion and that “employment by the federal government as share of all US employment is relatively low compared to most of the last 70 years.”

That’s a fact, not an “alternative fact”, or what we would call a “lie”.

Peter Thiel is the focus of Roy Poses’ ire this month, and that ire is well-placed.  The trump advisor supported one “Jim O’Neill, one of Mr Theil’s business associates, for this position [of head of the FDA], despite Mr O’Neill’s apparent complete lack of experience or training in medicine, health care, public health, or biomedical research, and Mr O’Neill’s obvious conflicts of interest.”

Other news of note

Brad Flansbaum’s penned a piece on healthcare CFO and CEO ratings at The Hospital Leader. Interesting take on how administrators – who currently are not being “rated” – perhaps should be. Brad provides his views on a few evaluation standards; good to see the proverbial shoe being placed on another foot!

And the ever-wonderful Hank Stern informs us that healthcare inflation is not limited to this side of either pond; costs are going up in other countries too – driven there by a demand for private care.

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Healthcare’s Future? Population Health and Information Technology

Many people are wondering if we are living in a post-ACA world. The uncertainty has pundits posturing all over the political map. No matter how the economy or politics turn, there are a few constants where people can have some control.

We live in a technology-driven world so no matter how we feel about it, that train has left the station. The potential of technology will continue to improve our ability to monitor our own health and for providers to cure disease. Admittedly, some of it is expensive but much of it, such as personal wearables, are inexpensive and allow patients to self-monitor. We all have friends and family who track the number of steps they take every day.

The wellness movement is another trend that is making a difference in the cost and effectiveness of the care we provide. This week I saw an interview with a leading light in the wellness movement, Dr. Mark Hyman, who is the founder of the Cleveland Clinic’s Center for Functional Medicine in which he discussed the fact that people’s health status is most heavily influenced by the health status of their friends. He talked about the implication of this finding for population health.

Dr. Hyman’s main message is that the food we eat is the key driver to our health. He is behind movements to change the way people eat and focuses on implementing the social supports around their habits. On the one hand, his message is not new or revolutionary. On the other, as our country faces a way to pay the health bill for an aging and chronically ill population, perhaps these messages will begin to make serious inroads in the public consciousness.

As we look at a possible post-ACA world, perhaps the discussion can revolve around health and health care, and move away from health insurance. When we squarely face the unsupportable cost of our healthcare system,  that may be the trigger for us to reframe what we actually seek – health or a way to pay for healthcare products and services that we may not need in such great amounts if we change the way we live.

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Puppies and Kittens Edition of Health Wonk Review

Hank Stern’s roundup of wonkery and punditry as the Health Wonk Review group looks at where things are going under a new administration in DC in this Puppies and Kittens edition of our beloved HWR.

Here come da fuzz.


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