For the previous Health Wonk Review, Brad Wright chose a Baby New Year theme. However, there were some problems with the new beginning represented by the turnover from 2012 to 2103. For example, with the New Years fiscal cliff deal, one might have hoped that we would leave our budget crisis behind for a while and start with a fresh fiscal slate. But of course, that did not happen. Not only did we not escape our budget crisis, it multiplied into three crises: the debt ceiling, the still looming sequester, and the coming expiration of government funding –“The Trouble With Trillions,” one might say.
So I decided to give us a fresh chance at a new start by choosing an “Inauguration” theme for this Wonk Review, referring both to Monday’s celebration of a new presidential term but also to the word’s broader meaning of a formal beginning. And in the spirit of looking forward, we’ll lead with a post from Health Wonk Review cofounder Joe Paduda laying out his health policy predictions for the coming year. At Managed Care Matters, Joe offers five predictions, including these: most states will end up expanding Medicaid, and there will be a lot more mergers and acquisitions at the highest levels, among providers, health care systems, and payers.
Health Care Spending
Speaking of trillions, several posts in our collection focus on the trillions of dollars spent on health care in the United States. Jason Shafrin at Healthcare Economist presents some informative visuals and text from the report on 2011 national health expenditures by Micah Hartman and colleagues at the Office of the Actuary at the Centers for Medicare and Medicaid Services, published in Health Affairs. And at Drug Channels, Adam Fein takes a deep dive into what the CMS spending numbers tell us about who paid what for prescription drugs in 2011. Among the highlights: For the second year, spending on outpatient prescription drugs grew more slowly than overall national health expenditures, with Medicare Part D as the fastest growing source of Rx drug expenditures and the consumer share of such spending dropping to a new low.
Using a recent JAMA essay by Victor Fuchs as an example, Roy Poses at Health Care Renewal suggests that one reason U.S. health care costs so much is that the policy community avoids talking about certain issues, such as problems of leadership and governance and widespread unethical behavior. And Jaan Sidorov questions claims by Richard Kronick and Rosa Po at HHS that the Affordable Care Act deserves credit for Medicare per-beneficiary spending growth of only 0.4 percent in 2012. (When the first sentence of Jaan’s post contained the words “North Korea,” I had a sense this wasn’t going to end well for the ACA.) At the Disease Management Care Blog, Jaan notes that the 2012 claims database isn’t complete. Even if costs remain low, he says, it’s too early to give credit to value-based purchasing; fraud and abuse remains rampant; and Medicare’s innovations are years away from being completed.
Here at Health Affairs Blog, in a Contributing Voices post, Arthur Kellermann and David Auerbach focus on the impact of health care costs on consumers. In 2011, Kellermann and Auerbach wrote a Health Affairs article documenting how increases in health care costs had consumed the 1999-2009 income gains of a median-income family. In their post, they say that things have only gotten worse in the two years since then:
To put the cumulative effects of health care cost growth in perspective, consider this: If health care costs over this 12-year interval had kept pace with the growth of other consumer prices, this family would have had an extra $6,000 to direct towards other priorities in 2011 alone. Imagine what that might have meant to them, to millions of middle-class families like them, and to our struggling economy.
At his eponymous blog, John Goodman offers five principles for thinking about the relative costs of public and private insurance. John observes that some providers seem to be responding to incentives to lower costs “using some of the techniques the Obama administration says it likes (medical homes, coordinated care, evidence-based medicine, etc.) and that appear not to work well when the government funds pilot programs to try them out. Even more surprising, where these efforts to make medical care more cost effective are most visible is in the Medicare Advantage plans — the very plans that president Obama and many Democrats in Congress seem to be hostile to.”
Health reform critics claim Americans will soon feel “sticker shock” over climbing insurance premiums, but at healthinsurance.org Blog, Maggie Mahar says they aren’t telling the whole story. Thanks to tax credits, lower administrative costs, and an influx of younger customers, many small firms and individuals will pay less for coverage, she states.
And writing on the eve of Governor Jerry Brown’s presentation of his proposed 2013-2014 California budget, Anthony Wright says that the new budget cycle offers an opportunity for a positive health policy agenda after years of tough cuts. At Health Access Blog, Wright says California can leverage federal funding not just to expand Medicaid, but to improve it along with the entire state health infrastructure.
Risky Behaviors, Nursing Workforce Projections, And Workers’ Comp Issues
At Colorado Health Insurance Insider, Louise Norris examines the question of whether smokers should pay more for their health insurance. Under the ACA, smokers can be charged up to 50 percent more than nonsmokers. Some have called for a higher tobacco-use surcharge, but Norris notes that premium tax credits will be calculated before any tobacco rate-up, meaning that low-income smokers may find coverage unaffordable and end up uninsured. Moreover, she says, the ACA protects overweight Americans, who are far more numerous than tobacco users, from premium surcharges. Norris prefers the carrot over the stick, endorsing the requirement that all plans cover tobacco cessation programs as part of the ACA’s preventive services mandate, although she cites evidence showing that implementation of this requirement has been inconsistent.
At his blog Wright on Health, Brad Wright takes a look at the recent Institute of Medicine report on the U.S. health disadvantage relative to other wealthy nations. Brad says the report’s data on preventable deaths among young people points to the importance of public health interventions such as reducing access to guns, discouraging drug use, and encouraging safer driving.
In a post at Health Business Blog, David Williams continues his skepticism regarding claims of a looming nursing shortage. David says that warnings of a shortage when older nurses retire fail to take into account the sort of technological changes that have eliminated the need for many flight engineers, actuaries, and junior lawyers and paralegals; he reiterates predictions that robots will take over many nursing functions over time.
At Workers’ Comp Insider, Jon Coppelman points out that our century-old workers’ comp system is not designed to handle the increasing numbers of older workers in the modern workforce. To illustrate, he describes the case of Von Brock, a 77-year old greeter at Walmart. After Brock was permanently disabled, a Mississippi appeals court reduced his lump-sum workers’ comp award based on his age and on actuarial tables, despite Brock’s good health and his already having beaten the odds on mortality. “Even if Brock had prevailed, the nest egg represented by the maximum lump sum settlement would only have covered his expenses for a few years; as it is, he now walks away with a substantially lower amount…. Mr. Brock is in the vanguard of a multitude of aging workers in a dire situation,” Jon writes.
Flu Vaccines, Co-Ops, And Cognitive Screening
The severe influenza season has produced many calls for people to get vaccinated, but Brad Flansbaum at The Hospitalist Leader suggests that some claims about the vaccine and about Tamiflu amount to “oversell.” We’ve entrenched our focus on influenza into routine, Brad says, not considering the “opportunity cost” — whether the same efforts transferred to other areas might bring an even greater return on investment.
What do Freelancers and co-ops have in common? The answer, says InsureBlog’s Mike Feehan, is that the Freelancers Union received a co-op start-up loan under the ACA. This and other existing loans were not affected by the fiscal cliff deal’s shutdown of new loans, but Mike questions whether co-ops will be able to compete with established insurers, and he suggests that co-op funding is an example of the government making investments it does not understand.
Finally, at Innovative Health Media Blog, David Wilson explains the benefits of cognitive screening during Medicare’s Annual Wellness Visit. Catching any impairment early can give patients and their families more time to intervene or prepare and can save money over the long run, he writes.
That’s it for now. Watch for the next Health Wonk Review on January 31, hosted at healthinsurance.org Blog.