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Closing The Rural Health Connectivity Gap: How Broadband Funding Can Better Improve Care


April 1st, 2015

Broadband access is not usually highlighted in policy prescriptions for improving outcomes and lowering costs of health care. But it is a prerequisite for a range of technologies that can provide more cost-effective and higher-quality care, such as video consultation, remote patient monitoring, and electronic health record operability. And in many places—particularly rural areas that have the most to gain from telemedicine and connectivity—broadband remains too expensive, unreliable, or simply not available at the speeds required to enable innovations in care. This “connectivity gap” remains an important obstacle to achieving better care in rural areas.

Federal statutes and regulations provide subsidies, administered by the Federal Communications Commission (FCC), that attempt to close the connectivity gap. But these subsidies have been underutilized because they are too hard to use; they have also not kept pace with changes in health care delivery and broadband technology. Below, we examine the connectivity gap and current federal efforts to address it, and we offer proposals to make those efforts more up-to-date and effective.

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Supreme Court Turns Back Payment Suit By Medicaid Providers


March 31st, 2015

While all eyes in the health policy community have been fixed on the Supreme Court, awaiting its decision in King v. Burwell regarding the legality of premium tax credits granted through the federally facilitated marketplaces, a case of arguably equal importance has been quietly awaiting a decision.  On March 31, 2015, a closely divided Supreme Court decided in Armstrong v. Exceptional Child Center, Inc. that health care providers cannot sue state Medicaid programs in federal court to enforce  42 U. S. C. §1396a(a)(30)(A) which requires states to “assure that payments are consistent with efficiency, economy, and quality of care” while “safeguard[ing] against unnecessary utilization of . . .care and services.”

Justice Scalia’s majority opinion, written for himself, Chief Justice Roberts, and justices Thomas and Alito, would have arguably swept away nearly a half century of Medicaid law and hold that lawsuits could not be brought by providers in federal court to enforce the requirements of the Medicaid program.  A dissenting opinion, written by Justice Sotomayor for herself and Justices Kennedy, Kagan, and Ginsburg would have held that providers could have a cause of action under some circumstances to enforce the Medicaid law’s provider payment requirements against the states.  Justice Breyer, the deciding vote for the majority, wrote a narrow opinion, joining Justice Scalia’s opinion only in part, leaving the law somewhat unsettled as to rights under the Medicaid program going forward.

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Good And Bad News For Diabetes Prevention In The Community


March 25th, 2015

The findings from a recent synthesis of the literature about the effectiveness of prevention initiatives focused on reducing the risk of Type 2 diabetes among high-risk populations (people already obese or inactive or diagnosed as having prediabetes) are largely encouraging.

The synthesis includes a comprehensive and systematic review of the medical, diabetes, and public health literature for evaluation studies of interventions published between 2002 and 2013. The search was undertaken using medical subject headings and keywords related to diabetes and its risk factors.

A number of interventions—such as the National Institutes for Health’s Diabetes Prevention Program and the Group Lifestyle Balance Program—focused on helping people eat better and become more physically active are effective in reducing the risk of diabetes onset. Robust studies show that these interventions work even better than medication to prevent diabetes.

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Unpacking The Burr-Hatch-Upton Plan


March 24th, 2015

Anticipating the upcoming Supreme Court decision on King v. Burwell, which could halt health insurance subsidies available through the federal exchange, Republican Senators Richard Burr and Orrin Hatch joined with Representative Fred Upton to propose a comprehensive replacement for the Affordable Care Act (ACA). The Patient Choice, Affordability, Responsibility, and Empowerment Act, or Patient CARE Act, is modeled on a proposal of the same name offered last year by Senators Burr, Hatch, and Tom Coburn, who has retired from the Senate. The Burr-Hatch-Upton plan, like its predecessor, adopts consumer-based reforms of the insurance market, modernizes the Medicaid program, and makes other changes intended to lower cost and increase choices.

In an earlier post, we described in detail the provisions of the Burr-Coburn-Hatch bill. In this post, we discuss how the Burr-Hatch-Upton plan differs from the earlier proposal. We also discuss the impact of the new proposal on health insurance coverage, premiums, and the federal budget based on a new analysis from the Center for Health and Economy (H&E), a non-partisan think tank focused on producing informative analyses of trends in U.S. health care policy and reform ideas. We conclude by commenting on the direction Republicans are likely to take in reforming the health system in the aftermath of a Supreme Court decision in the King v. Burwell case.

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Implementing Health Reform: Medicaid & CHIP Enrollment; Tax Forms; And SEP (March 30 Update, IPAB Challenge Dismissal)


March 22nd, 2015

The Centers for Medicare and Medicaid Services released a number of items to close out the week on March 20, 2015.  First, CMS released the January 2015 Medicaid and CHIP Monthly Applications, Eligibility Determinations, and Enrollment Report.  (CMS blog post,  one pager)  The 50 states and the District of Columbia reported nearly 70 million enrollees in comprehensive Medicaid and CHIP programs as of the last day of the month.

Second, CMS and the Internal Revenue Service released updates regarding the issuance of corrected 1095-A forms.  The 1095-As are the forms that exchanges are providing to individuals who received premium tax credits for 2014; they are supposed to help individuals reconcile the advance premium tax credits they received for 2014 with the tax credits they should have received.

Finally, CMS has further clarified eligibility requirements for the special enrollment period (SEP) for people who owe an individual responsibility fee for 2014.

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Moving In Reverse? Potential Coverage Impacts For Children Of King v. Burwell, Medicaid And CHIP Eligibility Changes


March 17th, 2015

Over the last three decades, the US has taken important steps to reduce financial barriers to health insurance coverage for low and moderate-income children. These steps began with the Medicaid expansions for children in the 1980s and early 1990s, which were followed by the creation of the Children’s Health Insurance Program (CHIP) in 1997. Most recently, Congress reauthorized CHIP in 2009 and enacted the Affordable Care Act (ACA) in 2010.

This commitment to children has resulted in substantial increases in coverage. The uninsured rate among children decreased from 15.0 percent in 1989 to 6.6 percent in 2012 (Exhibit 1).

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Implementing Health Reform: Wraparound Benefits Final Rule; Coverage Report (Revised)


March 17th, 2015

With open enrollment closed for 2015 and the Departments having finalized the Benefit and Payment Parameters Rule and Letter to Issuers for 2016, we have entered the Spring Affordable Care Act regulatory doldrums.  Reports, minor regulations, guidances, and court decisions continue to appear, however.  Two appeared on March 16.  This post addresses the final wraparound coverage excepted benefits rule, and a report on health insurance coverage and the ACA (technical appendix here), both released on March 16, 2015.

The wraparound coverage rule creates a new category of excepted benefits.  The concept of excepted benefits was created by the Health Insurance Portability and Accountability Act of 1996 and is carried forward in the ACA.  Excepted benefits plans provide benefits that resemble in some way the health benefits that have been regulated by HIPAA and are now regulated by the ACA, but are more limited or are more tangential to medical care.  These include benefits that are not generally medical benefits but do afford some medical coverage (auto liability, workers’ compensation); health coverage that is not medical coverage (dental, vision, long-term care); benefits that are not coordinated with medical benefits (specific disease coverage, fixed dollar indemnity coverage); and coverage that is supplemental to medical coverage (such as Medicare supplement policies).  Additional specific conditions must be met for some of these benefits to qualify as excepted benefits.

Excepted benefits are generally not subject to Affordable Care Act requirements, such as the ban on dollar coverage limits or preexisting conditions clauses.  But excepted benefit coverage explicitly does not qualify as minimum essential coverage.  An individual who has only excepted benefit coverage and does not qualify for a shared responsibility requirement exception must still pay the individual mandate penalty.  Large employers that offer only excepted benefits may have to pay the employer responsibility penalty, but individuals offered only excepted benefits by their employers are not disqualified from receiving premium tax credits to purchase individual coverage through the marketplaces.

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Can Safety-Net Hospital Systems Redesign Themselves To Achieve Financial Viability?


March 16th, 2015

Safety-net hospital systems have long played a special role in the nation’s health care system by serving low-income, medically, and socially vulnerable patients regardless of their ability to pay. Beyond caring for people regardless of insurance coverage, safety-net systems provide comprehensive care to meet the needs of their diverse, complex patient populations, including culturally-responsive health and social services that other hospital systems do not.

As providers of last resort, some safety-net systems, especially public hospitals, are expected by their communities and by state and local governments to offer needed but unprofitable services, regardless of whether adequate revenue streams exist to support these services.

 In recognition of that role, national, state, and local government agencies historically have provided supplemental funding to these systems to offset unreimbursed and under-reimbursed care. Under the Affordable Care Act, however, that is changing. With the expectation that most people will be insured under the new law, policy makers have planned to reduce much of this supplemental funding. In this view, safety-net systems will either become financially independent or close.

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Implementing Health Reform: Supreme Court Remands Contraceptive Case; ACA Cost Estimates Go Lower


March 10th, 2015

On March 9, 2015, the Supreme Court waded once again into the waters of the Affordable Care Act, or at least got its toes wet.  The Supreme Court granted certiorari in Notre Dame v. Burwell, vacated the decision of the federal Court of Appeals for the Seventh Circuit, and remanded the case for reconsideration in light of Hobby Lobby v. Burwell.  Both Hobby Lobby and Notre Dame, of course, involve the regulations that require health plans and insurers to provide contraceptive services to female employees and students.

Also on March 9, 2015, the Congressional Budget Office issued its March, 2015 baseline report.  The CBO and the Joint Committee on Taxation (JCT) now project that the major insurance provisions of the ACA will cost $1.2 trillion over the period 2016-2025, $144 billion less than it projected in January, 2015.  Current projections for the years 2015-2019 are over $200 billion less than costs projected in 2010 when the law was adopted, while projected costs for 2019 are $56 billion, or 33 percent, lower.  The CBO also projects, however, that the ACA will reduce the number of uninsured by 25 million by 2025 rather than the 27 million it had projected in January.

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Effective Public Engagement To Improve Palliative Care For Serious Illness


March 10th, 2015

Editor’s note: This post is part of a periodic Health Affairs Blog series on palliative care, health policy, and health reform. The series features essays adapted from and drawing on a recent volume, Meeting the Needs of Older Adults with Serious Illness: Challenges and Opportunities in the Age of Health Care Reform, in which clinicians, researchers and policy leaders address 16 key areas where real-world policy options to improve access to quality palliative care could have a substantial role in improving value.

Public engagement is necessary to improve care for individuals suffering with serious illness. Fortunately, several drivers of potential change exist for advocacy. In the following blog post, we outline some areas for change and specify advocacy efforts we can undertake to improve the overall face of palliative care.

First, palliative care here is defined as being a type of specialized medical care for people with serious illness. Its goal is to improve quality of life for both person and family. It is provided by a team of doctors, nurses, and other specialists who work with the patient’s other providers to provide an extra layer of support. Although some people think palliative care is only for those at the end of life, it is actually appropriate at any age and at any stage in a serious illness and can be provided together with curative or disease-modifying treatment.

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Who Authored Obamacare’s Exchanges? King v. Burwell And Justice Kagan’s Law Clerks


March 6th, 2015

Editor’s note: Watch Health Affairs Blog for more posts on King v. Burwell and the Supreme Court oral arguments in the case by Tim Jost, Grace-Marie Turner, Sara Rosenbaum, Bill Sage, and others.

Despite all the media hubbub and intense scrutiny, we didn’t learn all that much from the oral argument in King v. Burwell. The four liberal justices—Ginsburg, Breyer, Sotomayor, and Kagan—clearly believe that an exchange established “for” or “in” a state by the federal government is the same as an exchange “established by the state” (or at least that it’s ambiguous and the tie goes to the IRS). Justices Scalia and Alito—and presumably the silent Thomas—equally believe that words mean what they say.

So the case, as expected, turns on the views of Chief Justice Roberts and Justice Kennedy, who gave very little away. Indeed, I’ve never seen John Roberts so quiet at an oral argument—holding his cards so close that they risk being permanently imprinted on his vest—while Anthony Kennedy was characteristically inscrutable. In other words, 4-3 in the government’s favor with two wild cards.

That’s exactly what everyone knew going into the argument, and 85 minutes later if anyone tried to tell you that they knew what the outcome would be, they were engaging in spin or wishful thinking. To put an even finer point on it: whichever side you thought had the better chance of winning, downgrade your expectations to 50-50.

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King v Burwell: The NFIB Medicaid Coercion Argument Returns


March 5th, 2015

Editor’s note: Watch Health Affairs Blog for more posts on King v. Burwell and the Supreme Court oral arguments in the case by Tim Jost, Grace-Marie Turner, and others.

The March 4, 2015 oral argument in King v Burwell, which will determine whether millions of low- and moderate-income Americans will continue to have access to affordable health insurance coverage, revealed a United States Supreme Court very much in play.  In this climate, observers inevitably are paying heightened attention to each of the many parries and thrusts that unfolded over more than an hour of rapid give-and-take between the Justices and the lawyers, as they battled over the meaning of 4 words in a 1000-page statute.

Perhaps no exchange will receive more attention than the one between Justice Anthony Kennedy and Michael Carvin (representing the challengers) that took place approximately 5 minutes into his argument.  It was Justice Sotomayor who actually kicked things off with the following observation:

The choice the state had was to establish [an] Exchange or let the Federal government establish it. . . .That was the choice.  If we read [the statute] the way you’re saying, then we’re going to read a statute as intruding on the Federal-State relationship, because then the States are going to be coerced into establishing their own Exchanges. . . Tell me how that is not coercive in an unconstitutional way?  And if it is coercive in an unconstitutional way [isn’t there] a primary statutory command that we read a statute in a way where we don’t impinge on the basic Federal-State relationship?

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How Many Americans Will Lose Coverage If The Supreme Court Kills The ACA Tax Credits?


March 2nd, 2015

In March, the U.S. Supreme Court is slated to hear King v. Burwell, a case that challenges the authority of the federal government to provide tax credits and other financial assistance to people who buy Affordable Care Act (ACA) coverage through the federal health insurance marketplace. The federal government runs the health insurance marketplace in 34 states where states chose not to set up a state-based exchange.

Estimates on how many people could lose tax credits in these 34 states vary widely from 4.5 million to 13 million. After talking to executives and lobbyists for health care related entities in 20 of the 34 states affected, I believe that about 6.5 million people who have tax credits in 2015 will lose them. The difference in these numbers will be important to policymakers, since politicians are likely to make decisions on how to respond to a Court ruling based on the actual number of their constituents who are receiving tax credits or other support.

In addition, the impact of a Court ruling will be affected by state action. Some observers have questioned whether states will set up exchanges if the Court eliminates tax credits from the federal exchange. These observers have said that establishing a state exchange is costly and time consuming and that most federal exchange states will not take this step. I argue in the following post that setting up a state exchange could be easy and inexpensive if the federal exchange operations are used.

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New Health Policy Brief: Risk Corridors (Updated)


February 26th, 2015

The latest Health Policy Brief from Health Affairs and the Robert Wood Johnson Foundation (RWJF) provides an update to an earlier brief on the Affordable Care Act (ACA)’s risk corridor program, which allows the Department of Health and Human Services (HHS) to collect and make payments to qualified health plans. As the brief explains, a recent amendment to federal appropriations raises questions as to whether insurers will receive their full risk corridor payments for 2014.

While the Consolidated and Further Continuing Appropriations Act of 2015, which funded the government for the 2015 fiscal year, did give HHS the authority to collect user fees, an amendment was included that specifically prohibited HHS from transferring money from either trust fund.

The amendment did not eliminate the risk corridor program, nor did it prevent HHS from using payments received from insurers to pay out claims under the program (that is, user fees), but it effectively made the risk corridor program budget neutral unless HHS can find another source of funding. As a result, insurers expecting payments from HHS may not receive the full amount due.

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Implementing Health Reform: Beginning The Cadillac Tax Regulatory Conversation And Other ACA News (Updated)


February 24th, 2015

The Cadillac high-cost health plan excise tax, which goes into effect in 2018, is one of the last-to-be-implemented provisions of the Affordable Care Act (ACA). It was one of the most controversial provisions of the ACA, which contributed to its delayed effective date. But 2018 is now getting closer, and the Internal Revenue Services (IRS) is beginning a discussion about implementation of the Cadillac plan tax.

The Cadillac plan provision of the ACA will impose a 40 percent excise tax on the cost of employer-sponsored health plans when that cost exceeds certain thresholds. It is projected to be one of the biggest sources of revenue under the ACA; the Congressional Budget Office (CBO) in its 2015 Budget and Economic Outlook Report estimated that it would account for $149 billion in revenue between 2018 and 2225. Of this, however, only one quarter will come from the tax itself, while three quarters will come from increases in taxes on income as employers shift compensation from health benefits to taxable wages.

While the tax will affect few plans initially, it is likely to affect many more plans over time as the cost of health care continues to grow faster than inflation generally. The tax is expected to reduce health care expenditures by individuals, as it will drive employers to increase employee cost sharing as they cut the cost of coverage, and employees are likely to spend less on health care if they have to purchase it out-of-pocket rather than drawing on insurance coverage.

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An Era Of Precision Medicine And Rapid Learning


February 20th, 2015

At a recent White House event, President Obama presented his proposals for a Precision Medicine Initiative. The key elements include a national research system where 1 million or more volunteers can share their (privacy protected) electronic health records, genetics, and other data, and a national cancer initiative. The proposals will be developed in more detail based on meetings led by the National Institutes of Health (NIH) Director Francis Collins.

If national health policy adopts these proposals, much about today’s medical care system—including biomedical science, medical education, diagnostics, treatment options, comparative effectiveness research, quality metrics, payment systems, the role of patients, the personalization of medical care and prevention, and an understanding of the roles of environment, nutrition, culture, and many other factors—may greatly change.

The Obama administration proposes a highly collaborative, non-partisan public-private process. These proposals bring the era of “big data” to the center of the heath policy arena (see the July 2014 Health Affairs theme issue, “Using Big Data To Transform Care”). Many in the health system may want to take part in developing the proposals and being part of the implementation.

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How Open Data Can Reveal—And Correct—The Faults In Our Health System


February 18th, 2015

In April 2014, the Centers for Medicare and Medicaid (CMS) released millions of lines of Medicare Part B physician payment data, that led many researchers, analysts, journalists, and the general public to use the data to answer a number of pressing health care questions. And while the dataset does not include patient-level information, it does offer provider identifiers, which can facilitate data aggregation, highlight practice patterns, and cost trends (i.e. specialties with disproportionately higher payments and individual providers as “outliers”).

Our goal here, like many before us, is to highlight striking disparities in this dataset (despite its limitations); attempt to understand why they occur; and provide opportunities to address them.We examine three major issues: geographic variation; individual provider variation; and variation across care settings. Finally, we outline recommendations for future data releases to encourage more practical analyses.

Geographic Variation in Practice Patterns

A popular example highlighted by the CMS data was the rate of use of Lucentis — a drug prescribed for patients with age-related macular degeneration (AMD). Although a clinical study demonstrated similar outcomes for Lucentis ($2,000 per dose) versus Avastin ($50 per dose), the CMS data revealed total Lucentis spending of $1 billion.

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Implementing Health Reform: Enrollment Figures, Tax Forms, And More


February 13th, 2015

We are rapidly reaching the end of the 2015 open enrollment period, and the pace of enrollment seems to be picking up a bit. On February 11, 2015, the Centers for Medicare and Medicaid Services (CMS) released their enrollment snapshot for week twelve, covering the federally facilitated marketplace from January 31 to February 6.

During that time period, 275,676 individuals selected plans, bringing of enrollees in the federal exchange up to 7,749,375. The Department of Health and Human Services (HHS) reportedly announced on a press call on February 11, however, that 200,000 individuals will be dropped from enrollment in February for failure to satisfactorily document compliance with citizenship or residency requirements.

Enrollment is expected to continue to pick up during the final ten days of open enrollment, as it did last year. CMS has said that if an individual cannot get through at the call center or online on February 15, CMS will make sure that he or she can apply for coverage, but the agency has not announced any further relief nor any new special enrollment periods for 2015. I continue to urge CMS to provide a special enrollment period for people who were subject to the individual responsibility penalty for 2014 to allow them to avoid the penalty for 2015.

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Oregon Bridges The Gap Between Health Care And Community-Based Health


February 12th, 2015

It is now commonly accepted that to achieve health, the U.S. health system must address the social determinants of health. While the integration of health care with social services and public health is happening relatively infrequently across the country, one bright spot can be found in Oregon, where an innovative Medicaid health system model, referred to as the coordinated care model, is showing early signs of success in bridging the gap between the community and the health care system.

Under Oregon Governor John Kitzhaber’s leadership, newly created coordinated care organizations (CCOs)—partnerships between physical, behavioral, and oral health providers—have over the past two years adopted Oregon’s coordinated care model, which was created as the foundation for Oregon’s health system reform efforts to ensure care is coordinated, performance is measured, positive outcomes are rewarded, and that there is a shared responsibility for health, sustainable rate of growth, and transparency in price and quality—all with the goal of promoting positive health outcomes.

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New Narrative Matters: How Access, Knowledge, And Attitudes Shaped My Sister’s Care


February 6th, 2015

Health Affairs‘ February Narrative Matters essay features a woman who helps her sister get the care she needs when a tooth infection turns into a health emergency. Elizabeth Piatt’s article is freely available to all readers, or you can listen to the podcast.

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