Watch this informative/funny/tragic video by Mary Harron from the We The Economy channel on YouTube. It packs a lot of information into an entertaining video. Please share with your friends, neighbors, family, co-workers, and anyone else you can think of!
The Affordable Care Act (ACA) continues on its painful journey. Major technical problems remain in the statute, such as the “family glitch,” in which lower-income workers are offered employer coverage but their families are not and are also ineligible for exchange subsidies.
The congressional leadership wants to repeal the ACA rather than fix it, but lacks the votes to override a veto. Many Republican states have refused to implement the ACA’s Medicaid expansion. And in the pending King v Burwell case, the US Supreme Court could strike down subsidies in federal exchanges, leading to chaotic gridlock.
But a provision of the ACA is now attracting attention as a way out of this mess. It provides not only what is essentially an exit strategy for Republican states but also, paradoxically, a way for supporters of the ACA to preserve the law.
The Opportunity for States
Section 1332 of the ACA, known as “State Innovation Waivers,” allows states, starting in 2017, to apply to the federal government for 5-year renewable waivers from key provisions of the legislation. For instance, states could request changes to or exemptions from the individual and employers mandate, the market exchanges, the exchange subsidies, the Essential Health Benefits requirements, and other provisions. Moreover, states can combine waivers from ACA provisions with waivers from Medicaid provisions (so-called 1115 waivers), Medicare, the state Children’s Health Insurance Program, and waivers available through “any other Federal law relating to the provision of health care items or services.”
The opportunity for states to transform the ACA within their borders is breathtaking. It’s little wonder that a former top aide to the late Senator Edward Kennedy describes Section 1332 as “state innovation on steroids.”
Section 1332, however, is not a blank check for states to ignore the whole intent of the ACA, even assuming the White House or the next administration were open to that. It has important fine print. To obtain a waiver, a state’s proposal must retain important protections, such as guaranteeing that health plans accept an applicant regardless of their health status or other factor. The proposal’s coverage must be “at least as comprehensive” and cover “at least a comparable number of its residents” as the ACA, and insurance must be as affordable. Any state plan must also be budget neutral for the federal government.
Even with these limitations on state plans, section 1332 could lead to state health plans in the future that change the ACA beyond recognition. A Republican state like Arkansas, Utah, or Texas, for instance, could use the section to take the federal money for Medicaid expansion as a block grant and turn it into subsidies for families to buy private coverage. These or other states could also end the mandates on individuals and employers, perhaps using government-encouraged auto-enrollment for insurance to meet the ACA’s coverage projections. Meanwhile, states like Vermont, Oregon, and Hawaii could design waivers to create a form of single-payer health system.
Room for Maneuvering
The so-called guardrails associated with section 1332 could also be looser than they seem. For instance, since the US Supreme Court in 2012 struck down the requirement on states to expand Medicaid, the “comparable number” waiver stipulation for coverage in a nonexpansion state like Texas is much less onerous for the state.
In addition, the definition of federal budget neutrality could get rather metaphysical, depending on how baseline is defined—in other words, the amount of federal spending that would occur in the future without a 1332 waiver. Again, for a state like Texas or Florida, the baseline could be calculated only on the basis of projected exchange plan subsidy costs (because these states have not expanded Medicaid). But if such states declared that in principle they want to expand coverage to the Medicaid-eligible population, albeit in another way, then the baseline could include the extra projected spending. If so, nonexpansion states could propose a budget-neutral waiver that uses billions of “new” federal dollars to construct a market-based health plan.
The political ramifications of this wide flexibility under section 1332 are immense. For instance, Republican opponents of the ACA, recognizing that the foreseeable congressional makeup means outright repeal of the ACA is not feasible even if Republicans win the White House in 2016, would have a strategy for states to exit much of the ACA. Meanwhile liberals in other states would have a tool to move closer to their dream of a single-payer system. And the White House could claim that even in the Republican states with sweeping waivers, the ACA had been fully implemented. Moreover, the 1332 waivers would allow many of the technical problems of the ACA to be fixed at the state level without going to Congress.
A Solution for King v Burwell
If the Supreme Count decides in favor of the plaintiff in the King v Burwell case, striking down subsidies in states with federal exchanges, the ruling could also trigger a critical role for section 1332. Because 1332 does not even require exchanges and permits states to use the money for federal subsidies in quite different ways, it could be possible for states with federal exchanges today to finesse a King decision by using 1332. Republican states currently with federal exchanges could use the money for subsidies to empower residents to buy coverage in other ways. Democratic supporters of the ACA could redesign their exchanges or move in a different direction without needing to pursue legislation from Congress.
The wrinkle in this scenario right now is that section 1332 does not go into effect until 2017. But if the King v Burwell ruling results in millions of Americans losing affordable coverage, it would be the kind of crisis that produces a political deal in Congress. In return for agreeing to change the law to permit exchange subsides to continue at least temporarily in federal exchanges, Congress could insist on making 1332 take effect immediately and allow states to develop plans for waivers before a subsidy extension ends. It would be in the White House’s interest to agree to that. Republicans would avoid a potential backlash from physicians, hospitals, and newly uninsured constituents and allow many states effectively to take an exit ramp from the ACA.
The Republican Congress might also be able to force the White House to agree to changes in 1332 to make the Administration less able to block waivers, making the procedure less politically risky for Republicans. One way to do that would be to make certain types of waivers subject to automatic approval unless the Administration can show technical flaws. Another, as I proposed some years ago, would be for states to apply for fast-track congressional approval of waivers cleared by a federal-state commission.
With all these possibilities, it is little wonder that there’s growing interest in section 1332.
by Roberta Hall, Oct. 17, 2014
Despite all the bad news about Cover Oregon, its CAC met Oct. 17, with new Executive Director Aaron Patnode in attendance throughout. As a final comment, he reported that there is NO option for any state NOT to have an exchange, though Cover Oregon likely will be housed under another agency. A brief update concerning 2015 and for details contact member Bobbi Hall at firstname.lastname@example.org:
Budget will be 12 to 15 million dollars, down from 90 million this year; expanded Medicaid enrollees who entered via Fast-Track (Food-Stamp recipients) will need to apply, but other current enrollees will be sent a form to certify that their financial situation has not changed (or has); most people will apply via Healthcare.gov; new OHP clients can enroll anytime as can tribal members and certain others, but for most, enrollment begins Nov. 15; Navigators as well as Agents are receiving training on the use of Healthcare.gov. This past year approximately 100 small businesses (with 2 to 50 employees) were enrolled; they did not use the website and again will enroll directly but the federal government has told Cover Oregon that internet access must be ready for these businesses before the end of 2015.
Main news is the numbers: Medicaid increased 58% this year, from 614,000 to 976,000; about 77,000 Oregonians enrolled in a Qualified Health Plan. Currently about 1,694,657 people are in either OHP or Medicare, out of 3,961,514 people so that makes ~43% covered by what is primarily federally-paid health insurance. About 5.1% of the population now lack health insurance (down from 14%) while about 5.5% have private insurance and ~46.5% have group insurance (mostly through employers). Much insurance covers an average of 70% of health care costs, however.
Explained in 7:35 minutes.
Meet the chair and coordinator
The Community Advisory Council elected Larry Eby, MD, Albany, as its chair in April, 2013. In a separate action, Rebekah Fowler, PhD, Corvallis, was hired as the coordinator for the volunteer body.
Eby is a graduate of the University of Michigan Medical School and practiced medicine mainly as a general surgeon in Ohio, Puerto Rico, and Nigeria and briefly as an emergency room physician in Newport. He has been active in health care access and improvement issues in the Albany and Corvallis areas for several years.
“I am a strong advocate for health delivery reform as a means for improved health outcomes and satisfaction leading to lower cost,” said Eby. “My son, Dr. Douglas Eby, is vice-president for medical services for the South Central Foundation, which is the agency for medical care for much of the Alaska Native population. There he has been one of the architects of a delivery system that is being copied in many other parts of the U.S. and Canada, especially their Patient-Centered Medical Home system. He was in this area about two years ago and spoke to several groups in Corvallis and Albany. I have visited Medical Homes in Alaska on several occasions and have seen how their system works. This is my strongest asset to bring to any role within the coordinated care system.”
As the Council’s chair, Eby also serves as a voting member of InterCommunity Health Network Coordinated Care Organization's (IHN-CCO) Governing Board.
View live video of Eby's address during a recent public meeting hosted by IHN-CCO.
Fowler, the Council’s coordinator, works council representatives to ensure that they have the support they need to meet the requirements spelled out by the Oregon Health Authority in its contract with IHN-CCO.
Previous to her work on the Council, Fowler, a native Oregonian, coordinated Oregon Health Plan member advisory councils for the Accountable Behavioral Health Alliance. She also worked to develop non-traditional health worker programs within that agency’s five-county region. She holds a doctorate in social psychology and a master’s of science in experimental psychology.
“I look forward to working with the Council and applying my strong commitment to transforming health care through effective collaboration and communication,” said Fowler.
“With the selection of Dr. Eby as chair, and Dr. Fowler as coordinator, our Advisory Council now has all the elements in place to begin their work to oversee a regional health improvement plan that supports Oregon’s triple aim of better health, better care and lower cost of care,” said Kelley Kaiser, chief executive officer of IHN-CCO.
The Advisory Council also works with IHN-CCO to identify and advocate for preventive care practices, oversees a community health assessment, and annually publishes a report on the progress of the improvement plan.
The public is welcome to attend any meeting of the Advisory Council and participate during the public comment period allowed. Meeting dates, agendas, and minutes of the Advisory Council are published on this website. Anyone wishing to receive an email notice of events can sign up for this service.
The March meeting of the Cover Oregon Consumer Advisory Committee (CAC) provided little new information except that enrollments by hand and, to some extent, using agents operating directly through the internet, are continuing, but still are behind schedule. Agents help clients with commercial products and community partners help clients who qualify for the Oregon Health Plan (OHP/Medicaid), and at least as I understand it, no agents have yet been compensated for the time taken out of their business to do this. The hope is there, but in this health care episode, there are many uncompensated players. Beneficiaries are those who have succeeded in getting signed up for Oregon Health Plan or gotten lower cost and improved insurance coverage, many (about 79%) with federal tax credits covering part of their premium. Some who qualify, however, still lack coverage.
The relationship between Cover Oregon and Oracle continues to be difficult. The Oregonian reported on Mar. 13 that a federal report on Oracle and Cover Oregon is scathing. However, it did corroborate the statements of some Cover Oregon employees that Oracle had repeatedly denied requests for information--that is, Cover Oregon had attempted to manage the contract, but been rebuffed. Clearly, the contract itself had been deficient, based on non-existent trust.
At the April CAC, members will discuss what other things Cover Oregon can do to accomplish its mission of improving the health of the population.
One optional ACA expansion, Basic Health, is being studied. It is a program to extend health services to more low-income people (those under 200% of the poverty line), including legal immigrants with less than 5 years residence who heretofore have been excluded from Medicaid (OHP). A bill to establish this study, HB 4109, passed in March. A discussion I had with the Chair and Vice-chair of the House healthcare committee about what Basic Health is aired Mar. 10 on KBOO and can be heard here.
John A. Kitzhaber, MD, Governor
February 4, 2014
Oregon‘s fourth Health System Transformation report indicates that the coordinated care model is continuing to improve key areas of care for Oregon’s Medicaid population, while keeping costs down. The report released today shows coordinated care organization (CCO) progress for the first nine months of 2013 on key performance and cost measurements.
“Emergency department visits and spending are decreasing under the coordinated care model,” said Tina Edlund, acting OHA Director. Measurements indicate Oregon’s CCOs are lowering unnecessary hospitalizations for conditions that can better be treated elsewhere. “There are also reductions in hospital readmissions, largely due to community efforts to achieve the highest quality care and to keep people at their healthiest,” she said.
• Decreased emergency department visits: Nine full months of reporting shows that emergency department visits by people served by CCOs has decreased 13 percent from 2011 baseline data.
• Decreased hospitalization for chronic conditions: Coordinated care organizations reduced hospital admissions for congestive heart failure by 32 percent, chronic obstructive pulmonary disease by 36 percent, and adult asthma by 18 percent.
• Increased primary care: Spending for primary care is up more than 18 percent. Enrollment in patient-centered primary care homes has also increased by 51 percent since 2012, the baseline year for that program. More than two-thirds of CCO members are now enrolled in patient-centered primary care homes.
• Increased adoption of electronic health records: Electronic health record adoption among measured providers has doubled. In 2011, 28 percent of eligible providers had adopted electronic health records. By September of 2013, 58 percent of eligible providers were using them.
• All-cause readmission: The percentage of adults who had a hospital stay and were readmitted for any reason within 30 days of discharge dropped from a 2011 baseline of 12.3 percent to 11.3 percent in the first nine months of 2013, a reduction of 8 percent.
Full press release here
Vermont Tests Single Payer and the Country is Watching
By Darshak Sanghavi, M.D., and Sarah Bleiberg
KevinMD blog, Jan. 28, 2014
While the Affordable Care Act, or Obamacare, has been criticized by its opposition as “socialized medicine,” it relies heavily on private health insurance. On the other end of the political spectrum is the idea that a government-run single payer system, similar to Canada’s, is the best way to deliver health care. (This is sometimes shorthanded in the U.S. as “Medicare for All.”) However, this system has been believed politically impossible here—until now. In May 2011, Governor Pete Shumlin of Vermont signed into law “An Act Relating To A Universal And Unified Health System,” House Bill 202 (HB 202), establishing a single payer health care system beginning in 2017. In passing this legislation, Vermont has become a closely watched laboratory for health reform.
What are the pros and cons of a “single payer” system?
In general, single payer health care means that all medical bills are paid out of a single government-run pool of money. Under this system, all providers are paid at the same rate, and citizens receive the same health benefits, regardless of their ability to pay.
There are a number of proposed benefits to a single payer system. Currently, providers must follow different procedures with each of many insurance companies to get paid, creating an enormous amount of administrative work. Under a single payer system, providers might reap significant savings from reduced administrative expenses, and be able to focus more on delivering care. As with Medicare, a single payer system may also give the state stronger leverage to negotiate lower rates for drugs, medical devices, payments to providers and other expenses, resulting in lower overall costs. Additionally, a single payer system provides universal access to health insurance, which eliminates the problem of the uninsured.
InterCommunity Health Network Coordinated Care Organization (IHN-CCO) serves Oregon Health Plan members from Linn, Benton, and Lincoln counties. The Community Advisory Council works together with InterCommunity Health Network CCO to identify and advocate for preventive care practices, oversee a community health assessment, adopt a regional health improvement plan, and annually publish a report on the progress of the improvement plan.
Date: Monday, January 13, 2014
Time: 2:00 p.m. – 5:00 p.m.
Location: Sunset Building, Sunset Conference Room (first floor)
Address: 4077 Research Way, Corvallis, Oregon
Call-In: 1-866-439-0933, participant code 5093665467
Here is the Agenda.