Washington Post columnist looks at data, talks to experts and concludes Obamacare is working, at less cost than expected

The federal health-reform law "has accomplished its goal of expanding coverage — at a significantly lower cost than expected," columnist Ruth Marcus writes for The Washington Post "after talking to numerous health-care experts and examining the data."

Marcus writes up front, "There is a legitimate ideological debate about whether it is a wise use of federal power to require individuals to obtain health insurance or a wise use of federal resources to spend so much on subsidizing coverage. What’s more puzzling, and more disturbing, is the still-raging division over the real-world effect of the ACA."

She says President Obama "over-promised when he told people that, if they liked their health insurance, they could keep it; by its own terms, the law set new standards for required coverage. Certainly, some individuals, particularly younger and healthier customers, find themselves paying more; again, such winners and losers were an inevitable consequence of the individual mandate and minimum-coverage rules. Meantime, the scariest warnings — of employers rushing to drop coverage and insurance markets ensnared in death spirals of ever-rising premiums — have not come to pass.
Where the law has yet to fully deliver on its promises — and some wonder whether it will — is in the area of cost containment and quality improvement."

Marcus backs up her assessment with facts. For example, "Health-care costs and premiums for employer-sponsored insurance (the way most of us obtain coverage) have been rising at their lowest levels in years. On the exchanges, premium increases during the law’s second year mirrored that modest growth — averaging 2 percent on some mid-range plans and 4 percent on the lowest-cost ones, according to the Kaiser Family Foundation."

Health reform law has been good for hospital finances, health-care costs, Obama administration says

U.S. hospitals have saved billions of dollars because the federal health-reform law has provided coverage for patients who were once charity cases, the Obama administration announced Monday, the fifth anniversary of the Patient Protection and Affordable Care Act.

"Hospitals also saw fewer emergency room visits, which rack up far higher costs and often leave hospitals with the tab," Sarah Ferris writes for The Hill, which covers Congress. "The government’s report, which focuses on the benefits of Medicaid expansion, is an effort to entice states that have been politically resistant to expanding the program."

Kentucky hospitals have acknowledged that the law has reduced their losses from "uncompensated care," but say other aspects of the law have created a mixed effect, depending partly on hospitals' ability to adapt. The increase in coverage has brought hospitals much more money, but they say continued problems with managed-care Medicaid have cause them financial difficulty.

From paying patients' point of view, the law appears to have reduced inflation in health-care costs, but has not achieved advocates' goal of reducing costs. A White House report said, "Since the Affordable Care Act was enacted, health care prices have risen at the slowest rate in nearly 50 years. Thanks to exceptionally slow growth in per-person costs throughout our health care system, national health expenditures grew at the slowest rate on record from 2010 through 2013."

For the White House's Kentucky-specific list of benefits of the law, click here.

Reform law 'quietly accomplishing the goals it was created to achieve,' McClatchy Newspapers reporter writes

The federal health-reform law is still controversial and still facing a legal challenge, but "is quietly accomplishing the goals it was created to achieve," Washington correspondent Tony Pugh reported for McClatchy Newspapers on the occasion of the law's fifth anniversary. (The Lexington Herald-Leader is a McClatchy paper.)

"The nation’s uninsured rate has plummeted as more Americans enroll in Medicaid or in federal and state marketplace coverage," Pugh notes. "The law’s consumer protections and insurance-benefit requirements have improved the quality of coverage for millions of people who get health insurance outside the workplace. Premiums for marketplace health insurance have largely been reasonable and have increased only moderately thus far. Long-term cost estimates for providing coverage under the law have been falling."

Howver, Pugh writes, "The law may never overcome the bitter politics that surrounded its enactment and that partly define its legacy. Long viewed as a government overreach, the health-care law has been problematic for those who want the private insurance market to dictate who gets health insurance and what it should cost. . . . Moreover, the law’s requirement that most Americans have health insurance is seen as an infringement on individual freedom. The Supreme Court ruled in June 2012 that the so-called individual mandate didn’t violate the Constitution."

The White House issued a state-specific list of the law's benefits. For Kentucky's, click here.

Health foundation says consumers need price transparency; Medicaid health officer says some commercial interests want it

Kentucky Health News

The Foundation for a Healthy Kentucky says a major step needed to improve the health of Kentuckians is transparency of their health-care cost and quality.

"Consumers can (then) compare apples to apples," Susan Zepeda, the Foundation's president and CEO, told Greg Stotelmyer of Public News Service. "What is a particular procedure going to cost if I have it at this hospital versus that outpatient surgery center? What are my co-pays going to be or my deductibles under my insurance plan?"

The foundation recently recommended that Kentucky develop and establish an all-payer claims database, or APCD, for consumers and stakeholders as a tool for transparency. John Langefeld, chief medical officer of the state's Department of Medicaid Services, told Stotelmyer that "support for the idea is growing, including from many on the commercial side of health care."

But this type of transparency is not likely to happen without a law to require it, which Kentucky does not have, Stotelmyer reports.

Massachusetts is the only state that requires the type of health-care transparency the foundation is talking about. And while it is not a perfect system, with reported prices not reflecting all of the involved charges, frequent price changes and weak information about the quality of care, it is still "unlike anything else in the country," Martha Bebinger reports for Kaiser Health News.

Oregon could possibly become the second state to require health-care transparency. Two bills for it are pending in the current legislative session. One that would require hospitals to reveal their median prices for common inpatient and outpatient procedures, "is expected to get very little opposition as it makes its way through the legislative session," Chris Willis reports for KGW in Portland.

But physician and system theorist Deane Waldman argues in the Huffington Post that price transparency won't work. She says that transparency can't reflect the real cost of health-care, doesn't reflect health outcomes or quality of care, and when it does reflect outcomes, it only reflects the average outcome and not individual probabilities. She also says that because the current health-care in the U.S. is not a free market, consumers have no reason to economize.

The Foundation for a Healthy Kentucky disagrees. "Sunshine on pricing will make sure that we're all playing by the same rules," Zepeda told Stotelmyer. Kentucky has the ability to gather the data, but it still needs "the political will" to do so, she said.

Foundation for a Healthy Kentucky wants a claims database to increase transparency about health-care cost and quality in Ky.

Kentucky has experienced rapid changes in health care since the implementation of the Patient Protection and Affordable Care Act, and the next step is to implement a program that will provide more transparency about the cost and quality of health care so consumers can make informed, value-based health decisions, says a news release from the Foundation for a Healthy Kentucky.

A recent Kentucky Health Issues poll found that most Kentuckians think they can find out what doctors charge for treatments and procedures if they need this information. They seem to believe that transparency already exists, but this is often not the case.

The foundation recommends that Kentucky develop and establish an all-payer claims database, or APCD, for consumers and stakeholders as a tool to address this issue of price transparency.

"Clear, factual information about the cost and quality of health care is necessary for consumers to select value-driven care and for consumers and providers to be involved and accountable in their decision about their health and health care services," says the release.

The APCD Council defines APCDs as “large-scale databases that systematically collect health-care claims data from a variety of payer sources which include claims from most health-care providers," says the news release. The information includes patient demographics, provider codes, and clinical, financial and utilization data. This information is then made available to the public.

The foundation said it analyzed national and state expert presentations, reviewed studies and held a meeting in October with more than 60 Kentucky leaders in government, business, policy and health care to discuss the issue.

Participants discussed barriers, feasibility, solutions and other factors in implementing price transparency in Kentucky from the perspectives of the consumer, provider, policymaker and researchers. Here are some of their collective findings, according to the release:

• Current cost and health service information are difficult to understand. 
• Price and quality data need to be useful to the consumer through simple, useful tools, currently it is not. 
• The state must be involved in implementing an APCD by passing laws to require the collection and sharing of data and requiring the data to be reported publicly. 
• An effective APCD would allow estimates and cost comparisons between providers; would include expected out-of-pocket costs and quality measures that can be compared across providers; would have the ability to see spending patterns over time for all enrolled under one policy; would offer individual level data; and would offer health care value-based cost saving tips.
• There is a significant variation in health-care pricing, and physicians may need an incentive to consider cost when making decisions for patients.

Colorado was one of the first states to establish price transparency legislation, data collection and reporting on a state-wide level. Representatives from that state's APCD said it was initially funded by foundations, but will use fees to sustain itself going forward.

Bill to cap co-payments for drugs is backed by emotional testimony, but opposed by health insurers and employer groups

By Melissa Patrick
Kentucky Health News

FRANKFORT, Ky. -- People with chronic conditions are often denied the best medication for their condition because it is not on their insurance plan's preferred formulary, which makes the co-payment more for that medication than they can afford.

Sen. Tom Buford

Senate Bill 31, sponsored by Tom Buford, R-Nicholasville, would put a $100-per-month cap on co-payments for a 30-day supply of a medication for drugs subject to a tiered formulary, and not to exceed $200 per month total for all medications. House Bill 146, sponsored by Rep. James Kay, D-Versailles, has a similar bill that is currently in the House Banking and Insurance committee.

The Senate Health and Welfare Committee heard discussion on this bill Feb. 25, which opened with an impassioned plea from Buford to pass it. He said 18 states have passed or are in the process of passing similar bills. But they face strong opposition from the insurance industry and employers, and the bill has been on the committee agenda "for discussion only."

Buford said insurance companies have avoided big increases in premiums by raising co-payments, "which have gone over 54 percent and some 80 percent." Saying the average salary of Kentuckians is $23,700, he said many have to chose between living expenses and paying for medicine. "You may have insurance, but you may not have health care," he said.

The state Department of Insurance estimates that the bill would increase premiums by $3.20 to $4 per month and, because of greater utilization of services, raise the ultimate health-care costs of all insured Kentuckians (except those on state plans) by $2.58 to 3.23 per month.

Buford disputed the estimate, saying it essentially comes from the insurance industry. He acknowledged that capping co-pays would raise costs, but said the increase could be modest. He said that after Vermont passed a cap, the cost averaged only 32 cents per month per member for large-group plans and 74 cents per month for small-group plans.

Tom Underwood, state director of the National Federation of Independent Business, said the bill would primarily affect small-group employers, partly because small businesses have no power to negotiate with insurance companies.

Julie Davis of Glasgow, who has epilepsy, told the committee that she was forced to switch insurance this year, and a $60-per-month medication that she had been taking for seizures now cost $1,200 per month. She said they made her switched to a generic medicine, against the advice of her neurologist, and since has had her first breakthrough seizure in two and one-half years.

Getting emotional, Davis said that when she has such seizures, "I am out of commission for almost a month" and this has forced her to give up a job that she loved, move in order to be closer to a support group, and only allows her to work from home. She also said that at times she "fears for her life," and her insurance company has denied her appeals.

Deb McGrath of the Epilepsy Foundation said it had found that the most commonly prescribed and effective epilepsy drugs are on the non-preferred list of the "silver" plans on the state health-insurance exchange, the most common type of plan. A patient must pay a 40 percent co-insurance or a high deductible plus a co-pay to get a preferred drug on these plans.

She said the U.S. Department of Health and Human Services has called the practice of limiting coverage and imposing high cost-sharing for drugs that treat certain conditions "discriminatory."

McGrath said, "These barriers make it impossible, near impossible, for individuals, for those living with chronic health conditions like epilepsy, like arthritis, Alzheimers, crones disease, diabetes, and AIDS access to care that they desperately need."

Carl Breeding, a lobbyist for American Health Insurance Plans, gave the committee a letter from the Insurance Commissioner Sharon Clark, which he summarized as saying this bill would "prevent the state from being able to work" under federal health reform because of the way deductibles work and would "eliminate the bronze plan," the lowest-cost plan.

But Mark Guimond, a lobbyist for the Arthritis Foundation, said the lack of co-pay caps can increase costs because the resulting lack of medication can lead to hospitalizations, surgeries and time off work. "These are extremely expensive medications: $1000, $2000, $3000 a month," Guimond said, and patients "are being stuck with co-pays or co-insurance that may be 30-40-50 percent of these amounts."

The Kentucky Association of Manufacturers, which opposes the bill, wrote in the Lexington Herald-Leader that "These increased costs take away capital that state manufacturers could otherwise deploy to reinvest in their plants and more importantly remain competitive globally, so that we can continue to employ hard-working Kentuckians."

In animated remarks to the committee, Buford replied, "I hate to say this, but I could care less if we beat Japan in making toys if it depends on someone's life and health and the ability for them to live. It's more important apparently for some to deny the insurance than it is to make that profit on the bottom line of their company."

Poll illustrates how having insurance and access to a health care provider doesn't mean you can afford the care

Just because a person has appropriate access to a health care provider doesn't mean they can afford to pay for their services, according to the latest Kentucky Health Issues Poll.

The poll found that three out of every four Kentuckians with health insurance now have access to a health-care provider, defined as a usual or appropriate source of care. However, it found that lower-income Kentuckians are choosing to forgo or skip medical care because they still can't afford it. The poll found only about half of uninsured adults have a "typical and appropriate" health care provider.

The poll, taken Oct. 8-Nov. 6, found that 22 percent of Kentuckians said they or a family member needed health care in the past 12 months, but did not get care or delayed it because of cost. That was a decrease from 32 percent in 2009.

Not surprisingly, those with less money are more likely to forgo health care because they can't afford it. The poll found almost one-third, or 32 percent, of people with household incomes at or below 138 percent of the federal poverty level ($32,913 for a family of four) said they were likely to defer medical care due to cost. That figure was 14 percent among people with incomes more than 200 percent of the poverty line.

As for those who did seek medical care, 31 percent reported they or a family member had difficulty paying the bill in the previous 12 months. Among those without insurance, 47 percent said they had trouble paying a medical bill in the past 12 months.

“Being able to afford needed medical care and having access to appropriate usual sources of care are two important challenges that may prevent a person from receiving care,” said Susan Zepeda, President/CEO of the Foundation for a Healthy Kentucky, which co-sponsors the poll. “KHIP data indicate lower income Kentucky adults have to forgo treatment more often than their higher income neighbors and are more likely to have problems paying for their care.”

The poll is conducted by the Institute for Policy Research at the University of Cincinnati and is co -sponsored by Interact for Health, formerly the Health Foundation of Greater Cincinnati. It surveyed a random sample of 1,597 adults via landline and cell phone, and has a margin of error of plus or minus 2.5 percentage points.

The price for health care could be right, if it's known

By Molly Burchett
Kentucky Health News

People often shop around and compare prices when making a large purchase, and some consumer advocates, employers and health plans are pushing for price transparency in health care so it's easier for consumers to compare prices. However, many questions remain about whether or not price transparency is possible, or if it would even affect health costs and outcomes.

Making it easier for consumers and patients to compare prices encourages them to look around for a better deal, says a study published in the Journal of the American Medical Association. The study focused on the use of Castlight Health's online pricing platform and explored whether there was a reduction in costs to employers and employees for laboratory tests, advanced imaging services and clinician office visits.

Lab tests and imaging saw the biggest savings in the study, dropping 14 percent and 13 percent, and primary care offices visits also dropped by 1 percent, according to the study. Additionally, the study showed that claim payments were lower for all services for employes who used Castlight versus those employees who did not.

But less expensive care doesn't always equal higher quality care. Price transparency’s impact is realized only to the extent that it empowers consumers and influences their behavior, and price is only one of the variables that consumers need to evaluate the value of health services.

"One thing the study can't answer is whether patients are making better decisions or just cheaper ones. They're finding lower-cost options, the study finds, but it doesn't tell us how patients are taking into account things like patient satisfaction, years of clinician experience and other provider characteristics," writes Jason Millman of The Washington Post.

Another important thing the study both can't and wasn't designed to predict is whether transparency will reduce overall health spending, writes Millman. Health-care economist Uwe Reinhardt writes, in a separate JAMA editorial, that early results of research suggest that price transparency in health care can result in less spending.

Other experts have expressed doubts about this "free market" approach. In a Huffington Post article, physician and systems theorist Deane Waldman says that price is not one of the pieces of information consumers need to re-install free market forces into health care because the present health-care market in the U.S. is not free.

"The consumer can have all the information in the world, but without control of his/her own money, and without sellers competing for those dollars, the market will not work. One cannot have the advantages of free market forces if the market is not free," writes Waldman.

Similarly, Reinhardt says that comparing the costs of procedures only works if people have a choice between healthcare providers. That may be a major complication for Kentuckians in rural areas where providers may be scarce or insurance coverage may not be comprehensive.

Massachusetts is the first state to mandate some level of price transparency. However, resistance from both provider and payer communities suggests that large-scale adoption of transparency initiatives will likely be both heavily debated and slow.

Health-care forum examines 'incredible change' in Kentucky's health-care system, looks forward to more access to care

By Molly Burchett and Al Cross
Kentucky Health News

What does health-care reform mean to Kentucky? What impact has Medicaid expansion had? Can we work together to do care differently in Kentucky? Answers to these questions and more were offerd by national, regional, and local health care experts Sept. 16 in Louisville at the Foundation for a Healthy Kentucky's annual Howard L. Bost Health Policy Forum.

This year's topic was "Doing Care Differently," but as foundation chair David Bolt, deputy director of the Kentucky Primary Care Association, told the crowd, "It could have just as easily been named after the Bob Dylan song, 'The Times They Are A-Changin'."

As a health-care provider for 44 years, Bolt said, "I have lived through almost every change since the implementation of Medicare and Medicaid. And I am actually excited about the changes I see on the horizon." He said he thinks the late Dr. Bost would look at what Kentucky is doing and say," It's about time we moved away from a treat-'em-and-street-'em mentality to integrated health care delivery services and systems rooted in accountable outcomes and founded in a value-drive system of improving health."

One of the biggest recent changes in Kentucky health care is Gov. Steve Beshear's expansion Medicaid at the beginning of the year, which offered coverage to Kentuckians under 65 in households up to 138 percent of the federal poverty level. As a result, Medicaid is now the largest health-care payer in the state, serving 1.1 million Kentuckians, one out of every four, Cabinet for Health and Family Services Deputy Secretary Eric Friedlander told the crowd.

"We had incredible enrollment. It's an incredible change." said Friedlander. "We hope it is a change for the better."

Friedlander said enrollment in every county exceede estimates for the state by the accounting firm PriceWaterhouse Coopers, based on estimates from the Congressional Budget Office. Those estimates anticipated 55 percent of eligible persons enrolling in the first year, leveling out at 70 percent in future years. Instead, enrollments through June were almost double the prediction.

Medicaid paid more than $284 million to Kentucky health-care providers in the first half of this year for treating the newly eligible Medicaid beneficiaries, with hospitals receiving 48 percent of those reimbursements, Friedlander said. He said that number will be $1 billion to $2 billion by the end of the year. (Medicaid payments sometimes take months to complete.)

The federal government is paying the entire cost of the newly eligibles through 2016. State officials have said that they won't be able to update cost estimates for 2017 a few more months because additional data must be collected about enrollees after the insured population has stabilized.

"Medicaid expansion is not static," Friedlander said. "It is dynamic, and the individuals that make up that enrollment are constantly changing."

Friedlander said employment in Kentucky health care has increased by 3,800 jobs, but the study estimated that 7,600 jobs would be added in the first year. This means enrollment is almost double what was projected yet job expansion is almost half. That undercuts Beshear's contention, based on the study, that Medicaid expansion will pay for itself by adding heath-care jobs.

As more Kentuckians get insurance, there may be shortages of primary-care doctors, especially in rural areas of states like Kentucky, reports Kaiser Health News. That need could be overstated, Sheila Schuster, a clinical psychologist and executive director of the Advocacy Action Network, said at the forum.

Kentucky has 3,929 advanced practice registered nurses, Schuster said, 54 percent more APRNs than in 2010. A new state law that took effect July 15 "removed a barrier that was keeping them from opening practices," she said. The law allows APRNs to prescribe non-narcotic drugs independently after they have prescribed under physician supervision for four years.

The law was passed after negotiations among the Kentucky Medical Association, the Kentucky Academy of Family Physicians and the Kentucky Coalition of Nurse Practitioners and Nurse Midwives. Schuster suggested that other such compromises are needed to expand access to health care.

"We aren't playing very well with each other in the sandbox," she said, adding that turf battles need to be set aside to keep health-care innovation people-centered.

The forum was co-sponsored by KET, Louisville's Health Enterprises Network, the Kentucky Health Information Exchange, the Kentucky Medical Association and Leadership Kentucky.