After my very fulfilling 2016 of learning new things, I want to spend 2017 learning new skills. I’ve come up with a list, but I’m want your input on what I might do. I also want to see if you have better ideas.
Ideally, I think that I’d like to dedicate two months each skill. I think that a month may not be enough for some of these, and I want to do them right. Some will also clearly require more than two months to “master”, but I think that’s enough to get me off the ground. Here are my thoughts so far:
Knitting
Meditation – I’ve tried before, but I really need to set aside time for this if I’m going to do it
Photoshop/Photography
A language (something like Duolingo or Rosetta Stone)
Drawing
An instrument – I played piano as a kid, but I’d be open to something new
A couple of years ago, I was reading a biography of Albert Einstein. I was struck by how much he, and scientists like him, we versed in philosophy. I realized it was one of the areas in which my education was deficient.
This seemed like a big hole, especially given the rhetoric being flung around about health care reform. People cited the values of our founders, those of America, and how they would feel about reform. I realized I knew shockingly little about this. I did what I usually do in that situation – I took a whole pile of books and spent many summer evenings reading in my backyard with a glass of scotch. My wife is still making fun of me.
That summer led to this post. It also led to this paper. And then years passed.
I like learning new things. I think it’s important. It keeps me fresh. It makes me a better person. I decided, last December, that I wanted to dedicate a significant amount of time this year to learning more about topics I knew little about. I asked for your help in picking them, and in suggesting things I should read or watch. Each month, I wrote up what I learned, and reviewed the materials.
I only missed two months, which isn’t that bad considering I still had a full-time job, wrote 30 or so columns for the NYT, made a hundred videos for Healthcare Triage, wrote a handful of times for the JAMA Forum, and two dozen more for the AcademyHealth blog. Not to mention blogging for TIE. Oh, and I wrote a book.
The individual posts are still available from both The Schedule and here. I wanted to collect all of the sources together in one place, though. The bolded green entries are those I especially recommended. When I look at the list altogether, I can’t believe I managed to get it done. I’m pretty proud of this.
The following originally appeared on The Upshot (copyright 2016, The New York Times Company).
Republicans in Congress will soon be able to repeal Obamacare, as they have long wished to do. The Upshot’s health care columnists, Aaron E. Carroll and Austin Frakt, discuss the possibilities — the practical and the political.
Austin: Though they could change their minds, members of the Republican majority in Congress have said they want to repeal portions of the Affordable Care Act very early in the Trump administration. They’d target key provisions like premium and cost-sharing subsidies; the individual mandate; and various taxes that finance the expansion of coverage.
Instead of repealing these immediately, they will probably delay the repeal so it takes effect in a few years. During that time, they would work (or could work) to develop a replacement plan, possibly with the involvement of Democrats, though that is highly uncertain.
To some people, that might sound like a prudent course of action: to delay major changes so there is time to provide another way for people who rely on Obamacare to get health insurance.
But such a delay is also necessary, because congressional Republicans have not yet coalesced around a replacement plan. That’s not a big surprise because, until now, there was never a reasonable prospect of repeal, so getting specific about replace wasn’t necessary. Also, developing a coherent replacement plan involves challenging policy trade-offs and political risks. It will take considerable time for it to come together.
Aaron: I think the prudence goes even further than that. I’ve seen no proposal for repealing the A.C.A. that doesn’t result in a major disruption of health insurance. Such disruptions are usually extremely unpopular. It’s unlikely that Republicans want to see an electorate mobilized like we saw in the 2010 midterms after the passage of the A.C.A.
Delaying any changes until 2019 or later means that no changes will go into effect until after the 2018 House and Senate elections. No one will yet feel the pain of having to change insurance or providers. Republicans can go into their campaigns claiming to their base that they met their promises to repeal Obamacare without actually having to deal with any repercussions. They could also theoretically claim a mandate for continued change if they retained power.
This isn’t too much different than how the Democrats delayed the implementation of much of the A.C.A. until after the 2012 presidential election. Of course, that didn’t protect them from the backlash they felt in 2010. It’s not clear that delaying would completely shield Republicans either. There are other potential downsides from this plan.
Austin: By downsides, you’re probably thinking of how uncertainty associated with delay will affect health care markets and providers. Think about the major stakeholders:
Insurance companies considering offering marketplace plans might wonder if the investment in the market is worth it. If the A.C.A. will go away — and with any replacement uncertain — perhaps they’ll decide to wait and see. Likewise, insurers already offering plans might decide not to continue to do so since it’s not so clear there’s a future in it.
Hospitals will worry about whether they’ll see an increase in uninsured patients who are unable to pay for their care. That would certainly happen under repeal and is likely to happen under the types of replace plans Republicans are considering, which cover fewer people. Additionally, if some markets are left without plans because all insurers withdraw, hospitals will also experience greater demand for uncompensated care.
Drug and device companies will also worry about potential loss of revenue if fewer people are covered in the future and, therefore, cut back on care and prescriptions.
Finally, states that have expanded Medicaid might retrench, worried they’ll be left with the full costs of expansion once repeal goes into effect. And, states that haven’t expanded are more likely to hold off. Again, why invest in a program that’s going away?
None of this is good for patients and consumers who just want affordable coverage and accessible care. Are there other downsides I’ve not mentioned?
Aaron: It’s the downsides on the patient end that I think are being ignored most of all. Sure, this would be bad for insurance companies, hospitals and device and drug companies. But I think the largest group hit would be the 20 million people who could stand to lose their insurance overnight if repeal kicked into gear without a replacement plan ready to go. Can you imagine the turmoil if people with chronic illnesses are constantly worried about losing their plans?
Speaking as someone with a chronic illness, which I’ve written about before, the thought of losing my insurance would keep me up at night. If my child was ill, I’d be even worse off.
I think we could even get into a situation where people are delaying life decisions until this is resolved. Some women on an A.C.A. plan might put off getting pregnant as long as there’s a chance that they could lose their insurance and not be able to get on a new plan because pregnancy is now a “previously existing condition.” I don’t think it’s crazy to believe that repeal and delay could have a noticeable impact on the birthrate in this country.
Austin: We’re in agreement that even repeal with delay would be very disruptive, and possibly harm health care markets and consumers. If we’re right — and we’re far from the only ones predicting this — do you think there’s a chance Republicans wouldn’t follow through, or that they’d wait for a replacement plan before repealing?
Aaron: I really can’t see them waiting long to pass something. They’ve been campaigning on this for so long that I think they probably feel they have to act pretty fast. There’s so much work needed to get a replacement plan done, scored and passed that I think something like repeal and delay is a real possibility.
Call me a pessimist, but I think this could also turn into a long-term problem for Congress and the country. Back when we lived under what was called the “sustainable growth rate,” we had to go through a “doc fix” scare every six months to a year as it looked as if Medicare reimbursement rates were going to fall off a cliff. Instead of fixing the problem, Congress just kept kicking the can down the road and letting doctors and hospitals freak out every so often that the world was going to fall apart. (After more than a decade, the “doc fix” issue was finally resolved last year.)
I think the health care system can sustain more panic than many believe. I also think kicking the can down the road is one of Congress’s specialties.
You probably know where to pump the cheapest gas and how to get price comparisons online in seconds for headphones and cars. But how would you find the best deal on an M.R.I. or a knee replacement? No idea, right?
This lack of price transparency in health care has been cited as one of the reasons we spend too much on it. It’s easy to overpay. Health care prices vary tremendously. And there is no established relationship with quality.
In Los Angeles and San Francisco, one analysis found, mammography prices vary by over a factor of five — from a low of $128 to almost $700. Prices for IUDs and lower-back M.R.I.s vary by a factor of three. An examination of Massachusetts health care prices found nearly a fourfold variation in M.R.I. prices. Despite these differences, even patients motivated to find the lowest price often can’t.
That’s changing. Over half of the states have passed laws that either establish websites with health care prices or require plans, doctors and hospitals to disclose them to patients. Some employers and other organizations also provide health care prices to employees and the public.
But improved transparency isn’t working as well as hoped. Health care pricing apps and websites don’t always help patients spend less.
That’s the conclusion from a study published this year in The Journal of the American Medical Association. It investigated the effect of the Truven Treatment Cost Calculator, a website available to more than 21 million workers and their family members. It provides users with the costs — both the total price and the portion the user would be responsible for — from over 300 services, including various sorts of imaging, outpatient operations and physician visits.
The researchers compared outpatient health care spending of about 150,000 employees who had access to the website with that of about 300,000 comparable employees who didn’t. (They did not examine inpatient spending because it is dominated by nonelective procedures that are not amenable to shopping.)
Despite its features, the cost calculator wasn’t popular. Though 60 percent of employees with access to it faced a deductible over $500, only 10 percent used it in the first year of availability and 20 percent after two years. The study found that price transparency did not reduce outpatient spending, even among patients with higher deductibles or who faced higher health care costs because of illness.
Study after study has showed the same thing. Health plans report that use of their price transparency tools is limited, with many enrollees unaware they exist. The vast majority of plans now provide pricing information to enrollees, but only 2 percent of them look at it. Aetna offers a price transparency tool to 94 percent of its commercial market enrollees, but only 3.5 percent use it.
One study found that only 1 percent of residents of New Hampshire used the state’s health care price comparison website over a three-year period. Another study found that use of the price transparency platform Castlight Health was associated with lower payments for lab tests, advanced imaging and office visits. However, the study did not examine outpatient spending over all.
Dennis Scanlon, a Penn State health economist, is not surprised. “Health care choices are different than most product and services,” he said. “Most decisions are driven by physician referrals, and insured patients usually face little variation in costs across options.”
Another reason people may not price-shop for health care is that they could find the process too complex. Providing more information to consumers doesn’t always improve their decision making. In many settings, it can overwhelm a person and lead to poorer choices. It’s far easier to go on a recommendation, even if it costs more.
And not every kind of health care is amenable to shopping. According to one analysis, only about 40 percent of spending on health care is. Patients can reasonably shop only for care that is for nonemergencies and would be motivated to do so only if they stood to gain. If patients’ out-of-pocket costs are the same at both a high-cost and low-cost doctor, what’s to prompt them to select the cheaper one? Insurance is paying for the difference anyway.
Even consumers who use price comparison tools may select more expensive providers because they think higher health care prices imply higher quality, even if that’s often not the case. Yet only half of price transparency tools offered by health plans include information about quality. One study found that including easy-to-understand quality information alongside prices helped patients select higher-value care.
But a 10-year study across 16 communities funded by the Robert Wood Johnson Foundation and published in the journal Health Services Research found that newly available reports comparing the quality of care of physician practices and physician groups had only a modest effect on the awareness and use of this information. Only about 5 percent of chronically ill people reported that they considered such information when making care decisions, an increase from just above 3 percent a few years earlier, although this increase varied across communities.
Changes to how health insurance works might improve the effectiveness of price transparency. For example, when an enrollee in a plan for California’s retired public-sector employees selects a hip or knee replacement more expensive than a preset price, she pays the entire difference. The shopping that this motivates is credited with reducing hip and knee replacement prices by 20 percent.
Direct outreach to patients to help them find services that cost less is another approach. One program used by commercial insurers targeted patients who had been referred to low-value M.R.I. providers. Getting them to voluntarily switch to ones with lower prices but adequate quality and convenience saved $220 per scan.
If there’s one thing we’ve learned time and again, it’s that there’s no single best way for reducing health care spending. Price transparency may be part of the answer, but it clearly isn’t the entire answer.
Per a rule released last week, CMS will now require qualified health plans
to count the cost sharing paid by the enrollee for an essential health benefit provided by an out-of-network ancillary provider at an in-network setting towards the enrollee’s in-network annual limitation on cost sharing for QHPs in certain circumstances.
Let’s say you go to an emergency room at an in-network hospital, but the ER doctor who treats you isn’t part of your insurer’s network. Because she hasn’t agreed to the insurer’s negotiated rates, the doctor can send you a bill for an extravagant sum. These sorts of “surprise bills” have become common; one recent study estimated that one in five of all ER inpatient admissions involved a surprise bill.
CMS’s rule won’t end the unfair practice. Out-of-network doctors can still send you a huge bill. But, starting in 2018, you only have to pay up to the amount of your annual limit on cost sharing. For 2018, that’ll be $7,350 for an individual and $14,700 for a family. Your insurer has to cover the rest.
In other words, the rule will relieve you of the very harshest financial consequences associated with surprise bills. But it won’t stop ER doctors from charging exorbitant fees, which will drive up premiums for everyone. Some states—including California and New York—have limited surprise bills to a percentage of Medicare rates. CMS doesn’t go that far.
In addition, CMS’s rule applies only to qualified health plans, not to employer-based coverage. And, because of ERISA preemption, states that have adopted legislation to address surprise bills can’t apply those laws to employers that self-insure.
So what’s to be done about self-insured plans? Writing at Brookings, Mark Hall offers some suggestions to the Department of Labor, which is responsible for ERISA implementation. For one thing, he encourages Labor to adopt a rule that resembles CMS’s—a proposal that I first floated back in 2014 at the blog. But the cleanest approach would be for Labor to
issue a formal ruling or guidance that clarifies its interpretation of the extent of state authority to regulate out-of-network billing by providers who treat patients covered by employer-sponsored plans, including those that are self-funded. This should leave states free to establish maximum and minimum billing rates for providers in surprise billing situations and to establish dispute resolution mechanisms between patients and providers, as New York State has done, for instance.
As Mark rightly notes, the Supreme Court’s case law is clear that states remain free, under ERISA, to regulate the rates that providers charge. The trouble is that “few aspects of ERISA pre-emption are truly clear to many people.” A clarification could offer comfort to states that are looking for ways to address surprise bills.
Let’s hope it happens. The need to tackle surprise bills could be one of those rare areas of bipartisan consensus on health care. No one who’s got insurance should suffer bankruptcy for seeking care from an in-network hospital.
The recent election has caused many to question whether significant changes are about to happen to Medicaid. Repeal of the Affordable Care Act would, of course, lead to the elimination of the Medicaid expansion, which could result in significant numbers of adults losing their coverage overnight. But even without repeal, many Republican replacement proposals also result in significant changes to Medicaid, whether it be through funding, eligibility, or benefits.
When discussing such changes, it’s worth examining the evidence on the effect of Medicaid on society. With respect to children, a new NBER working paper does just that.
In a recent Health Affairs article, the Commonwealth Foundation conducted their periodic survey of eleven countries to see how access issues might have improved or worsened. We’ve covered these data before. Let’s update. This is Healthcare Triage News.
This episode was adapted from a post I wrote for the AcademyHealth blog. Links to references and further reading can be found there.
When it comes to repealing the ACA, one of the trickiest questions concerns timing. Congressional Republicans don’t want to pitch 20 million people off of their insurance right away. Nor do they want the midterm elections to be fought amidst the collapse of the individual market.
At the same time, they’re committed to repeal. To thread the needle, Republicans initially said they’d delay the effect of repeal until 2019 or maybe 2020. But even that might be too soon. Now, Republicans are toying with the idea of a four-year delay, until 2021.
Lost in all this, however, is precision about what will be delayed—and what won’t be. The reconciliation bill that Obama vetoed, and which is serving as a template for repeal, would have delayed the subsidy cuts and the repeal of the Medicaid expansion. All of the tax cuts, in contrast, would have taken effect immediately.
That included the individual mandate. Remember, it’s a tax. Heck, the reconciliation bill didn’t just eliminate the mandate. It made the repeal retroactive. If you paid the mandate penalty in 2015 or 2016, you could get your money back.
Congress doesn’t have to take the same approach when it repeals the ACA for real. Negotiations over timing are fluid and ongoing. But the individual mandate is the most unpopular part of the ACA and its repeal has been a centerpiece of Republicans’ political strategy. Retaining it for several years might be hard to stomach.
If Congress zeroes out the individual mandate—and my hunch is that it will—it’s game over for the exchanges, even if subsidies continue to flow for years. In many states, the exchanges are already precarious. Without the spur to get healthy people into the market, adverse selection will do its inexorable work.
Congress may try to devise an alternative—a continuous-coverage requirement, perhaps, or maybe auto-enrollment. But those alternatives probably can’t be passed in a reconciliation bill because they don’t involve revenues or outlays. Even if one or the other is adopted, it’s unlikely to be effective enough to forestall huge premium spikes for 2018 coverage.
So unless Republicans opt to retain the mandate for several years, the states should brace themselves for the collapse of their individual insurance markets. It’s that simple.
But here’s a wild idea. Nothing prevents state legislatures from adopting their own individual mandates. What if California, say, passed a law with the same structure as the federal mandate, to go into effect when and if the federal mandate lapsed?
The gambit might not work. Insurers might still head for the hills because they doubt that the Republicans will pass a viable replacement. But the California exchange is healthy and, if a mandate replacement is in place by mid-2017, the economic picture for insurers in 2018 and 2019 won’t look all that different than it does today. There’s a chance that California could save 1.6 million people from losing coverage.
The strategy won’t fly in most states. In Michigan, for example, a Republican-dominated legislature isn’t about to adopt an individual mandate. But its prospects might be brighter in blue states like New York, Connecticut, Washington, and Oregon.
Why not give it a shot? Republicans say they want to replace Obamacare with something that gives more power to the states to chart their own path. Maybe states should take them at their word.
Austin and Aaron are participants in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising fees by advertising and linking to amazon.com.
12/29/2016
Aaron Carroll
