What’s The Story With Obamacare?

By Katherine Baicker and Amy Finkelstein
Health Affairs Blog, December 9, 2016

States, patients, and voters are wrestling with the pros and cons of dramatic changes in public health insurance coverage, including extending, maintaining, or rolling back Medicaid expansion under the Affordable Care Act (Obamacare) — an often emotional topic of debate. The stories that are told about the effectiveness—or lack thereof—of coverage in improving health and health care usually relate compelling personal experiences, putting a human face on an otherwise abstract argument.

Policies are not enacted in the abstract; they affect real people’s lives, and we should all be concerned with how policy changes help or harm them. Unfortunately, as moving as those stories can be, they can just as easily lead us in the wrong direction as the right one. What we need is evidence, not anecdote.

Medicaid Coverage And Care Use

A key question in the Medicaid debate is whether expanded coverage reduces the use of the Emergency Department (ED) — getting people into the doctor’s office earlier, improving health, and reducing health care spending. Solid evidence is very hard to come by, but we had an opportunity to evaluate the impact of expanding Medicaid using scientifically rigorous methods rarely available in answering public policy questions.

In 2008, Oregon used a lottery to allocate a limited number of Medicaid slots — generating, in essence, a randomized controlled trial of Medicaid. This let us gauge the effects of the program itself, isolated from the usual confounding factors, and allowed us to collect thousands of stories—otherwise known as data!—about people’s experiences on and off of Medicaid.

We found that, contrary to many people’s expectations, Medicaid increased use of the ED by 40 percent. New research tells us that this increase persisted for at least two years, and that Medicaid did not make patients more likely to substitute a visit to the doctor for one to the ED.

In addition to this evidence, gleaned from a randomized evaluation of the experiences of tens of thousands of uninsured and newly insured Oregonians, we also conducted hundreds of interviews to learn how people felt that having Medicaid—or not—affected their lives. These individual narratives were invaluable for deepening our understanding of the experiences of those in study. But they also underscored how easy it is, in the absence of solid evidence, to find an anecdote to match any “answer.”

Conflicting Anecdotes About Medicaid

This is an all-too-common situation. The Oregon experiment has produced a wealth of data and rigorous evidence on the impact of Medicaid on people’s lives. We found that Medicaid increases health care use, improves financial security, improves self-reported health, and reduces rates of depression. For nearly every outcome of interest, we heard stories of experiences that matched the average effect of the expansion on the newly covered population, as well as compelling stories that did not.

Anecdotes Cannot Substitute For Rigorous Research

It’s tempting to think that we can recognize which anecdotes are most representative of the “real story” when we hear them — but we really can’t. We might be more likely to believe the story that is more poignant. Or maybe the one that lines up with our prior beliefs.

This is why, wherever possible, we need to rely on evidence from rigorous research—rather than compelling anecdotes—to get an accurate assessment of a policy’s effects

The Oregon example highlights that it is possible to use randomized evaluations to investigate important health policy questions. As researchers, we need to do a better job of providing the public with that evidence. Policymakers need to be receptive both to partnerships in building the evidence and to using the evidence to make better-informed policy decisions. And the media needs to resist the urge to allow unsubstantiated anecdotes to stand in for real evidence — despite the fact that readers may be drawn in by anecdotes.

Personal narratives can yield vital insight into how policies affect people’s lives, humanizing the stories behind the numbers and suggesting important areas for further research. Dismissing these compelling stories as “mere anecdotes” in favor of more rigorous—but impersonal—data analysis can seem heartless. But making policy based on unrepresentative anecdotes can inflict much greater harm on many more people. We hope that use of rigorous evidence will become the norm rather than the exception in health policy.

***

Reader Comment:

By Don McCanne, M.D.

As Professors Baicker and Finkelstein indicate, rigorous research in health policy provides a foundation based on fact for making policy decisions – certainly valuable in our contemporary scene driven by political ideology. But it is imperative that the valid facts be applied with care and not to the exclusion of non-research based knowledge of health policy.

As an example, the Oregon natural experiment provided helpful but limited data. The authors would surely disagree with some statements made by a few politicians and other individuals in the policy community to the effect that the Oregon experiment proved that Medicaid is a wasteful program and should be abandoned, with even at least one saying that Oregon Medicaid patients were worse off than the uninsured. Part of the problem is that the study was underpowered – an unavoidable consequence since is was a natural experiment.

Another example is the RAND HIE. It was a study of cost sharing in workers and their families – a relatively healthy subset of our population. Since the study was for a relatively short time during the healthy years of their lives, the intrinsic validity of this study does not necessarily have extrinsic validity, so the findings should not be extrapolated to apply to the entire population. Yet that is exactly what has been done, especially with the escalation in the use of high deductibles in insurance plans.

The purpose of cost sharing is to reduce spending, but it can be harmful, both because it causes individuals to forgo beneficial health care services, and it creates financial hardships for people in need. Yet ideologues have largely ignored the harm and have pushed this as a means of making patient-consumers more responsible purchasers of health care. One advocate has carried this to the extreme that cost sharing should be inflicted on poor people with no disposable income – a heartless public policy – and she is about to become administrator of CMS.

We do not need rigorous research studies to show us that a well designed single payer system can slow the rate of health care spending while including absolutely everyone and making it affordable for each individual through equitable progressive tax policies. Other nations already do that – providing health care at a fraction of what we are spending through our dysfunctional health care financing system.

There would still be plenty of research opportunities for Baicker and Finkelstein in a single payer system, but at least it would be within a system designed to serve, above all, the health care needs of patients, rather than a system designed to support the administrative excesses and egregious pricing of the stakeholders in our current system.

Incidentally, studies on administrative waste and excess pricing have already been done. We should use them.

http://healthaffairs.org…

***

Comment:

By Don McCanne, M.D.

Katherine Baicker and Amy Finkelstein are correct. Rigorous policy research can provide a beneficial input to the policy making process. But there is the risk that policy science can lead only to minor tweaks in the health care financing system when comprehensive overhaul is an imperative.

For instance, many studies have been done that have determined whether various factors influence the numbers of individuals who remain uninsured. Based on these results, the financing system can be tweaked to encourage greater enrollment. But all of these measures combined have still left about 29 million people uninsured.

Suppose instead of doing a study, you simply approved legislation that would automatically enroll everyone, for life, in a national single payer program. What policy study would you need to carry out to determine whether that would be effective in including many or most of the remaining uninsured? Well, you don’t need a rigorous policy study. All of the remaining uninsured would be covered automatically. If someone slipped through the cracks, they would be enrolled at the time they accessed the health care system.

When you look at the various policies being applied in either the public or private sectors, you see that many are based on research that has been narrowly focused on our current fragmented, dysfunctional financing system – simply trying to fix an irreparably broken system.

You do not need research when the system is designed to specifically meet reform goals. Besides requiring that it be truly universal, financing can be made affordable for each individual through equitable, progressive tax policies. Resource allocation can be improved through central planning, which improves access. Administrative efficiency is achieved by eliminating the multitude of expensive, superfluous financing intermediaries. You do  not need to study this. You just do it.

The Oregon health insurance experiment (OHIE) – a study conducted by Baicker and Finkelstein – produced some interesting results. But how much impact has it had in reducing the major, fundamental deficiencies in our current health care financing system? I do not recall having seen any policy changes resulting from it. That is not to say that it was an inappropriate study. Being a natural study, it was a rare opportunity to advance policy science, and it was quite appropriate that the study was done.

The point is that the policy community buries itself in these studies that really do have very little impact on the major problems facing us in health care financing today. Besides, the studies would be more valuable done within a health care financing infrastructure that was designed to serve patients rather than to meet medical-industrial business goals, including fine tuning a wasteful private insurance industry that should be discarded instead.

Let’s replace the financing infrastructure with one that meets our goals and then study it to see what beneficial tweaks we can provide.

New Coalition Will Push Back on Repeal of Obama Health Law

By The Associated Press
The New York Times, December 9, 2016

Supporters of the 2010 health care law will launch a political coalition Friday to block its repeal.

The initial goal is to stop Congress from repealing the law without simultaneously passing a replacement for some 20 million people covered through subsidized private health insurance and expanded Medicaid.

Called “Protect Our Care,” the group brings together organizations that helped pass the Affordable Care Act, also known as “Obamacare.”

On the list are the NAACP, liberal advocacy groups like Families USA and the Center on Budget and Policy Priorities, the Service Employees International Union, which represents many health care workers, and the Center for American Progress, a think tank closely aligned with the Obama White House.

http://www.nytimes.com…

***

Comment:

By Don McCanne, M.D.

The conservatives want to repeal much of the Affordable Care Act (ACA) and replace it with something similar. The centrists want to preserve ACA pretty much as it is. Although the specifics are important since many people could lose their coverage and the effectiveness of health plans could diminish further, in the global perspective we’ll still be left with a highly dysfunctional health care financing system that will not cover everyone while perpetuating inadequate coverage for many of those who are insured.

The national dialogue leading up to ACA early on was a debate between making modest adjustments in the financing system we had or replacing it with a much more effective and equitable system that would truly cover everyone while making health care affordable for all.

But very soon the Democratic Party leadership along with representatives of a multitude of supposedly liberal organizations (many through HCAN) coalesced around reform that would greatly benefit insurers, the pharmaceutical industry, and other vested interests. Those supporting comprehensive reform through a single payer national health program were quickly booted out of the process, and the media became silent on single payer. That ended the debate, and we moved on to providing some beneficial tweaks to the existing dysfunctional system, when instead we should have had an honest dialogue over the weak, inadequate policies of what became ACA and the profound, sweeping benefits that characterize the single payer model.

Here we go again. Our health care financing system is still in shambles with tens of millions remaining uninsured and the insured having increasing difficulties in obtaining care in the narrow provider networks while facing financial hardship because of the insurers shifting ever more risk onto the patients. And the “Protect Our Care“ coalition of centrists wants to make this a debate between protecting the shambles versus making them even worse through “replace” policies that would further weaken health care coverage.

No!! The debate needs to be between accepting or tweaking a system in shambles or moving on to a well-designed single payer system – an improved Medicare for all – affordable, accessible health care for everyone.

The same people who took control last time and led us down the wrong path are now regrouping as the “Protect Our Care” coalition with a mission to protect a program in shambles. We cannot let them get away with it this time. We need to form a large coalition of healer activists to lead us to the high-performance system we desperately need. And, yes, we need to be sure that members of the media understand the difference.

The Obama Years: Tepid Palliation for America’s Health Scourges

By Steffie Woolhandler, MD, MPH and David U. Himmelstein, MD
American Journal of Public Health (AJPH), January 2017

President Obama inherited an economy in crisis, burgeoning inequality in wealth and health, and a legion of medically uninsured Americans whose ranks had grown by 11 million under the previous administration. He staunched the bleeding but provided no cures.

The Affordable Care Act (ACA; Pub L No. 111–148), Obama’s signature achievement, covered millions, but leaves 9% uncovered. It minimally regulated insurers and imposed a modest new tax on the wealthy but accelerated the corporate takeover of health care and endorsed high-deductible insurance plans that offer illusory protection. It provided $11 billion in new funds for community health centers and public health agencies but drained money from safety-net hospitals and failed to reverse the downward trend in funding for public health.

Conclusions

Could Obama have done better? Not by waging policy battles largely inside the Washington, DC, Beltway. Even during Obama’s first two years in office, when the Democrats controlled Congress, the lobbying clout of insurers and pharma (generous donors to Democrats as well as Republicans) made fundamental reform unwinnable in an inside game. The compromised ACA legislation, crafted to appease these corporate interests, offered nothing to the majority of Americans dissatisfied with the health care status quo, precluding grass roots mobilization and allowing Republicans to rally opposition. It is striking that, in a 2016 Gallup poll, 51% of Americans wanted to repeal the ACA, but 58% (including 41% of Republicans) would replace it with single-payer reform (findings that accord with a recent Kaiser survey).

The Sanders and Trump campaigns (and, indeed, Obama’s historic 2008 victory) demonstrated the electorate’s hunger for new directions. America has taken bold and difficult steps in the past: the abolition of slavery, women’s suffrage, Social Security, civil rights, and marriage equality, to name a few. All were gained through powerful, persistent social movements that eventually got their message through to Washington.

Our health and health care deficits are man-made scourges, not products of nature. Curing them will require broad popular mobilizations, not just a well-intentioned president.

http://ajph.aphapublications.org…

***

Comment:

By Don McCanne, M.D.

Although this AJPH editorial was written a couple of weeks before the surprise results of the presidential election were known, it does not change the message. Curing our heath care deficits will require broad popular mobilization, not just the wishes of a president, no matter his or her intentions.

Taking Stock Of Health Reform: Where We’ve Been, Where We’re Going

By Timothy Jost
Health Affairs Blog, December 6, 2016

Almost from the moment of its inauguration in 2009, the Obama administration has struggled, often against adamant resistance, to enact and implement the Affordable Care Act (ACA). The 2016 election has brought to power opponents of the ACA who will control the presidency, both houses of Congress, and many state houses and governorships. ACA repeal, or “repeal and replace,” seems to be a very real, indeed likely, possibility. It is important, therefore, to take a sober look at what the ACA has achieved in its nearly six years of existence, and what repeal, or repeal and replacement, might look like.

(Use the link below to see a precise explanation of what ACA has achieved and what repeal and replace might look like.)

Summing Up

The ACA has made many Americans better off, and can boast of important achievements. In particular, it has ensured that Americans cannot be denied coverage or have their coverage limited because of health problems. Millions of lower-income Americans are receiving health coverage through Medicaid and the marketplaces who would otherwise be unable to afford coverage. But many still face unaffordable cost-sharing burdens and narrow networks, and many middle-income individuals can no longer afford coverage in the individual market.

While there are real opportunities for the new administration and Congress to improve the ACA, it is essential that they not precipitously undo its achievements. Repeal must await a clear plan for replacement. And the timing of repeal must take into account not only the time it takes to adopt replacement legislation but also the time it takes to write the rules, formulate guidance, and create and staff programs to administer a replacement program. If there is anything we have learned from the last six years, it is that implementation is hard work and takes time.

Careful and objective analysis must be given to replacement proposals and their effects. Many of these are not new but rather resurrect policy initiatives of the past that proved problematic in important respects. They have track records that can be studied. The effects of other proposed provisions can be modeled.

What preliminary analysis of Republican replacement proposals shows is quite clear: they would provide considerably less help for lower-income Americans and people with health problems, and could mean increased costs for these groups. They might at the same time lower costs and provide more assistance for middle- and higher-income Americans. They would shift costs from the federal government to the states. They would shift costs from the government to individuals and families, and to providers. They would make health care less accessible and less affordable to those who have been helped by the ACA, but might make it more affordable to some whom the ACA has not helped.

Elections have consequences, and, arguably, to the victors go the spoils. But transparency is important; no one should be under any illusion that an ACA replacement will make everyone better off — it could cause serious harm and disruption to some who were helped most by the ACA. If Congress and the administration are to embrace this harm and disruption, it is vitally important that the American people understand the consequences.

***

Submitted comment:

By Don McCanne, M.D.

Timothy Jost provides an invaluable service by by bringing truth to the dialogue on reform. Those who are satisfied with benefits gained through the Affordable Care Act will have to concede that it has still fallen significantly short of many goals of reform. Those who would replace many or most of the features of ACA will have to be honest about the severe deficiencies of their leading proposals, likely leaving many people worse off. Either way, we will still not end up with the high-performing system that the $3.2 trillion we are spending on health care should be bringing us.

Although it was not the intent of this article to discuss other options for reform than those on which the current political dialogue is focused, nevertheless one other model should be under discussion and that is a well-designed single payer national health program. For the same amount that we are already spending, we could have a high quality system that is truly universal, comprehensive, accessible, and affordable for everyone. At the time of another pending upheaval in our health care system a model that would actually work to achieve these goals clearly should be on the table. Many of the perverse features of a fragmented, dysfunctional multi-payer system discussed in Jost’s article would simply go away.

http://healthaffairs.org…

***

Comment:

By Don McCanne, M.D.

There will likely be considerable heat in the discussions ahead on repealing and replacing the Affordable Care Act. Based on current observations, much of it will be clouded with failure to adhere to the actual facts which are based on sound health policy science. This article will be particularly helpful as a resource since Timothy Jost is meticulous with the facts as he explains what has happened and what might happen under the various proposals for replacement.

By reading this fairly long article, you can reinforce your understanding of the issues so that you can help bring truth to the national dialogue on reform. Also you should save the link and make it available to others who wish to have an unbiased understanding of the facts without having to wade through rhetorical embellishment.

When the facts are known, it will be clear that neither the status quo under ACA nor the replacement plans currently under consideration will be adequate to ensure that everyone would have affordable access to essential health care services. That is why we need to be sure that a model that would give us this assurance – single payer – is back on the table, front and center, during our national dialogue on reform.

The Financial Burdens Of High-Deductible Plans

By Salam Abdus, Thomas M. Selden and Patricia Keenan, from the Agency for Healthcare Research and Quality
Health Affairs, December 2016

Abstract

The increased prevalence of high-deductible health plans raises concerns regarding high financial burdens from health care, particularly for low-income adults.

From the Introduction

The prevalence of high-deductible health plans within employer-sponsored insurance has more than doubled since the mid-2000s. However, no recent research has measured the actual financial burdens associated with high-deductible health plans, and we know of no prior nationally representative studies examining these burdens by income level. In this study we attempted to fill that research gap by examining the association between high-deductible health plans and high out-of-pocket burdens among people at various income levels with employer-sponsored insurance.

From the Discussion

This study examined the association between high-deductible health plans and high out-of-pocket burdens among those with employer-sponsored insurance by income level. Two key results stand out. First, the frequency of high family out-of-pocket burdens increased sharply with plan deductible levels among low-income enrollees (those with family incomes below 250 percent of poverty), reflecting both higher health care spending and higher premium contributions. In contrast, there were much smaller differences in high burden frequencies by deductible level in the higher-income groups. Second, regardless of deductible level, those in the low-income group were far more likely to have high burdens compared to those in the higher-income groups.

http://content.healthaffairs.org…

***

Comment:

By Don McCanne, M.D.

This is one more highly credible study that demonstrates that high-deductible health plans are creating great financial burdens amongst enrollees in employer-sponsored health plans. These burdens are especially large for low-income employees – a group that already suffers from high financial burdens.

The nation continues to push forward with expanding deductibles in health plans in spite of evidence that they are creating great harm by increasing financial burdens on individuals and families and by impairing access to essential health care services and products.

Why does the policy community continue to support high deductibles? Because it slows the rate of increases in the premiums charged for insurance plans – protecting the insurers’ market, though at a cost of placing a greater burden on patients.

By replacing the private insurers with a single payer system we would not have to be concerned about how high premiums are since a single payer system is equitably funded through the tax system and premiums go away. Furthermore, the greater costs that result in higher premiums would be far better controlled though the patient-friendly policies that are inherent in a well-designed single payer model.

Instead of making people suffer more, let’s just get rid of high-deductibles and the private insurers who create them and move on by enacting an improved Medicare for all.

NBER Working Paper No. 22876; Insurers’ Response to Selection Risk: Evidence from Medicare Enrollment Reforms

By Francesco Decarolis, Andrea Guglielmo
National Bureau of Economic Research, December 2016

Abstract

Evidence on insurers behavior in environments with both risk selection and market power is largely missing. We fill this gap by providing one of the first empirical accounts of how insurers adjust plan features when faced with potential changes in selection. Our strategy exploits a 2012 reform allowing Medicare enrollees to switch to 5-star contracts at anytime. This policy increased enrollment into 5-star contracts, but without risk selection worsening. Our findings show that this is due to 5-star plans lowering both premiums and generosity, thus becoming more appealing for most beneficiaries, but less so for those in worse health conditions.

From the Conclusions

The reform that, starting in 2012, allowed Medicare enrollees to switch at any point in time to the highest quality, 5-star plans could have backfired. By undermining the use of rigid open enrollment periods, a pillar of most insurance markets, this policy could have exacerbated the adverse selection faced by 5-star plans, potentially triggering premium spikes or even plan exit. The fact that this did not happen and that, despite the substantial growth in within-year enrollment in 5-star contracts, their risk pool did not worsen creates a puzzle.

This paper shows that a relevant force behind these facts is the sophisticated response adopted by suppliers. Both 5-star insurers and their competitors responded to the new policy. The 5-star insurers lowered their premiums, while, at the same time, worsening the amount of coverage offered by their plans. This contributed to expand their enrollment base, without worsening their risk pool.

In terms of policy, our results are both encouraging and problematic. On the one hand, the flexibility in product design that insurers retain in Medicare Pact C and D has allowed the 5-star SEP to achieve the goal of bolstering enrollment into 5-star plans. More generally, such flexibility is likely to help making the market sustainable for insurers. On the other hand, however, the very presence of such flexibility implies difficulties in designing rules capable of steering the market toward any public goal. In the context of the 5-star SEP, the reduced generosity of 5-star plans could negatively affect the well being of the weakest beneficiaries and could also represent a diminished allocative efficiency in the market.

http://www.nber.org…

***

Comment:

By Don McCanne, M.D.

This study adds one more bit of evidence to the abundance of studies that show that private Medicare Advantage plans will always game the system to benefit themselves to the detriment of patients.

Specifically, this program that allowed patients to change to a five-star Medicare Advantage plan during a special open enrollment period potentially exposed the insurers to adverse selection – having to accept patients with greater health care needs. Instead the insurers were able to reduce their premiums and the amount of coverage, thus expanding their enrollment bases while avoiding worsening of their risk pools.

What was the net result? This made the market more sustainable for insurers but at a cost of negatively affecting “the well being of the weakest beneficiaries,” and diminishing “allocative efficiency in the market.”

Instead of wasting taxpayer funds on embellishments that benefit the private Medicare Advantage insurers, let’s dump them and redirect our efforts to improving the traditional Medicare program so that it benefits patients instead – making it a program that would be ideal for all of us.