Previous Medicaid expansions by states did not erode perceived access to care

Bottom Line: Previous expansions in Medicaid eligibility by states were not associated with an erosion of perceived access to care or an increase in emergency department (ED) use.

Background: In January 2014, the Patient Protection and Affordable Care Act (ACA) expanded Medicaid eligibility so coverage in the public insurance program could be offered to more low-income Americans. However, some have suggested that the demand for medical services created by Medicaid expansion may erode access to care for individuals already enrolled in Medicaid, which can be restrictive.

How the Study Was Conducted: The authors examined previous Medicaid expansions to gauge self-reported perceptions of access to care and the use of ED services by enrollees. The authors examined data from 1,714 adult Medicaid enrollees in 10 states that expanded Medicaid between June 2000 and October 2009, and from 5,097 Medicaid enrollees in 14 bordering states that did not expand Medicaid.

Results: In Medicaid expansion states, the proportion of Medicaid enrollees reporting poor access to care declined from 8.5 percent before the expansion to 7.3 percent after the expansion. In the control states where Medicaid was not expanded, enrollees reporting poor access to care remained constant at 5.3 percent. The proportion of Medicaid enrollees reporting emergency department use decreased from 41.2 percent to 40.1 percent in expansion states and from 37.3 percent to 36.1 percent in states that did not expand Medicaid.

Discussion: "We found no evidence that expanding the number of individuals eligible for Medicaid coverage eroded perceived access to care or increased the use of emergency services among adult Medicaid enrollees."

Authors: Chima D. Ndumele, Ph.D., of the Yale School of Public Health, New Haven, Conn., and the Brown University School of Public Health, Providence, R.I., and colleagues.

JAMA Intern Med. Published online April 7, 2014. doi:10.1001/jamainternmed.2014.588.

Editorial: Health Insurance is Not Health Care

In a related editorial, Mitchell H. Katz, M.D., director of the Los Angeles County Department of Health Services and a deputy editor of JAMA Internal Medicine, writes: "The Congressional Budget Office estimates that by 2022 there will be 12 million new enrollees into Medicaid. Although this is an unprecedented leap forward in providing low-income Americans with health insurance, it is important to remember that health insurance is not health care. Health insurance is a financial mechanism for paying for health care. It is not the care itself, or even a guarantee of care."

"The gap between health insurance and health care can be particularly challenging for many Medicaid recipients to bridge. Studies have shown that a substantial proportion of physicians do not accept new Medicaid patients," he continues.

"Therefore, amid the optimism that millions of previously uninsured persons will gain Medicaid coverage, there is a fear that the newly insured will not be able to find physicians who will care for them, or that the influx of new enrollees will make access harder for those persons who already have Medicaid. In this vein, the results of the study by Ndumele et al in this issue of JAMA Internal Medicine are reassuring," he notes.

JAMA Intern Med. Published online April 7, 2014. doi:10.1001/jamainternmed.2014.598.

http://www.medicalnewstoday.com/releases/275157.php

Decoding The High-Stakes Debate Over Medicare Advantage Cuts

By Jay Hancock

KHN Staff Writer

APR 07, 2014

This KHN story was produced in collaboration with 

Health insurers often try to influence Washington through quiet persuasion in plush offices. To fight potential government cuts for private Medicare plans, however, they’ve hit the streets.

The Obama administration has proposed reducing what insurers collect for Medicare Advantage plans — HMOs and PPOs, mainly — that cover about 15 million seniors. (Regular Medicare, which still covers most seniors, pays doctors and hospitals directly.)

The rate change, part of the Affordable Care Act, is the next step in winding down a subsidy that pays Medicare Advantage plans substantially more than what traditional Medicare costs. Proponents say the move will end what they call an industry windfall and pressure insurers, hospitals and doctors to deliver care more efficiently.

The industry, which maintains the cuts will raise costs and reduce consumer benefits, has launched a massive national counterattack, running numerous “seniors are watching” ads, getting beneficiaries to pepper politicians with calls and letters, and lobbying the administration to back off.

The final 2015 Medicare Advantage rates are expected to be released Monday. Here are some common questions about the controversy.

I’m not in a Medicare Advantage plan. Does this affect my traditional Medicare?

No. Fewer than a third of Medicare beneficiaries use Medicare Advantage. Nor do proposed cuts affect “Medigap” policies that supplement regular Medicare coverage. 

Why is the insurance industry trying so hard?

The stakes are enormous and Democrats in Congress and the Obama administration are seen as more susceptible than usual to pressure. It’s an election year. The Affordable Care Act remains unpopular. And threats to Medicare often motivate older voters.

“For a lot of these vulnerable Democrats, one, they need the seniors. Two, there’s a lot of money that could go for or against them” in November, depending on what the administration does Monday, said Lee Drutman, a lobbying expert with the Sunlight Foundation, a Washington, D.C.-based organization focused on government transparency.

A spokesman for America’s Health Insurance Plans, the main industry lobby, said the effort is its “largest-ever mobilization.” Industry critic and former insurance executive Wendell Potter said it may be the biggest insurance publicity campaign since the “Harry and Louise” ads, which helped undermine the Clinton administration health-reform effort in the 1990s.

Ads criticizing Democrat Alex Sink for supporting “deep cuts to Medicare Advantage… to pay for Obamacare” helped her lose a special congressional election in Florida last month, analysts said. (The U.S. Chamber of Commerce sponsored the spot. AHIP, which has given the chamber money in the past for advocacy, didn’t pay for it, said AHIP CEO Karen Ignagni.)

What are the stakes?

The nonpartisan Congressional Budget Office estimates the health law would reduce Medicare Advantage payments by $156 billion over a decade. In February the Department of Health and Human Services announced tentative cuts that most analysts calculated to be around 5 percent, which would reduce insurer payments by $7 billion next year alone.

At UnitedHealth Group, one insurance giant, Medicare Advantage plans account for a fourth of all profits, said Ana Gupte, an industry analyst for Leerink Partners. Another, Humana, owes two-thirds of its profit to Medicare Advantage, she said.

“It’s a big deal. It’s huge,” she said of Monday’s expected announcement. “2015 earnings are very, very dependent on what the rates look like.”

Why do insurers say more Medicare Advantage cuts would hurt seniors?

The extra 6 percent that Medicare Advantage costs taxpayers compared with traditional Medicare pays for things that benefit members such as gym memberships, care coordination and better health outcomes, insurance executives say.

Lower government payments would induce them to offer fewer Medicare Advantage plans and raise costs for members, they say.

Last year, similar pressure on payments caused “reductions in benefits, increases in out-of-pocket costs and changes in provider networks,” said Ignagni. “A number of seniors are living in areas where they’ve had a reduction in choice” of plans. Others see little change.  

Did last year’s changes hurt Medicare Advantage’s popularity?

No. Medicare Advantage membership grew 9 percent last year. Nearly 100 percent of beneficiaries have the option of choosing a Medicare Advantage plan where they live.

While some carriers withdrew from some markets, others expanded. The number of Medicare Advantage plans stayed about the same from 2012 to 2013, according to the Medicare Payment Advisory Commission. 

“Enrollment growth suggests that Medicare Advantage continues to be attractive,” said Gretchen Jacobson, associate director of the Kaiser Family Foundation’s Medicare policy program. (KHN is an editorially independent program of the foundation.)

What happens if my Medicare Advantage plan leaves town?

You’re still eligible for regular Medicare.

Do Medicare Advantage plans really offer higher-quality care?

Evidence is mixed. Some studies show higher clinical quality on several measures and more appropriate use of procedures. Other research suggests that results for Medicare Advantage plans seem better only because gym memberships and other perks attract members who are substantially younger and healthier.

How profitable are Medicare Advantage plans for insurance companies?

The plans earned an average profit of 4.5 percent in 2011. Policies covering more than half the members that year would have met new requirements to spend a minimum on medical care rather than administration and profits, according to the Government Accountability Office.

A new paper by economists from the University of Pennsylvania's Wharton School finds that the higher rates HHS pays for Medicare Advantage contribute more to insurer profitsand advertising spending than consumer benefit.

“It doesn’t seem obvious to me that we should do any delaying in the cuts on Medicare [Advantage] reimbursement,” said Mark Duggan, one of the authors. “It appears that it will cause minimal adverse effect to consumers.”

If the Affordable Care Act says to cut Medicare Advantage payments, how much room does HHS have to do something else?

HHS has broad administrative power to adjust what insurers get for Medicare Advantage beyond changes required by law. For example, the agency’s decision to temporarily increase bonuses for plans that met “star” quality targets starting in 2012 counteracted some of the mandated cuts.

This article was produced by Kaiser Health News with support from The SCAN Foundation.

http://www.kaiserhealthnews.org/Stories/2014/April/07/Decoding-The-High-Stakes-Debate-Over-Medicare-Advantage-Cuts.aspx

10 Questions: The Healthcare Debate with Zeke Emanuel

BY DAVID GREGORY

1) The success of the Affordable Care Act is partly based on how many young people signed up – As of February, 27 percent of enrollees selecting a marketplace plan are under age 35. Are you worried that premiums will go up next year because not enough young people have signed up?

No. To the extent premiums rise next year, it will be because of health care inflation, not the number of young people in the exchange. Let’s remember that from 2000 to 2009, premiums went up 84% with no exchanges. The key for the future is not to eradicate premium increases entirely; it is to make sure they aren't excessive.

The whole issue of “young invincibles” in the exchanges is a bit of a red herring. The important factor is health, not age. About 10% of people use about 67% of all health care resources. Thus in order for the exchanges to be viable, they need to include enough healthy people to balance the 10% who might need a lot of medical services. Young age is only a proxy for good health. There are plenty of 40 year olds who are just as healthy as the typical 25 year old.

We can expect the proportion of young enrollees to increase as the final data are tallied because we know from Massachusetts that young people tend to be among the last to enroll. But even if the 27% figure doesn’t budge, premiums in the exchange will be stable. The insurance companies expected the percentage of young people to be in the high 20s or low 30s. As the CEO of Aetna indicated, they are more than happy with the age distribution of enrollments so far.

Furthermore, since there was uncertainty about who would enroll in the first few years of the exchanges, the ACA built in protections, such as risk adjustment, risk corridors, and reinsurance, to protect insurance companies who might have too many high cost enrollees. Companies that disproportionately enroll young and healthy people have to compensate companies that disproportionately enroll older and sicker people, which levels the playing field and guards against cherry picking.

For all these reasons, I’m really not worried about the percentage of young invincibles enrolled for year one. The exchanges are stable. Premiums are likely to rise a little but not excessively.

2) Will all those who did not sign up for health insurance be penalized? Will we see the IRS pursuing people who don’t pay penalties?

Funny, the Republicans said such modest penalties were not enough to get people to sign up. I guess 7.1 million people did not agree.

If you don’t sign up for health insurance you will be penalized. The penalties phase in slowly, so they are only $95 or 1% of income (whichever is higher initially) but rise to $695 per adult or 2.5% of income by 2016. But they will be and should be enforced.

3) Should the government disclose how many have started to pay premiums?

They already have. This is not a mystery. The latest data show that between 80 and 85% of enrollees nationwide have started to pay premiums. In Connecticut, it’s actually 92% at last count. And it will rise as insurance companies and exchanges contact people to remind them to pay the premium. Refusal to pay is another red herring issue.

Close to 3 million individuals bought policies in the last month of open enrollment, and some of those policies don’t start until May. People are signing up for coverage because they really want health insurance. And they understand they need to pay their premiums in order to get that coverage.

4) What’s the next test for the law now that the enrollment period is up?

The ACA is designed to improve a $3 trillion sector of our economy. So there will be many “next tests.” It is a never-ending process. Companies that launch e-commerce web sites don’t just put them up and walk away. They require constant attention. The same is true for healthcare.gov and the state exchange web sites.

The two biggest “to-do’s” are to improve the exchanges and concentrate on implementing more cost control measures.

The administration pulled off an incredible feat fixing the website as quickly as they did and exceeding the CBO enrollment projection. But the victory cannot make them complacent. That would be a huge mistake. I would like to see a private-sector style management structure erected to run the federal exchanges, complete with a CEO who has experience in the health insurance industry, and a tech savvy team of e-commerce veterans. Going forward, the exchanges should look like Zappos or REI. That means they need to have a relentless focus on customer service and improving the user experience—reducing the shopping time to 30 minutes, having less than 1 minute wait times for answers from the call center, better tools to help people compare insurance plans, etc.

The second test is sustaining the slowdown in health care inflation. For the past three years, health care has grown at roughly the same rate as the economy overall, which is an historic achievement. The ACA has helped by reducing excessive prices for Medicare managed care plans, home health care agencies, and hospitals. We need to keep this going but we also have to begin transforming how we deliver care. That requires changing the way we pay doctors so that we reward value, not volume. We need to give doctors the right tools and incentives to redesign care so that they keep people healthy, not simply care for them when they are sick.

5) Polling data shows this law is unpopular. Will the fact the White House hit their 7 million target mean Democrats will stop being afraid to be associated with the President and the law in the mid-terms?

I am not the political brother. I do not know how this achievement will influence races in individual states. Let’s just say it is a victory for health reform and it indicates there is plenty of pent up demand for health insurance across the country.

6) Republicans have constantly been trying to amend and repeal the law. Are any of their alternatives plans viable?

Let’s be serious: There has never been a Republican replacement plan. Every plan that Republicans put out, such as the most recent Coburn-Burr-Hatch plan, disappears within 24 hours. They do not comprehensively address cost, quality and access. And when you analyze them just a little bit, it turns out they would significantly increase costs for average Americans. As I pointed out in the New York Times a few months ago, the Coburn-Burr-Hatch plan would have increased costs over $1400 for the average family without guaranteeing coverage for people with pre-existing conditions or improving quality.

The problem for Republicans is that the Affordable Care Act is their health care reform. It adopts a market-based approach—creating exchanges in which private sector health insurance companies compete to offer the best products and individual Americans decide what plan they want. Sounds pretty Republican to me. But if they aren’t happy with the ACA, and they think they can craft another market-based reform that can pass both houses of Congress, they are welcome to do so. I’d be interested to see what they come up with.

7) The US still spends more than two and a half times more than the average for developed countries on healthcare. Will the Affordable Health Care act do anything to reduce this?

The Affordable Care Act is already doing a lot. For the last 3 years health care cost growth has dramatically slowed and is just about even with growth in the economy. Some of this is due to lingering effects of the recession in 2008. But a part of it is undoubtedly due to the ACA. The ACA reduced excessive prices for Medicare managed care plans, home health care agencies, and hospitals. It has also begun to incentivize changes in how care is delivered. Accountable Care Organizations (ACOs) are groups of physicians and hospitals that provide coordinated care to patients. They are incentivized to reduce wasteful tests and treatments and deliver high-quality, lower cost care. There are over 400 ACOs; some working with Medicare and some with private insurance companies. Many are making tremendous strides in driving efficiency in medicine. As we learn the “secret sauce” to high quality-lower cost care, those lessons will spread.

In addition, the ACA creates new incentives for hospitals to reduce costly errors and duplication. The 30-day hospital readmission rate for Medicare patients was over 19% in 2009. Since the ACA began penalizing hospitals that fail to reduce readmissions, that number has dropped below 18%. That translates in to billions in savings. And in 2015, similar penalties will be imposed on hospitals that fail to lower preventable infections.

Make no mistake; more will have to be done. But the ACA has made a good start in helping with cost control.

8) The health website was riddled with glitches in the beginning, and still had issues even until the last day of enrollment. How should the federal government fix their Web infrastructure issues with the law?

The health insurance exchanges aren’t just a new federal program or a website; they are a giant tech start-up. They need to be operated as such. Luckily, there are plenty of good examples of how to run a successful, start-up-like exchange. Probably the best example is the exchange in Connecticut. It starts with bringing in the right people and empowering them to succeed. In Connecticut, they hired a CEO with insurance experience and surrounded him with other C-suite executives with tech experience. They also instilled a culture of entrepreneurialism that led to the creation of avatars and apps, they kept their web developers on a very short leash, and they created feedback loops designed to identify and fix problems quickly. Nearly everything that was done in Connecticut can be done at the federal level. This isn’t rocket science—and I’d be very surprised if open enrollment wasn’t smoother in November 2014.

9) There’s a lot of talk about improving the law, what do you think needs to be done to make it better?

In my book Reinventing American Health Care, I lay out a strategy for what I call Health Care Reform 2.0. We are reforming a $3 trillion industry—almost 20% of the economy—and we need to constantly be thinking about how to improve it. Here is a short list of to-do items:

1. Raise the cigarette tax 50 cents per package. This will lower smoking rates by 15-20%. And that will have a huge impact—preventing lung diseases such as asthma and emphysema as well as lung and other cancers. This is something both Democrats and Republicans should be able to get behind; it’s a good to promote health and CBO has shown it would be a money saver.
2. More competitive bidding. Nobody wants the government setting prices in health care. The ACA required competitive bidding for wheel chairs, oxygen equipment, hospital beds at home and other items. The early efforts have reduced prices for these items by roughly 40%, saving Medicare and seniors billions. We should expand competitive bidding to more health care goods and services. Why not bid out laboratory tests and X-rays, too? And let’s get a committee of private sector procurement specialists to run the competitive bidding process.
3. More administrative simplification. No one likes paperwork. The ACA contained provisions to encourage the use of electronic claims and payment. But it did not go far enough. Physicians and hospitals should be required to transmit health information and bill insurers electronically, and all quality measures and credentialing should be electronic as well. And we should create a new position in the executive branch whose sole job it is to try to simplify and eliminate health care paperwork—and thus save a lot of money.
4. More payment reform. We need to push Medicare harder to change how it pays for health care. One of the biggest cost drivers in the U.S. health care system is the fee-for-service payment system that rewards physicians for ordering more tests and treatments and making mistakes that require more services. We need to shift off the fee-for-service system in an orderly way. The government needs to establish a timeline so everyone knows the change. Next it needs to implement alternatives to fee-for-service that already work. There is a program that pays bundled payments for orthopedic and cardiac procedures that has shown to improve quality and save some money. Let’s roll that out over the next few years to more and more physicians. Then let’s start creating bundles for expensive diseases like cancer. Getting more payment reform fast is key.

10) The president and his team went everywhere to market the ACA – even doing “Between Two Ferns” and talking to writers to have them insert “get signed up” lines in their TV shows and movies. Your brother is in the entertainment business, was this proof that Hollywood is a liberal town?

I am not the Hollywood brother either. But I think this makes no sense. There are lots of people in Hollywood who aren’t Democrats. That is just superficial. Just like the media being liberal. Ever hear of Fox?

First published April 5th 2014, 10:45 am

http://www.nbcnews.com/meet-the-press/10-questions-healthcare-debate-zeke-emanuel-n71961