Archivi delle etichette: Affordable Care Act

BETTER HEALTH CARE AND LOWER COSTS @leadmedit @medici_Manager @pash22 @WRicciardi


Executive Summary

In recent years there has been success in expanding access to the health-care system, with millions gaining coverage in the past year due to the Affordable Care Act. With greater access, emphasis now turns to guaranteeing that care is both affordable and high-quality. Rising health-care costs are an important determinant of the Nation’s fiscal future, and they also affect the budgets for States, businesses, and families across the country. Health-care costs now approach a fifth of the economy, and careful reviews suggest that a significant portion of those costs does not lead to better health or better care.

Other industries have used a range of systems-engineering approaches to reduce waste and increase reliability, and health care could benefit from adopting some of these approaches. As in those other industries, systems engineering has often produced dramatically positive results in the small number of health-care organizations that have implemented such concepts. These efforts have transformed health care at a small scale, such as improving the efficiency of a hospital pharmacy, and at much larger scales, such as coordinating operations across an entire hospital system or across a community. Systems tools and methods, moreover, can be used to ensure that care is reliably safe, to eliminate inefficient processes that do not improve care quality or people’s health, and to ensure that health care is centered on patients and their families. Notwithstanding the instances in which these methods and techniques have been applied successfully, they remain underutilized throughout the broader system.

The primary barrier to greater use of systems methods and tools is the predominant fee-for-service payment system, which is a major disincentive to more efficient care. That system rewards procedures, not personalized care. To support needed change, the Nation needs to move more quickly to payment models that pay for value rather than volume. These new payment models depend on metrics to identify high-value care, which means that strong quality measures are needed, especially about health outcomes. With payment incentives aligned and quality information available, health care can take advantage of an array of approaches using systems engineering to redesign processes of care around the patient and bring community resources, as well as medical resources, together in support of that goal.

Additional barriers limit the spread and dissemination of systems methods and tools, such as insufficient data infrastructure and limited technical capabilities. These barriers are especially acute for practices with only one or a few physicians (small practices) or for community-wide efforts. To address these barriers, PCAST proposes the following overarching approaches where the Administration could make a difference:

  1. Accelerate alignment of payment systems with desired outcomes,
  2. Increase access to relevant health data and analytics,
  3. Provide technical assistance in systems-engineering approaches,
  4. Involve communities in improving health-care delivery,
  5. Share lessons learned from successful improvement efforts, and
  6. Train health professionals in new skills and approaches.

Through implementation of these strategies, systems tools and methods can play a major role in improving the value of the health-care system and improving the health of all Americans.

Summary of Recommendations

Recommendation 1: Accelerate the alignment of payment incentives and reported information with better outcomes for individuals and populations.


1.1  HealthandHumanServices(HHS)shouldconvenepublicandprivatepayers(includingMedicare,Medicaid, State programs, and commercial insurers) and employers to discuss how to accelerate the transition to outcomes-based payment, promote transparency, and provide tools and supports for practice transformation. This work could build on current alignment and measurement-improvement efforts at the Center for Medicare and Medicaid Services (CMS) and HHS broadly.

1.2  CMS should collaborate with the Agency for Healthcare Research and Quality (AHRQ) to develop the best measures (including outcomes) for patients and populations that can be readily assessed using current and future digital data sources. Such measures would create more meaningful information for providers and patients.

Recommendation 2: Accelerate efforts to develop the Nation’s health-data infrastructure.
2.1 HHS should continue, and accelerate, the creation of a robust health-data infrastructure through widespread adoption of interoperable electronic health records and accessible health information. Specific actions in this vein were proposed in the 2010 PCAST report on health information technology and the related 2014 JASON report to the Office of the National Coordinator for Health Information Technology (ONC).

Recommendation 3: Provide national leadership in systems engineering by increasing the supply of data available to benchmark performance, understand a community’s health, and examine broader regional or national trends.

3.1 HHS should create a senior leadership position, at the Assistant Secretary level, focused on health-care transformation to advance information science and data analytics. The duties for this position should include:

  • Inventory existing data sources, identify opportunities for alignment and integration, and increase awareness of their potential;
  • Expand access to existing data through open data initiatives;
  • Promote collaboration with other Federal partners and private organizations; and
  • Create a more focused and deep data-science capability through advancing data analytics and
  • implementation of systems engineering.

3.2 HHS should work with the private sector to accelerate public- and private-payer release of provider-level data about quality, safety, and cost to increase transparency and enable patients to make more informed decisions.

Recommendation 4: Increase technical assistance (for a defined period—3-5 years) to health-care professionals and communities in applying systems approaches.

4.1 HHS should launch a large-scale initiative to provide hands-on support to small practices to develop the capabilities, skills, and tools to provide better, more coordinated care to their patients. This initiative should build on existing initiatives, such as the ONC Regional Extension Centers and the Department of Commerce’s Manufacturing Extension Partnership.

Recommendation 5: Support efforts to engage communities in systematic health-care improvement.


5.1  HHSshouldcontinuetosupportStateandlocaleffortstotransformhealthcaresystemstoprovidebetter

care quality and overall value.

5.2  Future CMS Innovation Center programs should, as appropriate, incorporate systems-engineering

principles at the community level; set, assess, and achieve population-level goals; and encourage grantees

to engage stakeholders outside of the traditional health-care system.

5.3  HHS should leverage existing community needs assessment and planning processes, such as the

community health-needs assessments for non-profit hospitals, Accountable Care Organization (ACO) standards, health-department accreditation, and community health-center needs assessments, to promote systems thinking at the community level.

Recommendation 6: Establish awards, challenges, and prizes to promote the use of systems methods and tools in health care.

6.1 HHS and the Department of Commerce should build on the Baldrige awards to recognize health-care providers successfully applying system engineering approaches.

Recommendation 7: Build competencies and workforce for redesigning health care.


7.1  HHS should use a wide range of funding, program, and partnership levers to educate clinicians about

systems-engineering competencies for scalable health-care improvement.

7.2  HHS should collect, inventory, and disseminate best practices in curricular and learning activities, as well as encourage knowledge sharing through regional learning communities. These functions could be accomplished through the new extension-center functions.

7.3  HHS should create grant programs for developing innovative health professional curricula that include systems engineering and implementation science, and HHS should disseminate the grant products broadly.

7.4  HHS should fund systems-engineering centers of excellence to build a robust specialty in Health-

Improvement Science for physicians, nurses, health professionals, and administrators.

Full Report:

Predicting the next 4 years of health reform @Medici_Manager @kevinMD

 | POLICY | DECEMBER 21, 2012

Predicting the next 4 years of health reform

Although members of the Obama team are now celebrating their election victory, the next four years will not be smooth sailing. Ignoring the campaign rhetoric, there is still much more work to be done in order to reshape our health care system; the effect on academic medical centers and teaching hospitals will be significant.

The political conscience is still being driven by the fear of the fiscal cliff, which dominates most Washington conversations. Both political parties agree that health care is a significant contributor to our present and future deficit and that we have to figure out how to deliver more care at a lower cost. But, they argue about what to call it, who gets credit, and whether the solution is bigger government involvement or a dominant private market?The potential cuts to NIH funding and graduate medical education support do not go away with another four Obama years. We anticipate that the president will reform the tax code and transform how we deliver health care. The latter will be his lasting legacy.

However, in all this chaos, there are opportunities. While we no longer hope for a bipartisan middle ground on health care — and rancor will certainly escalate if President Obama is reelected — to many people, the Affordable Care Act is starting to look like a tangible business opportunity. Every insurer is looking at the 30 million uninsured people who will receive coverage through a mix of subsidized private insurance for middle-class households and expanded Medicaid for low-income people. These new markets could be worth $50 billion to $60 billion in premiums in 2014, and as much as $230 billion annually within seven years. The structure and implementation of these programs present specific challenges for AMCs.


Academic medical centers currently deliver 28 percent of inpatient care for Medicaid recipients and 40 percent of uninsured care in the United States — in only 6 percent of the acute care facilities. We have the Medicaid specialty care market cornered — because no one else will accept these patients. The expansion of Medicaid will create stress in our historical access points: emergency rooms and primary care offices. We will be overwhelmed if we do not dramatically reengineer where we deliver care and rethink who should deliver care for what conditions. We will experience costs that quickly spiral out of control if we just expand our current system.

Obama’s re-election removes the indecision about whether to opt in or opt out for many state governors. Most insurers are betting on the fact that dual eligibles (patients who are disabled or poor enough to qualify for both Medicaid and Medicare) will be moved into the managed Medicaid plans. This will require active care management, better EHRs, geomapping of resource utilization, and a greater understanding of the impact of social determinants of health on this population. It will be interesting to see if the role of the insurer really expands to manage the outcome instead of just the cost.

Health exchanges

The implementation of the exchanges poses challenges for states, because they are supposed to be self-sustaining by 2015. Their ability to achieve this comes down to demographics and the size of their insured pool. Small high-risk pools will need to be intensively managed (like the District of Columbia), in contrast to larger populations that can be more loosely managed as they develop state-wide infrastructure. For academic medicine, the exchanges will present specific challenges. Our services could be subject to higher deductibles, copays and even co-insurance if the exchanges choose to tier providers according to cost. As a result, our care could be inaccessible to many patients without means.

There has also been very little discussion about how to transition graduate medical education support into the exchange market. Currently Medicare, Medicaid, and other insurers support the educational mission through explicit or implicit support. Supporting the training of the health care workforce has been considered a public good that increases access and quality for patients. Medicare Advantage programs use a “carve out” to preserve this support, but this option has not yet been part of the exchange discussions.

Physician shortages

The Center for Workforce Studies at the AAMC estimates that the nation will face significant physician shortages by 2020. As the newly insured begin to seek care in 2014, and as we anticipate these shortages, one must wonder who will care for these patients? By 2017, the number of physician retirees will be close to the number of new medical school graduates. While medical schools as a whole have been expanding the number of students they admit, there may not be enough residency positions to accommodate them. The Obama team can ignore the growing physician shortage — but at their peril. Unfortunately, we also continue to debate within specialty societies about who should provide the services, rather than talking about how we can deliver care as a team more efficiently. Use of interprofessional teams holds great promise for improving the efficiency of the physician workforce, and we anticipate that the administration will continue to support innovative reforms in health care delivery.

The election outcome is good news … with caution. Health care reform will continue to move forward, imperfect as it may be. I have great hopes for bipartisan solutions, but I won’t hold my breath. The really hard work is not over; it has just begun.

Joanne Conroy is Chief Health Care Officer at the Association of American Medical Colleges.  She blogs at Wing of Zock and can be reached on Twitter@joanneconroymd.


How Obamacare will create a new normal for medicine @Medici_Manager @kevinmd

 | POLICY | DECEMBER 7, 2012

The 2012 Presidential election is over. Obamacare is the law of the land and is certain to remain so.  There was tremendous uncertainty not knowing whether the law would be repealed, revised or remain.  Many of us opposed the bill, and there certainly are negatives.  Like it or not, it is time to “get over it,” and not a second later than now.  The new-found certainty offers an opportunity to reassess and adapt to the coming changes.

In addition to Obamacare, other pillars of our “new normal” include patient satisfaction surveys, threats of reimbursement cuts, increasing pressure from administrators obsessing over “metrics,” more time drained by cumbersome electronic health records, resentment from patients who blame us for the failings of the healthcare system, as well as a steady stream of frivolous lawsuits with no end in sight.  It’s time to adapt to our “new normal.”

Comparing and contrasting with other industries

In this modern age of Medicine, these factors have been piled on top of the traditional responsibilities of physicians such as life and death, health and wellness, and paradoxically have seemed to rise above them in importance like unstoppable flood waters drowning the ghosts of Hippocrates, Osler and Marcus Welby M.D.  This contributes to poor morale among physicians and understandably so.  Other industries have had to deal with the same concepts for decades, however.  The service industries are bound by “patient satisfaction” measures and always have been.  Businessmen also have to guard against lawsuits. They expect them and manage the risk and accept it as a norm. I doubt they perceive a lawsuit where they did nothing wrong, as life altering like so many physicians do.  Companies often times have decreases in sales just as our reimbursements may drop and constantly have to adapt.  Just about everyone else in the “real world” has to deal with a “boss” of some variety and a necessary part of their job is to keep that person or entity happy, regardless of whether they like them personally or not.  So why do we find it so difficult to deal with such factors?

Are we special?

Are we different?

In a word, “No.”  Not anymore.  It’s time to accept that fact and move on.  We are now cogs, replaceable de facto employees of a massive business-medico-legal-political machine; nothing more.  All indications are that it will remain this way.  Much can be learned from such other industries that have had to adapt to the stark realities ahead of us.  I think for the profession of Medicine to reinvigorate itself, and for us to truly value what we do have again, we must properly manage expectations.

What government will (or will not) do

Though we might each individually be very replaceable, the reality is that we still have extremely high paying jobs in a profession that is relatively recession proof with greatly increasing demand for our services. There are some other positives and ironic realities that I think many physicians are glaringly overlooking.  One is that Obamacare proposes to commit about 1 trillion more dollars towards healthcare over the next 10 years, with tens of millions newly insured.  Necessarily, demand for our services will go up, way up.  And the best (or worst) news is that despite all the talk about “severe rationing” and “draconian reimbursement cuts” there’s good reason to believe that talk is a big load of … nonsense.  That’s right; they’re not going to cut a damn thing.  How can I be so sure?

There has been essentially no real political will, whatsoever, by either political party to make any significant cuts from the federal budget, ever.  Even the most “harsh” and “cruelest” proposals only call for a decrease in the rate-of-increase, of overall spending.  There never has been any, and there’s no reason to predict there ever will be, any policy other than kicking the can down the road until after the next election, and the next one and the next one. The voters have spoken and they want to spend an extra $1,000,000,000,000 on healthcare.  Santa Claus is in fact coming to town! That may be terrible for the country, but it may well be very good for doctors; that is the smart ones.  There may be more hoops to jump through, more requirements and regulations, as well as creative strategies needed to get a “piece of the pie,” but demand for doctors’ services will necessarily increase, and tremendously so.  Also, despite much posturing, tough talk and threats of showdowns year after year, the SGR-fix has always been passed and the budget debt ceiling has always been raised.  Medicare expenditures will necessarily continue to go up, and up, and up. More patients will be insured wanting our services. The elderly baby-boom population will be sick and growing older and need us desperately.

I was told a story by a retired physician about his long deceased cardiologist father who practiced before Medicare was instituted.  He tells of his father who was a very compassionate physician, but a staunch free-market conservative who like many physicians at the time vehemently opposed the proposed Medicare system.  His father would say that physicians provided charity care for free to the disabled and elderly all the time and that Medicare was just a Trojan-Horse for socialists who wanted to take over the American healthcare system.  He may or may not have been correct, but ultimately to his dismay, Medicare passed and became law.  All of a sudden and very unexpectedly, his salary … doubled.  He never complained about Medicare again.

The point of this anecdote is not to suggest that physicians’ salaries will double as a result of Obamacare.  They will not.  However, it is to suggest that despite the 2000 pages of regulations and requirements in the cloud of Obamacare that hangs over our heads, there will be an unexpected silver lining, somewhere.  I think we can simultaneously work vigorously to reform our profession, yet shed the “culture of victimhood” that has grown like mold upon physician attitudes and search for positive opportunities.

Some physicians will “opt-in”

Such new opportunities will not be the same as in the dead era of Osler, Hippocrates and Marcus Welby M.D.  Also, I cannot say that chugging along with the same old strategy, expectations, and disappointments of a bygone Golden Age will be a winning plan, either.  It may involve simply being content as a cog in a large machine or “system.”  It may involve thriving in the role of “corporate soldier,” learning how to “play the game” while finding ways to save costs, increasing efficiency for your group or other groups and “promoting” your hospital.  Others may move into the government side of healthcare and find opportunities in healthcare policy planning and consulting.  Clearly, knowing “the medicine” isn’t enough anymore and in fact, seems the least important of that which is expected of us.

Other physicians will “opt-out”

Greater numbers of physicians will find opportunity in opting-out of the system by making their practices cash only, concierge, or declining to participate in Medicare and a more dominant Medicaid system.  Another option may be for more Emergency Physicians and surgeons to exploit technicalities in Obamacare and States with liberal certificate of need laws and open their own centers that offer services for a flat fee outside of traditional government or private insurances.  As more insurance plans require deductibles in the thousands of dollars and refuse to pay for certain services entirely, such centers may gain more traction where they are feasible.

Others may “opt-out” more insidiously.  The new generation of physicians may very well evolve into protocol-following, brown-nosing, corporate mantra-spewing clock-punchers, indistinguishable from other “providers” all while refusing to make the tremendous sacrifices of doctors past, such as incredibly long hours, over-burdensome call schedules with great sacrifice to marriage, family, and personal well-being.  Maybe that’s okay, and maybe that’s what our new Overlords of Healthcare want and will reward.

More primary care physicians and other specialties likely will take the “9-5, no call” route and leave the after-hours hassles to the ED and hospitalists.  More medical students may pick careers in cosmetics over critical care.  More Emergency Physicians may leave high-stress clinical shift work in the Emergency Department for Administration, group management, Hospice and Palliative care fellowships, Urgent Care ownership or anything else seen as less stressful.  More surgeons and specialists may opt out of emergency call for a less stressful life and a focus on elective cases with higher reimbursement to liability ratios.  I see more Anesthesiologist moving to “lifestyle” positions at ASCs doing elective cases, or pain procedures with little or no call.  Many physicians will consider early retirement.

The silver lining

The pioneers of Medicine did not have to worry about our “new normal” of Obamacare and all of its 2000 pages of regulations and requirements.  They didn’t have to worry about $300,000 of medical school debt, mega-million dollar frivolous lawsuits or being fired over patient satisfaction surveys based on complaints that may or may not even be valid.  But they also didn’t have our modern-day luxuries, salaries, exploding technologies, or a nation of patients soon to be more widely insured and in demand of our services than ever.  There is much worth fighting to reform, yet even more worth fighting to preserve.  All things considered, we are tremendously better off.

Be sure, Obamacare will change modern medicine, and it will change it mightily.  Also be sure, that with us or without us, and whether we look forward to seize new opportunities or look back upon shattered expectations, the profession of Medicine will be alive and well, and thriving more than ever before.

“BirdStrike” is an emergency physician who blogs at WhiteCoat’s Call Room at Emergency Physicians Monthly.


Interesting US report on healthcare payment reform from UnitedHealth Group @Medici_Manager @helenbevan


A “Real World” Strategy For Health Care Payment Reform

Qualche spunto interessante anche per il SSN italiano?


Brandeis professor traces efforts to reshape health care @Medici_Manager @DonaldsonLiam


When President Nixon wanted to overhaul the health care system to provide universal coverage, his administration turned to Stuart Altman.

Ten years later, when Congress created a commission to improve the Medicare payment system, Altman led the effort. And, in the early ’90s, when newly elected Bill Clinton assembled a team to guide his health care policies, Altman was among the first chosen.

There may be no single person with a longer or deeper history in the health care overhaul efforts of the past 40 years than Altman, a professor of national health policy at Brandeis University in Waltham. He has advised five presidents, both Democratic and Republican; authored countless articles about health policy; and served on a variety of task forces aimed at fixing health care on both the national and state levels.

These four decades as policy maker, adviser, and scholar play a central role in Altman’s new book, “Power, Politics, and Universal Health Care,’’ which traces 100 years of debate and confrontation over one of the nation’s most intractable issues. With President Obama’s health care overhaul under attack from Republicans – and certain to be a defining issue in the November election – Altman and his coauthor, former Brandeis fellow David Shactman, show that today’s controversies have roots in the political and philosophical battles that raged a century ago.

In 1915, for example, the American Association for Labor Legislation, a workers advocacy group, proposed that the US government provide health insurance for low-income workers and their families, similar to programs adopted in Germany and England. Special interests, including the insurance industry and American Medical Association, lined up against the plan. Conservatives, raising alarms about government intervention into the private sector, joined the opposition.

“Opponents claimed that national health insurance was a tool of socialists and communists – rhetoric that still reverberates today in the halls of Congress,’’ Altman and Shactman wrote.

Altman first became involved in health care reform in the early 1970s. He earned his doctorate in economics at the University of California, Los Angeles, where he wrote his dissertation on unemployed married women, then went to teach at Brown University. Former colleagues, working at the US Department of Health, Education, and Welfare during Lyndon B. Johnson’s administration, recruited him to study the supply of registered nurses in the workforce.

When Nixon was elected president, Altman stuck around. Although a Republican, Nixon was eager to propose a universal health care plan to compete with more far-reaching alternatives pushed by liberals such as Massachusetts Senator Edward M. Kennedy. Altman was asked to examine policy options. “I was sort of thrust into it,’’ Altman said.

The challenges he confronted – ballooning health care costs and high numbers of uninsured – were “the exact problems we have today,’’ he said. Watergate intervened before the administration’s proposal got very far, and Altman returned to teaching, at Brandeis, after Nixon resigned. But his involvement in policy making was far from over.

From 1984 to 1996, Altman chaired the congressional Prospective Payment Assessment Commission, an independent panel created to oversee Medicare payments to hospitals to help control health care costs. He worked on Clinton’s transition team, only to see his recommendations to build on the existing system rejected in favor of a more sweeping plan that died in Congress.

Altman later served on the Commission on the Future of Medicare during Clinton’s administration, and advised Obama on health policy during the 2008 campaign. Altman conceived the idea for his book during the early debates over Obama’s health care proposals. Ultimately, Obama got his overhaul passed without a single Republican vote.

Altman wanted to explore why health care has proven such a difficult, divisive issue, and why so many attempts to make it more available and affordable did not succeed. Franklin D. Roosevelt, Harry S. Truman, John F. Kennedy, Nixon, Clinton, and any number of lawmakers all failed to push through major proposals.

In fact, Altman and Shactman began their book assuming that Obama, too, would fall short. The book’s working title: “Failure Again.’’

Health care reform has been so intractable because it provides a lightning rod for long-running political and philosophical conflicts over the role of government, according to Altman. While the left favors a social safety net, the right fears creeping socialism. Conservatives prefer to let market forces meet health care needs, but liberals distrust the motives of private business. Advocacy groups representing special interests such as doctors, hospitals, and senior citizens fight any proposal that may cost them money, jobs, or influence.

With these opposing forces constantly in play, the history of health care reform is replete with attempts at compromise, but short on success stories.

In 1974, in a church basement near the US Capitol, opposing factions met in secret to craft a deal on universal health care. Among the attendees were Altman, representing the Nixon administration, and an aide to Kennedy, then advocating a single-payer system, similar to those in Europe and Canada.

“It would make a good ending to the story if the secret church meetings in June resulted in a successful compromise, but it was not to be,’’ Altman and Shactman wrote. “Neither side felt they could agree to the concessions necessary to make a deal.’’

At 74, Altman remains immersed in health care policy. He advises lawmakers, administration officials, and nonprofit groups about health care economics. Chris Jennings, a consultant in Washington who worked with Altman in the 1980s and ’90s, said Altman “is still incredibly relevant.’’

“He continues to be viewed as a substantive and intellectual health policy reform expert,’’ said Jennings.

Altman said the Patient Protection and Affordable Care Act, aka Obamacare, will reduce the number of uninsured Americans – if it survives court challenges and repeal efforts. If the law is undone, Altman predicted, the nation faces “the worst of all worlds’’: high numbers of uninsured and soaring medical costs.

Altman has donated to Democratic candidates, but he is more pragmatist than partisan. Incremental, rather than revolutionary, change, he said, is the best approach for improving the complex patchwork of government programs and private coverage that has evolved over the past century.

The insurance industry remains important to the US economy and must be included in overhaul efforts, he said. At the same time, the federal government’s involvement is vital to ensuring that all have access to health care.

“The idea that you can do it without the government is pure nonsense,’’ he said. “People have a legitimate concern with ‘too much government,’ but the question is, where is the balance?’’

After The Election: A Consumer’s Guide To The Health Law @Medici_Manager @KHNews

By Mary Agnes Carey and Jenny Gold KHN Staff Writers NOV 08, 2012

Now that President Barack Obama has won a second term, the Affordable Care Act is back on a fast track.

Some analysts argue that there could be modifications to reduce federal spending as part of a broader deficit deal; for now, this is just speculation. What is clear is that the law will have sweeping ramifications for consumers, state officials, employers and health care providers, including hospitals and doctors.

While some of the key features don’t kick in until 2014, the law has already altered the health care industry and established a number of consumer benefits.

Here’s a primer on parts of the law already up and running, what’s to come and ways that provisions could still be altered.

I don’t have health insurance. Under the law, will I have to buy it and what happens if I don’t?

Today, you are not required to have health insurance. But beginning in 2014, most people will have to have it or pay a fine. For individuals, the penalty would start at $95 a year, or up to 1 percent of income, whichever is greater, and rise to $695, or 2.5 percent of income, by 2016.

For families the penalty would be $2,085 or 2.5 percent of household income, whichever is greater. The requirement to have coverage can be waived for several reasons, including financial hardship or religious beliefs.

Millions of additional people will qualify for Medicaid or federal subsidies to buy insurance under the law.

While some states, including most recently Alabama, Wyoming and Montana, have passed laws to block the requirement to carry health insurance, those provisions do not override federal law.

I get my health coverage at work and want to keep my current plan. Will I be able to do that? How will my plan be affected by the health law?

If you get insurance through your job, it is likely to stay that way. But, just as before the law was passed, your employer is not obligated to keep the current plan and may change premiums, deductibles, co-pays and network coverage.

You may have seen some law-related changes already. For example, most plans now ban lifetime coverage limits and include a guarantee that an adult child up to age 26 who can’t get health insurance at a job can stay on her parents’ health plan.

What other parts of the law are now in place?

You are likely to be eligible for preventive services with no out-of-pocket costs, such as breast cancer screenings and cholesterol tests.

Health plans can’t cancel your coverage once you get sick – a practice known as “rescission” – unless you committed fraud when you applied for coverage.

Children with pre-existing conditions cannot be denied coverage. This will apply to adults in 2014.

Insurers will have to provide rebates to consumers if they spend less than 80 to 85 percent of premium dollars on medical care.

Some existing plans, if they haven’t changed significantly since passage of the law, do not have to abide by certain parts of the law. For example, these “grandfathered” planscan still charge beneficiaries part of the cost of preventive services.

If you’re currently in one of these plans, and your employer makes significant changes, such as raising your out-of-pocket costs, the plan would then have to abide by all aspects of the health law.

I want health insurance but I can’t afford it. What will I do?

Depending on your income, you might be eligible for Medicaid. Currently, in most states nonelderly adults without minor children don’t qualify for Medicaid. But beginning in 2014, the federal government is offering to pay the cost of an expansion in the programs so that anyone with an income at or lower than 133 percent of the federal poverty level, (which based on current guidelines would be $14,856 for an individual or $30,656 for a family of four) will be eligible for Medicaid.

The Supreme Court, however, ruled in June that states cannot be forced to make that change. Republican governors in several states have said that they will refuse the expansion, though that may change now that Obama has been re-elected.

What if I make too much money for Medicaid but still can’t afford to buy insurance?

You might be eligible for government subsidies to help you pay for private insurance sold in the state-based insurance marketplaces, called exchanges, slated to begin operation in 2014. Exchanges will sell insurance plans to individuals and small businesses.

These premium subsidies will be available for individuals and families with incomes between 133 percent and 400 percent of the poverty level, or $14,856 to $44,680 for individuals and $30,656 to $92,200 for a family of four (based on current guidelines).

Will it be easier for me to get coverage even if I have health problems?

Insurers will be barred from rejecting applicants based on health status once the exchanges are operating in 2014.

I own a small business. Will I have to buy health insurance for my workers?

No employer is required to provide insurance. But starting in 2014, businesses with 50 or more employees that don’t provide health care coverage and have at least one full-time worker who receives subsidized coverage in the health insurance exchange will have to pay a fee of $2,000 per full-time employee. The firm’s first 30 workers would be excluded from the fee.

However, firms with  50 or fewer people won’t face any penalties.

In addition, if you own a small business, the health law offers a tax credit to help cover the cost. Employers with 25 or fewer full-time workers who earn an average yearly salary of $50,000 or less today can get tax credits of up 35 percent of the cost of premiums. The credit increases to 50 percent in 2014.

I’m over 65. How does the legislation affect seniors?

The law is narrowing a gap in the Medicare Part D prescription drug plan known as the “doughnut hole.” That’s when seniors who have paid a certain initial amount in prescription costs have to pay for all of their drug costs until they spend a total of $4,700 for the year. Then the plan coverage begins again.

That coverage gap will be closed entirely by 2020. Seniors will still be responsible for 25 percent of their prescription drug costs. So far, 5.6 million seniors have saved $4.8 billion on prescription drugs, according to the Department of Health and Human Services.

The law also expanded Medicare’s coverage of preventive services, such as screenings for colon, prostate and breast cancer, which are now free to beneficiaries. Medicare will also pay for an annual wellness visit to the doctor. HHS reports that during the first nine months of 2012, more than 20.7 million Medicare beneficiaries have received preventive services at no cost.

The health law reduced the federal government’s payments to Medicare Advantage plans, run by private insurers as an alternative to the traditional Medicare. Medicare Advantage costs more per beneficiary than traditional Medicare. Critics of those payment cuts say that could mean the private plans may not offer many extra benefits, such as free eyeglasses, hearing aids and gym memberships, that they now provide.

Will I have to pay more for my health care because of the law?

No one knows for sure. Even supporters of the law acknowledge its steps to control health costs, such as incentives to coordinate care better, may take a while to show significant savings. Opponents say the law’s additional coverage requirements will make health insurance more expensive for individuals and for the government.

That said, there are some new taxes and fees. For example, starting in 2013, individuals with earnings above $200,000 and married couples making more than $250,000 will paya Medicare payroll tax of 2.35 percent, up from the current 1.45 percent, on income over those thresholds. In addition, higher-income people will face a 3.8 percent tax on unearned income, such as dividends and interest.

Starting in 2018, the law also will impose a 40 percent excise tax on the portion of most employer-sponsored health coverage (excluding dental and vision) that exceeds $10,200 a year and $27,500 for families. The tax has been dubbed a “Cadillac” tax because it hits the most generous plans.

In addition, the law also imposes taxes and fees on several major health industries. Beginning in 2013, medical device manufacturers and importers must pay a 2.3 percent tax on the sale of any taxable medical device to raise $29 billion over 10 years. An annual fee for health insurers is expected to raise more than $100 billion over 10 years, while a fee for brand name drugs will bring in another $34 billion.

Those fees will likely be passed onto consumers in the form of higher premiums.

Has the law hit some bumps in the road?

Yes. For example, the law created high-risk insurance pools to help people purchase health insurance. But enrollment in the pools has been less than expected. As of Aug. 31, 86,072 people had signed up for the high-risk pools, but the program, which began in June 2010, was initially expected to enroll between 200,000 and  400,000 people. The cost and the requirements have been difficult for some to meet.

Applicants must be uninsured for six months because of a pre-existing medical condition before they can join a pool. And because participants are sicker than the general population, the premiums are higher.

Enrollment has increased since the summer, after the premiums were lowered in some states by as much as 40 percent and some states stepped up advertising.

A long-term care provision of the law is dead for now. The Community Living Assistance Services and Supports program (CLASS Act) was designed for people to buy federally guaranteed insurance that would have helped consumers eventually cover some long-term-care costs. But last fall, federal officials effectively suspended the program even before it was to begin, saying they could not find a way to make it work financially.

Are there more changes ahead for the law?

Some observers think there could be pressure in Congress to make some changes to the law as a larger package to reduce the deficit. Among those options is scaling back the subsidies that help low-income Americans buy health insurance coverage. The amount of the subsidies, and possibly the Medicaid expansion as well, could be reduced.

It’s also possible that some of the taxes on the health care industry, which help pay for the new benefits in the health law, could be rolled back. For example, legislation to repeal the tax on medical device manufacturers passed the House with support from 37 Democrats (it is not expected to receive Senate consideration this year). Nine House Democrats are co-sponsoring legislation to repeal the law’s annual fee on health insurers.

Meanwhile, the Independent Payment Advisory Board (IPAB), one of the most contentious provisions of the health law, is also under continued attack by lawmakers. IPAB is a 15-member panel charged with making recommendations to reduce Medicare spending if the amount the government spends grows beyond a target rate. If Congress chooses not to accept the recommendations, lawmakers must pass alternative cuts of the same size.

Some Republicans argue that the board amounts to health care rationing and some Democrats have said that they think the panel would transfer power that belongs on Capitol Hill to the executive branch. In March, the House voted to repeal IPAB.

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IOM: #Physicians play key role in stopping health system waste @HarvardSPH_ECPE @Medici_Manager

The institute, which concludes that 30 cents of every health care dollar is wasted, seeks payment incentives and health IT adoption to improve patient outcomes.

By JENNIFER LUBELL, amednews staff. Posted Sept. 24, 2012

Washington To cut down on what it says is a massive amount of waste and inefficiency in health care, an Institute of Medicine report is recommending that physicians and other health professionals become part of a “learning” system that uses new clinical support tools and payment models linking performance to patient outcomes, as well as a team approach to care management.

A panel convened by the institute to look at the challenges facing the U.S. health system found that unnecessary services, fraud and excessive administrative costs accounted for about 30%, or $750 billion, of total health spending in 2009. Wasted resources have human consequences, according to the report, “Best Care at Lower Cost: The Path to Continuously Learning Health Care in America.” According to one outside estimate, 75,000 deaths may have been prevented in 2005 if the quality of care in all of the states had risen to the level of care of the highest-performing state in the nation.

“Our health care system lags in its ability to adapt, affordably meet patients’ needs and consistently achieve better outcomes,” said Mark Smith, MD, chair of the IOM committee that wrote the report. Dr. Smith cited examples of these inefficiencies during a press event to discuss the report’s 10 main recommendations on transforming the health care system.

Cost and complexity of health care are the two issues at stake, Dr. Smith said. Physicians in private practices can interact with as many as 229 other physicians in 117 different practices for their Medicare patients alone. Some of this interaction relies solely on outdated technology from the last century, such as telephones and faxes. “Who uses faxes anymore?” he asked.

The cost problems are known as well, Dr. Smith continued. For 31 of the past 40 years, health care has been increasing at a greater rate than the economy as a whole and now comprises roughly 18% of the nation’s gross domestic product.

Getting rid of health care inefficiencies and waste requires a broad transformation to a system that adopts new clinical and information technology tools to manage patient care better. Unlike the situation in 1999, when the IOM’s landmark patient safety report “To Err Is Human: Building a Safer Health System” was released, the industry today has newfound access to computing and connectivity tools to make substantial gains on cost and quality, Dr. Smith said. “Our sense is the system must learn continuously, that patients, clinicians and the communities they reside in have to be part of constant circle of the generation of evidence and capturing of information from patient care that can then be returned to scientific knowledge.”

Pay-for-performance, technology promoted

Current payment methods also foster inefficient care, the report stated, advising that pay instead should be based on care outcomes and the principle of providing optimal care at lower cost, instead of on individual products and services. “Payers should adopt outcome- and value-oriented payment models, contracting policies, and benefit design to reward and support high-quality, team-based care” that focuses on patients’ needs, the IOM report stated.

Physicians, particularly older ones, have been resistant to such changes, said Paul Keckley, PhD, executive director of the Deloitte Center for Health Solutions in Washington. “They invest a lot of time to get prepared to practice, and then the rules change and they’re frustrated,” he said.

Health care comprises roughly 18% of the U.S. gross domestic product.

Investment costs are tied to information technology, to transferring from a physician-centric to a team-based delivery model, and to shifting incentives from volume to outcomes. “And it’s coming at a pretty difficult time, when the health system’s costs are a major issue.”

Keckley said the new generation of physicians in medical school has a clearer idea of what medicine will look like in the future and will be better equipped to deal with the changes the IOM report is recommending. “They know they’re going to be using iPads and mobile devices, they know they’re going to be dealing with educated consumers that have Bluetooth devices that are looking at treatment options and cost.”

Roy Schoenberg, MD, MPH, president and CEO of American Well Systems, a telehealth company based in Boston, said the IOM study’s focus on new technology is significant. “This report should fuel the momentum we see today within the physician community to embrace innovative technologies such as telehealth, which improves access to quality care while reducing costs.”

Telehealth in particular is advancing quickly and boosting efficiency, Dr. Schoenberg said. “What used to require very costly and sophisticated hardware and IT investments can now be done simply with a computer or a smartphone.”

Also critically important to this transformational process is the report’s emphasis on a team-based approach to improve wellness, said T. Bruce Ferguson Jr., MD. He’s a member of the IOM committee that wrote the report and a professor of cardiovascular sciences and inaugural chair at the Brody School of Medicine at East Carolina University in Greenville, N.C.

Physicians won’t be able to keep patients with multiple disease processes out of the hospital without the support of their families, the communities in which they live and community-based resources, Dr. Ferguson said. “It is an impossible task for a physician to accomplish by themselves. Part of that lack of ability is inherent in our lack of connectivity, our lack of using technologies to create those ways to follow our patients and provide them with the support they need.”

The IOM committee recommended that health care professionals employ various tools such as patient portals to share health decisions with patients and families.

The findings also emphasized the role of medical specialty societies in encouraging the adoption of its recommendations, Dr. Ferguson said. “I think there’s going to be a lot of interest among organizations as they digest this.”

Jeremy A. Lazarus, MD, president of the American Medical Association, praised the IOM’s work, stressing that new health care delivery models should be patient-centered and physician-led. “We look forward to the day when a more robust digital infrastructure exists to further these goals, and we remain committed to working closely with regulators and industry partners to meet these goals in a manner that best supports patients and physicians,” Dr. Lazarus said.

Keckley said the incentive models the report discussed still are works in progress. This area is one where physicians should be very proactive in determining what process measures and outcomes measures are valid, reliable and science-based. “And I think there’s a lot of appropriate debate and concern among clinicians around some of these measures. That part of the puzzle hasn’t been solved yet,” he said.


10 IOM recommendations for a better health care system

To promote the transformation to a “learning” system that continuously improves care management and patient outcomes — and that aims to reduce the estimated 30% of health spending that is wasted — the Institute of Medicine made 10 major recommendations:

  • Improve capacity to capture clinical, care delivery process, and financial data for better care, system improvement and generation of new knowledge.
  • Streamline and revise research regulations to improve care, promote capture of clinical data and generate knowledge.
  • Accelerate integration of the best clinical knowledge into care decisions.
  • Involve patients and families in decisions regarding health and health care, tailored to their preferences.
  • Promote community-clinical partnerships and services aimed at managing and improving health at the community level.
  • Improve coordination and communication within and across organizations.
  • Continuously improve health care operations to reduce waste, streamline care delivery and focus on activities that improve patient health.
  • Structure payment to reward continuous learning and improvement in the provision of better care at lower cost.
  • Increase transparency on health care system performance.
  • Expand commitment to the goals of a continuously learning health care system.

Source: “Best Care at Lower Cost: The Path to Continuously Learning Health Care in America,” Institute of Medicine, Sept. 6 (

JAMA Forum: End of the Threat to Obamacare? Not at All @Medici_Manager

The JAMA Forum

By Stuart M. Butler, PhD


President Obama’s narrow victory has left proponents of the Affordable Care Act (ACA) breathing a collective sigh of relief, believing that the legislation is safe. It’s true, of course, that the election’s outcome has ended the prospect of a new administration using Republican majorities in both chambers and the budget reconciliation process to force outright repeal. But the reality of the economic and political situation means the core elements of the ACA remain very much in play.

The primary reasons for this are the continuing problems with the federal budget deficit and the national debt and the worrying long-term weakness of the economy. Add to that the increasing skepticism that the ACA’s blunt tools will slow costs.

Let’s remember that the most important provisions of the ACA, such as penalties for Americans lacking insurance and firms not offering it, the expansion of Medicaid, and the heavily subsidized exchange-based coverage, do not go into effect until 2014. Meanwhile, new taxes on self-employment and limits on flexible spending accounts are scheduled to go into effect next year, just as Congress will be trying to boost employment growth. Additionally, lawmakers will be desperately searching for ways to delay or cut spending to deal with the deficit. That adds up to 2013 being a year for buyer’s remorse in Congress and around the country.

The reaction of employers to the ACA is likely to be the first pressure point for changes in the ACA or at least the suspension of some of its provisions. Employers have been reporting for some time that concerns about mandatory benefits are slowing their hiring. And as the Wall Street Journal recently reported, lower-wage employers are moving towards hiring part-time employees to avoid the ACA’s penalties. These patterns will only grow in 2013 as many employers eye the prospect of putting their employees into the heavily subsidized exchange plans. And the possibility of larger-than-expected enrollment in health insurance exchanges will sharply increase the budget costs, adding to the deficit pressures to curb the ACA.

These developments in the economy will force Congress to reopen key ACA coverage provisions, perhaps as part of a deficit reduction package. Effects on employment and continued increases in health care costs could also increase the prospects of a bipartisan redesign of employer-based coverage within a tax reform package. That could involve switching clumsy mandates and penalties on employers for the kind of structural tax reform that many Republican and administration insiders have actually long supported—measures that gradually curb and eventually replace the current tax exclusion for employer-sponsored coverage with tax credits and subsidies that would apply to all employees.

It’s also hard to imagine the expansion of Medicaid proceeding as planned. The number of Republican governors has now grown to at least 30, from 29. If slow economic growth continues, and statehouse fears of unsustainable employee pensions and other mounting costs continue to grow, even the short-term prospect of Washington picking up expanded Medicaid costs is not likely to prevent a strong pushback by states. That’s going to be exacerbated by a Congress that is desperately trying to curb spending. So expect structural reform of the ACA’s Medicaid, including some version of a block grant, to be on the deficit-reduction table.

Perhaps most important of all, the prospects for serious Medicare reform are actually on the rise. The Ryan version of premium support (in which the federal government would provide a limited payment to beneficiaries that could be used toward purchasing a private insurance plan or for the traditional Medicare program) was initially seen by the Obama campaign as a gift from heaven that would doom Romney among the elderly. But that didn’t happen. Indeed Obama’s initial large lead as the best defender of Medicare slid to just 5 points by the election.Exit polls show Romney also won the senior vote (and those older than 45 years) and even increased the Republican share over 2008.

What this suggests is that a version of premium support is now likely to gain renewed traction as budget pressures and underlying costs of health care force congressional action. The approach has actually had bipartisan support since the Clinton Administration and, in private, among many Democratic politicians. Versions have garnered strong support in the Bowles-Simpson Commission, from leading organizations outside Congress, such as the Bipartisan Policy Center and the Brookings Institution. And compared with alternative ways of slowing Medicare spending, it doesn’t look so bad politically. Relying on the Independent Payment Advisory Board (IPAB) of experts in health care economics and the health care system to crack down on physicians and hospitals is hardly going to make the ACA more popular among seniors. Let’s remember that repealing the IPAB had strong bipartisan support in the House, with even liberal Rep Barney Frank (D, Mass) as a cosponsor.

The Obama administration is arguing that the election means the ACA is a settled issue. It is far from that.


About the author: Stuart M. Butler, PhD, is Director of the Center for Policy Innovation at the Heritage Foundation in Washington, DC, where he focuses on developing new policy ideas. Previously he served as Vice President for Domestic and Economic Policy Studies. He is also an Adjunct Professor at Georgetown University’s Graduate School.


Forecasting Health Policy For The Post-Election Landscape @Medici_Manager @KHNews

Various news stories examine how the outcome of the presidential election could lead to very different  courses for the health law’s implementation and approaches to Medicare reform.

Kaiser Health News: How The Health Law Might Be Changed By The Next President
On the presidential campaign trail, Republican Mitt Romney has repeatedly called for repeal of the 2010 health law and President Barack Obama has vowed to implement it. Yet both men could face obstacles: Romney may be stymied by the lack of a majority in Congress to do his will and Obama could be forced by fiscal concerns or public opinion to revamp parts of the law. Here is a look at how Obama and Romney might change the health law in the years ahead based on interviews with health policy experts (Carey, 10/31).

The Medicare NewsGroup: Romney Presidency Could Mean Substantial Changes In Access To Health Care, Approaches To Medicare Reform
If Mitt Romney wins the presidential election, this much is certain: He will do everything he can to make good on his vow to repeal the Affordable Care Act, President Obama’s 2010 health care overhaul. However, his ability to follow through on this promise depends on more than just winning the presidential election. There are several “what ifs” that would need to fall into place to bring about substantial changes to Medicare and the Affordable Care Act (ACA) in a Romney presidency; and chief among them is the shape of Congress after next Tuesday’s election (Pasternak, 10/31).

The Medicare NewsGroup: A Second Term For Obama: What It Would Mean For Medicare
If President Obama wins the election and another four years in office, Medicare would be saved from the major overhaul GOP candidates Mitt Romney and Paul Ryan have endorsed. Right? Well, sort of. The notion that Obama is “saving Medicare” certainly is one the Obama campaign hopes will stick with the voting public and, in particular, with seniors and soon-to-be seniors in key swing states, such as Florida, Ohio and Virginia, who want to maintain Medicare in its current form. An Obama victory would almost certainly mean another four years would pass without the possibility that Medicare would be converted into a premium-support, or voucher, program, the GOP’s plan for reform (Szot, 10/31).

This is part of Kaiser Health News’ Daily Report – a summary of health policy coverage from more than 300 news organizations. The full summary of the day’s news can be found here and you can sign up for e-mail subscriptions to the Daily Report here. In addition, our staff of reporters and correspondents file original stories each day, which you can find on our home page.

How The Health Law Might Be Changed By The Next President @Medici_Manager @KHNews

By Mary Agnes Carey KHN Staff Writer NOV 01, 2012

On the presidential campaign trail, Republican Mitt Romney has repeatedly called for repeal of the 2010 health law and President Barack Obama has vowed to implement it. Yet both men could face obstacles: Romney may be stymied by the lack of a majority in Congress to do his will and Obama could be forced by fiscal concerns or public opinion to revamp parts of the law.

Here is a look at how Obama and Romney might change the health law in the years ahead based on interviews with health policy experts.


President Barack Obama waves to an audience of about 15,000 supporters during a campaign rally in Virginia (Photo by Chip Somodevilla/Getty Images).

President Barack Obama has urged voters to re-elect him so that he can put the law fully into effect. But some analysts predict the mounting pressures to reduce federal spending will complicate that plan.  And others note that in a second term, Obama may be more open to working with Congress to tweak provisions of the law that have raised concerns. Leading up to this tight election, Obama and Democrats have been reluctant to make modifications to the law, known as the Affordable Care Act (ACA).

“Right now (Democrats) can’t criticize the ACA. It’s just not politically smart,” said Dan Mendelson, chief executive of the consulting firm Avalere Health who oversaw health programs at the Clinton administration’s Office of Management and Budget. But should Obama win a second term and Democrats retain control of the Senate, “I think that adjustments are on the table” as part of a larger deal to reduce the federal deficit, he said.

Scale Back Subsidies: As part of that effort to reduce federal spending, there could be pressure to scale back the health law’s subsidies that help low-income residents afford coverage. People who earn up to 400 percent of poverty – currently about $92,000 for a family of four – are eligible to get financial help in purchasing coverage.  Another big-ticket item is the expansion of Medicaid coverage to anyone up to 133 percent of the poverty level, or about $30,656 for a family of four.

The ACA is “so vast that by default it has to be impacted if there is a bipartisan, grand bargain debt deal,” said Mike Tuffin, managing director of the consulting firm APCO Worldwide’s Washington, D.C., office and formerly executive vice president of America’s Health Insurance Plans, an insurance industry trade group. “You can imagine the subsidies being impacted, the Medicaid expansion being impacted.”

Changing the law’s implementation schedule is wishful thinking among Republicans, Mendelson said. Any delay in full implementation could risk political backlash from consumers, who have waited years for the major provisions of the ACA to kick in. Delays may also open the law to other changes that Obama and Democrats don’t want.

“My feeling is that it would be a major political liability for the president to encourage delay,” he said, “and that if this is going to be his legacy, I see no indication from the policy makers that they either want or expect there to be a delay.”

The president “is willing to work with anyone with good ideas to improve the Affordable Care Act.  What he is not willing to do is reopen old partisan battles over the central guarantees of Obamacare,” said Adam Fetcher, a spokesman for the Obama campaign.

Change in Age Rating Bands: The ACA prohibits insurers from charging more than three times as much for a policy sold to an older person than to a younger person. (This does not affect people over 65 who are covered by Medicare.)  This is a change from current law in most states where there are no limits on how much more insurers can charge older people. America’s Health Insurance Plans is advocating that the law’s rating bands be changed to 5:1 to prevent what the group describes as “rate shock” for younger people and families.

The issue that arises is that the law “makes coverage more affordable for the elderly but more expensive for the young people they want to buy coverage,” said Paul Heldman, senior health policy analyst with Potomac Research Group, a Washington research firm.

Medical Device Tax Cut: Of the many taxes in the health law, one has come under especially withering criticism: a 2.3 percent tax on the sale of any taxable medical device. Medical device manufacturers have loudly opposed the tax and won some key congressional support.

“For some, it could truly be the difference between surviving and having to close their doors,” Michael R. Minogue, CEO and chairman of the board of Abiomed, Inc., which makes cardiac medical devices, told Congress this summer. But other analysts contend that the industry will do better under the law because more people will have coverage for treatments that use medical devices.

Legislation to repeal the tax passed the House in June with 37 Democrats joining Republicans to support the measure, although it is unlikely to receive Senate consideration this year.

The problem with this – or any change – in the law’s taxes is finding another area to make up the loss of revenue. “It’s easy to hate a tax. It’s harder to find a pay for,” says Mendelson.

Nonetheless, Tuffin says that this and other taxes could raise concerns if the public sees them as making health insurance or medical care more expensive.

“All of those hit simultaneously and overnight in 2014 and they are going to drive up the cost of coverage,” he says. “Consumers are going to feel that, small businesses are going to feel that.”

IPAB: One of the most contentious provisions of the health law is the creation of a 15-member panel charged with making recommendations to reduce Medicare spending if the amount the government spends grows beyond a target rate.  Congress must pass alternative cuts of the same size, or the recommendations from the panel, known as the Independent Payment Advisory Board (IPAB), become law. IPAB members are prohibited from making recommendations that would increase revenues or change benefits, eligibility or Medicare beneficiary cost-sharing.

The board is disliked by many lawmakers. Some Republicans charge it amounts to health care rationing while members from both parties hate the idea of surrendering the power of the purse.

“IPAB is not a political must-have for the president,” Mendelson said. “It is the kind of thing that could be treated in the context of other legislative adjustments….”


GOP presidential candidate, former Massachusetts Gov. Mitt Romney greets supporters during a campaign rally in Ohio (Photo by Justin Sullivan/Getty Images).

Gov. Mitt Romney has promised a full-scale repeal of the ACA. “He will repeal it in its entirety and replace it with reforms of his own,” Romney spokeswoman Andrea Saul said in an e-mail.

But short of Republicans controlling both chambers of Congress, he would have to rely on the federal regulatory process to choke off funding and give states wide latitude to implement – or ignore — the law. If Republicans took control of the Senate but had fewer than the 60 votes needed to pass most legislation, Romney could be forced to use a difficult legislative process known as “reconciliation” to try to dismantle the measure.

Still, some of the law’s supporters believe such a Republican effort could be successful. “I would say the bulk of it can be dismantled,” said former Senate Majority Leader Tom Daschle, D-S.D. “[Romney] can use reconciliation for certain amounts affecting the budget of the federal government….He could have a profound effect on the outcome of the ACA in a very short period of time.”

Slowing Down Implementation: The health law gives tremendous power to the secretary of Health and Human Services to implement the health law, and a Romney administration could use that power to slow the rulemaking process to a crawl.

“[Romney] can really do a lot to change the course of the legislation because – especially with the Affordable Care Act – the secretary and the president were given wide latitude,” Daschle said.

If Republicans win control of the Senate, they could also use the reconciliation process—which requires only a majority instead of the 60 votes usually needed to pass a measure — to strip out sections of the law that relate to the federal budget. That would include some of the law’s biggest provisions – such as the health insurance exchanges, subsidies to purchase coverage and the Medicaid expansion. Removing those sections would gut the law’s goal of covering 30 million more Americans.

But reconciliation can be a cumbersome and difficult process. In addition, it only applies to budget measures so large chunks of the law would be unaffected. And changes made under the process can’t increase the deficit.

“I think as people get into the details, it doesn’t work quite the way they thought,” Senate Budget Committee Chairman Kent Conrad said when Senate Democrats were debating using reconciliation to pass the health law. Reconciliation, he said, “is anything but a slam dunk.”

Waivers: Romney has said he would allow states to opt-out of the health law by using a waiver process. He could also use the process to give states wide latitude to implement provisions, like health insurance exchanges, that differ from requirements in the ACA. But there are many rules that govern the waiver process; ignoring those might not be so easy, analysts say.

An article in the Journal of the American Medical Association this week examines the power an administration would have to block the law. It points out that under the Constitution, the president is required to “take care that the laws be faithfully executed” and can’t “refuse to execute laws passed by Congress with which he disagrees,” unless Congress grants that discretion.

Authors John Kraemer and Lawrence Gostin note that because the ACA “provides no such blanket waiver authority, granting states authority to disregard the ACA’s key provisions would likely violate the ‘take care’ clause.” The ACA, however, does allow states to seek waivers starting in 2017 if they can demonstrate an alternative approach that could increase coverage and reduce cost without raising the federal deficit.

If Romney opted not to move forward on the law, the administration could also be sued by individuals and groups. That litigation could take months – maybe years – to be resolved.

What Might Stay: Romney has said that he expects insurers to keep coverage that allows adult children to stay on a parent’s health insurance policy until age 26, although it’s unclear if he would support legislation or regulations to make that happen. He also has expressed support for states to set up health insurance exchanges and high-risk pools to cover the uninsured.

Avik Roy, a senior fellow at the conservative Manhattan Institute and an outside adviser to the Romney campaign, says Romney wants most people to own their own health insurance rather than rely on their employers for coverage. “There are still other things you can do to expand [existing federal] protections to people who have credible coverage,” he said. “And then for people who still have those gaps, do more with high-risk pools and do other things to make sure that the people who can’t get insurance today have the ability to get it through subsidized high-risk pools at the state level.”

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Health Policy and The 2012 Election @Medici_Manager @KHNews

Here’s the latest from Kaiser Health News on the 2012 election and what’s at stake for health care in America.

Kaiser Health News has extensive coverage of the 2012 election. Here are some stories grouped by party or political race:

Comparing and contrasting the candidates and plans:



On the campaign trail:

Debate videos:

First Presidential Debate

Vice Presidential Debate

Town Hall Presidential Debate

Convention videos:



More KHN political coverage

Medicare, Health Law Part Of Obama, Romney Pitches For Votes @Medici_Manager @KHNews

In the campaign’s final days, President Barack Obama and GOP challenger Mitt Romney deliver closing arguments about their health care positions, among other issues.

Los Angeles Times: Romney Resumes Criticizing Obama On The Stump
With five days to go until election day, Romney said voters faced a clear choice, and painted a dim picture of the nation’s future if Obama were reelected – seniors unable to find doctors who were taking additional Medicare patients, middle-aged Americans seeing stagnant wages, annual trillion-dollar debts (Mehta, 11/1).

The Washington Post: Obama Returns To Campaign Trail To Deliver Closing Argument In Whirlwind, Multi-State Trip
Republican presidential nominee Mitt Romney spent the day in the battleground state of Virginia, where he hammered home the central theme of his closing argument to voters: that he is a champion of business whose policies would usher in new jobs and rising incomes for America’s workers and entrepreneurs. … Then [Obama] ticked off more policies he said Romney would pursue that did not represent change: rolling back Wall Street reform, giving a tax cut to the wealthy and overturning the Affordable Care Act, Obama’s signature health-care reform legislation. “Turning Medicare into a voucher system is change, but we don’t want that kind of change,” Obama said (Nakamura, 11/1).

The Associated Press/Washington Post: Obama Harkens Back To The Past And Pitches Change In Closing Argument To Voters
Obama blitzed Thursday from Wisconsin to Nevada to Colorado, where he wrapped up his day with a 10,000-person rally in Boulder. The president acknowledged that many Americans may be “frustrated” that change hasn’t come fast enough. To them, Obama offered a new definition of change that included passing the health care overhaul, bailing out the auto industry, ending the Iraq war and putting the U.S. military on a path to leave Afghanistan (11/2).

The Associated Press/Washington Post: Former CEO Romney Would Enter White House With Broad Agenda, Focus On Data Over Ideology
Should he prevail Tuesday, Mitt Romney would bring a CEO’s eye to the White House and a policy agenda based on a general set of principles and focused more on data than ideology. … Chief on the “To-Do” list, out of necessity: dealing with the so-called fiscal cliff of tax increases and budget cuts. He also promises to start repealing and replacing the president’s signature health care law and overhauling the nation’s tax system. And he would likely have to work with a divided Congress to accomplish it all (11/2).

NPR: Romney’s Baffling Claim About Medicare Pay Cuts For Doctors
Health care in general — and Medicare, in particular — have been big parts of this year’s presidential campaign. But over the last couple of weeks, Republican Mitt Romney has been making a new claim that doesn’t quite clear the accuracy bar. It has to do with $716 billion in Medicare reductions over 10 years included in the federal health law, the Affordable Care Act. And it’s become a standard part of Romney’s stump speech (Rovner, 11/2).

ABC: Obama, Biden Now Sing Different Tune On Medicare ‘Cuts’
Democrats have defended the $716 billion in Medicare savings in the health care law by arguing that seniors would not be affected because  the only spending cuts would be in future payments made to Medicare providers — there would be no cuts whatsoever to actual Medicare benefits. But in 2005, then Sens. Joe Biden and Barack Obama had an entirely different view of spending reductions to Medicare providers. First, some context: The $716 billion in Medicare cost savings in the health care law includes $415 billion in reduced future payments to providers (primarily hospitals, Medicare Advantage, home care, and about $20 billion in fraud prevention). These are only “cuts” in the way Washington defines “cuts” — the payments to providers continue to rise, but at a slower rate (Karl, 11/1).

Detroit Free Press: As Election Draws Near, President Barack Obama Expands Lead In Michigan
President Barack Obama heads into the final weekend of the campaign with a 6-percentage-point lead in Michigan over Republican rival Mitt Romney, a new Free Press/WXYZ-TV (Channel 7) poll shows. The survey suggests that the Democratic incumbent has regained some momentum heading into Tuesday’s election. Obama had 48% support to Romney’s 42%. Ten percent of likely voters were undecided or chose a third-party candidate. … Three-quarters of Romney’s supporters considered themselves enthusiastic — about the same as the number for Obama. Obama got higher marks in the poll on issues such as protecting Social Security and Medicare; making health care available to everyone, and handling the war in Afghanistan. Romney, who made a fortune in private equity and venture capital, slightly topped the president — 46%-44% — on handling the economy and creating jobs (Spangler, 11/1).

The New York Times’ The Caucus: In Swing States, Obama Leads On Handling Medicare
President Obama continues to lead Mitt Romney on the question of who would better handle Medicare in the crucial swing states of Florida, Ohio and Virginia, recent polls of likely voters in all three states found. But as Election Day nears Mr. Romney has narrowed the gap in Florida and Virginia. A series of Quinnipiac University/New York Times/CBS News polls released this week found that while Mr. Romney still trails Mr. Obama on Medicare in all three states, he has made up ground in Florida and Virginia (Cooper and Kopicki, 11/1).

The Washington Post: Michael Bloomberg Endorses Obama
New York City Mayor Michael Bloomberg endorsed President Obama on Thursday, citing climate change as the primary factor and Hurricane Sandy as the event that impelled him to make a choice. The mayor also cited the education competition Race to the Top, health-care reform, gay marriage and abortion rights as reasons to vote for Obama (Weiner, 11/1).

The Wall Street Journal: Union Is Top Spender For Democrats
The Service Employees International Union has emerged as the top outside spender on Democratic campaigns this year, surpassing even President Barack Obama’s main super PAC. SEIU has had particular success in recent years in organizing workers in the health-care and service industries. About half of its members work in health care, including everything from janitors and nurses to home-care workers and security officers. The union’s membership of 2.1 million is up from 1.6 million 10 years ago, even after it lost some during the economic downturn (Trottman and Mullins, 11/1).

Medscape Today: The Last Medscape 2012 Election Survey
When looking at how the responses trended, the surveys suggest that, like the general electorate, healthcare providers’ opinions on President Barack Obama and former Governor Mitt Romney have shifted over time — sometimes dramatically. The surveys provide insight into what healthcare professionals think about the platforms of the presidential candidates and highlight the role of healthcare in the upcoming election (Peckham, 11/1).

This is part of Kaiser Health News’ Daily Report – a summary of health policy coverage from more than 300 news organizations. The full summary of the day’s news can be found here and you can sign up for e-mail subscriptions to the Daily Report here. In addition, our staff of reporters and correspondents file original stories each day, which you can find on our home page.

Romney unlikely to repeal health reform law @Medici_Manager

The Republican candidate shows gains in voter support on healthcare issues
October 31, 2012 | By 

Despite vows to repeal the health reform law on his first day of office, Republican presidential candidate Mitt Romney isn’t likely to entirely repeal the Affordable Care Act, attorney experts wrote in a Journal of the American Medical Association.

With a social platform based on “repeal and replace,” according to the candidate’s website, the former Massachusetts governor will likely target the individual mandate, federal Medicaid payments to states and the controversial Independent Payment Advisory Board, according to John Kraemer at the Georgetown University School of Nursing and Health Studies and Lawrence Gostin at Georgetown University Law Center.

“‘Repealing and replacing’ the ACA is unlikely, requiring Obama to lose the presidency and Republicans to hold the House and 60 Senate seats to prevent a filibuster,” they wrote.

The Constitution requires the president execute on laws regardless of whether he disagrees with them, unless Congress grants discretion. The ACA does not provide a blanket waiver that allows states to disregard the ACA’s key provisions, as they would likely violate the “take-care” clause, the authors noted.

However, the ACA does allow waivers for certain provisions that can better fulfill the act. Nevertheless, states must specifically request waivers, which would not become available until 2017. Obama has sought an amendment to make innovation waivers available by 2014.

Romney, although unclear on how it would be carried out, says, he “will issue an executive order that paves the way for the federal government to issue Obamacare waivers to all fifty states,” suggesting states could waive all or parts of the ACA.

According to a Kaiser Family Foundation poll, Romney is gaining ground on voter support for healthcare issues. For instance, Obama and Romney are neck and neck on which candidate would do better for Medicare, with 46 percent support, compared to 41 percent, respectively, according to Kaiser Health News.

For more information:
– read the JAMA article
– see the Romney website details on healthcare
– here’s the Kaiser Health News article and Foundation poll

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KFF Poll: Obama Lead On Health Issues Lessens @Medici_Manager


OCT 31, 2012

The latest Kaiser Family Foundation health care tracking poll — the last one that will be released before the election — found that President Barack Obama’s advantage on several health issues has diminished.

Kaiser Health News: Capsules: Poll: Romney Narrows Gap With Obama On Medicare Issue
Most troublesome for Obama is that, among likely voters, GOP candidate Mitt Romney has pulled nearly even with him on which candidate would do a better job with Medicare — an issue that resonates in battleground states with large elderly populations like Florida and Pennsylvania. … While the economy remains voters’ most important issue, the poll found over a third of likely voters polled say the Affordable Care Act and Medicare are ”extremely important” to their vote. The law appears to be motivating supporters and opponents of the law about equally (Galewitz, 10/30).

Los Angeles Times: Obama Edge Over Romney On Healthcare Issues Shrinking
More likely voters still trust Obama to do a better job than his Republican challenger in handling the Medicare and Medicaid programs, lowering healthcare costs and determining the future of the healthcare law he signed in 2010. But Romney has cut the president’s lead in half on most issues and nearly eliminated it entirely on Medicare, the Kaiser survey found, compared with a similar poll taken in September (Levey, 10/31).

Politico Pro: Kaiser: Obama’s Lead On Health Issues Drops
[J]ust 46 percent of likely voters now say they trust Obama over Mitt Romney, while 41 percent say they prefer Romney. That’s a sharp drop from the 52 percent-36 percent lead Obama had over Romney in the September poll. And even though 72 percent of seniors opposed a premium support system for Medicare — the overhaul Romney and Paul Ryan are proposing — they actually trust Romney more than Obama on the future of Medicare. Forty-eight percent of those age 65 or older said they trust Romney more, while 43 percent say they prefer Obama (Smith, 10/31).

(KHN is an editorially independent program of the Kaiser Family Foundation.)

In related news, the Los Angeles Times takes a look at what Mitt Romney might do about the health law if he wins –

Los Angeles Times: Romney Says He’ll Undo Obama Healthcare Reform On Day 1. Can He?
Mitt Romney has pledged to do away with President Obama’s healthcare reform law if he wins next week’s election. But would he — or any other president — have the power to do so? Not exactly, according to two Georgetown University professors writing this week in the online version of the Journal of the American Medical Assn. But there are some things President Romney would be able to do if he won … The ACA does allow the president to issue waivers to the states, but only so that they can implement alternatives to the law that are better, not worse, write John D. Kraemer and Lawrence O. Gostin. In any case, those waivers won’t be available to states until 2017 (Kaplan, 10/30).

This is part of Kaiser Health News’ Daily Report – a summary of health policy coverage from more than 300 news organizations. The full summary of the day’s news can be found here and you can sign up for e-mail subscriptions to the Daily Report here. In addition, our staff of reporters and correspondents file original stories each day, which you can find on our home page.

Obama and Romney Need To Debate Health Care – Not Health Coverage @Medici_Manager @LeapfrogGroup

When my husband Sam and I were new parents, we visited our family in Maine to show off our beautiful six month old boy. The morning after our arrival, he became very sick (even struggled to breathe) and we were forced to take him to a local hospital. At that moment, we were living every parent’s worst nightmare and though we were covered by the health insurance that my employer offered, that was the last thing on our mind – we needed the best people at our side to care for our son.

But listening to the Presidential debate last night, when the topic turned to health care, all we heard about was health coverage. We didn’t hear about doctors and nurses, terrified parents, hospitals and nursing homes, or saving lives.

Both candidates seem to assume a good plan for health coverage equals a good plan for health care.  But is that really the case? Governor Romney wants more competition in the health insurance market, across state lines, and more competition in Medicare, so seniors can choose among health plans. President Obama’s plan also pivots on reforming health insurance—indeed, when it was first signed into law, Obamacare was called “health insurance reform.” Obamacare fosters competition among health plans through statewide exchanges and new regulation of health plans, such as outlawing pre-existing condition exclusions and requiring coverage of adult children through age 26.

Yet the only thing that mattered when I walked through the doors of the ER was the quality of care my baby would get, not the plastic laminated card in my wallet when we registered. I chose a health plan among competing plans offered by my employer on the basis of premium cost, deductibles, copays, prescription coverage, the plan’s customer service—but all of that seemed very small when I faced an emergency.

Sam and I chose an emergency room based on word of mouth. What if we could have reviewed made the decision based on a reliable report on which hospital had the best track record for saving sick children or which one had the lowest infection rate? That information was not at our fingertips, but it should have been. Private employers hadn’t invented a Hospital Safety Score then. This really goes back to transparency. Obamacare includes some improvements in transparency and spurring competition among providers to get the best results for patients. But even now we don’t have the information we need as patients to drive a market for the best care at the best places.

My friend Dr. Marty Makary’s much-talked-about book, “Unaccountable: What Hospitals Won’t Tell You and How Transparency Can Revolutionize Health Care,” reveals just how much information is hidden from patients before and after they decide where to seek care.

The consequences: U.S. health care costs are a ball and chain on our economy and our future, and the statistics on patient safety and quality are literally frightening. One in four Americans admitted to a hospital is harmed there. Tens of thousands will die from an unnecessary error or accident in a hospital.

We need to shift the debate on health care and an election season is a good time to do it. I want the candidates to debate about what my husband and I debated about as our son struggled to breathe: how can we find the best possible care? Americans deserve to get the information they need to make choices among hospitals and doctors and if they use that information wisely, they will drive real competition for the right things.

My baby was given good care that day and recovered quickly, thanks to excellent doctors and nurses and a terrific hospital. My son is now a teenager, very healthy, and taller than I am. I forget what insurance company covered him that day, but I’ll never forget the people who cared for him. That’s what matters in health care and that’s where the debate belongs.