In Colorado, the snow is melting and the flowers are blooming. The health wonks around the blog world have given us an excellent collection of articles this week, many with suggestions of ways the ACA could be improved. Our favorite part of hosting the HWR is reading all of the different perspectives that the writers bring to the table. There’s a little something for everyone here. Let’s watch the snow give way to wildflowers as we check the pulse on the latest healthcare dialogue from the worlds biggest health wonks.
Welcome to the Ways the ACA Could Be Improved edition of the Health Wonk Review!
One of my favorite articles this week comes from Billy Wynne of Healthcare Lighthouse. Billy takes us on a “let’s pretend” trip where bipartisan solutions are hammered out in congress. It’s a great look at the ways the ACA could be improved at some point in the future with a less contentious political 
atmosphere, and he also details some of the fixes that have already taken place.
Joe Paduda of Managed Care Matters reminds us that even the very low-end estimates on the total net increase in the number of Americans with health insurance is 5 million+ (and that was as of April 9… the total increased significantly the following week), which means that the ACA is here to stay. There is no way that politicians are going to take health insurance away from millions of people without a fight on their hands. We also have to keep in mind that millions more have enrolled in expanded Medicaid and off-exchange (but still ACA-compliant) health insurance plans. Joe is absolutely right: the ACA is here to stay. As Billy Wynne pointed out, there are ways the ACA could be improved. But it’s not going away – far too many people are benefiting from it for that to happen.
Writing at HealthInsurance.org, Wendell Potter explains how increasing dental costs and a lack of comprehensive dental insurance in the US are driving significant numbers of Americans over the border to seek dental care in Mexico. People come from all over the US to visit Mexican dentists, where they can obtain care for a fraction of the price they would pay here at home. We’ve been in the health insurance industry since 2002, and dental plans haven’t really changed at all in those years. Discount plans still abound, and the plans that are actually insurance typically have the same sort of benefit maximums that plans had more than a decade ago (usually in the range of $1000 to $2000 per year). This is despite the fact that the cost of dental care has been steadily increasing. Unfortunately, the ACA doesn’t address dental plans, other than to require pediatric dental coverage as an essential health benefit (but even that is complicated). Maybe comprehensive dental coverage could be an issue for ACA Round 2 someday?
Ellen Goodman, writing at Health Affairs, poignantly describes her sister Jane’s battle with Alzheimer’s, and it’s a perfect illustration for her message that “it’s always too soon until it’s too late” when it comes to having a conversation about end-of-life wishes. Her point is that if you wait until after a cognitive 
decline diagnosis, the conversation becomes significantly harder. Check out The Conversation Project that Ellen co-founded for more information about having conversations with your own loved ones before it’s too late.
The Healthcare Economist, Jason Shafrin, writes about why providers have been slow to adopt electronic medical records, but how the right incentives can change that. Accountable Care Organizations bring economies of scale into the equation, making it easier for providers to adopt EMR systems. Digital records are certainly the way of the future, it’s just a matter of catching up to the future without putting undue financial strain on medical offices.
The Disease Management Care Blog’s Jaan Sidorov weighs in on President Obama’s nomination of Sylvia Mathews Burwell for HHS Secretary, and raises an interesting point: Ms. Mathews Burwell has never run for public office. Jaan questions whether outgoing HHS Secretary Sebelius had an advantage when it came to drumming up support for the ACA because of her experience running for office and courting voters. He predicts that Burwell’s confirmation might not be a given, and questions whether her credentials – while certainly robust – will be enough to get the job done.
Tom Lynch of Workers’ Comp Insider gives us a very thoughtful look at the current fight in Massachusetts over Zohydro ER, the first pure opiate painkiller to be approved by the FDA. The governor has banned its sale, citing the fact that the capsules are not abuse-resistant as they can be crushed and 
injected or snorted (taken orally, they are extended release capsules). A district court judge appears to be siding with the drug manufacturer, as does Tom – and he outlines several reasons for his position in the post.
And it looks like Governor Patrick doesn’t have the health wonks on his side of the Zohydro ER fight… David Williams of Health Business Blog agrees that the governor’s unilateral decision to ban the sale of an FDA-approved drug is a bad idea. David notes that he’s not the only one who was surprised by the fact that FDA approved Zohydro ER. But he doesn’t see much merit in states attempting to overturn FDA decisions.
Roy Poses from Health Care Renewal is always on target with his investigative journalism, and this article is no exception (the fact that the title starts off with “knee deep in the hoopla” is an excellent bonus that will make you dance a little in your chair). A “miracle” drug that defeats Hepatitis C? Awesome, right? Except maybe there are too many conflicts of interest in the studies (which do not follow patients long-term), and maybe it’s not really all that much better than the treatment that was already available. And it might have higher rates of serious adverse events, including death, although not all of that data is readily available (Roy’s always manages to unearth the important details that might otherwise be obscured, possibly because of the aforementioned conflicts of interest). Not surprisingly, the new Hep C drug is a whole lot more expensive ($1000 per pill!) than the old one. That’s bad news for everyone… except the drug manufacturer. Roy’s articles are always a reminder to follow the money.
At InsureBlog, Kelly Beloff digs into the recent reports about a handful of physicians who have been raking in millions of dollars in Medicare payments. The study looked at more than 825,000 doctors, and found that 344 of them were being paid more than $3 million per year by Medicare. Of course that generated plenty of media interest, but Kelly focuses instead on the other 824,656 doctors, and notes that the median payments for them came to just over $30,000 per year. And Medicare accounts for 30% of the average doctor’s payer mix (although private insurance reimburses at a higher rate). While there are probably some doctors who are abusing the system, the vast majority are certainly not getting rich on Medicare.
Brad Flansbaum, writing at The Hospital Leader, brings us an interview with Humayun (Hank) J. Chaudhry, President and CEO of the Federation of State Medical Boards (FSMB), a not-for-profit organization that represents all of the state medical boards in the US. He describes how medical boards protect 
the public and support physicians, including helping those who are facing disciplinary issues, including substance abuse problems. He notes that the FSMB is working to create a program that would simplify the process of obtaining medical licenses in multiple states, and explains how the FSMB partners with other organizations across the country.
Writing at John Goodman’s Health Policy Blog, Linda Gorman questions the claim that failure to expand Medicaid will cause up to 17,000 deaths per year. Although I’m very much in favor of Medicaid expansion in every state, Linda’s post is thoughtful and detailed, and I always like to see data and claims deconstructed and thoroughly examined rather than just accepted. Linda focuses particularly on data that purports to show a steady decline in nonelderly adult mortality rates in states that expanded Medicaid long before the ACA, including New York, Maine and Pennsylvania. She points out that the World Trade Center attack creates a spike in the mortality rate graph at the time that Medicaid was expanded in NY, leading to a subsequent decrease in death rates the following year. And the availability of antiretroviral therapies for HIV have dramatically lowered mortality rates from HIV since the mid-90s, which could explain some of the lowered mortality rates – particularly in NY – over the past 15 years or so. HIV is an interesting discussion point though, since the government has a program to help people pay for their HIV meds even if they are uninsured. Unfortunately, there are plenty of other medical conditions that are similarly expensive to treat but do not have assistance programs available for uninsured people – hence the need for expanded Medicaid or something similar. Although this is certainly a discussion that pertains to ways the ACA could be improved, the question of whether or not to expand Medicaid was summarily answered by the ACA – it was a given when the law was written. It was only in 2012 when SCOTUS ruled that states couldn’t be penalized for opting out of Medicaid expansion that the complications and coverage gap issue arose.
For a post that’s sure to generate opinions on both sides of the issue, read Jonena Relth‘s article at Healthcare Talent Transformation. She presents a compelling argument, and her point is valid: For people who already had good health insurance and affordable premiums, the ACA doesn’t necessarily improve things from an individual perspective. That is especially true if your income is high enough that you don’t qualify for subsidies in the exchange. I wrote last fall about our family being in a similar situation, but my perspective is a little different. I’ll admit that the possibility of having to change providers is not something that I’m excited about. But overall, those of us who have had good access to a wide variety of providers in the past might be putting too much emphasis on broad networks and being able to choose any doctor we want. This New Republic article on that subject is a very good one. This topic isn’t one that’s likely to be settled anytime soon, as it’s very personal and everyone has a different situation. The law directly impacts a large number of people, and while many are ecstatic about having access to healthcare for the first time in years, others are less than thrilled at having to pay more for their coverage or switch to a new plan when they were happy with their old policy. For some people who are having to switch to more robust coverage – at a higher price – one possibility for improving the ACA would be the addition of a “copper” level plan in the individual market, allowing people who prefer a higher out-of-pocket exposure (in trade for lower premiums) to purchase a less expensive option that is still ACA-compliant (under slightly relaxed standards).
My own contribution to ways the ACA could be improved is about the new open enrollment window in the individual health insurance market, and a suggestion for making it a smoother process. Some sort of open enrollment (followed by a time when coverage cannot be purchased) is essential now that health insurance is guaranteed issue, because year-round enrollment would result in too much adverse selection. Group plans are guaranteed issue, and they all have open enrollment windows – you cannot just enroll in your employer’s plan anytime you want. Qualifying events that result in a special open enrollment are spread out across the whole year, but do we really want to compress all of the remaining enrollments and plan changes into one open enrollment window for everyone? It might make more sense to spread them out across the year in order to provide better customer service and allow carriers and exchanges to function more efficiently. I’ve also included some ideas from Families USA on ways the ACA could be improved and how to make the enrollment process work better in future years.
That does it for this Ways the ACA Could Be Improved edition. Be sure to check out the next Health Wonk Review, being hosted by Jason Shafrin at Healthcare Economist on May 8. If you’ve got a blog and write about healthcare issues, send him your best recent post!