Tag Archives: Aaron Carroll

Health Policy Updates: September 9 2017

The September issue of Health Affairs was a special edition, focusing on the topic of health care market concentration in the US. I’ve pointed to the closely related issue of hospital consolidation as one of the biggest drivers of increasing health care costs.

As one of the featured studies in this special issue found, the health care market in the US continues to concentrate, with more and more health systems merging into larger and larger networks. The end result of this is not more efficient care for the patient, but simply higher prices, as these large networks exert their monopoly power:

“Although provider concentration could produce efficiencies that benefit purchasers of health care services, the evidence does not point in that direction. For example, reviews of studies of hospital markets have found that concentrated markets are associated with higher hospital prices, with price increases often exceeding 20 percent when mergers occur in such markets. Of even greater concern, the reviews found that these price increases did not appear to improve quality: In some cases, higher hospital concentration was associated with higher mortality rates.” 
Continue reading Health Policy Updates: September 9 2017

Health Policy Updates: July 16 2017

On Thursday, the Senate released its latest version of its Obamacare-repeal bill, known as the BCRA. Vox.com ran a brief explainer on the key provisions that have changed since prior versions, including a shift towards low-premium (and low-coverage) plans:

“The bill will include a provision based on a proposal by Sen. Ted Cruz (R-TX), which allows health plans to offer skimpy coverage options so long as they have at least one plan that covers a robust set of benefits. The insurance industry opposes the policy, calling it ‘infeasible’ and fearing it would create ‘greater instability.'”

Politico ran a similar outline of the bill’s contents.

The GOP efforts at health care reform, overall, continue to be a “solution in search of a problem.”

“The GOP health care bill doesn’t even have pretextual justifications. Republican leaders like to claim that Trumpcare is necessary because Obamacare is “collapsing” into a “death spiral,” but not only is Trumpcare non-responsive to a death spiral, the death spiral they posit as the basis for Trumpcare is wholly fabricated.”


The supposed urgency behind Obamacare repeal is that it is “collapsing.” This doomsday claim is a bit premature, however, as the exchanges have continued creep along slowly but surely. In fact, a new report out from Kaiser appears to show that the Obamacare insurance exchanges are looking healthier than ever.

“Early results from 2017 suggest the individual market is stabilizing and insurers in this market are regaining profitability. Insurer financial results show no sign of a market collapse…Although individual market enrollees appear on average to be sicker than the market pre-ACA, data on hospitalizations in this market suggest that the risk pool is stable on average and not getting progressively sicker as of early 2017. Some insurers have exited the market in recent years, but others have been successful and expanded their footprints, as would be expected in a competitive marketplace.”


The ongoing challenge for the GOP in passing health care legislation is that different GOP senators have different goals. Some want sustained Medicaid spending, others want even deeper cuts. The NY Times gives a summary of which senators are breaking with the party line to request more changes to the bill – and which senators are pulling in opposite directions.


More great writing on Medicaid by Aaron Carroll and Austin Frakt this week. This time, the topic at hand is the idea that private insurance is inherently “better” insurance than Medicaid. This is one of the chief arguments among Medicaid critics (typically, the GOP) that Americans would be better off by defunding Medicaid and transitioning people to some for of private plans. While it is true that some doctors do not accept Medicaid, causing access problems, in general Medicaid is actually better than private insurance. Medicaid simply pays more of your medical costs; that is, it has lower “cost sharing” requirements – low/no deductibles, copayments, and coinsurance.

And based on well-established research, having low cost sharing is important for the quality of health care that people receive…

“The Senate’s health care plan, for example, would offer much less generous plans. A 64-year-old woman with an income of $11,400 would face a deductible of at least $6,000. For her, such a plan is not better than Medicaid; it is most likely much worse if she is also sick. Because of the deductible, the care she’d need would be financially out of reach.”


Kaiser Health News has recently started a new health policy news podcast called “What the Health.” I just listened to episode #3, a conversation including Margot Sanger-Katz at the NYTimes and Sarah Kliff at Vox.com about the politics behind the BCRA.

I’ll be a new subscriber! Highly recommended.


 

Health Policy Updates: July 8 2017

One of the arguments from Republicans to support the BCRA’s steep cuts to Medicaid is that it is “bad insurance” – that having Medicaid somehow causes its beneficiaries to have WORSE health outcomes than those without insurance at all. Clearly, this is an extraordinary claim; how could having health insurance make one worse off? Is there “extraordinary evidence” to support the notion that Medicaid is harmful?

Health policy experts Austin Frakt and Aaron Carroll examine the available evidence. Moving beyond purely correlational studies (Medicaid patients are also quite poorer than average Americans, and so have many reasons to be unhealthy besides having Medicaid), it becomes clear that Medicaid does not, in fact, harm people.

“Findings from more recent studies looking at expansions in enrollment, in the 2000s and then under the Affordable Care Act in 2014, are consistent with older ones. One can argue that Medicaid can be improved upon, but the credible evidence to date is that Medicaid improves health. It is better than being uninsured.”
Continue reading Health Policy Updates: July 8 2017

Health Policy Updates: January 7 2017

In the big health policy news of the week, the Republican-controlled congress has taken its first – expected – steps towards repealing the ACA/Obamacare by means of the budget reconciliation process.

“The concurrent resolution also establishes a “reserve fund for health care legislation,” which is intended to pocket any savings from repeal for subsequent replacement legislation, as well as a “deficit neutral reserve fund” to revise allocations within the budget resolution and adjustments to the pay-as-you-go ledger in the Senate to ensure that repeal legislation does not violate budget requirements. The reserve fund would allocate $2 billion of savings from the repeal toward reducing the deficit, but hold the rest for eventual replacement legislation.”


Meanwhile, away from the partisan circus of Congress, some leading conservative health policy thinkers are having serious concerns about the repeal-and-delay strategy:

“Antos and Capretta’s piece goes into much more detail on the technical problems of repeal and delay, and is worth reading in full. But they avoid the fundamental issue animating the whole strategy: Republicans don’t know how to replace Obamacare, and they don’t know how to force themselves to figure it out.”

Full details of Joseph Antos’ and James Capretta’s concerns about repeal-and-delay can be found here.

“We do not support this approach to repealing and replacing the ACA because it carries too much risk of unnecessary disruption to the existing insurance arrangements upon which many people are now relying to finance their health services, and because it is unlikely to produce a coherent reform of health care in the United States. The most likely end result of “repeal and delay” would be less secure insurance for many Americans, procrastination by political leaders who will delay taking any proactive steps as long as possible, and ultimately no discernible movement toward a real marketplace for either insurance or medical services.”


Meanwhile, with all the commotion about whether and how to dismantle the ACA, the law itself continue to truck along, providing insurance to some 20 million Americans. Sarah Kliff of Vox.com has some pretty charts showing this.

The uninsured rate is at an all-time low. The federal government announced in September that 8.6 percent of Americans lacked health insurance. That’s a big decline from 2010, when the health care law passed and the uninsured rate was 16 percent.”


In some local North Carolina health policy news, incoming governor Roy Cooper has announced plans to expand Medicaid in the state. Don Taylor of Duke shares his thoughts on how this may play out.


From Aaron Carroll at The Incidental Economist, in which the adjective “crazypants” is used to describe US health care spending.

“Between 1996 and 2013, more than $30 trillion was spent on personal health care. Let that sink in for a minute or two. Over that time period, spending increased between 3% and 4% annually for most age groups.”


The prices for drugs are going up. A lot. And not just in cancer, as I’ve written about many times, but for multiple sclerosis as well.


The 21st Century Cures act that President Obama just signed into law, which both funded the cancer “Moonshot” and weakened FDA regulatory power, is not universally loved. Drs. Aaron Kesselheim and Jerry Avorn share their thoughts in this JAMA commentary.

“Among the most concerning sections of the new law are components that address the types of data that manufacturers will be able to use to gain FDA approval of new products or additional indications for existing products…When biomarkers used as the basis for drug approval are not rigorously validated, they may not actually predict patient benefit, can mislead physicians about whether a drug works, and have the potential to expose patients to poorly effective treatments or unanticipated adverse effects.”


 

 

 

Health Policy Updates: November 26 2016

It is important to remember that rising insurance costs are not a phenomenon limited to the Obamacare exchange plans. Health care costs continue to rise overall, and insurance companies have to charge higher premiums and copays to keep up. Employment-based health insurance plans will be costing 5.5% more, and employee out-of-pocket costs continue to increase even faster and have now nearly doubled since 2009.


A recent study in JAMA Oncology highlighted an important point regarding the “financial toxicity” of cancer care – having Medicare coverage is often not enough to protect from catastrophic costs. 10% of Medicare patients with a new diagnosis of cancer will spend two-thirds of their annual income on health care bills.

“Beyond highlighting the need for innovative initiatives for delivery of care, the high level of hospital-associated OOP costs may also demonstrate potential adverse consequences of Medicare’s current design of benefits…Assigning beneficiaries such a high responsibility of cost sharing for inpatient care may not be an effective use of cost sharing, as hospitalizations are usually not at the discretion of beneficiaries.”


A conversation on the potential for Obamacare repeal, from The Incidental Economist bloggers Aaron Carroll and Austin Frakt.

“They’re actually in a tough policy spot. They’ll get the blame if they don’t fix or repeal the A.C.A., and they’ll get the blame if they don’t replace it with something people like better. Health policy is a very difficult and thankless task. I think they’ll opt for something they can call repeal and replace, but they could also just let Obamacare struggle and die. Neither looks good.”


In order to convince health insurance companies to engage in the ACA/Obamacare exchanges, the law included a provision known as the “risk corridors.” In sort, if insurance companies ended up losing money because they insured sicker-than-average patients who incurred higher-than-average health care costs, the risk corridor system would give them money to recoup the losses. So, insurance companies joined the ACA exchanges. And they dutifully lost money. However, Congress did not appropriate money for the risk corridors, so these insurers are still short billions of dollars that was promised to them, and are suing the government to get it.

Nicholas Bagley reports on the debacle at the NEJM.

“For now, the Justice Department is fighting the lawsuits. But the insurers’ legal arguments have considerable force. Indeed, HHS has openly acknowledged that risk-corridor payments are ‘obligation[s] of the United States for which full payment is required.'”


Surgeon General Murthy on ending the opioid epidemic.