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May 31, 2016

Washington Health Policy Week in Review Archive cd851aa0-6156-4ce3-a6d3-5d63c73e434a

Newsletter Article


Most Americans Satisfied with Marketplace Coverage, Survey Shows

By Erin Mershon, CQ Roll Call

May 25, 2016 -- Two-thirds of Americans getting their coverage through and the state exchanges consider their coverage good, very good, or excellent, according to a new survey from The Commonwealth Fund. That number is even higher for new Medicaid enrollees: 77 percent reported positive experiences.

The survey results highlight the gains in coverage and access to care made since the passage of the 2010 federal health overhaul. The poll follows another recent survey from the Kaiser Family Foundation that showed similar rates of satisfaction with coverage, though it noted consumers are less satisfied with the affordability of their insurance.

The Commonwealth Fund reports that most consumers are "very" or "somewhat" satisfied. About 77 percent of Marketplace enrollees and 88 percent of new Medicaid patients gave those answers. Most are using their coverage: 72 percent of the newly insured said they used their coverage to go to a provider or to fill a prescription.

More than 60 percent of those people said they wouldn't have been able to afford that care previously. Low-income Americans were more likely to say they would not have been able to afford care before their new coverage, but 48 percent of those who had coverage before the health law passed also said they couldn't have afforded it before.

"These findings show that the Affordable Care Act is working as it was designed to, specifically to get people the health care that they need," said David Blumenthal, president of The Commonwealth Fund.

But he added that there is "room for improvement."

"A minority people are not satisfied with their coverage and said their ability to get care got worse," he said. "Moving forward, it will be important to continue to monitor the law's effects, and make adjustments to fill any remaining gaps."

The study also shed light on a looming challenge in exchanges: enrollment. It found the uninsured rate remained around 12.7 percent, slightly higher than recent administration estimates. That figure doesn't represent a statistically significant difference from the uninsured rate of 13.3 percent in a comparable period the year prior--a sign there is more work to be done to sign up the uninsured. Many experts say convincing Americans who are still uninsured to sign up for coverage is essential to the sustainability of the marketplaces.

The study's researchers also highlighted details about churn between the marketplaces, employer-sponsored coverage and Medicaid, noting that the law seemed to fill gaps for those who had lost jobs or coverage from their employers. While most marketplace enrollees lacked any insurance before the health law, 34 percent said they previously had employer coverage. About 7 percent had bounced from the exchanges to employer coverage back to the exchanges, while 11 percent shifted from Medicaid.

The survey also found that doctor availability and wait times for the newly insured were comparable to those for insured Americans overall.

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Rate of Americans Skipping Necessary Care Drops, CDC Data Show

By Erin Mershon, CQ Roll Call

May 24, 2016 -- The percentage of Americans who forgo needed medical care due to cost has dropped significantly since the 2010 federal health law passed, according to new data from the Centers for Disease Control and Prevention (CDC) released last week.

The CDC-run National Health Interview Survey found that 4.5 percent of Americans couldn't afford needed medical care in 2015, compared with 6.9 percent in 2009 and 2010. The metric hit a peak in those two years and has been steadily declining since—coinciding with the passage of the 2010 federal health overhaul.

That drop is good news for advocates of the health law, who have seen the overhaul hit with criticisms that the coverage provided is unaffordable for many, especially as premiums and deductibles rise. It highlights the dramatic impact the law has had on access to care for low-income Americans, many of whom benefit from an expansion of Medicaid or from tax credits and cost-sharing subsidies.

Before the passage of the health law, the data shows a steady climb in the percentage of Americans who skipped necessary care because of high costs, from about 4.2 percent in 1998 to 6.5 percent by 2008.

In 2015, more women than men skipped necessary care because of cost. More black Americans and Hispanic Americans skipped care than non-Hispanic white Americans, at rates of 5.8 percent, 5.4 percent and 4.1 percent, respectively.

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Aetna, Humana Merger Gets Home State Approval

By Jad Chamseddine, CQ Roll Call

May 27, 2016 -- Consumer advocates in Connecticut are criticizing the state's insurance department for approving Aetna Inc.'s acquisition of fellow health care insurer Humana Inc. without a public hearing, pointing to potential job losses from the combination.

The Connecticut Campaign for Consumer Choice, which is made up of several organizations, expressed particular concern at the closed-door process in which the merger was approved, saying the department hurt consumers by "rubber stamping" the deal in the "dark of the night."

Insurance Commissioner Katharine Wade has been singled out by consumer advocates.

"She had tools to make this more public and to protect jobs in Connecticut, she has failed to use them and this is unconscionable," said Tom Swan, executive director of the Connecticut Citizen Action Group.

Swan added Aetna had already eliminated 10 percent of its job force in Connecticut and pointed to statements made by Aetna CEO Mark Bertolini that he wasn't committed to keeping Aetna's headquarters in Connecticut, and was considering a potential move to Kentucky, where Humana is located.

Frances Padila, the president of Universal Health Care Foundation of Connecticut, called the decision to approve the deal without including the public "shameful," saying it would lead to a bad precedent to exclude the public's input going forward when reviewing other mergers.

Aetna agreed to buy Humana last year for $37 billion in a stock-and-cash acquisition, in a deal that has been criticized by consumer advocates for the possibility of raising premiums and damping competition.

The deal is under review by the Justice Department and the attorneys general of individual states. It's also getting looked at by the insurance division of individual states, where the representatives of the merging parties have often appeared in public hearings to discuss the mergers' consequences.

Mathew Katz, the CEO of the Connecticut State Medical Society, was particularly concerned the deal would restrict access to care and lead to rising costs for Connecticut patients.

Connecticut's decision comes as Missouri expressed concern over the merger with its decision, finding the deal would be anti-competitive in four product areas. The Missouri Department of Insurance said the deal would reduce competition in the sale of individual health insurance, small group health insurance, group Medicare Advantage and individual Medicare advantage in about half of Missouri's counties.

Aetna called the decision a "setback" but vowed to work with Missouri to address the Insurance Department's concern. The decision in Missouri, however, won't stop the merger from going, unless it sets a precedent for other states to impose its own limits. Ultimately, the deal could be blocked outright by the Justice Department.

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Missouri Regulator Moves to Block Aetna-Humana Deal

By Erin Mershon, CQ Roll Call

May 25, 2016 -- Missouri's insurance regulator is taking the first steps toward blocking the proposed merger of insurance giants Aetna and Humana in the state, the first time a state regulator has fought against the pending deal.

The Missouri Department of Insurance filed a preliminary motion opposing the merger Tuesday, saying that the $37 billion proposed merger would "substantially lessen competition in the state" in the individual, small group, and Medicare Advantage markets. The motion gives Aetna and Humana 30 days to offer remedies that would address the outlined harms.

It's a limited step: even if the regulator finalizes its opposition, the overall merger can still proceed. But the argument still underscores the precarious position for Aetna and Humana, as well as their competitors, Anthem and Cigna, which are together seeking approval for their own $54.2 billion merger. The U.S. Department of Justice (DOJ) has yet to approve either arrangement.

Missouri's opposition can serve as a "roadmap" not only for other regulators, but for the Justice Department as it evaluates the deal, said David Balto, an antitrust attorney who represents consumer and provider groups who oppose the merger. He called the order a "tremendous victory for consumers."

"This really steps Aetna back severely," he said. "The Justice Department will say, 'You couldn't even convince the insurance commissioner in Missouri [the deal isn't anticompetitive]? How in the world are you going to convince a federal judge of that?'"

Aetna remains confident the overall deal will proceed and is committed to working with Missouri regulators toward remedies that would mitigate their concerns, company spokesman T.J. Crawford said.

"This order does not impede the DOJ approval process," he said. "We are disappointed with the Missouri order but expect to have a constructive dialogue with the state to address their concerns."

Executives for both companies said on recent earnings calls that they expect the overall merger to be approved in the second half of this year.

Twenty states—which do not include Missouri—have the power to stymie the merger. In those states, officials must agree to allow local Humana subsidiaries to be taken over by Aetna in what is known as a "change of control approval." The Aetna-Humana deal has already been cleared by 15 of those 20 states.

Those states and others where Aetna and Humana are major market players, like Missouri, can undertake a separate process to investigate the competitive impacts of the merger on consumers. If a state uses that process to oppose the merger, it can consider preventing the companies from combining within the borders of the state. State attorneys general can also launch their own antitrust investigations or work with the DOJ.

In comments to the Missouri Department of Insurance, consumer advocates in the state outlined the higher premiums, fewer benefit choices and lessened quality they expect to result from the merger. Many focused specifically on the Medicare Advantage market, in which Humana is a major player and in which the two companies currently compete directly. Provider groups, including state and national hospital and physician organizations, also weighed in, opposing the merger.

Aetna and Humana executives, meanwhile, argue that the deal will result in increased efficiency and savings that will be passed on to consumers. They say it will improve their bargaining power with providers that are also consolidating and growing their market shares.

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House Panel Likely to Advance Bill with Hospital Penalty Change

By Kerry Young, CQ Roll Call

May 24, 2016 -- The House Ways and Means Committee on Tuesday began considering a package of changes to Medicare payment policies, including one designed to address long-standing concerns about how hospitals that serve poor communities are hit by readmission penalties.

The panel began marking up a bill (HR 5273) that also would ease a new restriction on when hospitals can collect more generous Medicare outpatient reimbursements for off-campus offices. The measure would address cases where hospitals had substantial plans in place for new sites before the enactment of last year's budget deal (PL 114-74), which required many hospital outpatient centers to receive the lower reimbursements that physicians get. The cut was projected to save $9.3 billion over a decade.

Separately, certain hospitals and lawmakers have pushed for some flexibility in the Medicare rules on readmission penalties, which were established in the 2010 health law. Hospitals are penalized if the number of their patients that are readmitted within 30 days is considered excessive. The current design "puts hospitals that treat a large share of low income patients at a financial disadvantage," wrote Francis J. Crosson, the chairman of the Medicare Payment Advisory Commission, in a comment last year to the Centers for Medicare and Medicaid Services (CMS).

The Ways and Means draft calls for officials to compare data among hospitals that serve a similar proportion of patients who are dually eligible for both Medicare and the state–federal Medicaid program for low-income people, according to a bill summary. The American Hospital Association welcomed this measure, noting that CMS later could use a more refined methodology to adjust readmission penalties. Future changes could be based on information from broader reports on post-hospital care that are mandated by the Improving Medicare Post-Acute Care Transformation Act (PL 113-185).

At the markup, though, Rep. Charles B. Rangel, D-N.Y., questioned whether this provision would have the effect of lowering the standards for hospitals that serve the poor. He argued that the challenge is to make sure that hospitals serving low-income communities should have the resources they need to prevent admissions of their patients, rather than rejigger the penalty. Still, Rangel agreed with a need to preserve the funding for medical centers serving the poor.

"I don't want these hospitals to be put out of business just because we don't provide the funds for them to do the right thing," Rangel said.

Many lawmakers in both parties and chambers support adjusting the hospital readmission policy. A bill (HR 1343) by Rep. James B. Renacci, R-Ohio, has 42 GOP and 40 Democratic cosponsors. These include Rangel, a point Renacci raised in a cordial way at the hearing.  A companion Senate measure (S 688) from Sen. Joe Manchin III, D-W.Va., has six Democratic and five Republican cosponsors, including Sen. Rob Portman of Ohio.

Portman, who serves on the Senate Finance Committee, on Tuesday said he plans to look at the Ways and Means bill. Senate Finance earlier had considered taking up a measure that would address the readmission penalties "along with four or five other relatively noncontroversial items" regarding healthy policy, Portman said.

"Those hospitals are penalized because of the readmission policy without taking into account the makeup of their patient pool," Portman told CQ HealthBeat. "It's unfair to them."

Len Marquez, director of government relations at the Association of American Medical Colleges, said people living in poverty often don't have the same support at home as those with more money. That can lead to complications unrelated to the quality of care provided to them during their initial hospital stays, which then force patients to return.

"They may not have the transportation necessary" for follow-up care, he said in an interview. "They may not be able to go to the drugstore to pick up the prescription."

Medicare officials are driving hospitals to "look beyond their walls"  and consider what needs and challenges senior citizens and the disabled will have once they return home, Andrew Boozary, a visiting scientist at the Harvard School of Public Health, told CQ HealthBeat in a Tuesday interview. He last year published an article in the Journal of the American Medical Association about readmission penalties, with Manchin and Sen. Roger Wicker, R-Miss., as coauthors.

The key for lawmakers and policy analysts is striking the right balance, which will maintain the benefits of the readmission penalty, Boozary said. The policy has given hospitals more incentive to help people obtain needed services to regain or maintain their health after treatment.

"This is about not letting folks off the hook, but figuring out what that right adjustment is," Boozary said.

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Catastrophic Plans Could Help with Long-Term Care, Study Says

By Marissa Evans, CQ Roll Call

May 26, 2016 -- Catastrophic plans could be an important factor in saving money on long-term care services (LTSS) in the Medicaid program, according to a new SCAN Foundation and Urban Institute report.

A recent study found providing long-term support and services through a catastrophic insurance program could potentially offset the costs for Medicaid by about 38 percent, a move researchers say could provide financial relief for states. Medicaid is the joint federal–state insurance program for the poor. The catastrophic plans analyzed in the study would be insurance policies that would require enrollees to initially pay for services during a waiting period before receiving long-term care benefits for as long they need.

"Our research is only the first step in the analysis required to design new LTSS financing programs, but it illustrates the potential power of our simulation tool in demonstrating how new options can interact with existing programs," according to researchers.

The study also looked at front-end plans, which cover patients not long after they need long-term care benefits but only for a limited time. The study found that plans could potentially save Medicaid programs 15 percent of the usual cost.

Bruce Chernof, president and CEO of The SCAN Foundation said in an interview that both types of insurance could help prevent financial hardships for family members providing care and relieve pressure on Medicaid programs.

"This is an additional level of protection and level of support that isn't available today and that's a good thing," Chernof said.

Chernof also said that the big question would be if states would be open to participating in such plans and would be willing to help finance them.

Researchers also found that front-end plans would help save more money on out-of-pocket spending on long-term care compared to catastrophic plans. Front-end plans could save 45 percent on out-of-pocket spending compared to only 33 percent for catastrophic plans. In addition these types of plans could also fund new types of services and save money for patients. The study found savings on new services could be as much as 37 percent for front end plan policy holders and 27 percent for catastrophic plan holders.

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