Friday, September 19, 2014

N.C. Obamacare numbers remain elusive

Participation in the health insurance marketplace created by the Affordable Care Act has dropped by about 700,000 people,  from 8 million when enrollment closed March 31 to 7.3 million as of Aug. 15, the nation's top Medicare/Medicaid administrator said Thursday.

That partially answers questions many have posed this summer about developments on the insurance exchange,  which includes subsidies for low- and moderate-income people buying individual policies.

Medicare/Medicaid administrator Marilyn Tavenner (AP photo)

It still doesn't offer details on how many have failed to pay premiums,  how many have left the marketplace for other reasons  and how many have been added during special enrollment.  Nor have the state tallies posted in May been updated.

North Carolina had the nation's fifth-highest enrollment at that point,  with 357,584 enrollments as of March 31.  If the state's numbers reflect the 8.75 percent drop the nation has seen,  we'd have lost about 31,300.

As the Department of Health and Human Services notes,  enrollment changes on a daily basis.  People may sign up,  then lose coverage if they fail to pay premiums.  They move from one state to another.  They gain or lose jobs and go through family changes that affect their health insurance.

Earlier this week,  DHHS announced that 115,000 people nationwide will lose their coverage because they failed to provide immigration documents required to verify their citizenship or immigration status.  The department initially flagged 966,000 people whose applications didn't match data on file.  In July,  after repeated attempts to reach those people,  they sent warning letters to 310,000 saying they'd lose coverage if they didn't verify their status by Sept. 5.  That included 12,300 in North Carolina.

The update on people who will lose coverage because of immigration status didn't include state breakdowns;  a DHHS official said that would come later.

In a conference call with reporters,  Andy Slavitt of the Centers for Medicare and Medicaid Services proudly noted that the overwhelming majority the immigration cases that were initially flagged had been resolved.  But he didn't have answers when a reporter asked whether "resolved" included people who kept their coverage and people who lost it,  and if so,  what the mix was.

Thursday, September 18, 2014

Survey: N.C. doctors are stressed, but morale improving

A majority of doctors in North Carolina and across the country are unhappy with the state of their profession,  but morale has improved over the last two years,  according to a survey by The Physicians Foundation.

The foundation,  a nonprofit grant-making and research group,  polled more than 20,000 physicians,  including 565 from North Carolina.  Only 39 percent of N.C. doctors and 44 percent of all doctors described their morale and feelings about the profession as positive,  the survey found.  However,  most national measures of morale had climbed since the last poll in 2012,  with young doctors describing themselves as more upbeat than older ones.

The group sent me a breakout on North Carolina,  which didn't include a prior-year comparison.  The state numbers generally tracked national ones,  though Tarheel docs tended to be a bit more negative.  Numbers below are for North Carolina.

First the good news:  Just over two thirds said medicine is still rewarding,  with patient relationships and intellectual stimulation cited by a strong majority as the best part of their practice.  However, fewer than half said they'd recommend medicine as a career for young people.

Just over 42 percent said changes in medicine are prompting them to accelerate retirement plans.  In the next one to three years,  16 percent said they plan to cut back hours,  13 percent said they'll seek a non-clinical health care job and 12.5 percent said they plan to do locum tenens,  or temporary,  work.

About 34 percent said they're  "overextended and overworked,"  while only 17 percent said they have time to see more patients and take on more duties.

Two-thirds disagreed with the statement that hospital employment of doctors  "is a positive trend likely to enhance quality of care and decrease costs."

When asked about the causes of rising health costs,  "defensive medicine,"  or trying to avoid malpractice suits,  was by far the most-cited factor at 60.5 percent.  Next were an aging population  (37 percent),  the cost of pharmaceuticals  (35 percent)  and state and federal insurance mandates  (34 percent).

Most doctors say they're using electronic medical records,  a practice promoted by the Affordable Care Act,  but they're not convinced it's doing much good.  The physicians were about evenly split on whether the electronic records improve or detract from care,  but they were much more likely to say the switch detracts from patient interaction and efficiency.

When asked to grade the ACA  "as a vehicle for healthcare reform,"  47 percent gave the act a D or F,  compared with 25 percent awarding an A or B.

Monday, September 15, 2014

Employers: Obamacare isn't biggest problem

The Affordable Care Act may be pushing up the cost of your workplace benefits, but it's not at the top of employers' list of challenges,  according to an August report by the National Business Group on Health.

Like many of you,  I've heard my employers talk about how Obamacare is shaping our health insurance benefits.  For instance, McClatchy is among many companies trying to bring down costs now to avoid the 40 percent excise tax on "Cadillac plans" that will be levied in 2018.

But when the nonprofit group representing large employers asked representatives of 136 companies to name the top three factors driving costs up,  the ACA didn't make the top five.

High-cost claimants  (individuals with expensive medical conditions)  topped the list, with 40 percent putting it at No. 1 and 62 percent putting it in the top three.

Specific diseases or conditions were named by 63 percent,  with 24 percent citing that as the top cause.

$1,000 per pill
Specialty drugs were named by 58 percent, though only 6 percent called that the top factor.  Brian Marcotte,  CEO of NBGH,  said that refers to extremely costly drugs,  such as a new hepatitis C medication that costs $84,000 for an 84-tablet course of treatment.

Overall medical inflation was cited by 35 percent,  with 12 percent putting it in the top spot.

Hospitalization was named by 26 percent,  with 7 percent putting it first.

Complying with the ACA was cited by 19 percent, with 7 percent saying it's the biggest factor in driving up costs.

I mentioned that to Steve Graybill,  a partner with Mercer's human resources consulting business in Charlotte.  He said he'd attribute  "better than half"  of next year's rising costs to the ACA,  though he agreed those expenses are entwined with all the other factors that have been driving up costs for years.

Friday, September 12, 2014

Oregon study: Does Medicaid matter?

"Medicaid doesn't make people healthier;  just look at the Oregon study."

I heard that comment a couple of times while I was reporting on Medicaid expansion,  from people supporting North Carolina's decision not to participate.

While I think that assessment is oversimplified,  I was intrigued to learn about Oregon's Medicaid lottery.  In 2008 the state randomly selected people to receive Medicaid coverage.  In the years that followed that provided a unique chance to study the role that coverage played in low-income people's health.

Image: Kaiser Health News
As you might expect, the results were complex and sometimes confusing.

Two years after the lottery,  people with Medicaid were more likely to have been diagnosed with diabetes and placed on medication.  But there was no significant improvement in their blood sugar levels,  which would have been a sign of ultimate success. There was also an increase in cholesterol monitoring,  but no significant differences in blood pressure or cholesterol between the Medicaid and non-Medicaid groups.

On the other hand, people with Medicaid were less likely to be diagnosed with depression and reported their own health as better.

On the financial front,  people who got Medicaid were less likely to have unpaid bills sent to a collection agency, "which also benefits health care providers since the vast majority of such debts are never paid," a National Bureau of Economic Research report notes.  But getting Medicaid also increased the rate of emergency room care for non-emergency ailments,  one of the least effective ways of getting treatment.

I don't think that justifies a conclusion that Medicaid does no good,  but the folks who raise that issue make an important point:  Just getting people covered isn't really the goal.  We want better health,  especially when we're spending billions of dollars.  And it's smart to take a close look at whether any reform brings the hoped-for results.

If you want to learn more about the Oregon experience,  here's a New England Journal of Medicine article and a 2013 Kaiser Health News/Washington Post interview with one of the Medicaid lottery winners.

"My blood pressure is still not perfect, but over the last two years I have stopped taking two different blood pressure medicines and am only taking half of a third,"  Mary Carson told interviewer Jordan Rau.  "That is a health improvement but it doesn't necessary show up in the study. My blood sugar is not perfect, but it's more consistently in the right zone. But according to the study, I haven't improved."

Thursday, September 11, 2014

You won't believe latest on employer health benefits

The most shocking thing about the Kaiser Family Foundation's 2014 report on employer health benefits may be the lack of shocking data.

The foundation,  which has been tracking health benefits since 1999,  reports that 2014 continues a period of  "historic moderation" in premium increases,  in the words of CEO Drew Altman.  The average premium for family coverage rose 3 percent,  to $16,834 a year,  with employers covering about $12,000 and employees about $4,800.

Altman and Kaiser VP Gary Claxton,  the study's lead author,  said Wednesday they know that talking about moderation clashes with the experience of many employees,  who are seeing out-of-pocket costs rise while wages stagnate.  And it contradicts some people's expectation that the Affordable Care Act would send rates through the roof.

"If you say that to an average person,  they may look at you like you're out of your mind,"  Altman told reporters.

Deductibles  --  the amount people are required to pay out of pocket before coverage kicks in  --  have been climbing steadily for the last few years.  Sometimes high-deductible plans are accompanied by a pre-tax savings account with employer contributions,  but the biggest recent growth has been in  "plain old vanilla high-deductible plans,"  Altman said.

Thirty-four percent of employees in small firms  (fewer than 200 employees)  and 11 percent of employees in larger companies have deductibles of at least $2,000 for an individual,  the report found.  That's up from 20 percent and 4 percent,  respectively,  in 2010.  Sixty-one percent of employees in small firms and 32 percent of those in large ones must cover at least $1,000 for an individual.  (Some preventive services are covered before the deductible is met,  as required by the ACA.)

"You've got both the ACA and market forces reinforcing each other on the issue of deductibles,"  Altman said.

The report,  done in partnership with the American Hospital Association's Health Research & Educational Trust, is based on a survey of more than 2,000 employers,  done between January and May.  Almost 150 million people are covered by employer-sponsored insurance.

While the Affordable Care Act is forcing changes in costs and coverage,  it also follows years of soaring costs for insurance and health care.  From 1999 to 2004,  for instance,  premiums increased 72 percent while average earnings rose 17 percent.  In the most recent five-year stretch,  premiums rose 26 percent while wages rose 11 percent.  Thus changes that feel extreme for workers  --  especially those whose plans are changing  --  can look modest in the historic context.

Of course,  the ACA is just starting to kick in.  And the health care market is very much in flux,  as my colleague Karen Garloch reported from this week's Carolinas HealthCare System board meeting.  As employers gear up for 2015 insurance enrollment this fall,  I'm working on a look at's happening locally and what lies ahead.  If you're willing to talk about your experience with a high-deductible plan in your workplace,  please get in touch  (my phone number and email are at right, below the photo).

Wednesday, September 10, 2014

Southern parents most likely to lack insurance

Almost half the parents who lack health insurance live in Southern states, according to a new report from the Urban Institute's Health Monitoring Center.

The institute and Georgetown University's Health Policy Institute released two reports this week on how the Affordable Care Act has affected children and parents.

For children,  the answer is  "not much."  The act was designed to expand health-care access for adults;  most low-income children are already covered by Medicaid and the Children's Health Insurance Program,  known as CHIP.  The study on children found no significant change in insurance rates,  though researchers had hoped there might be a  "welcome mat effect,"  with publicity about the act helping impoverished parents who hadn't enrolled their children realize they're eligible for aid.

Parents saw the biggest increases in insurance coverage in the 28 states that have expanded Medicaid coverage for low-income adults.  There, the uninsured have gone from 15 percent of the population in the second quarter of 2013 to 10 percent in the second quarter of this year,  the report says.  In the states that didn't participate in Medicaid expansion,  the rate went from 21.5 percent to 19 percent.

Such large Southern states as North Carolina,  Florida and Georgia are among those that didn't expand,  which probably explains the disproportionate regional showing.  The South accounted for 49.9 percent of the nation's uninsured parents,  with the West at 30 percent,  Midwest at 12.6 percent and Northeast at 7.5 percent.  State data won't be available until next year,  the researchers said Tuesday.

Researchers grouped the two studies in the belief that expanding coverage for parents ultimately benefits children,  especially if it means parents get treatment for depression and other issues that detract from family well being.

Most uninsured parents described their health as good or excellent,  though almost one in three said they had at least two days of  "poor mental health" in the past 30 days.

Tuesday, September 9, 2014

ACA survey: Rising costs trump better coverage

Most people have yet to see any personal impact from the Affordable Care Act, but those who have are more likely to say they've been hurt by rising costs than helped by greater access,  the latest Kaiser Health Tracking poll shows.

Like most opinions on  "Obamacare,"  views of the personal impact vary with political affiliation.  Democrats are more likely to say they and their family have been helped by the law,  which provides subsidies for insurance premiums and extends coverage to people who may have been blocked by prohibitive costs or preexisting medical conditions.  Republicans and independents are more likely to report negative results,  with most citing higher costs for insurance and/or health care.

While views of the act remain negative,  more respondents said they want their members of Congress to work to improve the law  (63 percent)  than repeal it  (33 percent).

Health care ranks well below the economy and jobs as a voting issue,  the foundation reports,  and among people who describe themselves as enthusiastic voters  --  a group that skews Republican  --  the Affordable Care Act ranks low on the list of motivators.

The Kaiser Family Foundation has been tracking public opinion on the act since it was passed in 2010.