ObamaCare’s impact on health costs.
“Better access to data about real world patient experience holds enormous potential to help achieve many of the goals of health reform, including improving the quality and delivery of medical care, reducing costs, and improving safety and outcomes by accelerating the knowledge base upon which the development of new treatments and cures relies.
Capturing data about the actual experience of patients outside of the carefully controlled clinical trial setting – Real World Data – can help fill the knowledge gap between clinical trials and clinical practice. RWD offers a treasure-trove of information that could allow providers, innovators, health plans, researchers, and others in the scientific and medical communities to make faster, more efficient, and less costly advances in medical research and clinical treatment. Life sciences companies can use this data to explore the benefits and risks of treatment options including their effectiveness in patient subpopulations, expedite enrollment in clinical trials, identify new targets for research and development, and transform the value equation in medical care.”
“The top federal prosecutors from South Dakota and North Dakota say they have increased their efforts to fight healthcare fraud.
U.S. Attorney Brendan Johnson of South Dakota said he has restructured his office to allow lawyers in the criminal and civil divisions to devote “significant time” to investigating medical fraud. He predicted it will be among the fastest-growing area of criminal investigation and wants his office to be in position to pursue increasing “complex and egregious” cases.
“My advice to the medical community is to stay away from gray areas or outright fraud that wastes tax dollars, because we will be watching,” Johnson told the Sioux Falls Argus Leader. “The end result in many of these cases will be that the taxpayers get their money back with interest and penalties, and the medical professional loses their license.”
Johnson’s office recently settled an alleged fraud case involving two doctors at Dakotas-based Sanford Health. Court documents show that Sanford paid $625,000 to settle the lawsuit, in which the doctors and the hospital did not admit wrongdoing. Cindy Morrison, Sanford’s executive vice president for marketing and public policy, said the hospital settled to avoid distraction.
“For us, it’s the issue of time and expense,” she said.”
“Nancy Pippenger and Marcia Perez live 2,000 miles apart but have the same complaint: Doctors who treated them last year won’t take their insurance now, even though they haven’t changed insurers.
“They said, ‘We take the old plan, but not the new one,’” says Perez, an attorney in Palo Alto, Calif.
In Plymouth, Ind., Pippenger got similar news from her longtime orthopedic surgeon, so she shelled out $300 from her own pocket to see him.
Both women unwittingly bought policies with limited networks of doctors and hospitals that provide little or no payment for care outside those networks. Such plans existed before the health law, but they’ve triggered a backlash as millions start to use the coverage they signed up for this year through the new federal and state marketplaces. The policies’ limitations have come as a surprise to some enrollees used to broader job-based coverage or to plans they held before the law took effect.
“It’s totally different,” said Pippenger, 57, whose new Anthem Blue Cross plan doesn’t pay for any care outside its network, although the job-based Anthem plan she had last year did cover some of those costs. “To try to find a doctor, I’m very limited. There aren’t a lot of names that pop up.””
Words mean what they say. That’s the basis for the decision of the U.S. Court of Appeals for the D.C. Circuit in Halbig v. Burwell invalidating the Internal Revenue Service regulation approving subsidies for Obamacare consumers in states with federal health insurance exchanges.
The law passed by Congress, Judge Thomas Griffith explained, provided for subsidies in states with state-created exchanges, but not in states with federal exchanges. That’s factually correct, and under the Constitution, the government can’t spend money not authorized by Congress.
This has not prevented Democrats from calling the decision “judicial activism,” which makes as much sense as the claims that the Supreme Court decision overturning the Obamacare contraception mandate cuts off all access to contraception.
“We reach this conclusion,” wrote Judge Griffith, “with reluctance.” Judge Roger Ferguson, writing for the Fourth Circuit whose King v. Burwell decision upholding the IRS was announced the same day, wrote that those challenging the government “have the better of the statutory construction arguments.”
One has a certain sympathy with both judges. They’re being asked to overturn a regulation that has paid most of the cost for health insurance for some 4.7 million Americans. But the problem arose not from sloppy legislative draftsmanship.
Under previous court decisions, Congress can’t force state governments to administer federal laws. So congressional Democrats, seeking to muscle states into creating their own health insurance exchanges, chose to provide subsidies only for those states. Those opting for the federal exchange would have to explain to voters why they weren’t getting subsidies.
“MIAMI (AP) — Linda Close was grateful to learn she qualified for a sizable subsidy to help pay for her health insurance under the new federal law. But in the process of signing up for a plan, Close said her HealthCare.gov account showed several different subsidy amounts, varying as much as $180 per month.
Close, a South Florida retail worker in her 60’s, said she got different amounts even though the personal information she entered remained the same. The Associated Press has reviewed Close’s various subsidy amounts and dates to verify the information, but she asked that her financial information and medical history not be published for privacy reasons.
“I am the kind of person the Affordable Care Act was written for: older, with a pre-existing (condition) and my previous plan was being cancelled. I need it and I’m low income,” said Close, who has spent more than six months appealing her case. “The government pledged to me that original tax credit amount. It’s crazy.”
“Federal officials have capped the amount of money scofflaws will be forced to pay if they don’t buy insurance this year at $2,448 per person and $12,240 for a family of five.
The amount is equal to the national average annual premium for a bronze level health plan. But only those with an income above about a quarter of a million dollars would benefit from the cap. Those making less would still have to pay as much as 1 percent of their annual income.
The penalty for the first year starts at $95 per adult or $47.50 per child under 18. The penalty for not buying insurance increases to 2 percent of income or $325, whichever is higher, for 2015. The fines are due when people file their 2014 taxes.
The figures, released late Thursday, are important because the White House has only provided theoretical caps in the past. Conservative lawmakers and groups that are critical of the Affordable Care Act encouraged consumers to skip buying insurance, arguing it would be cheaper to pay a $95 penalty, but often failed to mention the 1 percent clause.”
“A lot of attention is being paid to the dueling decisions in two U.S. appeals courts about whether the U.S. government can provide tax credits to people in federal- as well as state-run insurance exchanges. In human terms, the stakes are high: Millions of moderate-income people will not be able to afford health coverage without a subsidy, and a court ruling could gut coverage expansion in the 36 states with federally run insurance exchanges, unless states decide to set up their own exchanges. One of the cases, Halbig v. Burwell, also adds uncertainty to the enrollment process set to begin this fall, when millions more people are expecting to get tax credits–and wondering if they may be taken away.
Amid the reaction, little attention has been paid to whether Americans will perceive Halbig as a legitimate legal question or as more inside-Washington politics. The plaintiffs paint this as a case about statutory language and intent. The health-care law said that tax credits would be provided only in state-run exchanges, they argue, and it is executive overreach to provide credits in federal exchanges. Proponents of the Affordable Care Act see this as a thinly veiled game of gotcha being played over imperfect legislative language despite clear legislative intent. They believe that providing tax credits in the exchanges was always a central element of the Affordable Care Act’s strategy to expand coverage whether in state or federal exchanges–and that everybody knows it.”
“PORTLAND — Low-income Oregon residents were supposed to be big winners after the state expanded Medicaid under the federal health care overhaul and created a new system to improve the care they received.
However, an Associated Press review shows that an unexpected rush of enrollees has strained the capacity of the revamped network that was endorsed as a potential national model, locking out some patients, forcing others to wait months for medical appointments and prompting a spike in emergency room visits, which state officials had been actively seeking to avoid.
The problems come amid nationwide growing pains associated with the unprecedented restructuring of the U.S. health care system, and they show the effects of a widespread physician shortage on a state that has embraced Medicaid expansion.”
“For decades, the United States has had a fragmented health policy. States called the shots on major elements of how health care and health insurance were financed and regulated. The result: a hodgepodge of coverage and a wide variance in health.
The Affordable Care Act was intended to help standardize important parts of that system, by imposing some common rules across the entire country and by providing federal financing to help residents in all states afford insurance coverage. But a series of court rulings on the law could make the differences among the states bigger than ever.
The law was devised to pump federal dollars into poorer states, where lots of residents were uninsured. Many tended to be Republican-leaning. But the court rulings, if upheld, could leave only the richer, Democratic states with the federal dollars and broad insurance coverage. States that opted out of optional portions of the law could see little improvement in coverage and even economic damage.
“It will be essentially health reform for blue states,” said John Holahan, a health policy fellow at the Urban Institute, a research group.”
“Today’s 2-1 decision by the DC Court of Appeals striking down federal premium subsidies, in at least the 27 states that opted for the feds to run their Obamacare insurance exchanges, has the potential to strike a devastating blow to the new health law.
The law says that individuals can get subsidies to buy health insurance in the states that set up insurance exchanges. That appears to exclude the states that do not set up exchanges––at least the 27 states that completely opted out of Obamacare. Another nine states set up partnership exchanges with the feds and the impact on those states is not clear.
The response by supporters of the law, and the IRS regulation that has enabled subsidies to be paid in the states not setting up exchanges, hinges on the argument that the language is at worst ambiguous and the Congress never intended to withhold the subsidies in the federal exchange states.
But in the DC Court ruling one of the majority judges said, “The fact is that the legislative record provides little indication one way or the other of the Congressional intent, but the statutory text does. Section 36B plainly makes subsidies only available only on Exchanges established by states.”
My own observation, having closely watched the original Obamacare Congressional debate, is that this issue never came up because about everybody believed about all of the states would establish their own exchange. I think it is fair to say about everyone also believed a few states would not establish their own exchanges. Smaller states, for example, might opt out because they just didn’t have the scale needed to make the program work. I don’t recall a single member of Congress, Republican or Democrat, who believed that if this happened those states would lose their subsidies.”