Health Wonk Review: Spring Forward Edition


by Brad Wright

Health Works Collective

This has been a record-setting winter, and not in a good way (here’s looking at you, New England). It’s also been a volatile time in the world of health policy–and the ACA in particular. We’ve had the second open enrollment period come and go, the Supreme Court has heard oral arguments around the provision of federal subsidies to health insurance exchanges not run by the states, and three Republican members of Congress have come out with a proposal to repeal and replace Obamacare. With much of the country still blanketed by snow, and the fate of the ACA up in the air until the Court’s expected ruling on King v. Burwell in June, let me assure you that there is a light at the end of the tunnel. We’ve just moved our clocks forward one hour this week, which will usher in the longer days and warmer temperatures that so many of us desperately await. As the mercury climbs higher, the snow begins to melt, and policy wonks ramp up their prognostications, I offer this Spring Forward edition of the Health Wonk Review. I hope that it will help you shake off the winter blues and be better informed about current developments in the world of health policy.

It should come as no surprise that the overwhelming majority of submissions for this edition are focused on the Supreme Court and King v. Burwell. Writing at the Healthcare Economist, blogger Jason Shafrin does a good job of presenting an overview of King v. Burwell for those who are not thoroughly familiar with the case, what’s being argued, and what’s at stake. As such, this seemed like a fitting piece to lead things off.

A close second, thanks to its comprehensive tackling of the case, is the Health Affairs Blog. While they have an entire set of posts on the topic, I’m linking solely to a post by Tim Jost, which in turn links to all the others. Tim’s post delves into the nuances of the oral arguments, looking specifically at the doctrine of constitutional avoidance raised by Justices Sotomayor and Kennedy. Lest you think that means they were suggesting that the ACA is unconstitutional, it doesn’t. Rather, it means that they were suggesting that the ACA be interpreted in such a way as to “avoid any constitutional issues.”

If that’s not enough for you, I encourage you to check out a post by Billy Wynne of the Healthcare Lighthouse. Billy’s reading the tea leaves from the oral argument and offers up his top 6 most pivotal moments during King v. Burwell. Some developments that have flown under the radar are Justice Alito’s assertion that the decision could be stayed to allow time for Congress or states to respond, if necessary, and the challengers’ concession that the context of the operative provision of the ACA is important to interpreting it. Ultimately, the post suggests that it was a better day for the Administration but warns against drawing strong conclusions from oral arguments.

After something of a hiatus, Maggie Mahar is back blogging at Health Beat. In a post asking “Will the Supreme Court Scuttle Subsidies?” she takes a clear stance. The rest of her post’s title is: No. (What Can’t Happen Won’t). Her reasoning? Legal precedent doesn’t support cherry-picking from the text of the law out of context, the Court would undermine its integrity if it sided with the plaintiffs, and the political fallout would hurt Republicans.

By contrast, John R. Graham, a senior fellow of the National Center for Policy Analysis, anticipates that the Court will find for the plaintiffs and that millions of people who are suddenly without subsidies will drop their coverage. According to Graham, however, that is not the cause for alarm that many policy wonks are suggesting. Rather, this will simply be an opportunity for Congress to work with the President to fix the various elements of the ACA that nobody seems to like. The idea is that rather than making a simple fix, Congressional Republicans can use this as an opportunity to make more significant changes to the law.

One such proposal is that put forward by Senator Burr, Senator Hatch, and Representative Upton. They proposed what they are calling the “Patient CARE Act” and I have been writing about that plan extensively of late. I encourage you to read about starting with this overview before proceeding to learn about what the GOP would like to do that will lessen consumer protections, make life more difficult for people with pre-existing conditions, reduce the amount of federal subsidies for health insurance, give more power to the states at the expense of the people, and provide more tax shelters for the wealthy under the label of consumer-directed health savings accounts.

Regardless of the outcome of the case, Wendell Potter isn’t optimistic. In a recent piece for the blog at healthinsurance.org he writes: “Regardless of how the Court eventually rules in King v. Burwell, your premiums will likely go up next year simply because the justices agreed to take the case in the first place.” He goes on to explain how the case has introduced uncertainty into the rate setting process, and how insurers tend to hedge their bets against such uncertainty by raising rates. Under that logic, you can thank those who are trying to get rid of Obamacare for raising your insurance premiums.

Fortunately, for some states that have decided to run their own exchanges, like California, King v. Burwell is irrelevant. As Anthony Wright (no known relation–although maybe he and I share consider partnering up at Wright on Health) writes at the Health Access Blog: “We have our own state exchange, and while some worry about the political fallout, I have a hard time believing the President (or for that matter, Pelosi and Reid from CA and NV) would accept a compromise that undid coverage in the states that did the right thing, like California and Nevada. With a new President, all bets are off, but that was always true.”

And, while we’re talking about the states, it’s worth noting that many states are creating special open enrollment periods for residents who are just finding out about the individual mandate (and the associated tax penalty) when they go to file their taxes this year. The issue, of course, is that open enrollment ended February 15th, while the tax deadline isn’t until April 15th. Rather than penalize people for two years, states came up with the idea to let these individuals purchase coverage if they attest that they only learned about all these requirements to have insurance or pay a tax when they went to pay their taxes. But Louise at the Colorado Health Insurance Insider tells us that this won’t be happening in Colorado. According to the state’s insurance commissioner, Marguerite Salazar: “After considering all the factors and consulting with Connect for Health Colorado, the Division determined that the negatives of starting up another enrollment period outweighed the positives.”

Of course, not all wonks lead to SCOTUS. We also have a number of wonderful submissions on a variety of topics. Among these are David Williams’ piece on emulsifiers in the Health Business Blog. He highlights an intriguing and plausible new study in the journal Nature that suggests synthetic emulsifiers that are common in processed food could be a key cause of the obesity epidemic and a trigger for ulcerative colitis and Crohn’s Disease. He says that his family is avoiding emulsifiers as much as they can, and that food companies should develop emulsifier free products now in anticipation of rising demand.

Both Joe Paduda of Managed Care Matters and Tom Lynch of Workers’ Comp Insider are focused on the topic of workers comp. Joe explains that NPR and ProPublica have published the first in what will be a series of articles on workers’ compensation. What’s striking about the reportage, he says, is how misguided, misinformed, and just plain distorted it is. Tom explains that, by law, workers’ comp is the exclusive remedy for workers who are injured on the job. He underscores that, in exchange for relinquishing the right to sue, the employee receives employer-paid medical care and temporary wage replacement, but he also asks: Is they system fair? Some new research suggests maybe not.

Over at Health System Ed, Peggy Salvatore writes about health IT, exploring the disconnect between the cutting edge technology we’re developing and our ability to implement more basic technology throughout the healthcare delivery system. The result is likely to be a lot of wasted money. As she puts it “Our society and its component businesses are financing an infrastructure that serves the needs of people who live to be 100 in a time when babies are born who will live to see 2515.”Colorful_spring_garden

Friend of the HWR and InsureBlog author, Hank Stern, is also exploring some of the issues with healthcare delivery systems. In particular, he’s exploring the problem of nationalized healthcare schemes and economic inelasticity. SPOILER ALERT: Every nation rations healthcare.

At Health Care Renewal, Roy Poses explores what the recent U.S. experience with Ebola–and the fiascoes at one Texas hospital in particular–can teach us about another type of disconnect: that between the preparedness of our hospitals and health systems to respond to such threats and the public relations managers that paint an undeniably rosier picture. Hospitals managers are eager to maintain their pay and privileges, he says, especially when events lead to questions about them.

And speaking of hospitals, Bradley Flansbaum of The Hospital Leader, offers some thoughtful commentary on the limitations of using mortality rates as an outcome indicator of hospital quality. It might be easy to measure, but he argues it doesn’t provide us with the whole picture.

In an interesting post on the Population Health Blog, Dr. Jaan Sidorov applies the lessons of Joel Kotkin’s book on “The New Class Conflict” to health reform. He leaves it to readers if this paranoid perspective has an element of truth or if he’s being a right wing nut job. At the very least, you’ll learn about an obscure word: “clerisy.”

Finally, it is my pleasure to welcome newcomer Al Lewis to the Health Wonk Review. Al submits two posts for your consideration. The first, co-authored by Vik Khanna, focuses on Healthcare’s Biggest and Most Expensive Urban Legend. The second, co-authored by Vik Khanna and Jon Robison, examines how Weight Loss Fines are Discriminatory and Counterproductive. I encourage you to show him some love so that he’ll continue submitting to HWR.

Well, that’s it, folks. I hope you’re now up to speed on the latest and best health policy blogging, and I trust that this edition has prepared you to go outside and enjoy the better weather. If it hasn’t reached you yet, don’t despair. It will arrive soon enough. Up next: Jennifer Salopek at Wing of Zock will host on March 26th.