Hundreds of healthcare journalists will be attending the Association of Health Care Journalists’ (AHCJ) conference in Boston this week to hear from many speakers with rose-colored ideas about both our Romneycare law and a brand new state cost-control law. Yet all is not well in the Commonwealth. State officials now predict “extreme premium increases” for many small businesses under Obamacare.

In a letter to federal regulators the day after Christmas 2012, a perfect day to bury news, Massachusetts officials floated the idea of obtaining a waiver from the Affordable Care Act (ACA) out of fear of the premium spikes. Yet, recently finalized federal regulations slammed the door on that flexibility. Many small companies justifiably feel sick over the decision.

The small business community has been paying more for health insurance since the commonwealth’s 2006 reform merged sicker individuals into the same risk pool. The legislature has also added to costs by passing 12 additional mandated benefits since then, a cost borne completely by small companies and individuals.

Now the future looks even bleaker for small business. Not only will their highest-in-the-nation premiums go up because of these new regulations, but they will be paying on average $8,000 per family, per plan more in taxes over the next ten years. That translates into employers and consumers in Massachusetts paying $213 million in 2014 and $3 billion more over the next decade.

Conference speakers will be sure to mention that the Connector was created to help small companies obtain competitively priced insurance, and other states will experience this benefit in the exchanges required under the federal law. Only one problem, the rhetoric doesn’t match reality in Massachusetts.

At the end of 2012, after spending tens of millions on advertising, the Connector covers less than 1 percent of the small business market and premiums are similar to those outside the exchange.

Finally, those in attendance will hear about a promising law passed in July that will save the Commonwealth $200 billion over 15 years. Yet its approaches are rehashed old ideas. State government gets a steroid shot of market oversight and permission to write regulations freely. The law is heavy with groups of “experts,” requiring 278+ new appointees, with some instructed to “rationally distribute health care resources.” Is this the future of Obamacare?

Requesting a waiver from the ACA implies that Massachusetts deserves to be treated differently. What about the dozens of states nationally where premiums will spike anywhere from 30 to more than 100 percent, especially for young adults?

Massachusetts has embarked on a seven-year health care experiment. It has worked on some fronts and not on others. To argue that we are special because we are leading the way on cost containment is premature and begs the question of whether the ACA’s “one-size-fits-all” approach is misguided to begin with. Let’s hope visiting reporters see the clear picture.

Josh Archambault is the director of healthcare policy at Pioneer Institute, a think tank in Boston.

When the new bill does become law, the Bay state will be the first in the country to attempt to slow rising health care costs through numerous strategies including tethering the growth in health care spending to the state’s overall economy, moving away from fee-for-service payments to doctors and more heavily managing and coordinating medical care.

After the bill passed earlier this week, Representative Steven M. Walsh, a Democrat and House Chair of the Joint Committee on Health Care Financing, who has shepherded the legislation, underscored the consumer’s perspective. “The passage of today’s bill is all about seeing our health care system through the eyes of the patient. We have the highest quality medical system in the nation and the highest percentage of health care coverage, yet it is a struggle for families to afford their health insurance premiums. This legislation focuses on increasing efficiency and cutting costs within our system, while enhancing the quality of care that our patients receive and empowering them to make the best personal health decisions.”

Even if you don’t live in Massachusetts, many of these changes — in some form or another — will likely be coming to your state or doctor’s office too. We’re still digesting all the details and implications. But here’s an early snapshot of five things you might like to know:

1. Try Not To Get Sick In The First Place

Prevention and wellness are a priority in the new Massachusetts cost-cutting plan. If you lead a healthy lifestyle and try to care for your body through diet, exercise, not smoking, good attitude (when possible) etc. you can spend more time away from the doctor and out of the hospital thus saving the system money and just generally making life better. Under the Mass. plan, there’s $60 million for a prevention and wellness trust fund to boost such efforts. There are also tax credits for small businesses that run wellness programs.

2. The Cost Of Care

Speaking of budgeting, there will now be even greater pressure on your doctor, hospital or hospital system to save money. That means you will have to start thinking much more about how much your health care costs. Under the Mass. plan, hospitals and doctors will have to cut their rate of growth by about half. You, as the patient, may experience this in various ways, for instance, fewer non-critical tests, procedures and imaging (though what is considered “non-critical” remains highly debatable).

Drafters of the new Mass. reform plan are estimating about $200 billion in savings over 15 years (our estimate, based on analyses from folks at the Harvard School of Public Health, is closer to $197 billion by 2022) and some of that will come from changes in how care is delivered. The president of the Massachusetts Medical Society, Richard Aghababian, worries this may mean more headaches for patients, who, he says should prepare for the changes.

“I think it may affect accessibility to physicians,” he told WBUR. “It may mean that some patients can’t get in to a procedure because there’s no one to staff the machine or to do the procedure, at least as quickly as they have been up to this time.”

3. Acronyms Await You

Warning: There will be new acronyms in your life, chief among them, the ACO, or accountable care organization. (If you crave more on this, see our cartoon, “What The Heck Is An ACO.“) In Mass. at least, it’s mostly the public insurance programs that will be mandated to join such ACO’s — clusters of providers that will manage care (theoretically) in a more efficient, coordinated way.

Currently in Mass., about 1 in 4 residents with private insurance are already under another new model in which doctors and hospitals are paid through a global budget per patient. (Some of these arrangements are called AQC’s or alternative quality contracts. If you’re already confused, see our Glossary for Reform 2012 here.) The new bill requires the state’s Medicaid program, the state’s employee health care program and all other state-funded health care programs to transition to new health care payment methodologies. These payment models will seek to “incentivize the delivery of high-quality, coordinated, efficient and effective health care over quantity of services to reduce waste, fraud and abuse.”

4. “Noctor” Alert

Nurse Practitioners and Physician’s Assistants may play a bigger role in your care. Under the state plan, these practitioners can act as primary care providers in order to expand access to cost-effective care, particularly for more routine medical matters. Doctors will still supervise nurses and PAs, but the major doctors groups, not surprisingly, remain wary.

5. You May Someday Hear Your Doctor Say, “I’m Sorry.”

If your doc, or another provider, makes a mistake, you may get an apology. To reduce the costs of unnecessary litigation and malpractice claims, the bill creates a “182-day cooling off period while both sides try to negotiate a settlement, and it allows for providers to offer an apology to the patient.” This isn’t always easy for highly trained medical experts to manage, as studies have shown. Also, we’ll see if the risk managers comply.

On August 1, insurers for the first time in history were required to start providing women with a set of basic preventive health services — not just birth control — for no extra fee. Though contraception and some of the other newly covered services, such as breast feeding support and equipment, have received most of the media and political attention, the new coverage spans a range of screening, counseling and other health services for women of all ages.

The new provisions fall under the federal Affordable Care Act and, according to Dr. Paula Johnson, Chief of the Division of Women’s Health at Brigham and Women’s Hospital in Boston, “represent a paradigm shift from a health care system built on diagnostic treatment of disease toward a foundation of disease prevention and wellness promotion.”

Johnson is a member of the Institute of Medicine Committee on Women’s Health Preventive Services — the group that recommended the new services be covered — and Executive Director of the Connors Center for Women’s Health and Gender Biology at the Brigham. She says that “cost has been a significant barrier for women” in accessing these basic medical services, and the new requirements “will allow women to get the preventive care that they need without the financial worry.” Moreover Johnson says, having these eight new services covered by insurers “raises the bar for preventive care for women,” and will ultimately strengthen the bond between doctors and patients.

Here, Johnson summarizes the 8 services women with private health insurance will now have access to without cost-sharing, and why these tests and services are vital for overall health:

1. Well-woman visits: Half of women delay or avoid well-woman preventive services due to cost barriers.

2. Screening for gestational diabetes: Gestational diabetes affects 1 in 20 pregnant women with 18% higher associated health care costs.

3. Human papillomavirus (HPV) testing: HPV, associated with many conditions including cervical cancer and head and neck cancers infects one in four U.S. females with direct costs of $3.6 billion annually.

4. Counseling for sexually transmitted infections: Nineteen million new occurrences of STIs emerge each year at an estimated annual cost of $17 billion.

5. Annual counseling and screening for HIV for all sexually active women: Women represent one in four HIV cases. Lifetime direct medical costs are about $1 billion or between $73 million and $93 million annually.

6. Contraceptive methods and counseling for all women with reproductive capacity: Nearly half of U.S. pregnancies are unplanned resulting in three million pregnancies each year and a cost of $19 billion annually.

7. Breastfeeding support, supplies, and counseling: Breastfeeding helps reduce Sudden Infant Death Syndrome, chronic childhood conditions and lowers the risk of breast and ovarian cancers in mothers. If 80 percent of mothers breastfed their children exclusively for the first six months of life, the U.S could save 741 lives and $10.5 billion annually.

8. Screening and counseling for interpersonal and domestic violence (IPV): One in three women will report IPV in their lifetime. Millions of women in the U.S. are abused by their partners each year at a cost of over $5 billion annually.

Johnson makes the fairly obvious but important point that nothing in health care is truly free. “We all pay premiums, we contribute to the cost of our care,” she said. “The difference here is that this takes away the additional cost burden of having a co-pay.” And, of course it only applies to women with private health insurance.

In some states, like Massachusetts, women already received some of these benefits. As Johnson noted in an earlier post on this topic:

The ACA enhances Massachusetts’ existing benefits in two important ways. First, the federal law eliminates consumer cost-sharing for some of Massachusetts’ mandatory women’s health benefits like contraception and pap smears. Commonwealth Care has voluntarily covered contraception without cost-sharing since Summer of 2011, and now most employer-sponsored plans and Commonwealth Choice Plans will follow suit. Second, the ACA provides Massachusetts women with additional mandatory benefits, including well woman visits, breastfeeding support, gestational diabetes screening and screening for interpersonal violence. Overall, the U.S. Department of Health and Human Services estimates that 1,212,350 women in Massachusetts will have guaranteed access to these additional preventive services without cost-sharing for policies renewing on or after August 1, 2012. While Massachusetts women continue to gain access to preventive care under health reform, many women in other states may not be as fortunate.

Still, the piece by these health policy luminaries (including Ezekiel Emanuel, M.D., Ph.D., Stuart Altman, Ph.D., Donald Berwick, M.D., M.P.P., David Cutler, Ph.D., Tom Daschle, B.A., Arnold Milstein, M.D., M.P.H., John D. Podesta, J.D., Uwe Reinhardt, Ph.D., Meredith Rosenthal, Ph.D., Joshua Sharfstein, M.D., and Peter R. Orszag, Ph.D., among others) is worth reading, as it lays out numerous smart strategies for cost-saving and quality improvement as part of the medical journal’s election 2012 coverage. The piece also comes, coincidentally, as Massachusetts approves its own first-in-the-nation health cost savings plan, with many similar strategies.

The author’s write:

Although the Affordable Care Act (ACA) will significantly reduce Medicare spending over the next decade, health costs remain a major challenge. To effectively contain costs, solutions must target the drivers of both the level of costs and the growth in costs — and both medical prices and the quantity of services play important roles. Solutions will need to reduce costs not only for public payers but also for private payers. Finally, solutions will need to root out administrative costs that do not improve health status and outcomes.

Among their suggestions:

– Promote payment rates within global targets

– Accelerate the use of alternatives to fee-for-service payments

– Use competitive bidding for all commodities

– Require exchanges to offered tiered products

– Simplify administrative systems for payers and providers

– Require full transparency of prices

– Make better use of non-physician providers

– Expand the Medicare ban on physician self-referrals

– Leverage the federal employees program to drive reform

– Reduce the cost of defensive medicine

August 1, 2012 marks the first time in history that insurers will be required to provide women with a set of core women’s health preventive services without cost-sharing. These services are part of the Affordable Care Act’s (ACA) robust plan of preventive care for women across the lifespan and represent a paradigm shift from a health care system built on diagnostic treatment of disease toward a foundation of disease prevention and wellness promotion.

Unfortunately, not all U.S. women will benefit from the new system of care. With June’s Supreme Court ruling, some states may refuse to expand Medicaid to millions of our country’s poorest women, many of whom are near elderly, depriving them of access to preventive services available to Medicaid recipients and a better chance at a healthy life.

Let’s be clear that the preventive health services available under the ACA will allow women to become healthier and help reduce cost. Prior to reform, more than half of U.S. women were not up-to-date on recommended preventive health services, a fact not surprising given the growing epidemic of chronic illness among women that is costly, at an estimated $466 billion per year, yet preventable.

The new preventive services available to women with private insurance include:

Well-woman visits: Half of women delay or avoid well-woman preventive services due to cost barriers.

Screening for gestational diabetes: Gestational diabetes affects 1 in 20 pregnant women with 18% higher associated health care costs.

Human papillomavirus (HPV) testing: HPV, associated with many conditions including cervical cancer, infects one in four U.S. females with direct costs of $3.6 billion annually.

Counseling for sexually transmitted infections: Nineteen million new occurrences of STIs emerge each year at an estimated annual cost of $17 billion.

Annual counseling and screening for HIV for all sexually active women: Women represent one in four HIV cases#. Lifetime direct medical costs are about $1 billion or between $73 million and $93 million annually.

Contraceptive methods and counseling for all women with reproductive capacity: Nearly half of U.S. pregnancies are unplanned resulting in three million pregnancies each year and a cost of $19 billion annually.

Breastfeeding support, supplies, and counseling: Breastfeeding helps reduce Sudden Infant Death Syndrome, chronic childhood conditions and lowers the risk of breast and ovarian cancers in mothers. If 80 percent of mothers breastfed their children exclusively for the first six months of life, the U.S could save 741 lives and $10.5 billion annually.

Screening and counseling for interpersonal and domestic violence (IPV): One in three women will report IPV in their lifetime. Millions of women in the U.S. are abused by their partners each year at a cost of over $5 billion annually.

The Supreme Court recently ruled that states can decide whether to expand Medicaid coverage to the poorest Americans. In states refusing to expand coverage, many women will be denied access to care, including preventive care. Given that the uninsured are less likely to obtain preventive services, expanding Medicaid offers an avenue for women to receive preventive care, crucial to stemming the rising tide of chronic disease among this population. Furthermore, the resultant increase in preventive service utilization that insurance is likely to bring can lower chronic illness rates and the associated health care costs that often contribute to growing government budgets.

And for Massachusetts women in particular:

Massachusetts has a long history of requiring private insurers to cover a list of comprehensive medical and preventive services for its residents. Many of these mandates existed prior to Massachusetts reform (Chapter 58) and were incorporated into the 2006 state health reform law. The ACA enhances Massachusetts’ existing benefits in two important ways. First, the federal law eliminates consumer cost-sharing for some of Massachusetts’ mandatory women’s health benefits like contraception and pap smears. Commonwealth Care has voluntarily covered contraception without cost-sharing since Summer of 2011, and now most employer-sponsored plans and Commonwealth Choice Plans will follow suit. Second, the ACA provides Massachusetts women with additional mandatory benefits, including well woman visits, breastfeeding support, gestational diabetes screening and screening for interpersonal violence. Overall, the U.S. Department of Health and Human Services estimates that 1,212,350 women in Massachusetts will have guaranteed access to these additional preventive services without cost-sharing for policies renewing on or after August 1, 2012. While Massachusetts women continue to gain access to preventive care under health reform, many women in other states may not be as fortunate.

America, one of the world’s wealthiest countries, spends more per capita on health care than any other nation yet has one of the lowest life expectancy rates in the developed world. To improve quality and reduce cost, all roads lead to prevention. Today marks another step in the right direction. States can do their part by accepting federal Medicaid expansion funding extending prevention and wellness to all women, regardless of income or state of residence.

Paula Johnson, MD, MPH was a member of the IOM Committee on Women’s Health Preventive Services. She is the Executive Director of the Connors Center for Women’s Health and Gender Biology and Chief of the Division of Women’s Health at Brigham and Women’s Hospital.

The Advisory Board (see their map above) says these five states won’t participate in the expansion of the federal program:

Florida: Gov. Rick Scott (R) said, “Florida will opt out of spending approximately $1.9 billion more taxpayer dollars required to implement a massive entitlement expansion of the Medicaid program.” In addition, the governor said the state will not establish an insurance exchange (Pear, New York Times, 7/2).
Louisiana: In an interview on NBC’s “Meet the Press,” Gov. Bobby Jindal (R) said, “Every governor’s got two critical decisions to make. One is do we set up these exchanges. And, secondly, do we expand Medicaid. And, no, in Louisiana, we’re not doing either one of those things” (Barrow, New Orleans Times-Picayune, 7/2).
Mississippi: Gov. Phil Bryant (R) does not plan to participate in the Medicaid expansion, according to Bryant spokesperson Mick Bullock, Bloomberg reports (Niquette/Wayne, Bloomberg, 7/5).
South Carolina: Gov. Nikki Haley (R) on Sunday announced via Facebook that South Carolina “will NOT expand Medicaid, or participate in any health exchanges” (Hawkins, TheDigitalCharleston, 7/2; Dudley, Charleston Post and Courier, 6/29).
Texas: Gov. Rick Perry (R) in a statement Monday said, “If anyone was in doubt, we in Texas have no intention to implement so-called state exchanges or to expand Medicaid under Obamacare.” Perry’s staff said he will send a letter to HHS Secretary Kathleen Sebelius Monday to assert this position (Ramshaw, Texas Tribune, 7/9; Fikac, Houston Chronicle, 7/9). [updated on July 9 at 10 a.m.]

Austin Frakt translates the data here, based on this map:

States with populations that would benefit more from the expansion are disproportionately against adopting it. It also may be true that in those states the price of expansion is higher (more people, higher price, though you can’t infer the price from the proportion of uninsured). However, most of that price tag will be covered by the federal government and, on balance, many states will actually see a net savings due to reform.

So, the mandate is constitutional. Chief Justice Roberts joins left of court. Medicaid provision is limited but not invalidated, says Scotusblog.

Bottom line: “The entire ACA is upheld, with the exception that the federal government’s power to terminate states’ Medicaid funds is narrowly read,” says Scotusblog. “Roberts saved the ACA.”

Amy Howe blogs: “The money quote from the section on the mandate: Our precedent demonstrates that Congress had the power to impose the exaction in Section 5000A under the taxing power, and that Section 5000A need not be read to do more than impose a tax. This is sufficient to sustain it.”

Howe: “The Court holds that the mandate violates the Commerce Clause, but that doesn’t matter b/c there are five votes for the mandate to be constitutional under the taxing power.

(Thank you Scotusblog!)

More from Kennedy’s dissent, from Scotusblog: “In opening his statement in dissent, Kennedy says: “In our view, the entire Act before us is invalid in its entirety.”

For a laugh between all this serious talk, check out tumblr’s “When Scotus Upheld ObamaCare.”

Amy Howe summarizes the ruling in plain English:

The Affordable Care Act, including its individual mandate that virtually all Americans buy health insurance, is constitutional. There were not five votes to uphold it on the ground that Congress could use its power to regulate commerce between the states to require everyone to buy health insurance. However, five Justices agreed that the penalty that someone must pay if he refuses to buy insurance is a kind of tax that Congress can impose using its taxing power. That is all that matters. Because the mandate survives, the Court did not need to decide what other parts of the statute were constitutional, except for a provision that required states to comply with new eligibility requirements for Medicaid or risk losing their funding. On that question, the Court held that the provision is constitutional as long as states would only lose new funds if they didn’t comply with the new requirements, rather than all of their funding.

Howe notes Roberts’ rationale for his opinion here:

From the beginning of the Chief’s opinion: “We do not consider whether the Act embodies sound policies. That judgment is entrusted to the Nation’s elected leaders. We ask only whether Congress has the power under the Constitution to enact the challenged provisions.”

The New York Times front page declares: Victory For Obama

Tonight is going to be all candy, so let’s start the week with a few vegetables, as we sometimes refer to our health policy posts. Not that the above video is lima-bean-like; it’s a lively — though civil — Republican-Democrat debate about whether it’s fair to consider Massachusetts health reform as the “parent” of the federal health overhaul.

As CommonWealth magazine executive editor Michael Jonas introduces it:

We recently launched a new video feature on CommonWealth’s website involving webcam-based discussions between two people. I thought our most recent installment of “Face to Face” might be of interest to you and CommonHealth readers: a discussion of “Romney” and “Obamacare” between two of the people best qualified to chew over the issue that dogs Romney’s campaign perhaps more than any single topic.

Talking over the issue are Tim Murphy, who was Romney’s secretary of health and human services and the administration point-man on the 2006 Massachusetts law, and John McDonough, who was in the thick of the 2006 reform as director of Health Care for All and then went on to serve as senior policy adviser to Ted Kennedy’s Senate Health, Education, Labor and Pensions Committee, where early work on the federal law took place.