Obamacare Preview? Mass. Studies Find Some Hospital Use Stays Same



Today is an Obamacare milestone: the end of the first enrollment period for new insurance plans the health care law spawned. More than 6 million previously uninsured people have signed up for private plans and 4 million more for Medicaid, The New York Times reports.

Opposition and skepticism remain, the Times says.

Yet beneath the loud debate, the law is quietly starting to change the health care landscape. In Kentucky alone, more than 350,000 people — about 8 percent of the state’s population — have signed up for coverage. Insurers and medical providers are reporting steady demand from the newly covered for health care, ranging from basic checkups to complex surgical procedures.

As that landscape changes, now seems a good time for a couple of reality-check studies from Massachusetts (yes, the state website has been messed up, but we did go through the current Obamacare stage of new enrollments years ago). They find that in certain ways — emergency room usage and readmission rates — expanded insurance coverage may not change health care, at least not immediately.

A study just out today in the medical journal BMJ finds that increasing health coverage does not quickly bring down readmissions — those unfortunate cases of patients who quickly bounce back into the hospital soon after being discharged. The hope is that having insurance and thus regular medical care will reduce those expensive readmissions. From the press release:

Boston—In a first of its kind retrospective study, Boston University School of Medicine researchers have found that providing health insurance coverage to previously uninsured people does not result in reducing 30-day readmission rates. The study, which appears in the British Medical Journal, used data on actual (versus self-reported) use of care and also found no change in racial/ethnic disparities in this outcome, despite a markedly higher baseline of uninsured among African-Americans and Hispanics in Massachusetts.

According to the researchers there are several possible explanations for their findings. For example, following health reform in Massachusetts, newly insured individuals were more able to seek medical attention after a hospital admission, which in turn may have uncovered medical problems requiring readmission. Another reason may be the inability to access a personal doctor in the state due to the primary care physician shortage, which has been well documented since 2006.

Other studies in Massachusetts have shown that access to care improved less than access to insurance, as many newly insured residents who obtained Medicaid or state subsidized private insurance still reported cost-related access barriers.

The conclusion: Expanding insurance coverage isn’t enough. Dr. Karen Lasser of the Boston University School of Medicine, the paper’s lead author, emailed that we also need to “reduce financial access barriers to care (e.g. copays), increase reimbursement rates for new insurance plans (so that more physicians accept these forms of insurance), implement medication reconciliation and patient coaching, improve disease management and coordination of care, and provide hospital based incentives to reduce use of inpatient services. Interventions could also tackle the shortage of primary care providers in MA.”

Meanwhile, another recent study, released last week, reported that, contrary to hopes that increased insurance coverage would cut expensive emergency-department use, the Massachusetts experience is that ER use slightly rose after health are reform. Continue reading

Christopher Lydon Is Back On WBUR — And Talking Health Care

Christopher Lydon

Christopher Lydon

Mark your calendar (that is, set a smartphone alarm) to tune your dial (that is, set your tablet to livestream WBUR.org) tonight. It’s old news that the lively intellect of Christopher Lydon is back on WBUR, but the fresh news is that tonight, he’s going to be talking health care, with some lofty interlocutors (uh oh, my anticipation seems to be making me channel his vocabulary…) From Radio Open Source:

We’d love to begin the show with some vox pop, as we call it. Please call 617 353 0692 and leave a short message that we can use at the top of the program. Here’s the question: Speaking as a patient, and think of your own health, how is the modern “miracle” medicine working for you?

Our guests in this conversation (9 p.m. Thursday, January 16th on WBUR, Boston at 90.9 FM) will include Dr. Tom Lee, former CEO of Partner’s Healthcare, professor at Harvard Medical School and author of “Eugene Braunwald and the Rise of Modern Medicine”; Dr. Don Berwick, pediatrician and candidate for governor in Massachusetts; and cardiologist Eugene Braunwald.

The Rise of Modern Medicine: do you think of the miracle tech that has made death by heart attacks a rarity? Or do you think of a money-driven industry that’s made heroes out of hospitals at a huge price to patients and the national economy? Dr. Tom Lee makes it a history lesson that unfolded over the last 50 years in Boston. What happened to health in healthcare?

The conversation has already begun in the comments, including this one:

I’ve been in the healthcare business for 25 years as a sales representative. The buildings keep getting bigger, the administrations more dense, the regulation more arcane…There is so much money thrown at healthcare; how could this NOT happen?

Listeners, would love to hear afterward what you think.

Want Better, Cheaper, More Seamless Health Care? Ask Me How

Dr. Myechia Jordan (Courtesy)

Dr. Myechia Minter-Jordan (Courtesy)

By Dr. Myechia Minter-Jordan
Guest contributor

Dr Myechia Minter-Jordan is president and CEO of the Dimock Center, a nationally recognized community health center in Roxbury.

Growing up, I always knew I wanted to be a doctor. I remember being fascinated by all the cool gadgets in the doctor’s office, from the cold feeling of the stethoscope on my skin as the doctor listened to my breathing, to the funny feeling as my doctor tapped my knee with the small hammer to test my reflexes. It always felt exciting to me, even when we had to make two or three visits to separate clinics for doctor’s appointments and medical care. As a young child, it seemed like an adventure.

What I didn’t realize was that it was not an adventure for my parents. They often had to take multiple days off of work to go to those appointments and they weren’t happy about it. They ran in circles giving the same information over and over to different nurses and doctors, receiving few helpful results. They often left those appointments more frustrated and perplexed than when we arrived.

Now, as an adult and a doctor reflecting back on those times, I can say with certainty that my family’s primary care provider never spoke with our dentist and eye doctors about our health and wellness. My mother’s OB-GYN never communicated directly to our pediatrician about her care or anticipated my needs as a new infant. Fragmented, clunky and often disempowering, that was our health care system then in many ways. And it still is now.

Why are there not more people knocking at my door to learn from our model of care?

Throughout its history, our health care system became increasingly disjointed, and we are now faced with the reality that we must seek alternate models that are centered on the patient. We must seek models that are streamlined, efficient, less expensive and more empowering for the patient. We need models that enhance communication among providers about the patient and their health care experience. And we need to improve the collective health of our communities.

In other words, we need a model that has existed in our country since 1965: the community health centers.

Here’s what community health centers offer: Continue reading

Dr. Tim’s ‘Truth About Obamacare’ Podcast: Jan. 1 As Decisive Moment?

Dr. Timothy Johnson, retired Medical Editor for ABC News, in the WBUR studios. (Jesse Costa/WBUR)

Dr. Timothy Johnson, retired Medical Editor for ABC News, in the WBUR studios. (Jesse Costa/WBUR)

What just happened? That is, Jan. 1. 2014, has long been the date most commonly mentioned as the moment when Obamacare really kicks in. So now that 2014 is launched, what has really changed?

Dr. Timothy Johnson, retired medical editor for ABC News and author of ”The Truth About Getting Sick in America,” focuses on that question in his latest ‘Truth About Obamacare’ podcast, above. He discusses it with his regular guests: John McDonough, a professor at the Harvard School of Public Health; Dr. Gail Wilensky, a health official under the first President Bush; and Larry Levitt, a senior vice president at the Kaiser Family Foundation.

Levitt offers a brief summary of where Obamacare now stands: the expected December surge in enrollment has yielded 2.1 million people who picked a private plan for health insurance coverage, and 3.9 million people who qualified for Medicaid, he said. And he expects to see a much bigger surge as time for sign-up runs out in March.

So did the world actually change as of Jan. 1? Dr. Johnson asks John McDonough.

I’d sum up McDonough’s answer as “Hell, yes.”  Most people aren’t aware of the significance of what happened, he says, but “I find it hard to compare another single date in terms of change to our health care system actually taking effect.” He highlights four major changes: Continue reading

Come On, Massachusetts, Get This Pregnant Woman Covered

Jessica Stanford is now on MassHealth and has her first prenatal visit next week. She says she qualified for free coverage because she’s pregnant. Her husband still doesn’t know if he has temporary coverage and hasn’t been told if he qualifies for a ConnectorCare plan. That’s frustrating, says Jessica, “but we do not need to spend time fighting that battle. Our priority was to make sure I could see a doctor as soon as possible.”

Connector 1

Jessica Stanford of Sharon, Mass., is 40 and newly pregnant. She’d really like to see a doctor soon because she’s had several miscarriages and developed gestational diabetes during her last pregnancy. But she doesn’t have health insurance and is worried about racking up medical bills.

Stanford applied for subsidized coverage in early December. She keeps calling the Connector to find out about her enrollment status. One customer rep told Stanford she could take her application number to a doctor’s office for proof that the state will cover her, at least temporarily, but Stanford wants something more certain.

The Connector says it has extended coverage, through March, to 254,000 residents who applied for free or subsidized insurance and all residents who have had government backed coverage.

The agency is sending out letters explaining a temporary coverage plan that begins today (Jan. 1) for 22,371 residents who, like Stanford, are applying for the first time. Continue reading

The Great Healthcare.gov Mistake: Having An ‘Older Accountant’ Create It

President Barack Obama speaks about his signature health care law, Thursday, Nov. 14, (AP)

President Barack Obama speaks about his signature health care law, Thursday, Nov. 14. (AP)

By Michael Doonan
Guest contributor

The Center for Medicare and Medicaid Services is the behemoth federal agency that, despite limited resources, does a pretty good job of carrying out its core mission: running programs that provide health insurance for older and poorer Americans.

Expecting that this agency can also run the federal health insurance exchanges for Obamacare, however, sets it up for trouble right from the start.

The failure to locate accountability in the appropriate hands helps explain the Website debacle and anemic early enrollment, if not the president’s early miscue that everyone would be able to keep their current health insurance.

CMS simply does not know how to regulate health insurance for individuals and small business at the state level. Case in point: The agency’s previous troubles implementing insurance reforms that were part of the Health Insurance Portability and Accountability Act of 1997 (HIPAA), which, among other things, stipulated that the federal government would step in if a state was non-compliant.

Michael Doonan (Photo: Mike Lovett)

Michael Doonan (Photo: Mike Lovett)

This was like telling your kids to clean their rooms or else you will do it for them — and in the end, national regulations turned out to be weak and ineffectual.

Turned out CMS didn’t know much about the range of health plans and insurance products in certain states. Federal officials were more scared of taking over state regulation than the states. As a result, they begged the states to comply and bent over backwards in the regulations to find any state “effort” acceptable.

With the roll out of the federally mandated health exchanges, it is déjà vu all over again. Continue reading

Dr. Tim Johnson’s ‘Truth About Obamacare:’ Is The Law Doomed?

Dr. Timothy Johnson, retired Medical Editor for ABC News, in the WBUR studios. (Jesse Costa/WBUR)

Dr. Timothy Johnson, retired Medical Editor for ABC News, in the WBUR studios. (Jesse Costa/WBUR)

“Tumultuous,” is how Dr. Timothy Johnson describes the recent roll-out of Obamacare in his latest podcast. (Click on the “play” arrow above right to listen.) And that’s not nearly strong enough, he adds. “Many people are saying Obamacare is doomed,” in the wake of all the current Website and insurance problems, he says.

Is it? Dr. Johnson, retired medical editor for ABC News and author of ”The Truth About Getting Sick in America,” discusses the outlook with his regular podcast guests: John McDonough, a professor at the Harvard School of Public Health; Dr. Gail Wilensky, a health official under the first President Bush and Larry Levitt, a senior vice president at the Kaiser Family Foundation.

The first answer to the “Is it doomed?” question comes from McDonough, who offers a clear “no.”

“I’m just dumbfounded by the media’s unbelievable hyperventilation about every small detail and the implications it has for the law as a whole and Obama’s presidency and the fate of the republic,” he says. “This is on track to open up affordable coverage for tens of millions of Americans starting Jan. 1. Once we get past Jan 1, i don’t believe there’s any retreat…and I think we will get through this difficult patch.”

Wilensky agrees that the law is not doomed, but adds:

“There is a problem, and it’s not just that people are having great difficulty accessing the Website, some of whom are at risk of losing their individually purchased insurance by the end of the December….The most serious issue is that there has been a real loss in trust in the president, and that is way more of an issue than the hiccups that have gone on with regard to the Website. When people don’t feel like they can trust what their president says, it has ramifications far greater than the Affordable Care Act. And wait until people discover the second part of the president’s pledge – ’And if you like your doctor you can keep your doctor’ – isn’t true either, not for a lot of people. That’s the next shoe that’s going to fall.”

Listen to the full podcast above, and check out Dr. Johnson’s previous Obamacare podcasts here, here and here.


Dr. Tim Johnson’s Obamacare Podcast: The ‘Unbelievable Bumble’

Dr. Timothy Johnson, retired Medical Editor for ABC News, in the WBUR studios. (Jesse Costa/WBUR)

Dr. Timothy Johnson, retired Medical Editor for ABC News, in the WBUR studios. (Jesse Costa/WBUR)

As president, you know things are really getting bad when every humor outlet from The New Yorker’s Andy Borowitz (“Snowden Offers To Fix Healthcare.gov“) to The Onion (“New Improved Obamacare Program Released On 35 Floppy Disks“) is mocking your program’s failures.

President Obama himself expressed his frustration today over the widespread technical glitches besetting people trying to sign up for health insurance under Obamacare, saying that “nobody is madder than me,” NPR reports.

Here, in his latest podcast on health reform, Dr. Timothy Johnson, retired medical editor for ABC News, takes on what he calls “the very rocky start to the centerpiece of the Affordable Care Act: the insurance exchanges.” He and his guests discuss the technical SNAFUs that are marking the launch of the exchanges and dissect their causes. He begins with a New York Times article today that says federal health authorities simply did not have the expertise to do the job of setting up the technological infrastructure needed for Obamacare. He asks, “Question #1, are they right, these reporters? And question #2, can it be fixed?”

Listen to the podcast above to hear some answers (and to hear guest Dr. Gail Wilensky, a high health official under the first President Bush, refer to Obamacare’s technical failings as “an unbelievable bumble” — what a fun phrase, rolling so nicely off the tongue!) And here’s one useful tip: For those who have trouble on healthcare.gov, the Kaiser Family Foundation is offering a simple calculator of health insurance subsidies on its website, www.kff.org.

Readers, reactions? Please share below. And catch Dr. Johnson’s inaugural podcast here.

What Obamacare Is Really About, From One Who Knows

I hate Obamacare. That is not a political statement; it’s a journalistic one. The complex, 800-plus-page law is an explanatory nightmare, and every time I think I really understand it, my clarity slips away.

So I’m always grateful when John McDonough weighs in. A professor at the Harvard School of Public Health and author of a definitive account of the law – Inside National Health Reform — he’s a leading (and openly partisan) Obamacare expert. His new piece – Obamacare 101: Promises, Pitfalls and Predictions —  is the first in a new series run by WBUR’s opinion page, Cognoscenti. Called Policy for a Healthy America, it will look at “the challenges and opportunities facing the U.S. health care system.”

Among the future questions the series will address: Why is tackling the nation’s obesity problem so difficult? How is technology changing health care delivery? Is a single-payer system the answer?

Here’s a bit from today’s piece by John McDonough:

The biggest changes will transform people’s ability to buy health insurance. An insurance concept known as “guaranteed issue,” set to take effect on the first of the year, bans the practice of “medical underwriting” and the imposition of pre-existing conditionexclusions. The individual responsibility provision, called the individual mandate, will impose a new tax penalty on individuals who do not buy health insurance and who can afford to do so. Continue reading

No, Obamacare Doesn’t ‘Start’ Oct. 1, But Here’s What Changes

In this March 23, 2010, file photo, President Obama signs the Affordable Care Act. (J. Scott Applewhite/AP)

In this March 23, 2010, file photo, President Obama signs the Affordable Care Act. (J. Scott Applewhite/AP)

By Georgia Feuer
Guest contributor

“I heard the ACA is starting October 1st,” an acquaintance mentioned the other day.

I was confused. The Affordable Care Act — better known as Obamacare — is a massive law with wide-ranging effects all throughout the health-care system and many, many start dates; in fact, 65 start dates have already passed. They include the start date for letting young adults up to age 26 stay on their parents’ insurance; for progress towards closing the Medicare drug coverage gap; and for money to explore health care delivery reform through creation of the Center for Medicare and Medicaid Innovation.

So what was she referring to when she said “the ACA is starting Oct. 1st”?

When I google “Obamacare”, it becomes clear that right now, the word is synonymous with just one aspect of the health care act, the section that calls for the creation of health insurance exchanges. Oct. 1, 2013, marks the opening of these health insurance exchanges; marketplaces where John Q. Public can shop for and enroll in a health insurance plan that will provide coverage as of Jan. 1, 2014. He cannot be denied coverage and the amount that he pays for this coverage cannot be influenced by his current health status (although he can be charged more if he is a smoker).

(You may also want to check out today’s Here and Now which answers many questions about Obamacare.)

Health care consultant Georgia Feuer (Courtesy)

Health care consultant Georgia Feuer (Courtesy)

Every state will have its own exchange, which may be run by a state agency or a federal agency, but in some states, information about the exchange can be hard to come by. The reason: controversy over Obamacare is abundant, and one tactic used to derail Obamacare involves preventing people from hearing about how the law might positively affect them.

A USA Today story about Oklahoma Republicans resisting efforts to help people navigate the new exchanges also helps to explain why ignorance about aspects of the law remains so high. For example, only 49% of people polled in a recent survey knew that federal subsidies will be available to help low-income residents buy health insurance5.

Alongside the opening of the exchanges comes the option for more people to enroll in Medicaid. However, many states have not opted into the Medicaid expansion, despite evidence that the expansion is in a state’s financial best interest. One of the consequences of not expanding Medicaid is a cost gap, depicted below, that I refer to as the “Sorry, you aren’t making enough money to qualify for assistance” conundrum: Continue reading