ACA sustainability, productivity growth and the complex relationship between Medicare and private provider payments
A presentation by Louise Sheiner entitled "ACA Sustainability, Productivity Growth and the Complex Relationship between Medicare and Private Provider Payments" delivered on July 21, 2015 at the Altarum Institute CSHS Symposium—New Dimensions on Sustainable U.S. Health Spending.Downloads
About 7.5 million Americans paid an average penalty of $200 for not having health insurance in 2014 — the first year most Americans were required to have coverage under the Affordable Care Act, the Internal Revenue Service said Tuesday.
By contrast, 76 percent of taxpayers checked a box indicating they had qualifying insurance coverage all year. Counting another 7 million dependents who were not required to report their coverage but also filed returns, the proportion rises to 81 percent, the IRS said.
The government had estimated in January that from 3 million to 6 million households would have to pay a penalty: 1 percent of their annual income or $95 per adult in 2014, whichever is greater.
Final figures for the tax year aren’t available. The IRS has so far processed about 135 million of the estimated 150 million returns expected. IRS Commissioner John Koskinen said the agency was reporting preliminary figures because it has received “numerous requests” from members of Congress.
In addition to penalty totals, the IRS reported Tuesday on tax subsidies the health law provided for people who were buying coverage through the state or federal online exchanges and who qualified based on income. People had a choice of filing for credits in advance — money the government paid to their insurers — or when filing tax returns.
About 2.7 million taxpayers claimed approximately $9 billion in subsidies, reporting an average subsidy of $3,400. About 40 percent claimed less than $2,000, 40 percent claimed $2,000 to $5,000, and 20 percent claimed $5,000 or more.Use Our Content This KHN story can be republished for free (details).
Among taxpayers who claimed a subsidy, about 1.6 million, or half of taxpayers who claimed or received a subsidy, had to pay money back to the government because their actual income was higher than projected when they applied for the subsidy. The average amount repaid was about $800.
When looking at the individual mandate, the report said the vast majority of people automatically satisfied the individual mandate because they were insured last year. Another 12 million had exemptions, including people whose incomes were too low and Native Americans.
In all, the IRS said it has collected $1.5 billion from the individual mandate penalty included in the health law. About 40 percent of taxpayers who paid a penalty paid less than $100.
About 300,000 taxpayers who made an individual mandate penalty payment should have claimed an exemption but did not, the government said. The agency is sending letters to these taxpayers telling them they generally have three years to file an amended tax return.
More than 5 million taxpayers did not check the box on their tax form saying they had coverage, claim a health care coverage exemption, or pay a penalty. “We are analyzing these cases to determine their status,” the government said.
This week’s interview is with Lucy Jones, a foreign law intern working this summer in the Global Legal Research Directorate of the Law Library of Congress.
Describe your background
I am from a small village (Coolagown) in Cork, Ireland. I have just graduated with my undergraduate law degree (BCLI) from University College Cork. During my studies I spent one year studying abroad in Philadelphia at Temple Beasley School of Law. My primary interest is international law. Last summer I interned for the Office of the Prosecutor at the International Criminal Tribunal for the former Yugoslavia and this April I competed as a member of the Irish team at the Philip C. Jessup International Moot Court Competition.
I am currently part of the 2015 class of the Washington Ireland Program. This program identifies 30 individuals from across Northern Ireland, the Republic of Ireland and Great Britain who have demonstrated a passion for both service and leadership. The Washington Ireland Program aspires to strengthen the values, skills and networks of emerging leaders who are committed to a peaceful Northern Ireland and the Republic of Ireland.
This September I will begin studying towards an LL.M at the London School of Economics. Following my studies I will begin work with Freshfields Bruckhaus Deringer LLP, a multinational law firm headquartered in London.
How would you describe your job to other people?
The Law Library of Congress provides research on foreign, comparative, international, and U.S. law in response to requests from Congress, executive agencies, federal courts and the general public. As an intern in one of the two foreign, comparative, and international law divisions I am called upon to research certain requested legal topics in my assigned jurisdictions. I am also asked to attend congressional hearings of interest and report back to my supervisors on the content of these hearings. I write for the Global Legal Monitor and hope to contribute to this blog. My job is challenging and interesting. No two days are the same!
Why did you want to do research at the Law Library of Congress?
As there’s really no better place in the world to do legal research! The Law Library of Congress has the largest collection of law books in the world and wonderful expert staff. I knew that interning here would give me access to unrivaled resources. I had hoped to use this summer to hone my research and writing skills. The Law Library has given me this opportunity.
What is the most interesting fact you have learned about the Law Library of Congress?
Viewing the closed stacks in the sub-basement was fascinating. Much of the Law Library’s vast collection is housed in the Madison Building’s sub-basement stacks, which are equivalent to one and a half football fields in length. Walking through the seemingly never-ending stacks highlighted for me the extent of resources available.
What’s something most of your co-workers do not know about you?
I love horses! I have two horses at home in Ireland who I miss very much. When I get the chance I love to show jump.
Tens of thousands of people have been removed from the state’s Medicaid program during the first phase of an eligibility review, according to figures from Gov. Charlie Baker’s administration obtained by The Associated Press.
The eligibility checks, required annually under federal law but not performed in Massachusetts since 2013, began earlier this year as part of Baker’s plan to squeeze $761 million in savings from MassHealth, the government-run health insurance program for about 1.7 million poor and disabled residents.
At $15.3 billion, MassHealth is the state’s single largest budget expense.
Based on the results of the redetermination process so far, the state was on track to achieve the savings it had hoped for in the current fiscal year without cutting benefits for eligible recipients, said Secretary of Health and Human Services Marylou Sudders.
The first phase of the process involved letters sent to 503,286 Medicaid recipients over the first six months of the calendar year notifying them of the need to reapply for benefits, according to numbers provided to the AP by the Executive Office of Health and Human Services.
Final figures were not expected until Aug. 1, but of the nearly 293,000 applications processed through late June, 78 percent remained eligible for Medicaid based on income. Of those deemed ineligible, the majority will have access to subsidized private insurance through the state’s health connector, though about 5 percent, according to Sudders, would not qualify for subsidized coverage.
The results of the eligibility redeterminations to date, Sudders said, were in line with the typical rate of change in the Medicaid population and she did not believe it had deprived deserving residents of coverage.
“Given the fact that the history is that 30 percent of MassHealth population turns over every year, and (nearly) 80 percent of the individuals who contacted were re-enrolled, I feel OK about that number,” she said. “If that number had been 50 percent, I would say there has to be people out there eligible for MassHealth we are not finding.”
Yet the figures also show about 116,000 people, or 23 percent of the total number in the first redetermination phase, have yet to respond to multiple requests from the state and will be dropped from MassHealth, said Sudders. Any who subsequently resurface would be offered care on a fee-for-service basis until their eligibility is determined, she added.
The state enlisted the independent advocacy group Health Care For All to help get the word to Medicaid recipients statewide that they needed to reapply to maintain their benefits.
The organization’s campaign includes media ads in nine languages.
“We want to make sure that anyone in Massachusetts who qualifies for MassHealth has access to MassHealth,” said Amy Whitcomb Slemmer, executive director of Health Care For All. “It’s a life-saving insurance program.”
Officials say they suspect that most people who did not reapply had left the state or no longer needed the benefits due to other life changes. Slemmer said she hoped many had moved into private health coverage.
In what Sudders called a first-of-its-kind move, the state extended Medicaid eligibility for more than 48,000 recipients who did not respond to the state inquiries, but made some sort of recent contact with the system – a visit to a community health center, for example, or even a phone call to MassHealth.
State budget writers had expected the redeterminations to save about $200 million in the fiscal year that started July 1.
Conversations about end-of-life care are difficult. But even though most people now take some steps to communicate their wishes, many may still receive more intensive care than they would have wished, a study this month found.
The study, published online in JAMA Oncology, examined survey data from the Health and Retirement Study, a national study of U.S. residents older than age 50. Researchers analyzed the responses from the next of kin, usually a spouse or child, of 1,985 participants with cancer who died between 2000 and 2012.
The patients’ family members responded to questions about how frequently patients had signed durable power of attorney documents or living wills or participated in conversations about their end-of life-preferences. Researchers then examined the association between those advance-care-planning activities and the medical care the cancer patients received at the end of life.
Over the study period, the use of durable power of attorney assignment, sometimes called a health care proxy, grew from 52 percent to 74 percent among participants. Small declines were reported in other planning activities — from 49 percent to 40 percent for living wills and 68 percent to 60 percent for end-of-life discussions — but they weren’t statistically significant because the levels varied throughout the study period, says Dr. Amol Narang, a radiation oncologist at Johns Hopkins School of Medicine and the lead author of the study.
“Our hypothesis was that we’d see significant increases over the study period in advance directives,” Narang says. “What we saw was that important aspects of advance care planning haven’t increased.”More from this series
At the same time, the proportion of patients who were reported to have received “all care possible” at the end of their lives increased substantially over the study period, from 7 percent to 58 percent, even though such intensive treatment may have been counter to their stated wishes.
A durable power of attorney allows consumers to appoint someone to make health care decisions for them if patients are unable to do so. Living wills describe the types of medical care people wish to receive (or don’t wish to receive) if they’re incapacitated. Neither requires a lawyer, and forms are often available online.
Simply signing a document isn’t enough, experts say. There’s no substitute for regular communication with friends and family about end-of-life preferences.
“Patients may have signed that power of attorney, but if they haven’t discussed their preferences with that person the proxy may default to ‘all care necessary,'” Narang says. In other words, lacking clear guidance, the health care proxy may choose to err on the safe side and approve more care rather than limit or withhold it.Use Our Content This KHN story can be republished for free (details).
Living wills spell out which treatments someone would want — specifying that they would want to be put on a ventilator, for example, or fed through a tube. But some experts say treatment-focused specificity may not serve patients’ best interests.
Spelling out treatment preferences is only useful in context, says Dr. Diane Meier, director of the Center to Advance Palliative Care.
“Of course you would want to be put on a ventilator if it was going to return you to health,” Meier says.
The more important question is a qualitative one: What is the quality of life that is unacceptable to you? Would you want every measure taken to treat an illness or injury even if it meant enduring extreme pain with little likelihood of improvement? Or would you rather forgo such intensive treatment and be kept comfortable instead? Those are the conversations that need to happen, experts say.
The issue is front and center these days as policy makers debate the recent federal proposal to reimburse physicians for conversations with Medicare patients about advance care planning.
“It’s a significant step in the right direction,” says Jonathan Keyserling, senior vice president for health policy at the National Hospice and Palliative Care Organization.
“Now that health care professionals can soon be reimbursed for these intimate and thoughtful conversations, I think we’ll see changes in practice patterns and in decisions by family members.”
Some policy experts say that changing payment practices won’t be enough to change clinical practice.
For physicians, offering treatment, even if there’s little chance it will help, is the only way they may know to show their loyalty and love for a patient, says Meier.
“We have to change the training or nothing will change,” she says.
For that reason, she hopes that the Centers for Medicare and Medicaid Services will require doctors to get some training in how to introduce and take part in conversations about advance care planning rather than simply check a box on a form that says a conversation took place.
Please contact Kaiser Health News to send comments or ideas for future topics for the Insuring Your Health column.
Bristol County is seeing a surge in suicides.
Monday, the Bristol County Regional Coalition for Suicide Prevention and the Bristol County District Attorney’s office released data on the extent of the issue in the county.
In the last three and a half years, 171 people in the county have died by suicide.
- 2012: 35 confirmed suicides; 25 men and 6 women
- 2013: 44 confirmed suicides; 29 men and 15 women
- 2014: 58 confirmed suicides; 50 men and 8 women
The rash of suicides in Bristol County has affected mostly men in their early- to mid-fifties. The number of men who have died by suicide has increased 72 percent over the past three years. These men often suffer from depression and substance abuse. And when they seek help, they are unable to find inpatient residential care.
“What we have happening in Bristol Country is not a bump in the road, and what we have happening is not a pothole. We have a sinkhole happening here in this county,” said Annemarie Matulis, director of the Bristol Country coalition.
There has been 34 confirmed suicides, 22 men and 12 women, so far this year. This means the county is on track to match the 2014 statistics or potentially surpass them, the coalition and DA’s office announced Monday.
Matulis says people close to someone who has died by suicide become themselves more prone to taking their own lives.
Resources: You can reach the National Suicide Prevention Lifeline at 1-800-273-TALK (8255) and the Samaritans Statewide Hotline at 1-877-870-HOPE (4673).Related:
My friend was looking peaked and pained the other day. Today, she was vastly better.
“UTI,” she said, and I nodded knowingly. Urinary tract infections are so common that up to half of all women get them at some point. There are many wonderful things about being a woman; cystitis is not one of them.
It was no big deal. She called her doctor and the prescription was phoned over to her pharmacy. But a recent editorial in the British medical journal BMJ argues for an even simpler solution: She should have been able to just diagnose herself and pick up the treatment over the counter.
Dr. Kyle Knox, a general practitioner, writes that letting women treat UTIs without a prescription could cut 3 million unnecessary visits to the doctor each year in the United Kingdom. From the BMJ press release:
Acute uncomplicated urinary tract infections (AUUTIs) such as cystitis are the most common bacterial infections in women. Cystitis affects around half of women at least once in their lifetime and is coded as the reason for 1% of the 300 million GP consultations held annually in the UK.
Management of cystitis is straightforward – a short course of the antibiotic nitrofurantoin and symptoms usually start to improve after a day or two.
“Therefore, in an era of ready access to information, increasing patient autonomy, and overstretched primary care services, it would seem a good idea for women to be able to access safe and effective treatment without the costs and delays associated with consulting a clinician to obtain a prescription,” suggests Knox.
However, despite clear guidance, characteristic clinical syndrome, and predictable efficacy and safety, nitrofurantoin remains a prescription-only drug.
The current prescription-only approach does nothing to limit antimicrobial use but creates urgent demand in primary care – and an additional hurdle for women to access safe and effective treatment, he argues.
Dr. Knox explains in the article that the prescriptions are usually given on the basis of symptoms rather than medical tests (dysuria is painful urination and nocturia is excessive night-time urination):
Because the goal of treatment is to improve the classic symptoms that most women are able to describe, strategies are now based on these, rather than on tests, to determine management. Three clinical variables (dysuria, nocturia, and cloudy urine) give a positive predictive value (PPV) of 82% for urinary tract infection, and, although dipstick testing had a higher PPV, it did not improve the negative predictive value. Therefore, for AUUTIs in non-pregnant women, UK guidelines now advocate an empirical three day course of nitrofurantoin or trimethoprim when a woman presents with more than two symptoms of AUUTI.
So why can’t women just identify their own symptoms? At a time when emergency contraception and two other antibiotics — for chlamydia and conjunctivitis — are available without prescription, Dr. Knox writes, it’s time to add nitrofurantoin to the list, or at least that option should be explored.
Readers, thoughts? Reactions?
As you may have seen from Andrew’s pics over the last several months, work on our Reading Room has been coming along apace. We are in the home stretch now as the new reference desk and other furniture are being installed. However, before we can transfer operations back to the renovated space on the second floor of the Madison building, we have to move the 35,000 volumes that comprise our Reading Room collection. Moving these volumes will begin on Tuesday, July 28, and take about ten days. Once a book has been moved, it will not be available until the renovated Reading Room opens in late August. Patrons will continue to be able to visit our temporary Reading Room in LMG15 while the books are being moved.
Although the books are being moved, the Law Library has second copies of many of the titles in its collections. Patrons can locate these books and request them from the Law Library’s closed stacks using the Automated Call Slip system (ACS). A previous blog post, “Accessing Reading Room Materials During Our Move,” by our former colleague Anne Guha, provides more detailed information on this process. The post also provides information about other local law libraries that may be able to help you with your research needs during our transition.
We will update you with information about the opening date of the renovated Reading Room in future posts. As always, feel free to visit us in person, contact us by phone at 202-707-5080, or submit an inquiry through the Ask A Librarian system.