ACA signups top 3M since start of open enrollment, a 17% bump compared to last year

https://www.fiercehealthcare.com/payers/aca-signups-top-3m-start-open-enrollment-17-bump-compared-last-year

Nearly 3.4 million people have signed up for 2023 Affordable Care Act insurance coverage since the start of open enrollment on Nov. 1, a record-setting pace that is a 17% boost over last year, new federal data shows. 

The signup data released Tuesday by the Centers for Medicare and Medicaid Services shows a major hike in new signups on HealthCare.gov. 

“We are off to a strong start — and we will not rest until we can connect everyone possible to healthcare coverage this enrollment season,” Department of Health and Human Services Secretary Xavier Becerra said in a statement Tuesday.

The nearly 3.4 million in signups represents activity through Nov. 19 on HealthCare.gov, which is used by residents in 33 states to pick an ACA plan, and through Nov. 12 for the 16 states and District of Columbia that run their own marketplaces.

There are 655,000 people who are new to the exchanges that picked a plan already, making up 19% of the total plan signups so far. CMS added that 2.7 million people who already have 2022 coverage renewed or selected a new plan for 2023. 

“These plan selection numbers represent a 17% increase in total plan selections over last year,” CMS said in a release. 

There is especially major growth on HealthCare.gov, which has seen 493,216 new enrollees compared to 354,137 for the same time period last year.

“Providing quality, affordable health care options remains a top priority,” said CMS Administrator Chiquita Brooks-LaSure in a statement. “The numbers prove that our focus is in the right place.”

The new signups come as the Biden administration made new investments in expansions for marketing and outreach, including record-setting funding for the ACA navigator program. Administration officials are hoping for another robust period of signups thanks to enhanced subsidies to lower insurance costs. 

“Four out of five people will be able to find a plan for $10 or less after tax credits,” CMS said. 

The boosted tax credits were supposed to expire after this year but have been extended into 2025 by the Inflation Reduction Act.

The 2022 coverage year saw a record 14.5 million signups. The latest open enrollment for HealthCare.gov for 2023 coverage will run through Jan. 15.

Congressional control still undecided, but voters protect and expand state-level healthcare access in midterms

https://mailchi.mp/cfd0577540a3/the-weekly-gist-november-11-2022?e=d1e747d2d8

While the final balance of the House and Senate are still unknown after Tuesday’s midterm elections, both chambers are expected to be narrowly divided. 

Ballot initiatives on reproductive health produced more unambiguous results, with three states—California, Michigan, and Vermont—amending their constitutions to affirm reproductive rights, and two states—Kentucky and Montana—voting down proposals that would have imposed greater legal barriers to abortion access. South Dakota became the seventh, and likely final, state to expand Medicaid via ballot initiativemaking an additional 28K South Dakotans eligible for coverage, and reducing the number of states that have yet to expand Medicaid to 11.

The Gist: Democrats beat expectations, bucking historical trends in which midterm voters swing strongly against the President’s party. But healthcare did not feature prominently in voters’ choices, with this being the first election in over a decade where the state of the Affordable Care Act and protecting individuals’ access to care and coverage was not a significant choice driver. 

The fallout from the Supreme Court’s decision in June to overturn Roe v. Wade had a clear impact on voter turnout, with abortion tying inflation for voters’ top concern in exit polls. At the state level, South Dakota voters approved Medicaid expansion, where over 40 percent of the state’s uninsured adults could now gain access to coverage—another clear sign that voters, regardless of party affiliation, are behind the ACA’s expanded vision for the safety net program. 

Moving forward, a closely divided Congress is unlikely to take on significant healthcare legislation, regardless of who ultimately holds the House and Senate.

Tenth year of Affordable Care Act (ACA) marketplace enrollment begins

https://mailchi.mp/46ca38d3d25e/the-weekly-gist-november-4-2022?e=d1e747d2d8

Tuesday marked the start of the tenth season of open enrollment in the ACA’s health insurance exchanges. Last year, a record 14.5M Americans obtained coverage through the exchanges, and this year’s total is expected to surpass that. That’s thanks to the extended subsidies included in the Inflation Reduction Act, a fix to the “family glitch” that prevented up to 1M low-income families from accessing premium assistance, and expanded offerings by most major insurers, who have been enticed by the exchanges’ recent stability. The average unsubsidized premium for benchmark silver plans in 2023 is expected to rise by about four percent, but the enhanced financial assistance will lower net premiums for most enrollees. 

The Gist: ACA marketplace enrollment has grown nearly 80 percent since opening in 2014, and exchange plans now cover 4.5 percent of Americans. After enrollment lagged during the Trump administration, the combination of policy fixes and improved risk pools are attracting insurers back into the exchanges, where enrollees are finding more affordable plans than ever before. 

We consider this a commendable first decade, but the success of the exchanges over the next ten years remains subject to political winds. Congress must revisit the extended subsidies by 2025, and a different administration might deprioritize marketplace advertising and navigation support, policies have which proven crucial to the exchanges’ recent growth. 

An overhaul for Medicare’s pay transformation program

The Biden administration is trying to jump start a Medicare program that pays health providers based on patient outcomes rather than by how many services they perform.

Why it matters: The alternative payment effort was created through the Affordable Care Act, but participation has plateaued since 2018 amid waning interest from providers.

Driving the news: The Biden administration finalized an overhaul of the initiative, known as the Medicare Shared Savings Program, on Tuesday. Changes include offering groups of providers in rural and other underserved areas upfront payments to help them start out in the program.

  • The rule includes other provisions to make it less financial risky for provider groups to join, and makes it easier for participants to earn money back from the government year after year — a central perk of joining the program.

Zoom out: Medicare traditionally pays on a “fee-for-service” basis pegged to the number of patients seen and volume of procedures performed.

  • But one of the main funding sources for Medicare is set to run dry in 2028 if the federal government doesn’t make changes. Advocates say the solution at least partially lies in value-based care programs, like the Shared Savings Program.
  • Under the program, doctors, hospitals and other providers join form groups known as accountable care organizations. ACOs take responsibility for the care of a set of traditional Medicare patients.
  • If ACOs reduce total care costs for their members, they can get back a portion of that savings from the government. ACOs at more advanced stages of the program must pay the government back if total patient spending crosses a threshold.

By the numbers: ACOs have saved the federal government more than $17 billion since 2012, according to the National Association of Accountable Care Organizations.

  • In 2022, 483 ACOs participated in the program and took care of more than 11 million Medicare enrollees. But that’s down from 517 ACOs participating in 2020.
  • CMS set a goal last year to bring all 63 million-plus Medicare beneficiaries into a value-based care model by 2030. ACOs are a key player in achieving the goal.

Go deeper: Providers and value-based care advocates are also pushing Congress to extend a 5% pay bump for providers that participate in advanced alternative payment models, including some tracks of the Medicare Shared Savings Program. The bonus expires Dec. 31.

  • “If the bonus is not continued, it will soften or dampen the momentum toward alternative payment models, because it would create this mentality, or the view, that we’re not serious about that transformation,” said Mara McDermott, vice president at McDermott+Consulting and executive director of the Value Based Care Coalition.
  • Losing the bonus would also make it harder to recruit new providers into alternative payment models, she added.
  • The American Medical Association and five other health care groups launched a separate coalition Tuesday to rally around an extension of the 5% bonus.
  • “Patients and the healthcare system in the United States quite literally cannot afford to return to the days before Medicare incentivized healthcare providers for generating good results,” Clif Gaus, CEO of the National Association of ACOs, said in a news release about the coalition.

Also notable: The rule finalized Tuesday outlines physician payment rates for 2023. Interventional radiologists and vascular surgeons will see the largest Medicare cuts among physician specialties next year, though the final cuts are slightly lower than what CMS proposed in July.

  • Congress could stave off the cuts when they come back to Washington later this month.
  • “The Medicare payment schedule released today puts Congress on notice that a nearly 4.5 percent across-the-board reduction in payment rates is an ominous reality unless lawmakers act before Jan. 1,” American Medical Association President Jack Resneck said in a statement.
  • CMS finalized a slew of other policy proposals Tuesday, including provisions to reduce barriers to behavioral health care.

The next health care wars are about costs

All signs point to a crushing surge in health care costs for patients and employers next year — and that means health care industry groups are about to brawl over who pays the price.

Why it matters: The surge could build pressure on Congress to stop ignoring the underlying costs that make care increasingly unaffordable for everyday Americans — and make billions for health care companies.

[This special report kicks off a series to introduce our new, Congress-focused Axios Pro: Health Care, coming Nov. 14.]

  • This year’s Democratic legislation allowing Medicare to negotiate drug prices was a rare case of addressing costs amid intense drug industry lobbying against it. Even so, it was a watered down version of the original proposal.
  • But the drug industry isn’t alone in its willingness to fight to maintain the status quo, and that fight frequently pits one industry group against another.

Where it stands: Even insured Americans are struggling to afford their care, the inevitable result of years of cost-shifting by employers and insurers onto patients through higher premiums, deductibles and other out-of-pocket costs.

  • But employers are now struggling to attract and retain workers, and forcing their employees to shoulder even more costs seems like a less viable option.
  • Tougher economic times make patients more cost-sensitive, putting families in a bind if they get sick.
  • Rising medical debt, increased price transparency and questionable debt collection practices have rubbed some of the good-guy sheen off of hospitals and providers.
  • All of this is coming to a boiling point. The question isn’t whether, but when.

Yes, but: Don’t underestimate Washington’s ability to have a completely underwhelming response to the problem, or one that just kicks the can down the road — or to just not respond at all.

Between the lines: If you look closely, the usual partisan battle lines are changing.

  • The GOP’s criticism of Democrats’ drug pricing law is nothing like the party’s outcry over the Affordable Care Act, and no one seriously thinks the party will make a real attempt to repeal it.
  • One of the most meaningful health reforms passed in recent years was a bipartisan ban on surprise billing, which may provide a more modern template for health care policy fights.
  • Surprise medical bills divided lawmakers into two teams, but it wasn’t Democrats vs. Republicans; it was those who supported the insurer-backed reform plan vs. the hospital and provider-backed one. This fight continues today — in court.

The bottom line: Someone is going to have to pay for the coming cost surge, whether that’s patients, taxpayers, employers or the health care companies profiting off of the system. Each industry group is fighting like hell to make sure it isn’t them.

Affordable Care Act (ACA)’s required coverage of preventive care services in further jeopardy

https://mailchi.mp/f1c5ab8c3811/the-weekly-gist-october-28-2022?e=d1e747d2d8

The plaintiffs in Braidwood v. Becerra filed a motion on Monday asking a US District Court judge in Texas—the same judge who ruled the entire ACA unconstitutional in 2018—to block enforcement of the ACA’s no-cost requirement for preventive care services. This judge already sided with the plaintiffs in September, ruling the government cannot require a company to fully cover preventive HIV drugs, also known as PrEP therapy, for its employees, on the grounds that doing so violates owners’ religious freedom.

In that ruling, the judge also asserted that the government’s system for deciding what preventive care services should be covered under the ACA is unconstitutional. This latest motion now asks him to invalidate all parts of the ACA requiring preventive health services on the grounds that the Preventive Services Task Force was never appointed by Congress, and thus lacks the authority to say which services insurers must cover. The final ruling is expected early next year, after which the case will certainly be appealed, regardless of outcome. 

The Gist: Given the judge’s initial ruling in Braidwood last month, this motion from the plaintiffs was expected. While the US Supreme Court reversed a 2018 ruling by this judge that struck down the entire ACA, it could potentially find the narrow targeting of this case more reasonable, making preventive care coverage optional for employers. 

If that happens, millions of Americans would once again have to pay for some of the most common and highest-value healthcare services, including screening tests for a variety of cancers, sexually transmitted infections, and diabetes. That additional financial burden, along with likely tightening of health plan benefit designs, would create barriers to access and exacerbate health disparities.

The next step in Biden’s effort to lower drug prices

https://www.axios.com/2022/10/21/bidens-effort-lower-drug-prices

The next phase of the Biden administration’s bid to curb rising drug costs is in the hands of an under-the-radar federal office called the Center for Medicare and Medicaid Innovation (CMMI).

Driving the news: The center will publish a report within three months on how it can use new payment and delivery models to lower drug costs and boost access to treatments for beneficiaries of the two government health programs, per a recent executive order from President Biden.

Zoom in: CMMI was created through the Affordable Care Act to experiment with new ways of paying for and delivering health care.

  • Pilot programs typically last for years. Participation is usually voluntary, but the center can require provider involvement in some cases.
  • CMMI programs can become permanent fixtures of Medicare and Medicaid —  if they’re found to save money or improve care quality.

Be smart: The expectation is the center will tackle the prices health providers pay for Medicare drugs like infusions or injectables. Under the Inflation Reduction Act, the government can’t negotiate prices for these drugs until 2028.

  • Experimenting with price negotiation or payments based on patients’ health outcomes could help regulators learn best practices before that start date.
  • The center may also look for ways to incorporate drug pricing reforms into its existing projects and across different federal payers, said David Ault, a lawyer at Ropes & Gray and a former CMMI employee.

Refining policies from recent congressional action on Medicare prescription drug pricing could also be on the agenda.

  • The center could test alternative versions of the $2,000 annual cap on out-of-pocket costs for Medicare prescription drugs, for example.
  • Incorporating a monthly spending limit “could avoid having people pay everything in one month, after which all of their treatments are free,” Stacie Dusetzina, a health policy professor at Vanderbilt University Medical Center, wrote in an email.

Flashback: CMMI has tried to tackle drug prices under previous administrations, with mixed success.

  • Both the Obama and Trump administrations failed to implement experiments meant to lower health providers’ Medicare drug costs. But 106 health plan sponsors currently participate in a center program that gives seniors access to lower-cost insulin.

Reality check: It could take some time to get new drug pricing experiments up and running.

  • Programs typically take a year and a half to two years to be approved and implemented, so any new drug pricing model likely wouldn’t start until at least 2024, Ault said.

Don’t forget: The Centers for Medicare and Medicaid Services, the center’s parent, will continue its own work on drug pricing as it implements policies from the Inflation Reduction Act.

  • Congress also hasn’t tapped out of the discussion. Lawmakers seem keen to continue talking about insulin costs and pharmacy benefit manager practices, Rachel Sachs, a law professor at Washington University in St. Louis, told Axios.

Zoom out: Expect to see more from CMMI in the next couple years, on drug pricing reforms and other federal health care policy issues.

  • “You oftentimes see the innovation center being very active in the last few years of administration, trying to take ideas or concepts … far enough along that they’re in place, should there be a change in political party,” Ault said.

 Federal Public Health Emergency (PHE) Extended

https://mailchi.mp/tradeoffs/research-corner-5267789?e=ad91541e82

Earlier this month, the Biden administration officially extended the federal public health emergency (PHE) declaration it had set in place for COVID-19. That means the PHE provisions will stay in effect for another 90 days — until mid-January at least.

When the PHE does end, a number of rules developed in response to the pandemic will sunset. One of those is a provision that temporarily requires states to let all Medicaid beneficiaries remain enrolled in the program — even if they have become ineligible during the pandemic.

Estimates suggest that millions could lose Medicaid coverage when this emergency provision ends. Among those who would lose coverage because they are no longer eligible for the program, about one-third are expected to qualify for subsidized coverage on the Affordable Care Act (ACA) marketplaces. Most others are expected to get coverage through an employer. It remains an open question, though, how many people will successfully transition to these other plans. 

recent paper by health economics researcher Laura Dague and colleagues in the Journal of Health Politics, Policy, and Law sheds light on these dynamics. The authors used a prior change in eligibility in Wisconsin’s Medicaid program to estimate how many people successfully transitioned to a private plan when their Medicaid eligibility ended.

Wisconsin’s Medicaid program is unique. Back in 2008 — before the ACA passed — Wisconsin broadly expanded Medicaid eligibility for non-elderly adults. After the ACA came into effect, Wisconsin reworked its Medicaid program in a way that made about 44,000 adults (mostly parents) with incomes above the federal poverty line ineligible for the program. To remain insured, they would have to switch to private coverage (via Obamacare or an employer). 

Using data from the Wisconsin All-Payer Claims Database (APCD), the researchers found that:

  • Only about one-third of those 44,000 people had definitely enrolled in private coverage within two months of exiting the Medicaid program.
     
  • The remaining two-thirds of people were uninsured or their insurance status couldn’t be determined.
     
  • Even using the most optimistic assumptions to fill in that missing insurance status data, the authors estimated only up to 42% of people might have had private coverage within three months.
     
  • Nearly 1 in 10 enrollees had re-entered Medicaid coverage within six months, possibly due to fluctuations in household income. 

This paper has several limitations. Health insurers are not required to participate in Wisconsin’s APCD, so the authors may not be capturing all successful transitions from Medicaid to private insurance. The paper also does not distinguish between different types of private insurance: Some coverage gains may have resulted from employer-based insurance rather than the ACA marketplace. 

Still, the findings suggest that when a large number of Wisconsin residents lost Medicaid eligibility in 2014, many were not able to transition from Medicaid to private coverage. Wisconsin’s experience can help us understand what might happen when the national public health emergency ends and Medicaid programs resume removing people from their rolls.

Still a long way away from real “value” 

https://mailchi.mp/cd392de550e2/the-weekly-gist-october-21-2022?e=d1e747d2d8

The belief that healthcare should, and would, transition from “volume to value” was a key pillar of the Affordable Care Act (ACA). However, with more than a decade of experience and data to consider, there is little indication that either Medicare or the healthcare industry at large has meaningfully shifted away from fee-for-service payment. Using data from the National Association of Accountable Care Organizations, the graphic below shows that the Medicare Shared Savings Program (MSSP)—the largest of the ACA’s payment innovations, with over 500 accountable care organizations (ACOs) reaching 11M assigned beneficiaries—has led to minimal savings for Medicare. In its first eight years, MSSP saved Medicare only $3.4B, or a paltry 0.06 percent, of the $5.6T that it spent over that time.  
 
Policymakers had hoped that a Medicare-led move to value would prompt commercial payers to follow suit, but that also hasn’t happened. The proportion of payment to health systems in capitated or other risk-based arrangements barely budged from 2013 to 2020—remaining negligible for most organizations, and rarely amounting to enough to influence strategy. The proportion of risk-based payment for doctors is slightly higher, but still far below what is needed to enable wholesale change in care across a practice.

While Medicare has other options if it wants to increase value-based payment, like making ACOs mandatory, it’s harder to see how the trend in commercial payment will improve, as large payers, who are buying up scores of care delivery assets themselves, seem to have little motivation to deal providers in on risk. 

While financial upside of moving to risk hasn’t been significant enough to move the market to date, we aren’t suggesting health systems throw out their population management playbook—to meet mounting cost labor pressures, systems must deliver lower cost care, in lower cost settings, with lower cost staff, just to maintain economic viability moving forward.

Court ruling threatens Affordable Care Act’s (ACA) no-cost requirement for preventive care services

https://mailchi.mp/6a3812741768/the-weekly-gist-september-9-2022?e=d1e747d2d8

The same Texas federal judge who ruled the entire ACA unconstitutional in 2018—a decision overturned by the Supreme Court last year—ruled this week that the ACA cannot require a company to fully cover preventive HIV drugs for its employees, on the grounds that doing so violates owners’ religious freedom. He also asserted that the government’s system for deciding what preventive care services should be covered under the ACA is unconstitutional, a broader declaration that potentially jeopardizes a wide swath of no-cost preventive services enshrined in the ACA for millions of Americans, including screening tests for a variety of cancers, sexually transmitted infections, and diabetes. The ruling did not include an injunction and is likely to be appealed. 

The Gist: Fully-covered preventive care services are a cornerstone of the ACA, and have increased access to basic healthcare services for many Americans. While there is still some uncertainty about the scope of this ruling, if it were to stand, millions of Americans would once again have to pay for some of the most common and highest-value healthcare services. That additional financial barrier, along with potential tightening of health plan benefit designs, would create barriers to access that only exacerbate our nation’s already stark healthcare disparities.