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Dinged, Dented, Defiant: The ACA Is Still Standing

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https://www.healthleadersmedia.com/dinged-dented-defiant-aca-still-standing

Texas v. Azar is the latest in a long line of lawsuits and legislation that Republicans have used to undermine the Affordable Care Act, which has shown itself to be remarkably resilient.

KEY TAKEAWAYS

A federal judge in Texas could slap a preliminary injunction on the ACA.

The case is the latest in a long string of efforts to dismantle the ACA since its inception in 2010.

A federal judge in Texas is poised to drop a ruling that could determine the future of the Affordable Care Act.

Or, maybe not.

The Republican plaintiffs from 20 states in Texas v. Azar argued before U.S. District Judge Reed O’Connor in early September that the entire ACA became unconstitutional when Congress zeroed out the individual mandate penalty, effective 2019.

Led by Texas Attorney General Ken Paxton, the Republican plaintiffs are asking for a preliminary injunction. The Department of Justice, which declined to defend portions of the ACA, also urged O’Conner to delay any injunction until after the enrollment period, saying any attempts to impose the injunction during the enrollment period would invite “chaos.”

If the injunction goes through, it could end premium subsidies for ACA beneficiaries and cripple enrollment. The Urban Institute has estimated that 17 million people would lose their health insurance coverage if the ACA was overturned.

As potentially catastrophic as this sounds, the healthcare sector doesn’t seem to be overly concerned. In fact, business couldn’t be better.

A report in Axios shows that many players in the healthcare sector are prospering under the ACA. The website notes that S&P 500 healthcare index of 63 major companies has grown by 186% since the ACA became law in 2010, outstripping the S&P 500 and the Dow Jones.

In addition, health insurance companies are flush. Shares of UnitedHealth Group have gone up more than 700% since 2010, and the stock price of ACA marketplace insurer Centene has gone up 1,100% over the same period, Axios reports.

While hospitals have had a tougher time of it, especially in states that refused to expand Medicaid, they’re still seeing reductions in charity care and bad debt owing.

Regardless of how O’Connor rules in Texas v. Azar, ACA payers, providers, and other stakeholders will continue to presume that the law isn’t going anywhere, says healthcare economist Gail Wilensky.

“They’re assuming it’ll be around, or something very similar will be,” says Wilensky, a former director of Medicare and Medicaid, and a former chair of the Medicare Payment Advisory Commission.

“I don’t think people are regarding any serious likelihood of it going away again,” she says.

Even if O’Connor, appointed to the court in 2007 by President George W. Bush, agrees with the severability arguments raised by the Republican governors and attorneys general in 20 states who brought the suit, the matter likely would get shot down on appeal, Wilensky says.

” I would be surprised if it doesn’t get reversed someplace else,” says Wilensky, now a senior fellow at Project HOPE.

“If it had go all the way to the Supreme Court, the Supreme Court isn’t going to tolerate it, but I don’t know that it would even get that far,” she says.

The case is just one in a long string of legal and legislative actions Republicans are taking at the state and federal level to either undermine or bolster the ACA.

Earlier this year, O’Connor sided with Texas and five other states and threw out an Obama administration tax on states receiving Medicaid funds.

The Republican-controlled Congress has tried more than 50 times to repeal Obamacare, and Senate Majority Leader Mitch McConnell said this week that Republicans may try again in 2019.

While the signature legislation of the Obama era has been dinged and dented, it’s also proven to be remarkably resilient.

Wilensky says the ACA is resilient because it solves a problem “for a small but non-trivial group of people,” and that Republicans don’t have a credible alternative.

“Once a benefit is in place for any measurable amount of time, certainly two or three years would qualify, there’s no precedent for removing it,” she says.

“And most of the proposals that had come up did not seriously get the job done,” Wilensky says.

“They really weren’t effective as an alternative and you simply aren’t going to take away a benefit, like the extension of insurance to people who are above the poverty line and not offered traditionally employer sponsored insurance without having a credible alternative.”

“It’s just not going to happen because there are too many issues that have already been adjudicated at a more serious level,” Wilensky says. “I don’t know why they did this other than that this is 20 attorneys general and they’re running for something.”

 

 

 

 

Jersey City hospital to pay ‘voluntary’ taxes after city challenged tax-exempt status

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https://www.nj.com/hudson/index.ssf/2018/10/jersey_city_hospital_settle_legal_matter_over_hosp.html

Jersey City Medical Center will pay Jersey City $550,000 annually in exchange for the city dropping an appeal of the hospital's tax-exempt status.

After city officials appealed Jersey City Medical Center’s tax-exempt status, the Downtown hospital has agreed to kick in $550,000 annually to the city’s coffers for the next six years.

The agreement, which is part of a legal settlement between the hospital and the city, comes three years after a tax court judge ruled that Morristown Medical Center should pay Morristown property taxes because it fails to meet the legal test that it operates as a nonprofit. That ruling led dozens of towns statewide to sue hospitals seeking tax revenue.

JCMC, now part of the RWJBarnabas Health system, owns four properties in Jersey City, tax records show. Its main campus, located on Grand Street in an upscale area of the city, is assessed at $126 million. If the hospital were not tax-exempt, it would pay $800,000 in property taxes this year, city attorney Nick Strasser told the City Council on Oct. 9.

The settlement, approved by council members on Oct. 10, comes in two parts. The first includes JCMC’s agreement to pay $300,000 in “voluntary” property taxes annually until 2023, retroactive to 2016. In exchange, the city will end its challenge of the hospital’s tax-exempt status and the hospital will drop its counterclaim.

A second agreement has JCMC agreeing on annual “health care collaboration” payments to the city, also retroactive. The payments for 2016 and 2017 will be $1 million total and from 2018 through 2023 they will amount to $250,000 annually.

The tax agreement does not preclude the city from challenging the hospital’s tax-exempt status after 2023.

A bill under review by state lawmakers would require nonprofit hospitals in New Jersey pay a “community service contribution” equal to at least $2.50 per bed daily. If that becomes law, the agreement between the city and JCMC would allow JCMC to reduce that contribution by the amount JCMC will pay under the settlement.

JCMC has about 320 beds.

At the council’s Oct. 9 caucus, Councilwoman Joyce Watterman asked if the settlement was the best the city could do.

“It’s perhaps not the best we could do but it’s definitely not the worst we could do,” Business Administrator Brian Platt told her. “The worst is actually zero, is what we get now.”

The council approved the JCMC agreements 8-0-1. Council President Rolando Lavarro abstained from voting. His wife, Veronica, works at Barnabas in media relations.

“Jersey City Medical Center is pleased that the City of Jersey City has accepted this agreement,” Veronica Lavarro said in a statement. “We look forward to our collaborative work to reduce health disparities and improving health equity in Jersey City.”

 

Bad Debt Grows as Out-Of-Network Benefits Shrink

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Doc taking money

A lack of OON benefits leads to never-ending financial obligations for patients and a greater likelihood of bad debt for providers.

Surprise, sky-high medical bills have been irking patients and legislators a lot lately, but as the number of patients with out-of-network (OON) benefits shrinks, the problem of high bills will continue to grow, according to research from the Robert Wood Johnson Foundation.

A lack of OON benefits leads to never-ending financial obligations for patients and a greater likelihood of bad debt for providers, according to Katherine Hempstead, PhD, senior policy adviser at the Robert Wood Johnson Foundation.

Hempstead authored the new analysis, which looked at trends in OON benefits in the individual and small group markets.

“Out of network benefits have become much less common, especially in the individual market, where the proportion of plans with OON benefits has declined from 58% in 2015 to 29% in 2018 in the individual market,” she tells HealthLeaders via email.

“In the small group market, the decline was smaller: 71% to 64%,” she says.

However, even plans that do offer OON benefits increasingly have very high deductibles and maximum out-of-pocket (MOOP) caps.

For instance, in the individual market, the median OON deductible is approximately $12,000, the analysis shows. Some are even higher.

“A sizable share of plans in the individual markets have OON deductibles that exceed $20,000, and have no MOOP, meaning that patient obligations can continue infinitely,” Hempstead says.

For hospitals and health systems, all of this adds up to more patients who will be unable to pay their bills.

“The takeaway for revenue cycle managers is that most customers in the individual and small group market have little or no out-of-network coverage,” Hempstead says.

Because of this lack of OON coverage, hospitals and health systems should do some investigating beforehand.

“It will be important to ascertain in-network status before providing services, or the likelihood of bad debt will be high,” Hempstead says.

That’s something that hospitals and health systems can feasibly do, “especially if they have a price estimator tool,” says Donella J. Lubelczyk, RN, BSN, ACM-RN, CRC, CRCR, executive director of revenue cycle at Catholic Medical Center in Manchester, New Hampshire.

“They would need to do this with the patient and make sure the patients understand their out-of-network costs prior to selecting the service(s),” Lubelczyk says via email.

Patients also have a responsibility to know which providers are in and out of their networks.

A recent HealthSparq survey shows that 40% of patients who received a surprise bill said they could have done more to better understand their benefits and healthcare processes.

“Patients really need to understand their in-network plans, but most people do not and need to get assistance,” Lubelczyk says.

 

Hospitals Still Lagging on Cost Transformation Measures

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Health system executives have to pick up the pace on implementing effective cost transformation initiatives, according to a new survey from Kaufman Hall.

The focus on adequately addressing the rising cost transformation issues facing health systems has not resulted in significant progress, according to an annual survey from Kaufman Hall.

The healthcare management consulting firm reported that less than 20% of healthcare executives surveyed saw cost reductions exceed 5% in priority areas in 2017. Additionally, the report raised concerns on the lack of accountability measures in place to ensure that leaders have consequences for achieving cost transformation goals for their respective organizations.

Data from executives surveyed:

  • 32% saying that goal setting for cost reduction is absent in their organizations.
  • More than 70% indicating a lack of confidence in the accuracy of their current costing accounting solutions.
  • 12% increase reporting that their organizations have implemented processes to hold leaders accountable for cost transformation goals.
  • 56% witnessing effective use of clinical pathways, protocols, and guidelines to develop a common approach to treatment, a 9% increase compared to last year.
  • 73% saying cost transformation improvement targets have been distributed across the organization, up from 53% in 2017.

Lance Robinson, managing director of Kaufman Hall’s performance management improvement practice, told HealthLeaders that while health system executives have focused on traditional areas of cost, like labor operations, they have overlooked other areas like service rationalization, clinical variation, length of stay, and integrating the physician enterprise. Robinson said those areas require immediate attention from hospital executives in order to sustain opportunities going forward.

“One thing I found surprising was that they’re not actually holding people accountable to the targets that are set,” Robinson said. “On the positive side, I think they have a good idea of what needs to happen. If you look at what factors are driving the need for cost transformation, like the move toward value-based care models and the advent of many disuptors in the industry, they need to be more price conscious and competitive.”

The report added that the need to generate capital to fund strategic initiatives is also driving system executives to revisit their cost transformation goals. Robinson said that as factors surrounding the system change, such as labor market and supply chain operations, executives have to evolve their cost transformation goals as well rather than seeking a “shot in the arm” to fix organizational weaknesses. 

While focus still revolves around traditional areas like labor and non-labor costs, Robinson said leading health systems are analyzing ways to address clinical variation, service rationalization, and other areas that can create meaningful change to their capital structure rather than reducing costs “around the edges.”

 

 

 

Both Parties Seek to Energize Base Voters on Health Issues

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http://www.rollcall.com/news/politics/both-parties-seek-to-energize-base-voters-on-health-issues?utm_source=just-in&utm_medium=email&utm_campaign=energize-health-parties&utm_content=101918&bt_ee=05ccTe0Lp820lMqsIKZ9rsEC84uBk8tCGVMHpj2I80iDh%2BrNDK%2BwJpRqg0%2BFWTO2&bt_ts=1539981664412

Image result for pre existing conditions

As Republicans talk Obamacare repeal, Democrats re-emphasize top issue.

Democrats are seeking to energize their core supporters by repeating Senate Majority Leader Mitch McConnell’s remark this week that Republicans hope to revive a push to overhaul the 2010 health care law.

“McConnell gave us a gift,” Senate Minority Leader Charles E. Schumer told MSNBC on Friday. “That’s a game-changer when he shows who he is and wants to really hurt people on health care.”

McConnell said Wednesday that the GOP may pursue repeal next year if it wins enough seats in the elections. The Kentucky Republican also said entitlement programs such as Medicare and Medicaid are driving deficits.

Democratic candidates are issuing press releases and tweets warning that a GOP-controlled Congress might roll back the law and its protections for pre-existing conditions, which has enjoyed growing support nationwide since Republicans targeted it last year. They also say Republicans want to reduce the growth of popular entitlement programs.

But McConnell appears to expect the idea of repeal to also rile up GOP base voters. For months, polls have shown that health care is the top issue for Democratic voters, but Republicans still want to repeal the health care law, also known as the Affordable Care Act.

“Republicans overwhelmingly disapprove of the law,” said Ashley Kirzinger, a senior survey analyst at the Kaiser Family Foundation. “I think that Sen. McConnell is trying this out because despite the fact that some of the provisions that are part of the ACA are really popular, the ACA overall is still not.”

A Kaiser Family Foundation poll released Thursday found that of Republican voters who said health care was their top campaign issue this year, 18 percent said they specifically meant repealing the health care law. That comes behind 23 percent of survey respondents who said they meant addressing high health care costs.

In Nevada, where health care has been a marquee issue in the Senate race between Republican incumbent Dean Heller and Democratic Rep. Jacky Rosen, 29 percent of GOP voters said a candidate’s commitment to overhauling the law is most important to determining their votes.

In Florida, where the health care law is less of an issue in the Senate race between Democratic incumbent Bill Nelson and Republican Gov. Rick Nelson, 31 percent of Republican voters said wanting to scale it back is the most important issue in determining who they would vote for.

But while Republican voters may say they’re clamoring for Congress to overhaul the law, GOP candidates are not talking loudly about their plans to do so on the campaign trail. When it comes to health care, many are campaigning to protect pre-existing conditions, which the 2010 law does. Polls show a majority of voters across the political spectrum support keeping that provision.

GOP on defense

President Donald Trump said Thursday on Twitter that if any Republican did not support pre-existing conditions coverage, “they will after I speak to them.”

Texas GOP Sen. Ted Cruz built his national political ambitions around his opposition to the health care law, going so far as to shut down the government in 2013. Now, as he faces off against Democratic Rep. Beto O’Rourke, Cruz has taken a quieter tone on the law, vowing to maintain protections for pre-existing conditions although he has said he wants to roll back other parts of the law.

While Republicans say they could revisit legislation to overhaul the law, they’re also doubling down on a commitment to guarantee coverage for people with pre-existing conditions. Those protections have become a focal point across the country after the Trump administration declined to defend those provisions against a lawsuit. A group of conservative state officials sued to overturn the law after Republicans used a tax overhaul last year to effectively end the requirement that most Americans have health insurance.

The repeal measure that House Republicans passed last year would have weakened protections for pre-existing conditions by allowing states to seek waivers that would allow insurers to charge sick patients more for coverage. In the Senate, Cruz proposed to let insurers sell plans that do not meet all of the health care law’s requirements if they also offer policies that do comply with it, which health experts said would lead to higher costs for sick patients.

In both chambers, allowing insurers to sell plans that would not comply with all of the law’s requirements were critical to earning votes from more conservative members.

Two Republican lawmakers fighting for re-election, Reps. David Young of Iowa and Pete Sessions of Texas, each recently proposed nonbinding resolutions that commit to protecting pre-existing conditions if a federal judge rolls back the protections.

U.S. District Judge Reed O’Connor has yet to rule on the lawsuit by the conservative state officials, but said during oral arguments last month that he would try to do so as soon as possible. The administration asked that O’Connor postpone judgment until after the sign-up period for insurance sold on the federal and state exchanges ends in December in order to avoid chaos in the markets.