Tag Archives: ACA

For Covered California, Uncertainty Is The New Certainty

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For Covered California, Uncertainty Is The New Certainty

Covered California’s board made several multimillion-dollar decisions Thursday, all addressing one unsettling theme: uncertainty.

Over and over, board members blamed “uncertainty” at the federal level for interfering with their ability to finalize premiums for 2018 and prepare consumers for open enrollment, which begins Nov. 1.

In response to that uncertainty, the board agreed to delay a critical decision on 2018 rate hikes, boost Covered California’s marketing budget by more than $5 million and allow its participating insurers to make higher profits in the future — under certain circumstances.

“The lack of clarity and direction at the federal level continues to be a challenge,” said Covered California Executive Director Peter Lee. “While we are doing our best to manage a difficult situation, we hope Congress and the administration will provide clear guidance on how [they intend] to stabilize the individual insurance market.”

One of the most pressing questions facing Covered California and other Obamacare exchanges across the country is whether President Donald Trump will continue to fund critical subsidies that help reduce many consumers’ out-of-pocket expenses.

The White House announced this week it would fund those so-called cost-sharing reduction payments this month but did not say whether it would continue to do so after that.

Covered California is seeking a long-term commitment to fund the subsidies, which are available only to consumers whose incomes are low enough to qualify and who purchase silver-level plans, the second-least expensive among the exchange’s four tiers of coverage. The subsidies reduce what they pay for medical expenses such as copayments and deductibles.

Earlier this month, the exchange announced proposed average statewide rate hikes of 12.5 percent for 2018. It also floated an additional average surcharge of 12.4 percent on silver plans if the federal government does not commit to making the payments.

Covered California was supposed to decide by the end of this month whether to apply the surcharge next year. But on Thursday, its board announced it will push the deadline to Sept. 30.

“Our hope is that by changing the deadline to allow Congress to act, we will not have to deal with the … surcharge,” Lee said.

The surcharge would vary by region and plan, ranging from 8 percent to 27 percent — on top of the regular annual premium increases, Lee said.

Covered California consumers who receive tax credits to reduce their monthly premiums would not bear the full brunt of the increase, however, because those credits would also rise.

Delaying the decision until the end of September doesn’t leave much time for Covered California — its health plans — to finalize rates and prepare consumers to renew their health plans or shop for new ones, said Diana Dooley, board chair and secretary of the state Health and Human Services Agency.

But the board doesn’t want to raise silver plan rates prematurely, in case Congress acts next month to fund the cost-sharing subsidies on a more durable basis, she said.

If Congress doesn’t act until the very end of September, “that will put extraordinary pressure on our system,” she said.

Charles Bacchi, president and CEO of the California Association of Health Plans, said 1.2 million renewal packets will have to be dispatched to enrollees on a very tight timeline.

“It is going to be a heavy lift, but the plans will work to do the best we can under difficult circumstances,” he said.

The board also agreed to modify its contracts with participating insurers to allow them to make higher profits in 2019, 2020 and 2021 if they lose money next year as a result of continued uncertainty or changes in existing federal policy.

For example, one way insurers could lose money is if the federal government stops enforcing the Obamacare requirement to have health insurance, known as the individual mandate, Covered California said.

The change also requires plans that reap increased profits next year — again, because of uncertainty or changes in federal policy — to lower their premiums over the next one to three years.

Lee explained that Covered California’s insurers usually make a profit of about 1 to 3 percent annually. But, for example, if one should lose money next year, its profit margin could grow to 6 to 8 percent in the subsequent three years, he said.

Any profit increase would be decided on a case-by-case basis and depend on the amount of the loss, he said.

The contract amendment would not change any laws or violate any rules, such as the Medical Loss Ratio provision of the Affordable Care Act, Lee said. That provision requires most insurance companies that cover individuals and small businesses to spend at least 80 percent of their premium dollars on medical care and the remaining 20 percent on administration, marketing and profit.

Consumer advocates testified Thursday that they were initially skeptical of the change, but they now hope it will save consumers money in the long run.

“We like the idea that it is balanced and if [there is profit], it could go to reducing premiums,” said Doreena Wong, project director at Asian Americans Advancing Justice, a Los Angeles-based civil rights group.

In another move tied to the uncertainty over federal policy, the board agreed to increase its marketing budget by $5.3 million, bringing the total to $111.5 million for 2017-18. The additional money will pay for more radio and television spots, and more direct mail to consumers.

Some of the advertising will target Covered California enrollees who are losing their Anthem Blue Cross plan next year.

Anthem will exit the individual market in 16 of the state’s 19 pricing regions, which will force 153,000 enrollees to find new plans. Anthem cited uncertainty and market instability for its pullout.

“This open enrollment is going to be our most challenging since year one,” Lee said.

Podcast: ‘What The Health?’ Why Is It So Difficult To Control Drug Prices?

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Mary Agnes Carey of Kaiser Health News, Sarah Karlin-Smith of Politico, Margot Sanger-Katz of The New York Times and Julie Appleby of Kaiser Health News discuss the recent extension of cost-sharing subsidies for millions of low-income beneficiaries on the Affordable Care Act’s marketplaces — as well as the state of play on Capitol Hill and in the states concerning efforts to lower prescription drug costs.

Doctor Shortage Under Obamacare? It Didn’t Happen

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When you have a health problem, your first stop is probably to your primary care doctor. If you’ve found it harder to see your doctor in recent years, you could be tempted to blame the Affordable Care Act. As the health law sought to solve one problem, access to affordable health insurance, it risked creating another: too few primary care doctors to meet the surge in appointment requests from the newly insured.

Studies published just before the 2014 coverage expansion predicted a demand for millions more annual primary care appointments, requiring thousands of new primary care providers just to keep up. But a more recent study suggests primary care appointment availability may not have suffered as much as expected.

The study, published in April in JAMA Internal Medicine, found that across 10 states, primary care appointment availability for Medicaid enrollees increased since the Affordable Care Act’s coverage expansions went into effect. For privately insured patients, appointment availability held steady. All of the gains in access to care for Medicaid enrollees were concentrated in states that expanded Medicaid coverage. For instance, in Illinois 20 percent more primary care physicians accepted Medicaid after expansion than before it. Gains in Iowa and Pennsylvania were lower, but still substantial: 8 percent and 7 percent.

Though these findings are consistent with other research, including a study of Medicaid expansion in Michigan, they are contrary to intuition. In places where coverage gains were larger — in Medicaid expansion states — primary care appointment availability grew more.

“Given the duration of medical education, it’s not likely that thousands of new primary care practitioners entered the field in a few years to meet surging demand,” said the Penn health economist Daniel Polsky, the lead author on the study. There are other ways doctor’s offices can accommodate more patients, he added.

One way is by booking appointment requests further out, extending waiting times. The study findings bear this out. Waiting times increased for both Medicaid and privately insured patients. For example, the proportion of privately insured patients having to wait at least 30 days for an appointment grew to 10.5 percent from 7.1 percent.

The study assessed appointment availability and wait times, both before the 2014 coverage expansion and in 2016, using so-called secret shoppers. In this approach, people pretending to be patients with different characteristics — in this case with either Medicaid or private coverage — call doctor’s offices seeking appointments.

Improvement in Medicaid enrollees’ ability to obtain appointments may come as a surprise. Of all insurance types, Medicaid is the least likely to be accepted by physicians because it tends to pay the lowest rates. But some provisions of the Affordable Care Act may have enhanced Medicaid enrollees’ ability to obtain primary care.

The law increased Medicaid payments to primary care providers to Medicare levels in 2013 and 2014 with federal funding. Some states extended that enhanced payment level with state funding for subsequent years, but the study found higher rates of doctors’ acceptance of Medicaid even in states that didn’t do so.

The Affordable Care Act also included funding that fueled expansion of federally qualified health centers, which provide health care to patients regardless of ability to pay. Because these centers operate in low-income areas that are more likely to have greater concentrations of Medicaid enrollees, this expansion may have improved their access to care.

Other trends in medical practice might have aided in meeting growing appointment demand. “The practice and organization of medical care has been dynamic in recent years, and that could partly explain our results,” Mr. Polsky said. “For example, if patient panels are better managed by larger organizations, the trend towards consolidation could absorb some of the increased demand.”

Although the exact explanation is uncertain, what is clear is that the primary care system has not been overwhelmed by coverage expansion. Waiting times have gone up, but the ability of Medicaid patients to get appointments has improved, with no degradation in that aspect for privately insured patients.

Trump administration, HHS stepping away from Affordable Care Act promotion, bundled payments

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New bundled payment models for cardiac care may be on chopping block, along with changes to joint replacement.

Lacking a repeal and replacement bill for the Affordable Care Act, President Trump appears to be following through on his Twitter promise to “let Obamacare implode.”

The Trump administration and the Department of Health and Human Services is distancing itself from several groups which in the past have helped market open enrollment, according to talkingpointsmemo.

HHS has not reached out to the Latino Affordable Care Act Coalition, the United Methodist Church, the American Congress of Obstetricians and Gynecologists, the American Medical Student Association, the National Urban League, the National Latina Institute for Reproductive Health, the National Hispanic Medical Association, and the National Partnership for Women and Families, according to the report.

Open enrollment in the ACA marketplace starts November 1.

The new bundled payment model for cardiac care coordination and cardiac rehabilitation may also be on the chopping block, along with unspecified changes to the joint replacement model, according to a proposed rule published August 10 in the Office of Management and Budget.

The models were introducted by the Centers for Medicare and Medicaid Services’ Innovatoin Center, or CMMI, run by Patrick Conway, MD, who last week announced he was leaving CMS to head Blue Cross Blue Shield North Carolina.

HHS Secretary Tom Price, an orthopedic surgeon appointed by the president, has consistently voiced his opposition to mandatory bundled payment programs.

What’s the Near-Term Outlook for the Affordable Care Act?

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If Congress abandons efforts to repeal and replace the Affordable Care Act (ACA), President Trump has said he would “let Obamacare fail.” This Q&A examines what could happen if the Affordable Care Act, also called “Obamacare,” remains the law and what it might mean to let Obamacare fail.

Is Obamacare failing?

The Affordable Care Act was a major piece of legislation that affects virtually all payers in the U.S. health system, including Medicaid, Medicare, employer-sponsored insurance, and coverage people buy on their own. One of the biggest changes under the health reform law was the expansion of the Medicaid program, which now covers nearly 75 million people, about 14 million of whom are signed up under the expansion. Most Americans, including most Republicans, believe the Medicaid program is working well.

When people talk about the idea of the ACA failing, they are usually referring to the exchange markets, also called Marketplaces. These markets, which first opened in 2014, are part of the broader individual insurance market where just 5-7% of the U.S. population gets their insurance. People who get insurance from other sources like their work or Medicaid are not directly affected by what happens in the individual insurance market.

The exchange markets have not been without problems: There have been some notable exits by insurance companies and premium increases going into 2017, and in the early years of the exchanges, insurers were losing money. The structure of the ACA’s premium subsidies – which rise along with premiums and cap what consumers have to pay for a benchmark plans a percentage of their income – prevents the market from deteriorating into a “death spiral.” However, premiums could become unaffordable in some parts of the country for people with incomes in excess of 400% of the poverty level, who are ineligible for premium assistance.

Insurer participation in this market has received a great deal of attention, as about 1 in 3 counties – primarily rural areas – have only one insurer on exchange. Rural counties have historically had limited competition even before the ACA, but data now available because of the Affordable Care Act brings the urban/rural divide into sharper focus. On average at the state level, competition in the individual market has been relatively stable – neither improving nor worsening.

Premiums in the reformed individual market started out relatively low and remained low in the first few years – about 12% lower than the Congressional Budget Office had projected as of 2016 –before increasing more rapidly in 2017. Most (83%) of the 12 million people buying their own coverage on the exchange receive subsidies and therefore are not as affected by the premium increases, but many of the approximately 9 million people buying off-exchange may have difficulty affording coverage, despite having higher incomes. As might be expected, after taking into account financial assistance and protections for people with pre-existing conditions, some people ended up paying more and others paying less than they did before the ACA. Our early polling in this market found that people in this market were nearly evenly split between paying more and paying less. About 3 millionpeople who remain uninsured are not eligible for assistance or employer coverage and many of them may be going without coverage due to costs.

Our recent analysis of first quarter 2017 insurer financial results finds that the market is not showing signs of collapse. Rather, insurers are on track to be profitable and the market appears to be stabilizing in the country overall. In other words, those premium increases going into 2017 may have been enough to make the market stable without discouraging too many healthy people from signing up. However, there are still markets – particularly rural ones – that are fragile.

How would administrative actions affect market stability?

Despite signs that the individual insurance market is generally stabilizing on its own, certain administrative actions could cause the market to destabilize again. Actions the Administration might take that would weaken the market include:

STOP ENFORCING OR WEAKEN THE INDIVIDUAL MANDATE

The individual mandate is the Obamacare requirement that most people either have insurance or pay a penalty. The purpose of it is to get young and healthy people into the market to bring down average costs. If there are not enough young and healthy people signing up, insurers have to raise premiums. If the administration signals it will either stop enforcement of the individual mandate or give broad exemptions, insurers will respond by raising premiums or exiting the market. The Congressional Budget Office (CBO) estimates that without the individual mandate, premiums in the individual insurance market could rise by 20%.

SCALE BACK OUTREACH AND CONSUMER ASSISTANCE

The individual market is often a transitional source of insurance when life circumstances change. People who are temporality unemployed, in school, or early retirees make up a substantial share of the individual market. Additionally, people in this market often experience income volatility and may cycle between Medicaid and subsidized exchange coverage. Those who are sick will be most likely to seek insurance coverage on their own when they go through a change in life circumstances, but outreach and consumer assistance programs – particularly those targeted at young and healthy individuals – can help balance out the risk pool and bring down average costs.

This coming open enrollment period (November 1 – December 15, 2017) is shorter than previous periods and may require more outreach to get people signed up before the deadline. This will also be the first enrollment period run from start to finish by the Trump administration and it is not yet clear how much outreach the administration will take on. Toward the end of the last open enrollment period, the Trump administration cut marketing and more recently has used outreach funds for messages critical of the health care law.

STOP MAKING COST-SHARING SUBSIDY PAYMENTS

Under the Affordable Care Act, insurers are required to offer low-deductible plans to low-income people (58% of marketplace enrollees benefit from these cost-sharing subsidies). For the lowest-income enrollees, these subsidies can bring down the deductible from a few thousand dollars to a couple hundred dollars (Figure 2 below). Providing these higher-value plans to low-income enrollees costs insurers more money (an estimated $10 billion dollars in 2018), so under the ACA the federal government reimburses insurers in the form of a cost-sharing subsidy payment. However, these payments are the subject of a lawsuit and the Administration has signaled they might stop making payments.

If these payments stop, we estimate that insurers would need to raise rates on silver-level plans – which are the only plans where consumers can access cost-sharing reductions – by 19 percent, with states that did not expand Medicaid (primarily red states) facing higher premium increases (Figure 3 below). Lower-income marketplace enrollees receiving premium subsidies would be protected from premium increases because subsidies would rise as well. However, higher-income enrollees not receiving premium subsidies would face higher premiums if insurers expect cost-sharing subsidy payments to end.

The combined effect of these policy changes (not enforcing the individual mandate and defunding cost-sharing subsidies) could cause some insurers to raise premiums on some plans by as much as 40 percentage points higher than they otherwise would. Because premium subsidies increase as premiums rise, administrative actions that cause premiums to rise can also cause taxpayer costs to increase. For example, we estimate that ending cost-sharing subsidy payments could increase net federal costs by about $2.3 billion per year.

Insurers have already submitted their preliminary premiums for the upcoming calendar year to state regulators. Since there has not been clarity on these issues, some insurers are already assuming that the Trump Administration or Congress may take an action that would destabilize the market. Some companies have either significantly raised premiums for next year, scaled back their footprints, or made plans to exit the exchange or individual market all together. Insurers are still negotiating rates for 2018, so if they do not get clarity soon, premiums could go up even more or more insurers could leave.

Again, these premium increases would only affect people who buy their own insurance (particularly middle-income or upper-middle-income people who buy their own insurance without a subsidy to offset the costs), and this group does not make up a large share of the American public. Nonetheless, more insurer exits or large premium increases on the exchange markets could be seen as Obamacare failing. It is worth noting, though, that a majority (64 percent) of the public – including 53 percent of Republicans – say that because President Trump and Republicans in Congress are now in control of the government, they are responsible for any problems with the ACA moving forward.

What happens if the market fails?

Following some announcements of 2018 exits by major insurers, there are some counties at risk of having no insurer on the exchange next year. This would be a first; thus far, all counties have had at least one insurer on the exchange. As negotiations between insurers and state regulators are still underway, there is still time for other insurers to come in and fill these gaps. Thus far, in most cases, a new or expanding insurer has already moved in to cover counties once thought to be “bare.” However, administrative actions that destabilize the market could encourage more insurers to exit.

If no exchange insurer ultimately moves in to some of these counties, people buying their own insurance will not be able to get subsidies and would have to pay full price for insurance. Paying for unsubsidized insurance would be particularly difficult for low-income and older adults living in high-cost areas like many rural parts of the country. Our subsidy calculator can show the difference in cost. For example, in Knox County Ohio, a low-income 60-year-old could get a silver plan for $83 per month but would have to pay $775 per month if he bought that plan without a subsidy, plus he would have a higher deductible because he would no longer benefit from cost sharing subsidies that are only available on the exchange. That same person would also qualify for a free ($0 premium) bronze plan if he buys on exchange, but off-exchange without a subsidy he would have to pay more than $600 per month for a similar plan. People shopping for coverage off-exchange in a county left without an exchange insurer – particularly lower income or older exchange shoppers – may not be able to afford any option and may drop their coverage.

If the market becomes destabilized, and particularly if the individual mandate is not enforced, insurers may decide to exit the off-exchange market as well. This would mean that people in these counties who would otherwise buy their own insurance may not have any option even if they could afford to pay full price.

What might be done to strengthen the Marketplaces?

Although the individual health insurance market is stabilizing on average, insurer financial performance varies and some companies in some states are still struggling. Additionally, some insurers have already decided to increase premiums significantly or exit the market in 2018 on the assumption that the Trump Administration or Congress will take actions that destabilize the market. Although there are many ideas on both the left and the right for how to improve these markets, there are not many options that have bipartisan support.

One possible policy response that could receive bipartisan support would be to reestablish a reinsuranceprogram. Reinsurance programs provide funds to insurers that enroll high-cost (sicker) individuals and can work to lower premiums. The Affordable Care Act included a reinsurance program but it was temporary and phased out in 2016. Republicans in Congress and the Administration have also signaled a willingness to establish reinsurance programs: Both the House and Senate repeal bills included stability funds for reinsurance and Health and Human Services Secretary Price has supported Alaska’s request for a waiver to support its reinsurance program. Though such a program could receive bipartisan support, it would require additional funds (for example, taxing insurers in other markets).

Additional state flexibility to address local challenges in implementing the health care law may also receive some bipartisan support. The challenge of attracting insurers to rural areas or certain states, for example, may warrant state-specific solutions – either as part of the ACA’s waiver program or by Congress giving states additional flexibility.

CBO: Ending cost-sharing reduction payments will increase premiums, federal deficit

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If the Trump administration stops funding cost-sharing reduction payments, silver-plan premiums on the Affordable Care Act exchanges will rise considerably and the federal deficit will increase, the Congressional Budget Office said Tuesday.

Officially, the administration remains undecided about how long it will continue making CSR payments, which are at the center of a federal court case that challenges their legality. Many insurers have had to factor this uncertainty into their preliminary rate filings.

To map out the consequences of one possible move by the administration, the CBO examined what would happen if federal officials announced at the end of August that they would continue CSR payments through the end of the year but discontinue them after that.

That policy would result in silver-plan premiums rising by an average of 20% in 2018 and 25% by 2020, the CBO estimates. Because tax credits rise in tandem with premiums, most eligible enrollees would not pay higher rates than they would if CSR payments continued—though the report also notes that overall, “the share of people facing slight increases would be higher during the next two years.”

Since more people would likely receive premium tax credits and in greater amounts, the CBO predicts that ending CSR payments would raise the federal deficit by $6 billion in 2018, $21 billion in 2020 and $26 billion in 2026.

The CBO also predicts that ending CSR payments would cause some insurers to exit the individual marketplaces, leaving about 5% of people living in areas that have no ACA exchange insurer in 2018. However, the agency predicts that more insurers would likely return to the exchanges in 2020 after having adjusted to the new policy.

Overall, the number of uninsured people would be slightly higher in 2018 but slightly lower starting in 2020 under the scenario the CBO examined, per the report.

A snapshot into why some providers are eliminating positions

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http://www.healthcaredive.com/news/healthcare-workforce-growth-cuts/446182/

Employment in the healthcare industry has risen since the ACA was passed, but many health systems have been trimming their workforce under financial pressure.

It’s clear there have been a fair amount of hospital and provider layoffs in 2017.

In the past few months, hospitals of all sizes, and in all parts of the country, have said they are cutting jobs or eliminating open positions. Major providers affected have included Memorial Hermann, Brigham and Women’s Hospital, NYC Health + Hospitals, Summa Health and Hallmark Health. In May, Becker’s Hospital Review listed 48 layoffs across the industry the publication had reported on in 2017.

The layoffs come in contrast with the sharp rise in hiring in the healthcare sector ever since the Affordable Care Act (ACA) was enacted. While the hiring growth is a long-term trend — though it’s yet to be determined at what rate in 2017 — these layoffs are due in part to the short-term trends of softening admissions and flattening reimbursements. Many providers cited similar problems: declining reimbursements, lower admissions and shrinking operating incomes. Layoffs aren’t the only play for struggling organizations, but hospital expenses are rising on multiple fronts, and executives have to make some hard choices.

Big drivers of the growth are the aging population and the pending retirement of many registered nurses. It’s unclear how or when the layoff and healthcare job growth trends will change, but the underlying themes are not going away. The Bureau of Labor Statistics (BLS) is scheduled to release 2016-2026 occupational projections in October, while layoffs will continue to be tracked throughout the year.

Then there’s the elephant in the room over the buzzword of 2017: Uncertainty. Whether it be in Congress or in the executive branch, uncertainty over U.S. healthcare policy is making providers nervous as the insurance open enrollment period nears with no clear ACA reform or repeal in sight.

Healthcare hiring still on the rise, but the pace may be slowing

To date, the healthcare employment bubble hasn’t burst. Healthcare jobs, including hospital jobs, still are on the rise. While job growth is a different metric than layoffs and require different considerations, both underscore the themes affecting the industry’s workforce.

Ani Turner, co-director of Altarum Institute’s Center for Sustainable Health Spending, told Healthcare Dive there have been some clear trends in hospital job growth in recent years. In 2013, there was little job growth but the expanded coverage affect — where more individuals gained health insurance for the first time under the ACA — helped spur hospital job growth in 2014.

This expanded coverage helped hospitals experience new revenue opportunities thanks to more people entering the care delivery space, especially in states that expanded Medicaid. In addition, since the implementation of the ACA, the level of uncompensated care nationwide has gone down from $46.4 billion in 2013 to $35.7 billion in 2015.

Since that time, hospitals experienced great growth from a jobs perspective. In a 2015 Forbes article, Politico’s Dan Diamond noted that healthcare job growth surged at its fastest pace since 1991 starting in July 2014 up through May of 2015. In fact, healthcare practitioners and healthcare support positions are expected to be among the fastest growing jobs from 2014 to 2024. BLS notes the aging population and expanded insurance coverage will help fuel this growth as demand for healthcare services increases.

The recent surge is “somewhat unexpected,” Turner says. “One would think hospitals would be conservative in their hiring. Everything I’m seeing is flat or slightly declining volumes, especially on inpatient side.”

“The data don’t always cooperate with the story that makes sense,” Turner added.

Brian Augustian, principal at Deloitte, believes the job growth is going to continue to slow this year in part because there will be a push for greater automation and productivity. “As organizations are able to use machine learning, artificial intelligence and better utilize technology to get tasks done, it will not only result in…needing fewer people but also different types of people,” he told Healthcare Dive.

The rate of job growth will be an issue to watch throughout the year. As shown above, just two months worth of data changes the story from a narrative of “slowing growth” to “continuing to soar.” The looming retirement of registered nurses and the aging population do point to hospitals and providers arming themselves to smooth the transition of both the workforce as well as the pending flood of baby boomers entering into the care space.

Job growth doesn’t stop financial troubles for providers

However, as seen in the job cut announcements and recent quarterly earnings for hospital operators, providers are facing challenges that are affecting their bottom lines.

One of the biggest challenges for providers is declining or flattening admissions. In 2010, all hospital admissions totaled 36.9 million admissions. By 2013, admissions had dropped by 1.5 million; 35 million patients were admitted in 2015.

In the latest rounds of quarterly earnings, most for-profit hospital operators took a lashing, all acknowledging softening markets and weaker-than-expected patient volumes. Community Health Systems (CHS) reported it underperformed in Q2 2017 and is exploring more divestitures while HCA Healthcare reported it missed Q2 estimates due in part to higher expenses and lower-than-expected patient admissions. On Monday, Tenet Health reported a 4.5% decline in total admissions for the first six months of 2017.

Indiana University Health’s operating income suffered a 46% loss while seeing less individuals coming into the facilities, Modern Healthcare reported.

As seen in HCA Healthcare’s Q2 earnings call, lower acuity visits declined in the last quarter. At CHS, emergency department volume declined on the outpatient side, which Tim Hingtgen, president and COO of CHS, attributed to “industry dynamics, including urgent care growth, freestanding ED competition in select markets.” As Turner notes, the average person seeking a care setting visit is likely going to a physician’s office. This puts pressure on operators to rethink their lower acuity setting strategies and not rest on the strength of organic patient growth seen in previous years.

Another major issue for providers are expenses. More jobs equals more expenses, for example. Facility maintenance, equipment, electricity, telephone lines, internet, etc. all add up. According to the American Hospital Association, expenses for all U.S. registered hospitals are currently $936 billion, up from $859.4 billion in 2013. In addition to these changes, turning toward value-based care exposes providers more to risk-based contracts which can affect reimbursement formulas.

Hospitals know they need to lower cost structures, and personnel changes is one means

Ben Isgur, director of PricewaterhouseCoopers’ Health Research Institute, adds that squeezing costs isn’t a new concept for hospitals. There are many options for executives to manage out costs from its overhead. Supply chain, infrastructure and third party contracts are all go-to areas for such efforts. If two systems merge, departments can be streamlined or share services. In some cases, third-party contractors may be more beneficial to a provider than hiring for internal positions.

Igor Belokrinitsky, healthcare strategist at Strategy&, a member of the PwC network of firms, told Healthcare Dive in March many administrators faced with financial challenges tell their departments during the budgeting process to budget for zero cost increases or even for a reduction. “In the longer run, we are seeing and are working with health systems to take out pretty significant amounts of cost out of their operations, both clinical and nonclinical, and setting targets like 15-20%, which is a transformative change,” he said. “When talking about a 20% cost improvement, you’re questioning, ‘Do we need this facility? Do we need to provide this service at this location? Does this service need to be provided by a physician?'”

The current political landscape isn’t helping matters either

Isgur tells Healthcare Dive that healthcare industry layoffs should be watched closely and agrees with Turner that one of the biggest reasons is uncertainty in the industry.

As an example, he points to the Congressional Budget Office’s figure that 15 million individuals could have lost health coverage in 2018 if the Senate ACA repeal bill had become law. “Providers look at that and have to be ready for an environment where they have potentially fewer paying patients,” Isgur told Healthcare Dive.

During the heady time when ACA repeal-and/or-replace was on Congress’ plate this summer, many projections showed healthcare jobs would’ve been affected. One analysis of the House ACA bill estimated 725,000 jobs across the entire industry would be lost by 2026 if it had become law. The primary cause of the job disappearances and state economic downturns would have been attributable to cuts to healthcare funding, such as more than $800 billion to Medicaid, and lower premium subsidies.

Moody’s Investor Services projected the Senate ACA repeal bill would have caused uncompensated care costs to rise at hospitals.

The fight over healthcare policy is likely now headed to the executive branch, as Congress has failed to pass a bill that repeals or replaces the ACA. President Donald Trump has cost-sharing reduction payments to insurers hanging in the balance, and hasn’t publicly stated if the White House will continue to make these payments.

If these payments are discontinued, Fitch Ratings found in a new report that premiums could increase to the point where customers won’t be able to pay for coverage, thus increasing the chance for uncompensated payments to rise.

In addition, state Medicaid waivers will have to be looked at. Some applications, such as the Maine’s, could include work requirements, mandatory premiums and asset testing. It would be one of the most conservative state programs, and some health policy experts warn that the restrictions would push out many low-income adults who would otherwise qualify.

“When you add uncertainty to what’s already been going on in the reimbursement environment around how many more uninsured there may be going forward, that’s not the cause of [layoffs] but it’s certainly going to accelerate the thinking of executive teams to make sure [their organizations] are efficient and ready for anything,” Isgur said.

Isgur does think the industry will see more layoff announcements this year, but that it is an important trend to watch, especially as more decisions come out of Washington.

 

Why ACA market upheaval still looms large despite failure to repeal the law

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Whether lawmakers are done with efforts to repeal the ACA or not, some important changes for healthcare could be on the horizon.

At least one part of the healthcare industry is still looking to Washington D.C. after the flurry of activity last month, if only for one action. In addition to the highly public failure to pass major healthcare legislation before leaving town for a month, Congress and President Donald Trump also left the Affordable Care Act (ACA) exchange markets in a dangerous flux by not taking action on the cost-sharing reduction (CSR) payments for insurers.

It’s not clear whether Congress will continue to take up Republican healthcare legislation to repeal the ACA when it returns. Even within the party, senators are singing different tunes, while President Donald Trump continues to pressure lawmakers to get an ACA repeal bill on his desk. A bipartisan group with members from both chambers has a few ideas, but the majority of lawmakers appear ready to move on. Regardless, they will still have to take up reauthorization of the Children’s Health Insurance Program (CHIP) in September, potential reigniting some debates around the ACA.

If GOP leaders do declare ACA repeal off the table for this year, its opponents will look to the executive branch for efforts to weaken the law and its effects. Here’s what to look out for.

Cost-sharing reduction payments

Payers have been begging for assurance that CSRs will continue to be paid, but the White House and Congress have so far refused. The result has been many payers pulling out of the exchange markets or reducing their footprints, as well as premium hikes of 30% or more. Just last week, Anthem announced it is pulling out of the Nevada and Virginia exchange markets and reducing its participation in Georgia.

Not paying the CSRs would increase federal spending, because the higher premiums will require higher premium subsidies for the 84% in the exchanges who qualify for help. That’s not to mention the 30,000 or more who would have no insurance options.

Trump hasn’t been shy about his plan to halt any efforts that stabilize the exchange markets (like CSRs) in an effort to sabotage the ACA and force unwilling Democrats to cooperate on a repeal bill. Others in the GOP, however, have been reluctant to hurt constituents with such an overtly political play.

America’s Health Insurance Plans has said it is imperative the CSRs are funded. “These benefits are essential to making coverage and care affordable for American families who receive them,” the organization said. “Clarity and commitment to this funding is needed to eliminate confusion and anxiety for consumers.”

It may soon be too late for CSR payments to matter for next year. Payers must sign their contracts with HealthCare.gov by Sept. 21. The CMS and some states have tried to give insurers more flexibility because of the uncertainty by pushing back rate filing deadlines. Connecticut said it will allow payers to refile their rates if the CSR payments are eliminated, and California allowed them to file two sets of rates, one of which assumes no CSRs.

Weakening the ACA

Trump’s threat to “let Obamacare implode” may go beyond refusing to shore up the exchange markets. His administration has already pulled advertising and promotion of the exchanges, and is being investigated by the Government Accountability Office for pushing the GOP healthcare bills in official HHS communication channels. Immediately after his inauguration, Trump signed a wide-ranging executive order instructing federal agencies to “exercise all authority and discretion available to them to waive, defer, grant exemptions from, or delay any provision or requirement” of the ACA that imposes a fiscal or regulatory burden.

No major changes have resulted from the order so far, but it could be used to roll back benefit requirements for preventive care, contraception and mental health services.

HHS Secretary Tom Price could also make changes that weaken the ACA’s individual mandate. Repealing the mandate would mean 15 million fewer Americans would have coverage by 2026 and result in premium increases of about 20%, according to the Congressional Budget Office. Watering down the requirement instead of ditching it completely would have less drastic results, but there would still be an impact.

Price could create more exemptions for the mandate or attempt to force the Internal Revenue Service to stop enforcing it. Either of these actions would add turmoil to the exchanges markets and undermine the efforts of the ACA.

Reauthorizing CHIP

Those watching health legislation in Congress are eyeing CHIP reauthorization as a possible vehicle for changes to the ACA. Lawmakers will be hesitant, though, as CHIP is a successful program with bipartisan support.

The program, which turned 20 years old this past weekend, covered nearly 9 million children in fiscal 2016. CHIP coverage is more affordable than employer-sponsored or marketplace coverage, while children covered under CHIP are more likely to have a usual source of care and regularly attend well-child visits, according to the Medicaid and CHIP Payment and Access Commission, which recommends Congress extend CHIP funding through 2022.

The commission estimates more than a million children would lose coverage if CHIP loses funding.

Bipartisan legislation and state waivers

A bipartisan group of about 40 members of the House is proposing some relatively small changes to the ACA that have received support from both sides of the aisle in the past. The plan is to put them in a bill that would also immediately fund the CSRs.

Their suggestions include exempting smaller businesses from the employer mandate, a fund states can go to for help covering people with high care costs and more flexibility and guidance for states looking to apply for ACA waivers. Another possible measure is repeal of the medical device tax.

Their proposal is to change the employer mandate by having it apply only to businesses with 500 or more employees, instead of the current requirement for businesses with 50 or more workers. Analysis from the Urban Instituteand Rand Corporation has shown the employer mandate has little effect on the number of people who have coverage, partly because nearly all businesses with at least 50 employees offered coverage even before the mandate went into effect.

The ACA has always given states the option of applying for a waiver that allows them to eschew essential health benefits and other requirements — as long as they can prove their plans will cover the same number of people with coverage that is just as comprehensive and affordable. HHS under President Barack Obama was careful in ensuring that state proposals met those guidelines, but current HHS Secretary Tom Price has said he wants to encourage more waivers and will be less strict with approvals of those waivers and Medicaid demonstration waivers.

With this in mind, some recent proposals have included aspects that would have previously been rejected. Last week, Maine applied for a Medicaid demonstration waiver that includes work requirements and asset testing. Those measures are likely to restrict access to coverage for people with low incomes.

Many of the options available for Congress and the executive branch could roil the industry, but some bipartisan options could provide much needed clarity. Summer is usually pretty quiet in Washington D.C., but this year has not been business as usual. Healthcare leaders would be wise to be ready for new developments with the ACA and beyond.

CBO to release analysis of ending key ObamaCare insurer payments

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CBO to release analysis of ending key ObamaCare insurer payments

CBO to release analysis of ending key ObamaCare insurer payments

The nonpartisan Congressional Budget Office (CBO) will release an analysis next week detailing the effects of ending key ObamaCare insurer payments.

The CBO announced Friday the score would be released next week.

President Trump has threatened to cancel the payments, known as cost-sharing reductions, which reimburse insurers for giving discounted deductibles and copays to low-income people.

The administration has made the payments on a month-to-month basis but insurers have pleaded for long-term certainty.

The reimbursements total $7 billion for fiscal 2017, and regardless of whether the administration pays them, insurers would still be on the hook to offer these discounts to enrollees — they just wouldn’t be reimbursed for doing so.

Uncertainty over the future of the payments has contributed to insurers exiting the healthcare exchanges and proposed premium increases for 2018. More insurers might leave or increase premiums if the payments aren’t continued.

The Senate Health Committee will hold bipartisan hearings in September on ways to stabilize and strengthen the individual market.

The goal is to craft a bipartisan, short-term proposal by mid-September, which could include funding the payments.

The Hidden Subsidy That Helps Pay for Health Insurance

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As Republican senators work to fix their troubled health care bill, there is one giant health insurance subsidy no one is talking about.

It is bigger than any offered under the Affordable Care Act — subsidies some Republicans loathe as handouts — and costs the federal government $250 billion in lost tax revenue every year.

The beneficiaries: everyone who gets health insurance through a job, including members of Congress.

Much of the bitter debate over how to repeal and replace the law known as Obamacare has focused on cutting Medicaid and subsidies that help low-income people buy insurance.

But economists on the left and the right argue that to really rein in health costs, Congress should scale back or eliminate the tax exclusion on what employers pay toward employees’ health insurance premiums. Under current law, those premiums are not subject to the payroll or income taxes that are taken out of employees’ wages, an arrangement that vastly benefits middle- and upper-income people.

That one policy tweak could reduce health care spending, stabilize the health insurance market and, according to Congressional Budget Office estimates, shrink the federal budget deficit by between $174 billion and $429 billion over a six-year period

Lawmakers briefly pondered the idea this year but quickly abandoned it, recognizing how politically explosive it would be. Still, as Congress seeks to push ahead with major changes to the health system and the tax code, there has been a growing awareness of how long-established tax subsidies — like the mortgage deduction for homeowners — have contributed to economic inequality in the United States.

Republicans who have been fighting for seven years to repeal the Affordable Care Act argue that the Medicaid expansion has cost too much, that the subsidies for lower-income insurance customers are in some cases handouts. Senator Orrin G. Hatch of Utah, the chairman of the Finance Committee, likened the expenditures recently to “the dole.”

“The public wants every dime they can be given,” he told reporters in May as he left a health care meeting to explain the difficulty in cutting those programs. “Let’s face it, once you get them on the dole, they’ll take every dime they can.”

The tax exclusion, though, is also a subsidy, one that disproportionately helps the affluent, who are more likely to receive generous health benefits from an employer and who fall into higher tax brackets, making the tax break worth more.

A 2008 study by the Joint Committee on Taxation found that not paying taxes on these benefits saved people with incomes less than $30,000 about $1,650. For people with incomes above $200,000, the average tax savings was $4,580.

The Affordable Care Act required companies to start reporting the value of employer-sponsored health benefits on W-2 forms (Box 12; Code DD). But most people don’t even realize they get a subsidy typically worth thousands of dollars a year.

For the federal government, the health benefits exclusion is the single largest tax expenditure, accumulating over the next decade to about 1.5 percent of the nation’s gross domestic product. (Economists say it is effectively the federal government’s third-largest health care expenditure, after Medicare, which cost about $581 billion last year, and Medicaid, at $349 billion.)

It costs five times as much as the subsidies the Affordable Care Act set up to help people buy health insurance, which are estimated to total $49 billion this year. And it is far more than the $70 billion the federal government is spending to expand Medicaid under Obamacare this year.

But few lawmakers, Republican or Democrat, have ever argued to change the exclusion. The closest Congress came to making the system more progressive — that is, to make it scale up according to income — was the so-called Cadillac tax included in the Affordable Care Act.

That was supposed to tax the most generous employer benefits to help pay the subsidies in the law, but its effective date got pushed back to 2020. Both the Republican House and Senate health bills shove it back further, so long — a decade in the Senate bill — that many analysts say it is unlikely to ever take effect.

What Different Health Policies Cost

“This seems like a natural place to look for revenue to expand coverage,” said Stephen Zuckerman, a senior fellow and co-director of the health policy center at the left-leaning Urban Institute. But, he said, “It becomes a political problem.”

Business groups, which tend to back Republicans, argue that a cut in the tax exclusion is a tax increase; labor unions, which tend to support Democrats, say it will lead them to lose benefits at the same time their wages have stagnated.

“We don’t think it does the things economists say it’s going to do,” said James Gelfand, senior vice president for health policy for the Erisa Industry Committee, which lobbies for large employers. “Ultimately these proposals are designed to end the employer-sponsored system,” he said. “They’re not indexed to reality.”

The benefit began with the wage controls of World War II. Employers got around those limits by offering more generous health benefits, and the Internal Revenue Service and later Congress said those benefits did not have to be taxed.

Employer-based health insurance now covers more than half the non-elderly population in the United States. The average premium in 2016, according to the Kaiser Family Foundation, was $6,435 for an individual and $18,142 for a family, and the tax exclusion reduced the cost of insurance by about 30 percent.

Even economists who dislike the exclusion recognize its benefit: It pools risk, the way some countries have done with national health insurance, and reduces adverse selection by encouraging the healthy to buy insurance.

But economists also argue that the exclusion creates perverse incentives that drive up the cost of coverage. Studies have found it encourages workers to buy more expensive insurance and to use more medical services than they need.

“Because we have invented a system where most people have extremely generous coverage, no one asks about the price, and no one tells them what the price is,” said Joseph Antos, an economist and scholar in health care policy at the American Enterprise Institute, a conservative think tank.

Every year the Congressional Budget Office analyzes options for reducing the deficit, including reductions in the tax exclusions for employer-provided health insurance.

In its 2016 analysis, the C.B.O. found that imposing income and payroll taxes on premiums higher than the 50th percentile beginning in 2020 — this would be contributions above $7,700 a year for individuals and $19,080 for families — would cut the federal deficit by $429 billion by 2026, more than either the House or Senate health bills would achieve, according to C.B.O. analyses.

It would also cause four million fewer people to have employer-based health insurance, the analysis found. Half of those people would go to health insurance exchanges set up by the Affordable Care Act, fewer than 500,000 would enroll in Medicaid, and one million would remain uninsured.

Subjecting premiums at the 75th percentile or higher to payroll and income taxes beginning in 2020 — premiums higher than $9,520 for an individual and $23,860 for a family — would reduce the deficit by $174 billion by 2026, the C.B.O. found.

Economists bet that employers would pay less for health insurance and pass on that savings in the form of higher wages. But business groups and business owners say that is unlikely.

Particularly in high-cost states, employers say offering a less attractive package of health benefits hurts their ability to hire.

“Good employees are the most important resource companies have, and this is part of the landscape that folks expect,” said William McDevitt, a shareholder with Wilkin & Guttenplan, an accounting and consulting firm in New York and New Jersey. “Messing with that matrix to generate revenue, I just see it as anarchy, politically.”

Even if companies did increase wages, employees would have to pay higher taxes, leaving them with less money to buy health insurance.

“You’re going to tell every employee they’re going to pay 20 percent more in federal taxes? Is that going to change what they need and their behavior?” asked Bill Grant, the chief financial officer of Cummings Properties in Massachusetts, a real estate firm that spends about $2 million a year to pay about 70 percent of the health insurance premiums for its 350 full-time employees. “And if part of that premise is that they are using more than they need, is paying more to Uncle Sam going to change that lifestyle? I don’t think so.”