KHN Morning Briefing

Summaries of health policy coverage from major news organizations.

Kaiser Health News Original Stories

Political Cartoon: 'Tear Down This Wall?'

Kaiser Health News provides a fresh take on health policy developments with "Political Cartoon: 'Tear Down This Wall?'" by Joel Pett.

Here's today's health policy haiku:

WALK A MILE FOR A CAMEL?

Tobacco makers
Don’t want to have to breathe in
your secondhand smoke

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Health Law Issues And Implementation

Rules On Marketplace Forms May Put Immigrants At Disadvantage

The Associated Press reports that immigrants and naturalized citizens will not be allowed to use the new EZ application for healthcare.gov. Other outlets report on enrollment efforts in North Carolina, Maryland, Minnesota, Oregon and Michigan.

Politico Pro: Obamacare Foot Soldiers, Armed With Experience
The second season of Obamacare enrollment begins Nov. 15. Advocates expect a way smoother start than last years’ debacle. The websites should be in better shape, the political opposition isn’t quite as intense and people working on signups had plenty of missteps from last year to learn from. (Villacorta, 10/22)

The Associated Press: Blue Cross Reveals 2015 Health Insurance Rates
North Carolina's largest health insurer said on Wednesday that 2015 rates will rise by more than 13 percent on average for people who buy their own Affordable Care Act policies. ... Blue Cross said rates would rise an average of 13.5 percent for 315,000 customers who enrolled this year in individual plans that comply with President Barack Obama's health insurance law. It cautioned that the actual increase for each policy will be affected by factors including age, location and plan level. As an example, the insurer said a 45-year-old nonsmoking man in the Raleigh area who didn't receive subsidies would see his monthly premium rise by about $57 to $421.32 per month on a typical individual ACA silver plan. The vast majority of customers, however, receive subsidies that will insulate them from rate increases. (Drew, 10/22)

And, a sampling of news from state exchanges -

The Associated Press: Maryland To Keep Testing Health Exchange Website
Maryland’s information technology secretary says the state will be testing how well its revamped health exchange website can handle thousands of users over different periods of time. Isabel FitzGerald gave an update on Tuesday about how work is going. The state has incorporated new technology from Connecticut to revamp the website, which crashed on the day it opened last year. (10/21)

Minneapolis Star-Tribune: State Sought Lower MNsure Rates From PreferredOne
Sometime after the insurer PreferredOne submitted its proposed rates for the first year of the MNsure exchange, state regulators asked the company to consider lowering the numbers. Ultimately, the insurer responded with “a total rate decrease of 37 percent,” according to a July 2013 letter from an outside actuary to the company. Those final rates were the lowest in the Twin Cities — and across the country, in many cases — and helped Preferred­One to grab nearly 60 percent of the MNsure business. Now, those subscribers face an average premium increase of 63 percent if they stay with PreferredOne — a yo-yo scenario that health policy experts say points to the challenge in setting prices under the federal health law. The big swing also suggests that the low prices were out of step with the reality of the business. (Snowbeck, 10/22)

The Associated Press: Oregon Cuts Ties With Oracle's Health Exchange
Oregon is cutting its last ties with a botched health insurance exchange portal built by Oracle Corp. as the state and the high-tech company pursue lawsuits against each other. In April, Oregon announced it was giving up on the troubled state exchange and would use the federal site HealthCare.gov for signing people up for private insurance policies. Oregon had planned to salvage some of the Oracle-built portal to enroll people in Medicaid, but officials have now decided to scrap that project as well and will use another state's Medicaid enrollment system instead. Low-income Oregonians who are eligible for Medicaid will also enroll via HealthCare.gov during the upcoming open-enrollment period, which starts Nov. 15. The new system for the state will not be ready until next year. (Wozniacka, 10/22)

On the Medicaid expansion front -

The Associated Press: Report: Planning Helped Medicaid Expansion Rollout
The initial success of Michigan's Medicaid expansion could be useful to other states considering their own plans under the Affordable Care Act, according to a report by a team of University of Michigan Medical School researchers. ... Michigan rolled out its plan as much as three months later than some states, which allowed residents to find out more about what it offered and how to sign up. Michigan also used networks of organizations to publicize the plan and hired a company to take calls from potential applicants. (10/22)

Health Law Foes Build Subsidy Challenge

Using blog posts, conferences and subpoenas, the Cato Institute and others are ramping up efforts to persuade the Supreme Court to hear a lawsuit challenging subsidies for Americans who purchase health coverage in federal, as opposed to state-run, insurance marketplaces. Other stories look at the role of federally qualified health centers and who should get the credit for the slowed growth of Medicare costs.

CQ Healthbeat: Cato Ramps Up Campaign To Cancel Health Law Subsidies
Opponents of health law subsidies designed to help lower income people buy health insurance are working to persuade the Supreme Court to review the legality of the federal program for distributing the financial assistance. Using blog posts, conferences and subpoenas, the Cato Institute and other health law foes are trying to buttress legal cases challenging the subsidies and shorten the timetable for possible Supreme Court review. They also hope to embolden Senate Republicans opposed to the law, who could take control of the chamber in the mid-term elections.The main target of the campaign are the Supreme Court justices, who are scheduled to meet Oct. 31 to confer over whether to grant a petition filed by subsidy opponents in the case King v. Burwell. The justices could decide as soon as Nov. 3 or hold the case over and respond at some future time. (Reichard, 10/22)

NJ Spotlight: Health Centers Serving State's Low-Income Patients Carving Out Wider Role
For decades, federally qualified health centers (FQHCs) have played a crucial role in providing care to low-income New Jerseyans. Now, two trends are combining to make the centers even more essential – the rising number of people covered by Medicaid and other health insurance as a result of the Affordable Care Act and expanded services ranging from pharmacies to dental clinics. But state regulations represents a major roadblock to effort to integrate healthcare services for patients who may have chronic physical conditions, such as diabetes or hypertension, and behavioral or mental health conditions like depression. New Jersey has long-standing rules that require facilities like FQHCs to have separate entrances and service areas for patients in need of behavioral health and addiction services. (Kitchenman, 10/22)

The Washington Post's Wonkblog: You May Want To Thank George W. Bush — Not Obamacare — For The Remarkable Medicare Cost Slowdown
The cost of Medicare has been slowing dramatically in recent years, leading to much head-scratching by health economists and much credit-mongering by politicians. President Obama, for instance, claimed earlier this month that his Affordable Care Act is driving down both Medicare costs and the overall cost of healthcare. Now comes evidence that an entirely different program may deserve more of the credit, at least as far as Medicare is concerned -- the Medicare prescription drug program, enacted under president George W. Bush. (Montgomery, 10/22)

Capitol Hill Watch

What A GOP Senate Could Mean For The Health Law

Under the assumption that Republicans will win control of both houses of Congress, economists weigh in on Republican budget plans, which did not include repeal of the Affordable Care Act.

The New York Times: Economists See Limited Gains In G.O.P. Plan
Anticipating a takeover of Congress, Republicans have assembled an economic agenda that reflects their small-government, anti-regulation philosophy, but also suggests internal divisions that could hinder a united front against President Obama ... The proposals would mainly benefit energy industries, reduce taxes and regulations for businesses generally, and continue the attack on the Affordable Care Act. It is a mix that leaves many economists, including several conservatives, underwhelmed. ... Omitted were two of House Republicans’ most far-reaching and divisive proposals: repeal of the president’s Affordable Care Act — senators instead propose changes to its employer mandates — and the so-called Ryan Plan, a long-term budget to revamp Medicare and Medicaid and significantly reduce other domestic and military spending enough to balance the budget in 10 years, while sharply cutting taxes. That House budget never gained much support among Senate Republicans. (Calmes, 10/22)

Minnesota Public Radio: In First Debate, Peterson, Westrom Battle Over Health Care
In their first debate before the Nov. 4 election, Democratic U.S. Rep. Collin Peterson and his Republican challenger, state Sen. Torrey Westrom, repeatedly clashed over health care. But not unlike other Republican candidates across the nation, Westrom, of Elbow Lake, repeatedly tried to link his opponent to President Barack Obama, whom he attacked during the 30-minute debate. (Gunderson, 10/22)

Meanwhile, the president's pick for surgeon general loses support from a previous backer -

WBUR: Surgeon General Nominee Murthy Loses Support Of Key Backers
One of the country’s leading medical journals is withdrawing support for a Brigham and Women’s Hospital physician nominated by President Obama to become the next surgeon general. The New England Journal of Medicine (NEJM) endorsed Vivek Murthy in May, but an editorial published Wednesday withdraws that support. (Bebinger and Becker, 10/22)

Medicare

Doctors Still Profit From Medicare Referrals Despite Law

A federal law since the 1990s has prohibited “self-referral,” in which doctors profit from Medicare-reimbursed procedures they order. But many physician groups have found ways to do it anyway, exploiting a loophole to the law in ways its writers didn’t anticipate, reports The Wall Street Journal.

The Wall Street Journal: How Medicare ‘Self-Referral’ Thrives On Loophole
In a letter to a friend, the manager of a Florida urology practice worried in 2010 that her company would attract federal scrutiny for its frequent use of an expensive bladder-cancer test. The manager’s concern involved a program at 21st Century Oncology Holdings Inc.—a national chain of cancer practices—that gives its urologists a financial incentive to order the test from a central in-house lab. A federal law since the 1990s has prohibited “self-referral,” in which doctors can profit from Medicare-reimbursed procedures they order. But 21st Century Oncology and many physician groups around the country have found ways to do it anyway, exploiting an exception to the law in ways its writers didn’t anticipate. (Carreyrou and Adamy, 10/22)

The Wall Street Journal: Pete Stark: Law Regulating Doctors Mostly Helped Lawyers
Pete Stark’s landmark law to curb medical self-referral hasn’t worked out how he planned. His retirement, on the other hand, is playing out just how he’d like it to. “It’s a lot of fun,” the former California Democratic congressman said of life after Capitol Hill during a recent interview. “I’m lazy and just enjoying getting ready for the winter.” Self-referral occurs when doctors refer patients needing services such as lab tests or MRIs to entities from which they benefit financially. The Stark Law, passed two decades ago, sought to ban self-referral when the patient is covered by Medicare or another government plan. But many medical groups have gotten around the law, as the Journal reports in a page-one article today. (Adamy, 10/22)

In related news -

The Denver Post: DaVita To Pay $389M To Settle Anti-Kickback Investigations
Denver-based DaVita HealthCare Partners will pay $389 million to settle a criminal and civil anti-kickback investigation into transactions with doctors spanning nearly a decade, the U.S. Justice Department announced Wednesday. The kidney dialysis company's payment includes $350 million for the settlement and a civil forfeiture fine of $39 million for two joint ventures DaVita entered into with physicians in Denver. "This case involved a sophisticated scheme to compensate doctors illegally for referring patients to DaVita's dialysis centers," U.S. Attorney for Colorado John Walsh said in the release. "Federal law protects patients by making buying and selling patient referrals illegal, so as to ensure that the interest of the patient is the exclusive factor in the referral decision," he said. The settlement resolves allegations regarding the company's arrangements with physicians and physician groups from March 2005 to last February, the U.S. attorney's office said.

Public Health And Education

Ebola Causes Revenue Drop At Texas Presbyterian Hospital

As President Obama reassured the public, the hospital's parent corporation, Texas Health Resources, said most of the revenue decline came from the ER.

The Washington Post: Obama ‘Cautiously More Optimistic’ On Ebola
President Obama said Wednesday that he was "cautiously more optimistic" that the chances of additional infections in the U.S. stemming from Ebola victim Thomas Eric Duncan are ebbing." The fact that Duncan's closest associates have not fallen ill, the president added, "just gives, I think, people one more sense of how difficult it is to get this disease." (Eilperin, 10/22)

Bloomberg: Dallas Hospital With First Ebola Patient Sees Revenue Dip
The Dallas hospital that treated the first patient in the U.S. diagnosed with Ebola saw its patient count and revenue drop by more than 20 percent in October compared with the first nine months of the year. ... The data was released the same day President Barack Obama called nurses at the hospital “to offer words of encouragement and support,” the hospital said in a separate statement. The negative financial impact “is primarily the result of the emergency department being placed on diversionary status” from Oct. 12 to Oct. 20. (Preston, 10/23)

The Associated Press: Hospital Of Ebola Patient Posts Poor ER Benchmarks
For all the strengths of Texas Health Presbyterian Hospital Dallas, the first U.S.-diagnosed Ebola patient walked through its seemingly weakest link: the emergency room. Presbyterian met or exceeded 75 percent of 138 specific measures of care, according to its most recent data. But its emergency department failed to meet all five national patient safety and quality benchmarks the hospital reported. (Mendoza and Sedensky, 10/23)

The Wall Street Journal: Ebola Still Weighs On Texas Hospital
Texas Health said it believed it had sufficient financial reserves to cover losses ... Last week, Moody’s Investors Service revised its outlook for bonds issued by Texas Health Resources to “developing” from “positive,” as analysts attempt to gauge the effect the Ebola scare may have on patient volumes. (McCabe and Weaver, 10/22)

The Hill: Texas Health Official: Funding Boost Needed On Outbreaks
“Hospital preparedness needs to be improved. It’s not all about making a vaccine or a new drug against Ebola or new leadership. Some of it is just preparedness right on the ground. I think that would yield tremendous benefits to the system,” Dr. Brett Giroir said on CNN's "New Day." Giroir is the head of the Texas Task Force on Infectious Disease Preparedness and Response. (Shabad, 10/22)

State Watch

Calif. State Ballot Initiatives Prove To Be Political Flashpoints

Also, in North Dakota, voters will consider a "personhood" ballot measure that could have significant repercussions for health care in the states; and, in New Hampshire, Medicaid expansion is becoming a big issue in the state's gubernatorial contest.

Sacramento Bee: Poll: Prop. 45 Trails, Water Bond, Jerry Brown Up
Support for the Nov. 4 ballot initiative requiring that health insurance rate changes be approved by the state’s elected insurance commissioner is eroding, according to a new poll out late Wednesday, with the measure faltering under the weight of a $57-million campaign funded largely by insurers. The Public Policy Institute of California survey found that Proposition 45 is supported by just 39 percent of likely voters, sliding nine percentage points since September. Some 46 percent would vote no and 15 percent remain undecided. (Cadelago, 10/22)

Los Angeles Times: Nader Assails Brown For Not Backing Prop. 46 To Raise Lawsuit Caps
Consumer advocate Ralph Nader blasted his onetime ally California Gov. Jerry Brown on Wednesday for failing to back a November ballot proposition that would raise the cap on pain-and-suffering awards in medical malpractice suits. “It’s inexplicable to me. It’s disappointing beyond my ability to explain to you,” Nader said in an interview, a day after he wrote a letter to Brown voicing his displeasure over his refusal to climb aboard Proposition 46. (Mehta, 10/22)

Santa Cruz Sentinel: Prop. 46 Battle Pits Doctors, Lawyers Overshadowing Los Gatos Family Tragedy
Since Adam [Glover]'s inexplicable death five years ago, his mother has been trying to find out what went wrong. Five independent doctors who [Sarah] Hitchcock-Glover consulted told her that Adam's death was preventable and that he died from hypovolemic shock, when the heart is unable to pump enough blood due to severe fluid loss. This November, voters will consider Proposition 46, a patient safety initiative, in part because of Hitchcock-Glover's work. (Clark, 10/22)

Modern Healthcare: North Dakota 'Personhood' Ballot Measure Raises Concerns On Broader Health Care Impact
A type of “personhood” amendment North Dakotans will vote on next month could have broad ramifications for healthcare in that state, some experts say. Voters will decide whether to adopt a seemingly simple amendment to the state's constitution. “The inalienable right to life of every human being at any stage of development must be recognized and protected,” reads the ballot measure that voters will consider. Measure 1 was originally viewed as an anti-abortion measure. But opponents say it could insert the government into crucial decisions about medical care because its unusually broad language could apply to end-of-life care and other types of treatments as well. If passed, it would be the first such personhood law in the country. (Demko, 10/22)

The Associated Press: Medicaid Expansion Top Issue In N.H. Gov's Debate
Medicaid expansion and the state budget emerged as key issues Wednesday in Democratic Gov. Maggie Hassan and Republican businessman Walt Havenstein's first televised debate. Hassan, who is seeking her second term, has centered her campaign on bipartisan accomplishments during her first term, while Havenstein says his background leading large defense companies such as BAE Systems makes him better qualified to manage the state budget. In the debate, broadcast on WBIN-TV, the two also sparred over casino gambling and a recent increase in the gas tax and disagreed on almost every issue. The election is Nov. 4. Hassan signed a Medicaid expansion bill earlier this year that aims to bring 50,000 low-income people onto private insurance plans using federal dollars through the Affordable Care Act. Three Republican and three Democratic senators crafted the plan. (10/23)

State Highlights: Calif. Official Protests Rate Hike; Baltimore Cancels Medicare Drug Payments

News outlets report on health care developments in California, Georgia, Maryland and Nebraska.

Los Angeles Times: Anthem Rate Increase 'Excessive,' State Insurance Regulator Says
In the final days of a battle over Proposition 45, California's insurance commissioner criticized Anthem Blue Cross for an "excessive" rate increase affecting 120,000 people with small-business health coverage. Dave Jones said Anthem had failed to justify its 10% average rate increase and used an "unwarranted accounting maneuver" to mask its high profits. But Jones has no power now to stop Anthem's increase, a fact he's been campaigning hard to change with Proposition 45. (Terhune, 10/22)

The Baltimore Sun: City Plans To Stop Paying For Medicare Prescription Drugs
Baltimore officials this week sent about 40,000 letters to city employees and retirees, telling them the city will no longer pay for prescription drugs under Medicare as of 2020. City officials are touting the move -- which they say is made possible by President Barack Obama’s Affordable Care Act closing a coverage gap that Baltimore supplemented -- as a way to save millions for cash-strapped Baltimore. But union workers are criticizing the plan, which they argue could drive up costs for some seniors who’ll need to find coverage in the private market. (Broadwater, 10/23)

Georgia Health News: Is Georgia's Medical Access Law Too Weak?
The state insurance department is looking at possible ways to strengthen a Georgia law that requires health insurers’ networks to give consumers adequate access to doctors and hospitals. “Georgia is not alone: The feds and all the states are looking at the issue,’’ Trey Sivley, director of the Division of Insurance and Financial Oversight for the Georgia agency, told GHN recently. (Miller, 10/22)

The Associated Press: Nebraska Health Care Cost Dispute Still Unresolved
A letter from one of Nebraska's biggest medical networks suggests a costs dispute with a major insurer, Blue Cross Blue Shield, likely will continue into next year. UniNet Healthcare Network, the CHI Health entity that negotiates contracts with doctors and insurers, shared that likelihood in letters to insurance brokers. ... Blue Cross has said CHI Health, which used to be Alegent Creighton Health, routinely charges 10 to 30 percent more than other Omaha hospitals. CHI Health has said those figures are misleading and that its total cost of treatment is lower even if certain services cost more. (10/22)

Los Angeles Times: Cal State Awarded $60 Million In Federal Grants To Help Diversify Biomedical Research
Three California State University campuses Wednesday were awarded more than $60 million in federal grants to help train low-income and minority students for biomedical research careers. The National Institutes of Health grants are for five years and include $22.7 million to Cal State Long Beach, $21.8 million to Cal State Northridge and $17 million to San Francisco State University to develop mentorship programs, engage students' families, improve instruction and develop community-based research projects. (Rivera, 10/22)

Editorials And Opinions

Viewpoints: CDC Ebola Plan Better Than Travel Ban; Health Care Law Is 'Election Albatross'

A selection of opinions on health care from around the country.

The New Republic: The CDC's New Ebola Plan Is Better Than A Travel Ban
The Centers for Disease Control just announced new measures designed to stop international visitors from spreading Ebola in the U.S. Under the new system, anybody who has been recently to Guinea, Liberia, or Sierra Leone will be subject to what CDC officials call “active monitoring”—which will involve, among other things, mandatory temperature checks for 21 days after arrival in the U.S. It’s not the travel ban that Republican politicians, some Democrats, and most of the public seem to want. But, if the experts are right, that’s a good thing: The new proposal will make the public safer, at least at the margins, without imposing restrictions that would, indirectly, make the epidemic worse. (Jonathan Cohn, 10/22)

The Washington Post: The Politics Of Ebola
Voters are unhappy with both parties and there is no driving issue, so a play-all-the-angles approach takes whatever story is dominating the news cycle and tries to turn it into a wedge. Nowhere has this pattern been clearer than in the rise of public worries about Ebola and the effort by Republicans to turn fear into a closing argument. (E.J. Dionne Jr., 10/22)

USA Today: Misinformation Mars Ebola Travel Ban Debate: Our View
With Ebola ravaging West Africa, an infected Liberian traveler dead in Dallas and confidence in government assurances shaken, it's no wonder people are grasping at anything that looks like it might provide a measure of safety. And what they're grasping at now are proposals to ban travel to the USA from the three West African countries hardest hit by Ebola. At first glance, a travel ban looks like a quick, easy answer. ... The problem is, much of the debate has been fought on glib generalities from both sides. (10/22)

USA Today: Implement Ban On Travel Now: Opposing View
The U.S. should implement an immediate temporary travel ban preventing entry by citizens of the West African countries afflicted by the Ebola virus, as I said in July. Had we done that, we wouldn't have Ebola in the U.S. right now. (Rep. Alan Grayson, D-Fla., 10/22)

The New England Journal of Medicine: Where Is The Surgeon General?
As an unchecked Ebola epidemic moves out of West Africa to touch the United States and the rest of the world, we should rightfully ask, “Where is the Surgeon General?” The answer is, quite simply, that we do not have one. We face a growing crisis of confidence in our ability to protect patients and health care workers, and the position of the chief public health officer of the United States remains unfilled. (Gregory D. Curfman, Stephen Morrissey and Jeffrey M. Drazen, 10/22)

The Wall Street Journal: ObamaCare Returns As An Election Albatross
Democrats assumed earlier this year that ObamaCare would be a political advantage by Election Day. ... It isn’t working out that way. As the election nears, ObamaCare is re-emerging as a major liability for the Democratic Senate that passed it. According to an Oct. 2 Gallup survey, 54% of Americans said the Affordable Care Act had hurt them and their families compared to 27% who said it had helped them. (Karl Rove, 10/22)

Bloomberg: Sorry, Obamacare Is Still Unfixable
Democratic Senators Mark Warner and Mark Begich deserve credit for advancing specific legislation to change the law. The main change they're advocating, though, is unlikely to make people any happier with the law -- and could cause new problems. The senators want to give customers buying insurance on the Obamacare exchanges a new option with low premiums and high deductibles. ... A pro-copper plan study put out by the insurance industry assumes that some people who were uninsured will buy the new product: hence the coverage increase. And it assumes that some people who bought higher-premium plans will migrate: hence the lower average premium and taxpayer subsidy. That migration could, however, make the exchanges less stable by reducing the amount of money that healthy people are putting into them through their premiums. (Ramesh Ponnuru, 10/22)

Forbes: Why You Have The Wrong Kind Of Health Insurance: Obamacare
High deductibles are causing patients to skip health care they really need. At the same time, there are no deductibles or copayments for a whole slew of services that people don’t need or could easily pay for out of pocket. What’s the common denominator here? Obamacare. (John C. Goodman, 10/22)

Indianapolis Star: Medicaid Expansion Hurts Indiana’s Competitiveness
The plan Indiana originally submitted for federal approval is predicted to cost $18 billion through 2020, with the state paying $1.5 billion of that total. But according to recent analysis by the nonpartisan State Budget Solutions, the plan could actually cost the state an additional $2.9 billion. That is the equivalent of almost 177,000 Indiana jobs or $3,700 for every Indiana household for these costs. Even more troubling is the potential impact that an Indiana expansion would have on the incentives for able-bodied adults to seek work. (Naomi Lopez Bauman, 10/22)

Richmond Times Dispatch: Gillespie Plan Elicits A Shrug
In a meeting with The Times-Dispatch last month, Republican senatorial candidate Ed Gillespie would not disclose details about his plan to replace Obamacare. Evidently he wanted to keep the public in suspense. Last week he finally unveiled his plan. It hardly seems worth the wait. (10/22)

The New England Journal of Medicine: Launching The Healthy Michigan Plan — The First 100 Days
Michigan is one of five Republican-controlled states (along with Arizona, North Dakota, Ohio, and Pennsylvania) to expand Medicaid, and one of four states (along with Arkansas, Iowa, and Pennsylvania) that received a federal waiver to implement state-mandated modifications. Michigan's early experience with Medicaid expansion may provide useful insights as this new coverage option continues to be debated and implemented in other states. (John Z. Ayanian, Sarah J. Clark and Renuka Tipirneni, 10/22)