Thursday, June 01, 2017

Alternative Facts, Alternative Realities Edition of Health Wonk Review

In a divided country and interconnected world, it often feels as if reality is fracturing before our eyes. When a spokesperson for the President asserts the administration's right to promulgate "alternative facts," it's a major challenge to convince a critical mass of people that verifiable facts are in fact verified. On the plus side, as ever more of the previously voiceless find or create a forum, we have the chance to see how differently a given law or trend may affect different people -- not alternative facts, but variant effects.  This week's Health Wonk blog reflects that variety, as well as battles over fact and interpretation.

First up is Harold Pollack in, tilting against alternative facts of the pure variety -- a.k.a. lies. In You can only lie about policy in Washington D.C., Pollack takes on four of Paul Ryan's assertions about the AHCA (delivered in short space) that the Congressional Budget Office (CBO) analysis of the bill directly contradict.  Most of them boil down to claims that the AHCA will make insurance and healthcare more affordable to more people, but Ryan also avers for the umpteenth time that the ACA marketplace is collapsing under its own weight.

At InsureBlog, conversely, Patrick Paule takes on CBO the old fashioned way -- with a factual critique rather than a go-team cry of fake news. Paule asserts "four reasons the CBO score is flawed."noting that CBO  1) pits AHCA individual market enrollment against CBO's 2016 baseline for the ACA, which overestimated enrollment by 4 million; 2) assumes that under current law, more states would embrace the ACA Medicaid expansion; 3) assumes (thanks to the MacArthur Amendment, allowing states to waive ACA coverage rules) that some health plan enrollees won't have comprehensive coverage, but does not define what coverage must be provided to make the cut; and 4) does not delve into the implications of its forecast that millions will voluntarily drop insurance in the absence of a mandate to obtain it.

The assumptions underpinning each of these objections can be argued rationally on either side. For example, while CBO did overestimate 2017 marketplace enrollment in 2016, its ten-year forecast was for slow subsequent growth, and its original projection for the AHCA (in March) had just 2 million in individual market coverage losses by 2026, with 14 million in Medicaid and 7 million in the employer-sponsored insurance.

Louise Norris, also in,  takes on the endlessly repeated Republican claim that the ACA marketplace is collapsing under its own weight by meticulously documenting 10 ways the GOP sabotaged Obamacare -- from short-changing the co-ops to gutting risk corridor payments to challenging (and more recently, threatening to cut off) federal payments to insurers for the Cost Sharing Reduction subsidies that the ACA requires insurers to provide. This slow march through seven years of sabotage brings to mind a different kind of alternative reality, the counterfactual: what if Republicans had channeled their energy into making the law work as well as possible, once it had been duly enacted? Louise also provides evidence that the ACA marketplace was not collapsing prior to the most recent, and intense, acts of sabotage.

At Health Care Renewal, Roy Poses imagines a different kind of counterfactual: an economy and healthcare system that's less tolerant of corruption. Riffing off a Matthew Yglesias essay asserting that the U.S. is "uniquely bad" among advanced democracies at policing corporate malfeasance, Poses wonders whether its metastasizing under Trump will shock the country out of "a state of denial about corruption."

At the Health Business Blog, David E. Williams argues that the AHCA makes coverage unaffordable for millions, mainly by repealing without replacing the ACA's Cost Sharing Reduction subsidies. For 7 million lower income current enrollees, the AHCA would replace insurance with CSR-enhanced actuarial values of 94%, 87% or 73% (depending on income, topping out at 250% FPL) with plans likely to average AV 65%, according to CBO.  As Williams points out, more than half of current marketplace enrollees currently access CSR.

While several of this week's contributors assert reasons why the AHCA (or a close Senate cousin) shouldn't pass, Joe Paduda argues that it can't pass the Senate, mainly because "taking benefits away from your core supporters is political suicide" and "core Republican voters are those most hurt by AHCA."  Q.E.D.?   Click through and judge.

Here at xpostfactoid, I argued this week that the AHCA is not quite what it seems. We all know that it radically cuts Medicaid spending (by $834 billion over ten years, according to CBO), but we assume that it also deeply cuts spending on private insurance. And indeed, when first introduced, it did. But in the long struggle toward passage, various patches slapped on ran up a tab -- and when you include new tax breaks, the bill spends almost as much subsidizing private insurance as the ACA does (with inferior results). More than ever, the bill's core function is to pay for tax cuts with Medicaid cuts.

Health Access California executive director Anthony Wright takes us into a political alternative universe -- California -- where government and electorate are bent on expanding coverage, not contracting it. Wright recounts that in November, California voters supported three separate ballot measures to support Medi-Cal, the state Medicaid program, including two revenue measures—one to extend upper income taxes, and the other a tobacco tax increase. The California Assembly and Senate are proposing to use $1.2 billion raised from the tobacco tax to improve provider rates, restore benefits like dental and podiatry, and expand eligibility to all young adults up to age 26, regardless of immigration status.

In a CareCentrix podcast, CEO John Driscoll, talking to David E. Williams, asserts that when it comes to dealing with the opioid crisis, U.S. Attorney General Jeff Sessions is in another kind of alternative reality: a prior century.  Sessions, Driscoll laments, is focused on pot and punishment, when he should be focused on opioids and treatment. Driscoll and Williams also discuss the Medicaid expansion and "hospitals at home."

The world of civil liberties and workplace protections that American citizens enjoy too often does not exist for the undocumented, as Tom Lynch in Workers' Comp Insider graphically illustrates. In The Iceman Cometh, Lynch tells the tale of a longtime undocumented construction worker, married with three children born in the U.S., who fell off a ladder and broke his leg. Fortunately -- one might think -- he lived in one of 14 states that expressly allow workers' comp benefits to undocumented immigrants. Alas, his employer collaborated with a federal agency gone wild:
the owner calls to tell you not to worry about anything. He says he wants to make things easier for you and the family. He thinks it would help if he gave you some cash to tide you over until the workers’ comp kicks in. Why not come into the office tomorrow at, say, 11:00, so he can do that? You’re grateful, and, in your broken English, you thank him and tell him you’ll be there.

Tomorrow comes. Eleven AM and you’re hobbling in the door to the office, broken leg and all, which is when the train comes off the rails. The owner’s not there, but ICE is. Immigration and Customs Enforcement, ICE, come to arrest you. 
True story, and it happened this past month.

Reality has done a 180 at HHS since Tom Price took over. Charles Gaba of the ACASignups blog confronted the new world order when HHS put out a brief trumpeting a 105% average premium increase from 2013-2017 in the individual market nationally. Having previously pointed out that comparing pre- and post-ACA premiums is apples-to-oranges, given the skimpiness in many pre-ACA plans, this week Gaba focused on HHS's failure to take premium subsidies, accessed by a bit more than half of individual market enrollees, into account. Gaba ran the numbers state by state and came up with a weighted average premium increase of 22% for subsidized and unsubsidized enrollees combined.

We will all face an ultimate reality -- death -- and as responsible adults we need to plan for it. David Anderson of Duke, writing at Balloon Juice, urges us all to have that conversation about end-of-life care:
Have that conversation if you are young and healthy. Have that conversation if you are old and planning a six month hike along the Appalachian Trail. Have that conversation if you are seeing a doc a week. Have that conversation and then ask your loved ones to have their conversation about what they wish with you.
Finally, at Healthcare Economist, Jason Shafrin summarizes results of a new study he just co-published, examining whether healthcare payers actually use "value frameworks" to help assess the value of different treatments. The researchers found that payers do in fact use such tools, and they interviewed some users in depth.  Among respondents' recommendations for such tools: take a firm position on product value,and allow product comparisons in lieu of comparative clinical trials. Some also expressed some support for allowing manipulation of inputs and inclusion of quality-of-life and patient-reported outcome data.

In the Trump era so far, fact-based reporting and analysis has been challenged and vilified, but not actively suppressed. We're still a polyphonic, if also often cacophonic, society. May we remain so.

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