Source: https://dashealth.com/tag/affordable-care-act-aca
Timestamp: 2019-04-19 10:30:31+00:00

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I was wrong. Wrong about an important part of ObamaCare.
When I joined the Obama White House to advise the president on health-care policy as the only physician on the National Economic Council, I was deeply committed to developing the best health-care reform we could to expand coverage, improve quality and bring down costs. We worked for months to pass this landmark legislation, and I still count celebrating the passage of the Affordable Care Act with the president one balmy spring night in 2010 as one of my greatest Washington memories.
What I got wrong about ObamaCare was how the change in the delivery of health care would, and should happen. I believed then that the consolidation of doctors into larger physician groups was inevitable and desirable under the ACA. I joined my White House health-care colleagues – Ezekiel Emanuel and Nancy-Ann DeParle – in writing a medical journal article arguing that “these reforms will unleash forces that favor integration across the continuum of care.” We added that “only hospitals or health plans can afford to make the necessary investments” needed to provide the care we will need in a post-ACA world.
Well, the consolidation we predicted has happened: Last year saw 112 hospital mergers (up 18 percent form 2014). Now I think we were wrong to favor it.
I still believe that organizing medicine into networks that can share information, coordinate care for patients and manage risk is critical for delivering higher-quality care, generating cost savings and improving the experience for patients. What I know now, though, is that having every provider in health care “owned” by a single organization is more likely to be a barrier to better care.
Over the past five years, published research, some of it well summarized on a Harvard Medical School site, has indicated that savings and quality improvement are generated much more often by independent primary-care doctors than by large hospital-centric health systems.
Look at accountable-care organizations (ACOs), in which doctors and health-care providers come together to provide complete care for an individual and are compensated for keeping them healthy and generating savings. Based upon the latest data the Centers for Medicare and Medicaid Services has released, from 2014, independent physician-led ACOs, like the Rio Grande ACO on the Texas border, are outperforming ACOs from many of the most famous health systems. Johns Hopkins Hospital in Baltimore has been ranked as one of the top three health systems in the nation, but its ACO failed to achieve shared savings in 2014.
Small, independent practices know their patients better than any large health system ever can. They are going up against the incumbent and thus are driven to innovate. These small businesses can learn faster without holding weeks of committee discussions and without permission from finance, legal and IT departments to make a change.
In my White House days, we believed it would take three to five years for physicians to use electronic health records effectively. We were wrong about that too. At every opportunity, organized medicine has asked to delay and lower thresholds for tracking and reporting basic quality measures; yet they have no reason to delay.
In the ACOs run by Aledade, which advises small medical practices (I sit on its board), we have found that independent primary-care doctors are able to change their care models in weeks and rapidly learn how to use data to drive savings and quality. For small practices, it does not take years to root out waste, rewire referrals to providers who charge less but deliver more, and redesign schedules so patients can see their doctors more often to avert emergency-room visits and readmissions.
Recognizing the strength in the small practices, the federal government needs to write rules that make it easier for them to thrive under ObamaCare and don’t tip the scales toward consolidation. That means introducing payment models that limit losses for small providers to the Medicare dollars they receive rather than total spending, and which rely on multiyear benchmarks instead of single-year swings. It also means comparing small practices to other small ones—instead of to large health systems with large balance sheets—when determining if a practice deserves bonus payments for savings.
Large health systems deliver “personalized” care in the same way that GM can sell you a car with the desired options. Yet personal relationships of the kind often found in smaller practices are the key to the practice of medicine. They are the relationships that doctors want to forge with patients, and vice versa. It may sound old-fashioned, but what I have learned is that we do not need to sacrifice this unique feature of our health-care system as we move forward in adapting new value-based payment models and improving the health of patients.
Just months after the Affordable Care Act (ACA) survived a serious legal threat at the Supreme Court, a federal judge gave a boost Wednesday to what could be yet another a major court challenge to the healthcare law.
U.S. District Judge Rosemary Collyer decided House Republicans have standing to sue over their allegation that the administration is illegally spending money that Congress never appropriated for the law’s cost-sharing provisions. Those provisions include reduced deductibles, copays and coinsurance for many beneficiaries depending on income.
The judge also wrote, however, that the House does not have standing to sue over a separate allegation in the lawsuit that the administration had no right to delay the law’s employer mandate, which requires companies with 50 or more employees to provide coverage.
The administration also argued that the House shouldn’t be granted standing because the fight is essentially a political one.
House Speaker John Boehner (R-Ohio) issued a statement praising Collyer’s opinion. “The president’s unilateral change to Obamacare was unprecedented and outside the powers granted to his office under our Constitution,” Boehner said.
The U.S. Justice Department said it plans to appeal the decision.
Now that the case is moving forward, some experts say it could pose a significant threat to the law itself.
About 56% of Americans who receive coverage through the ACA’s insurance exchanges get cost-sharing reductions, lowering the amounts they pay out-of-pocket for deductibles, coinsurance and copayments, according to the CMS. That equals about 5.6 million people.
Without the reductions, “most of the people in the exchanges are not going to want to participate in the exchanges because most exchange participants are receiving cost-sharing subsidies,” said Michael Cannon, a director of health policy studies for the libertarian Cato Institute and a key influence behind the lawsuit that led to the Supreme Court’s King v. Burwell opinion in June. If many healthy people drop out of the exchanges because cost-sharing subsidies disappear, then premiums may rise for those left in the exchanges, he said.
It’s a concern that’s similar to the one many expressed in the debate about King v. Burwell. The challengers in that case argued that the law said insurance premium subsidies should only be available to Americans in states with their own exchanges. The Supreme Court, however, sided with the government in that case in a 6-3 decision that many experts say saved the overall law.
Tim Jost, a law professor at Washington and Lee University who supports the ACA, said healthcare could become unaffordable for many Americans if House Republicans prevail in this latest case.
“If the insurers are required to provide cost sharing reductions but not reimbursed, that’s going to cause very serious financial problems for the insurers, and if they cease to provide cost-sharing reductions, it’s going to cause very, very serious problems for a lot of Americans,” Jost said.
Then again, Jost said, if the House succeeds in the lawsuit, Congress might just have to appropriate the money for cost-sharing because it’s required under the law.
There are other reasons, too, that a Republican victory in the case might not shake the foundations of the law as much as a loss for the government in King v. Burwell would have.
Richard Kogan and Edwin Park of the left-leaning Center on Budget and Policy Priorities recently wrote that beneficiaries will continue to receive cost-sharing reductions regardless of the case’s outcome because they are an entitlement under the ACA.
If Congress refused to appropriate money for the reductions, insurers could then seek relief in the U.S. Court of Federal Claims and would likely win, Kogan and Park wrote.
Meanwhile, Collyer’s ruling on standing may get reversed on appeal before the lawsuit is decided.
Jost said her decision runs contrary to precedent. “She basically concludes that she’s in uncharted waters and can decide for herself what the law should be,” Jost said.
Kermit Roosevelt, a University of Pennsylvania constitutional law expert, said it’s difficult to predict how the case might unfold given that most similar questions haven’t made it past the hurdle of establishing standing. Roosevelt said the case might end up making new law.
Insurance premium subsidies will continue to flow to Americans in all states under the Affordable Care Act, the U.S. Supreme Court decided 6-3 in King v. Burwell on Thursday.
The justices sided with the Obama administration in the historic decision, saying the healthcare law allows Americans in all states—not just those that established their own exchanges—to receive the subsidies.
Chief Justice John Roberts and Justice Anthony Kennedy were the swing votes in the case, siding with the more liberal justices.
An estimated 6.4 million Americans receive the subsidies in the 34 states that don’t have their own exchanges, in many cases relying on them to afford their health insurance, according to HHS.
Many had worried a decision in the opposite direction would lead to a dramatic spike in the nation’s uninsured and the disintegration of the healthcare law itself.
The challengers in the case pointed to one part of the law that says subsidies are available only to those who enroll through an “exchange established by the state.” The federal government, however, argued that the law’s purpose is clear in allowing Americans in every state to be eligible for subsidies and that other parts of the law indicate that.
In siding with the Obama administration Thursday, the justices refused to consider the phrase “exchange established by the state” in isolation. Instead, they looked at the broader context and structure of the law.
“In this instance, the context and structure of the act compel us to depart from what would otherwise be the most natural reading of the pertinent statutory phrase,” Roberts wrote in the opinion.
The Internal Revenue Service has interpreted the law to allow subsidies in all states, but the four individual plaintiffs in the case said that interpretation was wrong. The Supreme Court, however, refused to entertain that idea in their opinion.
The justices declined to apply what’s known as the Chevron doctrine, an oft-cited precedent that says federal agencies must follow the letter of the law where the law is clear. Under the doctrine, if a law is ambiguous, courts must defer to a government agency’s reasonable interpretation of it.
The justices said in their opinion it’s extremely unlikely Congress would have delegated interpretation of the law to the IRS, so the Chevron doctrine wasn’t appropriate for this case.
“Had Congress wished to assign that question to an agency, it surely would have done so ex­pressly … It is especially unlikely that Con­gress would have delegated this decision to the IRS, which has no expertise in crafting health insurance policy of this sort,” Roberts wrote in the opinion.
Some had speculated that if the court had used the Chevron doctrine to decide the case—finding the language of the law ambiguous and allowing the IRS’ interpretation—future presidential administrations could have re-interpreted the statute and pulled the plug on subsidies.
Roberts didn’t seem to want to expose the law to that type of uncertainty by applying the Chevron doctrine, said Ankur Goel, a partner with McDermott Will & Emery who co-authored an amicus brief siding with the government on behalf of the American Public Health Association.
Last summer, a 4th U.S. Circuit Court of Appeals panel in Virginia unanimously ruled in favor of the administration in King v. Burwell, saying subsidies should be allowed in all 50 states.
Dissenting on the decision were Justices Antonin Scalia, Samuel Alito and Clarence Thomas.
Chip Kahn, CEO of the Federation of American Hospitals, called the decision “welcome news” in a statement Thursday.
The three dissenting justices, however, criticized the majority for performing “somersaults of statutory interpretation” in their dissent, written by Scalia.
Scalia argued that the phrase “established by the state” is clear. Context matters, he said, but should be used as a tool for understanding laws, “not an excuse for rewriting them.” He added that the context of the ACA actually undermines the majority’s reading.
But Tim Jost, law professor at Washington and Lee University and a prominent ACA proponent, countered that the majority made the only logical decision.
“It was obvious from the beginning that Congress intended the federally facilitated as well as state exchanges to grant premium tax credits, and if the court was willing to read the statute as a whole and not just focus on four words, it could not avoid that conclusion,” Jost said.
Others, however, agreed with Scalia.
“In the end, the court once again had to rewrite the plain text of Obamacare, in the words of Justice Scalia, to save the Affordable Care Act,” said Josh Blackman, an assistant professor at South Texas College of Law who filed an amicus brief in the case on behalf of the Cato Institute siding with the challengers.
Blackman added that it was curious that Roberts pointed out in his opinion that key parts of the law were written behind closed doors rather than through the traditional legislative process. Roberts also noted that much of the act was passed using a complex budgetary procedure known as reconciliation, which limited chances for debate and amendment.
President Barack Obama remains optimistic that the Affordable Care Act will remain the law of the land for years to come despite a pending Supreme Court decision that could derail the legislation.
Before the end of June, the high court is expected to issue a ruling in King v. Burwell, in which ACA opponents claim that only states with their own exchanges are eligible to receive subsidies. If the court rules against the administration, an estimated 6.4 million Americans in states using the federal exchange would lose subsidies totaling $1.7 billion, according to the Kaiser Family Foundation.
President Obama didn’t explicitly address the pending case during his remarks at the closing of the Catholic Hospital Association Conference, but spoke about the law being around for years to come, to the point that his own daughters would have coverage options after they turned 26.
He went on to say that most people who have obtained coverage as the result of the law are generally happy with their care and the premiums they pay, and noted they would have been as much as $1,800 more today had trends over the decade before the ACA passed continued.
“In the years to come, countless Americans who can now buy plans that are portable and affordable on a competitive marketplace will be free to chase their own ideas, unleash new enterprises across the country, knowing they’ll be able to buy health insurance,” Obama said.
The CHA, which is celebrating it’s 100th anniversary during this week’s conference, was one of Obama’s most reliable allies in getting the Affordable Care Act passed. During his speech, Obama said he could not have gotten the law passed without CHA President and CEO Sister Carol Keehan. Keehan wrote in a 2013 Modern Healthcare op-ed that the law would help Catholic systems advance their mission of caring for the underserved.
The burgeoning group of official and unofficial GOP presidential candidates all agree on one thing when it comes to healthcare policy: They really, really hate Obamacare.
But differences are emerging on the candidates’ approaches to strengthening the long-term finances of Medicare, with former Arkansas Gov. Mike Huckabee bucking Republican orthodoxy. That could become an important fissure in the GOP presidential primary campaign.
Some candidates, while providing few details, have offered clues on their vision for repealing and replacing the ACA. Sen. Marco Rubio (R-Fla.) has proposed a three-part plan including premium tax credits for individuals that he says would be comparable to the tax breaks for employer-based health plans.
He also backs a menu of long-standing conservative policy nostrums, including allowing insurers to sell plans across state lines and expanding health savings accounts.
But Bush’s tenure as a well-paid board member for Tenet Healthcare Corp.—which has strongly supported coverage expansion efforts under the ACA—has prompted skepticism among some conservatives about his anti-Obamacare bona fides. Bush stepped down from the board in December, when he began actively exploring a presidential campaign.
The GOP field, with two major exceptions, is also unified in rejecting the ACA’s Medicaid expansion. Louisiana Gov. Bobby Jindal and Wisconsin Gov. Scott Walker have boasted about their refusal to take the federal dollars, which hasn’t been broadly popular in their own states. In contrast, New Jersey Gov. Chris Christie and Ohio Gov. John Kasich supported Medicaid expansion in their states.
Differences also are emerging over Medicare. Christie has made major Medicare and Social Security restructuring the centerpiece of his agenda, proposing to gradually raise the Medicare eligibility age to 69 and hike premiums for seniors with incomes above $85,000. His proposal is seen as an effort to revive his scandal-marred presidential prospects, but it could alienate the GOP base of older voters.
Last month, Bush and Rubio also came out in favor of raising the retirement age for future Medicare beneficiaries. “The math is unmistakable,” Rubio said. Two other declared candidates, Sens. Rand Paul (R-Ky.) and Ted Cruz (R-Texas), have long backed gradually raising the Medicare age. None of them have addressed the Congressional Budget Office’s 2013 finding that raising the Medicare age to 67 would have only a modest effect on the federal deficit because it would lead to higher spending on Medicaid and ACA premium subsidies.
But Huckabee has staked out a sharply different, populist stance on Medicare, vowing to protect the program from cuts. “I’ll never rob seniors of what our government promised them and even forced them to pay for,” he said last week.
That could cause headaches for other Republican candidates because most have embraced the ambitious entitlement restructuring agenda laid out by Rep. Paul Ryan (R-Wis.). Medicare is highly popular with voters, especially seniors, and Democrats effectively pummeled the GOP ticket of Mitt Romney and Paul Ryan on the Medicare issue during the 2012 president campaign.

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