Daily Health Policy Report

Thursday, October 10, 2013

Last updated: Thu, Oct 10

KHN Original Reporting & Guest Opinion

Capitol Hill Watch

Health Reform

Coverage & Access

State Watch

Weekend Reading

Editorials and Opinions

KHN Original Reporting & Guest Opinion

Health On The Hill: Health Law Fight Complicated By Shutdown, Debt Ceiling Battles

Kaiser Health News' Mary Agnes Carey and CQ Roll Call's Emily Ethridge discuss the latest developments on Capitol Hill. For instance, fights over defunding the health law remain at the center of legislative battles eight days into a federal government shutdown and just a week before the nation hits its debt ceiling (10/9). Listen to the audio or read the transcript.

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Five Lessons From Massachusetts About Obamacare Rollout

WBUR's Martha Bebinger, working in partnership with Kaiser Health News and NPR, reports: "A lot of the Affordable Care Act supporters point to Massachusetts as proof that signing up the uninsured is a big, but doable task. Here, in 2013, that’s a reasonable conclusion. But back in 2007 and 2008 things were a lot messier, and some advocates for universal coverage were worried" (Bebinger, 10/10). Read the story.

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Capsules: Hawaiians Still Unable To Shop On State Exchange

Now on Kaiser Health News' blog, Phil Galewitz reports: "Ten days after the Hawaii Health Connector was supposed to allow consumers and small employers to shop and enroll for coverage, officials are using paper applications and referring people to insurers’ websites to check prices. About 100,000 people are uninsured in Hawaii. It is the only one of the 14 state-run marketplaces, also called exchanges, that has no major functions online. Oregon’s marketplace does not yet allow online enrollment, but consumers can shop for health plans on its website" (Galewitz, 10/10). Check out what else is on the blog.

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Political Cartoon: 'Queue D'Etat?'

Kaiser Health News provides a fresh take on health policy developments with "Queue D'Etat?" by Chip Bok.

Here's today's health policy haiku:

IRS Offical On The Health Law's Implementation

It's going "smoothly."
Consorting with the devil?
Apparently not.
-Anonymous

If you have a health policy haiku to share, please send it to us at http://www.kaiserhealthnews.org/ContactUs.aspx and let us know if you want to include your name. Keep in mind that we give extra points if you link back to a KHN original story.

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Capitol Hill Watch

Obama Meets With Congressional Delegations As GOP Mulls Change In Tactics To End Budget Crisis

The president is having separate meetings with Democrats and Republicans from the House and Senate as both sides seek a solution to the impasse. Some Republicans are looking at a plan on entitlement changes from Rep. Paul Ryan as a roadmap, but others complain that he is abandoning the fight over the health law.

The New York Times: Obama To Meet With Congressional Democrats And Republicans
On Wednesday afternoon, it is the turn of the House Democratic minority, for what some Democrats characterized as a likely pep rally in the East Room for Mr. Obama’s hard-line position. Democrats are united behind the president's stance of not negotiating with Republicans about his health care law or anything else until House Republican leaders agree to fund and reopen the government, and increase the debt limit so the Treasury can keep paying the nation's bills. Mr. Obama has invited the Senate's Democratic majority and its Republican minority as well as, of course, the House Republicans, a White House official said (Calmes, 10/9).

The Associated Press: Obama Seeks Opening On Shutdown With House GOP Leaders Eyeing Short-Term Debt Limit Extension
Obama had House Democrats over to the White House, while Republican conservatives heard a pitch from the House Budget Committee chairman, Rep. Paul Ryan, R-Wis., on his plan to extend the U.S. borrowing cap for four to six weeks while jump-starting talks on a broader budget deal that could replace cuts to defense and domestic agency budgets with cuts to benefit programs like Medicare and reforms to the loophole-cluttered tax code. Curbs to "Obamacare" were not mentioned. At the White House, Obama told House Democratic loyalists that he still would prefer a long-term increase in the nation’s $16.7 trillion borrowing cap but said he’s willing to sign a short-term increase to "give Boehner some time to deal with the tea party wing of his party," said Rep. Peter Welch, D-Vt. (Taylor, 10/10).

The Wall Street Journal: Shutdown Standoff Shows Signs Of A Thaw
Solving an immediate impasse over the debt ceiling wouldn't necessarily resolve the spending fight that has closed the government. Many of the same conservatives who backed a short-term extension of the country's borrowing authority said they are willing to keep parts of the government shuttered in order to keep fighting over the health law. Mr. Obama said Tuesday—and again in a Wednesday meeting with House Democrats—that he was open to a short-term debt-limit increase. White House officials view Thursday's meeting as an opportunity for Mr. Obama to make his case directly to lawmakers who are leading the fight to try to win policy changes, among them curbs to the health law, a senior administration official said (O'Connor, Hook and Lee, 10/9).

The New York Times: As Pressure Mounts, House GOP Weighs Short-Term Debt Deal
House Republicans, increasingly isolated from even some of their strongest supporters more than a week into a government shutdown, began on Wednesday to consider a path out of the fiscal impasse that would raise the debt ceiling for a few weeks as they press for a broader deficit reduction deal. That approach could possibly set aside the fight over the new health care law, which prompted the shutdown and which some Republicans will be reluctant to abandon (Weisman, 10/9).

The Washington Post: Key Republicans Signal Willingness To Back Down On Effort To Defund Health-Care Law
Key GOP figures on Wednesday sent their clearest signals that they are abandoning their bid to immediately stop the federal health-care law — the issue that forced the government to shut down — and are scrambling for a fallback strategy. Republican Party leaders, activists and donors now widely acknowledge that the effort to kill President Obama’s signature initiative by hitting the brakes on the government has been a failure. The law has largely disappeared from their calculus as they look for a way out of the impasse over the shutdown and for a way to avoid a possible default on U.S. debt (Tumulty and Hamburger, 10/9).

Politico: GOP Quietly Backing Away From Obamacare
A fight over Obamacare? That’s so last week. With the government shutdown firmly in its second week, and the debt limit projected to be reached next Thursday, top House and Senate Republicans are publicly moving away from gutting the health care law — a practical move that could help resolve the stalemate and appear more reasonable in the eyes of frustrated voters (Sherman and Raju, 10/10).

Roll Call: Republicans Refocus From Obamacare To Spending
As the GOP searches for a way to save face with conservatives, climb out of the government shutdown and raise the debt ceiling, senior House Republicans are hoping to shift the focus from Obamacare to spending. Wednesday’s Wall Street Journal ran an op-ed from Rep. Paul D. Ryan titled “Here’s How We Can End This Stalemate,” and noticeably absent was the one word that prompted the shutdown chess match: Obamacare (Fuller, 10/9).

Los Angeles Times: Rep. Paul Ryan Fails To Close Republican Divide
The complaint: His plan, which centered on trimming back spending on government entitlement programs, failed to mention the demise of Obamacare as a top Republican objective. Conservatives accused him of abandoning their cause and caving in to Democrats (Mascaro and Memoli, 10/9).

Politico: Paul Ryan: I Haven't Dropped Obamacare
Rep. Paul Ryan on Wednesday insisted that he wasn't giving up the fight against Obamacare as he defended an op-ed he wrote that proposed a solution to end the stalemate in Washington without mentioning the health care law. The day the op-ed touched off blowback from conservatives, the Wisconsin Republican told radio host Bill Bennett that even though he didn't mention Obamacare in his piece in the Wall Street Journal he still sees it as part of his reform proposal because it is an "entitlement" (Weinger, 10/9).

The Hill: Ryan: 'We're Going To Keep Going after ObamaCare'
Rep. Paul Ryan (R-Wis.) said is not giving up on halting ObamaCare, he just wants to add other reforms to the list in budget negotiations with Democrats and President Obama.  Ryan received criticism Tuesday for proposing a host of compromises to end the government shutdown and lift the debt ceiling because he failed to mention defunding or repealing ObamaCare — a chief demand of conservative Republicans that led to the government shutdown (Trujillo, 10/10).

The Associated Press: A Look At The Bruising Basics Behind The Struggle Over The Shutdown, Debt And Health Care
These are complicated times in the affairs of Washington and the nation, with death stars everywhere and all of them a struggle to comprehend. The partial government shutdown, the debt limit squeeze just around the corner, sequestration, how they fit with the health care law, how they don’t — it just goes on. So we’ve cooked up some questions about this grim galaxy and taken a stab at answers (Woodward, 10/9).

Kaiser Health News: Health On The Hill: Health Law Fight Complicated By Shutdown, Debt Ceiling Battles
Kaiser Health News’ Mary Agnes Carey and CQ Roll Call's Emily Ethridge discuss the latest developments on Capitol Hill. For instance, fights over defunding the health law remain at the center of legislative battles eight days into a federal government shutdown and just a week before the nation hits its debt ceiling (10/9).

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Rubio Backs Cruz On Shutdown, McCain Calls Fight 'Fool's Errand'

While news outlets identify fissures among Republicans in the fight tying government funding to derailing the health care law, the billionaire Koch brothers deny playing any role.

The New York Times: Republicans Using Shutdown To Stake Positions For Potential 2016 Bids
Eager to regain favor with conservatives as he considers running for president, Mr. Rubio has fully embraced Mr. Cruz’s effort to block financing for the new health care law, standing with him at news conferences and through procedural maneuvers that led to the shutdown (Martin, 10/9).

Politico: John McCain: Obamacare Fight 'A Fool's Errand'
Sen. John McCain said Wednesday that there was never a chance of defunding Obamacare, blaming politicians who said it was possible for the current government shutdown. "We started this on a fool's errand, convincing so many millions of Americans and our supporters that we could defund Obamacare," McCain (R-Ariz.) told Wolf Blitzer on CNN. "[That] obviously wouldn't happen until we had 67 Republican senators to override a presidential veto." McCain stopped short of naming any of his colleagues specifically when asked who was to blame for the shutdown, but he did say that he believes those who initially advocated for tying the president’s signature health care law to budget negotiations were responsible (Delreal, 10/9).

The New York Times: Kochs Deny Pushing For Shutdown Over Health Law
Koch Industries, whose co-founders, Charles and David Koch, are major donors to Tea Party-inspired conservative causes, accused Harry Reid, the Senate majority leader, on Wednesday of spreading "false information" about the brothers by suggesting they are behind the move to end financing for President Obama's healthcare law and the partial shutdown of the federal government (Stolberg, 10/9).

Bloomberg: Koch Industries Distances Itself From Obamacare Fight
Koch Industries Inc., a holding company led by two billionaire brothers who help finance Republican-aligned public policy groups, sent a letter to U.S. senators yesterday saying the company hasn’t advocated using Obamacare as leverage in the debate about government spending (Bykowicz, 10/10).

NBC News: Kochs To Congress: Focus On Spending Not Obamacare
In a move that highlights a growing rift in conservative ranks, Koch Industries -- the privately held energy conglomerate owned by billionaires Charles and David Koch -- today distanced the firm from allied political groups lobbying to keep the government shut down unless Obamacare is defunded. A letter, signed by the company's chief lobbyist and sent to members of Congress, says that Koch Industries has taken no position on the shutdown dispute in Congress "nor have we lobbied on legislative provisions defunding Obamacare (Isikoff, 10/9)."

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Medical Device Tax Gets Attention In Budget Fight

Opponents of the tax, which helps fund the health law, have proposed killing it to help defuse the current standoff, but there is not yet consensus on that effort.

The Wall Street Journal: Medical-Device Tax Repeal Gains New Life
Medical-device makers are finally gaining traction in their three-year effort to repeal a tax on their products that helps fund the Affordable Care Act. In recent weeks, House Republicans had made repeal of the 2.3% tax a proxy for their bigger fight against the health-care law championed by President Barack Obama, and device makers stepped up their lobbying efforts (Mundy and Walker, 10/9).

The Boston Globe: Shutdown Splits Foes Of Medical Device Tax
Members of the Massachusetts congressional delegation have campaigned against the new federal tax on medical devices, agreeing with industry executives that it hurts the Bay State economy by costing device manufacturers hundreds of millions of dollars a year. Some Republicans also are demanding repeal of the tax — but they are making it a condition of ending the government shutdown. And therein lies the problem. Despite having the ingredients for a bipartisan deal on a pet cause, Massachusetts lawmakers are not interested. To join ranks with Republicans would mean breaking ranks with President Obama, who has repeatedly opposed tying the funding of government to any other legislation (Jan, 10/10).

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Lawmakers Grill IRS Chief On Obamacare Rollout

Media outlets report that a House panel questioned Sarah Hall Ingram, the Internal Revenue Service official running the agency’s Obamacare office, who testified the health law rollout is going smoothly. Another House panel heard conflicting views of the law's impact on businesses.

The Associated Press/Washington Post: Lawmakers Hear Differing Views On Health Care Law’s Effect On Business
Some businesses say they’ll be forced to hire fewer people or cut employee hours to avoid having to offer insurance coverage to workers under the new health care law. But an economic researcher says there’s too much misinformation circulating about the law and that there’s no data to support claims that companies have already been cutting workers hours. These views were expressed Wednesday at House Small Business subcommittee hearing to look into the part of the law that requires companies with 50 workers or more to offer an affordable insurance plan to those working an average of 30 hours a week in any month (10/9).

The Wall Street Journal’s Washington Wire: IRS Official: Not 'Consorting With Devil' On Obamacare
Sarah Hall Ingram, who oversees the Internal Revenue Service role in the health-care overhaul, hasn’t been “consorting with the Devil,” she testified at a hearing on Wednesday. But Republicans suggested she has been doing a few other bad things, notably discussing taxpayer information in emails with the White House, contrary to IRS rules. That’s clear from the fact that the IRS itself redacted the taxpayer identities before turning over the email conversations, citing confidentiality rules, lawmakers said (McKinnon, 10/9).

Politico: IRS Obamacare Official: Rollout Smooth On Our End
A House panel finally got to question the Internal Revenue Service official running the agency's Obamacare office today — and she calmly maintained that her part of the health law rollout is going just fine. At a House Oversight and Government Reform Committee hearing Wednesday, Sarah Hall Ingram stepped into a political hotbed and was plied with questions from Republicans about her former leadership of the IRS department that targeted tea party groups last year (Cunningham, 10/10).

The Hill: GOP Grills IRS’s ObamaCare Chief
House Republicans accused the IRS on Wednesday of illegally sharing confidential tax information with political officials at the White House. Republicans on the House Oversight and Government Reform Committee questioned whether Sarah Hall Ingram, the head of the Internal Revenue Service's Affordable Care Act Office, shared private tax information with top healthcare officials in the Obama administration (Baker, 10/9).

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Health Reform

Health Exchange Issues? There Are Many, Say Experts And Consumers

The reviews may not be good, but people are visiting the new health care web sites, according to the new AP-GfK poll. In addition, experts offer possible reasons for the problems that continue to plague the federal health insurance web site. Meanwhile, various news outlets examine how certain states are faring with the federal and state exchanges.

The Associated Press/Washington Post: Poll: Health Care Exchange Rollout Gets Poor Reviews; 7 Percent Of Americans Have Tried It Out
The government’s new health insurance marketplaces are drawing lots of rotten tomatoes in early reviews, but people are at least checking them out. Seven percent of Americans report that somebody in their household has tried to sign up for insurance through the health care exchanges, according to an AP-GfK poll (10/10).

The Washington Post: Some Say Health-Care Site’s Problems Highlight Flawed Federal IT Policies
Problems with the federal government's new health-care Web site have attracted legions of armchair analysts who speak of its problems with "virtualization" and "load testing." Yet increasingly, they are saying the root cause is not simply a matter of flawed computer code but rather the government’s habit of buying outdated, costly and buggy technology (Timberg and Sun, 10/9).

CBS News: Obamacare Website Looks "Like Nobody Tested It," Programmer Says
White House officials initially blamed the website problem on an unexpectedly high volume as they had more than 8 million hits in the first week, but after it went offline over the weekend for repairs, officials now acknowledge other problems. "We've identified the glitches, we've added hardware, we're recoding software, and I can tell you today is better than yesterday, and we are hoping in the very near future to have a seamless process that's what we are aiming for," Health and Human Services Secretary Kathleen Sebelius said. However, computer experts say the website has major flaws. "It wasn't designed well, it wasn't implemented well, and it looks like nobody tested it," said Luke Chung, an online database programmer. Chung supports the new health care law but said it was not the demand that is crashing the site. He thinks the entire website needs a complete overhaul (10/9).

Fox News: $93M Obamacare Website May Face Months Of Glitches, Experts Warn
The $93 million website launched to process customers through the new Obamacare marketplace may experience significant technical glitches for months, computer software experts told FoxNews.com. “I wouldn’t rule out that possibility,” said George Edwards, a computer scientist and professor at the University of Southern California. It all depends on when they identify the bugs, where they are, and if they can be resolved easily, he said -- all while the site is running and open to millions of customers. “[It's] like trying to repair a car while someone is driving it,” he told FoxNews.com (Vlahos, 10/9).

The Associated Press: Ohio’s Insurance Director Among Those Experiencing Glitches With Health Overhaul Website
Ohio's insurance director said Wednesday that while exploring the federal government's website on the new health care system, she has encountered the same computer glitches and delays that have frustrated many consumers looking for insurance coverage. Lt. Gov. Mary Taylor, a Republican and one of the state's more vocal critics of President Barack Obama's health care overhaul, told a group of small business owners that her insurance department is asking people to be patient and to try the healthcare.gov website during off hours (Sanner, 10/9).

Kaiser Health News: Capsules: Hawaiians Still Unable To Shop On State Exchange
Ten days after the Hawaii Health Connector was supposed to allow consumers and small employers to shop and enroll for coverage, officials are using paper applications and referring people to insurers’ websites to check prices. About 100,000 people are uninsured in Hawaii. It is the only one of the 14 state-run marketplaces, also called exchanges, that has no major functions online. Oregon’s marketplace does not yet allow online enrollment, but consumers can shop for health plans on its website (Galewitz, 10/10).

The CT Mirror: Doctor Lists Not Easy To Find For All Obamacare Exchange Plans
Access Health CT, the state’s exchange, is relying on the insurance companies to provide links to directories of health care providers who accept their exchange plans. Shoppers who enter their age, county and income on Access Health's website can view a list of available plans and prices. Under each option there's also a link to "Check if your doctor is in-network." But those links don't all lead to provider directories. For Anthem Blue Cross and Blue Shield's plans, the links go to Anthem's main website. There's no obvious way to find the provider directory for exchange plans. There is a way to do so, but it requires some website navigation and some knowledge of how Anthem labels its exchange plans (Becker, 10/9).

Kansas Health Institute: Fixes To Kansas’ Online Health Insurance Marketplace Coming This Week
A key player in efforts to steer uninsured and underinsured Kansans toward the new health insurance marketplace says she’s been told that most of the system’s troubles should be corrected yet this week…Officials at the Center for Medicare and Medicaid Services’ regional office in Kansas City, Mo. provided the assurances to Harding during a conversation on Tuesday (Ranney, 10/9).

The Baltimore Sun: Consumers, Advocates Seek Health Insurance Work-Arounds
If there is a good health insurance plan out there for Baltimore scientist Luke Goembel, it's as big a mystery as the space he studies…He and some advocates for the new marketplace — which aims to cover 800,000 uninsured Marylanders, plus the underinsured — are pressing the state to provide more information on the plans as they wait for glitches to be resolved (Cohn, 10/9).

CQ HealthBeat: DC Exchange A Window On How Immigrants View Health Law
Perhaps more than any other insurance exchange in the country, DC HealthLink brings society’s haves and have-nots to a single marketplace. While much has been made of the fact that the district’s exchange will serve members of Congress and their staffs, there’s another potential large customer base: Washington’s Hispanic immigrant community (Reichard, 10/9).

Health Policy Solutions (a Colo. news service): Young And Not So Invincible
The hottest targets for health insurance this fall are the so-called “young invincibles.” It’s no coincidence that an upstart selling some of the lowest-priced plans that might appeal to young people in Colorado, the Colorado HealthOP, deployed beautiful young models to try to make the decidedly unalluring topic of health insurance sexy. Buff, shirtless men and nearly naked young women prowled downtown Denver’s 16th Street Mall last week as Colorado’s health exchange opened. They wore little more than signs reading: “Without health insurance, you’re exposed: #GetCoveredCO” (Kerwin McCrimmon, 10/9).

California Healthline: What Covered California Did Right In Week One – And What Other States Did Better
In California, like in most of the nation, most launch day stories didn't center on the people signing up for coverage through the new exchanges, but on all the people who couldn't. … But there's too much being made of the computer glitches in California and elsewhere, according to Stan Rosenstein, principal adviser at Health Management Associates and a former state official who spent decades working with Medi-Cal, California's Medicaid program, and other public health insurance plans (Diamond, 10/9).

Health News Florida: $51B Waiting For FL: Sebelius
Health and Human Services Secretary Kathleen Sebelius has become the Obama administration's envoy to Florida on behalf of the Affordable Care Act. She has visited the state half a dozen times since June, trying to get the word out to the state's millions of uninsured to sign up for a health plan (Gentry, 10/9).

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Deadline For Getting Coverage And Avoiding Fines -- Valentine's Day, Not March 31

The Associated Press reports on this development -- which it called a "new wrinkle" -- that will move up by about six weeks the date by which consumers will need to have health insurance or face penalties. Also in the news, lots of talk -- some of which came from President Barack Obama himself -- about how the health law helps or hurts workers and how it impacts health care costs.

The Associated Press/Washington Post: New Wrinkle: Deadline To Avoid Health Law Fines Will Fall Around Valentine's Day, Not March 31
You’ll have to get coverage by Valentine’s Day or thereabouts to avoid penalties for being uninsured, the Obama administration confirmed Wednesday. That’s about six weeks earlier than a March 31 deadline often cited previously. The explanation: health insurance coverage typically starts on the first day of a given month, and it takes up to 15 days to process applications (Alonso-Zaldivar, 10/9).

USA Today: Got A Health Concern? Insurance Advocates Can Help
Beginning last week, uninsured Americans could begin signing up for insurance at HealthCare.gov because of the Affordable Care Act. The law prohibits insurance companies from charging people more or denying them coverage because of pre-existing medical conditions, or setting lifetime spending limits. People who make less than 400 percent of the federal poverty level, or about $94,200 for a family of four, may be eligible for insurance subsidies to help pay for their insurance, or obtain free coverage through Medicaid (Kennedy, 10/9).

CBS News: Obama Refutes Claims That Obamacare Is Hurting Workers
Amid ongoing problems with the Affordable Care Act's new online insurance marketplaces, President Obama on Wednesday defended the law's economic impact, refuting claims that it's hurting workers. In an interview with Richmond, Va., CBS affiliate WTVR, the president pushed back against the claim the health care law is increasing premiums and discouraging full-time job growth. The president noted that economic trends tell a different story. Premiums, he pointed out, are still rising but at a slower rate than at any time in the last 50 years. "A lot of this stuff has been happening for the last several years, that doesn't have to do with the Affordable Care Act," he said. "The problem that we've had for a long time is that employers have found health care costs really burdensome, they've been loading off costs onto workers for a very long time, the only thing the Affordable Care Act has done is to create a marketplace -- essentially a group plan -- a pool for people who don't have employer-based health care" (Condon, 10/9).

CBS News: Will Obamacare Bring Down Health Costs? Expert Weighs In
For the latest edition of Morning Rounds, CBS News chief medical correspondent Dr. Jon LaPook sat down with Sherry Glied, dean of the NYU Wagner Graduate School of Public Service, to find out just how much costs are expected to be curbed under the law. She points out provisions in the law that aim to cut costs. For example, it requires insurance companies to keep administrative costs below a certain threshold, or pay customers the difference. Many customers have already received rebate checks. Further down the road, the law hopes to tackle health care costs on a societal level (Jaslow, 10/9).

The Fiscal Times: Obamacare Premiums Are the Tip of Consumer Costs
Now that the plans are available, there’s a range of premiums—including some relatively low cost options—depending on the age and location of the purchaser, the size of his family, and whether he smokes. Most analyses find that young, healthy consumers will pay higher premiums than those they’re currently paying on the individual market (with richer benefits), while older consumers will find plans with lower premiums than they find now. Looking solely at the premiums, however, doesn’t give a true picture of a plan’s cost, since many of the low-premium plans come with extremely high deductibles and other out-of-pocket costs. “Some of the premiums are competitive and lower than we thought they’d be, but those offer relatively skinny benefit packages,” says Caroline Pearson, a vice president with Avalere Health (Braverman, 10/9).

Kaiser Health News: Five Lessons From Massachusetts About Obamacare Rollout
A lot of the Affordable Care Act supporters point to Massachusetts as proof that signing up the uninsured is a big, but doable task. Here, in 2013, that’s a reasonable conclusion. But back in 2007 and 2008 things were a lot messier, and some advocates for universal coverage were worried (Bebinger, 10/10).

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Indiana Sues To Halt Health Law's Employer Mandate

The state attorney general and 15 school districts filed a lawsuit against the Internal Revenue Service, claiming that tax penalties for businesses with 50 or more full-time employees that fail to provide health benefits cannot be enforced against state or local governments. That mandate has been delayed until 2015.

Indianapolis Star: 15 Indiana School Districts, Attorney General Sue To Block Obamacare Penalties
The state and school districts filed a lawsuit Tuesday in U.S. District Court in Indianapolis against the Internal Revenue Service and other federal agencies. They claim the IRS overstepped its authority earlier this year when it set up financial penalties for employers in states such as Indiana that did not create their own health insur­ance exchanges (Russell and Grope, 10/9).

North West Indiana Politics: Indiana Sues Feds To Halt Obamacare Employer Mandate
Attorney General Greg Zoeller is taking a second legal shot at halting a piece of the Affordable Care Act, also known as Obamacare. The Republican sued the Internal Revenue Service on Tuesday, claiming that tax penalties for businesses with 50 or more full-time employees that fail to provide qualifying health benefits cannot be enforced against state or local governments. ... The state's challenge has been joined by 15 school corporations, none in Northwest Indiana. The schools claim the health law has forced them to cut employee hours because it requires employers provide adequate health insurance to all employees working at least 30 hours a week, or be fined $2,000 for every full-time worker on their payroll (Carden, 10/9).

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Coverage & Access

Employees At Big Companies Will Pick Up A Bigger Share Of Health Care Price Tag, Predicts Aon Hewitt

The Associated Press/Washington Post: Aon Hewitt Predicts That More Employers Will Offer High-Deductible Health Insurance
More workers at big U.S. companies will likely start paying a greater share of their doctor’s bill because of a health insurance shift forecast by benefits consultant Aon Hewitt. Consumer-directed health plans, or CDHPs, could become the most common form of coverage offered by companies with 500 or more workers in the next three to five years, Aon Hewitt said Wednesday, as companies continue trying to cut health-care costs (10/9).

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State Watch

State Highlights: Audit Questions Facts In N.C. Medicaid Managed Care

A selection of health policy stories from California, North Carolina and Oregon.

Los Angeles Times: Gov. Jerry Brown Signs Bill To Increase Access To Abortions
Giving California women more access to abortion, Gov. Jerry Brown signed a bill Wednesday that allows nurse practitioners and certain other non-physicians to perform the procedure during the first trimester of pregnancy. The governor acted on 32 bills in all, approving measures that will cap drug costs for cancer patients, expand the number of people on CalFresh, the state's food stamp program, and promote breastfeeding (McGreevy and York, 10/9).

The New York Times: California Expands Availability of Abortions
Gov. Jerry Brown on Wednesday expanded access to abortion in California, signing a bill to allow nurse practitioners, midwives and physician assistants to perform a common type of the procedure, an aspiration abortion, during the first trimester. Washington, Montana, Vermont and New Hampshire allow nurse practitioners to perform such abortions, which use a tube and suction, while several other states, including California, permit nonphysicians to provide drugs to terminate pregnancy (Lovett, 10/9).

The Associated Press: Key Details Withheld From Audit Of North Carolina Medicaid
Strategic edits made to the N.C. Department of Health and Human Services response to an audit critical of the state's Medicaid program raises questions about whether key facts were withheld to make the program appear worse off than it really is.  Gov. Pat McCrory has used the January audit to make a case for privatizing the state's $13-billion Medicaid system (Biesecker, 10/9).

North Carolina Health News: Audit Edits Eliminated Defense Of Medicaid Program
As last year’s audit of the Medicaid program widened in scope, the state auditor critiqued the performance of a highly regarded program that manages low-income patients. Those criticisms stood, uncontested, in the final report (Hoban, 10/9).

Los Angeles Times: State Mental Hospitals Remain Violent, Despite Gains In Safety
It has been nearly three years since psychiatric technician Donna Gross was strangled on the fenced grounds of Napa State Hospital -- a slaying that helped expose a system wide problem with patient violence. Although safety has improved since then, violence is still far too high, exacerbated by an increasingly prison-savvy population with predatory tendencies, an Assembly committee was told Wednesday. The committee focused its attention on the Napa facility, but will also be examining the other four state-run mental hospitals (Romney, 10/9).

The Lund Report: Regence BlueCross BlueShield Objects To Making Health Care Costs More Transparent
The Oregon Health Policy Board laid out five straw proposals last week in an attempt to carry out Gov. John Kitzhaber's request to transform the health care system by coordinating care, rewarding quality outcomes and using a global budget to pay for health care costs. One tool that could be helpful in driving down costs is a statistical warehouse known as the all-payer, all-claims database, created by a 2009 law, which lets the state collect mountains of healthcare information (Gray, 10/7).

The Lund Report: Prenatal Care Expansion A No Brainer For Undocumented Patients
The expansion of the Citizen-Alien Waived Emergency Medical (CAWEM) benefit package to include prenatal services on Oct. 1 comes at a time health care advocates are getting on the same page as those who want to reign in costs. CAWEM-Plus is the name of the new benefits package administered by the Oregon Health Authority, which will expand an existing pilot program from 16 Oregon counties to the entire state (McDonald, 10/8).

California Healthline: Mental Health Program Shows Success
A decade-old comprehensive mental health program in California that has put about $4 billion into community-based programs improves the chances of people with serious mental illnesses being able to transition to independent living rather than end up homeless or in jail, according to a study released last week. Adults who have an uninterrupted stay in California's Full Service Partnerships programs are 13.5 percent more likely to successfully transition into independent living, according to the study by Oregon State University's College of Public Health and Human Sciences. The study was published in October's American Journal of Public Health (Norberg, 10/9).

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Weekend Reading

Longer Looks: More TV Characters With Mental Illness

Every week reporter Ankita Rao selects interesting reading from around the Web.

Time: Hey, Obamacare Complainers: Regular Insurance Has Tons Of Glitches, Too
Whether you’re one of the 50 percent or so of Americans who already have private health insurance (mostly through an employer, as I do) or one of those who may now turn to the exchanges to buy coverage, the bureaucracy is often maddening. Sure, the Affordable Care Act may seem opaque and unwieldy, but make no mistake: Employer-provided healthcare—which offers plans by the very same companies now on the exchanges—is equally Byzantine. No wonder that only 22 percent of American consumers reported themselves as satisfied with the health care system in a 2012 survey (Randye Hoder, 10/9).

Gawker: Applying for Health Insurance: Before And After Obamacare (Video)
One popular Republican talking point asserts that the Affordable Care Act is unnecessary at its core because it replaces a system that was just fine the way it was. John Green of Vlogbrothers fame decided to put that trope to the test by signing up for health insurance twice: Once using the "old" system (i.e., through a health insurance provider), and once using Obamacare's newly launched "Health Insurance Marketplace." What Green found was that, despite HealthCare.gov's acknowledged glitchiness, it took him less than an hour to sign up for insurance. By comparison, the "old way" took over twice as long and would have likely taken much longer had Green not come prepared to answer 25 pages worth of invasive medical history questions ranging from "has the applicant received a moving violation" to "has the applicant in the last 10 years discussed surgery" (Neetzan Zimmerman, 10/8).

Time: Homeland And Bipolar Disorder: How TV Characters Are Changing The Way We View Mental Illness
Convinced that her medication for bipolar disorder clouded her judgment, Homeland’s protagonist began the show’s third season self-medicating with exercise and alternative therapies. And doctors say that decision, along with others Carrie Mathison has made concerning her condition, are influencing the way real patients are approaching the mental illness. Once a taboo topic, mental illness is an increasingly prominent plot line on television, ... The portrayals can be a double-edged sword, however, as they raise awareness of the realities of living with mental illness while frequently focusing on some of the more extreme symptoms and therapies (Alexandra Sifferlin, 10/9).

The Atlantic: U.S. Women Are Dying Younger Than Their Mothers, And No One Knows Why
Whether you think the Affordable Care Act is the right solution or a dangerous step toward tyranny, it’s hard to dispute that the U.S. health-care system is broken. … growing health disadvantages have disproportionately impacted women over the past three decades, especially those without a high-school diploma or who live in the South or West. In March, a study published by the University of Wisconsin researchers David Kindig and Erika Cheng found that in nearly half of U.S. counties, female mortality rates actually increased between 1992 and 2006, compared to just 3 percent of counties that saw male mortality increase over the same period (Grace Wyler, 10/7).

Dr. Kevin Campbell: Exploring The Leadership Potential Of Three Little Words: Applying 'I Don’t Know' To Medicine
Recently I read an interesting article on leadership published at Inc.com.  Although most of the journal is focused on those in business, many of the pieces on leadership are very applicable to those of us in Medicine.  In this article author Curt Hanke writes about the inspiration and leadership positives found in the three simple words:  "I Don’t Know." On first blush, we may think that a leader speaking these words may no longer inspire confidence and may lose the support of his or her troops.  However, as Mr. Hanke goes on to detail, the words "I Don’t Know" may provide inspiration and motivate teams to perform even better (Dr. Kevin R. Campbell, 10/7).

WeNews: Closure of Bronx Maternity Ward Stirs Activist Ire
In the borough with the city's highest maternal mortality rate, two women in labor in August died at Jacobi Medical Center, a public hospital in the Bronx, N.Y. Days later, health authorities closed a highly regarded maternity care center nearby and shifted patients and staff to Jacobi, a decision that has riled health and community activists. ... Giving staff and patients just three days' notice, North Central Bronx Hospital ended after 36 years its maternity care services on Aug. 12. All of the hospital's maternity care services, including a prenatal clinic, were transferred to Jacobi Medical Center, a 10-minute-taxi-ride away but at least 50 minutes for those relying on public transportation (Crystal Lewis, 10/7).

Slate: Deadly Disbelief
Tommy Morrison, once the heavyweight boxing champion of the world, died of AIDS last month. His case, however, was not typical for someone with HIV: He and his wife, Trisha, denied he had the infection to the bitter end. In fact, not only did they deny that Morrison was infected, they denied that HIV causes AIDS at all. And it's not even clear that they think the condition called AIDS actually exists. ... But the Morrisons’ vigorous denial that AIDS is caused by a transmissible virus, called HIV, falls well outside mainstream thinking. In their nonbelief, however, they are not alone (Kent Sepkowitz, 10/8).

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Editorials and Opinions

Viewpoints: 'Death Throes' Of Health Law Opponents; Ryan's Plan On Entitlements May Offer Way Out Of Budget Crisis

WBUR Cognoscenti blog: Obamacare 101: Promise, Pitfalls And Predictions
Politically, the biggest challenges facing the ACA are behind us. By my count, the law has already survived three near-death experiences: the Democrats' loss of a filibuster-proof Senate majority with the election of Scott Brown in Jan. 2010, the Supreme Court's June 2012 decision upholding (with one exception) the law's constitutionality, and President Obama's re-election last Nov. Much of what we see going on in Washington now is the death throes of the opposition, especially now that Americans are beginning to sign up for coverage (John McDonough, 10/9).

The New York Times' Taking Note: A New Danger For Democrats: Boehner's Delegation
Speaker John Boehner isn't taking the House Tea Party coalition with him to the White House on Thursday. Though President Obama invited the entire Republican caucus to discuss the budget crisis, Mr. Boehner is only bringing 17 others along. … But the delegation — which Mr. Boehner provocatively called a group of "negotiators" — includes Paul Ryan, the budget chairman, and several other leaders who have been far more interested in extracting a budget deal out of the shakedown than an end to health care reform. And that poses a novel set of dangers for Democrats who may be tempted by some of the new negotiating ploys that these leaders are trying out (David Firestone, 10/9).

The Washington Post: Obamacare Saved My Family From Financial Ruin
House Speaker John Boehner and his tea party friends shut down the U.S. government because of people like me. I am the mother of an insurance hog, someone who could have blown through his lifetime limit of health coverage by the time he was 14. My son has managed to survive despite seemingly insurmountable challenges, and he wears his preexisting condition like a Super Bowl ring (Janine Urbaniak Reid, 10/9).

The Washington Post: Paul Ryan Hints At A Way To End The Political Paralysis
The House Republicans, egged on by a couple of bomb-throwing senators, are responsible for the stalemate. Having essentially won the budget battle, when Democratic senators agreed to keep the government operating at GOP-preferred spending levels, they came up with additional demands that they knew could not be met: defunding, then delaying, the Affordable Care Act. As long as their strategy was nihilism, Mr. Obama was quite right to say that negotiation would be pointless. Now Mr. Ryan, the chairman of the House Budget Committee and a former vice presidential candidate, has offered a different approach, although he doesn't explicitly label it that way. In an op-ed in the Wall Street Journal on Wednesday, Mr. Ryan proposes negotiations not over Obamacare but about "common-sense reforms of the country’s entitlement programs and tax code" (10/9).

Politico: Train Wreck: The Obamacare Rollout 
Nancy Pelosi infamously said that we had to pass the law to find out what’s in it. But the then-House speaker erroneously assumed, evidently, that people would be able to get onto the government-run exchanges created by the law. So far the law's implementation has been as ugly as its passage. Judging by the haphazard rollout — incomprehensible error messages have been the norm, and the federal website has had to be taken offline several times — you'd guess that this was a back-burner project for the Obama administration, or the start-date for the exchanges had been sprung on it a few weeks ago. Of course, it is the president's most cherished initiative, and his team has had more than three years to get the exchanges up and running (Rich Lowry, 10/10).

Houston Chronicle: Gov. Perry's Political Health Care Circus Will Cost Texans Billions
The only questions left to answer are whether states such as Texas will create barriers to implementing these good changes and whether they'll expand Medicaid to cover, in our case, about 1.3 million to 1.7 million more uninsured citizens. The federal government would pick up nearly all of the costs of the expansion. So far, the tragic answers are "yes" to barriers and "no" to more people being covered. Gov. Rick Perry and others have made a political circus out of health care in Texas by turning their backs on billions of your tax dollars that now won't come back to Texas for your benefit (State Sen. Kirk Watson, 10/8).

Houston Chronicle: Congress Doesn't Need Health Subsidies
Those following the debate in Congress over President Barack Obama's health care reform law are by now well-versed in the arguments over health care exchanges, the rising costs of premiums and deep cuts to Medicare. I represent a diverse House district with different perspectives and understand that there will be differences of opinion over our nation's health care system But one aspect of the health care law seems to unite just about all my constituents: how it applies to members of Congress, the president and his appointees (Rep. Michael McCaul, R-Texas, 10/9).

Houston Chronicle: Affordable Care Act Brings Health Benefits To Texans
Yet opponents of the law drown out this positive news with shrill distortions. The latest myth rattling around is that Congress and their staff are exempted from the Affordable Care Act. That is not true. Members and their staff will be moved from their current coverage and required to seek insurance in the marketplace; their employer, the federal government, will continue to contribute to the premiums -just like everyone else in the private sector with employer-sponsored premiums (Rep. Joaquín Castro, D-Texas, 10/9).

The Washington Times: The Obamacare 'Myth' Becomes All Too Real
On health care, the president's pile of broken promises keeps getting a little higher. Consider this gem from Aug. 20, 2009: "Let's be clear about the fact that nobody has proposed anything close to a government takeover of health care." Well, yes, somebody did. President Obama is now well on his way to orchestrating the federal government’s "takeover" of Americans' health care (Robert E. Moffit, 10/9).

Jackson Clarion-Ledger: Mississippi's Medicaid Opt-Out Creates A Gap For Working People
There's nothing new about spreading the cost of health care or any other risk among a lot of people. That's what insurance does. The big difference is having government and tax funds in the picture. Too many wrongly think Obamacare is a handout. There's great concern that giving people access to health insurance is a disincentive, but think about that (Charlie Mitchell, 10/9).

National Review: The Politics Of Federalizing Medicaid Dual Eligibles
Though I assume the architects of the health law thought deeply about the politics of Medicaid expansion, one wonders if advocates of coverage expansion made a mistake. Rather than convincing states to expand eligibility by promising to meet the cost of new beneficiaries, Congress might have proposed fully federalizing the costs associated with the dual eligible population. This would obviously have benefited some states (like North Dakota) much more than others (like Arizona), yet it would relieve all states of a fast-growing burden. And by consolidating responsibility for the dual eligible population, one assumes that the Medicare program could achieve efficiencies by eliminating the buck-passing dynamic, in which one system attempts to shunt off costs to another (10/9).

The Seattle Times: EU Ambassador Surprised By Shutdown Over Obamacare
On Tuesday, our editorial board met with Joao Vale de Almeida, the first European Union Ambassador to the United States. On tour to promote U.S.-European relations, he expressed surprise House Republican leaders are holding a vote on a federal budget hostage unless Obamacare is repealed. "People in Europe sometimes have trouble understanding your health care debate particularly after legislation was passed," de Almeida says. "(President Barack Obama) was reelected and the Supreme Court ruled. In Europe, health care is much less controversial and ideological, so it’s unlikely to risk the functioning of the government" (Tan, 10/9).

JAMA: The Affordable Care Act After Week 1: What We Know And What We Don't Yet Know
It is now common knowledge that the new health insurance marketplaces (also known as "exchanges") created under the Affordable Care Act (ACA) got off to a rocky start last week. Indeed, it's possible that more Americans now know about the technical glitches experienced by the exchanges than even knew open enrollment was beginning October 1 (Larry Levitt, 10/9).

The San Francisco Chronicle: Tales Of Obamacare Love And Betrayal
In response to my Tuesday column about Obamacare, a Santa Cruz man who describes himself as a "staunch" Obama supporter tells me he feels "betrayed." Anthem sent him a notice that his private plan, which also covers his spouse, ends Jan. 1. But he is eligible for a comparable Affordable Care Act plan. Alas, the premiums will rise from $766 to $1,251 per month.  He was angry before because he wanted a European-style single payer system, but he wrote, "Honestly I gave this little thought because I knew I could keep what I had, but as it turns out, this apparently is not possible" (Debra J. Saunders, 10/10).

Health Policy Solutions (a Colo. news service): On The Health Exchange Rollout, Take The Long View
The new health insurance marketplaces, or exchanges, opened a week ago. Even though we are only a few days into a six-month enrollment period, pundits on all sides have used the rollout to forecast the success or failure of the new health care law. When reading the instant-analysis accounts, it’s best keep in mind that there is a great deal more to the health care reform law than the new marketplaces. And the success of these marketplaces will be clear only after they have been in business a whole lot longer than a week. The current open-enrollment period continues until the end of March 2014, and that gives the federal and state exchange websites time to correct problems that are inevitable with such large and complex IT systems (Bob Semro, 10/9).

And on other issues --

Los Angeles Times: New California Abortion Law: More Dangerous Than Skydiving
At a time when so many states are chipping away at reproductive rights, making it nearly impossible for women to exercise their constitutional right to terminate a pregnancy, how refreshing to see California standing up for women's rights. On Wednesday, Gov. Jerry Brown signed a bill into law that gives some medical professionals who are not doctors the right to perform early abortions. The bill, introduced by Democratic Assemblywoman Toni Atkins of San Diego, followed a years-long pilot program involving more than 11,000 women who underwent first-trimester abortions. Half of the procedures were done by physicians, the other half by nurse practitioners, certified nurse midwives and physician assistants (Robin Abcarian, 10/9).

Los Angeles Times: In Medicine, More Care May Not Be Better
The dull whir of the computer running in the background seemed to have gotten louder as the patient fell quiet. She was a young woman, a primary-care patient of mine, seeking a referral to yet another gastroenterologist. Her abdominal pain had already been checked out by two of the city's most renowned gastroenterologists with invasive testing, CAT scans and endoscopic procedures. But she wasn't satisfied with her diagnosis — irritable bowel syndrome — or the recommended treatment and wanted a third opinion. I tried to reason with her but failed to convince her otherwise. Even when I acquiesced and gave her the referral, she walked out visibly unhappy. I sat there listening to the whirring, feeling disappointed (Haider Javed Warraich, 10/10).

New England Journal of Medicine: Professionalism and Caring for Medicaid Patients — The 5% Commitment?
Medicaid is an important federal–state partnership that provides health insurance for more than one fifth of the U.S. population — 73 million low-income people in 2012. The Affordable Care Act will expand Medicaid coverage to millions more. But 30% of office-based physicians do not accept new Medicaid patients, and in some specialties, the rate of nonacceptance is much higher — for example, 40% in orthopedics, 44% in general internal medicine, 45% in dermatology, and 56% in psychiatry. Physicians practicing in higher-income areas are less likely to accept new Medicaid patients (Dr. Lawrence P. Casalino, 10/9).  

Health Policy Solutions (a Colo. news service): A Path To Pay For Integrated Health Care
Patients’ mental and physical health problems are interwoven, especially for the chronically ill. The vast majority of patients with chronic diseases such as diabetes, congestive heart failure, asthma, lung disease and others have co-occurring mental health and/or substance use issues. And there is significant evidence that integrating primary and behavioral health care leads to improved outcomes and reduced costs of care. Yet few payers, either public or private, pay for integrated care. Why is that, and what can be done to change it? (Edie Sonn, 10/9).

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EDITOR:
Stephanie Stapleton

ASSOCIATE EDITOR:
Andrew Villegas

WRITERS:
Marissa Evans
Lisa Gillespie
Shefali Luthra

The Kaiser Daily Health Policy Report is published by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation. (c) 2014 Kaiser Health News. All rights reserved.