Daily Health Policy Report

Monday, October 14, 2013

Last updated: Mon, Oct 14

KHN Original Reporting & Guest Opinion

Capitol Hill Watch

Health Reform

Health Care Marketplace


Public Health & Education

State Watch

Editorials and Opinions

KHN Original Reporting & Guest Opinion

Why Some Virginia Health Plans Cost So Much

Kaiser Health News staff writer Julie Appleby, working in collaboration with The Washington Post, reports: "Consumers shopping for coverage in new online marketplaces may scratch their heads when they come to a handful of plans in Virginia: Why do some cost more than $1,800 a month? No, the plans do not include gold-plated hospital beds or guaranteed same-day access to doctors. Instead, those premiums reflect an add-on benefit for a type of costly surgery for obesity which makes them up to six times more expensive than plans without such coverage" (Appleby, 10/13). Read the story.

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Geography Is Destiny When It Comes To Enrolling In Health Insurance Exchanges

Kaiser Health News: Geography Is Destiny When It Comes To Enrolling In Health Insurance Exchanges
Kaiser Health News staff writer Jenny Gold, working in collaboration with NPR, reports: "Alexandra Dixon threads her way among the people waiting to see a doctor at the Community Clinic, Inc. in Silver Spring, Maryland. She introduces herself with a bright smile and an outstretched hand: 'I'm one of the new health care navigators. Have you heard of the Affordable Care Act?' While some folks mumble, 'um, no I don't think so,' Dixon is nonetheless booked up with appointments. She's one of 350 people in Maryland who have been hired and certified to help consumers enroll in the new health insurance options that are offered as part of the health law" (Gold, 10/13). Read the story.

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FAQ: What's At Stake If Congress Repeals The Medical Device Tax

Kaiser Health News staff writer Mary Agnes Carey reports: "As Republicans and Democrats have battled over reopening the federal government and raising the federal debt ceiling, one idea that keeps coming up is a repeal of the 2010 health law's tax on medical devices" (Carey, 10/11). Read the story.

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Political Cartoon: 'Off Track?'

Kaiser Health News provides a fresh take on health policy developments with "Off Track?" by Nick Anderson.

Here's today's health policy haiku:


Health care for the poor --
impossible to achieve
when men's pride prevails.

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

Battle Lines Change As Negotiators Appear To Drop GOP Efforts To Derail The Health Law

As the nation approaches its debt limit and the federal government remains shut down, a deal continues to be elusive.  

The Wall Street Journal: Senate Democrats Press New Front In Budget Battle
Senate Democrats have been strengthened by the sidelining, at least for now, of House conservatives, who dropped nearly all their major policy demands only to see Mr. Obama reject their proposal for ending the stalemate. With Senate leaders now negotiating, the fiscal battle focused for the first time in weeks on the budget itself, not on side issues that had dominated, such as the Republican demand that the 2010 health-care law be delayed or altered. Republicans who had opposed the GOP's "defund Obamacare'' strategy welcomed the return of interest to basic spending issues (Hook, 10/14).

Politico: Senate Remains At An Impasse
Monday will be critical. With financial markets fearful of a prolonged impasse, there is little margin for error before Thursday, when the Treasury Department warns the government will begin to run out of money and could fail to pay its bills for the first time in history. That possibility would intensify a budget crisis that started Oct. 1, when government agencies shuttered for the first time in 17 years because of lawmakers’ inability to pass a funding bill on time. It’s far from clear how the high-stakes fight will play out this week. Republicans have already dropped their push to gut Obamacare, which prompted the shutdown in the first place. But McConnell has yet to accept Democratic demands for higher spending levels for at least a portion of the current fiscal year (Raju and Kim, 10/13).

The Washington Post: Senate Leaders' Talks On Shutdown, Debt Limit Stall As Sides Await Market's Reaction
What started as a mad dash to strike a deal to lift the federal debt limit slowed to a crawl over the weekend as stalemated Senate leaders waited nervously to see whether financial markets would plunge Monday morning and drive the other side toward compromise. Republicans seemed to think they had more to lose. After talks broke down between President Obama and House leaders, GOP senators quickly cobbled together a plan to end the government shutdown — now entering its third week — and raise the $16.7 trillion debt limit. Senate Minority Leader Mitch McConnell (R-Ky.) then asked Majority Leader Harry M. Reid (D-Nev.) to elevate negotiations to the highest level (Montgomery and Helderman, 10/13).

The New York Times: Spending Dispute Leaves A Senate Deal Elusive
With a possible default on government obligations just days away, Senate Democratic leaders — believing they have a political advantage in the continuing fiscal impasse — refused Sunday to sign on to any deal that reopens the government but locks in budget cuts for next year. … Republicans once said that they would finance the government only if the president’s health care law was gutted. A bipartisan Senate framework drafted by Ms. Collins and Senator Joe Manchin III, Democrat of West Virginia, started with a face-saving move for Republicans of a repeal of a tax on medical devices that helps pay for the Affordable Care Act. When Senate Democratic leaders objected, that was tempered to a two-year delay of the tax (Weisman, 10/13).

Los Angeles Times: Government Shutdown Talks Hit Snag In Senate
The protracted stalemate has left Congress facing twin crises: Thursday’s deadline to raise the nation’s borrowing limit or risk a potentially catastrophic debt default, and a federal government shutdown that will enter its third week Tuesday. Republicans had hoped they could use the standoff to gain leverage in their fight with Democrats over the budget and President Obama’s healthcare law, but find themselves in a dramatically weakened position. They have failed to unify around a common negotiating position and face polls showing that the public by large margins blames them for the stalemate (Mascaro, 10/13).

The New York Times: Stuck On Usual Quarrel: Raising New Revenue
But even if the current talks soon resolve the immediate impasse, which did not look likely on Saturday, any renewal of negotiations for a long-term fiscal plan will run into the same underlying problem that has doomed efforts for the past three years. Republicans refuse to raise additional tax revenue, and until they do, Mr. Obama will not support even his own tentative proposals for reducing spending on fast-growing social benefit programs, chiefly Medicare. During a White House meeting with Senate Republicans on Friday, he reiterated that the two go hand in hand, according to people who were there (Calmes, 10/12).

Kaiser Health News: FAQ: What's At Stake If Congress Repeals The Medical Device Tax
As Republicans and Democrats have battled over reopening the federal government and raising the federal debt ceiling, one idea that keeps coming up is a repeal of the 2010 health law's tax on medical devices (Carey, 10/11).

Kaiser Health News also tracked weekend health policy headlines, including reports about the direction of congressional budget talks (10/13).

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GOP Lawmakers Probe Marketplace Bugs

Republicans on both sides of the Capitol are investigating technical problems with the health law's online health insurance marketplaces -- with one senator going so far as to call for the resignation of Health and Human Services Secretary Kathleen Sebelius. Others bemoan the lost opportunity to publicize the balky rollout because public attention was focused instead on the government shutdown.

The Hill: GOP Fear: Shutdown Thwarted Exposure Of ObamaCare Flaws
House Republicans, now seeking a way out of the current fiscal impasse, fear that the government shutdown robbed them of a chance to highlight the problems in ObamaCare's rollout. ... To make matters worse, Republicans have taken a public relations hit for their strategy , a fact not lost on the lawmakers who — along with GOP leadership — opposed making government funding contingent on healthcare changes. "I think we have missed a big issue. I don’t think there’s any question that this whole shutdown episode has covered for the bad rollout of ObamaCare," said Rep. Tom Cole (R-Okla.), an ally of Speaker John Boehner (R-Ohio). "A lot of us warned that" (Becker and Baker, 10/13).

CBS News: Republicans Open Investigation Into Flawed Obamacare Rollout
Since the Affordable Care Act's new online insurance marketplaces launched on Oct. 1, they've been plagued by technical problems, and congressional Republicans intend to find out why. Rep. Darrell Issa, R-Calif., chairman of the House Oversight and Government Reform Committee, and Sen. Lamar Alexander, R-Tenn., the top Republican on the Senate Health, Education, Labor and Pensions (HELP) Committee, sent a letter Thursday to Health and Human Services Kathleen Sebelius asking about the alleged architectural problems with the federally-run website Healthcare.gov that serves 36 states. HHS spent almost $394 million over three years in contracts to build the online marketplace (referred to as an exchange). Yet from day one, Issa and Alexander wrote, "healthcare.gov has been plagued by what Administration officials initially referred to as technical glitches” (Condon, 10/11).

Politico: GOP Questions Obamacare Contractors
Republican lawmakers are demanding answers from the White House about the technical flaws that have crippled Obamacare’s online enrollment system in its opening week. Top House watchdog Darrell Issa and others say the troubled reality doesn’t jibe with the rosy predictions administration officials and contractors were making ahead of the Oct. 1 launch of HealthCare.gov, the online portal most of the country will use to enroll new Obamacare coverage programs (Cheney, 10/11).

Kansas Health Institute: Roberts Calls On Sebelius To Resign Cabinet Post
U.S. Sen. Pat Roberts of Kansas today called for the resignation of Secretary of Health and Human Services Kathleen Sebelius, the former Kansas governor who is overseeing what has proven to be a rocky roll-out of the Affordable Care Act's online insurance marketplace (10/11).

In other news, the Senate Finance Committee starts talking about entitlement changes -

CQ HealthBeat: Senate Finance Committee Talks Over Entitlement Changes
Republicans and Democrats on the Senate Finance Committee agree: It’s time to talk about changes to entitlement programs. Based on a hearing held by the committee Thursday, those changes could involve savings of up to half a trillion dollars over the next decade. Seniors could see a slower increase in Social Security checks. They might have to put up with Medigap policies that cover less (Reichard, 10/11).

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Health Reform

Experts Worry About Other Trouble Spots With Health Law Marketplaces

Politico reports that other steps in the online enrollment process, including computing subsidies and transferring signup information to insurers may also have bugs. The Associated Press reports that some insiders predicted the problems well before the website launch, while The Washington Post notes that paper applications are increasingly popular because of the problems.

Politico: Tech Experts Wary Of More Obamacare Glitches
The glitch-plagued Obamacare rollout might be just the beginning: A series of potential technology problems could thwart the Obama administration’s goal of getting 7 million people enrolled in the new exchanges by the end of March. Millions of people have already encountered error messages, delays, crashes and stuck accounts. Technology experts and Obamacare backers worry that each step ahead in the process — filling out applications, checking on subsidies and selecting a health insurance plan — creates a potential technology choke point. And that doesn’t even count any additional chaos when people try to use their new health insurance come January (Norman and Millman, 10/12).

The New York Times: From the Start, Signs Of Trouble At Health Portal
For the past 12 days, a system costing more than $400 million and billed as a one-stop click-and-go hub for citizens seeking health insurance has thwarted the efforts of millions to simply log in. The growing national outcry has deeply embarrassed the White House, which has refused to say how many people have enrolled through the federal exchange. Even some supporters of the Affordable Care Act worry that the flaws in the system, if not quickly fixed, could threaten the fiscal health of the insurance initiative, which depends on throngs of customers to spread the risk and keep prices low (Pear, LaFraniere and Austin, 10/12).

The Associated Press: Insiders Saw Health Insurance Marketplaces Woes Coming
In March, Henry Chao, the chief digital architect for the Obama administration’s new online insurance marketplace, told industry executives that he was deeply worried about the website’s debut. “Let’s just make sure it’s not a third-world experience,” he told them. Two weeks after the rollout, few would say his hopes were realized (10/13).

The Washington Post: Federal Health Exchange Sending Confusing Enrollment Information To Insurers
The federal health-care exchange that opened a dozen days ago is marred by snags beyond the widely publicized computer gridlock that has thwarted Americans trying to buy a health plan. Even when consumers have been able to sign up, insurers sometimes can’t tell who their new customers are because of a separate set of computer defects (Goldstein and Cha, 10/11).

The Washington Post: Glitches On Health-Care Sites Prompt Increased Interest In Paper Applications
The dead-tree version of health insurance enrollment is turning out to be surprisingly popular. Unable to use new government insurance Web sites that have been plagued by technological problems, those tasked with helping the uninsured sign up for health coverage are bypassing the sites altogether, relying instead on old-fashioned paper applications (Sun and Somashekhar, 10/12).

Meanwhile, news outlets report that it's hard to gauge enrollment so far because of lack of data - 

The Associated Press/Washington Post: Obamacare A Success So Far? Lack Of Enrollment Numbers From Many States Makes It Hard To Say
After more than a week in action, is a key feature of President Barack Obama’s health care overhaul a success or a bust? Judging by the dearth of data, it’s virtually impossible to say. The federal government has released no comprehensive data on how many people have enrolled for health insurance using federally run exchanges, the online marketplaces being used in 36 states for residents to compare and buy insurance. In the 14 states running their own exchanges, the situation isn’t much better (10/11).

CBS News: How Many Americans Have Signed Up For Obamacare?
A new poll by The Wall Street Journal shows more Americans think the president's health care law is a good idea. Last month, 31 percent said they liked it; now it's 38 percent. The health care exchanges went online on October 1 with long delays when millions of Americans tried to shop the federal website. But how many are actually buying policies? More than 8 million people have visited the healthcare.gov website designed for consumers in 36 states to buy health insurance. But the White House is not ready to say how many have successfully chosen a health plan until next month. "We'll have a monthly release of numbers," said David Simas, the White House senior advisor on healthcare. "At some point in November, you'll be able to see and go through the data (and see) how many people enrolled and break it out however you'd like (Werner, 10/11)."

The Hill: HHS Touts Visits To ObamaCare Site, But Mum On Enrollment
ObamaCare's enrollment portal garnered 14.6 million unique visits in its first 10 days, the Health and Human Services (HHS) Department said Friday. HHS touted improvements to the troubled site and said that fixes over the last two weeks have substantially reduced wait times and allowed more users to shop for coverage (Viebeck, 10/11).

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State-Run Marketplaces Rebounding From Opening Snags

Politico Pro examines how the marketplaces operated by states compare to the federally run operation. Other outlets look at some of the individual issues in states.

Politico Pro: State Obamacare Health Exchanges Recovering From Rocky Start
The 15 state-run exchanges, with a few exceptions, have overcome major hiccups that marred their Oct. 1 rollout. They have also been more transparent than their federal counterparts about the levels of early consumer interest — as well as their technical problems. People have until the end of March to enroll, although Dec. 15 is the deadline to get benefits starting Jan. 1. Most — though, not all — of the states running their own exchanges have Democratic governors who back the president’s health law. Many Republican governors resisted, thrusting the federal government into having to run a lot more of the state infrastructure than it had anticipated or budgeted for. Still, most of the state marketplaces haven’t provided detailed information about who’s coming to their websites and what they’re signing up for — the kind of data that will help paint a fuller picture of the health care law’s performance (Millman, 10/11).

The CT Mirror: Obamacare Update: More Than Half Of Enrollees Getting Medicaid, Many Callers Complaining About Price
More than half of the people who have signed up for coverage through Access Health CT, the state's health insurance exchange, qualified for Medicaid, according to figures released Friday. Among people shopping for private insurance, meanwhile, price is a main concern, according to an Access Health official. The exchange's call center has received 10,997 calls and the website has gotten 126,055 visitors since the launch. Among the callers, many have concerns about the price. "It's too expensive. I can't afford it," is the most frequent feedback from callers, Peter Van Loon, Access Health's chief operations officer, told a committee of the exchange's board during a meeting Thursday (Becker, 10/11).

The Associated Press: Governor Says Work On Maryland's Health Care Website Could Take Another Month And A Half
Fixing glitches on Maryland's online marketplace could continue for as long as another month and a half, Gov. Martin O'Malley said Friday, comparing the effort to dealing with a hurricane or a snowstorm. Still, he said improvements are being made every day. Maryland Health Connection, the online portal where people can shop for health plans and enroll in them, also updated the numbers of people who have visited the website and created accounts since it opened on Oct. 1, when it ran into problems almost immediately (Witte, 10/11).

Miami Herald: South Floridians' Biggest Question About Affordable Care Act Health Plans: Will They Be Affordable
South Floridians are sifting through information about the most sweeping social program to affect Americans since Congress enacted Medicare in 1965. How will the law, with all its complexities, affect them? For many, the most important question to be answered is: How much will it cost? (Borns, 10/13).

Minnesota Public Radio: Brokers: Website Delay Stalling MNsure Enrollment
Kim Johnson hopes MNsure, the state's new health insurance marketplace, will help him find reasonably priced coverage for his 15 employees. But when he sought help recently from a local agent certified as a MNsure "assister," the Hinckley, Minn., business owner was told to come back later. The agent couldn't help — MNsure hadn't given her access to a special broker-only website. ... Insurance agents are key contacts for Minnesotans trying to navigate MNsure. They make up most of the 1,600 MNsure-certified helpers. Outside of MNSure's call center, agents have been the main source of help for people like Johnson since the insurance marketplace opened nearly two weeks ago. Agents, however, say there's little they can do until MNsure gives them access to the broker site (Richert, 10/11).

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Health Law's Success Hinges On Whether The Goal Of Enrolling 7 Million Is Met -- Making Outreach Strategies Key

News outlets examine the work of navigators and other efforts to enroll people without health insurance into new coverage under the health law.

The Texas Tribune/New York Times: For Aid Insuring Latinos, Groups Look Close to Home
Though they make up roughly a third of the state’s population, Latinos account for nearly two-thirds of the more than six million Texans without health insurance. But in the 13 days since a federal insurance marketplace aimed at helping the uninsured find coverage opened, health care advocates across the state have encountered common obstacles in getting Latinos registered, including limited access to computers and the lack of an e-mail address (Aaronson, 10/12).

USA Today: Pushing Health Care In USA's Poorest City
Today's door-to-door insurance salesmen may seem worlds apart from the residents of these often-tattered row houses, but they share one big thing in common. They haven't been able to afford insurance either. They face the daunting task of helping to convince the nearly 200,000 uninsured residents of Philadelphia County that they can — and should — buy it now. The new exchange's success, the cornerstone of the Affordable Care Act, will hinge on whether it can meet the federal goal of 7 million enrollees, but also on whether it can sign up enough healthy younger people like these canvassers to make up for all the ailing older ones (O’Donnell, 10/12).

Kaiser Health News: Geography Is Destiny When It Comes To Enrolling In Health Insurance Exchanges
Alexandra Dixon threads her way among the people waiting to see a doctor at the Community Clinic, Inc. in Silver Spring, Maryland. She introduces herself with a bright smile and an outstretched hand: "I'm one of the new health care navigators. Have you heard of the Affordable Care Act?" While some folks mumble, "um, no I don't think so," Dixon is nonetheless booked up with appointments. She's one of 350 people in Maryland who have been hired and certified to help consumers enroll in the new health insurance options that are offered as part of the health law (Gold, 10/13).

The Associated Press: Detroit-Area Group Boosts Hours Of Obama 'Navigators' As Health Care Sign-Ups Rise
Amid the problems and political finger-pointing since the launch of online health care exchanges, Adnan Hammad sees progress. The community health director at Dearborn-based nonprofit organization ACCESS said his staff has helped hundreds of people enroll in plans under the federal health care overhaul and educated thousands about the available options (Karoub, 10/13).

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Ohio Gov. Needs One More Vote To Expand Medicaid

After trying unsuccessfully to get Medicaid expansion through the state legislature, Ohio Gov. John Kasich is asking a bipartisan board to expand the program under the federal health law. Ohio media outlets say he is shy a single vote.

Toledo Blade: Ohio Nears Medicaid Expansion
Instead of 132 lawmakers, six apparently will decide whether roughly 275,000 more Ohioans will be added to the Medicaid rolls under the federal health-care law. For eight months, Gov. John Kasich’s Medicaid expansion plan has gone nowhere with fellow Republicans, but on Friday he took steps to bypass the General Assembly and ask a bipartisan, mostly legislative panel to accept nearly $2.6 billion in federal funds to pay for it (Provance, 10/12).

Columbus Dispatch: One More 'Yes' Needed To Expand Medicaid
Kasich’s move follows a months-long stalemate with his fellow Republicans, who dominate the legislature, that can’t be broken — at least not in time to begin accepting the money under the Affordable Care Act on Jan. 1. Kasich just needs four people on the Controlling Board to approve his request. But so far it sounds like he has only three votes (Varden, 10/12).

Cleveland Plain Dealer: Kasich Administration Will Seek State Controlling Board's OK To Use Federal Funding To Expand Medicaid In Ohio
The Kasich administration will ask the controlling board at its next meeting for authority to spend about $2.5 billion in federal aid over the next two years to expand the state’s Medicaid program to cover Ohio’s working poor. Approval from the board, which meets Oct. 21, would clear the last hurdle toward expanding Medicaid in Ohio to cover people with incomes up to 138 percent of the poverty level. That group would be able to start getting health insurance coverage on Jan. 1, 2014, said Greg Moody, director of the state’s Office of Health Transformation (Higgs, 10/12).

Meanwhile, New Hampshire lawmakers are poised to take up the expansion question --

The Associated Press: N.H. Lawmakers To Take Up Medicaid Expansion Question
State Rep. Marjorie Porter sympathizes with people who would benefit from New Hampshire expanding Medicaid because she still owes medical bills from the four years when she was uninsured. ... After much angst, a special panel is poised to issue a report Tuesday recommending that New Hampshire add an estimated 49,000 poor adults to the state’s Medicaid program (Love, 10/14).

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Health Law Impact: Some Consumers Likely To Run Into Penalties

News outlets look at a variety of policy issues surrounding the health overhaul, including what might lead people to not sign up and face a fine, how Virginia insurers priced their plans based on bariatric surgery costs and the campaign to sign up Native Americans.

Politico: Obamacare: Who Will Ignore Law's Requirements?
Millions of Americans may be wrestling with computer glitches to try to sign up for Obamacare — but many people eligible just won't bother and will pay a price for it. Some will flout the mandate to buy coverage on ideological grounds, a health insurance version of civil disobedience (Bade and Norman, 10/14).

Kaiser Health News: Why Some Virginia Health Plans Cost So Much
Consumers shopping for coverage in new online marketplaces may scratch their heads when they come to a handful of plans in Virginia: Why do some cost more than $1,800 a month? No, the plans do not include gold-plated hospital beds or guaranteed same-day access to doctors. Instead, those premiums reflect an add-on benefit for a type of costly surgery for obesity which makes them up to six times more expensive than plans without such coverage (Appleby, 10/13).

The Associated Press: Ind. Sees Subsidy Loophole In Health Care Suit
The lawsuit Attorney General Greg Zoeller and 15 Indiana school districts have filed against the IRS could also block federal subsidies for state residents enrolling in the health exchange that's part of the federal health overhaul. The lawsuit, filed earlier this week, says the federal government lacks standing to require health benefits for any employee who works more than 30 hours in a week (LoBianco, 10/11).

Bloomberg: More Republican Districts Have Low Health-Coverage Rates
Republicans represent more U.S. congressional districts with below-average health-insurance coverage than Democrats, an irony ensnared in a government shutdown triggered by a law designed to expand access to care.  Districts with less coverage are especially common in Texas, where each of the 36 House seats represents an area with a rate lower than the national average, according to U.S. Census Bureau data compiled by Bloomberg (McCormick and Giroux, 10/14).

The Philadelphia Inquirer: Don't Base Your Selection Only On Premium Price
Everyone was asking about premiums in the months before the rollout of the Affordable Care Act. But many people are mistaken if they think the premium represents the bottom-line cost of health insurance. It doesn't (Calandra, 10/13).

Stateline: ACA – A Hard Sell For Native Americans
Longstanding treaties with the federal government guarantee all Native Americans free health care. As a result, the Affordable Care Act exempts them from paying a penalty if they choose not to purchase insurance. More than 2 million Native Americans receive free health care at federally supported Indian health facilities. Many others receive care from tribal facilities and urban Indian organizations. So why would an American Indian or Alaska Native sign up for reduced-rate insurance on the exchanges? Indian health advocates said the benefits are many. "It's an unprecedented opportunity," said Roxane Spruce Bly, who is working with New Mexico’s health insurance exchange to provide outreach to Native Americans. "It's the biggest thing to happen in Indian health in my lifetime. It solves so many problems for Indian people" (Vestal, 10/14).

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Health Care Marketplace

A New Alliance: Medicine And Finance

The New York Times reports on how health professionals are increasingly urging patients to pay costs not covered by insurance with lines of credit or special credit cards -- all of which can be arranged in the provider's office. Meanwhile, Bloomberg takes a look at a new trend regarding the payment of deductibles.

The New York Times: Patients Mired In Costly Credit From Doctors
In dentists’ and doctors’ offices, hearing aid centers and pain clinics, American health care is forging a lucrative alliance with American finance. A growing number of health care professionals are urging patients to pay for treatment not covered by their insurance plans with credit cards and lines of credit that can be arranged quickly in the provider’s office. The cards and loans, which were first marketed about a decade ago for cosmetic surgery and other elective procedures, are now proliferating among older Americans, who often face large out-of-pocket expenses for basic care that is not covered by Medicare or private insurance (Silver-Greenberg, 10/13).

Bloomberg: Patients Pay Before Seeing Doctor As Deductibles Spread
When Barbara Retkowski went to a Cape Coral, Florida, health clinic in August to treat a blood condition, she figured the center would bill her insurance company. Instead, it demanded payment upfront. Earlier in the year, another clinic insisted she pay her entire remaining insurance deductible for the year -- more than $1,000 -- before the doctor would even see her (Armour, 10/14).

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Medicare Open Enrollment Starts Tuesday

Beneficiaries are encouraged to take a close look at their options during their upcoming enrollment period, which is separate from the sign-up in the health law's marketplaces.

The Wall Street Journal: It's Time For Medicare Open Enrollment
Medicare's annual open-enrollment period starts Tuesday, and this year beneficiaries need to take a particularly close look at their options, many of which have been tweaked. ... Overall, premiums for Advantage plans, the private-insurer version of Medicare coverage, are projected to go up next year—by 5%, or $1.64, on average, to $32.60 a month, according to the Centers for Medicare and Medicaid Services, the agency that runs Medicare. For drug plans, the average basic-plan premium will be $31, which it said was about the same as this year. But analysts say that the steady average masks a lot of tweaks that insurers are making to Advantage plans in response to cutbacks in payments from the federal government—including that at least a few plans' premiums will go up sharply (Mathews, 10/13).

The Oregonian: Medicare 2013: How Health Reform Lurks Behind The Scenes Of Your Plan
With all the talk about health reform, some seniors – worried about changes to Medicare – have understandably wanted to take some sort of pill. Let's put you at ease right up front. The new health exchange has nothing to do with the open enrollment period that comes along every year at this time for Medicare managed care and drug plans. You don't need to visit Cover Oregon to enroll for or switch Medicare plans. You can do that, as usual, until Dec. 7 through Medicare.gov, insurer or broker (Hunsberger, 10/12).

Meanwhile, The Fiscal Times offers a list of considerations for workplace open enrollment season, too.  

The Fiscal Times: 10 Ways Your Health Benefits at Work May Change
Despite all the attention the public Obamacare exchanges have been getting, the vast majority of Americans will still sign up for health insurance this year the way they always have: by using the open enrollment process at work this fall. While many of the plans and benefits for workers will be similar to those in the past, continued corporate efforts to rein in health care costs and other trends in corporate benefits mean there may be some changes. Here's a guide to 10 changes you may see to your health and other workplace benefits this year (Braverman, 10/14).

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Public Health & Education

Asthma: The Costs Of Meds And Challenges Of Care

Although asthma can usually be controlled with prescription medications, being able to afford them requires good insurance or lots of disposable income. Meanwhile, reducing the emergency-room visits of children who suffer from asthma is a key to holding down costs and having better luck controlling the condition.

The New York Times: The Soaring Cost Of A Simple Breath
Asthma — the most common chronic disease that affects Americans of all ages, about 40 million people — can usually be well controlled with drugs. But being able to afford prescription medications in the United States often requires top-notch insurance or plenty of disposable income, and time to hunt for deals and bargains. The arsenal of medicines in the Hayeses’ kitchen helps explain why. Pulmicort, a steroid inhaler, generally retails for over $175 in the United States, while pharmacists in Britain buy the identical product for about $20 and dispense it free of charge to asthma patients. Albuterol, one of the oldest asthma medicines, typically costs $50 to $100 per inhaler in the United States, but it was less than $15 a decade ago, before it was repatented (Rosenthal, 10/12).

The Washington Post: Children’s Hospital Aims To Cut Asthma-Related ER Visits
Three times in one week in September, 13-year-old Ellis Powell struggled to breathe. Three times, his mother called an ambulance and raced the gasping boy to the emergency room. ... Powell has again come to the ER at Children’s National Medical Center on this October day, not because Ellis has had another crisis, but because he has an appointment in the Asthma Clinic, in the only ER in the country that tries to do what other doctors do not: teach families how to manage the chronic condition with medication so they can avoid terrifying and costly trips to the ER (Schulte, 10/12).

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State Watch

State Highlights: Md. Submits Plan To Tie Hospital Charges To State's Economy

A selection of health policy stories from Maryland, California, Missouri and Florida.

The Baltimore Sun: Md. Submits Plan To Overhaul Hospital Charges
Maryland health officials on Friday turned over to the federal government a plan that would overhaul how hospitals are paid for treating patients to promote lower admissions and better care. The state Department of Health and Mental Hygiene plan would replace a model in which hospitals are reimbursed for care based on numbers of hospital admissions with one that instead ties that spending to the state economy (Dance, 10/11).

The New York Times: Gov. Brown Of California Vetoes Biotech Drug Bill
The first year of skirmishes in state legislatures over bills that would govern the use of cheaper versions of expensive biotechnology drugs is nearly over. Health insurers and generic drug companies have prevailed in most states over brand-name pharmaceutical companies (Pollack, 10/13).

The Sacramento Bee: Jerry Brown Vetoes Bill To Give Medi-Cal Interpreters Union Rights
Gov. Jerry Brown vetoed legislation Sunday that would have given thousands of Medi-Cal interpreters the right to join a public employee union and bargain collectively with the state. Assembly Bill 1263, by Assembly Speaker John A. Pérez, D-Los Angeles, would have established a certification process and registry of medical interpreters, a measure proponents said would better regulate a service that is critical to patients who do not speak English. But the bill was also significant to labor unions that believe implementation of the federal healthcare overhaul will result in a wave of new patients and medical professionals they hoped to add to their union ranks (Siders, 10/13).

California Healthline: Governor Signs Midwives Bill
A bill removing barriers for licensed midwifes to deliver children in normal births and improving communication between physicians and midwives if a hospital transfer is necessary was signed into law Thursday by Gov. Jerry Brown (D). … The law removes the requirement that a licensed midwife be under a physician's supervision, a provision since 1999 that some considered unworkable and not enforced by the Medical Board because of an administrative judge ruling (Norberg, 10/11).

Los Angeles Times: Mental Health Court Helps Save A Troubled Talent From The Street
Kim Knoble's past tracks an arc of promise, mental illness and descent into what her parents call "living hell." But Knoble is not homeless, in prison or dead — outcomes common with stories like hers. Instead, on Wednesday, the woman with a head of wild red curls plans to walk into the St. Francis Yacht Club, tell her tale of recovery and lift the instrument she did not touch for a decade to play Massenet's "Meditation From Thais" (Romney, 10/13).

St. Louis Beacon: SLU’s Student-Run Clinic Emphasizes Prevention, Healthy Living
Each Tuesday evening, some of the most medically underserved residents in St. Louis gather at a clinic in the Victor Roberts Building on the north side for generous access to medical advice. The discussions focus less on pills and prescriptions and more on wellness and prevention, with primary emphasis on measures the patients can take to improve their health (Joiner, 10/14).

Modern Healthcare: Hospitals Play With Medicare Patients’ Status
A growing number of senior citizens are ensnared in a Medicare crackdown on hospitals over costly inpatient admissions. Hospitals nationwide are responding by classifying more overnight visitors as outpatients held for observation. Caught in the middle are senior citizens, who aren't warned about the consequences of observation and can't appeal, patient advocates say (Schorsch, 10/13).

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Editorials and Opinions

Viewpoints: Marketplaces' 'Technical Foibles' May Keep Young People From Coming Back; Health Law May Be Ushering In Era Of Narrow Networks

The Washington Post: Obamacare's Balky Web Sites Endanger Its Launch
The encouraging view is that the overwhelming number of visitors to the site indicates high demand for insurance in the new system. That's critical, because the more people who participate, the better the system works. The danger is that the technical foibles since Oct. 1 will discourage people from coming back, particularly the young and healthy customers the system needs to keep rates reasonable. With some big deadlines approaching, the Obama administration needs to fix the bugs, and fast. People who need insurance from the federal marketplace have until mid-December to buy coverage that begins Jan. 1. If enrollment figures aren’t robust by then, the new health-care system will have a problem even bigger than a frustrating Web (10/11). 

The Wall Street Journal: ObamaCare's Serious Complications
The functional failures of the Affordable Care Act websites are well-documented, but the fundamental flaw is the law's mind-numbing complexity. The officials who planned ObamaCare blame their Web engineers, but they're passing the buck. ObamaCare is a hugely complicated approach to addressing problems in health care that have simpler solutions. Software glitches are no surprise with such a complex system. For example, signing up uses a Byzantine process to check if a family is entitled to a subsidy, requiring data from dozens of federal and state agencies using databases built on different technology platforms (L. Gordon Crovitz, 10/13).

Bloomberg: Glitchy Rollout Doesn't Spell Doom For Obamacare
More than 8 million Americans tried to log on to federal or state exchanges, despite concerted efforts by conservatives to dissuade them. Software glitches foiled many of these inquiries and undermined supporters' claims that the program is ready for prime time. The confusion also underscored again that this measure is the focus of greater partisan rancor than any major U.S. legislation in recent memory. High emotion often distorts reality. The Oct. 1 rollout was interesting, instructive and not all that important. Over the next year or so, there are at least four crucial benchmarks (Albert R. Hunt, 10/13).

The New York Times: Obamacare: The Rest Of The Story
Unless you've been bamboozled by the frantic fictions of the right wing, you know that the Affordable Care Act, familiarly known as Obamacare, has begun to accomplish its first goal: enrolling millions of uninsured Americans, many of whom have been living one medical emergency away from the poorhouse. You realize those computer failures that have hampered sign-ups in the early days — to the smug delight of the critics — confirm that there is enormous popular demand. You have probably figured out that the real mission of the Republican extortionists and their big-money backers was to scuttle the law before most Americans recognized it as a godsend and rendered it politically untouchable. What you may not know is that the Affordable Care Act is also beginning, with little fanfare, to accomplish its second great goal: to promote reforms to our overpriced, underperforming health care system (Bill Keller, 10/13). 

Bloomberg: One Way Obamacare Could Save You Money
The opening of the Affordable Care Act’s state insurance exchanges has produced justified guffaws about the ability of the federal government to build a working website. It may also spur something more useful: a reconsideration, with new information for both employees and employers, of the tradeoff between greater choice and lower costs in health care. ... Florida’s experience is instructive. The state’s largest health insurer, Blue Cross Blue Shield, has a narrow-network plan, Blue Select, for individuals shopping on the Florida exchange. The plan has also seen increased demand from companies, which can cut their premiums by 5 percent to 15 percent. WellPoint Inc. (WLP), which offers exchange plans in 14 states, says it too has seen more interest in narrow networks because of the exchanges. This suggests that Obamacare may be softening a longstanding taboo in American health care: Limiting choice, something associated with health-maintenance organizations (10/13).

The New York Times: It's Not Only Mothers And Children
Traditionally, Medicaid, and other government anti-poverty programs, have largely ignored childless adults under the antiquated rationale that only children, their parents, older Americans and the disabled are deserving of help. The sheer number of childless adults in poverty defies that notion, as does compassion and economic necessity — an economy cannot thrive with a significant share of the working-age population stuck in poverty. That is why one of health reform's greatest goals is to extend Medicaid to all low-income childless adults with the federal government paying all of the costs for three years and at least 90 percent after that. The refusal of many states to go along undermines that important step forward (10/12).

The Los Angeles Times: Another Special Interest Tries To Wriggle Out Of Paying For Obamacare
Now that the medical device industry appears to be on the verge of snaking out from under its Obamacare-related tax, another industry lobby has stepped up to the plate with the words, "Us too!" We're talking about the health insurance industry, which has launched a campaign to kill a premium excise tax that will start being collected next year. As with the medical device tax, this is an example of pure special pleading. The Affordable Care Act is shot through with fees and taxes affecting almost all stakeholders in healthcare, largely because conservatives in Congress insisted that the law pay for itself. The health insurance industry simply doesn't want to carry its share (Michael Hiltzik, 10/11).

JAMA: Young Adults And The Affordable Care Act – Invincible Or Convincible
As the marketplace for the Affordable Care Act (ACA) opened for business last week, software glitches and the volume of consumer interest prevented some people from accessing the sites, perhaps an encouraging sign of demand. But the success of the ACA hinges not just on the overall number of people who ultimately purchase insurance but also on whether a substantial number of those who sign up are young adults—those aged 18 to 35 years, about 19 million of whom are currently uninsured (Dave A. Chokshi, 10/11).

The New York Times: Out Of Network, Out Of Luck
For several hundred patients at the University of Pittsburgh Medical Center, it started with a certified letter informing them that they were no longer allowed to see their physicians. The reason? They were unlucky enough to have insurance called Community Blue, which is offered by a rival hospital system. Astoundingly, they were barred even if they could pay for the care themselves. ... Community Blue is sold by a company called Highmark. Like U.P.M.C., it is both a hospital system and an insurance provider, part of a growing trend toward vertical consolidation in the two industries. These and other companies insist that such consolidation streamlines the caregiving system and thus benefits the patient. But in the short term, they are waging a vicious war over patients — and as the experience in Pittsburgh shows, it's often the patients who are losing (Theresa Brown, 10/12).

And on other topics --

The New York Times: Hope For A Malaria Vaccine
The most ambitious clinical trial of a malaria vaccine has shown some effectiveness in children over an 18-month period. While its efficacy is modest, it is nonetheless a significant advance in the long struggle to control a disease that kills some 600,000 people a year, mostly children under the age of 5 (10/13).

The Washington Post: Miriam Carey Didn't Have To Die. Police Need Better Training In Mental Illness.
Officers fired 17 shots over several minutes before one round killed the driver, 34-year-old Miriam Carey, on the northeast side of the Capitol. Of course, the officers couldn't have known that Carey had been diagnosed with postpartum depression with psychosis and that her understanding of their commands may have been clouded by an alternate reality in her head. But if they'd had better training, they might have realized that she wasn't intentionally defying their orders as much as she was panicked, confused and in the midst of an emotional breakdown. They might have figured out a way to calm her down without killing her (James Mulvaney, 10/10).

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Shutdown Commentaries: The Man Who Championed The Strategy; 'Opening Salvo In A Generational War;' Lack Of Funding Hurts Public Health Efforts

The Wall Street Journal: Michael Needham: The Strategist Behind The Shutdown
'I really believe we are in a great position right now," says Michael Needham, the 31-year-old president of Heritage Action, the lobbying arm of the nation's largest conservative think tank. By "we" he means the Republican Party and the conservative movement; their "great position" refers to the potential to win the political battle over the government shutdown. Though Texas Sen. Ted Cruz is the public face of the high-risk strategy to "defund" ObamaCare, the masterminds behind it are a new generation of young conservatives, chief among them Mr. Needham. From a tactical view, the strategy has been deployed with precision. In August, only Mr. Cruz and a band of renegade tea-party Republicans in the House favored this approach, and the media collectively scoffed. But by September, House Republicans couldn't pass a budget without attaching the defunding rider that has grounded much of government (Stephen Moore, 10/11).

Los Angeles Times: Obamacare: Don't Trust Anyone Over 60? 
But the idea of closing down the government, and even threatening to precipitate a global credit crisis, over the healthcare law has been widely written off as myopia on the part of the live-free-or-die crowd. We're not so sure. Focusing on Obamacare in general, and mandatory coverage in particular, could prove a plausible strategy for broadening the anti-Obama coalition to include voters in their 20s and 30s by bringing attention to what economists call the "cross-subsidy" inherent in any insurance system based on mandatory coverage. And, with hindsight, it may yet be seen as the opening salvo in a generational war, one fed by the reality that older Americans are a rapidly growing burden on younger workers, who can ill afford it (Robert Hahn and Peter Passell, 10/14).

The Wall Street Journal: The Best Budget Outcome: Tax Reform
But guess what? Republicans don't want to fight over the old-age retirement programs either. A secret of the tea party is that it's largely made up of Medicare and Social Security recipients who revile ObamaCare—and food stamps, and Medicaid and other means-tested programs—as giveaways to the poor that threaten to crowd out funding for their programs of universal "earned" entitlements (Holman W. Jenkins Jr., 10/11). 

Los Angeles Times: For The GOP, Rightward Ho!
The Republican Party is at war with itself. It's divided over how best to shrink the federal budget and how to undo President Obama's healthcare law. It hasn't been notably successful at either, which helps explain why the GOP's standing in the eyes of most voters has plummeted to depths not seen in three decades of modern polling. None of this was planned, of course; parties don't flirt with political suicide on purpose. But it wasn't accidental either. Behind the GOP crackup over the government shutdown lies a much bigger battle for control of the party (Doyle McManus, 10/13).

The New York Times: Rolling The Dice On Food-Borne Illnesses
The government shutdown has caused staff reductions at two important federal health agencies, increasing the risk of serious harm to American consumers from food-borne illnesses. The two agencies — the Food and Drug Administration and the Centers for Disease Control and Prevention — have decided to focus their remaining resources on imminent threats. But they have shut down very important work that allows them to spot potentially serious problems in advance and take steps to head them off. The longer Congressional Republicans allow the shutdown to continue, the greater the danger of harm (10/11). 

Bloomberg: What If A Flu Breaks Out When CDC Can’t Track It
As director of the U.S. Centers for Disease Control and Prevention during the last government shutdown, in 1995-1996, I can attest to the very real potential for unnecessary pain, suffering and death when the work of public-health officials is curtailed. As a consequence of the current shutdown, the CDC has been required to furlough two-thirds of its staff, leaving only 4,000 people to conduct vital public-health responsibilities. This translates into reduced protection for Americans (Dr. David Satcher, 10/13).

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Stephanie Stapleton

Andrew Villegas

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.