Daily Health Policy Report

Friday, November 8, 2013

Last updated: Fri, Nov 8

KHN Original Reporting & Guest Opinion

Administration News

Capitol Hill Watch

Health Reform

Coverage & Access

State Watch

Health Policy Research

Editorials and Opinions

KHN Original Reporting & Guest Opinion

A Reader Asks: Can Adult Children With An Offer Of Family Coverage Instead Get Subsidies?

Kaiser Health News consumer columnist Michelle Andrews answers this reader's question. Her response: Yes, if their parents have not claimed them as tax dependents (11/8). Read the complete answer.

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Enrolling In Obamacare In Alaska Is Possible – A Computer Degree Helps

APRN's Annie Feidt, working in partnership with Kaiser Health News and NPR, reports: "Despite extensive problems with healthcare.gov, a few dozen Alaskans have managed to enroll in a health plan on the marketplace, and Lara Imler is one of them. … Even without health insurance, Imler spends a lot of time in doctors' offices. She has Hashimoto's disease, an autoimmune disorder that affects the thyroid. The treatments and blood work she needs are expensive -- but not as expensive as buying insurance in Alaska's individual market" (Feidt, 11/8). Read the story.

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Capsules: Make Tax Day Also Enrollment Deadline, One Health Expert Says; Conn. Governor To Feds: Get Your Act Together On Healthcare.gov

Now on Kaiser Health News' blog, Julie Appleby writes about one rationale for a change in the health law’s open enrollment period: "With one small fix, the administration could satisfy calls from some members of Congress to extend the time people have to enroll in new health insurance through online marketplaces, a health policy expert says" (Appleby, 11/7).

Also on the blog, WNPR's Jeff Cohen, working in partnership with KHN and NPR, reports on the Connecticut governor's take on the federal exchange: "Gov. Dannel Malloy said the rollout of Obamacare in Connecticut has been a success — but it would be a bigger success if the federal health marketplace weren’t doing so badly. 'I hope that the federal folks get their act together in the remainder of the month, because I'm tired of sharing their bad news interrupting our good news,' Malloy said Thursday, speaking at the opening of a retail store for Access Health CT, the state’s marketplace" (Cohen, 11/7). Check out what else is on the blog.

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Political Cartoon: Political Cartoon: 'Surprise Ending Beginning?'

Kaiser Health News provides a fresh take on health policy developments with "Surprise Ending Beginning?" by Rick McKee.

Here's today's health policy haiku: 


RUC is not perfect.
Primary care docs complain.
Prefer gov control?
-William F. Gee, M.D. 

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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Administration News

Obama Apologizes For His 'You Can Keep It' Promise

President Barack Obama issued the apology in an interview with NBC News that aired Thursday evening. He also said his administration was working on a fix for the problem.

NBC News: Exclusive: Obama Personally Apologizes For Americans Losing Health Coverage
President Obama said Thursday that he is "sorry" that some Americans are losing their current health insurance plans as a result of the Affordable Care Act, despite his promise that no one would have to give up a health plan they liked. "I am sorry that they are finding themselves in this situation based on assurances they got from me," he told NBC News in an exclusive interview at the White House (Todd, 11/7).

The New York Times: Apologizing, Obama Yields To Criticism Of Health Law
President Obama bowed Thursday night to mounting criticism that he had misled the American people about the health care law, apologizing to people who were forced off their health insurance plans by the Affordable Care Act despite "assurances from me" (Shear, 11/7).

McClatchy: Analysis: Tens Of Millions Could Be Forced Out Of Health Insurance They Had
Some or much of that loss of favored insurance is driven by normal year-to-year changes such as employers changing plans to save money. And many people could end up with better plans. But it is not what the president pledged. Caught in the firestorm of his broken promise, Obama on Thursday apologized (Hall and Kumar, 11/7).

Los Angeles Times: Obama 'Sorry' For Health Insurance Cancellations
President Obama apologized Thursday for the fact that some people are losing their current health insurance plans even though he had told Americans they could keep their plans if they wanted to, saying his administration was working on changes to his healthcare law to address the problem. "I am sorry that they are finding themselves in this situation based on assurances they got from me," the president told NBC News in an interview that aired Thursday evening (Parsons and Hennessey, 11/7).

The Washington Post: President Obama Apologizes To Americans Who Are Losing Their Health Insurance
The president said he had asked his staff to see whether there was an administrative fix to preserve insurance for some Americans who may have lost their coverage and do not qualify for subsidies that would make new policies affordable. "I've assigned my team to see what we can do to close some of the holes and gaps in the law," he said, "because, you know, my intention is to lift up and make sure the insurance that people buy is effective — that it's actually going to deliver what they think they’re purchasing" (Eilperin, 11/7).

The Wall Street Journal: Obama Apologizes For Insurance Cancellations
President Barack Obama said Thursday he was sorry that thousands of Americans were losing their health insurance, expressing regret for the first time that the Affordable Care Act hadn't lived up to his promise that people who liked their coverage could keep it. Mr. Obama said he had intended to make good on his pledge but the administration wasn't as clear as it should have been in describing the changes the new health law would bring. Now, facing a chorus of complaints as many people receive notice that their plans have been canceled, Mr. Obama signaled he was open to some kind of relief, although he didn't give specifics (Nelson, 11/7).

The Wall Street Journal: How Obama's Language Has Shifted On Insurance
President Barack Obama, in an interview with NBC News, said he was sorry that many Americans were losing their current coverage, despite promises by the White House that people who were happy with their coverage could keep their plan. Here is what the president said in the interview, compared with previous statements on the issue (11/7).

The Associated Press/Washington Post: Obama To Americans Losing Health Care Coverage Because Of New Law: 'I Am Sorry'
Officials said the president was referring to fixes his administration could make on its own, not legislative options proposed by congressional lawmakers. The president’s apology comes as the White House tries to combat a cascade of troubles surrounding the rollout of the health care law, often referred to as "Obamacare" (11/7).

USA Today: Obama Says He Is Sorry For ‘You Can Keep It’ Declaration
The comments, which Obama made in an interview with NBC News, come as he faces a steady stream of criticism as millions of Americans on the individual insurance market received notices that their plans do not meet the minimum benefit requirements set under the ACA and will be canceled (Madhani, 11/7).

Politico: Barack Obama: 'I Am Sorry'
President Barack Obama offered an apology Thursday to those Americans who have been told they’re losing their health insurance plans, contrary to his promise that no one would be forced off a plan they wanted to keep. "I am sorry that they are finding themselves in this situation based on assurances they got from me," the president said in a Thursday interview with NBC News, offering his first mea culpa for an issue that’s generated negative headlines for the White House for the past two weeks (Epstein, 11/7).

Bloomberg: Obama Says He’s Sorry Over Americans Losing Health Plans
President Barack Obama said he’s sorry that thousands of Americans are losing their medical insurance as a result of his health-care law, as his administration works to contain the political damage from the troubled rollout of his signature domestic achievement. Hundreds of thousands of individual health insurance plans are being canceled, contradicting Obama’s repeated pledge that people who like their coverage would be able to keep it when the law took effect (Lere, 11/8).

CNN: Obamacare: After Obama’s Apology, Talk OF Solutions And – Still – The Website
Some insurance companies also appear to be canceling policies for other reasons, such as withdrawing from states where they have fewer subscribers. The president contends many of the people who have received cancellation notices actually will wind up with better coverage at lower cost. But he acknowledged that's a hard sell when people are still having trouble logging onto the Obamacare website to enroll (Simpson, 11/8).

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Capitol Hill Watch

10 GOP Senators Want Sebelius To Be Fired; Some Dems Press For Individual Mandate Delay

Health law politics are triggering a new wave of political posturing among lawmakers who are attempting to position themselves for the upcoming election season.  

Los Angeles Times: 10 Republican Senators Want Sebelius Fired Over Obamacare Rollout
Ten Republican senators have called on President Obama to fire Health and Human Services Secretary Kathleen Sebelius, who is overseeing the implementation of the Affordable Care Act and its troubled website. Sen. Pat Roberts (R-Kan.) and nine other senators told Obama they were concerned not only with the botched rollout of healthcare.gov, but the implementation of the broader law, which they all oppose. Dozens of House Republicans have also pushed for Sebelius' dismissal (Mascaro, 11/8).

Modern Healthcare: 10 GOP Senators Call For Firing Of Sebelius In Letter To Obama
HHS Secretary Kathleen Sebelius' appearance before the Senate Finance Committee on Wednesday failed to convince GOP lawmakers she's capable of overseeing the rest of the health reform law's implementation. On Thursday, 10 Republican senators asked the president to fire her (Zigmond, 11/7).

Politico: Dems Give White House Tight Deadline To Fix Obamacare
Democratic senators facing reelection have a green light to bash the White House and call for certain legislative fixes. But they've been urged by senior administration officials not to insist on delaying the controversial law's core: The mandate for individuals to purchase insurance coverage or face penalties (Raju and Kim, 11/7).

The Fiscal Times: Fearing Senate Losses, Dems Now Urge Obamacare Delay
For months, the president has been fending off aggressive efforts by Sen. Ted Cruz of Texas and other Republicans to postpone and defund his signature health insurance law – including a 16-day government shutdown aimed at blocking the signup effort that began Oct. 1. But now the president is faced with an equally daunting task of defusing a simmering revolt among key allies in the Senate and the House who are worried about their reelection prospects next year (Pianin, 11/7).

Politico: Tea Partier Shifts Tactics On Obamacare
But this week, as he wheeled through county after county, lambasting his congressional leadership and the Obama administration with equal fervor, [Rep. Tim Huelskamp, R-Kan.] is publicly admitting that a government shutdown to choke off funding for Obamacare likely isn't in the cards when government funding runs out again in January (Sherman, 11/8).

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Health Reform

Officials Acknowledge New Capacity Problems With Healthcare.gov

New Healthcare.gov capacity problems are emerging -- this time as people trying to sign up for coverage get further along in the process, officials said in a conference call Thursday.

The Washington Post’s Wonk Blog: Uh-Oh: Techies Are Finding New Problems With Healthcare.gov
Every day, the Centers for Medicare and Medicaid Services hosts a phone call with reporters. This is the "Operational Update on the Health Insurance Marketplace" and usually happens around 1:30 or 2 p.m. Today's "Operational Update on the Health Insurance Marketplace" was not especially good news: As capacity problems at the start of HealthCare.gov get fixed, tech workers are finding new capacity problems later in the application process -- ones that, up until now, they didn't know about (Kliff, 11/7).

The Hill: More O-Care Site Problems 'Downstream'
The agency tasked with implementing the president’s health care law said Thursday it had uncovered "new stresses further downstream in the system" that revealed the need for a fresh look at the back-end capacity needs of the online healthcare portal. Centers for Medicare and Medicaid Services (CMS) spokeswoman Julie Bataille opened a conference call with reporters by acknowledging for the second consecutive day that while the system was stable, it remains slow for many users (Easley, 11/7).

One investment industry leader weighs in on the problems -

The Wall Street Journal's CIO Journal: Goldman Tech Leader Says Lack Of Accountability Hamstrung HealthCare.gov
HealthCare.gov, the government's beleaguered health insurance website, was hurt by a lack of coordination between policy makers and IT leaders managing its development, according to Don Duet, co-head of the technology division of Goldman Sachs Group Inc. This lack of coordination also led to a lack of accountability, he said (Hickins, 11/7).

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USA Today Reports 140,000 People Have Enrolled In Plans On Marketplaces Run By 13 States

State officials say the numbers are low because of snags in the websites and because consumers aren't yet worried about the sign-up deadline. Other news organizations examine some of the marketplace issues in states.

USA Today: States Report Low Health Insurance Enrollment Numbers
Enrollment for health insurance on state-run exchanges has been low in the first month, as officials in various states cite website glitches, a months-away deadline and even the government shutdown as reasons for the low numbers. Officials from 13 of the 15 states with their own exchanges, said 757,000 have registered for the exchanges, but only 139,170 people have bought or enrolled in health insurance plans (Kennedy, 11/7).

Kaiser Health News: Capsules: Conn. Governor To Feds: Get Your Act Together On Healthcare.gov
Gov. Dannel Malloy said the rollout of Obamacare in Connecticut has been a success — but it would be a bigger success if the federal health marketplace wasn't doing so badly. "I hope that the federal folks get their act together in the remainder of the month, because I'm tired of sharing their bad news interrupting our good news," Malloy said Thursday, speaking at the opening of a retail store for Access Health CT, the state’s marketplace (Cohen, 11/7).

The Associated Press/Washington Post: Conn. Opens Nation's First Insurance Stores To Help People Sign Up For Health Care Coverage
Connecticut is opening the nation's first insurance stores as part of an effort to fight the perception there are problems with its insurance marketplace that's separate from the flawed federal website. State officials hailed the brightly lit storefront, modeled after Apple's stores, as another sign that the rollout of the health care overhaul in Connecticut has been a success. Connecticut is one of 14 states plus the District of Columbia that created their own insurance marketplaces (11/7).

The CT Mirror: CT's Exchange Store Is Open To Sell Obamacare Insurance
Connecticut's first health insurance "storefronts" are open for business, and so, officials want you to know, is the state's health insurance exchange. Gov. Dannel P. Malloy and Lt. Gov. Nancy Wyman used Thursday’s ceremonial opening of the New Britain insurance enrollment center as a chance to draw contrasts between Connecticut’s relatively problem-free exchange, known as Access Health CT, and the problem-plagued federally run exchanges (Becker, 11/7).

Kaiser Health News: Enrolling In Obamacare In Alaska Is Possible – A Computer Degree Helps
Despite extensive problems with healthcare.gov, a few dozen Alaskans have managed to enroll in a health plan on the marketplace, and Lara Imler is one of them. … Even without health insurance, Imler spends a lot of time in doctors' offices. She has Hashimoto's disease, an autoimmune disorder that affects the thyroid. The treatments and blood work she needs are expensive -- but not as expensive as buying insurance in Alaska's individual market (Feidt, 11/8).

The Oregonian: Cover Oregon: Health Exchange To Hire 400 To Process Paper Applications
Cover Oregon, the state's online health marketplace, will hire 400 temporary workers to process paper applications while its website is fixed, a spokeswoman said Thursday. Ariane Holm, spokeswoman for the insurance exchange, said the hirings were called for in Cover Oregon's backup plan and fit within its budget.  The move is a sign that Cover Oregon's website woes are posing serious threats to enrolling individuals by a key Dec. 15 deadline (Hunsberger, 11/7). 

The Boston Globe: Vermont Governor Grappling With Health Website Woes
Vermont is among the states that opened its own version of the online health insurance exchange on Oct. 1, similar to the one Massachusetts has had in place since 2007. But to build it, Vermont hired the same principal contractor – CGI Group Inc., of Canada – as the US Department of Health and Human Services. The results have been similar: a plague of glitches (Rowland, 11/7). 

The Star Tribune: First Wave On MNsure Flocks To Public Plans
Amid a rocky national rollout for President Obama’s health care law, enrollments in publicly subsidized plans in Minnesota have significantly outpaced private insurance purchases so far on the state's new insurance exchange. The early trend, which has been mirrored nationally, is feeding a debate about the viability of health care reforms that depend on a major influx of new and healthy customers to keep premiums in check. But state officials and industry analysts say it is little surprise that, in the early going at least, those eligible for free or subsidized public programs would outnumber premium-paying customers shopping on the private insurance market (Diaz, 11/7).

Minnesota Public Radio: Probe: MNsure Data Breach Was Unintentional
An investigation by the Minnesota Office of the Legislative Auditor has found that a data breach at MNsure earlier this year was unintentional and that there was "no evidence of malicious intent." But the report also said that MNsure made a series of critical decisions that made personal information connected to 1,500 Minnesota insurance brokers vulnerable to a breach. Fast-moving timelines, not enough workers and inadequate data security are all to blame, the report said (11/7).

Health Policy Solutions (a Colo. news service): Stuck In Colorado's Black Hole
Connect for Health Colorado's online system then asked [Donna] Smith if she wanted to try to qualify for financial assistance. Why not? She knew she wouldn't qualify for Medicaid, but thought she might receive a federal tax subsidy. The health exchange website then bumped her to Colorado’s Medicaid enrollment website, known as PEAK. That's when Smith began her trip into a black hole. Connect for Health Colorado customers who know they don't qualify for Medicaid nonetheless must fill out an onerous, detailed application and get a denial for the government run, low-income insurance program before they can qualify for tax subsidies and buy health insurance on Colorado's exchange (Kerwin McCrimmon, 11/7).

In related news -

USA Today: Even Doctors In Dark About New Health Plans
More than a month after HealthCare.gov and 15 state-based exchanges opened for business, consumers and even physicians are finding it isn't easy or even possible sometimes to find out which doctors and hospitals are in the plans' provider networks (O’Donnell and McGinnis, 11/7).

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Administration Pushes GOP-Controlled States To Accept Medicaid Dollars

The White House is pushing Florida and Louisiana to accept the health law's Medicaid expansion -- and the federal dollars that come with it. In the meantime, lawmakers from New Hampshire and Pennsylvania look for ways their states can also expand the state-federal health care program.

Politico: White House Pushes Florida, Louisiana On Medicaid
The Obama administration again called out states that have refused to expand Medicaid on Thursday, calling it a "reckless" play to undercut Obamacare at the expense of their constituents' health. The White House held a conference call featuring officials in Florida and Louisiana who made the case for expanding the program and attacked those holding it up. President Barack Obama is traveling to the two states tomorrow on unrelated business, but the messaging is part of a larger drive to draw attention to the states that have refused to cover low-income people -- and away from the tidal wave of bad news about Americans whose health plans are being canceled (Norman, 11/7).

The Associated Press: N.H. Lawmakers Offer Ways To Expand Medicaid
Democratic and Republican political leaders continued Thursday to work behind the scenes on a possible compromise to expand Medicaid in New Hampshire as they publicly lauded different ways to get the job done. Democratic Gov. Maggie Hassan and legislative leaders have been trying to negotiate a compromise for weeks, but with nothing decided, the Republican-led Senate and Democratic-led House filed different expansion bills Thursday (Love, 11/7).

The Associated Press: Casey Asks Corbett To Expand Pa. Medicaid Program
U.S. Sen. Bob Casey is asking Gov. Tom Corbett to embrace an expansion of Medicaid to ensure that federally funded health insurance is accessible to hundreds of thousands of Pennsylvania's working poor when it becomes available next year. In a Thursday letter, Casey warned Corbett that refusing the Medicaid expansion unnecessarily penalizes people who would otherwise have coverage beginning Jan. 1 if the federal government does not agree to changes in the program being sought by Corbett (Levy, 11/7).

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People With Canceled Policies Could Dampen Financial Risks Of Exchanges

People who had their insurance policies canceled could improve the financial risks for the health law's online marketplace risk pool, a fact often ignored by those hammering the law. In the meantime, the uninsured and young aren't flocking to the marketplaces yet, and a health policy expert says one fix could help improve marketplace enrollment.

The Associated Press: People Whose Coverage Is Being Canceled Could Improve Overall Risk Of Obama Insurance Plan
It’s Economics 101, a little-noticed consequence of a controversial policy decision. And there are winners and losers. Millions of people who currently buy their own health insurance coverage are losing it next year because their plans don't meet requirements of the health care law. But experts say the resulting shift of those people into the new health insurance markets under Obama's law would bring in customers already known to insurers, reducing the overall financial risks for each state's insurance pool (Alonso-Zaldivar, 11/7).

Politico: Uninsured Not Surfing Health Sites
Less than a quarter of uninsured Americans who plan to get health insurance through the Affordable Care Act exchanges have been to an exchange website, a new poll shows. Asked if they've been to any government health insurance website since they were launched on Oct. 1, only 22 percent of the uninsured who said they planned on using the exchanges said yes, according to a Gallup poll out Friday (Topan, 11/8).

Politico: For Younger People, Obamacare Sign-Up Comes Later
Everyone knows that a couple of million young, healthy people will have to sign up for Obamacare to succeed. But there's one big problem with that: They'll probably wait until the last minute. While older and sicker people have good reason to more aggressively try to get covered, the younger, healthier people aren't likely to exhibit much patience with a balky website. They're likely to put off the mandatory insurance sign up until much closer to the March 2014 deadline (Villacorta, 11/7).

Kaiser Health News: Make Tax Day Also Enrollment Deadline, One Health Expert Says
With one small fix, the administration could satisfy calls from some members of Congress to extend the time people have to enroll in new health insurance through online marketplaces, a health policy expert says (Appleby, 11/7).

The Washington Post's The Fact Checker: Read The Fine Print: GOP Spin On Premium Hikes
[Sen. Rob Portman, R-Ohio] first refers to President Obama's repeated claim, during the 2008 campaign, that his health plan would reduce costs by $2,500 a year for a typical family. As we have noted before, Obama's claim at the time was quickly criticized by fact checkers, including The Fact Checker, as dubious. ... Portman might have remained on solid ground if he has simply referred to Obama's pledge. But then he contrasted Obama's $2,500 number with a Congressional Budget Office estimate that premiums would go up $2,100 under the health care law. Oops. There are several problems with using this CBO number in this way (Kessler, 11/8).

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Small Businesses, Too, Are Getting Insurance Cancellation Notices

Some small businesses are getting notice of insurance policy cancellations, just like their individual coverage counterparts. Other small business owners continue to wait to learn what options will be available to them through the law's online marketplaces.

Marketplace: Now Small Businesses Are Receiving Health Insurance Cancellation Notices 
In Arizona, Drs. Courtney and Matthew Dunn own DunnOrthodontics in central Phoenix. It's a small but profitable practice, which they've had for about seven years. They don't have to offer health insurance, but Matthew Dunn says, they choose to. On Tuesday, the Dunns received a letter from their health insurer, Humana. It informed them that they would not be able to continue with their current medical plan in 2014,  as it did not meet all of the ACA requirements (Heppermann, 11/7). 

The Washington Post: Health Care Law's Exchange Problems Leave Small-Business Owners In A Difficult Position
David Glazier and Jody Manor each own small businesses in Old Town Alexandria, just outside the nation's capital, and in the months leading up to the launch of the federal government's new health insurance exchange, both were eager to see what kind of savings they could find on the new marketplaces. It has now been six weeks since the exchange opened for business — but for Glazier, Manor and many other small employers, the wait continues (Harrison, 11/7). 

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Coverage & Access

Long-Awaited Rules Requiring Parity In Mental Health Coverage To Be Unveiled Today

The New York Times: Rules To Require Equal Coverage For Mental Ills
The Obama administration on Friday will complete a generation-long effort to require insurers to cover care for mental health and addiction just like physical illnesses when it issues long-awaited regulations defining parity in benefits and treatment (Calmes and Pear, 11/8).

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State Watch

State Highlights: Judge Greenlights Medicaid Contractor's Lawsuit Against La.

A selection of health policy stories from Louisiana, Texas, Georgia, North Carolina and California.

The Associated Press/Washington Post: Judge Refuses To Delay Fired Medicaid Contractor’s Lawsuit Against The Jindal Administration
A Maryland company fired from its $200 million Medicaid contract can continue to move forward with its wrongful termination lawsuit against Gov. Bobby Jindal’s administration, a Baton Rouge judge ruled Thursday. State District Judge Tim Kelley rejected a request from the attorney general’s office to delay witness interviews and evidence-gathering until January in the case filed against the state by Client Network Services Inc., or CNSI (11/7).

The Texas Tribune: In Austin, A Push To Combat Lack Of Black Mental Health Providers
Black communities in Texas and across the country face a shortage of black mental health care professionals. Huston-Tillotson University, a historically black college in Austin, is taking steps to solve that problem for students on campus (Diaz, 11/8).

Georgia Health News: State Health Centers Get $5.3 Million From Feds 
The federal government announced Thursday that it has awarded $5.3 million to 10 Georgia health organizations to create new sites to deliver care. Nationally, the Department of Health and Human Services awarded $150 million under the Affordable Care Act to support 236 new health center sites across the country across the country. The funding comes on top of $19 million awarded nationally in September to create new health care centers, including five in Georgia (Miller, 11/7).

North Carolina Health News: Health 2.0 Attempts To Understand The ePatient Of The Future
More than 100 entrepreneurs, health workers and tech industry insiders gathered at RTI International this week for the Health 2.0 NC Triangle meet-up. Health 2.0, in the same vein as TED talks and South by South West, has chapters around the world that bring together different speakers on a single topic. This week, the Triangle chapter brought together keynote speakers on the future of the ePatient (Hoban, 11/8).

California Healthline: 3 Projects Push Personal Health Records
California is launching three demonstration projects to put personal health records in the hands of patients. California's Office of Health Information Integrity yesterday announced contracts for three pilot projects to explore the use of different types of personal health records. According to Pamela Lane, director of CalOHII, there is no pilot of this kind currently running in California, and she hopes it will be a boon to health information exchanges and providers, to see how personal health records can work best (Gorn, 11/7).

California Healthline: As Healthy Families Shift Goes, So Goes Rural Expansion Of Medi-Cal Managed Care
Rural Californians already have challenges accessing health care and changes to Medi-Cal, the state's Medicaid program, could further complicate matters. Rural areas have fewer physicians and facilities and services are spread out over greater distances than they are in urban and suburban areas. Rural areas also have a disproportionately high number of lower-income, Medi-Cal-eligible residents which creates a challenging situation for state health officials charged with providing medical coverage in rural settings. On Nov. 1, the state launched an ambitious plan to transition Medi-Cal beneficiaries in rural areas from fee-for-service care arrangements to managed care plans. The move shifts 28 rural counties to the financial model the state is using throughout the rest of the state (Gorn, 11/7).

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Health Policy Research

Research Roundup: Pricing And The SHOP Exchange

Each week, KHN compiles a selection of recently released health policy studies and briefs.

Health Affairs: Small Employer Perspectives On The Affordable Care Act's Premiums, SHOP Exchanges, And Self-Insurance
Beginning January 1, 2014, small businesses having no more than fifty full-time-equivalent workers will be able to obtain health insurance for their employees through Small Business Health Options Program (SHOP) exchanges in every state. ... Based on a telephone survey of 604 randomly selected private firms having 3–50 employees, we found that both firms that offered health coverage and those that did not rated most features of SHOP exchanges highly but were also very price sensitive. More than 92 percent of nonoffering small firms said that if they were to offer coverage, it would be "very" or "somewhat" important to them that premium costs be less than they are today (Gabel et al., 10/16).

Health Affairs: Rural And Urban Medicare Beneficiaries Use Remarkably Similar Amounts Of Health Care Services
Medicare payment policies for rural health care providers are influenced by the assumption that the limited supply of physicians in rural areas causes rural Medicare beneficiaries to receive fewer health care services than their urban counterparts do. This assumption has contributed to the growth in special payments to rural providers. As a result, Medicare pays rural providers $3 billion more each year in special payments than they would receive under traditional payment rates. ... we analyzed claims data for all Medicare fee-for-service beneficiaries in 2008, stratified by rural/urban status and region. After adjusting for health status, we found no significant differences between rural and urban beneficiaries in either the amount of health care received or satisfaction with access to care (Stensland, 10/30).

Pediatrics: Randomized Controlled Trial Of Universal Postnatal Nurse Home Visiting: Impact On Emergency Care 
The Durham Connects program was developed in collaboration with community leaders as a brief, universal, postnatal nurse home visiting intervention designed to screen for risk, provide brief intervention, and connect families with more intensive evidence-based services as needed. ... Intervention families were offered 3 to 7 contacts between 3 and 12 weeks after birth to assess family needs and connect parents with community resources to improve infant health and well-being. ... families assigned to intervention had 50% less total emergency medical care use across the first 12 months of life. ... This approach offers a novel solution to the paradox of targeting by offering individually tailored intervention while achieving population-level impact (Dodge et al., 11/4). 

Annals of Internal Medicine: A Home Score For Streptococcal Pharyngitis Enabled By Real-Time Biosurveillance: A Cohort Study
Objective: To help patients decide when to visit a clinician for the evaluation of sore throat. ... Patients: 71 776 patients aged 15 years or older with pharyngitis who visited a clinic from September 2006 to December 2008. ... Results: If patients aged 15 years or older with sore throat did not visit a clinician when the new score estimated the likelihood of GAS pharyngitis to be less than 10%, ... 230,000 visits would be avoided in the United States each year and 8500 patients with GAS pharyngitis who would have received antibiotics would not be treated with them. ...  A patient-driven approach to pharyngitis diagnosis that uses this new score could save hundreds of thousands of visits annually by identifying patients at home who are unlikely to require testing or treatment (Fine, Nizet and Mandl, 11/5).

Journal Of The American College Of Radiology: The Increasing Role Of Non-Radiologists In Performing Ultrasound-Guided Invasive Procedures 
Recent proliferation of mobile diagnostic ultrasound (US) units and improved resolution have allowed for widespread use of US by more providers, both for diagnosis and US-guided procedures (USGP). This study aims to document recent trends in utilization for USGP in the Medicare population. Source data were obtained from the CMS Physician Supplier Procedure Summary Master Files from 2004 to 2010. .... The year 2010 represents the first year that nonradiologists performed more USGP than radiologists. From 2004 to 2010, radiologists and surgeons experienced only modest growth in USGP volume, whereas several other provider types experienced more rapid growth. It is likely that many procedures that were previously performed without US guidance are now being performed with US guidance (Sharpe et al., Nov. 2013).

The Kaiser Family Foundation/Topics in Antiviral Medicine: Implications Of The Affordable Care Act For People With HIV Infection And The Ryan White HIV/AIDS Program: What Does The Future Hold?
There are numerous aspects of the Affordable Care Act that will be important for people with HIV in the U.S., including consumer protections and private insurance reforms, establishment of health care marketplaces in every state, new benefit standards, Medicare fixes, prevention enhancements, expansion of Medicaid, and health system improvements. However, it is unlikely that these changes will address all the needs of people with HIV. The Ryan White HIV/AIDS Program will thus remain crucial for the provision of adequate health care to HIV-infected individuals, but it will need to change. Changes in the Ryan White Program's role will depend largely on state decisions on Medicaid expansion and health care marketplaces (Kates, 11/1).

The Centers for Disease Control and Prevention/Preventing Chronic Disease: The Association Between Insurance Status And Cervical Cancer Screening In Community Health Centers: Exploring The Potential Of Electronic Health Records For Population-Level Surveillance, 2008–2010
In the general population, receipt of cervical cancer screening is positively associated with having health insurance. Less is known about the role insurance plays among women seeking care in community health centers, where screening services are available regardless of insurance status. ... In our study uninsured non-Hispanic white women were less likely to receive a Pap test than were uninsured women of other races. Young, uninsured Hispanic women were more likely to receive a Pap test than were young, fully insured Hispanic women. ... Electronic health records enable population-level surveillance in community health centers and can reveal factors influencing use of preventive services (Cowburn et al., 10/24). 

Here is a selection of news coverage of other recent research:

Reuters: Black Patients Less Likely To Ask For Lower-Cost Meds
African American patients may feel less comfortable than white patients asking doctors if they can take cheaper drugs, a recent survey from an emergency department shows. White patients in the study were also more likely to be aware of low-cost prescription drug programs, according to lead author Dr. Preeti Dalawari, of Saint Louis University School of Medicine, and her colleagues (Huggins, 11/1).

PBS NewHour: Will Your Specialty Care Be Impacted By The Changing Health Care Landscape?
Take a mental snapshot of the U.S. health care system as it is today, because in 10 years, you might not recognize it. And if something isn't done now to boost the number of doctors in the U.S., you may not like it, either. If current trends hold, the number of physicians -- particularly specialists -- in the pipeline today may not be enough to keep pace with the future needs of a graying population, let alone the challenges of the new health care landscape, according to a study published Monday in the journal Health Affairs (Corapi, 11/4).

Medpage Today: Diabetes Teams With NPs, PAs Mostly Successful
A study comparing care teams with physician assistants (PAs) and nurse practitioners (NPs) with those of just physicians found outcomes were generally the same in 13 of 20 measures for diabetic patients without highly complex conditions. However, patients with care supplemented by PAs and NPs with highly complex conditions experienced worse outcomes in several areas compared with patients receiving physician-only care, Christine Everett, PhD, PA-C, MPH, professor in the physician assistant program at Duke University School of Medicine in Durham, N.C., and colleagues found (Pittman, 11/4).

Reuters: Surgeon All-Nighters Don't Lead To Complications: Study
Sleep-deprived surgeons don't make any more mistakes than usual during gallbladder operations, a new study suggests. Whether doctors had been up doing emergency surgery the previous night did not affect a patient's risk of having complications during or after the procedure (Pittman, 11/5).

Medscape: Colorectal Cancer Screening Rates Remain 'Far Too Low'
About 1 in 3 Americans aged 50 to 75 years, or 23 million people, have not been screened for colorectal cancer as recommended by the US Preventive Services Task Force (USPSTF), according to new data released today by the Centers for Disease Control and Prevention (CDC). This is a "disturbing fact," CDC Director Tom Frieden, MD, MPH, said during a media briefing. "Despite research showing that colorectal cancer screening saves lives, screening rates remain far too low" (Brooks, 11/5).

Medscape: After-Hours Call Centers Over-Refer Children To Emergency
About 1 in 3 children and adolescents referred to the emergency department by an after-hours nurse telephone triage service were considered nonessential referrals, a new study has found. "Although after-hours nurse telephone triage services improve the lifestyle of the outpatient pediatrician — and have been shown to standardize care — our research suggests that a large number of nonurgent patients are referred to the emergency department when perhaps they could be managed in the outpatient setting," said Kaynan Doctor, MD, from the Children's National Medical Center in Washington, DC. (McNamara, 11/6).

MedPage Today: Seniors Gain From Fall Prevention Program
A community-based fall prevention program effectively reduced the risk for falls among older adults, researchers said here. The evidence-based program, called Step Up to Stop Falls, includes exercise, home assessment/modification, and community and/or healthcare provider education, according to Mary Gallant, PhD, MPH, at the University of Albany School of Public Health in Rensselaer, N.Y., and colleagues (Buckley, 11/6).

Time: Primary-Care Doctors Don't Have The Best Tools For Treating Depression
Not all doctors are able to treat depression effectively, including those who are most likely to see patients' first symptoms. Even though patients may turn first to their primary-care physicians with any concerns about depression, the tools that those doctors use to evaluate their patients for mental-health disorders aren't necessarily helping to improve their patients' symptoms, according to the latest study published in the Journal of the American Medical Association of some of the most common practices used by these physicians (Sifferlin, 11/6).

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Editorials and Opinions

Viewpoints: Campaigning Won't Help Solve Health Care Problems; Health Law Sought 'Sturdier Safety Net;' Court's Decision On Contraception Benefit 'Goes Wrong Way'

The Washington Post: Rhetoric Vs. Reality
The Obamacare Web site doesn't work. Hundreds of thousands of insured Americans are seeing their plans summarily terminated. Millions more face the same prospect next year. Confronted with a crisis of governance, how does President Obama respond? He campaigns (Charles Krauthammer, 11/7).

The New York Times: Evaluations: Different Kinds Of Health Care Disruption 
Last week, amid the ongoing coverage of rising premiums and cancelled plans, the health care law's defenders took a new tack, arguing that the most plausible conservative alternatives to Obamacare would involve even more disruption of existing arrangements — with the implication being, then, that Republican outrage over "rate shock" is either straightforwardly cynical or else a sign that the G.O.P. would never, ever be willing to embrace a reform that disrupts the status quo at all (Ross Douthat, 11/7). 

The Washington Post: Obamacare: Weaving A Sturdier Safety Net
This is not to excuse President Obama for peddling a misleading claim or to excuse those of us in the news business for failing to press him on it earlier. The president's weaselly rewording of his pledge — "What we said was you can keep it if it hasn't changed since the law passed" — insults anyone who heard what he said repeatedly. Yet there was always an unstated asterisk to the presidential promise. Existing plans would be grandfathered in and not subject to the heightened requirements (i.e., better benefits) of the Affordable Care Act (Ruth Marcus, 11/7).

The New Republic: It's True: Obamacare Will Force Some People To Pay More For The Same Coverage
But some of the people getting cancellation notices had generous coverage—not the "junk insurance" that, as President Obama now acknolwedges, the new law prohibits. ... They will pay more for insurance next year but they won't get more for it. Some will actually get less. ... a system that discriminates against some people inevitably discriminates in favor of others. If you had asthma or diabetes or had survived cancer, you basically couldn't get coverage in the old market. If you had a less severe condition—maybe you had a bad bone break last year—you might be able to get coverage but with related services, like physical therapy, excluded. But if you were in good health, you could get insurance. And precisely because you seemed like a good risk, insurers were willing to give you a pretty good price—at least by the standards of American health insurance (Jonathan Cohn, 11/7).

Forbes: Fact-Checking The President's Kind-Of Sort-Of 'Apology' For Obamacare-Driven Insurance Cancellations
What makes Obamacare such a deeply flawed piece of work is not that it disrupts our existing arrangements, but that it disrupts those arrangements by forcing people to buy costlier coverage. And not only does Obamacare force people to buy costlier coverage, it most significantly punishes a population that is already disadvantaged in our current system: people of average income who buy coverage on their own, and don’t benefit from the heavy subsidies enjoyed by people with government- or employer-sponsored insurance. Critics of the President are right to hold him accountable for the inexcusable deception contained in his "like your plan, keep your plan" pledge. But if they in turn promise unrelenting fealty to the status quo, they will doom any efforts to reform our health care system in a better way (Avik Roy, 11/8).

Bloomberg: Fear Of Mooching Threatens Obamacare
The U.S. has spent four years arguing about the political, legal and technological impediments to Obamacare. We may have missed an even higher barrier: the American stigma around feeling like a freeloader (Christopher Flavelle, 11/7).

JAMA: Remodeling Health Care Requires A Care Coordinator
President Obama has appointed management consultant Jeffrey Zients to ensure repair of the [federal health] website as soon as possible. One of the first actions taken by [Jeffrey] Zients was to hire Quality Software Services "to manage the overall effort like a general contractor on a home improvement project." ... Zients’ comment indicates that the failure of HealthCare.Gov could be attributed, at least in part, to a lack of coordination among multiple software companies with areas of highly technical specialty expertise. In many ways, the lack of coordination in building the federal health insurance marketplace website parallels the same lack of coordination in the delivery of US health care (Andrew Bindman, 11/7).

USA Today: Sebelius, You're Not Fired!
On Oct. 1, millions of citizens came face to face with one of the greatest blunders of our generation. After almost half a billion dollars spent on the computer registration system for Obamacare, the website coughed, sputtered and appeared to descend into an immediate coma as millions tried to log on. One reason is that the Obama administration never fully tested it. For many, the greatest surprise was not that the government spent wildly on a defective system, but that the failure did not result in a single termination. While the agency's top technology officer, Tony Trenkle, wisely is retiring, the appearance of the still employed Health and Human Services Secretary Kathleen Sebelius at a congressional hearing this week led many to ask a reasonable question: What does it take to lose a government job? (Jonathan Turley, 11/7).

The New York Times: Religion, Contraception And Bosses' Rights
The federal health care law's mandate that employer health plans cover birth control has sparked dozens of lawsuits by secular, for-profit companies and their owners seeking to be exempted on religious grounds from having to comply. At this point, a handful of federal appeals courts have ruled on the question, with a few correctly rejecting the specious religious liberty claims. The latest ruling, issued last week, goes the wrong way (11/7).

The National Review: Hold the Line On Medicaid
[Gov. Rick] Perry and the Texas legislature have made the right decision. To begin with, Medicaid is a terrible program. It provides few if any measurable health-care benefits, and a number of studies — not from right-wing think tanks, but from the Annals of Surgery, among others — have suggested that it has negative effects on the health outcomes of its so-called beneficiaries. From overall hospital deaths (University of Virginia study) to certain cancers (University of Pennsylvania study) to vascular disease (Columbia-Cornell study), Medicaid patients do no better, and often do worse, than those with no insurance at all; their outcomes reliably lag those of patients in private insurance. And their access to health care is far from guaranteed: Doctors do not want to see Medicaid patients, for reasons of reimbursement and bureaucratic hassle (11/8).

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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.