Life-Saving Data That Is Nowhere To Be Found: Hospitals’ C-section Rates

By DANI BRADLEY, MS, MPH 

The United States is the only developed nation in the world with a steadily increasing maternal mortality rate — and C-sections are to blame. Nearly 32% of babies are born via C-section in the United States, a rate of double or almost triple what the World Health Organization recommends. While C-sections are an incredibly important life-saving intervention when vaginal delivery is too dangerous, they are not devoid of risks for mom or for baby. Hospitals and doctors alike are aware, as it’s been widely reported that unnecessary C-sections are dangerous — and hospitals and doctors agree that the number one way to reduce this risk is to choose a delivery hospital with low a C-section rate. However, information on hospitals’ C-section rates is incredibly hard to find, which leaves women in the dark as they try to make this important choice.

In an effort to help women make informed decisions about where to deliver their baby, we set out to collect a comprehensive, nationwide database of hospitals’ C-section rates. Knowing that the federal government mandates surveillance and reporting of vital statistics through the National Vital Statistics System, we contacted all 50 states’ (+Washington D.C.) Departments of Public Health (DPH) asking for access to de-identified birth data from all of their hospitals. What we learned might not surprise you — the lack of transparency in the United States healthcare system extends to quality information, and specifically C-section data.

After contacting 51 DPHs, 44 departments provided some level of birth data upon request — but the majority of those shared C-section rates for their state’s counties or districts, which doesn’t help when a patient needs hospital-specific data in order to select where she’ll deliver. Some states, such as Alabama, California, Massachusetts, Pennsylvania, Vermont, and West Virginia, have very transparent data-sharing practices, posting the vital data on their websites for the public to access and use. Other states, such as Wisconsin, Missouri, and Nebraska, put obstacles to accessing their data in place, including charging fees, requiring a signed data use agreement, and sometimes demanding institutional review board exemption. Still, six states — Illinois, Kentucky, Georgia, Wyoming, and Connecticut — outright refused to share their data, citing verbiage in their state’s statutes as the rationale.

Type of data shared from each state’s Department of Public Health

While it’s clearly difficult for patients to access these quality data on their own, thankfully there are organizations working to address the issue of unnecessary C-sections head on. On the West Coast, the California Health Care Foundation developed a comprehensive initiative to reduce unnecessary C-sections, and on the East Coast, Ariadne Labs, a research group out of Harvard Medical School, has an entire department devoted to “Addressing the world’s most common and consequential surgical error: the decision to perform a C-section.” While these programs are making great strides, the U.S. could be doing a lot more to give the patient a voice and promote informed healthcare decision-making.

For organizations who want improve health outcomes, reduce healthcare spending, or enhance patients’ interactions with the healthcare system, allowing access to a comprehensive, accurate dataset of hospital C-section rates should be a top priority. The publication of C-section data at the hospital level would allow women to make informed decisions about their healthcare, mitigate unnecessary adverse outcomes, and reduce healthcare spending. Public data might also help influence change among healthcare providers and hospitals. Healthcare advocates, payers, patients, researchers, and the public alike need to band together to change this opacity. Mothers’ lives depend on it.

Dani Bradley leads the research team at Ovia Health, a health technology company providing innovative solutions to support women and families.

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Facts, Conclusions, and More Questions on the Road to Solving Disparities

By SCOTT COOK, PhD

We tested whether new payment mechanisms could be harnessed in health care delivery reform to reduce health and health care disparities. Here’s what we found.

First, there were facts that couldn’t be ignored:

#1: Children in rural Oregon on Medicaid suffered more health-related dental challenges compared to children with private insurance, including the pain, systemic health problems and disruptions to education that come with them. Advantage Dental, the state’s largest provider of Medicaid services, was determined to do something about it.

#2: New mothers on Medicaid in a New York City hospital were less likely to have a postpartum care visit compared to privately insured women. As a result, they missed assessments and screenings for a number of health conditions, some of which can lead to chronic health problems throughout their lives. For many women, the postpartum visit is one of the few chances to engage them in ongoing health care. The providers and care teams at the Icahn School of Medicine and the Mount Sinai Health System wanted to find out what it takes to increase postpartum visit rates.

#3: In Fairfax County, Virginia, multi-racial and multi-ethnic populations being served in three County-funded safety-net clinics were less likely to receive the typical high-quality care provided for hypertension, diabetes, and cervical cancer screening when compared to their Hispanic counterparts. The providers and teams at the Community Health Care Network stepped forward to address the issue.

Beginning where the Roadmap ends

At Finding Answers: Solving Disparities Through Payment and Delivery System Reform, a national program of the Robert Wood Johnson Foundation, we have known the best practices for reducing and eliminating disparities like these for a while now. That knowledge was derived from the work of 33 other health care organizations around the country that had also identified disparities in their own patient populations. We partnered with them between 2006 and 2013 to evaluate and collect detailed implementation data in over 200 clinical settings on their novel solutions to the health and health care disparities that their patients faced. We also conducted 13 systematic reviews of the disparities intervention literature.

We integrated all of this knowledge into the Roadmap to Reduce Disparities (Roadmap). The Roadmap guides organizations through the processes of identifying and reducing disparities in their own patient populations. We have also provided technical assistance to health care organizations that followed the Roadmap, partnering with them as they tackled subsequent challenges and successes.

Reducing and eliminating health and healthcare disparities is possible. We know what to do, but the path laid out by the Roadmap requires time and resources. Unfortunately, dedicated care teams like those at Advantage Dental, the Icahn School of Medicine and the Mount Sinai Health System, and the Community Health Care Network who are motivated to eliminate disparities are operating within a national system that does not provide the business incentives necessary for providers to devote the time and resources required. This is why we selected three investigators four years ago — to help us chart a new course in developing the business case. We took advantage of the nation’s efforts to move away from fee-for-service to newer financial models that incentivize improving quality of care while also reducing costs.

We asked these organizations to partner with at least one payer to design and implement an integrated model of payment and health care delivery reform that would make going down the path of the Roadmap a bit easier. We hoped that their new integrated models would help us learn best practices for similar efforts in the future. The teams at these organizations rose to the challenge because of their dedication to their patient populations and to reducing the pain, suffering, and early deaths that often result from the disparities they face. You can learn about their unique integrated payment and health care delivery reform models here.

Key lessons learned

In a nutshell, here are a few lessons learned from our recent grantees’ experiences:

  • Health system leaders and payers are key to changing how vulnerable groups are cared for.“But it takes prioritization, work, readjustment, and persistence,” says Finding Answers Director Marshall Chin, MD, MPH. “Giving these projects authority and staying power requires commitment from the C-suite. It means restructuring payment to support and incentivize the reduction of disparities. Utilizing value-based payment reforms to give organizations the resources and incentives they need to address disparities is a critical next step.”
  • Team-level incentives hold promise. They encourage integrated care management as team members strive toward a common goal.
  • Payers should partner closely with front line providers and other care delivery staff members when designing a financial incentive program. Designing an effective financial incentive program is a multifaceted, complex endeavor and no single organization or group has all the information needed for success.
  • Sometimes the most effective use of funds is to allow the flexibility needed to redesign the care delivery system to address health and health care disparities. Mount Sinai Health System increased timely postpartum visits among women on Healthfirst Medicaid plans from 58% to 74% largely through a cost-sharing arrangement with Healthfirst that allowed them to hire a social worker and patient navigator. Capitated models with global budgets provided the flexibility needed for Advantage Dental and the Fairfax County Virginia Community Health Care Network to redesign their delivery models to focus on goals of improving quality, reducing costs, and reducing disparities.
  • Providers are motivated to reduce disparities, once they find out they exist. New financial models might make it possible to reduce or eliminate disparities, especially when aligned with state Medicaid programs and federal policies.

The next questions

After three years of implementation, analysis, and adjustments, Advantage Dental, Icahn, and the Community Health Care Network provided insights to make moving down the path laid out by the Roadmap easier. While there is still more work to be done to discover best practices and recommendations for integrating payment and health care delivery reform to address disparities, we are excited about what we’ve learned so far. You can see more of our top-level findings here.

Over the next few months, we will update Finding Answers’ resources and tools to incorporate the knowledge gained from their experiences. Please check back to our blog at www.SolvingDisparities.org and follow us on Twitter @FndgAnswers for further developments as we continue down the path.

Scott Cook, PhD, is deputy director of the Robert Wood Johnson Foundation program Finding Answers: Solving Disparities Through Payment and Delivery System Reform, and a Quality Improvement and Clinical Transformation Strategist in the Department of Diversity, Inclusion and Equity at the University of Chicago Medical Center.

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Silencing Noisy Health Care?

By MATTHEW HOLT

As you’ve probably heard (enough!) from me and Indu Subaiya over recent months on video, at Health 2.0 or here on THCB, we are finally arriving at the point where health care tech is “flipping the stack” — where we realize that we can’t practice the old way, and instead need to move the care of the chronically ill to an always on, always monitoring, always measuring, always messaging tech platform.

But we need to figure out a way to both create that platform and the services for the people who need help–without overwhelming them. Too often we are putting too much technology into patients’ and clinicians’ lives and creating too much noise. While I’ve been aping Bob Wachter calling for an air traffic control function in health care, one of the most interesting new companies in health tech/services, Livongo, has been working on a  related idea. They’ve been promoting it by looking to #SilenceNoisyHealthCare on Twitter and Linkedin recently

Tuesday 30th at 1 ET – 10 PT I’m hosting a webinar with Livongo’s CEO Glen Tullman & Chief Medical Officer Jennifer Schneider, M.D. Jessica DaMassa tweeted that Glen and I are in a cage match, and it is an Oxford v Cambridge affair (although Jennifer brings some Stanford & Hopkins class to the proceedings).

But what’s really going on is that Livongo is adopting a new philosophy that they think will silence the noise and fix the patient experience. What do they mean by that? Join me on the webinar to learn more

 

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All Health Policy Is Local: The Case of the Individual Mandate Penalty in New York

By CHRISTINE EIBNER, SARAH NOWAK, PREETHI RAO

Sarah Nowak
Preethi Rao
Christine Eibner

Although signed into law in 2010, the Affordable Care Act has been in constant flux, with key aspects changing due to time-dependent provisions, Supreme Court decisions and shifts in U.S. policy. The effects of changes to the ACA on health insurance enrollment and premiums often depend on state regulatory decisions and other state-specific factors. The elimination of the individual mandate penalty is a prime example of this when applied to New York state, which has unusual rules in its individual insurance market.

In 2019, consumers will no longer face financial penalties stemming from the ACA’s individual mandate, which requires most people to secure health insurance. Without pressure from the individual mandate to enroll, younger and healthier people might drop coverage, leading to premium increases. New York’s health insurance regulations and expansive safety-net programs could make the state’s insurance market particularly susceptible to premium increases after the penalty’s elimination.

New York uses what is known as “full community rating” in its individual health insurance market, which means that all adult enrollees, regardless of age or whether they use tobacco, are charged the same premium. In most states, the youngest adults in the market pay one-third of what older adults do, and tobacco users are charged 1.5 times as much as non-users. New York’s flat premium structure raises costs for younger enrollees and nonsmokers, making them more likely drop coverage when the penalty goes away.


In addition, New York is one of two states—Minnesota is the other—to take advantage of an ACA provision that allows individuals with incomes below 200 percent of the federal poverty level to enroll in a Medicaid-like program known as a “basic health plan.” In other states, people with incomes between 138 and 400 percent of the poverty level may be eligible for tax credits on the ACA’s health insurance exchanges, if they don’t have access to affordable employer coverage. 

The basic health plan means that New Yorkers with incomes between 138 and 200 percent of poverty are not eligible for exchange tax credits, and are insured through a separate program. As a result, only 59 percent of enrollees on N.Y.’s health insurance exchange are eligible for tax credits, compared to 83 percent nationwide. Like the individual mandate, the tax credits provide an incentive for the young and healthy to enroll, potentially stabilizing premiums in the individual market when the individual mandate penalty is eliminated. However, with fewer tax-credit-eligible enrollees, the stabilizing force of the tax credits is likely to be less pronounced in New York relative to other states.

We used a microsimulation approach to estimate how much New York insurers would need to increase individual market premiums to addresses the elimination of the individual mandate penalty, given community rating and the basic health plan. We found that premiums in New York would need to increase by an average of 23 to 25 percent in 2019 to avoid losses after the mandate penalty is eliminated. By comparison, in most other states, premiums would only have to increase by 3 to 13 percent. These estimates assume that insurers set premiums accurately in 2018, meaning that premiums were high enough to cover enrollees’ health care costs, but not so high that they resulted in a margin exceeding 20 percent—a situation that would require insurers to provide rebates to enrollees

However, preliminary financial data from 2018 suggest that some insurers may have set premiums too high, perhaps due to uncertainty regarding how other recent policy changes—such as a shorter open enrollment period—would affect enrollment. If insurers overshot in 2018, they may have wiggle room to absorb the elimination of the individual mandate penalty without facing financial losses. Regulators in New York appear to believe that absorbing these extra costs will be feasible—in August they announced they would not accept premium increases attributed to the elimination of the individual mandate penalty. While insurers on average requested a 24 percent rate increase, New York allowed increases of only 8.6 percent.

Open enrollment for 2018 won’t start until November, and it could take several years before premiums fully adjust to the elimination of the individual mandate penalty. However, New York’s unusual insurance market, which includes full community rating and the basic health plan, may cause premiums and enrollment in the state to differ from national trends once the penalty is removed. As with many ACA policies—particularly in an era of reduced federal regulation and increased emphasis on state choices—how New York is dealing with the absence of the individual mandate penalty is a potent reminder that all health policy is local.

Christine Eibner is the Paul O’Neill-Alcoa chair in policy analysis at the nonprofit, nonpartisan RAND Corporation and a professor at the Pardee RAND Graduate School.

Sarah A. Nowak is a physical scientist at RAND and a professor at the Pardee RAND Graduate School.

Preethi Rao is an associate policy researcher at RAND.

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Hospitals Can and Should Support Employees Who Are Victims of Domestic Violence: Here’s How

By PATRICK HORINE

Every October we recognize Domestic Violence Awareness Month, an important opportunity to discuss this widespread social and public health problem and to take stock of what we can do better to protect victims of domestic abuse.

Unfortunately, the data shows us that health care is often a dangerous profession that is also rife with domestic abuse. Earlier this month a new poll of ER physicians revealed nearly half report having been physically assaulted at work (largely by patients and/or visitors in the ER). However, other data shows us that individuals in the health care professions – especially women—may be at greater risk of domestic abuse from a spouse or partner, while on the job as well. Data on domestic violence nationwide shows us one in four women are in a dangerous domestic situation, and one in four victims are harassed at work by perpetrators.  Women make up 80 percent of the healthcare workforce and an even greater percentage in most hospitals. When we do the math, this means one in 20 female healthcare workers are likely to be harassed or even assaulted on the job.

Furthermore, given that hospitals and most healthcare organizations are “open” facilities where anyone can walk onto the premises this further heightens the risk of a violent incident happening in the workplace. Over half of the homicides committed by intimate partners occur in parking lots and public buildingsNews stories like the ones about a California healthcare worked stabbed in the hospital parking lot by her estranged husband while her co-workers looked on are all too tragic and common.

 Fortunately, a growing number of hospitals are taking proactive steps to keep employees safe and minimize the risk of domestic violence (and violence in general) both at the hospital and beyond. Because our organization accredits hospitals, we are in the business of working with them to enhance both patient safety — and employee safety. We recommend any hospital take these seven steps to minimize workplace violence for all employees:

·      A Clearly Written Company Workplace Violence Policy Statement

·      Establishment of a Threat Assessment Team

·      Hazard Assessments (For Workplace Violence)

·      Workplace Hazard Control and Prevention

·      Training and Education

·      Incident Reporting, Investigation, Follow-up and Evaluation

·      Recordkeeping

These policies can help protect victims and would-be victims of domestic violence, especially when specific refinements are made to them. For example, a company workplace violence policy statement can/should include a police regarding domestic violence, and a zero-tolerance policy. Hazard assessment and control and prevention should look at all the ways an abuser might enter the premises to stalk, harass and or harm a victim.

In the case of domestic violence prevention hospitals can also go one step further to protect specific individuals. For example, by establishing a relationship with a local hotel and taxi company, the organization can give victims help with a safe place to stay.

During a recent presentation at our annual conference, Jim Sawyer, Security Director for Children’s Hospital Seattle, outlined additional concrete steps hospitals can take to protect victims. For example, because domestic abuse often occurs in an employee parking lot when the abuser confronts a victim coming to or leaving from work, the simple step of changing an employee’s assigned parking spot can provide some protection. Assisting a victim with a car rental can help as well, as can changing her (or his) schedule so the perpetrator is unaware of the hours the victim may be expected at work. Sharing the perpetrator’s photo, work schedule and vehicle make with security and grounds-keeping staff can help others be on the lookout as well.

For all forms of violence prevention in the workplace, staff training is key. With domestic violence, staff need to understand how to recognize the signs of abuse so they can support a victim and encourage him or her to seek help. Often these signs are not well understood or are overlooked. Moreover, staff need to understand the policies that exist, and specific steps they can take to help keep their co-worker safe while she or he is on the job. For example, staff need to understand they must report issues of concern to the police, such as when an abusive spouse or partner violates a restraining order and enters the premises. Staff directly involved in security at the hospital can and should receive additional training specifically related to domestic violence.

So much has been written about how healthcare staff can help identify and support victims of domestic abuse. But we have not spent enough time also focusing on our own employee populations. Unfortunately, the demographics and physical layout of a hospital put our own staff at heightened risk while on the job. If we take the time to put the right policies, protections, and staff training in place, we can help turn our hospitals into a place of safety and support for everyone.

Patrick Horine, MHA serves as the President of DNV GL Healthcare where he is responsible for the North American healthcare business of DNV GL

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The Futility of Patient Matching

By ADRIAN GROPPER, MD

The original sin of health records interoperability was the loss of consent in HIPAA. In 2000, when HIPAA (Health Insurance Portability and Accountability Act) first became law, the Internet was hardly a thing in healthcare. The Nationwide Health Information Network (NHIN) was not a thing until 2004. 2009 brought us the HITECH Act and Meaningful Use and 2016 brought the 21st Century Cures Act with “information blocking” as clear evidence of bipartisan frustration. Cures,  in 2018, begat TEFCA, the draft Trusted Exchange Framework and Common Agreement. The next update to the draft TEFCA is expected before 2019 which is also the year that Meaningful Use Stage 3 goes into effect.

Over nearly two decades of intense computing growth, the one thing that has remained constant in healthcare interoperability is a strategy built on keeping patient consent out of the solution space. The 2018 TEFCA draft is still designed around HIPAA and ongoing legislative activity in Washington seeks further erosion of patient consent through the elimination of the 42CFR Part 2 protections that currently apply to sensitive health data like behavioral health.

The futility of patient matching without consent parallels the futility of large-scale interoperability without consent. The lack of progress in patient matching was most recently chronicled by Pew through a survey and a Pew-funded RAND report. The Pew survey was extensive and the references cite the significant prior efforts including a 100-expert review by ONC in 2014 and the $1 million CHIME challenge in 2017 that was suspended – clear evidence of futility.

Pew’s chronicle of futility is capped by a 2-hour panel discussion designed to highlight innovations in patient matching. Pew’s experts did not include privacy experts. Nobody was there to call patient matching what it really is: involuntary surveillance. The new idea in the Pew reports is “referential matching” where the surveillance system is enhanced with information about us from data brokers and credit bureaus. What could possibly go wrong, especially as we add artificial intelligence into the surveillance toolkit?

Why is healthcare the only industry with a person matching problem? The reason is partly historical. In the days before HITECH incentives and BIG EHRs, each hospital had dozens of proprietary software vendors, many of them with their own patient ID. Within a single hospital, patient consent was not an issue and probabilistic patient matching can work when the patient universe is a single hospital. As hospitals and practices began consolidating, probabilistic patient matching still made some sense because the governance was effectively a single entity and the number of patients was in the few millions. But regional or national interoperability is a very different ballgame. Governance is now spread across competitors and the universe of patients to match within is hundreds of millions.

The solution to patient matching and to interoperability is the same: patient-directed exchange. With the patient-directed exchange, patient matching is trivial and non-proprietary, consent is automatic by definition, and the costs of data brokerage are eliminated. Furthermore, the patient-directed exchange allows interoperability across 42CFR Part 2 behavioral health practices and includes community organizations and social services that are typically not covered by HIPAA. The quantity and the quality of patient data are both improved.

The next round of regulations from ONC will be a definition of information blocking and an updated version of TEFCA. Will this ONC continue to promote a strategy of involuntary surveillance by ever more powerful incumbents or will they finally allow patients to say: “Nothing about me without me”?

Adrian Gropper, MD is CTO of Patient Privacy Rights and leads the HIE of One project for patient-directed health information exchange.

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The November 6 Midterm Elections and Their Impact on Obamacare:Q&A

By ETIENNE DEFFARGES

1) What is the likelihood the ACA will be repealed?

This straightforward question has a very simple answer: It depends on the results of the upcoming November 6 U.S. congressional elections.

If the Republicans retain control of both the House and the Senate, the probability that the ACA will be repealed is very high: The Republicans would be emboldened by such a victory and would most probably attempt in 2019 to repeal the health care law—again. It is worth remembering that in July of last year, the repeal of the ACA (a version of which had passed the House in May) was defeated in the Senate by the narrowest of margins, because three Republican Senators, Susan Collins, Lisa Murkowski, and the late and much regretted John McCain, voted against the repeal. This is very unlikely to happen again, although one would also have to consider the margins by which the Republican would have gained control both Chambers after these November midterms. In July of 2017, the Republicans held a 52-48 advantage in the Senate. Given ever-increasing polarization, such a margin, plus Republican control of the House, would likely spell the end of the ACA in 2019.

If the Democrats gain control of either the House of Representatives or the U.S. Senate, then the ACA will remain the law of the land. The only issue in the horizon will be the lawsuit filed in February of this year by a coalition of 20 states, led by Texas and Wisconsin. This lawsuit claims that Obamacare is no longer constitutional after the Republicans eliminated in December of 2017 the tax penalty associated with the ACA’s individual mandate. The 20 Republican attorney generals argue that without the tax penalty, Congress has no constitutional authority to legislate the individual mandate. Even if this case reaches the Supreme Court, one has to remember that the Court affirmed twice the constitutionality of the ACA, in June of 2012 and then 2015, with Chief Justice John Roberts voting with the majority on both occasions.

2) What do recent congressional changes to the ACA mean for those who buy insurance on health care exchanges?

The answer to this question has to be more nuanced: What will happen this year on the ACA healthcare exchanges can only be predicted at this stage, because the enrollment period for the 2019 ACA plans available on the exchanges has not started yet—it runs from November 1 to December 15. Let’s start by what we do know:

  • The ACA remains the law of the land, including the mandate to purchase health insurance (the ACA’s “individual shared responsibility provision”).
  • What was repealed in the Republican tax bill signed into law on December 22, 2017, is the tax penalty one would owe under the ACA if one failed to maintain “minimum essential coverage.” Most medical plans qualify for this under the ACA, as long as they meet a number of requirements, such as not charging more for pre-existing conditions and offering ten essential health benefits.
  • This means that an individual could elect to purchase one the alternative and non-ACA compliant coverage options the Trump White House has directed health agencies to implement, and not pay any tax penalty. These short-term insurance plans are low-cost and low-benefit and do not adhere to ACA standards such as minimum essential coverage and availability to those with pre-existing conditions.
  • In June of this year, the Department of Labor issued the regulatory guidelines that put in place a version of such alternative coverage—association health plans for small businesses and self-employed individuals. This was immediately followed by litigation from 12 states, their attorney generals noting that such low regulation plans have led to fraud and insolvency in many cases in the past.

Now for what we don’t know:

How will the above changes to the ACA affect the cost of insurance on the exchanges? My prediction is that these costs will not change much, and the number of available insurance plans in the exchanges will actually increase.

Why do I say that? After all, one theory is that many healthy and low-income people will choose some of the new, low cost and non-ACA compliant plans now on offer. This will mean that there will be fewer people buying coverage on the exchanges and that these people will be less healthy on average. Insurance companies selling plans on the exchanges will thus have to raise their prices—a negative consequence for those who buy insurance on health care exchanges.

Ah yes, but that is the theory. Actual events have taught us that a few facts run counter to this argument.

First, we have the actual 2017 ACA exchange enrollment data. Despite the Trump administration cutting funds for advertising and outreach to the exchanges by 90%, enrollment essentially stayed flat: According to the Henry J. Kaiser Family Foundation, 11.8 million Americans purchased coverage on the exchanges for 2018, versus 12.2 million enrolled in the ACA in 2017, and 10.4 million in 2016.

Second, the new low cost and non-ACA compliant plans are still in early stage, far from representing an option for lots of people, and there are many concerns about their quality. Some people may also elect not to have any health coverage at all, but in all likelihood, there will not be enough of them to affect pricing on the exchanges significantly. Preliminary data state-by-state appears to confirm this, compensating in some way for the widespread price increases seen in 2018.

Third, all the subsidies available for low-income families and individuals under the ACA remain in place, which means that people who qualify for the subsidies will not pay more than today. Preliminary data also shows new insurers entering the exchanges, unlike what was seen in 2017: Increased competition will help keep prices flat.

The reality as shown by the above figures is that there is a large number of Americans who want both quality and affordable health coverage, despite ongoing efforts by the Trump administration to derail the ACA.

3) Why are so many Americans misinformed about the ACA, and about open enrollment?

This question has an easy answer: Because of the actions that were taken by the Trump administration after the Republican-led U.S. Senate failed to pass a bill repealing the ACA in July of 2017. Since then, the Trump administration has undermined the ACA through executive orders and its tax bill.

Specifically, the Republican tax bill signed into law on December 22, 2017, repealed the tax penalty one would owe under the ACA if one failed to maintain “minimum essential coverage.” This action did not end the ACA, not even its mandate to purchase health insurance. Yet, on December 26, 2017, Trump tweeted: “Based on the fact that the very unfair and unpopular Individual Mandate has been terminated as part of our Tax Cut Bill, which essentially Repeals (over time) Obama Care, the Democrats & Republicans will eventually come together and develop a great new HealthCare plan!” This statement is one of many made by Trump and Republicans that likely have confused a lot of people regarding the actual status of the ACA.

Furthermore, the Trump administration started pushing, via executive orders, low-cost health plans not compliant with the ACA. This means that an individual could elect to purchase non-ACA compliant coverage options the Trump White House has directed health agencies to implement, and not pay any tax penalty. As seen above, after some of these low-costs and low-benefits alternative plans were put in place by the Labor Department, 12 states sued the federal government. Given this ongoing litigation, the status of these plans is unclear, adding to the confusion.

The Trump administration has also ensured that the ACA no longer benefits from advertising and outreach efforts to explain how to enroll, what benefits to expect, and how to navigate the websites to prospective buyers. As seen above, 90% of the funds for advertising and outreach to the ACA exchanges were cut in 2017. It is also important to remember that 19 states, all led by Republican governors, have refused the very popular extension of Medicaid provided in the ACA. This extension is funded at 100% during its first few years by the federal government, so governors who have opposed this extension are denying fellow state citizens their share of federal dollars that could have been allocated to their state. Obviously, these state governments are not engaged in any type of effort promoting enrollment and information about the ACA, including its November 1 to December 15 enrollment period.

4) What can be done to make people more aware of the ACA and the open enrollment period?

First, the good news: despite all the Republican efforts to undermine the ACA, Obamacare remains very popular, and enrollment remains very healthy. Can more be done?

To increase awareness about the ACA, one has to rely on the health departments on the 31 states (plus the District of Columbia) that have expanded Medicaid, and local efforts by hospitals and health insurers, who can serve as an important link to ACA health coverage.

Hospitals support the ACA: They have a legal obligation to treat uninsured patients through their Emergency Departments, a very expensive proposition since those are staffed by physicians trained to save lives in emergency situations, not to act as general practitioners for the uninsured. Therefore the fewer uninsured there are, the better for hospitals. Plus, hospitals and physicians are trusted by most.

Insurers too want more patient insured. This is why the “repeal and replace” efforts by the Republican Congress in 2017 achieved the rare feat of triggering unanimous opposition from the whole medical sector, hospitals, health insurers, associations of physicians, etc. Local NGOs helping patients navigate our complex health care system and the ACA exchanges are also lining up to supplement local outreach efforts by states and health providers.

5) What should healthcare insurance buyers do to maximize their ACA experience? 

First, they should get as much advice as possible: from their physicians, local hospitals, and local associations helping promote the ACA.

Second, they need to learn to navigate the ACA websites; again if possible with the advice of colleagues, friends, and medical professionals they know.

Third, they should keep in mind a key, and counterintuitive feature of most ACA websites, which can lead to an unwarranted “sticker shock.” The first quotes for coverage one will see do not take into account the subsidies one is likely to be eligible for. These subsidies have not been touched by the Trump administration, and provide protection against potential nominal price increases first seen on the website. Therefore, health insurance buyers should go through the whole journey on their ACA website, keeping in mind that the actual, real price they will pay is not what they will have seen quoted first, but what they will see at the end when those subsidies have been factored in. Navigating these sites is not easy, so again insurance buyers should get all the advice and help they can garner.

Etienne Deffarges has counseled, created, and invested in countless organizations during his professional life as a management consultant, business executive, and entrepreneur

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