Tag: ACA

Trump’s stealth attack on Obama’s legacy

While many of us have been distracted by Rudy Giuliani’s latest legal theories — and President Trump’s latest tweets — the Trump administration is making two big moves that will get him closer to his goal of erasing President Obama’s biggest policies.

What’s happening: The administration is allowing the sale of health insurance plans that undermine some of the main rules of the Affordable Care Act. And today, it will freeze federal fuel efficiency standards, undermining Obama’s goal of making them progressively tougher.

obama

Why it matters: This is being done through rulemaking, which gets the attention of health care and environmental reporters, yet flies under the radar of the cable news networks. These moves have huge, long-term consequences — and they show how easily Trump can achieve his policy goals while the TV cameras are focused on the outrage of the day.

  • “The President’s daily feeding of the outrage machine allows us to get work done on the agency level that would invite much more scrutiny in a ‘normal’ administration,” a former senior Health and Human Services official tells Swan.
  • “Cable news anchors spend hours and hours of airtime dissecting the latest Trump tweet, yet they barely notice when we achieve long-sought conservative policy goals” — like adding work requirements to Medicaid and stripping federal funds from Planned Parenthood.

The details on the fuel rollback, from energy columnist Amy Harder:

  • The proposal includes a range of options, but the administration’s preferred one is the most aggressive: Freezing the standards at 35 miles per gallon in 2020 for six years, instead of rising to 50 mpg under Obama’s plan.
  • It would also revoke a federal waiver California has to issue tougher standards, which a dozen states also follow. The rollback goes further than most automakers have said they want.
  • Between the lines: Early in Trump’s administration, business urged him to slow down on deregulating, stressing that narrow regulation is better than none in a changing political climate. Today’s announcement is one of the starkest signs that Trump is throwing that advice out the window — and inviting lawsuits and regulatory uncertainty.

The details on the health care rule, from health care editor Sam Baker:

  • HHS finalized new rules yesterday that expand access to inexpensive, bare-bones insurance plans that don’t have to comply with the rest of the ACA’s rules. They’re technically “short-term” plans, but they can be renewed for up to three years.

This isn’t the only swipe the Trump administration has taken against Obama’s health care law since the repeal effort failed:

  • The administration has also expanded access to other forms of non-ACA coverage.
  • Plus, it has slashed the budgets for programs that promote enrollment.
  • Congressional Republicans nullified the law’s individual mandate, and now the Justice Department is using that move to try to knock out pre-existing condition protections.
  • None of those cuts are fatal in isolation. But they’re not happening that way: Each one will pull a few more healthy people out of the ACA’s insurance markets.

The bottom line: There’s a lot that the agencies can do to wipe out Obama’s legacy on their own — and they’re making full use of the space that Trump’s rhetorical battles are giving them.

Go deeper: What Trump’s latest changes mean for the ACA.

Hidden From View: The Astonishingly High Administrative Costs of U.S. Health Care

It takes only a glance at a hospital bill or at the myriad choices you may have for health care coverage to get a sense of the bewildering complexity of health care financing in the United States. That complexity doesn’t just exact a cognitive cost. It also comes with administrative costs that are largely hidden from view but that we all pay.

Because they’re not directly related to patient care, we rarely think about administrative costs. They’re high.

A widely cited study published in The New England Journal of Medicine used data from 1999 to estimate that about 30 percent of American health care expenditures were the result of administration, about twice what it is in Canada. If the figures hold today, they mean that out of the average of about $19,000 that U.S. workers and their employers pay for family coverage each year, $5,700 goes toward administrative costs.

Such costs aren’t all bad. Some are tied up in things we may want, such as creating a quality improvement program. Others are for things we may dislike — for example, figuring out which of our claims to accept or reject or sending us bills. Others are just necessary, like processing payments; hiring and managing doctors and other employees; or maintaining information systems.

That New England Journal of Medicine study is still the only one on administrative costs that encompasses the entire health system. Many other more recent studies examine important portions of it, however. The story remains the same: Like the overall cost of the U.S. health system, its administrative cost alone is No. 1 in the world.

hospital

Using data from 2010 and 2011, one study, published in Health Affairs, compared hospital administrative costs in the United States with those in seven other places: Canada, England, Scotland, Wales, France, Germany and the Netherlands.

At just over 25 percent of total spending on hospital care (or 1.4 percent of total United States economic output), American hospital administrative costs exceed those of all the other places. The Netherlands was second in hospital administrative costs: almost 20 percent of hospital spending and 0.8 percent of that country’s G.D.P.

At the low end were Canada and Scotland, which both spend about 12 percent of hospital expenditures on administration, or about half a percent of G.D.P.

Hospitals are not the only source of high administrative spending in the United States. Physician practices also devote a large proportion of revenue to administration. By one estimate, for every 10 physicians providing care, almost seven additional people are engaged in billing-related activities.

It is no surprise then that a majority of American doctors say that generating bills and collecting payments is a major problem. Canadian practices spend only 27 percent of what U.S. ones do on dealing with payers like Medicare or private insurers.

Another study in Health Affairs surveyed physicians and physician practice administrators about billing tasks. It found that doctors spend about three hours per week dealing with billing-related matters. For each doctor, a further 19 hours per week are spent by medical support workers. And 36 hours per week of administrators’ time is consumed in this way. Added together, this time costs an additional $68,000 per year per physician (in 2006). Because these are administrative costs, that’s above and beyond the cost associated with direct provision of medical care.

In JAMA, scholars from Harvard and Duke examined the billing-related costs in an academic medical center. Their study essentially followed bills through the system to see how much time different types of medical workers spent in generating and processing them.

At the low end, such activities accounted for only 3 percent of revenue for surgical procedures, perhaps because surgery is itself so expensive. At the high end, 25 percent of emergency department visit revenue went toward billing costs. Primary care visits were in the middle, with billing functions accounting for 15 percent of revenue, or about $100,000 per year per primary care provider.

“The extraordinary costs we see are not because of administrative slack or because health care leaders don’t try to economize,” said Kevin Schulman, a co-author of the study and a professor of medicine at Duke. “The high administrative costs are functions of the system’s complexity.”

Costs related to billing appear to be growing. A literature review by Elsa Pearson, a policy analyst with the Boston University School of Public Health, found that in 2009 they accounted for about 14 percent of total health expenditures. By 2012, the figure was closer to 17 percent.

One obvious source of complexity of the American health system is its multiplicity of payers. A typical hospital has to contend not just with several public health programs, like Medicare and Medicaid, but also with many private insurers, each with its own set of procedures and forms (whether electronic or paper) for billing and collecting payment. By one estimate, 80 percent of the billing-related costs in the United States are because of contending with this added complexity.

Read More:https://www.nytimes.com/2018/07/16/upshot/costs-health-care-us.html?hp&action=click&pgtype=Homepage&clickSource=story-heading&module=first-column-region&region=top-news&WT.nav=top-news