Florida's insurance officials said today that health insurance rates will rise 5 to 20 percent for small businesses and 30 to 40 percent in the individual market through the state's new exchange under the federal health law.

Some of the state's largest individual health insurers, including Florida Blue and Cigna, will be among 11 plans competing through the exchange in the individual market and five insurers will offer plans in the small group market. Florida insurers have until Wednesday to approve plans in the exchange.

Under the Affordable Care Act, coverage sold on the individual market has to undergo a significant upgrade. As of Jan. 1, insurers can no longer turn away people with pre-existing medical conditions, and they will be limited in what they can charge to older policy holders. Consumers' financial exposure will be capped. Insurers are also required to offer a certain set of benefits under the plans, so while prices may increase, consumers will be getting an upgraded product.

But residents making less than $48,000 a year will receive a voucher from the federal government to help offset premium costs. The less a person makes, the more the government will pay.

In general, premiums in the individual market will be higher on average, but after the tax credits, most people will end up paying less, said Larry Levitt of Kaiser Family Foundation, who commented on the exchanges in general and was not speaking specifically to Florida's rates.

Several other states have already released rates in the past few months, but the Republican-led Florida Legislature, which has been reluctant to implement the new health law, decided to let the federal government run the state's online marketplace. Federal officials aren't expected to release the rates until September.

The new marketplaces, which are open for enrollment Oct. 1, will have the feel of an online travel site where individuals, families and small businesses can compare private insurance plans. Individuals will be required to either have health insurance from their employer or purchase it and will pay a roughly $100 penalty next year if they don't. Anyone making below the poverty line, $11,490 for an individual or $23,550 for a family of four, won't be eligible to buy insurance through the online marketplace.

"Everyone is so focused on price that they're giving the consumer a false sense that it's only the price that's important to them," said Ray Smithberger, general manager in charge of Cigna Individual and Family Plans. For example, they want potential customers to understand that even though a premium may be low, there could be a $5,000 deductible before the plan kicks in.

Cigna will offer two to four plans at the bronze, silver and gold levels to residents in the Orlando, Tampa and South Florida that will include a variety of deductibles. The insurer will not offer platinum or catastrophic plans. Cigna officials also said they will not participate in the small business exchange.

Cigna surveyed 7,300 people in five states including Florida to find out what they were looking for from plans under the exchange. Not surprisingly, price was the most important factor, followed by having a relationship with a doctor and round the clock customer service.

Florida Blue, the largest domestic insurer in the state, will offer a range of plans through the exchange in all 67 counties in the individual and small group market at different price points that tend to increase in plans that have a broader network of providers.

For insurers, the online marketplace marks a distinct change in the way they conduct business as they begin selling directly to consumers. Florida Blue has 11 retail stores, which they say take the confusion out of purchasing insurance by offering customers face to face interaction. The insurer is also experimenting with onsite clinics staffed by primary care doctors at two stores in Pensacola and Polk County and plans to expand to wellness products, including vitamins and fitness equipment.

Educating Americans about the Affordable Care Act will be paramount for the federal government and insurers as 78 percent of uninsured adults don't know about opportunities that will be available to them in 2014 under the new health laws, according to Enroll America, a nonprofit group sponsoring a national campaign that includes home visits and passing out brochures at farmers markets and churches.

The insurance commission warned Tuesday that enticing young healthy adults to buy insurance was also a significant concern. Many experts predict rates will rise for these so-called "young invincibles" and if too many young adults avoid the new insurance marketplace, it could throw off the entire equilibrium of the Affordable Care Act.

"We've got to do something to make sure that we're protecting the integrity of this program for years to come. If it starts off that you don't get that right risk pool, it's very, very hard to recover from that," said Jon Urbanek, a senior vice president with Blue Cross and Blue Shield of Florida.

“Florida officials: National health care to raise rates,” by Kille Kennedy of Associated Press, July 30, 2013

From our It’s Worse Than You Think File: Not only does Florida refuse to take federal funds to expand Medicaid — spurning $51 billion over the next decade — but it now turns out that it also trails nearly every other state when it comes to accepting federal grants from Washington for healthcare reform.

A report from Health News Florida says state agencies usually refuse to compete for grants, which other states eagerly snatch up. Even worse: Some agencies have on occasion won grants from the feds — and then given the money back! One recent instance involved a $2.3 million grant for a toll-free consumer health information line, which a state agency won but then decided not to take.

It defies logic and common sense for any state to act against the interests of its own residents in this way, particularly in Florida. The state consistently ranks near the bottom in health statistics and has one of the largest medically needy populations in the country, but that apparently counts little in the face of ideological opposition to the healthcare reform law that opponents in Tallahassee scornfully label “Obamacare.”

The refusal to accept federal grants tied to ACA is part and parcel of this anti-Washington political strategy. But as federal officials publicly declared last week, it’s not too late for Florida to accept Medicaid expansion, and as the deadline for full implementation of ACA draws near, the case for acceptance becomes stronger.

Gov. Rick Scott came out in favor of Medicaid expansion after winning federal permission for a special plan to let Floridians obtain insurance through a state-subsidized system. But then Mr. Scott failed to lift a finger to support this action during the legislative session after the House of Representatives under Speaker Will Weatherford signaled that it would reject the idea as a matter of “conservative” principle.

The expansion plan died — and with it the hopes of 1 million or more people in Florida who will be left without coverage.

But that must not be the end of the discussion.

Patrick J. Geraghty, president of Florida Blue, the state’s biggest private health insurer, points out that the mandated changes in the fee system will produce an improved and more efficient healthcare system, but hospitals and other health providers have to adapt to a new payment system. This is no time to starve the state’s healthcare system of dollars, he told Herald Editorial Board last week.

The business sector will feel the impact of the failure to fund Medicaid expansion because its absence will oblige employers to pick up some of the costs, and it will add to their tax burden. The costs of emergency care for the poor will continue to be passed on to the insured and to taxpayers, including businesses.

Accepting federal Medicaid dollars would reduce the number of uninsured and the amount of uncompensated care administered at hospitals. That’s why both of the state’s major business groups, The Florida Chamber of Commerce and Associated Industries of Florida, support Medicaid expansion.

The money the state rejects came from our taxpayers to begin with. Sending it back short-changes Florida’s residents, denies money to its hospitals and denies the state the chance to gain about 120,000 private sector jobs those funds would create.

As Brian E. Keeley, president of Baptist Hospital, points out on the Other Views page, all Floridians will pay a price for inaction because everyone is affected, one way or the other.

Gov. Scott paid lip service to the idea of Medicaid expansion, but he failed to expend any political capital on the effort. Now it’s time for him to show leadership on this issue. He should call a special session, even if there is no guarantee of victory, and tell the state’s lawmakers to put the welfare of the people of Florida above political ideology.

“Florida’s Medicaid debacle requires special session of the Legislature,” Miami Herald Editorial, July 27, 2013

If you pay attention and listen closely, you can hear it.

That’s the sound of the death rattle. Soon we’ll need to put the undertakers and gravediggers on notice. 

It is just a matter of time, no more than a few years, before we will be bidding farewell to the U.S. health insurance industry as we have grown to know it.

The big New York Stock Exchange-listed insurance firms have known for several years that their core business models are not sustainable, but they have dared not talk about it publicly. The demise of those companies started way before Barack Obama was elected president but, with the passage of ObamaCare, it has accelerated.

It is ironic, but the companies have become victims of their own success, or more accurately, victims of the prevalent industry business practices that contributed to that success.

Even more ironic: these companies, which got their start by assessing and assuming risk, have gone to great lengths in recent years, because of pressure from Wall Street, to shun as much risk as possible. That’s why with one notable exception — WellPoint — the big for-profit “insurers” are not looking at the new health insurance marketplaces, which will go online October 1, as opportunities. Aetna, Cigna and UnitedHealthcare have all said they will be participating in only a few of those state-based marketplaces, at least in 2014.

The big companies turned away from risk after realizing they could better meet shareholder profit expectations by simply administering the health care benefits of large employers, most of which now assume the financial risk of providing coverage to their workers.

As the big “health services companies” — the firms previously known as insurers — have competed aggressively for those clients, they have jacked up the premiums for their individual and small business customers to the point that both “covered lives” and revenues from the real insurance they sell have dwindled.

Only about 15 million Americans — less than 5 percent of the U.S. population — have sufficient resources to buy coverage on their own in the so-called individual market these days because of the hefty premiums. Many Americans who have been sick in the past can’t buy coverage at any price because insurers won’t sell it to them. And far fewer small businesses offer coverage to their employees now than a decade ago for the same reason: the premiums have become unaffordable. That is why almost 50 million of us are uninsured.

But just because the big companies are taking a wait-and-see approach to the new insurance marketplaces doesn’t mean there won’t be plenty of smaller companies competing for millions of individuals — individuals who work for small employers that no longer can afford to provide health benefits. One of the good things about ObamaCare is that by banning the discriminatory practices that have defined the industry for years, and requiring much more transparency in pricing, insurers will no longer be able to cherry pick the customers they want or entice us into buying plans that are profitable for them but of limited value to us.

And other provisions of ObamaCare will lower the barriers to new entrants in the health insurance market. New York, for example, recently granted a license to a new insurer — called “Oscar” — which has the potential to revolutionize the marketplace. New Yorkers and residents of at least 20 other states will also have new non-profit co-op health plans available to them on the online marketplaces.

Because these companies will not have the huge and costly bureaucracies of the big firms — and won’t have to answer to Wall Street — they will be able to offer policies with more affordable premiums than we’ve seen in the past. And the federal government will provide subsidies to millions of Americans to help them pay their premiums.

These changes will be transformative, in ways we can’t even imagine today. And the most recognized brands in today’s health insurance market will be known for something else. Not health insurance.

Don’t believe me? Well just look at history.

The big five “insurers” — Aetna, Cigna, Humana, UnitedHealth and WellPoint — have all changed radically in the past 25 years ago. When I went to work for Humana in 1989, it was known primarily as a hospital company. When I joined Cigna in 1993, it was a big multi-line insurance corporation, as was Aetna. Both had big property and casualty and financial services divisions. Under pressure from shareholders and Wall Street financial analysts, they sold those divisions to focus on managed care.

The other big multi-line insurers at the time were Prudential, which sold its health care operations to Aetna in 1999, and Travelers and MetLife, whose health care businesses are now part of UnitedHealthcare. United, now the largest of the big five, has only been around as a publicly traded company since 1984. WellPoint, the second largest, just turned 21 this year.

The point is this: big stock companies change rapidly in response to changes in the marketplace and the changing expectations of shareholders.

Five years from now, those companies will be largely unrecognizable. And their health “insurance” divisions will have been dispatched to the dust bin of business history. If not the cemetery.

By Wendell Potter, author of Deadly Spin: An Insurance Company Insider Speaks Out on How Corporate PR is Killing Health Care and Deceiving Americans, at the Center for Public Integrity http://www.publicintegrity.org/2013/07/29/13065/opinion-brave-new-world-health-insurance

Last week U.S. News and World Report released its annual list of “Best Hospitals.”  Web sites are being updates to celebrate victories.  (Johns Hopkins ranks No. 1!)  Magazines will be plump with advertisements.  (New York-Presbyterian is first in New York and tied for seventh nationally!)  

But what does this annual exercise mean for patients?  And what does it say about American health care?

After all, Harvard and Princeton, which tied for No. 1 in the magazine’s 2013 Top 10 national universities list, didn’t take out ads to proclaim their triumph; they will fill their classrooms no matter.  And as in the college ratings, there are no big surprises in the top hospital group: they are the big academic medical centers – the Mayo Clinic, Massachusetts General Hospital, the Cleveland Clinic.  More to the point, even though you might well fly across the country for four years of schooling, you are far more likely to stay near your home for medical care.  No one’s flying to Mayo in Minnesota to get inhalers for asthma, even though it ranks No. 1 for pulmonary medicine.

But American hospitals are a bit like restaurants, competing for your business (and donations).  As such they will go all out to promote their brand, even though hospitals and doctors are permitted to advertise on many other countries.

For American hospitals large and small, it clearly pays to advertise, particularly in these tough economic times and with the Affordable Care Act poised to throw tens of millions of newly insured patients in the market.  But for patients the rankings and, especially, the subsequent promotions generally have limited benefit, experts say.

“Nearly every hospital has a banner out front saying they’re a ‘top hospital’ for something in some rating system,” said Dr. Nicholas Osborne, a Robert Wood Johnson Clinical Scholar at the University of Michigan.  “Those ratings have become more important for hospital marketing than for actually helping patients find the best care.”

What’s more, Dr. Osborne compared the outcomes of two ranking programs – one by U.S. News and World Report and the other by Healthgrades – and found a “large discordance” in their reports.  “The two biggest rating systems come up with completely different lists,” he said.  “What does that tell you?”

If such advertising often adds little in the way of useful information, it certainly adds ro health care costs.  Hospitals with more than 400 beds spent an average of $2.18 million on advertising in 2010, surveys have found.

“We’re pushing $3 billion in health expenditures, and one-third of that is waste,” said Dr. Eric Topol, chief academic officer at Scripps Health in California.  “Those TV commercials saying ‘I got my cancer care at X hospital’ are a shame, definitely wasteful.”

To be fair, U.S. News cautions that its national ratings reflect ho hospitals perform in treating “technically challenging” cases and that the list is merely a starting point after which “patients have to do their own research.”

But those caveats are lost in the subsequent barrage of advertising.  And the magazine encourages hospitals to post its seal of approval.  In return, the U.S. News Web site is bursting with hospital advertising.

Some critics decry the glut of hospital self-promotion as not just wasteful and costly, but also potentially dangerous.

“There are general fraud laws, but there is no law specific to hospital advertising, and there should be,” said Robert Steinbuch, a professor of law at the University of Arkansas at Little Rock, who studies the topic.  “I can’t tell you how many hospitals say, ‘We have state-of-the-art CAT scanners – there is no such thing!  It’s an old technology.”

In a country where numerous organizations – including Yelp – accredit, rate, and rank hospital care, some accolades many indicate excellence and some don’t mean that much at all, he added.  And while teams of academics and scores of for-profit companies are developing “quality” metrics to guide health care reform and to help patients shop for their care, it turns out that rating a hospital accurately is extremely complicated.  For one thing, hospitals that take on sicker patients might have more complications after surgery.

Yet even smaller hospitals tend to advertise their profit-making departments, like cardiology, even though they may not offer the full range of heart services.

“If they advertise cardiac care and doesn’t have angioplasty, that’s essentially fraud,” Mr. Steinbuch said, adding that if a patient dies, “that could be considered criminally negligent homicide.”

But health care advertising is probably here to stay.  “Hospital advertising sets up an arms war, so that hospitals feel they can’t survive without aggressive marketing,” said Dr. Topol  of Scripps Health.

And even skeptics concede that health care ratings, when properly developed and employed, may health hospitals improve their performance and provide patients with valuable information.

If you have a rare lung condition that has flummoxed local doctors, for example, you may want to fly to Mayo since U.S. News has ranked it No. 1 in pulmonary medicine.  And if a dozen hospitals in your area offer hip replacements, a search for regional rankings on the magazine’s Web site will yield some useful statistics.  But take all those hospital advertisements with a grain of salt.

Indeed, with thousands of good hospitals across the nation, the best selling point for routine medical care many simply be convenience: some studies show that patients prefer nearby hospitals with worse results over ones with better outcomes farther away.

“The Hype Over Hospital Rankings” by Elizabeth Rosenthal, The New York Times, July 28, 2013

Volunteers will fan out across Florida today, knocking on doors to identify uninsured residents and get them ready to enroll in Obamacare.  But they won’t be knocking blindly.  Behind the scenes is a sophisticated data operation that will guide volunteers to the right neighborhoods in Palm Beach County and elsewhere, and hopefully, even the right door to find those who can benefit from the law.

A team of data experts at Enroll America in Washington has built a model designed to identify not just who has no insurance but who may be persuaded to buy it.  The canvassing and outreach effort has the potential to become among the most significant since the presidential election.

The organization’s data director is an alumnus from the renowned Obama re-election cave.  Programmers, analysts and others worked 16-hour days there developing a model, for example, that showed the campaign could win in Florida, despite conventional wisdom that it would swing to Mitt Romney.

As in political campaigning, turnout is crucial to the success of the Affordable Care Act.  If people do not enroll in health insurance, the law will fail both politically and economically.

If the only people drawn to buy insurance are those who truly need it, people who are sick or older but not old enough for Medicare, the cost of insurance could be driven up for everyone.

Targeting the 49 million uninsured in a country of nearly 314 million is only a little easier than finding a proverbial needle in a haystack.  That is – without the use of data.

Data director Matthew Saniie used census data, Enroll America’s own survey of 10,000 consumers and databases on the market, likely to include voter data.

The numbers have given his team some helpful indicators.  Two-thirds of uninsured American live in 13 states.  Florida has about 4 million residents with no health coverage.

Those oldest and most well-to-do are more likely to have insurance.  Categories of those least likely to be insured included singles, Latinos, the young and the poor.

Data that are publicly available or that can be bought is only the first step.  The campaign also relies on results from its own survey.  Callers used landlines and cellphones to interview 10,000 residents in English and Spanish.

Face-to-face interactions between volunteers and the public will provide some of the most useful data to focus the outreach efforts.

“When people volunteer information to us, we record it and ultimately track it,” Saniie said.  “No longer are we making decisions based on a model, but now we can base decisions on conversations we’ve had with thousands of people.”

Real time data input was one of the keys to Obama’s success in 2012, said Soren Dayton, senior vice president at Prism Public Affairs.  Dayton worked on messaging and voter contact for John McCain’s 2008 campaign.

“The hardest parts of this aren’t mathematical,” he said.  “The most remarkable thing about the Obama campaign wasn’t the data – although the data were really cool – it’s their ability to, one, trust their volunteers, and, two, create a cultural system among their staff that works.”

More than a dozen volunteers in Palm Beach County participating in Weekend of Action will visit communities today in Delray Beach and Boca Raton.  If they meet someone who has insurance, they’ll ask about friends or family members who don’t.

And when the person who answers their knock says they don’t have insurance, the volunteers will collect as much information as they can.  Is the person interested in insurance?  How much money do they earn?  That will help Enroll America determine whether they may qualify for a government subsidy to help buy a plan.  Potential enrollees will be added to lists to be called or visited again.  Maybe again and again.  After the federal government announces its grants for navigators, the people who will actually help consumers sign up, Enroll America will connect its contacts with navigators.

As a fiend organizer is Palm Beach County, Florence French has already started knocking.  She gets a list, which includes the likely names of the people who live there, their address and phone number. 

Advocates of the law are up against a growing negative perception of it.  A new CBS poll found that a record 36 percent of Americans want to the law repealed, and 54 percent have an unfavorable opinion of it.

Enroll America’s own data show that their target audience is hardly primed to receive the message.  Of those Americans who may be eligible to enroll in insurance come October through an online marketplace operating in each state, 78 percent don’t know about it.

French is finding that in her early conversations.

“Most people didn’t even understand that the Affordable Care Act has been passed, [number] 1 [and] [number] 2, they really didn’t understand what that meant,” she said.

One of French’s biggest jobs is recruiting volunteers.  The group’s efforts in Palm Beach County this weekend will primarily focus on Boca, which isn’t the most intuitive pick when one’s goal is finding uninsured.

The town does have more than 10,700 residents without insurance. According to census data.

Boca was where they had a volunteer network, French said.  The organization will continue to recruit volunteers and take its door knocking to other parts of the country, its spokeswoman said. 

French is prepared to knock on lots of doors and to keep coming back.

“Once we know that they’re uninsured,” we know that our job’s done,” she said.

“Data mine helps target health care enrollees” by Laura Green, The Palm Beach Post, Saturday, July 27, 2013

Changes could be on the way for one of the state’s largest employers and political donors.

Florida Blue wants to restructure itself.

However, the health insurance giant has its critics that warn the move could create a conflict between turning a profit and the obligation to provide low-cost insurance to four million policy holders.

The Office of Insurance Regulation will hold a public hearing Thursday night in Miami on Florida Blue’s bid to switch from a not-for-profit mutual insurance company to a not-for-profit mutual insurance holding company. Florida Blue is a political powerhouse with nearly $5 million in campaign contributions during the 2012 election, including $2.4 million to the Republican Party of Florida and nearly $700K to the Florida Democratic Party, according to state campaign finance reports. The Jacksonville-based company employees 9,500 in Florida.

CEO Pat Geraghty says the move will allow Florida Blue to expand its assets outside the insurance industry. For example, Florida Blue currently has 11 retail centers around the state where customers can purchase insurance, ask about a claim or get their blood pressure checked. Those retail centers will likely get more traffic because of the Affordable Care Act’s provision requiring individuals to purchase health insurance. Florida Blue wants to capitalize on that business, selling vitamins, fitness gear and other non-insurance related items, Geraghty said.

“It really is about financial flexibility and making sure in this time of great change for the health care industry that we’re positioned in a way that’s most supportive of taking care of our customers for the long run,” he said in a phone interview with The Associated Press.

But critics say the switch to becoming a mutual insurance holding company is just a bid to become a publicly traded company and boost executives’ pay. Florida Blue is currently an independent licensee of the Blue Cross Blue Shield Association.

“Mutual insurance holding companies create a shell, a parent company, that doesn’t do any business. It doesn’t issue insurance anymore. The only reason it exists is so the shareholder cannot control the corporation,” said Brendan Bridgeland, director of the Massachusetts-based Center For Insurance Research.

As long as that shell company is at the top, it gives management a majority control of the voting power, he said.

The New York Assembly Standing Committee on Insurance called the concept “fundamentally flawed” in a 1998 report.

The Florida Alliance for Retired Americans cited that report when it spoke out against Florida Blue’s proposed reorganization on Thursday.

Geraghty said consumers will be “absolutely protected” under the new structure and will still have the same policyholder rights they currently have, including the ability to vote on key issues.

He stressed the stocks will not be publicly traded but will be held by the mutual insurance holding company.

It’s management nirvana really. It gives them the ability to issue stock through a subsidiary holding company, which means you can start giving yourself stock awards, stock options that you can cash in but you avoid the problem of having to answer to shareholders,” said Bridgeland.

Opponents said the company could transfer $1.6 billion in surplus to a for-profit entity and that money would be available to give to company executives and outside investors if stock goes public, according to a lengthy statement from Florida Alliance for Retired Americans.

“The result of such a stock issuance would be crippling conflicts of interest between the interests of the policyholders (who want lower cost health insurance) versus the new outside investors,” the organization said.

Lawmakers this year passed a last-minute amendment to allow mutual holding companies like Florida Blue to acquire not-for-profit subsidiaries. Previously, such companies had only been allowed to own for-profit subsidiaries.

“This was an amendment that never really got a chance for public debate. It looked like a pretty shrewd lobbying effort that got that amendment on,” said Ben Wilcox, research director for the independent government watchdog group Integrity Florida.

But Florida Blue said the amendment was not needed for the reorganization and noted it passed unanimously in the House and Senate.

The Florida Times-Union reported the state’s top insurance regulator originally opposed the move amid concerns the restructure “may not adequately protect the interests of the policyholders.”

A spokeswoman for the Office of Insurance Regulation said the commissioner had not made any decision yet.

When asked about the commissioner’s original concern, Geraghty said “there was some confusion as the process started.” He added, “I think today there is support for what we’re trying to do.” 

CBSMiami/AP

President Barack Obama, campaigning for his health care law, said Thursday that thanks to the act, more than 8.5 million Americans were getting rebates this summer from their insurance providers.

 

Obama was flanked by families who have benefitted from a provision in the law, which requires health insurers to spend at least 80 percent of the revenue from premiums on medical care rather than administrative costs.  Insurers who fail to meet that benchmark must reimburse customers, a process that began in 2012. 

 

“Last year, millions of Americans opened letters from their insurance companies, but instead of the usual dread that comes with getting a bill, they were pleasantly surprised with a check,” Obama said in a midday ceremony at the White House.

 

The checks typically amount to no more than a few hundred dollars.  But the president, recounting stories of middle-class families arrayed on the stage behind him, celebrated these modest windfalls as an early sign of the tangible benefits of the law.

 

Republicans did not let up on Thursday, claiming that the benefits tolled by Obama would be more than offset by higher costs.

 

With the Republican-controlled House of Representatives voting yet again this week to repeal the Affordable Care Act, however, the president seized on new statistics that demonstrate the law is driving down premiums in some states.

 

The Department of Health and Human Services just released a report asserting that, in 11 states and the District of Columbia, proposed health insurance premiums for 2014 are nearly 20 percent lower than the administration projected.

 

“Today’s report shows that the Affordable Care Act is working to increase transparency and competition among health insurance plans and drive premiums down,” Kathleen Sebelius, the secretary of health and human services, said in a statement. 

 

Thursday’s carefully choreographed even in the East Room was intended to put the White House back on the offensive on health care after it was forced to delay the employer mandate, which requires companies with more than 50 employees to offer health insurance, or pay a penalty.

 

The delay came after heavy pressure from businesses, which said the law was too complex and cumbersome to implement on time. 

 

Mark Landler, New York Times, July 19, 2013.

To follow what’s happening with the new health care law right now, you have to understand that for all the deep divisions on the issue, there’s actually a real bipartisan consensus about how the American health care system ought to be reformed.

Or rather, there are two of them – a dishonest consensus among politicians and an honest consensus among people who study public policy for a living.

The politicians’ consensus is that health care reform shouldn’t alter or disrupt the way the majority of Americans get their insurance today.  This is President Obama’s official position on the issue: again and again throughout the fraught 2009 debate, he reassured voters that if they liked their existing health care plan , his bill wouldn’t prevent them from keeping it.  It’s also the official position of his Republican critics, who have consistently attacked Obamacare for undercutting that presidential promise – for slashing Medicare, for driving up premiums and for threatening the employer-provided insurance status quo.

The policy consensus, though, is that the status quo is actually the problem, and that it deserves to be threatened, undermined and replaced as expeditiously as possible.  Wonks on the left and right disagree on what that replacement should look like.  But they’re united in regarding employer-provided coverage as an unsustainable relic: a burden on businesses, a source of perverse incentives for the health care market and an obstacle to more efficient, affordable, and universal coverage.

Yet woe betide the politician who dares to publicly agree.  That’s what John McCain discovered in 2008, when he proposed a sweeping reform that would have eliminated the tax incentives that undergird employer-provided coverage.  Conservative policy types loved the idea (as well they should, being responsible for it), but it cost McCain dearly: the Obama campaign used it to attack him, relentlessly and effectively, as an enemy of the way most middle-class people get health insurance, and thus of the middle class itself. 

These attacks, in turn, constrained the Obama White House when it came time to design its own health care reform.  Obamacare has an unwieldy, Frankenstein’s monster quality in part because the law is trying to serve both consensuses at once.  The core of the bill, the subsidies for the uninsured and the exchanges where they can purchase plans, is designed to offer a center-left alternative to the existing system.  But much of the surrounding architecture is designed to prop up existing arrangements – and in the process, protect Obama from exactly the kind of criticisms he one levied against McCain.

Or at least, it was designed that way.  But then came last week’s announcement that the White House would be delaying, for a year, the new health care law’s employer mandate, which required businesses with more than 50 employees to offer health coverage of face a fine.

Republicans reacted by hyping the announcement as a sign that the entire law is unraveling, Democrats by minimizing the significance of the move.  But the more telling reaction came from the policy world, where conservatives and liberals took a break from their usual disagreements to agree that the White House and Congress should just scrap the employer mandate altogether.

That’s because the mandate is mostly just a political device designed to hide the full cost of the bill and discourage employers from eliminating employee coverage too quickly once Obamacare’s new exchanges are up and running.

Like many politically minded regulations, it risks perverse economic consequences – delayed hiring, reduced work hours – which explains why the White House decided to punt it to 2015.  But the mandate’s outright abandonment is more desirable, because that would have a clarifying effect on the entire health care debate.

Right now, both parties are still pretending that H.R. departments will go on doubling as welfare states forever.  If it dropped the employer mandate, the Obama White House would be fully committed to a more disruptive future, in which exchanges and subsidiea gradually replaced the employer-based system.  And since those exchanges and subsidies are going to be implemented by this administration no matter what – barring a Martian invasion or a zombie apocalypse, at least – the sooner we find out if they really work and what they really cost the better.

As Avik Roy, one of the mandate’s conservative critics, wrote last week in Forbes, “if you like Obamacare, and you want it to work, you don’t need the employer mandate.”  And if you don’t like Obamacare (as Roy doesn’t), and don’t expect it to work, then all the mandate does is delay a necessary reckoning with the new system’s flaws.

Either way, the White House’s decision is a step toward honesty in policymaking.  It takes us a little closer to a world where politicians of both parties actually level with the public, and acknowledge that employer-provided health insurance is an idea whose time has passed.

Excerpted from "A Hidden Consensus on Health Care" by Ross Douthat in The New York Times on Sunday July 7, 2013.

Osteoporosis Management Guidelines Updated for Women and Men by Laurie Barclay, MD, for Medscape Medical News on July 01, 2013.

The National Osteoporosis Guideline Group (NOGG) has updated its 2009 guidelines on the diagnosis and management of osteoporosis in postmenopausal women and men at least 50 years of age in the United Kingdom. The new recommendations were published online June 17 in Maturitas.

"Since [2009] there has been a number of advances in the field, particularly with respect to glucocorticoid-induced osteoporosis, the role of calcium and vitamin D therapy, and the benefits and risks of long-term bisphosphonate therapy," write J. Compston, MD, from the University of Cambridge School of Clinical Medicine, United Kingdom, and colleagues from the NOGG. "In addition new pharmacological interventions have been approved for the prevention of glucocorticoid-induced osteoporosis and the management of osteoporosis in postmenopausal women and men at increased risk."

Selected Highlights of the 2013 Guidelines

• Pharmacotherapies shown to lower the risk for vertebral fracture (and for hip fracture in some cases) include bisphosphonates, denosumab, parathyroid hormone peptides, raloxifene, and strontium ranelate.

• Generic alendronate is usually first-line treatment because of its broad spectrum of antifracture efficacy and low cost.

• Ibandronate, risedronate, zoledronic acid, denosumab, raloxifene, or strontium ranelate may be appropriate therapy when alendronate is contraindicated or poorly tolerated.

• Because of the high cost, parathyroid hormone peptides should be used only for patients at very high risk, especially for vertebral fractures.

• Postmenopausal women may benefit from calcitriol, etidronate, and hormone replacement therapy.

• Approved treatments for men at increased fracture risk are alendronate, risedronate, zoledronic acid, and teriparatide.

• Patients at increased risk for fracture should start alendronate or other bone-protective treatment at the onset of glucocorticoid therapy.

• For postmenopausal women, approved pharmacotherapy for prevention and treatment of glucocorticoid-induced osteoporosis includes alendronate, etidronate, and risedronate; approved treatment options in both sexes are teriparatide and zoledronic acid.

• Calcium and vitamin D supplementation is widely recommended for older persons who are housebound or live in residential or nursing homes and is often recommended as an adjunct to other treatments for osteoporosis.

• Potential adverse cardiovascular effects of calcium supplementation are controversial, but it may be prudent to increase dietary calcium intake and use vitamin D alone rather than using both calcium and vitamin D supplementation.

• Withdrawal of bisphosphonate treatment is associated with decreases in bone mineral density (BMD) and bone turnover after 2 to 3 years for alendronate and 1 to 2 years for ibandronate and risedronate.

• Continuation of bisphosphonates without the need for further evaluation is recommended for high-risk individuals. When bisphosphonates are continued, treatment review, including renal function evaluation, is needed every 5 years.

• If bisphosphonates are discontinued, fracture risk should be re-evaluated after every new fracture, or after 2 years if no new fracture occurs.

• After 3 years of zoledronic acid treatment, the benefits on BMD density persist for at least another 3 years after discontinuation. Most patients should stop treatment after 3 years, and their physician should review the need for continuation of therapy 3 years later.

• Persons with a previous vertebral fracture or a pretreatment hip BMD T-score of −2.5 SD or less may be at increased risk for vertebral fracture if zoledronic acid is discontinued.

"At present there is no universally accepted policy for population screening in the UK to identify individuals with osteoporosis or those at high risk of fracture," the guideline authors write. "Patients are identified opportunistically using a case finding strategy on the finding of a previous fragility fracture or the presence of significant [clinical risk factors]. Some of these risk factors act independently of BMD to increase fracture risk whereas others increase fracture risk through their association with low BMD (e.g. some of the secondary causes of osteoporosis)."

An independent expert related the new UK guidelines to those used in Canada, released and published in 2010. "As with the current Canadian guidelines, the UK guidelines generally recommend fracture risk assessment in advance of making treatment recommendations," said Joanna Sale, PhD, associate scientist, Mobility Program Clinical Research Unit, St. Michael's Hospital, Toronto, Ontario, Canada, in an interview with Medscape Medical News.

"The recommendations in the guideline are intended to aid management decisions but do not replace the need for clinical judgment in the care of individuals in clinical practice," the group contributors conclude.

These guidelines were developed without financial support from any commercial organization. Some NOGG members reported various disclosures with Servier, Consilient Health, Amgen, GSK, Shire, Eli Lilly. MSD, Novartis, Proctor & Gamble, ProStrakan, Roche, Medtronic, Tethys, Bayer, GE Lunar, Hologic, Merck, Pfizer, Warner-Chilcott, Innovus 3i, Alliance for Better Bone Health, Biointetica, Celtrix, D3A, General Electric, Kissel, Medimaps, Sanofi-Aventis, UBS, Warner-Chilcott, Nycomed, Acuitas, Olympus, Synthes, Stryker, Biomet, and Medtronic. Dr. Sale has disclosed no relevant financial relationships.

The latest issue of AARP magazine features a MoneySaver article by Jean Chatzky on how to pay less out-of-pocket for medical care.

 “What hurts more than ripping off a Band-Aid?  Taking a good, hard look at your medical bills.  Annual out-of-pocket health care spending jumped 4.6 percent, to an average of $735m in 2011 (the most recent year for which figures are available) for people with employer-sponsored insurance, the Health Care Cost Institute reports.  To ease the sting, consider these three strategies—but be sure you’re not compromising your health.

Avoid unnecessary or duplicative care  The biggest way to save—by far—is to avoid treatment or tests you don’t need.  Not rushing into questionable back surgery, for example, “will save you a lot of pain and money,” says Jeffrey Rice, M.D. CEO of Healthcare Blue Book, a Kelly Blue Book-type guide to medical care.  Before you give that blood sample or get that MRI, ask your physician if this needs to be done immediately.  He or she might suggest a more financially conservative approach, or a safe amount of time to wait and see if the problem improves on its own.

Compare costs of treatment  Many of us purchase health care services without a clue as to cost.  Before treatment, ask doctors and facilities how much they’re going to charge.  Compare those answers with typical costs in your area; you can get that information at healthcarebluebook.com.  Call around to check prices at specific facilities near you.  It can save you thousands of dollars, especially if you have not met your deductible or decide to go out of network.  Also, ask your doctor about cheaper versions of any drug you take.  If you feel uncomfortable talking process with a doctor, consult you pharmacist.

While both patients and employers are looking to keep the cost of care down, they are also seeking providers with a reputation and track record for quality care and positive outcomes to help reduce the need for future care and additional costs.

But the search for providers that can deliver low-cost, high-quality care is no longer limited to a setting located within a reasonable drive.  Patients and employers are surgery shopping outside of their states and regions to identify the best providers available and at the best price—prices that do not necessarily just look at the cost of treatment but may factor in expenses associated with travel to and from a setting.

The State of Florida’s Agency for Health Care Administration (AHCA) hosts several online tools for patients to compare the cost and quality of surgeons and facilities at www.FloridaHealthFinder.gov.    Expert assistance on how to navigate AHCA’s and similar websites is available from patient advocate Evette White-Rosenthal.  Contact Evette at ewrosenthal@noif-fl.com or (561) 844-0120 ext 407.