Healthcare Reform: The Path Forward

Healthcare reform: path forward - Colorado health insurance insider

Welcome to the Health Wonk Review!

It’s been nearly six years since the ACA was signed into law. And although most aspects of the law have now been implemented, the debate over its merits have not let up. In this election year, healthcare reform continues to be a hot topic, even dividing Democrats in terms of the best path forward.

When I look at the entries for this edition of the Health Wonk Review, I notice that a common theme is all about the path forward… what we can do – including small tweaks as well as major changes – to build on what we’ve already got and make it better. In honor of those posts, I’m dubbing this edition of the Health Wonk Review “Healthcare Reform: The Path Forward” and I’ll let the entries speak for themselves.

At, Andrew Sprung wonders whether we could expand on the Basic Health Program (BHP) model – which so far, has only been implemented by New York and Minnesota – and open up coverage to more people by using 1332 “innovation” waivers. Coverage through these expanded BHPs could be available to the current subsidy-eligible population, or to anyone who doesn’t have access to an employer-sponsored plan, with a sliding fee scale for premiums. New York proposed a similar program back in 2009, and has already implemented a BHP for people with incomes up to 200% of the poverty level this year. Andrew wonders whether they might be able to build on that model to pull more people into the BHP over time, and whether other states might follow suit if it proves to be successful. You can read more about Andrew’s ideas here.

Basic Health PlanAt ACAsignups, Charles Gaba writes prolifically about healthcare reform. I highly recommend his site if you’re looking for data and/or perspective on ACA implementation and possible future avenues for reform. Much has been said recently about health insurance carriers losing money in the ACA’s exchanges, including small local carriers like Colorado HealthOP, as well as national carriers like UnitedHealthcare. But Charles explains that although the losses in the individual market are real, they pale in comparison to the profitability of the Medicaid Managed Care and Medicare Advantage markets. When we consider how small the individual market is – compared with the employer-sponsored market and Medicaid/Medicare – Charles wonders whether it might make more sense to wrap the individual market into a Medicaid/Medicare-style managed care system. This is a good extension of the ideas Andrew posited, with a perspective of how insurers can make a profit while still conforming to the new rules.

IMG_2524In keeping with the ideas the Andrew and Charles have suggested, at Balloon Juice, Richard Mayhew questions the idea that employer-sponsored insurance is always a better option than Medicaid, CHIP, or individual insurance purchased through the exchange. One of the reasons that exchange enrollment has been lower than originally projected is that employers have not dropped their health plans en masse. While this can be seen as a positive in terms of being less disruptive to the status quo, Richard explains why ESI isn’t always the best option – for the employees, or for the cost of our healthcare system as a whole.

On Health Affairs Blog, Nicole Garro, Brittany Hernandez, and Cynthia Pellegrini explain why HHS should make pregnancy a qualifying event, allowing a pregnant woman access to a special enrollment period during which she could enroll in a health plan through the exchange. HHS already considered this possibility and rejected it in early 2015, although New York‘s law allowing pregnant women to enroll took effect in January 2016. The Health Affairs piece makes a compelling case for the pregnancy SEP from an individual perspective (ie, that outcomes for the otherwise-uninsured mothers and babies will be much improved), and from the perspective of how limited the impact would be, since only about 1.5% of pregnant women are currently uninsured at the time of delivery.

IMG_2528But there are other implications to consider… would a pregnancy SEP chip away at the strength of the individual mandate? Would women be more likely to skip health insurance if they knew they could enroll if and when they became pregnant? Would health plans be more likely to drop the best obstetric hospitals from their networks, in an effort to avoid adverse selection during pregnancy SEPs? It’s true that pregnancies are often unplanned, but that’s even more true of most medical conditions. Cancer is easier to treat (and less expensive) if treatment is available early on, yet we aren’t considering adding a SEP for people newly-diagnosed with cancer. Then again, a pregnancy includes a future person – the baby – which perhaps makes a moral argument for the SEP. And since pregnancy lasts nine months, most women already have access to coverage for the birth itself (even if they don’t qualify for Medicaid or CHIP) simply because they’re likely to be pregnant as of January 1, and therefore eligible to enroll in a health plan during open enrollment, in anticipation of the birth. I find the discussion around this topic fascinating, and I can certainly see both sides of the issue.

At Managed Care Matters, Joe Paduda brings us his aptly-titled The Bern, the Buffoon, and healthcare. Joe notes that Donald Trump’s “healthcare plan” (it’s gonna be “really great!”) isn’t really worth discussing, but he explains that Bernie Sanders’ plan seems like a long shot at best. He notes that he loves Sanders, but directs readers to Charles Gaba’s explanation of why Clinton’s healthcare plan might be a more workable solution, at least in the short-term (Charles added another post about Clinton’s health plan earlier this week).

At Health Business Blog, David Williams has an entry that’s sure to catch your attention. David notes that the majority of Democrats and Republicans think that Medicare should negotiate drug prices. But he then goes on to explain why that’s actually a bad idea, and he makes some very good points. The media is quick to jump on the fact that drugs like Sovaldi can cost $1,000 per pill, but if a three month course of the medication cures Hepatitis C, how much are we saving down the road in transplant and cancer costs – not to mention the qualify of life improvement for the patient? David notes that we do certainly need to do something about the cost of drugs. But he calls for “something more innovative than squeezing unit price” and notes that we have to look at the big picture, and take into account whether the cost of the drugs is offset by lower medical costs in other areas because of the use of the drugs. Very good food for thought here, as health payers grapple with ever-increasing drug costs.

Speaking of which, at InsureBlog, Hank Stern highlights the growing problem of pharmacy costs in health plans. Hank explains that only 3% of prescriptions are considered specialty drugs, but they account for 30% of health plans’ pharmacy costs. This situation doesn’t appear to be getting any better, at least in the short term. When health plans submitted their rate proposals last spring for the 2016 plan year, pharmacy costs were mentioned over and over in terms of justification for rate increases.

Writing at Health System Ed, Peggy Salvatore examines a recent study by the California Health Care Foundation about how digital health can help close healthcare disparity gaps for underserved populations. Low-income patients are more likely to have chronic medical conditions, and don’t always have access to a primary care provider. Peggy explains that “pilot programs have shown that even the poorest of the poor in unstable living situations often have a cell phone or even a smart phone, and internet access at a computer. With just those tools, a few low-cost, high-touch digital outreach programs have moved the needle with medication compliance, attending appointments and maintaining health regimens recommended by their providers.” Modern technology provides us with a wealth of possibilities for improving health outcomes, and the gains could be particularly significant among underserved and low-income populations.

At Flow Health, Robert Rowley, MD, explains how our current electronic health records (EHRs) are designed to work with the fee-for-service model that has been the standard for basically as long as we’ve had third party payers for healthcare services. But that’s changing, as Medicare and IMG_2531private insurers are shifting towards paying for value rather than volume. EHRs will need to evolve to keep up. Robert notes that the next generation of EHRs will need to be able to collect and accurately combine data from all sources where a patient receives medical care, and highlights the need for this evolution to happen quickly, but also efficiently. Some existing EHRs might be adaptable, while others will need to be replaced.

How things stand today

In addition to focusing on the path forward, there’s still a lot to learn about where we are today in terms of healthcare reform, healthcare outcomes, the ethics of the healthcare industry, and how we pay for all of it. Several wonks have contributed articles on these fronts:

At Wright on Health, Brad Wright explains the various Forms 1095 that you may have received from your employer, health insurance carrier, or exchange recently. There are three versions of the form – A, B, and C – and they are all used to tell you (and the IRS) about the health insurance coverage you had during the prior year, what months you had coverage, how much you paid, whether you received a premium subsidy, etc. You’ll use the information on those forms to tell the IRS whether you had coverage (if you didn’t, you may owe a penalty). And if you got a subsidy through the exchange (or if you paid full price through the exchange but ended up with an income that makes you eligible to claim your subsidy on your tax return), you’ll need the information on your 1095-A to complete Form 8962 and reconcile (or claim) your subsidy. If you’re confused about any this, check out Brad’s explanation.

At Health Care Renewal, Roy Poses is on a tireless mission to expose unethical (and illegal) behavior among healthcare executives. He’s been doing this for a long time, and the stories just keep coming. As such, his article is titled “Ho-hum, another month, another set of multi-million dollar settlements by health care corporations acting badly.” These settlements are starting to become routine, but as Roy points out, they almost invariably result in a financial penalty for the company, rather than for top executives. So the burden of the settlement is carried by shareholders, employees, and customers/patients (who had nothing to do with the bad behavior in the first place), instead of the top executives who caused the problems. But this issue is starting to get traction in the media, and Roy notes that “maybe now that the impunity of corporate leaders is becoming a mainstream topic of discussion, we can start talking about, and then doing something about the impunity of corporate leaders in health care.” One can hope.


At Workers’ Comp Insider, Julie Ferguson shows us what life was like for US workers in 1915. Julie focuses on workplace safety and working conditions, and it will make you glad you’re not working in a factory a century ago. The beginnings of workplace safety regulations were just starting to be developed, but there was clearly still a very long way to go. Julie notes that “in this election year, it’s a reminder that policy matters and elections have consequences!” Well said. When casting votes this fall, keep in mind the views that various elected officials have in terms of working conditions, access to healthcare, and workplace safety.

Jason Shafrin, aka The Healthcare Economist, digs into an analysis of paying for hospital care in England versus Scotland. Both countries are part of the UK – along with Wales and Northern Ireland – and all four countries have NHS health coverage. But in 1999, the NHS decentralized their system to allow each country to run its own system. Jason takes a look at how hip replacements are reimbursed in England and Scotland, and finds the results unsurprising from an economics perspective.

My own contribution to this edition is a piece I wrote for, all about grandfathered health plans. President Obama famously said that if you like your health plan, you can keep it… and he’s been thoroughly called-out for over-promising. Grandfathered health plans are rapidly disappearing (and consumers are switching away from them). But even if people could keep their grandfathered health plans “forever,” would they want to? Would they be able to afford the premiums as the years went by? Probably not. Grandfathering was a way to provide a transition to the ACA, with less disruption to the status quo. But it’s unrealistic to expect any health plan to remain unchanged, with a closed risk pool, over a long period of time.

That does it for this edition of the Health Wonk Review. It’s always an honor to host, and a pleasure to read all of the excellent entries. The next edition of the HWR will be hosted by David Williams at Health Business Blog on March 10. If you write about health policy or healthcare, send him your best piece for consideration. Cheers, and enjoy your health wonk reading today!

About Louise Norris

Louise Norris has been writing about health insurance and healthcare reform since 2006. In addition to the Colorado Health Insurance Insider, she also writes for,, Verywell, Spark by ADP, and Boost by ADP, and Gusto. Follow on twitter and facebook.

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