Pa., Del. to Identify as State-Based Exchanges


There seems to be a trend in the United States of people formerly identifiable as a person with one set of easily recognized characteristics deciding that they “identify” as having another set of characteristics.

This is also happening with Obamacare exchanges. The Supreme Court will soon announce its decision in King v. Burwell, resolving the question of whether Obamacare tax credits can be paid in states using the federal exchange ( or only states with their own exchanges. Some states with federal exchanges are trying to “identify” them as state exchanges.

Pennsylvania is one. Delaware is too, but it is called a State Partnership Marketplace. These State Partnership Marketplaces are not defined in the Affordable Care Act. The law defines clear blue sky between state and federal exchanges, and that tax credits can only flow through state exchanges. This difference was supposed to create the incentive for states to establish exchanges. It did not work.

King v. Burwell: How Important Is Obamacare’s Individual Mandate?


HEALTHCARE LAW PROTESTS AT SUPREME COURT(A version of this Health Alert was published at Forbes.)

Later this month, the Supreme Court will likely announce its decision on King v. Burwell, the lawsuit which asserts tax credits currently being paid to health insurers in 34 to 37 states that use the federal health insurance exchange are illegal. If the Supreme Court stops these tax credits, over six million people will be required to pay the full premiums for their Obamacare policies. This will cause a crisis, which will demand a response by Congress and the president.

President Obama recently stated that, “Congress could fix this whole thing with a one-sentence provision.” True: Repealing Obamacare in its entirety would only take one sentence. However, that is not likely what he meant. Congress would have the opportunity to propose changes to Obamacare, but they would have to be signed by a reluctant president who will never again face the voters.

Now that both chambers of Congress have Republican majorities, any legislative response will surely include eliminating the individual mandate, the most unpopular feature of the law. Victory for King would make Obamacare policies in most of the country “unaffordable” and thereby relieve 11.1 million people of the individual mandate. Any “fix” that re-imposes the mandate would be political kryptonite for this Congress.

Trans-Pacific Partnership: Intellectual Property Rights Won’t be Strong Enough


A few days ago, I discussed my concern that intellectual property rights for pharmaceutical innovators would not be strong enough in the Trans-Pacific Partnership agreement for which President Obama seeks Trade Promotion Authority.

Well, they won’t be strong enough, according to information leaked from the negotiations:

Facing resistance from Pacific trading partners, the Obama administration is no longer demanding protection for pharmaceutical prices under the 12-nation Trans-Pacific Partnership, according to a newly leaked section of the proposed trade accord.

But Pacific accord negotiators appear ready to grant pharmaceutical and medical device makers more power to influence participating governments. The 12 countries involved, and any others that might join later, would have to disclose rules and guidelines for deciding which medical products would be made available through government programs and at what rate providers would be reimbursed.

(Jonathan Weisman, “U.S. Shifts Stance on Drug Pricing in Pacific Trade Pact Talks, Document Reveals,” New York Times, June 10, 2015)

Call me old-fashioned, but I think that’s a pretty reasonable request.

Electronic Health Records: Physicians, Hospitals “Literally Terrified” of Next Stage


In a hearing on Meaningful Use Stage 3, interoperability and patient access to data, Sen. Lamar Alexander (R-Tenn.) cut right to the heart of the problem.

“To put it bluntly, physicians and hospitals have said to me that they are literally terrified of the next implementation stage … because of the complexity and because of the fines that will be levied,” he said. (Katie Dvorak, FierceHealthIT, June 10, 2015)

Well, okay, but let us recall that these doctors and hospitals were happy to take the almost $30 billion of taxpayers’ money the government handed them to install the Electronic Health Records subject to these regulations

Obamacare Beneficiaries Skip Care


Kaiser Health News covers an issue we’ve discussed:

A key goal of the Affordable Care Act is to help people get health insurance who may have not been able to pay for it before. But the most popular plans – those with low monthly premiums – also have high deductibles and copays. And that can leave medical care still out of reach for some.

Renee Mitchell of Stone Mountain, Georgia is…… generally pleased with her insurance — a silver-level Obamacare plan. It’s the most popular type of plan with consumers because of the benefits it provides for the money. But she still struggles to keep up with her part of the bills. She is not alone. (Jim Burress, “Some Insured Patients Still Skip Care Because of High Costs”, June 10, 2015).

Here’s something to think about: Every penny of the billions of dollars taxpayers are paying to underwrite Obamacare goes to health insurers, either as premium tax credits via exchanges or cost-sharing subsidies for low-income households. Not one penny goes to the beneficiaries directly, so they can decide themselves which health goods and services to pay for.

Render Unto Caesar: Obama Preaches to Catholic Health Association


Yesterday, President Obama made a speech on healthcare to the Catholic Health Association’s meeting in Washington, DC, where the CHA celebrated its 100th anniversary. The president recycled his campaign speech, making many claims about the cost of care, medical bankruptcy, and uninsurance, all of which we have debunked countless times in this blog.

He also asserted that Obamacare created jobs, claiming the health law was responsible for job growth since 2010. In fact, quality job growth coming out of the Great Recession has been remarkably slow in comparison with previous recessions, as I discussed in a previous blog post.

The most depressing part of the speech was his cheering the CHA for its role in passing Obamacare: “We would not have succeeded, if it had not been for you.” He got that right. Hospital lobbyists were critical in dragging Obamacare over the line, and the CHA comprises the largest denominational trade association of hospitals.

Doctor Who Billed Medicare Over $16 Million in 2013 Explains It on YouTube


Last year, I had a very rare opportunity to congratulate the Obama Administration for its decision to release Medicare’s physician payment data for public scrutiny. It followed up quickly with a data dump of hospital claims.

I also anticipated that this would lead the physicians with the highest spending to justify their claims to the citizens at large. Last week, the Administration released the 2013 physician file, which is causing a this to happen. Here is one high-cost specialist explaining his practice on YouTube:

I discovered this thanks to USA Today, which has done a first cut of the 2013 dataset:

Calorie Counts on Menus Don’t Work


Obamacare mandates that chain restaurants post calorie counts on menu boards. This is an example of “nudging.” Wouldn’t it be great if America’s obesity epidemic could be solved by just ensuring people are better informed about how many calories are in those French fries?

Well, the evidence is in, and calorie counts are ineffective. Dr. Aaron Carroll tells the story at his always informative and engaging Healthcare Triage YouTube channel:

I had the pleasure of meeting Dr. Carroll recently at the National Institute for Health Care Management Foundation’s Health Care Digital Awards dinner, where he won well deserved recognition. All I can add to Dr. Carroll’s explanation of the evidence is an argument for why the government finds this nudging irresistible.

Trans-Pacific Partnership: Will Intellectual Property Rights Be Strong Enough?


Having passed the Senate, it is now up to the House of Representatives to decide whether to give President Obama Trade Promotion Authority (TPA, or “fast track”) to negotiate the Trans-Pacific Partnership.

Most Congressional Republicans who support TPA also advocate strong intellectual property rights. However, one concern with TPA is that it is uncertain the President will negotiate strong intellectual property rights in the TPP. What will these Republicans do if the final version of the TPP does not have adequate protection for investment in intellectual property?

One example is the protection of data exclusivity for inventors of new biotech products. The U.S. has the gold standard – 12 years – and it is reasonable to seek this standard in the TPP.

When it comes to pharmaceutical patents, U.S. Senator Orrin Hatch is on the side of protection intellectual property with respect to current trading partners. He recently criticized the president for not doing enough to pressure India (which is not in the TPP) to improve its patent protection.

On the other hand, he was the Senate champion for fast track for TPP. Is this consistent?

More Price Transparency Problems


Writing in Health Affairs, Ge Bai and Gerard F. Anderson have highlighted the fifty U.S. hospitals with the most “extreme markups” from what Medicare pays to their list prices (from the hospital chargemaster). The paper, available by subscription, is written up by Olga Khazan in The Atlantic (which you can read online for free):

The study found that, on average, the 50 hospitals with the highest markups charged people 10 times more than what it cost them to provide the treatments in 2012.


Bai and Anderson call for more government interference in hospital pricing: