Healthcare-related initiatives were on the ballot in several states on Tuesday, with mixed results.
California voters on Tuesday voted to approve a ballot initiative that authorizes $1.5 billion in bonds to fund capital improvements at the state's 13 children's hospitals.
Proposition 4, the Children’s Hospital Bond Act of 2018, passed with more than 60% of the vote. It will cost California taxpayers $80 million a year for the next 35 years, for a total of $2.9 billion, according to the state's Legislative Analyst's Office.
California Children’s Hospital Association President and CEO Ann-Louise Kuhns said the state's pediatric hospitals were "grateful to voters."
"These funds will allow our hospitals to upgrade their facilities to meet new seismic safety requirements, update technology and expand capacity so that we can continue to provide the best care and save more lives," Kuhns said.
Some observers questioned whether a ballot initiative was the proper way to secure a bond offering. California voters approved a $750 million bond in 2004 and a $980 million bond in 2008.
"I think it's a misuse of the initiative process for private groups to sponsor ballot measures that are intended to benefit them exclusively," Elizabeth Ralston, a former president of the League of Women Voters of Los Angeles, told Kaiser Health News.
The league had recommended a "no" vote on the measure.
Another healthcare-related California ballot initiative did not fare so well. Proposition 8 would have capped the profits of kidney dialysis providers at 15% above direct patient costs, but it was roundly defeated 62% to 38%.
"Yes of Prop. 8" leader Emanuel Gonzales said dialysis corporations used scare tactics in a $111 million campaign to defeat the initiative, but Gonzales said he hopes to have it back on the ballot in 2020.
"We're proud to have exposed the unacceptable conditions in many clinics caused by understaffing, including reports from patients about cockroaches and unclean facilities," said Gonzales, a dialysis technician whose father is a dialysis patient.
"We exposed the massive profits this industry makes off people who literally can't live without this treatment," he said.
Nevada Nixes Sales Tax on Medical Equipment
Voters in Nevada approved a ballot initiative to remove the sales tax from medical equipment.
Local media in Nevadaare reporting that more than 67% of voters in state voted for Question 4, which amends the Nevada Constitution to require the state legislature to exempt some durable medical goods, including oxygen delivery equipment and prescription mobility-enhancing equipment, from sales tax.
The proposal passed a first time in 2016 and would become law if it passes again. Proponents of the initiative argued that it would but Nevada in line with other states, but critics said the measure is vaguely worded, as the Reno Gazette Journal reported.
OK Not OK with Optometrists in Walmart
Oklahoma voters rejected the Walmart-backed Question 793, which would have amended the Oklahoma Constitution to give optometrists and opticians the right to practice in retail stores.
Walmart gave nearly $1 million in the third quarter alone to proponents of the initiative, which was narrowly defeated by less than 6,000 votes. Those opposing the measure consist primarily of individual optometrists, as NewsOK.com reported.
The Oklahoma Council of Public Affairs, which backed the initiative, accused opponents of mounting "a scare campaign that worked."
"To protect their profits, a special interest convinced Oklahomans that a few more choices for eye care would be dangerous," the council said.
The ad hoc group "Yes on 793" said it was "disappointed" with the outcome, but would seek "legislative remedy" to resolve the impasse.
University of Michigan Health executive Paul King will become CEO of Lucile Packard Children's Hospital in early 2019.
Veteran pediatric healthcare executive Paul King has been named president and CEO of Lucile Packard Children's Hospital Stanford and Stanford Children's Health, effective in early 2019, the California-based health system announced.
"The possibilities that are within reach for the world-class Stanford Medicine academic medical institutions are truly limitless," King said in a media release.
"I look forward to working with the board and executive leadership, the physicians and staff, as well as with partners at the School of Medicine and Stanford Health Care, to continue to advance pediatric care and research and raise the bar for patient experience and outcomes not just for our patients, but for children and expectant mothers everywhere," he said.
King succeeds Interim CEO Dennis Lund, MD, who took over following the retirement of long-serving CEO Chris Dawes, in March 2018.
"As a physician leader it is vital to have executive and board leadership who embrace the voices of our physicians and care teams, as front line providers, researchers and innovators," said Mary Leonard, MD, Lucile Packard's physician in chief.
"Paul's experience and understanding of how to nurture growth within academic medical institutions make him a wonderful leader and ally to pursue our goals in science, education and patient care," Leonard said.
King has more than 30 years of experience as an executive at pediatric health providers and has been executive director at University of Michigan Health System's C.S. Mott Children's Hospital and Von Voigtlander Women's Hospital since 2013.
Before that, King was president and CEO for the Pediatric Management Group, a 550-physician academic pediatric subspecialty group practice affiliated with Children's Hospital Los Angeles.
"With more than 35 years in healthcare, including 22 years in executive roles leading pediatric healthcare enterprises, Paul brings a wealth of experiences and leadership expertise to Stanford Children’s Health," said Lucile Packard Board Chair Jeff Chambers.
An injuction against the Affordable Care Act would create chaos for the statute's Marketplace plans, which begin enrollment on November 1. If such a ruling were handed down before the midterms, it would be a welcome gift for Democrats.
It's been nearly two months since a U.S. District Judge in Fort Worth, Texas, heard oral arguments in Texas v. Azar challenging the constitutionality of the Affordable Care Act.
But court watchers hoping for a ruling soon probably shouldn’t expect anything from Judge Reed O'Connor until after the midterm elections next week, says Timothy S. Jost, professor emeritus at Washington and Lee University School of Law, and coauthor of the casebook Health Law.
"I'm sure Judge O'Connor is going to wait until after the election to rule," Jost says. "He's keeping his ear to the political news."
Healthcare has emerged as a top issue in the midterm elections, with 58% of voters in a recent Reuters/Ipsos poll saying they want to keep the ACA intact.
Jost says a ruling in favor of Texas Attorney General Ken Paxton and Republican officials from 19 other states who want to slap an injunction on the ACA would provide a pre-election gift to Democrats, as well as create upheaval for Marketplace plans, which begin open enrollment on November 1.
That was not lost on Department of Justice attorneys, who during oral arguments last month urged O'Connor to delay any injunction until 2019 to avoid "chaos."
The Republican attorneys general argued that the ACA became unconstitutional when Congress zeroed-out the tax penalty for the individual mandate, thus invalidating the sweeping legislation in its entirety.
A secondary argument by the plaintiffs focuses on the language in the 2010 statute, which says that the individual mandate is essential to creating a market in which guaranteed issued and preexisting condition exclusion bans are possible.
"The real question is what did the 2017 Congress intend to do when they zeroed out the tax?" Jost says. "Did they intend to get rid of the preexisting condition exclusions or not? You ask anyone in the Senate right now whether they think preexisting conditions should be excluded or not, they'll say, 'Oh no that's not what we did!'"
"So, the important question is when Congress repealed the tax in 2017 did they mean to get rid of the rest of the ACA?" Jost says. "Obviously they didn’t. They tried to amend parts of it in 2017 and they failed. To argue otherwise is just ridiculous."
Plaintiffs win likely
"When O'Connor does rule," Jost says, "he will probably hold that the individual mandate is unconstitutional and throw out the guaranteed issued community rating and the pre-existing condition ban."
"He might also throw out all of Title I, the exchanges, premium tax credits, and the premium stabilization programs, maybe even insurance reforms such as the age rating," Jost says.
"It's very unlikely he is going to throw out the Medicare donut hole closing, and the generic biologics provisions and the reforms to the Indian Health Service and all the other things that are inconceivably, not related to the individual mandate," Jost says.
Appeal is Certain
If O'Connor rules in favor of the Republican plaintiffs, that will most assuredly prompt an appeal to the 5th Circuit Court by the Democratic attorneys general from 17 states, who intervened when the DOJ said it would not fully defend the ACA.
"The 5th Circuit, last time I checked, had as many Trump appointees as from prior Democratic presidents," Jost says. "Although frankly I think the argument is ridiculous, there is some chance the 5th Circuit would uphold it."
"Then it goes to the Supreme Court. I think the Supreme Court would very likely reverse," he says, "but we do have a fairly conservative court at this point. I am not absolutely sure if they would."
Gail Wilensky, a former director of Medicare and Medicaid and a former chair of the Medicare Payment Advisory Commission, previously told HealthLeaders that she's skeptical this case will make it all the way to the Supreme Court. If it does, though, she would expect the justices to side against the plaintiffs, rejecting their approach to severability.
A president who rails against the ACA and champions free markets now calls for expanding Obamacare's marketplace coverage and government controls on drug prices. Go figure!
With midterm elections looming, the Trump administration has provided another interesting week for healthcare policy.
Consider this:
On Tuesday, the same administration that has done as much as it could to undermine the individual health insurance markets created under the Affordable Care Act unveiled a new proposal that could send 7.5 million people into those plans.
On Thursday, President Donald Trump floated an idea to link Medicare Part B prescription drug prices to the prices paid by other developed nations, most of which have some sort of single-payer, government-run, national health plan.
The proposals have left observers and stakeholders either scratching their heads or dismissing the initiatives as a pre-election stunt to provide cover for Republicans who polls show are getting pummeled on healthcare.
"For decades, other countries have rigged the system so that American patients are charged much more—and in some cases much, much more—for the exact same drug," Trump said Thursday, after floating the Part B pricing initiative, which would not take effect until 2020.
"In other words, Americans pay more so that others can pay less. It's wrong. It's unfair," said Trump, sounding more like Sen. Bernie Sanders, I-VT than a conservative Republican.
Trump launched the proposal just as Health and Human Servicesissued a report showing that the price of 27 of the most expensive physician-administered drugs is 80% higher in the U.S. than it is in other wealthy nations.
PhRMA was not amused.
"The administration is imposing foreign price controls from countries with socialized healthcare systems that deny their citizens access and discourage innovation," PhRMA President and CEO Stephen J. Ubl said in a media release.
"Americans have access to cancer medicines on average about two years earlier than in developed countries like in the United Kingdom, Germany and France," Ubl said.
Republican leaders in Congress mostly said nothing. Senate Minority Leader Chuck Schumer, D-NY, dismissed the proposal and said it stands in stark contrast to the administration's efforts to kneecap the Affordable Care Act.
"It's hard to take the Trump administration and Republicans seriously about reducing healthcare costs for seniors two weeks before the election when they have repeatedly advocated for and implemented policies that strip away protections for people with pre-existing conditions and lead to increased health care costs for millions of Americans, Schumer told The New York Times.
HRA Proposal Protects Workers
Trump's HRA expansion proposal—which has been months in the making—didn't generate much attention in the media, even though the proposal could send about 7.5 million people away from employer-sponsored coverage and into individual Marketplace plans.
When the president announced earlier this year that the HRAs program would get an overhaul, critics had raised concerns that employers would send their sickest employees to the marketplace, undermining them with adverse selection.
It appears that robust protections for workers were baked into the proposed rule.
"I'm having a hard time understanding it," John Barkett, who served in the Obama administration's Office of Health Reform, says of the Trump administration's proposal to expand Health Reimbursement Arrangements.
"What leapt off the page for me after reading the proposal was how much they cared about protecting the individual market from adverse selection," he says. "They were very concerned about putting this rule out in a way that wouldn't let employers send their sickest workers into the individual marketplace."
Barkett notes that the proposal requires employers to offer HRAs or traditional group coverage.
"You can't do both," says Barkett, now senior director of policy affairs at Willis Towers Watson. "If they wanted to create a way for employers to keep their sickest people on their own plan and send other employees out to the individual market, they wouldn't have put that requirement."
The Treasury Department's estimates that average premiums will change by less than 1% as a result of the projected 7.5 million people transition to the individual market under the new HRA.
"Adding 7.5 million people and having no change effectively in premiums shows that they don't necessarily agree with the idea that the sickest people only are going to be the ones who are going into it," Barkett says.
The Prospects
Trump's Part B proposal got a lot of attention in the mainstream media, but it's not clear how much enthusiasm it will generate after the elections. The silent response to the proposal from Republicans was deafening. Efforts by the Obama administration to lower drug prices were quashed in 2016.
Even if the proposal goes nowhere, Rick Weissenstein of Cowen Washington Research Group in a note to clients called it "politically shrewd."
"The timing, less than two weeks before the mid-term elections clearly gives him the high ground on a topic that is as populist as they come," Weissenstein said, according to Politico. "It also puts the Dems on the defensive on an issue they have used to hammer Republicans for years."
Barkett says the HRA proposal may not be see the sort of blistering partisan opposition that other Trump Administration healthcare reforms have faced, in part because there are components of the proposal that appeal to Democrats and Republicans.
"This is not an issue that falls neatly into ideological storylines," he says. "It would give the Affordable Care Act side of the House more lives the individual market and not necessarily just sick people. It would give the conservative healthcare side policies that they've been pushing for a long time, like flexibility, portability, and competition."
The provider allegedly billed Medicare for non-reimbursable procedures, and offered improper remuneration to physician investors and medical directors.
Philadelphia-based Vascular Access Centers L.P. and its 23 subsidiaries in eight states will pay at least $3.8 million to resolve False Claims Act allegations involving kickbacks for referrals, the Department of Justice said.
Federal prosecutors alleged that VAC violated the False Claims Act by billing Medicare for non-reimbursable vascular access procedures performed on end stage renal disease beneficiaries and that the company used kickbacks to entice referrals for the procedures.
"Medicare patients with end stage renal disease, like other beneficiaries, are entitled to receive care in accordance with their clinical needs and not based on the financial interests of healthcare providers," DOJ Civil Division Assistant Attorney General Joseph H. Hunt said.
HealthLeaders' calls to VAC were not returned.
VAC allegedly billed Medicare for vascular access surgical procedures performed on ESRD beneficiaries, including fistulagrams and percutaneous transluminal angioplasties, without all of the required supporting medical documentation.
The settlement also resolves Anti-Kickback Statute allegations that VAC submitted false claims to Medicare for services from referrals that VAC had induced through improper remuneration to physician investors and medical directors.
VAC agreed to pay a minimum of $3.8 million in a series of fixed payments over five years, and could pay up to $18.3 million if contingencies in the settlement are triggered.
VAC has also entered into a five-year Corporate Integrity Agreement with the Department of Health and Human Services Office of Inspector General that will focus on VAC's arrangements with physicians and other providers.
The settlement resolves whistleblower allegations brought in two lawsuits. The whistleblowers will collectively receive at least $612,000 as their share of the settlement.
While the president has undermined the ACA's individual marketplace, his HRA expansion proposal would transition a projected 10.7 million people into these plans in the next decade.
A proposed expansionof the health reimbursement arrangements (HRA) program announced this week by the Trump administration provides surprisingly robust protections against adverse selection, according to a former Obama administration policy wonk.
"What leapt off the page for me after reading the proposal was how much they cared about protecting the individual market from adverse selection," says John Barkett, who served in the Obama administration's Office of Health Reform.
"They were very concerned about putting this rule out in a way that wouldn't let employers send their sickest workers into the individual marketplace," he says.
"For example, they require employers to only offer this or to offer their traditional group coverage. You can't do both," says Barkett, now senior director of policy affairs at Willis Towers Watson. "If they wanted to create a way for employers to keep their sickest people on their own plan and send other employees out to the individual market, they wouldn't have put that requirement."
Barkett says he was also struck by the Treasury Department's estimates that average premiums will change by less than 1% as a result of the projected 7.5 million people transition to the individual market under the new HRA.
"Adding 7.5 million people and having no change effectively in premiums shows that they don't necessarily agree with the idea that the sickest people only are going to be the ones who are going into it," he says.
The administration's efforts to expand the individual market appear at odds with its simultaneous efforts to undermine the individual markets. That effort includes draconian funding cuts to the "navigator" enrollment program, virtually no budget for advertising, and the introduction of cheaper, less-comprehensive short-term insurance plans.
"I know. I know. I'm having a hard time understanding it," Barkett says.
Undermining the Marketplace
Critics have contended that the proposal could allow employers to push their sickest employees into Marketplace plans. Barkett says those fears are "simplistic."
"It's not a slam dunk to just say the only people moving are the ones who have the sickest people," he says. "There are some countervailing forces that will prevent a lot of employers who do have, on average, sicker populations from taking on this model."
"Employers are not monolithic," he says. "Some have employees that remained at their company for a long time, and those employers invest heavily in the health and well-being with generous benefit plans that cost a lot of money. Other companies employ people for not that long and there aren't great returns to justify heavily investing in their employees' health and well-being."
Payers and Providers
"Treasury estimates that by 2028, 10.7 million people would be getting individual coverage," Barkett says, which could reinvigorate interest in the marketplace plans among payers and providers.
Those estimates include 6.8 million people shifting from group coverage to individual coverage, 800,000 uninsured people who now have access to coverage, and 3.8 million who were in the individual market already but now they have the employer option.
"That's a lot of people," Barkett says. "That's another 7 million customers that insurance companies could pursue. That's a lot of premium dollars, if you think about the typical person maybe spending $7,000—$10,000 a year on healthcare. Multiply that by seven-and-a-half million new customers and that markets growing by tens of billions of dollars. Does United Healthcare or Humana look to get back into that market?"
Individual plans usually have narrow networks, and Barkett says many providers have stayed away because of low reimbursements. That may have to change, he says, if the individual market hits the growth numbers projected by Treasury.
"They might feel more compelled to contract with insurers who provide individual coverage," he says.
Own your Plan
Barkett praised the proposal's call to let employees "own" their coverage.
"If an employee who get his coverage through the individual market with an HRA leaves the job, your HRA goes away but your health care coverage doesn't. If you want to keep paying your premium out of pocket you can," he says. "That's a that's a sea change in U.S. healthcare, where normally leaving your job means disrupting your coverage."
"Let's go a step further," he says. "What if you move from one job that offered this type of benefit to another job that offered this type of benefit? Then you really could stay in your plan, replaced one HRA way with the other, and you're not having to change doctors."
"Your insurance company doesn't have to write off the investments they're making in you because they know you're going to change jobs in a couple of years," he says. "They can realistically look at you as someone they're trying to keep as a customer for life. That's a different approach than insurers have taken in the past."
Partisan appeal
Barkett says the HRA proposal may not be see the sort of blistering partisan opposition that other Trump Administration healthcare reforms have faced, in part because there are components of the proposal that appeal to Democrats and Republicans.
"This is not an issue that falls neatly into ideological storylines," he says. "It would give the Affordable Care Act side of the House more lives the individual market and not necessarily just sick people. It would give the conservative healthcare side policies that they've been pushing for a long time, like flexibility, portability, and competition.
Advocates say the proposal would expand coverage options for small employers. Critics say the proposal could allow employers to shift high-cost employees into ACA plans.
The Trump Administration this week unveiled a proposalthat "expands the usability" of tax-free health reimbursement arrangements (HRAs) for employer-sponsored health insurance.
"Of those smaller employers that provide health benefits, 81% offer only a single option," Labor Secretary Alexander Acosta said in a media release.
"This proposalis about empowering American workers to have more consumer-driven healthcare choices," he said. "Health Reimbursement Arrangements can provide another way for employers to help their employees access quality, affordable health coverage."
The proposed rule is a response to President Donald Trump's executive order "Promoting Healthcare Choice and Competition Across the United States."
The proposed rule removes an existing regulation that prohibits employers from reimbursing employees for individual health insurance coverage.
Critics contend that the proposalcould allow employers to push higher-risk employees away from company-sponsored coverage and into individual coverage offered through the Affordable Care Act's Marketplaces.
The Trump Administration says there are conditions built into the proposal to "mitigate the risk that health-based discrimination that could increase adverse selection in the individual market." Those conditions include a disclosure provision to ensure employees understand the benefit.
The proposed rule would extend to HRAs the same tax breaks that workers receive for medical reimbursements from traditional employer-sponsored coverage, and would not affect the tax treatment of traditional employer-sponsored coverage.
Instead, the proposal would create a new tax-preferred option for employers of any size to use when paying for employee health coverage. The employer would fund the cost of the individual health insurance, but the employee would "own the coverage," which would allow them to keep their plan if they left that job, the Administration said
The proposed regulation also would allow employers offering traditional employer-sponsored coverage to offer an HRA of up to $1,800 per year to reimburse an employee for some medical expenses, including premiums for short-term, limited-duration insurance plans.
The Treasury Department estimates that about 800,000 employers are expected to provide HRAs to pay for individual health insurance coverage to over 10 million employees when the proposal is up and running.
Comments on the proposal will be accepted by Dec. 28, 2018, and the regulation is expected to go into effect on Jan. 1, 2020.
The Health Care Payment Learning & Action Network study shows that the percentage of healthcare payments tied to APMs have increased at a steady pace from 23% over a two-year span.
One-third of all U.S. healthcare payments in 2017 involved alternative payment models, including shared savings, shared risk, bundled payments, and population-based payments, a new report shows.
The Health Care Payment Learning & Action Network study, which calls itself "the largest and most comprehensive measurement effort of its kind," shows that the percentage of healthcare payments tied to APMs have increased at a steady pace from 23% over a two-year span.
LAN divided healthcare dollars into four buckets, and found that:
41% of healthcare dollars in Category 1 (Fee-for-Service – No Link to Quality & Value)
25% of health care dollars in Category 2 (Fee-for-Service – Link to Quality & Value)
34% of health care dollars in Categories 3 (APMs Built on Fee-for-Service Architecture) and 4 (Population-Based Payment)
LAN, is a public-private partnership that was created by the Department of Health and Human Services in 2015 with a mission is to accelerate the transition to APMs.
"The report’s findings reinforce our understanding that there is sustained, positive momentum in the effort to shift healthcare payments from traditional fee-for-service into value-based payments," said Mark McClellan, co-chair of the LAN Guiding Committee.
LAN's Measurement Effort this year reported findings at the payment or subcategory level. Most of the spending tied to Category 3 and 4 APMs falls within the Framework's 3A category, which focuses on shared savings.
Only 12.5% of payments were made in Categories, 3B, 4A, 4B and 4C combined, which McClellan said illustrates additional opportunities to increase payments through episode- and population-based payments that have additional risk.
"While we celebrate the increase in overall APM adoption, we also know further progress on payment reform will be important to ensure healthcare dollars flow through models that have more risk," he said.
This year also marks the first time the LAN reported payment data by line of business, rather than across lines of business only. For Categories 3 and 4, 5he report found that:
Medicare Advantage had 49.5% of healthcare dollars.
FFS Medicare had 38.3% of healthcare dollars.
Commercial plans had 28.3% of healthcare dollars.
Medicaid had 25% of healthcare dollars.
The APM Measurement Effort includes FFS Medicare data, in addition to data from 61 health plans and 3 FFS Medicaid States, representing a total of 77% of covered lives in the United States.
McClellan announced the results of the LAN’s measurement effort today at the LAN Summit in Tysons, Virginia.
LAN's goal is to tie 50% of U.S. healthcare payments to APMs by the end of 2018.
Texas v. Azaris the latest in a long line of lawsuits and legislation that Republicans have used to undermine the Affordable Care Act, which has shown itself to be remarkably resilient.
A federal judge in Texas is poised to drop a ruling that could determine the future of the Affordable Care Act.
Or, maybe not.
The Republican plaintiffs from 20 states in Texas v. Azar argued before U.S. District Judge Reed O'Connor in early September that the entire ACA became unconstitutional when Congress zeroed out the individual mandate penalty, effective 2019.
Led by Texas Attorney General Ken Paxton, the Republican plaintiffs are asking for a preliminary injunction. The Department of Justice, which declined to defend portions of the ACA, also urged O'Conner to delay any injunction until after the enrollment period, saying any attempts to impose the injunction during the enrollment period would invite "chaos."
If the injunction goes through, it could end premium subsidies for ACA beneficiaries and cripple enrollment. The Urban Institute has estimated that 17 million people would lose their health insurance coverage if the ACA was overturned.
As potentially catastrophic as this sounds, the healthcare sector doesn't seem to be overly concerned. In fact, business couldn't be better.
A report inAxios shows that many players in the healthcare sector are prospering under the ACA. The website notes that S&P 500 healthcare index of 63 major companies has grown by 186% since the ACA became law in 2010, outstripping the S&P 500 and the Dow Jones.
In addition, health insurance companies are flush. Shares of UnitedHealth Group have gone up more than 700% since 2010, and the stock price of ACA marketplace insurer Centene has gone up 1,100% over the same period, Axios reports.
While hospitals have had a tougher time of it, especially in states that refused to expand Medicaid, they're still seeing reductions in charity care and bad debt owing.
Regardless of how O'Connor rules in Texas v. Azar, ACA payers, providers, and other stakeholders will continue to presume that the law isn't going anywhere, says healthcare economist Gail Wilensky.
"They're assuming it'll be around, or something very similar will be," says Wilensky, a former director of Medicare and Medicaid, and a former chair of the Medicare Payment Advisory Commission.
"I don't think people are regarding any serious likelihood of it going away again," she says.
Even if O'Connor, appointed to the court in 2007 by President George W. Bush, agrees with the severability arguments raised by the Republican governors and attorneys general in 20 states who brought the suit, the matter likely would get shot down on appeal, Wilensky says.
" I would be surprised if it doesn't get reversed someplace else," says Wilensky, now a senior fellow at Project HOPE.
"If it had go all the way to the Supreme Court, the Supreme Court isn't going to tolerate it, but I don't know that it would even get that far," she says.
The case is just one in a long string of legal and legislative actions Republicans are taking at the state and federal level to either undermine or bolster the ACA.
Earlier this year, O'Connor sided with Texas and five other states and threw out an Obama administration tax on states receiving Medicaid funds.
The Republican-controlled Congress has tried more than 50 times to repeal Obamacare, and Senate Majority Leader Mitch McConnell said this week that Republicans may try again in 2019.
While the signature legislation of the Obama era has been dinged and dented, it's also proven to be remarkably resilient.
Wilensky says the ACA is resilient because it solves a problem "for a small but non-trivial group of people," and that Republicans don't have a credible alternative.
"Once a benefit is in place for any measurable amount of time, certainly two or three years would qualify, there's no precedent for removing it," she says.
"And most of the proposals that had come up did not seriously get the job done," Wilensky says.
"They really weren't effective as an alternative and you simply aren't going to take away a benefit, like the extension of insurance to people who are above the poverty line and not offered traditionally employer sponsored insurance without having a credible alternative."
"It's just not going to happen because there are too many issues that have already been adjudicated at a more serious level," Wilensky says. "I don't know why they did this other than that this is 20 attorneys general and they're running for something."
The study finds no association between hospital accreditation and lower mortality, and only slightly better outcomes for 30-day readmissions for 15 common conditions.
Hospitals that earn certification by independent accreditors, such as The Joint Commission, have no better outcomes than hospitals reviewed by a state survey agency, according to a new report in the BMJ.
"Furthermore, we found that accreditation by The Joint Commission, which is the most common form of hospital accreditation, was not associated with better patient outcomes than other lesser known, independent accrediting agencies," the study concluded.
Researchers at Harvard T.H. Chan School of Public Health compared 4,400 hospitals across the United States, of which 3,337 were accredited, including 2,847 by The Joint Commission, and 1,063 hospitals that underwent state-based reviews between 2014 and 2017.
The study reviewed more than 4.2 million Medicare inpatient records for people ages 65 and older who were admitted for 15 common medical and six common surgical conditions, and respondents to the Hospital Consumer Assessment of Healthcare Provider and Systems survey.
"Hospital accreditation by independent organizations is not associated with lower mortality, and is only slightly associated with reduced readmission rates for the 15 common medical conditions selected in this study," the study said.
Among the findings:
Thirty-day readmissions for The Joint Commission-accredited hospitals were 0.4% lower than those at hospitals that were reviewed by state survey agencies, which the researchers called "not statistically significant lower rates."
Mortality rates for the six surgical conditions were "nearly identical," and "no statistically significant differences were seen in 30-day mortality or readmission rates (for both the medical or surgical conditions) between The Joint Commission-accredited hospitals, and hospitals rated by other independent accreditors.
Readmissions for the 15 medical conditions "were significantly lower at accredited hospitals than at state survey hospitals (22.4% v 23.2%, 0.8% (0.4% to 1.3%), but did not differ for the surgical conditions (15.9% v 15.6%, 0.3% (−1.2% to 1.6%), the study found.
Patient experience scores were modestly better at state survey hospitals than at accredited hospitals. Among accredited hospitals, The Joint Commission did not have significantly different patient experience scores compared to other independent organizations.
While not the only hospital accrediting entity in the United States, the study authors note that private, not-for-profit The Joint Commission plays an outsized role, and controls more than 80% of the accreditation market as the accrediting agency of choice for nearly all major hospital systems.
"There was no evidence in this study to indicate that patients choosing a hospital accredited by The Joint Commission confer any healthcare benefits over choosing a hospital accredited by another independent accrediting organization," the study concluded.
The Joint Commission could not immediately be reached Friday morning for comment.
