President Donald Trump's executive order on Inauguration Day did not provide administration officials with any new powers to unravel parts of the Affordable Care Act.

This article first appeared January 24, 2017 on Kaiser Health News.

By Julie Rovner

The Trump administration has significant power to undermine the workings of the Affordable Care Act. The bigger question is how much of that power it will use.

President Donald Trump's executive order on Inauguration Day urging federal officials to "take all actions consistent with law to minimize the unwarranted economic and regulatory burdens" of the federal health law did not provide administration officials with any new powers to unravel parts of the law.

"They had all this authority before," said Len Nichols, a health policy professor at George Mason University in Virginia who supports the health law. Trump, he said, "is signaling 'I care' " about this issue.

In the short term, efforts will be minimal, said Joe Antos of the conservative American Enterprise Institute, because the White House is still getting its personnel on board. There are no high-level political appointees yet installed at the Department of Health and Human Services, Labor and Treasury, which have primary authority over the law.

"They need their appointees," said Antos. Until more Trump personnel actually start work, he added, "I don't think they're going to be able to do much." The nominees for secretaries of HHS, Labor and Treasury are encountering various degrees of turbulence in their Senate confirmation process.

But even when the new personnel do take office, it remains unclear exactly how far the new administration will go. That's because while they can make the law stop working, it will take Congress to actually put in place something new.

"If they start down that road" of unraveling the law, said Nichols, "then the insurers will pull out as soon as possible. And 2018 will not be pretty." That's a reference to the fact that plans offering coverage in the individual market are concerned that changes would make it easier for healthy people to exit the market, leaving only sicker and more expensive people behind and no way to spread costs.

Yet both Trump and Republican leaders in Congress have vowed not to strip away anyone's insurance and to provide a "stable transition" to a new system. Trump told The Washington Post earlier in the month his goal was "insurance for everybody."

And Antos said that many of the administration's options might be more difficult than they first appear.

For example, he pointed to one item that has been widely speculated as a possible change the administration is considering: cutting back the specific requirements for benefits that have to be included in various health plans.

Although such alterations are theoretically subject to rewrite through regulations, "it's the state insurance commissioners that approve that," he said. "The states all changed their regulations in order to conform with the federal rules."

Indeed, according to the National Conference of State Legislatures, 46 states enacted more than 175 separate laws between 2011 and 2013 to bring their rules into accord with the federal health law.

Those states "might have to repeal or amend their laws if the ACA were repealed," said Timothy Jost, an emeritus law professor at Virginia's Washington and Lee University who has studied the health law extensively. "For example, states that adopted the insurance reforms into law might find their markets nonviable without the federal subsidies and mandates."

In addition, any changes made by the Trump administration would have to take care to stay within the confines of federal requirements, including allowing for public notice and comment, said Antos, which gets particularly complicated with health care because it crosses so many boundaries.

"There has to be coordination between HHS and Treasury and maybe Labor, and it has to be legal," he said. "So understanding what you can and cannot do is going to be very difficult."

To be clear, there are a couple of actions the administration could take fairly easily that would have a major impact. The largest would likely come from dropping the appeal of a lawsuit that would immediately end cost-sharing help for up to 6 million people with incomes under 250 percent of the poverty line.

That would almost certainly send the insurance market for individuals into chaos, both backers and opponents of the health law agree, and would interfere with GOP promises to try to ensure stability in the market until they can come up with a replacement.

A second, more strategic change would be to eliminate the special rule that ensures that members of Congress and their staffs can still get employer contributions for their insurance, even though the law requires them to purchase that coverage through the health law's insurance exchanges.

"If Trump undoes that, then members and staff take a pay cut of up to $12,000 immediately," because they would have to make up the premium costs on their own, said Michael Cannon of the libertarian Cato Institute, an opponent of the health law. "That will motivate members of both parties to behave differently" in the speed with which they might come up with a health law replacement.

But even Cannon, who would like to see the law eliminated as soon as possible, concedes that "the politics of those two things would be dicey."

This story has been updated to correct a reference to the Trump administration's decision on the appeal of a lawsuit over the health law. That suit deals with funding for cost-sharing help for low-income marketplace customers and does not affect premium subsidies.

Research published in the Annals of Internal Medicine found that the number of chronically ill Americans with insurance increased by about 5 percentage points in 2014, the first year the law required Americans to have coverage.

This article first appeared January 23, 2017 on Kaiser Health News.

By Shefali Luthra

As President Donald Trump and Republicans in Congress devise a plan to replace the 2010 health law, new research suggests a key component of the law helped people with chronic disease get access to health care — though, the paper notes, it still fell short in meeting their medical needs.

Research published Monday in the Annals of Internal Medicine found that the number of chronically ill Americans with insurance increased by about 5 percentage points — around 4 million people — in 2014, the first year the law required Americans to have coverage, set up marketplaces for people to buy coverage and allowed for states to expand eligibility for Medicaid, the federal-state insurance plan for low-income people. If states opted into the Medicaid expansion, people with chronic illnesses such as heart disease, diabetes, depression and asthma were more likely to see those gains.

Still, the study suggests, the law fell short in terms of guaranteeing those people could get medical treatment, see a doctor and afford medications.

The study is the first to examine how the health law affected people with these long-term diseases, which require careful and continuous management, and whose treatment drives a vast majority of the nation's health care costs. If these people don't get regular treatment they are especially likely to wind up needing emergency care.

"This hones in on the patients that are most dependent on having coverage and access," said Danny McCormick, an associate professor at Harvard Medical School and senior author on the study. "Most chronic conditions require ongoing treatment. And if you don't get it, often it results in more expensive care downstream."

As the GOP crafts its replacement plan, those findings could indicate what elements of the law are worth keeping, and what needs to be addressed. The Medicaid expansion in particular has come under heightened scrutiny from the GOP. This past weekend, a senior aide to President Donald Trump also said the administration wants to turn control of the program over to states, which experts say could result in less funding.

The researchers say their findings suggest reversing the Medicaid expansion would pose significant problems for people with long-term illness.

They used data from the Behavioral Risk Factor Surveillance System — an annual survey jointly run by state health departments and the Centers for Disease Control and Prevention — to examine records for more than 600,000 adults with at least one chronic condition. Diseases included coronary artery disease, stroke, asthma, pulmonary disease, diabetes, depression and arthritis. They compared insurance rates in the three years and examined whether people used that insurance to see a doctor.

"There's a clear difference between what happened for [chronically ill] individuals in states, based on how states implemented Medicaid. The Medicaid expansion was one of the strongest parts of the law," McCormick said.

If policymakers are serious about using health dollars more efficiently, and getting better health outcomes, he added, the findings support including such an expansion in any new policy platform.

The paper builds on research suggesting people generally were more likely to get insurance if they lived in states that expanded Medicaid. States such as West Virginia, Illinois and Kentucky — which opted into the expansion — saw double-digit gains in coverage of chronically ill people.

"Medicaid expansion is one of the tools you would think of to help people with chronic conditions – and we are seeing more evidence this is the case," said Benjamin Sommers, an associate professor of health policy and economics at Harvard's public health school, who was not involved with this study. "The question of whether this informs [the policy] debate — it clearly should. It clearly should be relevant."

That said, Obamacare was hardly a panacea, the researchers argue. Even after the law's insurance changes, about 15 percent of people with chronic disease didn't have coverage. More than one in four didn't have a check-up in 2014. About 23 percent of people with chronic disease still had to go without doctors' visits because of factors like cost. And those gaps were more pronounced for blacks and Hispanics. They were more likely on average to remain uninsured even after the health law took effect and to face obstacles in using new health insurance if they had it.

The paper suggests some possible causes: People didn't understand how to use their insurance, or they had plans that required them to pay out of pocket large copays or deductibles — flat spending fees consumers have to front before coverage kicks in. Many marketplace plans were categorized as "high-deductible plans."

"You've got hypertension or diabetes, and you have a very low income. It's really hard to take your medications" without coverage and minimal cost-sharing, McCormick said. "Someone who's insulin dependent who doesn't get insulin? it's going to result in an emergency room visit, or a hospital visit. There's a large potential for downstream complications."

But those gaps in coverage and access to care probably got smaller in the years following 2014, Sommers suggested. Other research has shown that with time, more people got insurance and learned how to use it.

"This is likely the tip of the iceberg in terms of what the Affordable Care Act was doing," Sommers said. "It's useful and part of a larger body of evidence making it clear access to care has improved among a range of populations."

But, he noted, the findings do emphasize an important issue: The health law by itself did not expand health care to all Americans, or even all Americans with chronic conditions.

"The Affordable Care Act is not a universal coverage law. It's a huge expansion for coverage but still left 20 to 30 million uninsured," he said. "Even for those with coverage, some are still experiencing challenges."

Trump has not yet offered his plan but said universal coverage will be part of his health care plan — although aides have since walked back on that claim. Meanwhile, an analysis this month by the nonpartisan Congressional Budget Office suggested that the repeal plan offered last year by Republicans eventually would increase the uninsured population by as many as 32 million.

In Houston, tackling the problems of super-utilizers took unprecedented planning among typically disjointed city and county agencies, hospitals and nonprofits. Now, many hospitals and the fire department pool their data.

This article first appeared January 23, 2017 on Kaiser Health News.

By Sarah Varney

HOUSTON — Donning a protective gown, rubber gloves and a face mask, Dayna Gurley looks like she's heading into surgery. But Gurley is a medical social worker charged with figuring out why her client, a man who uses more health care services than almost anyone else in Houston, has been in three different hospitals in the last month.

The patient, who asked not to be identified, has chronic massive ulcers, AIDS and auditory hallucinations. He rents a cot in another person's home but is more often homeless, with no family to help him.

"It's almost like self-sabotage," Gurley said about her many attempts to steady her client's life. "We get really close to an important doctor's appointment or getting him connected with stable housing, and his impulsiveness gets in the way of that."

Patients like the Houston man are health care's so-called "super-utilizers"— people with complex problems who frequent emergency rooms for ailments more aptly handled by primary care doctors and social workers. They cost public and private insurers dearly — making up just five percent of the U.S. population, but accounting for 50 percent of health care spending.

As health care costs continue to rise, hospitals and doctors are trying to figure out how to find these patients and get to the root of their problems.

An effort to do just that started in New Jersey's poorest city, Camden, more than a decade ago. Inspired by the way police departments mapped crime data to detect "hot spots," family physician Dr. Jeffrey Brenner dug into ambulance records and emergency department data to show how high-cost patients were shuttling between city hospitals.

"In America, we're medicalizing social problems and we're criminalizing social problems, and we're wasting huge amounts of public resources," Brenner said. "We have the wrong tools to solve the wrong problem."

To steer patients away from expensive emergency care and push health systems to change the way they do business, the Affordable Care Act funds programs called Accountable Care Organizations. These are networks of hospitals, physicians and others who team up to improve care, lower costs and reap the savings.

Brenner's team at the Camden Coalition includes Latonya Oliver and Bill Nice, social workers who seek out patients like Peter Bowser in local neighborhoods. Bowser was once homeless and went to the emergency department nearly 30 times in one year.

But after Oliver and Nice helped get a permanent roof over his head, Bowser's trips to the ER all but stopped.

"I think you'd prefer to spend your time here than in the hospital any day of the week," Nice said to Bowser on a recent afternoon, gathered at the kitchen table in his tidy apartment.

This high touch, data-driven approach has yielded big savings. ER visits for the first group of patients dropped by 40 percent, cutting monthly hospital bills from $1.2 million dollars to $500,000.

Since then, Brenner has sought to spread the model around the country. One example is the Patient Care Intervention Center in Houston, a sprawling city desperate to aid its sickest and most isolated patients.

While the more than 100 hospitals here typically know their own super-utilizers, they had no way of knowing the top users across the entire city.

Tackling that problem took unprecedented planning among typically disjointed city and county agencies, hospitals and nonprofits. Now, many of the hospitals in Houston and the fire department pool their data and send it to Kallol Mahata, a former oil industry IT engineer with the patient care intervention center who combines it into one database.

Mahata and Dr. David Buck, the group's founder, help to identify patients at the top of the list—the outliers of the outliers.

Teams are dispatched to parks and neighborhoods to find the patients.

Firefighters and paramedics like Thomas Pierrel often know these residents from 911 calls. But this time, their mission is different: to encourage them to enroll in the volunteer program.

Inside one super-utilizer's threadbare home, Pierrel makes his pitch. "We go with you to your doctors, we make appointments, we find specialists. We try to maximize the resources that you have," he tells the prospective client.

The results of these intensive interventions can be stunning.

Timmy Williams was dying when Dayna Gurley found him.

He was holed up at home and reeling from untreated HIV that had progressed to AIDS. He couldn't take care of his young son and cycled through Houston's hospitals.

"When we first met Timmy, he was very hard to engage," Gurley recalled. "We knew that he probably was not taking any of his medication, and he was very skinny."

She arranged for a home aide to care for Williams seven days a week, got his apartment cleaned and the lights turned back on.

Now, Williams' HIV is undetectable and his health — and life — have been steadied.

In the two years since Houston's Patient Care Intervention Center has been up and running, costs for those in the program have gone down 83 percent and hospital visits by 70 percent.

But it can be difficult to keep these programs moving. Often insurance companies and government payers reap those savings, rather than hospitals. Buck and Dayna Gurley were once banned from a Houston hospital whose executives feared losing money if their high-cost patients stopped showing up.

"Nobody wants to take ownership of any of it," said Buck, his voice bristling with frustration. "The people just want ownership of what they have authority over, and that's really the issue: each of these areas are little fiefdoms."

Back in Camden, even Brenner is less optimistic than he once was. His office now overflows with pillows and kitchenware for clients the Camden Coalition is trying to place in housing. And he thinks homelessness and entrenched financial interests in health care are the biggest barriers.

"I think this is going to take a lot longer than I ever imagined," he said. "I think we're in a 20-year arc of recalibrating and rethinking what is health and what's health care? What's the purpose of our health care system? What are we trying to accomplish?"

But Brenner still believes these intensive efforts are the best way to help patients like Timmy Williams. He's now healthy enough to make his way around the city on his own, says Gurley, and her super-utilizer team did more than rescue him from his darkest days.

"I had to put it in my head that no one is going do it for me," he said. "I have to do it for myself. I have to step out and do it myself."

At home now with his son, his illness no longer gets in the way of being the father he wants to be.

But it's unclear how these efforts will be affected by a Trump administration, which along with congressional Republicans wants to repeal the health law.

This KHN story also ran on PBS NewsHour. PBS NewsHour producer Jason Kane contributed to this report.

Federal officials this month warned 21 Medicare Advantage insurers with high rates of errors in their online network directories that they could face heavy fines or have to stop enrolling people if the problems are not fixed by Feb. 6.

This article first appeared January 18, 2017 on Kaiser Health News.

By Phil Galewitz and Susan Jaffe

Federal officials this month warned 21 Medicare Advantage insurers with high rates of errors in their online network directories that they could face heavy fines or have to stop enrolling people if the problems are not fixed by Feb. 6.

Among the plans that were cited are Blue Cross Blue Shield of Michigan, Highmark of Pennsylvania, SCAN Health Plan of California as well as some regional plans owned by national carriers such as UnitedHealthcare and Humana.

The action follows the government's first in-depth review of the accuracy of Medicare Advantage provider directories, which consumers and advocates have complained about for years. More than 17 million Americans, or nearly a third of Medicare beneficiaries, get coverage through private Medicare Advantage plans, which are an alternative to traditional Medicare.

The Centers for Medicare & Medicaid Services in October reported some of the results of the audit, but they had not released names or statistics from the individual plans.

"Because Medicare Advantage members rely on provider directories to locate an in-network provider, these inaccuracies pose a significant access-to-care barrier," Medicare officials wrote in a report released last week outlining the problems.

Unlike traditional Medicare, the private Medicare plans typically restrict beneficiaries to a network of doctors and hospitals.

Piedmont Community Health Plan, a small Medicare plan with about 5,200 members in southwest Virginia, had the highest rate of inaccuracies among the 54 insurers examined. Officials found errors in the listings of 87 of 108 doctors checked in Piedmont's directory, according to the report. Most of the errors involved providing the wrong locations for doctors and doctors who should not have been listed.

Piedmont officials did not return calls for comment.

Piedmont and two other plans with the highest error rates — a WellCare plan in Illinois and Emblem Health's ConnectiCare subsidiary — were required by Medicare to submit specific business plans detailing how they intend to address the issue.

The individual plans receiving warning letters cover more than 1.4 million beneficiaries. Most operate in numerous states, although CMS generally limited its review to a specific state or geographic area.

The federal review focused on reviewing primary care doctors, cardiologists, ophthalmologists and oncologists. It involved individual calls to check on the listings for 108 doctors in each health plan. "We encountered several instances where a call to a provider's office resulted in determining that the provider had been retired or deceased for a long period of time, sometimes years," the report said.

The CMS report found almost half of the 5,832 doctors listed had incorrect information, including wrong addresses and wrong phone numbers. Most health plans had inaccurate information for between 30 to 60 percent of their providers' offices, the report said. The report blamed the insurers for failing to do enough to keep their directories accurate. Members rely on the directories in both deciding whether to join a plan and then in searching for doctors to treat them.

"We saw a general lack of internal audit and testing of directory accuracy among many" Medicare Advantage organizations, the report said.

CMS' survey found the most error-prone listings involved doctors with multiple offices that did not serve health plan members at each location.

The health plans were sent the warning letters Jan. 6 and given 30 days to fix the mistakes or face possible fines or sanctions, which could include suspending marketing and enrollment. CMS officials said the report was not issued before the annual open enrollment period — which ended Dec. 7 — because of the need to allow the health plans to review the findings before the report was made public.

Medicare Advantage members have until Feb. 14 to disenroll and join traditional Medicare but after that they are locked into their plan for the rest of the year. Seniors may be able to request permission to change plans on a case-by-case basis by calling 800-MEDICARE.

Another 32 companies with less serious mistakes also received letters saying their directories did not comply with a rule that took effect last year requiring plans to contact doctors and other providers every three months and to update their online directories in "real time."

ConnectiCare spokeswoman Kimberly Kann acknowledged the difficulties. "Keeping these directories up-to-date is a two-way street and we are working with doctors and other medical professionals to continue providing quality service," she said.

WellCare spokeswoman Crystal Warwell Walker said the Tampa, Fla.-based company took the survey results seriously. "We modified our data gathering techniques and online reporting options to ensure that when more than one address is listed for a provider, that provider is practicing at that location on a routine basis and access to care is not compromised," she said.

CMS is continuing its investigation of provider directories this year and expects to examine all 300 companies by end of 2018.

See table on this page.