Experts offer story ideas for covering health reform

More than 30 attendees heard local experts sketch the particular challenges and issues presented by the Affordable Care Act in California in the latest “Implementing health reform in the states” panel, hosted by AHCJ’s San Francisco Bay Area chapter on Wednesday night at the San Francisco Chronicle.

The panel, one of a series sponsored by AHCJ, the Alliance for Health Reform and the Robert Wood Johnson Foundation, began with an explanation of exchanges and what’s happening with their implementation (or lack thereof) around the country by Larry Levitt of the Kaiser Family Foundation.

He posed some story ideas, such as: How vigorously will the states promote enrollment through the exchanges? What sort of variations to the ACA might emerge once states have the ability to ask for waivers in 2017?

Kim Belshe, a board member of the California exchange, and Marian Mulkey of the California HealthCare Foundation discussed the California scene, with lots of detail, touching on the state’s large undocumented immigrant population, the challenge of getting people enrolled (since the law of the land is now “performance” –  which means maximum participation), new opportunities for medical professions, such as nurses, to fill gaps in care delivery, and how to ensure coordinated care during the transition period to exchanges so no patient is harmed. This is the accountability part of the ACA, and needs thought and new procedures, Belshe stressed.

Belshe noted that Medicaid (Medi-Cal) is the foundation of reform, a subject which reporters sometimes overlook. Both she and Mulkey noted that California is a national pacesetter when it comes to reform implementation - a story idea in itself.

The session was moderated by Ed Howard, executive vice president of the Alliance for Health Reform.

On Tuesday night, a similar briefing was held at the University of Southern California, featuring Walter Zelman, Ph.D., a professor and director of health science at California State University-Los Angeles; Daniel Zingale, senior vice president of the Healthy California program at The California Endowment; Anthony Wright, executive director for Health Access, a California health care consumer advocacy coalition; and Deborah Crowe, the health care and biotechnology industry reporter for the Los Angeles Business Journal. Howard, of the Alliance for Health Reform, moderated the session.

Zelman posed a number of questions about reform, mostly about exchanges. To a reporter from Orange County, he suggested a story about the origin of the individual mandate – an idea championed by Republicans early on, he noted, and opposed by Obama and many Democrats. To a question about accountable care organizations and bundling, he suggested stories about how fee-for-service medicine is anything but dead.

Wright offered a look at what’s happening in Sacramento, including a hearing held just a few hours before the briefing.

Zingale mentioned the importance of prevention, and how the ACA encourages prevention. He too pointed out how nonprofits in the state can team up with reporters to educate people about the ACA. He said that the more people know about the law, the better they like it.

From a reporter’s perspective, Crowe offered several practical story ideas that reporters can start writing about today.

John Gonzales  of the California HealthCare Foundation Center for Health Reporting wrote about the panel and Michelle Levander of the California Endowment Health Journalism Fellowships program offers some of the story ideas mentioned by the panelists.

Special thanks to Colleen Paretty, chair of the Bay Area chapter, and Bill Erwin, of the Alliance for Health Reform, for contributing details about the panel discussions for this post.

Americans unprepared to pay for long-term care

In the Chicago Tribune, Deborah Shelton examines how unprepared Americans are to pay for their own long-term care needs as they age. Long-term care tends to slip under the radar because, as one of Shelton’s sources told her, “People buy insurance for their life because they know they are going to die, for their car because they know that can get in an accident and for their health because they know they can get sick, but people don’t tend to buy insurance because they think they are going to need someone to help them take a bath.”

Long-term care encompasses everything from nursing home fees to in-home assistance with everyday routines. It all comes with a price tag; Medicare only covers a limited amount and Medicaid programs apply only to those below certain economic thresholds. That leaves the middle class, who can’t afford the services but don’t really qualify for Medicaid, in the lurch, Shelton writes.

Most people assume Medicare will pay the bills, but the program covers long-term care only under certain conditions and for a limited time. While Medicaid covers long-term care, beneficiaries have to be poor or willing to “spend down” their assets to be eligible. Private insurance can be expensive and excludes applicants with serious medical problems.

As a result, many families pay out of pocket until they exhaust their resources and then turn to Medicaid.

The Affordable Care Act attempted to fill in the blanks, but long-term care provisions of that reform plan withered under intense cost pressure.

An initiative that would have incorporated long-term care into the Obama administration’s health reform plan was scrapped in October after actuaries determined that it would not be financially self-sustainable over the long haul. The Community Living Assistance Services and Supports Act would have created a voluntary, self-funded, employer-based insurance option to help people save for long-term care.

Related

• CLASS Act is gone but long-term care problem remains
• Long-term care insurance premiums jump

Kenen explains why the mandate matters

Usually I blog about topics that that lend themselves to local coverage, that explain health reform in the context of a state or community. But I think it’s worth taking a quick look at the individual mandate, or “shared responsibility,” because it’s so important – as politics and as policy. It’s back in the news after the Aug. 12 ruling. We won’t know its fate until the Supreme Court tells us, but it’s worth noting now:

• Courts have been divided and, on the appeals court level, it hasn’t been all partisan. One Democratic-appointed judge ruled against the mandate as written, and one Republican-appointed judge ruled for it.
• The federal health reform law doesn’t go away if the mandate is struck. But it will look different.
• Even with a mandate, the Affordable Care Act by 2019 would cover about 32 million people – and still leave 23 million uncovered. (That’s the CBO estimate from 2009.)
• The insurance industry’s [reluctant?] support for the Affordable Care Act was contingent on having the mandate. States that have changed the insurance rules – requiring plans to accept people with pre-existing conditions, etc. – without a mandate have seen costs skyrocket, which in turn means fewer, not more, people end up covered.
• There’s a lot of speculation about when the Supreme Court will rule – the timing could affect the presidential elections – but that’s speculation at this point. “If the court upholds the law, the Republican base gets energized four months before the election,” Bradley Joondeph, a Santa Clara University law professor, told the Wall Street Journal. “If it gets struck down, well, there go the guts of the centerpiece of Obama’s domestic agenda.”

I’m going to give you some links that will help follow the legal case, (AKA are we all wheat farmers?) and then highlight articles that have outlined some of the policy alternatives to the mandate – other steps that would encourage, although not require, more people to get covered. Of course, getting any changes through the Republican-controlled House is daunting, but not impossible if it were part of a larger “must-pass” or compromise legislation.

Legal issues

• Health Affairs/RWJF did a recent issue brief.
• The SCOTUS (Supreme Court of the United States) blog – which I suspect most of us health policy types have heard of but don’t actually read – is mandate madness. Seems to be rivaled only by same-sex marriage as the topic of choice.
• Linda Greenhouse (from last December) had an online ‘Opinionator” piece in The New York Times.

Policy Alternatives

• Austin Frakes, of the Incidental Economist blog (a good blog, by the way), recapped some of the main policy alternatives and I looked at a few approaches here for Kaiser Health News. (I don’t usually link to my own work on this blog, but am making an exception today.)
• Paul Starr has been worried about the mandate all along (here and here).
• Julie Rovner of NPR (among others) reported on the history of the mandate, which is generally regarded as a Republican idea when it emerged during the first President Bush’s administration. Republicans now generally oppose it, as this essay at the Heritage Foundation makes clear.

Covering Health Issues 6.0, coming soon to a mailbox near you*

*Assuming you’re an AHCJ member. If you aren’t a member, then keep in mind that a free copy of each revision of the sourcebook is one of many perks you’ll gain by joining.

Thanks to a grant from the Robert Wood Johnson Foundation, the Alliance for Health Reform has released the sixth edition of its “Covering Health Issues” sourcebook. Since the fifth edition, released in 2009, editors have added loads of new content, particularly in areas related to the 2010 Affordable Care Act. The free online edition also comes with links to local stories that exemplify sourcebook-inspired reporting. If you can’t wait for your hard copy to arrive, you can also get the full book in PDF format.

As always, the book promises “fast facts, background, tips for reporters, story ideas and experts with contact information,” as well as “an extensive glossary, ideas and examples for TV and radio reporters, and links to polls on health issues.”

For tips on how to take advantage of this resource, scope out this video, presented by AHCJ member and NPR health reporter Julie Rovner.

Panelists suggest stories about health reform implementation

By Sue Pondrom
Independent journalist

There are three key aspects for journalists to watch as the Affordable Care Act moves into its second year: Congress, the courts and the states, according to panelists speaking about “Health Reform: Repeal, replace of implement?”

Noam Levy, health policy reporter for the Los Angeles Times, suggested that reporters be aware of several Republican proposals.  These include medical malpractice, high risk pools, interstate sale of insurance, association health plans, variable health premiums and individual/employer mandates.  Additionally, watch the Obama administration for its implementation on initiatives that don’t require legislative action. These include regulations for Accountable Care Organizations (ACOs), medical loss ratios (MLRs), food labeling, and patients’ Bill of Rights.  Also grants (such as for the exchanges that will be set up by states, and premium review), small business tax breaks, donut hold relief, dependent and preventive health coverage, quality/efficiency measures such as the innovation center, and health information technology.

“The exchanges won’t start until 2014, so you’ll probably see more focus on speeding implementation of ACOs” and similar areas implemented this past year, he said.

“The big issues in the next year will be Republicans proposing block grants, with a lot of discussion expected on how states can save money with Medicaid,” he said.  Additional areas are maintenance of effort, dual eligibles and managed care. For Medicare, issues include cost sharing (such as whether seniors should pay more) and vouchers.

Going forward, Levy suggested coverage of delivery system reform, whether doctors and hospitals are forming ACOs, where providers are participating in ACOs, medical homes and hospital quality. Some questions he suggested pursuing:

• Is your state seeking a waiver from HHS?
• How extensively does your state us managed care and how it working?
• What has been the effect of previous cutbacks?
• Are small businesses taking advantage of tax breaks?
• Is your state going to restrict abortion?

Covering the Court action of health reform, Ken Jost, Supreme Court editor for CQ Press and associate editor of CQ Researcher, said an appellate court case to watch this spring includes Virginia ex rel. Cuccinelli v. Sebelius, Secretary of the Department of Health and Human Services (in which Judge Henry Hudson ruled the health reform law unconstitutional).

In June, appellate courts should rule on Tomas More Law Center v. Obama (in which Judge George Steeh ruled the law constitutional) and Florida ex rel. Bondi v. U.S. Department of Health and Human Services (where Judge Roger Vinson ruled the law unconstitutional.  Additional lawsuits to watch include Liberty University v. Geithner, Secretary of Treasury (where Judge Normal Moon ruled the law constitutional), and Mead v. Holder, where Judge Gladys Kessler ruled the law constitutional).

“The three judges ruling the law constitutional were Democrats; the two ruling unconstitutional were Republicans,” he said.  “But there is no way to make a reliable prediction about how the appellate courts will rule.”

He noted that the state of Virginia has said it will ask the Supreme Court to immediately take on the law.  But, the Supreme Court “rarely does this,” Jost said.

Sarah Kliff, health care reporter for Politico, discussed the states, noting that the biggest issue is development of the health exchanges.  She said states should be on track in 2013 for a 2014 implementation.  If they aren’t, then the federal government will develop the exchange.  She noted that seven states have been given innovator grants to help them in development: Wisconsin, Kansas, Oregon, Maryland, Massachusetts, New York and Oklahoma.  But, Oklahoma just sent back its money, “under pressure from Republicans,” she said.

Story ideas around the exchanges could include the governor’s office and whether he/she supports running an exchange or leaving the task to the HHS, a profile of legislators who are pushing exchange bills or those who are obstructing, and an explanation of what the exchange will look like in your state.

Additional topics include insurance rate hikes (how are insurers reacting to the new scrutiny, and how have the 45 states who got ‘rate review’ been using it?).   Also medical loss ratio waivers is a possible topic.  Thus far, nine states have gotten MLR waivers: Maine, New Hampshire, Nevada, Kentucky, Florida, Georgia, North Dakota, Iowa and Louisiana.

“Ask if your state is applying for a waiver,” she suggested.  “Reach out to your state commissioner to find out their current position.”

Sue Pondrom is an independent journalist based in San Diego.

Berwick debuts website featuring health data

By Susan Jaffe, Independent Journalist
From Health Journalism 2011

Journalists have a key role to play making health care safer and informing the public, Medicare chief Donald Berwick told reporters attending the annual conference of the Association of Health Care Journalists in Philadelphia on Thursday.

To help them do their job, Berwick unveiled a government website, the “Health Indicators Warehouse,” and offered a live demonstration. He said the site offers “a treasure trove of data,” including information never released before in an easily accessible form, including patient safety data, preventive health care indicators, Medicare payment claims and hospital performance at the state and hospital referral region level. Information is searchable by topic, location, health outcomes among other factors.

After highlighting well-publicized features of the Affordable Care Act, Berwick explained how the law provides tools to reduce health care costs that can also improve the quality of care.

“The best way to make care more affordable and sustainable is to make care better,” he said. “Higher quality and lower cost go together.”

To reduce health care costs, he promised continued scrutiny of Medicare Advantage plans, the government-subsidized private health plans, noting that the health law rewards top-performing plans with bonus payments. The law creates accountable care organizations, in which health care providers coordinate patient care in various medical settings. The new Center for Medicare and Medicaid Innovation “can now nurture invention around the country… that have the effect of lowering cost and raising quality.”

Berwick criticized a Republican proposal to use state block grants to replace Medicaid, the state-federal partnership that provides health insurance to low-income families.

“They are untested, they are hazardous,” he said, and could short change states during an emergency. “What happens if we issue a block grant to a state and then there’s a flu outbreak or the recession comes back? Well, you’re on your own.”

During the question and answer period, reporter Jodie Jackson of the Columbia (Mo.) Daily Tribune, had a query related to his reporting that showed a lack of communication about inspection findings between CMS, the FDA and The Joint Commission. After hearing about Jackson’s findings, Berwick said he wanted to read that series of articles.

Berwick spoke for about 90 minutes, without a prepared text, and chatted with individual reporters for another half-hour. It was his second appearance at an AHCJ conference; in 2005, he was key-note speaker when he headed the Institute for Healthcare Improvement, a nonprofit organization dedicated to improving patient care and safety. Unlike his first visit, Berwick did not stay and join AHCJ members in watching a basketball game.

Meeting the challenges of explaining health reform

Editor’s note: Today we introduce Joanne Kenen as AHCJ’s health reform topic leader. She will be writing blog posts, tip sheets, articles and gathering resources to help our members cover the complex implementation of health reform.

Health reform, to say the least, is confusing. The Kaiser Family Foundation had a great “data note” recently establishing just how little the American people know about reform. (The lack of knowledge apparently did not correlate with the intensity of political feeling).

So, how did people do? Fewer than one in 100 got all 10 questions right. Only a quarter scored seven or more right – a “C” or above if we were grading.

A third got four or fewer right (F minus, minus?) Two percent didn’t get one single question right. Most were in the low-performing middle, correctly answering 4 to 6.

What killed me (no pun intended) is that only 45 percent knew – after all the zillions of words we’ve written about this – that there are no government panels making life-and-death decisions for older Americans. Can’t you see the tabloid headline: “Zombie Death Panels Refuse To Die.”

Sorting out the details

Why should we, as journalists, care about this non-knowledge – aside from the fact that it’s just depressing? I think it’s a two-fold challenge.

The first challenge is internal. Many health care reporters are juggling several health and science or health and domestic policy beats, or so immersed in local coverage that it’s hard to find time to sort out the 8 gazillion arcane details of the Patient Protection and Affordable Care Act . That’s where I come in – AHCJ has asked me to be its – or rather your – “health reform topic leader.” My task: help you get unconfused. I’ve done one tip sheet on the one-year mark of ACA (which is March 23), with more to come.

The second challenge is external – or maybe existential. We have all reported and reported and reported on this. Some of our work has been very good. But it hasn’t gotten through the noise and buzz and screeching and tweeting of the current media world – or through editors pressing us to write about who is up and who is down politically, rather than about the substance. I don’t have any easy answers on how to fix that – how to make sure that our readers/watchers/listeners (and sometimes our editors) understand and value our credibility – and find time to pay attention.

Find creative ways to tell the story

One tool is to translate the policy locally and sometimes narratively. I am always looking for fresh ways to tell readers about health care, in ways they can come to it anew and understand. A couple of years ago, just before I left Reuters, I did a story about how many college kids were studying health policy – a field that barely existed during the last big national debate in the Clinton years. Another time I wrote a magazine feature about a family with three generations of doctors (plus a 5-year-old carrying his dad’s black bag and talking about aortas). Without loading a lot of overt policy in the piece – which would not have flown in Washingtonian Magazine – I was able to illustrate how this family’s experiences had spanned a half-century of changes in American medicine. If you do stories like that (which are fun by the way) or see great work by colleagues, let me know about them. I’ll be writing for this blog regularly and will share some of your creative approaches.

Another tool – and obligation – is to just understand the policy and the politics and the changing health care system so well that we can break it down and make it clear for our readers. There are a lot of resources out there. I’ll try to bring some of them to your attention, and when you find useful ones, bring them to mine by sending e-mail to joanne@healthjournalism.org.

The sheer amount of resources – issue briefs, timelines, webcasts, transcripts – can be daunting but having so much at our online fingertips is still way easier than it was 15 years ago, when we had to go to events in person, collect stacks of documents, remember where we filed the documents, and then frantically search through the pages when we needed a fact on deadline (unless NPR’s Julie Rovner was within shouting distance of my desk in the Senate press gallery, then I could just ask her … )

Here’s one way to start. Kaiser followed up by putting that pop quiz online. Test yourself. (Or test your editor? Or how about your spouse or partner – unless you really don’t want confirmation of how well they do or do not listen?) And maybe then think about what, if anything, confused you. Or them. And try to end the confusion for someone else.

About me

Joanne Kenen

For those of you who don’t know me – I’ve covered both the politics and policy of health in Washington, D.C., for years, and written about it for numerous kinds of publications. I have been a health-focused Congressional correspondent for Reuters, a Kaiser Media Fellow writing about palliative care, aging and end of life in 2007, a think-tank based blogger, and I have freelanced for everyone from Slate to the AARP to Health Affairs.

I have written about both the cost/coverage side of things, and the delivery system changes, particularly about chronic disease and aging. I’ll be in Philly for Health Journalism 2011, AHCJ’s annual conference, so say hello, and feel free to email me or comment below on how I can help you.

Reform opponents got millions from industry

Caitlin Ginley, of the Center for Public Integrity, used data from the National Institute on Money in State Politics to demonstrate that the state officials who have joined forces to file a lawsuit challenging American health care reform have, together, received more than $5 million in campaign contributions from hospitals, pharmaceutical companies, doctors and insurers. Among the governors and attorneys general in the 20 states supporting the suit, a few stood out.

… the Center found that top recipients of industry money include Texas Attorney General Greg Abbott, who has received more than $1 million from health care professionals since 1996, and former Georgia Governor Sonny Perdue, who took in at least $970,163 from the industry starting in 1992, when he was a state senator, until he left the governor’s office this week. Other major recipients involved in the lawsuit include former Pennsylvania Attorney General and newly-elected Governor Tom Corbett, who has received about $830,000, and Mississippi Governor Haley Barbour, with more than $770,000.

Ginley provides details on the donations each of those officials received, as well as several others. No word on how this compares to other samples of 40 high profile state politicians. Physician groups and private doctors played a major role in many of the cases she examined.

Reporter uncovers $86 million from insurers to fight reform

The flow of money into politics in general, and health reform in particular, has been thoroughly opaque this election season, yet Bloomberg’s Drew Armstrong has still managed to pull back the curtain and figure out that insurers gave $86 million to the U.S. Chamber of Commerce, which then lobbied heavily to either hamstring reform or to reshape it in the insurers’ favor. Armstrong traced the money to America’s Health Insurance Plans through classic reporting tools: public records and well-placed sources.

Tax forms require organizations to list only the amounts granted or received from other groups, not the organizations’ identities. Health insurers expressed opposition to parts of the health-care legislation while they conferred with congressional Democrats writing the bill and the White House. At the same time, the Chamber of Commerce was advertising its opposition.

The Chamber spent $45.5 million on a campaign against the bill in 2009, according to TNS Media Intelligence/Campaign Media Analysis Group, an Arlington, Virginia-based company that tracks political advertising.

The Chamber began in March 2010, weeks before the bill became law, another $10 million effort focused on pressuring lawmakers to vote against the bill. Blair Latoff, a spokeswoman for the Chamber, wouldn’t say how much of the money was spent in 2009 and how much, if any, was used in 2010.

Understanding the administrative side of implementation

Coverage of health care reform implementation has generally focused on the issues and effects of the roll-out, rather than the arcane governmental mechanisms involved. It makes sense, of course, as “here’s how you can now get coverage despite your pre-existing condition” is significantly more relevant to most readers than “23 states miss federal 90-day deadline for creation of high-risk pools, partly because already established pools don’t always conform to reform requirements, and partly because it’s too much hassle and they’d rather let the feds do it for them.”

Service-oriented as it may be, this focus has led to a few gaps in my understanding of the administrative moving parts involved in implementation. Which is why the Robert Wood Johnson Foundation’s guide to state and federal roles in the implementation of health care reform is such a handy document. It’s worth a quick scan, if only to give all those implementation stories a little context. It’s got everything from “how informal rulemaking becomes law” (hint: it involves both “notice” and “comment”), to the aforementioned business about why some states ceded control of their high-risk pools to the federal government. And it’s only four pages long.

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