Predictions and Outcomes for the Affordable Act: May 2014

May 5, 2014

ACA-health-reform-logoWEBThe ACA was the political hot topic throughout 2013.

Multiple story lines emerged that were – and continue to be – focal points for and against the success of this landmark legislation. Now that the enrollment period is finally completed as of mid-April 2014, it is possible to look back and survey the main topics. How did things turn out? You may listen to Fox News or CNN, the Tea Party spokespersons or Nancy Pelosi and House Democrat leaders. We have summarized what we see as the main stories. We rank them in order of how HOT or COLD these stories are today at the start of the second quarter of 2014.

We have compiled a table of outcomes that were predicted for the Affordable Care Act. The debated outcome is in the center column. Positions pro and con are listed with a sample source for each side. The predictions are presented in order of their controversial temperature; that is, how HOT or COLD the topic is today at the start of the second quarter of 2014 after the initial data have been reported.


HOT TOPIC #1: Did a sufficient number of Millenials enroll? The economic viability of the ACA is predicated on having enough healthy young people in the premium-paying pool between ages 18 and 40. How many were needed? The target was 40% of total enrolled. The reported outcome has increased from 24% to 27% within months. We are gradually reaching our goal. This remains, in our view, the hottest topic and one that will remain vital in the coming year.

HOT TOPIC #2: President Obama announced in November 2013 that “you can keep your plan if you want it.” The White House had to scramble on this one because 6 million people lost their so-called “catastrophic” plans when the new minimum standards for ACA eligible health plans were clarified. What became clear was that 6 million insured persons lost their crummy plans while 8 million people were newly enrolled; a net overall gain. A related story was that premiums would generally increase. A recent OMB report estimates premiums will in fact decrease. Decreasing premiums also has its exceptional cases because states with low enrollments will likely see increases in premiums. The White House extended the deadline to dump non-conforming plans for a year, which cooled this story off a little… for a while. We expect the story will heat up again.

WARM TOPIC #3: Not enough people will enroll to make the ACA work. The target was 8 million and it was exceeded; California accounted for half! The next test will be whether enrollees pay their premiums. The number of estimated uninsured is between 30 and 40 million. Over the next decade these individuals must also be enrolled. 8 million is a very good start. Look for a new round of predictions for continued enrollment and the pace of enrollment especially around the Fall 2014 voting season.

NEUTRAL TOPIC #4: Will the Health Exchanges enroll enough people? The Health Exchanges are supposed to provide elective opportunities for citizens to change their current health plans (marking the end of catastrophic coverage plans which we refer to as “your money or your health”). This was the candy that incentivized insurance companies to offer conforming plans to would-be paying consumers; in other words the Health Exchanges encouraged greater competition among insurance plans. For many the concept of business competition among insurance plans was as incomprehensible as how reimbursements work (see Stephen Brill’s defining 2012 article). Many states with GOP governors elected to opt out of creating their own Health Exchange. The impact was to force residents in these states to enroll on the federal Health Exchange. Covered California is the largest state operated exchange and our enrollment was highly successful; 1.4 million new members under new plans. We believe this topic never got much traction the result of complicated essential questions: who is participating and who is not in terms of insurance companies, hospitals, and providers? With 13 insurance plans participating in the nation’s largest exchange –Covered California – enrollment was a sure winner.

COOL TOPIC #5: Are there enough providers to meet consumer demand? This is the “access to care” issue. According to an early LA Times article there were not going to be enough doctors to take care of the wave of newly eligible patients wanting services. It remains difficult to find information supporting the sufficiency position. Lawmakers in California have been working on expanding the practice scope of health professionals such as Physician Assistants, Nurse Practitioners, and Pharmacists. There are insurance plans with more physicians contracted than other plans which will surely lead to an imbalance of care for patients enrolled with fewer providers. What patients and analysts need to know is the ratio of contracted primary care providers and specialists for each plan. It will be awhile before we see those data.

COLD Topic #6: There appears to be considerable confusion and misunderstanding concerning participation of non-white persons, especially Latinos, in the health exchange. The overall enrollment goal has been met however, the national enrollment demographics are unclear. Slightly more than half of California’s population is Latino, yet only twenty-eight percent of enrollees in California have identified themselves as Latino.  Outreach and education programs, in particular targeting Latinos, were late getting started. When these programs did get underway they may have helped  account for the late surge in Latino enrollment over the final 60 days. As a population group Latinos are younger and more healthy. The participation of eligible Latinos in the ACA is critical to its success.

ICY TOPIC #7: The federal ACA website rollout was big news in the fourth quarter of 2013. It was the most talked about failure of the ACA. People were not able to enroll in healthcare plans. How could the government penalize would-be enrollees for not having insurance if it was not possible to login and sign up? Now that the initial enrollment deadline has passed, and the initial target has been reached, this story is colder than San Francisco in August.

Looking into the future we anticipate the following stories will provide plenty of material for the media and policy analysts in 2014.

What will be the follow-through on the 8.2 million who signed up? How many will actually pay their first premium? And how many will renew their enrollment come the October 2014 enrollment period?future-next-exitWEB

How many new enrollees are projected in 2014-2015? With a target between 30 and 40 million over five years what is the White House enrollment forecast through 2018?

How will wait-times-to-be-seen by a physician – one form of access to care – and the availability of providers to see newly insured patients, play out? We expect to see more of these stories reported this Summer and Fall.

California is the mule team pulling this wagon. This bodes very well for California and the ACA. Some folks will be very unhappy about this. However, we believe more will be happy.

This article was prepared by Mary Bezjian and Steve Stumpf. Ms. Bezjian is a senior at California State University Northridge majoring in Health Administration.


White Collar Unions for Healthcare Providers

June 9, 2013

opeiu_logoI attended the tri-annual Office and Professional Employees International Union – OPEIU – conference in San Diego last week. The event is as much a gathering of the tribes as it is a working convention of the 50-plus OPEIU member unions and guilds. I took pages and pages of notes as I sat through presentations in the main hall, and met in small groups with the OPEIU leaders, as well as leaders of member unions or guilds. Here is what I came away with.

White collar professionals will comprise the new members of unions and guilds. They will join because they need protection that can only come with numbers.

As John Mattiacci, President of OPEIU Guild 45/The First National Guild for Healthcare Providers of the Lower Extremity, said “The issue is not political. It is economic. We are fighting big business. I joined the OPEIU for its influence.”

Unlike unions a guild does not collectively bargain and it does not strike. Mattiacci had organized his own independent podiatric guild with a thousand members when he approached the OPEIU in the mid 1990s. He wanted a law passed that would expand podiatrists’ scope of practice so they could reconstruct ankles for which they had been trained.

“40 years we couldn’t get this law passed. Once I was in the OPEIU the law was passed in 30 days.”

Mike Goodwin President OPEIU

Mike Goodwin President OPEIU

I have been working with acupuncturists since 2008 trying to figure out how to organize them under the National Guild of Acupuncture and Oriental Medicine (NGAOM). Our guild has grown from 6 members in 2008 to 25 one year ago to 100 today. The Podiatric guild has 6500 members of 16,000 DPMs in the nation. There are approximately 25,000 licensed acupuncturists (LAcs) in the country. California has a plurality with about 10,000.

The hurdles that must be cleared have gotten lower since this meeting. They include the following.

1. Work within mainstream medicine if we want to earn a living wage. This has been a contentious issue within acupuncture but it is no longer. The national professional organization of acupuncture understands this is the only path to survival and success.
2. LAcs must market themselves as healthcare providers which means LAcs must learn to work within medicine, “speak medicine,” refer back and forth with mainstream providers, act and look like they are a part of mainstream medicine.
3. Join the NGAOM so we have strength in numbers. The NGAOM is small. But the OPEIU with 103,000 members across all the member unions and guilds is big. The AFL-CIO of which OPEIU is a member is huge. With all our brothers and sisters we are 4 million strong.

Every speaker from the dais began their presentation with the words “brothers and sisters.” It was not corny. It was heartfelt. The diversity among OPEIU groups was astounding. Here is partial list: Allstate agents (the “good hands” company tried to fire all the employees then hire them back as independent contractors without benefits of course), real estate appraisers, actuaries, street vendors, tax drivers, civil service employees in a group of South Florida towns and cities, and 10,000 nurses across the nation.

Acu Guild President Steve Paine chats up Richard Trumka AFL-CIO President

Acu Guild President Steve Paine chats up Richard Trumka AFL-CIO President

Mattiacci has begun to organize a profession that has to be the least likely to ever be organized under a guild or union: physicians. He explained why he believes this will happen by confirming something I have observed in my hometown. Private hospitals are buying up private physician groups as doctors have come to understand they will never be able to realize their traditional exit strategy: selling their office files to a younger version of themselves seeking to start his or her own private practice. Those days are gone. Doctors are selling to private hospitals so they can continue to work without the burdens of malpractice insurance, overhead, staff salaries, diminishing reimbursements, and less autonomy.

Mattiacci points out “this has created an unexpected consequence. All those doctors are now employees. And employees can be organized as a group.” If you do not think doctors are feeling burned and left out of decisions about how they work, then you do not know many doctors.

Acupuncturists have never been organized. In fact, many profess to be content to exist outside the realm of medicine with its insurance, pharma and governmental nuisances. This view is not less simplistic than Mattiacci’s view with one major difference. Being isolated leaves you alone. Being organized gives you a say in your destiny.

NGAOM member Mario Mancici, OMD, joined us for a day at the OPEIU conference. We visited his clinic which is decidedly mainstream. He is a graduate of a California program and has a thriving acupuncture practice in San Diego. He has 14 individual treatment rooms and is opening his version of a community acupuncture treatment room where he will treat up to 10 patients at a time in a group setting filled with negative ions. He does not use a sliding fee scale but he does accept health insurance, works with the only group in the nation that feeds referrals to LAcs – American Specialty Health or ASH, and he is enrolled in Medicare. Each of these choices remains controversial among many acupuncturists.

Acu Guild meets with Podiatry Guild

Acu Guild meets with Podiatry Guild

Here are a few excerpts from his brochure which, in my mind, offer a guideline for how to market oneself as an LAc who wants to work with and be seen as a partner for other healthcare providers.

His Center for Integrative Care is focused on optimal health and personalized patient-centered care.

His purpose is to help patients achieve optimal health and to educate them about the benefits of nutrition and Oriental medicine.

He educates patients to focus on a lifestyle of optimal function for health and wellness instead living by disease maintenance.

Mario lists a range of diagnostic tests none of which exceeds his scope of practice and common conditions he helps none of which are fantastic or outside an evidence base.

Here is how he explains acupuncture. “Acupuncture or needling therapy stimulates the nervous system to increase the flow of blood bringing oxygen, nutrients, hormones and immune cells to targeted areas of the body. Acupuncture points are junctures on the body where blood vessels and a dense collection of nerves intersect.”

Mancini believes acupuncture belongs in functional medicine which is something integrative physicians have told me. The way Marion sees it “functional medicine is the biomedicalization of acupuncture.” The path is clear. Those who choose to follow it will find strength in numbers and a new community of brothers and sisters.


Affordable Care Act: Handicapping the Players

March 20, 2013

Peter_LeeCalifornia is set to be the flagship for the implementation of the Affordable Care Act (ACA). Our state has the largest contingent of about-to-be newly insured. Our state has gone all-in with regards to enrollment, technology, and spending. We are among the first states to establish our own Health Benefits Exchange. While red states with similarly huge numbers of uninsured – who could and should be among the soon-to-be newly enrolled such as Texas are dragging their feet to make further pointless political statements – California is moving full steam ahead to make the White House proud. At least we look like we are moving that quickly. (more…)


Knox-Keene license is the entry ticket to the Affordable Care Act

March 13, 2013

ACA_signingWEB The Knox-Keene license is about to become more important than ever before. The holder of a Knox-Keene license has the right to create and offer health plans in the California healthcare marketplace. That market is about to undergo the greatest change in 50 years. The Medicare Act that was created in 1965 changed everything about healthcare by providing government sponsored coverage for two vulnerable and uninsured populations – elderly and the poor. It’s déjà vu all over again. (more…)


How Did They Decide to Award the $1B?

June 27, 2012

Grant writing is competitive. The greatest stakes are at the federal level where the awards are the largest and the competition is most fierce. Proposals I often find myself working on involve community healthcare which means coordinating between multiple entities such as community clinics, FQHCs, hospitals and community based organizations (CBOs). A substantial funding pie was divided into 107 slices this month as the CMS Innovation Center (created as part of the Affordable Care Act announced the awardees for the $1 billion Innovation Challenge competition. The program was well received by the national healthcare community involved with Medicare and especially Medicaid services. Approximately 3,000 proposals were received in a very tight 60 day window between November 2011 and January 2012 during the busiest holidays of the year. There’s a challenge! The ambitious timetable for processing and evaluating the avalanche of proposals in March was predictably extended another 90 days. Seventeen California proposals comprised the largest number of awardees among the 52 states, Puerto Rico and one site “not geographically defined.” Massachusetts and New York were next with 12 awards each. (more…)


The California Senate is Concerned with How the California Acupuncture Board Functions

March 14, 2012

On March 12, 2012 the Senate Committee on Business, Professions and Economic Development conducted a hearing under its Sunset Review function during which the California Acupuncture Board (CAB) Chair and Executive Director were advised, in the opinion of the committee, the CAB was “too caught up in professional issues.” The CAB was instructed to respond to the committee’s Background Paper [click here Acupuncture Board Background Paper 2012TRUNC], which is a worthwhile read for those interested in California acupuncture or in the legislative oversight process. The very brief 20 minute hearing ended with the committee letting the CAB Chair and Executive Director know the committee was “concerned about how the board functions.” (more…)


The Ark and the Mothership

April 19, 2011

I have been waiting for months to write this post. I wanted to attend the April 8-10 CANference in Portland and learn what the most innovative organization in the acupuncture world has been planning before writing anything more about changes taking place in the acupuncture profession. I found out the CAN folks are building an ark.

It is no longer difficult to build a persuasive case describing how the acupuncture profession has been drifting for at least a decade. Until recently, the Community Acupuncture Network (CAN) spent considerable energy trying to blow holes in the belly of that ship. The workforce papers I co-wrote provided a few torpedoes. Now CAN has shifted their energies. The perception among conventional acupuncturists and acupuncture leadership organizations has been that CAN is destructive, led by unruly amateurs who enjoy their outlaw image. Just when the heat created by CAN hit a level that began melting the eyeballs of those who would try to peer within, they have shifted direction 180 degrees. CAN is no longer interested in upending the acupuncture profession. They are re-inventing it. (more…)


What will the National Healthcare Workforce Commission do? A lot.

October 6, 2010

less providers + more patients = system breakdown

The Patient Protection and Affordable Care Act (PPCA) of 2010 – aka healthcare reform – included a provision to create a National Healthcare Workforce Commission (NHWC). The purpose is to create a body of expert representatives who are “who are nationally recognized in health care labor market analysis including workforce, health financing and economics, health facility management, heath plans and integrated delivery systems, workforce education and training, health care philanthropy, and providers of health care services” []. Their job is to “serve as a national resource for the purpose of assessing if the demand for health care workers is being met, identify barriers to coordination between federal, state and local levels, and encourage innovations” [Summary of the Health Workforce Provisions in the Patient Protection and Affordable Act: H.R. 3590, March 2010, Rachel Morgan, Senior Health Policy Specialist.] (more…)


Time for Change in For-Profit Education

July 24, 2010

The most overused political phrase – “it’s time for a change” – may be finally growing some teeth when it comes to private for-profit education. The Federal Department of Education has taken a hard line position with regards to reigning in private for-profit schools, such as ITT and the University of Phoenix, that have profited from lax Title IV Federal loan provisions.

Witness the proposed federal recommendations from the Office of Postsecondary Education, Department of Education issued June 18 2010 concerning Program Integrity Issues. Here are some of the salient points from the Federal Register Vol. 75, No. 117. (more…)


The BLUEPRINT for health care reform is in the May 2010 issue of Health Affairs

June 19, 2010


Health Affairs journal is the premiere journal for healthcare policy. If it appears in Health Affairs then it is generally a done deal. The May 2010 issue of Health Affairs is devoted to the reinvention of primary care. The Patient Protection and Affordable Care Act of 2010 has triggered all sorts of projects that have been in the queue for some time or will soon be put to the test. Make no mistake…what is reported and proposed in this journal edition is here to stay for the next decade. It cannot be unwound. Things are going to change in healthcare over the next three years and for decades thereafter. (more…)