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Health Cost Growth Is Down, Or Not. It Depends Who You Ask.

In this Policy Insight, Kaiser President and CEO Drew Altman explores the disconnect between experts, national studies and the public about whether health care costs are slowing or accelerating—it’s a matter of perspective.

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Obamacare Vital Signs Not Just Numbers

In his latest column, Kaiser President and CEO Drew Altman discusses the focus on first year metrics, especially enrollment projections, in the ACA debate.

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No Quick Verdict on Obamacare

This column originally appeared in Politico on September 30. Dr. Altman’s future Politico columns will be posted on kff.org one day after publication. October 1, the focus of great attention in the Obamacare wars, is finally here. Today is the day open enrollment begins for the new health insurance marketplaces,…

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How Obamacare May Be Holding Down Costs

In his latest column published in Politico, Kaiser President and CEO Drew Altman examines the recent historic slowdown in health-care costs and discusses whether Obamacare is a contributing factor.

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Kaiser and the Affordable Care Act

Drew E. Altman, Ph.D., President and Chief Executive Officer. Updated: August 2014 Many of you have commented over the years on my President’s Message on this website which explains our purpose and mission in creating the modern day Kaiser Family Foundation and how we operate. I update it periodically to keep it…

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Pre-X Redux

With the focus now mainly on exchanges, Medicaid expansions, and enrolling the uninsured in newly available coverage arrangements, there is less attention lately to the ACA insurance reforms which have always been the most popular parts of the law – changes which could affect every American’s insurance in some way…

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                    [post_content] => Studies show that health care costs have been rising more slowly than at any time in the last fifty years, but the American people think they are rising faster than ever. Who’s right, the experts or the public? They both are, they just look at the problem from different perspectives.

The most recent government study of national health spending was published by the Centers for Medicare and Medicaid Services and found that health spending grew by a very modest 3.7 percent in 2012, the fourth straight year of historically low increases in spending.  Our annual survey of premiums for employer based health insurance in 2013 told a similar story. Premiums rose just 4 percent.  There is debate among experts about how much of the slowdown is due to the weak economy and how much is due to changes in the health care system but everyone agrees both factors have played a role.  The government report says the slowdown is mainly due to the economy.  Our own analysis also found that the economy explains most of the diminishing rate of growth but changes in health insurance and health care have also played a significant role.  There is uncertainty about when and how rapidly costs will accelerate when the economy improves, but no one disputes that the slowdown is real.

No one that is except the American people, who see health costs from a different perspective.  In our monthly tracking poll, almost sixty percent of the American people said “the cost of health care for the nation has been going up faster than usual in recent years”.  Less than a third say costs have been going up “about the same as usual” with just 4 percent saying they were growing “slower than usual”.  No one (correctly) said they were going down.

One reason people see health costs differently than experts do is that what they pay for health care has been steadily going up.  They pay less attention to the fact that they are going up more slowly than before.  For example, the average deductible five years ago in employer plans was $735 per person and by 2013 it had grown to $1,135.  Premiums have been growing at historically low rates, but the average family premium in an employer plan in 2008 was $12,680 and in 2013 it was $16,351.  Over that time the share of the premium paid by workers rose from $3,360 to $4,560.

What people pay for health care has also been going up when their wages have been flat or even falling in real dollars.  The result is that when people look at their family budgets and try to make ends meet, the pain level from paying their health care bills does not necessarily feel smaller to them and may feel larger.

An estimated 1 in 3 Americans report having difficulty paying their medical bills.  They have had problems affording medical bills within the past year, or they are gradually paying past bills over time, or they have bills they can’t afford to pay at all.  People also hear and read a lot about health care costs in the media; in stories about the Affordable Care Act, or the federal budget, or about waste fraud and abuse in the health care system. That gives them a sense that costs are rising even if studies show they are rising more slowly.

And, as the Wall Street Journal reported recently, people can be shocked by confusing medical bills and high health care prices. It’s a simple equation: price times volume of services equals spending. The studies reporting the slowdown focus on the change in total national health spending, but people focus on the eye-popping prices.

For its part, the Affordable Care Act attacks both the health spending problem experts worry about and the affordability concerns people have, chiefly by reducing future increases in Medicare payments and by providing coverage to a projected thirty million Americans with tax credit subsidies for many of them, lowering their out-of-pocket expenses.  Other provisions of the law dealing with costs appear to be working well, such as its review of outsized premium increases in the non-group market and requirement that insurance companies devote most of their premium dollars to patient services.  The Affordable Care Act’s ultimate impact on costs is hard to gauge but it puts downward pressure on costs for the system and consumers. The Congressional Budget Office projects that Medicare will cost significantly less in the future than previously thought, both because of the ACA’s changes to Medicare’s payments, as well as the general slowdown in health spending growth.

There are huge vested interests in the health care industry with a stake in declaring that health costs are under control, because the more the nation believes the health cost problem is solved, the less likely we are to keep the pressure on to try new, more innovative, and perhaps more painful cost control strategies.  We have not seen this many years in a row of slow growth in spending like this before and we can be hopeful that cost growth will remain modest, but we should also be careful not to declare victory too soon, and we should remember how the consumer sees it in a rough economy when the next  study of national health spending comes out.
                    [post_title] => Health Cost Growth Is Down, Or Not. It Depends Who You Ask.
                    [post_excerpt] => In this Policy Insight, Kaiser President and CEO Drew Altman explores the disconnect between experts, national studies and the public about whether health care costs are slowing or accelerating—it’s a matter of perspective.
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                    [post_content] => This column originally appeared in Politico on October 27. Dr. Altman's future Politico columns will be posted on kff.org one day after publication.

The battle over the Affordable Care Act and its problem-plagued rollout is fast becoming a numbers game: How many people have gone to HealthCare.gov, established an account or actually enrolled in a health plan? How will the website’s problems affect enrollment in the first year? Will the administration need to make major changes, such as extending the open enrollment period or delaying the individual mandate penalty?

Obviously, the website must be fixed soon, or the ACA will be in deep trouble. If it is not fixed, the political fallout will worsen, and one of the ACA’s gateways to coverage, the federal exchange, will remain dysfunctional. But assuming the website is repaired fairly soon, the public’s judgment about Year One will be based much more on whether people believe the coverage they get is a good deal than on early website numbers or projections made in Washington for first-year enrollment.

And what about those numbers? The figure most frequently used as a metric for first-year enrollment under the ACA comes from the Congressional Budget Office. The CBO estimated that 7 million people will be covered in the state and federal insurance exchanges and 9 million more by expanded state Medicaid programs in 2014. The CBO does estimates to gauge impact on the federal budget, not to evaluate the implementation of laws, but these numbers have taken on a life of their own. The 7 million figure, in particular, has become the yardstick for measuring the ACA’s success or failure in Year One. But that’s sort of like mistaking fantasy football for real football.

Let’s be honest: Any projection like this is largely an informed guesstimate about something that has never been done. It’s not an exact science. Just last week, Ohio changed the numbers when it decided to expand its Medicaid program. There’s no way the CBO’s number crunchers could have anticipated either that eleventh-hour expansion or the troubled rollout of the federal exchange website, which could have an impact on both the mix and number of people enrolled in the first year if it is not fixed soon. But the impact of these serious website problems on the total number of enrollees may not be huge, since the majority of the uninsured projected to be covered in the first year will be enrolled through state Medicaid expansions and state-operated exchanges. Medicaid and state-exchange enrollment seem to be working more smoothly than enrollment through HealthCare.gov. While some people of low income will be directed to Medicaid through the federal exchange, states are conducting outreach and many applicants will enroll directly through a state program. The impact on the mix of enrollees could be more problematic if younger, healthier people are turned off and stop trying to enroll. There is concern about this but no evidence yet that it is actually happening. One misconception about the 7 million number creeping into the conversation is that it is a target necessary to achieve a viable insurance pool with a good mix of healthier and sick people. The principle is right — the larger the number, the better the chances of spreading risk — but the CBO was calculating the number who might be covered in the first year to estimate federal spending, not to lay down a threshold for the program’s success. So let’s not make too much of the CBO estimate: What people should be paying attention to at the end of the first year is not whether a specific projection is attained but whether people feel the coverage they are getting is a good deal and whether the states that have chosen to move forward with the ACA are satisfied. For instance, let’s say 10 million people are covered in the state and federal exchanges, substantially more than the 7 million projected by the CBO. If people widely complain about the individual mandate or affordability of coverage, and states that have embraced the law balk, would that be a success? Imagine, on the other hand, that enrollment ramps up more slowly than the CBO expected simply because it takes more time than expected to enroll the uninsured. That could happen not only because of early website problems but because the uninsured are largely uninformed about the law and many do not know that they are eligible for tax credits. Say 5 million people enroll in the state and federal exchanges (plus millions more in Medicaid), but most people are happy with their coverage and enrollment reflects a good mix of healthier and sicker folks. Media reports would become increasingly upbeat, or at least they should, and states that have chosen to sit on the sidelines might take notice. ACA’s first year could be judged a success despite the early hiccups. Maybe it’s asking too much to expect the pundits and partisans on both sides to resist turning this into a ballgame scorecard, with a simple measure of whether Obamacare wins or loses in its first year. But for those of us just trying to understand whether the ACA is really working or not, it’s definitely too early to say which way things will go, and there is no single magic number that will tell us whether the law succeeded or failed in the first year. [post_title] => Obamacare Vital Signs Not Just Numbers [post_excerpt] => In his latest column, Kaiser President and CEO Drew Altman discusses the focus on first year metrics, especially enrollment projections, in the ACA debate. [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => obamacare-vital-signs-not-just-numbers [to_ping] => [pinged] => [post_modified] => 2014-03-04 11:16:30 [post_modified_gmt] => 2014-03-04 16:16:30 [post_content_filtered] => [post_parent] => 0 [guid] => http://kff.org/?post_type=perspective&p=89737 [menu_order] => 0 [post_type] => perspective [post_mime_type] => [comment_count] => 0 [filter] => raw ) [2] => WP_Post Object ( [ID] => 86880 [post_author] => 48951013 [post_date] => 2013-10-01 12:40:47 [post_date_gmt] => 2013-10-01 16:40:47 [post_content] => This column originally appeared in Politico on September 30. Dr. Altman's future Politico columns will be posted on kff.org one day after publication. October 1, the focus of great attention in the Obamacare wars, is finally here. Today is the day open enrollment begins for the new health insurance marketplaces, where Americans can log on and sign up for coverage. The media, opponents, and proponents have been gearing up for a big day — or, maybe, a big week — when they can make pronouncements about how well Obamacare is working. But all we will really know at this point is how well eligibility and enrollment systems are working initially, since actual coverage doesn’t begin until January 1. When they throw the switch today, do the lights shine brightly, flicker, or not come on at all? The media will jump on early glitches, but if they are addressed, the memory of them will fade. It will take weeks, if not months or more, before anyone knows how many people are signing up for coverage. People might take a wait-and-see attitude before they sign up or just procrastinate. And if you are uninsured, bewildered by the debate about the Affordable Care Act (Act), and wondering whom to believe, it’s not crazy to wait just a little while to enroll, as long as you don’t wait too long and miss out on your coverage kicking in next year. We may not really have a good sense of how many people will show up for coverage and whether they feel the premiums they are paying (after tax credits) are a good deal or not until the open enrollment period ends in March 2014. Plus, how many sign up and how they perceive the affordability of the premiums themselves is only half the story. In addition to premiums, people will face out-of-pocket costs when they seek health-care services. And there are the benefits that Obamacare requires all insurers to provide — the usual hospital care and doctor visits, plus maternity care, mental health, prescription drugs, and more. We won’t know how they feel about their coverage overall until people begin to use health services. If you think about your own family you know that not everybody will go to the doctor or the hospital or purchase drugs right away. Only when people start to use care will they pay their up-front deductibles, which in some cases will run thousands of dollars for plans sold in the exchanges, or pay their other forms of costs-sharing for doctor visits and drugs, or get free preventive services under Obamacare. All this will probably take at least a year to shake out, and maybe longer. The Congressional Budget Office has estimated that about 14 million more Americans will be insured in year one, primarily through the exchanges or the state Medicaid expansions, which the Supreme Court made a state option in its ruling on the ACA. People’s experiences with their coverage will vary widely, depending on their state Medicaid programs, the plans offered in the exchanges in their states, and the health-care delivery systems where they live. Some people will be in a state-run exchange and others in a federal exchange. Every state Medicaid program is different. With so much variation, it will be even harder to come to a quick summary judgment about how the law is working nationally. This same variation offers opportunities to learn what is working best and to make improvements in the law, assuming our polarized Congress can ever get its act together to agree on changes to the ACA. Then, in year two, an additional six million people are expected to be insured. More states might also choose to expand Medicaid or run exchanges themselves. It should be easier to get a broad picture of how the law is working by then. October 1 is a handy news hook for coverage of Obamacare as it moves from a political dogfight to a reality — a new phase for the law. But it is not a magic moment to make a judgment about the ACA. All sides will be spinning their version of the early implementation experience, but it will take longer to come to any kind of reasonable judgment about how the law is working and what its lessons are. And while the noise level will be highest in Washington, in the end it’s the American people who will decide whether they like what they are getting from Obamacare or not. [post_title] => No Quick Verdict on Obamacare [post_excerpt] => [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => no-quick-verdict-on-obamacare [to_ping] => [pinged] => [post_modified] => 2014-03-04 11:14:31 [post_modified_gmt] => 2014-03-04 16:14:31 [post_content_filtered] => [post_parent] => 0 [guid] => http://kff.org/?post_type=perspective&p=86880 [menu_order] => 0 [post_type] => perspective [post_mime_type] => [comment_count] => 0 [filter] => raw ) [3] => WP_Post Object ( [ID] => 86626 [post_author] => 36621681 [post_date] => 2013-09-27 08:00:25 [post_date_gmt] => 2013-09-27 12:00:25 [post_content] => This column originally appeared in Politico on September 26.  Dr. Altman's future Politico columns will be posted on kff.org one day after publication.  The historic slowdown in health-care costs is continuing. Earlier this month, the government’s actuaries found that total national health spending continues to grow at the lowest rate we’ve ever seen. And our annual employer health benefits survey released in August found premiums up just 4 percent on average for family policies this year, while overall health spending is growing at the slowest rate in 50 years (dating back to when the government first started tabulating health expenditures). Experts debate how much of the slowdown is due to the weak economy, which causes people to use less health care, and how much is due to changes in health insurance and the health-care system, such as higher cost-sharing or new efforts to limit avoidable tests or hospital days. But the consensus – including the actuaries – is that both factors are playing some role. What is far less clear is how much Obamacare may also be contributing to the slowdown in costs. Proponents of the law say it is helping to control costs because the cost- containment provisions of the law are working as advertised. These include new limits on how much insurance companies can charge for administration and profits (with rebates to consumers if they charge too much), and state review of rates proposed by insurance companies. There is solid evidence that these provisions are working as intended, but they mainly apply to the individual and small group markets, just a small slice of the overall health care marketplace. Obamacare also reduced the rate of increase in future payments to providers for Medicare. These reductions are projected to take more than $700 billion out of health spending over the next 10 years, but they haven’t had much effect yet. Other provisions of the law, such as the Medicare experiments in payment and delivery, are still just getting started. Critics of Obamacare, of course, dispute that the law is having any effect on costs because, well, there is basically nothing they like about Obamacare. Even though its direct effects on system-wide costs may be limited so far, I believe Obamacare is having a significant indirect effect, although cause and effect and the magnitude are hard to prove. (As the actuaries rightly point out, insuring more people will boost the rate of spending growth temporarily, but the effect should be small and short-lived.) Historically, we have always seen the health-care marketplace respond by lowering costs when there is the threat of impending health reform legislation or government action on costs. Now we have not only the threat but the reality. When President Jimmy Carter threatened aggressive cost-containment legislation in 1977, the industry responded with something called “the voluntary effort,” and for several years cost growth came sharply down. Similarly, cost increases came down when Bill Clinton’s health reform loomed, spurring the so-called managed-care revolution that reached its apex in the mid to late 90s. Costs also have responded to direct government intervention, as they did when President Richard Nixon imposed temporary wage and price controls in the early 1970s, including in health. Health inflation came down but, not surprisingly, rose again when the regulations were lifted. Obamacare appeared first in the form of the threat of sweeping health-reform legislation and then the reality when the law passed. It is likely that what Obamacare has mainly done so far is accelerate changes already underway in the marketplace as part of a constellation of forces affecting the health-care industry. Already feeling pressure from insurers and employers, providers saw Obamacare coming, with its reductions in the rate of growth in Medicare reimbursement and Medicare payment demonstrations. The old saying in health policy is “when Medicare sneezes, health care catches cold.” The market saw these changes as harbingers of the future. The bill’s rate review and limits on insurance-company overhead and profits – as well as more intense price competition coming in the new exchanges – put new pressure on insurers to be more innovative and to take on providers more aggressively, even if they only apply to relatively small slices of the marketplace. Public and private payers in general seemed to be aligning behind a new interest in redesigning reimbursement incentives and the delivery of care. Obamacare became part of a larger handwriting on the wall, not just in Medicare but in the private marketplace as well. The marketplace has also reacted defensively to protect its bottom line, and not all of the changes in the system will lower costs. The raft of mergers and consolidation of market power in the delivery system could raise costs as providers get bigger and drive a harder bargain with insurers. Revenues and profits have not been abandoned as the basic yardstick for CEOs and boards of directors. The cost slowdown preceded Obamacare, so there is no doubt that other forces have been at play as well. Cost-sharing has been increasing in the market for years, and we know it has a very real impact on the use of health services. The bad economy has had the biggest influence on health care utilization and spending, as our recent study and this month’s actuaries’ report both suggest. But, history tells us that the health-care market has always responded to the threat (and now, for the first time, also the reality) of health reform. For this reason it is entirely likely that Obamacare has played and will continue to play a role in the slowdown in health-care cost growth and accelerating market change. Ask almost any hospital administrator or insurance CEO, and that’s the answer you’ll get. Just don’t ask me to prove it. [post_title] => How Obamacare May Be Holding Down Costs [post_excerpt] => In his latest column published in Politico, Kaiser President and CEO Drew Altman examines the recent historic slowdown in health-care costs and discusses whether Obamacare is a contributing factor. [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => how-obamacare-may-be-holding-down-costs [to_ping] => [pinged] => [post_modified] => 2014-03-04 11:14:32 [post_modified_gmt] => 2014-03-04 16:14:32 [post_content_filtered] => [post_parent] => 0 [guid] => http://kff.org/?post_type=perspective&p=86626 [menu_order] => 0 [post_type] => perspective [post_mime_type] => [comment_count] => 0 [filter] => raw ) [4] => WP_Post Object ( [ID] => 82451 [post_author] => 36621681 [post_date] => 2013-08-14 12:37:33 [post_date_gmt] => 2013-08-14 16:37:33 [post_content] => Drew E. Altman, Ph.D., President and Chief Executive Officer. Updated: August 2014 Many of you have commented over the years on my President’s Message on this website which explains our purpose and mission in creating the modern day Kaiser Family Foundation and how we operate. I update it periodically to keep it current as we evolve. With the passage, implementation and continuing debate about the Affordable Care Act, I thought I would provide a companion essay about our role on the ACA. Our mission, stated at the top of our home page, is “filling the need for trusted information on national health issues.” It is inspired by our benefactor Henry Kaiser’s motto: “find a need and fill it.” Henry Kaiser was talking about finding a niche in American industry, but that is also what we try to do in a different time and in the very different world of health policy. Our mission doesn’t change because of the passage of the ACA or the hyper-partisan environment in which it is being implemented. We have addressed all kinds of health policy legislation over the years, dating back to the Clinton reform effort which unfolded just as we were creating the modern day KFF, and we are accustomed to operating in a highly politicized health policy environment. In fact, when it comes to politicized health policy issues, I can remember earlier election-driven Medicare debates that would give the current ACA discussion a run for its money. As in these past debates, our role on the ACA is to inform the debate and give the American people information they can use to understand the law and make the best choices for themselves and their families. We do this through the facts and analysis we produce; our polling and survey research; our news service (Kaiser Health News) and our many other efforts to help strengthen news coverage; and through the events we hold and our daily role in the field as explainers and technical experts. Certainly we want to see more Americans have insurance coverage and better protection from the sometimes crushing burden of health care costs. But at Kaiser we take no position on the ACA, or any other law or proposal for that matter. Some laws are good, some bad, and most are a mix of good and less good. Some are popular and some less so. Our role is the same whether we are working on Medicaid, Medicare, the ACA, or any other law or health policy issue. One difference now is that the ACA is a law that has actually passed and is being implemented. But it is a difference mainly of scale and complexity. We have worked to inform the implementation of other laws in the past, such as CHIP and the Medicare drug benefit, and we have long specialized in Medicaid which like the ACA involves a big role for the states. With this in mind, we have a five-part strategy for our work on the ACA: 1. PRODUCING FACTS AND ANALYSIS. This is the backbone of what we do. The key to our work, on the ACA or any issue, is picking the right topics to work on so that we are useful and relevant, getting the timing of what we do right, and getting information to our core audiences in understandable and digestible forms, especially policymakers and the media. Many of us have PhDs and have been in academia, but our business is different from the academic enterprise. We do not start with what the unanswered or interesting research questions are, we start with what information is needed by policymakers, the media and the public to inform policy debates. Occasionally we are called a “think tank.” I like to believe we think, but we function differently from most think tanks. We operate large programs such as a national news service, an in-house polling operation and large national media campaigns such as Greater Than AIDS. Another difference from most think tanks is that everything we put out is an organizational product, not the work of individual scholars, authors or opinion leaders. 2. INFORMING JOURNALISTS AND NEWS ORGANIZATIONS. We have always placed equal weight on policy analysis and media at Kaiser, and the ACA is no exception. With Washington and the Congress in a hyper-partisan boil, the news media play an even more important role than at any time since we established the modern day KFF at mediating national policy debates and informing the public. One of our biggest and most resource-intensive commitments as an organization is to be an everyday resource for journalists and news organizations as they cover the ACA. Our goal is not to be cited or quoted, it is to improve the quality of health policy information the American people get, and we are keenly aware that anything we do directly ourselves to put out information pales in comparison to the reach of the media, in all of its current day forms. We also have long operated fellowship and other programs to help journalists better understand the intricacies of health policy. 3. PRODUCING OUR OWN JOURNALISM. In June of 2009, we established our own news service, Kaiser Health News (KHN), to provide in-depth coverage of health policy, free of the competitive and bottom line pressures that affect most commercial news organizations. KHN is the successor to kaisernetwork.org, which produced daily news summary reports and webcasting but not original journalism. KHN is a regular foundation program but it is editorially-independent, and a fully credentialed national health policy news service. We distribute our KHN content free through a wide range of partners such as The Washington PostUSA Today, and NPR. An important thrust now at KHN is to cover the ACA story as it unfolds in states and communities beyond the Beltway. To that end, we have established a new regional newspaper network and partnerships with many NPR affiliates across the country, and we are expanding our west coast coverage and developing a California bureau. KHN also produces two highly popular daily news summary reports, as well as original programming from our broadcast studio in our D.C. building.  We are also now producing health policy coverage for the NewsHour. You can catch KHN reporters frequently on C-SPAN or the NewsHour explaining health policy developments. As the ACA gradually fades from the headlines there will be an even greater need for KHN. 4. POLLING AND SURVEY RESEARCH. Our monthly tracking polls are among our most prominent products and familiar to many of you. Our polling group designs our polls not just to monitor opinion, but more importantly to examine people’s experiences with the ACA and their level of knowledge about the law. Because we have been polling about health reform since the early 1990s, we have a well-tested battery of questions and a repository of experience that we can bring to polling about the ACA. We always adhere to the highest methodological standards in our polls and maintain sample sizes that allow us to report confidently on relevant subgroups of the population. In addition to the polls we conduct ourselves, we also conduct in-depth special project surveys with news media partners, most notably The Washington Post, with whom we have conducted twenty-seven survey projects, as well as The New York Times. We are also fielding several large-scale special surveys at Kaiser designed to assess the impact of the ACA, with a focus on the lower income and uninsured populations. Many of you are also familiar with our benchmark annual survey of employer health benefits and premiums, which we release every year around September. 5. CONSUMER INFORMATION. With ACA implementation moving forward and our polls showing that so many people are uninformed or confused about what the law means for them, we are ramping up our consumer information materials. We have made a solid start with our ACA Calculator, our animation narrated by our Trustee Charlie Gibson, our FAQs, and our quizzes. But, we plan to do much more, including translating much of our consumer information into Spanish. Our goal in doing all of this is not to be a direct resource for consumers, since that is generally not our role and we don’t have the means to answer questions from millions of people about their individual circumstances. Rather, we will distribute what we produce through media partners and direct people to local resources that will help them make individual choices. The more time I spend talking about the ACA, the more I am convinced of the need for basic information about what the law does and does not do. Overall this has been one of our greatest discoveries at Kaiser about health policy information: basic facts and explanations are as powerful in our world as the seminal study. We try to do both and everything in between. These roles and strategies – facts and analysis, assisting news media coverage, our own news service, polling and survey research, and consumer information – are the main tools we use to take on ACA implementation. Every day, in each of these areas, we make decisions about what analyses we want to do, what polls and surveys to do next, what news stories we do at KHN, what events to hold, what media appearances to accept or decline, how many journalists and news organizations we can assist that day, and so forth. For an operating organization, all these choices require resource commitments. Many organizations make these kinds of decisions. These tactical decisions translate the strategy into impact. There is no manual for making them; they are the art of what we do and hopefully we mostly make the right calls. Lastly, across all of the elements of Kaiser’s ACA strategy, we maintain a consistent focus on the issues and developments that most affect people, and especially people with the greatest health and economic needs. The focus on people is the hallmark of our organization. Others will focus on health professionals and health care institutions or the health care industry, all important issues as well. But, with some exceptions, that is not what we emphasize. We put information to work for people and try to focus on the policy issues and choices that affect millions. The choices we make about what we choose to do and choose not to do with our limited staff and financial resources are always guided by this compass. [post_title] => Kaiser and the Affordable Care Act [post_excerpt] => [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => kaiser-and-the-affordable-care-act [to_ping] => [pinged] => [post_modified] => 2014-08-05 18:29:50 [post_modified_gmt] => 2014-08-05 22:29:50 [post_content_filtered] => [post_parent] => 0 [guid] => http://kff.org/?page_id=82451 [menu_order] => 0 [post_type] => page [post_mime_type] => [comment_count] => 0 [filter] => raw ) [5] => WP_Post Object ( [ID] => 76279 [post_author] => 36621681 [post_date] => 2013-06-20 09:00:41 [post_date_gmt] => 2013-06-20 13:00:41 [post_content] => With the focus now mainly on exchanges, Medicaid expansions, and enrolling the uninsured in newly available coverage arrangements, there is less attention lately to the ACA insurance reforms which have always been the most popular parts of the law – changes which could affect every American’s insurance in some way and which go into effect regardless of the implementation decisions states make.  In this column, I draw on our recent tracking polls to review where the public stands on the most prominent of these insurance reforms – guaranteed issue. This is another area where information could matter because many people with pre-existing medical conditions who stand to benefit from the law don’t seem to know about it. Forty-nine percent of the American people under the age of 65 report that they or a family member have a pre-existing medical condition such as heart disease, diabetes, asthma, and cancer. Among this group, a quarter (25%) say that they or someone in their household has been denied coverage or had their premium raised because of a pre-existing condition. Thirty-five percent say they worry that they will have to pass up a job opportunity or forego retirement plans to maintain coverage and nearly one in ten (9%) say they or someone in their household has passed up a job opportunity or decided not to retire in the past year because of “job lock”. The “guaranteed issue” requirement in the ACA fixes this problem, which is called medical underwriting. It requires insurers to issue health plans to anyone in the individual or group markets, regardless of their health status, and prohibits rate surcharges based on health status in the individual and small group markets.  Like most of the ACA’s major revisions, it kicks in January 1 of next year, with open enrollment beginning this October. The provision is popular; 66% of the American people support it. It is also one of those ACA provisions Republicans like, with 56% of Republicans supporting it. The President has talked about it often, journalists have publicized it, and experts have debated the impact of eliminating medical underwriting on the costs of insurance since passage of the law.  But like many elements of Obamacare, many people who will benefit from it don’t seem to know about it. Among those who report that someone in their household has a pre-existing condition, four in ten are not aware of the guaranteed issue provision. Just like the other group who will benefit most from the ACA, the uninsured, a large number – in this case half of all people who have someone in their household with a pre-existing condition – say they don’t have enough information about the ACA to know how it will impact them or their family. Not everyone with a pre-existing condition has had a problem getting health insurance. People with employer-based coverage are protected under the previous law unless they lose their job and experience a coverage gap. Nor does liking the idea of guaranteed issue necessarily mean someone will support the ACA; people like or dislike the ACA for various reasons. And, there are tradeoffs in eliminating underwriting against people with pre-existing conditions. Premiums may rise somewhat to accommodate coverage for people who are sick (the idea is to balance this to some extent by insuring people who are young and healthy as well). But there is a large constituency of people with major illnesses who will benefit from the law who do not seem to know it, and virtually everyone benefits from the peace of mind of knowing that if they get sick they no longer can be denied coverage or priced out by surcharges, even if they have large group coverage and lose it. Right now, working people who get sick and need to leave their jobs have only expensive COBRA coverage as a temporary solution. The ACA awareness and outreach effort now getting underway is aimed more at the goal of connecting the uninsured to new coverage opportunities than helping people to understand the security of knowing that they can’t be denied coverage if they get sick. There is obvious logic in that, since the law cannot succeed without getting people enrolled. But, many people with pre-existing conditions such as cancer, heart disease, or diabetes are represented by organized and usually very effective disease groups. They have a role to play in informing their constituents about this issue as do health professionals whose patients may benefit from the guaranteed issue provision. Fifteen percent of those with a pre-existing condition say they have talked with their doctor or a medical professional about the ACA. One reason this is important now: as the economy improves, people will be looking for better job opportunities, and there is a significant group of people still afraid to change jobs because they are sick and who seem not to know that they soon will not have to worry about that anymore. ________________ (Note: In this column, I report data on pre-existing conditions from our March, April and June 2013 Kaiser Tracking Polls and our September 2011 Tracking Poll. I focus on the non-elderly because seniors are protected from medical underwriting by the Medicare program.) [post_title] => Pre-X Redux [post_excerpt] => [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => pre-x-redux [to_ping] => [pinged] => [post_modified] => 2014-03-04 11:14:32 [post_modified_gmt] => 2014-03-04 16:14:32 [post_content_filtered] => [post_parent] => 0 [guid] => http://kff.org/?post_type=perspective&p=76279 [menu_order] => 0 [post_type] => perspective [post_mime_type] => [comment_count] => 0 [filter] => raw ) ) [post_count] => 6 [current_post] => -1 [in_the_loop] => [post] => WP_Post Object ( [ID] => 103817 [post_author] => 36621681 [post_date] => 2014-03-05 13:00:19 [post_date_gmt] => 2014-03-05 18:00:19 [post_content] => Studies show that health care costs have been rising more slowly than at any time in the last fifty years, but the American people think they are rising faster than ever. Who’s right, the experts or the public? They both are, they just look at the problem from different perspectives. The most recent government study of national health spending was published by the Centers for Medicare and Medicaid Services and found that health spending grew by a very modest 3.7 percent in 2012, the fourth straight year of historically low increases in spending.  Our annual survey of premiums for employer based health insurance in 2013 told a similar story. Premiums rose just 4 percent.  There is debate among experts about how much of the slowdown is due to the weak economy and how much is due to changes in the health care system but everyone agrees both factors have played a role.  The government report says the slowdown is mainly due to the economy.  Our own analysis also found that the economy explains most of the diminishing rate of growth but changes in health insurance and health care have also played a significant role.  There is uncertainty about when and how rapidly costs will accelerate when the economy improves, but no one disputes that the slowdown is real. No one that is except the American people, who see health costs from a different perspective.  In our monthly tracking poll, almost sixty percent of the American people said “the cost of health care for the nation has been going up faster than usual in recent years”.  Less than a third say costs have been going up “about the same as usual” with just 4 percent saying they were growing “slower than usual”.  No one (correctly) said they were going down. One reason people see health costs differently than experts do is that what they pay for health care has been steadily going up.  They pay less attention to the fact that they are going up more slowly than before.  For example, the average deductible five years ago in employer plans was $735 per person and by 2013 it had grown to $1,135.  Premiums have been growing at historically low rates, but the average family premium in an employer plan in 2008 was $12,680 and in 2013 it was $16,351.  Over that time the share of the premium paid by workers rose from $3,360 to $4,560. What people pay for health care has also been going up when their wages have been flat or even falling in real dollars.  The result is that when people look at their family budgets and try to make ends meet, the pain level from paying their health care bills does not necessarily feel smaller to them and may feel larger. An estimated 1 in 3 Americans report having difficulty paying their medical bills.  They have had problems affording medical bills within the past year, or they are gradually paying past bills over time, or they have bills they can’t afford to pay at all.  People also hear and read a lot about health care costs in the media; in stories about the Affordable Care Act, or the federal budget, or about waste fraud and abuse in the health care system. That gives them a sense that costs are rising even if studies show they are rising more slowly. And, as the Wall Street Journal reported recently, people can be shocked by confusing medical bills and high health care prices. It’s a simple equation: price times volume of services equals spending. The studies reporting the slowdown focus on the change in total national health spending, but people focus on the eye-popping prices. For its part, the Affordable Care Act attacks both the health spending problem experts worry about and the affordability concerns people have, chiefly by reducing future increases in Medicare payments and by providing coverage to a projected thirty million Americans with tax credit subsidies for many of them, lowering their out-of-pocket expenses.  Other provisions of the law dealing with costs appear to be working well, such as its review of outsized premium increases in the non-group market and requirement that insurance companies devote most of their premium dollars to patient services.  The Affordable Care Act’s ultimate impact on costs is hard to gauge but it puts downward pressure on costs for the system and consumers. The Congressional Budget Office projects that Medicare will cost significantly less in the future than previously thought, both because of the ACA’s changes to Medicare’s payments, as well as the general slowdown in health spending growth. There are huge vested interests in the health care industry with a stake in declaring that health costs are under control, because the more the nation believes the health cost problem is solved, the less likely we are to keep the pressure on to try new, more innovative, and perhaps more painful cost control strategies.  We have not seen this many years in a row of slow growth in spending like this before and we can be hopeful that cost growth will remain modest, but we should also be careful not to declare victory too soon, and we should remember how the consumer sees it in a rough economy when the next  study of national health spending comes out. [post_title] => Health Cost Growth Is Down, Or Not. It Depends Who You Ask. [post_excerpt] => In this Policy Insight, Kaiser President and CEO Drew Altman explores the disconnect between experts, national studies and the public about whether health care costs are slowing or accelerating—it’s a matter of perspective. 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