A review of health care reform bills proposed by Congress shows that many of them would cover more uninsured Americans than the current administration proposal. The review, conducted by the Lewin Group on behalf of the Commonwealth Fund Commission, determined that in addition to reducing the number of uninsured Americans, the proposals would also decrease overall health care expenditures — including expenditures for insurance administration and prescription drugs.

The analysis looked at 10 health care plans introduced in the 109th and 110th Congresses. In addition to reviewing President Bush's and other sweeping proposals, researchers looked at more modest ideas such as expanding existing public health insurance programs such as Medicare and the State Children's Health Insurance Program. The report also suggested that these proposals could serve as a first step toward universal coverage.

Highlights of congressional health care proposals

A simulation model was used to estimate the number of people who would gain coverage under the proposals and what the bills' effects would be on national health care expenditures overall and on federal and state governments, employers, and households. The number of uninsured in the United States is projected to rise in 2007 to 47.8 million, 16.2 percent of the total population.

  President Bush's tax reform plan Healthy Americans Act Federal/state partnership AmeriCare
Aims to cover all people  
Individual mandate or auto enrollment  
Employers share responsibility  
Public program expansion    
Subsidies for lower income families  
Risk pooling  
Comprehensive benefit package  
Quality and efficiency measures
Uninsured covered in 2007 (millions) 9.0 45.3 20.3 47.8
Net health system cost in 2007 (billions) ($11.7) ($4.5) $22.7 ($60.7)
Net federal budget cost in 2007 (billions) $70.4 $24.3 $22.0 $154.5
Source: The Commonwealth Fund

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There’s a lot more going on in health care than mergers (Aetna-Humana, Anthem-Cigna) creating huge players. Hundreds of insurers operate in 50 different states. Self-insured employers, ACA public exchanges, Medicare Advantage, and Medicaid managed care plans crowd an increasingly complex market.

Major health care players are determined to make health information exchanges (HIEs) work. The push toward value-based payment alone almost guarantees that HIEs will be tweaked, poked, prodded, and overhauled until they deliver on their promise. The goal: straight talk from and among tech systems.

They bring a different mindset. They’re willing to work in teams and focus on the sort of evidence-based medicine that can guide health care’s transformation into a system based on value. One question: How well will this new generation of data-driven MDs deal with patients?

The surge of new MS treatments have been for the relapsing-remitting form of the disease. There’s hope for sufferers of a different form of MS. By homing in on CD20-positive B cells, ocrelizumab is able to knock them out and other aberrant B cells circulating in the bloodstream.

A flood of tests have insurers ramping up prior authorization and utilization review. Information overload is a problem. As doctors struggle to keep up, health plans need to get ahead of the development of the technology in order to successfully manage genetic testing appropriately.

Having the data is one thing. Knowing how to use it is another. Applying its computational power to the data, a company called RowdMap puts providers into high-, medium-, and low-value buckets compared with peers in their markets, using specific benchmarks to show why outliers differ from the norm.
Competition among manufacturers, industry consolidation, and capitalization on me-too drugs are cranking up generic and branded drug prices. This increase has compelled PBMs, health plan sponsors, and retail pharmacies to find novel ways to turn a profit, often at the expense of the consumer.
The development of recombinant DNA and other technologies has added a new dimension to care. These medications have revolutionized the treatment of rheumatoid arthritis and many of the other 80 or so autoimmune diseases. But they can be budget busters and have a tricky side effect profile.

Shelley Slade
Vogel, Slade & Goldstein

Hub programs have emerged as a profitable new line of business in the sales and distribution side of the pharmaceutical industry that has got more than its fair share of wheeling and dealing. But they spell trouble if they spark collusion, threaten patients, or waste federal dollars.

More companies are self-insuring—and it’s not just large employers that are striking out on their own. The percentage of employers who fully self-insure increased by 44% in 1999 to 63% in 2015. Self-insurance may give employers more control over benefit packages, and stop-loss protects them against uncapped liability.