The Kaiser Family Foundation predicts that the Affordable Care Act will cut the number of uninsured in the United States by half in three years by adding 30 million people to the insurance rolls, says its study “The Uninsured: A Primer” (http://kff.org/uninsured/upload/7451-08.pdf).

However, even with the ACA, Kaiser expects there to be about 26 million uninsured in 2016, and while that’s better than had the law been repealed, some of the uninsured are likely to be with us for some time. “These individuals are likely to include: immigrants who are not legal residents and are therefore not eligible for Medicaid coverage or for federal premium subsidies; people who are exempt from the mandate, in most cases because they do not have access to affordable coverage; [and] people who are subject to the mandate but choose to pay the penalty rather than purchase health insurance,” says the report.

That something needed to be done about those falling through the coverage cracks is something policy makers of all political stripes agreed on. They also agree that health care costs are rising at an unsustainable rate — and, so far, no one’s figured out how to solve that problem. The Congressional Budget Office says that long-term spending will be caused primarily by entitlement programs such as Medicare, Medicaid, Social Security “and (to a lesser extent) the insurance subsidies that will be provided through the health insurance exchanges established by the Affordable Care Act.”

Some will fall through the cracks in 2016

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CBO’s 2012 Long-Term Budget Outlook, released in June, adds that “The health care programs are the main impetus behind that growth; they are responsible for about four fifths of the total projected rise in spending on that set of programs over the next 25 years.”

The CBO expects that through 2022, the aging of the population will cause spending on the major health care programs to rise significantly. The agency adds that growth in spending per beneficiary will increase as well.

The CBO’s predictions are based on two different assumptions. One, the extended baseline scenario (at right), maintains that “current laws generally remain unchanged” and that lawmakers will forgo “adjustments routinely made in the past that have boosted deficits.”

Federal spending on major health care programs

Percentage of gross domestic product

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Sources: “The Uninsured: A Primer,” Kaiser Commission on Medicaid and the Uninsured, October 2012; Congressional Budget Office

Managed Care’s Top Ten Articles of 2016

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.