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Attorneys general from twenty states filed a lawsuit in February of this year to nullify the Affordable Care Act (ACA). Typically, it falls on the executive branch to defend federal legislation, but the current administration filed a memorandum agreeing with the plaintiffs that key provisions of the ACA should be nullified: guaranteed-issue (that everyone can buy health insurance, regardless of pre-existing conditions and that insurers cannot raise prices for those who have pre-existing conditions) and community rating.

Attorneys general from twenty states filed a lawsuit in February of this year to nullify the Affordable Care Act (ACA). Typically, it falls on the executive branch to defend federal legislation, but the current administration filed a memorandum agreeing with the plaintiffs that key provisions of the ACA should be nullified: guaranteed-issue (that everyone can buy health insurance, regardless of pre-existing conditions and that insurers cannot raise prices for those who have pre-existing conditions) and community rating.

The arguments rely on previous Supreme Court commentary for two other cases in which plaintiffs argued that the ACA was unconstitutional. In the first case, NFIB v. Sebelius, the Supreme Court ruled that the federal government did indeed have constitutional authority to impose the individual mandate (a penalty for people who did not have health insurance) because it was a tax. In the second case, King v. Burwell, the Supreme Court ruled that the individual mandate is central to ACA. The plaintiffs in this case, Texas v. USA, argue that since the 2017 tax changes removed the individual mandate (a tax) and the individual mandate is central to ACA, the entire ACA must now be found unconstitutional. The Department of Justice in its memorandum did not go so far as the plaintiffs, but rather only agreed that guaranteed-issue and community rating should now be found unconstitutional.

The individual mandate and guaranteed-issue were the two most interesting features of the ACA. Interestingly, AHIP (which represents health insurers in the US) released a statement indicating that it was against the nullification of both guaranteed-issue and community rating.

As noted by many media outlets, the president signed legislation known as "right to try," where terminally ill patients will supposedly have better access to experimental medications. The move appears controversial, with various groups either diminishing the impact of the legislation or highlighting that it might make things worse for patients.

As noted by many media outlets, the president signed legislation known as "right to try," where terminally ill patients will supposedly have better access to experimental medications. The move appears controversial, with various groups either diminishing the impact of the legislation or highlighting that it might make things worse for patients.

CBS News published a piece that gives an overview of the landscape before the legislation: although there was no federal legislation, 38 states already have similar laws. In addition, FDA already had a program in place where it approved of the vast majority of requests for experimental medication. Others have noted that easier access might mean that patients suffer more unsafe medications.

Propublica published an interesting piece explaining why health insurers might actually not mind high prices from healthcare providers. In theory, the insurance company (the payer) wants to minimize its cost so that it can maximize its profits or at least offer more competitive offerings to its customers. The explanation for payers' acceptance of high prices is that while the profit in any given year is determined by the absolute difference between revenues and costs, the long-run profits of payers can essentially be modeled as a percentage of their total premiums collected. If true, the long-term incentive of insurance companies is not so much to minimize the absolute costs; rather, they benefit more as the costs rise from year to year.

Propublica published an interesting piece explaining why health insurers might actually not mind high prices from healthcare providers. In theory, the insurance company (the payer) wants to minimize its cost so that it can maximize its profits or at least offer more competitive offerings to its customers. The explanation for payers' acceptance of high prices is that while the profit in any given year is determined by the absolute difference between revenues and costs, the long-run profits of payers can essentially be modeled as a percentage of their total premiums collected. If true, the long-term incentive of insurance companies is not so much to minimize the absolute costs; rather, they benefit more as the costs rise from year to year.

Interestingly, the Affordable Care Act set a maximum percentage of premiums collected that insurance companies can use for non-medical purposes (including profits). In a non-competitive market with that regulation, insurance companies would indeed benefit from higher healthcare costs. Also interesting is the online resource that the article mentions in helping employees of certain companies shop for healthcare. Insurance companies could be rolling out their own versions of such tools, and one wonders why those tools are not more prevalent among insurance companies.

The New England Journal of Medicine published a review of metrics used to assess the performance of healthcare providers. Some interesting statistics from the piece: "The National Quality Measures Clearinghouse now lists more than 2500 performance measures" and physician practices spend about $40,000 per physician annually to report on performance. This review was undertaken by the American College of Physicians (ACP). Of the 271 measures included in Medicare's Quality Payment Program, the ACP committee roughly roughly a third of them as valid, a third not valid, and a third of uncertain validity. The piece also talked about how different standards bodies come to adopt their measures.

The New England Journal of Medicine published a review of metrics used to assess the performance of healthcare providers. Some interesting statistics from the piece: "The National Quality Measures Clearinghouse now lists more than 2500 performance measures" and physician practices spend about $40,000 per physician annually to report on performance. This review was undertaken by the American College of Physicians (ACP). Of the 271 measures included in Medicare's Quality Payment Program, the ACP committee roughly roughly a third of them as valid, a third not valid, and a third of uncertain validity. The piece also talked about how different standards bodies come to adopt their measures.

A lot of money (and presumably attention) is supposedly being spent on collecting these performance metrics, and yet, patients lack visibility into physician performance. These standards bodies have been building consensus for years, perhaps even decades. One significant move to help drive adoption would be for industry groups (whether physician societies such as ACP or standards groups such as National Quality Forum or government agencies such as CMS) to genuinely push for metrics that are not disputed and push for the public disclosure of physician performance in those areas. While controversial, once a substantial number of physician groups start disclosing their performance, the public will come to expect these numbers and the debate around physician performance will beyond simply debating the validity of measures.

Public reporting of patient outcomes by physician has been controversial. In theory, patients have better information to select a doctor. People from the medical community have countered that disclosure of outcomes will cause some providers to avoid accepting high-risk patients since those patients might skew their statistics. New York State endured this controversy when they decided to disclose outcomes for cardio-thoracic surgeons. UK also went through this question recently as well. The BMJ published a study showing that some of the stated fears of the medical community appear to be overblown.

Public reporting of patient outcomes by physician has been controversial. In theory, patients have better information to select a doctor. People from the medical community have countered that disclosure of outcomes will cause some providers to avoid accepting high-risk patients since those patients might skew their statistics. New York State endured this controversy when they decided to disclose outcomes for cardio-thoracic surgeons. UK also went through this question recently as well. The BMJ published a study showing that some of the stated fears of the medical community appear to be overblown.

More studies will come out, some probably in favor of public disclosure and some against. An interesting finding from this study is that mortality dropped. If true, opponents of public disclosure of outcomes will need to weigh that benefit against hypothetical risk-adverse patient selection (which this study did not seem to find). It's possible that there are particular details of the context of this study that might have made the patients less susceptible to doctors' avoidance of high-risk patients.