Axios Vitals

A briefcase with a red cross on the front.

November 16, 2018

Good morning ... For the first time in my life, I can relate to Ted Danson.

1 big thing: Who's still uninsured

Data: CDC; Chart: Andrew Witherspoon/Axios
Data: CDC; Chart: Andrew Witherspoon/Axios

Overall, the number of Americans who don’t have health insurance is holding pretty steady under President Trump. The uninsured rate stood at 12.5% in the first half of this year, according to the latest data from the Centers for Disease Control and Prevention.

  • That’s in line with where it’s been since the Affordable Care Act’s coverage expansion began in 2014.

Although coverage has expanded significantly across the board, the CDC’s report offers a good snapshot of who’s still uninsured.

By the numbers: Being uninsured is often temporary. About 17% of people said they had been without coverage for part of the year, compared with 7% who had been uninsured for over a year.

  • A quarter of the people who were uninsured at the time the CDC interviewed them were Hispanic; 14% were black, 9% were Asian and 7% were white.
  • People between the ages of 18 and 24 were more likely to be uninsured than older or younger adults.
  • Unsurprisingly, poor people still lack health care coverage — 25% of uninsured adults in the CDC’s survey had incomes at or below the poverty line.
  • Another 25% were “near poor," meaning their household income was less than roughly $25,000 for an individual, or $50,000 for a family of 4.

The big picture: Most of those people should be eligible for Medicaid if their states expanded, or for heavily subsidized ACA coverage.

2. Big changes in primary care

Nurses and nurse practitioners are gaining a bigger foothold as primary-care providers, while doctors’ roles are slipping.

Details: Among people with employer-based insurance, the number of office visits to primary care physicians fell by 18% from 2012 to 2016, according to new data from the Health Care Cost Institute.

  • Over the same period, office visits to nurses and nurse practitioners rose by 129%.

Between the lines: Nurse practitioners have been lobbying aggressively for state laws that would allow them to practice “at the top of their license” — which would allow them to perform many of the services patients seek from their regular family doctor.

  • That’s been framed largely as a cost-saving measure, under the assumption that nurses would be paid less than doctors for the same service.

Yes, but: Those savings haven’t materialized yet, even amid a pretty significant shift from doctors to other providers.

  • According to HCCI’s data, the average office visit to a primary-care doctor cost $106 in 2016, compared to $103 for an office visit to a nurse practitioner or physician’s assistant.

3. Why the Atrium Health settlement matters

States that want to crack down on hospital prices and market power may use yesterday’s Atrium Health settlement with the Justice Department as justification, my colleague Bob Herman writes.

DOJ felt Atrium Health, a powerful hospital system in North Carolina, was locking in above-market rates through potentially lopsided contracts, and wanted to give health insurers the option of cutting out high-cost or low-quality providers.

  • “This gives the DOJ momentum to bring similar actions elsewhere,” said Barak Richman, a health care business law professor at Duke University.

Details: DOJ was investigating whether Atrium was coercing insurers into take-it-or-leave-it contracts that would not allow Atrium to be cut out of networks.

  • These types of anti-steering contracts are not uncommon, as the Wall Street Journal recently reported.
  • The settlement says Atrium cannot penalize insurers for excluding its hospitals and doctors or putting them in lower tiers, among other stipulations.
  • But, the system will retain some power.

Hospitals generally argue the contracts are not about creating anticompetitive terms, but about ensuring they get patient volume in return for pricing discounts.

What’s next: DOJ won’t necessarily bring forward a slew of new hospital lawsuits on its own, and states may not act either, said Bill Berlin, a former DOJ health care antitrust attorney who’s now at Hall Render. “But as a provider, I wouldn’t take solace in that.”    

4. Watchdogs gun for hospital coding

Some advice from Bob: Keep an eye on this. The Centers for Medicare & Medicaid Services and HHS’ Office of Inspector General will conduct a “two-part study,” expected to completed by 2020, that will scrutinize how hospitals overcharge Medicare — a practice known as upcoding.

Why it matters: Medicare paid hospitals $114 billion for inpatient stays in 2016, or about 17% of all Medicare payments. OIG has long criticized inpatient coding, a main artery for hospital finances, and this move foreshadows potentially bigger clawbacks on bad actors.

5. ACA premiums are higher in rural areas

Insurance plans offered on the ACA exchanges generally cost more in rural areas than urban ones in 2016 and 2017, according to a new analysis by the Urban Institute.

  • Rural areas tend to have less competition among both insurers and providers, driving costs up.

By the numbers: Premiums for a “benchmark” plan were 9% higher, on average, in rural areas in 2016, increasing to 10% in 2017. That's $26 more per month in 2016 and $39 more per month in 2017, compared with urban areas.

Why it matters: Rural areas offer unique health care challenges, my colleague Caitlin Owens notes. People who live in rural areas tend to not only have more problems in affording care, but also face access issues as rural hospitals continue to shut down.

6. Oscar is losing less money

Health insurer Oscar — the very buzzy startup with a big ACA footprint — is on track to lose less money in 2018 than it did in 2017, Business Insider reports (subscription required).

  • Oscar reported a $96 million loss last year. But it lost only $12 million in the first 9 months of this year, according to BI's review of state insurance filings.
  • The company's revenue across 6 states was $539 million, and it paid out $418 million in claims.