A summary of what to expect when the Supreme Court hears arguments about the health-care reform law

How big a deal will it be when the U.S. Supreme Court hears arguments about the constitutionality of the new federal health-care reform law later this month? Big, concludes Stuart Taylor Jr. for Kaiser Health News.

"It's big enough for the justices to schedule six hours of arguments — more time than given to any case since 1966," he reports. "It's also big enough to attract more briefs than any other case in history ... and, finally, it's big enough to cause the justices to postpone until October half of the 12 cases that they were ordinarily going to hear in April in order to clear time to get started on the health care opinions."

The most pressing issues deal with the individual mandate of the law, which requires people without insurance to buy some or pay fines. The question is whether the mandate "represents an unconstitutional exercise on Congress' power to regulate commerce and to levy taxes," Taylor notes. There is also the question of state sovereignty, since the law requires states "to spend more of their own money or forfeit all of the federal Medicaid money they now receive," Taylor reports.

As for the outcome, that's the million-dollar question, Taylor writes. "It's clear that the court's four more liberal members, like almost all other liberal legal experts, will find the law constitutional in all respects. It's also clear that conservative Justice Clarence Thomas will vote to strike down much or all of the law. It's less clear what swing-voting Justice Anthony Kennedy and conservative Chief Justice John Roberts as well as Justices Antonin Scalia and Samuel Alito will do."

As for the major arguments regarding Medicaid and for and against the individual mandate, Taylor provides an excellent summary that is worth reading in its entirety. (Read more)

What health reform changes to expect in 2012 — assuming the Supreme Court doesn't strike down the entire law

The U.S. Supreme Court is set to hear arguments later this month about the federal health care-reform law, and is expected to decide the law's future this summer. While the court mulls the constitutionality of an individual mandate to buy health insurance, "implementation marches on, and a number of notable changes will take effect for consumers this year," writes Michelle Andrews for Kaiser Health News.

If the high court strikes down the Patient Protection and Affordable Care Act, "all bets are off," Andrews writes. Popular provisions, such as allowing children to stay on their parents' insurance until age 26 and the 50 percent discount on brand-name drugs for seniors under the prescription drug doughnut hole, could be eliminated — and provisions set to take effect this year could be cancelled. But, if the Supreme Court does not invalidate the entire law, here's a list of new provisions consumers can expect this year:

Free contraception coverage: "Women in a new health plan or in an existing one that has changed its benefits enough to not be considered grandfathered under the law will be able to receive contraceptives without an out-of-pocket charge," Andrews writes. Insurance plans will also have to provide basic health services for women, including screening for gestational diabetes; HPV testing; STD counseling; screening and testing for HIV; and screening and counseling for interpersonal and domestic violence. Religious employers such as churches are exempt from the new regulation, but colleges, hospitals and other employers that are religiously affiliated are not — though they do have a one-year grace period to implement it. Employees of those institutions will receive their free benefit from their employer's insurance.

Consumer rebates: Under the law, insurance companies have to spend at least 80 to 85 of their premium revenues on medical claims and quality improvement. If they don't, they have to pay the difference to policyholders, which, in most plans, means the employer. If the provision had been in place in 2010, an analysis by the National Association of Insurance Commissioners estimated that would have meant $2 billion going to consumers. In December, the Obama administration said that about 9 million Americans could receive rebates that added up to $1.4 billion.

Clearer descriptions: Starting in September, all health plans will have to give consumers benefits information that is easy to understand. "Every plan will be required to give people a short summary of coverage and a uniform glossary of terms," Andrews reports. "It will also have to provide examples of how much the plan would cover if someone had a baby or was managing Type 2 diabetes — two common situations that should make it easier for people to compare plans."

Smaller doughnut hole: "This is the break in Medicare prescription drug benefits that, in a standard plan, begins after total drug spending by the beneficiary and the health plan exceeds $2,930 and continues until the beneficiary has hit the $4,700 out-of-pocket limit," Andrews reports. Last year, people on Medicare with high drug costs got a 50 percent discount on brand-name drugs once they reached the doughnut hole. This year, they'll also get a 14 percent discount on generic drugs. (Read more)

Cost of an MRI in America? $1,080. France? $280. Why? providers 'largely charge what they can get away with'

Why does getting an MRI in the United States cost $1,080 when it only costs $280 in France? The answer comes down to how the prices are set, reports Ezra Klein for The Washington Post.

"That may sound obvious," he writes. "But it is, in fact, key to understanding one of the most pressing problems facing our economy. In 2009, Americans spent $7,960 per person on health care. Our neighbors in Canada spent $4,808. The Germans spent $4,218. The French, $3,978."

The difference in expenditures isn't linked to the idea that Americans just use more health-care services (the opposite is actually true) or that we are sicker. A 2003 study on international heath-care costs and a survey released Friday by the International Federal of Health Plans both concluded it comes down to pricing. The latest survey showed that in 22 of 23 medical services, whether that was a routine doctor visit or coronary bypass surgery, Americans paid more than other developed countries.

The difference is based on the way the pricing is set. "Other countries negotiate very aggressively with the providers and set rates that are much lower than we do," said Gerard Anderson, who was involved in the 2003 study. In Canada and Britain, prices are set by the government. In Germany and Japan, the prices are "set by providers and insurers sitting in a room and coming to an agreement, with the government stepping in to set prices if they fail," Klein reports.

Outside of Medicare and Medicaid, which are cheaper than the commercial average, "it's a free-for-all" in the U.S., Klein wriotes. "Providers largely charge what they can get away with, often offering different prices to different insurers, and an even higher price to the uninsured."

Because the customer often doesn't have choice in whether or not he or she will purchase health care — one could be unconscious or very ill — "sellers of health-care services in America have considerable power to set prices, and so they set them quite high," Klein reports.

Fixing the problem is fraught with complication, Klein writes, because "centralized bargaining cuts across the grain of America's skepticism of government solutions." The prices are also set by very powerful industries. The federal health care reform law is not expected to fix the issue, Klein writes, though might spread awareness since there are provisions to expand transparency; hospitals will have to publish their prices, for example. "But this is, for the most part, a fight the bill ducked, which is part of the reason that even its most committed defenders don't think we'll be paying anything like what they're paying in other countries anytime soon," Klein write. (Read more)

As with health care reform, dentistry should move from volume to value, report urges

Dentists should be paid according to the outcomes of their patients and should be monitored more closely given that there is great variability and expense when it comes to dental care, a new report argues.

"I think there is broad consensus that the current oral health system doesn't meet the needs of a significant portion of the population," said Paul Glassman, professor of dental practice at University of the Pacific Arthur A. Dugoni School of Dentistry and lead author of the report "Oral Health Quality Improvement in the Era of Accountability."

The report, funded by the W.K. Kellogg Foundation and the DentaQuest Institute, was released as the U.S. healthcare system is undergoing a transition from the "pay-for-performance" model to "value-based care." The paper argues oral health should likewise move in the same direction and make the transition from "volume to value."

The report found dentistry is the second-highest out-of-pocket health care cost after prescription medicines, and, like health care in general, its cost is increasing, reports Laird Harrison for Medscape News. Another issue is the government just pays for about 6 percent of dental care nationally, the report found, leaving people to pay for care themselves.

While expensive, the care dentists give can be inconsistent, the report found. Though Glassman said dentistry is not lacking in standards, there is limited evidence of the best practice for most dental procedures, the report found.

Another issue, the report contends, is dentists are paid according to what they produce, not by how successful they are in their outcomes. As such, dentists are resistant to change since there are few incentives to implement quality improvement programs. "If the question is 'what's the optimum system for providers,' then many feel the optimum system is what we have now," Glassman said. "If the question is 'what's the optimum system for the public,' then you will come to a different set of assumptions."

To help improve the system, the report recommends a number of proposals, including:

• The increased use of electronic health records

• Development and use of measures for oral health outcomes

• Tying incentives to the oral health of the population being served

• Relying more on allied dental professionals and non-dental professionals

It also suggests relying more heavily on telemedicine, with Glassman envisioning "hygienists and dental assistants going into schools, nursing homes, and other areas with underserved populations to deliver preventive care," Harrison reports. "Dentists, monitoring from afar with access to dental charts stored on the Internet, could gain more patients."

Steven Silverstein, director of the graduate program in dental public health at the University of California San Francisco, said the report was "outstanding" and agreed that the care dentists give can be inconsistent, saying, "If you ask 10 dentists to look at a patient you will get 10 different opinions." Part of the problem, he said, is 98 percent of dentists either practice alone or with one or two partners.

Silverstein did take issue with the fact that the report did not mention the high cost of dental education; didn't take cosmetic dentistry into account; and it did not explain how reform could lower the cost of dental care. (Read more)

Several pieces of federal health reform law taking effect in 2012

At the beginning of the new year, family doctors started facing a 1 percent cut in Medicare reimbursement if they hadn't nixed their paper-based prescription pads in favor of an electronic version. The change is part of another piece of the federal health-care reform law taking effect, USA Today reports.

"There will be a significant number of folks that will incur the penalty," said Robert Tennant, senior policy adviser with the Medical Group Management Association.

E-prescribing, which allows physicians to generate, transmit and file patient prescriptions, is part of the federal government's effort to get doctors to use electronic health records. Last year, doctors received bonuses from Medicare and Medicaid to set up EHRs, but this year they will start being penalized if they haven't already done so — 1 percent this year, 1.5 percent in 2013 and 2 percent in 2014.

Another piece of the federal health care reform law that will begin falling into place in 2012 involves Medicare's Shared Savings Program, "under which groups that qualify as accountable care organizations will be eligible for shared savings in 2013," USA Today reports. "Under the program, savings from participants in an ACO — including hospitals and doctors working together to improve patient care and reduce costs — would be shared between Medicare and the providers."

One study showed Kentucky already has three ACOs established, though several Kentucky experts have said no ACOs have been formed in the state yet.

Jan. 1 also marked the beginning of consumers being eligible for rebates if their insurer spent less than it should have on medical care. As per the new law, insurers have to spend 85 percent for large group plans and 80 percent for small groups and individuals on medical care as opposed to administrative and other costs. Kentuckians will not be privy to these rebates this year, however. Kentucky got a one-year break from the rule after applying for an exemption. (Read more)

Health insurance exchange benefits will be decided at the state level; Kentucky can now proceed to set up its exchange

For months, Kentucky officials have said the state cannot move forward with setting up a health-insurance exchange under the new federal health law because there weren't enough details about which benefits they had to offer. On Friday, the Obama administration answered that question when it "let states, rather than the federal government, define which medical benefits insurance companies will have to offer consumers starting in 2014," reports Noam L. Levey of the Los Angeles Times. "This is significantly more state-flexible and friendly than many would have expected," Alan Weil, head of the National Academy for State Health Policy, told Levey.

The law says that by 2014, each state must offer an insurance exchange, an online insurance marketplace in which people can choose from a variety of plans from companies like Anthem or Bluecross/Blueshield and then, for the most part, be given federal subsidies to help pay their premiums. About 30 million individuals and employees of small businesses are expected to use the exchanges. The plans in an exchange must cover a basic set of benefits, including hospitalizations, emergency care, newborn and maternity care and pediatric services, but until now the federal government could have decided how generous the benefits had to be.

"Under the guidance issued Friday, state leaders can define their own set of benefits by using an existing major health plan in their state as a benchmark," Levey reports. "That means that some states may require insurers to cover services such as chiropractic therapy and in vitro fertilization, while others may not."

It's this variability between states that worries some. "In passing a good deal of the decision-making to states, the administration has guaranteed that Americans will continue to face a patchwork of state regulations that make coverage uneven and inefficient," report Gardiner Harris, Reed Abelson and Robert Pear in a news analysis for The New York Times.

Some consumer advocates also worry the move will allow states to make benefits too meager. Timothy Jost, a law professor at Washington and Lee University, said the policies "could restrict, for example, the number of covered visits a pregnant woman could make to her obstetrician or which prescription drugs to pay for."

However, by passing the responsibility on to the states, "President Obama will most likely make his plan for health care reform more politically palatable," the Times reporters write. "States will be allowed to set benefits at levels similar to what they are now, making coverage not much more expensive than it is today."

While some Republican state officials were happy with the decision, saying it makes it easier for states to comply with the law, others opposed to the law were critical. "All they're trying to do is avoid making tough calls before the election," said Ed Haislmaier, a senior research fellow at the Heritage Foundation. (Read more)