NBC touts its coverage of the 2012 London Olympic Games, which drew a total of 219 million viewers, as “the most-watched television event in U.S. history.” However, the same cannot be said for network’s treatment of the Paralympic Games.

Though the closing ceremony of the Paralympic Games drew 7.7 million viewers last night, NBC’s coverage of the games does not begin until September 16 and will consist of just five and half hours of highlights. In contrast, the United Kingdom’s Channel 4 aired 400 hours of Paralympic coverage, Australia’s ABC aired more than 100. Viewers in Japan watched nightly one-hour highlights during the Paralympics.

The president of the International Paralympic Committee, Sir Philip Craven, told BBC his group will examine their potential broadcasting partners’ values more closely after NBC failed to broadcast any live coverage of the games:

CRAVEN: We’ll examine their values as they will examine ours. If the values fit, we’ve got a chance. If they don’t we’ll go somewhere else. [...] The people of the USA, for example, particularly the parents and families of the athletes, they are all ready for Paralympic sport.

NBC said that this year’s five and a half hours of Paralympics coverage is an improvement of its coverage of the 2008 Paralympics in Beijing, which consisted of “a single 90-minute highlights package.” For some Paralympics advocates, however, that improvement doesn’t go nearly far enough.

– Greg Noth

The individual mandate may not be “essential” to the Affordable Care Act’s successful implementation, a new study published yesterday in Health Affairs has concluded. Researchers John F. Sheils and Randall Haught agree that removing the incentive for younger and healthier people to purchase coverage would increase overall premiums (and create a premium spiral), but argue that “other provisions of the law that would greatly mitigate this effect” resulting in a slightly lower than expected premium increases and smaller coverage loss rates.

“We estimate that if the mandate were lifted, premiums in the individual market would increase by 12.6 percent—somewhat less than other estimates—with 7.8 million people losing coverage, versus other estimates for coverage loss of 16–24 million people,” the study says. “In sum, the Affordable Care Act would still cover 23 million people who would have been uninsured without the law”:

The premium subsidies provided under the act would also serve to restrain a premium spiral by absorbing much of the impact of premium increases. According to the Congressional Budget Office, about two-thirds of people with nongroup coverage under the act would receive premium subsidies. These subsidy amounts are tied to the premium for the second-lowest-cost of the “silver” plans offered by insurers through the health insurance exchanges (one of five plans of different actuarial values that are to be offered in the exchanges). Thus, any increase in the premium for that plan results in increased subsidy amounts, which will cover much or even all of the increase in premiums, depending on the plan a family has selected. [...]

For example, the act also permits plans to limit enrollment to an annual “open enrollment period” of about six weeks beginning in October of each year. Open enrollment periods, which are used by many employer health plans, typically limit enrollment of workers to one month of the year. Limiting this period of enrollment encourages people to take coverage by forcing them to forgo insurance for up to eleven months before they have another opportunity to enroll. The risk of going without coverage over that long a period causes many workers to take up insurance when they can.

There is great uncertainty surrounding these estimates — previous research by Jonathan Gruber, for instance had found that “the number of uninsured people would increase by twenty-four million people in the absence of the mandate” and the Congressional Budget Office (CBO) reported that 16 million could lose coverage.

The problem is that if you take away the mandate, you’re really eliminating any strong incentive for younger individuals who would otherwise forgo coverage to purchase insurance, balance out the risk pool and drive down costs. If you’re not attracting that population in the first place and only enrolling sicker individuals who need coverage (and can take advantage of the tax credit), that doesn’t sound like a terribly sustainable model — and certainly not one that the insurers or tax payers who are footing the tax credit bill will agree to live with.

In the latest issue of Health Affairs, Jon Kingsdale — who until recently ran the successful Commonwealth Health Insurance Connector Authority in Massachusetts — suggests that the new state-based health exchanges should function as shops for insurance and help customers choose a compatible insurance plan. A purchaser of insurance should be able to “generate rate comparisons for any level of benefits simply by providing his or her date of birth, household size, and ZIP code. These rating rules make it possible to automate insurance pricing and facilitate comparison shopping in an exchange,” Kingsdale writes.

In July, the Department of Health and Human Services (HHS) is preparing to unveil a new website that will allow individuals and small businesses to comparison shop between different coverage options, “including private insurance plans, high risk pools, CHIP and Medicaid.” Here is how Karen Pollitz — head of the new Office of Consumer Information and Insurance Oversight — explained the new web portal during yesterday’s ‘web-chat’:

POLLITZ: The first thing we’re going to do is open a new website. That’s going to be a great big website. I don’t have the name of it yet, but that is a big project that’s in the works and that will show, on July 1st, all of the big health insurance policies that are for sale, for individuals and small businesses throughout the country. So you can go on the website, look up your state and see what’s available for you. A little bit later this year, we’ll put out information about pricing, sort of what, at least the sticker price is for those policies. And then, a few months down the road after that, we’ll start loading up some really important performance information. So how do these place really work for people. What kind of enforcement actions and complaints and what are the things they do well, so that folks can have a really better understand of what their options are.

Watch it:

The federal government hopes that states will adopt the new portal as a model for providing consumers with information in the exchanges and all the different stakeholders are advising the agency for how best to design the new site. As Politico’s Pulse notes, “Reform proponents like Families USA want HHS’s new consumer insurance portal to include an ‘in-depth compendium of plan information‘ in multiple languages. Others, such as Aetna, say that HHS’s sky-high demands for information go beyond Congressional intent and that the portal should ‘not be a mandatory, comprehensive and continuous reporting obligation for insurers on all open and closed insurance products.’”

Kingsdale notes that the exchanges will have to determine how to present information to consumers in the most useful and usable manner. “How many choices to offer, and of what kind, are matters of judgment and consumer preference,” Kingsdale suggests. “Too much choice may confuse consumers and lead to adverse selection. On the other hand, too little choice may conflict with consumers’ preferences and stifle innovation in the design of insurance policies and benefits.” Kingsdale writes that exchanges have to create administrative efficiencies and add transparency to the health care system. “Today, in the absence of exchanges, the non group and small-group markets offer a bewildering array of benefit choices and crate hurdles to purchasing coverage.” “Many of the functions associated with sales, enrollment, premium billing, and collections could be streamlined through a combination of manual rating and economies of scale,” he predicts.

I’ve been arguing that the states suing the federal government over the constitutionality of health care reform or nullifying reform through the state legislature are home to Americans who are most in need of health care coverage. These populations have the most pronounced instances of chronic disease and live in states that simply don’t have the tax base or political will to invest in public health care programs. Thus, they often go uninsured and their conditions only worsen.

In the newest issue of Health Affairs, Leighton Ku also points out that “paradoxically, the opposition in these states appears to run contrary to the economic and health interests of their residents”:

On average, 39 percent of the Medicaid-eligible adults in the twenty-one “opposing states” were uninsured, compared to 26 percent in the rest of the nation. Because opposing states have relatively more eligible-but-uninsured adults, their residents have much more to gain form the Medicaid expansions, and these states would draw down far more federal funding.

Look:

Given that many states are interpreting the Medicaid expansion as an unfunded mandate, Ku argues that “some states’ projections of new costs appear to be overstated,” as governors have “not accounted for factors such as the reduced costs of serving the newly eligible.” Not only would the federal government be picking up the tab for most of the expansion (meaning that states would be covering more residents at little direct and will be able “reduce payments they make to support uncompensated care costs”), but Ku says that “most economists expect the economy and employment to brighten by 2014, so there should be fewer income-eligible people and higher state revenues than today.”

Of course, the expansion and increase volume of patient needs will require plans to expand networks and states will have to take steps “to design simple application forms and procedures, including online systems, that can operate across multiple points of enrollment; to develop systems to enroll applicants in the right programs; and to share date securely across programs.”

States will have to face their share of challenges in implementing reform, but in choosing to challenge the law rather than accept it, they are placing politics ahead of sound policy, kicking the can down the road and undermining the interests of their residents.

Today, Health Affairs released its new issue, dedicated to exploring how policymakers can effectively implement the new health care reform law. The issue asses “why reform finally passed” and makes suggestions for how regulators can design the new health insurance exchanges, implement the insurance market reforms, expand the Medicaid program, and transform the delivery system. I’ll have more on the issue as I read through it, but this study from the RAND corporation struck me as significant.

The researchers took an analytical approach to determining if reformers got the best deal possible (given the political limitations) and concluded that the bill “provides health insurance coverage to the largest number of Americans while keeping federal costs as low as reasonably possible.” The only alternatives that would have covered more Americans at a lower cost to the federal government were all politically untenable “– substantially higher penalties for those who don’t comply with mandates, lower government subsidies and less-generous Medicaid expansion,” the researchers found.

The study used this graph to illustrate the trade-offs between the number of people who are newly insured on the horizontal axis and the annual cost to the government on the vertical axis. The red square in the middle represents the new law. The blue line represents a boundary that contains all of the combination of policy parameters and the four territories are defined by the researchers’ estimate of the number of newly insured people—the horizontal line—and the annual cost to the government—the vertical line:

- Policies in 1: would produce results that are better than the new law (more insured people at a lower cost). The individual-mandate penalty would have to be much higher. To increase the number of newly insured people by 10 percent, the penalty would have to increase 47%.

- Policies in 2: would produce unequivocally worse results (fewer insured at a higher cost)

- Policies in 3A and 3B: would produce more newly insured people, but at a higher government cost than under the new law.

- Policies in 4A and 4B: would produce fewer newly insured people at a lower government cost.

Look:

“The key drivers of where a policy scenario falls,” the author note, “are the size and design of the individual mandate penalty and the eligibility threshold for Medicaid” (other policy options like level of subsidies, rate bands, and the employer mandate are also significant, but not determinative). Higher penalties for failing to comply with the requirement to purchase coverage specifically targets the uninsured and would produce a higher insured rate, while the Medicaid expansion also targets lower income Americans without coverage. But as the Medicaid threshold increases, more people are encouraged to “switch from employer-sponsored insurance to Medicaid—a phenomenon known as crowd-out.” “High rates of crowd-out are undesirable because they increase the cost of coverage expansion to the government without making a comparable reduction in the number of uninsured people,” the report argues. “Therefore, thresholds at 100 percent and 133 percent of the federal poverty level are preferred to higher thresholds.”

All this makes some sense, but it’s not entirely clear — as the researchers themselves admit — that more efficient policies would result in better or more affordable coverage for patients. For instance, while reducing the generosity of the subsidy, lowering the Medicaid expansion threshold or increasing the mandate penalty would reduce government spending, it would make health care less affordable for the consumer or force him to purchase coverage he can’t afford with less government aid.

So did Democrats find the sweet spot for reform or could they have secured a more “efficient plan?” Territory 1 suggests that they could have done a bit more, but that wouldn’t’ have necessarily endeared them any closer to their constituents.