| By Jonathan Easley (@joneasley) Today's Legal Brief: Today's Washington Read: Today's Business Brief: Today's Chart Review: Poll: Americans Believe Medicare Needs To Change from Morning Consult by Michael Ramlet
 Mark Your Calendars (All Times Eastern): Wednesday: National Center for Policy Analysis briefing on healthcare expenditures @12pm Wednesday: House Small Business Committee hearing on technology and innovation @1pm Wednesday: Wednesday: Quarterly Earnings – Biogen, Gilead, Omega Healthcare, Omnicare, USANA Health Sciences, Varian Medical Systems Thursday: Senate Finance Committee hearing on Social Security @10am Thursday: Quarterly Earnings - Alexion Pharmaceuticals, Boston Scientific, Bristol-Myers Squibb, Cerner Corp., Eli Lilly, IMS Health Holdings, Proto Labs, Universal Health Realty Friday: National Committee for Quality Assurance primary care briefing @9am Friday: Quarterly Earnings – AbbVie, Aon, Covidien, LifePoint Hospitals, Magellan Health NEWS ARTICLES 1-9: General 10-13: Payers
14-16: Providers 17-20: Pharma/Biotech/Device 21: Health IT OPINIONS, EDITORIALS, PERSPECTIVES 22: Wall Street Journal
23: Health Affairs
24: Washington Post
25: Bloomberg
26: Healthcare Policy and Marketplace Review
27-28: Morning Consult
29: Forbes
RESEARCH REPORTS, ISSUE BRIEFS, CASE STUDIES
30: Morning Consult  NEWS ARTICLES General
1) Appeals Courts Issue Conflicting Rulings On Health Law Subsidies from Wall Street Journal by Brent Kendall and Stephanie Armour Two U.S. appeals courts issued conflicting rulings on whether consumers can receive subsidies for health coverage purchased on insurance exchanges established by the federal government, clouding implementation of a major component of the Obama administration's signature health care law. In a substantial blow to the administration, the U.S. Court of Appeals for the District of Columbia Circuit, on a 2-1 vote, invalidated an Internal Revenue Service regulation that implemented a key piece of the 2010 Affordable Care Act. The regulation said subsidies for health insurance were available to qualifying middle- and low-income consumers whether they bought coverage on a state exchange or one run by the federal government. Two hours later, a Richmond, Va.-based appeals court reached the opposite conclusion, unanimously upholding the IRS rule and handed the White House a victory that counteracted the administration's loss in the other case.
2) Rulings On Health Law Far From the Last Word from New York Times by Margot Sanger-Katz An appellate court ruling issued Tuesday would be very bad news for the Affordable Care Act if it became the law of the land. But it's still a long way from a settled issue, as a second appellate decision, issued a few hours later, highlighted…The disagreement, called a circuit split, means that we are still a long way from any possible concrete actions. The cases will be appealed further, either for reconsideration by the appeals courts that issued the ruling, or go to the Supreme Court.
3) Democrats Still Haven't Learned Obamacare Lesson
from Politico by David Nather and Jennifer Haberkorn Memo to Democrats: This is what happens when you pass a law where you can't fix simple drafting errors. Within hours of each other, two federal courts came to the exact opposite conclusions Tuesday about whether the vague wording of Obamacare allows people to get subsidies through the federal health insurance exchange. One said, sorry, that's not what the law says. The other said, sure they can get the subsidies — the Obama administration has the power to do that. The conflicting rulings were another wake-up call for Democrats about the fragility of the health care law — and a reminder that whenever they think a lawsuit is no threat to the law, it's probably a threat to the law.
4) The Potentially Huge Cost of the Halbig Decision
from Washington Post by Jason Millman The D.C. appellate court ruling in Halbig v. Burwell, that the federal government isn't authorized to administer insurance subsidies in the 36 states that refused to set up their own health insurance exchanges, is a major blow to the key feature that makes coverage affordable. Of the 5.4 million people who signed up for coverage in the 36 states with a federal exchange, 87 percent of them received federal subsidies to purchase insurance, according to the Obama administration. Those discounts, on average, meant those customers are paying about one-fourth of their actual premium, the Department of Health and Human Services reported. The consulting firm Avalere Health calculated that those states by 2016 would forfeit about $36 billion in federal subsidies to purchase insurance.
5) Court Rulings Raise Fear of Instability from Modern Healthcare by Andis Robeznieks Healthcare providers and insurers fear that today's conflicting appellate court rulings on the legality of Obamacare premium subsidies offered through the federal insurance exchange could have a destabilizing effect on the newly expanded insurance market.
6) GAO Sting Finds Obamacare Premiums Easy To Fake
from NBC News by Maggie Fox and Joel Seidman Eleven out of 12 fake applications for government-subsidized health insurance got through a verification process and the bogus beneficiaries are still covered, the Government Accountability Office said Tuesday. The GAO launched the sting to check to see how well the Obamacare process checks for counterfeit applications. The results were messy, GAO's Seto Bagdoyan says in testimony prepared for a hearing Wednesday of the House Ways and Means oversight subcommittee.
7) White House To Tweak Birth Control Coverage Rule For Nonprofits
from Huffington Post by Laura Bassett The Obama administration is developing a new accommodation for religious nonprofit organizations that want to opt out of covering contraception in their health plans without having to fill out a form, according to a brief the Department of Justice filed on Tuesday in the U.S. 10th Circuit Court of Appeals.
8) Americans Believe Obamacare Is Helping Them, Poll Finds
from CNN by Paul Steinhauser More than half the public says Obamacare has helped either their families or others across the country, although less than one in five Americans say they have personally benefited from the health care law, according to a new national poll. A CNN/ORC International survey also indicates that a majority of Americans oppose the Affordable Care Act, but that some of that opposition is from people who don't think the measure goes far enough.
9) U.S. Stock Index Futures Rise Amid Earnings Reports
from Bloomberg by Anna Hirtenstein U.S. stock-index futures advanced, after the Standard & Poor's 500 Index rose to within two points below a record, as investors weighed earnings by Microsoft Corp. and Apple Inc. Microsoft gained 2.3 percent in premarket trading after fourth-quarter revenue beat estimates and the company said its Nokia handset business will break even in two years. Apple was little changed after reporting a drop in iPad demand and projecting third-quarter revenue below analysts' predictions. Juniper Networks Inc. declined 5.4 percent as its financial forecasts trailed expectations. Futures on the S&P 500 expiring in September added 0.2 percent to 1,978.8 at 7:31 a.m. in New York. The equity gauge rose yesterday after inflation data signaled the Federal Reserve won't be compelled to raise interest rates in the near future. Dow Jones Industrial Average contracts climbed 20 points, or 0.1 percent, to 17,053 today. Payers
10) Obamacare Premiums Not Living Up To Doomsday Predictions
from National Journal by Sam Baker Obamacare's critics promised the law would send insurance premiums skyrocketing. They were wrong. Or, if they're not wrong, they're at least not right yet. Nearly 20 states have released preliminary information about premiums for insurance policies sold on their insurance exchanges, and the nightmare scenarios have not come to pass. In most of those states, the average increase across all exchange plans is in the single digits. According to a PricewaterhouseCoopers analysis of 18 states' initial filings, 10 states will see average premium increases of less than 10 percent—nominal hikes in line with the standard increases that have happened every year with or without Obamacare.
11) Industry Grapples With Narrow Networks Backlash
from Modern Healthcare by Paul Demko Narrow networks are a reality of the new health insurance landscape. Nearly half of all insurance plans sold on the public exchanges in 2014 were narrow network plans, defined as those with less than 70% of area hospitals included, according to an analysis by the research firm McKinsey & Company. But given that reality, insurers and providers need to do a better job of providing consumers with accessible, easily understandable information about networks when they shop for coverage. That was the message conveyed by participants in a panel discussion about network adequacy on Monday in Washington sponsored by the Alliance for Health Reform.
12) Businesses Back Bill To Nix Obamacare Auto-Enroll Feature from The Hill by Ferdous al-Faruque Major businesses want to overturn an ObamaCare provision that requires large employers to enroll workers automatically into a health insurance program if they don't sign up on their own. Businesses including 7-Eleven, Lowe's, Petco Animal Supplies and White Castle wrote to Sen. Johnny Isakson (R-Ga.) on Tuesday supporting his bill to overturn the mandate they call too much of an administrative burden.
13) Dual-Eligibles Opting Out of Care Coordination
from Modern Healthcare by Virgil Dickson People who are eligible for both Medicare and Medicaid are opting out at high rates from voluntary state initiatives aimed at better coordinating their care. So-called dual-eligibles often have a difficult time navigating the policies of both programs to get the services they need. Caring for them is also significantly more expensive than for other beneficiaries in the programs, costing the state and federal programs about $350 billion a year. The 9 million dual-eligibles make up just 13% of the population enrolled in both programs but account for 40% of all Medicaid spending and 27% of all Medicare spending. Providers
14) Missouri's Unprecedented Push To Ease the Doctor Shortage
from Governing by Chris Kardish A new Missouri law allows recent medical school graduates to practice primary care in underserved areas without completing a residency in a teaching hospital. The Missouri State Medical Association, the law's chief backer, is calling it an unprecedented effort to help deal with doctor shortages in rural and other underserved areas, but opponents raise questions about whether circumventing the traditional path to the exam room will do more harm than good.
15) California Nurses Union Braces For Contract Battle
from NPR by April Dembosky The California Nurses Association is rousing its troops for battle. The powerful union will begin bargaining Thursday with on a new four-year contract for nurses at its northern California hospitals. Kaiser operates the largest hospital system in the state — largest by number of hospitals and by number of hospital beds — and is the eighth largest health system in the country.
16) Nurses Shift, Aiming For More Time With Patients
from Wall Street Journal by Laura Landro Hospitals are freeing up nurses to do the one thing they often don't have enough time for: taking care of patients…Now hospitals are changing traditional work practices, shifting more routine tasks to certified nurse assistants and other less highly skilled staffers. They are eliminating inefficient processes that make nurses walk as many as 5 miles around the hospital in a single shift. Some hospitals are aiming to triple the amount of time nurses spend with patients. Pharma/Biotech/Device
17) Americans Prefer Brand-Name Drugs To Generics, Study Finds
from Huffington Post by Alexander C. Kaufman A 100-pill package of CVS-brand aspirin costs $1.14 on the company's website, while pharmaceutical giant Bayer's version sells for $6.99. Yet time and time again, the typical shopper chooses the pricier brand-name drug, even though it's essentially the same, according to a recent study by Dutch economist Bart J. Bronnenberg and three University of Chicago professors. The researchers, whose findings were published this month by the National Bureau of Economic Research, estimated American consumers are spending an extra $44 billion a year on brand-name drugs, healthcare items and pantry goods that are no more effective than cheaper, generic equivalents.
18) Most Americans Worried About the Cost of Specialty Meds, Poll Finds
from Wall Street Journal by Ed Silverman As the debate over pharmaceutical pricing continues to rage, a steady stream of reports, charts and surveys are being issued in support of the various arguments over cost and value. The latest example is a poll that finds a large majority of Americans are mostly satisfied with the prices of their medicines, but worry they will not be able to afford expensive specialty medicines, if needed.
19) FDA To Overhaul Generic Drugs Division from Regulatory Affairs by Alexander Gaffney The US Food and Drug Administration's (FDA) long-awaited reorganization of its Office of Generic Drugs (OGD) is finally getting underway, the agency said in a statement today. Since late 2012, FDA has been planning to elevate OGD to a so-called "Super Office"—an office which reports directly to the director of the Center for Drug Evaluation and Research, a position now held by longtime Director Janet Woodcock…But since Woodcock announced the changes, FDA has suffered several major departures that threatened to derail—or at least delay—the effort.
20) HHS Reissues Disputed 340b Policy On Orphan-Drug Discounts
from Modern Healthcare by Jaimy Lee HHS issued an interpretive rule that requires drug companies to provide discounts on orphan drugs sold through a federal program just months after a judge struck down the government's previous version of the rule. The drug industry has contested the Obama administration's interpretation of a provision in the Patient Protection and Affordable Care Act, arguing that the government didn't have the authority to issue the legislative rule in 2013. The Pharmaceutical Research and Manufacturers of America, the drug industry's lobbying group, sued HHS last year, and a federal judge ruled against HHS in May. The administration, however, took the position that the outcome allowed it to reissue the same policy in a different form. Health IT
21) Crowd-sourced Data Sheds Light on Healthcare Costs, Payment Systems from Association of Healthcare Journalists by Joanne Kenen Here's a resource for health care costs – and a creative journalistic model of crowdsourcing, data collection, mapping, reporting and blogging. ClearHealthCosts.com was started by former New York Times reporter and editor Jeanne Pinder…It's about shedding light on a health care cost and payment system that, to use Pinder's word, is "opaque." Some of what they are doing is specific to a half-dozen cities; other projects are building out nationally.The data collected by ClearHealthCosts focuses on elective or at least nonemergency procedures such as imaging, dental work, vasectomy, walk-in clinics, screening (mammograms and colonoscopy) and blood tests. Much of the data is crowdsourced, and focused on New York area, including northern New Jersey and other suburbs; the San Francisco and Los Angeles areas; and Houston, Dallas-Fort Worth, Austin and San Antonio in Texas.
From Hope to Cures:
Hepatitis C attacks the liver of more than three million Americans, and is directly linked to 15,000 deaths each year. But America's biopharmaceutical companies are fighting back – with new and forthcoming breakthrough treatments curing more than 90% of patients. OPINIONS, EDITORIALS, PERSPECTIVES
22) Reining In Obamcare and the President from Wall Street Journal by Jonathan Adler and Michael Cannon A three-judge panel of the U.S. Court of Appeals for the D.C. Circuit—a tribunal second only to the Supreme Court—ruled on Tuesday that the Obama administration broke the law. The panel found that President Obama spent billions of taxpayer dollars he had no authority to spend, and subjected millions of employers and individuals to taxes he had no authority to impose. The ruling came in Halbig v. Burwell , one of four lawsuits aimed...
23) The Controversy, Stakes, and Way Forward After Halbig
from Health Affairs by Timothy Jost July 22, 2014 was arguably the most important day in the history of the implementation of the Affordable Care Act since the Supreme Court issued its ruling in the National Federation of Independent Business case in June of 2012…It is hard to avoid the impression that the Fourth Circuit was lying in wait for the D.C. Circuit, intending to issue its opinion immediately in the wake of the D.C. Circuit's, thus taking the edge off of the challenge the D.C. Circuit decision presents to the ACA.
24) Conservative Party Over Halbig Short-Lived
from Washington Post by Greg Sargent Only hours after Obamacare opponents celebrated the D.C Circuit Court's decision invalidating subsidies to those the federal exchange, the Fourth Circuit Court has now weighed in with precisely the opposite decision, upholding the IRS rule extending those subsidies. That was a short party wasn't it? Now the story is no longer "crushing blow" — the first decision would have invalidated subsidies in three dozen states, taking subsidies from millions — but "split decision."
25) Obamacare Suffers A Body Blow
from Bloomberg by Megan McArdle
Courts are cautious about fatally damaging major laws, and if this ruling stands, it would be pretty damaging. Most of the people who bought new insurance on the exchanges qualified for subsidies; many of them will exit if the subsidies are withdrawn, and those most likely to exit are the young and healthy. Which brings us back to the specter of an insurance-market death spiral in states with federal exchanges. That's not a guaranteed outcome -- I'll write more about the possible permutations later today. But even if it's not guaranteed, it's certainly a risk. So this is a major ruling, which will potentially have a major impact on a major law.
26) Halbig Decision A Huge Political Headache For Republicans
from Healthcare Policy and Marketplace Review by Bob Laszewski This would put Republicans in the federal exchange states in a heck of a political bind. It seems to me these governors and legislators could opt to immediately proactively contract with the feds to operate their exchanges for them in order to preserve the subsidies (If a state can contract with Accenture to build and run and exchange, why couldn't it contract with HHS to do the same?). If the states were to do this immediately, no one would have to lose their subsidies. So what would these Republican governors and legislators do? In effect, the political consequences for all of these people losing their subsidies and their coverage would immediately shift to the Republicans who control these state governments.
27) Sovaldi: Charting An Unsustainable Path
from Morning Consult by John Rother we stand at a crossroads in drug discovery. We can either continue down a path of widespread access to life-saving drugs or go down a road where the prices of some new drugs are so unsustainably high that it may render their existence nearly meaningless for many of us. Perhaps nowhere is the threat of following the latter path more obvious than with Sovaldi, a new treatment for hepatitis C.
28) For Bigger and Better Health Systems, Scale Matters
from Morning Consult by David Johnson and Nathan Bays
This increasing merger activity has ignited a vigorous debate from Boston to Boise regarding industry consolidation (more efficient, anti-competitive or both). The high profile and now controversial acquisition of three Boston area hospitals by Partners Health System is just the latest example of the tension between efficiency, outcomes, market presence and price. Often lost in this debate is whether bigger health systems deliver better health care. In the battles for regulatory approvals and consumers' hearts, minds and wallets, health systems that can demonstrate better post-merger outcomes, lower costs and improved patient experience will lead industry transformation.
29) Led By Missouri, Politicians Lower Standards For Practicing Medicine
from Forbes by Leah Binder The new law means that in Missouri, you can be seen by a 20-something whose training consists of courses like Organic Chemistry and perhaps dissecting a cadaver or a frog. This person will have a medical school degree from the U.S. or abroad, but very little hands-on experience in caring for live human patients. Missouri allows this politician-created version of a doctor to treat your diabetes, congestive heart failure, back pain, and/or pneumonia; he'll give you a shot, set your fracture, or prescribe you a narcotic. If you are worried about your kid's high fever, you had better hope he remembers the stuff about infections from Biology class last year. That may not be enough, anyway. This politician-created doctor does not have to pass the medical test that proves he can translate the science into sound patient treatment. From Hope to Cures: Without new treatments and cures for Hepatitis C, annual U.S. medical costs associated with the disease are projected to nearly triple over the next 20 years – from $30 billion to $85 billion. But now new and forthcoming treatments are curing more than 90% of patients and driving down future medical costs like liver transplants – which often cost more than $500,000.
RESEARCH REPORTS, ISSUE BRIEFS, CASE STUDIES
30) Poll: Americans Believe Medicare Needs To Change
from Morning Consult by Michael Ramlet About 8 in 10 voters from each party agree that Medicare needs a major or minor change. Independents and Republicans were similar in that 4 in 10 wanted to make minor changes and about 4 in 10 wanted to make major changes. Three in 10 Democrats want to make major changes and the 5 in 10 who want to make minor changes. | 
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