By Katherine Hobson

Put on your green eye shades, because we’re about to dive into one of the hotter recent issues in health care: the McKinsey report on implications of the health-care overhaul law.

The report, issued earlier this month, surveyed 1,329 employers and concluded that when fully implemented in 2014, the law could prompt 30% of employers to drop coverage for their employees. Instead, companies would pay a fine and let employees purchase coverage through one of the health-insurance exchanges.

This caused quite a to-do, for two reasons: first, McKinsey’s findings were very different than analyses by other organizations (including the Rand Institute and the Congressional Budget Office), which found a much smaller impact on employer-sponsored insurance. Second, until today, McKinsey refused to discuss the methodology behind the study. Some congressional Democrats publicly called for the company to do so.

In a statement released this afternoon, the consulting firm said it stands “by the integrity and methodology of the survey,” but that it was never intended as “a predictive economic analysis” of the health law’s impact. “Rather, it captured the attitudes of employers and provided an understanding of the factors that could influence decision making related to health benefits,” McKinsey said.

The survey, conducted by an outside market-research firm, asked employee medical benefit-decision makers about their familiarity with nine provisions of the health law. They were given “factual information” about those provisions and asked how they would likely react to them starting in 2014, in terms of maintaining or changing coverage. They were also asked about their concerns about ceasing coverage.

“As noted, the survey only captured current attitudes,” McKinsey said, and comparing it to findings from the other studies “is comparing apples to oranges.”

About those other studies: earlier in the day,  Avalere Health issued an analysis of what Rand, the CBO, the Urban Institute and the Lewin Group had concluded, based on their own simulation models. The net change estimated by those studies ranged from a 0.3% drop in the number of workers covered by their employers to a 8.4% increase. Other surveys also pointed towards relative stability in employer-sponsored insurance, Avalere said.

The research and consulting firm also addressed an analysis by a former CBO director that found a larger negative impact for employer-sponsored insurance, but said it didn’t take into account factors like the tax treatment of that benefit and the expected increase in wages if coverage is dropped.

While the net effect is projected to be pretty minimal, Avalere says that some types of companies, mostly those employing low-wage workers, will see changes after 2014. Those companies are more likely to pay the penalties, while their employees get coverage through Medicaid or the insurance exchanges. And coverage for early retirees is likely to be curtailed, Avalere said.

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Would you work for one third of what you’re usually paid because the government demanded it? That’s what doctors are asked to do in Medicaid, the joint state/federal health care program for the poor.

“One of the challenges for Medicaid is that the reimbursement levels for doctors are lower than they are for Medicare, that’s true across the country,” says Neera Tanden of the Center for American Progress, a liberal-leaning think tank. And Medicare pays some 20 percent less than private insurance.

With Medicaid reimbursement so far below Medicare, access to care is endangered.

Virginia’s Republican Governor Robert McDonnell says, “You don’t want to undermine the quality of care for Medicaid patients because you have a shrinking number of doctors and hospitals that accept Medicaid.”

One of the oft-hidden truths about government-funded health care is that it is hard to get a doctor because they’re paid so little.

The costs of Medicaid are shared by the states and the federal government, but the states manage it. And they approach it in very different ways.

“What you tend to see is larger, more urbanized, more politically liberal states tend to provide more generous eligibility,” says Ed Haislmaier of the conservative Heritage Foundation.

Those states make people further up the income scale eligible for Medicaid. Some offer benefits to those with incomes as high as three times the poverty level — close to 60,000 dollars in income for a family of three.

But that drives up costs, and to afford them, those states have to pay doctors rock bottom rates.

“The worst offender is New York state,” says Haislmaier. “A primary care physician in New York state gets paid about a third from Medicaid what that doctor would get from an elderly Medicare patient … under Medicare.”

California pays 46 percent of what Medicare pays.

That raises the question of whether being eligible means anything if beneficiaries have trouble getting a doctor.

“Good luck trying to find a doctor cause the pay is so bad the doctors just would go broke if they took Medicaid patients,” says Haislmaier.

“If doctors aren’t being reimbursed at a proper level, then they choose not to offer coverage and that, that becomes an access issue,” adds Neera Tanden of the Center for American Progress.

However, other states, like those with big rural populations such as Oklahoma and Mississippi, limit eligibility but pay doctors at or near 100 percent of Medicare rates because they want to make sure people in rural areas can find a doctor when they need one.

So, ironically, some poor states pay doctors better than rich ones.

Under the new health care law, the federal government will give states the money to pay primary care doctors at 100 percent of Medicare rates, but only for two years. Then the states are back on their own — facing the same old dilemma of deciding between broad eligibility or broad access to care.

The staff of the Department of Veterans Affairs Tennessee Valley Health-care System Nashville/Murfreesboro (VA TVHS) is proud to serve America’s heroes and strives to provide a safe, high-quality environment for our veterans, their families and our volunteers.

Part of our proactive approach includes both internal and external inspections to help us identify opportunities to improve upon the services we provide. All of these inspections are part of our organization’s commitment to the ongoing quality journey to provide unsurpassed care to America’s heroes. VA TVHS is a fully accredited health-care system with the Joint Commission, the College of American Pathologists, and is certified by many other organizations. The Office of the Inspector General (OIG) is another part of our quality journey.

In March 2011, VA TVHS completed its biennial internal VHA Office of the Inspector General Comprehensive Assessment Program. This proactive review ensures that VA TVHS has the most effective processes in place to ensure high-quality health services. The OIG has a dual role during their assessment to identify opportunities for improvement as well as recognizing areas where facilities are performing well. During our assessment, VA TVHS was recognized for our effective processes in place to provide comprehensive care coordination for our veterans and to meet the complex medication management needs to the more than 80,000 veterans throughout Middle Tennessee and Southern Kentucky.

All health-care organizations in both the public and private sectors participate in health-care surveys, reviews and inspections; there are always findings for improvement. VA TVHS views these findings as opportunities to improve the health care we provide our veterans. The findings in the OIG report were not concerning direct patient care, but were about systems or processes relating to management that needed further development. Of these recommendations for improvement, several findings were addressed immediately and others have action plans in place to provide prompt corrective actions.

Commitment to transparency

The Veterans Health Administration (VHA) is committed to public transparency including the sharing of performance and quality data as a way to help veterans and their families make informed decisions about their medical care. Many inspection reports, such as the OIG and Joint Commission reports, are made available to the public.

Public transparency is not a new activity for VHA. VHA Core hospital measures have been available on the Joint Commission website, www.qualitycheck.org, since 2005. VA has published additional performance measures on the VA Quality of Care website, www.qualityofcare.va.gov, since 2008. More recently, in March 2010, VA expanded outreach to veterans and their families by offering direct comparisons of VA facilities with private-sector counterparts on www.hospitalcompare.va.gov.

As a learning organization, VA TVHS openly accept all reviews and recommendations for improvement from all of our regulatory and accrediting bodies. VA TVHS is a dynamic organization with highly qualified and dedicated individuals who truly care about the veterans we serve. Our employees and volunteers are committed to ensuring that our veterans continue to receive the highest quality of care they have earned and deserve.

(CNN) — A federal appeals court in Atlanta was openly skeptical Wednesday that the sweeping health care reform law championed by President Barack Obama would survive constitutional scrutiny.

A three-judge panel heard arguments in a massive lawsuit brought by Florida and 25 other states.

The 11th Circuit Court of Appeals was the latest of three similar federal panels across the country to hear challenges by states and private groups to the Patient Protection and Affordable Care Act. Separate rulings from those courts in coming months will form the basis of a certain appeal to the Supreme Court, which could offer the final word on the landmark legislation, perhaps in time for the 2012 election year.

Supreme Court won’t jump into health care fray — for now

The main issue was the law’s so-called individual mandate, the requirement that most Americans purchase health insurance by 2014 or face severe financial penalties. Lawyers for the states said forcing people to buy a product like health insurance is unconstitutional and unprecedented.

“If we uphold the individual mandate in this case, are there any limits on congressional power?” asked Judge Joel Dubina, who was named to the bench by President George H.W. Bush. His daughter is a first-term GOP congresswoman from Alabama, Rep. Martha Dubina Roby.

The two other judges who heard the nearly 2 1/2 hours of arguments — Judges Frank Hull and Stanley Marcus — were also concerned the law went too far in mandating that states expand various Medicare health coverage requirements. Both judges were appointed by President Bill Clinton.

Health reform, one year later

The case, Florida v. U.S. Department of Health and Human Services, was moved up from District Court after a judge in January declared key provisions of the health care law unconstitutional.

Initial arguments refocused attention on the issue of “coercion.” Basically, the 26 states are arguing that the requirement that states expand Medicaid coverage amounts to compulsion and coercion of the states, in violation of the 10th Amendment to the U.S. Constitution.

The judges also heard arguments on “severability” — whether the determination that one provision of the law is unconstitutional invalidates the entire act. District Court Judge Robert Vinson, who heard the case in January, ruled that the unconstitutionality of one individual mandate voided the entire piece of legislation.

The appellate court heard arguments regarding the individual mandate as well, but focused much of their time and attention on the issue of coercion.

Paul Clement, who argued for the state of Florida, said after the hearing, “We were very gratified that the court … was very interested in the coercion arguments, and the fact that this is the most coercive statute ever passed, that really limits the ability of states to make a decision or not.”

Florida Attorney General Pam Bondi issued a statement congratulating Clement on his work.

“Our attorney … did an excellent job,” the statement said. “The federal government could not rebut our argument that the individual mandate is an unprecedented intrusion on individual liberty. … I am encouraged by the judge’s response to our arguments that the health care law’s Medicaid expansion unconstitutionally coerces the states by forcing them to assume billions in uncompensated Medicaid costs.”

Acting U.S. Solicitor General Neal Kuma Katyal presented the Department of Health and Human Services’ case. He specifically addressed the individual mandate. Katyal said it was a tax and, therefore, constitutional.

Texas Attorney General Greg Abbott picked at Katyal’s argument: “The lawyer for the Obama administration actually threw President Obama under the bus, because the Obama administration lawyer came out and said, ‘This is a tax,’ which is contrary to what President Obama promised, which is that he would not raise taxes on people.”

Joining Florida in its challenge are Alabama, Alaska, Arizona, Colorado, Georgia, Idaho, Indiana, Iowa, Kansas, Louisiana, Maine, Michigan, Mississippi, Nebraska, Nevada, North Dakota, Ohio, Pennsylvania, South Carolina, South Dakota, Texas, Utah, Washington, Wisconsin and Wyoming.

Virginia and Oklahoma have filed separated challenges, along with other groups and individuals opposed to the law.

There are about 450 components to the health care law. Some will not go into effect for another two years, but some have already gone into effect.

The parts of the law currently being administered include small-business tax credits, federal grants and consumer protection measures.

The 6th Circuit Court of Appeals in Cincinnati heard arguments last week in another case related to the health care act. The 4th Circuit in Richmond, Virginia, heard two challenges last month.

Judges in Florida and Virginia have found parts of the law unconstitutional in recent months, while courts in Michigan and Virginia have upheld provisions.

Legal experts expect challenges to the health care law to ultimately end up before the Supreme Court, although that could take at least a year or two.

CNN’s Kim Hutcherson and John Sepulvado contributed to this report.

People with pre-existing conditions, like arthritis, were pleased when the Affordable Care Act was passed and signed in March 2010. The law created the Pre-Existing Condition Insurance Plan (PCIP) which made health insurance available to people who had been denied coverage by private insurance companies because of their pre-existing condition. PCIP is an interim program until further access to affordable health care becomes available in 2014.

The Pre-Existing Condition Insurance Plan is administered by either your state or the U.S. Department of Health and Human Services, depending on where you live. Initially, PCIP rules stated that, to qualify, you had to have a pre-existing condition, have been denied health coverage because of your condition, be a U.S. citizen or reside in the U.S. legally, and be without health coverage for at least 6 months. As of July 2011, there will be some changes to PCIP, in large part because a lower-than-expected number of Americans have signed up for PCIP. The premiums for PCIP are being cut considerably — perhaps as much as 40% in some states. Also, applicants will no longer be required to produce a letter from the insurance company that denied coverage. Applicants will just need a letter from their doctor or health professional stating they have a medical condition. Applicants will still be required to prove they have been without health insurance coverage for at least 6 months. More information: All About PCIP and the Change in Requirements.

Related Resources:

• Health Care Reform Bill – What People With Arthritis Should Know
• Cost of Biologic Drugs Steers Some Arthritis Patients Away
• Comorbidities Increase Financial Burden of Rheumatoid Arthritis

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