A look back at the week's health policy news with a
focus on ACA implementation
New Kaiser survey data, subsidy case developments,
enrollment numbers, HHS going all in on payment reform, CBO projections, Indiana
expands Medicaid while trying to call it something else, measles and more.
But first, a lost puppy finds its way
home. OK, everyone in a good mood now?
Here we go.
ACA: Opposition/Court Cases
This week, an op-ed was printed in the Washington Post with
the provocative title End
Obamacare, and people could die. That’s okay. The
argument was that society makes choices all the time that lead to deaths. Needless
to say, some took issue with the piece: “He fails not because conservative
health policy ideas are inherently immoral, but because he must gloss over the
fact that the right’s current approach to implementing them is abominable.” (The
Conservative Plan to Repeal Obamacare Is Insanely Immoral) and then my personal favorite: “Some
people think it would be moral to force the staff of the American Enterprise
Institute to engage in gladiatorial bouts to the death for our amusement.” (the
author of the original piece works there) (Repealing
Obamacare Would Be Extremely Immoral).
The Senate
panel unanimously OKs bill letting employers exempt vets from sparking health
coverage. This is a feel good bill that will have little real impact. It
says that vets don’t count when calculating the number of employees relative to
the mandate. It has already passed unanimously on the floor of the House and is
supported by the White House. However, the floor vote in the Senate may still
get messy.
Republican leadership appeared on 60 Minutes for a wide
ranging discussion of their plans. Not surprisingly the talk turned to health
care when this happened: Boehner
and McConnell Bomb On 60 Minutes When Asked For GOP Alternative to Obamacare
“Republicans have had almost six years to come up with an ACA alternative. They
have had even longer to come up with a plan to reform health care. The
Republican plan is to return the country to a system where tens of millions of
Americans lack access to health care, and those with insurance are one medical
crisis away from bankruptcy.”
And speaking of not having a plan, Republicans
Are At A Loss On What To Do If SCOTUS Nixes Obamacare Subsidies This quote
from a Republican staffer is telling: “"It's an opportunity that we've
failed at for two decades. We've not been particularly close to being on the
same page on this subject for two decades," said a congressional
Republican health policy aide who was granted anonymity to speak candidly.
"So this idea — we're ready to go? Actually no, we're not."”
Now they are trying to force themselves to come up with
something: House
Bill To Repeal Obamacare Will Tell Committees To Write GOP Alternative
All this talk about alternatives comes as we near the SCOTUS
case on the availability of subsidies on the Federal marketplace. This week the
Administration filed its brief with the court: ACA
clear on allowing subsidies, Obama administration tells high court “The administration,
however, in its new brief, makes a number of arguments, including that the law
is clear, when read fully, in allowing tax credits in all states. The brief
cites a number of other places in the law that the administration says prove
that the credits were meant to be available to individuals in all states.”
Also this week, more amicus briefs were filed: “Health
insurance companies and hospitals mounted an aggressive defense of Obamacare's
insurance subsidies Wednesday, warning the Supreme Court that eliminating the
payments would be "grossly inequitable" to millions of Americans.” (Can
The Health Care Industry Save Obamacare? Hospitals and insurance companies are
coming to the law's defense before the Supreme Court.)
This week there was lots of discussion about how weak the
case against subsidies is. A key point made is that if the law was written with
no subsidies on the Federal Marketplace as an inducement for states to create
their own, then the states should have known about the threat. That was not the
case: Republican
state officials cast doubts on anti-Obamacare lawsuit “Several state
officials who were directly involved at the highest levels in early
deliberations over setting up state exchanges — all of them Republicans or
appointees of GOP governors — have told me that at no point in the
decision-making process during the key time-frame was the possible loss of
subsidies even considered as a factor. None of these officials — who were
deeply involved in figuring out what the law meant for their states — read the
statute as the challengers do.”
Also, if that were the case you would expect Republicans in
the House would have known about it: Republicans
Know Their Obamacare Case Is Bogus. Here's the Proof. “But that assumption didn't hold in
April 2011. Something else must explain CBO's 1099-repeal score, and the
Republican votes that followed it. What we have in the form of this bill is
clear evidence that everyone who voted for it (including every single
Republican, save the two GOP congressmen and one GOP senator who weren’t
present) understood the Affordable Care Act to provide subsidies everywhere.”
Since we’re not talking about the Founding Fathers, we can
actually ask some of the players in passage of the law. A key one is former
Nebraska Sen. Ben Nelson: “Nelson, a Democratic holdout as Congress debated the
bill, insisted that states take the lead in establishing the exchanges. And the
challengers use that to support their theory that Congress was using the tax
credits to induce states into establishing the exchanges, rather than having
the federal government do it. But Nelson, who announced his retirement in 2011,
speaks for himself in a brief filed by Democratic congressional leaders and
others. “I always believed that tax credits should be available in all 50
states regardless of who built the exchange, and the final law also reflects
that belief as well,” Nelson wrote in a letter to Sen. Bob Casey (D-Pa.) who
sought Nelson’s view.” (Supreme
Court case on key Obamacare provision takes up this senator’s account)
To sum up, The
Latest Obamacare Challenge Has Entered 'X-Files' Territory “That’s where we
are today. These conservatives have come a very long way. But there’s something
conspicuously missing from this widely shared conviction: any evidence of the
intent on which their entire argument rests. The truth is out there.”
In the height of irony those responsible for the potential
problem are asking how it would be fixed: GOP
to White House: What's your ObamaCare backup plan? “GOP lawmakers have a
big question for President Obama about the upcoming Supreme Court case that
could undo much of his signature healthcare law: What happens if we win?”
An issue with a legislative fix after SCOTUS rules is that
once the ruling occurs, the CBO will change their baseline budget. Putting back
what the court took away would “cost” $350 billion, a bill Congress is unlikely
to pay. (King
v. Burwell: The Prohibitive Cost of Any Congressional Response to a Ruling
Against the Affordable Care Act) Of
course this problem goes away if Congress fixed the law before the case was
heard, thus making the case moot. But that’s not likely to happen.
Unfortunately, there are no easy administrative fixes if the
court does rule against the subsidies: What
Obama Can Do If SCOTUS Cripples Obamacare “"There are no
administrative fixes that are realistic," said Neera Tanden, president of
the liberal Center for American Progress.” We don't believe there's any
administrative fix." … Without a fix in Congress or a good administrative
option, the only solution would be to convince the states to set up their own
exchanges. That would involve convincing Republican governors and
Republican-controlled state legislatures, all of whom have already refused to
set up their own exchanges once, to cooperate.”
Outside the beltway, things are a bit more rational: If
Supreme Court Rules Against Insurance Subsidies, Most Want Them Restored “But
if the court were to invalidate subsidies in the federally run states, 64
percent said Congress should restore them, and 59 percent said states should
create their own exchanges.” (From this month’s Kaiser survey discussed in more
detail below.)
But it’s inside the beltway we have to worry about, and last
night we received this not surprising message: Republicans
to Block Legislative Fix to Health-Care Law “Congressional Republicans say
they won’t move to preserve consumers’ health insurance tax credits if the
Supreme Court strikes them down, raising the stakes in the latest legal
challenge to the Affordable Care Act.”
ACA: Polls
This month’s Kaiser Tracking Poll is out (Primary Source: Kaiser
Health Tracking Poll: January 2015) In
addition to the subsidy question discussed above, one of the important findings
was: “With less than a month left in this year’s open enrollment period, most
uninsured are unaware of the deadline to enroll and a substantial share remains
unaware of the financial assistance available to help eligible people buy
insurance.”
Another survey from Kaiser looked specifically at the
uninsured: Some
Seeking Insurance Told They Didn’t Qualify, Others Balked At Cost, Poll Finds
“Nearly half of Americans lacking health insurance during the first year of the
health law’s marketplaces appeared to be eligible for government assistance,
but two-thirds of them said they found the health plans too expensive or were
told they didn’t qualify, according to a survey released Thursday.” Primary
Source: Adults
who Remained Uninsured at the End of 2014.
One puzzling result: “More than one-third of people who are still
uninsured under Obamacare -- but appear to be eligible for coverage -- were
told that they were not eligible for health insurance under the law, according
to a new report. … "People may have been confused about what they were
being told," Levitt said. "Or, they may have been told they were
ineligible for marketplace coverage but eligible for Medicaid, or vice versa,
and were confused by that or didn’t follow up."” (WTF?
Experts Stumped By New Finding On Obamacare And The Uninsured)
ACA: Enrollment
In addition to the weekly report, this week HHS released a
more comprehensive look at enrollment including both the Federal and State
marketplaces: Nationwide
9.5 million consumers are signed up for Health Insurance Marketplace coverage
“Today’s report includes data for individuals who selected or were
automatically reenrolled in coverage through Jan. 16 for the 37 states using
the HealthCare.gov platform, and through Jan. 17 for the states and Washington,
D.C. using their own Marketplace platforms.”
Obamacare
Nears Enrollment Goal “The total
includes new sign-ups and renewals of 2014 coverage, as of Jan. 16. It is the
first full picture of insurance exchange sign-ups for 2015, including both the
federal and the state marketplaces. The Obama administration hasn't met its
enrollment goal yet, but it's close. The Health and Human Services Department
said it aims to have between 9 million and million enrolled in exchange
coverage this year. Open enrollment closes Feb. 15.”
For those interested in rankings, acasignups.net has tried
to answer the question Which
states are doing the BEST this year? He compares the states across 4
different benchmarks.
You can find the weekly report here: Open
Enrollment Week 10: January 17, 2015 – January 23, 2015. Many areas saw a bit of a lull
following the 1/15 deadline for 2/1 coverage. That should change as momentum
builds to the 2/15 end date of this year’s open enrollment period.
And finally, a look at how Obamacare
advocates refine their pitch to millennials “Obamacare advocates stress
that the lower-key strategy reflects what has been learned about their target
group’s response to the health care law. A more direct, organic conversation,
they say, works better than some broad, national push relying in part on pop
stars, pro athletes or other big names.”
ACA: Taxes
Is everybody ready for tax-time? This year there will be something new since your
tax-return is where both the individual mandate is enforced and premium subsidies
are reconciled. You can read a good overview here: Here's
How Obamacare Is Going To Affect Your Taxes
While for many it will simply mean checking a box indicating
you have health insurance, the U.S.
Government Says Obamacare Could Affect Up to 29 Percent of Taxpayers: 2-4% expected to pay a penalty, 3-5% could have to
reconcile the federal and 10-20% percent are expected to use their tax filings
to seek exemptions from the law's coverage requirements
Given this is new to all of us, and that many people don’t
actually do their own taxes, HHS to work
with non-profit organizations and tax preparers to help consumers understand
the intersection of taxes and health care “U.S. Department of Health and
Human Services’ Secretary Sylvia M. Burwell announced today that HHS is
collaborating with a wide range of non-profit organizations and some of the
nation’s largest tax preparers to ensure that the public understands how health
care and their taxes intersect.” Link includes list of resources
Another development related to taxes this week: IRS
Waives Penalties for Late Payments Linked to Obamacare “The U.S. Internal
Revenue Service will waive some penalties for taxpayers who owe taxes because
of Obamacare. … The IRS will waive penalties for making that payment late or
for failing to pay estimated taxes throughout 2014.” Note that what is being waived is NOT the
penalty for not having insurance nor is it the amount that might need to be
paid back once subsidies are reconciled. For the details as always we turn to
Tim Jost (who covers some additional developments as well in this posting: Implementing
Health Reform: ACA-Related Tax Penalties Waived; High Court Turns Back Oklahoma
AG
ACA: Other
While in some ways insurers and consumers interests are more
aligned post-ACA, this is not always the case. It seems clear now that some
insurers are Using Drugs
to Discriminate “The complaint alleges that insurance companies in some
states are structuring their drug formularies in such a way as to discourage
patients with HIV from signing up. “ Primary Source: Using Drugs to
Discriminate — Adverse Selection in the Insurance Marketplace.
Bad behavior does not seem to be needed as those playing by
the (new) rules are doing will under the ACA: Health
insurer stocks have crushed market averages since Obamacare passed “Back
when Obamacare became law, there was lots of worry from the health care
industry about how a new layer of government bureaucracy would be terrible for
business.” The opposite happened “Health plans have handily outperformed the
S&P 500 during Obamacare's implementation. And it's easy to see why: the
health care law required Americans to purchase the products they sell or pay a
penalty. Enough healthy people have apparently turned up — and insurers are
doing great in the post-Obamacare landscape.”
Last week we reviewed a report regarding the use and safety
of consumer information on healthcare.gov. In response to those concerns, the
administration quickly took action: Added
Protections For Consumer Information On Health Website “The Obama
administration appears to be making broader changes to protect consumer
information on the government's health insurance website, after objections from
lawmakers and privacy advocates. … An independent analysis of the health care
website, released Saturday, showed that the number of embedded connections to
private companies had dropped from 50 to 30.”
Part of the ACA that hasn’t received much focus is the
requirements for non-profit hospitals. Those rules have now been finalized: Additional
Requirements For Charitable Hospitals: Final Rules On Community Health Needs
Assessments And Financial Assistance “Health – not just health care –
needs. The final rule makes clear that a CHNA can assess not only significant
unmet need for health care, but also significant health needs arising from
social conditions such as inadequate access to proper nutrition and housing and
“the mitigation of social, environmental, and behavioral factors that influence
health, or emergency preparedness.” In
response to extensive public health comments, the final rules thus embrace an
approach to the CHNA process that prioritizes “not only the need to address
financial and other barriers to care but also the need to prevent illness, to
ensure adequate nutrition, or to address social, behavioral, and environmental
factors that influence health in the community.” This strong signal that the
CHNA process is about community health — not simply access to health care — is
reinforced by IRS efforts in recent years to clarify that community benefit
spending can encompass not only subsidized access to health care but also
investments in community health improvement and community building that is
linked to community health.”
Payment Reform
On Monday (1/26/15) HHS made a “historic” announcement
regarding how Medicare will change the way it pays for medical care. I wrote a
separate posting detailing the announcement and some of the initial reaction,
you can read it here: HHS
announces they are going for Better, Smarter, Healthier
Below I’ll briefly review the announcement and some of the
follow-up analysis along with a companion announcement by a group of private
payers.
“…Health and Human Services Secretary Sylvia M. Burwell
today announced measurable goals and a timeline to move the Medicare program,
and the health care system at large, toward paying providers based on the
quality, rather than the quantity of care they give patients.” (Better,
Smarter, Healthier: In historic announcement, HHS sets clear goals and timeline
for shifting Medicare reimbursements from volume to value)
The basic idea is to finally move away from the fee-for-service
payment structure. The announcement sets out admirable goals and is gutsy in
that it lays out specific benchmark numbers by which success can be judged. But
as is to be expected with any announcement of this scope, there are elements to
be admired and elements to be questioned.
There was also a piece by the Secretary in the New England
Journal of Medicine: “The Department of Health and Human Services (HHS)
now intends to focus its energies on augmenting reform in three important and
interdependent ways: using incentives to motivate higher-value care, by
increasingly tying payment to value through alternative payment models;
changing the way care is delivered through greater teamwork and integration,
more effective coordination of providers across settings, and greater attention
by providers to population health; and harnessing the power of information to
improve care for patients.” (Setting Value-Based
Payment Goals — HHS Efforts to Improve U.S. Health Care)
This piece, while calling it: A
Courageous First Step includes a cautionary note about moving forward:
“Many have dipped a timid toe, or hedged their bets with low-regret moves like
buying up practices and forming organizations that are Accountable Care Organizations
(ACOs) in name only. Unfortunately, this strategy is already too widespread,
and likely to grow as long as large organizations are allowed to continue in
“one-sided” (upside only) shared savings models, as recently proposed by CMS.
It’s also a major reason why so few hospital-sponsored ACOs have actually
achieved savings bonuses. Defensive moves by hospital systems provide a veneer
of action, while consolidating regulator-blessed market dominance that can
raise local prices without improving quality at all.”
And this: ““We still have very little evidence about which
payment methods are going to be successful in getting the results we want,
which are better quality care and more affordable care,” said Suzanne Delbanco,
executive director of Catalyst For Payment Reform, a California-based nonprofit
that has been tracking the spread of alternative payment models in the private
sector. “We’re just wanting to avoid a situation where a few years from now,
where we’ve completely gotten rid of fee-for-service, we don’t want to wake up
and say, ‘Oh my gosh, we did it and we’re no better off.’”” (HHS
Pledges To Quicken Pace Toward Quality-Based Medicare Payments)
But it wasn’t just HHS making big announcements re payment
reform: Industry
Group to Back Results-Focused Care The coalition said it was committed to
finding a way to change the financial incentives, moving the bulk of payments
to so-called value-based arrangements by 2020, in which cost and quality would
be part of the equation. Many health care systems and insurers are already
experimenting with such arrangements. The announcement comes on the heels of a
similar vow by Health and Human Services Secretary Sylvia M. Burwell on Monday.
She said half of all traditional Medicare payments would be based on quality of
care or value by 2018. … While largely rhetorical, the commitments by Medicare
and the private sector group reflect a fundamental shift in thinking. “We’re
very much aligned and share a common goal here,” said Fran S. Soistman, an
executive vice president for Aetna, who said the federal government’s
announcement “bodes well” for the overall effort.”
One element of value purchasing is reference pricing. Here’s
a look at how effective that has (and hasn’t) been so far: Reference
pricing, what could possibly go wrong?
Here is a good overview reminding us
that so far these goals are aspirational. Measuring quality is
hard and to date providers have been reluctant to share risk: “Gilfillan said
the task force members are committed to revamping how hospitals and doctors are
paid even if they're not entirely sure how to do it. “We go out and we set ambitious
goals that are consistent with our commitment to the great healthcare providers
and we don't know everything we need to know about how to get there,” he said.
… The declarations, however, leave many questions unanswered, raising doubts
about whether meeting the targets will accomplish the desired improvements in
quality and efficiency. Medicare's newly announced push to rapidly adopt
accountable care and other new payment models was met with concerns from health
policy experts that Medicare incentives are tied to weak measures of quality.” (Where
healthcare is now on march to value-based pay)
My bottom line, while we must move away from fee-for service,
the data is not yet clear on exactly where we should be going. The
announcements this week are great steps forward, but we need to remember that
the new ways to compensate providers are still being refined. In the end the
system may need even more radical changes than those currently being discussed to
achieve the stated goals.
And finally, two reminders from today’s headlines that that
change is hard. First: Medicare
Payments Surge for Stents to Unblock Blood Vessels in Limbs Just as progress is being made to reduce unnecessary
cardiac procedures we see a spike in unnecessary peripheral revascularizations as
some providers find a way to make up for lost revenue with procedure of
questionable value.
Second: “New reports show that two big experiments run by
the health law’s innovation lab, known as the Center for Medicare &
Medicaid Innovation, delivered mixed early results in enhancing primary care.
The programs reduced expensive hospital visits in some cases but struggled to
show net savings after accounting for their cost.” (Mixed
Results For Obamacare Tests In Primary-Care Innovation)
Costs
The CBO released new projections this week. They included
several new numbers related to the ACA. I’ll let the numbers speak for
themselves:
“Meanwhile, the CBO said that the
cost of the Affordable Care Act continued to come in substantially below the
March 2010 estimates. Because the program gets more expensive over time, the
10-year cost estimates have risen. But costs compared year by year remain
lower.
In March 2010, the CBO and Joint
Committee on Taxation projected that the ACA would cost the federal government
$7billion during fiscal years 2015 through 2019. The newest projects put the
cost at just $571 million over those years, about 20 percent lower than the
original estimates, the CBO said in its report. The latest projections for the
cost in 2019 are $132 billion, or 23 percent less than the original projection.
The CBO said that the ACA had
reduced the number of uninsured people by 12 million in 2014 and would by 19
million in 2015. It said that between 2016 and 2025 the legislation would reduce
the number of uninsured by 24 million to 27 million people.
That would still leave 31 million
people uninsured in 2025, about 30 percent of them “unauthorized immigrants,”
about percent in states that have chosen against expanding Medicaid coverage,
15 to 20 percent of whom would be eligible for Medicaid and choose not to use
it, and about 40 to 45 percent of whom would have access to insurance but
choose not to use it.” (CBO:
Interest on federal debt will triple over coming decade)
Also on the cost front, in Drew Altman’s latest he discusses
the limitations of price transparency in curbing cost problems. This sentence will
sound familiar to my regular readers: “While consumers urgently need better
price information, it’s hard to see that being a complete antidote to massive
price variation.” (Why
Data on Health-Care Price Variation Doesn’t Itself Solve the Problem) Or in other words, cost transparency is a necessary
but not sufficient condition to stemming out of control prices.
Medicaid
Lots of Medicaid news this week. Let’s start with a
question: Do
Low-Income Consumers In Medicaid Opt-Out States Pay More Out Of Pocket? “Under
Medicaid, far fewer of these adults’ family health costs would exceed percent
of their income: 6.0 percent, compared to 17.1 percent under silver exchange
plans.” No surprise there, (but data!) evidence that Medicaid is less burdensome
than private insurance.
Keep that in mind as we turn to the news out of Indiana,
where Gov.
Pence gets federal OK for Medicaid alternative. “Everyone
on the Healthy Indiana Plan will be required to make a contribution ranging
from $1 to about $27 per month, depending on income. This money, which amounts
to about 2 percent of family income, funds a $2,500 Personal Wellness and
Responsibility, or POWER, account, which functions like a Health Savings
Account.”
That’s some of the complexity of the
plan that received a waiver from HHS. You can read more of the details here: Press
release: CMS and Indiana Agree on Medicaid Expansion.
Whatever you do, don’t call this a Medicaid expansion (even
though that’s exactly what it is): “"Republicans are reticent to embrace
expansion of entitlement programs, and thus they are quick to avoid calling it
Medicaid expansion," Caroline Pearson, vice president at Avalere Health,
an independent consulting firm, told TPM in an email. "They also use
branding with other program and waiver names to further distance themselves
from the Obamacare Medicaid expansion."” (Republican
Rhetorical Gymnastics On Medicaid Expansion Are Getting Crazy)
Why so afraid of the name, one reason is Republican Party
politics: Another
Republican Governor Has Accepted the Medicaid Expansion—and He Might Run for
President “The early consensus is that, if indeed Pence decides to run,
this decision would cause him trouble in the GOP primary. But the issue poses a
dilemma for the Republican Party more broadly, especially its hopes of
recapturing the White House.”
But Pence would not be alone: “Should Pence decide to run
for the 2016 Republican nomination, he could join other rumored hopefuls Chris
Christie of New Jersey and John Kasich of Ohio as governors who bucked party
orthodoxy to accept Obamacare Medicaid expansion funding.” (More
evidence that conservative Republicans are caving to Obamacare).
When the ACA was passed The
Goal Was Simplicity; Instead, There’s a Many-Headed Medicaid “But advocates
for Medicaid beneficiaries worry that the added complexities of the new
programs — with premiums and co-payments and other requirements — will be a
burden for the program’s poor beneficiaries, and a hassle for state officials
and medical providers to oversee. “It’s hard to imagine feeling nostalgic for
Medicaid as an administratively simple program,” Ms. Alker said. “But I’m
beginning to feel that way.” Some people have argued that managing all the
rules and collecting premiums and payments may cost a state more money than it
will earn. And there are studies that show that premiums, in particular, tend
to discourage low-income people from signing up for coverage and seeking the
care they need.””
Unfortunately we’ve seen elsewhere that for this population,
premiums will suppress enrollment: “Premiums aren’t supposed to be a means to
discourage people from gaining access to the health care system. But that seems
to be how they’re functioning in Medicaid.” (Medicaid
Gives the Poor a Reason to Say No Thanks “)
We have also seen time and time again, the fallacy of
cost-sharing being a useful tool. Yes it may suppress care, but it suppresses
needed care as much as unneeded care: People
With Chronic Illness Fare Worse Under Cost-Sharing “What we see from this study is that families
with higher levels of cost-sharing were significantly more likely to delay or
avoid going to the office or emergency room for their child’s asthma. They were
more likely to have to borrow or cut back on necessities to afford care. They
were more likely to avoid care. This isn’t a good outcome. We’re talking about
children with a completely manageable chronic condition who are being hampered
by cost-sharing. That’s not what cost-sharing is supposed to do.” … “Plans
that increased co-pays saw two additional hospitalizations and 13 more days in
the hospital per 100 people. These increases were worse in older people who
lived in low-income areas, and among those who were documented to have high
blood pressure, diabetes or a history of heart attack.”
So bottom line, while many would say any expansion is better
than no expansion, this one pushes the limits.
Another unique aspect of the plan is that even after the
100% Federal reimbursement steps down to 90%, there will be no added cost to
the state: “Under the agreement, Indiana will pay for its share of the
expansion costs beginning in 2017 with hospital fees and a cigarette tax. … “I
think this raises the level of interest in looking at these issues in states
that have not expanded Medicaid,” said Joe Antos, a health economist at the
conservative American Enterprise Institute. “Lawmakers in Texas may not be
influenced but there are other states that will want to know more.”” (Indiana
Medicaid Expansion May Tempt Other GOP-Led States)
Also news this week in other states. 2017 will bring with it
the 1332 waiver program that is part of the ACA. These waivers allow states to
drastically change the way they comply with the law (with certain
qualifications regarding not reducing coverage, etc.). As part of his speech
last week encouraging extension of the private option for 2 years, Arkansas Gov.
Hutchinson said the state should start planning its waiver program. Here is a
look at the Arkansas marketplace report on the topic: Arkansas
Health Insurance Marketplace report examines 1332 waivers, potential tool for
future reform. This is the first specifics we’ve seen about preparing a
waiver application, there will be a lot more on this in the coming months.
And finally, it looks like Wyoming
headed toward Medicaid expansion “Mead initially opposed Medicaid expansion
under the Affordable Care Act, and the state joined a Republican-backed lawsuit
aimed at overturning the health law. But, he said in a recent interview, now
that the Supreme Court has upheld the law, Wyoming should take advantage of
federal money that would cover uncompensated care that costs state hospitals
more than $100 million a year.”
Measles/Vaccination
Lots of coverage this week as the number of measles cases
continued to spread. We saw Arizona
tracking up to 1,000 potentially exposed to California-linked measles virus. In California we saw Demand
for Measles Vaccine Sends Crowds Even to Anti-Vax Docs “Demand for measles
vaccines has overwhelmed some pediatricians in California — even the doctor
best known for treating anti-vaccine activist Jenny McCarthy's son.”
At the same time, Kaiser
calling parents who refused to vaccinate against measles. They thought that by next week they will have reached
out to everyone in their records who was not vaccinated. All the attention may
have another benefit, Forget
‘anti-vaxxers.’ The Disney measles outbreak could change the minds of an even
more crucial group. “But doctors believe the current outbreak could change
the minds of a less-known but even larger group: parents who remain on the
fence about the shots.”
But what should be done moving forward? Sick
Child’s Father Seeks Vaccination Requirement in California. Others are putting forward a more radical plan: Measles
Is Spreading And Kids Are At Risk. Sue Parents Who Didn't Vaccinate?
Absolutely. When all else fails, sue! Sounds funny, but the article does a
thorough review of the topic and comes to the conclusion that it may be the
only way to motivate some people.
On a more moderate note, this reminder from Melinda Gates
that we don’t know how good we have it: "We take vaccines so for granted
in the United States," Gates told the Huffington Post in a prerecorded
interview published on Thursday. "Women in the developing world know the
power of [vaccines]. They will walk kilometers in the heat with their child and
line up to get a vaccine, because they have seen death. [Americans have]
forgotten what measles deaths look like."" (Melinda
Gates has the perfect response to the anti-vaccine movement)
There are some who argue that more than those opting out, the
bigger problem is access: The
Real Reason Kids Aren't Getting Vaccines. While that might be a factor,
this startling fact says that access doesn’t have to be a problem: Mississippi
– yes, Mississippi – has the nation’s best child vaccination rate. Here’s why. “It’s tough being a child in Mississippi. The
state has the nation’s worst rates for infant mortality and low-weight
newborns. Its childhood poverty rate ranks as the nation’s second worst.
Overall, the residents of Mississippi are the unhealthiest in the country. But
there is one notable exception to these dour health stats: Mississippi has the
highest vaccination rate for school-age children. It’s not even close. Last
year, 99.7 percent of the state’s kindergartners were fully vaccinated. Just 14
students in Mississippi entered school without all of their required shots. … The
secret of Mississippi’s success stems from a strong public health program and —
most importantly — a strict mandatory vaccination law that lacks the loopholes
found in almost every other state.”
So we see it can be done, even in a state with few resources.
Other coverage looked at how the disease may have started,
in both the current case and with this article, in an outbreak from last year: How an Amish
missionary caused 2014's massive measles outbreak.
But at the end of the day, the initial case is not the
issue. For now there will always be a way for these outbreaks to get started,
it’s what happens next that we need to focus on: This
is how outbreaks occur. It isn’t complicated. “1) Someone travelling/living
abroad contracts the disease and comes to the US 2) Other people who are
susceptible to the disease come into contact with them here at home 3) Those
people contract the disease 4) Go back to step 2. That’s it. It doesn’t matter
if the person from step one was an illegal immigrant, a doctor working
overseas, or an Amish Missionary. Since we can’t control what other countries
do, and we live in a world where people travel, (1) is going to occur at some
point.”
So what we have to do is get those vaccination rates up,
plain and simple.
Ebola
“There's finally good news on the ongoing struggle to stamp
out the world's worst Ebola outbreak: the number of new cases is falling
quickly. Fewer than 100 Ebola cases were discovered in West Africa last week:
there were 30 in Guinea, four in Liberia, and 65 in Sierra Leone. The World
Health Organization says the epidemic has entered its "second phase,"
and that the global community can now focus on slowing transmission to get to
the finish line. “ (There are fewer
than 100 Ebola cases in West Africa. Is the end in sight?)
System Transformation
Efficacy/Quality of Care
The President mentioned this in his State of the Union
address. Today (1/20/2015) he attached specific numbers to his proposal: Obama
Wants $215 Million For 'Precision Medicine' Plan “The vast majority of the
proposed funding would go to the National Institutes of Health: $131 million,
plus another $70 million for the National Cancer Institute, which is part of
NIH. Many of the biggest advances in precision medicine, also known as
personalized medicine, have come in the field of cancer treatment, and cancer
would be a major focus for Obama's new initiative as well.”
One of the reasons an initiative like this is needed is
because “In truth, medical care is often far less effective than most believe.
Just because you took some medicine for an illness and became well again, it
doesn’t necessarily mean that the treatment provided the cure.” (Can
This Treatment Help Me? There’s a Statistic for That) As this piece points out, we have tools to understand
this (number needed to treat!), they are just not used regularly.
In addition to treatments that are not effective, we also
suffer from medical errors. A topic we’ve covered before, but as Vox begins a
yearlong project with ProPublica on the topic, they provide this comprehensive
overview on how bad the situation truly is: Medical
errors in America kill more people than AIDS or drug overdoses. Here's why.
And then, in addition to errors (which are by definition
unintentional) we have those who intentionally mislead: Read this
before you ever believe another guest on the Dr. Oz Show.
End of Life Care
It’s never too soon to talk about what your priorities are
when it comes to health care and extreme measures. Here are The 6 questions
every good doctor should ask you to help start the planning.
Similarly we are reminded that Learning
About Hospice Should Begin Long Before You Are Sick. This is a great overall review of hospice
care including questions to ask potential providers. “But experts in
end-of-life care say most Americans need to start thinking about hospice long
before the final six months is near. As the American Cancer Society notes on
its website: “One of the problems with hospice is that it’s often not started
soon enough. Sometimes, the doctor, patient, or family member will resist
hospice because he or she thinks it means you’re ‘giving up,’ or that there’s
no hope. This is not true. If you get better or the cancer goes into remission,
you can leave hospice and go into active cancer treatment.””
On a less crucial but nonetheless important note, another
part of planning concerns social media accounts: What
I'll Do With My Parents' Facebook After They Die. Understanding people’s
wishes (and having passwords available to carry them out) is another sign of
respect.
Handling death in all its forms is hard, but what does it
say that we sometimes do a better job with our pets than with our parents? In
My Cat’s Death, a Human Comfort “Recently, when I told a friend about my
cat’s death from cancer, I found myself saying, “It was such a better
experience than when my mom died!” I realized how crazy it sounded — I hadn’t
meant to compare their deaths like accommodations on Trip Advisor — but it was
true.”
Etc.
OK, if anyone is still with me, we’re almost done for this
week.
A long overdue emphasis on EHR interoperability is finally
here: Federal
health IT coordinator sets 2017 deadline for interoperability “The federal
health IT coordinator released a wide-ranging report Friday morning on how to
improve interoperability in electronic health record systems. The report,
“Connecting Health and Care for the Nation, A Shared Nationwide
Interoperability Roadmap,” calls for most providers to be able to use their
systems to send, receive and use “a common set of electronic clinical
information. . . at the nationwide level by the end of 2017.””
Continued back and forth regarding how to regulate new
healthcare technology: This
Medical Supercomputer Isn’t a Pacemaker, IBM Tells Congress, but some in
Congress aren’t listening: Dems
balk on medical technology bill
And finally, from someone who has experienced both, a
comparison of the US and British healthcare systems: What
It's Like When You're An American Using Britain's NHS.
All
comments and suggestions are welcome; please let me know what you think. And as
always, thanks for reading!
Funded by support from
the Maine Health Access Foundation
*The title is a tribute to the BBC show, the NBC show and the amazing Tom Lehrer album "That Was The Year That Was"
