That Was The Week That Was - Issue 48

A look back at the week's health policy news with a focus on ACA implementation

“The only constant in life is change” – Heraclitus

This week I present to you Issue 48 of That Was The Week That Was. And with mixed emotions I write to tell you that the last edition will be Issue 52 (to be published on March 13).

I cannot thank the Maine Health Access Foundation enough for supporting this publication. Through their support I have been able to, as my wife says, read more about healthcare than is probably good for me. It has been a tremendous learning experience and a lot of fun. However it’s time for me to move on to my next adventure.

Like John Stewart (that other guy who announced this week he was leaving his current gig), I’m not yet sure what my next step will be. I’m interested in moving back to a full-time position related to health policy, either here in Maine or elsewhere. For those of you not familiar with my background, I spent 20 years working in various capacities for Mercer Human Resource Consulting (employer-sponsored health care). Since coming to Maine I worked at Health Dialog, where I created a new department - The Office of Program Coordination, and was the Policy Director at Consumers for Affordable Health Care. You can read more about me on my LinkedIn Profile. If any of you have any thoughts or suggestions, please let me know

In the meantime, we still have a month together that will include the wrap-up of open-enrollment, the Supreme Court hearing oral arguments on the subsidy case, and I’m sure many surprises. So without further ado, here is this week’s issue where we look at an ACA replacement plan, more on the subsidy case, open enrollment ending, Medicaid expanding or not, measles, provider consolidation, end of life and more. Here we go.

ACA: Opposition

Last week we took an initial look at the “replacement” plan introduced by Burr/Hatch/Upton. Now other smarter people have taken a more detailed look and have also found it lacking: “The Hatch-Upton-Burr plan claims to provide affordable coverage and improved access to care as a replacement for the Affordable Care Act. But relative to current law, the plan would likely disrupt existing coverage for millions of people — including many poor beneficiaries who rely on Medicaid today — and cause many of them to become newly uninsured or underinsured. It would move the United States backward, toward the poorly functioning individual market that existed prior to health reform.” (Republican Health Plan Would Cause Millions to Lose Current Coverage and Add to the Ranks of the Uninsured and Underinsured). 

And this: “And there is a deeper lesson. One should not be fooled by slogans and generalities. One has to examine details in order to know whether a plan is or is not a basis for negotiation. Make no mistake—details of Obamacare do need fixing-- but those repairs involve filling holes in coverage, not making more holes. It requires making benefits more generous, not less. The Burr-Hatch-Upton plan proposes to move in the wrong direction. Such a plan cannot serve as a basis for negotiation.” (Not Ready for Prime Time: The Burr, Hatch and Upton Obamacare Proposal)

ACA: Court Cases

Lots of talk this week about the subsidy case (King v Burwell). With oral argument less than a month away, the media is taking stock of all the briefs that have been filed. First let’s note that “… not a single business group—not the US Chamber of Commerce, not any of the health industry companies and trade groups that opposed the law when it was being drafted—has presented a brief endorsing this lawsuit.” (America's Largest Health Care Company Tells Supreme Court That Anti-Obamacare Argument Is "Absurd")  In addition to no businesses supporting the suit, many have filed defending the existing subsidies: “Among those filing amicus briefs defending health reform are HCA, the American Hospital Association, America's Health Insurance Plans, the National Alliance of State Health Co-ops, the Catholic Health Association of the United States, the American Cancer Society, and the National Association of Community Health Centers.” (Backing Obamacare Ahead of Supreme Court Hearing).

Also, more theorizing about the case itself. Starting with a new email unearthed showing intent of the staff that drafted the bill: Key Premise Of Obamacare Lawsuit Contradicted By Email Senate Aide Sent In 2010 “The premise of the latest legal attack on Obamacare has always been shaky. An email that a key Senate staffer wrote in January 2010 would appear to make it even shakier.”

And these two (warning, legal theorizing ahead), the first deals with federalism: “When it comes to the exchanges, however, the ACA is not a conditional spending program. And it’s not a close call: the ACA doesn’t look like any other conditional spending program in the U.S. Code. … For starters, Congress isn’t coy about what happens when a state fails to participate in a conditional spending program. It speaks clearly—the state doesn’t get the money—and that consequence is spelled out in a provision that speaks directly to states.” (Respecting the states.) And the second deals with the word “such”: “The fate of Obamacare might hinge on the Supreme Court’s interpretation of just one word: “such.” Perhaps never before has so much been asked of “such.” It is a key part of the Obama administration’s argument urging the high court not to invalidate the Affordable Care Act’s insurance subsidies in most of the country.” (The One Word That Could Save Obamacare)

Also this week, the media started to look at the actual petitioners in the suit – remember, an individual has to be harmed to have standing to sue. Looks like it was tough to find such people: The Conservative Obamacare Challenge Has Become an Absurdist Comedy “The Supreme Court case that could eliminate Affordable Care Act subsidies in 34 states is nested in a fictional history of Congressional intent, and thus has a lot to answer for. Its credibility sustained a further hit this week, when reports in the Wall Street Journal and Mother Jones revealed damaging information about at least three, and possibly all four, of the King vs. Burwell petitioners.” 

“To be clear, the standing questions almost certainly won’t be enough to disable the lawsuit. All it needs is one plaintiff with standing. And there are other people out there — on other lawsuits, and beyond — who can legitimately claim injury. This legal challenge will go forward one way or another. But all of these new, emerging details feed the generally trumped-up, circus-like sense that is increasingly enveloping this lawsuit. And there are plenty of questions about it that remain unanswered.” (Morning Plum: Anti-Obamacare lawsuit comes under intense media scrutiny)

As the day of reckoning gets closer, a reminder that you should be careful what you wish for: Health Law Case Poses Conundrum for Republicans “On the one hand, Republicans in Congress are urging the Supreme Court to strike down subsidies for health insurance provided to millions of people in more than 30 states. On the other, they are chiding the Obama administration because it has no plan to avert the hardship that could occur if they win in court.”  Understanding the consequences, both practical and political, brings us here: Why Republicans Secretly Hope the Supreme Court Will Save Obamacare “If the Court grants Republicans a “victory,” many actual Republicans won’t consider it a victory at all, and the competing concerns of anti-Obamacare zealots, industry-friendly pols, swing state incumbents, governors, and presidential candidates will break out into the open.”

Remember that if the suit is successful, it impacts only states that use the federal marketplace. That means there are states where the suit will have no impact, leading to this: Get ready for deeper polarization of our health care system “For a time, it looked as if supporters of the Affordable Care Act had reasons for optimism about the law’s long-term prognosis in red states, as one GOP governor after another accepted the logic of the Medicaid expansion, which promises state lawmakers huge amounts of federal dollars to improve the lives of their own constituents. But it now looks like such optimism may have been premature: That logic is hitting a wall of opposition from conservative legislators even in states where GOP governors had thrown themselves behind versions of the expansion. All this — taken with the possibility that the Supreme Court could soon gut subsidies in three dozen states – suggests we may be heading for deeper polarization in our health care system.”

ACA: Enrollment

As I write this on Thursday night, there are three days left to open enrollment. So if you’re reading this and are not covered, stop reading and go sign up. OK, everyone else, let’s start by looking at the most recent enrollment report. It showed the expected uptick for the week before the deadline: Open Enrollment Week 12: January 31, 2015 – February 6, 2015 “Since Open Enrollment began on November 15, 7.75 million consumers selected a plan or were automatically re-enrolled through the HealthCare.gov platform, which includes the Federally Facilitated Marketplaces, State Partnership Marketplaces and supported State-Based Marketplaces.”

Here in Maine, last week showed double the activity we had the week before - mirroring the activity for the week of the Feb 1 effective date deadline – but remember, unlike that deadline, this one is for keeps marking the end of the open enrollment period (there are exceptions for life events, but if you’re reading this you probably know that, if not you can find info here: Your options outside Open Enrollment).

Week Ending	Cumulative	Week
9-Jan	59,126
16-Jan	61,964	2,838
23-Jan	62,983	1,019
30-Jan	64,069	1,086
6-Feb	66,118	2,049

The Marketplace has staffed up and is ready for the final rush since as a species, we do love to wait for the last minute: “Thousands of more friendly and better-trained call-center employees will be working starting Monday to deal with the expected late onslaught of people signing up before the Obamacare open enrollment ends Feb. 15. A 40% increase, to a 14,000-person workforce, is expected to help with wait times, which averaged about 2 ½ minutes the last week of January, but are likely to get longer as the deadline nears.” (A friendlier Healthcare.gov call center prepares for rush)

ACA: Marketplaces

Three reports out this week looking at coverage details on the marketplace:

Almost 6.5 million consumers qualify for an average tax credit of $268 per month through the Health Insurance Marketplaces “The U.S. Department of Health and Human Services released today a report outlining the impact of advanced premium tax credits on premiums in the Health Insurance Marketplaces. Almost 6.5 million individuals in the 37 states using the HealthCare.gov platform are estimated to qualify for an average of $268 per person/month in advanced premium tax credits. Among consumers who are signed up for 2015 coverage to date in the 37 HealthCare.gov states, 8 in 10 could choose a plan with a premium of $100 or less after tax credits, based on available options.”

Characteristics of Those Eligible for Cost-Sharing Reductions and Premium Tax Credits Under the Affordable Care Act Primary Source – Urban Institute study “The authors find that if all those eligible enroll in a plan by 2016, they would save, on average, $479 per year on things like co-pays, deductibles and co-insurance. Co-insurance is the percentage of the actual cost of health services—things like prescriptions, imaging tests, hospital stays, etc.—that a person has to pay out-of-pocket for covered services.”

New Reports Analyze Cost Sharing in 2015 ACA Marketplace Plans in 37 States “In a new brief and collection of 36 charts, the Foundation compares cost sharing across standard silver plans and their variants in federally-facilitated ACA marketplaces, examining average deductibles and out-of-pocket limits, as well as copayments and coinsurance for hospital stays, physician visits, emergency room visits, and prescription drugs.”

ACA: Affordability

Unfortunately, with the battle continuing for the mere existence of the law, there is little prospect in the near future of trying to improve it. And make no mistake, as much as an improvement the law was over the status quo, there is still work that needs to be done. One of the main areas that could be improved is affordability.

We know that everything is trade-offs. If you want low premiums, you end up with high cost sharing. The law as it currently exists tries to soften the blow with cost sharing subsidies and out-of-pocket limits, however the current situation is not all we might wish it to be. One of the issues with high cost sharing is that it indiscriminately leads to less care – both needed and unneeded care and that can have unintended consequences: High deductibles could stymie efforts to slow healthcare spending “That's because patients are likely to forgo highly effective treatment to escape medical bills under high deductibles. The new study found use of preventive medicine dropped when one employer switched to high-deductible health benefits. … “This study adds confirmation to the simple adage: If you make people pay more for something, they will buy less of it, regardless of the clinical value,” Fendrick said.”

The NY Times also took a look at the issue. However, one lack in this piece is that it focuses on some examples of people that have real issues without providing balance or magnitude.  Yes these people need more help, but do they represent 5% of those covered or 50%? “The Affordable Care Act has ushered in an era of complex new health insurance products featuring legions of out-of-pocket coinsurance fees, high deductibles and narrow provider networks. Though commercial insurers had already begun to shift toward such policies, the health care law gave them added legitimacy and has vastly accelerated the trend, experts say.” (Insured, but Not Covered)

But to end on a positive note, a Study finds it cheaper for students to buy insurance than go without “A new analysis from the CSU Health Insurance Education Project found that half the approximately 445,000 students in the CSU system are able to purchase health insurance for less than they would have to pay in fines for remaining uncovered.”

ACA: Other

This piece takes a look at Puerto Rico, it is a fascinating story – they have Medicaid expansion with no insurance subsidies or individual mandate, but they do have a no pre-existing condition exclusion – a situation that many states could find themselves in if SCOTUS rules against the subsidies: In Puerto Rico, Health Overhaul Gets An Incomplete

Many of the new insurance plans set up with government loans (COOP plans) are struggling. However the S&P report singled out our own Maine Community Health Options as the exception: Obamacare Insurance Co-Ops Struggle With Cash Flow “Obamacare’s startup health insurance plans are flirting with financial distress, as all but five of the 23 nonprofit companies had negative cash flow from operations in the first three quarters of 2014, Standard & Poor’s said in a report today.”

Medicaid

Let’s start this week’s Medicaid look with a focus on Maine. First, Mike Tipping takes a look at the predictions of last year’s Alexander report in light of the new MaineCare budget, and confirms (yet again) how bad the report was: LePage-authorized Alexander Report was a complete con job, new numbers show.

Also a look at the impact of not expanding Medicaid on our community health clinics: Community health clinics struggle with impact of MaineCare cuts ‘’ Since Maine trimmed eligibility for MaineCare, reducing the ranks of Medicaid patients from 357,000 in 2011 to about 290,000 this year, community health centers have increasingly felt the financial fallout.”

The problems providers face when Medicaid isn’t expanded are not unique to Maine, here’s a look at Baton Rouge: When a state blocks Obamacare, ERs close: The lesson of Louisiana “Baton Rouge, La., is about to lose one of its crucial hospital emergency rooms, and the reason is clear: The administration of Gov. Bobby Jindal has refused to expand Medicaid under the Affordable Care Act, and won't put up any other money to keep the facility open.”

It’s worth remembering that Medicaid is a big program and there are other topics to discuss besides expansion. While we know the President’s budget will not be passed as is, there are reforms included that will become part of the discussion. One important one is this: Is Obama Budget The Beginning Of The End For Nursing Home-Based Medicaid? “Under a new pilot program, as many as five states could effectively skip that waiver process. Instead, they could assess a person’s care needs and simply determine where she could receive the most appropriate, cost- effective care. No longer would a nursing home be the default solution.”

And with that exciting news behind us, back to Medicaid expansion…  Here is a great review by the NY Times of this week’s developments. Chief among them are the two red states where the Governors were supporting expansions but the legislature said no: Complicated Politics of Medicaid Expansion Are Playing Out State by State “These new developments underscore just how complicated the politics of expanding Medicaid have become — and just how different the results of seeking an expansion have been from state to state.”

Medicare

“On Thursday the CMS issued a national coverage determination giving certain Medicare beneficiaries immediate coverage for the screening test.” (Medicare will pay for lung CT scans for cancer screening)

However, there was those who questioned the decision: Can I interrupt your repeating a Medicare press release to talk about cost-effectiveness? “Wait, what? For current smokers, the cost effectiveness for current smokers of this screening was $116,000 per QALY. For former smokers – which Medicare is going to cover – the incremental cost-effectiveness was more than $2.3 million per QALY. And this study was using 2001 $US, cause it was published back in 2003. Now, people in this country may think that’s money well spent. That’s fine. But let’s acknowledge that this is a pretty high cost per QALY gained. I see nothing but praise for this development in the media, while Sovaldi (incremental cost-effectiveness of less than $26,000 per QALY $54,000 per QALY) is often portrayed as a budget-busting, crazily priced monstrosity.”

We know we can’t do everything, so we really do need to be having frank discussions on what we cover and don’t cover.

Measles

So much has been written in the past few weeks on this topic, what else is there to say?  We are in the middle of an outbreak that could have been a lot less severe if everyone was up-to-date on their vaccines. Some want nothing to do with vaccines, some think they know better and should spread them out more, and some have busy lives and can’t get everything done on time. All the attention is good, with a bit of perseverance and luck it will lead to higher vaccination rates.

With that in mind, and again sparing you all the links I could have shared, here are a few highlights from this week:

A look at the delayers: The vaccine delayers: They hate anti-vaxxers — but don't quite vaccinate on time

An important public endorsement, once again trying to combat one of the more pervasive lies about vaccines: Autism Speaks, leading autism advocate, urges vaccination “A leading autism advocacy organization, Autism Speaks, is urging parents to vaccinate their children amid a measles outbreak that has swept 14 states. As some continue to cite unfounded fears that vaccinations can lead to autism, Autism Speaks chief science officer Rob Ring has released a statement saying vaccinations cannot cause the disorder — and telling parents to vaccinate their children.”

Most politicians are rallying together (note I said most, not all): Bipartisan support voiced for vaccinations, as one critic stays away ““Too many parents are turning away from sound science,” said Sen. Lamar Alexander (R-Tenn.), chairman of the Senate Committee on Health, Education, Labor and Pension during a hearing. “Sound science is this - vaccines save lives.””

An update to an employment policy that can help those too young to be vaccinated: KinderCare requiring measles shots for infants' caregivers “A national day care provider says that as of next week it will require measles vaccinations for all staff members who work with children less than months old, after health officials in Illinois announced measles diagnoses in five infants who attended a suburban Chicago center.”

And finally a look at the dollars involved in combatting an outbreak: Measles Outbreak in Dollars and Cents: It Costs Taxpayers Bigtime “But only a handful of folks have talked about costs. Measles is expensive. Really expensive. And even if you live in a highly vaccinated area with no outbreaks, a measles case in your state – that’s a third of the U.S. right now – still means health department tax dollars diverted from other programs to deal with a disease that was eliminated from the U.S. in 2000.”

Drugs

Ever wonder why I’m not a big fan of the pharmaceutical industry?  One big reason is that they expect profit margins that hospitals, providers, and insurance companies can only dream of. They claim they deserve that because of the amount they spend on research. But take a look at this: 9 of 10 top drugmakers spend more on marketing than research “These spending numbers are at odds with a common claim by pharmaceutical companies that they need to patent drugs for extraordinary amounts of time to justify the massive amounts of money spent on research. Not only do many top drugmakers appear to spend more on advertising, but their profit margins, the BBC noted, are often larger than their research spending.”

John Oliver in his show this week took a look at the industry, it’s worth watching if for no other reason than this wonderful line: “"Drug companies are a bit like high-school boyfriends," Oliver said. "They're much more concerned with getting inside you than being effective once they're in there."” (John Oliver returns with a devastating message about pharmaceutical companies)

When did this country turn its back on science?  I have no answer, but I do have two examples this week.

Prescribing off-label: It’s gotten out of control “Modern medicine was meant to be different — it would be based on scientific evidence that could tease out real effect from placebo effect. Unfortunately, evidence-based medicine is only as good as the evidence it is based on. And in many instances our evidence is not very good because it comes from biased drug company studies.”

Stupid Pills: The Politics of Fraudulent Dietary Supplements  “To understand how we got here, you have to go back to 1994, when Senator Orrin G. Hatch of Utah midwifed through Congress a new industry protected from all but minimal regulation. It is also an industry that would make many of his closest associates and family members rich. In turn, they’ve rewarded him with sizable campaign contributions.”

Costs

Yes cost increases have moderated recently, but don’t be fooled. We still have a long way to go and worse, we are really not sure of the path to true cost control.

One possibility is called all-payer rate setting. Here Vox takes an in-depth look at the issue: All-payer rate setting: America’s back-door to single-payer? “All-payer rate setting, as the system is known, shares the same goals of single-payer: it aims to increase efficiency and reduce insurer overhead in the health care system. Single payer does this by eliminating private plans for one government plan. All-payer rate setting gets there by setting one price that every health insurer pays for any given medical procedure.”

The ACA does not address the issue, but in an interview, the President seemed to point in that direction (at least when it comes to prescription drugs): On health-care prices, Obama goes where Obamacare doesn't “In an interview with Vox, Ezra Klein asked Obama whether America should have "private insurers band together with Medicare, with Medicaid, to jointly negotiate prices." Obama answered by saying: "I think that moving in the direction where consumers and others can have more power in the marketplace, particularly when it comes to drugs, makes a lot of sense."”

One sign that we are still figuring things out has to do with provider consolidation. On the one hand it’s claimed that it improves efficiency and patient care, on the other hand it gives the consolidated organization more market power which can lead to higher rates.

This week, the courts weighed in: Courts prove tough crowd for consolidating providers ““I think this is sort of a wake-up call for hospital systems,” said Matthew Cantor, an antitrust lawyer with the firm Constantine Cannon in New York. “Just stating that you're merging to better patient outcomes to achieve the goals of the Affordable Care Act—that you somehow intend to gain cost efficiencies without providing the flesh to that argument—that's not going to work under antitrust laws,” Cantor said.”

One way consolidation contributes to price increases is the different ways hospitals and independent physicians are compensated. But that may change: When Hospitals Buy Doctors’ Offices, and Patient Fees Soar “Still, Robert Berenson, a physician and a senior fellow at the Urban Institute, said it’s clear that a lot of recent doctor-hospital mergers have been driven by Medicare’s disparate pay policies. He thinks the budget proposal lacks needed subtlety, but he supports equalizing many payments in concept. “If hospitals are going to employ physicians, it should be done for the right reasons, not the wrong reasons,” he said.”

And finally, for all the talk about paying for quality instead of quantity – it’s easier said than done: We really want to pay for quality, but it’s so darn hard. “Paying for quality, not quantity is getting to be almost cliché. Recently, the Obama administration doubled down, however, announcing ambitious targets for Medicare payments to be “tied to” quality in the future. Unfortunately, the evidence behind such programs working continues to elude us.”

System Transformation

Quality of Care

Here’s a quick list you should share with your family. We all are consumers of health care, know what you’re buying: 9 facts about medical errors you should know before entering a hospital

Unfortunately, all bad treatment is not done unintentionally. This piece takes a look at overuse of certain cardiac procedures: Are Doctors Exposing Heart Patients to Unnecessary Cardiac Procedures? ““You have to wonder what’s going on,” says Harvard physician and historian Dr. David Jones, author of "Broken Hearts: The Tangled History of Cardiac Care." “Are these doctors going to get bigger paychecks at the end of the month for doing more of these procedures? That may be an uncomfortable question to ask, but it’s something patients should wonder about.””

But knowledge is power, and Google is here to help…  They are working to insure that information you get when you search includes some credible sources: Google works with Mayo to add medical facts to search results “But the distinguishing characteristic of the new feature will be added credibility, the company contends. Each piece of data will be reviewed by an average of 11.1 doctors — led by Google's Dr. Kapil Parakh — before being published, according to the company.”

Data Security

Last week’s announcement of the Anthem hack continues to reverberate.

We have the NAIC taking a look at this specific incident: Anthem's data hack prompts probe by national insurance group ““We are in agreement that an immediate and comprehensive review of the company's security must be a priority to ensure protection of consumers who are covered by Anthem,” Monica Lindeen, the NAIC's president and Montana's insurance chief, said in a news release.”

In case you were wondering why health care data is a target: Cyber hackers see potentially rewarding targets when they attack health care companies “"If someone steals your credit card and home address, they might be able to buy something, but you can usually get that locked down quickly," said Tony Anscombe, a security expert with the cybersecurity firm AVG Technologies. "With medical records and a social security number, it's not so simple."”

And no, it’s not just your insurance company, your doctor’s office is vulnerable too: Is Your Doctor's Office the Most Dangerous Place for Data? “Last year, more than million people in the U.S. were affected by health care data breaches — including hacking or accidents that exposed personal information, such as lost laptops — according to a government database that tracks incidents affecting at least 500 people.”

And finally, it’s not going to stop: Experts Warn 2015 Could Be 'Year of the Healthcare Hack' “Stolen healthcare data can be used to fraudulently obtain medical services and prescriptions as well as to commit identity theft and other financial crimes, according to security experts. Criminals can also use stolen data to build more convincing profiles of users, boosting the success of scams. "All of these factors are making healthcare information more attractive to criminals," said Rob Sadowski, marketing director at RSA, the security division of EMC Corp.”

End of Life Care

It should never come to this (warning, have tissues ready): “Everyone on the oncology unit chipped in two dollars, and she had enough medication to last at least ten days. She only needed enough for five days.”  She only needed enough for five because she only lasted that long: Be aware of cost savings available to every patient

We are still really bad at this stuff. Frontline partnered with Atul Gawande to take a look at “Being Mortal. Vox reviews the program here: Atul Gawande explains the biggest problem with dying in America and you can watch it in full here: Frontline: Being Mortal.  (In case you forgot, Atul is going to be the keynote speaker at this year’s Quality Counts Conference – Registration is now open)

Some say allowing physicians to help ease one’s passing would be helpful, but it is a topic of great controversy. This week Canada legalizes physician-assisted suicide: “In a landmark decision, Canada's Supreme Court ruled that physicians should be allowed to aid a patient in dying so long as "the person affected clearly consents to the termination of life" and is suffering from ""grievous and irremediable medical condition."” While in California, a Lawsuit Seeks to Exempt Doctors From Assisted Suicide Ban “A cancer patient and five doctors filed a lawsuit Wednesday seeking to exempt physicians who help terminally ill patients end their lives from a state ban on assisted suicide.” 

Regardless of if we allow for this or not, we have to do better at handling the last stage of life.

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"

That Was The Week That Was - Issue 47

A look back at the week's health policy news with a focus on ACA implementation

Repeal and replace, SCOTUS, enrollment, measles, a data breach and as always, much, much more. We better get started.

ACA: Opposition

Apparently, Congress has nothing better to do than vote to repeal the ACA and promise a replacement plan: House votes to repeal ObamaCare “The GOP House on Tuesday voted for the fourth time to completely repeal ObamaCare, but this time with instructions for several committees to replace the healthcare law with new policies. Passage fell largely along party lines by a vote of 239-186. Every Democrat in the chamber opposed the measure, and three Republicans, Reps. Robert Dold (Ill.), John Katko (N.Y.) and Bruce Poliquin (Maine) voted against repeal.”  Yes, you read that right, Maine’s new Congressman from the Second District Poliquin votes against repeal of Obamacare, one of only 3 Republicans. However, there is less here than meets the eye – he is still against the law, but he wants to have something to replace it with before voting to repeal.

As you may recall, this is not the first time Republicans have promised a replacement plan (20 Times GOP Leaders Have Promised Their Own Obamacare Replacement Plan).

Meanwhile, “President Barack Obama gathered with beneficiaries of his health care law Tuesday to argue that the persistent effort to wipe it out “makes absolutely no sense,” as the House was poised to take the first repeal vote of the new Congress.” (Obama highlights health law; says repeal makes ‘no sense’)

Will the Republican’s really come up with a replacement plan this time?  It will not be easy: GOP chairmen to lead task force to develop Obamacare alternative “The House GOP is seriously split on almost every issue, and it’s an open question as to whether they’ll be able to coalesce around any plan. Ryan’s involvement in the group does give Republicans some home — he’s been able to persuade the GOP to follow his plans on numerous occasions.”

There are competing thoughts as to what the replacement plan should be. On Thursday, a group announced a plan (very similar to the one they announced last year: Here’s how the GOP would repeal and replace Obamacare While this is how some would replace, this is not the group designated by the House bill passed Tuesday. “The GOP plan outlined by congressional aides Wednesday is similar to one that the senators offered last year, which the GOP never united around.”

That said, the plan is receiving a lot of attention, so here are the basics (edited from the article):

• No more individual mandate
• A pre-existing condition ban, with a catch (if you let your coverage lapse for a couple of months, insurers are allowed to take this into account)
• A cap on tax preference for employer health plans (very similar to Cadillac tax)
• Eliminates the ACA's employer mandate requiring businesses with 50 or more full-time employees to offer health insurance or pay a penalty.
• Less generous subsidies (credits up to 300% FPL, based on age/family status, not cost of premiums)
• Medicaid expansion rolled back, credits available at all income levels.  Subsidies vary by age and income, not by price of premiums
• No Essential Health Benefits including no guarantee of maternity care
• Community rating band widened to 5:1

A final note of caution: An Obamacare 'Replacement?' Don't Believe The Hype “Even though the proposal is virtually identical to the one that Hatch and Burr issued a year ago with then-Sen. Tom Coburn (R-Okla.), the duo -- along with Upton -- scored headlines describing their framework as the Obamacare replacement plan. But remarks from House Speaker John Boehner (R-Ohio) on Thursday underscore how far congressional Republicans are from having an actual alternative in place. “Clearly, our three chairmen have an awful lot of work to do to come up with our replacement. But I would expect all of this to be part of the discussion -- all of it. Listen, there’s a lot of ideas out there," Boehner said. "The key is going to be to boil those concepts down to what a real replacement would look like."”

ACA: Courts

One of the reasons for all the “replacement” talk now is the theory that having an alternative in place will make it easier for SCOTUS to find for the plaintiffs and eliminate subsidies on the Federal Marketplace.

Lots of other activity on the subsidy case this week. Here Tim Jost takes a look at several of the amicus briefs submitted to the court: The Amicus Briefs Supporting the Government's Position in King v. Burwell. Maine’s Attorney General signed on to one of them: Keep health care law subsidies, Maine urges U.S. Supreme Court “The “friend of the court” brief, signed by Maine Attorney General Janet Mills, was filed Jan. 28 in the “King vs. Burwell” case that’s scheduled to go before the Supreme Court on March 4 and is likely to be decided this summer.”  Most likely this was done without consulting with the Governor.

Secretary Burwell was on Capitol Hill Wednesday to talk about open-enrollment. When questioned about contingency planning for the elimination of subsidies, she once again said “…there is no backup plan to support Obamacare if the Supreme Court strikes down federal subsidies.” (No backup plan at HHS if Supreme Court strikes down subsidies Obamacare, Back at the Supreme Court: Frequently Asked Questions)

Before the case was accepted by SCOTUS, many thought it was without merit. Given it was accepted, there has been a certain level of pessimism regarding the outcome. Here is one more optimistic thought on how it may turn out: Here’s one way the Supreme Court might save Obamacare “However, it’s also possible that Justices could decide the case isn’t just about statutory draftsmanship, and conclude that siding with the challengers would raise serious federalism concerns, ones involving the role of states as separate, independent sovereigns. The Justice to watch in this regard, some legal observers think, may be Anthony Kennedy.”

And on a similar note, this author thinks Overturning Obamacare Would Change the Nature of the Supreme Court “To reject the government’s defense of the law, the justices would have to suspend their own settled approach to statutory interpretation as well as their often-stated view of how Congress should act toward the states.”

A reminder of what’s at stake as Public Health Experts Have Estimated How Many Americans Will Die If the Supreme Court Repeals Obamacare ““Researchers found that, in the first four years of the [health care reform] law in Massachusetts, for every 830 adults gaining insurance coverage there was one fewer death per year,” the brief reads. “Using the national estimate that 8.2 million people can be expected to lose health insurance in the absence of subsidies on the federal marketplace, this ratio equates to over 9,800 additional Americans dying each year.”

ACA: Enrollment

As I write this there are only 10 days left to this year’s open enrollment period. This week’s report showed that “Since Open Enrollment began on November 15, nearly 7.5 million consumers selected a plan or were automatically re-enrolled through the HealthCare.gov platform” (Open Enrollment Week 11: January 24, 2015 – January 30, 2015).

Here is a look at this month’s numbers here in Maine:

Week Ending	Cumulative Enrollment	Week’s Enrollment
9-Jan	59,126
16-Jan	61,964	2,838
23-Jan	62,983	1,019
30-Jan	64,069	1,086

Note there was a surge in the run-up to Jan 15, the deadline for a Feb 1 effective date. This week we saw a slight uptick but that should explode in these last two weeks.

I’m not the only one expecting a surge: “The federal health insurance marketplace will have 40% more call center workers on hand starting Monday to help consumers deal with the final week of Obamacare open enrollment, the Department of Health and Human Services said Wednesday.” (ACA sign-ups estimated near 10 million as deadline looms).

Here’s a look at one of the (other) states that’s having success with enrollment: Why Florida Is No. 1 In Obamacare Enrollment Despite GOP Opposition ““It is truly ironic that Florida leads the nation in enrollment … with leadership that has actively opposed the law,” said Leah Barber-Heinz, executive director of Florida CHAIN, an advocacy group involved in outreach efforts. “It shows true commitment on the part of many and it portrays an extremely high need for affordable coverage. There are other reasons cited for Florida’s robust enrollment —including intense competition among insurers in several big counties and the high degree of coordination among the nonprofits and community groups which received federal grants to sign people up.”

Last week the Kaiser survey showed a significant number of people who thought they were ineligible for help when they were eligible. This piece takes a look at how that might have happened: How subsidy-eligible enrollees got ‘false negatives’ “Millions eligible for Medicaid or ACA's subsidized exchange coverage concluded they were ineligible. Here's how it might have happened.” Important reminders as we approach the end of open-enrollment.

Measles, etc.

We’ve been talking about this since the first reports of the Disneyland outbreak. This week as the numbers infected continued to climb (There were more new measles cases in the past month than in all of 2012), mainstream media caught fire with the story. You probably all know the basics by now – someone infectious with measles visited Disneyland. Probably because of a relatively low rate of immunization, the infection spread. This has led to the public taking a long hard look at vaccination policies and the group of “anti-vaxers” who don’t want to vaccinate their children.

In order to spare you, I will not include all the 50+links that I amassed this week on the topic. What I have done below is focus on a few key issues: 1) Why are we talking about this 2) The politics of the issue 3) What can/should be done going forward 4) Etc.

1) Why are we talking about this?

Having you child vaccinated does not only impact your child. As a society, we rely on “herd immunity” to protect those who either can’t be vaccinated (one group is infants younger than 12 months) or for whom the vaccine is ineffective (a small percent of those inoculated).

From CA (Baby contracts measles, closing day-care center at Santa Monica High) to Chicago (Measles Hits Chicago: Five Infants Diagnosed With Disease) some of those at risk are catching the disease.

Jon Stewart, in that way that he has, summed it up simply: "Your choice puts other people in jeopardy"

2) The politics of the issue

On Super Bowl Sunday, in the traditional Presidential game day interview (did you know that is a thing?) the President said very simply everyone should Get your kids vaccinated. What seems like simple uncontroversial message didn’t get to stay that way, as one of the potential 2016 Republican presidential candidates, Chris Christie won’t recommend measles vaccines to parents. Jumping on the inexplicable bandwagon, Rand Paul says he’s heard of vaccines leading to “profound mental disorders” in children. Something that we know from study after study just isn’t true.

Then, in a burst of rationality, the Wall Street Journal editorial page had this to say: Christie’s Vaccine Stumble: The Governor panders amid an outbreak of preventable disease. Wall Street Journal editorial taking to task Christie and complimenting Obama. “The U.S. is experiencing an outbreak of measles and other diseases long thought to be eradicated, and some politicians aren’t helping as much as they could. On this score President Obama has it all over Chris Christie.”

More of the 2016 Republican Presidential field joined in on the side of rationality: GOP 2016ers: We love vaccines! As Rand Paul causes a stir, his potential presidential rivals praise vaccinations. As did these 7 Republicans who love vaccines.

So there is reason to be optimistic that we can keep this from becoming a partisan issue: All our politicians should join together to end the dangerous anti-vaccination madness “It’s all-too-easy to see how these issues could become enmeshed in the culture wars, partisan politics or even the 2016 presidential campaign. This would be a public health disaster. We will never sustain herd immunity if Americans’ beliefs and behaviors in the realm of vaccination harden along cultural or religious or ideological lines.” Some additional thoughts on the topic: Vaccine support is bipartisan. Here’s how to keep it that way.

3) What can/should be done going forward

With infants and others being put at risk, and politicians (and some doctors) encouraging irrational behavior, there is anger out there. This piece reviews some of the options: Measles Keeps Rising. Should We Tax Vaccine Deniers, Shame Them -- Or Jail Them? “How do we get vaccination rates where we need them to be? How do we steer wayward Americans back into the herd? … I’ve listed out seven much-discussed proposals to win over vaccine holdouts. Think of these as rational strategies designed to deal with irrational arguments — and note that every single one of these tactics is ultimately imperfect.”

While there are already laws in place requiring vaccination, over time their effectiveness has eroded with the increased use of religious and personal exemptions. So, to get vaccination rates back up, consider eliminating those exemptions: Want More Vaccinated Children? End Religious and Personal Exemptions.

One of only two states that currently do not allow either of those types of exemptions, Mississippi, had some in the legislature trying to add them in, that attempt failed this week: Mississippi, a Leader on Vaccination Rates, Stands By Strict Rules  “By a voice vote, they advanced a heavily amended version of the bill that now calls for only technical changes to Mississippi’s law, which has been largely untouched since the late 1970s. The law requires all children in public and private schools to have certain immunizations, including for chickenpox, hepatitis B and measles. Generally, children must have the vaccines by the time they are in kindergarten.”

Meanwhile in CA where use of personal exemptions is high, attempts are underway to scale them back: California legislators want to make it way harder for parents to opt out of vaccines “California lawmakers on Wednesday introduced a bill that would require parents to vaccinate all school children unless a child's health is at risk, the Associated Press reported.”

And in case you were wondering, it was decided long ago that Yes, the Government Can Make You Vaccinate Your Child - The courts agree: It's not a violation of your constitutional rights “But it’s instructive to remember that the Supreme Court settled the question of compulsory vaccinations more than 100 years ago. And just last month, the U.S. Court of Appeals for the Second Circuit, which sits in Manhattan, cited that century-old precedent in rejecting a constitutional challenge to a New York law requiring that all kids attending public schools be vaccinated.”

4) Etc.

Here in Maine there are several bills dealing with vaccination up before the legislature: Maine Lawmakers to Weigh in on Vaccination Debate “Maine lawmakers will have a chance to weigh in on the controversy when they consider a number of vaccination bills this session.”

And I’ll end with these notes of caution. Even though the science is crystal clear, 1 in 5 millennials thinks vaccines cause autism “A survey of 1,000 US adults by YouGov, conducted between January 26 and January 28, found 21 percent of young adults believe the long-debunked idea that vaccines cause autism, while just 13 percent of all US adults agree.”  And that may be the reason that Young adults more likely to say vaccinating kids should be a parental choice “A Pew Research Center report released last week shows that a majority of Americans say children should be required to get vaccinated. Further analysis of the survey data reveals significant age differences in views about vaccines.”

There is more education that needs to be done and that education should go hand in hand with tougher laws removing the option to skip vaccinations. However, as we were reminded by the Press Herald, there is a secondary issue regarding making it easier for those parents who want to vaccinate: Our View: Too many Maine children lagging on vaccinations: A bill targets the high opt-out rate, but a much greater number of kids skip some shots.

I’ll end this section with my favorite quote on the topic “The science is clear: The earth is round, the sky is blue, and #vaccineswork. Let's protect all our kids. #GrandmothersKnowBest” (Hillary Clinton loves vaccines and wants you to know about it).

Costs

The President released his 2016 budget proposal this week. While there is absolutely no chance it will be adopted, it is an important document as it shows the administration’s position. Here is a look at how the budget handles ACA funding: Implementing Health Reform: President Obama’s FY 2016 Budget And The ACA.

Keeping in mind the same qualification that the budget won’t be passed as submitted, here is a Summary of Medicare Provisions in the President’s Budget for Fiscal Year 2016 from Kaiser.

Also included in the budget, Obama Wants Price Negotiations For High-Cost Drugs “The proposal will surely meet strong resistance from the pharmaceutical industry and isn't likely to go anywhere on Capitol Hill. Critics, including Republicans, say price "negotiations" would actually turn into price controls, given Medicare's purchasing power, and that lower payments would cut into the industry's research budgets.”

This week, the Congressional Budget Office released new spending projections. They show that Obamacare is costing way less than expected “So even adding all the spending in Obamacare, the CBO is projecting the federal government will spend $600 billion less on health care than the agency expected in 2010, when they weren't counting even a dollar of the spending in Obamacare.”

And while we’re on the topic of budgets, here is an interesting take on the annual “doc fix” ritual. Maybe it’s not such a bad thing after all: Doc Fix: The Budget Gimmick That Actually Isn’t So Bad “The pressure on Congress to find a way to finance doctors’ pay every year has actually reduced federal health spending in general and the Medicare budget in particular.”

In response to last week’s announcements regarding value-based care, some additional pushback regarding exactly how the goals will be accomplished: The biggest challenge facing the government’s new plan for better health care “On its face, it sounds reasonable enough. Who doesn't want to cut waste in America's $2.9 trillion health-care system and improve the kind of care that patients get? But actually determining the quality of this care is tough business.”  And speaking of quality measures: Quality measures are going through growing pains “Everyone wants high-quality health care. It’s obvious in the abstract. But how do we know what that is?”

There was also this cautionary note: Beware vaporware on value-based care “Expanding those programs, assuming the targets announced last week are met, will encourage the healthcare system's evolution toward value-based care. But the radical transformation of payment policy implicit in last week's rhetoric remains, in a word, vaporware.”

With all the talk of an ACA replacement, it’s worth looking at this piece regarding malpractice insurance. Malpractice insurance reform is always one of the GOPs talking points about a replacement plan, but the evidence is just not there to show it would have much of an impact: Barking up the wrong tree: Non-economic damages caps reduce medical malpractice payments, but not costs. “Damages caps are arbitrary, limiting financial recovery for those patients with the greatest losses, and fail to address the bigger issues of prevention and quality improvement.”

Medicaid

While the marketplaces have a set open enrollment period (for most people) that’s not the case for Medicaid. So measuring the impact of the ACA is a little different: Medicaid and CHIP Enrollment Reaches 10 million More Than the Average Monthly Enrollment for July Through September 2013 “The most recent Medicaid and CHIP data shows enrollment reaching over 10.1 million additional Americans as of November 2014. This represents a 17.5 percent increase over the average monthly enrollment for July through September of 2013, the pre-Marketplace open enrollment timeframe.”

We’ve seen a few more states adopt Medicaid expansion. Here is a look at one of the unique ways states are addressing its financing: “Budget Neutral” Funding for State Share of Medicaid Expansion: Hospital Fees and Taxes? “One mechanism to reach budget neutrality is to propose a fee or tax on hospitals within the state to either partially or fully fund the expansion. Hospitals are willing to consider this option because the benefits to their bottom lines are so great.”

A reminder today that even when a previously reluctant governor decides to pursue expansion there is no guarantee his legislature will go along with him. Haslam health plan Insure Tennessee is dead “Tennessee will not expand health benefits to hundreds of thousands of low-income residents, with state senators rebuking Gov. Bill Haslam's controversial health care proposal.”

At least Arkansas' 1st-in-the Nation Medicaid Expansion Survives “Arkansas' first-in-the-nation program using federal funds to purchase private insurance for the poor survived another year after the state House reauthorized the program on Thursday, despite an influx of new Republican lawmakers elected on a vow to kill the hybrid Medicaid expansion.”

Medicare

Problems with Aetna’s Medicare prescription drug plans are being addressed: “More than 400,000 Medicare beneficiaries who may have been confused or misinformed about the pharmacy details of their 2015 Aetna prescription drug plans have until the end of this month to find participating pharmacies or switch plans, according to the Centers for Medicare & Medicaid Services.” (Medicare Offers Relief To 400,000 Caught In Aetna Pharmacy Network Mix-Ups)

This week, despite complaints regarding the first released it was announced that Medicare Physician Data to be Released Annually “CMS’s decision to release more data every year is therefore a move in the right direction. Hopefully, the first Medicare physician payment data release in 2014 served as a starting point and the future data that CMS is planning to publish will learn from its limitations.”

Drugs

Supplements are in the news this week as the New York Attorney General Targets Supplements at Major Retailers “The authorities said they had conducted tests on top-selling store brands of herbal supplements at four national retailers — GNC, Target, Walgreens and Walmart — and found that four out of five of the products did not contain any of the herbs on their labels.”

So you may not be getting what you pay for, but that begs the question why are you paying for them to begin with?  Americans are ignoring the science and spending billions on dietary supplements “Researchers from the same Inspector General's report found that 20 percent of the weight loss and immune system support supplements they purchased made illegal claims about their ability to treat and cure disease. A year later, Harvard researchers found that between 2004 and 2012, there were 237 recalls of dietary supplements — accounting for more than half of FDA recalls of Class 1 drugs, which mean the products contain substances that can cause death or serious health problems. And in October, a JAMA study found most of supplements that were recalled for containing dangerous banned drugs were still available to consumers at least six months later.”

There are a few supplements where there is evidence base showing their effectiveness, this resource can help you figure out which those are: How to spot the rare dietary supplement that’s actually legit “But not all supplements are created equal. Information Designer David McCandless wanted to know which supplements' claims were backed by scientific evidence, and which weren't. So after pouring over hundreds of scientific studies, he built a visualization of which supplements are supported by research, and which aren't.”

But it’s not just alternative medicine where people take things that aren’t of any use: Doctors know they shouldn't give antibiotics for bronchitis, do it anyway “Researchers have known for decades now that antibiotics aren't an effective treatment for bronchitis. And prescribing them actually comes with a risk: overuse of antibiotics can speed up the creation of deadly, antibiotic resistant superbugs. Yet despite years and years of warnings, 71 percent of bronchitis cases are treated with antibiotics, research published in May 2014 in the Journal of the American Medical Association finds.”

System Transformation

Anthem Data Breach

A huge data break was reported by Anthem this week: Hackers breach health insurer Anthem “Hackers infiltrated Anthem's information technology system and gained access to the personal information of about 80 million current and former members. It appears to be by far the largest cyberattack ever disclosed by a healthcare company.” 

“Anthem is Maine’s largest private health insurer, with roughly 312,000 members across the state. The company provides coverage to small and large businesses in Maine, as well as to individuals.” (Health insurer Anthem hit by massive cybersecurity breach, personal data stolen)  Late Thursday, word that Anthem Attack Investigators See Signs of Chinese Hackers “Investigators of Anthem Inc.’s data breach are pursuing evidence that points to Chinese state-sponsored hackers who are stealing personal information from health-care companies for purposes other than pure profit, according to three people familiar with the probe.”

Medical Care

It’s so important to understand what a potential treatment could do for you, and how likely it is help vs. harm: How to Measure a Medical Treatment’s Potential for Harm “We hope that every therapy has a benefit. The N.N.T. shows us that benefits are often much less likely than many might think. The N.N.H. can show us how likely we are to have a harm compared with a benefit. Considering both, especially in light of how practice often differs from studies, can help us make better decisions about how to care for ourselves and those we love.”

That extends to screening tests as well as treatments: “We have to remember that screening matters only if detecting a disease early makes a real difference in terms of outcomes, and if screening leads to a significant decrease in the detection of advanced disease. In practice, screening often doesn’t lead to earlier diagnosis. Additionally, the later development of better treatments for later-stage disease can mitigate the advantages seen from screening in earlier studies. What screening often does, though, is cause some level of harm. Overdiagnosis and overtreatment can have detrimental consequences. Even the psychological worry from a false-positive result can have real-world implications.” (JAMA Forum: How Useful Are Screening Tests?)

Technology

Several fascinating developments on the technology front this week, I’ll let them speak for themselves:

Athenahealth, BIDMC to craft records system “The health care technology company Athenahealth Inc. is teaming up with Beth Israel Deaconess Medical Center to design an Internet-based system to manage medical records and compete in a growing, multibillion-dollar market for sales to big hospitals around the country.”

Exclusive: Apple's health tech takes early lead among top hospitals “The pilots aim to help physicians monitor patients with such chronic conditions as diabetes and hypertension. Apple rivals Google Inc. and Samsung Electronics, which have released similar services, are only just starting to reach out to hospitals and other medical partners. Such systems hold the promise of allowing doctors to watch for early signs of trouble and intervene before a medical problem becomes acute. That could help hospitals avoid repeat admissions, for which they are penalized under new U.S. government guidelines, all at a relatively low cost.”

Feds move into digital medicine, face doctor backlash “The Centers for Medicare and Medicaid Services responded to the criticism late last week, saying it would ease reporting burdens on doctors in a proposed rule to come this spring. The rule, however, wouldn't eliminate penalties. … Even most critics believe electronic health records are the future. But it's unfair to levy penalties at this stage, they say, while the technology is still so flawed that it takes time away from patient care, often won't allow information to be shared between different offices, and can even create safety problems.”

Smartphone accessory diagnoses HIV and syphilis in 15 minutes “The researchers estimate that the completed dongle will carry a manufacturing cost of $34, significantly lower than the $18,450 cost of the equipment runs typical of this form of diagnostic testing.”

Some Maine hospitals can predict your next trip to the ER: Here’s how “By combing through the electronic medical records of nearly all of Maine’s 1.3 million residents and applying sophisticated modeling software, the computerized tool predicts which patients are most likely to land in the ER.”

U.S. government releases draft plan for electronic health data “The Obama administration on Friday proposed a plan to move most doctors, hospitals and their patients to national standards for handling electronic clinical data by the end of 2017.”

End of Life Care

There is more of a focus on end of life care than ever before. But a new survey shows that it hasn’t had much of an impact yet: Study: Suffering At End Of Life Getting Worse, Not Better “The number of Americans experiencing pain in the last year of life actually increased by nearly 12 percent between 1998 and 2010, according to a study released Monday in the Annals of Internal Medicine. In addition, depression in the last year of life increased by more than 26 percent.”

More reminders that it doesn’t have to be that way:

Dying on your own terms: A physician’s advice for a better death “To a certain kind of Washington policy wonk, the trouble with "doing everything" is that it causes soaring medical costs and billion-dollar financial woes. But those are not the concerns of Volandes, a Harvard researcher who practices as a hospitalist. Instead, he sees the extreme end-of-life measures as a tragedy for patients - a tragedy that could be prevented if only doctors asked patients what they want. The patients are the ones who must bid farewell to life being poked and prodded and filled with tubes by strangers in the hospital.”

Dying Shouldn’t Be So Brutal. “As the end of life approaches, whether death is welcomed or feared, there is a lot we can do to make the process of dying safer.”

We forget to ask patients what their goals are A simple question can make a huge difference

And finally, a look at the question of how public should your grieving be. This piece talks about the 

loss of a pet, but the conversation is equally as relevant to a family member. The role that social media should play is the one you want it to play, there are no wrong choices: #R.I.P.: Grieving My Dog Offline

Thanks for reading.

All comments and suggestions are welcome; please let me know what you think. And as always, thanks for reading!

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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"