Medicaid expansion in Texas

It's interesting to contrast liberal and conservative media's discussion of Medicaid expansion.

1. The Atlantic, arguing that Texas should expand Medicaid. 

"Maybe governors like Perry don't believe in higher spending or a bigger social safety net. But surely they believe on getting a good deal on insuring a large number of their residents, rather than a bad deal on insuring just a few of them. Failing that, they have to believe in retrieving as much of their citizens' tax dollars as they can. Really, that's just fiscal conservatism."

2. The Texas Public Policy Foundation published an article a few days ago (and another today) defending Texas' decision to reject Medicaid expansion. 

Their argument is based off of:

-fear of post 2020 costs, fueled by doubt that the government will, as promised, fund 90% of these costs

-worry about what effect changing the system would have on existing Medicaid recipients in their state. 

They don't, however, suggest alternatives for what they see as "our nation’s worst health care program," and  don't discuss their state's poor performance among most measures of health outcome.

Are their other conservative media think tanks engaging in discussions about the benefits and drawbacks of expansion, or proposing alternate solutions within the parameters of the ACA? 

ACA Infographics

Hello,

Check out this infographic that helps explain the ACA to Americans.  Keith and I helped work on it for a Health Information class at the School of Information. http://imgur.com/lPFHQ

Profiles Of The Robert Wood Johnson Foundation's Young Leader Awardees

• http://www.healthaffairs.org/young_leaders.php
• 
  
• "Each winner has made an exceptional contribution to improving the health of the nation. Their accomplishments range from building a network of urban community gardens to addressing disparities in treating chronic kidney diseases." 

It's inspiring to see how young leaders are improving the health of communities nationwide through using leadership, innovation, creativity, and strategic tools. 

HHS releases Health Insurance rules

This Article I found on the Forbes website discusses that the recent release of the HHS regulations for Health Reform. It focuses on the rule that will not allow health insurers to make consumers pay a surcharge or be excluded for pre-existing conditions. The author suggests that this ban will make premiums increase for everyone. The author further speculates that people will opt to pay the penalties as opposed to paying high monthly premiums.

Frivolous ACA Lawsuits?

As some of you may know, despite the SCOTUS upholding the ACA, there are still legal challenges being fought. Chief among them, at least in terms of newsworthiness, is Liberty University's claim that the ACA violates First Amendment rights in requiring employers to provide health insurance for employees where that insurance covers contraception. Their argument is essentially that the requirement violates their religious freedoms--contraception being against the religious beliefs of the Christian evangelical school's doctrine.

A quick primer on First Amendment and religion: there are 2 primary 'rights' under the First Amendment related to religion. The first is the Establishment Clause, which essentially enforces the concept that church and state should be separate--another way of saying this is that the Federal government cannot favor one religious institution over another. The second is the Free Exercise of Religion clause which protects the beliefs of individuals from encroachment by the government (which is why, for example, we have laws protecting the right of refusal of treatment in favor of prayer).

So how exactly would the ACA be violating one or both of these rights? I am curious as to their Establishment Clause argument, as the law makes no mention of any religion, let alone favoring one over another. This leaves the Free Exercise clause.

A classic First Amendment case on point is the practically stone-age Reynolds vs. United States (1878) which held that laws banning polygamy did not violate the free exercise clause. The Court drew a clear distinction between beliefs and practices, saying that laws could not touch beliefs, but could regulate practices which may be extreme (i.e. polygamy, human sacrifice, etc.). The practice here, would be the failure to provide health insurance in furtherance of religious beliefs (guarding against sinful contraception).

Without going into the whole mess, I believe very strongly that Liberty University will lose this lawsuit. Among other reasons, the ACA does not require Liberty University to directly provide contraceptive services. It requires Liberty University to provide health insurance, a requirement which has been upheld by SCOTUS. The fact that health plans are required to provide contraceptive services is irrelevant. Liberty University's lawsuit is a poorly-veiled dig at the Obama Administration and, I believe, verges on the edge of frivolity.

A little humor

Pearls Before Swine is one of my favorite comic strips.  I think today's strip is just to make us smile as we go into crunch week(s)!!

Liverpool Care Pathway

End of life care, while one of the most important questions for anyone facing a terminal illness has turned into a dirty political issue in US. This article talks about an approach taken in the UK known as the Liverpool Pathway. While this type of end of life care may or may not be feasible in the US, I think the Liverpool Pathway can frame the discussion we currently have about end of life in a different manner. Instead of focusing on cost-benefit analysis that drive a majority of policies in U.S. perhaps end of life care should be driven by a different philosophy. The philosophy that patients deserve a kinder death than is currently afforded to them by our medical system, cost shouldn’t matter and we should resist the temptation of pushing palliative care based on a cost benefit analysis. http://www.guardian.co.uk/society/2012/nov/13/importance-open-end-to-life

Dr. Berwick's Pink Slip

This is an old NYTimes op-ed, but it does a good job of summing up what Republican's lost when they refused to confirm Don Berwick as head of the Centers for Medicare and Medicaid Services last year.

Namely: the country lost someone who dared to think of the agency as an improvement organization, and a powerful force for healthcare improvement. In 17 months, he trained executive agency staffers as "improvement coaches" and made strides toward helping health insurers and hospitals find simple ways to improve things like preventing hospital readmissions for chronic conditions.

Imagine what he could do with four more years... Is anyone pushing for this? (Shouldn't we be?)

Dr. Berwick's Pink Slip

Parkinson's Voice Initiative

In the context of our "value" discussions, thought I'd post something about an interesting project I recently heard about, called the Parkinson's Voice Initiative.

Researchers are trying to fine-tune their ability to diagnose Parkinson's over the phone through a 30-second voice test. This method would be much faster, easier and cost-effective than how people are currently screened for Parkinson's, a neurological test performed at a clinic or doctor's office. They're hoping that this will lead to more screenings, earlier diagnosis, and better monitoring for those who already have the disorder.

The initiative aims to collect 10,000 voices (with or without Parkinson's) from around the globe, so if anyone wants to participate, the number's on their website. You'll hear a lovely British lady asking you questions and prompting you to sit up straight and say your vowels.

Here's a Ted Talk about the effort for more details.

Republican concerns about health exchanges

Since the beginning of this course, I have been trying to learn how the Republicans can be so against the insurance exchanges mandated by the PPACA when the original idea was, in fact, a Republican idea.  This week, Forbes magazine has a column written by Avik Roy, who was also a healthcare policy advisor for the Romney campaign, outlining his (Roy's) primary concerns with the exchanges.  As it turns out, his complaint is not with the exchanges themselves but with the mandated minimum requirements for the plans included on the exchanges, and to some extent the requirement for community rating.

I don't necessarily agree with his ideas, but it's refreshing to actually know which ideas I'm not agreeing with!!  I wish he had put forward this coherent of an argument during election season; I would have understood Romney's position better.

Here's the link:
http://www.forbes.com/sites/aroy/2012/11/19/what-states-should-build-instead-of-obamacares-health-insurance-exchanges/

The Impact of Provider Consolidation on Rising Costs

Interesting article on Health Affairs Blog. We have focused on several reasons why health care costs are rising, including technology and changing standards of care, an older and relatively healthier population, and inefficiencies/waste. One thing we almost never talk about is the impact that provider consolidation has on unit price of doctors and hospitals. As insurers and hospitals are continually merging in light of health reform and the impending health exchanges, it will be important to keep an eye on how these consolidations impact rates--particularly for the private insurance market.

Basic Health Plans?

As some of us know, the ACA includes a provision for states to set up a Basic Health Plan (BHP) that would essentially prevent families from churning (the process of losing and gaining coverage) between Medicaid and the exchange, and reduce coverage disruptions. I thought this was an interesting new article that discuss the pros and cons for states thinking about establishing a BHP. The article also notes that California will be considering a bill to establish a BHP in the upcoming special session. It will be interesting to see how the BHP debate in CA will play out, especially since this only now being seriously considered by states on the brink of 2014.

Throughout the ACA conversation, it has been said that little was included to expand the supply of doctors that would meet the needs of the newly insured. This article suggests that the demand for additional doctors is not mainly driven by the ACA, but instead by an aging population:

http://www.washingtonpost.com/blogs/wonkblog/wp/2012/11/16/maybe-obamacare-isnt-driving-the-doctor-shortage/

Here is an article from the Wonk Blog on changes the insurance industry is seeking on ACA implementation: Four ways Blue Cross Blue Shield wants to change Obamacare

Shrinking CA budget

The last week (OK, 8 days) have held plenty of good news, right? Election results, cancelled final exam for PH220, California's budget deficit nearing elimination... Wait, what? Yep, per the Legislative Analyst Office (and covered in plenty of news sources, so you can read the executive summary), it'll be down to $1.9 billion by summer 2013. But the full report (I skipped to the "Health and Human Services" section towards the bottom of the page) relies on several assumptions. Some of these seem predictable--of course CA will adopt the Medicaid expansion--and others not so much.

What do we think of this projection overall? In terms of the HHS section, are these assumptions realistic?

One thought of mine: Below there is a section that mentions reduced costs for other state health programs, including the Family Planning, Access, and Care Treatment Program (FPACT). That's the program that folks are enrolled in when they access family planning services at pretty much any CA safety-net clinic, including Planned Parenthood, La Clinica, Lifelong, and teen clinics, such as those at local high schools. It covers to low-income individuals without health insurance, regardless of documentation status, and also to those who are unable to use their parent, guardian, or spouse's insurance for reasons of confidentiality. Many of the low-income individuals will be able to purchase Medical with subsidies. But this does bring up questions about how safety-net clinics will provide services for those who are ineligible for Medical. Not to mention how they'll continue reassuring notoriously wary teenagers that they can access sexual/reproductive health care safely under a program who's reputation for confidentiality is poor.

• Several Key Assumptions and Remaining Policy Decisions Result in Significant Fiscal Uncertainty. Our fiscal estimates related to ACA implementation are subject to substantial uncertainty and depend heavily on several key assumptions, meaning that actual costs could be several hundreds of millions of dollars higher or lower over this period. In addition, the state is still awaiting additional federal guidance on ACA implementation and several major state–level policy decisions have yet to be made that would be critical to informing a projection of the net fiscal impact of the ACA. Some of the major policy decisions facing the Legislature include:
• Determining whether to adopt the Medicaid expansion and how to fund it.
• Selecting the benefits that would be provided to the expansion population.
• Determining how the state and local governments will fund medical care provided to the remaining medically uninsured population.
• Determining how the existing Medi–Cal eligibility standards and enrollment processes will change in response to the new ACA requirements.
• Evaluating whether to modify existing state health programs that provide services to persons who would become eligible for Medi–Cal, or other federally subsidized health coverage, in 2014.

• Implementation of Federal Health Care Reform. Our spending projections assume that implementation of the ACA will have several significant fiscal effects on the Medi–Cal Program.
  
• Medi–Cal Expansion. As mentioned above, our forecast assumes the state will adopt the Medicaid expansion authorized under the ACA. While this expansion would have a significant impact on the program’s total caseload beginning in 2014, the federal government will pay the large majority of the costs of the expansion during our forecast period. Our forecast projects costs in the low hundreds of millions of dollars in 2016–17 and 2017–18.
• ...
• Reduced Costs for Other State Health Programs. As a result of ACA implementation, we project reduced General Fund spending for some non–Medi–Cal state health programs, such as the Breast and Cervical Cancer Treatment Program and the Family Planning, Access, and Care Treatment Program. These programs currently pay for services for populations that will become newly eligible for Medi–Cal or other subsidized health insurance coverage in 2014. We project about $100 million in reduced General Fund costs in 2013–14, with annual ongoing reductions of about $200 million. There is a significant amount of uncertainty surrounding these estimates as the fiscal effects will largely depend on future policy decisions about the potential modification of these existing programs in response to the ACA coverage expansions.

Junk Food Ads on the School Bus

ChangeLab Solutions just put out an interesting fact sheet about advertising on school buses.  A practice that some desperate school districts are employing to try to raise money.  It is sad that our public schools are in such a position and it is understandable that they would resort to creative ways to get more money, but these ads have potential negative public health impacts.

The link below will take you to a brief fact sheet with more information about the legal issues associated with advertising on school buses.

Also, ChangeLab Solutions is based in Oakland (formally Public Health Law and Policy) and does some interesting work.  BARHII (Bay Area Regional Health Inequities Initiative) which I co-chair, has collaborated with them on some projects.  Might be a good internship possibility for someone.

http://changelabsolutions.org/publications/school-buses-ads

On Monday, the American Medical Association’s House of Delegates voted to approve a resolution in support of the Prevention and Public Health Fund.  The resolution calls for the AMA to “oppose policies that aim to cut, divert, or use as an offset, dollars from the Prevention and Public Health Fund for purposes other than those stipulated in the Affordable care Act of 2010.”  Support for protecting these funds from a group as powerful as the AMA is good news for Public Health.

A little expansion support in Alabama

I thought this was a refreshing local op-ed piece coming out in favor of Alabama expanding their Medicaid program. I've noticed that much of the rhetoric coming out of states opposed to the expansion have seldom mentioned the basic fact that expanding health coverage is in the interest of the state both from a societal standpoint as well as an economic one. Hopefully more states can do analysis, like this one out of Texas, that actually shows what states have to gain or lose through expansion. Hopefully all is not lost!

Rise of Social Entrepreneur

Good morning All! I thought this was a neat op-ed piece that discussing the increasing number of social entrepreneurs. It somewhat ties into the new innovations that are leading to change and how private industry is getting involved with "social problems." Alecia

Social behavioral sciences used to move votes... could it work for healthcare?

This was an interesting article on the use of behavioral social science research by the Obama re-election team -- not just in generally applying concepts, but in consulting with top experts in the field. Couldn't help but think that this approach could have positive results on a national and state level if it were incorporated in increasing support for health care improvement efforts.

http://www.nytimes.com/2012/11/13/health/dream-team-of-behavioral-scientists-advised-obama-campaign.html?ref=health

No more wait-and-see on health reform

With election uncertainty behind us, it looks like the U.S. Department of Health and Human Services is getting down to business on health reform implementation.

By this Friday, we'll know which states will opt to set up their own health insurance exchanges for 2014. That's the deadline for states to notify HHS of their intent, although the department has extended the deadline for states to submit their blueprints until Dec. 14. Politico reported last week that 13 states and Washington, D.C., have told HHS they'll run their own exchange, and at least five Republican governors say they won't (including Texas, Louisiana, Florida).

HHS has also started issuing more regulations on health reform. This also from Politico:

We all saw this one coming, now that the election’s over and the Affordable Care Act lives. HHS is starting to send regulations out the door like they’re going out of style. The department on Friday sent three more ACA documents to OMB for review: a proposed rule on wellness programs, a request for information on the law’s health care quality provisions and a “notice” on the enhanced FMAP for 2014. The document delivery came a day after HHS also sent over proposed rules on health insurance market reforms and another on exchanges covering essential health benefits and actuarial value, quality and accreditation.

Less Experience Physicians Have Higher Cost Profile

I just came across this article in Health Affairs that discusses the level of experience of physician and their cost profile. They found that less experienced physicians had a higher cost profile. They speculate that the difference may be due to newer physicians using newer and more costly treatments, have a panel of patients with more complex health conditions,and/or lack of experience.

role of the courts

For those of us in Health Policy and Decision Making, I was intrigued to see the food policy writer Mark Bittman blatantly acknowledge the power of the courts to set policy in this article.  About halfway through this piece which plays off of the defeat of the GMO-labeling proposition here in California, he suggests that sugar is the tobacco of the 21st century but until somebody successfully sues for getting type II diabetes from it, policy initiatives will languish.  Maybe I was more intrigued to recognize that I now understand a whole background to a sentence in an article that wouldn't have meant much to me a couple of months ago.

Here it is:  http://opinionator.blogs.nytimes.com/2012/11/10/the-food-movement-takes-a-beating/

The link below is to a really good comprehensive analysis of the impacts of the 2012 election. Amazing that something like this could come out so quickly after the election. There is a concise and easy to read section on the impacts on "Health" that starts on page 44.

Enjoy!

http://www.cgagroup.com/news/2012ElectionAnalysis.pdf

It's not over yet...

In the midst of my avid (and borderline irritating to those around me) use of the internet to get minute-by-minute updates of election results on Tuesday, I noticed that several states were voting on state-level measures that directly contradict the PPACA.  In Alabama, Montana, and Wyoming, the measures passed, and in Florida it narrowly failed (which I'm guessing coincides with the narrow win for Obama).  Here's the wording of a brief description of each bill as described by politico.com:

• Alabama: Would prohibit any person or employer from being forced to participate in any health care system
• Florida: Would create an amendment to the state constitution to prohibit laws from requiring a person or employer to purchase health care coverage. (FAILED)
• Montana: Would prohibit state and federal governments from requiring the purchase of health insurance or imposing any penalty for those who do not.
• Wyoming: Would reserve health care decisions of residents, allow them to pay for any health care and give the state legislature authority to regulate health care.

I've been looking for some discussion online about the implications of these measures and haven't been able to find much.  The only hint I am seeing is a quote from Jonathan Turley, a law professor at GW Law School, who says that "these laws may promise more than they can deliver... What the laws certainly do is to give state officials more of a basis to go to court and challenge the national health care law." (CNN election coverage, URL: http://m.cnn.com/primary/cnnd_fullarticle?topic=newsarticle&category=cnnd_latest&articleId=urn:newsml:CNN.com:20121106:ballot-initiatives:1&cookieFlag=COOKIE_SET)

I'm hoping to crowdsource more information from our class - do any of you know more about these measures?  Have you seen any reporting or analysis of their impact?

Hospitals, Urgent Care Clinics, and the Value of Health Care

Interesting story on NPR this morning about the role that pop-up urgent care clinics are playing in our ever-changing field and how these clinics fit into a hospital's bottom line.

Bringing new drugs to market

This article was an interesting read after yesterday's class discussion: on a current effort to get new cholesterol reducing drugs to market. Two drug companies are currently starting a Phase 3 trial of a drug that looks promising for people who don't respond well to or can't take Lipitor, and a handful of other drug makers are working to bring similar drugs to market. Now their use of the words "racing to market" and "still two to three years out" make far more sense!

http://www.nytimes.com/2012/11/06/business/new-drugs-for-lipids-set-off-race.html?hp

Red State Blue State

Interesting podcast about politics, family, and friends.

512 Paths to the White House

The NY Times published a great interactive infographic yesterday showing how each candidate might win based on the outcomes of seven swing states plus North Carolina and Nevada. Obama has more ways to win at the outset, but a lot rests on Florida and Ohio. Check it out: 512 Paths to the White House.

Welfare use in US

I have the elections on my mind, as I'm sure most of you do too.  I am constantly amazed by groups of people who consistently vote against their own best interest and nothing highlights this better than healthcare.  This article came out in the NY Times in February and perhaps everyone has already seen it, but I wanted to post it because the image of this map keeps resurfacing for me.  It's a powerful visual, especially when compared to the red and blue maps we've all been seeing during election season.  It saddens me that some of the people who are in greatest need of government services are those who vote for a president who vows to deeply cut the programs that deliver these services.

Hospitals Sue Obama Administration

A quick little article, but I thought it was interesting that hospitals filed a federal suit against HHS over Medicare payments. Apparently, government auditors decide whether hospitals should have admitted Medicare patients or arranged for their care on an outpatient basis. If an auditor finds that the hospital did not need to admit the Medicare patient, the hospital will need to return the money it received for the patient's care.

I had a difficult time figuring out where I fall on this policy. On one hand, hospitals typically have a financial incentive to admit patients which may result in overutilization when it isn't appropriate. However, the admitting physician should be making a medical judgment based upon the patient's health status at the time they present to the hospital. The medical judgment in this instance can be a gray area and I don't understand how a government auditor can retrospectively quantify if it was an appropriate decision or not. I imagine it might take a while for this lawsuit to play out.