Women and minorities with atrial fibrillation less likely to receive standard of care, study says
Tuesday, June 30, 2015
Anal fissure
Anal fissure: A tear in the anal canal, one of the most common causes of red blood in the stool.
MedTerms (TM) is the Medical Dictionary of MedicineNet.com.
We Bring Doctors' Knowledge To You
To Reduce Unnecessary Care, Choosing Wisely Moves from Awareness to Implementation
In 2012 the ABIM Foundation launched the Choosing Wisely campaign with the goal of kick-starting an important and needed national conversation about unnecessary health care tests and procedures. A pervasive and persistent problem in our health care system, unnecessary care was estimated by the Institute of Medicine to amount to $750 billion a year—roughly 30 percent of health care spending—and was projected to keep growing.
Since then, Choosing Wisely has grown precipitously, adding more than 100 new partners and evolving its approach to make a lasting impact. Most recently, through the support of grants from the Robert Wood Johnson Foundation (RWJF), the campaign has turned from creating awareness of overuse to supporting and measuring the implementation of solutions to the overuse problem.
Planting the Seeds of Change
Building off of its mission to advance medical professionalism, with the Choosing Wisely campaign, the ABIM Foundation took an elegant and surprisingly unprecedented approach, inviting physicians themselves to take the lead in recommending solutions. This was done through national medical specialty societies that developed lists of “Five Things Physicians and Patients Should Question,” which offer specific, evidence-based recommendations that physicians and patients should discuss to help patients make wise decisions about the right care for their individual situations.
The idea was that by having the recommendations come from physicians themselves, they would be trusted by the medical community, and these important conversations would finally start to take place at the point of care delivery. Consumer Reports, a key partner, worked with many of the specialty societies to create patient-friendly translations of their recommendations to ensure patients and physicians could make informed decisions about their care.
Launched with an initial cohort of nine medical specialty societies, in less than a year, a total of twenty-five medical specialty societies with a collective membership of more than 725,000 physicians had joined Choosing Wisely, and they released lists covering 130 recommendations. Today, more than seventy medical specialty societies have joined the campaign, and it has begun to spread internationally to Canada, the Netherlands, Australia, the United Kingdom, and beyond. The success meant that a consistent, thoughtful discussion that surpassed our wildest expectations was taking place within the medical community, and among patients and physicians, about unnecessary care.
From Awareness to Implementation
Following Choosing Wisely’s early success, the ABIM Foundation and the RWJF began to discuss ways in which to maximize the impact of the campaign and drive measurable changes in the U.S. health care system.
The RWJF had long been aware of the costs of overuse and unnecessary care that was being delivered in the U.S. health care system—both in terms of individual health and dollars. The RWJF believes that it is critical that the United States find solutions to these issues to foster a Culture of Health that enables all Americans to live longer, healthier lives.
In recent years the RWJF has supported initiatives at the community level through programs such as its flagship Aligning Forces for Quality initiative. In these the foundation saw the potential for meaningful, lasting health care transformation. The reasoning was that health care is delivered locally, and therefore real change must take place at the local level.
That led the RWJF to provide grants to the ABIM Foundation to spread the trusted content and resources developed by Choosing Wisely into local communities across the country. The result? As of now, the RWJF has funded two cohorts of community-level Choosing Wisely grantees, including an initial set of twenty-one grantees led by state medical societies, specialty societies, and regional health collaboratives. From 2013–2015 they worked to help educate and provide resources to physicians and patients about the recommendations and how to have such conversations.
Supporting Local Synergy and Alignment
Building on the local strategy, in June 2015 the ABIM Foundation and the RWJF announced the selection of seven multistakeholder alliances that will focus on the local implementation of Choosing Wisely at health systems, hospitals, and medical groups (in their regions) that are participating in the grant program. What is most exciting to us is that each of the grantees will be focusing on achieving measurable reductions of at least three Choosing Wisely recommendations, including reducing the use of antibiotics for viral infections by at least 20 percent over nearly three years. This work aligns with recent efforts announced by the Obama administration to combat antibiotic resistance.
The most recent phase of Choosing Wisely represents an exciting and potentially powerful development in the campaign. It brings together a potent triad of organizations to work together at every level of the local health care systems, including physicians (through state medical or specialty societies); consumers (through regional health collaborative or multistakeholder groups); and health care delivery systems (through health systems, hospitals, and medical groups).
For example, a new grantee, the University of California, Los Angeles (UCLA) Department of Medicine, is leading a strong coalition of six partners including the Los Angeles County Department of Health Services, the Los Angeles County Department of Public Health, the Los Angeles County Department of Health Services Primary Care Practice-Based Research Network, the Wellness Center at Historic General Hospital, and the Society of General Internal Medicine. Through their Choosing Wisely grant, the partners will collaborate to reduce use of (1) imaging for nonspecific low back pain, (2) preoperative testing, and (3) antibiotics for viral-based upper respiratory illness.
Another grantee, the North Carolina Healthcare Quality Alliance, is partnering with the North Carolina Medical Society, Duke Medicine, Cornerstone Health Care, Blue Cross Blue Shield of North Carolina, and the State Health Plan for Teachers and State Employees. Over the course of their grant, these groups will focus on reducing (1) the use of antibiotics to treat viral infections in adults, (2) DEXA scans to measure bone density in women younger than age sixty-five and men younger than age seventy, (3) carotid artery stenosis screening in asymptomatic patients, and (4) routine annual Pap tests for women of average risk who are between the ages of thirty and sixty-five.
The Washington Health Alliance, a previous ABIM Foundation Choosing Wisely grantee, will continue to partner with the Washington State Medical Association, also a former ABIM Foundation grantee, and provider organizations including Group Health Cooperative and Swedish Health Services. They will target the overuse of (1) antibiotics for upper respiratory viral infections, (2) imaging for uncomplicated headaches, and (3) overly frequent Pap tests for women between the ages of thirty and sixty-five.
Working together, these groups (1) will make Choosing Wisely “real” for patients across America and (2) expect to drive measurable reductions in unnecessary care. Their work holds great promise, and we look forward to seeing what comes of it.
Related content:
“Foundations Supporting Stewardship of Health Care Resources through Medical Education and Training,” by Daniel Wolfson and Leslie Tucker of the ABIM Foundation, Health Affairs Blog, January 22, 2014.
Most U.S. Hepatitis C Infections May Be Missed: Study
In one state, only one from 183 diagnosed cases met reporting criteria for CDC
The ACA Survives — But With A Note Of Caution For The Future?
Chief Justice Roberts has once again saved a core provision of the Affordable Care Act (ACA). In King v Burwell, a majority of six Justices upheld the validity of an Internal Revenue Service (IRS) rule interpreting the text of the ACA to permit tax credits to be distributed through both state and federal insurance exchanges. As a result, the millions of Americans receiving subsidies through federally established exchanges in the states that have not chosen to establish their own exchanges will continue to receive them.
The Reasoning of the Opinion — And Why It’s Important
Much of the briefing and argument in King involved the legal principle known as Chevron deference, in which courts generally defer to agencies’ reasonable interpretations of statutes if the statutory language is ambiguous. In this case, the government first argued that the statutory language clearly permitted tax credits to be made available on federally established exchanges. But even if the statute was ambiguous, it contended, Chevron counseled deference to the IRS’ reasonable interpretation of the statute.
Critically, Chief Justice Roberts held for the government without resorting to Chevron at all. That is, the majority opinion declared that it was the task of the Court, not the IRS, to interpret the relevant provision of the statute. And in the Court’s view, a thorough consideration of not only the text but also the purpose and structure of the Act led it to agree with the government’s interpretation.
Although on its face the choice to apply Chevron deference or to have the Court interpret the statute on its own may seem of interest only to lawyers, it is important more broadly. If the Court had held that the language of the ACA was ambiguous but then opted to defer to the IRS’ interpretation under Chevron, a subsequent presidential administration (perhaps a Republican one) might have been able to reinterpret the statute and decide that subsidies would no longer be made available on federal exchanges. The reasoning of the Chief Justice’s opinion precludes that possibility: the subsidies are here to stay.
With regard to the subsidies, King offers stability. But the Chief Justice’s decision not to apply Chevron deference deserves further scrutiny; his reasoning may create more uncertainty for administrative agencies and the government going forward.
Why the Court Chose Not to Apply Chevron
Chief Justice Roberts offered two reasons for declining to defer to the IRS’ interpretation of the ACA. First, whether tax credits are available on federal exchanges is an “extraordinary” question of deep “economic and political significance.”
In other words, because the tax subsidies play such an important role in the structure of the ACA, the Court will not defer to the IRS unless Congress had explicitly requested it. Second and relatedly, the IRS “has no expertise in crafting health insurance policy,” and therefore “[i]t is especially unlikely that Congress would have delegated this decision” to that agency.
Administrative law professors like Jody Freeman, Cass Sunstein, and Chris Walker have written about what the Chief Justice’s logic here may mean for administrative law more broadly. But I want to focus on what these two aspects of the Chief Justice’s logic may mean for health law in particular.
What Does the Court’s Logic Mean Going Forward?
With his first argument, the Chief Justice invoked what administrative law scholars call the “major questions” doctrine. If Congress wants to delegate interpretive authority over a major policy question to an administrative agency, it must speak clearly in doing so.
This may seem straightforward, but the problem is that the Court rarely invokes the major questions doctrine, and it has not given content to the term. How do we know when a question is “major”? The doctrine is applied inconsistently, and the Court has avoided invoking it in some of the biggest, most high-stakes cases.
As early as 2012, legal scholars had supposed that this very IRS rule might provide an opportunity for the Court to give content to the major questions doctrine. But Chief Justice Roberts spent just one sentence in King explaining the importance of the IRS’ rule. In his words, the tax credits “involve[] billions of dollars in spending each year and affect[] the price of health insurance for millions of people.”
But many—perhaps most—of the ACA’s myriad reforms “involve[] billions of dollars in spending each year and affect[] the price of health insurance for millions of people.” And based on the Court’s past invocations of the major questions doctrine, the relevant “spending” need not even be government spending, as it is in this case — it might simply be that the industry involved plays a sufficiently large role in our economy, as the many facets of the health care system surely do.
The Chief Justice’s logic could apply far more broadly, if the Court so chose. In some of these cases Congress may have delegated interpretive authority explicitly, but in many or most of them it will not have. The effect would be for the judiciary to arrogate power to itself which most observers (academics, policymakers, and the regulated industry alike) believe resides within the administrative state at present. This would create uncertainty within the regulated industry, as hospitals, insurers, employers, and others would be less sure about the legal validity of the rules that are enforced against them.
Perhaps the Chief’s second argument, though, might cabin this expansive interpretation of the major questions doctrine. That is, in King the problem is not only the importance of the question – it is also the asserted naivete of the agency deciding it. (The Chief Justice does not explain the relationship between the two arguments, and so although it is possible that each individually provides a sufficient basis on which to avoid applying Chevron, it is also possible that only together do the two arguments justify that conclusion.)
But here’s the problem: the IRS regularly makes health-related rules. There are hundreds of health-related federal regulations implemented by the IRS, dealing with topics as central as discrimination on the basis of health status, minimum essential coverage, and mental health parity, to name just a few. It is conceivable that the major questions doctrine would now apply to each of these rules.
Health law history buffs will remember that before the Internal Revenue Code of 1954 explicitly made health insurance a non-taxable benefit rather than taxable income, it was an IRS rule from 1943 that had made it so. Today, this law provides a subsidy estimated at $250 billion per year to 149 million people. Considering that the ACA’s premium tax credits in the 34 states potentially imperiled by a decision in King implicated only $20 billion per year to 6.4 million people, I’d say that’s “major.”
Going forward, it is difficult to say whether courts will be interested in invoking the major questions doctrine more frequently after King, particularly in the health field. But there are still lessons for all parties involved. For instance, the IRS might seek to issue regulations jointly with other agencies, as it has in the HIPAA context.
At present, the IRS surely consults with the Department of Health and Human Services and other relevant agencies in issuing rules like the one involved in King, but involving those agencies formally might mitigate the force of the Chief Justice’s second argument. More generally, scholars and policymakers will want to watch future cases closely for further developments.
Too Few Men With Low-Risk Prostate Cancers Get 'Watch and Wait' Approach
Study finds 12 percent or fewer getting active surveillance
Post-King: Moving Forward In A New Normal
Despite its monumental achievement, the Affordable Care Act (ACA), like any landmark piece of legislation, was only the beginning. Its aim was grand, but even putting aside the wild circumstances of its enactment, it was evident that effective implementation would raise major challenges. A plausible assumption shared by many was that following the ACA’s legislative odyssey, life would settle down and the hard job of building out (and modifying where needed) its initial legislative scaffolding would get underway.
Things didn’t work out this way, of course. Since it was signed into law, the ACA has faced an unprecedented attempt at legislative nullification: in Congress, with more than 50 separate repeal votes; through a pileup of ongoing legal challenges in the courts; through a “50 vetoes” state strategy involving refusal to establish Exchanges and denial of the Medicaid expansion once the option became legally available in the wake of National Federation of Independent Business (NFIB) v. Sebelius; in the court of public opinion, through endless polls asserting a deep hatred of the law; and even in the ACA’s “Obamacare” moniker, an inherent sneer. (Who can blame the Administration for its ultimately unsuccessful effort to embrace and thus neutralize the name?) The demise of the law could not have been better scripted.
And yet the Affordable Care Act has prevailed. Five years after passage, it has succeeded in covering over 30 million Americans and has reduced the percentage of uninsured Americans by 20 percent from its 2010 high. The ACA has spawned a wide array of efforts to improve the accessibility, quality, and efficiency of health care. Primary care has been extended to an additional 5 million residents of the most severely medically underserved urban and rural communities. Efforts to transform Medicaid into a full pillar of health reform proceed steadily, through a combination of eligibility expansions and initiatives aimed at improving how care is organized, delivered, and financed.
In his Health Affairs Blog post on King, Tim Jost notes the lawsuits that await resolution. But the Court’s decision in King is an undeniable watershed. The Court’s opinion took far too long to emerge from behind the velvet drapes. But it amounts to a total legal refutation of the single greatest challenge to the ACA’s ability to function—a challenge that actually argued that Congress intentionally designed the law to fail—just as NFIB represents the most important test of the law’s basic constitutionality.
This is not to say that the war over health reform is over. It probably wouldn’t be summer were opponents not to try to wrap either an outright or a de facto ACA repeal effort inside an FY 2016 budget reconciliation bill. CBO’s estimated cost impact of repealing the law, between $137 billion and $353 billion depending on whether macroeconomic effects are accounted for, would seem to make such an effort impossible unless Congress were to set aside its own legislative process, which it always has the option of doing; alternatively, Congress could cobble together deep cuts in Medicare and Medicaid to come up with the necessary funds to pay for a repeal. (Such a bill surely would be vetoed, probably to many Republicans’ relief.)
Of course, the King decision is sure to give an added boost to efforts by Republican Presidential candidates to run campaigns based in large part on an ACA repeal, while forcing Democratic candidates to once again commit time and resources to a defense of the law. No matter how much the general public may tire of this process—especially as the law touches more and more families—and want to move on, the topic of ACA repeal will remain a staple of the political landscape.
But at some point, rage has to abate and the changes envisioned under the ACA have to be either overtly or tacitly allowed to become part of the basic legal fabric of the American health care system. Maybe that time is now finally approaching.
The Work That Remains
Assuming that the nation is one Presidential election away from the final word on whether the ACA is here to stay, it is worth reflecting on some of the near-term concerns that emerge as important follow-on policy issues. (Perhaps the deepest question raised by the ACA—whether it makes sense to keep a legal framework that continues to favor health coverage as an employer benefit at all—is put off for another day).
1. Expanding Medicaid To Cover The Poorest People
King’s triumph in validating the entitlement to premium subsidies for all qualified Americans regardless of where they live brings into even sharper relief the enormous disgrace of the Medicaid problem — both the refusal of all states to adopt the expansion and the exclusion of the millions of otherwise-eligible low income people who cannot meet the ACA’s long-term U.S. residency test.
Both problems need to be addressed, the first through persuasion, the second through legislation. There simply is no explanation other than ideology for the decision by 21 states to nullify the Medicaid expansion. There are those who say that patience is the way to go and that ultimately all states will embrace Medicaid expansion. But the impact of the coverage gap, especially on minority Americans (Medicaid expansion was one of the Reverend Clemente Pinkney’s enduring issues in the South Carolina legislature.) simply is too great to think in terms of “ultimately.”
To be sure, a §1115 demonstration strategy has borne fruit. But allowing certain “experiments”—such as enabling states to impose premiums on the very poorest adults on pain of lock-out, or imposing superfluous work requirements—would simply throw up new and harsh access barriers under cover of expansion. (Most excluded adults either work or live in working families; those who do not by and large have serious health conditions). A combination of political and negotiating strength is needed to overcome this most terrible of all ACA weaknesses.
2. Making the ACA’s Private Insurance Provisions Work Better For Children, Low- And Moderate-Income Families, And People With Disabilities
The ACA’s most enormous strides have been made in the pathways to affordable coverage it has created for low- and moderate-income individuals and families, including families with children, as well as in its elimination of coverage barriers for persons with serious health needs. But significant challenges remain. The so-called “family glitch” means that low- and moderate-income workers’ own employer coverage may be affordable (as defined by law), but their family coverage is not. Yet they are unable to qualify for tax subsidies in order to purchase reasonably priced coverage for their children. GAO estimates that a half million children are affected. The Children’s Health Insurance Program (CHIP) only partially offsets this problem, since in many states the upper bounds of CHIP eligibility fall well below the ACA’s premium subsidy standard.
Beyond the family glitch is the problem of dental coverage for children. Oral health care arguably is the single most important insurance benefit for children given the universality of oral health concerns and the cost of appropriate care. Under the ACA, pediatric oral health coverage was supposed to be an integral element of all plans subject to the essential health benefit standard, and its cost therefore taken into account when calculating premium subsidies. But this has turned out not to be the case as the law has been implemented. Depending on where they live, families purchasing subsidized Exchange coverage may be unable to find a plan that includes dental benefits for their children, meaning that they must buy stand-alone dental plans that are subject to separate premiums and cost-sharing requirements, maintain separate out-of-pocket limits, and continue to apply pre-existing condition exclusions. This problem has to be fixed.
For low- and moderate-income families, subsidy assistance is too low. The gap between subsidies and reality shows up most clearly when the Exchange subsidy structure is compared to that used for separate CHIP plans. A family living at twice the federal poverty level can purchase a CHIP plan with roughly a 90 percent actuarial value. Under the Exchange system, not only would the family have to pay a higher family premium, but cost-sharing assistance would bring the actuarial value for covered benefits to only about 73 percent. Considering everything a family might need that falls outside the scope of an exchange plan (e.g., vision care or adult dental benefits), leaving these families with such high financial exposure clearly poses real access problems.
Especially for people with disabilities, the ACA’s market reforms — specifically its ban on the use of pre-existing condition exclusions and discriminatory pricing techniques — were clearly the law’s signature achievement. But in the face of these non-discrimination provisions, some insurers have devised other types of discriminatory techniques, such as redlining people with costly conditions by hiking out-of-pocket costs for selected prescription drugs, attempting to classify mental health conditions such as autism as physical conditions in order to avoid mental health parity requirements, or structuring their networks to create barriers to certain types of specialty care.
Overcoming these practices and weaknesses may, in some cases, require new legislation. In others, what is needed is clearer regulatory standards and a greater commitment to oversight and enforcement, which have been weak. (Who has time for active oversight and enforcement when the battle just to hang onto paper gains is so great?)
3. Making The ACA A More Potent Force For Cost Containment And Quality Improvement
Building on trends already underway in the health care industry, the ACA sought to propel forward progress through the creation of new efficiency and quality improvement tools in the form of Medicare and Medicaid organizational and payment reforms, and multi-payer system transformation initiatives. The legislation introduced spending control innovations such as broader oversight of insurance pricing in order to create downward pressure on health care prices. But whether these indirect efforts to control health care costs will achieve long-lasting change remains to be seen; without long-lasting change, Americans’ coverage will continue to erode, as most powerfully evidenced by the creation of a new generation of under-insured Americans as a result of the growth of high-cost-sharing plans.
Any decision to take a more direct approach to health care cost containment will need an unprecedented level of agreement across the political spectrum, but the nation can expect little to no real progress if it remains engulfed in a battle over government’s role in the threshold matter of coverage itself.
4. Building Primary Health Care Access For Medically Underserved Communities And Populations And Addressing The Underlying Social Conditions Of Health
The ACA’s Community Health Center Fund, recently extended for two additional years as part of the Medicare Access and CHIP Reauthorization Act (MACRA, Pub. L. 114-10), has helped health centers extend their reach to an additional 5 million people since 2010. But even with this expansion, health centers are able to offer affordable primary health care in only a fraction of all medically underserved communities, and health centers as well as other safety-net providers face a critical shortage of trained medical, nursing, dental, mental health, and other professionals. Of all the questions we should not have to ask ourselves as we think about how the ACA can be strengthened, whether there ought to be an ongoing public investment in the development of primary care infrastructure is high on the list.
Nor should we have to ponder whether health care systems that treat medically complex children and adults should be equipped to address social as well as medical care needs. The attributes of health care systems equipped to tackle both tasks in an effective manner have been described in numerous reports and studies, and CMS’ proposed Medicaid managed care regulation represents an important step in creating a policy framework for the growth of such systems.
Financing the social and population health services element of integrated delivery systems remains a challenge. Josh Sharfstein has put forth an excellent suggestion on how Medicaid managed care payments themselves might play a role, and grant-based funding will continue to be crucial in this regard.
All this is to say that King should be understood for its fuller policy implications: It’s time to stop fighting over whether access to affordable insurance and high-quality health care is part of government’s basic role in the lives of Americans. Indeed, this is the only wealthy nation in which this question seems to remain open to debate. King’s bigger meaning is that it is now time to move on, so that the ACA’s deeper promises can be effectively translated into reality.
How Do New Blood Thinners Compare to Warfarin?
WebMD describes how warfarin compares to new blood thinners that are prescribed to prevent blood clots and stroke.
A Healthy Body Often Equals a Healthy Brain
Experts stress that exercise, good diet help maintain memory as much as mental challenges do
Under-the-Tongue Hay Fever Pills Offer Little Benefit: Study
For serious grass allergy, shots may be more effective, researcher says
Implementing Health Reform: Contraceptive Coverage Religious Accommodations, House v. Burwell, And More
The Supreme Court’s decision in King v. Burwell that the federally facilitated exchanges can grant premium tax credits was clearly the big Affordable Care Act implementation news for the end of June, if not for the year. But it was not the only ACA-related news.
First the Supreme Court ended its term this year, as it did last year, by entering an order in one of the cases challenging the accommodation the federal government has offered religious organizations with respect to the contraceptive mandate. The accommodation that the Departments of Labor, Treasury, and Health and Human Services offered religious organizations — after last year’s end-of-term order in the Wheaton College case called into question an earlier HHS rule — requires religious organizations to inform the government of their objection to covering all or some contraceptives for their employees, and to identify the insurer or third party administrator that covers their employees. The government will then arrange with the insurer or third party administrator to offer contraceptive coverage without further involvement from the religious organization.
Some religious organizations have continued to contest this accommodation, claiming that it still makes them responsible for allowing their employees to commit a sin and thus violates the Religious Freedom Restoration Act by substantially burdening their free exercise of religion. The Third, Fifth, Seventh, and D.C. Circuits have rejected this argument; they have upheld the most recent accommodation, saying that it does not substantially burden the plaintiffs’ religious beliefs and is a reasonable accommodation for fulfilling the compelling governmental interest of ensuring employees’ access to contraceptive coverage. But litigation continues.
The plaintiffs in Zubik v. Burwell had asked the Supreme Court to stay the mandate of the Third Circuit, which had rejected their arguments. Justice Alito had granted a temporary stay of the mandate in April. The June 29 order denied the plaintiffs’ request for a stay, but it enjoined the government from enforcing the contraceptive rule against the plaintiffs as long as they qualified as a religious organization and self-certified their opposition to contraceptive coverage to the government.
The order specified that nothing in it affected the ability of employees to receive contraceptive coverage or of the government to rely on information supplied to it by the religious organizations to ensure coverage. It may not always be the case, however, that the government can identify the insurer or third party administrator responsible for coverage if a religious organization does not provide that information — thus some employees may go without coverage. Justice Sotomayor would have denied the request.
In any event, the order is only in effect pending the filing and disposition of the plaintiffs’ pending request for certiorari (review). Given that all of the circuits that have ruled on last summer’s accommodation have so far ruled against the plaintiffs, it is not a foregone conclusion that the Court will grant certiorari.
What A Decision On Legislative Standing Might Mean For House v. Burwell
Another case decided by the Court on June 29 is likely also to have ramifications for pending Affordable Care Act litigation. Arizona State Legislature v. Arizona Independent Redistricting Comm’n concerned legislative redistricting in Arizona, an issue remote from the ACA. But a major issue in the case was the standing of the Arizona State Legislature to bring a lawsuit to challenge the redistricting. The standing of a legislature to sue if, of course, a key issue in House v. Burwell, arguably the most serious remaining case challenging the ACA.
House v. Burwell is a case brought by the House of Representatives challenging the administration’s delay of the employer mandate and, more importantly, arguing that the federal government is improperly paying out cost-sharing reduction payments in the absence of a specific annual appropriation. It is a serious challenge to the ACA, because the ACA’s cost-sharing reductions are what makes health care affordable for the almost 60 percent of exchange enrollees who receive them. Although insurers would be required to continue to reduce cost-sharing even if the courts found for the House, they would not, absent a specific appropriation, be paid for the cost-sharing reduction, causing financial distress and dramatic premium increases on the part of insurers.
The government has moved to dismiss this litigation based on existing precedent, notably the 1997 Supreme Court decision of Raines v. Byrd, which held that members of Congress cannot sue to challenge executive action. The Court in the Arizona case distinguished Raines and found standing in the Arizona State Legislature to challenge the redistricting, in part because Raines involved individual legislators while the Arizona case involved the state legislature suing as an institution pursuant to a vote to authorize litigation. This is arguably the situation also presented in House v. Burwell, where the majority of the House authorized the litigation. The Court in the Arizona case, however, explicitly noted at footnote 12 that its decision does not “touch and concern the question of whether Congress has standing to bring suit against the President,” suggesting that this raises serious separation of power issues.
Justices Scalia and Thomas dissented in the Arizona case, and would have held that the Court had no jurisdiction to hear a challenge brought by a legislature. Although they emphasized the separation-of-powers basis for rejecting standing, they observed that the lack of standing argument may be stronger where state legislatures are suing than when Congress sues.
House v. Burwell is currently awaiting further briefing of the government’s motion to dismiss the case. It is likely that the Arizona case will play a major role in its decision.
Health Plan Efforts To Improve Quality And Reduce Disparities
On June 19, while all the world including myself was awaiting the Court’s decision in King, the Department of Health and Human Services released further details on its ongoing quality improvement strategy for qualified health plans, in a notice published in the Federal Register and in documents filed at its Paperwork Reduction Act website. The documents include a Quality Improvement Strategy Implementation Plan and Progress Report Form to be filed by qualified health plans, as well as a cross-walk showing changes in the form from earlier versions.
CMS claims to have streamlined the form to eliminate redundancies and reduce effort on the part of insurers. Substantively, CMS clarified that an insurer can meet the requirement that it reduce health and health care disparities by either selecting it as a topic area or by integrating relevant activities in the issuer’s quality information system (QIS). CMS states that it has developed a flexible QIS form to encourage issuer innovation and promote a culture of continuous quality improvement.
Insurers may make annual changes to their activities, quality measures, and/or performance targets without creating a new QIS. An insurer will, however, have to submit a new QIS if it changes the topic area or market-based incentives of its QIS, if it achieves one or more performance targets, if it does not realize the QIS impact as expected, or if the QIS results in negative outcomes or unintended consequences.
In the initial years of QIS implementation, CMS will not establish any standardized or uniform set of performance measures for the QIS and does not require insurers to select measures from any specific set of measures. CMS will require insurers to submit updates using performance measures as a measure of progress along with a narrative description. Insurers will be allowed to focus on the issues of greatest importance to their markets and covered populations. In particular, CMS intends to collect information regarding alternative payment models linking quality and value to promote transparency, align with HHS delivery system reform efforts, and help Marketplaces make better informed QHP certification decisions.
Insurers will be required to collect quality information beginning in 2016 for the 2017 coverage year.
Reinsurance And Risk Adjustment Payments
Finally, on June 30, 2015 health insurers will be notified regarding the reinsurance and risk adjustment payments they will receive and of any risk adjustment payments they may have to make for 2014 under the ACA’s premium stabilization programs. It is likely that these amounts will be substantial and that they will not always be in line with what insurers anticipated. Stay tuned for further developments.
Monday, June 29, 2015
Can Orange Juice, Grapefruit Raise Your Melanoma Risk?
Study authors think compounds in citrus may sensitize skin to sunlight, but further study needed
Plague
Plague: The plague is an infectious disease due to a bacteria called Yersinia pestis.
Y. pestis mainly infects rats and other rodents. Rodents are the prime reservoir for the bacteria. Fleas function as the prime vectors carrying the bacteria from one species to another. The fleas bite the rodents infected with Y. pestis and then they bite people and so transmit the disease to them.
Transmission of the plague to people can also occur from eating infected animals such as squirrels (e.g., in the southeastern U.S.) Once someone has the plague, they can transmit it to another person via aerosol droplets.
History -- Yersinia is named after a Swiss bacteriologist Alexandre- Emile-Jean Yersin (1863-1943) who identified it in 1894 after a trip to Hong Kong looking for the agent that was killing thousands of people in southern China. The same discovery was made at the same time by a Japanese bacteriologist Shibasaburo Kitasako.
The plague has been responsible for devastating epidemics. The disease occurs endemically (at a consistent but low level) in many countries including the United States. "La Peste" (The Plague), a novel (1947) by the Nobel Prize-winning French writer Albert Camus (1913-1960) is set in the Algerian city of Oran overrun by a deadly epidemic of the plague.
Bioterrorism -- The General Accounting Office, the investigative arm of the US Congress, in a 1999 report considered plague to be a "possible, but not likely" biologic threat for terrorism, as it is difficult to acquire a suitable strain of Y. pestis and to weaponize and distribute it. Seed stock is difficult to acquire and to process and heat, disinfectants and sunlight render it harmless.
The plague is also known as pest and pestis.
MedTerms (TM) is the Medical Dictionary of MedicineNet.com.
We Bring Doctors' Knowledge To You
AHRQ And The Essential ‘Both/And’ Of Federal Investments In Medical Discoveries
Congressional appropriators face difficult decisions in a time of imposed national budget constraint. However, the move by the House Appropriations Committee to terminate the Agency for Healthcare Research and Quality (AHRQ) is the wrong way to address these challenges.
In an era of austerity driven by sequestration, the desire to fund new discoveries has once again been placed in direct competition with complementary, equally critical efforts to insure equitable and safe access to these same innovations across America. I believe this is a false choice that put us all at risk by ultimately constraining both aims.
Others have cataloged the diverse activities sponsored by AHRQ and the benefits accrued. I won’t repeat them here, except to say that societal investment in AHRQ specifically, and health services research (HSR) in general, is key to designing, building, and sustaining critical infrastructure and capabilities so that the health system can work better, serving the needs of patients and those who care for them. This is not sexy work — it will not trend on Twitter, nor is it likely to make the front page of USA Today, at least not that you’d notice.
However, the problems and solutions at the heart of HSR and core to the mission of AHRQ—from health disparities to patients gaining reliable access to new discoveries—underlie some of the most compelling medical stories there are. Take, for example, the patient who gets sicker or dies because she doesn’t receive necessary and recommended medical services; the health system innovations that encourage the highest quality care; or changes in medical procedures that reduce costs and save lives.
We do and should hold leaders accountable for the folly and risk of poor infrastructure planning and investment. For example, placing new trains capable of higher speeds on tracks and control systems from the last century is unacceptable. We systematically upgrade highways and communications infrastructure as invention progresses, and we couple discovery of exciting and life-changing new technologies with assurances around broad access and safety. Innovation in health care is no less deserving of robust infrastructure investment, improvement, and spread. Yet, the move to eliminate AHRQ cripples our ability to plan and upgrade our health care infrastructure and puts our national ability to realize the full benefit of care discoveries at inappropriate risk.
Decades have been spent balancing the portfolios of the agencies that comprise the Department of Health and Human Services so that they can provide the country with an integrated approach to discovery and delivery of care improvement and innovation. This includes the identification of the causes of disease at Centers for Disease Control (CDC), the development of cures at National Institutes of Health (NIH), and the identification and dissemination of the best strategies for delivery and organization of those innovations at AHRQ.
Unlike its peers, AHRQ research is not focused on a single disease or treatment, but on the cross platform and multidimensional aspects of care delivery. AHRQ and the HSR it fosters work to make the health system function better. As such, it is charged to work with its sister agencies to “produce evidence to make health care safer, higher quality, more accessible, equitable, and affordable, and to work within the U.S. Department of Health and Human Services and with other partners to make sure that the evidence is understood and used.”
AcademyHealth President and CEO Lisa Simpson said in her official statement, “Investments in discovery and development will fall short if we don’t have research on how best to deliver them to the right patients, at the right time, and in the right setting.” That is where AHRQ makes its greatest contributions.
In a resource limited environment, we have to make tough choices, but eliminating funding for AHRQ is short sighted and places patients and their families at inappropriate risk. AcademyHealth and our partners in the research community look to the Senate to restore funding for AHRQ and maintain a balanced portfolio of investment in research that protects and improves the health of individuals and communities across America.
Paul Wallace MD is the Chair of the Board of Directors for AcademyHealth, the national organization serving the fields of health services and policy research and the professionals who produce and use this important work.
Saturday, June 27, 2015
Vibrio vulnificus
Vibrio vulnificus: a type of bacteria that belong to the same family as the bacteria that cause cholera. Vibrio vulnificus is found in warm salt water and causes infections in people who eat contaminated seafood or swim with an open sore or wound in water where V. vulnificus is present. In people with an intact immune system, the infection can cause nausea, abdominal pain, and vomiting. The infection can be much more serious in those whose immune function is compromised. In these persons, the bacteria can infect the bloodstream, leading to septic shock, fever and chills, and skin lesions. When the bacteria infect the bloodstream, the infection is fatal in about half of cases. Most cases in the US are reported from states along the Gulf coast. The infection is treated with antibiotics.
MedTerms (TM) is the Medical Dictionary of MedicineNet.com.
We Bring Doctors' Knowledge To You
Two Years Later: How Kynect Has Impacted Kentucky’s Healthcare System
By CAMPBELLSVILLE UNIVERSITY SPONSORED CONTENT
Since its second enrollment period ended in March, Kentucky’s health benefit exchange has been celebrated by state government leaders as a success story of the Affordable Care Act. Known as Kynect, the exchange has provided thousands of uninsured citizens with health insurance coverage. It has also drawn its share of controversy.
Although much of the discussion surrounding Kynect and the Affordable Care Act has focused on their political implications and other debates, little has been said about how the changes to Kentucky’s healthcare system have affected patients, nurses, doctors and hospitals. With two enrollment periods complete, how has Kynect worked and what benefits has it provided the state?
Overview of Kynect
The primary emphasis of the Affordable Care Act was giving the 3.8 million Americans without health insurance an opportunity to become insured. The primary method of providing coverage was through health benefit exchanges, which were created by both the federal government and some states. Kentucky Governor Steve Beshear and his administration elected to develop a state-based exchange to make finding coverage easier for Kentuckians. Thus, Kynect was born.
The Objective and Goals of Kynect
On its website, Kynect promises to provide “individuals, families and small businesses with easy, one-stop shopping” to find the healthcare coverage they need. Although the site is open for applications 365 days a year, the majority of health insurance plans are available during the three-month enrollment period that stretches from Nov. 15 to Feb. 15 of each year.
Kentuckians can use Kynect to obtain health insurance, as required by the Affordable Care Act. The site allows applicants to compare plans and check whether they’re eligible for Medicaid.
What Kynect Does Differently
While the federal government created a national health benefit exchange called HealthCare.gov, Kentucky and 14 other states developed their own marketplaces. This immediately paid dividends when the national marketplace encountered countless issues upon launch. Meanwhile, Kentucky’s simple but robust Kynect system outperformed all expectations.
In an interview with National Public Radio, Beshear described what his administration did differently in building Kynect: “Our folks at the health cabinet and the Medicaid department were all intricately involved in designing this website, and they worked with the vendors.”
Beshear explained that the process of building Kynect focused on user experience. Kynect has yet to have the significant problems that followed the launch of HealthCare.gov. Kynect also involved insurance agents, who now have more clients to work with. The site even allows users to check eligibility for programs like Medicaid without creating an account.
Kynect’s Success
Kentucky’s extensive effort was recognized as a success by state residents and national observers. Soon enough, the Bluegrass State became a poster child for demonstrating how to implement the Affordable Care Act well. Countless news outlets, from The New York Times to Fortune magazine, declared Kynect a success. Beshear and his cabinet were praised for creating a user-friendly website that was easy to navigate.
As a result of Kynect’s well-organized interface and a strong marketing campaign, uninsured Kentuckians signed up for health coverage in droves. The state reported more than 413,000 applicants enrolling during the first enrollment period that ended in March 2014. Of those who registered, about 75 percent previously lacked health insurance. Those residents gained improved access to preventative care and other benefits.
Impact on the Individual
When discussing Kentucky’s commitment to Kynect and the Affordable Care Act, Beshear touted “untold health benefits for the commonwealth.” By providing uninsured citizens with health insurance, the state expects to eventually save money because more people will engage in preventative health measures. The benefits of Kynect are potentially far-reaching.
How to Obtain Health Insurance via Kynect
Applications on Kynect are completed either online or on the phone. Users can create an account, begin their application and answer a series of questions. Unlike submitting a paper application and waiting for a response, individuals see what options are available to them right away.
Easy–to-understand descriptions of all available plans are provided. Users can also call customer service representatives with further questions. If eligible, a user will be able to apply for certain programs such as Medicaid or payment assistance.
Services Offered by Kynect
The robust healthcare marketplace of Kynect offers a variety of services for potential applicants. These benefit not only individual users but also other groups. The services include:
Plan applications and enrollment for both individuals and families
Tools for small business owners to offer insurance for their employees
Resources for insurance agents to recommend specific plans to individuals, families and business owners
Information for community leaders on how to get the general public enrolling in Kynect
The site has a wide variety of resources available to all users that can help them better understand what Kynect offers.
Cost to the Individual
Kynect is not only making healthcare available to the uninsured, it’s making it affordable. Beshear offered the following examples of how Kentuckians will save.
A 22-year-old college student earning $18,000 per year could get a monthly subsidy of $104, lowering his monthly cost to $20.
A 35-year-old single parent of two children earning $35,000 per year could get a monthly subsidy of $240, lowering her monthly cost to $93.
A family of four earning $65,000 per year could get a monthly subsidy of $249, lowering their monthly cost to $336.
A retired couple earning $50,000 per year could get a monthly subsidy of $526, lowering their monthly cost to $160.
By reducing the monthly cost of insurance, it makes far more sense for the uninsured to apply. They can reduce out-of-pocket costs and have easier access to health treatment.
Impact on the Healthcare System and Professionals
After understanding how Kynect affects the citizens of Kentucky, it is interesting to consider how it affects the healthcare system as a whole. By altering who has access to healthcare and how insurance companies charge consumers, there are extensive changes happening at all levels of the healthcare system.
What Does It Mean for Nurses and Doctors?
In many ways, Kynect is helping healthcare providers. By allowing the uninsured easier access to healthcare, providers are reaching more patients than ever before. Although it is still early to study concrete numbers, doctors and nurses should see a higher volume of patients. Unfortunately, this could add to the current and anticipated shortage of nurses and physicians.
One major tenet of the Affordable Care Act is the end of discrimination against patients with pre-existing conditions. Doctors and nurses may now treat patients who could not obtain or afford health insurance because of a pre-existing condition. Plans on Kynect also have no annual limits, so patients no longer have to wait until a specific date to get the care they need.
What Does It Mean for Hospitals?
The Affordable Care Act also sought to improve the quality of care in hospitals, both in Kentucky and across the country. An increase in insured Americans will add to the number of patients for hospitals. Some might suggest that could overpopulate healthcare facilities and dumb down service.
However, new laws withhold Medicare payments from hospitals with too many patients returning with specific ailments. This will hopefully prevent hospitals from sending patients home too early and improve postsurgical treatment. Hospitals will also offer more quality outpatient services to help weather increased patient volumes.
Connecting the Uninsured
It’s clear that Kynect has been a boon for the state healthcare system. The Affordable Care Act will remain an issue in politics, especially after costs to the state are measured. And as the system grows, new challenges will arise. More nurses, doctors and healthcare administrators will be needed to serve Kentuckians. Tomorrow’s professionals will have the chance to improve the overall well-being of Kentucky and the nation. Learn more about meeting this demand through Campbellsville University’s RN to B.S. in Nursing program.
Surgery May Help Teens With Frequent Migraines, Study Contends
At least one expert questions whether improvements are due to the procedure
Real Mentoring Lessons From the Liver Queen
The “outpatient” consisted of the Prof seeing patients while the students watched. The room was arranged with six cubicles, three on each side of her desk, each guarded by a watchful nurse (sister) with a neat uniform and starched hat. In front of The Prof’s desk were several rows of chairs; perhaps a total of 16, for students who were to sit quietly unless specifically ask to speak or to feel the liver of one of the patients.
If the Prof wanted one to feel the liver, she would actually take your hand in hers and place it on the abdomen. The Royal Free was formerly a women’s medical school. By the time I was there it had accepted men but there were still many more women than one typically saw in American medical schools. One day in the middle of outpatient, The Prof turned to one of the women student’s and declared: “You’re pregnant.” “No, I’m not said the shocked student.” “Oh, yes you are. Do you know how I know?” The Prof scanned the room as she often did when looking for a response to her typically Socratic questions. “No, I don’t believe I am,” repeated the now red faced student. “Yes, you are. There are two reasons that I know. One, you have a new spider angioma on your face and two, you have chorea.” And yes, the Prof was later proved correct. Don’t try this one in the current era.
Another day she looked at a student and said: “You’re jaundiced. I notice you have a cold. You have Gilbert’s.” (notably pronounced with a hard “G” as if it were an English name). And yet another time, she was feeling the liver of a patient who had travelled from afar to see her, as many did. “You must be a Greek farmer.” Correct again. She had felt what she had diagnosed as an echinococcal cyst (what she called hydatid disease) and she was Sherlock (Holmes) for the rest.
There were detractors, of course. Some considered her brash and theatrical. I once heard a senior professor opine that she had only been successful because she wrote her book on the liver during the war while the men were all in the service. A little jealousy and bitterness, perhaps? It wasn’t all milk and honey. One day at a radiology conference I raised my hand to make a comment. When the Prof ignored me I persisted, until she finally said sternly: “Students are not to speak in this conference!” I feared that I had ruined my relationship with her, but no, it just wasn’t my place. Students are not the center of the universe, something I had not learned very well from my American medical school experience. She later told me that she admired my willingness to participate but that I had to learn when to speak and when to keep quiet. That’s a lesson I try to keep in mind (not always successfully) in many of the meeting of my current life.
On the day I left the Royal Free, I made an appointment to visit her in her office (a Quonset hut on the roof of the old hospital, which then was in Gray’s Inn Road near King’s Cross). I wanted to go home with an inscribed copy of her book. That was all I expected that day. But, after inscribing her book, Diseases of the Liver and Biliary System, the Prof said to me: “You have been successful here. What are your plans?” I told her that I was enamored with neurology, an interest that was stimulated by Charles Aring, a mentor in Cincinnati, and fueled even more by my experience with the neurological complications of chronic liver disease that I had seen while working at the Royal Free. “Where are you going for your medical houseoffership?” I didn’t know yet, though Dr. Aring, who had trained at Boston City Hospital, had suggested that I should go there. There was a matching system and I had not even had my interviews. She immediately went to her phone and put in a call to one of her friends in Boston and said within my earshot: “I’ve got a good boy here. You should take him.” The rest is history. I applied to Boston City Hospital and was accepted. Four years later I was serving as the Chief Resident on the Medical Service at BCH and invited The Prof to serve as visiting professor. I had no right to believe that the world’s leading hepatologist would accept this invitation, but I was one of her “boys,” so she accepted and I was considered a miraculous rain maker. She came and spent three days with us, dazzling everyone with her usual brilliance, flamboyance and wit. In fact, she had come mainly just to help me. She had used her eminence and power to again energize a mentee. Thereafter, I wrote The Prof whenever a major personal event occurred or I was contemplating a move. On each occasion I always received a brief handwritten note, which invariably ended: “We’re very proud of you.”
In the current era, there is a lot of talk about mentoring. Our residency applicants invariably ask about whether our residency has a mentoring “program.” Of course, we respond that we do. We analyze people’s CVs and try to match them with a faculty mentor who shares their interests and personal characteristics. These initial matchings sound good, but they almost never stick. This is because it is practically impossible to predict the chemistry of a mentor-mentee relationship. In fact, finding someone who is different than oneself is much better than affiliating with someone who is similar. Diversity is, after all, not a matter of altruism. It is a Darwinian issue of survival. Institutions that do not reflect the community that they serve become progressively atrophied and irrelevant and morph into quaint relics rather than dynamic, living organisms. The same is true of individuals. A mentor who is different than oneself can open doors and offer perspectives that otherwise would never be realized. Mentoring is not simply offering advice. It is actually doing something actively to help a younger colleague gain access to the resources necessary to succeed. The Prof and I were different in most ways (see our attached photograph). She was short and I was tall. She was old and I was young (actually I calculated that she was only 52 when I met her, but seemed old to me at the time). She was a woman and I was a man (actually a boy as she was wont to call me). She was Christian and I was Jewish. She was British and I was an American. She liked the liver and I liked the brain. Yet, she was one of the most important role models and mentors in my entire career. As I interact with my students and residents, I try to emulate her in so many ways. I try to be a great clinician and teacher. I try to not only talk a good game but actually do something to make a difference. I try to act immediately, while the mentee is in my presence, and in a tangible and useful manner. I try to stay with them even after they have left my immediate purview and, yes, I try to end each correspondence with the words: “We’re very proud of you.”
Recommended reading: The Prof: The Life of Sheila Sherlock ‘The Liver Queen’ by Om P. Sharma. The Royal College of Physicians, 2007.
Martin Samuels is a professor of neurology at Brigham and Women’s Hospital.
Same-Sex Marriage Offers Couples Psychological Benefits, Experts Say
Supreme Court decision to support it would also boost well-being of couples
Friday, June 26, 2015
How Population Health Is Driving Merger Mania Among Anthem, Cigna and the Rest of the Big Insurers
The nation’s Big 5 health insurers have thrived under the Affordable Care Act, seeing their profits grow and their stock prices soar.
They also continue to dwarf their main sparring partners—hospital systems—in size. Consider that the largest health insurer, United Health Group, has annual revenue of $130 billion, while revenue at the largest hospital system, HCA, is a tick under $37 billion. The second-largest health insurer, Anthem Inc., has $74 billion in annual revenue, while the second-largest hospital system, Ascension, has $20 billion.
So why are health insurers so desperate to get bigger? Anthem has offered $47 billion to acquire Cigna Corp., and United, Humana and Aetna are all trying to counter with mega-deals of their own.
Well, it’s about economies of scale and all that—the Affordable Care Act and other changes are squeezing the amount of profit insurers can make per customer, even as the pool of paying customers is growing. Also, hospital systems, while still more fragmented than insurers, are consolidating, as are drug and device makers. So insurers want to boost their bargaining power.
But the real reason is population health.
“In order to do population management, you need populations,” Dhan Shapurji, a Deloitte consultant to health insurers, quipped in a phone call with me this week.
He was being a bit tongue-in-cheek, but he hit on the key word: “populations.”
It’s no longer enough just to have lots of members in your health plans—Anthem has 38.5 million; Cigna has 14.7 million.
To do population health, insurers must have a critical mass of people in local markets— otherwise why would health care providers enter population health-based contracts with them?
To do population health, insurers must have a critical mass of members in each of several high-cost diseases: diabetes, heart disease, cancer, behavioral health. Otherwise, it will be too expensive to hire the clinical staff to develop the necessary clinical protocols, to staff the high-touch patient intervention programs and to develop the data analytics and customer engagement technology seen as vital for doing effective population health on a large scale.
Just on the technology side, a recent Deloitte report calculated that the average Big 5 health insurer spent $554 million on any sort of capital spending—not just technology development—in 2012. That same year, Google alone spent $6.8 billion on research and development.
Since companies like Google are setting the standard for how today’s consumers want to interact digitally with services companies, it’s no wonder that Anthem CEO Joe Swedish has made a habit the past year of saying that, among health insurers’ customers, “frustration is pre-eminent and growing by virtue of the intolerance of health care’s inability to match the experiences in other aspects of our lives.”
“We intend to change this dynamic and our strategy is to create an improved customer experience as a distinguishing characteristic of Anthem,” Swedish told investors during a January presentation at the J.P. Morgan Healthcare Conference in San Francisco. But to make that vision a reality, while still growing profits, Anthem needs the scale it would get from acquiring Cigna.
Also to do population health, it’s also critical for insurers to have a critical mass of patients in each program—not just employer insurance but also individual, not just individual policies but also exchange policies, not just exchange policies but also Medicaid managed care programs, and not just Medicaid but also Medicare and Medicare Advantage.
“We’ve always said we wanted to participate in a lifecycle” with our members, Anthem Chief Financial Officer Wayne DeVeydt told investors after Anthem publicized its buyout offer for Cigna, which Cigna has so far rejected. The two companies together, he said, would have “the largest footprint or largest catcher’s mitt if you will regardless of where the consumer is at in their lifecycle.”
Of course, every company wants to keep customers as long as possible. But in the era of population health, keeping members longer, even as they move between commercial or government programs, between employer and individual insurance, is the only way to make profits from those population health efforts.
“As you start to truly have populations, then regardless of which disease state you’re in, regardless of which line you’re in, we’re going to capture you,” said Shapurji, the Deloitte consultant. “And if you move, then it doesn’t really matter.”
J.K. Wall is a health care reporter at the Indianapolis Business Journal and author of The Dose blog on the business of health care.
Hearts, Minds, And Health Care Reform
Thinking about the Affordable Care Act (ACA), King v. Burwell was not a difficult case. The congressional majority that passed this long and complicated statute sought to expand health insurance coverage for all Americans and found constitutionally permissible ways to do so. In a 6-3 ruling released on June 25, the Supreme Court interpreted a technical provision that had been poorly drafted in a way that furthers rather than frustrates the law’s larger purpose.
Oral arguments last March offered little intellectual novelty; the straightforward majority opinion contains even less. As President Obama said to conclude his public statement applauding the decision, “Let’s get back to work.”
But sometimes one also should feel a law and a Supreme Court opinion. So let us pause to do so.
Feeling The Affordable Care Act
I have never personally suffered racism, violence, poverty, or discrimination based on gender or sexual orientation. Laws that shape our society in those areas—for better or for worse—are felt by those who face such challenges or affronts. And when the nation’s highest court speaks on those issues, its words are deeply felt.
I do feel the Affordable Care Act, and therefore I feel the Court’s words in support of it. I have personally experienced the fear and actuality of illness, the successes and failures of medical treatment, the deaths of people I love, and the emotional and financial burdens that resulted. As a physician, I have cared for others, and often succeeded but sometimes failed. As a legal and policy scholar, I have worked for many years to build a health care system that is more accessible, more respectful, more reliable, and less costly.
Late in the evening of March 21, 2010, my wife and I gathered our two young children in front of the television in our bedroom to hear the last arguments about the Affordable Care Act in the House of Representatives and watch the votes be registered. As the affirmative votes inched toward a majority, the suspense was palpable. My family knew that I had spent my entire professional life working toward that moment; when the votes in favor passed 200, our 9 year-old son was particularly (and viscerally) affected. The final tally of 219-212 did not feel like triumph but affirmation, not closure but a path forward.
Opponents of federal health care reform feel the ACA in very different ways. Some of those feelings seem deserving of respect, others markedly less so. I do not pretend to understand them all, but I hope that they will soften over time. We are, after all, in this together.
In Praise Of The Chief Justice
Three years ago, I wrote in this space about the Supreme Court’s decision in National Federation of Independent Business (NFIB) v. Sebelius, which was a full-throated constitutional challenge to the ACA, not an administrative dispute over four relatively random words. In that essay, I praised Chief Justice John Roberts for “preserving the Republic” and repeat that sentiment now. Our democracy is continually challenged, which I suppose is the nature of democracy. Today, as in 2012, a majority of the Court voted for our noble if flawed democratic institutions. When it could have divided us further, King v. Burwell helps move us forward together.
The Chief Justice’s majority opinion is plain-spoken and commonsensical. Justice Scalia’s dissent is, forgive me, intemperate and sarcastic. The majority addresses the citizenry; the dissent seems directed at a more sophisticated, more jaded, and considerably smaller audience. On both sides, however, the Court deals with the case on its merits, without much apparent need to secure longer term advantages in the federal jurisprudential contests that often consume the nine strong-willed, life-tenured justices.
Unconstitutional coercion, raised as a possible bargaining chip during the litigation, is not mentioned in the resolution. Administrative law makes an undramatic appearance (perhaps presaging an imminent environmental ruling in another case), though the Internal Revenue Service is put in its place a bit too harshly. Overall, the focus is where it should be, on the goals and means of expanding health insurance throughout the nation.
Getting Back To Work
Let me end, therefore, with a tribute to the combatants that emphasizes their commonalities rather than their differences. First, to Chief Justice Roberts, whose views on the ACA seem to have changed from grudging acquiescence in the will of Congress to appreciation of the intricacies of health care reform:
Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them. If at all possible, we must interpret the Act in a way that is consistent with the former, and avoids the latter. Section 36B can fairly be read consistent with what we see as Congress’s plan, and that is the reading we adopt.
Second, to Justice Scalia, who recognizes a moment in history even if he will not embrace it:
Perhaps the Patient Protection and Affordable Care Act will attain the enduring status of the Social Security Act or the Taft-Hartley Act; perhaps not. But this Court’s two decisions on the Act will surely be remembered through the years.
Third, to President Obama, who in his remarks on the decision publicly articulated—to my knowledge, for the first time—the core challenge of building social solidarity around health care in a nation skeptical of domestic policy-making:
And unlike Social Security or Medicare, a lot of Americans still don’t know what Obamacare is beyond all the political noise in Washington. Across the country, there remain people who are directly benefitting from the law but don’t even know it. And that’s okay. There’s no card that says “Obamacare” when you enroll. But that’s by design, for this has never been a government takeover of health care, despite cries to the contrary. This reform remains what it’s always been: a set of fairer rules and tougher protections that have made health care in America more affordable, more attainable, and more about you — the consumer, the American people.
As for me, I am glad that my confidence in our system of government has been reaffirmed and my optimism for health reform restored, but I feel that there is still much to be done. My current project: helping the health care system become more competitive and more efficient. Like the President said, “Let’s get back to work.”
Fat No Longer the Focus of New U.S. Dietary Guidelines
Nutrition experts endorse decision to drop restrictions, focus on quality of food instead
King vs. Burwell: Chalk One Up For Common Sense
But the law said that such credits could be paid in exchanges ‘established by a state,’ which led some to claim that the credits could not be paid to people enrolled by the federally operated exchange. In his opinion, Chief Justice Roberts euphemistically calls that wording ‘inartful.’ Six Supreme Court justices decided that, read in its entirety, the law provides tax credits in every state, whether the state manages the exchange itself or lets the federal government do it for them.
That decision is unsurprising. More surprising is that the Court agreed to hear the case. When it did so, cases on the same issue were making their ways through four federal circuits. In only one of the four circuits was there a standing decision, and it found that tax credits were available everywhere.
King v. Burwell And A Right To Health Care
Do Americans have a fundamental right to health care? This oft-debated question is timely given the Supreme Court’s stunning ruling yesterday in King v. Burwell, in which health insurance subsidies on the federal exchange were upheld in a 6-3 decision.
Here I will place the King v. Burwell opinion in the larger context of to what extent Americans are provided a right to care. The Constitution itself does not stipulate a general right to health care, but a patchwork of rights to certain aspects of health care have emerged over time from both constitutional and statutory law.
Constitutional Law
Reproductive Health
In Griswold v. Connecticut (1965), for example, the Supreme Court found a right of privacy in the Due Process Clause of the 14th Amendment and invalidated a state law against the use of contraceptive agents. Similarly, in Roe v. Wade (1973) and Planned Parenthood v. Casey (1992), the Court identified a woman’s right to have an abortion, a liberty that, as in Griswold, was found in the 14th Amendment. In Casey, however, the Court permitted states to regulate abortion services as long as the regulations did not present an undue burden to women’s access to abortion services.
Thus, in the area of reproductive health, the Supreme Court has protected certain limited rights to reproductive care. The Court has consistently denied, however, that the government has an obligation to pay for reproductive care, and in another recent development, unless the Court issues a stay in Whole Women’s Health v. Cole, most of the abortion clinics in Texas will soon close down.
Health Care For Prisoners
The Court also established a right to health care for prisoners, a right that was found in the 8th Amendment against cruel and unusual punishment (Estelle v. Gamble, 1976; Brown v. Plata, 2011). In Brown v. Plata Justice Kennedy wrote, “Prisoners retain the essence of human dignity inherent in all persons,” and human dignity includes a right to adequate health care.
Statutory Law
In statutory law Congress has provided broad rights to health care for the elderly, disabled, people living in poverty, and children by establishing Medicare, Medicaid, and CHIP. Also, in 1986 Congress passed EMTALA (Emergency Medical Treatment and Active Labor Act), which requires Medicare-funded hospitals with emergency departments to provide appropriate, though limited, emergency and labor care.
Mental health parity implies a right to receive mental health services among patients with mental health conditions. Persons with mental illness are among the most vulnerable members of our society, yet it was not until 2013 that final regulations were released for the Mental Health Parity and addiction Equity Act (MHPAEA).
The law prohibits coverage for mental health conditions, including substance abuse, from being less comprehensive than coverage for medical or surgical conditions. This important law, which was a long time coming, provides a right to equal care for patients with medical and mental health problems, but the key going forward is how well compliance with the law will be enforced.
The Affordable Care Act
Legal challenges to the Affordable Care Act (ACA) have stripped away some of the expanded access to health care originally provided by the law. While the individual mandate survived a constitutional challenge in 2012 (NFIB v. Sebelius), the ACA’s mandate for states to expand Medicaid was overturned on the grounds that it was coercive, and despite the availability of generous federal funding, 21 states have as yet declined to undertake voluntary Medicaid expansion.
The ACA also extended a right to preventive health care by adopting a set of eight categories of preventive services recommended by the Institute of Medicine that must be covered by insurers without a copayment. While this was a significant step forward, in Burwell v. Hobby Lobby Stores Inc., the Supreme Court struck down mandated coverage for contraceptive services in certain circumstances as a violation of the Religious Freedom Restoration Act. When it comes to a right to preventive health services, the Court has left women with incomplete coverage.
The Supreme Court’s King v. Burwell Opinion
The Court’s opinion in King v. Burwell, validating the subsidies provided on the federal health insurance exchange, lends clear support for a right to health care. The Court recognized that the loss of subsidies would create severe instability in insurance markets and likely send them into a death spiral, a result that could not possibly have been intended by Congress.
Writing for the Court, Chief Justice John Roberts concluded, “Those (tax) credits are necessary for the Federal Exchanges to function like their State Exchange counterparts, and to avoid the type of calamitous result that Congress plainly meant to avoid.”
In the three cases to date involving the ACA, the Court curtailed access to care by overturning mandated Medicaid expansion and contraceptive coverage, but endorsed expanded access in validating the individual mandate and the premium subsidies. Thus, the halting approach to declaring a universal right to health care for all Americans has continued in the Supreme Court.
Subscribe to:
Comments (Atom)