Thursday, July 12, 2018

Health Care Reform Articles - July 12, 2018

Universal quality healthcare coverage—a commitment to building a healthier and more productive society

by Edward Kelley et. al. - British Medical Journal - July 5, 2018

High quality healthcare involves the right care, at the right time, in the right place, and by the right care provider, while minimizing harm and resource waste and leaving no one behind. Unfortunately, many countries around the world fail to meet these requirements and struggle to provide healthcare services that deliver clinical value to patients, are safe, and meet the needs and preferences of patients.
Poor quality healthcare prevails in countries at all levels of economic development, manifesting every day in inaccurate diagnosis, medication errors, inappropriate or unnecessary treatment, and inadequate or unsafe clinical facilities or practices. The implications are devastating for patients and their families. In low and middle-income countries, for example, 10 percent of hospitalized patients can expect to acquire an infection during their stay, compared with seven percent in high income countries [1]. According to the World Bank Service Delivery Indicators initiative, healthcare workers in seven low- and middle-income African countries were only able to make accurate diagnoses one third to three quarters of the time, and clinical guidelines for common conditions were followed less than 45 percent of the time on average [2]. A recent study found that even if access to care is improving around the world, the clinical benefits for patients and populations remain limited: in eight high-mortality countries in Africa and the Caribbean, effective coverage averaged 28% for antenatal care, 26% for family planning, and 21% for paediatric care [3].
Poor quality healthcare also has significant costs on people’s lives, health systems, and societies. In high income countries alone, harmful medical errors and preventable complications account for 15% of hospital costs, according to OECD analyses [4]. Globally, misuse and inappropriate use of antimicrobials is fueling the rise of antimicrobial resistance, leading to significant additional health spending, affecting labor supply and productivity.  
Improving access to care, especially for the poor, through Universal Health Coverage is not enough to achieve better health outcomes. This is a simple and powerful reminder from a new report co-authored by the World Health Organization (WHO), the World Bank Group and the Organization for Economic Cooperation and Development (OECD) and available here. The report, Delivering Quality Health Services: An Imperative for Universal Health Coverage, is the first global report co-authored by the three multilateral organizations.
The report calls for urgent action from governments, clinicians, patients, civil society, and the private sector to help rapidly scale up quality healthcare services for Universal Health Coverage. To start with, governments should develop national quality policies and strategies that address the foundations of quality health systems. Building quality health services requires a culture of transparency, engagement, and openness about results, that should be promoted in all societies. National quality policies and strategies should ensure that healthcare workers are motivated and supported to provide quality care; that healthcare services are accessible and well-equipped; that action is taken to ensure that medicines, devices, and technologies are safe in design and use; that information systems continuously measure, monitor, report and drive better quality care; and finally, that the way healthcare providers are paid for encourages and enables quality of care.
While high quality healthcare for all may seem ambitious, it can be achieved in all settings with good leadership, robust planning, and intelligent investment. For example, in Uganda a model involving citizens and communities in the design of healthcare services has improved a range of indicators, including a 33% reduction in child mortality [5]. Costa Rica has also achieved remarkable improvements in primary care quality through a carefully planned, implemented, and resourced improvement strategy focused on quality [6].
Around the world, lessons abound on what works and what does not, providing a rich foundation from which to rapidly scale up a quality revolution. For the first time, the report reviews evidence available for 23 distinct interventions that governments, managers, and clinicians can take to improve quality of care. Among those, seven categories of interventions stand as priority interventions: changing clinical practice at the front line; setting standards; engaging and empowering patients, families and communities; information and education for healthcare workers, managers and policy-makers; use of continuous quality improvement programs and methods; establishing performance-based incentives (financial and non-financial); and legislation and regulation.
Each country requires different sets of interventions to improve quality of caredepending on its quality baseline, resources available, capacities and capabilities, and needs and expectations from the populations served. The report describes how four countries with vastly different contextsCanada, Ethiopia, Mexico, and Sudanare doing so systematically.
Of course, quality care requires some investment, but it is affordable, especially when the costs and consequences of poor quality are considered. Many of the interventions to improve qualitythink of checklists or basic hygiene, for exampleare inexpensive and within reach for all countries. The returns are plentifulbetter individual and population health, more productive workers, and pupils that perform better in school and will contribute better to the economy. In other words, investment in quality health care contributes to growth in human capital and economic development. So striving for universal quality health coverage is not just an investment in better healthit is a commitment to building a healthier and more productive society.

Trump administration takes another swipe at ‘Obamacare’

by Ricardo Alonzo-Zaldivar - Associated Press - July 8, 2018

WASHINGTON — The Trump administration is freezing payments under a provision of the Obama health law that protects insurers with sicker patients from financial losses, a move expected to add to premium increases next year.
At stake are billions in payments to insurers with sicker customers. The latest administration action could disrupt the Affordable Care Act, the health care law that has withstood President Trump’s efforts to completely repeal it.
In a weekend announcement, the Centers for Medicare and Medicaid Services said the administration is acting because of conflicting court rulings in lawsuits filed by some smaller insurers who question whether they are being fairly treated under the program.
The so-called ‘‘risk adjustment’’ program takes payments from insurers with healthier customers and redistributes that money to companies with sicker enrollees. Payments for 2017 are $10.4 billion. No taxpayer subsidies are involved.
The idea behind the program is to remove the financial incentive for insurers to ‘‘cherry pick’’ healthier customers. 
The government uses a similar approach with Medicare private insurance plans and the Medicare prescription drug benefit.
Major insurer groups said Saturday the administration’s action interferes with a program that’s working well.
The Blue Cross Blue Shield Association, whose members are a mainstay of Affordable Care Act coverage, said it was ‘‘extremely disappointed’’ with the administration’s action.
The Trump administration’s move ‘‘will significantly increase 2019 premiums for millions of individuals and small business owners and could result in far fewer health plan choices,’’ association president Scott Serota said. ‘‘It will undermine Americans’ access to affordable coverage, particularly those who need medical care the most,’’ he said.
Serota noted that the payments are required by law and said he believes the administration has the legal authority to continue making them despite the court cases. He warned of ‘‘turmoil’’ as insurers finalize their rates for 2019.
America’s Health Insurance Plans, the main health insurance industry trade group, said it is ‘‘very discouraged’’ by the Trump administration’s decision to freeze payments.
‘‘Costs for taxpayers will rise as the federal government spends more on premium subsidies,’’ the group said.
The administration argued in its announcement that its hands were tied by conflicting court rulings in Massachusetts and New Mexico.
Medicare and Medicaid Administrator Seema Verma said the Trump administration was disappointed by a New Mexico court ruling that questioned the workings of the risk program for insurers. The administration ‘‘has asked the court to reconsider its ruling, and hopes for a prompt resolution that allows [the government] to prevent more adverse impacts on Americans who receive their insurance in the individual and small group markets,’’ she said.
More than 10 million people buy individual health insurance plans through and state insurance marketplaces. The vast majority of those customers receives taxpayer subsidies under the Obama-era health law and would be shielded from premium increases next year.
The brunt of higher prices would fall on middle-class consumers who are not eligible for the income-based subsidies. Many are self-employed people and small-business owners.
The latest change does not affect most people with employer coverage. More than 20 million people have coverage through the federal program. Close to half get subsidized private coverage that would be affected by the change.

Trump Officials Slash Grants That Help Consumers Get Obamacare

by Robert Pear - NYT - July 10. 2018

WASHINGTON — The Trump administration announced on Tuesday that it was slashing grants to nonprofit organizations that help people obtain health insurance under the Affordable Care Act, the latest step in an escalating attack on the law that threatens to destabilize its insurance markets.
The cuts are the second round in two years. The government will provide $10 million this fall, down from $36 million last autumn and $63 million in late 2016 — a total reduction of more than 80 percent.
Trump administration officials said the insurance counselors, known as navigators, did not enroll enough people to justify more spending. Insurance agents and brokers do much better, they said.
The announcement on Tuesday, by Seema Verma, the administrator of the Centers for Medicare and Medicaid Services, came three days after the administration suspended a program that stabilizes health insurance markets by paying billions of dollars to insurers that enroll large numbers of unhealthy people under the Affordable Care Act. Insurers said the freeze would cause turmoil in insurance markets and drive up premiums.
The administration is not only cutting grants to navigators, but fundamentally changing their mission. They will, for the first time, help people enroll in health insurance plans that do not comply with the consumer protection standards and other requirements of the Affordable Care Act.
Since they began work in 2013, navigators have helped people enroll in health plans that comply with the Affordable Care Act. Now the Trump administration says they should also inform consumers of other options, like “association health plans” and short-term, limited-duration insurance.
Such plans do not have to provide the standard health benefits like preventive services, maternity care or prescription drug coverage, but administration officials say they will also be more affordable to consumers.
“It’s time for the navigator program to evolve, which is why we are announcing a new direction for the program today,” Ms. Verma said Tuesday.
In each of the past two years, she said, navigators enrolled less than 1 percent of the people who signed up for coverage in the federal marketplace. In the most recent enrollment period, about 8.7 million people signed up for coverage in states using the federal marketplace, the administration said.
Senator Ron Wyden of Oregon, the senior Democrat on the Finance Committee, expressed outrage at the administration’s effort to redefine the purpose of the navigator program.
“This move amounts to federally-funded fraud — paying groups to sell unsuspecting Americans on junk plans,” Mr. Wyden said.
Having failed to persuade Congress to repeal the Affordable Care Act, the president is now engaged in a “sabotage crusade” to wreck the law, Mr. Wyden said.
Fred Ammons, who supervises the Insure Georgia navigator organization, said: “This is a huge cut to navigator programs across the country. It will virtually eliminate face-to-face in-person assistance. It means less help, much less help, to underserved, hard-to-reach populations, people who live in rural areas or have low literacy or don’t speak English as their primary language.”
The House Democratic leader, Nancy Pelosi of California, said, “Yet again the Trump administration is trying to trick Americans into buying junk health insurance plans and making it harder for families to enroll in real affordable, quality health coverage.”
President Trump declared last fall that the health law was “dead” and “gone,” but it has proved to be surprisingly durable and evidently meets a significant need. Nationwide, in federal and state marketplaces, 11.8 million people signed up for coverage in the last open enrollment period, down from 12.2 million in the prior year but substantially more than many experts had predicted.
The Trump administration on Tuesday defended its decision to cut grants to insurance counselors, saying consumers had many other ways to learn about their options. It said, for example, that insurance companies had “significantly increased their marketing and promotional spending.”
However, insurance companies typically push their own products, while navigators are not supposed to favor or recommend a specific company or product.
In addition, the administration said the insurance exchange was now “an established marketplace” for people seeking coverage. “Last year,” it said, “we had our most cost-effective and successful open enrollment to date. As the exchange has grown in visibility and become more familiar to Americans seeking health insurance, the need for federally funded navigators has diminished.”
Ms. Verma said grants to navigators would be based on their performance in past years. Some, she said, had performed poorly.
In 2016-17, she said, 17 navigator groups enrolled fewer than 100 people each, at an average cost of $5,000 for each person enrolled.
By contrast, she said, agents and brokers accounted for more than 40 percent of enrollment in the federal exchange for the current year, and the cost to the government, for training and technical assistance, was just $2.40 for each person enrolled.
Agents may receive commissions from insurance companies — typically modest payments for marketplace plans — but navigators are generally forbidden to accept compensation from insurers.
The Trump administration said it was also eliminating a requirement that navigator groups have a physical presence in the areas they serve. This would presumably allow federal grantees to provide aid by telephone or through web portals, like online insurance brokers.
Navigators can help consumers fill out applications, complete enrollments and renew coverage online, the administration explained.
Rachel Fleischer, the executive director of Young Invincibles, an advocacy group for young adults, said she was dismayed by the cuts announced on Tuesday. Research, she said, has shown the effectiveness of in-person assistance provided to people shopping for health insurance, a notoriously complicated product.
The cuts, she said, “will result in far fewer in-person assisters and huge swaths of the country lacking any in-person help.”

LePage foils Medicaid expansion again when House sustains his veto

by Scott Thistle - Portland Press Herald - July 9, 2018

AUGUSTA — The Maine House sustained Gov. Paul LePage’s veto of a funding bill for Medicaid expansion Monday, handing the Republican another victory in his long campaign to stifle expansion of the program to another 70,000 Mainers.
However, the Maine Supreme Judicial Court could alter the expansion picture next week, when it hears arguments in a challenge brought by advocates who want to force the governor to file an expansion plan with the federal government.
Conservative Republicans stood with the governor in Monday’s 85-58 vote, which fell short of the two-thirds majority needed to overturn his veto of a bill allotting $60 million to help fund a law that 59 percent of voters approved at referendum in 2017.
The veto marks the seventh time during his two terms in the Blaine House that LePage – with the backing of minority House Republicans, many of them first elected with him in 2010 – has been able to thwart legislative efforts to expand the state and federally funded health insurance program for the poor.
The bill provided state funding that would be supplemented by more than $500 million in federal funds to expand Medicaid to between 70,000 and 80,000 more Mainers. Supporters say costs to the state would be less than $50 million once the expansion is fully implemented, but opponents contend the cost could be twice that. LePage and his allies have demanded that the Legislature provide a “sustainable” funding mechanism for the expansion.
The governor’s obligation to move forward with expansion is the focus of the hearing before the Supreme Judicial Court next week. Justices will take up a lawsuit that pits advocates for expansion against the administration, which has argued that it cannot implement the law without funding approved by the Legislature.
LePage had said in his veto message to the Legislature that the state needed to come up with a long-term way to fund the expansion and not depend on one-time gimmicks. The bill he vetoed would have funded expansion with surplus revenue and money from the state’s tobacco settlement fund. In his message, LePage also criticized those who supported the ballot measure for not writing a funding method into the citizen-backed law.
House Speaker Sara Gideon, D-Freeport, who supported the funding bill, said LePage’s successful veto does not change the fact that expanding Medicaid is required by law as a result of last fall’s referendum vote, and that it was still up to LePage and the Legislature to pay for it.
“This latest action is yet another tactic to not just delay, but to obstruct the law that Mainers passed overwhelmingly at the ballot box,” Gideon said in a prepared statement. “Regardless of the outcome of this veto, Medicaid expansion is the law of the land. The only item for discussion is whether we fund it now or fund it later.”
Mainers who earn up to 138 percent of the federal poverty level were eligible to submit applications for coverage as of July 2, but it’s unclear how quickly the state will make benefit decisions with LePage in office until January 2019. This month, Maine Equal Justice Partners, a nonprofit that advocates for the poor in Maine and a primary backer of the ballot-box law, was urging those who believe they may be eligible to begin applying for coverage.
The organization’s staff and other advocates said that once the funding for expansion is finally settled, those newly eligible for coverage would be receive benefits retroactively.
But it remains uncertain whether the state’s highest court will force LePage to file a plan for expansion with the federal Centers for Medicare and Medicaid Services as prescribed for under the Affordable Care Act.
Kathy Kilrain del Rio, a policy analyst for Maine Equal Justice Partners and a member of Mainers for Health Care, the coalition that backed the ballot measure, asserted that Monday’s vote means Maine will miss out on available federal funding.
“Those funds will sit on the table while the people who have a legal right to care turn to the courts to force the administration to implement the law,” Kilrain del Rio said. “A bipartisan group of legislators stood against this senseless obstruction and delay, but a minority of lawmakers blocked the will of the voters once again.”
The Maine Democratic Party was quick to weigh in Monday, noting their party’s nominee to replace LePage, Attorney General Janet Mills, has said she would support an expansion of the program and find ways to cover the state’s share of the expense.
“Janet Mills knows expanding Medicaid will make Mainers healthier and be a substantial boost for our economy,” said Maine Democratic Party Chairman Phil Bartlett. He noted that the Republican candidate for governor, Gorham businessman Shawn Moody, has vowed to work to repeal the expansion law if elected.
Lauren LePage, the governor’s daughter and Moody’s campaign spokeswoman, said in an email that Moody would “enforce the laws on the books with appropriate funding from the Legislature who under the Constitution must pass all spending bills.” She did not say if Moody has any ideas on how he would pay for expansion.
Mills said expansion would inject millions of dollars into the state’s economy, help create jobs, support rural hospitals and assist in the state’s ongoing struggle against an opioid epidemic that claims, on average, one life a day in Maine.
“As governor, I will work to see that Medicaid expansion is fully implemented so that people across the state can access the care they need and deserve, and I will fight back against any attempt to undermine it or repeal it,” Mills said in a prepared statement. “Maine people deserve more health care, not less.”
Alan Caron, an independent running for governor, called LePage’s veto the latest in “a long string of mistakes on health care,” and noted that the federal government funds 90 percent of costs.
State Treasurer Terry Hayes, also an independent running for governor, said she understands some of LePage’s concerns about funding sources, but criticized him for refusing to work with lawmakers.
“If there were collaboration between the executive branch and the legislative branch, then there is a greater likelihood that the governor’s preferences could have been included in the bill or there would have been a dialogue,” she said.
Hayes said she would look to use tobacco settlement funds and revenue from the state’s wholesale and retail liquor contract to fund expansion costs in the long term.

Maine Voices: Want better, less complicated health insurance? Push the narrative, not the name

by William Rosenberg - Portland Press Herald - July 12, 2018

MOUNT VERNON — In February 2017, President Trump famously said: “Nobody knew health care could be so complicated.” Nobody other than about 99.9 percent of the almost 300 million people in the U.S. with insurance, that is. Yesterday, I received a copy of “Get to know your benefits,” the 236-page “booklet” for my new health plan. Like most people, I’ll never read the book, but its weight alone says “complicated.”
And it’s safe to guess that Trump also will never read his Federal Employee Health Plan information, even though one Aetna choice available to him has a “brochure” of only 184 pages. Thinking about the amount of information available to health insurance plan consumers, I began to wonder what Health and Human Services Secretary Alex Azar meant, also last February, when he said, “Americans need more choices in health insurance so they can find coverage that meets their needs.” 
Presumably, were we to have more choices, we could study the hundreds of pages of information about each available plan and make better choices. According to the federal Office of Personnel Management, federal employees who live at 1600 Pennsylvania Ave., Washington, D.C. 20500, have a choice of 35 monthly plans. Too bad the president doesn’t live in Maine, where he’d have only 20 plans to study! 
How does the average American deal with this? The same way the average lawmaker does: with a bumper-sticker narrative. Keep the government out of my health care, but don’t touch my Medicare. If you like the Division of Motor Vehicles, you’ll love the Democrats’ plan. Or, as President Trump said last February: “We have a plan that I think is going to be fantastic. It’s going to be released fairly soon. I think it’s going to be something special. … I think you’re going to like what you hear.” Who could be against that?
So, why do many Democrats push for a single-payer plan? Broader access, lower prices, less administrative burden, consistent claim payment rules all make sense, but a “single-payer” plan (read “socialized medicine”) is a target on the back of its supporters. What most Americans want is a “fantastic” (read: “covers a lot and costs less”) plan. I just want someone else to pay for most or all of the cost when I get sick. I don’t want to have to give up the plan I have now for something new and untested. 
Instead of pushing for “single-payer,” the policy wonks should work on the narrative. How about a “great, less costly plan that is available, but not required”? Or a plan where “your employer continues to pay the lion’s share of cost and there is not one cent of government funding,” where “the prices you pay for hospital care are 40 percent to 50 percent lower than what you pay now,” or that “has the largest percentage of in-network doctors and hospitals of any plan in the country”? 
These bumper stickers describe what would happen were private employers allowed to pay for and offer an exact duplicate (a “clone”) of the Medicare plan to their 157 million covered employees and their families. The plan that fits the above narrative would not be government-run, and enrollment would not be required. Most importantly, it would be promoted by employers because it would maintain or improve benefit levels and save them and their workers money. It might be called a Medicare Public-Private Partnership plan.
Employers know how to move employees to new plans “voluntarily,” i.e., by using short-term financial incentives like reduced premium payments to encourage enrollment in preferred options. Over 14 years starting in 1982, employers increased enrollment in so-called managed-care plans from 0.3 percent to 86 percent. If employers offered the Medicare Public-Private Partnership plan starting in 2019, a similar rate of adoption would mean an enrollment of roughly 135 million “private members” added to the projected 80 million Medicare beneficiaries.
With over 200 million Americans enrolled in the same plan (differing only by who pays the premium), virtually everyone in the U.S. would have a family member enrolled in Medicare or have a friend or relative enrolled in Medicare Public-Private Partnership; i.e., we’d be well past a “tipping point” when Medicare for All is as comfortable as an old pair of slippers. 
Compare this scenario to a push today for “single-payer,” remembering that Medicare came in 1965, about 20 years after Harry Truman became the first president to propose a national health insurance plan. And then it took another 45 years for President Barack Obama to get the Affordable Care Act enacted by a hair. Ask yourself: Will we be closer to a single-payer plan just 15 years from now by pushing single-payer or a narrative that gives us Medicare Public-Private Partnership?
— Special to the Press Herald

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