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Thursday, June 19, 2014

Health Care Reform Articles - June 19, 2014



Expand Medicare to serve all veterans

By Dr. Philip Caper, Special to the BDN
Posted June 19, 2014, at 9:29 a.m.
The problem of long wait times for veterans seeking care at some (but not all) Veterans Health Administration facilities has been front-page news for the past several weeks, and seems to be resulting in an unusually prompt response from a normally gridlocked Congress. The wait times and the consequent attempts to cover them upseem to have multiple causes.
First, there is the uneven but growing demand for some types of services, resulting from casualties suffered in the recent Iraq and Afghanistan wars. Then there are predictable increases in the demand for services due to the aging of veterans from past military conflicts. This increased demand has been somewhat but not completely offset by the attrition in the number of veterans from past wars due to normal mortality as they age.
Then there are problems on the supply side, as the number of primary care physicians and other caregivers relative to the number of specialists dwindles in the American health care system as a whole. (I have written about this more extensively in past columns.) Like everywhere else, the VA cannot keep up with the demand for primary care physicians.
Finally, it’s clear that some VA administrators, wanting to make their performance numbers look good so they would qualify for bonuses, manipulated the waitlists and their reports about wait times. Of course politics has magnified and distorted the nature of these problems.
As a way of relieving the pressure on some VA centers and providing quicker access to services by veterans facing a long wait to get into the system, both the Senate and the House are processing legislation that would require the VA to pay for services in the private sector. (Maine 2nd District Rep. Mike Michaud, a candidate for governor this year, is the ranking minority member of the House Committee on Veterans Affairs.)
In a June 2 letter to the New York Times, Dr. Philip Lee, a two-time assistant secretary for health in the federal government, and I wrote the following:
“If Congress is serious about helping to alleviate the problem and showing our gratitude to and support for our veterans, it will expand Medicare coverage to include all veterans. If that is done, our veterans could choose between the VA system and any doctor who participates in Medicare.
“Medicare is approaching its 50th anniversary as one of the most durable, successful and popular federal programs ever created. Do our veterans deserve any less?”
We believe that simply making every veteran eligible for Medicare following discharge from military service would provide a technically (if not politically) quick and simple means of providing them with access to additional resources as a supplement to those available to them through the VA. And it would eliminate the need to create a new bureaucracy within the VA to deal with private-sector doctors and other providers.
There are precedents for expanding Medicare to those under the normal eligibility age of 65. Starting in 1972, Congress opened up Medicare to all patients who otherwise met Medicare’s eligibility requirements and have chronic renal failure and other disabilities regardless of age. In 2009, Sen. Max Baucus, almost on a whim, inserted a provision into the Affordable Care Act that made Medicare available to all of his constituents with pulmonary disease living in Libby, Montana.
Making every veteran eligible for Medicare would provide them with more choice of doctors, hospitals and other providers, and relieve some of the short- and long-term pressure on the VA for some routine, non-combat-related services, allowing the VA to focus more on those services only it can provide.
Even more important, it would move us toward the ultimate goal of universal coverage for all residents of the U.S. I agree with those who point out that you can’t leap across a giant chasm, such as the one between where our dysfunctional health care system is now and where it should be, in two jumps. But we can take steps to narrow that chasm so as to make the inevitable final jump easier. This could be an important one of those steps.
In doing this, we should avoid sanctioning the “voucherization” of veterans’ health benefits. We should rebuff those who would cast vets into the dog-eat-dog private insurance market, dismantling or radically weakening the VA in the process.
The vast majority of Americans fervently believe that our veterans deserve this kind of help. It’s a shame more of us don’t feel that way about everybody.
Physician Philip Caper of Brooklin is a founding board member of Maine AllCare, a nonpartisan, nonprofit group committed to making health care in Maine universal, accessible and affordable for all. He can be reached at pcpcaper21@gmail.com.

Scientists Identify Mutations That Protect Against Heart Attacks


 JUNE 18, 2014
Two major studies by leading research groups published on Wednesday independently identified mutations in a single gene that protect against heart attacks, the leading killer of Americans, by keeping levels of triglycerides — a kind of fat in the blood — very low for a lifetime.
These findings are expected to lead to a push to develop drugs that mimic the effect of the mutations, potentially offering the first new class of drugs to combat heart disease in decades, experts say. Statins, which reduce LDL cholesterol, another cause of heart disease, became blockbusters in the late 1980s, but since then there have been no major new drugs approved for lowering heart disease risk. About 720,000Americans a year have heart attacks.
Although statins are effective in reducing heart attack risk, many users still often have high levels of triglycerides and go on to have heart attacks. So the results of the new studies are good news, said Dr. Daniel J. Rader, the director of the Preventive Cardiovascular Medicine and Lipid Clinic at the University of Pennsylvania, who was not involved in the research.
“We’ve been looking for something beyond statins,” Dr. Rader said. “After we have put people on high-dose statins, what else can we do? Essentially nothing.”
Experts differ in their estimates of how many Americans might be candidates for a triglyceride-lowering drug. If the eligible group included all adults with triglyceride levels of 200 or more — the normal level is 150 or less — that would mean about 20 percent of adult Americans. If it was just those with the highest levels, above 500, then 2 percent to 3 percent of adults would qualify.
The discovery announced Wednesday was hinted at in 2008 in a much smaller study in the Amish conducted by researchers from the University of Maryland’s medical school. One in 20 Amish people has a mutation that destroys a gene, APOC3, involved in triglyceride metabolism, as compared to one in 150 Americans generally. The scientists were intrigued but did not have enough data to nail down the gene’s role in heart attacks.
Sam, a 55-year-old Amish farmer who declined to have his last name published, saying he was uncomfortable about being conspicuous, has such a beneficial mutation. He recalls little heart disease in his family. On a cold day last fall, as an icy rain fell outside, he sat at a small wooden table in his daughter’s house and laid out a sheet of paper that showed he had a triglyceride level of 45. The average in the United States is 147.
“It’s nice that something came out that is positive,” he said.
Triglycerides have long puzzled researchers, although they are routinely measured along with cholesterol in blood tests and are often high in people with heart disease. Many experts were unconvinced they actually caused heart attacks. Clinical trials of drugs that lowered triglycerides by a small amount added to doubts about their role in heart attacks. The drugs had no effect on heart attack rates.
http://www.nytimes.com/2014/06/19/health/scientists-identify-mutations-that-protect-against-heart-attacks.html?emc=edit_tnt_20140618&nlid=1311158&tntemail0=y&_r=0

Obamacare subsidies on track to cost billions this year, report says




The large subsidies for health insurance that helped fuel the successful drive to sign up approximately 8 million Americans for coverage under the Affordable Care Act are on track to cost billions of dollars this year, a new federal report indicates.

Nearly nine in 10 Americans who bought healthcare coverage on the federal government’s healthcare marketplaces received government assistance to offset their premiums.
That assistance helped lower premiums for consumers who bought healthcare coverage on federal marketplaces by 76% on average, according to the new report from the Department of Health and Human Services.
Premiums that normally would have cost $346 a month on average instead cost consumers just $82, with the federal government picking up the balance of the bill.
Though the generous subsidies helped consumers, they also come at a price.
The report, though missing data from some states, paints one of the fullest pictures to date of the actual cost of the 2010 healthcare law’s coverage expansion.
It suggests that the federal government is on track to spend at least $11 billion on subsidies for consumers who bought healthcare plans on marketplaces run by the federal government, even accounting for the fact that many consumers signed up for coverage in late March and will only receive subsidies for part of the year.
That total does not count the additional cost of providing coverage to millions of additional consumers who bought coverage in states that ran their own marketplaces, including California, Connecticut, Maryland and New York. About a third of the 8 million people who signed up for coverage this year used a state-run marketplace.
Federal officials said subsidy data for these consumers were not available.
If these state consumers received roughly comparable government assistance for their insurance premiums, the total cost of subsidies could top $16.5 billion this year. Making precise estimates is difficult because of expected fluctuations in enrollment over the year.
That total would be approximately in line with projections from the nonpartisan Congressional Budget Office.

 

DOCTORS

Who Can Speak for the Patient?

By JESSICA NUTIK ZITTER, M.D.
 

Our patient was never going to wake up. He had an unrecoverable brain injury. The prognosis had become clear over time. As the patient’s attending physician in the intensive care unit, I arranged a meeting with his sister, the only visitor we’d seen for days, and explained. She was resolute. “He’ll wake up,” she said. “He’s a fighter. Do everything you can to keep him alive.”
The next day I told the social worker what the patient’s sister had said. “What about the wife?” the social worker asked.
That was the first I’d heard of a wife. A spouse is the official next of kin. No decision should ever be made without the spouse. But I hadn’t known she existed. I discovered that she visited the patient after her work shift, usually at 8 p.m. By that hour, our team was gone. The doctors on night duty were on for emergencies, not conversation. And so she was invisible to us.
How could we have missed this most basic and vital piece of information? It’s easier than you might think. The sister didn’t get along with the wife and apparently wasn’t moved to tell us of her existence. The social worker had been out sick, and his replacement assumed that we knew. And we had a concerned sibling at the bedside who fulfilled our mental checkbox for who makes an acceptable surrogate decision-maker.
We hastily called a meeting with the wife. She arranged to leave work early, and she met us in our conference room. Feeling a combination of shame and relief at the averted disaster, we apologized for not being in touch. We didn’t mention that we hadn’t even known about her.
http://well.blogs.nytimes.com/2014/06/19/who-can-speak-for-the-patient/?_php=true&_type=blogs&emc=edit_tnt_20140619&nlid=1311158&tntemail0=y&_r=0

Time has come for single-payer healthcare

BY 

Recently, it has been reported that 7.5 million Americans have enrolled in Obamacare, many more than expected. Yes, it’s better than before: overall, Americans are insured, and insurance companies are no longer allowed to overcharge or deny coverage to the elderly and people with pre-existing conditions. Key issues persist, however: Some people still cannot afford adequate insurance or insurance at all. New issues have arisen as well: 14 million people are left scrambling after their plans were canceled, and others are ignored by the system all together. Going backward is not the answer. But clearly, the Affordable Care Act is not the answer either. So where do we go from here? According to prestigious organizations such as Physicians for a National Health Program, the American Medical Student Association and the California Nurses Association, the answer is clear: single-payer health care.
Single-payer health care is a system in which a single payer — in our case, the federal or state governments — fronts the cost for all health care. There is no insurance industry, and there are no insurance companies to deny people coverage. The system is funded by progressive taxes, so people pay exactly as much as they can afford and no more.
The ACA falls short of a single-payer system on several key points. First off, 29 million people still won’t have health care. Part of this is inherent in any system for which people must proactively sign themselves up — they won’t. Maybe they don’t know how to enroll, or as the Obamacare website demonstrates, enrollment will go awry. In addition, some people are lost in the gap between where their state’s Medicaid ends and Obamacare begins. For example, in states such as Virginia, where requirements for eligibility for Medicaid are notoriously strict, single men are not eligible for state-sponsored care under any circumstances. Obamacare has an income minimum, operating on the assumption that anybody below that minimum will be covered by their state. But as Virginia law demonstrates, this is not always the case. In a single-payer system in which every resident is automatically enrolled at birth, nobody will fall through the cracks.
In addition, Obamacare has proven enormously expensive, both for the federal government and for some citizens. Much of the federal government’s health care expenditures go to administrative costs, which are high for this very complex system. Because single-payer is simpler to administer, it costs less. The ACA is the longest and most intricate piece of legislation passed by Congress in 10 years, whereas the single-payer system is simple enough to be described in the 56 words that make up the second paragraph of this piece. Administering the ACA will cost the government $1.1 trillion over the next 10 years, while the single-payer system would save $400 billion.

AARP: Long-term care often more costly, harder to access in Maine

Despite significant deficiencies, Maine is ranked 10the best on the association’s scorecard.

BY KELLEY BOUCHARD STAFF WRITER
Long-term care for seniors is often more expensive and harder to get in Maine than in many other states, according to a new state-by-state scorecard released Thursday by the AARP.

Despite significant deficiencies, Maine ranks 10th best overall in “Raising Expectations 2014: A State Scorecard on Long-Term Services and Supports for Older Adults, People with Physical Disabilities, and Family Caregivers.”
AARP officials qualified Maine’s overall ranking – down from No. 8 in 2011 – saying it’s far from a ringing endorsement in a nation that’s largely unprepared to meet the needs of a rapidly growing senior population.
“It doesn’t mean we’re doing well,” Lori Parham, state director of AARP Maine, said Wednesday. “It just means we’re not doing as badly as other states. We shouldn’t be patting ourselves on the back. We still have a lot of work to do.”
A rapidly aging population poses a variety of challenges across the nation, but the situation is particularly acute here.
Maine has the highest median age in the United States – 43.5 years – in part because Maine also has a dwindling younger population, according to the U.S. Census. The state’s proportion of people age 65 and older – 17 percent – is second only to Florida’s 18.2 percent.
Maine also has the nation’s highest proportion of baby boomers – 29 percent of its 1.3 million residents were born between 1946 and 1964 – and they’re turning 65 at a rate of 18,250 a year, according to AARP Maine. By 2030, more than 25 percent of Mainers will be 65 or older, and 52,273 of them will be at least 85 – more than double the number of people in the oldest category in 2000.

AARP: Maine Slipping in Cost, Availability of Long-Term Health Care

By 
Maine is slipping in the cost and availability of so-called "long-term" health care. That according to the seniors group AARP.
It says Maine's ranking went from 8th in 2011 to 10th in its latest survey. AARP's Susan Reinhardt says the survey is meant to spur action on what will be a growing need in a nation with a growing percentage of older residents.
"We hope there is data in one place for states to be examining what's going on in their own state," she says "We hope that they can look at it; that they will target areas for improvement and engage both the public and private sectors. This isn't all related to what public policy makers can do, but public policy makers can do a lot. Together, we can do even more."
The AARP report says "unpaid family caregivers provide the bulk of care for older Mainers, in part because the cost of long-term care remains unaffordable for most middle income families." It says more than 191,000 Mainers help aging parents spouses or other loved ones with medical tasks like wound care and injections. AARP estimates paying for such care would cost more than $2 billion a year.
To see the full state scorecard, along with an interactive map of state rankings and information, visit www.longtermscorecard.org.






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