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Saturday, January 31, 2015

Health Care Reform Articles - January 31, 2015

Barriers to More Healthcare Reform Are Numerous

Apathy and fear are among the biggest stumbling blocks, experts say.


WASHINGTON -- The lack of greater movement toward universal healthcare coverage -- especially a single-payer system -- in the U.S. can be boiled down to four letters: AFIG, according to Philip Caper, MD.
The "A" stands for Apathy, Caper said Wednesday during a briefing on barriers to healthcare reform sponsored by the National Academy of Social Insurance (NASI). Caper is with Maine AllCare, an organization devoted to getting universal healthcare in Maine.
The attitude of many people is "'I've got mine; why should I worry about anyone else?'" said Caper, a founding member of NASI, whose mission is to increase public understanding of how social insurance contributes to economic security.
"Or think of young invincibles, who think it's worth the risk to go uncovered," continued Caper, who was speaking by phone from Maine. "Perhaps apathy is the result of our emphasis on personal liberty and personal responsibility."
The "F" stands for fear, Caper continued -- "fear of change; the fear of losing coverage they already have; or the fear of loss of income or profitability" on the part of those working in the healthcare industry.
"I" is for ignorance, he said, making it clear that he was not equating ignorance with stupidity, rather a lack of information and understanding. "Most Americans don't understand the healthcare system and don't understand there are better ways of financing this," Caper said.
"I definitely include doctors in this group," he added. "I can tell you from personal experience that it's almost impossible to get health policy into the medical school curriculum, where the focus is rightly on clinical medicine."
And finally, there is the "G" -- for greed. "This may seem harsh [but] the widely accepted view of healthcare as just another business is uniquely American, at least in degree," he said. "I have heard some people say the healthcare system is becoming a wealth extraction machine. This view is reinforced by news stories of opportunistic pricing of drugs for chronic diseases such as hepatitis."
Satisfied With the Status Quo
Another barrier to changing the way health insurance is delivered comes from the fact that many people are satisfied with their employer-provided health insurance, said Laurence Seidman, PhD, professor of economics at the University of Delaware in Newark.
"But they don't seem to realize two things," he continued. "First, what would happen if they lose their job? And second, [they don't realize] that the rising premiums for medical care that their employers are paying is a key reason why their wage and salary growth has been so low."


Did Obamacare Just Have Its Best Week Ever?

byJessicaAdair
But at America’s kitchen tables, or more likely, at family computers, a different story is unfolding – and enrollment success stories are popping up in the places you’d least expect.
According to new data released by HHS, more than 9.5 million people had signed up for a Marketplace plan by January 18th. That figure does not include millions more enrolled in Medicaid. Given that the Administration’s own goal was 9.1 million enrolled, this year’s Open Enrollment period is looking quite rosy. One more sign of growing interest in health care: 42% of this year’s enrollees have selected plans for the first time on the federal Marketplace.  
In states where elected officials tried to position themselves as skeptics of affordable health care during 2014 campaigns, their constituents have chosen to enroll regardless, indicating a shift in political tides.
In Florida, for example, Governor Rick Scott spent millions painting his opponent as an Obamacare supporter in his race for the Governor’s seat. Since then, Florida has led the nation in enrolling residents: 1.2 million Floridians have signed up for a plan. One zip code outside of Miami holds the record of the most enrollees in the country.
Other states where anti-Obamacare in past years ran deep, such as North Carolina, Georgia, Idaho and Virginia have also seen higher than average percentages of eligible residents sign up for coverage. In North Carolina, Senator Kay Hagan lost her seat after enduring millions of dollars worth of ads pillorying her support of the ACA. The state is now 6% above the national average in percentage of eligible residents enrolled. In Georgia and Kentucky, senatorial candidates Michelle Nunn and Alison Lundergan Grimes refused to even say whether they would’ve voted for the law for fear of being tied to it. Despite their reluctance, both still lost their elections. Now, both states have seen above average enrollment percentages.


Don't Trade Away Our Health

By JOSEPH E. STIGLITZ
A secretive group met behind closed doors in New York this week. What they decided may lead to higher drug prices for you and hundreds of millions around the world.
Representatives from the United States and 11 other Pacific Rim countries convened to decide the future of their trade relations in the so-called Trans-Pacific Partnership (T.P.P.). Powerful companies appear to have been given influence over the proceedings, even as full access is withheld from many government officials from the partnership countries.
Among the topics negotiators have considered are some of the most contentious T.P.P. provisions — those relating to intellectual property rights. And we’re not talking just about music downloads and pirated DVDs. These rules could help big pharmaceutical companies maintain or increase their monopoly profits on brand-name drugs.
The secrecy of the T.P.P. negotiations makes them maddeningly opaque and hard to discuss. But we can get a pretty good idea of what’s happening, based on documents obtained by WikiLeaks from past meetings (they began in 2010), what we know of American influence in other trade agreements, and what others and myself have gleaned from talking to negotiators.

First U.S. doctors' strike in decades

By 
A handful of doctors providing medical services to students at UC San Diego — and their colleagues at nine other University of California campuses — went on strike Tuesday.
It's the first time in 25 years that fully licensed doctors are picketing a U.S. employer, according to the Union of American Physicians and Dentists, which represents the physicians at the UC schools.
The work stoppage began at 7:30 a.m. and is scheduled to last one day. It involves 150 health center doctors who manage the primary care and mental health needs of students.
UC San Diego said there are 10 such physicians on its campus. Dr. Amol Doshi, a staff physician at UC San Diego, said five of them work full time while the others are part-timers.
Doshi, one of four doctors in the union’s bargaining team, said the strike is needed because the UC system refuses to provide enough financial information on student health services for the union to make accurate judgments about whether resources are well-allocated.
He also said many doctors are concerned that staffing levels are not high enough to meet students’ needs, especially in the mental health area.
“This isn’t a strike about salary,” Doshi said Monday.

Indiana Will Allow Entry to Medicaid for a Price

By 
WASHINGTON — After a lengthy back-and-forth, the Obama administration has agreed to let Gov. Mike Pence of Indiana, a Republican, expand Medicaid on his own terms, including some that have not been allowed before under federal rules.
The plan will extend coverage to an additional 350,000 Indiana residents with incomes of up to 138 percent of the federal poverty level — about $16,100 for a single person and $27,310 for a family of three — starting next month. As in the 27 other states that have expanded Medicaid under the Affordable Care Act, the federal government will cover the entire cost through this year and at least 90 percent in future years.
But Mr. Pence, like several Republican governors before him, insisted on adding a conservative twist to the expansion, mostly by requiring beneficiaries to pay something toward their coverage. Under his plan, most people will have to pay monthly premiums equaling 2 percent of their household income — between about $3 and $25 a month for a single childless adult — for coverage that includes dental and vision benefits.
At the Obama administration’s insistence, people who earn less than the poverty level will not have to pay premiums. But if they do not, their coverage will be downgraded to exclude dental and vision benefits. And they will owe co-payments for medical care, including $4 for a doctor’s visit and $75 for a hospitalization.
“There are a lot of first-in-the-nation aspects to this,” Mr. Pence said in an interview. “It gives Hoosiers the dignity to pay for their own health insurance, and that transaction is important to starting people on a path toward really embracing greater ownership of their health care.”
In another unusual concession, the Obama administration will let Indiana lock some people out of coverage for six months if they stop paying monthly premiums. This provision will not apply to people earning less than the poverty level or to those deemed “medically frail.” Still, it is a first for Medicaid coverage, which has not permitted lockout periods until now.

The Goal Was Simplicity; Instead, There’s a Many-Headed Medicaid


The Affordable Care Act was supposed to simplify Medicaid’s myriad programs across the country to provide a more uniform medical safety net for poor Americans in every state.
It hasn’t worked out that way. In fact, Medicaid programs now vary more widely state to state and even within states than they did before. Some states have scaled back their Medicaid programs, while others have expanded to new groups of people. Among those that have expanded, many are pursuing new policy experiments instead of expanding their existing programs. This may result in confusion — for administrators and clients alike.
Indiana has become the latest Republican-led state to expand its Medicaid program as part of the Affordable Care Act. As has become the pattern, it was done with a series of waivers from particular federal requirements. Beginning next week, anyone in Indiana earning less than around $16,000 a year can sign up for the government health insurance program.
When the state’s governor, Mike Pence, announced the news on Tuesday, the focus of his speech was less about his state’s decision to embrace this part of Obamacare than about the special concessions he’d been able to extract from the Obama administration.

Sick Child’s Father Seeks Vaccination Requirement in California

By 
In the latest salvo in the vaccination wars that have shaken California since a measles outbreak originated at Disneyland last month, the father of a 6-year-old boy with leukemia has asked the superintendent of his Marin County school district to keep unvaccinated children out of school.
“I respect people’s choices about what to do with their kids, but if someone’s kid gets sick and gets my kid sick, too, that’s a problem,” said the father, Carl Krawitt of Corte Madera, Calif., whose son, Rhett, was found to have leukemia in 2010. “What we need to do, for all our children, is increase the herd immunity.”
Rhett is in remission now, but four years of chemotherapy have left him vulnerable to infection and unable to be vaccinated. Until his immune system strengthens, his best protection from infectious diseasesis the so-called herd immunity of a community where almost everyone has been vaccinated.
But he lives in a part of the Bay Area where an unusually high number of parents refuse vaccinations for their children. Over all, about 7 percent of the children at Rhett’s school, Reed Elementary, are unvaccinated — a rate that is higher than the statewide average but far lower than at some other schools in the county, where fully half of the students are not vaccinated, according to Dr. Matt Willis, the county health officer.

More Than 1,000 in Arizona Are Watched for Measles

By 
DENVER — Arizona health officials on Thursday were tracking more than 1,000 people, including at least 195 children, who might have been exposed to measles as part of an outbreak that began at Disneyland in Southern California and has grown to 67 cases in seven states.
Arizona has seven confirmed cases of measles, and officials in three counties in the Phoenix area — Maricopa, Gila and Pinal — are asking residents who have not been vaccinated and who might have been exposed to stay home from school, work or day care for 21 days.
The announcement comes as thousands of people are arriving in Phoenix for the Super Bowl on Sunday.
“This is a critical point in this outbreak,” the state health director, Will Humble, wrote on his blog. Any missed cases, he wrote, could cause “a long and protracted outbreak.”
In a conference call with reporters, a Centers for Disease Control and Prevention official advised anyone with symptoms not to attend the Super Bowl. “The very large outbreaks we’ve seen around the world often started with a small number of cases,” said the official, Dr. Anne Schuchat, director of the agency’s National Center for Immunization and Respiratory Diseases.

Doctors as Advocates for Family Leave

By 
 
Birdlike and in his 80s, the patient had come to the hospital complaining of a new cough. But it was not he whom my colleagues and I found most disquieting.
It was his middle-aged daughter. 
With a practiced dexterity, she had managed to wheel her father in the clinic, hoist him on to the examining table, smooth his hair, wipe his brow and tuck blankets around his legs to keep him warm without pause as she simultaneously fielded nearly a dozen calls and texts on her cellphone.
Still, every time her cellphone rang, buzzed, gurgled or popped, she jumped and sometimes even clutched her chest. After examining her father, I asked if she was O.K.
The woman’s eyes widened; she looked as if she was going to cry. 
Her father, she began to recount, had moved in with her and her husband a few years earlier to help with their young children. But over the last few months, his health had begun to fail, and she found herself spending more and more time taking care of him. An occasional doctor’s appointment escalated into frequent emergency room visits and missed workdays so she could watch over him at home. Now, with her own sick days used up, her vacation day stockpile dwindling and the goodwill of her colleagues and boss dissipating, she tried to do as much work as she could by phone. 
“I’m trying to do my best to take care of my father, but I can’t afford not to get paid,” she said, pushing away the strands of grey and brown hair that had fallen loose from her ponytail. 
“But thanks, anyway,” she added, “for asking.” 
I remember smiling in response. Asking, and listening, I thought, was the best I could do for someone who was a family caregiver and not my patient. 
But over the last few months, I have begun to think differently, thanks to a New England Journal of Medicine editorial by two pediatricians who argue that doctors and other health care providers can do more, by acting as patient advocates and supporting broader family leave policies.

For V.A. Hospitals (and Patients), a Major Health Victory

by Tina Rosenberg
Earlier this month, the Centers for Disease Control and Prevention announced that the United States is making modest progress in bringing down rates of hospital-acquired infections.
Progress is good, but modest is not. Hospital-acquired infection is one of the country’s leading causes of death, killing 75,000 people per year — more than car accidents and breast cancercombined. As antibiotic resistance increases, we are already seeing infections no drugs can cure. And these infections are preventable. Still, one in 25 patients who goes into the hospital without an infection will get one there.
Yet hospitals have only started to take prevention seriously in the last decade, most in the last five years. The bulk of the effort, and the progress, has come with infections associated with devices, especially central vein catheters. But device-related infections make up only a quarter of hospital-acquired infections. Hospitals have had far less success with other types of infections.
One hospital group, however, has done more than all others. It is not the Mayo Clinic’s hospitals, nor the Cleveland Clinic’s, nor Kaiser Permanente, nor Sutter, nor Geisinger. These are all hospital chains known for their quality, but another big name leaves them in the dust: the V.A.
Veterans Affairs Medical Centers have been in the news lately, but not for their high quality of care. It’s for endless waiting times, falsification of wait-time data and labyrinthine bureaucracy. Yet in the matter of “first, do no harm,” the V.A. stands out. (Here and here are other studies showing the V.A.’s edge in patient care.)
The C.D.C.’s survey of (non-V.A.) hospitals nationwide found the following improvements: in the last five years, bloodstream infections associated with a central line fell by 46 percent, and surgical site infections fell by 19 percent. Infections associated with a urinary catheter rose by 6 percent, although they may now have started to decrease.
That’s infections by site. Now by type of bug: Hospital-acquired infections from Clostridium difficile — a superbug so determined that even hand sanitizer doesn’t kill it — dropped by 10 percent between 2011 and 2013. And bloodstream infections from the resistant staph bacteria known as MRSA dropped by 8 percent between 2011 and 2013.
The C.D.C.’s baseline for this survey is 2007/2008. Since that point, invasive MRSA infections acquired in the hospital have dropped by 30.8 percent. We’re moving in the right direction, and that’s notable especially because MRSA infections in the community have risen, which means more people come to the hospital already infected.
But the V.A. shows how much faster we could go.

Medicare Payments Surge for Stents to Unblock Blood Vessels in Limbs

By  and 
At a time of increasing scrutiny of procedures to open blocked heart arteries, cardiologists are turning to — and reaping huge payments from -- controversial techniques that relieve blockages in the arms and legs.
Unlike heart procedures, which must be done in a hospital or outpatient facility, where oversight is typically more intense, the opening of the peripheral arteries and veins of the arms and legs can be done in a doctor’s office.
Medical experts are questioning the necessity of some of these treatments, and many believe the condition is more safely treated with drugs and exercise. Nonetheless, some of the nation’s most highly reimbursed cardiologists are making millions of dollars from Medicare for performing these procedures, as payments for relieving blockages in the heart have fallen.
Earlier this month, the Justice Department said it joined two whistle-blower lawsuits accusing one of these doctors of performing unnecessary procedures, including placing a stent in the leg of a patient who later died of complications.
The cardiologist in question, Dr. Asad Qamar of Ocala, Fla., was paid $18 million by Medicare in 2012, making him the top-billing cardiologist in the country, according to an analysis by The New York Times of Medicare data. Dr. Qamar was also the leader in billing for procedures to treat peripheral blockages.
Nationwide, the shift in doctors’ emphasis is significant. The number of procedures to open blockages in heart vessels fell by about 30 percent from 2005 to 2013, to about 323,000 for patients covered under Medicare. Over the same time, the number of similar procedures for vessels outside the heart soared by almost 70 percent to 853,000, according to the Advisory Board Company, an analytics and research firm that analyzed Medicare payment data.
The Times’s analysis of the 2012 billing records for the 10 top-billing cardiologists in the country showed that eight of the doctors made about half of their reimbursements from Medicare by performing procedures to ease the narrowing in an artery or vein in patients’ arms or legs. Some continue to do a high number of coronary interventions.
These types of lucrative procedures — in 2012, Medicare paid nearly $12,000 for one type of these operations — have been the focus of a turf battle among specialists.
The county’s top billers for these procedures included a handful of vascular surgeons and radiologists in addition to the cardiologists.
The doctors who perform the procedures say they are saving Medicare money by doing them outside a hospital, that they reduce the number of more serious conditions, and that the Medicare payments are justified to cover their high expenses.
While there is considerable agreement among specialists about how and when to treat heart blockages, there is far less consensus in the treatment of blockages elsewhere.



King v. Burwell: Nurses, Doctors and Working People Tell U.S. Supreme Court: Millions of Americans Counting on Tax Credits for More Affordable Healthcare Premiums

Healthcare Professionals, Joined by SEIU, File Amicus Brief Dismantling 'Carrot and Stick' Argument
WASHINGTON - A group of healthcare professionals and SEIU members submitted an amicus brief in King v. Burwell on Wednesday to the U.S. Supreme Court on behalf of working families throughout America. The case under consideration challenges the power of the Internal Revenue Service (IRS) to issue tax credits to millions of working Americans who enroll in private health insurance through the federal healthcare exchange. The tax credits have meant that millions of working women and men in approximately 36 states have gained affordable, quality healthcare under the law and can now see a doctor, afford lifesaving prescription drugs, and be free of the fear of medical bankruptcy.
"As a postpartum nurse, I know firsthand that the tax credits the law provides are important to ensuring the health of mothers and their babies," said Marilyn Ralat-Albernas, RN, of Miami. "We should be looking for ways to expand affordable access to good prenatal care, not putting this care at risk."
The healthcare professionals are members of the Service Employees International Union (SEIU), America's largest healthcare union, which joined them in filing the brief.
The "friend of the court" brief takes apart the so-called "carrot and stick" premise presented by the petitioners of the court by making it clear that Congress never intended to present a "carrot" to incentivize states, nor a "stick" to penalize Americans in states that did not create and run their own state exchanges. Furthermore, the brief shows this theory is simply a politically motivated fabrication, not supported by the text of the law, by its purpose, by its legislative history, or by the understanding of any state when making the choice whether to create and operate its own state exchange.

Study Finds H.I.V. Drugs Priced Out of Reach 

    By KATIE THOMAS
    JANUARY 28, 2015
    Drugs to treat H.I.V. and AIDS are being priced out of reach for many patients enrolled in insurance plans through the new health care exchanges, despite warnings that such practices are illegal under the Obama administration’s health care law, according to a new analysis by Harvard researchers.
    The study, to be published on Wednesday in an article in The New England Journal of Medicine, looked at 48 health plans in 12 states and found that a quarter of the plans showed evidence of what researchers called “adverse tiering,” or placing all of the drugs used to treat H.I.V. in a specialty tier where consumers are required to pay at least 30 percent of the cost of the drug.
    The financial impact can be drastic, the researchers found: A patient taking a common H.I.V. treatment, Atripla, would pay about $3,000 more a year in a restrictive plan compared with someone enrolled in a more generous plan, even after accounting for the fact that the more restrictive plans tended to charge lower monthly premiums.
    “That’s really a large cost difference, and really is a very significant financial constraint for those with chronic conditions, particularly H.I.V.,” said Douglas B. Jacobs, the lead author of the study, who is pursuing degrees in public health at the Harvard T. H. Chan School of Public Health and medicine at the University of California, San Francisco.
    The study, which did not name the insurers whose plans it analyzed, looked only at the midlevel, or silver, plans offered in the marketplaces because they are the most popular plans among consumers. More comprehensive plans, known as gold and platinum plans, are often more generous in coverage but carry higher premiums. Insurers have said that these may be a better choice for people who have serious medical conditions.
    Clare Krusing, a spokeswoman for America’s Health Insurance Plans, an industry trade group, said that a crucial component of the marketplace was consumer choice, and that the study should have included an analysis of the gold and platinum plans. “Individuals have diverse health and financial needs, and health plans have designed a wide range of coverage options, including those with lower cost-sharing, so individuals can pick the policy that is best for them,” she said.


    Budget Office Slashes Estimated Cost of Health Coverage

    By 
    WASHINGTON — The Congressional Budget Office on Monday significantly lowered its estimate of the cost of providing health insurance coverage to millions of Americans under the Affordable Care Act.
    Douglas W. Elmendorf, the director of the budget office, said the changes resulted from many factors, including a general “slowdown in the growth of health care costs” and lower projections of insurance premiums that are subsidized by the federal government.
    In March 2010, when President Obama signed the health care law, the Congressional Budget Office estimated that the expansion of coverage would cost the federal government $710 billion in the fiscal years 2015 through 2019, Mr. Elmendorf said.
    “The newest projections indicate that those provisions will cost $571 billion over that same period, a reduction of 20 percent,” he said. The Affordable Care Act not only subsidized the purchase of private insurance, but also authorized a major expansion of Medicaid, the federal-state program for low-income people.
    The Supreme Court ruled in 2012 that the expansion of Medicaid was optional for states, not required, as Democrats in Congress had intended. Nearly two dozen states have yet to expand eligibility. And in states that did expand Medicaid, projections of federal Medicaid spending per beneficiary are lower than expected, the budget office said.



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