If you’re traveling over the long weekend, you’ll want to take along some reading material. While some might reach for a good novel by John Grisham or Dan Brown, the health policy blogs in this edition of the Health Wonk Review tackle equally compelling mysteries. Was the Medicare Trustees report really that gloomy? If Workers Comp did not exist, could it be invented today? Should California create a Basic Health Program?

Those are just a few of the topics tackled within, so without further ado …


On HealthBeat, Maggie Mahar argues that the Medicare Trustees report is much less gloomy than advertised. The trustees are hopeful that Medicare’s problems can be solved by “building on” the Affordable Care Act (ACA), and they point out that the ACA calls for structural reforms in how we pay for care and how it is delivered could lead to substantial savings. The Congressional Budget Office didn’t try to “score” these changes, but this would be money above and beyond the roughly $950 billion that CBO says the Affordable Care Act generates.  That $950 billion includes $196 billion saved by shaving annual updates to hospitals, skilled nursing facilities and other non-physician services by 1 percent a year for 10 years. Medicare Actuary Rick Foster has said this is “unsustainable”; using evidence from MedPAC, Maggie argues that Rick is wrong.

At Managed Care Matters, Joe Paduda also makes the case that the pessimism about the Trustees report is overdone. In Joe’s words (and with his emphases):

Reports indicate: “The Medicare hospital insurance fund will be exhausted in 2024, five years earlier than last year’s estimate, government accountants now figure.” That’s NOT what the report says. In reality, the HI fund will not be exhausted, but rather insufficient to pay ALL projected hospital costs. In 2024, it will be able to cover 90%, slowly decreasing to 75% in 2048 than back up near 90% in 2085. However, even that overstates the problem, as it is highly likely the IPAC’s provisions will kick in to reduce costs well before then.

On The Incidental Economist, Don Taylor presents an interview with Charles Blauhous, one of two public trustees for Medicare and Social Security. The interview stretches over three days, starting with an overview and then moving on to Social Security and finally to Medicare. Blauhous has some interesting things to say about Medicare’s incoherent mix of general revenue financing – “what you adopt when you mostly want upper-income people to pay for something” and a separate payroll tax – “what you adopt if you place a higher priority on all program participants funding their own benefits.” He also worries that Congress will undermine the Independent Payment Advisory Board if it imposes savings that begin to bite, and he suggests that federal health spending inflates private sector health costs, rather than vice versa.

The States

Much of the action under the Affordable Care Act takes place in the states. At the Colorado Health Insurance Insider, Louise Norris reviews the recent legislative session in Colorado. Louise notes that the Colorado legislature passed a bill setting up the broad framework for a health insurance exchange, while defeating two other health-related bills at opposite ends of the political spectrum.

On the Health Access Blog, Linda Leu discusses a briefing by the California HealthCare Foundation that focused on whether California should create a “Basic Health Program.” Under the Affordable Care Act, people with incomes from 133 percent to 400 percent of poverty would normally receive subsidized coverage through their state’s health insurance exchange, but some advocates fear that even subsidized coverage on the exchange might be unaffordable for those with the lowest incomes. The BHP would respond to such fears by replacing exchange coverage for Californians with incomes from 133 percent to 200 of poverty. The Federal Government would allocate 95 percent of the subsidies it would have provided to these individuals and give it to the State to run the BHP. Could the BHP provide better coverage for less money? The authors of a CHCF study offered a qualified “yes,” but Linda warns that the issue is complex and offers a list of pros and cons concerning a BHP.

What happens in a state when the problems with the workers comp system are so severe that your largest employers threaten to abandon ship? Jon Coppelman of Workers Comp Insider talks about the “nuclear option” in Illinois. Specifically, Jon says, state legislators there are getting so frustrated that they are threatening to blow up the whole system: A Democratic state House member has filed a bill that would abolish workers comp in Illinois and send all workplace injury cases into the court system. The bill is extremely unlikely to pass, but Jon uses the proposal as a vehicle to discuss whether states would adopt workers comp systems today if they didn’t already exist. The probable and unfortunate answer, according to Jon, is no.

Health Reform And Spending

It may look like chaos, but it’s all going according to plan. With some acknowledged artistic license, that’s how Jonathan Halvorson at The Health Care Blog assesses the post-Affordable Care Act health reform landscape. Only a year after the ACA, there is widespread acknowledgement of the need for new steps to control health care spending and to limit the growth of Medicare and Medicaid, but Jonathan sees this as in line with the staged strategy for deep reform developed in Massachusetts: Enact universal coverage first, then use the resulting sense of crisis to control costs in ways that would have been politically impossible before.  He points out that we have a little time to tackle spending before the major ACA costs begin in 2014.

Writing here on Health Affairs Blog, Steve Lieberman and Doug Hastings examine the proposal for “pioneer” accountable care organizations and other ACO initiatives recently released by the Center for Medicare and Medicaid Innovation (CMMI). After the proposed rules for the Medicare Shared-Savings Program (MSSP) were announced earlier, many expressed concern that they placed too many obstacles in the path of those wishing to form ACOs. Steve and Doug both say the new initiatives could be a step in the right direction, but they note that there are significant unanswered questions, and the shape of the final MSSP rules remains critical.

At The Apothecary, Avik Roy offers two takes on Mitt Romney’s recent health care policy address. Avik says the former Massachusetts governor did a poor job of differentiating the reform he signed in the Bay State from the Affordable Care Act, but Avik also offers praise for Romney’s new health policy proposal. Romney would have been better off being more open from the beginning about the problems that have developed in Massachusetts, Avik concludes.

David Williams says Romney deserves the abuse he has been taking over health care. Writing at the Health Business Blog, David says the former governor had a chance to present a coherent picture of his health care policy for a national audience but failed at the task. David outlines what Romney should have said, starting with the fact that reform in Massachusetts has achieved its main goal of near-universal coverage.

On his eponymous blog, John Goodman discusses a new RAND study finding that people with Health Savings Account plans consume less care than people with conventional insurance and have lower health care costs. HSA holders cut back on such “useful care” as mammograms, screenings for cervical and colorectal cancer and even childhood vaccinations, but John finds this a virtue rather than a vice. We could spend our entire incomes entirely on “useful” health care, he points out; to preserve money for housing, clothing, and other things, it is far better for individuals to determine what “useful” care is worth the price, as opposed to having government make the determination for us.


“Profits” and “profit margins” are two different things, despite what you might gather from reading the mainstream media, writes Hank Stern on Insure Blog. Hank faults the media for emphasizing that the nation’s major health insurers are entering a third year of record profits, while ignoring the fact that the insurance industry’s 4.4 percent profit margin is one of the lowest margins for any health industry sector.

At the Healthcare Economist, Jason Shafrin asks: “Does WellPoint really care about quality?”  Jason’s answer: “Maybe.” He notes that WellPoint has recently begun paying hospitals based on quality, but he also explains the ways in which this could improve WellPoint’s bottom line and/or reduce costs. “Rather than responding to pressure to increase quality of care, WellPoint’s [value-based purchasing] efforts may in fact be a response to employer and beneficiary pressure to reduce premiums.

Consumer Guidance

On the Prepared Patient Forum, Trudy Lieberman offers the fourth in a series of posts that examine the process of signing up for Medicare, navigating its rules, choosing supplemental coverage and planning for health care in a program with a very uncertain future. The subject of this installment is the challenging task of choosing a prescription drug plan, and Trudy offers a comprehensive and detailed guide to doing so.

Unnecessary trips to the emergency department are expensive and disruptive for doctors and patients.  They are also fairly common. Writing on the Medical Professionalism Blog, Jessie Gruman offers a patient’s perspective on the problem. Jessie explains why figuring out how to respond to a health crisis has become more complicated. She notes that, despite the presence of options, the default choice of many Americans is to call 911 or go to the ED, and she offers specific suggestions on how clinicians, employers, health plans, governments, and other stakeholders can help Americans become better informed about how to respond to a health crisis.

Health IT

The President’s Council of Advisors on Science and Technology (PCAST) report on health IT has been evaluated by Health IT experts through the Office of the National Coordinator for Health IT’s (ONC) PCAST Workgroup.  At Healthcare Technology News, Rich Elmore lays out the PCAST recommendations and the PCAST Workgroup feedback to ONC.

As meaningful use becomes a reality with e-prescribing, purchasers must be careful about what data they trust to help them choose the right vendor with the right e-Rx technology, Jonena Relth says on Healthcare Talent Transformation. Jonena argues that the healthcare profession is not policing the so called “experts” publishing studies that are totally out of the realm of scientific relevance.

Diseases And Treatments

At HealthBlawg, David Harlow talks about a new study showing that 1 in 10 cancer patients don’t take their meds. This trend is correlated with the transition from chemo via IV to meds that can be taken at home, in pill form.  David suggests that the real issue is the differential approach to cost sharing; he argues that third-party payers should belly up and pay for cancer meds so that patients have low or no deductibles and copays, thereby saving the patients and the payers the readmissions and treatments required as a result of nonadherence to medication regimens.

At the HealthNewsReview Blog, Gary Switzer offers a trifecta of reports on prostate cancer treatment:

  • a study questioning the benefit of radical prostatectomy surgery in low-risk, early-stage cancer.
  • another study that concludes that the prostate surgery rate is rising because of the use of robotic surgery;
  • and a third study that suggests that hospital websites hype robotic surgery, ignore risks, and are often influenced by manufacturers.

Laura Newman spent three days “listening to expert neurologists, demographers, caregivers, and policy people talk about Alzheimer’s,” and she has a host of interesting and informed questions about all aspects of the disease and how reporters and bloggers can most usefully write about it. She details her thoughts in a post on her blog, Patient POV.


Tinker Ready at Nature Network Boston discovers that stem cell researcher Piero Anversa of Brigham and Women’s Hospital can’t seem to get away from the controversy over his research methods – literally. In reporting on his new findings on stem cells in the lung, The Boston Globe noted that some scientists disputed the validity of Anversa’s earlier study of bone marrow stem cells. Turns out one of the “some scientists” — Amy Wagers, formerly of Stanford — is also now at a nearby Harvard research center – Joslin Diabetes Center – where she’s facing questions about her own work.

The notion that health care corruption is a prevalent and important problem has crept into a major medical journal, albeit laced with irony and a little indirection, Roy Poses notes at Health Care Renewal. A key point was that even mentioning health care corruption in an international health context may mean “professional suicide.” Of course, Poses points out, if one cannot even talk about corruption without sacrificing one’s career, an effective challenge to corruption is very difficult.

The Doctor Liberty blog employs a libertarian perspective to analyze Senator Rand Paul’s recent comments that making health care a “right” enslaves doctors. The post looks at why some libertarians might agree with Paul, but also why other libertarians might be uncomfortable with the Kentucky Republican’s remarks.

Nonmedical Determinants

At Improving Population Health, David Kindig stresses the important health effects of upstream social and economic factors such as income and education. “Interventions in these areas are often assumed to be the purview of the public and non-profit sectors, but for-profit activity in economic development and job creation are just as important as anti-poverty public policies and programs such as the Earned Income Tax Credit,” David writes. He adds that improving community health is a complex enterprise that requires broad collaboration and robust private sector support and financing that goes beyond job creation to upstream investments in education, particularly for early childhood.

Care Coordination And Quality Improvement

At the Disease Management Care Blog, Jaan Sidorov says he admires what he describes as “hyper-engineered” health systems. But he also draws some important points on the topic from a Health Affairs article on Intermountain Health Care System: docs gotta be involved, evidence-based medicine is imperfect, and it’s a stretch to believe that this approach will work in the outpatient care of chronic illness.

Racial Disparities

Glenn Laffel offers a post on Pizaazz that likens the fight against racial disparities in health care to the Hundred Years War. Glenn assesses the nation’s progress and reviews some reasons why the problem has proven so difficult. He concludes that we’ve got decades more work to do — at least.


A collaboration between the John A. Hartford Foundation and the RAND Corporation, “Building Interdisciplinary Geriatric Health Care Research Centers,” has yielded extraordinary results, Amy Berman writes on health AGEnda. The initiative, launched in 2004, recognized that meeting the needs of older patients requires contributions from disciplines including medicine, nursing, social work, anthropology, nutrition, biostatistics, psychology, dentistry, sociology, economics, law, and religious studies, to name just some. Twelve research centers across the country received $200,000, complemented by a 50 percent institutional match. A report on the initiative, Developing Interdisciplinary Research Centers for Improving Geriatric Health Care: Lessons from a John A. Hartford Foundation Initiative, has just been published, and work at participating centers yielded 1,248 accepted manuscripts, 678 conference presentations, and 240 new funded grants. The report offers valuable lessons on bridging gaps between disciplines and overcoming America’s siloed research enterprise, Berman says.

Medical Politics

On The Hospitalist Leader, Bradley Flansbaum begins by grading the speech of a representative of the American Medical Association to the Society of Hospital Medicine. He then proceeds to grade the AMA itself, offering 5 “Ups” and 5 “Downs” about the group. Flansbaum encourages his fellow SHM members to weigh in the group’s relationship with the AMA. “We are only in the inaugural stages of this relationship.  It is complicated,” he concludes.

The Legal Fight Over Reform

Jared Rhoads presents a collection of health policy-related reference materials posted at The Lucidicus Project. He explains: “We have added a new permanent fixture to the Lucidicus website: a collection of some key legal documents dealing with the various constitutional challenges to the health reform law. The collection is not exhaustive, but it does help people follow the progress of these cases.”