Blog Home

Archive for the 'Access' Category




Implementing Health Reform: CBO Projects Lower ACA Costs, Greater Coverage


April 15th, 2014
by Timothy Jost

On April 14, 2014, the non-partisan Congressional Budget Office, together with the staff of the Joint Committee on Taxation, released an updated estimate on the Effects of the Insurance Coverage Provisions of the Affordable Care Act. The CBO report brings good news for the ACA. The CBO projects now that the ACA’s coverage provisions will cost $5 billion less for this year than it projected just two months ago. Over the 2015 to 2024 period, CBO projects that the ACA will cost $104 billion less than it projected in February. At the same time, the CBO projects that the number of uninsured Americans will in fact decrease by an additional one million over the next decade, by 26 rather than 25 million, as it estimated in February.

The CBO report estimates that the net cost of the ACA’s coverage provisions will be $36 billion in 2014, $1,383 billion over the 2015 to 2024 period. This estimate consists of $1,839 billion for premium tax credits and cost-sharing reduction payments, Medicaid, CHIP, and small employer tax credits, offset by $456 billion in receipts from penalty payments, the excise tax on high-premium insurance plans, and the effects on tax revenues of projected changes in employer coverage. The CBO report does not include an estimate of the total reduction in the federal deficit attributable to the ACA, as the CBO has concluded that it is no longer possible to estimate the net effect of ACA changes on existing federal programs, but the most recent CBO estimate from 2012 projected that the ACA would reduce the federal deficit over the 2013 to 2022 period by $109 billion. Given projected further reductions in Medicare spending projected in a CBO budget report also released on April 14, it is reasonable to believe that the ACA’s impact on the budget may be even greater than earlier estimated.

Read the rest of this entry »

The Role Of Remote Care Management In Population Health


April 4th, 2014
by Alan Snell

Editor’s note: For more on this topic, see the February issue of Health Affairs, which features a series of articles on connected health. 

Remote care management (RCM) programs use telehealth technology to facilitate clinically driven, remote monitoring, care, and education of patients and are an absolute necessity for providers and payers striving to implement an effective population health management strategy. Historically, RCM programs have been viewed through a fee-for-service lens and, as a consequence, overlooked, because physicians would not be reimbursed for the time to monitor these patients outside the confines of their offices.

Yet the current shift to value-based care presents an imperative for health care providers to avoid costs by better managing the health of people with chronic conditions. This change will require more hands-on, effective support for patients that result in lasting behavior change.

Providers are working to keep the health of an individual from rapidly deteriorating once they develop a chronic condition(s). Two prominent barriers to providers’ efforts to keep their patients healthy are the providers’ intermittent contact with patients and limited access to clinical data. Remote care management addresses these barriers.

Read the rest of this entry »

Mental Illness In America’s Jails And Prisons: Toward A Public Safety/Public Health Model


April 1st, 2014
by Dean Aufderheide

Editor’s note: This post is published in conjunction with the March issue of Health Affairs, which features a cluster of articles on jails and health. 

Mental Illness in America’s Jails and Prisons

The United States continues to have one of the highest incarceration rates in the world, with 5 percent of the world population, but nearly 25 percent of the world’s prisoners.  Inmates are spending more time behind bars as states adopt “truth in sentencing laws,” which requires inmates to serve 85 percent of their sentence behind bars.

In 2012, about 1 in every 35 adults in the United States, or 2.9 percent of adult residents, was on probation or parole or incarcerated in prison or jail, the same rate observed in 1997.  If recent incarceration rates remain unchanged, an estimated 1 out of every 20 persons will spend time behind bars during their lifetime; and many of those caught in the net that is cast to catch the criminal offender will be suffering with mental illness.

Nearly a decade ago, I wrote an article with Patrick Brown titled “Crisis in Corrections: The Mentally Ill in America’s Prisons.”  It was about the alarming growth in the number of mentally ill individuals behind bars.  Since then, it has been shown that about 20 percent of prison inmates have a serious mental illness, 30 to 60 percent have substance abuse problems and, when including broad-based mental illnesses, the percentages increase significantly. For example, 50 percent of males and 75 percent of female inmates in state prisons, and 75 percent of females and 63 percent of male inmates in jails, will experience a mental health problem requiring mental health services in any given year.

Read the rest of this entry »

Exhibit Of The Month: More HIV Testing With Medicaid Expansion


March 28th, 2014
by Tracy Gnadinger

Editor’s note: This is the second post in the new “Exhibit of the Month” series. Readers who’d like to highlight other noteworthy exhibits from the same issue are encouraged to make their pitch in the comments section below.

This month’s exhibit examines the potential impact of the Affordable Care Act’s Medicaid expansion on HIV testing from 2013-2017, comparing a nationwide eligibility expansion with one limited to the eighteen states that had committed to expansion as of July 2013.

Read the rest of this entry »

HA Web First: New Medicaid Recipients Healthier Than Pre-ACA Enrollees


March 26th, 2014
by Tracy Gnadinger

The Affordable Care Act (ACA) gives states the option of expanding Medicaid coverage to individuals and families with incomes of up to 138 percent of the federal poverty level. A new study, being released today as a Web First by Health Affairs, used simulation methods to compare nondisabled adults enrolled in Medicaid before the ACA with newly eligible adults and those previously eligible but not enrolled in the program.

According to the study’s analysis, both the newly eligible and those not previously enrolled were healthier than the pre-ACA Medicaid enrollees. Authors Steven Hill, Salam Abdus, Julie Hudson, and Thomas Selden found that the pattern of results was similar for physical and mental health. They also determined that in states not expanding Medicaid under the ACA, adults in the income range for the law’s Medicaid expansion were healthier than pre-ACA enrollees.

Read the rest of this entry »

Health Insurance Coverage Is Just The First Step: Findings From Massachusetts


March 26th, 2014

As the rollout of coverage expansions under the Affordable Care Act (ACA) continues across the country, more Americans are gaining insurance coverage, with all the benefits that that implies in terms of health care access and financial protections. However, if, as President Obama has argued, affordable health care is a cornerstone of economic security for American families, findings from a survey of Massachusetts residents suggest that insurance coverage alone will not be enough.

Since its 2006 health reform initiative, Massachusetts has had the nation’s highest level of insurance coverage. But though there have been improvements in access to health care and health care affordability, insurance coverage has not eliminated the burden of high health care costs for Massachusetts families.

Health care costs are a problem for many insured adults. In 2012, more than one-third (38.7 percent) of Massachusetts adults with health insurance coverage for all of the past year reported problems with health care costs, with the level much higher for low-income insured adults (41.6 percent for those with family income at or below 138 percent of the poverty line—the income eligibility standard for the Medicaid expansion under the ACA) and middle-income insured adults (49.5 percent for those with income from 139 to 399 percent of poverty—the income group targeted by the new health insurance Marketplaces). Insured adults in Massachusetts report going without needed health care, cutting back on other spending, reducing savings, and taking on debt to deal with health care costs.

Read the rest of this entry »

The Health Workforce: A Critical Component Of The Health Care Infrastructure


March 24th, 2014
by Edward Salsberg

Editor’s note: This is the first in a periodic series of Health Affairs Blog posts on health workforce issues by Edward Salsberg. Mr. Salsberg has spent over 30 years studying the health workforce, including nearly 20 years establishing and directing three centers dedicated to workforce data collection, analysis and research. The first center, at the University at Albany, was focused on state health workforce data collection and issues. The second, at the Association of American Medical Colleges, was focused on the physician workforce across the nation. The third, the National Center for Health Workforce Analysis, was authorized by the Affordable Care Act. Mr. Salsberg has now joined the faculty at George Washington University where they are establishing a new Center for Health Workforce Research and Policy.

In the post below, Mr. Salsberg provides an overview of workforce issues. Future posts will discuss more specific health workforce questions and developments.

It could be argued that the health workforce — the people who provide direct patient care, as well as the staff that support caregivers and health care institutions — is the most significant component of the infrastructure of the health care system. Yet as a nation we have invested very little in collecting and analyzing health workforce data or in supporting the necessary research to inform effective public and private decision making. The results of this lack of investment are surpluses and shortages, significant mal-distribution, and less efficient and effective care than would be possible with better intelligence on our workforce needs.

For many health care professions, it takes years to build education and training capacity to increase, supply, or to change curriculum and modify the profession’s skill set. For these professions, we need to not only assess today’s needs but to project our future needs.

What the nation needs is a system to provide data, research findings, and information to thousands of individual stakeholders. This includes individuals considering a health career; colleges, universities and training programs that will educate and prepare them; the health organizations who will employ them; policy makers who need to decide what, if any, programs and policies to support; and the private sector that needs to decide whether to invest in workforce development. The responsibility for assuring an adequate supply and a well prepared health workforce is shared between the public and private sectors at both the national and the state and local level. Regardless of who is making the decisions related to health professions education and training capacity and health professions preparation, accurate and timely data is extremely important to support informed decisions.

Read the rest of this entry »

Implementing Health Reform: Ryan White Third-Party Payments, 2015 Letter To Issuers, And Other ACA Developments


March 15th, 2014
by Timothy Jost

On March 14, 2014, the Department of Health and Human Services released a flood of regulations, proposed regulations, and guidance addressing a host of Affordable Care Act implementation issues. From all indications, HHS has cleared the decks of all the regulatory issuances it had under consideration– nothing involving ACA implementation remains pending at the Office of Management and Budget. Perhaps someone made a promise that all would be completed by the end of the winter (or by Saint Patrick’s Day). More likely the necessity of having the ground rules for 2015 in place so that insurers could proceed with their 2015 forms and rates, and states with approving them, drove the deluge. In any event, it will take several posts to cover it all.

Yesterday’s post covered a notice on extending the federal preexisting condition high risk pool and a frequently asked questions document on coverage of same-sex spouses. The Internal Revenue Service also released a set of general Tax Tips for Same-Sex Couples (which covers general tax information and will not be discussed here), while HHS issued a blog post summarizing its frequently asked questions document.

This post will cover several other issuances released late in the day on March 14, 2014. These include an interim final rule (with comment period) dealing with third party payments for qualified health plans (QHPs) and stand-alone dental plans (SADPs); the 2015 final annual letter to issuers in the federally facilitated marketplace; a set of frequently asked questions on retroactive coverage, and a set of frequently asked questions on the use of exchange grants and no-cost extensions.

A final post will examine a proposed rule on exchange and insurance standards for 2015 and beyond and an accompanying bulletin on product discontinuance.

Read the rest of this entry »

Continuous Coverage Improves Costs And Quality For Children And Low-Income Adults


March 13th, 2014
by Paul Cotton

The termination of Medicaid and Children’s Health Insurance Program (CHIP) coverage due to short-term income changes or frequent reapplication requirements increases overall health care costs and negatively affects quality of care and quality measurement and improvement efforts. This may have a significant yet commonly overlooked impact on income-related health care disparities. By requiring at least twelve months of continuous coverage, we could prevent avoidable complications, reduce administrative burden, improve quality measurement and improvements efforts, and ultimately, reduce costs.

Current Medicaid Coverage Costs

One year of continuous adult Medicaid coverage costs, on average, 22 percent less per month than six months of coverage, and 42 percent less than just one month of coverage. That is because people who lose coverage have more emergency room visits, hospital admissions, and preventable problems such as the onset of asthma and diabetes; they also have more problems that could have been managed with ambulatory care and lower rates of cancer screening and early detection. Current re-enrollment requirements also contribute to additional administrative costs that will increase as people toggle back and forth between Medicaid/CHIP and the individual health insurance exchanges.

Less than twelve months of coverage also directly harms quality measurement and improvement efforts. Because accurate measurement requires at least twelve months of coverage, those with shorter coverage periods are excluded from performance evaluation. Most Healthcare Effectiveness Data & Information Set (HEDIS is a registered trademark of NCQA) measures, for example, require evaluation of at least twelve months of claims or record reviews to ascertain whether appropriate services were provided in a timely manner. As a result, plans and providers may not have enough people on which to report and do not get credit for high quality.

Read the rest of this entry »

Covered California: The Foundation of Obamacare, Success, Challenges, And The Road Ahead


March 13th, 2014
 
by Richard Scheffler and Jessica Foster

Editor’s note: This post is also coauthored by Jessica Foster, an MPH Candidate in Health Policy & Management at the University of California, Berkeley.

As the end of the open enrollment period on March 31 draws near, the Covered California state health insurance exchange is engaged in a final push for enrollees that will bring it beyond its baseline enrollment goals, launching a new advertising campaign and resolving application issues caused by a software glitch in February.

Throughout the open enrollment period, salient points and concerns have been raised about enrollment numbers, access to care, plan affordability, and benefit design in marketplace plans. These issues are being closely monitored and evaluated in California – the state which has the largest pool of subsidy-eligible individuals and accounted for 23 percent of national enrollments in 2013 – and are being discussed in forums nationwide.

A recent Kaiser Family Foundation briefing and panel discussion, “Affordable Care Act: A Spotlight on California,” discussed the importance of Covered California as a barometer of the success of the Affordable Care Act, and released a snapshot of California coverage at the outset of health reform implementation.

“California is a giant state with a big and diverse uninsured population that has embraced the law, has political will, has money for outreach, … and has been out front implementing the Affordable Care Act,” said Drew Altman, president and CEO of the Kaiser Family Foundation in the briefing.  “So both its successes and its challenges, they really matter for other states, and they really matter for the country.”

Read the rest of this entry »

Health Affairs Web First: Medicaid/Marketplace ‘Churning’ State-By-State


March 12th, 2014
by Tracy Gnadinger

The Affordable Care Act (ACA) requires almost all Americans to have health insurance. For most lower-income Americans, this means coverage through Medicaid, employer-sponsored insurance, or health exchanges, depending on their income and state of residence. Approximately half of all low-income, non-elderly Americans experience a change of income or family circumstance in a given year, which may result in an involuntary shift in how they are covered from health insurance purchased through an exchange to Medicaid — or vice versa. This process, called “churning,” could lead to both gaps in coverage and disruptions in the continuity of care.

A new study released today as a Web First by Health Affairs provides state-by-state estimates of churning. Using data from two Census Bureau sources — its 2008 Survey of Income and Program Participation, and American Community Surveys from 2009–2011 — Benjamin Sommers, John Graves, Katherine Swartz, and Sara Rosenbaum found that every state is likely to have significant numbers of residents whose eligibility changes over time: at least 40 percent of eligible adults over the course of twelve months. They observed that higher-income states and states with more generous Medicaid eligibility criteria in place before the ACA’s expansion experienced a higher rate of churning, although differences between states were small. (The authors’ analysis assumes that all states had expanded Medicaid under health reform. At the moment, twenty-five states and the District of Columbia have done so.)

Read the rest of this entry »

Neighborhood Grocery Stores Combat Obesity, Improve Food Perceptions


March 12th, 2014
by Yael Lehmann

The Cummins et al article “New Neighborhood Grocery Store Increased Awareness of Food Access but Did Not Alter Dietary Habits or Obesity,” published in the February issue of Health Affairs, generated considerable media attention, with headlines claiming that grocery stores do not contribute to healthy diets or reductions in obesity.  However, the study offered no conclusive proof showing that access to grocery stores is not a part of the solution to preventing obesity.  In fact, the study showed clear signs of promise that the intervention was working in key aspects during the short time the researchers collected data.  Within just a few months after the new supermarket opened, for example, researchers documented significant improvement in residents’ perceptions about the choice and quality of fresh fruits and vegetables, along with improvements in their perception of healthy food accessibility.

The subject of the study, the Fresh Grocer in North Philadelphia, is a beautiful store with a bountiful fresh produce section. The supermarket, which is now thriving in one of the poorest neighborhoods in the country, was built from the ground up after a 15-year hiatus in which the surrounding community had no grocery store. Its opening has revitalized a historic African-American owned shopping plaza and reinvigorated the local neighborhood’s retail economy.

Has the store reduced the rate of obesity among local residents? This is a crucial question, but one that cannot be adequately deduced from the present study. All we know from this study’s findings is that obesity rates did not change significantly during the first six to nine months after the store’s opening – not surprising, given the many decades of gradual changes in eating habits that have led to the obesity epidemic.

Read the rest of this entry »

Ethical Dilemmas In Prison And Jail Health Care


March 10th, 2014
by Nancy Dubler

Editor’s note: This post is published in conjunction with the March issue of Health Affairs, which features a cluster of articles on jails and health.

Prison and jail health care, despite occasional pockets of inspiration, provided by programs affiliated with academic institutions, is an arena of endless ethical conflict in which health care providers must negotiate relentlessly with prison officials to provide necessary and decent care.  The “right to health care” articulated by the Supreme Court pre-ordained these ongoing tensions.  The court reasoned that to place persons in prison or jail, where they could not secure their own care, and then to fail to provide that care, could result in precisely the pain and suffering prohibited by the Eighth Amendment to the Constitution.

Good reasoning was followed by a deeply flawed articulation of the “right” that defines the medical care entitlement as care provided to inmates without “deliberate indifference to their serious medical needs.” By forging a standard which was, and remains, unique in medicine and health care delivery — designed to avoid intruding on state malpractice litigation regarding adequacy of practice and standards of care — the court guaranteed that dispute would surround delivery.  That first framing, which did not establish a right to “standard of care” or to care delivered according to a “community standard,” set the stage for endless ethical and legal conflict.

The Eighth Amendment’s deliberate indifference standard, forbidding cruel and unusual punishment, presents a relatively demanding standard for proving liabil­ity.  The Eighth Amendment, as interpreted by the federal courts, does not render prison officials or staff liable in federal cases for malpractice or accidents, nor does it resolve inter-professional disputes — or patient-professional disputes — about the best choice of treatment. It does require, however, that sufficient resources be made available to implement three basic rights: the right to access to care, the right to care that is ordered, and the right to a professional medical judgment.

Read the rest of this entry »

Howard Koh To Keynote Health Affairs Briefing Tomorrow On ACA And HIV/AIDS


March 10th, 2014
by Chris Fleming

One of the least explored yet most important parts of the Affordable Care Act (ACA) are provisions that hold promise for addressing serious health care challenges facing the 1.1 million Americans who are living with HIV/AIDS — and others like them — most of whom are impoverished and uninsured.

Please join Health Affairs Founding Editor John Iglehart on Tuesday, March 11, in Washington, DC, for a Health Affairs briefing on our March issue where we will spotlight topics related to the ACA and people with HIV/AIDS. The briefing will be keynoted by Howard K. Koh, Assistant Secretary for Health, U.S. Department of Health and Human Services.

WHEN:
Tuesday, March 11, 2014
9:00 a.m. – Noon

WHERE:
National Press Club
529 14th Street NW, Washington, DC, 13th Floor (Metro Center)

REGISTER ONLINE

Follow live Tweets from the briefing @HA_Events, and join in the conversation with the hashtag #HA_HIVAIDS

Read the rest of this entry »

The ACA And People With HIV: The ACA’s Impact And The Implications Of State Choices


March 3rd, 2014
 
by Jennifer Kates and Rachel Garfield

Editor’s note: This post is also co-authored by Rachel Garfield, a senior researcher and associate director at the Kaiser Commission on Medicaid and the Uninsured, the largest operating program of the Henry J. Kaiser Family Foundation.

Among the groups that stand to benefit from the Affordable Care Act (ACA) are people living with HIV, a population with significant and high-cost health care needs but one that has historically faced barriers to coverage and care.  While several provisions of the ACA are of particular importance for this population, two are expected to have the most far reaching effects on coverage – the expansion of Medicaid eligibility to include most Americans with incomes up to 138 percent of the federal poverty level (FPL) (although the Supreme Court’s 2012 decision effectively made the Medicaid expansion optional for states) and the creation of new Health Insurance Marketplaces where individuals can purchase private coverage, including subsidized coverage for those with lower incomes.  Others include an end to pre-existing condition exclusions, a ban on premium rate setting based on health status, and an end to annual and lifetime caps on coverage, all of which posed barriers for people with HIV prior to the ACA.

Despite the importance of these changes for people with HIV, little has been known about how many are estimated to gain new coverage.  While there are more people living with HIV in the U.S. than ever before (an estimated 1.1 million), almost two-thirds are not yet in regular care, either because they have not yet been diagnosed or have not been retained in care, thus challenging efforts to develop nationally representative estimates of the population of people with HIV in the U.S. by income and coverage.  Indeed, a recent Institute of Medicine study concluded that no single data source was yet available that could establish baseline estimates of coverage before 2014; instead, the Committee recommended that multiple data sources should be considered.

Examining The Population Of Americans With HIV/AIDS

Two new studies, each using different data sources, shed light on this question — our study from the Kaiser Family Foundation, conducted in collaboration with researchers at CDC, and Snider et. al’s analysis published in the March issue of Health Affairs.  While the two studies use different data sources and methodological approaches, they arrive at a similar conclusion: significant shares of people with HIV stand to benefit from Medicaid expansion (as well as subsidized coverage in Health Insurance Marketplaces), but state choices about Medicaid expansion will affect the ACA’s reach for this population.  As such, both studies highlight the continued importance of the Ryan White HIV/AIDS Program (Ryan White Program), first created in 1990, which has become a critical safety net for people with HIV who have no coverage or face limits in their coverage.

Read the rest of this entry »

How Many Nongroup Policies Were Canceled? Estimates From December 2013


March 3rd, 2014
 
by Lisa Clemans-Cope and Nathaniel Anderson

Editor’s note: This post is co-authored by Lisa Clemans-Cope and Nathaniel Anderson of the Urban Institute.

Last fall, news reports focused on consumer discontent over “cancellation” notices of health insurance policies that did not meet the new minimum standards under the Affordable Care Act (ACA), but it’s difficult to determine exactly how many consumers were affected.  Starting in 2014, most non-group health insurance plans and small employer group plans must offer a minimum set of benefits and consumer protections—for example, plans must not exclude coverage of pre-existing conditions and must offer minimal coverage of certain health benefits such as prescription drugs.

Prior to reform, the nongroup health insurance market suffered from a number of shortcomings, such as benefit exclusions, denials of coverage, premiums that varied greatly by health status, benefit limits, high cost-sharing, and lack of information on plan benefits and design prior to purchase. The new minimum benefit standards and consumer protections work together with additional insurance market provisions that took effect in 2010, expansions of Medicaid eligibility, and income-based subsidies in the new health insurance Marketplaces. Together, these new reforms expanded coverage options for millions of people, and raised minimum benefits and consumer protections for millions more.

Among nongroup plans offered in 2013 that were not compliant with ACA standards, some were amended, some were cancelled, and some were granted “grandfathered” status and are not required to comply with the new rules if enrollees were holding the policy continuously before and since the passage of the ACA and insurers did not substantially change benefits or costs. Some insurers, however, chose to cancel policies that would otherwise have been legally grandfathered for business reasons, such as low enrollment or an enrollee group with high average cost, leading to unsustainable premiums. In fact, the non-group market has historically been highly volatile, with just 17 percent retaining coverage for more than two years.

Read the rest of this entry »

HA Issue Briefing: The ACA And The Future Of HIV/AIDS In America


February 28th, 2014
by Chris Fleming

One of the least explored yet most important parts of the Affordable Care Act (ACA) are provisions that hold promise for addressing serious health care challenges facing the 1.1 million Americans who are living with HIV/AIDS — and others like them — most of whom are impoverished and uninsured.

Please join Health Affairs Founding Editor John Iglehart on Tuesday, March 11, in Washington, DC, for a Health Affairs briefing where we will spotlight issues related to the ACA and people with HIV/AIDS.

WHEN:
Tuesday, March 11, 2014
9:00 a.m. – Noon

WHERE:
National Press Club
529 14th Street NW, Washington, DC, 13th Floor (Metro Center)

REGISTER ONLINE

Follow live Tweets from the briefing @HA_Events, and join in the conversation with the hashtag #HA_HIVAIDS

Read the rest of this entry »

Exhibit Of The Month: Virtual Visits On The Rise


February 27th, 2014
by Rob Lott

At Health Affairs Blog, we’re excited to introduce a new regular feature. Each month, Health Affairs editors will review all the tables, charts, graphs and maps that have run in the latest print edition of the journal. After deliberating in a dark, but smoke-free, backroom, we’ll emerge to crown the most compelling, creative or surprising exhibit as our Exhibit of the Month!  Readers who’d like to highlight other noteworthy exhibits from the same issue are encouraged to make their pitch in the comments section below.

This exhibit shows how, within the Kaiser Permanente Northern California system, the number of virtual physician visits grew from 4.1 million in 2008 to 10.5 million in 2013.

According to Pearl, “In 2008 KPNC implemented an impatient  and ambulatory care electronic health record system for its 3.4 million members and developed a suite of patient-friendly Internet, mobile, and video tools.”  Among these tools is a system that allows patients to send secure e-mail messages to their primary care physician.  KPNC physicians are now expected to respond within 24 hours of receiving the message.  This system builds on the 10-15 minute physician telephone visits that KPNC has offered patients for more than a decade.

Read the rest of this entry »

When The Only Cure Is A Transplant


February 21st, 2014

On Christmas Eve 2011, protesters from a local church marched to the entrance of our hospital, Rush University Medical Center in Chicago. They demanded we provide organ transplants for sick members of their congregation. We invited them in and listened to their gut wrenching stories. George, twenty-two, was brought to the United States as a six-month-old. He developed renal failure at age sixteen while covered under the Children’s Health Insurance Program. Now he was uninsured, on dialysis and refused a transplant evaluation at the same institution that treated him as a child. Another undocumented immigrant, Martin, was twenty-six. He too was uninsured and on dialysis.

Chicago has six adult transplant centers. Initially none would evaluate George or Martin for transplantation because they were uninsured. In the Narrative Matters essay, “Undocumented Immigrants And Kidney Transplant: Costs And Controversy,” published in the February issue of Health Affairs, Vanessa Grubbs tells a similarly heartfelt story of a patient in need of a transplant: Mr. Rojas. George, Martin and Mr. Rojas are not US citizens, but it was their lack of health insurance that kept transplantation out of reach. Foreign-born immigrants always have access to a transplant evaluation (the prerequisite for organ transplant) if they have insurance or the cash to pay.

In theory, the organ allocation system in the United States is based on justice and equity. The National Organ Transplant Act (NOTA) was passed in 1984 to create a fair system of organ transplantation in the United States. A federal task force, created by the act, was charged to design an organ allocation system “based on medical criteria that are publicly stated and fairly applied.” The task force emphasized that organs should be distributed to those eligible “regardless of their ability to pay.” Both NOTA and the bylaws of the United Network for Organ Sharing, the nonprofit organization that manages the national transplant network, require that need, not financial or citizenship status, guide transplant allocation decisions. Undeniably, the system of altruistic donation is only viable if a donating individual believes organs are allocated fairly.

Read the rest of this entry »

Doctors Without State Borders: Practicing Across State Lines


February 18th, 2014
by Robert Kocher

Note: In addition to Robert Kocher (photo and bio above), this post is authored, by Topher Spiro, Vice President, Health Policy, Center for American Progress ; Emily Oshima Lee, Policy Analyst, Center for American Progress; Gabriel Scheffler, Yale Law School student and former Ford Foundation Law Fellow at the Center for American Progress with the Health Policy Team; Stephen Shortell, Blue Cross of California Distinguished Professor of Health Policy and Management and Professor of Organization Behavior at the School of Public Health and Haas School of Business at the University of California-Berkeley; David Cutler, Otto Eckstein Professor of Applied Economics in the Faculty of Arts and Sciences at Harvard University; and Ezekiel Emanuel, senior fellow at the Center for American Progress and Vice Provost for Global Initiatives and chair of the Department of Medical Ethics and Health Policy at the University of Pennsylvania.

In the United States, a tangled web of federal and state regulations controls physician licensing. Although federal standards govern medical training and testing, each state has its own licensing board, and doctors must procure a license for every state in which they practice medicine (with some limited exceptions for physicians from bordering states, for consultations, and during emergencies).

This bifurcated system makes it difficult for physicians to care for patients in other states, and in particular impedes the practice of telemedicine. The status quo creates excessive administrative burdens and like contributes to worse health outcomes, higher costs, and reduced access to health care.

We believe that, short of the federal government implementing a single national licensing scheme, states should adopt mutual recognition agreements in which they honor each other’s physician licenses. To encourage states to adopt such a system, we suggest that the federal Center for Medicare and Medicaid Innovation (CMMI) create an Innovation Model to pilot the use of telemedicine to provide access to underserved communities by offering funding to states that sign mutual recognition agreements.

Read the rest of this entry »

Click here to email us a new post.