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Thoughts On The VA Scandal And The Future


June 13th, 2014

For eight years, until May 2013, I directed the Department of Veterans Affairs (VA) medical research program from its Central Office and became familiar with the operations of the Veterans Health Administration (VHA). It was my only VA job and I felt honored to be part of the VA’s vital mission, as did most VA employees I met. Based on this experience, I have some ground level observations on the state of the VA and its future planning in light of the present scandal.

VA’s Scope and Assets

VA has three components: a large health system (VHA), a benefit center (Veterans Benefits Administration, or VBA), and the highly regarded National Cemetery Administration. All report to the VA Secretary but have different missions, issues, and management requisites. For example VHA was a pioneer in the Electronic Health Record (EHR), while VBA has had a more recent painful conversion to information technology (IT). VHA is run by the Undersecretary for Health, on whom VA Secretaries almost totally rely given their general lack of experience in health care.

VHA is divided into 21 networks and has 8.9 million enrollees (out of the 22 million U.S. veterans). It cares for 6.4 million veterans annually at over 1,700 sites of care, including 152 hospitals, about 820 clinics, 130 long-term care facilities, 300 Vet Centers for readjustment problems, and a suicide hotline, as well as homelessness and other programs. It has partly trained two-thirds of U.S physicians and made groundbreaking medical research contributions. These assets create strong constituencies for VA both within and outside the veterans’ community.

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Implementing Health Reform: December Data On Medicaid And CHIP Applications And Eligibility Determinations


January 22nd, 2014

On January 22, 2014, the Centers for Medicare and Medicaid Services released the December (2013) Monthly Applications and Eligibility Determinations Report for the Medicaid and CHIP programs. The top line of this report is that 1,918,484 applications for Medicaid and CHIP were received by state Medicaid and CHIP agencies in December 2013, while 2,293,359 individuals were determined eligible for Medicaid and CHIP, for a total of 6,323,188 individuals determined eligible for Medicaid and CHIP since October 1, 2013. The bottom line is that a lot of new people are being signed up for Medicaid and CHIP — primarily in states that expanded Medicaid — but we don’t know how many more for certain..

Applications are reportedly up 14.4 percent from baseline figures for the three-month period preceding October 2013 data in states that have expanded Medicaid. More impressively, Medicaid eligibility determinations are up 73 percent in expansion states over baseline data, but only up 3 percent in states that did not expand Medicaid. Medicaid expansion states accounted for 1.2 million of the new determinations, non-expansion states for 1 million.

These numbers come with many caveats however. First, application data are only available from 46 states and the District of Columbia, not including New York, Ohio, Washington, and Pennsylvania — not insignificant states. Only 41 states reported both determinations and baseline data. Both applications and determinations data are, for most states, not limited to individuals newly eligible under the Affordable Care Act, but also include individuals in traditional Medicaid categories. The 1.9 million application number counts applications, not individuals, and an application may (and often does) include more than one individual. Four states include renewals in their application data.

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Against All Odds: What One Family’s Experience Tells Us About Medicaid’s Enduring Role


September 27th, 2013

Medicaid is nearly 50 years old. Is it a relic of a different era that should be repealed and replaced, or does its importance endure?

Ann Yurcek’s moving “Narrative Matters” essay in the September issue of Health Affairs demonstrates Medicaid’s vital role in health care. Re-imagined a quarter century later, her story underscores just how much this vital role endures. Indeed, Becca Yurcek’s very life is emblematic of the degree to which Medicaid goes where other payers fear to tread.

Ann’s Story

The events Ann Yurcek relates began nearly 25 years ago in 1989.

For readers familiar with Medicaid’s role in American life — especially its role in that incredible space in which health and disability policy intersect — Becca’s story is hardly uncommon. It started with young parents of a healthy and growing family, who were struggling to make ends meet even as a new baby was on the way. The father had begun a new job, but as a result of the peculiarities (a polite term under the circumstances) of the pre-reform insurance system, he was forced to pay for COBRA coverage at his old job even as he paid premiums at the new job — the new employer-sponsored health plan refused to cover Ann.

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Analysis Of Utilization Rate Declines Leads HA Blog March Top Ten


April 9th, 2013

Mark Grube, Kenneth Kaufman and Robert York’s analysis of the decline in hospital utilization rates leads the Health Affairs Blog most-read list for March. Also on the top-ten list are articles on: the human face of hospital readmissions by Risa Lavizzo-Mourey; the impact of the Affordable Care Act by Kathleen Sebelius; the health care workforce by Thomas Daschle; and physician payment reform by Bill Frist and Steven Schroeder.

The most-read list also includes David Muhlestein’s survey of the accountable care organization landscape; Diane Archer’s discussion of the effects of concentration in the health care market, and Jesse Singer’s look at the use of electronic health records by the New York City Primary Care Information Project. Also among the top ten are Tim Jost’s article about the role of federally facilitated and partnership exchanges; and an article by Sara Rosenbaum and Joel Teitelbaum on the impact of the Essential Health Benefits rule on persons with disabilities.

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A Lost Opportunity For Persons With Disabilities? The Final Essential Health Benefits Rule


March 11th, 2013

Among its myriad elements, the Affordable Care Act contains a breakthrough provision that, if implemented, could dramatically alter the way that health insurance coverage works for persons with disabilities. [PPACA § 1302(b)(4)(B)] This provision applicable to health insurance products sold in the individual and small group markets and therefore subject to the essential health benefits (EHB) coverage standard, requires the Secretary of Health and Human Services to bar the use of insurance coverage rules that discriminate on the basis of disability. See

However, final EHB rules issued on February 20th, 2013 effectively leave this ban unimplemented. A draft CMS document made available to the public on February 21 by Inside Health Policy suggests that the agency will monitor qualified health plans (QHPs) for potential discrimination. But the monitoring process suggested in the draft excludes any mechanism for detecting one of the most potent forms of plan discrimination, the use of benefit designs and coverage determination procedures that cause the denial of coverage for children and adults whose disabilities prevent them from “recovering” from their disability. Whether the ACA protections are left unimplemented remains to be seen.

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Health Policy Brief: Coordination Of Care For Dual Eligibles


June 14th, 2012

A new Health Policy Brief from Health Affairs and the Robert Wood Johnson Foundation examines efforts to better manage and coordinate care of more than nine million Americans covered by both Medicare and Medicaid, also known as dual eligibles. This heterogeneous group includes the sickest and most vulnerable adults, many with complex chronic medical or […]

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New Health Affairs Focuses On Americans Covered By Both Medicare And Medicaid


June 5th, 2012

Research and analysis in the newly released June 2012 issue of Health Affairs, supported by a grant from The SCAN Foundation, emphasizes the need to develop new ways of paying for and providing care for the roughly 9 million Americans who are eligible for both Medicare and Medicaid benefits because of age, income, and/or disability. […]

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Health Affairs Briefing: The Care Span For The Elderly And Disabled


May 24th, 2012

On Tuesday, June 5, Health Affairs will hold a briefing to discuss its June 2012 issue, “Focus On The Care Span For The Elderly And Disabled.” The volume explores a wide range of topics — from avoidable hospital admissions and readmissions, to coordination of care for dual eligibles, to reforming Medicare payment for skilled nursing […]

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Medicare Spending Issues Are A Focus Of New Health Affairs Issue


May 7th, 2012

To calculate physicians’ fees under Medicare—which in turn influence private payers’ decisions on how they will pay doctors—the Centers for Medicare and Medicaid Services (CMS) relies on the recommendations of a controversial advisory panel known as the RUC (the Relative Value Update Committee), which mainly represents a broad group of national physicians’ organizations. In recent […]

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Federal Support For Working-Age People With Disabilities: We Can Do Better


October 6th, 2011

The federal government is spending a lot to support working-age people with disabilities. Federal outlays in fiscal year 2008 for this population totaled $357 billion – representing 12 percent of all federal spending.  By way of comparison, the federal government spent $616 billion for national defense in the same year. States spent another $71 billion on federal-state […]

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