Health Affairs

In the May Health Affairs Narrative Matters essay, two graduate students describe their fight with the bureaucracy to gain coverage for their son under the Children’s Health Insurance Program, and they express the hope that provisions of the Affordable Care Act will cut the red tape. The article, “To Cover Their Child, One Couple Navigates A Health Insurance Maze In Pennsylvania, is by Ari Friedman, a fifth-year medical-doctoral student in health economics at the University of Pennsylvania’s Perelman School of Medicine and Wharton School, and Tara Mendola is a sixth-year graduate student in comparative literature at New York University.

“Medical home” has become a term of art within the current wave of health reform. It’s in the medical literature, on the internet and embedded in the Patient Protection and Affordable Care Act of 2010.

There is much debate over what “medical home” means and whether or not it works. The Patient Centered Primary Care Collaborative published an overwhelmingly positive compilation of evidence last year supporting the concept. At almost the same time, the Agency for Healthcare Research and Quality released a review of the literature that was much less positive, suggesting that the impact of practice transformation to the medical home is much less certain. So, in the end, what are we to believe when the messages are so mixed?

Given how the concept has evolved over time, it is not surprising that we are confused. Historically, the term “Medical Home” comes from the American Academy of Pediatrics, which, in 1967, coined the term to describe a repository of records that would offset the dispersal of records between pediatric offices, health departments and hospitals. Over the next 30 years, the concept developed into one of relationship between children, families and pediatricians. Pediatric medical homes were primary care pediatric practices, partnering with families to serve children and youth with special health care needs, and emphasizing the need for care coordination within the many systems that serve the needs of children.

April 2013 has been a quiet month for new Affordable Care Act rules and guidance. Activity to implement the ACA, of course, is moving full speed ahead at the federal level as efforts continue to implement the federal exchange and to gear up for federal enforcement of the market reforms in a number of states. The Centers for Medicare and Medicaid Services (CMS) is in the process of holding stakeholder calls in every state where a federal exchange (now called a “marketplace”) will be established. It is also locating navigator programs, signing up insurers, and preparing for the October 1, 2013 beginning of open enrollment. The states have also been very active, either trying to implement their own state exchanges and the 2014 ACA market reforms or doing everything they can dream up to keep implementation from moving ahead.

Final rules have been issued governing the exchanges, the 2014 market reforms, the premium tax credits, and the premium stabilization programs, while guidance has been issued on the federal exchanges and the navigator program. Final rules on Medicaid eligibility and appeals are expected shortly. A public hearing was held on April 23, 2013 regarding the proposed employer responsibility regulations, while another will be held on May 29, 2013 reviewing proposed individual responsibility regulations. Final rules will follow in due course. In sum, implementation is progressing, although a lot of ground must be covered between now and 2014.

A frequent statement of mine is, “We need public health leadership that cares enough, knows enough, is willing to do enough, and will be persistent.” Surgeon General C. Everett Koop was just such a leader, for he was caring; he was competent; he was courageous; and he was passionately persistent.

Before he was a Surgeon General, he was a pediatric surgeon. This was before the field was well-established. But he cared about children and their health. He gave conjoined twins the chance to live independent lives by performing surgery to separate them before the art was well developed. He cared about the education of medical students and residents, and spent time educating and counseling them. His former students still tell stories of their interactions with him.

The Office of the Surgeon General is not political. The American people look to the Surgeon General for reliable information based on the best available public health science, not politics, religion, or personal opinion. A combination of presidential nomination, Senate confirmation, and science-based expertise all have resulted in the Surgeon General maintaining, in the minds of the American people, a place of authority. As Surgeon General, Koop spoke and wrote with authority.

In 2004, Health Affairs’ Fitzhugh Mullan interviewed C. Everett Koop, who passed away on Monday. The full interview is freely available to all readers, as is a 1998 Health Affairs article coauthored by Dr. Koop evaluating health education programs designed to reduce health risks and costs. Health Affairs Blog will carry more about Dr. Koop’s life and work in the coming days.

Koop is probably best-known for his pioneering work as Surgeon General under President Ronald Reagan, but his interview with Mullan begins with a discussion of children’s health, reflecting Koop’s role in helping to found the discipline of pediatric surgery. Koop sounds a warning about the nation’s treatment of its children. “We always talk about children being our future,” he notes,

but I’m afraid we don’t always deliver … the older I get, the more I understand the relationship of poverty in a child and poor outcomes in everything else. I’m not beating a socialist kind of drum here. I think as we look to the future, unless we take into account what a severe role poverty plays in the lives of many children, we will never be able to achieve good child health in the United States.

Since children can’t vote or lobby as seniors do, “In the long run, child health is about advocacy,” says Koop, who also highlights the challenge of pediatric obesity.

States are in the midst of deciding whether and how to expand their Medicaid programs to nonelderly individuals with income below 133 percent of Federal Poverty Level (FPL), as permitted under the Affordable Care Act (ACA). The group that perhaps stands to benefit the most from Medicaid expansion is women of childbearing age and their future children.

One of the ACA’s main goals was to address the upstream determinants of health, shifting the focus of the health care system “sick care” to “well care.” However, the promise of preventive care will not be realized if women of childbearing age are denied access to health insurance coverage. Medicaid expansion has the potential to drive meaningful improvements in maternal and child health by promoting health at every stage of life, including before and between pregnancies.

Today, Medicaid coverage is unavailable in most states to childless women who are not pregnant.

As a result, low-income women may have little or no source of regular health care before or between pregnancies, or after their childbearing is concluded. These women often lack a medical home and go without both regular preventive care and acute care for illness or injury. This lack of preconception and interconception care can have a significant impact on women’s health, and on the health of future pregnancies and children. The ACA has the potential to transform this dynamic.

There is a health crisis in this country (as well as worldwide) that adversely affects one-fifth of the US population. Consequences of this crisis manifest in a wide variety of serious disease conditions. Physically it can exhibit as cancer and/or as any number of equally severe mental illnesses. Socially the disease is, in a word, criminality. Costs are estimated at over $100 billion per year, or similar to the annual expense of the war in Afghanistan. Investment in its prevention is estimated at a nickel on every $100 in research, compared to $2 for cancer. (See Note 1)

Despite considerable attention drawn to this issue this past year — the Surgeon General termed it an “epidemic” well over a decade ago — the crisis was not discussed during the presidential campaign. It remains largely ignored by the Congress (though just prior to adjourning sine die an innocuous bill to evaluate child welfare systems was passed), was unaddressed by the Affordable Care Act, and has been ignored as well to date by the Center for Medicare and Medicaid Innovation. “The leading journal of health policy thought and research,” Health Affairs, has never published on the topic.

The health crisis is child sexual abuse, which adversely affects the health status of 50 million survivors.

Editor’s note: This post discusses the second half of a January 14 proposed rule addressing Medicaid and premium tax credit eligibility and appeals, as well as other subjects, under the Affordable Care Act. The first half of the rule was analyzed in a post yesterday.

CHIP And Medicaid Coordination With The Exchanges For 2013

Open enrollment will begin in the exchanges on October 1, 2013, for coverage beginning January 1, 2014. To ensure seamless streamlined eligibility, state Medicaid and CHIP agencies must also be ready to accept Medicaid and CHIP applications and electronic accounts from the exchanges as of that date. They must also begin accepting Medicaid determinations made by the exchange as of that date, to be effective on January 1, 2014, or be capable of making their own determinations based on information received from the exchanges by that date.

Medicaid agencies must be capable of making MAGI-based determinations by October 1, whether or not they expand adult Medicaid coverage. (MAGI stands for “modified adjusted gross income.”) State Medicaid agencies must also begin transferring to the exchange electronic accounts of applicants who are not eligible for Medicaid but may be for premium tax credits as of October 1, 2013. States are encouraged, but not required, to determine 2013 eligibility based on the single streamlined application submitted after October 1, 2013. HHS is still considering to what extent states will have to implement 2014 changes for the 2013 open enrollment period, and may consider 1115 waiver requests to allow states to apply MAGI-based standards beginning on October 1, 2013.

Editor’s note: This post discusses the first half of a January 14 proposed rule addressing Medicaid and premium tax credit eligibility and appeals, as well as other subjects, under the Affordable Care Act. A second post discussing the rest of the rule is forthcoming.

A very long notice of proposed rulemaking (NPRM) issued on January 14, 2012, by the Centers for Medicare and Medicaid Services of the Department of Health and Human Services suggests that we may be nearing the end of a very active post-election rulemaking season, preparing the way for implementation of the 2014 reforms. HHS must still, of course, finalize the rules it has already proposed, presaging a very active February and March. We can also still expect further important rules from Treasury, which must promulgate rules on the individual responsibility (mandate) requirement and the prohibition against employer discrimination in favor of highly-compensated employees in the offer of insurance.

Also, we are likely to see a continuing stream of guidance and of forms and surveys released as paperwork reduction act notices (three of which were issued January 11). But the January 14 NPRM seems like an effort to tie up a lot of disparate loose ends as the final push begins towards 2014.

The proposed rule, which was issued together with a fact sheet, addresses a number of issues presented by the 2014 transition in the Medicaid, CHIP, and exchange premium tax credit programs. One major concern of the NPRM is the coordination of Medicaid and premium tax credit eligibility determinations and appeals. The original dream of a seamless, streamlined, no-wrong-door Medicaid, CHIP, advance premium tax credit, and cost-sharing reduction payment application and eligibility determination process has become a much more difficult reach with the Supreme Court’s still shocking interpretation of the Constitution’s spending clause, permitting the states to decline participation in the Medicaid expansion, and with a majority of the states declining the invitation to operate a state-based exchange as the bitter political division that has attended the implementation of the ACA shows no signs of abating. The proposed rule attempts to make sense of this mess, recognizing that full coordination of eligibility determination and appeal processes may take awhile.

On December 28, 2012, one of the last major regulatory building blocks of the Affordable Care began to fall into place. The Internal Revenue Service of the Department of Treasury issued a notice of proposed rulemaking (NPRM) addressing “Shared Responsibility for Employers Regarding Health Coverage” — the employer mandate. The IRS also released a series of questions and answers, explaining the provisions of the proposed rule in simplified form.

This post analyzes the provisions of the employer mandate NPRM. It will be supplemented shortly by a brief analysis of a guidance released by the Center on Medicare and Medicaid Services on December 28, instructing the states on how to convert their current Medicaid and CHIP net income eligibility thresholds into the modified adjusted gross income (MAGI) standards that will be used for determining eligibility for Medicaid, CHIP, and premium tax credits beginning in 2014.

The IRS NPRM addresses a modest number of seemingly simple but surprisingly complex questions. When does an employer have fifty employees, and thus become a “large employer” subject to the ACA employer mandate? When is an employee a “full time” employee, for whom a large employer must either provide “affordable” and “adequate” coverage or pay a penalty if the employee receives premium tax credits or cost-sharing reduction payments through the exchange? Who are the “dependents” of an employee for whom an employer must also provide coverage? How will the penalties be assessed? How will the now surprisingly short transition to 2014 be handled?

The horrific massacre of 27 children and adults in Newtown, Connecticut ranks second only to Virginia Tech among U.S. mass shootings. These tragedies are part of a lengthening list of mass killings in such varied places as a shopping mall, a movie theater, a Sikh Temple, a high school, a congressional constituent meeting, and a military base. But this one was different. Not only were the death toll particularly high and the killings particularly savage; the killer’s victims were first-grade students, teachers and school staff.

Millions are deeply touched by this tragedy, but few of us can fathom the shock and grief felt by the survivors, parents, family members and friends of those who died. Our first concern must be to comfort them and support what will likely be a long and difficult recovery. But few people are prepared to stop with that. This event, unlike its predecessors, has sparked a movement to challenge the inevitability of mass shootings, not to mention the thousands of individual gun homicides that occur each year in the United States.

In response, President Obama has signaled his intention to submit legislation to the Congress by end of January. To prepare for this action, he is convening an Administrative task force, led by Vice President Biden, to craft a package of proposals. What this panel recommends, and how the public reacts over the next few weeks, could be decisive in determining what will come from this terrible tragedy.

“Because early identification is a key to every prevention activity, every child in America should be screened for mental illness as a part of well-child examinations,” former Connecticut state legislator Paul Gionfriddo writes in “What Funders Can Do in the Aftermath of the Tragedy in Sandy Hook, Connecticut.” Gionfriddo’s post was published yesterday on GrantWatch Blog, the sister site of Health Affairs Blog.

Gionfriddo also stresses that most violence is committed by those who are not mentally ill, and is often directed at those who are. “Now more than ever, we need anti-stigma campaigns to disassociate mental illness from violence in the minds of so many people,” he states.

Note: This blog summarizes key findings from a report by the National Academy of Social Insurance (NASI) Study Panel on Health Insurance Exchanges and the Center for Health Policy and Research at the University of Massachusetts Medical School. The report draws some key lessons from the experiences of the states most advanced in their implementation... Read the rest of this entry »

Editor’s note: The themes discussed in this post are among those discussed in the new book “Unaccountable,” by Dr. Marty Makary.  A video trailer about the book is available here.  In addition to Dr. Makary (photo and linked bio above), this blog post is coauthored by Andrew Ibrahim, MD, Case Western Reserve School of Medicine,... Read the rest of this entry »

On Day Three of arguments about the constitutionality of the Affordable Care Act, the Supreme Court turned its attention to the question of severability. Should the Court find that the ACA’s minimum coverage requirement is indeed a proper exercise of Congress’s right to regulate interstate commerce, today’s arguments were all for naught. However, if the... Read the rest of this entry »

Wisconsin Republican Paul Ryan is frequently hailed for his fiscal responsibility and political courage.   After all, the Congressman has now put forward not one but two budget plans that offer “a blueprint for safeguarding America from the perils of debt, doubt and decline” and take on sensitive issues like Medicare.   Ryan seems to have emerged... Read the rest of this entry »

On March 16, 2012, the Department of Health and Human Services published a final rule regarding student health plans, an advanced notice of proposed rulemaking explaining how it intends to handle coverage of contraception services, and a notice regarding the early retiree reinsurance program.  This blog post addresses these issuances.  Separate blog posts will address... Read the rest of this entry »

Editor’s Note: The January 2012 issue of Health Affairs is a thematic volume titled “Confronting The Growing Diabetes Crisis.” Ariella was a different child, thin and shy, when I first met her about a year and a half ago, just after her 6th birthday. Her mother had noted her thirst and hunger, and, despite this... Read the rest of this entry »

“A child is not a small adult,” but an adolescent is not a large child.  Adult oncologists, reluctant to care for cancer patients under the age of 16, believe that adolescent and young adult (AYA) cancer patients should be within their purview.  We believe younger cancer patients are a special group needing special attention, even... Read the rest of this entry »

Having diabetes can carry  many health consequences, but a new study in the January issue of Health Affairs shows that it also highly influences a young person’s ability to complete high school, be employed, and earn a living wage.  High school dropout rates among young people with diabetes are six percentage points higher than for... Read the rest of this entry »