Health Affairs

Tens of millions of uninsured people will soon have the ability to gain health coverage as the first enrollment period under the Affordable Care Act (ACA) begins on October 1, 2013, with actual coverage starting in January 2014. New marketplaces will be established for the purchase of private insurance, pre-existing coverage exclusions and discriminatory premiums will end, and comprehensive benefits will be included in health plans.

Most significantly for the vast majority of uninsured Americans, the ACA offers unprecedented financial assistance (in the form of a tax credit) to make private health plan premiums more affordable and, in many states, expanded Medicaid coverage.

The ACA represents a truly historic series of improvements – a legislative triumph that eluded many presidents before Barack Obama. As noteworthy as this achievement is, however, substantial coverage expansion will only occur if uninsured families learn about these new opportunities and actually get enrolled in private or public health coverage.

Enroll America was formed in 2011 with that goal of educating consumers about the new law and helping them to enroll in the plan that is right for them. There remains an enormous amount of work to do and challenges to overcome to make sure the ACA lives up to its potential.

Yesterday, Senator Orrin Hatch (R-Utah) and Representative Fred Upton (R-Mich.) released their plan for “Making Medicaid Work.” One of the blueprint’s key proposals is to implement per capita caps, which would impose a cap on the funds that the federal government contributes to states for each Medicaid beneficiary. In April Health Affairs released a Health Policy Brief that explains how a per capita cap would work and looks at the arguments for and against the approach:

Supporters contend that instituting a system of per capita caps would moderate the growth of federal spending on Medicaid. They describe the approach as a middle ground between the program as it currently operates and other proposals such as block grants, which would more dramatically change the way federal Medicaid funding is calculated.

Critics contend that a per capita cap approach would not necessarily slow the rate of growth of Medicaid spending. If it did, they say, it would do so by shifting the costs to the states, which would face even greater pressures to cut services or limit eligibility, ultimately limiting many poor Americans’ access to care. What’s more, they contend that setting up a system of per capita caps would be very complex and difficult to administer.

Does the United States have at its disposal a method for predictably controlling the cost and improving the quality of our health care? Can we begin by budgeting or Indexing Health Care expenditures in the Medicare HMO program now called Medicare Advantage (MA) to grow at the same rate or more slowly than the gross domestic product (GPD)?

The Indexed Health Care proposal that I outline below builds on the success of MA, but it also calls for important reforms in that program. After indexing MA costs to GDP growth, the next steps should be to progressively convert Medicare from fee-for-service to prepaid capitated payments, and to index Medicare and all federal health care expenditures – including tax expenditures – to GDP growth. The private health care sector must be persuaded to move from FFS to capitated payments.

As the debate over federal budget allocations and cuts continues, the National Institutes of Health (NIH), a leading funder for both domestic and global health research, could experience a whopping $1 billion budget cut. To date, modest investments in global health have helped create platforms for discovery science, such as large multiethnic studies of genetics and epigenetics; transformative programs, such as the President’s Emergency Plan for AIDS Relief; and life-altering interventions, such as oral rehydration salts, now widely used in the management of dehydration caused by diarrhea. Not only would large cuts to the NIH slow our progress in improving health worldwide, but they would also be out of step with the burgeoning interest in global health at universities across the United States.

In his post “Why don’t Republicans Have a Vision for Health Reform” (April 2, 2013) John Goodman offers interesting comments on my earlier post “Reflections on The Federal Budget Resolutions” (March 21, 2013). I thank him for the comments.

My post was focused strictly on the vision for U.S. health care that Democrats and Republicans on Capitol Hill now project through the Senate budget resolution and the House budget resolution. Goodman, on the other hand, builds from my post a bridge to the vision some Republicans – including Goodman himself – have in the past projected for U.S. health care.

I can understand why Goodman used the well-known technique of the bridge, because he believes that Republicans currently do not have vision for health care. On this point, however, I beg to differ. There actually is a current Republican vision. It has been expressed through the House budget resolution.

On April 3, 2013, the Department of Health and Human Services released proposed regulations establishing standards to govern navigators and non-navigator assisters in the federally facilitated exchange as well as clarifying standards on the role of navigators and on who can serve as a navigator in all exchanges.

You are invited to join us on Wednesday, April 11, when Health Affairs will hold a briefing to discuss its April 2013 issue, “Triple Aim Goes Global.”

The April issue examines how all high-income countries are struggling to pursue better health, better care, and lower cost – and to bring all of these goals into alignment. The issue received funding support from The Commonwealth Fund, the Nuffield Trust, and Imperial College London.

The briefing will take place at the Barbara Jordan Conference Center at the Kaiser Family Foundation, 1330 G Street, NW, in Washington, DC, on Thursday, April 11, 2013, 8:00 a.m. – 12:30 p.m.

On Good Friday, March 29, 2013, the Department of Health and Human Services released a final rule regarding increased federal Medicaid percentage changes under the Affordable Care Act for covering adults who are newly eligible under the ACA’s Medicaid expansions. HHS published the original proposed rule on this topic in August of 2011 as part of a larger rule on the ACA’s Medicaid changes. Other parts of this rule dealing with Medicaid eligibility were finalized in March of 2012, but the parts of the proposed rule dealing with federal financial assistance were not included at that time. Because the final rule contains significantly more detail than the proposed rule, HHS is publishing the rule as final, but soliciting further comment on parts of the rule. HHS also released on March 29, 2013, a series of Frequently Asked Questions, explaining its approach to the expansion of Medicaid through the use of Medicaid funds to purchase private insurance for Medicaid recipients in the exchange, the approach that Arkansas and possibly other states are proposing. This FAQ is discussed at the end of this post.

For those who like to look for silver linings, there are at least two events in the past few weeks that could provide a glimmer of hope. First, both the Budget Committee in the Republican controlled House has passed a budget and, for the first time in four years, the budget committee in the Democratic controlled Senate has also passed a budget. Both the House and the Senate have passed their budgets. The Senate’s budget passed by a slim 50 to 49 vote margin. And for a short time, there had been some uncertainty whether the House would approve its budget because it doesn’t eliminate the deficit fast enough for some House conservatives – some indication of the pressure the right is putting on the leadership.

The second glimmer of hope is that the President has been reaching out to Congressional Republicans in a way that he had not done during his first term–taking a group of Senate Republicans to dinner and meeting with the House Republican leadership on their home turf. However, as Mitch McConnell (R KY) was quick to point out, meeting with Republicans is far different than finding common ground or strategies for compromise.

To no great surprise, the budget documents themselves suggest two very different and divergent views of the country’s future–differences that will make finding a compromise a serious challenge.

According to a process laid out in the Budget Act of 1974, the budget resolutions put forth by the House of Representatives and the Senate emerge as modifications, sometimes substantial, of the budget to be submitted by the first Monday in February by the President of the United States.

Alas, for governance, the President has missed that deadline for fiscal 2014 (starting in October 1, 2013). He is likely to submit a budget only by early April – two months late. In the meantime, both chambers have worked up their own budget resolutions, without the President’s budget as a starting point. It shows, because the tax- and spending numbers in these two budgets, and the visions for America they reflect, differ so starkly that it is hard to imagine the emergence of a joint conference report reconciling the two budgets in one that could pass both chambers.

But all is not lost. At least the American people now have before them the visions the two parties have for our country, especially in regard to health policy.

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.

Americans remain deeply divided over health care. Liberals emphasize the goal of comprehensive, lifelong health insurance for every citizen. Conservatives emphasize the goal of a more competitive free market in health care, without government getting between doctors and their patients. Everyone shares the goal of reducing the runaway costs of health care in the United States, which are the highest in the world.

Many doubt whether the Affordable Care Act, aka ObamaCare, can achieve any of these goals adequately. One widely held goal it clearly cannot achieve is to improve the global competiveness of American companies by removing, from employers, the costly burden of providing health insurance for employees. What shall be argued here is that national health insurance achieves every one of these goals, but only in a form much like that outlined below, incorporating ten features.

In health care quality improvement circles, the story of England’s East Lancashire has taken on almost mythical status: working with county and borough councils, local hospital organizations, and medical leaders in primary and secondary care, an executive of the National Health System (NHS) managed to close a substantial number of hospital beds — all the... Read the rest of this entry »

Great struggles sometimes result in unexpected opportunities. In the waning moments of 2012, Congress remained in session to bridge partisan divides to solve the fiscal cliff impasse with the passage of the American Taxpayer Relief Act (ATRA). Signing the ATRA into law also achieved policy change on items far beyond the tax code.

For example, the new law repealed the Community Living Assistance Services and Support (CLASS) provision in the Affordable Care Act, which would have created a new, national, voluntary, long-term care insurance product. Yet the problem of how to best finance and deliver care for our vulnerable loved ones has been looming for years and endures. As a much-needed acknowledgment of this, the Congress created a new Commission to propose policy solutions to address the long-term care challenges that a growing number of Americans face.

Given the sheer magnitude of this issue, the current political climate, and the short time span for turning around a meaningful legislative proposal (six months), the Commission’s charge is nothing short of colossal. However, its creation in the wake of the CLASS repeal is an important step towards system transformation that will enable Americans to age with dignity, independence, and choice. The Commission will consist of 15 appointees, nine Democrats and six Republicans, to be named in the next month, who will report back to Congress by the summer. They must devise a plan on the financing and delivery of a comprehensive and coordinated system that ensures available long-term services and supports for people in need today, and options for Americans to plan for their future needs.

Will pay for performance in health care backfire? That was the question addressed through the lens of behavioral economics by Steffie Woolhandler, Dan Ariely, and David Himmelstein in the most-read Health Affairs Blog post for 2012. Next on the most-read list were two posts, one by Diane Archer and the other by Archer and Theodore Marmor, contrasting Medicare and private insurance. They were followed by Rushika Fernandopulle’s rethink of primary care and Ken Kaufman’s post suggesting that the recent slowing in health care cost growth reflects more than just temporary effects from the economic slowdown.

Many thanks to our readers and authors for making 2012 a good year for Health Affairs Blog. We had 369 posts and over 50 million pageviews, more than a 60 percent increase from 2011. Since we had many good posts that were closely grouped in the readership numbers, we’ve expanded this year’s most-read list to a “top 15″ rather than a “top 10.” The full 2012 list is below.

Americans tend to blame rising health care costs on various “bad actors” — insurance companies, drugmakers, and others who overcharge their customers. But two polls conducted earlier this year suggest that, if views about health care costs in Massachusetts predict trends in national public opinion, policymakers may find the public increasingly receptive to using price transparency to control health care costs.

Price transparency is increasingly being discussed as an important mechanism to reduce health care costs. The recent Massachusetts cost containment bill had a number of provisions related to transparency, and there have recently been calls for national cost containment measures which would also address price transparency issues.

Massachusetts has long been an outlier in the area of health policy, as the state most notably enacted comprehensive health reform in 2006, and recently passed an ambitious package of cost containment measures. The residents of Massachusetts have had a unique experience with health reform, which has included an expanded role of government in the health care sector as well as a greater level of public discourse about cost containment.

Although Massachusetts differs from the rest of the nation in many ways, these experiences may have shaped public opinion about health costs. (See Oakman TS, Blendon R, & Buhr T, “The Massachusetts health reform law: A case study”, in Blendon R, Brodie M, Benson JM, Altman DE, eds., American Public Opinion and Health Care, Washington DC: CQ Press, 2011, p.128.) Massachusetts residents may well be more knowledgeable about health costs as compared with the rest of the country. To the extent to which Massachusetts is a national leader in the area of health policy, public opinion and party positions in the state may anticipate those of the nation as a whole.

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.

Tim Jost’s look at the 2012 election and the implementation of the Affordable Care Act in its aftermath tops the list of most-read Health Affairs Blog posts for November. Jost’s piece is joined on the list by election-related posts by Chas Roades, James Morone, and Jim Capretta.

Second on November’s top-ten list is a look at pay-for-performance through the lens of behavioral economics, by Steffie Woolhandler, Dan Ariely, and David Himmelstein. Other posts on the list discuss regulations issued under the Affordable Care Act; a new effort to promote outcomes measurement around the world; the VA Health System’s new “mega-database” for genomic medicine; and challenges for safety-net institutions in delivering accountable care.

The full list appears below.

Republicans were handed a convincing defeat at the polls, not only losing the race for the presidency but also losing ground in the Senate. The good news for the country is that Republican leadership is not in denial. The day after the election, Speaker of the House John Boehner outlined a balanced approach for easing federal policy off the fiscal cliff. He offered a combination of revenue increases and spending cuts, with an emphasis on “real changes to the structure of entitlement programs.”

Two days later, President Barack Obama responded by offering his own balanced approach—more federal spending, lower taxes for everyone but the wealthy, and the certainty of much higher budget deficits for years to come unless the savings proposed by the president last February actually materialize. This draws the line where it was before the election, with no sign that this will lead to meaningful policy negotiations.

This seeming recalcitrance is likely the result of the irrational exuberance that often strikes newly elected officials. To paraphrase Alan Greenspan, irrational exuberance has unduly escalated the president’s political asset value. Contrary to his current stance, President Obama does not have a strong hand in the upcoming fiscal debate. If he wants to avoid a double-dip recession and leave a positive legacy, he will have to accept compromises and sell them to his Democratic colleagues in the Senate. That inevitably means health policy, including the Affordable Care Act (ACA), will be on the negotiating table.