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Transcending Obamacare? Analyzing Avik Roy’s ACA Replacement Plan


September 2nd, 2014

Avik Roy’s proposal, “Transcending Obamacare,” is the latest and most thoroughly developed conservative alternative for reforming the American health care system in the wake of the Affordable Care Act. It is a serious proposal, and it deserves to be taken seriously.

Roy’s proposal is a curious combination of conservative nostrums (limiting recoveries for victims of malpractice), progressive goals (eliminating health status underwriting, providing subsidies for low-income Americans), and common sense proposals (enacting a uniform annual deductible for Medicare).

Most importantly, however, Roy proposes that conservatives move on from a single-minded focus on repealing the ACA toward building upon the ACA to accomplish their policy goals. He supports repealing certain features of the ACA—including the individual and employer mandate—but would retain others, such as community rating and exchanges. As polling repeatedly shows that many Americans are not happy with the ACA, but that a strong majority would rather amend than repeal it, and as it is very possible that we will have a Congress next year less supportive of the ACA than the current one, Roy’s proposal is important.

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A Health Reform Framework: Breaking Out Of The Medicaid Model


July 10th, 2014

Editor’s note: This post is coauthored by Joseph Antos and James Capretta.

A primary aim of the Patient Protection and Affordable Care Act (ACA) is to expand insurance coverage, especially among households with lower incomes. The Congressional Budget Office (CBO) projects that about one-third of the additional insurance coverage expected to occur because of the law will come from expansion of the existing, unreformed Medicaid program. The rest of the coverage expansion will come from enrolling millions of people into subsidized insurance offerings on the ACA exchanges — offerings that have strong similarities to Medicaid insurance.

Unfortunately, ample evidence demonstrates that this kind of insurance model leaves the poor and lower-income households with inadequate access to health care. The networks of physicians and hospitals willing to serve large numbers of Medicaid patients have been very constrained for many years, meaning access problems will only worsen when more people enroll and begin using the same overburdened networks of clinics and physician practices.

It does not have to be this way. It is possible to expand insurance coverage for the poor and lower-income households without reliance on the flawed Medicaid insurance model. Opponents of the ACA should embrace plans to replace the current law with reforms that would give the poor real choices among a variety of competing insurance offerings, including the same insurance plans that middle-class families enroll in today. Specifically, we propose a three-part plan that includes a flexible, uniform tax credit for all those who lack employer-based coverage; deregulation of Medicaid; and improved safety-net primary and preventive care.

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Repeal, And Replace, The Employer Mandate


June 4th, 2014

As it enters its fifth year, the Affordable Care Act has chalked up an impressive list of accomplishments. More than 8 million Americans have chosen a health plan through the ACA exchanges. At least another five million have likely enrolled in Medicaid. The minimum medical loss ratio requirement has saved privately insured Americans billions of dollars, while the closing of the doughnut hole has saved Medicare beneficiaries billions more. The percentage of Americans who are uninsured is dropping precipitously and is already at the lowest level it has been for years.

Recent polling, however, seems to show that Americans are not yet impressed — a majority still oppose the Affordable Care Act. Significantly, however, polling also consistently shows that Americans are not giving up on the law–a substantial majority of Americans are against repealing the ACA and would rather that problems with the ACA be fixed. Support for amending the law should create an opening for lawmakers who can identify real problems with the ACA and propose practical solutions.

One provision of the ACA that cries out for repair is the employer mandate. The Urban Institute has recently raised the question, “Why Not Just Eliminate the Employer Mandate?Conservative advocacy groups have called for its repeal for some time. Repeal of the employer mandate might, in fact, not be such a bad idea, as long as the current mandate was replaced with a better alternative.

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Patients’ Views On Reforming The Physician Fee-For-Service Payment System


February 28th, 2014

Virtually all serious proposals for health care cost containment include reforming the fee-for-service payment system.  Last fall’s bipartisan proposal to fix Medicare’s sustainable growth rate included provisions to reward physicians for providing high-value rather than high-volume care.  Ostensibly, realigning physicians’ financial incentives would lead to higher quality, better coordinated, and more appropriate care.

But would patients necessarily be aware that their physicians are being paid differently? And would they even care? A new research report from Public Agenda and the Kettering Foundation suggests that consumers could play a role in advancing payment reform.  But in order to work through the trade-offs of changing the system, employers and payers must help members of the public understand that most reimbursement is currently fee-for-service.

Public Agenda asked a total of 44 insured and uninsured Americans, 40 to 64 years old, to deliberate together in focus groups over the pros and cons of several approaches to cost containment. Participants had some recent contact with the health care system as patients but none were seriously ill. They considered payment reform, price transparency, increased consumer cost-sharing, government price-setting, and expanded access to Medicare, among other approaches.  We held the deliberative focus groups in February and March 2013 in Secaucus, New Jersey; Montgomery, Alabama; and Cincinnati, Ohio, as well as a pilot in Stamford, Connecticut. After the groups, we followed up with participants for in-depth interviews. These focus groups do not provide information about how other types of consumers, particularly young people, view different approaches to addressing health care costs.

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Open Payments: A Matter Of Maintaining Trust


February 27th, 2014

For decades, it’s been no secret that some physicians have financial relationships with health care manufacturing companies. For example, a pharmaceutical firm might fund a cardiologist at an academic medical center to research an experimental medication for lowering cholesterol. Or, an orthopedic surgeon might receive a consulting fee from a medical device manufacturer for counsel about an artificial hip.

These widespread collaborations can involve gifts, meals, speaking fees, travel support, or payment for research activities. The good news is that these joint efforts have led to the discovery, design, and development of landmark drugs and life-saving devices, as well as numerous other major therapeutic inventions and innovations.

However, these commonplace transactions between physicians and the makers of drugs, devices, biological and medical supplies, or group purchasing organizations (GPOs) also cause considerable controversy. That’s because such payments from manufacturers to providers sometimes introduce conflicts of interest. Improper influence over research, education, and clinical decision-making can be exerted. Clinical integrity and patient care can be compromised. More explicitly, a physician may tout one drug over another during a continuing education session, primarily because he happens to be receiving a grant from its manufacturer.

Among consumers’ most serious concerns is that such financial relationships have always occurred privately, known only to the parties directly involved while the public remained in the dark.

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Health Care Reform: Views From The Hospital Executive Suite


December 18th, 2013

Pessimism pervades the national dialogue surrounding healthcare reform. Despite fixes to the federal exchange website and marked improvements in enrollment, politicians and pundits continue to assail the Affordable Care Act (ACA), offering grim predictions about the future of healthcare after its implementation. The law, they claim, is an unworkable train-wreck. It will produce a healthcare system with significantly higher costs, lower quality, and bureaucratic confusion.

The public has seemed equally pessimistic. Fifty-four percent of Americans, according to a recent poll, believe the ACA will have a negative impact on the healthcare system, compared to only 24 percent who anticipate a positive impact. Nearly three-quarters expect the quality of healthcare to decline or stay the same, while only 11 percent expect it to improve. More than half expect costs to rise while only 9 percent expect them to fall.

Such pessimism, however, is hardly a credible predictor of the success or failure of the ACA. Politicians, pundits, and the public are largely removed from the inner workings of the healthcare system, so it is difficult for them to form an accurate, 360-degree view of reform. Moreover, most Americans (70 percent) readily admit they know little about the ACA or its potential impact.

A more meaningful source for an appraisal of healthcare reform, and for predictions about how it will fair, would be individuals who are especially informed—people who have spent their entire careers on the front lines of the healthcare system deciding how budgets are managed and how care is delivered—people like the leaders of America’s hospitals and health systems. Healthcare reform is catalyzing major changes for these executives and their institutions. Wouldn’t it be helpful to know if they share the public’s apprehension and pessimism?

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Eleven-Country Survey Finds US Insurance Most Complex


November 18th, 2013

According to a November 13 Health Affairs Web First survey of eleven different countries’ health care, US adults are significantly more likely than their counterparts in other countries to forgo care because of cost, to have difficulty paying for care even when insured, and to encounter time-consuming insurance complexity. Cathy Schoen and colleagues at The […]

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An ACA Navigator Massive Open Online Course: Using The Emerging U.S. Health Care System


August 30th, 2013

Many observers claim that we do not have a true “healthcare system” in the United States. Instead we have fragmentation across multiple dimensions resulting in unsustainable cost increases, compromised quality, and growing inequity. Streams of public, private, and individual funding for health care – each with their own rules, requirements, and information needs – are further complicated by unsynchronized provider organizations in hundreds of cities and thousands of communities across the country. This byzantine approach has also created a cottage industry of specialists whose sole job is to navigate these requirements and make sure that patients know their health insurance options, can enroll in coverage, and get access to the services that they are entitled to.

The Affordable Care Act (ACA) addresses this complexity in a number of important ways. For example, the expansion of Medicaid to all individuals with incomes under 138 percent of the federal poverty level greatly simplifies the enrollment criteria for low-income individuals. The ACA also provides clarity on the calculation of income, penalties, types and sources of required documentation, and clearly outlines the reconciliation process for eligibility and subsidies.

While enrollment has not yet been reduced to a single mouse click or finger swipe, there is considerable uniformity across the country. Under the ACA, a family of four living in the Coachella Valley of California will follow a largely similar enrollment process to a family of four in Cambridge, Maryland. Though their choices on plans and providers will differ, the process of calculating their eligibility and enrolling in Medicaid or a health plan through an Exchange should be similar.

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What Do You Mean I’m Getting Old? Denial About Aging And Our Impending Long-Term Care Crisis


June 12th, 2013

It is no secret that Americans are aging, but what is too often lost in this fact is that most people will need help as they grow older. Unfortunately, America does not have a strategy to deal with this growing demand. For some, this help comes in the form of needing just a little bit of assistance in the home with cooking meals or getting groceries. For others, it is more comprehensive daily help in assisted living or nursing home care.

As Chair of the newly created federal Commission on Long-Term Care, I believe it is imperative for Americans to understand that 70 percent of us who live beyond the age of 65 will need some form of long-term care, on average for three years. This is a potentially dangerous statistic given the reality that our nation’s system of care is outdated and lacks the tools to meet the needs of our growing senior population.

To better understand Americans’ attitudes and perceptions around aging and long-term care, as well as levels of preparedness for future care, the Associated Press – NORC Center for Public Affairs Research conducted a national poll of adults age 40 and older with funding from The SCAN Foundation. Implications of these findings are profound considering the population of adults over 65 will nearly double to 19 percent — nearly 72 million people — by 2030.

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Implementing Health Reform: Proposed Regulations for Exchange “Navigators”


April 4th, 2013

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.

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Rachael Fleurence on Patient Engagement


April 3rd, 2013

In today’s Q and A on Patient Engagenment, we feature Rachael Fleurence, a Senior Scientist at PCORI where she leads the research prioritization initiative to help identify important patient and stakeholder generated questions and establish a rigorous research prioritization process to rank these questions. (Also, check out her recent blog post and follow the link to her February Health Affairs article here.)

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The Effects Of Health Costs On Family Incomes Leads HA Blog January Top Ten


February 13th, 2013

Art Kellermann and David Auerbach’s look at the effects of health care costs on middle class incomes leads the Health Affairs Blog most-read list for January. Next on the list are three posts by Tim Jost looking at the implementation of the Affordable Care Act and the continuing legal battles over the law. Also in the top ten are Katherine Hempstead’s take on what Massachusetts public opinion can teach us about restraining health care spending; Richard Frank and Jack Hoadley’s argument in favor of requiring manufacturers to pay a minimum rebate on drugs covered under Medicare Part D for those beneficiaries who receive the program’s Low-Income Subsidy; and Coretta Mallery and Marilyn Moon’s look at methods for increasing stakeholder involvement in research.

The full list is below.

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Bringing Patients Into Health System Change


February 5th, 2013

Editor’s note: For more on the attitudes of Americans toward medical care and empowering patients to be active participants in their own care, see the February issue of Health Affairs, “New Era Of Patient Engagement.”

The attention now devoted to defining the proper role of patients and consumers in clinical decision-making is unusual, both in terms of who is addressing the issue and the intensity of the concern. Once, it was physicians and bioethicists who took the lead; now it is health policy analysts and health care administrators. Their aims go well beyond improving doctor-patient communication or promoting patient autonomy. The primary goal is to enlist patients in the effort to bring fundamental change to health care delivery.

The obligations conferred upon or assumed by patients have changed dramatically over the past half-century. Well into the 1950s, prevailing norms reflected Talcott Parsons’ formulation of the sick role. Patients were duty-bound to seek medical care when ill and follow physicians’ orders. In the 1970s and ‘80s, the new field of bioethics successfully challenged this paradigm, demanding that physicians obtain patients’ informed consent for all interventions, particularly in end-of-life decision-making.

Current expectations are different, less concerned with bioethical principles like autonomy and more committed to the idea that unless patients are genuine partners in medical decision making, altering the health care delivery system is not likely to succeed. The goal is not to advance patient rights but to transform patterns of care.

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Public Opinion About Costs And Transparency: Learning From Massachusetts


December 28th, 2012

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.

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Responding To Newtown


December 21st, 2012

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.

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Elections Reveal America: Ten Takeaways From The 2012 Election


November 14th, 2012

Elections explain America. They tell us — they tell the world — who we are. And, of course, elections define government and power. The 2012 election may be especially significant. Let’s begin with the returns: President Obama won eight out nine swing states and 61 percent of the Electoral College; the Democrats took ten out of twelve contested Senate races for a ten-seat majority in the Senate; and the Republicans lost just seven seats in the House and maintain a solid 35-seat majority.

How does all that add up? Here are ten takeaways from 2012.

1. Barack Obama’s chance. Only four other Democrats have won back to back terms since the people started voting for presidents in 1824: Andrew Jackson, Woodrow Wilson, Franklin Roosevelt, and Bill Clinton. All four remade the Democratic Party. And the first three profoundly changed the United States. Now Barack Obama gets his turn.

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Election 2012: A Win For Health Reform, But Much Work Remains


November 7th, 2012

Editor’s note: Watch Health Affairs Blog for more analysis of what yesterday’s election means for health policy.

When President Obama signed it into law in 2010, the Affordable Care Act’s 2014 final implementation date seemed a far distant goal. It has not always seemed clear that we would get there. In November 2010, when the tide of Obamacare rejectionists swept the congressional and state house elections, in March 2012 when the Republican–appointed majority of the Supreme Court pummeled the Solicitor General with skeptical questions, and for a number of minutes in June 2012 while the media reported that the Court had held the ACA unconstitutional, the future of the ACA seemed gravely in doubt.

But this morning, with the President reelected and the Democrats strengthening their control of the Senate, it seems possible—indeed likely—that less than a year from now millions of Americans will begin enrolling in qualified health plans expecting that premium tax credits will finally become available on January 1, 2014. Health status underwriting will disappear and pre-existing condition exclusions will be banned. In most states, Medicaid will become a program that covers all Americans with household incomes below 138 percent of poverty, not just favored categories of the poor. Medicare benefits will continue to improve as the doughnut hole is closed, while Medicare costs will be kept in check.

The election is at least in part a referendum on the ACA. Exit polls show that a slim majority of voters support the ACA, and a distinct minority favor full repeal. President Obama did not run away from the ACA in his reelection campaign, and the Republicans continued to attack it, with Governor Romney promising to work toward repeal beginning with his first day in office. The President’s reelection must be seen as a green light to move forward toward 2014.

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The Top Ten Health Affairs Blog Posts For September


October 4th, 2012

A post on improving care transitions leads the list of most-read Health Affairs Blog posts for September. Second on the list is Martin Makary’s post on excessive executive compensation at children’s hospitals, followed by Jeff Goldsmith’s take on the Census Bureau’s uninsured numbers.

Also on the list are posts on implementing the Affordable Care Act, Michael Saks’ look at what the polls really tell us about public attitudes towards the ACA, and Timothy Jost’s examination of what a President Romney and congressional Republicans could do to dismantle the statute. The list also includes Chuck Alston and Patrick McCabe’s discussion of communicating health care evidence to patients, as well as Blair Childs’ argument that a Medicare hospital quality improvement program is working.

Anthony Keck’s explanation of why South Carolina will not implement the ACA’s Medicaid expansion rounds out the list. The full list appears below.

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An Evidence-Based Approach To Communicating Health Care Evidence To Patients


September 25th, 2012

It has been 22 years since David M. Eddy—the heart surgeon turned mathematician and health care economist—put the term “evidence-based” into play with a series of articles on practice guidelines for the Journal of the American Medical Association.

But as we have learned in the years since, one person’s evidence-based guideline is another person’s cookbook. For some, a sound body of evidence is fundamental to sound medical decisions. After all, as Jack Wennberg and Dartmouth researchers have pointed out for decades, if the practice of medicine varies so widely from place to place in this country, everyone can’t be right. Yet for others, evidence connotes not just “cookie-cutter medicine,” it is only one step shy of a trip to the death panel. This heavy baggage influences the way evidence-based medicine is discussed from the doctor’s office to the clinic to Capitol Hill.

With this in mind, we and others working under the aegis of the Institute of Medicine set out to find an evidence-based approach to communicate with the public about evidence. The full fruits of our work can be seen in this new IOM discussion paper, “Communicating with Patients on Health Care Evidence.” What we found based on both focus groups and a national poll is that, in the context of shared decision-making, the public does not view evidence-based medicine as an indicator of cookbook medicine. Far from it. Patients actually put significant emphasis on the latest medical evidence.

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What Do Polls Really Tell Us About The Public’s View Of The Affordable Care Act?


September 21st, 2012

Since its passage, the public has been told repeatedly how it feels about the Affordable Care Act (ACA), namely, that most of us disapprove of the ACA and detest its “mandate” that we be insured. A closer look at the national opinion data reveals that on those and related issues, public opinion actually favors the ACA.

Let’s begin with the basic finding that has been repeated so often: public disapproval of the ACA outweighs approval by a gap averaging around 5 to 10 points. But very few polls ask why people disapprove. The answers to that question change the picture dramatically.

One study that did ask “why” found that quite a bit of the disapproval comes from people who want health care reform expanded. When asked what they want done with the ACA, only 38 percent of survey respondents want it replaced with a Republican alternative or simply repealed; 25 percent want it kept as is, and 28 percent want more than the ACA provides. These latter 28 percent doubtless are the remnants of the 46-65 percent of the public who wanted health care reform to include a “public option,” or the 35 percent who want a single-payer system. Put simply, most Americans (53 percent versus 38 percent) want either the ACA or something with a greater role for government.

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