Health Affairs

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.

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.)

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.

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.

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.

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.

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.

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.

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.

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.

Chief Justice John Roberts did right by America.  Thursday’s ruling by the U.S. Supreme Court upheld the constitutionality of the law’s minimum coverage provision and allowed the Affordable Care Act to move forward.  Health reform is often simpler than it looks, and so was the Court’s decision.  In practical terms, a majority of Justices ruled... Read the rest of this entry »

Before yesterday’s remarkable Supreme Court decision on the Affordable Care Act (ACA), I expected Chief Justice Roberts would lead a majority in a constrained decision which would avoid all but the narrowest consideration of constitutional questions.  Some of us expected he might act to strike the individual mandate, yet avoid the “legislating from the bench” which... Read the rest of this entry »

The Patient Protection and Affordable Care Act (ACA) establishes the executive-appointed 15-member Independent Payment Advisory Board (IPAB). The IPAB is an expert body charged with trimming Medicare costs and improving the quality of health care. Board members will be required to make recommendations to cut Medicare funding in years when spending growth exceeds targeted rates.... Read the rest of this entry »

In terms of both health and health care, America is an unequal nation. There are well-documented differences in health between whites and racial and ethnic minorities—for example, in life expectancy.  There are also demonstrable differences in health care provided to people of different races and ethnicities—for example, in screening rates for cancers. Despite these gaps,... Read the rest of this entry »

Of all the issues bandied about in the recent debate over the debt ceiling, none generated more contention, more TV ads and more unseemly rhetoric than potential changes to Medicare. Health economists generally believe that Medicare is on an unsustainable course and is desperately in need of reform. Yet public opinion polls show that most... Read the rest of this entry »

Other than the egg-laying exercise surrounding the ACO regulations, 2011 was a quiet year among Washington health policy experts until June 6 when McKinsey released the results of a survey of employer plans under the Affordable Care Act. The McKinsey study found that roughly 30 percent of employers were considering dropping their employee insurance coverage... Read the rest of this entry »

The women recounted how their lives had been saved as they pleaded for the Food and Drug Administration not to withdraw approval for Avastin as a treatment for advanced breast cancer. They did so even without evidence that it provides benefit and with evidence that it confers risks. Their efforts were ultimately not successful: the... Read the rest of this entry »

The Patient Protection and Affordable Care Act (ACA)  is designed to increase the number of U. S. citizens with access to health insurance.  Along with augmented access to health insurance and hopefully health care for millions of the currently uninsured, as well as some degree of overall health care cost containment,  the ultimate success of... Read the rest of this entry »

Republicans have aggressively announced their determination to overturn recently passed health reform legislation. However, GOP leaders could be in for an unpleasant surprise if they interpret their election victories as a mandate to repeal the Affordable Care Act and enact other elements of a strictly conservative agenda, Bob Benenson, senior election analyst at the CQ-Roll... Read the rest of this entry »