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Ethical Dilemmas In Prison And Jail Health Care

March 10th, 2014
by Nancy Dubler

Editor’s note: This post is published in conjunction with the March issue of Health Affairs, which features a cluster of articles on jails and health.

Prison and jail health care, despite occasional pockets of inspiration, provided by programs affiliated with academic institutions, is an arena of endless ethical conflict in which health care providers must negotiate relentlessly with prison officials to provide necessary and decent care.  The “right to health care” articulated by the Supreme Court pre-ordained these ongoing tensions.  The court reasoned that to place persons in prison or jail, where they could not secure their own care, and then to fail to provide that care, could result in precisely the pain and suffering prohibited by the Eighth Amendment to the Constitution.

Good reasoning was followed by a deeply flawed articulation of the “right” that defines the medical care entitlement as care provided to inmates without “deliberate indifference to their serious medical needs.” By forging a standard which was, and remains, unique in medicine and health care delivery — designed to avoid intruding on state malpractice litigation regarding adequacy of practice and standards of care — the court guaranteed that dispute would surround delivery.  That first framing, which did not establish a right to “standard of care” or to care delivered according to a “community standard,” set the stage for endless ethical and legal conflict.

The Eighth Amendment’s deliberate indifference standard, forbidding cruel and unusual punishment, presents a relatively demanding standard for proving liabil­ity.  The Eighth Amendment, as interpreted by the federal courts, does not render prison officials or staff liable in federal cases for malpractice or accidents, nor does it resolve inter-professional disputes — or patient-professional disputes — about the best choice of treatment. It does require, however, that sufficient resources be made available to implement three basic rights: the right to access to care, the right to care that is ordered, and the right to a professional medical judgment.

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When The Only Cure Is A Transplant

February 21st, 2014

On Christmas Eve 2011, protesters from a local church marched to the entrance of our hospital, Rush University Medical Center in Chicago. They demanded we provide organ transplants for sick members of their congregation. We invited them in and listened to their gut wrenching stories. George, twenty-two, was brought to the United States as a six-month-old. He developed renal failure at age sixteen while covered under the Children’s Health Insurance Program. Now he was uninsured, on dialysis and refused a transplant evaluation at the same institution that treated him as a child. Another undocumented immigrant, Martin, was twenty-six. He too was uninsured and on dialysis.

Chicago has six adult transplant centers. Initially none would evaluate George or Martin for transplantation because they were uninsured. In the Narrative Matters essay, “Undocumented Immigrants And Kidney Transplant: Costs And Controversy,” published in the February issue of Health Affairs, Vanessa Grubbs tells a similarly heartfelt story of a patient in need of a transplant: Mr. Rojas. George, Martin and Mr. Rojas are not US citizens, but it was their lack of health insurance that kept transplantation out of reach. Foreign-born immigrants always have access to a transplant evaluation (the prerequisite for organ transplant) if they have insurance or the cash to pay.

In theory, the organ allocation system in the United States is based on justice and equity. The National Organ Transplant Act (NOTA) was passed in 1984 to create a fair system of organ transplantation in the United States. A federal task force, created by the act, was charged to design an organ allocation system “based on medical criteria that are publicly stated and fairly applied.” The task force emphasized that organs should be distributed to those eligible “regardless of their ability to pay.” Both NOTA and the bylaws of the United Network for Organ Sharing, the nonprofit organization that manages the national transplant network, require that need, not financial or citizenship status, guide transplant allocation decisions. Undeniably, the system of altruistic donation is only viable if a donating individual believes organs are allocated fairly.

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Progress Report: The Affordable Care Act’s Extended Dependent Coverage Provision

December 16th, 2013
by T.R. Goldman

This week Health Affairs is releasing a Health Policy Brief by T.R. Goldman on Young Adults and the ACA. The brief focuses on the importance of enrolling young adults in coverage through the law’s new marketplaces and Medicaid expansion beginning in 2014. But another provision of the law also aimed at young adults took effect more than three years ago. Here Goldman provides a progress report on the ACA’s dependent coverage expansion.

One of the earliest and most popular provisions in the Affordable Care Act requires insurers to extend dependent coverage on a family plan until the age of 26. The requirement is essentially unconditional and does not depend on whether the young adult lives at home, is a full-time student, is married, is a tax dependent, or is eligible to buy insurance on a state health exchange.  Until 2014, dependent coverage was not available if the young adult had a separate offer of employer-based coverage, but starting on Jan. 1, 2014, even that exception will no longer apply. Typically, most employer-based health insurance plans have ended dependent coverage at either 19 or upon college graduation.

The law is straightforward: any insurance plan that already offers dependent coverage must offer the same level of coverage at the same price of coverage to dependents under 26.  This applies to insurance offered by employers who either self-insure or purchase insurance through an insurance company.  And it includes insurance plans parents buy for their families in the non-group market.  Dependent coverage under a parent’s plan, however, does not extend to the children and spouses of those dependents.

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Implementing Health Reform: Final Letter to Issuers on Federally Facilitated and State Partnership Exchanges

April 6th, 2013
by Timothy Jost

On April 5, 2013, the Department of Health and Human Services released its final Letter to Issuers on Federally Facilitated and State Partnership Exchanges. This letter lays down guidelines for insurers that will sell qualified health plans on the federal exchanges in 2014. A proposed version of this letter was published for comment on March 1, 2013, which I blogged about here. The final issuer letter tracks the proposed letter with few significant changes. In part because I am supposed to be on vacation in France and in part because of limited access to technology, I am not going to review the issuer letter in depth, but rather refer the reader to my earlier post, providing here only a brief overview of the final letter that highlights the respects in which it differs from the proposed rule discussed in my earlier post.

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Competing Visions: A Response to John Goodman

April 4th, 2013
by Uwe E. Reinhardt

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.

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In Rural China, a Successful Payment Reform Pilot Project

April 4th, 2013
by Stephen Langel

Today, Health Affairs released a Web First article by Tsung-Mei Cheng describing early results from a pilot project underway in several of China’s rural provinces that combines new case-based payments for providers and evidence-based clinical pathways for management of patients. Before and after studies and analyses show a reduction in overall length of hospital stays, drug spending and usage, and patients’ out-of-pocket spending. Patient-provider communication and relations reportedly improved, and hospitals did not experience any revenue losses.

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Implementing Health Reform: Proposed Regulations for Exchange “Navigators”

April 4th, 2013
by Timothy Jost

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
by Rachael Fleurence

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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Health Affairs Briefing: The Triple Aim Goes Global

April 1st, 2013
by Rob Lott

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.

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Implementing Health Reform: Final Rule on Increased Federal Medicaid Matching Funds and FAQ on Medicaid Premium Assistance Programs

March 31st, 2013
by Timothy Jost

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.

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Health Policy Brief: The Multi-State Plan Program

March 29th, 2013
by Rob Lott

A new Health Policy Brief from Health Affairs and the Robert Wood Johnson Foundation discusses the Multi-State Plan Program created under the Affordable Care Act. Under the program, at least two health insurance plans choosing to participate will offer coverage through every state-run, federally facilitated, and partnership exchange created under the law. Insurance companies meeting the eligibility criteria have until March 29, 2013, to submit applications to participate in 2014.

The program was created to enhance competition among health plans within the new exchanges. It will be administered by the federal Office of Personnel Management, or OPM, which also administers the Federal Employees Health Benefits program offering coverage through a variety of health plans.

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A Budget Compromise Seems Unlikely Any Time Soon

March 27th, 2013
by Gail R. Wilensky

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.

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Full Steam Ahead: In Wake of Supreme Court Decision, HHS Issues Funding Opportunities, Implementation Guidance

July 5th, 2012
by Timothy Jost

While all of the attention of the public and of the media has been focused on the Supreme Court’s June 28 decision upholding the constitutionality of the Affordable Care Act (ACA) and on examining the nuances and consequences of that decision, the federal government has steadily moved ahead with implementation of the ACA.  With the […]

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Super Committee Post-Mortem: Health Care Policy Is Central To Partisan Budget Divide

November 23rd, 2011
by James Capretta

The Joint Select Committee on Deficit Reduction wasn’t dubbed the “super committee” for nothing. In theory at least, it had immense and unprecedented power.  If the select committee had been able to produce a consensus plan on deficit reduction, that legislation would have been guaranteed an up or down vote in the House and Senate […]

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No Free Lunch – Reconsidering the Individual Mandate

December 21st, 2010
by William Pewen

In our current political environment, wins are more important than policy successes, and for too long that has driven a juvenile mindset which engages in “magical thinking” in which beliefs trump facts, and benefits can be achieved without costs. So it’s no surprise that Republican leadership recognized that opposition to the individual mandate would be […]

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Gawande Earns Impact Award at Policy Conference

February 11th, 2010
by Jane Hiebert-White

Physician/writer Atul Gawande was the winner of this year’s Health Services Research Impact award at the National Health Policy Conference cohosted by AcademyHealth and Health Affairs earlier this week. At Tuesday’s lunch, Gawande was scheduled to receive his award for the important policy impact of his efforts to bring surgical checklists into use around the […]

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Top 20 Health Affairs Journal Articles for 2009

January 29th, 2010
by Jane Hiebert-White

We are pleased to announce the “most-read” Health Affairs journal articles published in 2009. The number 1 article published in 2009 was on “Annual Medical Spending Attributable To Obesity” by Eric Finkelstein and colleagues.  All articles below are open to all readers for the next 2 weeks—through February 12, 2010. Top-viewed articles published in 2009 […]

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Low-Cost, High-Quality Care In America

July 28th, 2009
by John Iglehart

As President Barack Obama and his allies press their case for health care reform, the president exhorts that his vision will slow the growth of medical expenditures, expand coverage to millions, and improve the quality of care.  In the trenches, where millions of medical interventions occur daily, physicians and hospital managers who do the heavy lifting describe a […]

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Nurse Shortage Eases Under Recession

June 12th, 2009
by Jane Hiebert-White

A new study published today in Health Affairs finds that the decade-long nurse shortage is easing, or even ending, partly as a result of the continuing recession. Study author Peter Buerhaus of the Vanderbilt University School of Nursing and colleagues found that older nurses are delaying retirement or returning to the workforce and part-time nurses […]

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Following The Cost Conundrum: The Road To McAllen, TX, Through The Pages Of Health Affairs

June 4th, 2009
by Sarah Dine

Last week’s New Yorker article by Atul Gawande highlighted the phenomenally high variations in cost of medical care and services between regions in the United States, specifically focusing on McAllen, Texas. Gawande’s spotlight on McAllen was based on many studies of our health care system. For Gawande’s readers, we would like to point you to […]

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