Health Affairs

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.

The time is quickly approaching when health insurers must file the rates and forms they will need to put in place for 2014. The Department of Health and Human Services is rapidly releasing the final rules that insurers will need to determine the coverage and price of those plans, and that the states and exchanges will need to approve or disapprove them. On February 22, 2013, HHS released the final market reform regulations, which establish the ground rules under which insurers will market their products in the reformed health insurance market. (The fact sheet is here.)

Whereas health insurance underwriting in the individual and small group market is currently based heavily on health status and gender, health insurers in the reformed market will only be able to consider age, tobacco use, geographic area, and family unit size in setting premiums. Insurers will also have to guarantee the availability and renewability of coverage. Proposed rules implementing these reforms were published on November 26, 2012 and were covered by this blog. This post discusses the final version of these rules.

On February 22, 2014, the Department of Labor also issued interim final regulations on procedures for addressing complaints by employees that they have suffered retaliation from their employers because they reported violations of the ACA’s consumer protections, or because they have received advance premium tax credits. (See the press release here.)

In August, the Center for Sustainable Health Spending (CSHS) was awarded a grant from the Robert Wood Johnson Foundation to, among other things, examine the relationship between disease prevention and health care costs. This project heightened my interest in the wonderfully-researched report from the Congressional Budget Office (CBO) entitled Raising the Excise Tax on Cigarettes: Effects on Health and the Federal Budget, and its excellent summary in the New England Journal of Medicine (NEJM).

The report was years in the making and is noteworthy for its original research and its thorough and insightful literature review. As the title suggests, its economic focus is on the federal budget. In some ways this is a very broad perspective as it brings into play smoking’s impact on employment and earnings (hence tax payments), as well as health care costs and Social Security payments. But in other ways it is quite narrow, being limited to federal revenues and costs. Before discussing this CBO report, and the complex economics of disease prevention and longevity it underscores, I’d like to create some context.

Consumer-directed plans typically exempt recommended preventive visits and tests from the plan’s deductible, or require only a small copay. These plans have grown in popularity, increasing to 19 percent of all covered workers in 2012 from 8 percent just three years prior.

In the newly released December 2012 issue of Health Affairs, Mary Reed of Kaiser Permanente and coauthors report that more than half of 456 California-based respondents did not understand their plan benefits for preventive office visits, and approximately one in five delayed or avoided a preventive visit, test, or screening because of cost. The authors recommend concerted consumer education and support efforts to ensure patients are aware of their benefits and do not mistakenly avoid important preventive care due to concerns over cost, especially as more private and public health plans adopt the consumer-directed plan model.

Other notable articles in the December Health Affairs issue include:

Since the Supreme Court’s verdict on NFIB v. Sebelius in late June, considerable national attention has converged around the question of whether or not states will opt to expand Medicaid coverage for adults with incomes below 138 percent of the federal poverty level (FPL).  The argument for states to move forward – or not –... Read the rest of this entry »

According to four Harvard School of Public Health national surveys, 44 percent of all college students binge drink, and nearly 600,000 suffered injuries in 2001, many of them associated with alcohol-induced blackouts. A new study, released today as a Web First by Health Affairs, calculates that at a university with 40,000 or more students, blackout-associated... Read the rest of this entry »

Not surprisingly, the Affordable Care Act figures prominently in the list of the ten most-read Health Affairs Blog posts for August. The list includes posts on efforts to implement the Act, as well as essays on the legal fight over its constitutionality. Heading up the list is a post announcing a summer edition of the... Read the rest of this entry »

Provisions of the Affordable Care Act and other recent legislative changes will transform public substance abuse treatment in the United States, substantially increasing the funding, expanding access to care, and better integrating it with other health services. That’s the conclusion of an article by Jeffrey Buck, senior advisor for behavioral health in the Center for... Read the rest of this entry »

The rising availability through the Internet of commonly abused prescription drugs has raised public health concerns.  A new study released today as a Web First article by Health Affairs shows that a 10 percent increase in the availability of high-speed Internet service in a state was associated with an approximately 1 percent increase in admissions... Read the rest of this entry »