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05/04/2017

"Would Repealing the ACA Violate International Law?" (May 3rd )

 

The Health Care Blog (http://thehealthcareblog.com/) posted an essay under this title on April 28th by myself and Jason Chung. The blog post summarizes Washington Post opinion writer, Dana Milbank's, April 25th essay noting the UN forwarded to the Trump administration on February 2nd a letter arguing repeal of the ACA would likely violate several US-agreed to international treaties and other international agreements concerning the rights of everyone to enjoy the highest attainable standards of physical and mental health. As Milbank noted, and as repeated in the blog post, the Trump administration, despite the UN's request to make known the letter to Congressional leaders, buried the correspondence.  The letter was leaked by a DHHS employee who had obtained a copy from the State Department.   

Milbank's article and the UN letter are at: https://www.washingtonpost.com/opinions/apparently-repealing-obamacare-could-violate-international-law/2017/04/25/2794a77c-29f4-11e7-b605-33413c691853_story.html?utm_term=.3d3cbd497026 and  https://www.washingtonpost.com/r/2010-2019/WashingtonPost/2017/04/25/Editorial-Opinion/Graphics/103_17_ACA_Repeal_Request_for_Information.pdf?tid=a_inl

04/28/2017

The Current Status of Employer-Based Insurance: A Conversation with James Gelfand (May 3rd)

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Considering the debate over the past five months about repealing the ACA (and more generally reforming the Medicare program via premium support),  it is worth remembering that approximately 55% of non-elderly Americans, or 155 million, still receive their health care coverage via their employer.   In addition, as of 2016 the ACA requires employers with over 50 employees to either offer health benefits or face a financial penalty.   The question remains what is the future of employer based insurance coverage, both for employees and retirees) if, for example, the ACA's "employer shared responsibility" provision and/or the employer tax exclusion (addressed in the ACA by the so called "cadillac tax") is repealed. 

During this 25 minute discussion Mr. Gelband briefly describes ERIC's mission/work, identifies what methods large employers are using to continue to offer employee coverage, how retiree coverage is being addressed, how employers are incenting providers to deliver quality care, ERIC's view of much debated HRAs (Health Risk Assessments) and wellness programs and his organization's position on the employer tax exclusion.  (Listeners may recall I interviewed Dr. Joe Antos last August 5th on the tax exclusion.)

Mr. James Gelfand is Senior Vice President of Health Policy at ERIC where he works to develop and advance public policies to James Gelfand's Headshot support the ability of employers to design and administer health plans.   Previously, Mr. Gelfand was the Director of Federal Affairs at the March of Dimes Foundation.   Prior to, he served as Associate Director for Luntz Global Partners.  He served on Capital Hill as Counsel to Senator Olympia Snowe, on the Senate Small Business Committee and to Senator Tom Coburn.   Mr. Gelfland also was for four years a lobbyist for the US Chamber of Commerce.   Mr. Gelfand received his JD from the George Washington University Law School and his undergraduate degree from Northwestern. 

For more information on ERIC go to: http://www.eric.org/.

04/18/2017

CMS' "Market Stabilization" Rule Goes Final: My Comments (April 17th)

For those carefully following the ACA state marketplaces, i.e., the viability thereof, here's an update to my March 22 THCB essay (four posts down).  This one is titled, "The Strange Making of the 'Marketplace Stabilization' Rule," at: http://thehealthcareblog.com/blog/2017/04/17/the-strange-making-of-the-marketplace-stabilization-rule/.   The CMS rule is at: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2017-Press-releases-items/2017-04-13-2.html.

 

04/12/2017

"Teeth: The Story of Beauty, Inequality & the Struggle for Oral Health In America," A Conversation with the Author, Mary Otto (April 12th)

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 As former DHHS Secretary Louis Sullivan wrote in support of this work, "Mary Otto brings history, policy and painful personal realities together in this compelling and engaging book about our nation's highly preventable epidemic of oral disease.  Teeth should be read by every policy maker and health professional who believes we can and must ace to reduce the current barriers to dental care."  (Listeners of this podcast may be also interested in related interviews with Burton Edelstein, DDS, from April 2013 and my interview with the American Dental Association's Dr. Marko Jujicic from January 2016.) 

During this 22 minute conversation, Ms. Otto discusses the impetus for her work, i.e., the 2007 death of a 12-year old Maryland resident, Deamonte Driver, from an abscessed tooth, she discusses efforts to integrate oral health with overall physicial health, the problems of substantial racial/ethnic disparities in oral health in light of the industry's increasing financial interests in provided cosmetic dentistry, the battle between dentists and mid-level providers, e.g., dental hygienists, over the latter's efforts to improve oral health primary and secondary prevention and the possibilities for improved oral health coverage moreover for adults under both Medicare and Medicaid.   

Ms. Mary Otto is the oral health topic leader for the Association of Health Care Journalists.  She began writing about oral health Ottoat The Washington Post, where she worked for eight years covering social issues, including health care and poverty.  Ms. Otto is a resident of Washington, DC.  

Ms. Otto's volume is available via Amazon at: https://www.amazon.com/Teeth-Beauty-Inequality-Struggle-America/dp/1620971445.   A review of her work appeared in the March 23rd issue of The New York Times, at: https://www.nytimes.com/2017/03/23/books/review/teeth-oral-health-mary-otto.html?_r=0.   An executive summary of Surgeon General David Satcher's 2000 report, "Oral Health In America," noted during this conversation, is at: https://www.nidcr.nih.gov/datastatistics/surgeongeneral/report/executivesummary.htm

04/04/2017

Essay: "The Child Sexual Abuse Conspiracy" (March 31st)

Listeners may recall The Healthcare Blog (http://thehealthcareblog.com/) posted last June 4th my essay, "About Hastert's 'Known Acts': The Indifference is As Disturbing as the Crime" (at: http://thehealthcareblog.com/blog/2016/06/04/about-hasterts-known-acts-the-indifference-is-as-disturbing-as-the-crime/).  

Last Friday, THCB posted, "The Child Sexual Abuse Conspiracy."  Using the recent Larry Nassar/USA Gymnastics case I argue organizations that employ predators, political leaders in DC, the professional medical community and others continue to, de facto, conspire in ignoring the problem.  Again, per the CDC's ACEs study, one in four girls and one in six boys are raped/molested.  The essay is at: http://thehealthcareblog.com/blog/2017/03/31/the-child-sexual-abuse-conspiracy/

 

04/03/2017

What Was Discussed at February's "Climate and Health" Meeting: A Conversation with Dr. Jonathan Patz (March 31st)

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In mid-January the CDC abruptly canceled a three-day "Climate and Health Summit" the Center had been planning for months.  The meeting was intended to discuss public health risks caused by the climate crisis and steps being taken to reduce the emissions of carbon dioxide and other greenhouse gases or its adverse consequences on human health.   (It was speculated the meeting was canceled because the CDC did not want to run afoul of the incoming president who has repeatedly called climate change a “hoax” perpetrated by the Chinese.)   The American Public Health Association (APHA) and others however went ahead and held a one-day meeting on February 16 titled,"Climate and Health" at the Carter Center in Atlanta.  The meeting was keynoted by former Vice President Al Gore.   Dr. Jonathan Patz, the Director of the Global Health Institute at the University of Wisconsin-Madison, was one of the meeting's organizers and participants.    

During this 24 minute conversation Dr. Patz discusses how the meeting came about and what was accomplished, e.g., he summarizes the afternoon's panels that discussed what's being done to reduce green house gas emissions.  He also discussed how to better involve the professional medical community  and how to effectively communicate the reality of the climate crisis. 

Dr. Jonathan Patz is the Director of the Global Health Institute at the University of Wisconsin-Madison.  He is a professor and the John P. Holton Chair in Health and the Environment with appointments in the Nelson Institute for Environmental Studies and the Department of Population Health Sciences.  For 15 years, Dr. Patz served as a lead author for the United Nations Intergovernmental Panel on Climate Change (or IPCC)—the organization that shared the 2007 Nobel Peace Prize with Al PatzGore.  He also co-­chaired the health expert panel of the U.S. National Assessment on Climate Change, a report mandated by the Congress.  Dr. Patz has written over 90 peer-reviewed articles, a textbook addressing the health  the health effects of global environmental change and co-edited the five volume Encyclopedia of Environmental Health (2011).  He has been invited to brief both houses of Congress and has served on several scientific committees of the National Academy of Sciences.  Dr. Patz served as Founding President of the International Association for Ecology and Health.  He is double board-­certified, earning medical boards in both Occupational/Environmental Medicine and Family Medicine.  He received his medical degree from Case Western Reserve University (1987) and his Master of Public Health degree (1992) from Johns Hopkins University.

A webcast of the February 16 meeting is at: https://www.climaterealityproject.org/health.  Listeners are particularly encouraged to listen to Vice President Gore's 30 minute keynote address.  

For more information concerning the Medical Society Consortium on Climate and Health go to: https://medsocietiesforclimatehealth.org/.

Since I mention during the discussion the Obama administration's 2016 "The Impacts of Climate Change on Human Health in the US: A Scientific Assessment," a review of the paper is, again, at: http://altarum.org/health-policy-blog/nature-bats-last-a-warming-earth-will-exact-adverse-health-effects-but-our-responsibilities-are.   

 

03/27/2017

Playing Dice with the State Marketplaces: CMS' Proposed Market Stabilization Rule (March 22nd)

In mid-February CMS published a proposed rule intended to "stabilize" the state insurance marketplaces.  This essay, posted on The Health Care Blog last Wednesday, is my critique of the proposed.   What's actually amazing about the proposed is CMS admits the proposed changes have a 50-50 chance of succeeding, i.e., CMS summarizes the proposed changes by stating "on the one hand" the proposed changes may work, "on the other hand" they may not.  Imagine if this was the standard for drug approvals?

The essay was originally titled, "Playing Dice with the State Marketplaces: The Administration's Admittedly Ambiguous Market Stabilization Proposed Rule."  The editor changed the titled.  

http://thehealthcareblog.com/blog/2017/03/22/the-incredible-self-destructing-healthcare-marketplace/

03/13/2017

Does Pay for Performance Improve Care and Lower Spending? A Conversation with Stephen Soumerai (March 15th)

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Over approximately the past decade the health care industry has become increasingly committed to financially incenting physicians and other clinicians, or tying performance to reimbursement.  Commonly termed "pay for performance"(P4P), these arrangements are increasingly employed in the Medicare (i.e., under the Medicare Access and CHIP Reauthorization Act, or MACRA) and Medicaid programs and by commercial insurers, most notable accountable care models and bundled payment arrangements.   One might assume because P4P models are now common there is research evidence that demonstrates they are effective in, again, improving care quality, patient outcomes and lowering spending growth.  That is not the case.  For example, a systematic review published by Cochrane in 2011 found "there is insufficient evidence to support or not support the use of financial incentives to improve the quality of primary health care."  Among other examples, for all the attention the Massachusetts' Alternative Quality Contracts (AQCs) have received since they were launched in 2009, it remains unclear if they have reduced spending or spending growth.   Because P4P models have not proved out, payers and providers, for example, England's National Health Service and in the US the integrated, 12 hospital system, Geisinger Health, have substantially reduced incentive payments or are returning to paying providers straight salaries.            

During this 27 minute conversation, Professor Soumerai discusses his interest in the P4P topic, describes P4p arrangements, summarizes his and others' review of the research evidence relative to the effectiveness of P4P arrangements and suggests model designs that may be more effective.  

Stephen B. Soumerai is Professor of Population Medicine at Harvard Medical School and Harvard Pilgrim Health Care SsoumeraiInstitute.  He also co-chairs the Statistics and Evaluative Sciences concentration within Harvard University’s health policy Ph.D. program.  Dr. Soumerai recently served as International Trustee for the Canadian Health Services Research Foundation.  Dr. Soumerai has published more than 250 original scientific articles in leading scientific journal, such as the New England Journal of Medicine and the Journal of the American Medical Association.  He is well known nationally and internationally for his work on the impacts of health policies and methods to improve the quality of medical practice.  He frequently advises Congress, state legislatures and federal and international agencies on the design of drug cost containment, coverage and quality-of-care policies, evidence-based health policy and his research has been used extensively to support expanded economic access to medications in Medicaid and Medicare. He is the recipient of numerous honors including numerous article of the year awards from national and international scientific societies, named lectureships, and is the recipient of the Everett Mendelsohn Excellence in Mentoring Award from the Harvard University Graduate School of Arts and Sciences.

Professor Soumerai's 2015 and 2016 CDC articles noting in this discussion are at: https://www.cdc.gov/pcd/issues/2015/15_0187.htm and https://www.cdc.gov/pcd/issues/2016/16_0133.htm

03/07/2017

Proposed House Republican Changes to Medicaid: A Conversation with Matt Salo (March 6th)

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Late today, or within a few hours after this interview was completed, the House Republicans proposed ACA repeal or reconciliation legislation.  The legislation includes repealing Medicaid expansion under the Affordable Care Act (ACA).  More specifically, House Republicans propose repealing the  federal enhanced match rate for eligible beneficiaries on December 31, 2019 though states can keep the enhanced match rate for those Medicaid eligible before January 1, 2020 but only for those that do not have a break in Medicaid eligibility for more than one month after that January 1, 2020..  Moreover, the proposed legislation would reform federal Medicaid funding by creating a per capita cap model starting in 2020.  This means federal funding would be benchmarked to 2016 for the five Medicaid enrollee categories: the elderly; blind and disabled; children; non-expansion adults; and, expansion adults.  Year- over-year federal spending increases would be pegged to the medical care component of the Consumer Price Index (CPI).   While there is not yet a Congressional Budget Office (CBO) score for the proposed legislation, that's schedule for mark up on Wednesday, estimates by the Center for Budget and Policy Priorities (CBPP) project that if the 32 states that expanded Medicaid coverage under the ACA wanted to keep it, the cost to these states would be approximately $280 billion over the next decade.  CBPP also estimates that per capita caps will  increase the state's share of Medicaid costs, excluding expanded coverage, by another $280 billion also over 10 year budget window.   

During this 25-minute interview, Executive Director of the National Association of Medicaid Directors (NAMD), Matt Salo, discusses the mission of NAMD, his understanding of House Republican legislation to fundamentally reform the Medicaid program, the challenges with either Medicaid block grants or per capita caps, and other related policy issues the NAMD is working to resolve.  

Mr. Matt Salo has served as Executive Director of NAMD since 2011.  NAMD is a non-partisan association representing all 56 of Salothe nation's state and territorial Medicaid Directors.    Prior to NAMD, Mr. Salo spend 12 years at the National Governors Association where he  worked to forward the Association's health and human services policy agenda.   Prior still Mr. Salo worked for five years as a health policy analyst at the American Public Human Services Association.   Mr. Salo also spent two years as a substitute teacher in the Alexandria, VA public school system. Mr. Salo holds a BA in Eastern Religious Studies from the University of Virginia.

For more on the NAMD go to: http://medicaiddirectors.org/

For more on House ACA repeal or reconciliation legislation go to: 

https://energycommerce.house.gov/hearings-and-votes/markups/markup-committee-print-and-h-res-154

https://waysandmeans.house.gov/event/markup-budget-reconciliation-recommendations-repeal-replace-obamacare/

02/08/2017

Review of "Hell is A Very Small Place," (February 7th)

If you listened, or not, to my December 19th interview with Jean Casella (see below), one of the three editors of, "Hell is a Very Small Place, Voices from Solitary Confinement," here is my review of the work: http://thehealthcareblog.com/blog/2017/02/07/hell-is-a-very-small-place.

The essay begins with: 

It is well recognized that over the past several decades US prisons and jails have become the nation's largest inpatient psychiatric hospitals.  This is not surprising when you realize the majority of the US correctional population, the largest in the world at well over two million, suffers from mental illness.  Leaving aside the question of whether it is appropriate to incarcerate the mentally ill, at least those with serious mental illness, how we choose to treat a significant percent of mentally ill inmates is to place them in solitary confinement.  This means how we treat a significant percent of the mentally ill in this country is to torture them.