Common Image

Overview:

In this section we provide timely commentary on hot topics in health policy.  We will consider different questions as relevance rises and falls.

See our slider entry for a thorough report of all the issues the supreme court will rule on next spring or summer.   Tim Jost, a law professor at Washington and Lee, has written a nice summary and explanation of the recent impactful ruling out of the DC Circuit Court of Appeals, in which a well-known conservative judge ruled the individual mandate is constitutional.

Also, please check out our question of the month to see our polling on the subject.

Debate Item # 2: Is the Individual Mandate Necessary?

Center Director Len Nichols, and others, have written extensively on this question.  A recent summary of earlier work is here. Recent controversy on the question has been fueled by a recent study by Lewin Group researchers .  Be sure and read Wake Forest Law Professor Mark Hall’s reaction to this paper before making up your own mind.

Debate Item # 3: Is it Possible to Lower Costs without Rationing Care?

Much commentary exists on this topic as well.  Good places to start include work by the Brookings Institute’s Engleberg Center for Health Care Reform and by the Commonwealth Fund .Along with some  healthy skepticism from a former Medicare Administrator, Gail Wilensky .

Courtesy of PBS

The Kaiser Family Foundation released a snapshot of how health-care related issues shape the 2012 election to aid voters this November. This snapshot is one sheet full of graphs and charts that breakdown virtually all health care-related issues, deciphering information that would interest potential voters “including the percentage of Democrats, Republicans, and Independents who named health care or the economy as the issue that is most important in determining their vote for President”  [1]

You can see the snapshot tool here and here.

Graphic Credit - Adam Cole - NPR http://kutnews.org/post/supreme-courts-medicaid-decision-could-reach-far-beyond-health-care

Medicaid Works: Citizens Lose when States Opt Out

By Caryn Sever

Beginning in 2014, every state will have the option to expand Medicaid coverage to any adult whose income is more than 133% below the poverty line (a little over $31,000 for a family of 4).  At least 5 states, including Florida, Louisiana, Mississippi, South Carolina, and Texas will choose not to participate. Five other states are leaning towards not participating, and 27 states, including Virginia are currently undecided. This means that the majority of the United States is either not going to participate or is currently undecided about the expansion.  On August 23^rd, The Commonwealth Fund released a blog post explaining why Medicaid works, and what it means for these states to opt out of expansion. “Medicaid Works: Public Program Continues to Provide Access to Care and Financial Protection for Society’s Most Vulnerable” written by Karen Davis, President of the Commonwealth Fund and Kristof Stremikis, a senior researcher for the Commonwealth Fund,  outlines the need and benefits of Medicaid expansion as dictated by the Affordable Care Act (ACA).

According to the new projections released by the Congressional Budget Office, about “30 million previously uninsured Americans will gain coverage by 2022, 3 million fewer than had been predicted after the law was passed but before the Supreme Court decision.”[1] Furthermore, as per the ACA, the primary reason for trimming the annual payments to hospitals under Medicare was to compensate hospitals for the unrecoverable debts of previously uninsured patients. [2] This means that these adjustments will generate billions of dollars to help finance the expansion of coverage. Davis and Stremikis fear that repealing the coverage provisions, while maintaining the reduced payments would render it quite difficult for the hospitals to take on the debt that comes from providing care to the uninsured. “Repealing the law would increase the federal deficit by $109 billion over the next decade.” [3]

All money aside, there is a reason that Medicaid and Medicare exist. In 1965, when President Lyndon B. Johnson signed the programs into law, it was done so in response to meet the health care needs of the elderly and poor. [4] In his introduction of LBJ, President Harry Truman remarked “I am glad to have lived this long and to witness today the signing of the Medicare bill which puts the Nation right where it needs to be to be right.” [5] Johnson himself explained “There are more than 18 million Americans over the age of 65. Most of the have low incomes, most of them are threatened by illness and medical expense that they cannot afford. And through this new law, Mr. President [Truman], every citizen will be able, in his productive years when he is earning, to insure himself against the ravages of illness in his old age.”[6] Now, 47 years later states are debating expansion over an ever growing populous.

States that chose to opt out of the expansion are doing their citizens a disservice in several ways. Not only would the health of their state suffer, but resisting the expansion places a heavy burden state hospitals as well as “keeping the medically underserved community from receiving an enormous economic infusion”. [7] All the evidence points to the fact that expansion will save both the state and federal government’s money so even if certain states choose not to expand, the residents of each state will still be paying federal taxes to cover the expansion of those states that chose to opt in.

The facts stand for themselves, Medicare and Medicaid saves lives. In a study on Medicaid enrollment in Oregon, it was found that participants who receive coverage through the program were able and more likely to visit the doctor than those without coverage. In another study conducted by Harvard’s School of Public Health, it was found that states with Medicaid expansion showed a 6.1 percent decrease in deaths, or roughly 2,840 per year for every 500,000 US adults. [8] The study compared New York, Maine, and Arizona five years before and after expansion while comparing them with four neighboring states that had no Medicaid expansion. The United States Census Bureau recorded the US population in 2012 at 314,226,708 judging by the results of this study that means that Medicaid expansion saved about 1,784,807.70 people per year. This public program is critical to vulnerable populations such as the poor and elderly, who require public programs to survive and thrive. When states opt out the citizens suffer, the burden falls to the population who lose out on building a strong health care system with the funds specifically allotted for this purpose.

Through the Looking Glass: Required Transparency of Payments to Doctors by Drug and Device Companies 

By Caryn Sever

In 1983, the British sketch comedy group Monty Python created the satire movie “The Meaning of Life”. In the first scene of Part I, we see a women being wheeled into a delivery room to give birth. The room is quite empty and the doctors are told that the president of the hospital and a local politician are planning to visit their operating room. The troupe urgently begins to fill the room with the most expensive machines, including the one million pound priced “machine that goes ping”. Clearly, none of these machines have anything to do with the particular procedure, but the doctors are forced to use them because the hospital has already purchased them and the government has given the hospital money to do so. After much bedlam, the doctors realize that they are missing one key component, they rack their brains trying to remember; low and behold, it’s the patient who has been quietly suffering through contractions in the corner, but is not visible because the room is completely filled with unnecessary, expensive machinery. [1] This allegory, though dramatized, is a clear picture of the need for transparency in the costs and uses of medical devices, drugs, etc., in hospitals and doctors’ offices.

According to several news sources, the Obama Administration is prepared to require drug and medical device producing companies to disclose payments made to doctors for research, consulting, speaking, travel, and entertainment. Under these new standards, “if a company has just one product covered by Medicare or Medicaid, it will have to disclose all [of] its payments to doctors, other than its own employees”[2].  Robert Pear of the New York Times explains in his January 16^th, 2012 article “U.S. to Force Drug Firms to Report Money Paid to Doctors” that “many researchers have found evidence that such payments can influence doctors’ treatment decisions and contribute to higher costs by encouraging the use of more expensive drugs and medical devices”.  Pear’s data suggests that about one quarter of doctors take cash payments from drug and device makers, while about two thirds may accept food gifts, which could included lunches, breakfasts, and dinners for themselves and staff members. Further data submits that doctors who may take money from drug companies may practice medicine differently than those who do not. This could include prescribing more expensive medications that might put the patient at risk[3].  These new regulations will force companies that produce drugs and medical devices to report any payments made to doctors who may have helped develop or promote new products.

These rules were endorsed in a bi-partisan effort by Senators Charles Grassley (R-IA), and Herb Kohl (D-WI). Their bill: The Physical Payments Sunshine Act of 2009, requires the Department of Health and Human Services to “establish reporting procedures by October 1, 2011, and required manufactures to start collecting the relevant data by January 1, 2012.”[4] The rules were actually issued on December 14, 2011 and open for comment until February 17, 2012. Once these rules are finalized, the Centers for Medicare and Medicaid Services will publish the data on a public website, which is required to be both searchable and understandable for patients and advocacy groups.[5] Furthermore, if drug and device manufactures fail to report this data, “they can be fined up to $150,000 a year and up to $1 million a year for ‘knowingly’ failing to report”.[6]  The rules will also require senior officials of each manufacturing company to sign and attest to the “accuracy of each report” [7] which could render top executives liable to fines if the costs were inaccurately reported.

Consumer advocates have long awaited these regulations. In a statement issued on March 22, 2010, Allen Coukell, director of the Pew Prescription Project, remarked that “patients deserve to know if their doctors are receiving money from drug companies. Congress has added much needed transparency to the financial relationships between the pharmaceutical industry and physicians. The reporting requirements in the health care legislation will better protect patients and will help report trust in our health care system.” [8]

Relationships between doctors and drug and device producers can at times be beneficial to patients. When developed together, these medications and equipment could be life saving, however, according the Obama administration the relationship could also “lead to conflicts of interest that may affect clinical decision making, threatening the underlying integrity of the health care system.”[9]  The goal of these regulations is to “let the sun shine in and make information available to foster accountability” as Senator Grassley explained to the New York Times and not to define the proper or potentially improper use of payments, nor is it meant to punish productive doctor/manufacturer relationships.

Advocates for drug and device companies fear that regulations could cause doctors to “no longer want to engage in consulting arrangements and such reluctance could chill innovation.”[10]  However, senior vice president of the Pharmaceutical Research and Manufacturers of America, Matthew D. Bennett, supports the transparency but believes that it is also important that the data is presented in the correct context; meaning that it should emphasize interactions between doctors and companies which played critical roles in improving care, fostering education, and promoting the appropriate use of medication.

In the coming months, CHPRE will keep a close eye on these developing regulations and update our web visitors accordingly.

This is a Common Use Image

Physicians Overall Are Evenly Divided on PPACA being a “Good Start,” But Different Kinds of Docs Hold Starkly Different Views: Deloitte Study

 By Donald Yacoe

 In what may be a surprise, doctors in general are evenly divided on whether PPACA represents a positive step for health reform, a just-released national survey from Deloitte has found. At the same time, however, the doctors surveyed held starkly different opinions for and against PPACA, when specialty, age, time in practice, region, and gender were taken into consideration.

The survey from the Deloitte Center for Health Solutions, released on December 13, 2011, found that 44% of the 551 doctors that participated in the survey said that PPACA was a “good start,” while an identical percentage said it was “a step in the wrong direction.” The remaining 12% of the total said they “don’t know.”

However, by a huge margin, surgical specialists were more pessimistic about PPACA than any other specialty category. Only 28% of these doctors viewed PPACA favorably, while 60% said it was a step in the wrong direction, and 12% did not know. Similarly, doctors in the South very pessimistic: with 36% having a positive view of PPACA, and 54% a negative view.

In stark contrast, 68% of non-specialist doctors who were not primary care physicians had a positive opinion of PPACA, while 32% of these doctors had a negative opinion. 54% of doctors from the West viewed PPACA positively, while 34% did not, and 11% did not know.

The differences of opinion among types of doctors also extended to perceptions about the current state of the U.S. health system. Overall, only 35% of the docs surveyed gave our health system an “A” or “B” rating, while 65% rated it either “C,” “D,” or “F.” As with the opinions about PPACA, however, opinions held by different categories of doctors were widely divergent.

Surgical specialists, for example, had a relatively high opinion of the U.S. health system with 55% giving it an “A” or “B” rating. 44% of doctors in the Midwest gave the U.S. health system these ratings, and 43% of physicians who were more than 31 years past their residencies rating U.S. health care did so. However, non-surgical specialists (26%), doctors with less than 10 years since residency (26%), were considerably less enthusiastic about the U.S. health system than the average doctor.

Similarly male and female doctors diverged on their opinions of our healthcare system, with 38% of men giving it top grades, while only 29% of women doing so.

All specialty types were in agreement, however, on a number of topics. For example when it came to the drivers of health care costs, there was remarkable unanimity. Across all specialties, doctors agreed that consumer behavior—including unhealthy lifestyles that can lead to obesity—is the top driver of health care costs. The next greatest cost drivers were, in order of importance: defensive medicine, insurance company administrative costs, hospital costs, prescription drugs, end of life care, and new technologies and equipment. Surprisingly, given the current political debate, at the bottom of the list were: government regulation, payment incentives that reward volume instead of performance, fraud in the system, and over-utilization of surgery.

According to the survey, most physicians:

• Believe health reform will increase access to government insurance programs, but will not reduce costs.
• Are pessimistic about the future of medicine as a result of health reform and think physicians will consider other options.
• Believe health reform will negatively impact their income (especially surgeons).
• Believe evidence-based medicine improves quality of care but achieving physician adherence is difficult.
• Believe payment reforms, including bundled payments and performance-based incentives, will reduce their incomes and increase their administrative costs.
• Support tort reform.
• Consider a practice in a large integrated health system or concierge medical practice as a viable alternative to private practice.
• Hope to retire before they have to change the way they practice today.

Poverty in America and Health Care

Does Society Have a Responsibility to Help the Poor with Health Care? Two Recent Examples from the Debate over this Issue

 Some important public exchanges of ideas have recently underscored the core debate about society’s responsibility—or lack thereof—to help provide health care for those who cannot pay for it completely on their own.  Here are two.

Last week in an Op-Ed piece in the Los Angeles Times titled “‘Obamacare’ to the Rescue,” cancer patient Spike Dolamite Ward described her change of heart towards Obama after being diagnosed, three weeks earlier, with third-stage breast cancer. Ward describes how traumatized she and her husband had been on learning the news of her disease. Both had been thriving financially before her husband lost his job several years ago. Although her husband subsequently found work, their financial stress had deepened with the current floundering economy. Now, it appeared, they faced possible financial ruin. It was then that she realized the value of the Patient Protection and Affordable Care Act, which created a program, the Pre-Existing Condition Insurance Plan, which permits people who have a pre-existing condition to apply for health insurance after a diagnosis, even before more general insurance reforms and the purchase mandate goes into effect in 2014. Before PPACA passed and under current law in most states, insurers could and do refuse to cover such people.

Another recent telling exchange on the topic of society’s obligation to help the unfortunate with their healthcare occurred at Dordt College, a small Christian college based in Sioux Center, a rural town in the Northwest corner of Iowa.

Last Monday, Republican presidential candidate Rick Santorum, formerly a U.S. Senator from Pennsylvania, delivered a talk at Dordt. Santorum’s message championed the value of individual responsibility and how it largely precludes providing aid to the unfortunate, including medical care to the poor. His view was vigorously challenged by Ryan Walters, a student at the college, who said that his reading of the Bible did not square with Santorum’s philosophy.

Referring to a 2009 Harvard study that calculated the number of deaths every year that can be linked to a lack of health care coverage, Walters said that he didn’t “think God appreciates the fact that we have 50 to 100,000 uninsured Americans dying due to a lack of health care every year.”

Click here to view the full story on our site.

Poverty in American and Health Care

Does Society Have a Responsibility to Help the Poor with Health Care? Two Recent Examples from the Debate over this Issue

by Donald Yacoe

 Some important public exchanges of ideas have recently underscored the core debate about society’s responsibility—or lack thereof—to help provide health care for those who cannot pay for it completely on their own.  Here are two.

Last week in an Op-Ed piece in the Los Angeles Times titled “‘Obamacare’ to the Rescue,” cancer patient Spike Dolamite Ward described her change of heart towards Obama after being diagnosed, three weeks earlier, with third-stage breast cancer. Ward describes how traumatized she and her husband had been on learning the news of her disease. Both had been thriving financially before her husband lost his job several years ago. Although her husband subsequently found work, their financial stress had deepened with the current floundering economy. Now, it appeared, they faced possible financial ruin. It was then that she realized the value of the Patient Protection and Affordable Care Act, which created a program, the Pre-Existing Condition Insurance Plan, which permits people who have a pre-existing condition to apply for health insurance after a diagnosis, even before more general insurance reforms and the purchase mandate goes into effect in 2014. Before PPACA passed and under current law in most states, insurers could and do refuse to cover such people.

“If you are fortunate enough to still be employed and have insurance now through your employers, you may feel insulated from the sufferings of people like me right now,” Ward wrote. “But things can change abruptly. If you still have a good job with insurance, that doesn’t mean that you’re better than me, more deserving than me, or smarter than me; it just means that you are luckier, and access to healthcare shouldn’t depend on luck.”

“Fortunately for me,” she continued, “I’ve been saved by the federal government’s Pre-existing Condition Insurance Plan, something I had never heard of before needing it. It’s part of President Obama’s healthcare plan, one of the things that has already kicked in, and it guarantees access to insurance for U.S. citizens with preexisting conditions who have been uninsured for at least six months.”

In the Op-ed, Ward goes on to elaborate on an “apology” to President Obama prompted by her brush with financial catastrophe. She notes that, before learning of the PCIP, she had been so angry at the President for what she felt was his abandonment of the struggling middle class that she had blacked out the “h” on the “Got Hope” in a pro-Obama bumper sticker so that it read “Got nope.”  She concludes: “I’m sorry I didn’t do enough of my own research to find out what promises the president has made good on.”

Ward’s piece was immediately attacked for espousing excessive redistribution and an illegitimate infringement on individual rights. One reader, who wrote a response under the name ExCaliGuy, even slammed her for representing an unconscionable drain on hard working people’s earnings.  : “I’m glad it all worked out for you. And if you or anyone else can’t afford health coverage, just reach into my pocket, pull out my wallet and take whatever else you need. It’s OK. My family and I will just skip another day of meals…”

The sarcastic anger expressed in this comment is one thing, but there are two points here worth making clear to a broader audience.

1)    Despite the political partisanship we are burdened with now and the legitimate debate over the proper role of government, health reform is inextricably a discussion about life and death as illustrated in Ms. Ward’s description of her case.

2)    The critic of the policy that enabled Ms. Ward to get health insurance is expressing a fear that he and his family will be impoverished if we make access to health care a reality for all Americans.  That fear, and others like it, is understandable, if you get all your news and analysis from the echo chamber of the far right in this country.  But if you pay attention or are made aware of the facts, including the testimony from CBO Director Douglas Elmendorf, then you understand that PPACA does not raise payroll or income taxes except for Americans making more than $200,000 (families making more than $250,000), and that the total amount of money PPACA moves around – from Medicare savings and new revenues to enable access to coverage and care to be expanded — is about ¾ of one percent of GDP, hardly in the range of confiscatory taxation.  The fact that people describe it and interpret this degree of redistribution as confiscatory (“skip another day of meals”) says more about our politics than it does about our current health policy, even health reform implementation policy.

Another recent telling exchange on the topic of society’s obligation to help the unfortunate with their healthcare occurred at Dordt College, a small Christian college based in Sioux Center, a rural town in the Northwest corner of Iowa.

Last Monday, Republican presidential candidate Rick Santorum, formerly a U.S. Senator from Pennsylvania, delivered a talk at Dordt. Santorum’s message championed the value of individual responsibility and how it largely precludes providing aid to the unfortunate, including medical care to the poor. His view was vigorously challenged by Ryan Walters, a student at the college, who said that his reading of the Bible did not square with Santorum’s philosophy.

Walters began his remarks saying: “God is very angry toward societies that don’t care for the poor,” adding, “If not for our social programs, how can we as a society care for our poor?”

In a heated rebuttal, Santorum questioned Walters’ assertion and facts, and sought audience support for a very different notion of responsibility, one placing the obligation for health care squarely on the sick.

The student did not back off. Referring to a 2009 Harvard study that calculated the number of deaths every year can be linked to a lack of health care coverage, Walters      said that he didn’t “think God appreciates the fact that we have 50 to 100,000 uninsured Americans dying due to a lack of health care every year.”

Becoming heated, Santorum responded by saying: “People die in America because people die in America. And people make poor decisions with respect to their health and their healthcare. And they don’t go to the emergency room or they don’t go to the doctor when they need to,” he added. “And it’s not the fault of government for not providing some sort of universal benefit.”

Now Santorum has every right to argue that government should not have responsibility for our people’s access to timely health care.  And there is some dispute about how many people die from lack of timely access which they presumably would have had had they had normal health insurance.  The Institute of Medicine and the Urban Institute put the annual death figure at about half the rate estimated in the referenced 2009 study by researchers at Harvard.  But there should be no doubt that scriptures from many different faith traditions have admonished believers to prevent preventable starvation.  As CHPRE Director Len Nichols has written many times before, including articles for Health Affairs,  the New America Foundation, and the Hastings Center, health care today is like food once was, a unique gift capable of sustaining and enriching lives stricken with illness.  Any of us could be stricken with illness, unable to work and maintain their coverage, as Ms. Ward was, and thereby made into the proverbial “stranger,” vulnerable to perish unless the community comes to her aid.

A law like PPACA is not the only way to do this, and that may be Mr. Santorum’s follow-up point someday, but to argue that we collectively have no responsibility for those whose deaths we can prevent without heroic measures, to argue that it is not incumbent upon us to try to find ways to solve the problems of our health care system, and to argue that using government as one of many ways to provide aid to the unlucky is somehow everywhere and always illegitimate—well that is a stance that is far from any ethical framework worth the name.

Len Nichols’ role as editor-in-chief is to plan, review, edit, solicit, and contribute content to inform specialist physicians and the policy community generally about new incentive arrangements as they are implemented and proposed in both the public and the private sectors. This is a joint project of the American College of Cardiology and the American Journal of Managed Care .

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