Tagged Chronic Disease Care

Drop In Sudden Cardiac Arrests Linked To Obamacare

If 22 million Americans lose their health care coverage by 2026 under the GOP Senate’s plan to repeal and replace the Affordable Care Act, how many people could die? The question is at the heart of the debate raging in Washington, D.C., but has been difficult to answer.

“Show me the data on lives saved by Obamacare, please,” conservative political scientist Charles Murray requested in a recent tweet.

A pilot study published Wednesday in the Journal of the American Heart Association may provide an answer: Researchers found that the rate of sudden cardiac arrest outside of a hospital dropped by 17 percent among people ages 45-64 in Multnomah County, Ore., after the Affordable Care Act expanded insurance coverage.

The study analyzed sudden cardiac arrest data from the emergency medical system in 2011-12 before the ACA, and compared the data from 2014-15, after insurance coverage expanded. During that time, the percentage of people in Multnomah County with Medicaid coverage nearly doubled, from 7 percent to 13.5 percent.

Cardiac arrest can serve as an early indicator to show how an increase in health insurance coverage under the ACA might affect mortality.

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Each year, about 350,000 people in the United States have a sudden cardiac arrest, in which the heart unexpectedly stops beating. It is one of the most deadly types of heart attacks — only 1 in 10 patients survive it. “It speaks to the importance of predicting and preventing [cardiac arrest], because once it happens, it’s much too late,” said Dr. Sumeet Chugh, medical director of the Heart Rhythm Center of the Cedars-Sinai Heart Institute in California and one of the authors of the study.

The good news is that nearly half of patients experience warning symptoms, offering an opportunity for intervention, said Chugh. Cholesterol and blood pressure medication, diet and exercise, and surgical interventions can all help stave off sudden cardiac arrest. But patients without health insurance might ignore their symptoms and avoid seeing a doctor.

“Imagine that you’re someone with a warning symptom. If you had insurance or access to health care that was relatively easy, you might be more inclined to see a provider. If you didn’t,you might let it go for a while,” said Chugh.

Chugh cautions that the study population was small and did not examine other factors that could have led to a decline in cardiac arrests. Still, it is consistent with other studies that found a link between Medicaid expansion and a decline in mortality. Chugh and fellow author Eric Stecker of the Oregon Health & Science University plan follow-up studies to narrow in on the causes in Multnomah County.

J. Michael McWilliams of the Department of Health Care Policy at Harvard Medical School, who was not involved in the study, questioned the large reduction in cardiac arrests seen in the study, saying it “seems too good to be true.”

Still, he said assessing the effects of health insurance on clinical outcomes like cardiac arrest is notoriously difficult, and there is good evidence that health insurance improves access to care and diagnosis of important conditions.

“I think when we focus on the lack of consensus evidence on the effects of coverage on hard outcomes like mortality, and use that as an argument against covering the uninsured, I think we let perfect be the enemy of good,” McWilliams said.

James Frank (Courtesy of James Frank)

Take James Frank, 64, of Lancaster, Calif., who was uninsured several years ago when he first started experiencing the symptoms of heart disease.

“I couldn’t catch my breath, I was wheezing,” Frank recalled. “I felt like I had like a chest cold. My feet were tingling. I was getting the sweats.” In 2013, Frank had a heart attack and was taken to the emergency room.

He signed up for coverage under Covered California, the state’s health insurance exchange, which opened in 2013 for coverage that began in January 2014. His doctor put him on a statin and blood pressure medication to prevent another heart attack, and he started watching his weight religiously.

Frank was quick to add that the coverage he gained under the ACA has not been perfect — his premium and deductibles are high, and he thinks that Congress should repair it. Still, he believes the health law saved his life. “I had the same heart attack that killed my mother,” he said. “Had it not been for Obamacare, I probably would have had another one.”

Categories: Public Health, Repeal And Replace Watch, The Health Law

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Promises Made To Protect Preexisting Conditions Prove Hollow

Senate Republicans praised the Affordable Care Act replacement bill they presented Thursday as preserving coverage for people with cancer, mental illness and other chronic illness.

But the legislation may do no such thing, according to health law experts who have read it closely.

Built into the bill are loopholes for states to bypass those protections and erode coverage for preexisting conditions. That could lead to perverse situations in which insurers are required to cover chronically ill people but not the diseases they suffer from.

Depending on what states do, plans sold to individuals might exclude coverage for prescription drugs, mental health, addiction and other expensive benefits, lawyers said. Maternity coverage might also be dropped.

Somebody with cancer might be able to buy insurance but find it doesn’t cover expensive chemotherapy. A plan might pay for opioids to control pain but not recovery if a patient became addicted. People planning families might find it hard to get childbirth coverage.

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“The protection your insurance provides could depend a lot on where you live,” said Sabrina Corlette, a research professor at Georgetown University’s Health Policy Institute. In some states, “over time, [patients with chronic illness] might find it increasingly difficult to find insurance companies that will offer plans that cover their needs.”

The Senate provisions aren’t expected to affect job-based health plans or Medicare for seniors. It would mainly affect the kind of insurance sold to individuals through the Affordable Care Act’s online exchanges, which cover about 10 million people.

Obamacare overhauls in both the House and Senate would also limit spending on Medicaid for low-income people, which analysts say would cause coverage losses for millions.

The Senate legislation, expected to be voted on next week, follows a widely criticized House bill that would also overhaul the Affordable Care Act, in its case giving states the option of denying coverage or raising premiums for those with preexisting illness.

On Thursday Republican Senators touted their bill as avoiding those features.

“I feel comfortable that no one is going to be denied coverage because they’ve been sick before,” said Sen. Lindsey Graham (R-S.C.) The bill “doesn’t change [protections for] preexisting illnesses, which is good,” he said.

Not explicitly. But it still gives insurers a potential way to shrink coverage for the chronically ill, albeit less obviously, said health law scholars.

“There’s nothing in the Senate bill that specifically would allow withdrawal of coverage for a person with a preexisting condition,” said Timothy Jost, emeritus law professor at Washington and Lee University in Virginia and an expert on health reform. “What it does do is allow states to get waivers” allowing exceptions to rules requiring comprehensive coverage, he said.

The Affordable Care Act required carriers to offer “essential health benefits” covering a wide range of services including hospitalization, maternity, prescription drugs and mental health.

Both the Republican House bill and the Senate bill would let states change that rule. Under those measures, states could set their own standards that might not be as generous, allowing insurers to exclude benefits for those with preexisting illness.

“The Senate bill guarantees people with preexisting conditions access to insurance at the same rate as healthy people, but there is not a guarantee that the benefits they need will be covered by insurance,” said Larry Levitt, a senior vice president at the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

Obamacare, too, allows states to make exceptions for essential health benefits — but with strict limits. Coverage must be at least as comprehensive as the federal standard, for one thing. The Senate bill contains no such safeguard.

“As long as they can show that it’s budget neutral, states would have a lot of latitude” to cut essential benefits, said Christopher Koller, president of the Milbank Memorial Fund and a former Rhode Island insurance commissioner.

Insurance plans for individuals might again start to look as they did in the days before Obamacare, when they typically excluded coverage for maternity, mental health and substance abuse, the health policy expert said.

For their part, insurers may heavily pressure states to make such changes, analysts said.

Unlike the Affordable Care Act and the House bill, the Senate bill contains no incentives or inducements for healthy people to maintain medical coverage. That could result in a disproportionately sick group of people buying individual insurance, driving up carriers’ costs and prompting them to seek ways to trim coverage and cut claims.

“If the only people motivated to buy insurance are going to be the ones who really need it, insurers are really going to have a strong incentive to use their benefit design to deter enrollment for the sickest people,” said Corlette.

Categories: Cost and Quality, Insurance, Mental Health, Repeal And Replace Watch, States, The Health Law

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Survivors Of Childhood Diseases Struggle To Find Care As Adults

Rachael Goldring was born with congenital heart disease. Had she been born a few decades earlier, she probably would have died as a baby. Now 24, Goldring is part of a population of patients who present new challenges to a health care system unaccustomed to dealing with survivors of once-fatal conditions.

There are now more adults than kids living with some of these diseases, and medical training lags behind. Young adults who can’t find suitable doctors may drop out of care, and their conditions may worsen.

Goldring’s condition was pulmonary atresia with tetralogy of Fallot. She was born without a pulmonary valve directing blood from her heart to her lungs. It’s the condition that talk show host Jimmy Kimmel’s baby was born with this spring.

“I had my first surgery when I was 9 months,” Goldring said. “Now, they do it from birth.”

Her condition has also meant three more surgeries, a heart valve replacement, complicated secondary diseases and a lifetime in and out of doctors’ offices. “I just celebrated my one-year anniversary of staying out the hospital for the first time since birth,” she said. “So, this year, knock on wood, it’s been amazing.”

But she fears it might not last. Right now, she’s in limbo between pediatric and adult medical care. For Goldring, finding a good doctor could be a matter of life and death.

Today, congenital heart disease survivors can live well past childhood. Dr. Patrick Burke, a pediatrician at Valley Children’s Healthcare in Madera, Calif., said other once-fatal ailments like sickle cell disease and spina bifida have undergone similar advances.

“This is the so-called medical miracle promised to our parents and grandparents,” Burke said, adding that miracle kids like Goldring grow up to be complicated adults. “The job’s not done after the surgery or the initial treatment. Many if not most of these conditions require ongoing medical care — lifelong medical care.”

Burke is in charge of a new program at his hospital in the new field of “transitional care.” He said many conditions worsen around age 18, just as children age out of pediatric care. For instance, he said, that’s when patients with congenital heart disease suffer complications with their blood and organs. The trend is particularly stark for cystic fibrosis.

“We’re seeing this spike of deaths that are happening in the early 20s. And it’s bizarre,” he said.

Pediatrician Megumi Okumura at the University of California-San Francisco became interested in this transition during her residency in the early 2000s. She would see 40- and 50-year-olds in pediatric wards. The reason, she said, partly lies with our fragmented health care system.

“They are transferring from differing systems of care,” she said. “We have siloed pediatric-based care to adult-based care. We have different funding streams and programs.”

Now, Okumura and other researchers are looking for ways to remove what she considers artificial barriers. Clinics around the world are trying out new strategies like giving non-pediatric doctors more training or bringing in transitional specialists to connect chronically ill young adults with new providers.

Goldring is fortunate in that she can remain with her pediatrician until she finds the right adult provider. She’s working on the transition, but at the moment, she’s much more focused on another transition: She’ll get married in October.

This story is part of a partnership that includes Valley Public Radio, NPR and Kaiser Health News.

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