Tagged Cost and Quality

Research Roundup: Early Hospital Discharges; Missed Vaccinations; Growth In Spending

Each week, KHN compiles a selection of recently released health policy studies and briefs.

JAMA Surgery: Costs And Consequences Of Early Hospital Discharge After Major Inpatient Surgery In Older Adults
Do fast-track discharge protocols and shorter postoperative length of stay after major inpatient surgery reduce overall surgical episode payments, or are there unintended increased costs because of postdischarge care? … In a cross-sectional cohort study of 639 943 risk and postoperative complication–matched Medicare beneficiaries undergoing colectomy, coronary artery bypass grafting, or total hip replacement, hospitals with shortest routine postoperative length of stay achieved lowest overall surgical episode payments and did not offset shorter hospital stays with greater postdischarge care spending. (Regenbogen et al., 5/17)

Annals of Internal Medicine: Missed Opportunities for Measles, Mumps, Rubella Vaccination Among Departing U.S. Adult Travelers Receiving Pretravel Health Consultations
40 810 adult travelers were included [in an observational study in U.S. pretravel clinics]; providers considered 6612 (16%) to be eligible for MMR vaccine at the time of pretravel consultation. Of the MMR-eligible, 3477 (53%) were not vaccinated at the visit; of these, 1689 (48%) were not vaccinated because of traveler refusal, 966 (28%) because of provider decision, and 822 (24%) because of health systems barriers. Most MMR-eligible travelers who were not vaccinated were evaluated in the South (2262 travelers [65%]) or at nonacademic centers (1777 travelers [51%]). Nonvaccination due to traveler refusal was most frequent in the South (1432 travelers [63%]) and in nonacademic centers (1178 travelers [66%]). (Hyle et al., 5/16)

Urban Institute/Robert Wood Johnson Foundation: The Evidence On Recent Health Care Spending Growth And The Impact Of The Affordable Care Act
Conventional wisdom holds that health care cost growth is high and the Affordable Care Act (ACA) has done little to address the problem. However, overall increases in national health expenditures (NHE) since the law passed have been lower than anticipated, premiums and premium growth in the ACA’s health insurance marketplaces are high in some states but quite low in others, and growth in Medicare and Medicaid spending per enrollee has been very modest. NHE are still high, now at 18.3 percent of gross domestic product …. In this brief, we attempt to address several misconceptions about recent spending increases; these misconceptions are centered in three areas: the recent and projected growth in NHE the levels and recent growth of ACA marketplace premiums the recent and projected spending growth in the Medicaid program. (Holahan et al., 5/25)

Urban Institute: Medicaid/CHIP Participation Rates Rose Among Both Children And Parents In 2015
Using the 2013-2015 American Community Survey, this brief finds improvements for both parents and children in uninsurance, Medicaid/CHIP participation, and the number who are eligible for Medicaid/CHIP but not enrolled. Uninsurance fell nationally and in nearly every state, and the number of eligible but uninsured children fell to 2.1 million – declining by over half since 2008. Children’s participation reached 93.1 percent in 2015 (exceeding 90 percent in 36 states), while participation among parents rose to 80.2 percent, with larger gains between 2013 and 2015 in expansion states than nonexpansion states. Participation grew among every subgroup of children and parents examined. (Kenney et al., 5/17)

The Kaiser Family Foundation: Financing Family Planning Services For Low-Income Women: The Role Of Public Programs
Medicaid, the Title X Family Planning Program, and Section 330 of the Public Health Service Act (PHSA) are the leading sources of federal funding for the over 10,000 safety-net clinics across the country that provide reproductive health services to low-income women, men, and teens. The Trump administration and the Republican leadership of the 115th Congress have proposed to block federal Medicaid funds from going to Planned Parenthood …. Changes to these programs and funding to the clinics that provide family planning services could limit the availability of contraceptive services, STI screenings and treatment, and preventive cancer screenings, along with other primary care services to low-income women. … One in three low-income women reported that they obtained birth control from a family planning clinic such as Planned Parenthood or another health center or public health clinic. (Ranji et al., 5/11)

This is part of the KHN Morning Briefing, a summary of health policy coverage from major news organizations. Sign up for an email subscription.

State Highlights: Calif. Legislature Steps Into Tense Fight Over Tobacco Tax; Mass. Agency Finds Avoidable ER Visits Are Driving Up Costs

Media outlets report on news from California, Massachusetts, Connecticut, Ohio, Kansas, Minnesota, Louisiana, Texas, Georgia, Maryland, Arizona, Florida.

Los Angeles Times: California Senate, Assembly Advance Their Own Plans On How To Spend Tobacco Tax Revenue
Perhaps the biggest budget skirmish that remains unsolved this year is how California should spend revenue from the tobacco tax voters approved last fall. Gov. Jerry Brown wants to put that money to expand overall spending on Medi-Cal, which provides subsidized healthcare for the poor. But the some of initiative’s backers, namely doctor and dental groups, have cried foul, arguing that money is meant to go to increasing payments for providers. (Mason, 5/25)

WBUR: Tip No. 1 For Taking Charge Of Mass. Health Care Costs: Avoid The ER 
Forty-two percent of emergency room visits in Massachusetts in 2015 were for problems that could have been treated by a primary care doctor, according to the state’s Health Policy Commission. This state agency, which is charged with driving down costs, says a 5 percent cut in avoidable emergency room trips would save $12 million a year; 10 percent fewer such visits would save $24 million. (Bebinger, 5/25)

The CT Mirror: Advocates: Disabled Children Stranded In CT Hospital ERs 
Insufficient services, a complex funding system and deep state budget cuts have increasingly stranded developmentally disabled children in hospital emergency departments over the past year, often for weeks at a time, two state advocates told legislators Thursday. Sarah Eagan, Connecticut’s child advocate, and Ted Doolittle, the state’s healthcare advocate, said the problem is centered almost exclusively on children with “complex diagnoses,” meaning they face a combination of developmental and intellectual disabilities and mental health conditions. (Phaneuf, 5/25)

Cleveland Plain Dealer: Lawmakers Hear Opposition To Lead Amendment From Doctors, Parents, Elected Officials And Healthy Home Advocates
Doctors, parents, city leaders and healthy home advocates took turns Wednesday telling the Ohio Senate Finance subcommittee on Health and Medicaid why they oppose an amendment to the state budget that would strip municipalities of authority to create local efforts to address childhood lead poisoning… Rep. Derek Merrin, a Republican who represents parts of Lucas and Fulton counties, proposed the amendment last month and has argued that a fractured system of rules that change from city-to-city is not only unfair to landlords but doesn’t give all children in Ohio equal protection from lead exposure. (Dissell and Zeltner, 5/25)

Los Angeles Times: No One Knows How Many Untested Rape Kits There Are In California. This Bill Aims To Fix That
ens of thousands of rape kits are sitting on shelves in police and sheriff’s department evidence rooms nationwide. And no one has tested them to see what crimes they could help solve. A bill by Assemblyman David Chiu (D-San Francisco) would help determine how many of those unanalyzed exam kits exist in California, part of a national backlog that federal officials have grappled with for nearly two decades. (Ulloa, 5/26)

KCUR: Kansas Crisis Centers Say New Law Creates Mental Health Funding Need 
A new law will allow Kansas crisis centers to treat involuntary mental health patients for up to 72 hours, but it isn’t clear if lawmakers will fund it. Gov. Sam Brownback on Wednesday signed House Bill 2053, which allows crisis centers to treat people deemed a danger to themselves or others because of a mental health or substance use disorder. The bill had passed the House unanimously and passed the Senate 27-12 after some amendments. Lawmakers didn’t allocate funding for additional crisis center beds before they left for the Memorial Day weekend, although they have yet to finalize a budget. (Wingerter, 5/25)

California Healthline: For California Hospitals That Don’t Pass Quake Test, Money’s Mostly At Fault
With a state deadline looming, some California hospitals still need to retrofit or rebuild so that their structures can withstand an earthquake — and money remains a challenge. Some hospital officials are turning to voters to raise money, while others are pursuing more innovative financing schemes.About 7 percent of the state’s hospital buildings — 220 — are still designated as having the highest risk of collapse following an earthquake, according to the Office of Statewide Health Planning and Development. That’s a slight drop from 251 buildings a year ago. (Ibarra, 5/26)

The Star Tribune: HCMC Seeks To Ease Patient Bottlenecks With New Mental Health Crisis Center
To ease chronic bottlenecks in countywide mental health services, Hennepin County Medical Center (HCMC) is nearing completion of a new 16-bed home that will help people with mental illnesses transition back into the community after acute hospital stays. The Victorian-style home, located at 3633 Chicago Av. in south Minneapolis, will provide short-term housing and treatment for adults who are stable enough to be discharged from a hospital psychiatric unit but who may need more therapy and social support before returning to their regular homes and jobs. (Serres, 5/25)

New Orleans Times-Picayune: She Saved $3,786 By Shopping Her MRI; Here’s How You Can Save, Too 
It was only after her doctor recommended she get an abdominal MRI that a New Orleans woman learned just how costly it can be to have a medical procedure without first shopping around. The woman, who asked to remain anonymous in order to discuss her health, said her doctor suggested the MRI to help her understand a hereditary condition that might affect her years from now. A month later, the day before the test, she got a call from Tulane Medical Center asking how she planned to pay for it, she said. (Lipinski and Zurik, 5/25)

Texas Tribune: Behind Closed Doors, Texas Lawmakers Strip Funding For Sex Trafficking Victims
In recent private negotiations between the Texas House and Senate about which public programs to fund and how to fund them, state lawmakers opted to kill a $3 million initiative to rehabilitate victims of sex trafficking. That ended hopes from child welfare advocates that 2017 would be the first year in recent memory in which state lawmakers might set aside funds specifically intended to help victims who were sold for sex. (Waltersn, 5/25)

Cleveland Plain Dealer: AxessPointe Offers Healthcare Clinic For North Hill Refugees, Immigrants 
To serve the refugee community in Akron’s North Hill, AxessPointe Community Health Centers will provide a weekly healthcare clinic at the Exchange House. The Exchange House, created by the Better Block Foundation, serves as a community center for the large refugee population, predominantly Bhutanese, which travels mostly on foot and has a large number of children and senior citizens. (Conn, 5/25)

Georgia Health News: Not Just A School Clinic, But A Clinic That’s At A School
Five days a week, a team of nurses and a rotating cadre of pediatricians, nutritionists and dentists at the Gilbert Community Clinic see not just schoolchildren but Walker County residents of all ages… Although the idea of a general medical clinic on the grounds of a public school sounds novel, it’s not a new idea in Georgia. (Park, 5/25)

Georgia Health News: Meals On Wheels: Volunteers Deliver Food As They Fret About Funding
Last year, Meals on Wheels programs brought nearly 4 million meals to 28,000 seniors living in Georgia. But federal support for this program could shrink under President Trump’s proposed budget. If the federal portion of funding for the program is cut, the effects will reverberate in tiny towns like Chickamauga, where Betty Richardson delivers lunches every week. (Male, 5/25)

The Baltimore Sun: Emerging Hopkins Center Harmonizing Music And Medicine 
[Alex] Pantelyat, 34, a Johns Hopkins University neurologist (and, not so incidentally, an accomplished violinist) is a co-founder and co-director of the Center for Music & Medicine, an emerging collaboration between the Johns Hopkins medical community and the Peabody Institute. The mission, he said, is to combine the expertise of faculty members in both camps toward a pair of ends: integrating music and rhythm into medical care and improving the health of musicians worldwide. More than 80 Johns Hopkins faculty members across dozens of disciplines have affiliated themselves with the center, the first of its kind in the eastern United States. (Pitts, 5/26)

Arizona Republic: What To Know As Arizona’s Mandatory Paid Sick-Leave Law Takes Effect
Arizona’s new law mandating paid sick leave starts July 1, and employers had better be prepared for it. Businesses and non-profit groups could face penalties for failing to keep adequate records or post sufficient notice, and they could incur damages for failing to provide paid sick time. Employers who retaliate against workers exercising their rights could face fines of at least $150 per day, say attorneys at Gallagher & Kennedy, a Phoenix law firm that held a workshop to alert employers of the requirements. (Wiles, 5/25)

Miami Herald: Valley Children’s Hospital Has Volunteer Baby Cuddling Program 
Lynne Meccariello, unit support supervisor of the neonatal intensive care unit and a liaison for the hospital’s volunteer services department, describes the cuddling program as providing “developmental care and comfort to babies when their parents can’t be there.” Meccariello says holding a sick baby reduces pain and provides warmth, and the cuddler encourages “self-soothing” – children’s ability to comfort themselves when they aren’t being held. (George, 5/25)

This is part of the KHN Morning Briefing, a summary of health policy coverage from major news organizations. Sign up for an email subscription.

Viewpoints: Sessions’ War On Drugs; Contemplating Rural Hospitals; Packing Heat At Kansas’ Psychiatric Institutions, State Facilities

A selection of opinions on health care from around the country.

Detroit Free Press: Sessions’ Policies Stand To Destroy Minority Communities
U.S. Attorney General Jeff Sessions has announced he’s reigniting the “war on drugs,” ordering prosecutors to seek the toughest possible charges and sentences, even for minor drug crimes. What he’s really doing is declaring war on people of color, because his harsh policies will eviscerate struggling black and brown families across America. He is resurrecting a war that has destroyed generations of minority families without eradicating the commerce of illegal drugs or Americans’ appetite for them. (Benjamin Crump, 5/25)

JAMA Forum: Rethinking Rural Hospitals
Since 2010, 78 of the more than 2150 rural nonspecialty US hospitals have closed. While the closure rate has recently declined, the proportion of financially struggling rural hospitals has increased. When a rural hospital closes, the economic losses can devastate an already stressed community through loss of health care workers, emergency services, and primary care capacity, as well as higher unemployment and lower per-capita income, a drop in housing values, poorer health, and increasing health disparities. An urgent look at how to prevent these closures is merited, but it may also be time to rethink what a rural hospital should be. (Diana Mason, 5/24)

The Kansas City Star: Concealed Weapons Likely Are Coming To A Kansas Institution Near You
Hey, Kansans: Brace yourselves. Your state is about to change in a consequential way. Barring the unexpected, concealed weapons soon will be allowed in state hospitals, psychiatric institutions and on the state’s public university campuses. That’s happening in just 38 days unless pro-common-sense lawmakers pull a rabbit out of their hats and muscle through a new law. But that looks increasingly unlikely as the Legislature struggles with big issues in its ongoing wrap-up session. (5/24)

JAMA Forum: Payment Power To The Patients
There is broad consensus that the quality of care that is delivered in the United States is uneven and too often inadequate. For more than a decade, the approach to remedying deficiencies in health care quality has been through measurement, incentives, and accountability. But now consensus is emerging that efforts have not worked particularly well, and that doing more of the same is unlikely to lead to progress. It may be time to try a radically simple idea: let patients decide what comprises high-quality health care. (Ashish K. Jha, 5/22)

The New York Times: Get Married, Get Healthy? Maybe Not.
In a nation as divided and contentious as our own, it is rare to find a belief we all share. But trust in the transformative power of marriage is close to universal — and it has endured for decades. This isn’t just a matter of faith, we’ve been assured. It’s science. Research is said to have established what our fairy tales promised: Marry and you will live happily ever after. And you will be healthier, too. A new study challenges the claim that people who marry get healthier. (Bella DePaulo, 5/25)

JAMA: Finding Joy In Practice: Cocreation In Palliative Care
Four years ago, after nearly 20 years in practice, I walked out of the familiar world of infectious disease and into the world of palliative care. In the world I left, I cared for hundreds of patients, educated countless learners, led dozens of infection prevention efforts. But that world felt increasingly superficial, fragmented, isolated, a hard place to find joy and meaning in my work. (Kathryn B. Kirkland, 5/23,30)

The Columbus Dispatch: Treatment At Hospital Follows ‘Catholic Tradition’
A hospital policy with wide-ranging consequences for patients of Mercy Medical Center in Des Moines, Iowa, was made public recently through a Facebook post on a page for mothers. It came from a woman who was denied a tubal ligation after having a cesarean section because Mercy is a Catholic hospital. In verifying that prohibition, I discovered other religious-based restrictions at Mercy and 547 other Catholic hospitals across the U.S., which make up 14.5 percent of all acute care hospitals in the country. It raises a question of whether these institutions are fulfilling their legal and professional obligations to their patients and the taxpayers who subsidize them with billions of dollars. (Rekha Basu, 5/25)

St. Louis Post-Dispatch: The Immediate Need For Action On Life
The Missouri Legislature has for many years demonstrated a commitment to protecting the health and safety of women and the dignity of the unborn, passing various laws to further these ends. A number of recent developments, though, have dealt serious blows to these laws and merit immediate attention in a special session of the Legislature. On Monday, the maternity home Our Lady’s Inn, Archdiocesan Elementary Schools of the Archdioceses of St. Louis, and St. Louis businessman Frank O’Brien filed a federal lawsuit against the “abortion sanctuary city” ordinance passed by the city of St. Louis in February. As the plaintiffs note, the bill, which purports to be an anti-discrimination ordinance for those making “reproductive health decisions,” is so broad that it would “force nonprofit organizations like Our Lady’s Inn, whose mission is to promote and facilitate abortion alternatives, to hire abortion advocates, despite their opposition to the ministry’s reason for existence.” (State Sen. Bob Onder, 5/25)

This is part of the KHN Morning Briefing, a summary of health policy coverage from major news organizations. Sign up for an email subscription.

State Highlights: Vt. Gov. Vetoes Pot Bill; Pa. Gov. Taps Teresa Miller To Head Proposed Health And Human Services Department

Media outlets report on news from Vermont, Pennsylvania, New York, Minnesota, Massachusetts, Texas, California, Virginia and Arizona.

WBUR: Vermont’s Governor Vetoes Recreational Pot Bill
Vermont Governor Phil Scott, a Republican, said on Wednesday he was vetoing a bill to legalize marijuana, and sending it back to the legislature for changes… Though he said he views the issue “through a libertarian lens,” Scott vetoed the bill due to concerns about detecting and penalizing impaired drivers, protecting children, and the role and makeup of a Marijuana Regulatory Commission. (Wamsley, 5/24)

The Philadelphia Inquirer: Nominee For New Pa. Health And Human Services Dept. Digging In
Teresa Miller, nominated Tuesday by Gov. Wolf to be the inaugural secretary of the proposed Pennsylvania Department of Health and Human Services, said she is a big believer in her boss’s “government that works” mantra.“…Advocates worry that initiatives, such as heightened oversight of nursing homes by the Department of Health, could fizzle because of the proposed consolidation of the departments of health, human services, aging, and drug and alcohol programs. (Brubaker, 4/24)

ProPublica: In A Lonely Corner Of Coney Island, A Fight Over Care For The Vulnerable 
Today, Oceanview has taken on a distinctive role in the latest act of the legal saga surrounding the adult homes. Lawyers for the adult home industry have sued the state on behalf of a single former resident at Oceanview, a man who had taken advantage of the judge’s plan and moved into alternative housing, but who the lawyers say now wants to return. The man missed his friends and the conveniences of the Coney Island neighborhood, the lawyers argue. (Sapien, 5/24)

The Star Tribune: Annandale Nursing Home Is Faulted In Patient’s Death 
An Annandale nursing home resident developed internal bleeding and died after being denied crucial blood-thinning medication for 15 days, according to a state investigation that blamed the death on the facility’s procedural shortcomings. The state Health Department’s investigation into the stroke patient’s Nov. 28 death concluded that the nonprofit Annandale Care Center “had no system, policies or procedures in place” to ensure that certain medications and some other services were being provided as prescribed. (Walsh, 5/24)

Boston Globe: Surgeon Who Raised Concerns About Double-Booked Surgeries Faced Retaliation, Judge Rules 
A prominent Boston neurosurgeon was illegally forced out of his previous job at a New York hospital for strongly objecting to a policy that allowed another surgeon to perform complex spine surgeries on two patients simultaneously, a judge ruled. Double-booking, as the practice is sometimes called, triggered a fierce dispute among doctors at Massachusetts General Hospital in recent years, leading to the 2015 dismissal of an orthopedic surgeon who opposed it. But Dr. James Holsapple may be the first doctor to win a lawsuit alleging he faced retaliation for challenging the practice. (Saltzman, 5/24)

The Star Tribune: 26 Patients Die After Upgrading Abbott Blood Pump At Home 
At least 26 patients in advanced heart failure have died after replacing the controller for an Abbott Laboratories blood pump while out of the hospital. Abbott has issued an alert for 28,882 HeartMate II controllers that includes new software and alarm guides, after reports of 70 incidents in which the life-preserving device malfunctioned after a patient changed out the controller at home. Those incidents included 26 deaths and 19 injuries. (Carlson, 5/24)

Austin American-Statesman: Texas Senate Approves Priority House Bills To Address Foster Care Woes
The Texas Senate unanimously passed a priority House bill Wednesday that would make several changes to the foster care system, including keeping children at risk of entering foster care with their parents. House Bill 7, filed by Rep. Gene Wu, D-Houston, would, among several other provisions, bar a court from taking children away from parents on the grounds that they home-schooled their children, were economically disadvantaged, had reasonably disciplined their children or had been charged with a nonviolent misdemeanor. (Chang, 5/24)

San Jose Mercury News: Second Botulism Death Unrelated To ‘Extremely Rare’ Nacho Cheese Botulism 
The country’s foremost researchers on botulism in dairy products are calling the recent outbreak at a gas station in Walnut Grove a “perfect storm” of circumstances that left one dead and nine sickened… Although extremely rare, Northern California has seen two deaths from foodborne botulism in the last few months. Within the last month, Napa County has had one death from botulism related to canned goods, according to county health officials. (Davis, 5/24)

San Francisco Chronicle: Nearly 1 In 4 San Franciscans Struggle With Hunger 
According to the SF-Marin Food Bank, 23 percent of San Francisco residents struggle with hunger. The number is a striking amount, and much higher than the city’s homeless population, which the city said was 6,886 in 2015 (though others estimate it to be much higher), making it less than 1 percent of the population. (Duggan, 5/24)

Richmond Times-Dispatch: McAuliffe Signs Bill On Jail Deaths Related To Jamycheal Mitchell On Same Day Portsmouth Prosecutor Requests Special Grand Jury Into His Death At Hampton Roads Regional Jail 
In the name of Jamycheal Mitchell on Wednesday, the state’s highest elected official signed a bill in Richmond strengthening oversight of Virginia’s 60 local and regional jails, and a prosecutor in Portsmouth requested a special grand jury convene to investigate how the mentally ill 24-year-old wasted away behind bars… Still, no information has been provided publicly that explains what led to Mitchell’s death. His family has said he was physically healthy but had been diagnosed with schizophrenia and bipolar disorder. (Kleiner, 5/24)

Richmond Times-Dispatch: ‘This Is A Public Health Epidemic:’ Experts Speak To State Commission On Preventing Childhood Trauma In Virginia
Childhood traumatic experiences have strong links to dozens of adult health conditions, such as HIV, heart disease and cancer. In states that track such data, childhood trauma is considered a cause in between 11 and 89 percent of those health conditions. On average, whenever a toxin impacts more than 10 percent of health conditions, awareness grows and lawmakers, advocates and public health officials become interested in how to stop it to save lives, said Allison Sampson-Jackson. (O’Connor, 5/24)

Arizona Republic: Would Legalizing Marijuana Bring Money To Arizona Schools?
A fact sheet presented by the anti-marijuana group Arizonans for Responsible Drug Policy, which helped defeat Prop. 205 last November, mentions projected social costs outweigh the revenue provided by legalization… Merilee Fowler, vice chair of ARDP, said via email that “there are many unintended consequences of legalization that produce costs for the state.” (Jarvis, 5/24)

This is part of the KHN Morning Briefing, a summary of health policy coverage from major news organizations. Sign up for an email subscription.

Millions Of Ill People May Face ‘Extremely High Premiums’ Under House Bill, CBO Says

The Republican overhaul of the federal health law passed by the House this month would result in slightly lower premiums and slightly fewer uninsured Americans than an earlier proposal. But it would leave as many as one-sixth of Americans living in states where older and sicker people might have to pay much more for their health care or be unable to purchase insurance at all, the Congressional Budget Office said Wednesday.

In some states, said the report, “less healthy people would face extremely high premiums, despite the additional funding that would be available” in the bill to help offset those increases.

The report incorporates the changes to the bill made just before it narrowly passed the House on May 4. Those changes included an amendment offered by Rep. Tom MacArthur (R-N.J.) that would let states waive some key provisions of the health law, including requirements to cover “essential health benefits” and to offer insurance to people with preexisting conditions at no extra cost.

CBO said the current version would result in savings of $119 billion over 10 years and 23 million more uninsured people than would be expected under the current law.

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According to the estimate, premiums would be slightly lower than under the Affordable Care Act, but mostly because “the insurance, on average, would pay for a smaller proportion of health care costs.”

Prior to the changes, the CBO estimated that the bill would result in savings of $150 billion over the next decade and grow the number of uninsured Americans by 24 million. That dollar figure was a considerable change from the original version of the bill that CBO said would have saved $337 billion, but lawmakers decided to spend back some of those savings on help for those likely to be cut off from insurance.

The two earliest versions of the bill could not muster enough support for the House leadership to bring them to a vote on the floor. Later, MacArthur and leaders of the conservative Freedom Caucus negotiated changes that they said should help bring down premium costs for consumers. That is the bill approved and now evaluated by CBO.

The CBO also estimated that in states deciding to take the option to waive requirements related to charging sicker people more, “the nongroup market would start to become unstable.” In particular, said the report, “people who are less healthy (including those with preexisting or newly acquired medical conditions) would ultimately be unable to purchase comprehensive nongroup health insurance at premiums comparable to those under current law, if they could purchase it at all.”

And in states that chose to waive the requirements for essential benefits, even people with insurance “would experience substantial increases in what they would spend on health care,” because their policies might no longer cover expensive treatments like those for maternity care or mental health and substance abuse.

Despite repeated claims from President Donald Trump and congressional Republicans that the Affordable Care Act is collapsing, the CBO specifically said that the market would continue “to be stable in most areas” under current law. It predicted the same for the original version of the House bill.

In fact, the only place the CBO specifically said the individual insurance market might become unstable is in states that decide to waive the ACA’s coverage requirements. It did not guess which states might do that, but the report says that one-sixth of the population could be subject to that instability.

“What is clear is that these waivers make life much, much worse for people with preexisting conditions, for older people, for sicker people,” said Aviva Aron-Dine, a senior fellow at the Center on Budget and Policy Priorities and former Obama administration health staffer.

The savings in the bill are mostly the result of capping federal funding to states for the Medicaid program for those with low incomes and scaling back the tax credits that help some people with low and modest incomes pay for private insurance. An estimated 14 million of the 23 million people who would no longer have insurance would otherwise have obtained it through Medicaid.

The bill would also repeal nearly all the taxes imposed in the ACA to pay for the new benefits, including taxes on wealthy individuals and much of the health industry.

Reaction to the new estimate fell mostly along predictable party lines.

“CBO continues to find that through our patient-focused bill, premiums will go down and that our reforms will help stabilize the market,” said a statement from House Energy and Commerce Committee Chairman Greg Walden (R-Ore.) and its health subcommittee chairman, Michael Burgess (R-Texas).

By contrast, Rep. Steny Hoyer (D-Md.) said the new estimate shows “TrumpCare will kick millions of Americans off their insurance coverage and force consumers to pay more for less.”

But the reaction was not completely partisan. Sen. Bill Cassidy (R-La.), a key swing vote in the Senate, said that “Congress’s focus must be to lower premiums with coverage which passes the Jimmy Kimmel test,” referring to the late-night host’s tearful monologue about the health problems of his newborn son. The House-passed bill, he said, “does not. I am working with Senate colleagues to do so.”

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

Millones de personas enfermas enfrentarían primas altísimas, según nuevo informe

El informe de la Oficina de Presupuesto del Congreso (CBO) conocido el miércoles 24 de mayo indicó que, bajo el proyecto de salud republicano aprobado por la Cámara Baja a principios de mes, millones de personas tendrían que pagar mucho más por su atención médica, o incluso no podrían siquiera solventarla.

En algunos estados, dijo el informe, “las personas menos saludables se enfrentarían a primas muy altas, a pesar de la financiación adicional que estaría disponible” bajo el proyecto de ley para ayudar a compensar esos aumentos.

El informe incorporó los cambios al proyecto hechos justo antes de aprobarse el 4 de mayo. Esos cambios incluyeron una enmienda ofrecida por el representante Tom MacArthur (republicano de New Jersey) que permitiría a los estados renunciar a algunas disposiciones claves de la ley de salud, incluyendo los requisitos para cubrir los “beneficios esenciales de salud” y para ofrecer seguro a las personas con condiciones preexistentes sin costo adicional.

La CBO dijo que la nueva versión del proyecto de ley resultaría en un ahorro de $119 mil millones en 10 años y que habría 23 millones de personas más sin seguro, comparado con las estimaciones bajo la ley actual.

Según la estimación, las primas serían ligeramente más bajas que las de la Ley de Cuidado de Salud Asequible (ACA), en especial porque “el seguro, en promedio, pagaría una proporción menor de los costos de atención médica”.

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Antes de los cambios, la CBO había estimado que el proyecto de ley daría lugar a ahorros de $150 mil millones en la próxima década y aumentaría el número de estadounidenses sin seguro médico en 24 millones. Esa cifra en dólares fue un cambio considerable respecto a la versión original del proyecto de ley que la CBO dijo que habría ahorrado $337 mil millones, pero los legisladores decidieron gastar parte de esos ahorros en ayuda para aquellos que podrían no poder afrontar el costo de un seguro de salud.

Las dos primeras versiones del proyecto de ley no pudieron reunir suficiente apoyo para que los representantes de la Cámara Baja los sometieran a votación. Más tarde, MacArthur y los líderes del Freedom Caucus negociaron los cambios que, dijeron, deberían ayudar a bajar los costos de las primas (lo que se paga por mes por tener cobertura de salud) para los consumidores. Ese es el proyecto aprobado y que ahora evaluó la CBO.

La CBO también estimó que en los estados que decidan tomar la opción de renunciar a los requisitos relacionados con pagar por las personas más enfermas, “el mercado de los asegurados individuales sería inestable”. En particular, dijo el informe, “las personas menos saludables (con condiciones médicas preexistentes o enfermedades recién diagnosticadas) no podrían, en última instancia, comprar un seguro de salud integral con primas comparables a las de la legislación vigente”.

Y en los estados que optaran por renunciar a los requisitos para los beneficios esenciales, incluso las personas con seguro “experimentarían aumentos sustanciales en lo que gastarían en la atención de la salud”, porque sus planes ya no podrían cubrir tratamientos costosos como cuidados de maternidad, salud mental o abuso de sustancias.

A pesar de las repetidas declaraciones del presidente Donald Trump y de los republicanos del Congreso de que ACA se está derrumbando, la CBO dijo específicamente que el mercado continuaría “siendo estable en la mayoría de las áreas” bajo la ley actual. Predijo lo mismo para la versión original del proyecto de ley de la Cámara Baja.

De hecho, la CBO dijo específicamente que el único lugar en el que el mercado de seguros individual puede llegar a ser inestable es en los estados que decidan renunciar a los requisitos de cobertura de ACA. No predijo qué estados podrían hacer eso, pero el informe dice que una sexta parte de la población podría verse afectada por esa inestabilidad.

“Lo que está claro es que estas exenciones hacen la vida mucho, mucho peor para las personas con condiciones preexistentes, para las personas mayores, para las personas más enfermas”, dijo Aviva Aron-Dine, experta senior del Center on Budget and Policy Priorities y ex miembro del equipo de salud de la administración de Barack Obama

Los ahorros en el proyecto de ley surgen principalmente de limitar la financiación federal a los estados para el Medicaid, el programa que ofrece atención de salud a los más pobres, y de reducir los créditos fiscales que ayudan a algunas personas con ingresos bajos y modestos a pagar por un seguro privado. Un estimado de 14 millones de los 23 millones que ya no tendrían seguro lo habrían podido obtener a través del Medicaid.

El proyecto de ley también derogaría casi todos los impuestos que dispuso ACA para pagar los nuevos beneficios, incluyendo los impuestos a los individuos ricos y a gran parte de la industria de la salud.

La reacción a la nueva estimación fue predecible.

“La CBO continúa encontrando que, a través de nuestro proyecto enfocado en el paciente, las primas bajarán y que nuestras reformas ayudarán a estabilizar el mercado”, dijo en un comunicado el presidente del Comité de Energía y Comercio de la Cámara de Representantes, Greg Walden (republicano de Oregon) y el presidente del subcomité de salud, Michael Burgess (republicano de Texas).

Por el contrario, el representante Steny Hoyer (demócrata de Maryland) dijo que la nueva estimación muestra que “el Trumpcare expulsará a millones de estadounidenses de su cobertura de seguros y obligará a los consumidores a pagar más por menos”.

Pero la reacción no fue completamente partidaria. El senador Bill Cassidy (republicano de Louisiana), un votante clave en el Senado, dijo que “el enfoque del Congreso debe ser primas bajas con cobertura que supere la prueba Jimmy Kimmel”, refiriéndose al emocional monólogo que el conductor de TV hizo sobre los problemas de salud de su hijo recién nacido. El proyecto de ley aprobado por la Cámara, dijo, “no pasa la prueba. Estoy trabajando en eso con los colegas del Senado”.

Categories: Cost and Quality, Noticias En Español, Repeal And Replace Watch, The Health Law


Amazon Mulls Entering PBM Field, Even As These Middlemen Bear Brunt Of Blame Over High Drug Costs

News outlets report on stories related to pharmaceutical pricing.

Stat: Can Amazon Win As A Pharmacy Benefits Manager?
What kind of impact could Amazon have if the ubiquitous company enters the mysterious and complicated world of pharmacy benefit managers? The online retailer is reportedly exploring the pharmacy business and, as part of the plan, may build an internal PBM for its own employees, but later roll this out to the world at large. The possibility is intriguing because it comes at a time when these middlemen — which negotiate with drug makers for favorable insurance coverage — are under varying degrees of financial and political pressure. (Silverman, 5/18)

Stat: US Drug Prices Are So High That Canada Wants Other Countries As Reference Points
How high are drug prices in the US? So high that the Canadian government may remove the US from its long-standing list of countries that are used as a guide for determining whether prices are excessive. In a proposal issued last week, Health Canada said it wants to overhaul the framework used by the Patented Medicine Prices Review Board, which assesses therapeutic benefits and sets ceiling prices. Right now, this is accomplished, in part, by benchmarking prices against what drug makers currently charge in seven other countries — the US, France, Germany, Italy, Sweden, Switzerland, and the UK. (Silverman, 5/22)

The Wall Street Journal: How The FDA Approved A $300,000-A-Year Drug Its Own Experts Didn’t Believe Worked
Jennifer McNary, a stay-at-home mother, was desperate to find a medicine that might spare her two sons an early death from a rare form of muscular dystrophy. Chris Garabedian, the chief executive of a pharmaceutical firm, was desperate to find a profitable drug that would reverse his company’s slow fall. They met in June 2012 at a conference on Duchenne muscular dystrophy and joined forces, often behind the scenes and with little public disclosure, in a yearslong mission to push the government to approve a drug to treat DMD, as it is known. (Pulliam and Mullins, 5/19)

Stat: Generic Hepatitis C Meds Really Are Cost Effective: Study
For the past three years, various governments and patient advocacy groups have clamored for lower-cost hepatitis C medicines, given the high cure rate for these pricey new drugs. Now, a new study finds that upfront treatment with cheaper generic versions can offer a substantial payback. Using a mathematical model for patients in India, researchers found that copycat versions costing around $300 would increase life expectancy by more than eight years and reduce lifetime health care costs by more than $1,300 per person. (Silverman, 5/18)

The Wall Street Journal: FDA Approves Merck’s Keytruda To Treat Cancers With Genetic Defects
The U.S. Food and Drug Administration on Tuesday approved Merck & Co.’s Keytruda drug to treat tumors with a certain genetic defect—the first time the agency has cleared a cancer drug for a use not tied to the site of a tumor. The FDA approved Keytruda to treat tumors with genetic defects known as “microsatellite instability” or “mismatch repair” deficiencies, which are present in an estimated 4% of cancers. Studies showed the drug shrank tumors in a significant number of patients with colorectal and 14 other cancer types that had the genetic defect. (Loftus, 5/23)

CQ Roll Call: House GOP Tries Last-Minute Push For FDA Marketing Change
Republicans are attempting to address a major priority of the drug and medical device industries as part of a bill to fund the Food and Drug Administration, but in so doing risk injecting a controversial issue into what was supposed to be a smooth bipartisan negotiation. The makers of drugs and devices want the FDA to loosen the regulations governing how they can discuss and promote uses of their products that haven’t been explicitly approved. Approved uses are typically identified on a product’s label, but the practice of using drugs or devices in a so-called “off-label” way is common in some areas of medicine where treatment options may be limited, such as for cancer patients or pediatric populations. (Siddons, 5/24)

Stat: FDA Leaps Into Precision Medicine — With Caveats
The many proponents of precision medicine have long promised a world where terms like “lung cancer” and “melanoma” are rendered quaint by the awesome power of genomics. And the FDA, with its latest approval, just endorsed that vision of the future. The agency cleared Merck’s blockbuster cancer drug Keytruda to treat any solid tumor with one of two genetic abnormalities, marking the first time the FDA has granted such an agnostic approval. There are, of course, caveats — the mutations are rare, and Keytruda can be used only after a prior treatment has failed — but it’s a milestone approval nonetheless, and one that will be heartening to some forward-thinking biotech companies. (Garde, 5/23)

Stat: UK Regulator Says Merck Broke Competition Laws Over Biosimilars
The UK antitrust regulator accused Merck of illegally offering discounts for the Remicade biologic medicine in order to block lower-cost biosimilar versions. In a brief statement, the Competition and Markets Authority said it found that the drug maker “provisionally” broke the competition law and was “abusing its dominant position” in the market with its discount scheme. Remicade is used to treat chronic inflammatory diseases such as rheumatoid arthritis. (Silverman, 5/23)

Reuters: India’s Drug Pricing Regulator Clamps Down On Drug Cocktails
India’s drug pricing regulator has demanded explanations from 65 domestic and global drugmakers for selling new forms of essential diabetes and antibiotic drugs without its approval. The move could bring penalties for the drugmakers, among them Abbott Laboratories, Sanofi, Novartis and Indian firms such as Sun Pharmaceutical Industries and Lupin, the National Pharmaceutical Pricing Authority (NPPA) said on its website. (Siddiqui, 5/18)

Reuters: UK Competition Watchdog Accuses Merck Of Obstructing Biosimilars
Britain’s competition watchdog has accused Merck & Co of operating an unfair discount scheme for its medicine Remicade that it said was designed to restrict competition from so-called biosimilar copies. The Competition and Markets Authority (CMA) said on Tuesday it had provisionally found the U.S. company’s European unit, Merck Sharp & Dohme, had abused its dominant position through the scheme, opening it up to potential financial penalties. (Hirschler, 5/23)

Stat: Former Lilly Employee Wins An Ironic Lawsuit Over Disability Benefits
A federal appeals court ruled last week that Eli Lilly should not have ended disability benefits to a former human resources director who claimed she was unable to continue working because she suffered from fibromyalgia, a chronic neurologic condition. Yet at the same time the former employee was fighting in court to have those benefits restored, the drug maker was marketing a medicine in the US to treat the condition, which one of its own consultants had described as “very disabling,” according to court documents. (Silverman, 5/22)

Stat: How A Drug Ad Made Its Way Into ‘General Hospital’
[Anna] Devane is a soap opera character, as you might have guessed, appearing for the last 32 years on “General Hospital.” And her dramatic diagnosis is brought to you by Incyte Corp., a biotech company that happens to market a drug for her on-screen disease, the rare blood disorder polycythemia vera. The scene, which aired in February, is a novel twist on what’s called unbranded advertising, in which drug companies detail the symptoms of a disease but refrain from mentioning the names of any drugs. (Garde, 5/18)

FiercePharma: Drama And Diagnosis On Soap Opera Set Troubles Cancer Doctors, Puts Incyte In Hot Seat
Soap operas often include medical mysteries and miracles, but a couple of real-life doctors are concerned about Incyte’s connection to the latest drama on General Hospital. Writing in JAMA, oncologists Sham Mailankody and Vinay Prasad question the ABC soap opera’s rare-disease plot enabled by a partnership with the biopharma company Incyte. In the General Hospital storyline begun in February, leading character Anna Devane is diagnosed with a rare blood cancer called polycythemia vera (PV). The show doctors explain to the character, who is played by Incyte spokesperson Finola Hughes, that PV is part of a group of rare blood cancers called myeloproliferative neoplasms, and that there are treatments, but no cure. (Bulik, 5/22)

Stat: This Company Admitted Failure — And The Stock Market Rewarded It
Rather than shunning the company, investors embraced it. Only a small number of them cashed out their shares. (The coauthor of the paper who took responsibility for the error returned the stock, but made the shares a donation.) The IPO, delayed by a few weeks, went forward. And within a few years WntResearch stock went on a surge that to date has left it up nearly 500 percent over 6 1/2 years. In other words: Openness was a risk in the short run but a long-term boon for the company. (Oransky and Marcus, 5/23)

This is part of the KHN Morning Briefing, a summary of health policy coverage from major news organizations. Sign up for an email subscription.

State Highlights: Contract Dispute In Ariz. Leaves Many Out Of Network At Dignity Health Hospitals; Texas Lawmakers OK Maternal Health Bills

Media outlets report on news from Arizona, Texas, California, Minnesota, Georgia, Colorado and Florida.

Sacramento Bee: Health Care For Illegal Immigrants Proposed By California Senator
State Sen. Ricardo Lara doesn’t only want to reconstruct the way health care is delivered and paid for in California. As the debate around publicly funded universal health care heats up in the Capitol, Lara is also seeking to expand the state’s low-income health program to undocumented adults up to age 26. (Hart and Miller, 5/23)

Georgia Health News: State AG Backs Wider View Of Records In Hospital Court Fight 
The state’s attorney general has urged the Georgia Supreme Court to reverse a lower court opinion that barred access to Northside Hospital’s financial records. Chris Carr, in office since late last year, said in a Monday court filing that the Georgia Open Records Act is broader in its applications than what Northside Hospital has argued. (Miller, 5/23)

Atlanta Journal Constitution: GA Attorney General Weighs In On Northside Hospital Open Records Case 
Georgia law requires open government even when a private party is carrying out the public’s work, Attorney General Christopher Carr argued in a brief filed Monday in the Northside Hospital open records case before the Georgia Supreme Court… The Georgia Supreme Court asked the Attorney General’s office to file an opinion in the hotly-contested case that started when attorney E. Kendrick Smith requested documents from Northside under the state’s sunshine law. (Teegardin, 5/23)

Texas Tribune: Grieving Mom “Humbled” And “Relieved” After Senate Passes Autopsy Bill 
As the Texas Senate passed a bill on Tuesday that would ensure parents can view their deceased child’s body before an autopsy is conducted, a grieving mother shed tears from the gallery… Currently, parents need permission from a justice of the peace or medical examiner to see their deceased child if his or her death occurs outside a hospital or health care institution. (Mansoor, 5/23)

Austin American Statesman: Texas Senate Approves Bill Aimed At Identifying Postpartum Depression
The Texas Senate on Tuesday approved a bill aimed at increasing identification of postpartum depression among mothers participating in federally backed health care programs for low-income families. Under House Bill 2466 by Rep. Sarah Davis, R-West University Place, mothers who bring their kids in for checkups can get screened for postpartum depression by their children’s pediatricians. (Collins Walsh, 5/23)

Denver Post: New Leadville Hospital Dealt Major Setback After Feds Withhold Loan 
Lake County’s only hospital, St. Vincent in Leadville, has put plans to build a new facility on hold after financial projections came up shorter than expected, indicating the small hospital has recovered from the financial brink but still needs to improve its balance sheet before a much-needed building upgrade. In 2014, the hospital announced it would be shutting down because of critical building repairs and declining revenues, but service cuts and a partnership struck several months later with Centura Health — which also runs St. Anthony Summit Medical Center in Frisco — kept the 138-year-old hospital open. (5/23)

Sacramento Bee: Abortion Reversal Therapy Grows More Popular Despite Doubts
Several California clinics advertise the therapy, claiming to be able to undo the effects of the first dose containing mifepristone, which blocks progesterone production and causes the uterine lining to shed. The second set of pills contains misoprostol, which makes the uterus contract and initiates bleeding and cramping. More than 350 providers nationwide perform abortion reversal therapy, according to proponents of the treatment. (Caiola, 5/23)

Kansas City Star: Kansas Records: Several Hotline Calls Still Didn’t Save Adrian Jones 
The head of Kansas’ child welfare agency said earlier this month that social workers’ last contact with the family of Adrian Jones was in February 2012. But records obtained by The Kansas City Star on Tuesday show that social workers with the Kansas Department for Children and Families investigated a hotline call 10 months later, in December 2012. (Baurer and Woodall, 5/23)

Kansas City Star: Missouri Hospital And Clinic Settle Medicare Fraud Suit 
A Missouri hospital, clinic and infusion center have agreed to pay $34 million to settle a federal lawsuit that alleged they defrauded Medicare. The suit alleged that Mercy Hospital Springfield and its affiliate, Mercy Clinic Springfield Communities, had an improper financial agreement that provided kickbacks to oncologists based on the value of their chemotherapy referrals to the infusion center. (Marso, 5/23)

KQED: Valero Outage Prompts Benicia To Consider Industrial Safety Ordinance 
City officials would have greater oversight over the Valero refinery under a proposal set to be unveiled at the Benicia City Council meeting on Tuesday—a potential reform prompted by the major outage at the facility earlier this month. Mayor Elizabeth Patterson is proposing the city develop regulations similar to those in Contra Costa County, home to several refineries. That county’s industrial safety ordinance, considered to be one of the strongest in the country, requires oil refining facilities to undergo safety audits and have risk management plans. (Goldberg, 5/23)

Miami Herald: John Morgan ‘Prepared To Invest $100M’ In Medical Marijuana 
John Morgan spent nearly $7 million pushing two statewide ballot initiatives to expand medical marijuana throughout the state of Florida. But that’s a drop in the bucket compared to what the wealthy Orlando attorney and possible gubernatorial candidate says he’s prepared to invest in the industry now that it’s about to explode. (Smiley, 5/23)

This is part of the KHN Morning Briefing, a summary of health policy coverage from major news organizations. Sign up for an email subscription.

Putting A Lid On Waste: Needless Medical Tests Not Only Cost $200B — They Can Do Harm

It’s common knowledge in medicine: Doctors routinely order tests on hospital patients that are unnecessary and wasteful. Sutter Health, a giant hospital chain in Northern California, thought it had found a simple solution.

The Sacramento-based health system deleted the button physicians used to order daily blood tests. “We took it out and couldn’t wait to see the data,” said Ann Marie Giusto, a Sutter Health executive.

Alas, the number of orders hardly changed. That’s because the hospital’s medical-records software “has this cool ability to let you save your favorites,” Giusto said at a recent presentation to other hospital executives and physicians. “It had become a habit.”

There are plenty of opportunities to trim waste in America’s $3.4 trillion health care system — but, as the Sutter example illustrates, it’s often not as simple as it seems.

Some experts estimate that at least $200 billion is wasted annually on excessive testing and treatment. This overly aggressive care also can harm patients, generating mistakes and injuries believed to cause 30,000 deaths each year.

“The changes that need to be made don’t appear unrealistic, yet they seem to take an awful lot of time,” said Dr. Jeff Rideout, chief executive of the Integrated Healthcare Association, an Oakland, Calif., nonprofit group that promotes quality improvement. “We’ve been patient for too long.”

In California, that sense of frustration has led three of the state’s biggest health care purchasers to band together to promote care that’s safer and more cost-effective. The California Public Employees’ Retirement System (CalPERS), the Covered California insurance exchange and the state’s Medicaid program, known as Medi-Cal — which collectively serve more than 15 million patients — are leading the initiative.

Progress may be slow, but there have been some encouraging signs. In San Diego, for instance, the Sharp Rees-Stealy Medical Group said it cut unnecessary lab tests by more than 10 percent by educating both doctors and patients about overuse.

A large public hospital, Los Angeles County-University of Southern California Medical Center, eliminated preoperative testing deemed superfluous before routine cataract surgery. As a result, patients on average received the surgery six months sooner.

These efforts were sparked by the Choosing Wisely campaign, a national effort launched in 2012 by the American Board of Internal Medicine (ABIM) Foundation. The group asked medical societies to identify at least five common tests or procedures that often provide little benefit.

The campaign, also backed by Consumer Reports, encourages medical providers to hand out wallet-sized cards to patients with questions they should ask to determine whether they truly need a procedure.

Critics have knocked Choosing Wisely for playing it too safe and not going after some of the more lucrative procedures, such as certain spine operations and arthroscopic knee surgeries.

Daniel Wolfson, chief operating officer at the ABIM Foundation, said the Choosing Wisely campaign has been successful at starting a national conversation about unwarranted care. “I think we need massive change and that takes 15 years,” Wolfson said.

The state effort, dubbed Smart Care California, is in the early stages as well.

Initially, the group has focused on cutting the number of elective cesarean sections, reducing opioid use and avoiding overtreatment for patients suffering low-back pain. In its contract with health insurers, the Covered California exchange requires that their in-network providers meet a range of quality standards, including low C-section rates.

Dr. Richard Sun, co-chairman of the Smart Care group and a medical consultant at CalPERS, said he’s pursuing safer, more affordable treatments for low-back pain, a condition that cost the state agency $107 million in 2015. “One challenge is developing metrics that everyone can agree upon to measure improvement,” he said.

For patients, overtreatment can be more than a minor annoyance. Galen Gunther, a 59-year-old from Oakland, said that during treatment for colorectal cancer a decade ago he was subjected needlessly to repeated blood draws, often because the doctors couldn’t get their hands on earlier results. Later, he said, he was overexposed to radiation, leaving him permanently scarred.

“Every doctor I saw wanted to run the same tests, over and over again,” Gunther said. “Nobody wanted to take responsibility for that.”

At Cedars-Sinai Medical Center in Los Angeles, officials said that economic incentives still drive hospitals to think that more is better.

“We have excellent patient outcomes, but it’s at a very high cost,” said Dr. Harry Sax, executive vice chairman for surgery at Cedars-Sinai. “There is still a continued financial incentive to do that test, do that procedure and do something more.”

In addition to financial motives, Sax said, many physicians still practice defensive medicine out of fear of malpractice litigation. Also, some patients and their families expect antibiotics to be prescribed for a sore throat or a CT scan for a bump on the head.

To cut down on needless care, Cedars-Sinai arranged for doctors to be alerted electronically when they ordered tests or drugs that run contrary to 18 Choosing Wisely recommendations.

The hospital analyzed alerts from 26,424 patient encounters from 2013 to 2016. All of the guidelines were followed in 6 percent of those cases, or 1,591 encounters.

Sax said Cedars-Sinai studied the rate of complications, readmissions, length of stay and direct cost of care among the patients in whose cases the guidelines were followed and compared those outcomes with cases where adherence was less than 50 percent.

In the group that didn’t follow the guidelines, patients had a 14 percent higher incidence of readmission and 29 percent higher risk of complications. Those complications and longer stays increased the cost of care by 7 percent, according to the hospital.

In 2013, the first year of implementation of Choosing Wisely guidelines, Cedars-Sinai said it avoided $6 million in medical spending.

For perspective, Cedars-Sinai is one the largest hospitals in the nation with $3.3 billion in revenue for the fiscal year ending June 30. It reported net income of $301 million.

In Northern California, Sutter has incorporated more than 130 Choosing Wisely recommendations as part of a broader effort to reduce variation in care. In all, Sutter said, it has saved about $66 million since 2011.

That’s a significant sum. However, during the same period, Sutter reported $2.7 billion in profits. Last year alone, it posted an operating profit of $554 million on revenue of nearly $12 billion.

Giusto said her team of employees tasked with changing physician behavior and eliminating these variations is separate from administrators who are focused on maximizing reimbursement. She said there can be conflicting forces within a hospital.

“We get real excited about a project with [emergency department] doctors on reducing CT scans for abdominal pain,” said Giusto, director of Sutter’s office of patient experience. “Then I can hear the administration say that was a fee-for-service patient. I just lost money, right?”

Giusto meets with doctors to present data on how many tests or prescriptions they order and how that compares to others. At one clinic, she shared slides showing that some doctors were ordering more than 70 opioid pills at a time while others prescribed fewer than 20. In response, Sutter set a goal of 28 tablets in hopes of reducing opioid abuse.

“Most of the physicians changed,” Giusto said. “But there were still two who said, ‘Screw it. I’m going to keep doing it.’”

This story was produced by Kaiser Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

Categories: Cost and Quality, Health Industry

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Who Will Care For Abril? Parents Fear For Their Disabled Child If They Are Deported

Every few minutes, Abril begins to choke. Diagnosed as a baby with severe cerebral palsy and epilepsy, the Santa Cruz, Calif., 8-year-old has never spoken, or walked or cleared her own throat.

Dozens of times a day, her parents, Rafael and Sonia, use a special machine to suction out saliva and phlegm from their oldest daughter’s mouth. Because choking and seizures can strike Abril anytime, a parent is always by her side.

Rafael and Sonia, both from Mexico, have lived in this country without permission for more than a decade. But only since the recent presidential election has a question haunted them: If they are deported, what will happen to Abril?

As the Trump administration promises to deport a broader range of people, parents like Rafael and Sonia increasingly are seeking help to stay in the country so they can tend to very sick children, according to interviews with doctors, lawyers and others who work with immigrants. And these professionals say they are struggling to come up with sound advice.

Rafael and Sonia know that many neighbors in their crowded mobile home park — along with millions of other immigrants living in the country without permission — are keeping to the shadows to avoid detection by federal authorities.

But Abril depends on her parents to stay alive.

Abril sits in the living room while her parents make breakfast. Sonia and Rafael say the family always eats breakfast together and that dealing with Abril’s medical issues has made their family stronger. (Heidi de Marco/KHN)

The couple, along with other families in this story, spoke to California Healthline on the condition that their surnames be withheld, because they fear deportation. Abril and her younger sister are U.S. citizens.

Dr. Salem Magarian, pediatric director of the Santa Cruz Community Health Centers, said immigrant parents of his sickest patients are asking for letters documenting their children’s health care requirements. Some parents say they hope such letters will help them stay in the country if they are picked up by authorities.

“Some people are freaked out,” Magarian said. “Most people are concerned. Almost no one says ‘it’s not a big deal.’”

One of Magarian’s patients, a toddler named Leonardo, has had multiple surgeries for serious heart defects. The boy’s mother, Karla, has been in the country without papers for 23 years, having been brought to the United States at age 5. Karla is terrified by the prospect of leaving her children and being sent back to Mexico, a country she doesn’t remember.

Another child suffers from a life-threatening genetic condition that leaves him unable to speak or eat, Magarian said. Richey, 8, lost his father to cancer four years ago. His mother, Sugay, has been in the country illegally for 16 years.

“I try not to go anywhere,” Sugay said. “If I go anywhere, I’m very afraid. … I know this is not my country, I know this is not my place, but I’ve never done anything bad and I have a special baby who needs his mother.”

Such fears are reinforced by news accounts. The Salt Lake Tribune recently reported that the single mother and sole caretaker of an 18-year-old with cerebral palsy and epilepsy was deported to Colombia.

In another case, an Ohio mother of four children — including one with a history of seizures — was deported to Mexico. A spokesman for Immigration and Customs Enforcement (ICE) told The Guardian that the woman’s case had been reviewed several times by the courts.

“For parents who are ordered removed, it is their decision whether or not to relocate their children with them,” the spokesman said.

Immigration officials say they continue, as under the previous administration, to target for deportation people who have committed crimes — but they also say the new administration has changed policies to no longer support the practice of selective enforcement.

“Basically, there’s no exempted class for arrest,” said James Schwab, spokesman for the ICE field office in San Francisco.

Jessica Vaughan, director of policy studies at the Center for Immigration Studies, a pro-enforcement think tank that favors reduced immigration, says she sees plenty of benefits to enforcing immigration laws more rigorously — particularly increasing access to low-wage jobs for U.S. citizens and legal residents.

But she also says she “absolutely” believes exceptions should — and will — be made in cases where deporting parents would cause “undue hardship” for a young U.S. citizen.

“That’s why Congress created these forms of relief,” she said. “I think most Americans would support that.”

A Precarious Existence

Abril’s father, Rafael, arrived in Santa Cruz from Mexico as a teenager 19 years ago. His brothers are U.S. citizens and his mother is a legal permanent resident. In March 2001, before his 21st birthday, Rafael’s mother applied for a green card for him. He said he’s still waiting for the application to be processed.

After he’d been in California for nearly a decade, he fell in love with Sonia, who had arrived in the U.S. in 2006. She became pregnant. Everything seemed normal until she was 35 weeks along and stopped feeling the baby move. After an emergency cesarean section, Abril was rushed to Lucile Packard Children’s Hospital Stanford.

Magarian began caring for Abril when she came home at 6 weeks old. Given Abril’s serious brain damage and severe cerebral palsy, Magarian didn’t expect her to make it past six months.

Abril was in the hospital constantly at first. Her parents found great solace in their faith as they struggled to accept their new reality.

Over time, they learned the intricacies of caring for their daughter: how to suction her mouth, what to do if her gastrointestinal feeding tube gets blocked or she has a seizure, which of her grunts are normal and which require a call to 911.

Mostly because of her parents’ unwavering attention, Abril’s condition has stabilized over the years, Magarian said. Still, her health remains precarious, and she remains vulnerable to seizures and pneumonia. Many children in Abril’s situation end up hospitalized repeatedly, he said.

Sonia puts Abril down for a nap. (Heidi de Marco/KHN)

Even so, until recently, Rafael and Sonia had begun to feel they were living something of a normal life. Sonia watched their daughters. Rafael rode the bus each day to his job as a cook. A special-education teacher from the local school district came to the trailer twice a week to work with Abril.

Rafael and Sonia worried less about deportation during the Obama administration, which prioritized the removal of immigrants with criminal records. Donald Trump’s promises of a border wall and mass deportations made them nervous.

Their fear grew after helicopter flyovers in mid-February signaled federal immigration raids in Santa Cruz County.

Soon after, Rafael and Sonia hired an attorney to help them become legal residents.

Some advocates say they worry that desperate families with chronically ill or developmentally disabled children are unwittingly putting themselves at greater risk of deportation by seeking legal help.

Often the applicants get turned down, triggering deportation proceedings.

In the best-case scenario, a judge will cancel the parent’s removal because of the hardship it would cause for a medically dependent child. But judges don’t always do this. Barbara Pinto, a senior staff attorney at El Centro Legal de la Raza in Oakland, said more families have been asking her organization about this legal channel. She recommends against it.

“It’s seen as very irresponsible and unethical” for attorneys to suggest such a risky process, she said.

A Daunting Responsibility

Rafael and Sonia know they’re taking a risk. But they don’t know what else to do.

These days, they rarely venture out of their trailer. No more trips to the park. No more weekend strolls at the shopping mall.

Rafael spends time with his daughters. The fear of deportation has limited the family’s time outdoors. (Heidi de Marco/KHN)

In case they get picked up by immigration authorities, they have been writing down the details of Abril’s care. But those details could fill a book, they say, and they don’t even know who’d be willing to take her.

Her uncles feel so uncomfortable with her serious health problems they don’t visit anymore. Rafael’s mother is too frail to lift her 53-pound granddaughter. Certainly someone could care for Abril’s healthy younger sister. But Abril?

“Nobody wants that big a responsibility,” Sonia said.

They think their best option might be a couple whom they barely know, whose own disabled child passed away. If that doesn’t work out, Abril could end up in foster care.

Rafael and Sonia say they wouldn’t be able to get the same financial support for Abril’s care in Mexico. Medi-Cal and California Children’s Services pay for the expensive equipment and medication that keep Abril alive — but only here in the U.S. Together, Abril’s three seizure medications cost about $5,000 a month, an amount they say they cannot possibly afford on their own.

“If we go to Mexico and we have to bring her,” Sonia said, “it is certain she will not live much time.”

Priscila Rodríguez, associate director of Disability Rights International, said Sonia’s concerns are valid. Her organization has documented the condition of people with disabilities in Mexico, finding they often are segregated from society and abused.

Rafael and Sonia aren’t certain how much their daughter understands; her developmental delays are profound.

But, over time, they have learned to love things about her that other people don’t see: the peaceful expression that crosses her face when they hold her. The smile that started appearing much more often after her little sister was born. Her apparent affinity — shared with little girls the world over — for Anna and Elsa in the Disney movie “Frozen.”

Sonia smooths Abril’s hair and places her daughter gently on a bed made up with “Frozen” sheets.

“She gives us love how she can,” she says.

This story was produced by Kaiser Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

Categories: Cost and Quality

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Overwrought Marketing? Ads, Not Research, Create Some Pharma Best-Sellers

An overhead light drawing attention to his face, actor Danny Glover starts to cry, dropping his head into one hand — then, he abruptly switches over to deep belly laughs, before resuming a straight face. “When I act, if I do this it’s totally in my control,” he says, getting to the point: “But for someone with pseudobulbar affect, choosing to cry or laugh may not be your decision.”

The 60-second TV advertisement, which ran widely late last year, concerns a neurological condition known by the acronym PBA, characterized by inappropriate, uncontrolled outbursts of laughing or crying. Though no drug is mentioned, the advertisement is sponsored by Avanir Pharmaceuticals, an Aliso Viejo, Calif., firm that launched Nuedexta, a pricey, brand-name medicine that targets the disorder. The ad ends by referring people to a website and toll-free number for more information.

PBA is real, mostly affecting people with neurological conditions such as multiple sclerosis, a recent stroke or Lou Gehrig’s disease. It runs the spectrum from mild to severe impairment. Because the definition of the condition is ambiguous, estimates of its prevalence vary widely. Some clinicians say PBA is relatively uncommon among their patients, while Avanir sets the number at nearly 2 million.

But the ad campaign has helped fuel the controversy over how direct-to-consumer (DTC) advertising — typified by ads that call on you to “ask your doctor” about a possible treatment — takes niche medicine and promotes its use for a broad range of patients and fosters the use of pricey prescription products when cheaper ones might suffice.

“I suspect this disease is being redefined to include overly emotional people” through advertising, said Adriane Fugh-Berman, a doctor who teaches at Georgetown University Medical Center and has investigated pharmaceutical marketing practices. The United States is one of two countries that allows advertising of prescription drugs.

Not so, says the company in a written statement outlining that its efforts are “focused on raising awareness about PBA to help people better understand the symptoms of a condition that is often overlooked, misunderstood and misdiagnosed.”

The case of Nuedexta is notable because of its price, more than $700 a month for a supply of the twice-a-day pills. The drug is a combination of two low-cost ingredients — an over-the-counter cough medicine and a generic heart drug — that, purchased separately, would run roughly $20 a month based on online cost estimators. To be sure, the comparison is apples to oranges because the dosage of the heart drug is so much lower in Nuedexta than is generally available on its own by prescription. Experts say a do-it-yourself treatment would be difficult and potentially dangerous for a consumer to try to concoct. “You’d have to get the exact doses right, and that would be tricky,” said Dr. Aiesha Ahmed, a neurologist at Penn State Hershey Medical Center who has researched the prevalence of PBA and its treatment options.

The pill doesn’t cure PBA but must be taken for the rest of a patient’s life to help reduce the laughing or crying episodes. While it’s the only Food and Drug Administration-approved drug specifically for PBA, doctors have successfully treated the condition with several alternatives costing far less — all antidepressants.

“The cost for mixing two old drugs together is unconscionable,” said Jerry Avorn, professor of medicine at Harvard Medical School and chief of the Division of Pharmacoepidemiology and Pharmacoeconomics at Brigham and Women’s Hospital.

The strategic marketing of Nuedexta is part of a broader trend in which even small pharmaceutical firms turn to high-cost airwaves to encourage use of their products. Pharmaceutical industry spending on DTC television ads has been on the rise — up 62 percent since 2012 to an estimated $6.4 billion in 2016 — even as TV advertising for other product types stayed flat, according to Kantar Media, a consulting firm that tracks multimedia advertising. By last year, drug ads were the sixth-most-common category of television advertisement — behind such things as cars and restaurants — up from 12th just five years ago.

A number of the ads, like Nuedexta’s, promote medication for relatively unusual conditions, such as a sleep disorder that affects only people who are blind; or more common conditions, such as opioid-induced constipation.

Drugmakers defend the slew of advertisements as educating patients who may not understand they have a disease or that their symptoms can be treated. The uncontrolled laughing or crying of PBA “is quite debilitating,” and Nuedexta provides substantial relief for many, said Avanir’s chief medical officer, Rick Malamut, a neurologist who recently joined the company.

Avanir declined to say how much it is spending to market Nuedexta. In justifying the price, Malamut said the company had invested hundreds of millions of dollars over 10 years on research before winning FDA approval in late 2010. More is now being spent to research whether it — or other Avanir products — could help with other neurological conditions.

“We understand the cost of medication is burdensome for people without [insurance] coverage,” he said, noting the company offers financial assistance to help such patients.

Some experts say the cost isn’t worth it: “If it were your loved one, there would probably be a value to prevent these episodes,” said Mark Pauly, a health economist at the Wharton School of the University of Pennsylvania, of the bouts of laughter and crying. But, he added: “As a hardhearted economist, I have to ask if it’s worth $700 a month.”

Still, the market has proved lucrative. Nuedexta’s sales have risen from about $37 million in 2012 to $218 million last year, according to EvaluatePharma, which tracks pharmaceutical industry pricing and markets.

Strategically Raising A Drug’s Profile

The story of Nuedexta began with Richard Smith, a neurologist whose Center for Neurologic Study was looking to develop a new treatment for Lou Gehrig’s disease, also known as ALS. In the early 2000s, Smith combined dextromethorphan — the main ingredient in cough syrups such as Robitussin — with quinidine, a drug used to treat irregular heart rhythms. The heart drug helps boost and maintain levels of the dextromethorphan in the bloodstream.

What his research team observed in preliminary studies was that patients “almost immediately started reporting an effect on PBA,” said Smith, in a telephone interview. The drug was eventually sold to Avanir. In October 2006, the FDA responded that the drug looked approvable, but investigators had “fundamental questions about both the effectiveness and safety of the product.”

The company then lowered the dose of the heart drug and performed another clinical trial, which found the drug cut in half the number of episodes of uncontrolled laughing or crying by patients who took it rather than a placebo. It was not compared with other treatments already in use and the patients in the study had either MS or ALS. It gained the FDA’s OK in late 2010.

Early on, Avanir executives were clear that they had big ambitions for the new product. In 2013, then-CEO Keith Katkin touted the drug as a “pipeline in a pill” to investors, predicting it could eventually be used in a host of conditions, from pain related to MS to agitation in patients with dementia.

During and after approval of the drug, Avanir provided educational talks for doctors aimed at raising the profile of the little-known condition and expanding the use of their drug.

It made a pitch to consumers with a 2013 ad campaign online and on television that directed viewers to a website. The campaign produced “an overwhelming” response, with “350,000 new unique visitors to the website or calls to the hotline,” Keith A. Katkin, the chief executive at the time, told investors that year.

That potential — along with other drugs in Avanir’s research labs — helped prompt Japan-based Otsuka Holdings to purchase Avanir in 2014 for $3.5 billion.

But after marketing surveys found that, still, only about one-third of potential patients and primary care doctors who treat such patients knew about PBA, Avanir decided to enlist Glover’s celebrity firepower, said Lauren D’Angelo, senior director of marketing for Avanir.

The ad featuring Glover, who doesn’t himself have PBA or any personal link to it, was on cable and national news programs sporadically in 2015 and through the end of December the following year. Glover’s publicist didn’t offer any additional comment for this story.

The ad is “non-branded” — meaning the drug is not mentioned — and therefore isn’t required by the FDA to list side effects and risks. Instead, it simply suggests patients ask their doctor about treatment or go a website to find out more about PBA. Awareness among primary care doctors rose to 72 percent and 52 percent among patients.

“It was an extremely successful campaign,” D’Angelo said. “We drove a lot of patients into doctors’ offices. The challenge was they did not ask for Nuedexta by name.” For sales, that was a problem. Instead of getting Nuedexta, some patients were incorrectly diagnosed or prescribed an antidepressant, she said.

So, in 2017, the drugmaker unveiled a new advertising campaign.

This one, which is currently running on prime-time TV, features a man inexplicably bursting into tears at a child’s birthday party. It intends to move potential customers beyond “could you have PBA?” to “ask your doctor for Nuedexta.”

“We are mimicking what we want them to do, to ask about PBA and ask about Nuedexta,” said D’Angelo.

And there’s good reason for this kind of messaging. A 2016 poll, for instance, conducted by Medscape, an online physician education website, found that 62 percent of physicians said they would or might prescribe an innocuous, even placebo treatment to a patient who didn’t need it but demanded it.

Some neurologists are fans of the drug. Kenneth Heilman, a professor of neurology at the University of Florida School of Medicine and a fellow of the American Academy of Neurology says Nuedexta “seems to control [PBA symptoms] very well.” He also doesn’t object to the advertising campaign, since it might be useful in alerting family physicians who don’t know about the disorder. (Dr. Heilman does not get any money from Avanir.)

Who Needs Nuedexta? Do You?

But PBA can be difficult to diagnose, because symptoms — crying and emotional volatility — can be attributed to other conditions, such as depression. Inappropriate laughter or tears are relatively common in dementia, referred to merely as “emotional lability” in many other countries, but may not constitute a problem that needs treatment. Many experts worry that “patient awareness” and pressing doctors to write prescriptions will lead to overuse.

On the PBA informational website, created by Avanir, the company provides a seven-question self-assessment.

The questionnaire allows a range of answers about the frequency of symptoms, with test takers able to respond never, rarely, occasionally, frequently or most of the time. Questions include: “There are times when I feel fine one minute, and then I’ll become tearful the next over something small or for no reason at all.” “I find myself crying very easily.” “There are times when I won’t be thinking of anything happy or funny at all, but will suddenly be overcome by funny or happy thoughts.” 

The scale automatically awards seven points to those who take it — even when “never” is the answer to all questions. A score of 13 is needed to indicate the potential for PBA. A consumer answering “never” to one of the questions, “rarely” to five and “occasionally” to just one scores 14.

Early on, FDA reviewers raised questions about this test and some experts continue to express similar concerns.

Diagnosing who actually has a PBA condition requires asking how it affects a person’s life, said Dr. Laura Boylan, a neurologist and adjunct professor at New York University School of Medicine who treats patients with psychiatric concerns related to neurological diseases.

While she acknowledged that PBA — which she says is more accurately called “pathologic affect” — is under-recognized by the medical profession, she worries about overprescribing: “I’m the kind of person who gets all teary at AT&T ads,” said Boylan. “I’m just like that and would not want to take a medicine to stop that. What if we start giving Nuedexta to people who are just emotional people?”

Categories: Cost and Quality, Health Industry, Pharmaceuticals


Preexisting Conditions And Continuous Coverage: Key Elements Of GOP Bill

Before he was diagnosed with head and neck cancer in 2015, Anthony Kinsey often went without health insurance. He is a contract lawyer working for staffing agencies on short-term projects in the Washington, D.C., area, and sometimes the 90-day waiting period for coverage through a staffing agency proved longer than the duration of his project, if coverage was offered at all.

When Kinsey, now 57, learned he had cancer, he was able to sign up for a plan with a $629 monthly premium because the agency he was working for offered group coverage that became effective almost immediately. The plan covered the $62,000 surgery to cut out the diseased bone and tissue on the left side of his face, as well as chemotherapy and radiation. His share of the treatment cost was $1,800.

If the American Health Care Act, which the House recently passed, becomes law, people like Kinsey who have health problems might not fare so well trying to buy insurance after a lapse.

Michelle AndrewsInsuring Your Health

The Republican bill would still require insurers to offer coverage to everyone, including people who have preexisting medical conditions, such as diabetes, asthma or even cancer. But it would allow states to opt out of the federal health law’s prohibition against charging sick people more than healthy ones. In those states, if people have a break in coverage of more than 63 days, insurers could charge them any price for coverage for approximately a year, effectively putting coverage out of reach for many sick people, analysts say. After a year, they would be charged a regular rate again.

Coming up with a figure for how many people have preexisting conditions that could put them at risk for facing unaffordable health insurance premiums has been the subject of debate, with estimates ranging from 133 million on the high end to 2 million on the low end.

What we know is that before the Affordable Care Act, known as Obamacare, insurers in the individual market frequently charged people more if they were sick. According to a 2009 survey of individual market insurers by America’s Health Insurance Plans, a trade group, 34 percent of coverage was offered at higher-than-standard rates, while 6 percent of those offers included waivers that excluded coverage for specific conditions.

But some health policy analysts suggest that it’s not only people who have a gap in coverage who could be affected if a state seeks the health law waiver. There could be consequences for anyone with a preexisting condition, even those who have maintained continuous insurance coverage. That’s because the bill opens the door for insurers to set rates for people based on their health. For example, those without a health condition could be offered discounted premiums.

“If you have a preexisting condition, you’re going to be put into the block of business with the sicker risk pool,” said Sabrina Corlette, a research professor at Georgetown University’s Center on Health Insurance Reforms.

Requiring people to maintain continuous coverage is the Republicans’ preferred alternative to Obamacare’s individual mandate that requires people to have insurance or pay a fine. But there are many reasons people may have a gap in coverage, especially if they’re sick, say consumer advocates.

“If they’re diagnosed with cancer and going through a grueling treatment, they might move closer to their caregiver or the cancer center,” said Kirsten Sloan, vice president for policy at the American Cancer Society Cancer Action Network. “They may quit their job for that reason, or they may lose their job.”

Once people have a gap in coverage they may really be in a bind if the available coverage is unaffordable. To address this, the Republican bill requires states to set up a high-risk pool or reinsurance program or participate in a federal risk-sharing program.

State high-risk pools, which were available in 35 states before the ACA passed, have been widely criticized, however, as inadequate for people with expensive health care needs. Premiums were often extremely high, and there were frequently lifetime or annual limits on coverage. Some plans excluded coverage for as long as a year for the very conditions people needed insurance.

Still, Thomas Miller, a resident fellow at the American Enterprise Institute, says high-risk pools offer a reasonable solution for the 2 million to 4 million people in the individual market he estimates have preexisting conditions but would otherwise be medically uninsurable or offered such high-cost coverage that they couldn’t afford it. The $130 billion over nine years that the bill sets aside to use for high-risk pools or other individual market activities, along with an additional $8 billion over five years for states that get waivers from ACA community-rating requirements, “could be adequate” to meet the need, he said.

Besides, he argued, the higher rates would last for only a year.

“Once you’ve paid up, you graduate back to the regular market,” Miller said. “It’s not like being sentenced to the Gulag.”

Kinsey said he plans to keep his coverage up to date from now on, but he doesn’t think it’s fair to charge sick people higher rates even if they have a break in coverage.

“It would be problematic,” he said. “I’m not in favor of that.”

Please visit khn.org/columnists to send comments or ideas for future topics for the Insuring Your Health column.

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Trump Says He Knows About Health Care, But Some Of His Facts Seem Alternative

Lost in all the coverage of the firing of FBI Director James Comey last week were a pair of in-depth interviews President Donald Trump gave that included lengthy comments on health care — one with Time magazine and the other with The Economist.

He acknowledged to Time interviewers that health care was not an area of expertise in his previous job. “It was just not high on my list,” he said. But he added that “in a short period of time I understood everything there was to know about health care.”

Not really.

Among the president’s more questionable claims was his description of the House-passed health bill as “You’re going to have absolute coverage.”

The last full estimate from the Congressional Budget Office predicted that a previous version of the bill would result in 24 million fewer people with insurance after 10 years.

Trump also told The Economist that “we’re getting rid of the state lines,” a reference to allowing health insurers to sell across state lines. Not only is that not in the GOP bill, many experts agree such a policy would not work to increase competition.

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Possibly the most curious comment was this one, also in The Economist interview: “[T]his was not supposed to be the way insurance works. Insurance is, you’re 20 years old, you just graduated from college, and you start paying $15 a month for the rest of your life and by the time you’re 70, and you really need it, you’re still paying the same amount and that’s really insurance.”

“He seems to think it’s like a life insurance policy, which you can buy at a certain age and it keeps you at a fixed premium dollar forever,” said Gail Wilensky, a health economist who ran the Medicare and Medicaid programs under President George H.W. Bush. Except “you can’t buy health insurance that way,” Wilensky said. “Even if you stay continuously insured, that’s just not how it works.”

On the other hand, Wilensky said, it might not matter all that much how well a president understands the intricacies of health policy. “It matters whether he thinks it’s important,” she said. The president she worked for was much more comfortable on issues of foreign relations and defense. “It wasn’t that he didn’t care” about health, she said. “He just didn’t know that area the way he knew other areas.”

Jonathan Oberlander, a health policy professor at the University of North Carolina-Chapel Hill, points out that a deep understanding of a subject by itself is not enough to produce policy change.

“Bill Clinton thought he knew health policy, and look at how that turned out,” he said, referring to the collapse of his health reform plan in Congress in 1994. Still, “ignorance surely doesn’t help,” he added.

David Blumenthal, president of the Commonwealth Fund and co-author of a book on presidents and health care, agreed with both Wilensky and Oberlander.

“A president has to know enough to sell the plan” to Congress and the public, he said. “But presidents can make mistakes by getting too deep in the details.” He pointed to not only Clinton but also President Jimmy Carter as chief executives who got mired in the small print of health policy.

At the same time, however, Blumenthal said that a president has “to lay out principles and parameters that the Congress knows if they meet he will sign the bill.” And while Trump has done that, “I don’t think he’s been entirely consistent with what he’s said, so it’s not clear how much the Congress is being guided by his principles,” he said.

One health issue Trump is clearly not ignorant about is his power to stop paying insurance companies who are providing help to some low-income policyholders in the health insurance exchanges. The “cost-sharing reductions” are the subject of a lawsuit that was appealed by the Obama administration, and Trump could, in fact, stop the payments by dropping the appeal.

Insurers say uncertainty about whether they will get that money is a key reason they are asking for higher rates or dropping out of markets.

Trump did not help allay that uncertainty. He told The Economist that “we don’t have to subsidize it. You know if I ever stop wanting to pay the subsidies, which I will.”

Categories: Cost and Quality, Insurance, The Health Law

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