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Posts Tagged ‘Affordable Care Act

Science Policy Around the Web – March 14, 2017

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By: Liz Spehalski, PhD

Affordable Care Act

ACA Replacement Bill Released by House

Last Monday, House Republicans released their plan to repeal and replace former President Obama’s Patient Protection and Affordable Care Act (ACA), also known as Obamacare. The American Health Care Act (AHCA), a more conservative vision for the nation’s health care system, was created as a collaboration between the White House and the Senate Republicans. The Republican Party has been critical of the ACA because of the large role that it created for the federal government in health care, such as the need for the IRS to verify eligible people for financial help and federally mandating the public to have health insurance.

The AHCA will maintain some of the popular features of the ACA, such as allowing young adults to stay on their parent’s health care plans until the age of 26, banning lifetime coverage caps, and maintaining the ban on discrimination against people with pre-existing conditions. It also temporarily maintains the expansion of Medicaid to cover millions of low income Americans through January 1, 2020.

Instead of the individual mandate, a fine penalizing Americans for failing to have health insurance, the new bill would try to encourage people to sustain coverage by allowing insurers to impose a 30 % fine to those who have a gap between plans. The AHCA also changes the structure of tax credits given to those who want to buy insurance. Under the ACA, people who earn less than 200 percent of the poverty line get the highest subsidies. The Republican plan would instead give tax credits based mostly on age. The AHCA will also cut off federal funds to Planned Parenthood through Medicaid and other government programs for one year.

While Republicans did not offer any estimate of how much their plan would cost, or how many people would gain or lose insurance coverage, the Congressional Budget Office released its estimate yesterday, raising concerns. Two key House committees swiftly approved the bill, but uncertainty surrounds how this bill will fare in Congress, as some conservatives are concerned that it does not go far enough to remove government from health care, while others are concerned about their constituents losing coverage due to the loss of Medicaid expansion. No Democrats are expected to support the bill. (

Obesity

Fewer Overweight Americans Trying to Lose Weight

A study published in the Journal of the American Medical Association this week found that the percentage of Americans trying to lose weight is declining. In 1990, when researchers asked overweight Americans if they were trying to lose weight, 56% responded yes, while that number decreased to 49% in 2014. Researchers analyzed US government health surveys from 1988 through 2014 which involved in-person physical exams and health- related questions including whether the participants had tried to lose weight within the last year. The study included over 27,000 adults ages 20-59, and weight status was determined using body mass index (BMI).

The explanation behind this trend seems to be the shift in public perception over dieting and overweight people. “Socially accepted normal body weight is shifting toward heavier weight. As more people around us are getting heavier, we simply believe we are fine, and no need to do anything with it,” said lead author Dr. Jian Zhang, a public health researcher at Georgia Southern University. The authors of the study also discuss other possible reasons for this data, such as primary care physicians not discussing weight issues with their patients.

Though the decline of 7% may seem low, this number could represent up to seven million Americans, as more than two thirds of adults are considered to be overweight or obese, according to recent NIH statistics. Scientists say this is concerning because obesity increases the risk of a host of diseases such as heart disease, diabetes, cancer, liver disease, osteoarthritis, and stroke. However, “There’s a possible good news story in this,” says Janet Tomiyama, a psychologist at UCLA who studies eating behavior and weight stigma. “We’re not going to shame people into health,” Tomiyama says, “a lot of research shows that having a healthy body image is what leads to better health outcomes. Maybe people are taking the focus off the number on the scale, and going more towards focusing on their health.” The CDC’s current  obesity prevention efforts focus on policy and environmental strategies that target the affordability of healthy eating and active living, noting that fad diets can be unhealthy and tend to fail over the long term. (Allison Aubrey, NPR)

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March 14, 2017 at 10:00 am

Mental Health Policy and its Impact on the American Population

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By: Fatima Chowdhry, MD

           In the last 50 years, the U.S. has seen a migration in which individuals diagnosed with a mental illness, defined by the Diagnostic and Statistical Manual of Mental Disorders as “a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior”, are treated not in a mental health institution but rather in prisons, nursing homes, and outpatient facilities. To understand the implications of this trend, it’s important to frame this issue as a cascade of events. For example, we can start with a member of law enforcement, not adequately trained to recognize someone in the throes of a manic phase or a schizophrenic not on their medication, arresting an individual with a mental illness. We then find that this individual, upon release, did not receive treatment and now has trouble reintegrating into their community and is unable to find gainful employment. The combination of a lack of treatment, stable community, and employment leads them to continuous run-ins with the law, restarting a vicious cycle that had led us to a prison population in which the majority has a mental illness.

The move to deinstitutionalize people with mental illness from mental institutions began in the 1960’s and accelerated with the passage of the Community Mental Health Act of 1963. This bill was an important step forward to improve the delivery of mental health care because it provided grants to states to set up community health centers. In 1981, President Ronald Reagan signed the Omnibus Budget Reconciliation Act, which sent block grants to states in order for them to provide mental health services. Aside from these two bills, and the Mental Health Parity Act of 1996, which ensured insurance coverage parity of mental health care with other types of health care, there has been little in the way of significant mental health legislation. Mental health was put on the backburner and the result is a mental health infrastructure in tatters.

During the Great Recession, states cut billions in funding dedicated to mental health. A vivid example of how decreased state funding affects mental health services can be seen in the state of Iowa. The current Governor has been put in the difficult position of balancing fiscal responsibility with maintaining access to mental health care. At one point, there were four state mental health hospitals that provided care to each corner of the state. The Governor closed down two of the facilities to save the state money. While they were old facilities built in the 19th century and cost millions to maintain, many people in Iowa felt that he moved too quickly before alternative services were in place. In addition to closing these mental health facilities, the governor obtained a waiver from the federal government to modernize the state’s Medicaid program and move from fee-for-service to managed care. Under fee-for-service, health care providers are paid for each service provided to a Medicaid enrollee. Under managed care, Medicaid enrollees get their services through a vendor under contract with the state. Since the 1990s, the share of Medicaid enrollees covered by managed care has increased, with about 72% of Medicaid enrollees covered by managed care as of July 1, 2013. The move can be difficult because hospital networks and providers have to contract with a vendor and Medicaid beneficiaries may have to switch providers. Needless to say, it can be an administrative nightmare. The transition in Iowa, to say the least, has been rocky with the vendors threatening to pull out because of tens of millions of dollars in losses. The vendors and the providers might not get paid as much as they want but the people getting the short end of the stick are people on Medicaid, which includes individuals with mental health illnesses.

Given the patchwork of mental health care across the country and the lack of funding, what can be done? According to NAMI, 43.8 million Americans experience a mental illness in a year. Many don’t receive the treatment they need. It’s a multi-faceted problem facing families, employers, health care providers and community leaders. At the federal level, lawmakers have introduced several bills to address mental health. In the United States Senate, a bipartisan group of four Senators introduced S. 2680, the Mental Health Reform Act of 2016. This bill encouraged evidence-based programs for the treatment of mental illness, provided federal dollars to states to deliver mental health services for adults and children, and created programs to develop a mental health workforce.

It was encouraging to see that many components of S.2680 were included in H.R 34, the 21st Century Cures Act, which was signed into law on December 13th, 2016.  H.R 34 faces some headwinds because some of the funding portions are subject to Congressional appropriations, and if Congress is feeling austere, they can tighten the purse strings. Moving forward, a major issue of concern for mental health is the future of the Affordable Care Act. Under the Affordable Care Act, states were initially mandated to expand their Medicaid rolls. A Supreme Court decision, however, made the decision to expand optional. So far 32 states, including Washington D.C., have expanded. Some red states, like Iowa, Arkansas and Indiana have utilized the waiver process of the ACA to expand their program. If the ACA is repealed, policymakers will have to contend with the effects on the private insurance market as well as Medicaid.

Right now, the crystal ball is murky. Only time will tell.

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December 22, 2016 at 10:45 am

Challenges in the Translation of Science into Policy: The Case of Breast Cancer Screening Coverage

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By: Felisa Gonzales, Ph.D.

The appropriate role of science in policy making has been debated for centuries. Most theories of decision-making posit that decisions, including policy decisions, are based on beliefs and values. How best to incorporate scientific knowledge into policymakers’ beliefs and values is unclear, and doing so is particularly difficult when the science is not definitively conclusive. The challenges inherent to the use of science to inform policy were clearly demonstrated when the Patient Protection and Affordable Care Act (ACA) mandated free health insurance coverage for certain preventive services based on the science-based recommendations of the United States Preventive Services Task Force (USPSTF). The USPSTF is an independent, volunteer panel of experts and clinicians from the fields of preventive medicine and primary care charged with evaluating the scientific evidence regarding the benefits and harms of clinical preventive services. The target audience for the USPSTF recommendations is primary care clinicians, not policymakers. Because the use of their recommendations has been codified into law, the scientifically and clinically oriented USPSTF is now occupying a policy role for which it was neither designed nor intended. The scientific conclusions of the USPSTF may not match the beliefs and values of democratically elected policymakers, raising the question: Is USPSTF the appropriate body to be put in the position of determining coverage policy?

The direct linkage of the USPSTF’s science-based recommendations to health insurance coverage came to public attention in 2009 when the panel changed its breast cancer screening recommendation. Based on data from randomized trials of mammography screening, the USPSTF made age-specific recommendations that advised against routine breast cancer screening for women between the ages of 40-49 and called for women to weigh “the potential benefit against the potential harms” before deciding to initiate mammography before the age of 50. Although women older than 40 have long heard messages such as “screening saves lives” and “take the test, not the chance”, researchers had been expressing their uncertainty about the benefits of mammography for women in their 40s since at least 1993. Nevertheless, the 2009 recommendation was criticized as “gender genocide”, “incredibly flawed”, “disastrous for women’s health”, and “callous and poorly conceived”. Despite the backlash, the USPSTF reiterated the same recommendation in January of 2016.

A review of the available evidence in 2016 indicated that for every 10,000 women ages 40-49 screened for breast cancer, approximately 1,212 false-positives will result, 164 biopsies will be conducted, 10 cancers will be missed. With repeat screening over 10 years, only 4 breast cancer deaths among women ages 40-49 will be avoided. Based on this information, the USPSTF gave mammography for women ages 40-49 a grade of “C”, which indicates that “there is at least moderate certainty that the net benefit [i.e., the degree to which the benefits outweigh the harms] is small”. Only clinical preventive services with “A” or “B” grades, which indicate a moderate to high degree of certainty that the benefits outweigh the harms of a procedure by a moderate to substantial margin, are required to be completely covered by health insurers under ACA. The USPSTF grade definitions include assessments of certainty because science is not often absolutely conclusive. Commenting on the role and responsibility of expert bodies, the Organisation for Economic Co-Operation and Development Committee for Scientific and Technological Policy notes, “the policy and societal context for scientific advice is challenging, not only because the stakes are high, but also because the general expectation is that science can provide clear and unambiguous answers. The reality is that the results of scientific research are often provisional and sometimes heavily contested…” The fact that the USPSTF recommendations are based on the best available science and are of superior quality was not enough to convince policymakers that they were sufficient to be the sole determinant of coverage for mammography.

The “C” rating for mammography among women ages 40-49 was not a recommendation against screening or against coverage, but because the ACA linked the USPSTF recommendations to coverage decisions, some incorrectly interpreted it this way. As a “C” rating would result in mammography not being covered as a preventive service under ACA, Senators Barbara Mikulski (D-MD) and David Vitter (R-LA) drafted amendments requiring insurance plans to pay for annual mammograms for women ages 40 and older and not restrict mammography based on USPSTF recommendations. Mikulski’s amendment also included screenings for ovarian and lung cancer screening despite a lack of evidence of any benefit, and concerns about substantial harms, associated with these procedures. Members of the House and Senate have proposed additional actions including eliminating funding for future USPSTF recommendations and requiring people who are not experts in prevention or evidence-based medicine to serve on the panel (for example representatives from patient groups, specialty physicians, and relevant stakeholders from the medical products manufacturing community). Experts are wary of these efforts, noting that “political interference with science can discourage shared decision-making, increase harms from screening, and foster public doubt about the value and integrity of science.” These tensions highlight differences in scientists’ and policymakers’ beliefs and values despite a shared commitment to improved public health.

The USPSTF “is committed to using the best science to identify the most effective preventive services to improve the health of the public,” but carrying out this mission is much more complicated now that their recommendations are used to dictate health insurance coverage. One proposed solution, favored by the USPSTF and its critics, is the creation of a separate independent panel to be charged with reviewing the USPSTF screening recommendations as well as other considerations important for public policy, such as cost, context, and feasibility. As the current chair and members of the USPSTF have noted, “the science on effectiveness – although foundational – is only one factor that needs to be considered in developing policy coverage.” Others closely associated with the USPSTF have warned that “limiting first-dollar coverage to services supported by strong evidence of effectiveness, as determined by one panel, is potentially harmful for public policy and threatens the USPSTF and other independent panels like it.” The linkage of the USPSTF recommendations to health insurance coverage policy reminds us that scientists are not policymakers, and policymakers are not scientists. The development of evidence-based policy requires scientific advice that is “scientifically sound and politically suitable and legitimate at the same time.” In the absence of an independent, intermediate body that can consider both scientific beliefs and prevailing societal values in health insurance coverage decisions, we risk building walls rather than bridges between science and policy.

Written by sciencepolicyforall

May 12, 2016 at 11:00 am

Science Policy Around the Web – February 17, 2015

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By: Sara Cassidy, M.S., Ph.D.

Healthcare Policy

Everyone wants a piece of the action: The nation’s largest health insurer denied entrance into California’s marketplace

When the Affordable Care Act was initiated, it encouraged states to adopt their own insurance marketplaces to promote competitive pricing. Citizens and insurers alike were skeptical. To incentivize insurers’ participation from the outset, California was one of a few states to impose a waiting period of three years on companies who did not take part on opening day. Covered California surpassed its enrollment numbers in 2014 and is on target to increase enrollment by ~29% in 2015. UnitedHealthcare wants a piece of that pie, but its request to sell insurance statewide ex post facto was recently turned away by the Covered California advisory board. Consumer advocacy groups support the move by Covered California, as they believe insurers took a big risk being first-adopters, knowing that they likely would be signing up an unequal share of sicker-than-average people. However, California’s insurance commissioner believes restricting access is bad for business since more competition would likely drive down prices for the individual. The outcome from the Covered California advisory board was a compromise: Plans will be able to apply for entrance into the statewide market in 2016 if they were newly licensed since August 2012 (when the first-adopters opted in), or are managed care plans for Medicaid. Otherwise companies can apply to offer coverage in regions of the state where less than three carriers currently offer plans. This will allow large insurers like UnitedHealthCare limited participation into the marketplace until the moratorium is over is 2017.  (Michelle Andrews, NPR; Victoria Colliver, SF Gate; www.coveredca.com)

 

Regulatory Policy

Digital health monitors avoid FDA regulation

The wearable electronic health market (FitBit, smart phone apps, and the like) is predicted to be worth 11.6 billion dollars by 2020. Sustained lobbying by Apple, Intel and other digital health monitor companies has successfully persuaded the Food and Drug Administration to stay out of their business. Recently, the FDA agreed not to regulate technologies that receive, transmit, store, or display data from medical devices, and most mobile medication applications. However the industry and some members of Congress want more than promises; they want laws that assure the industry it can innovate and sell its products without government interference. For apps that monitor exercise routines and count calories, FDA regulation seems an over-reach, but what about apps that allow diabetics to plug glucometers into their smartphones to track insulin levels, or apps that take electrocardiograms to record cardiac events? These already exist, and sound like the types of medical devices the FDA would normally regulate to ensure safety and accuracy. And, as the market expands, it is easy to imagine it becoming increasingly difficult for patients and physicians to evaluate the quality and utility of these devices. As we enter the era of precision medicine, the mobile health market is posed to play a major role in personalized healthcare, but that position could be compromised without FDA oversight.  (Ashley Gold, Politico; Cortez et al (2014) NEJM 371:372-379; FDA)

 

Energy Policy

Republicans sign Keystone Pipeline Bill, Obama expected to veto

Speaker John Boehner (R-Ohio) staged a signing ceremony for a bill including plans to build the Keystone XL pipeline Friday the 13th, but the legislation won’t be forwarded to the White House until after the holiday weekend. President Obama is expected to veto the bill. The State Department has just finished collecting information on whether the project is in the nation’s best interest, and once Secretary of State John Kerry finishes reviewing the comments, they will be sent to Obama who will make the final decision. Opponents of the pipeline are optimistic Obama will reject the project, based on his recent negative comments. “It’s very good for Canadian oil companies, and it’s good for the Canadian oil industry but it’s not going to be a huge benefit to U.S. consumers, it’s not even going to be a nominal benefit to U.S. consumers,” Obama said in December. Despite this, the pipeline developer, TransCanada, has vowed not to give up on the project if Obama rejects the bill.  (Laura Barron-Lopez, The Hill)

 

 

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Written by sciencepolicyforall

February 17, 2015 at 11:24 am

Science Policy Around the Web – December 21, 2012

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photo credit: mikebaird via photopin cc

photo credit: mikebaird via photopin cc

By: Jennifer Plank

Our weekly linkpost, bringing you interesting and informative links on science policy issues buzzing about the internet.

Policy Lifts Otter-Free Zone in California – In 1987, the Fish and Wildlife Service moved 140 sea otters to San Nicolas Island off the California coast. The goal of this effort was to maintain two distinct populations of these endangered animals in the hopes of maintaining the species in case of an oil spill. At the same time, the service also established an “otter-free zone” at the request of fisherman and the Navy. This week, the “otter-free zone” restriction was lifted, a victory for environmentalists who did not believe the otters natural migration paths should be restricted. (Felicity Barringer)

The Gun Lobby’s Favorite Part of the Health LawA section of the Affordable Care Act (ACA) entitled “Protection of Second Amendment Gun Rights” states that the Department of Health and Human Services can not collect information about gun ownership. It also states that insurance providers cannot deny coverage or raise premiums due to gun use. This section in the ACA was added by the Senate majority leader, Harry Reid (D, NV). This language of the ACA is not without controversy as epidemiologists claim that gun use can kill as many people as influenza while gun-rights advocates maintain that any policies monitoring gun ownership is infringing on Second Amendment rights. (Jay Hancock)

Chicago’s Field Museum Cuts Back on ScienceThe Field Museum of Natural History in Chicago is cutting $3 million from its science budget this year including a program for research on the institutes collection of fossils, plants, and animals. Nationally, museum endowments have been low due to the recession, and the Field Museum has also been financing expansion projects resulting in a significant budget crisis. Staff at the museum will provide input on how to apply the budget cuts.  (Helen Shen)

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December 21, 2012 at 1:35 pm