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Posts Tagged ‘healthcare

How Easy is it to Access Health Care in the US?

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By: Rachel F Smallwood, PhD

Source: pixabay

         Access to health care has been a concern as long as there has been health care, and it is one of the hot-button issues of health care policy debates. The recent repeal of the Affordable Care Act and passing of the American Health Care Act (AHCA) in the House of Representatives has again brought this debate front and center. The Congressional Budget Office’s analysis of the first iteration of the AHCA indicated that it would result in 24 million less people having health insurance by 2026. It would also place more of the financial burden on people making less than $50,000 per year. However, substantial changes were made to parts of the bill before it passed in the House, and there will likely be more if it is to be passed in the Senate. There is much debate and dissension on what level of access to health care should be provided by the government and whether health care is a right versus a privilege. In addition to that debate, there are other facets of the United States’ health care system that need examination and work to ensure access to health care.

There are many reasons a person may not have access to health care – not having health insurance is just one. To measure access to health care, one must first define it. Is there some quality standard that must be met for treatment to be considered health care? How do we determine whether one person’s health care is equivalent to another’s? With health care measures that range from necessary, recommended but not dire, to completely elective, even these differences can be difficult to quantify. Most institutions collecting data on health care use a working definition like that set by the Institute of Medicine in 1993: access to health care means a person is able to use health care services in a timely manner to achieve positive health outcomes. This implies that a person can enter the health care system, physically get to a place where they can receive health care, and find physicians whom they trust and who can provide the needed services.

Indeed, there are differing opinions on what constitutes “access”, and this heterogeneity is further compounded by the multiple barriers to access. For example, with the recent AHCA proposal, many representatives spoke about separating the concepts of health care coverage and health care access, while others believe that the two are not separable. There are at least four factors that limit a person’s access to healthcare. The first barrier is the availability of health services; if the necessary health care is not provided within reasonable traveling distance of a person seeking services, none of the other factors matter. The other three factors are personal barriers such as a person’s perceptions, attitudes, and beliefs about their own health and health care, organizational barriers such as referrals, waiting lists, and wait times, and financial barriers such as inability to afford insurance, copays, costs beyond deductibles, and lost wages.

The current policy in the United States is the Affordable Care Act, put into place under the Obama administration. One of the most contentious points of the law is its requirement that every person have health care coverage or pay a penalty. A 2015 survey released by the National Center for Health Statistics indicated a substantial drop in the percentage of the US population without insurance over the previous few years. There was a slight increase in the percentage of people with a usual place to go for health care (i.e. a primary care provider or clinic for regular check-ups), and a decrease in the number of people who failed to obtain needed health care due to cost, but simply requiring everyone to purchase health insurance did not induce a commensurate rise in people gaining access to health care, in accordance with the steps and measures discussed by the Agency for Healthcare Research and Quality. Additionally, there have been substantial increases in premiums, which means that those consumers still have a significant financial barrier to health care.

The numbers and policies referenced above address the country as a whole, but statistics vary widely across regions of the United States. US News ranked states on their access to health care using six metrics: child wellness and dental visits, adult wellness and dental visits, health insurance enrollment, and health care affordability. Some examples of the ranges seen between states in these measures are that 20% of adults do not have regular checkups in the highest ranked states, while around 40% do not have regular checkups in the lowest ranked states. In the highest ranked state for affordability, the fraction of people who needed to see a doctor but could not because of cost was around 7%, while in the lowest ranked state this percentage was just under 20%. While some of this is due to the differing demographics and living conditions from state to state, the discretion and freedom that states have in applying health care laws also factor in.

When comparing to other similar (high-income) nations, the United States falls short on access to health care. Although the Affordable Care Act improved access to health insurance, the US is still lagging when it comes to its residents receiving actual care. This is partially due to fewer physicians practicing general medicine in the US. In 2013, the US ranked below all other Organization for Economic Co-operation and Development countries, except for Greece, for the density of general practitioners per 1,000 people. A related measure showed that the US also had a lower percentage of physicians choosing general practitioner/primary care as their specialty than all other 35 countries. These countries are all World Bank-categorized high-income countries except for Mexico and Turkey, which are upper middle-income (and had better stats than the US). This disparity has been noted in the US and is driven by many factors including physician salaries, patient loads, and medical education emphasis (or lack thereof) on primary care. This shortage also disproportionately affects rural areas, likely contributing to some of the state-to-state variability noted above.

The United States is struggling when compared with similar nations to provide health care access to its citizens. The reasons for this struggle are multifaceted, including access to health insurance, financial barriers, and lack of primary care physicians. The political tensions and opposing principles held by individuals can also be barriers to working toward a more accessible health care system. We should be focused on developing a health care system where all can reasonably obtain health insurance, where health care costs are not prohibitively expensive, and medical education should emphasize the importance of primary care in our nation’s health and communicate the need for practitioners in under-served areas. Shedding light on these areas for improvement will allow people to work together to address our weaknesses and create a system that improves and sustains the health of our nation.

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Written by sciencepolicyforall

May 19, 2017 at 10:16 am

Science Policy Around the Web – May 16, 2017

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By: Sarah L Hawes, PhD

Source: pixabay

Preventative Medicine

Fresh Foods a Day Keep Disease and Deficit Away

If you have recently shopped for health insurance, you likely encountered incentives for self-maintenance, such as discounted gym membership, or reimbursement for a jogging stroller. These incentives are motivated by the enormous ticket price of failing health. The CDC estimates that over $500 billion is spent annually on direct medical expenses to treat chronic diseases, which can be prevented or postponed through lifestyle practices – including heart disease, obesity, and diabetes.

The Geisinger health care system reports encouraging results from the first year of a lifestyle-modification program called Fresh Foods Pharmacy, piloted in central Pennsylvania. This program provides patients with Type 2 diabetes nutrition counselling, hands-on classes in healthy cooking techniques, and a weekly prescription for five days’ worth of fresh food – fillable for free at a hospital based “food pharmacy.” This means patients are not just advised to eat better; they are comprehensively enabled to eat better.

David Feinberg, president and CEO of Geisinger, reports that all 180 participants in the pilot group have made substantial improvements in their health, including reductions in blood pressure and body weight, and that many have seen a several-point reduction in a blood marker used to diagnose and monitor their disease, called A1C. A1C reduction means that blood sugar levels are being better controlled, which also means fewer costly diabetic complications for patients down the line. Feinberg calls the program “life changing,” adding that participants “won’t go blind; [they] won’t have kidney disease, amputations.”

Many Fresh Foods Pharmacy participants are low-income, so there is powerful financial incentive to ‘follow doctors’ orders’ and eat the free, healthy food. But what does supplying a person with nutritional counsel and weekly fresh foods cost?

Geisinger spends approximately $1,000 per year on each Fresh Foods Pharmacy patient. Meanwhile, a mere one-point drop in A1C levels saves Geisinger roughly $8,000 per year. Feinberg says that many participants trimmed about 3 points off their A1C level in the first year, saving roughly $24,000 on a $1,000 investment. “It’s a really good value” says Feinberg, who is already working to expand the program to additional sites.

Improved patient health and medical cost-cutting in the first year of this program are independently exciting. In addition, the value of engendering better patient health through comprehensive dietary support is very likely to extend beyond patient and provider. Patients who are enabled to engage in healthful food preparation will share a healthier diet and food-culture with their families, enhancing program benefits in as-yet unmeasured dimensions. (Allison Aubrey, NPR)

Research Funding

Climate Science Policy Lessons from Down Under

Pretend for a moment that everyone firmly believes that climate change is real, and is a real threat. Is this enough to safeguard basic climate science research? Recent events in Australia give us our answer – no.

Australia is the most active contributor to climate science in the Southern Hemisphere. As such, Australian researchers provide a truly international service. Public appreciation of this fact, together with public activism, recently saved funding for Australian climate science.

In 2015, Dr. Larry R. Marshall was appointed to lead Australia’s national scientific agency (CSIRO). Dr. Marshall planned to champion initiatives motivated by his faith in climate science. He wanted to develop technologies to respond to inescapable climate change, and to mitigate damage through reduced emissions. Paradoxically he proposed to fund these by laying off droves of basic climate researchers.

Dr. John A. Church was a climate scientist at CSIRO, having published highly regarded studies indicating accelerated sea level rise paralleling greenhouse gas emission. On catching wind of Marshall’s plan, Church reached out to his contacts in the media and wrote an open letter to Marshall in defense of basic science. Public marches, hearings, and protests from thousands of international scientists ensued.

Ultimately, the rally of public voices instigated by Dr. Church and others like him was effective. Far fewer layoffs occurred than were initially slated to occur. Dr. Church was among those let go by CSIRO, but was rapidly recruited by the University of New South Wales to continue his climate research.

Bear in mind that Dr. Marshall was no climate change denier. He showed great willingness to use scientific findings to guide policy, which is admirable. He addressed an Australian Senate committee saying that the climate “absolutely is changing,” and “we have to do something about it.” In a recent interview, he summarized his reasons for wanting to lay off scientists saying this: “Unfortunately, with a finite funding envelope, you’ve got to make choices where you fund.”

Australia’s example shows us that even in a political environment with great faith in science, reverence for basic research is a separate issue, and merits independent attention and protection. Staying abreast of science policy matters. And for those of us who believe there is no shortage of natural complexity, and no end to the fruitful pursuit of knowledge, it pays to speak out in defense of basic research. (Justin Gillis, The New York Times)


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Healthcare Policy – What’s in Store for Our Future Healthcare Needs?

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By: Emily Petrus, PhD

       There’s no question that the US spends too much on healthcare – in 2015 it cost 18% of its GDP, equivalent to $3.2 trillion dollars. In fact, we spend more on healthcare to cover just 34% of our population via Medicare and Medicaid than other countries who cover their entire population with universal healthcare. Most people assume that this higher spending equals better health, but unfortunately this isn’t the case.

According to a 2015 Commonwealth Fund survey, the US has the highest infant mortality and obesity rates and the lowest life expectancy of the top 13 Organisation for Economic Co-operation and Development (OECD) countries. In addition, we have the highest rates of prescription drug use, amputation due to diabetes mismanagement, and the second highest death rate from ischemic heart disease. Our relatively small percentage (14.1%) of people over age 65 also have the highest rate of at least two chronic illnesses per person. These numbers are estimated to increase as baby boomers age, so the outlook isn’t good when considering how many elderly people we can expect to suffer from chronic health issues.

However, it’s not all doom and gloom – we are in the top 3rd for surviving cancer, boast the lowest smoking rates, and have the highest access to diagnostic imaging services (such as MRI and CT scans). In this light, it makes sense that we spend more, have better access to expensive technology, and use more expensive prescription drugs. Another way to slice the data paints a different picture. The sickest 5% of the population accounts for 50% of medical spending, and accounts for 60% of spending on prescription drugs. Together these data indicate that the US could be in better shape if we had a healthier population.

How could we make the population healthier? Let’s consider that the determinants for health are 30% genetics, 70% behavior, environment and social factors, only 10% is mediated by healthcare. Other OECD countries spend significantly more on social services such as supportive housing, employment programs, retirement and disability programs. Social services are especially beneficial for people in lower income brackets, who incidentally have the poorest health in the US. The life expectancy for the poorest Americans is about 13 years less than the wealthiest. Racial disparities also contribute to gaps in healthcare outcomes for Black, Hispanic, Asian and American Indians/Alaskan Native Americans, all of whom experience worse medical care. The parameters measured included access to care, effective communication with medical staff, and a specific source of ongoing medical care, such as a primary care physician. It is estimated that these disparities amount to billions of dollars in economic loss – $35 billion in excess health care expenditures – for example, a trip to the emergency room for something that could be treated by better access to a primary care physician. Expanding Medicaid would increase medical access to poor and disadvantaged minority groups, for example, Blacks in the south. However, many states thatch have high at-risk populations decided not to expand Medicaid. Spending more on social services aimed at improving people’s health seems to be working in other OECD countries, and the National Academy of Medicine recommends the US increase spending in these areas.

Social services are unlikely to gain support from conservatives, so spending in this area is unlikely to be supported by the current administration. However, there are other areas in healthcare that can gain bipartisan support. 30% of medical expenses are considered wasteful – meaning they are for unnecessary services, fraud, and sky high pharmaceutical or administrative costs. Medicare has already saved billions of dollars by reducing overpayments to private insurers and tying medical provider payments to quality of care. Overall a goal of those involved in healthcare reform should seek to follow this example of prioritizing value over volume of care, which will translate to better outcomes at lower costs for patients and taxpayers.

So what did the Affordable Care Act (ACA, also known as Obamacare) achieve since it was passed in 2010? In the time leading up to the ACA, 82% of the American public wanted healthcare reform. Private insurance premiums were rising 10% per year, and insurance didn’t have to cover expensive benefits, so many plans came without services like mental health or maternity care. Maternity care is not just a women’s issue, healthier pregnancies result in healthier babies who become part of our population. Before the ACA, 50 million (17%) of the population was uninsured; by 2016 20 million people had gained health insurance, leaving only 10% of our population uninsured. Women and people with pre-existing conditions can’t be denied coverage or charged more by insurance companies. Lifetime spending caps were removed, meaning if you were a sick baby in the ICU you can’t be denied coverage for the remainder of your life. The most popular part of the bill allows young adults to stay on their parents’ insurance until age 26, which reduced the uninsured rate for young adults by 47%. Finally, tax credits made health insurance through exchanges more affordable for those at or below 400% of the federal poverty line.

Those are the good parts about the ACA – here’s the bad news.  High deductible plans have increased from 10% of plans offered in 2010 to 51% of plans in 2016, meaning people buying insurance can expect to pay at least the first $1,000 per year out of pocket. If it seems that premiums are jumping, they are: they rose 20% from 2011 to 2016. It’s easy to blame the ACA for rising premiums, but if we consider that premiums rose 10% per year before the ACA, 20% in 5 years doesn’t sound so bad. Some specific states are expecting huge increases, for example Oklahoma will see a 42% increase in 2016. Part of the reason premiums are rising is because healthcare gets more expensive each year – it outpaces inflation and wages. Insurance companies are also losing money because they have enrolled more sick, expensive people than they expected to when they set prices. The ACA attempted to mediate the sticker shock for insurance companies by setting up “risk corridors” to help shoulder the burden, but that part of the bill was scuttled for political reasons, and now insurance companies are passing the buck to consumers. Regarding taxes, under the ACA, those without insurance will face a penalty fee double that of the 2015 amounts.

A central campaign promise of Trump and Republicans was to repeal the ACA and provide better and more affordable coverage for all.  The American Health Care Act (AHCA) proposed several weeks ago by Republicans was a repeal and replace bill which was unpopular from the start. The AHCA was unpopular with conservatives for not going far enough to repeal the ACA, while moderates worried about the 20 million people, including their constituents, being denied or outpriced from insurance due to some elements of the bill. The AHCA removed the mandates requiring insurance companies to provide essential health benefits. This could lower premiums but insurers could also reduce services, leading to “junk plans”. Additionally, tax credits for people buying insurance would be significantly lower than current levels, making insurance too expensive for many middle-income people. Medicaid coverage was also proposed to shrink, resulting in less coverage for poor Americans. Finally, eliminating the community rating of the ACA would enable insurance companies to charge older and sicker people higher premiums, essentially pricing those who need insurance the most out of the market. The AHCA proposed to ameliorate this problem by providing larger tax credits to older individuals and setting up pools of high risk people subsidized by the government.

It is safe to assume that the Republican controlled House, Senate and the White House will try again to present bills that modify the ACA. However, it remains to be seen if they will try a bipartisan effort to fix certain parts of the bill that are flawed, or repeal and replace the ACA with something completely new.

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Written by sciencepolicyforall

April 14, 2017 at 9:22 am

Science Policy Around the Web – October 14, 2016

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By: Fabricio Kury, MD

Source: pixabay

2016 Elections

What 10 health care experts would ask Trump and Clinton about health care

Health care finally had presence in the U.S. presidential race during the second debate this last Sunday. While Politico fact-checked what was said at the debate, the team at Advisory Board listed questions that should be of concern to the presidential candidates. Below is an overview of the topics and contexts of some of these questions.

Amitabh Chandra brought the important issue of Medicaid expansion. The Patient Protection and Affordable Care Act (PPACA, or ACA, a.k.a. “Obamacare”), signed into law in 2010, included provisions to expand Medicaid eligibility to all people with income up to 133% of the federal poverty line. However, unlike Medicare which is federally funded, Medicaid is jointly funded by each state and the union. The Supreme Court has ruled that the federal government cannot coerce states into expanding Medicaid, and, as of early 2016, 18 states had opted not to expand.

Douglas Holtz-Eakin and Martin Gaynor bring the perennial topic of free market-based versus government-based health care. Proponents of market-based approaches, such as Donald Trump, argue that competition can lower costs and thereby increase access, including for people currently uninsured. Government-based health care, also known as single-payer health care, is the case where the government provides or subsidizes care for everyone. This option, to a degree, is supported by Hillary Clinton. The Affordable Care Act, defended by Democrats and despised by Republicans, sought to establish a “middle-ground” approach. It promotes a U.S. health care system based on private insurance, but competition among the insurers would be stronger thanks to health insurance exchanges, where consumers are empowered to make better decisions. Under the ACA, everyone is obligated to have insurance, and vulnerable population groups, such as those living close to the poverty line, receive subsidies to lower the costs of their premiums. Moreover, the ACA, as well as other pieces of legislation, promotes alternative payment models, which seek to reimburse care for its value rather than number of procedures, encounters, services, i.e., its volume. In 2015Centers for Medicare and Medicaid Services (CMS) announced plans to tie 90% of Medicare payments to value as early as 2018.

Farzad Mostashari makes a rather stingy question for Clinton because of her support for the ACA. One of the predicted impacts of this law is generalized consolidation in the health care industry. However, consolidation can hamper competition, and moreover there is evidence that smaller practices are those ripe for the best improvements in quality and cost. How will small physician practices compete with large conglomerates, the largest of which are akin to Kaiser Permanente or the Geisinger Health System? Nicholas Bagley and Margaret O’Kane reinforce this concern by inquiring directly about how to address such excessive consolidation.

Finally, Robert Wachter, author of the praised book The Digital Doctor, asks about how to rein the resilient costs of health care, which today occupy almost 1 dollar out of every 5 in the entire U.S. economy. Clinton’s answer could be something close to the ACA’s Accountable Care Organizations approach, in which a group of providers receive bonus payments if they spend less than expected. Trump, as he mentioned in the last presidential debate when answering a question from the audience, believes in the power of market competition to lower health care costs.

Overall, this presidential election is also a contrasting choice between proceeding with the Democrat-supported Affordable Care Act and realizing the Republican pledge of dismantling this law to come up with something else. Bob Kocher and Ezekiel Emanuel, who worked in the White House in drafting the ACA, have laid their defense for “Obamacare” in this article. (Daily briefing, Advisory Board)

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October 14, 2016 at 10:14 am

Posted in Linkposts

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Ebola or Measles: Which is the greater threat to the US?

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By: Aminul Islam, Ph.D.

With the public hysteria and extensive media coverage of Ebola in the US subsiding and the spread of Ebola in West Africa appearing to be coming under control with declining numbers of new cases in the region; I was asking myself, what should people in the US be really afraid of? Were we ever at risk from Ebola in the US? Or is there another very real epidemic-based threat to be concerned with here at home? According to CDC data, there were four cases of Ebola in the US resulting in one death during 2014. Measles however, accounted for 644 cases in 2014, spanning 23 different outbreaks across the nation. Measles has the propensity to cause severe complications, injury and death. Since 2010 the average number of measles cases per year has been nearly 160, culminating in the huge spike in 2014. It may be almost inevitable that we could soon see the first death from measles in the US since it was declared to be eliminated from the country in 2000.

So what are the underlying reasons for such an increase in the numbers of people with measles? Similar to why Ebola reached the US shores, we truly live in a globalized age where people, commodities, livestock and micro-organisms alike can travel and reach every corner of the planet. Unlike the US, not every nation has the best healthcare system and infrastructure backed with highly funded medical research programs; and until this issue is resolved, the US will always be at constant risk from overseas microbial threats. While scientists search for a vaccine for Ebola, there is an effective MMR (measles, mumps and rubella) vaccine available against measles. So why are increasing numbers of Americans getting measles since the declaration of 2000? One explanation for this could be that for a number of recent years an ideology has existed in the US via an ‘Anti-Vaccination Movement’ that supports the belief that vaccinations are associated with negative health benefits, and in the case of the MMR vaccine specifically a link to autism, for which there is no credible scientific evidence. This has led to a decline in MMR vaccinations in the US resulting in vaccination levels below the threshold to produce herd immunity (about 90%) in some parts of the country. Furthermore, this anti-vaccination message has been supported by vocal celebrity and health science activists alike through the new-age/populist tool of social media which is capable of reaching large audiences very quickly. Compared to the challenges in African communities facing Ebola, this American community is definitely not against vaccinations as a result of poor education and/or belonging to a low socio-economic class.

So how do we counteract such an issue? Drawing parallels to the reasons why we are seeing success with Ebola in West Africa, we have to target these communities directly and specifically. We need to engage them in a way to overcome their beliefs about vaccinations and use appropriate strategies to build trust and dispel myths about the scientific rational behind vaccines. In other words, we need to develop science and public health policies that are not only designed to deal with infectious disease but also with misleading ideology.

So to answer the question which outbreak is a greater threat to Americans, Ebola or measles? Based on the evidence so far, I would say measles. The challenge facing us now is to convince every American in every community across all 50 States.









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February 4, 2015 at 9:00 am

Posted in Essays

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Science Policy Around the Web – July 7, 2013

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By: Jennifer Plank

2012-06-10 11.41.56Our weekly linkpost, bringing you interesting and informative links on science policy issues buzzing about the internet.

Crowdsourcing may open up ocean science – Many oceanographers rely on a conductivity, depth, and temperature (CDT) instrument in order to adequately conduct experiments at sea. On average, a CDT device costs thousands of dollars. A team of scientists are trying to develop a project called OpenCDT. This project would provide the blueprints for marine biologists to build their own CDT device for approximately $200. In order to fund the OpenCDT project, the team has turned to the crowdsourcing website, RocketHub, in the hopes of raising $10,000 to test and calibrate their do-it-yourself device. (Daniel Cressey)

A disease without a cure spreads quietly in the west – An insidious airborne fungal disease called Coccidioidomycosis, or Cocci, has been infecting individuals in the southwest. Over 20,000 people in California and Arizona are diagnosed with Cocci annually. Thousands of infected individuals will require surgery to treat the illness and approximately 160 will die. While the news of the disease has been largely non-existent, the so-called “silent-epidemic” received a lot of press when a judge ordered that 2,600 vulnerable patients be transferred out of prisons where they can contract Cocci.  (Patricia Leigh Brown)

Is this the end of health insurers? – For years, healthcare practitioners and health insurance companies have been at odds in terms of what procedures should be covered and to what extent. Additionally, employers are having trouble covering the rising health insurance costs for their employees. One large healthcare provider, MedStar Health, chose to kill two birds with one stone- in addition to providing health care for patients, they will also provide insurance assuming that those insured will seek services only at MedStar facilities. Initially, only MedStar employees were covered by the policy, however, now the policies are available to the public. This provides a mechanism for hospitals to provide top care and also provide the insurance services patients require. (Sarah Kliff)

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July 7, 2013 at 5:12 pm