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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

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

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Science Policy Around the Web – August 5, 2016

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By: Fabrício Kury, MD

Genetic engineering

‘Gene drive’ organisms should be tested in field trials, not widely released, experts say

While the Zika virus shows spread into the US, with mosquito-borne transmission having been reported in Miami, the scientific community is eager to kick-start the use of the new biotechnology called Gene Drive. This technique allows for the creation of genes that cheat the trial of chance and get passed on to nearly 100% of the offspring. This way, it is possible to alter the genome of entire populations of species, for example, by making populations of Aedes mosquitoes unable to transmit the Zika or Malaria viruses — if not plainly kill all the Aedes.

The danger of Gene Drive is our lack of knowledge about the impact of drastic alterations in the behavior or biology of one species, and also the consequences from the quick removal of a pervasive species from an ecosystem. The slow progress of Zika into the U.S. through warmer and wetter edges such as Florida and Puerto Rico seems like a window of opportunity for attacking the spread of the disease while it is still relatively isolated. However, the National Academies of Sciences, Engineering and Medicine call for tightly controlled experiments before wide use of the gene drive. As MIT Media Lab professor Kevin Esvelt put it, “there is a nontrivial chance that [the genes] will spread from a single organism released into a wild population into most or all members of the local population — and very possibly into every population of the target species around the globe.” (Ike Swetlitz, STAT news)

Technology and Healthcare

Why lawmakers are trying to make ransomware a crime in California

Ransomware is a type of malware (a “virus”) that can make money for a hacker very quickly. The ransomware program encrypts files in the target computer, then demands a ransom, usually to be paid in cryptocurrency (the most popular is Bitcoin) which can be hard to track, to release the key that decrypts the files. Hospitals are perfect targets for ransomware attacks because they are often big institutions, are mostly unprepared to defend themselves against cybercrime, and hold precious data in its computers. Most often, ransomware makes the system of computers functionally “locked inside a black box” or completely unable to be used, creating mounting losses and outright risks that outweigh the price of the ransom.

This includes the medical data that is kept private inside those computers and becomes locked behind the ransomware’s military-grade encryption. Other times, the cyberattack consists of “kidnapping the privacy” of the patients. Here the hacker makes a copy of the data and requests a ransom not to release it to the public. In 2015 alone, 113 million patients had some or all of their health records stolen, and the hospital hacks showed increase of 600%. It has been called “The Year of the Hospital Hack.” Moreover, according to the FBI, ransomware as a broader industry is on the rise. In the first three months of 2016, victims of ransomware lost more than $209 million, compared to $25 million in the entire 2015. (Jazmine Ulloa, Los Angeles Times)

Affordable Care Act Effects

How I Was Wrong About ObamaCare

The strategy implemented by the Patient Protection and Affordable Care Act (PPACA, “ObamaCare”) for the purpose of controlling health care costs is one that strives for paying for healthcare by value provided instead of service provided. The promoted understanding, as summarized by former health policy advisor to the Obama administration Dr. Ezekiel Emanuel, 2011, is that such force will pressure the health care industry to undergo vertical consolidation into Integrated Delivery Systems. These systems, whose likes could be named as Kaiser Permanente, Geisinger Health Care System, and Intermountain Healthcare, are consolidations of all types of providers (physician, imaging, therapy, nursing, surgery, home care, specialty care etc.) and strives to be at least internally coordinated to provide the best value per cost, since its payment is not completely tied to the number of procedures or services performed.

Two PPACA-derived value-based reimbursed programs were launched in 2012 — the smaller and more cautious Pioneer Accountable Care Organizations, reserved for groups of providers with more experience in integrated health care delivery, and the larger and more ambitious Shared Savings Program Accountable Care Organizations. Their data has been released along the past year. The data shows that, along the first performance year of the Medicare Shared Savings Program, 58 ACOs generated $705 million in savings, feat which earned them $315 in bonuses as per the program’s workings, leaving net $260 million in savings to CMS. In April this year, the first study of the official CMS claims data indicated that the better savings were among the ACOs classified as small groups of providers. This is understood as evidence against the “Kaiserification” of healthcare as envisioned by Dr. Emmanuel, since the savings come not from having all providers as employees of a big conglomerate, but instead in giving more autonomy and power to the health care provider at the forefront of the contact with the patient. (Bob Kocher, Wall Street Journal)

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August 5, 2016 at 11:00 am