• It’s Easy for Obamacare Critics to Overlook the Merits of Medicaid Expansion

    The following originally appeared on The Upshot (copyright 2016, The New York Times Company)

    Three years into Obamacare and it seems as if much of the news is bad: private insurers exiting the exchanges, networks being narrowed, premiums rising and competition dwindling out of existence.

    But it’s important to remember that many, if not most, of the newly covered Americans became insured through an expansion of Medicaid. Here, too, you hear a lot of bad news: that Medicaid offers poor quality and little choice of providers, that it is expensive for the states to administer and that its growing cost will eventually bankrupt states. As of today, 19 states have still refused to participate in the expansion.

    Such declarations consider only one side of the equation, though. In most ways, Medicaid offers an excellent return on investment.

    A rigorous analysis of the health benefits of being insured shows that Medicaid works on a number of levels. Critics of the program will point to studies that show that having Medicaid is associated with poor outcomes, even worse than those for the uninsured. Such studies are often flawed, however, in that those on Medicaid are often poorer and sicker than those who are uninsured.

    Some good randomized trials do exist. The Oregon Health Insurance Experiment is one of the most recent and best known. Many news articles have been written on the short-term findings of that study, which have been interpreted in many ways, both good and bad. But even that study couldn’t answer many of the long-term, holistic questions about its effects on health.

    To see the longer-term benefits across a wider population, we need to turn to other types of studies. They exist as well, usually taking advantage of changes in policy. Medicaid coverage of children and births expanded rapidly from the late 1970s through the early 1990s. When expectant mothers got early prenatal coverage, babies were less likely to be obese when they grew up. They had fewer hospitalizations, especially preventable hospitalizations, for any number of chronic disorders.

    Another study from last fall went further. By exploiting new Medicaid eligibility policies, researchers were able to closely compare people with and without benefits. They found that African-Americans who had more years of Medicaid eligibility as children had fewer hospitalizations and emergency department room visits as adults. More years of coverage achieved better results, even with respect to mortality.

    Benefits from Medicaid extend beyond health. A 2016 National Bureau of Economic Research working paper examined the effect of the Medicaid expansion on financial outcomes of beneficiaries. Using credit report data, researchers showed that the expansion was associated with a reduction of collection balances of as much as $1,000 for those receiving Medicaid.

    The financial benefits extend to society. A study from early 2015 looked at how expanding coverage to children in the 1980s and 1990s affected long-term finances. The analysis showed that children whose eligibility increased were more likely to go to college, earn higher wages and pay more taxes by the time they were 28 years old.

    In fact, after accounting for other factors, the researchers estimated that the government would recoup 56 cents on each dollar spent on childhood Medicaid by the time beneficiaries reached age 60. Other studies confirm that Medicaid in childhood makes children more likely to finish high school and college.

    At a national level, the expansion of Medicaid continues to yield benefits. Its coverage was increased, and its quality raised. Some states that have expanded Medicaid are even expecting net savings for the next few years. In states where Medicaid was expanded, hospitals had fewer uninsured visits.

    Focusing on only the positives can be as misleading as focusing on only the negatives. Policy decisions, including those involving health, need to be considered in terms of trade-offs. It is true that providing Medicaid can cost the federal government, and even states, a lot of money, which can’t then be spent on other worthy pursuits. It is true that Medicaid reimburses physicians and hospitals less generously, and that it often leaves beneficiaries with fewer choices than private insurance might.

    But when we look at the balance sheet for Medicaid — health benefits, financial security, societal improvements through education — it’s not hard to argue that money allocated to Medicaid is well spent.


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  • Stuff for Health Care Systems (PHMD2350)

    What is this post about? Look here.


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  • Healthcare Triage: Medical Device Failure, and How Data Can Help Us Prevent It

    Things sometimes go wrong with airbags, food and drugs, prompting recalls. It can also happen with medical devices, though you’d think lifesaving devices like heart defibrillators or artificial hips would be closely monitored.

    But the data needed to systematically and rapidly identify dangerous medical devices are not routinely collected in the United States. Why not? It wouldn’t be that hard to do.

    That’s the topic of this week’s Healthcare Triage.

    This episode was adapted from a column Austin wrote for the Upshot. Links to sources and further readings can be found there.


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  • Three thoughts about stopping risk corridor settlements.

    Congressional Republicans will have to confront at least three tough strategic questions as they move to shut off risk corridor payments. (Prior coverage is here.)

    First, the courts will entertain congressional objections to any risk corridor settlements only if the House has standing to intervene in the litigation. But the question of whether the House has standing to bring an appropriations lawsuit is already teed up in House v. Burwell, which is now pending on appeal at the D.C. Circuit.

    In House v. Burwell, court is likely to be suspicious of the House’s standing argument for fear that it might open the floodgates to similar appropriations disputes. The House will need to emphasize that such cases are rare, almost unique. Intervening in the risk corridor dispute would embarrass that claim. Litigation strategy in House v. Burwell thus counsels against intervening to stop the risk corridor payments.

    Second, the ACA’s private-market reforms rely on the private sector to distribute government-supported benefits. In this, they reflect a conservative suspicion of the public sector and a desire to embrace private ordering. Think of proposals to voucherize Medicare or privatize Social Security.

    Will private actors agree to work with the government on anything remotely controversial if they know that shifting political winds might lead Congress would renege on its financial obligations? Refusing to make risk corridor payments may advance Republicans’ effort to undermine the ACA, but at the cost of undermining the long-term viability of privatization strategies.

    Third, in late 2015, the Obama administration really wanted to make full risk corridor payments. It knew that a bunch of health plans, especially the co-ops, might otherwise go under—and that’s exactly what happened.

    Matters are different now. With 2016 coming to a close, the risk corridor program is about to wrap up. The insurers that can’t weather the loss of risk corridor payments have mainly shuttered already. For 2017 and beyond, those plans that are still in business will participate on the exchanges if they think they can make money. Whether they also get their risk corridor payments probably doesn’t much matter to the health of the exchanges.

    That changes the politics. Cutting a big check to insurance companies is a bad look, and the Obama administration knows it. For good reason, the administration may feel some legal responsibility to settle. But if the Republicans try to amend the Judgment Fund and foreclose these lawsuits, I don’t know how vigorously a newly sworn in President Clinton would object. She might be secretly relieved if Republicans decide to throw her into that particular briar patch.


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  • The world’s greatest athlete

    Via Anna Marquardt:

    serena williams


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  • Restrictions on the Type of Food Stamp Purchases Can Help Fight Obesity

    The following originally appeared on The Upshot (copyright 2016, The New York Times Company)

    Often, when I discuss the obesity crisis in the United States, especially when I’m pointing out another failed effort to help people change their eating habits, it’s as if there’s nothing we can do.

    But sometimes it’s actually more that there’s nothing we will do. There’s a difference.

    The Supplemental Nutrition Assistance Program (SNAP), colloquially known as food stamps, provides aid to poor families in the United States so that they can buy food. More than 44 million Americans are in the program, with the average household receiving about $255 a month.

    Oddly, food insecurity is linked to obesity. This could be because calorie-dense food is cheaper than nutrient-dense food, so poor people find it harder to eat healthily. Simply providing money for food won’t change this. In studies, people who receive SNAP tend to be more obese than those who don’t.

    This has led some to call for a reduction in benefits, arguing that the program is causing obesity. It’s more likely that we need to change the behavioral economics of food, not the aid we supply.

    A very recent study adds credence to this hypothesis. Researchers gathered adults in the Minneapolis-St. Paul area who were earning no more than 200 percent of the federal poverty line and who were not already enrolled in the SNAP program.

    All received a debit card with money for food, much like in SNAP. But then they were randomized to one of four groups. The first received a 30 percent financial incentive to buy fruits and vegetables; the second was prohibited from buying sugar-sweetened beverages, candy or sweet baked goods; the third got both the incentives of the first group and the prohibitions of the second; the fourth got none of these, and served as a control.

    Researchers followed these groups for three months. They found that, compared with the control group, those in Group 3 (incentives plus prohibitions) consumed about 96 fewer calories per day, 64 of which were “discretionary” calories (from added sugars, solid fats and alcohol above moderate consumption). The third group also ate less of the prohibited foods and more fruit.

    Interestingly, those in the incentive-only and prohibition-only groups didn’t see significant differences. It seems that a combined approach was needed.

    The good news is that there seems to be something we can do about obesity. The bad news is that we probably won’t do it.

    There have been many, many, many calls for the food stamp program to promote more healthful diets. Many states have requested waivers allowing for restrictions on what benefits can buy (some items, like alcohol, tobacco and household supplies, are already prohibited). Further restrictions have been rejected by the Department of Agriculture, which administers this welfare program.

    Its reasons for doing so are not hard to understand. The U.S.D.A. harbors legitimate concerns that such restrictions could increase the stigma and embarrassment already associated with food stamps, driving away potential beneficiaries, some of whom are children. The agriculture department favors incentives, rather than exclusions, though this research shows incentives alone don’t seem to work. Most important, the department may be concerned that such changes would unfairly target poor people.

    That concern is not entirely unreasonable. Sometimes the people calling for restrictions on food stamp purchases are the same people trying to reduce benefits over all. Such calls are often also fueled by anecdotal accounts of people abusing the program to buy luxury items like lobster, filet mignon and crab legs. When we move beyond anecdotes, data show that food stamp recipients are not favoring shellfish or steaks over ground beef.

    But not all pushes come from those who seek to punish the poor. New York City, which tried to limit soft drink sales for everyone, also asked the U.S.D.A. for permission to restrict purchases of sugary beverages from food stamps as part of a two-year experiment and was denied.

    The department’s concerns seem odd when we look at other federal programs. The program for Women, Infants and Children (WIC) provides food to poor women during and after pregnancy and to their infants and children. That program’s restrictions on food are quite thorough. The School Lunch Program helps provide meals to more than 31 million children each school day. The regulations that govern what’s allowed under that program are complex and vast.

    The authors of the new study say that this is the first experiment to look at whether restricting certain foods on SNAP might lead to better health. It might be worthwhile for the Department of Agriculture to extend the experiment a bit more.


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  • Healthcare Triage News: Gluten-Free Diets on the Rise, and Contraception Works

    Celiac disease prevalence is stable; gluten free diets are not. And does contraception work? Spoiler… yes. This is Healthcare Triage News.

    For those of you who want to read more:


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  • #6things That Happened in Health Policy This Week

    6 Things That Happened in Health Policy This Week is produced by a mix of research assistants from the Healthcare Quality & Outcomes (HQO) Initiative at the Harvard T.H. Chan School of Public Health. In each edition we feature a variety of news articles, reports, and studies focused on U.S. health policy and health services research. This week’s edition includes contributions from Stephanie Caty (@stephaniecaty), Yevgeniy Feyman (@YFeyman), and Zoe Lyon (@zoemarklyon). 

    Hospital employment of physicians does not improve quality of care

    • A recent study in Annals of Internal medicine finds that employing physicians does not improve quality of care.
    • The study looks at 4 key quality indicators in U.S. non-federal acute care hospitals from 2003-2012: mortality, readmissions, length of stay and patient satisfaction.
    • Comparing 803 hospitals that did switch to an integrated salary model with 2053 hospitals that did not switch, Scott et al. found that there was no effect of switching to an employment model on any of the four metrics.
    • Proponents of the hospital employer model argue that it can improve quality because it encourages coordination efforts and “continuum of care services”.
    • However, as this study underscores, simply establishing the employment relationship is not sufficient to improve quality of care.
    • Work such as this is increasingly important as the general trend of consolidation in healthcare continues to increase.

    KHN: Remember The ‘Public Option’? Insurance Commissioner Wants To Try It In California

    • California’s insurance commissioner, Dave Jones, recently expressed support for a “public option” on California’s health insurance exchange.
      • Though the details haven’t been fleshed out, a public option would be a government run insurance plan that competes with other private insurers.
      • A public option was dropped from the final draft of the ACA when it passed, but the idea has gained traction recently as major insurers have pulled back from the individual market.
    • Because the public option idea has typically been for a national plan, details are particularly scarce as to how a state-run option would work.
    • Jones didn’t offer many specifics on what the plan might look like, noting that regional pilots might be one approach. Regardless of the details, a public option would require legislation.
    • Some experts questioned the usefulness of the proposal, noting that it might make sense where there are few or no alternative insurers operating. Additionally, a public option could also crowd out private insurers from the market.
      • While California has had better competition and availability of insurers than other states, 7.4 percent of the state’s exchange enrollees will only have two health plans to choose from in 2017.

    Modern Healthcare: Most physicians report low morale, burden from new payment models

    • A new report from The Physicians Foundation, which surveyed nearly 20,000 physicians across the US finds that physicians have low morale and feel burdened by new reimbursement models.
    • The survey, which is conducted biennially, contains questions related to professional morale, practice patterns, health reform, and career plans.
    • A few key findings:
      • 4% of respondents reported being very unfamiliar with what MACRA is.
      • 40% of respondents aged < 45 feel as though EHRs have improve quality, while 52% feel EHRs have detracted from patient interaction.
      • 5% of respondents participating in an ACO feel that it is unlikely to enhance quality/decrease cost.
      • 54% of all respondents surveyed rated their morale in the profession as somewhat negative or very negative.

    STAT: Colorado is latest state to be sued for restricting access to hepatitis C drugs

    • Colorado is the latest facing a lawsuit for restricting access to new hepatitis C medications in its Medicaid program.
      • The most recent therapies, including Gilead Sciences’ Harvoni and Sovaldi, are typically expensive but have cure rates of over 90%.
      • The lawsuit is challenging Colorado’s policy of restricting coverage of the drugs to people with advanced stage liver disease.
      • These restrictions are typically contrary to clinical recommendations that the drugs be made available at earlier stages of the disease.
    • This lawsuit comes on the heels of a push for public and private insurers to allow broader access to the drugs. Moreover, the Obama administration has already noted that state Medicaid programs might be violating federal law with these restrictions.
      • A prior lawsuit against Washington state resulted in the state being ordered to lift coverage restrictions.
    • Public programs in particular have faced budget constraints. Colorado’s Medicaid program, for instance, spent over $26 million to treat 326 patients. Coverage of every eligible patient would cost $237 million.
    • After the ACLU’s threat to sue last month, the state loosened restrictions to allow 70 percent of patients to become eligible.
      • The current lawsuit, however, claims that this did not go far enough and demands no restrictions.

    The Washington Post: Skyrocketing Obamacare premiums still lower than employer-sponsored insurance

    • Many policymakers have expressed concern and criticism over premium price hikes and recent announcements by large insurers that they are leaving the marketplaces established by the Affordable Care Act.
    • However, a new study from the Urban Institute finds that even when adjusted for enrollee age and plan generosity, unsubsidized plans in the marketplaces cost 10% less than employer-sponsored insurance premiums.
    • Most people who receive employer-sponsored insurance do not pay the full premium price, as their employer covers a large portion of it in the employee benefit package, so for those in marketplaces who pay unsubsidized premiums, the full premium feels drastically higher in comparison.
    • Premiums are rising for both marketplace plans and employer sponsored plans, albeit more for marketplace plans (11%) than for employer sponsored coverage (3%).
    • Looking at marketplace prices in the context of employer-sponsored insurance prices may be useful for identifying when there are serious issues in the marketplaces; when marketplace plans are significantly higher than employer-sponsored coverage, this could signal a market issue, such as too few competitors in the market, or too many sick patients.

    The Commonwealth Fund: The Health Care Reform Proposals of Hillary Clinton and Donald Trump

    • A new analysis done by RAND Health compares Hillary Clinton and Donald Trump’s health care proposals and their potential implications for insurance coverage, costs, and the federal deficit.
    • Clinton plans to maintain the ACA, whereas Trump intends to repeal it; before factoring in potential changes or replacement options, these two strategies would yield drastically different results for coverage and costs: Trump’s plans to repeal the ACA would result in 19.7 million people losing coverage and would increase the federal deficit by $33.1 billion.
    • However, both Clinton and Trump intend to do more than simply maintain or repeal the ACA, and their respective proposals have very different implications:
      • Among other things, Clinton is proposing to create refundable tax credits for those with private insurance premiums that are greater than 5% of their income, increase tax credits in the marketplaces so that eligible enrollees are paying no more than 8.5% of their income , and create a public insurance option.
      • Trump aims to replace the ACA by, among other things, making all premium payments in the individual market tax-deductible, creating block-grants for state Medicaid programs, and allowing insurance plans to be sold across state lines.
    • According to the RAND models, Clinton’s proposals would extend coverage and lower costs across the income spectrum, but especially for those with low income. However, it would likely increase the federal deficit, which could potentially be offset by some of her other policy proposals.
    • Trump’s proposals will likely be budget neutral given the large cuts in Medicaid funding, however they are projected to drastically decrease coverage.
    • Further analyses and resources can be found on the Commonwealth Fund’s website.
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  • The fight over the risk corridor program is heating up.

    From the Wall Street Journal.

    Congressional Republicans are warning the Obama administration not to settle with insurers that have sued the government over an Affordable Care Act program to compensate them for losses under the law, saying such a move would bypass spending limits set by Congress.

    I get what the Republicans are doing here. It’s easy to score points by railing against insurer “bailouts.” But the Obama administration isn’t exploring settlement (as Chairman Upton of the House Committee on Energy and Commerce says) because it “is panicked, and this ‘Better Call Saul’ sue-and-settle scheme is the pinnacle of desperation as the health law crumbles.”

    In point of fact, whether risk corridor payments are made doesn’t much matter to the future of the ACA. Sure, Republicans’ refusal to fully fund the program contributed to the collapse of a bunch of co-ops and small insurers. But that damage is done.

    For insurers that weathered the storm, they’ll participate on the exchanges if they think they can make money. Whether they win their lawsuits will affect their earnings, not their participation.

    No, the Obama administration is exploring settlement because it thinks it’s probably going to lose these lawsuits. As I have explained many times, the risk corridor program creates an entitlement in health plans to risk corridor payments. If HHS can’t make those payments directly—and it can’t, on account of congressional appropriations riders—health plans can seek damages in the Court of Federal Claims.

    Any judgment against the United States can then be paid out through the Judgment Fund, as is generally the case for suits against the government. And if the Judgment Fund is available to pay judgments, the government can settle claims out of the same fund.

    Nonetheless, in a letter sent to HHS on Tuesday, Chairman Upton claims that using the Judgment Fund to settle the lawsuits would “be a direct circumvention of clear Congressional intent to prohibit the expenditure of federal dollars on this program.”

    Chairman Upton is mistaken. Congress hasn’t expressed any such intention. It could easily do so. It just has to enact a statute that looks like this:

    No funds appropriated under section 1304 of chapter 31 of the U.S. Code [i.e., the Judgment Fund] may be used to make any payments in connection with the risk corridor program established under section 1342 of the Patient Protection and Affordable Care Act, Public Law 111-148.

    Conspicuously, Congress hasn’t done that. Instead, it has enacted two annual appropriations statutes saying that the administration can’t use money appropriated in those statutes to make risk corridor payments. Congress has said nothing about other sources of payment. Here’s the language if you don’t believe me:

    None of the funds made available by this Act from the Federal Hospital Insurance Trust Fund or the Federal Supplemental Medical Insurance Trust Fund, or transferred from other accounts funded by this Act to the ‘‘Centers for Medicare and Medicaid Services—Program Management’’ account, may be used for payments under section 1342(b)(1) of Public Law 111–148 (relating to risk corridors)

    That’s it. There’s nothing there about the Judgment Fund. House Republicans might wish that they’d said more—but they haven’t, at least not yet.

    In the meantime, the Obama administration seems to realize that it’s playing a losing hand. Any prudent litigator would think about settling these cases. Heck, the administration might even be able to settle them for less than their face value, which would save taxpayer dollars.

    I understand that Republicans don’t much like the ACA. But the fight here is over what the law demands, not whether you love or hate health reform. Unless and until Congress passes a statute limiting the use of the Judgment Fund, the Obama administration is right to think about settlement.


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  • JAMA Forum: Re-engaging in Health Care Reform

    As we approach the election this fall, it seems like the news media report on little else. Unfortunately, too little news coverage addresses health care reform. This is ill-advised because there is still much to be done to improve the cost, quality, and access for patients within the US health care system. In this post, I will attempt to cover most of the major issues related to health care coverage that US consumers face.

    This is my latest post over at the JAMA Forum. Go read it!


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