• Today’s repeal and replace reading list

    It’s hard to keep up. Here are things I’ve read so far today. I’ll add more throughout the day, as warranted. (Provision of this list does not imply endorsement or non-endorsement of anything at the links.)

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  • Repeal and replace: The Democrats’ role

    Avik Roy articulates how Democrats might be drawn onto the repeal and replace wagon:

    [I]t is definitely possible for the GOP to repeal and replace Obamacare. The sequence would go something like this:

    1. Partially repeal Obamacare via reconciliation, with the subsidies expiring in 2019.
    2. Get Republicans to agree on a pathway to market-based universal coverage that reduces, instead of increasing, the federal role in health care.
    3. Use the two-year window to achieve market-based universal coverage by repealing the ACA’s premium-hiking regulations, replacing it with a system of means-tested tax credits.

    There are likely to be 60 votes for the Obamacare replacement under this scenario, because once Obamacare’s subsidies have been repealed, Republicans will have negotiating leverage with Democrats who would prefer a more statist approach.

    This is clever. To get around a filibuster, it puts a gun to the Senate Democrats’ heads, so to speak. “Do you want something or nothing?”

    @afrakt

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  • Stuff for Health Care Systems (PHMD2350)

    What is this post about? Look here.

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  • Repeal and replace watch

    It’s way too early to tell with much certainty, but what could this mean?

    House Speaker Paul Ryan on Wednesday suggested Congress would seek to use a budget tool known as reconciliation to repeal the Affordable Care Act under the incoming Trump administration.

    But at a Capitol Hill press conference later in the day, Senate Majority Leader Mitch McConnell would not commit to using the process to repeal the law.

    Since Majority Leader McConnell has also indicated that repealing the ACA is “high on our agenda,” this could mean he intends to remove the filibuster as a means by which Senate Democrats could oppose repeal. (Budget reconciliation bills cannot be filibustered.)

    On the other hand “high on our agenda” leaves lots of wiggle room.

    More on the filibuster here.

    UPDATE: Ben Carson may be involved in crafting a replacement plan.

    Ben Carson says he’s still ironing out his role in the incoming administration of President-elect Donald Trump, but one thing’s certain: He’ll have a role in helping craft the replacement plan for Obamacare.

    “I think the replacement obviously must come first and it must be something that is very appealing and easy to understand. And then, only then, would you dismantle what’s in place,” the retired neurosurgeon said in an interview.

     Asked if he intends to be involved in designing that plan, Carson said, “Yes, of course.”

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  • Now that Trump has won, telling the story of research is more important than ever

    My first thought was that giving a midday talk at RTI today was, in hindsight, poorly scheduled. The day after the election — particularly this election — just isn’t the right time to talk about how to disseminate research. Who would care?

    But my second thought was much better. This is exactly the right time to talk about the importance of disseminating research.

    A Trump Administration, with a Republican Congress, is likely to be much less favorable to research and evidence, whether funding it or using it to inform policy, than a Clinton Administration would have been. This is not in and of itself wrong. There are other criteria that inform policy besides evidence. Values matter. Nevertheless, I agree with Bill that funding for research agencies like AHRQ, centers like CMMI, and institutes like PCORI is in jeopardy.

    What to do?

    What I told my audience was the same thing I would have told them any other day. We must keep telling the story of health care, if not all, research — why it matters, what it means, how we do it, where it leads to improvement, and how much more there is to do.

    There are so many ways to do this. We can write. We can make videos. We can tweet, post on Facebook, call our representatives, give talks in our communities, and on and on.

    I’m favorable to writing, so my talk focused on how to do that. I described my process of developing posts that translate research for a wider audience. I encouraged my audience to develop the skills to do the same, and I showed them how. (It’s up to them to put in the practice, of course. I cannot do that for them.)

    If we don’t redouble our efforts to communicate what we do as researchers, we will get what we deserve, which is less research support. That may be what we get anyway, but we have little to lose by trying to educate the public, our policymakers, and journalists why and how what we do matters.

    Telling the story of research has not become less relevant now that Trump has won. Now more than ever, it’s one of the most important things me and my colleagues at TIE and beyond can do.

    @afrakt

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  • The next health reform

    It’s not hard to guess what it might include.

    Trump’s agenda is far less detailed than the 37-page Ryan document. Of 7 items on the Trump agenda, 5 also are part of the Ryan plan: (1) complete repeal of the ACA; (2) permitting interstate sale of health insurance; (3) allowing individuals to deduct the cost of health insurance premiums on their federal tax returns; (4) expanding use of health savings accounts; and (5) reforming Medicaid by implementing state spending block grants (or per beneficiary enrollment caps as an alternative under Ryan’s plan). Trump’s plan also promotes price transparency for physicians and hospitals, and would permit the importation and domestic sale of drugs with regulatory approval in other countries.

    Ryan’s plan includes more details on the proposals it shares with Trump’s approach, plus policy proposals not included in Trump’s plan. Most of Ryan’s proposals reflect recommendations that are also key elements of other Republican and conservative plans, such as: capping the tax deductibility of employer provided health insurance; nationwide limits on noneconomic damages in medical liability litigation; continuing the ACA’s guaranteed issue of health insurance though only for individuals who maintain “continuous coverage,” and reestablishing state high-risk pools for uninsured persons with preexisting conditions; not allowing expansion of Medicaid as permitted by the ACA in states that had not expanded Medicaid by January 1, 2016; raising the eligibility age for Medicare to 67 years; and moving Medicare toward a premium support financing structure to limit the federal government’s financial obligations.

    Many of Ryan’s proposals are ambiguous. Moreover, the plan has not been written in legislative language, preventing scoring by the Congressional Budget Office to determine the likely cost and the impact on health insurance coverage. Regarding the Trump proposals, an analysis by the Committee for a Responsible Federal Budget, a nonprofit, nonpartisan organization, concluded that it would increase the number of uninsured by 21 million by 2018, raising the number of uninsured Americans from nearly 30 million to about 50 million, and increase the federal budget debt over 10 years by between $330 and $550 billion.

    That’s from a recently published JAMA Internal Medicine Viewpoint by John McDonough and David Jones to which I’ve inserted links. Find more here.

    UPDATE: Per my tweets, here’s more on this topic.

    See also Tim Jost and Margot Sanger-Katz.

    @afrakt

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  • Stuff for Health Care Systems (PHMD2350)

    What is this post about? Look here.

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  • Escape

    Via Jonathan Zdziarski:

    escape

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  • AcademyHealth: The U.S. paid sick leave landscape

    Lack of paid sick leave for workers is a rarely discussed barrier to obtaining health care. So, I discuss it in my new AcademyHealth post.

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  • The high costs of not offering paid sick leave

    The following originally appeared on The Upshot (copyright 2016, The New York Times Company). It also appeared on page A3 of the November 1, 2016 print edition.

    Maybe the person working near you, the one who dragged himself to work and is now coughing and sneezing, couldn’t afford to stay home.

    Each week about 1.5 million Americans without paid sick leave go to work despite feeling ill. At least half of employees of restaurants and hospitals — two settings where disease is easily spread — go to work when they have a cold or the flu, according to a recent poll.

    To address that issue, Chipotle began offering paid sick leave to all its employees in the United States this year. The restaurant chain is hoping to reduce the spread of infectious disease — like the norovirus outbreaks traced to its restaurants last year and earlier this year. Though many other industrialized countries already require employers to offer paid sick leave to all employees, the United States does not.

    Paid sick leave is not free, of course. Economic theory suggests that its cost would be passed from employers to their employees in the form of lower wages or reductions in other benefits like vacation time. Yet employees and their co-workers may be better off with an incentive to take time off when sick.

    A number of recent studies point to the benefits. A study by Philip Susser, now a medical student, and Nicolas Ziebarth, a Cornell economist, backs up Chipotle’s theory that paid sick leave could reduce the spread of contagion. Their study, published in the journal Health Services Research, estimated that 45 percent of the American work force does not have paid sick leave; that’s about 50 million workers.

    Low-income mothers are particularly likely to work while sick. Another study, by LeaAnne DeRigne of Florida Atlantic University and colleagues, explains why. It found that families with less ability to afford unpaid time off are more likely to lack paid sick leave. According to the study, published in Health Affairs, 65 percent of families with incomes below $35,000 had no paid sick leave, while the same was true of only 25 percent of families with annual incomes above $100,000.

    Paid sick leave slows the spread of disease. Cities and states that require employers to offer paid sick leave — Washington, D.C.; Seattle; New York City; and Philadelphia, as well as Connecticut, California, Massachusetts and Oregon — have fewer cases of seasonal flu than other comparable cities and states. Flu rates would fall 5 percent if paid sick leave were universal. According to one estimate, an additional seven million people contracted the H1N1 flu virus in 2009 because employees came to work while infected. The illnesses led to 1,500 additional deaths.

    Paid sick leave has other benefits besides reducing flu deaths. For example, workers may use it for preventive care, forestalling subsequent, more disruptive health problems. Workers lacking paid sick leave are more likely to delay needed medical care, a finding that holds for both insured and uninsured workers. In other words, though health insurance helps people pay for health care, it does nothing to help them afford to take time off to get it.

    Sicker workers may be more prone to job-related injuries. One study found that even within industries in which accidents and injuries are relatively more likely — like forestry, mining and construction — workers with paid sick leave experienced fewer of them than workers without it. Another study found that employees who work while sick are more likely to have heart attacks than those who take time off.

    Paid sick leave may also enhance productivity and reduce turnover. One study estimated that the lower productivity of sick workers costs employers as much as their medical care.

    Children benefit from their parents’ paid sick leave, too. Most directly, it helps workers afford to care for sick children. Additionally, the children of new mothers who return to work more rapidly, perhaps because they lack paid time off, are less likely to be breast-fed or to receive recommended medical checkups and immunizations.

    Though a few cities and states mandate paid sick leave, there is no national requirement. Under the Family and Medical Leave Act, enacted in 1993, employers with more than 50 workers must offer 12 weeks of leave within a 12-month period, but it is unpaid. Because of a new Obama administration rule, an estimated 300,000 private-sector employees working on government contracts will get paid sick leave starting on Jan. 1. New York State recently enacted a law that mandates paid leave to care for a newborn or a sick family member, but it is not applicable to employees who are themselves ill.

    Paid sick leave is not the only way to improve access to health care for workers. The ability to see a doctor or a nurse outside of business hours — for example, via telemedicine or at a health clinic at a drugstore or other retail location — can also improve access to care.

    We tend to focus on health care coverage as the only way to reduce the cost of care to patients. But there are many other costs we rarely consider, time taken from work among them. Even when they are insured, many workers in the United States — unlike those in every other industrialized country — are exposed to this cost.

    @afrakt

     

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