• Judges Shouldn’t Have the Power to Halt Laws Nationwide

      10/31/2018
      Nicholas Bagley

    That’s the headline to an article of mine, co-authored with Sam Bray of Notre Dame Law School and published today in The Atlantic. We highlight the disquieting possibility that a single district court in Texas might soon enter an injunction prohibiting the enforcement of all or part of the Affordable Care Act across the entire country.

    Something is very wrong with this picture. Under the Constitution, the federal courts are vested with the “judicial Power,” which has traditionally been understood to limit them to resolving disputes between the parties who appear before them. That makes sense in a democracy: Unelected judges shouldn’t adjudicate the rights of non-parties or referee abstract political fights.

    In a quiet shift over the last 60 years, however, the courts have gradually assumed the power to enter national injunctions against federal statutes and regulations, at least under some (not very well-defined) circumstances. The trend has accelerated dramatically in the last three-and-a-half years, as claims of executive overreach have proliferated.

    The Supreme Court has not expressly ruled on the legality of these national injunctions, though it has recently shown some interest in the issue. In our judgment, it should curtail the practice.

    The point is not a partisan one. (One of us is a Republican, the other a Democrat.) Before courts entered national injunctions against the Trump administration, they used them to thwart the Obama administration’s rule for overtime pay and its signature immigration policy, Deferred Action for Childhood Arrivals.

    National injunctions are equal opportunity offenders.

    Here’s the whole thing. If you want to learn more, I’d encourage you to read Sam’s excellent Harvard Law Review article on national injunctions.

    @nicholas_bagley

     
      Health Policy, Law
      Texas v. United States
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  • A Sense of Alarm as Rural Hospitals Keep Closing

      10/31/2018
      Austin Frakt

    The following originally appeared on The Upshot (copyright 2018, The New York Times Company). 

    Hospitals are often thought of as the hubs of our health care system. But hospital closings are rising, particularly in some communities.

    “Options are dwindling for many rural families, and remote communities are hardest hit,” said Katy Kozhimannil, an associate professor and health researcher at the University of Minnesota.

    Beyond the potential health consequences for the people living nearby, hospital closings can exact an economic toll, and are associated with some states’ decisions not to expand Medicaid as part of the Affordable Care Act.

    Since 2010, nearly 90 rural hospitals have shut their doors. By one estimate, hundreds of other rural hospitals are at risk of doing so.

    In its June report to Congress, the Medicare Payment Advisory Commission found that of the 67 rural hospitals that closed since 2013, about one-third were more than 20 miles from the next closest hospital.

    A study published last year in Health Affairs by researchers from the University of Minnesota found that over half of rural counties now lack obstetric services. Another study, published in Health Services Research, showed that such closures increase the distance pregnant women must travel for delivery.

    And another published earlier this year in JAMA found that higher-risk, preterm births are more likely in counties without obstetric units. (Some hospitals close obstetric units without closing the entire hospital.)

    Ms. Kozhimannil, a co-author of all three studies, said, “What’s left are maternity care deserts in some of the most vulnerable communities, putting pregnant women and their babies at risk.”

    In July, after The New York Times wrote about the struggles of rural hospitals, some doctors responded by noting that rising malpractice premiums had made it, as one put it, “economically infeasible nowadays to practice obstetrics in rural areas.”

     
      Health Policy
      hospitals, Upshot
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  • Healthcare Triage: Carrot vs Stick – The Social Safety Net, the Earned Income Tax Credit, and Work Requirements

      10/29/2018
      Aaron Carroll

    In the next year and a half, we here at Healthcare Triage are going to take some deep dives into issues of health policy, especially those that touch on social determinants of health and health equity. The episodes that do so will be a bit longer than usual. They’ll look a little different. They also come to you thanks to the support of the RWJF, which has generously supported their creation. We’re excited about this opportunity to really dig in, and we hope you will be, too.

    For the next three weeks, we’re going to talk about work requirements. First, we’ll talk about the basics and other government work promotion efforts, then we’ll discuss what we’ve learned from TANF, and finally, we’ll discuss what this might mean for Medicaid.

    Work requirements are the topic of the next three episodes of HCT.

    @aaronecarroll

     
      Health Policy
      EITC, food stamps, Healthcare Triage, Medicaid, RWJF, TANF, work requirements
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  • Healthcare Triage: Is the Apple Watch a Health Device or What?

      10/23/2018
      Aaron Carroll

    The latest and greatest gadget from Apple, the Watch Series 4, has doubled down on the health monitoring game, and is sporting an electrocardiogram, or ECG, function. But how useful is this thing? Does it make sense to monitor lots of healthy people? And does the Apple Watch really appeal to the people who are most at risk for heart conditions this device could detect?

    This episode is adapted from a column I wrote for The Upshot. Links to sources can be found there.

    @aaronecarroll

     
      Health Policy
      Apple watch, EKG, false negatives, false positives, Healthcare Triage, Upshot
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  • Healthcare Triage News: Most People Don’t Need Vitamin D Supplements

      10/18/2018
      Aaron Carroll

    There’s a big study out from The Lancet Diabetes & Endocrinology. Systematic Review. Meta-Analysis. Trial sequential analysis. This one’s got it all!

    @aaronecarroll

     
      Health Policy
      Healthcare Triage, supplements, Vitamin D
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  • Healthcare Triage: Dissemination: Get Out There and Strut Your Stuff!

      10/17/2018
      Aaron Carroll

    Let’s say you’re in the habit of doing scientific research. Or maybe you’re an expert in a field who can concisely and coherently discuss research. Disseminate! There are more avenues than ever before to make your voice heard, and share the knowledge you worked hard to obtain.

    @aaronecarroll

     
      Health Policy
      dissemination, Healthcare Triage, RWJF, science
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  • Is Medicare for All the Answer to Sky-High Administrative Costs?

      10/17/2018
      Austin Frakt

    The following originally appeared on The Upshot (copyright 2018, The New York Times Company) and on page B6 of the print edition on October 16, 2018.

    Calls for a Medicare for All system are growing louder. Many Democrats have embraced it, while President Trump said last week that it would raise health care costs drastically.

    Democrats say that giving people the option to partake in Medicare — no matter their age — will actually cut costs.

    American administrative costs for health care are the highest in the world, and they argue that one advantage of Medicare for All is that it would save money because Medicare’s administrative costs are below those of private insurers.

    Does that argument hold up?

    Medicare’s administrative costs were $8.1 billion last year, or 1.1 percent of total spending, close to the proportion it has been in recent years.

    But some have argued that the actual cost is higher because of services performed for Medicare by other parts of the government that aren’t accounted for: The Social Security Administration collects premiums, the Internal Revenue Service collects taxes for the program, the F.B.I. provides fraud prevention services, and at least seven other federal agencies and departments also do work that benefits Medicare.

    The claim that these administrative costs are overlooked is false. As annual reporting of Medicare’s finances plainly states, they are accounted for.

    But there is something missing from the $8.1 billion Medicare administrative cost figure, as Kip Sullivan explains in a 2013 paperpublished in the Journal of Health Politics, Policy and Law. Although it accurately accounts for the federal government’s administrative costs, it does not include those borne by private plans that also offer Medicare benefits.

    In addition to the traditional (public) Medicare plan, Medicare is also available from private plans through the Medicare Advantage program. Today, one-third of people using Medicare are in such plans, up from about one-fifth a decade ago. Moreover, all Medicare drug benefits are administered through private plans.

    National Health Expenditure data shows both the government’s administrative costs for Medicare and those of Medicare’s private plans. Putting them together for the most recent year available (2016), they reach $47 billion, or 7 percent of total Medicare spending — well above the administrative costs borne directly by the Medicare program.

    Medicare’s private drug benefit plans incur administrative costs that are about 11 percent of their spending. All of this additional, private administrative cost is paid for by taxpayers and, through their premiums, people who use Medicare.

    Medicare’s direct administrative costs are not only low, but they also have been falling over the years, as a percent of total program spending. Yet the program’s total administrative costs — including those of the private plans — have been rising.

    “This reflects a shift toward more enrollment in private plans,” Mr. Sullivan said. “The growth of those plans has raised, not lowered, overall Medicare administrative costs.”

    Making an accurate estimate of the administrative costs of Medicare for All would depend, in part, on whether it would be more like an expansion of traditional Medicare (with its 1.1 percent administrative cost rate) or of all of Medicare, including its private plans (with a combined 7 percent administrative cost rate).

    Yet both figures are well below private insurers’ administrative costs, which run about 13 percent of spending (this also includes profit), according to America’s Health Insurance Plans, an advocacy organization for the industry.

    Some critics have argued that Medicare’s administrative cost rate appears artificially low because Medicare enrollees’ health spending is so high. Average Medicare spending per beneficiary is just over $12,000 per year; for an average worker in a private plan, it’s about $6,000. If you simply divide administrative costs by total spending, you will get a lower number for Medicare for this reason alone.

    This is true, but the government’s administrative costs for Medicare are still below those of private plans. The government’s administrative costs are about $132 per person compared with over $700 for private plans. One reason Medicare’s are so much lower is that it reaps economies of scale. It also benefits from not needing to do much marketing, and it doesn’t earn profits.

    @afrakt

     
      Health Policy
      administrative costs, Medicare, Upshot
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  • Healthcare Triage: The 2017 Flu Killed 80,000 in the US. Get a Flu Shot!

      10/15/2018
      Aaron Carroll

    Influenza killed 80,000 people last year in the United States. That is the highest number of deaths since the CDC started keeping records in the 1970s. Help protect yourself and those around you. Get a flu shot!

    @aaronecarroll

     
      Health Policy
      flu, Healthcare Triage, influenza, vaccination
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  • That New Apple Watch EKG Feature? There Are More Downs Than Ups

      10/15/2018
      Aaron Carroll

    The following originally appeared on The Upshot (copyright 2018, The New York Times Company).

    The newest version of the Apple Watch will feature a heart monitor app that can do a form of an electrocardiogram. Many have greeted this announcement as a great leap forward for health. The president of the American Heart Association even took part in the product launch.

    For a more measured response, it’s worth looking at potential downsides, and it turns out there are a few.

    The upside potential is twofold. First, doctors could monitor — at a distance — how patients with known heart problems are functioning outside the office. Second, the device could diagnose heart problems in people who don’t know they have them, picking up abnormal heart rhythms earlier than would otherwise be possible.

    With respect to monitoring from a doctor, the Food and Drug Administration “cleared” the app — an easier hurdle to surmount than “approval.” But it specifically said people with diagnosed atrial fibrillation, one of the most common heart arrhythmias, should not be using the app.

    If that’s the case, the major potential for the device — which will arrive later this year — is to pick up arrhythmias in otherwise healthy people. That’s still a big selling point. Picking up abnormal function earlier could theoretically lead to improvements in health, such as reductions in strokes.

    But just because something seems like a good idea doesn’t mean it is. No screening test is perfect. In the simplest sense, whenever we consider the results of medical tests, they can be “positive” or “negative.”

    In general, we would like people who are sick to have a positive screening result, and people who are well to have a negative result. Unfortunately, people who are sick sometimes have a negative result. Those are false negatives. People who are well sometimes have a positive result. Those are false positives.

    Both of these outcomes are worrisome. A false negative might leave someone who needs medical help with a mistaken sense of assurance. Given that relatively few people have serious, undiagnosed arrhythmias with no symptoms (if people did, we would be screening for this more often), this isn’t the major concern. False positives are, because they cost us time and money, as well as cause emotional distress.

    The health care system is already busy, if not overloaded. No physician wants to field calls from patients who have no problems. Such patients will require visits and further testing, and will potentially receive interventions. They’ll generate bills and harms without benefits.

     
      Health Policy
      Apple, Apple watch, EKG, false positive, harms, Upshot
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  • Healthcare Triage Podcast: Breast Cancer, Genomics, and the Future of Treatment

      10/03/2018
      Aaron Carroll

    The next episode of the Healthcare Triage Podcast is up! This month we’re talking about breast cancer, specifically “triple negative breast cancer”:

    Dr. Bryan Schneider and Dr. Milan Radovich from the Indiana University Health Precision Genomics Program are talking to Aaron about breast cancer, and some of the cutting edge treatments that are in use, and on the horizon.

    The Healthcare Triage podcast is sponsored by Indiana University School of Medicine whose mission is to advance health in the state of Indiana and beyond by promoting innovation and excellence in education, research and patient care.

    IU School of Medicine is leading Indiana University’s first grand challenge, the Precision Health Initiative, with bold goals to cure multiple myeloma, triple negative breast cancer, and childhood sarcoma and prevent type 2 diabetes and Alzheimer’s disease.

    As always, you can find the podcast in all the usual places, like iTunes and Soundcloud.

    @aaronecarroll

     
      Uncategorized
      breast cancer, genomics, Healthcare Triage, IUSM, podcast, precision medicine
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