Posts Tagged ‘Congress’

Is End-of-Life Care Worthwhile?

Monday, August 27th, 2012

Even in the age of advanced healthcare directives and living wills, Americans still must cope with a dilemma when it comes to end-of-life healthcare for themselves or their loved ones.  Consider the fact that Medicare pays as much as $55 billion annually for physician and hospital bills during the last two months of patients’ lives.  That’s more than the budget for the Department of Homeland Security, or the Department of Education.  Estimates are that 20 to 30 percent of these medical expenses usually have no meaningful impact.  The federal government pays for a majority of the bills with no questions asked.  Medicare spends nearly 30 percent of its budget on beneficiaries in their final year of life.

Given this information, the question is whether extending someone’s life is worth the money it can potentially cost.  The solution potentially could have been a snap for Congress when it passed the Patient Protection and Affordable Care Act (ACA).  Unfortunately, the previously bipartisan issue quickly became a political hot potato.

According to Dr. Ira Byock, it costs as much as $10,000 a day to maintain someone in the intensive-care unit, even if the patient remains there for weeks or even months.  “This is the way so many Americans die. Something like 18 to 20 percent of Americans spend their last days in an ICU,” Byock said.  This discussion raises the philosophical issue of the value of human life.   According to Byock, “While many people question spending a lot of money to prolong the life of an elderly, frail patient, it was perfectly logical for a frail person to value life extension as much as a perfectly healthy person.  With advances in medical care, it can be argued that the value of hope has been increasing along with the statistical odds of staying alive until a cure is found.”

Over-treatment, according to Byock, is an unfortunate side effect of medical advances.   “We have enormous scientific prowess and remarkable diagnostic and treatment,” so that when you are admitted to the hospital, the system “moves you quickly towards the next diagnosis and then the next diagnosis after that for the next component problem in a whole picture that few people will see.  It’s a dysfunctional system that feels like a conveyor belt.  We have a disease-treatment system rather than a healthcare system caring for human beings.”  Byock notes that the same system can lead doctors and patients to regard any reduction in treatment, or even accepting that patients are going to eventually die, as failure.  There are amazing ways to combat disease and extend life.  “That’s all well and good.  The problem is, we have yet to make even one person immortal,” Byock concluded.

Dana Goldman, director of the Schaeffer Center for Health Policy and Economics at the University of Southern California and founding editor of the Forum for Health Economics and Policy, has a difference approach.  According to Goldman, “We think of healthcare as an expense, but we really should be thinking of healthcare as an investment.  We want to invest where we have the greatest return. I would put prevention in that bucket.  But the way we do it now, no one has an incentive to invest in things with a long-term return.”

ACOs Double in Size

Tuesday, July 17th, 2012

While the fate of Obama Care hung in the balance, the ACO became the voluntary dance that nobody wanted to show up to too early. Defined by the Centers for Medicare and Medicaid Services (CMS) as “an organization of health care providers that agrees to be accountable for the quality, cost, and overall care of Medicare beneficiaries who are enrolled in the traditional fee-for-service program who are assigned to it,” ACOs (Accountable Care Organizations) were promoted as a bigger, better model that allowed providers to get paid in a number of ways (capitation, fee-for-service, shared savings) in return for managing health at the population level across a broader swathe of the healthcare spectrum. But ACOs were tough, requiring greater accountability with providers having to report on 33 different performance measures to ensure they’re not skimping on care.  And then there was the little issue of whether reform would be repealed and make it all null and void. Well, a mere week and a half after John Roberts cast the tiebreaker to make the individual mandate — and essentially, Obama Care — a reality, the ACO program has doubled in size.  Eighty-nine participants joined 27 existing ACOs in the program. “The Medicare ACO program opened for business in January, and already, more than 2.4 million beneficiaries are receiving care from providers participating in these important initiatives,” acting CMS Administrator Marilyn Tavenner said in a statement.

According to the CMS, the selected ACO programs operate in a range of areas nationwide and nearly half are physician-led organizations that serve fewer than 10,000 beneficiaries, which indicates smaller organizations are interested in participating. Four hundred more organizations have already submitted a notice of intent to apply next month, according to the CMS. The application period is Aug. 1-Sept. 6, 2012 for organizations that want to participate in the Medicare shared-savings program starting in January 2013.

Now that reform has the imprimatur of the Supreme Court judges, the next court that the Administration will have to focus its efforts on is the court of provider and public opinion. According to a survey of 24,000 U.S. physicians by Medscape, WebMD’s flagship site for medical professionals, only about 3% of physicians participate with ACOs ; only another 5% say that they plan to become involved in the coming year.  52% percent of physicians believe that ACOs will cause a decline in income, while 12% say they will have little or no effect.  Overcoming that natural resistance to change may be the toughest part of putting the ACO in place.

Dying for Coverage

Tuesday, July 10th, 2012

More than 26,000 working-age adults die prematurely in the United States every year because they lack health insurance, according to a study published by Families USA.  The consumer advocacy group study, estimates that a record high of 26,100 people aged 25 to 64 died for lack of health coverage in 2010, up from 20,350 in 2005 and 18,000 in 2000.  That adds up to a rate of approximately 72 deaths per day, or three per hour.

The non-profit group based its report on data from the U.S. Census Bureau, the Centers for Disease Control and Prevention (CDC), and a 2002 Institute of Medicine (IOM) study that showed that Americans who lack insurance face a 25 percent higher risk of death than those with coverage.  The findings are in line with a study by the Urban Institute think tank that estimated 22,000 deaths nationwide in 2006.

“Lives are truly on the line,” said Ron Pollack, Executive Director of Families USA, who supports the Patient Protection and Affordable Care Act (ACA).  “If the Affordable Care Act moves forward and we expand coverage for tens of millions of people, the number of avoidable deaths due to being uninsured will decrease significantly.”  Pollack is not the only healthcare advocate to predict that the number of uninsured will continue to rise without reform as healthcare costs accelerate, employers cut benefits, and the social safety net unravels because of fiscal pressures.

The Affordable Care Act was passed by Congress to address an American tragedy and an American shame,” Pollack said.  “The fact remains that for the millions of Americans without health coverage, only the Affordable Care offers the promise of access to affordable coverage and to a longer and healthier life.”

According to the report, the reasons for being uninsured differ, but many without health insurance were denied coverage because of a pre-existing condition.  Others have been priced out of the market at a time when keeping their homes and feeding their families take priority over holding on to insurance in the face of rising premiums.  Some lost their benefits when employers stopped providing coverage.

Census Bureau data show that 50 million Americans lack healthcare coverage, and experts say that these people do without medical care, physician visits and preventive tests including cancer and blood pressure screenings.  “The uninsured get healthcare about half as often as insured Americans, on average,” said Dr. Arthur Kellermann, director of the think tank RAND Health and co-chairman of the committee that wrote the 2002 IOM study.  “There is an overwhelming body of evidence that they get less preventive care, less chronic disease care and poorer quality hospital in-patient care,” he said.

The $2.6 trillion American healthcare system, which totals nearly 18 percent of the economy, is accessible to a majority of working-age Americans only through private health insurance.  But insurance costs – premiums, deductibles, co-pays and co-insurance – are unaffordable for many.

Robert Zirkelbach, spokesman for America’s Health Insurance Plans, the national trade association that represents the insurance industry said the rising cost of care must be addressed.  “Health plans have long supported reforms to give all Americans the peace of mind and financial security that healthcare coverage provides.  The nation must also address the soaring cost of medical care that is adding a financial burden on families and employers and threatening the long-term sustainability of our vital safety net programs.”

Families USA counters that the current delivery system is stacked against Americans who lack insurance.  They pay more for care because they lack the ability to negotiate discounted prices on physician and hospital charges like insurance companies can.

Writing in Forbes, Matthew Herper points out that “This estimate is 19 years old, and this number doesn’t tell us much that’s new about what is wrong with our healthcare system.  If anything, it emphasizes how our total lack of information about what works and what doesn’t is trapping us in an economic and social death spiral around health costs.  If anything, available data seem to point to this estimate being low.  The real story is that we care so little about how much insurance matters to people’s life spans that we haven’t really bothered to find out.  It’s possible that the number is actually higher.  A 2009 article in the American Journal of Public Health actually found a 40 percent increase in the risk of death for those who lack insurance.  The IOM notes this finding, and that using it would have substantially increased the 26,000 number.  So how many people do die from lack of health insurance?  The short answer is that we don’t know, because we don’t look.  We should have data collection systems in place to answer questions about how healthcare is performing.  This should translate into more transparency, so that voters and consumers can find out how well the system is doing.  Instead, we tend not to track data about the healthcare system, and to keep it completely siloed.  And then we wonder why the system doesn’t work.”

GOP Proposes Putting Seniors on Congressional Healthcare Plan

Tuesday, July 3rd, 2012

In a highly controversial move, Republicans critical of Medicare have proposed opening up the Federal Employee Health Benefits Plan (FEHBP) to Medicare patients.  “We are going to offer a plan that would give all senior citizens in the country the same congressional healthcare plan that we have,” said Senator Rand Paul (R-KY).  “We are not willing to wait until after the next election to fix the entitlements.”

The National Active and Retired Federal Employees Association (NARFE) warned that the plan could shake the federal program, while asking seniors to pay more for healthcare.  “This is a kill-two-birds-with-one-stone kind of proposal that would both bring down Medicare as we know it and threaten the stability of the FEHBP,” Joseph A. Beaudoin, NARFE president, said.  Beaudoin said seniors should examine the proposal closely, because it throws open the doors of a stable healthcare program to millions of seniors currently enrolled in Medicare.  “Given the current environment of budget attacks on federal employees, retirees and Medicare, the federal workforce and all Americans should be wary of plans like the one proposed today,” he said.

Called the Congressional Health Care for Seniors Act (CHCSA), the plan’s supporters claim that it would save taxpayers $1 trillion in the first 10 years as well as provide enhanced healthcare benefits, choice, quality and outcomes by moving seniors into the FEHBP.

How would it work?  Federal employees can now choose from approximately 250 plans participating in FEHBP, including 20 nationwide plans.  The large selection provides access to better doctors, better quality healthcare, and the ability to pick plans that best suit the person’s individual needs.  The rationale also is that because Congress uses the plan, it must be the best in the country.  Additionally, the legislation would set up a “high risk pool” for the costliest patients within the FEHBP.  The federal government will directly reimburse healthcare plans for enrolling the most expensive five percent of patients, which keeps premiums low while allowing high-risk patients to get the same quality healthcare as every other enrollee – federal employees and seniors alike.  If the legislation is passed, seniors could enroll in FEHBP starting in 2014.

There is some bipartisan support for this proposal.  In 2004, Senator John Kerry (D-MA) proposed allowing uninsured people, not seniors, to enroll in FEHBP.  “Entitlements are broken,” said Paul.  “It’s not Republicans’ fault; it’s not Democrats fault.  I tell people, ‘It’s your grandparents’ fault for having too many kids and then your fault for not having enough kids.’  It’s a demographic problem.”

Paul said the plan “means-tests the benefits and gradually allows the age of eligibility to go up.”  Currently, Medicare eligibility age is 65; Paul’s plan would gradually increase it to 70 by 2034.  “There is means-testing in this — and the reason you have to do that is: we’re spending more on Medicare than is coming in.”  According to Senator Lindsey Graham, (R-SC), “What I would tell the person near retirement is don’t fear change, embrace it, because you’ll have more doctors available to treat you and your family.  “Think about not just what happens to you…think about where we’ll be as a nation if something doesn’t change pretty quickly with these big programs.”

Virtually everyone in Washington agrees that the federal government must control its deficits and rising debt by finding a way to reduce entitlement spending.  President Bill Clinton’s former budget director, Leon Panetta, now defense secretary, who reproached the Senate Budget Committee: “You can’t meet the challenge that you’re facing in this country” by only cutting discretionary spending, which is less than a third of all spending.  “If you’re not dealing with the two-thirds that is entitlement spending, if you’re not dealing with revenues, and you keep going back to the same place, frankly you’re not going to make it, and you’re going to hurt this country’s security.”

Paul acknowledges that adding seniors to the federal program would drive costs up for its current 8.5 million enrollees by approximately 24 percent.  “Federal employees are the one group of people who may have a legitimate argument with the Congressional Health Care Plan for Seniors,” according to Paul’s synopsis.  “Asking them to share their healthcare with the elderly will cause their premiums to increase.”  Not surprisingly, as soon as the legislation was announced, the National Active and Retired Federal Employees Association expressed concerns that the bill would destabilize the federal workers’ program.

Beaudoin notes that “As for the senators’ notion that America’s seniors should be in the same healthcare system as America’s elected officials, they seem to have forgotten that starting in 2014, members of Congress will no longer be covered by the FEHBP but will be in state-based healthcare exchanges.”

The Individual Mandate Passes: ObamaCare Survives Supreme Court

Monday, July 2nd, 2012

In one of the most significant rulings in recent memory (perhaps since the awarding of the Presidency to George W. Bush in 2000), the Supreme Court upheld President Obama‘s health care law  in a nuanced interpretation of Federal versus states’ rights. The historic 5-4 decision will affect the way 30 million uninsured Americans receive and pay for their personal medical care.   Chief Justice John Roberts cast the deciding vote (another surprise since most expected it to be Justice Kennedy if the law passed) and wrote the opinion. The key factor was classifying the penalty for not abiding by the individual mandate — the requirement that most Americans buy health insurance or pay a fine — as a tax and therefore constitutional. “Because the Constitution permits such a tax, it is not our role to forbid it, or to pass upon its wisdom or fairness,” wrote Roberts. The court’s four liberal justices, Stephen Breyer, Ruth Bader Ginsburg, Elena Kagan and Sonia Sotomayor, joined Roberts in the outcome; Conservative Justices Samuel Alito, Anthony Kennedy, Antonin Scalia and Clarence Thomas dissented.

The Obama Administration had taken a different approach in its argument, saying that Congress had the authority to pass the individual mandate as part of its power to regulate interstate commerce; the court struck this down, but preserved the mandate as within Congress’ constitutional taxing powers. As Roberts put it, a person who does not wish to carry health insurance is left with a “lawful choice to do or not do a certain act, so long as he is willing to pay a tax levied on that choice.”

The Republican-controlled House will vote July 11 for a full repeal of the health care law. It is a symbolic move that stands little chance of passage in the Democratic controlled Senate. Republican presidential candidate Mitt Romney and GOP congressional leaders have pledged to repeal the law if they take control of Congress and the White House in November elections. The decision may silence critics who have claimed that the Roberts Court has been one of the more partisan in recent memory, particularly with its decision in the 2010 Citizens United case which took the cap off independent political expenditures by corporations and unions. The ACA drew the Supreme Court into the election-year crossfire over the role of government and the concerns about deficit spending,

The court did find one part of the law unconstitutional, saying its expansion of the federal-state Medicaid program threatened states’ existing funding. According to the Wall Street Journal, “the court ruled that the federal government can’t put sanctions on states’ existing Medicaid funding if the states decline to go along with the Medicaid expansion.”

Some reactions:

House Budget Chairman Paul Ryan, R-Wis.: “It’s up to the American people in the next election and their representatives to determine the fate of this law.”

House Speaker John Boehner, R-Ohio: “The president’s health care law is hurting our economy by driving up health costs and making it harder for small businesses to hire. Today’s ruling underscores the urgency of repealing this harmful law in its entirety.”

Senate Minority Leader Mitch McConnell, Republican of Kentucky: “Today’s decision makes one thing clear: Congress must act to repeal this misguided law.”

The full  impact of the ruling politically remains to be seen. The Wall Street Journal reflected the uncertainty: “The court’s decision, while a relief to Democrats, could further energize voters who dislike the law to back Republicans in November. And it forces the Obama administration to continue defending the unpopular insurance mandate, which the court has now made clear is legally equivalent to a tax on those who refuse to carry health insurance. On the other hand, the court’s blessing could itself shape public opinion of the law, particularly among independents and undecided voters who view the justices as relatively free of the partisan agendas of the government’s elected branches. Polls consistently show that the public places greater confidence in the Supreme Court than either Congress or the presidency, although the justices’ approval ratings have slipped somewhat over the past year.”

Federal Government Bets $2 Billion on Oregon Medicaid Program

Thursday, June 14th, 2012

Oregon Governor John Kitzhaber, a former emergency room physician, has convinced the Center for Medicare and Medicaid Services (CMS) that he can significantly improve Medicaid treatment and do it cheaper by altering the way the sickest people in his state get healthcare.  If Kitzhaber’s experiment works, it could have repercussions for the entire nation.  According to Kaiser Health News, Oregon’s major cities — Portland, Salem and Eugene — will have their own umbrella groups for treating the Medicaid population, in effect, a “coordinated care organization.” (CCOs)  Under these umbrellas will be a majority of the heavy hitters in the health sector including hospitals, doctors, mental health providers and dentists.

Kitzhaber wants to switch Oregon’s 600,000 Medicaid patients into CCOs, which will accept a flat fee for delivering each patient’s care while remaining within that budget, with bonuses for quality metrics.  If patient care costs more than the flat fee, healthcare providers must eat the difference.

Kitzhaber’s idea is that healthcare businesses will stop competing for patients and instead link to each other electronically so that it’s easier for providers to share information.  Patients can see whichever provider they need to get maximal care.  The sickest people will have a $20-an-hour outreach worker to assist them in navigating the system and avoiding pricey hospitalizations.  Each outreach worker will manage a caseload of approximately 30 patients – with the goal of saving Medicaid hundreds of thousands of dollars.

I think this is really a defining moment for health care in the State of Oregon and, I think that if we’re successful, probably for healthcare beyond our borders,” Kitzhaber said.  The plan is supported by both Republicans and Democrats, with the state’s leaders putting their political reputations on the line for this deal.  The legislature passed its entire budget in the belief that the federal government was going to fund the program.  Unions and businesses in Oregon also support the program.  Malia Wasson, the president of US Bank in Oregon, celebrated the news.  “Governor, I know that you’re not prone to being overly demonstrative,” she said.  “But would you indulge me with a high five?”

Naturally, there are skeptics.  State Representative Jim Weidner voted against the Medicaid bill.  “It doesn’t really drive down the cost of healthcare.  It’s just shifting costs into different spots,” Weidner said.  He believes that the program ultimately will cost the state money.  Kitzhaber disagrees, noting that the coordinated care organization will be paid with a lump sum to manage Medicaid patients.

Under Oregon’s present system, hospitals and doctors don’t have a financial incentive to make people better.  To the contrary, if a patient keeps coming back, the provider keeps getting paid.  Under the new system, the faster a patient recovers, the coordinated care organization can keep more money.  Kitzhaber believes that over the next five years, Oregon will be able to save Medicaid every cent of the $2 billion the state’s been promised.

“We estimated that if every state Medicaid program in the country were to adopt this model, the net savings would be about $1.5 trillion dollars over 10 years,” Kitzhaber said.  Congress is looking at $1.2 trillion in cuts over the next 10 years after the super committee failed to come up with budget cuts.  Despite the fact that Oregon is pleased with itself, the federal government has said that if the state doesn’t show cuts to Medicaid spending by two percent next year, the new money could dry up.

Oregon is the only state to attempt to rethink Medicaid backed by federal tax dollars, said Dr. Roger Stark, a physician and healthcare policy analyst with the Washington Policy Center.  “The Oregon program is based on an HMO model which ties into quality controls to hold costs down.  But Oregon is broke, and they didn’t have the seed money to start the program because like all the states, they’re broke.  Oregon really stood on its head, and the CMS gave in.  Oregon’s program lines up with President Barack Obama’s law, and they probably sold it to the administration as a sort of pilot program,” Stark said.

According to Stark, the CCO approach resembles the HMO model, which was reviled by doctors and patients.  “The physicians hated it because they couldn’t control treatment decisions and had to focus on cutting costs, and the patients hated it because they couldn’t get complete treatment — they had no trouble seeing a primary care physician, but it was extremely difficult seeing a specialist,” Stark said, noting that rationing is inevitable under this approach.  “Oregon told CMS they could save money, which is pie in the sky.  Instead, there will be some form of rationing because they’re dealing with a fixed amount of money.  The rationing will be subtle and insidious.  Say you’re 60 years old and need a hip or knee replacement; they will tell that patient, ‘Oh, you don’t need that operation.’  Or they will tell him, ‘Take these pills, not those,’” Stark said.

Which One Do You Like? Healthcare Insurance Exchanges or Marketplaces?

Wednesday, May 23rd, 2012

If a Medicare staff recommendation is okayed, health insurance exchanges may be re-named.  According to Kaiser Health News , that is because, Medicare officials say consumers understand words like “marketplace” better.  “We are recommending not using the word ‘exchange’” in enrollment materials, said Julie Bataille, director of the CMS Office of Communications.  While Bataille didn’t mention the preferred substitute, she dropped hints.  “Words like ‘marketplace’ resonate much more with the consumer and also tend to be something that is all inclusive,” Bataille said.

According to Bataille, “exchange” can have a number of different meanings to consumers, including the idea that they may have something to trade.  The Patient Protection and Affordable Care Act (ACA) requires the federal government to establish health insurance exchanges in states that refuse to create their own.  They are often described as online marketplaces similar to Travelocity.com or Amazon.com, where consumers can search for insurance policies that fit certain criteria.  Enrollment information will become available in the fall of 2013 and the exchanges — or whatever the ultimate name is – will start operating in 2014, unless the Supreme Court declares the law unconstitutional.

The word “exchange” appears 247 times in the ACA, while “marketplace” is not mentioned once, according to Kaiser Health News.  But that doesn’t mean officials are obligated to use it, said Brenda Cude, a professor of consumer economics at the University of Georgia and a consumer representative for the National Association of Insurance Commissioners.  “I don’t believe that Congress is any kind of expert on how to communicate with consumers,” she said.  But “marketplace” may not be a fool-proof alternative, Cude said.  She is concerned that comparing a health insurance exchange to a shopping website encourages the notion that the lowest price policy is the best choice.  That may be true when looking for a commodity like a cheap airfare to a single destination, but not for healthcare policies offering different benefits.

Bataille said the Medicare staff’s advice to avoid the term “exchange” is supported by external research and the agency’s focus group testing this year in Cleveland, Dallas, Miami, Philadelphia and Phoenix.  CMS “routinely” tests its materials and websites with consumers “to make sure we are serving our beneficiaries as well as possible,” Bataille said.  “So we see our work on the exchanges as an extension of that.”  According to Bataille, CMS will seek public comment on the enrollment materials before finally deciding whether to use the word “exchange” or “marketplace”.

National Alzheimer’s Plan Launched

Monday, May 21st, 2012

President Barack Obama has thrown down the gauntlet in announcing the first National Alzheimer’s Plan, which sets a deadline of 2025 to find ways to effectively treat — or at least delay — the mind-destroying disease.  The Obama administration is laying out numerous steps the government and private partners can take over the coming years to fight what is poised to become a defining disease of the rapidly aging population.  Families and caregivers with a family member suffering from Alzheimer’s can visit a new website for information about dementia and where to get help in their own communities.

The National Institutes of Health (NIH) is funding new studies of possible therapies, including a form of insulin that is shot into the nose.  “These actions are the cornerstones of an historic effort to fight Alzheimer’s disease,” Health and Human Services Secretary Kathleen Sebelius said.

The National Alzheimer’s Plan comes as leading scientists and researchers are meeting at the NIH to debate what research needs to be prioritize to meet that 2025 deadline.  According to the researchers, the time is right to begin testing potential therapies before people have full-blown Alzheimer’s symptoms, when it may be too late to help.  “There’s a sense of optimism” as a result of some new discoveries, Dr. Francis Collins, director of the National Institutes of Health, said.  But, “we need to figure out exactly where is the best window of opportunity” to battle Alzheimer’s.  Collins noted that cardiologists don’t test cholesterol-reducing drugs on people who have advanced heart failure.

The research is being funded by grants of $16 million and $7.9 million respectively. Experts predict that unless more effective drugs are developed, the number of Americans with Alzheimer’s will double by 2050 and related healthcare costs could soar to more than $1 trillion.  Alzheimer’s affects approximately 5.1 million Americans today; current treatments address symptoms, but do not prevent the disease or halt its progression.

The 2025 goal was the subject of a long debate in the advisory council tasked with helping to write the national plan.  “We had people saying it was overly ambitious and we had people who said it wasn’t ambitious enough,” said Don Moulds, principal deputy assistant secretary for planning and evaluation at HHS.  According to Moulds, some were concerned that an earlier goal might skew research funding into treatments that might be easy hits, but not game-changing treatments.  The 2025 target was deemed to be the earliest date when an effective treatment could be found.  “It’s a huge initiative and a very ambitious step in the right direction,” Moulds said.

Researchers leading the largest clinical study ever done on Alzheimer’s disease have run into an unexpected hurdle.  With nearly 500 patients undergoing MRI scans, PET scans and even spinal taps, researchers hope to invent the first ever test to find Alzheimer’s before a patient loses any memory — or even knows there’s a problem.  “We may be able to screen and begin treatment even before any symptoms begin,” said Dr. Raymond Turner of Georgetown University Hospital, which is one of 57 centers participating in the study.

“The problem is finding volunteers to join the studies,” Turner said.  “Patients.”  The study of 750 patients is 250 patients short.  Nationally, the deficit is in the thousands, with virtually every clinical trial related to Alzheimer’s short of volunteers.  Alzheimer’s itself is part of the problem.  Patients who don’t know that they have the disease don’t know to volunteer, and patients with mild memory loss are often reluctant to participate.  The lead researcher of the imaging trial, Dr. Michael Weiner, says one answer is to recruit physicians who treat Alzheimer’s patients.  “We definitely could do a better job trying to get physicians to refer patients to our project,” Weiner said.  “The slower our trial goes, the slower the rate of progress.”

Eric J. Hall, president and CEO of the Alzheimer’s Foundation of America (AFA), “This day has been a long time coming. The release of the ‘National Plan To Address Alzheimer’s Disease’ reflects the growing impetus among the public and policymakers to act on a disease that has been in the shadows for far too long.  We commend President Obama, HHS Secretary Kathleen Sebelius and Congress for uniquely recognizing and responding to the implications of the Alzheimer’s Disease epidemic.  Recognition is essential for action, and their courage has forged enormous opportunity.

Little-Known ACA Proviso Stirs Controversy

Wednesday, May 9th, 2012

There’s a largely unseen battle raging among consumer advocates, physician groups and some Democrats in Congress over a key benefit in the Patient Protection and Affordable Care Act (ACA) — tax credits that will help millions of people purchase insurance.

According to Kaiser Health News, “At issue is a section of the law that outlines when low- and moderate-income employees can opt out of their employer’s coverage and instead get federal subsidies to buy insurance through new state-based marketplaces, called exchanges.  The debate over who qualifies for subsidies has been overshadowed by more-polarizing issues such as the government’s authority to require most people to buy insurance.  But if the Supreme Court upholds the law — or even most of the law — the way the tax-credit dispute is resolved will help determine how many people can get subsidized coverage.  A proposed Treasury Department rule says workers and their families cannot qualify for those subsidies unless their employer’s plan is unaffordable because it exceeds 9.5 percent of their household income.”

Consumer advocates are steadfast in their opposition to the rule because it bases affordability on how much an employee might pay for individual coverage, rather than on the cost of covering their entire family.  As a result, many workers won’t be able to afford family coverage, yet their spouses and children will be ineligible to get help to buy insurance.  Approximately 3.9 million dependents might be impacted, according to one estimate.

“The proposed rule excludes people Congress intended to cover,” said Bruce Lesley, president of First Focus Campaign for Children, who sent a letter to Treasury signed by more than 100 advocacy groups, including the American Academy of Family Physicians, the Children’s Defense Fund, the March of Dimes and the National Council of La Raza.  The letter asks President Barack Obama and congressional leaders to take “administrative action or legislation” to spell out what Congress intended.

Treasury officials are drafting final rules, which are expected to be released soon.  “We are working with consumers, businesses and all interested parties to ensure women and families get the affordable care they need,” Treasury Department spokeswoman Sabrina Siddiqui said.

Supporters of the proposed rule, primarily employer groups and insurance brokers, say it is in keeping with the wording in the ACA that defines affordability in terms of the cost of “self-only coverage.”  Critics, including the National Partnership for Women and Families, say it allows for basing the affordability standard on the cost of family coverage. The group notes that Treasury officials plan to use the cost of a family plan as a basis for exempting some people from penalties for not buying insurance.  “It’s unlikely that Congress intended affordability to be determined one way” for penalty fines and another for subsidies, according to the groups.

Several Democratic lawmakers who played key roles in writing and passing the law say the proposed rule is not what Congress intended.  “The notion that Congress wrote the law in a manner that would exclude many families from access to more affordable coverage…is simply incongruent,” according to Representative Sander M. Levin (D-MI), the ranking Democrat on the Ways and Means Committee, and Representative Henry A. Waxman (D-CA), the ranking Democrat on the Energy and Commerce Committee.

Employers and taxpayers have a lot at stake in the way this rule is interpreted. For every worker who forgoes “unaffordable” job-based coverage in favor of subsidized insurance, the employer pays either a $3,000 per subsidized-worker penalty or $2,000 per employee.  The government’s stake will be less if more workers retain job-based coverage and fewer people seek subsidies.  At the same time, tax credits are the main way the law is expected to help low- and middle-income Americans buy insurance if they don’t have access affordable employer-based coverage.  By 2019, for example, the Congressional Budget Office (CBO) estimated that the government will spend $70 billion in tax credits to help 18 million people buy coverage through the exchanges.

Workers paid an average of $921 for an individual health insurance policy last year. That equals 18 percent of the total cost of the plan, according to an annual survey by the nonpartisan Kaiser Family Foundation and the Health Research & Educational Trust.  An employee’s share of a family plan averaged $4,129, or 28 percent of the total cost.

Based on those figures, a worker earning $40,000 will be ineligible to get subsidies because the $921 is less than 9.5 percent of income, even though the cost of the family plan exceeds that cap. In that scenario, the worker’s dependents will be ineligible to receive subsidies.  The policy is certain to impact women, who are 2.5 times as likely as men to be insured as a dependent, the hardest, according to the National Partnership.

“It will force more people into not having an affordable option,” said Dana Cope, executive director with the State Employees Association of North Carolina.  According to Cope, family coverage costs increased the ranks of the uninsured in North Carolina, where the state subsidizes employee coverage, but does not contribute toward family insurance.  “State employees…who earn on average $41,000…cannot afford to cover their dependents,” Cope said.

49 States Are Acting to Implement the ACA

Tuesday, May 8th, 2012

Although 26 states oppose sections of the Patient Protection and Affordable Care Act, a new report suggests that a majority are taking steps to implement it – no matter what the Supreme Court decides.  The Commonwealth Fund study looked at provisions of the law that went into effect in 2010, specifically the so-called “patient’s bill of rights.”  The law gave states a choice on those matters — they could regulate insurance companies or opt out and let the federal government step in.  According to the report, every state but Arizona has taken some steps to establish its own system. The “bill of rights” contains 10 provisions, including rules that insurers cannot retroactively drop coverage when a customer becomes ill, as well as one that allows parents of young adults to keep their children on their insurance policies.  Ten states have acted on all of the provisions.  Twelve have passed laws or written final regulations.  Yet others have reviewed insurance policy forms providing unofficial guidance to insurers.  “States are responding to the federal law in pragmatic ways that suit their political culture and regulatory needs,” according to the report.

Rhode Island, Maryland and Oregon led the pack in implementing the ACA.  In fact, those states were working to expand health coverage well before the law was passed.  If the ACA is overturned by the Supreme Court, these states — and others supportive of the law’s goals – will keep pursuing reforms.  “What I hear is, they still intend to proceed,” says John Holahan, director of the Health Policy Research Center at The Urban Institute.

One provision of the ACA is that states must set up public insurance exchanges where uninsured residents can shop for coverage.  So far, 16 states and the District of Columbia already have passed legislation enabling implementation of the law, or have governors who have issued executive orders to move forward.  New York was the most recent when Governor Andrew Cuomo bypassed Republican lawmakers who were holding up the state’s effort to create a state insurance exchange by issuing an executive order to proceed.  Another 20 states either have legislation pending or have received some federal grant money to move forward.  The remaining 15 states have made little or no progress.

Two-thirds of the states will have viable exchanges up and running by 2013, according to Sam Gibbs, president of the Exchange Technology Group at eHealth Inc., which runs an online insurance marketplace and is bidding to help build state-level exchanges.  According to the law, the federal government will operate exchanges in states that don’t start them on their own.  That could be difficult to achieve in states that are hostile to the ACA, because implementation requires close cooperation with state government and insurance regulators.

The exchanges will be the entry portal for individuals and families who are currently uninsured.  They will be eligible for a federal insurance subsidy in cases where family income is less than 400 percent of the federally defined poverty level.  The size of the subsidy is based on a sliding scale to hold costs as a share of income between two and 9.5 percent.  States also are required to offer dedicated exchanges for small businesses that would let employers provide a subsidy for employee coverage.  Lower-income families will be eligible for Medicaid under a dramatic federally-financed expansion.  Between the exchanges and Medicaid expansion, coverage will be extended to 23 million uninsured Americans by 2019, according to the Congressional Budget Office.

If the Supreme Court declares the individual mandate unconstitutional and doesn’t touch the rest of the ACA, insurance companies are certain to push Congress for a remedy sometime after the November elections.  This would ensure that enough healthy young people sign up for insurance to balance the ACA’s requirement that carriers accept all applicants and don’t charge high-cost premiums based on age or health risk.  A Government Accountability Office study identified nine alternatives to the individual mandate; for example, setting strict open-enrollment windows with harsh financial penalties for failing to enroll.  That tactic works for Medicare, which charges senior citizens a 10 percent annual lifetime Part B surcharge for each year of delayed enrollment.

Congressional action on a fix would depend on who controls the next Congress — but the recent track record isn’t encouraging. “Since the two parties don’t speak to one another, the odds of a federal fix aren’t very good,” Holahan said.

Writing for Think Progress, Igor Volsky says that “Indeed, it seems that the law has already created an unstoppable momentum towards change and it’s very unlikely that they will take away these new benefits or obtain efforts to modernize their operations (in an effort to reduce spending). Regardless of the Supreme Court’s anticipated ruling on the law in late June, the changes the ACA inspired are here to stay — in one form or another.”