Author Archives

John Irvine

A Healthcare Reform Compromise That Just Might Work (Maybe)

Mar 23, 2017• 4

By BRIAN JOONDEPH, MD

Healthcare reform is stalled, so says Politifact. Fake news or the truth? Hard to know these days. President Trump and Speaker Ryan both sounded optimistic in recent public appearances. The Tweeter-in-Chief this week tweeted, “Great progress on healthcare. Improvements being made – Republicans coming together!” Maybe so, but remember that every TV news network was optimistic over Hillary Clinton’s landslide victory until about 9 PM on election night.

Is Trump’s enthusiasm part of “The Art of the Deal”? To quote from the book, “I never get too attached to one deal or one approach. For starters, I keep a lot of balls in the air, because most deals fall out, no matter how promising they seem at first.” Is the Ryan plan just but one ball floating in the Washington, DC air?

If conservative Republicans in the House and Senate revolt, Ryan’s plan ignominiously dies. What’s next? How about a compromise that just might garner support from all warring factions? There is an old saying, “Compromise is where nobody gets what they want.” But the corollary is that everyone gets something they like out of the deal.

The Incredible Self-Destructing Healthcare Marketplace

Mar 22, 2017• 1

By DAVID INTROCASO

Too frequently what gets overlooked in policy making are the regulations that implement or update legislation. As Henry Mintzberg observed over 30 years ago policy is oftentimes formed without being formulated. For example, the Congress did not define the most important provision in MACRA. The Congress simply defined financial risk under an Alternative Payment Model (APM) as monetary losses in excess of a nominal amount. It was CMS that determined via regulatory rule making specific revenue and benchmark-based standards. While the focus has largely been on Congressional Republican efforts to repeal the ACA, three weeks ago the Trump administration recommended regulatory changes, via a proposed “market stabilization” rule, that will likely, should it as anticipated go final this month or next, have a more near term negative effect on state marketplaces.

I Dub Thee “Three Pronged” Care

Mar 22, 2017• 16

By MARGALIT GUR-ARIE

There are approximately 18 million Americans who purchase health insurance on the so called individual market, on and off the Obamacare exchanges. There are another 14 million or so who could be buying insurance on the individual market, but choose not to buy anything. This puts the total individual market at about 10% of Americans. Half of those are, or are eligible to be, heavily subsided through Obamacare (including those huge deductibles). The other 5% are facing the full brunt of health insurance price increases under Obamacare. Of those, 3% are paying for Obamacare health insurance and getting garbage in return for their money, while the remaining 2% are uninsured.

This is the magnitude of the primary problem we are supposedly trying to solve. The 17% of Americans on Medicare are not upset at Obamacare. The approximately 23% of Americans on, or eligible to be on, Medicaid are not angry at Obamacare either (although the 1% eligible for the Medicaid expansion in states that chose not to expand it, might be angry with their Governors). Some of the 50% or so, who are getting health insurance through their employer, and used to get rather flimsy insurance in the past, may be somewhat disgruntled because the Obamacare imposition of “essential benefits” caused their share of premiums and deductibles to rise, and their ability to choose their doctors to plummet.

This is the secondary problem we are supposedly trying to solve. The American Health Care Act (AHCA) addresses neither problem and exacerbates both.

The AHCA (Full Text) Updated 3/13

Mar 22, 2017• 1

JOHN IRVINE

As of today, observers believe the American Health Care Act lacks the votes necessary to pass in the House. That may or may not change as events unfold. This version of the Republican’s draft health reform legislation will remain archived on THCB until an updated version is released. If you have a question about the bill’s language or there is an item you’d like to call out, you can comment below.

[pdf-embedder url=”https://thehealthcareblog.com/wp-content/uploads/2017/03/AmericanHealthCareAct-Budget.pdf”]

Make Trumpcare the First Big Step toward a Free Market in Healthcare

Mar 22, 2017• 15

By CHARLES SILVER and DAVID HYMAN

Say what you will about Obamacare—at least President Obama eventually took ownership of it. When it comes to the American Health Care Act, President Trump isn’t ready to do that. He’s discouraging people from calling it “Trumpcare.” Since Trump normally he puts his name on everything within reach—even the trash can liners at the Trump SoHo Hotel bear his moniker—he must be keeping his distance from the AHCA because he’s ashamed of it.

The editors of The New York Times think he should be. They accuse Trump and the rest of the GOP of “Trading Health Care for the Poor for Tax Cuts for the Rich.” The charge is based on the CBO’s prediction that Trumpcare will immediately cause 14 million Americans to lose their coverage through private insurers or Medicaid, with that number rising to 24 million by 2026. Adding those people to the existing un-covered population, 52 million Americans will be uninsured a decade after Trumpcare incepts.

The consensus among policy wonks on the left and the right is that this would be a disaster for the country. Rolling back Medicaid will harm the states that expanded their programs on the promise that the federal government would pick up the tab. It will damage hospitals and other providers too as the demand for charity care goes through the roof. The newly uninsured will suffer worst of all. Without private insurance or Medicaid to rely on, many will forgo needed medical treatments and all will face the risk of financial catastrophe associated with serious injury or illness. All of these possibilities worry Republican governors and legislators, who fear losing office when the healthcare sector revolts and voters take revenge at the polls.

One can, however, see the GOP’s predicament as an unparalleled opportunity. Instead of vewing the 52 million un-covered Americans as pathetic creatures with nowhere to turn, one could regard them as an enormous army of consumers who will have to buy their own healthcare and who will be hungry for medical services that are effective and cheap. If we were talking about housing, transportation, energy, food, clothing, televisions, cell phones, or computers, we might already see them that way.

Replacing the ACA; Closing the Deal

Mar 22, 2017• 1

By GARY MENDOZA

Last week, the CBO threw buckets of cold water on the American Health Care Act.

While there are serious questions concerning the CBO’s methods and its historical accuracy (see Avik Roy’s critique), Democrats fighting to defend the ACA as it heads towards collapse celebrated; they know CBO scores have potent political weight.

The Republican response was two fold—the loudest voices want to repeal the ACA and see what happens. They’re wishing away the concerns of millions of Americans to demand a rapid march over the political cliff.

Many other Republicans (e.g., Senators from Medicaid expansion states) are quietly eying the hills. To succeed politically and substantively, the AHCA needs to preserve the ACA’s most popular features in a fiscally sustainable way while building a base of political support that lasts beyond the next election.

Here’s a path forward.

ACA’s core flaws. The ACA has two fundamental flaws—it is financially unsound and politically unstable. The ACA’s financial instability is hard-wired. Combining a weak individual mandate, community rating that strongly tilts against young people, guaranteed issue and comprehensive benefits has produced predictable results. Too many young people have concluded the ACA’s a bad deal, too many others are gaming the system and premiums/deductibles are too high for too many.

Whether the ACA is in a death spiral is debatable. Whether it’s heading that direction is not.

The ACA’s enactment added political instability to the mix.

Had common ground with Republicans been found when the ACA was enacted, its repeal would not be today’s top legislative priority.

AHCA’s proposed fix; heat and light

The AHCA carries a heavy load of political peril. The AHCA replaces subsidies with refundable tax credits. Critics on the left believe the tax credits won’t be generous enough. Refundable tax credits give the Freedom Caucus real heartburn.

Democrats Paid a Steep Price For Ignoring the CBO. Republicans Will Too.

Mar 21, 2017• 8

By KIP SULLIVAN

Eight years ago it was Democrats who were criticizing the Congressional Budget Office. Now it’s Republicans who are bashing the CBO for estimating that 14 million Americans will lose their health insurance next year if the House Republicans’ “repeal and replace” bill becomes law.

The media and the blogosphere have done a reasonably good job of debunking the Republicans’ criticisms of the CBO. Any citizen paying attention can discover that although fewer people enrolled in the Obamacare exchanges in 2014 than the CBO predicted in 2010, the CBO correctly forecast that the uninsured rate would fall by about half and that employers would not stop offering health insurance. The attentive citizen can also discover that the CBO’s predictions were more accurate than those of many other experts.

The media has also reported that Democrats leveled their own unfair criticisms against the CBO back in 2009 and 2010. Obama, Nancy Pelosi, and Max Baucus, to name just a few prominent Democrats, criticized the CBO for not giving the alleged cost-containment provisions in the Affordable Care Act more credit.

I want to make three points here that I have not seen made elsewhere:

(1) The criticism that both Democrats and Republicans make of the CBO consists almost exclusively of raw opinion, usually delivered in a huff, and almost never cites or discusses research;

(2) The CBO may have been off in predicting how many people would enroll in Obamacare and Medicaid, but it was accurate in predicting the failure of the managed care fads written into the ACA to cut costs; and

(3) Today, more than ever, America needs the CBO because the CBO adheres to the quaint principle that evidence should trump ideology.

The Coming DRexit

Mar 19, 2017• 2

BRIAN JOONDEPH, MD

Brexit was a British version of “I’m mad as hell and I’m not going to take it anymore,” a famous line from the film “Network.” Brits were fed up with intrusive and nonsensical regulations from the European Union, including whether eggs could be sold by the dozen — really important stuff affecting the lives and well-being of our neighbors across the pond.

“Frexit” may be the next iteration, as one of the leading French presidential candidates, Marine Le Pen, promises voters a referendum to leave the E.U. Donald Trump’s election to the presidency is the American version, in which voters chose to leave behind the political and media Establishment and favored a new direction.

Now, in medicine, a similar movement is called “DRexit,” as described by Dr. Niran Al-Agba, a pediatrician in Washington State, who wrote about this in a blog post — and it may be pushing physicians away from stifling bureaucracies of government-run health care. Endless rules, regulations, and mandates are turning physicians from healers into robots and transforming the medical clinic into the post office or the Department of Motor Vehicles.

Hospitals Helping Hospitals Be Better Hospitals

Mar 18, 2017• 1

By PETER PRONOVOST, MD

The moment that an accreditation team shows up unannounced can spike the pulse of even the most seasoned hospital executive. The next several days will amount to one big exam for the safety and quality of care, as surveyors meet with executives, managers and care teams, and watch first-hand as care is delivered. Make the wrong move or give a wrong answer, have them see rust on a ceiling sprinkler, and your hospital may get dinged. Get dinged too many times or have findings of serious patient risks, and your accreditation (and the federal funds attached to that) may be in jeopardy.

This is a useful and essential exercise. It makes sure that hospitals are doing what they’re supposed to. For example, do they have an infection prevention and control plan? Do they conduct fire drills? Do they inspect, test and maintain medical equipment? Do doctors sign their orders and notes?

Regulators have been innovating how they evaluate hospitals to make their reviews more meaningful and impactful for patient safety. Yet, if we truly want to strive for the best possible care, end preventable patient harm and reduce needless costs, meeting regulations alone isn’t nearly enough. Regulations may help identify the “bad apples” and ensure compliance with minimum requirements. Yet these regulations alone have not been enough to transform a health care system that still harms patients too often, improves too slowly, wastes too much and innovates too little. How do we help hospitals to excel?

A Doctor’s Dilemma: A Case of Two Right Answers

Mar 17, 2017• 6

By ABRAAR KARAN, MD

Imagine you are a doctor running a clinic in a primarily lower-income neighborhood, where many of your patients are recent immigrants from different parts of the world. You are granted a fixed annual budget of $100,000 through your local public health department, and it is unlikely that you can obtain additional funding later in the year. Traditionally, you have used your entire budget for the past several years, which usually lasts from January until December. This allows you to care for all of the few thousand patients who come to you for treatment throughout the year.

One day in January, a frightened, thin young man appears to the clinic with a folder of medical records. He is accompanied by his aunt, who explains to you that he has recently traveled from El Salvador, where he was diagnosed with a rare type of cancer that, if untreated, will result in his death within 6 months. After further inquiry, you determine that his cancer is treatable, but will require $50,000 of your budget to save his life. What do you do?

Thinking Through the Moral Dilemma

The ethical dilemma in this case is one that physicians and public health practitioners confront often, particularly in very low-resource settings: the care of the individual versus the equitable distribution of resources to the society at large. For this case, treating this single patient means that there will not be enough money to treat all of the other patients who come to the clinic over the course of the year. In economic terms, we might say that his care is not cost-effective because for the same amount invested in supplying the clinic, we could prevent many more deaths or disability adjusted life years (DALYs) for a greater number of patients. However, allowing a patient to die of a treatable condition feels wrong on many levels.

Thinking through this further, we must look closely at our values as a country and a health system: thanks to EMTALA, we ensure that no patient will ever be allowed to die of an emergency condition while in a hospital; thus, we value saving people from imminent, preventable death.