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Above the Fold

If Mandate Is Defeated, Obama Will Need Help From Allies to Salvage Health Law

Mar 19, 2012• 3

By Jordan Rau

When Barack Obama ran for president in 2008, he insisted the nation could fix its health care system without requiring everyone to carry insurance. As the Supreme Court prepares to weigh in on the health law, Obama is facing the possibility that he may have to make good on his campaign claim.

Experts consider the requirement to hold insurance, known as the individual mandate, to be the most legally vulnerable part of the law.

The administration argues that the law’s main goal of providing health coverage to 30 million additional Americans could not be achieved without the mandate because too many healthy people would refuse to obtain insurance, leaving primarily sick people in the insurance pools and driving up premium costs. Obama came around to this viewpoint after he was elected.

There are ways that Obama—if he’s re-elected — might be able to salvage the law even if the court strikes down the individual mandate but leaves the rest intact, health policy experts say.

These fixes would create financial incentives for people to not delay enrolling in insurance.

One such approach would be similar to what happens in Medicare’s Part B program, where people who wait too long to sign up for physician coverage must pay higher premiums.

AARP Readying Armies for Medicare Battle

Mar 19, 2012• 4

By Marilyn Werber Serafini

“Imagine a world without Medicare.” That’s the rallying cry of a new grassroots campaign being unveiled today by the giant seniors group AARP that will include town hall meetings in 50 states and national television ads.

Against a backdrop of proposals to overhaul the popular social insurance program and a presidential campaign likely to address entitlement spending, AARP is launching “probably the biggest outreach effort we’ve ever done on any issue” to activate its 37 million members, said Nancy LeaMond, AARP’s executive vice president.

The group will gather seniors at town hall meetings today in four cities – Richmond, Va.; Columbus, Ohio; Denver, Colo.; and Miami, Fla. – to start a conversation about the program’s future entitled, “You’ve Earned A Say.” It is also releasing a survey showing that less than half of adults ages 18 to 49 are confident Medicare will be there when they’re ready to retire.

In coming weeks, the group will hold town hall meetings in every state, and also conduct large-scale forums by phone. It recently sent members a survey to assess their views about potential Medicare and Social Security changes.

Groups on the other side of the political spectrum are also galvanizing. This week, a conservative seniors group called the 60 Plus Association put out television ads that targeted five Democratic senators and asked supporters to press them about their support for the Medicare provisions in the 2010 federal health law.

Why States Should Move Forward with Health Insurance Exchanges

Mar 16, 2012• 19

By David Merritt

Imagine that you’re being required to buy a car. You will have to pay for most of it, but you can’t choose exactly what you want. There are so many restrictions on your options that you’re forced to choose from a few used, four-cylinder, two-door sedans with manual transmissions. And there’s one more catch: If you don’t choose one yourself, the dealer will decide for you.

It’s not an enviable position to be in, but most of us would grudgingly decide that if we have to get one of the cars, it’s better to have a small say in what we get than to have someone else decide for us.

This is the same predicament that many state policymakers find themselves in regarding the creation of health insurance exchanges.

Health insurance exchanges are a key part of the health reform law. Supporters argue that exchanges will provide consumers with valuable information on their coverage options, while at the same time providing stricter regulation of health insurers. They are also the only way people can benefit from the lavish subsidies included in the law.

On Monday, the Department of Health and Human Services released a final rule governing the exchanges. The rule sets an ambitious timeline for getting the exchanges up and running in every state by January 1, 2014. Between now and then, states can either build their own exchanges and tailor them as much as federal law will allow or decide not to build exchanges at all.

But there’s a catch: If states don’t build their own exchanges, the federal government will do it for them.

Learning from Massachusetts’ Health Care Experiment

Mar 16, 2012• 35

By Jim Stergios and Joshua Archambault

Former Gov. Mitt Romney has taken considerable heat during the Republican primaries for the health-care legislation that passed while he was in office.

Sadly, election-year politics have overshadowed the real lessons of Massachusetts’ experiment.

The core question then-Gov. Romney was trying to answer was this: Should Massachusetts continue to pay hospitals more than $1 billion a year to care for the poor, or should it create a way for individuals to purchase their own insurance?

Romney’s original proposal was simple: Stop subsidizing expensive hospital care and instead require all residents to carry at least catastrophic insurance. Anything beyond that would be a matter of individual choice. The idea was to prevent taxpayers from having to pick up the tab for people unable or unwilling to pay for their own medical care.

To facilitate reform, Romney’s plan established a central agency, an “exchange,” where individuals could buy health insurance directly.

Though the overwhelmingly Democratic Legislature amended Romney’s proposal, the new law, if properly implemented, could have made the health-care market far more customer-focused.

But that didn’t happen. Just months after the law was passed Romney’s successor, Democrat Deval Patrick, became responsible for implementing the 2006 law. Since then, almost every key bureaucratic decision has leaned toward government control and away from individual decision-making and the market.

For example, the exchange’s idea of “minimum coverage” is equal to some of the most generous plans in other states. Additionally, roughly 40 percent of the people in the exchange pay no monthly premium for insurance, while small businesses have been hit with a variety of onerous requirements. Instead of creating a market with many choices, insurance has been over-standardized and the number of available plans limited, curbing innovation in plan design.

A Safety Checklist for Patients

Mar 15, 2012• 2

By Peter Pronovost, MD

Far too many patients are harmed rather than helped from their interactions with the health care system. While reducing this harm has proven to be devilishly difficult, we have found that checklists help. Checklists help to reduce ambiguity about what to do, to prioritize what is most important, and to clarify the behaviors that are most helpful.

The use of checklists helped to reduce central-line associated bloodstream infections at The Johns Hopkins Hospital, in hospitals throughout Michigan, and now across the United States. Clinicians have begun to develop, implement and evaluate checklists for a variety of other diagnoses and procedures.

Patients can also use checklists to defend themselves against the major causes of preventable harm. Here are a few you can use:

Health care-associated infections

Ask about your hospital’s rates of central-line associated bloodstream infections in the intensive care unit. The best hospitals use the definitions provided by the Centers for Disease Control and Prevention and have rates less than one infection per 1,000 catheter days. A rate above three should cause concern.
Whenever clinicians enter your room, ask if they have washed their hands. Request that visitors also wash their hands often. Washing can be with alcohol gel or soap and water.
If you have any type of catheter, ask every day if that catheter can be removed.

THCB Calendar

Mar 15, 2012

The first Sex::Tech hackathon

Mar 15, 2012

I’m on the board of ISIS, a wonderful organization led by the irrepressible Deb Levine, that helps deal head on with issues of youth sexuality, mediated by technology. The annual conference is in three weeks, and there’s a hackathon the day before — Matthew Holt

ISIS is hosting our first ever hack-a-thon, together with our partners TechSoup. A hack-a-thon is a live event bringing together developers, designers, innovators and entrepreneurs to build exciting new apps and tools, in this case to improve young people’s health and wellness.

Theme: The Unmentionables

This short and focused event – 1 day only – will result in the rapid development of interesting concepts and working prototypes that will be developed further by the participating teams back at their desks and at future hack-a-thon events, with ISIS and TechSoup as partners for future product development and distribution.

Challenge: Design an app to solve the challenge of providing honest, real-time, private data from youth and young adults about “unmentionable” activities, like sexual behavior, substance use, sadness, and relationship drama to researchers and program experts who work with youth.

Date: March 31^st, 2012Continue reading…

Defending the Affordable Care Act

Mar 15, 2012• 19

By Merrill Goozner

What will they do? The Supreme Court (more or less) that gave us Bush v Gore in 2000 will later this month hear arguments by states challenging the Affordable Care Act, a.k.a. health care reform. The heart of the legal challenge raised by conservative state attorneys general is whether the individual mandate is constitutional. What happens if the Supremes say no? Does the entire law fall, or just the mandate?

The issue for lawyers is called “severability.” Did Congress when passing the law believe the mandate was necessary to the smooth functioning of the rest of the law? Clearly there are large swaths of the law for which the mandate is largely irrelevant: the physician payments sunshine act (disclosure of drug company payments to doctors); the creation of the Patient Centered Outcomes Research Institute to conduct comparative effectiveness research; the numerous payment pilot projects; and more.

But on the core question of the law’s desire to expand coverage for the uninsured and set minimum insurance standards like forcing insurance companies to guarantee policies to all comers at non-discriminatory rates, the issue of the mandate’s necessity becomes murkier. The Obama administration is simultaneously arguing that it is crucial to the law’s smooth functioning, yet isn’t necessary. How can both be true? Here’s how two physicians, Samuel Y. Sessions and Allan S. Detsky, writing in the New England Journal of Medicine explain the seeming contradiction:

Arguing that the mandate is constitutional under the Commerce Clause requires taking the position that it is “essential” to the statutory scheme, whereas arguing that it is severable dictates the seemingly opposite position that the ACA is “capable of functioning without it.” Politically, making both arguments may be awkward, which may be one reason why the administration endorses partial severability. Legally, however, the positions are consistent: the mandate may be an important part of the statutory scheme, and thus constitutional, but not absolutely vital, and hence completely severable.

Continue reading…

Don’t Try This at Home: The Mathematics of HIV Testing in Low-Risk Populations

Mar 15, 2012• 2

By Harold Pollack

This post considers potential pitfalls of home HIV testing. It provides an excuse to write a slightly less nerdy column on the mathematics of screening tests.

My friend and co-author A. David Paltiel flew in from Yale to speak with my University of Chicago students. David is a national authority on medical cost-effectiveness, particularly in matters connected with HIV. For example, this beautiful New England Journal of Medicine piece showed that population HIV screening is surprisingly cost-effective, even in relatively low-risk populations. In significant measure due to this analysis, the Centers for Disease Control and Prevention modified national guidelines to promote much more aggressive HIV screening in a variety of settings. So if your primary care doctor or emergency department nurse asks you whether you’d like an HIV test–blame Paltiel.

David and I have published related work on issues surrounding home HIV tests, now under FDA review. (See a great earlier commentary by Walensky and Paltiel here.) To simplify things, the idea here is that you could go to your local Walgreen’s and buy a test kit for about $40. You swab the thing around your mouth. In about 20 minutes, with impressive “accuracy” (in a minute I’ll explain why the commonsense word “accuracy” is a slippery way to describe screening tests), the test will say whether you are HIV-infected.

One natural group of customers might be romantically-involved University of Chicago students: They go out on a date. It goes well. They buy a pair of test kits (maybe romantically sharing one) for a quick HIV test. If the tests come out well…. whatever one cares to happen can now proceed.

Is this test a good idea? In some ways, yes. This normalizes testing. Some people will get tested who would not otherwise obtain care. But there are a variety of reasons to worry. One issue concerns the ability of ordinary people not to mess the test up. A second issue concerns whether home HIV tests will lead people to avoid other medical and public health systems that could provide better counseling and (if needed) stronger post-test linkages to care.

Feds’ Power Grab Must Be Stopped

Mar 15, 2012• 28

By PAM BONDI

Florida and more than half of the states in the nation have challenged the federal government’s Affordable Care Act because it deprives Americans of their individual liberty and violates the United States Constitution. The U.S. Supreme Court will decide whether to enforce constitutional limitations on federal authority — or, conversely, whether to allow the federal government to dominate states and individuals to the point of dictating day-to-day decisions.

The court should reaffirm the basic constitutional bargain struck among the states that makes our federal government one of limited, enumerated powers.

The act’s chief problem is its individual mandate, which requires virtually everyone to obtain health insurance coverage simply as a condition of living in America. Forced conscription into a commercial market is a startling new exercise of federal power that Congress has never before attempted.

The individual mandate’s stated goal is to lower insurance costs by forcing “healthy individuals” to buy expensive policies that they do not want or need so that insurers can charge less to others. Congress’s central planning on both the supply and demand side of the insurance market exceeds its constitutional authority because the bare power to “regulate” commerce does not include the power to force Americans into commerce. If it did, there would be no end to Congress “fixing” markets with the wallets of ordinary citizens. Congress could require Americans to obtain unwanted loans to bail out failing banks, to purchase a car to reinvigorate struggling carmakers or to buy solar panels to resuscitate failed Solyndra-like investments.Continue reading…