Health Affairs Blog

The Policy Journal of the Health Sphere

Updated: 1 day 31 min ago

Death Of A Sales Job (A Three Act Ploy)

Fri, 03/05/2010 - 13:15

With apologies to Arthur Miller …

President Obama went back before the cameras again Wednesday, providing yet another recycling of fading rationales for his health reform product that more voters would rather leave on the Capitol Hill store shelves than purchase.

But “attention must be paid” whenever the president speaks.

He tried to claim that “we have now incorporated most of the ‘serious’ ideas from across the spectrum about how to contain the rising cost of health care.” Perhaps that includes compromising on the implementation date for taxing the extra amount of premiums in the most expensive and comprehensive private insurance plans (just short of waiting either “in perpetuity” or “forever;” whichever comes sooner and still meets the approval of organized labor). Of course, the president’s search for Republican health care ideas he could deem “legitimate” was only slightly more aggressive than O.J. Simpson’s never-ending search for the killers of Nicole and Ron. He came up with four low-dose remedies that border on homeopathy.

The Meager Products Of The “Search”

First, a few million more dollars to assist small state-level experiments in medical malpractice reform featuring special health courts as an alternative to jury trials. Of course, no actual changes in permanent malpractice law and regulation would be supported before the light soon went out on these pilot projects, and they appear very unlikely to produce any consequential changes.

Second, Obama warmed to the idea of conducting undercover investigations of Medicare and Medicaid providers to search for waste, fraud, and abuse (standard line items in those programs’ annual budgets, to be sure). No one has figured out where the cops posing as patients will hide their badges when in the examining room, nor why private health insurers don’t have the same degree of such problems and manage to head them off much differently. (“We don’t need no badges! I don’t have to show you any stinkin’ badges!”)

Third, the president came out in favor of paying Medicaid doctors more. How much more? What would it cost? How would it be done? For how long? Actual details TBA later, if ever. (See Medicare and sustainable growth rate fixes for a measure of skepticism, although Medicaid reimbursement has nowhere to go but up.)

Fourth, Obama said that health savings accounts tied to higher-deductible insurance policies actually may be permitted to be sold in new health insurance exchanges. Note that the nation’s foremost expert on inadequate “Acme-brand” high-deductible insurance and defender of minimum federal standards for “real” insurance (see Health Summit, last week) did not actually say anything about changing the minimum actuarial values required in both the House- and Senate-passed health bills for qualified insurance plans within the exchanges, or whether contributions to HSAs would count as “insurance” dollars. Or whether HSAs would be exempt from the first-dollar coverage mandates and income-based caps on out-of-pocket spending supported by the president and his congressional allies.

The president again appeared to be frustrated that political opposition and the public’s aversion to his once-popular health plan had kept its journey to enactment long, halting, and still unfinished.

(“I’ve always tried to think otherwise, I guess. I always felt that if a man was impressive, and well liked, that nothing….” Cue the beginning of his tragic fall.)

Rhetorical Diversions

He resorted again to several well-worn diversions. First, the straw man of “do nothing” and “walk away” hopped onto the stage, as if the president’s embattled plan to do even worse than that, and prevent anything better from being considered, was a better alternative. Second, Obama rhetorically crossed his fingers and recited the howler that “I don’t believe we should give government bureaucrats or insurance company bureaucrats more control over health care in America.” He must have forgotten about the hundreds of future rules, standards, and implementation decisions delegated in the House and Senate bills to the HHS Secretary, the oxymoronic Health Choices Commissioner, and other new administrative bodies. Even a clear plurality (45%) of Americans has come around to the conclusion that, facing a prisoner’s dilemma in health coverage, they’d rather take their chances with private insurers.

President Obama also said that health care “easily lends itself to demagoguery and political gamesmanship, and misrepresentation and misunderstanding.” Look, that’s a legitimate point. For example, he mangled his recycling of the uncompensated care/emergency room/cost shifting factoid, concocted earlier this year by Families USA, that the uninsured are subsidized at the cost of $1,000 per family whenever they walk into an emergency room. He usually attributes that entire cost to the private insurance premiums of the average family; this time it was taxpayers picking up the entire tab. The actual costs are much lower and their distribution is quite different, but that would spoil a tall political tale. The president then rolled out his universal coverage ball of wax argument to assert that insurance reforms to prevent coverage denials for pre-existing conditions and to limit the amount that families are “forced” to pay out of their own pockets rest on everybody having access to coverage (read: individual mandate, except for those with economic hardships – who would seem to need subsidized coverage the most!). He must have dismissed out of hand proposals for substantially expanded federal funding of serious high-risk pools and extension of HIPAA portability protection to those with previous continuous coverage entering and exiting the individual market, because he certainly doesn’t understand them. Oh, and about those unlimited amounts of money paid out of pocket? They averaged less than 12 cents out of every dollar of U.S. health spending in 2008, they are projected to decline to 10.4 cents per dollar by 2019 , and the U.S. ranked sixth-lowest in this regard among 27 OECD countries as of 2007.

Sadly, there was more (double-counting Medicare savings, promising health choices as good as those for members of Congress, no actual legislative language yet, etc.) even though it all was packed into less than 15 minutes. However, there was no time left to spell out the imminent political strategy to go with a contorted version of budget “reconciliation” (the one whose name shall not be spoken).

But the president will be back on the road to Pennsylvania and Missouri next week to talk about the health legislation and “do everything in my power to make the case for reform.”

“He’s a man way out there in the blue, riding on a smile and a shoeshine…” (and a teleprompter).

Copyright © 2010 Health Affairs Blog. This Feed is for personal non-commercial use only. All material published on Health Affairs blog, excluding links, is covered under a Creative Commons Attribution - NonCommercial - No Derivs 2.5 license.
Plugin by Taragana

Categories: Health Care Policy

HA Blog Top Ten For February

Fri, 03/05/2010 - 00:03

Posts on health reform dominate the ten most-read Health Affairs Blog posts for February. Also on the list are reports on health spending and an innovative way to supplement the primary care workforce:

Health Reform: The Need To Move Forward
by Henry Aaron
Getting Health Reform Done
by Timothy Jost
The Grandparents Corps: A New Primary Care Model
by Arthur Garson and coauthors
Global E-Health Is Focus Of New Health Affairs Issue
by Chris Fleming
Rethinking Health Reform: The Need For A More Incremental Approach
by Joseph Antos
2009 U.S. Health Spending Estimated at $2.5 Trillion
by Chris Fleming
The President’s Health Reform Proposal: Insurance And Revenue Provisions
by Timothy Jost
Health Care Summit: Half-Time Report
by Timothy Jost
An Alternative Path On Health Reform: A Reply To Tim Jost
by Jeff Goldsmith
The President’s Health Reform Proposal: Other Provisions
by Timothy Jost

Categories: Health Care Policy

Latest Edition Of Health Wonk Review Is Up

Thu, 03/04/2010 - 23:25

Over at his blog “Wright On Health,” Brad Wright presents some of the best in recent health policy blogging in the latest edition of the Health Wonk Review.

Categories: Health Care Policy

A Pilot Program For Overweight Children Yields Results

Thu, 03/04/2010 - 21:43

An article published earlier this week by Health Affairs discusses a new approach to managing child obesity that supports the delivery of so-called secondary care — referral-based specialized visits — by primary care teams within community health centers. Eight centers in Massachusetts have launched the Healthy Weight Clinic, and the results over fifteen months show significant changes in clients’ physical activity, food consumption, and Body Mass Index (BMI), report Shikha Anand, assistant professor of pediatrics at the Boston Medical Center and pediatric director at the Whittier Street Health Center in Roxbury, Mass., and coauthors. Their article was published on the same day as the March issue of Health Affairs. which focuses on child obesity.

Since child obesity is a growing epidemic in this country, particularly among African American, Latino, and lower socioeconomic groups, the Healthy Weight Clinic has shown success by tailoring its approach to the special needs of these groups. In addition to the primary care physician, patients meet with a dietician and a case manager, making six monthly or semi-monthly visits in all During the initial intake, team members assess the client’s family history and other medical conditions, and review diet as well as lifestyle patterns (e.g., number of hours engaged in sedentary activities) in order to enable the patients and their families to develop goals for behavior modification. Team members record patient result data on a collection form known as the Pediatric Obesity Assessment Tool.

Based on that information, the authors analyzed results from 174 patients with more than one program visit between June 2008 and August 2009. They note that 29.9 percent have reported reduced screen time; 79.8 percent have made some sort of lifestyle change; and 50.0 percent have decreased their BMI. In a smaller sample (93 patients), 32.2 percent have decreased their intake of sweetened beverages, and 33.3 percent have increased their intake of fruits and vegetables.

“The early descriptive results from this initiative are encouraging … this approach could be effective in clinics throughout the country,” say the authors. “By giving primary care teams the tools, time, and collaborative infrastructure they need, we have created a system that can provide high-quality specialized care and improve access, and can potentially decrease costs.”

Categories: Health Care Policy

Audio Of Child Obesity Briefing Is Available

Wed, 03/03/2010 - 12:43

The March issue of Health Affairs, a thematic issue on child obesity supported by the Robert Wood Johnson Foundation, was released at a March 2 briefing in Washington D.C. Audio, slides, and an agenda from the briefing are available on the Health Affairs Web site, and video will be posted soon.

Categories: Health Care Policy

Study Showing Rise In Snacking By Children Generates Discussion

Wed, 03/03/2010 - 08:36

Children in the United States snack almost three times a day on salty chips, candy, and other junk food, according to one of the first studies to look at long-term eating patterns in children. The increase in snacking—which now accounts for more than 27 percent of daily caloric intake in children—added 168 calories per day to kids’ caloric intake between 1977 and 2006.

The new research was published yesterday in the March 2010 edition of Health Affairs, which focuses on the child obesity epidemic and was supported by the Robert Wood Johnson Foundation. “Our study shows that some children, including very young children, snack almost continuously throughout the day,” said Barry M. Popkin, a professor in the Department of Nutrition at the University of North Carolina at Chapel Hill, and lead author of the paper. The rise in childhood obesity, meanwhile, has put millions of children at risk of chronic conditions such as hypertension, heart disease, and diabetes.

Media Coverage. The work by Popkin and Carmen Piernas, also at the University of North Carolina at Chapel Hill, has attracted quite a bit of attention in the media. “The Web is abuzz” about the study, wrote Rebecca Ruiz at Forbes. Tara Parker-Pope wrote about the study in her New York Times blog “Well”; her story contains this quote from Popkin: “My underlying fear is that we’re moving away from being hungry and eating for satiation to just eating. Food is there, and we eat.”

In her blog at the Boston Globe, Lylah Alphonse noted the study’s indication that unhealthy eating habits begin early in life: “I thought the age group with the largest snacking increase would be teenagers — they eat pretty much everything that isn’t nailed down, right? Wrong. Young kids, age 2 to 6, were the ones who consumed the most calories via snacks, the study found.” The research by Popkin and Piernas was also discussed by CBS, USA Today, Reuters, the Los Angeles Times, and many other outlets from BusinessWeek to Nickelodean.

What The Study Found

Popkin and Piernas studied nationally representative surveys of food intake in more than 31,000 U.S. children from 1977 to 2006. The researchers zeroed in on snacking patterns and found large increases: For example, in 1977 to 1978, 74 percent of children ages 2 to 18 said they snacked on foods outside of regular meals. In 2003 to 2006, that number had jumped to a whopping 98 percent.

“Kids still eat three meals a day, but they’re also loading up on high-calorie junk food that contains little or no nutritional value during these snacks,” Popkin said.

The largest increase in the types of snacks kids were eating during the three-decade period: salty snacks like chips and crackers. Another surprising finding: Kids are eating more candy at snack time, an unhealthy habit that can lead not only to weight gain but also to cavities.

Children of all ages increased their caloric intake coming from snacks by an average of 168 calories per daybetween 1977 and 2006. As noted above, the largest increase was found in children ages 2 to 6, who consumed 182 more calories per day in snacks, a troubling finding that suggests an unhealthy eating pattern early in life.

Sugar-Laden Beverages, Sweets Are Replacing Milk, Fruits & Vegetables

In addition, the researchers found the type of snack food or beverage had changed during the last three decades. Children are less likely to drink milk, which contains calcium and nutrients needed for proper growth; and they’re more likely to reach for fruit juice, which is almost all sugar, or sweetened beverages such as sports drinks that contain a lot of calories.

At the same time, children today are less likely to grab a fresh apple or a vegetable at snack time. The trend toward more fruit juice and less fruit and vegetables is a dangerous one because fresh produce contains fiber and lots of valuable nutrients that children need to stay healthy, Popkin said.

He also noted that consumption of desserts declined from 1977 to 2006. However, children today still snack on cake, cookies, and other rich foods, which account for a significant source of calories.

“Kids are eating nearly three snacks a day, and that’s too much,” Popkin said. He recommends that parents try to limit snack time to once a day for children six and older and make sure they stock up on plenty of healthy snack food items like apple slices, carrots, and other fruits and vegetables. Parents should also curtail young children’s consumption of junk food and candy and talk to older children about the importance of a healthy diet, including snacks.

Categories: Health Care Policy

Health Affairs Policy Briefs Examine Child Obesity

Tue, 03/02/2010 - 12:43

In conjunction with its March 2010 issue on child obesity, Health Affairs has prepared a series of policy briefs. The new Health Affairs volume demonstrates that policy leaders can and should take crucial steps to address the obesity epidemic, and the briefs encapsulate policy recommendations from articles in the March issue. The briefs also contain links back to the full-length Health Affairs articles for additional information.

The briefs, which are freely available to all, include:

Overview: The State Of Childhood Obesity In America

The Role Of Agriculture Policy In Reducing Childhood Obesity

Food Marketing And Distribution’s Role In The Fight Against Childhood Obesity

Speeding Up Progress In Fighting Obesity In Schools

Lessons From States On Fighting Childhood Obesity

The Pervasive Effects Of Environments On Childhood Obesity

Categories: Health Care Policy

Child Obesity: Health Affairs Explores Strategies For Combating Epidemic

Tue, 03/02/2010 - 11:02

How should America tackle an obesity crisis that is threatening the health and well-being of nearly one-third of its children? That is the subject of the March 2010 edition of Health Affairs, which both describes the root causes of this pathology and offers prescriptions for improving the health of America’s children. The March issue is funded by the Robert Wood Johnson Foundation.

“Kids are becoming obese or overweight at the ripe old age of four, meaning that they are already predisposed to shorter, sicker lives from diabetes, heart problems, even certain types of cancer,” writes Health Affairs Editor-in-Chief Susan Dentzer. “What is this crisis if not some national form of child abuse?”

A new study by Christina Bethell of the Oregon Health and Science University shows that the rate of childhood obesity continues to increase nationally. What’s more, the highest combined rates of overweight and obesity are found among poor, black, Hispanic, and publicly insured children — and the disparities in weight between these groups and other children are growing.

Dentzer says that recent developments offer modest cause for hope. First Lady Michelle Obama has taken on childhood obesity as one of her signature causes. Changes in federal policy — to promote healthier school meals and eliminate the sale of junk foods at schools — are in the making. But more is needed to put the health of America’s children back on track.

Addressing the problem begins with understanding the multiple underlying causes. David Wallinga, director of the Food and Health Program at the Institute for Agriculture and Trade Policy in Minneapolis, reports that Americans’ average daily calorie intake in 2007 was 400 calories higher than in 1985 and 600 calories higher than in 1970. How did we get to this point? Wallinga points to thirty-five years of agriculture policy favoring production of cheap sugars as a key driver of increased calorie consumption. Yet eliminating crop subsidies to commodity farmers is not the answer, he says. Instead, he favors managing commodity crop overproduction and supporting farmers who produce more fruit and vegetables to balance U.S. agricultural policy — which, he adds, has as much to do with health as it does farming.

A study by Barry M. Popkin and Carmen Piernas, of the University of North Carolina at Chapel Hill finds that U.S. children are snacking more than ever — almost three times a day — on junk foods. As a result, they are consuming more than 27 percent of their daily caloric intake through snacks. Marketing of these calorie-dense, nutrient-poor foods and beverages aimed at children is frequently cited as another factor in the obesity epidemic. Placing restraints on this type of advertising might help mitigate its influence on young people. Yet there is little political support for policies restricting food marketing to youth.

A new survey conducted by Amir Goren, of Yale University, and colleagues finds that even parents are not likely to support such restrictions unless they already feel negatively about current food marketing practices. The authors recommend increased public education on the negative effects of food marketing on children.

Some experts believe that government must take aggressive action to reduce childhood obesity. Kelly D. Brownell, of Yale University, and coauthors call on policymakers at all levels of government to help Americans make healthier choices by regulating food ingredients, labeling, and marketing; and by taxing unhealthy foods and beverages. Thomas R. Frieden, the new director of the U.S. Centers for Disease Control and Prevention, says reversing the epidemic will require multiple policy changes, including taxes on unhealthy foods and beverages, new incentives to promote healthy crop production, a ban on advertising that fosters bad eating habits, and sustained efforts to increase physical activity among children. “If we do not act now, the epidemic of childhood obesity will become increasingly difficult to address,” says Frieden. “From the federal to the state and local level, in the public and the private sector, from Fortune 500 companies to families around their kitchen tables, there are simple things each of us can do to encourage physical activity, improve nutrition and help our kids live healthier lives. It will take us all working together to meet this challenge.”

Other highlights from this edition of Health Affairs include:

• How does federal food assistance affect childhood obesity? Rachel Kimbro, of Rice University and Elizabeth Rigby, of the University of Houston, find that food assistance — including, for example, the program formerly known as food stamps — may be both part of the solution and part of the problem. Their study shows that food assistance may unintentionally contribute to childhood obesity in cities with high food prices, but that subsidized meals at school and day care have a positive impact. They argue that expanding access to subsidized meals may be the most effective tool to combat obesity in poor children.

• Data collected by the U.S. Centers for Disease Control and Prevention (CDC) have helped reveal the extent of the obesity epidemic at a national level and provided some insights at the state level. However, according to Matt Longjohn, of Northwestern University and colleagues, more information is needed at the state and local levels to track childhood obesity trends — particularly concerning body mass index (BMI). To date, some thirty states have enacted or proposed BMI surveillance laws and regulations, many of them involving innovative systems that will increase the ability of public health agencies to contain the epidemic. In Texas, William M. Sage reports on how geographic information system (GIS) mapping identified two neighborhoods outside downtown Austin with high obesity rates. Armed with this information, community groups were able to design obesity interventions tailored to each neighborhood.

• States are employing a variety of tactics to reverse childhood obesity trends. For example, Debbie I. Chang describes how a statewide initiative in Delaware halted increases in obesity and overweight prevalence among children, by increasing knowledge of healthy eating behaviors and awareness of the need for more physical activity in school and child care settings. Pennsylvania has focused its efforts on increasing access to healthy foods by eliminating “grocery store gaps.” To date, Pennsylvania’s Fresh Food Financing Initiative, a public-private enterprise, has funded seventy-four fresh food outlets throughout the state, increasing fresh food access for 500,000 children and adults, according to Allison Karpyn, of the Food Trust in Philadelphia, and colleagues.

Meanwhile, Steve Bogira tells the stories of two young children living in different suburbs of Baltimore who are battling obesity with support from a behavioral intervention program called Weigh Smart, operated by Mt. Washington Pediatric Hospital. The goal is not short-term weight loss but a sustained change in children’s and families’ attitudes and habits regarding eating and physical activity. For kids, that means avoiding formerly beloved foods — like macaroni and cheese — and sweating more. For parents, it means supporting their kids’ efforts by reading food labels more carefully, preparing healthy meals, and getting their children to be more active.

• Schools are a key battleground in the war on childhood obesity. One critical issue is the sale of junk foods at so many schools. Nicole Larson and Mary Story of the University of Minnesota find that junk foods are more consistently available than healthy foods at many schools. The authors call for continued action at the federal, state, and local levels to eliminate the availability of junk foods in schools. Such policies can make a difference, as Emma V. Sanchez-Vaznaugh, of the University of California, San Francisco, and coauthors found in California. Following implementation of stricter nutrition standards for snacks and beverages sold to children at school, the rate of increase in overweight children fell significantly among fifth graders in Los Angeles and among fifth-grade boys and seventh graders in the rest of California.

Yet implementation of policy changes to school meals and nutrition and wellness programs sometimes yield mixed results. In an examination of Pennsylvania’s response to the federal WIC Reauthorization Act of 2004, Claudia Probart of Pennsylvania State University and colleagues found improvements to the nutritional quality of foods offered in conjunction with school meal programs. But they also found that several implementation steps were not followed, and that statewide enforcement was inadequate

• How does the childhood obesity epidemic affect employers? Very few data exist to answer that question, according to Martin J. Sepulveda, of IBM, and coauthors. Yet they believe strongly that employers should be concerned. They cite data showing that the average per capita health insurance claims cost for children with type II diabetes, at $10,789, exceeds the $8,844 average claims cost of adults with the same condition. These and other data “provide a compelling basis for greater employer engagement in efforts” to promote healthy weight among young people, the authors write.

Categories: Health Care Policy

Lessons From The Health Care Summit

Mon, 03/01/2010 - 11:54

Many journalists have called and asked me what I have learned from watching the much heralded Health Care Summit at Blair House.

Actually quite a bit, as the discourse there crystallized so clearly the ideological division that makes coherent and comprehensive health reform so difficult in this country, if not impossible.

In thinking about this question, I make a distinction between the policy-making elite and the “American people” — the plebs — for whom, allegedly, the elite makes policy. My counter-question then is: Are either the elite or the plebs actually ready for health reform at this time? I think not.

Let me focus on the policy-making elite first.

The view from the left. In the ideal world envisaged by the policy-making elite left of center of the ideological spectrum, the individual’s health care experience is independent of that individual’s socio-economic class, and the individual’s financial contribution to pay for health care is based on that individual’s ability to pay and completely divorced from that individual’s health status. Access to needed and locally available health care is viewed as an individual’s inherent right. This dream makes the financing of health care in the country a collective responsibility in which relatively healthier and/or wealthier people subsidize the health care used by relatively sicker and/or poorer members of society. Rationing health care by income class has no place in this picture. Heavy government involvement to enforce the implied redistribution of income does.

The view from the right. By contrast, the policy-making elite right of center of the ideological spectrum dreams of a world in which the individual’s use of health care is, in the first place, his or her own financial responsibility, although some collectively financed subsidies should be granted low-income families to help them afford at least a bare-bones, minimal package of health-care services. In this view, it is not only acceptable but entirely proper that sicker individuals should be charged higher health insurance premiums than are charged healthier individuals. Furthermore, rationing a good part of health care by income class – especially primary and secondary care — is countenanced with equanimity, because health care is viewed as basically not different from other basic commodities, such as food, housing and clothing, whose quantity and quality also is rationed by income class. Access to needed health care is decidedly not viewed as an individual’s right. It is, at most, a privilege bestowed on the less fortunate by the more fortunate. Government’s role in health care in this vision is to be kept to a minimum.

When I say “rationing by income class” I mean the following. Textbooks in economics explain that the role of prices in an economy is to ration scarce resources among unlimited wants. If prices and high cost sharing by patients are used as instruments of cost control in health care, they will ration low-income families much more out of health care than they will high-income families – hence rationing by income class.

Because these different visions of the ideal health system are driven strictly by ideology, one cannot judge one wrong and the other one correct, or even inferior or superior. They must both be respected, even if not shared, by all. And they cannot be resolved through health-services research, which can at most move closer to the facts the folklore on which ideology so often is defended.

A Uniquely American Ideological Impasse

Most industrialized countries in the world have closed this ideological gap long ago. They now slouch heavily toward the more egalitarian view espoused by left-of-center Americans.

Not so in the United States. And as long as I have lived in this country, I have seen efforts at health reform tumble into this ideological gulf, which has only grown wide over time. Health reform is likely to tumble into this ideological abyss in the future, until one or the other ideology clearly triumphs in the political arena, which would then make the imposition of one vision on the plebs possible. So far the center of the ideological spectrum has not been able to evolve an amalgamated vision that could carry the day on Capitol Hill.

Thus, short of a cram down of some reform by one or the other side in the ideological fray – e.g., through deft parliamentary maneuvers — reform of our health-care sector will not be possible in this country, and the sector will continue to both save Americans physiologically and devastate them financially for years to come. We may just have to get used to it.

In a recent address to the AcademyHealth conference on health policy, and on a blog post in The New York Times, I have suggested that one practical way to fathom the width and depth of this gulf might have been for the President to ask the Republican participants in the Summit to complete the following table after, of course, having the President entering the Democrats’ numbers first. (We can in fact find them in the 11-page description of the President’s ideas on health reform):

In the meantime, as the policy-making elite stews in its stalemate, the American plebs dreams of a political Messiah willing to build for them a health system that:

Lets only patients and their own physicians determine how to respond clinically to a given medical condition, never an insurance clerk or, even worse, government bureaucrats.
Limits their families’ out-of-pocket payments for health care to make it “affordable.”
Keeps insurance premiums and taxes for health care low.
Does not ever ration health care, because that is un-American and practiced only by un-American alien nations with inferior health systems.
Does not allow public or private insurers to let “costs” or “cost-effectiveness” ever enter coverage decisions, because that would implicitly put a price on human life which, in America, unlike elsewhere in the world, is priceless.
Does not mandate individuals to purchase health insurance, if they do not wish to do so, if for no other reason than that this would be unconstitutional and, therefore, un-American.
On the other hand, grants every American the moral right – backed up by a government mandate called EMTALA– to receive critically needed and possibly high cost health care from hospitals and their affiliated doctors, even if they are uninsured and could not possibly pay for that expensive care with their own resources.
Controls Medicare spending, which is widely thought to be completely out of control, as long as it does not reduce payments to hospitals or to doctors or to producers of medical technology, or to any other provider of health care.
Provides universal health insurance coverage to all Americans, provided it does not mean raising taxes or cutting Medicare spending or raising premiums on healthy Americans.
Keeps government out of health care but somehow makes sure that insurance companies do not exploit patients through incomprehensible fine print, no one engages in price gouging – e.g., charge $10 for an aspirin — and no one in health care earns excessive profits (or any at all).

That’s all.

One must wonder why America’s policy-making elite has found it so hard to satisfy these simple wishes of the American plebs. And as the American people anxiously wait for that Messiah, I wish them luck. In the meantime, we shall muddle through as usual.

Categories: Health Care Policy

Health Care Summit: The Conclusion

Fri, 02/26/2010 - 00:06

Editor’s Note: This is the second of 2 posts on the health care summit from Tim Jost. Part 1 looks at insurance reforms, premium rates and more.

Most of the last three hours of the summit was devoted to the effects of proposed legislation on the federal budget deficit (primarily on Medicare and Medicaid) and on expanding coverage. It seemed to me that the Democrats were stronger in the second half than in the first, less focused on telling stories (although there were still a lot of them) and more on substance. The Republicans kept to their talking points, but were at a disadvantage because their bills do not really address Medicare or coverage expansions.

Insurance Reform: Risk Pools and Mandates

Before turning to the deficit issue, several Congressmen who were not able to talk before the lunch break offered useful comments on the insurance reforms. Rep. Dave Camp (R-MI) pointed out a problem with the interim national high risk pool in the Senate bill. At $5 billion, it is not adequately funded and would run out of money well before the 2014, at which point the bill authorizes the Department of Health and Human Services (HHS) to close the pool. By contrast, the Republican high risk pools are more generously funded, although the Congressional Budget Office (CBO) does not score them as becoming fully funded until 2016. Rep. Marsha Blackburn (R-TN) noted that the interstate compacts in the Senate bill would require federal approval as well as the approval of each participating state, and would not become effective until 2016.

Democratic Congressmen, on the other hand, ably defended the comprehensiveness of their approach to reform generally, Sen. Tom Harkin (D-IA) noting that if someone is drowning 50 feet away it does not help to throw them a 10-foot rope. Senator Harkin also drew a parallel between the discrimination based on health status which still defines the health insurance industry and other forms of discrimination long since outlawed in the United States.

Several Republican commentators attacked the individual mandate, claiming that it has become a rallying point for opposition to the bill. A couple even called it unconstitutional. The President defended the mandate, noting that people who refuse to take responsibility for purchasing insurance simply shift their costs to the rest of us through public programs or uncompensated care once they need high cost care. He also pointed out that we cannot expect insurance companies to accept people with preexisting conditions if those people can simply wait until they become ill to purchase insurance.

Medicare and the Budget Deficit

Vice President Biden led off the discussion of the deficit and Medicare, noting that the CBO had scored the Senate bill as reducing the budget deficit by over $100 billion over the first decade and far more in the second decade. He also claimed that the proposal did not cut Medicare benefits but rather cut “waste,” in fact improving benefits by closing the donut hole and increasing coverage in preventive care.

Since the Republicans have not offered legislation to reduce Medicare spending, their contribution to this part of the discussion was mainly to criticize the Democratic proposals. Rep. Paul Ryan (R-WI) led off with a dizzying critique of the Democrats’ deficit reduction math, noting, for example, that the Center for Medicare and Medicaid Services (CMS) Actuary report was less sanguine than the CBO about the cost of the bill and that the Democrats’ budget numbers do not include the sustainable growth rate fix, which everyone agrees must happen. This led to a challenge from Rep. Xavier Becerra (D-CA), who called Ryan out on whether he accepted the CBO’s judgment, observing that if there was no agreement to the CBO as a referee, the business of Congress could not be done. Ryan claimed he was not challenging the CBO, only the Democrats’ math. Sen. Chuck Grassley (R-IA) followed on, pointing out, as have others, that the Democrats cannot claim the Medicare savings both as reducing the Medicare trust fund deficit and as a funding source for coverage expansions.

As the Medicare discussion progressed, the Republicans tried to focus on the effect that the cuts were likely to have on Medicare beneficiaries and providers. The Democrats, on the other hand, pushed the Republicans on the need to make hard choices if the deficit is going to be confronted. Rep. Jim Cooper (D-TN) and Sen. Kent Conrad (D-ND) were particularly eloquent on this point. President Obama pushed the Republicans on whether they could defend the fact that we spend 14 percent more on Medicare Advantage than on traditional Medicare for the same benefits, increasing not only the cost to the taxpayers but also the Part B premiums of beneficiaries who are not in MA plans. Their response was not convincing.

Although they were supposed to be discussing the deficit, the participants kept getting off topic. When his turn came, Rep. John Boehner (R-OH) simply recited a list of Republican talking points, which included major misrepresentations of the Democratic legislation. He claimed, for example, that the bills require all employers to provide health insurance (which the Senate bill does not) and would provide taxpayer funding for abortion, which neither bill does. Obama seemed nonplussed by Boehner’s misrepresentations, but said he would deal with them later. He did not get back to them, but Rep. Nancy Pelosi (D-CA) in her closing statement emphatically noted that the bills do not provide public funding for abortion.

Malpractice Reform Redux

The Republicans also kept returning to the theme of malpractice reform. Sen. John McCain (R-AZ) talked at length about what malpractice reform had done for Texas, reducing malpractice insurance premiums and attracting doctors to the states, including obstetricians for rural areas. Sen. Dick Durbin (D-IL) in response noted that medical negligence is in fact a serious problem and simply denying justice to its victims does not solve it. The figures offered by the parties as to the cost of malpractice litigation strikingly illustrated the depth of disagreement on this issue, with Senator Durbin claiming that malpractice litigation accounted for one-fifth of one percent of health care costs, while Rep. Joe Barton (R-TX) claimed it cost $150 billion a year. Senator Durbin’s numbers are closer to those of the CBO, which has determined that the Republican reforms would save the federal government about $5 billion a year, one-half of one percent of total federal costs. (This includes defensive medicine reduction.) Democratic speakers also noted the irony of the Republicans, who otherwise favor state’s rights, being eager to override state law on the malpractice issue. President Obama claimed several times that HHS Secretary Kathleen Sebelius was working on an approach to the malpractice issue that would involve giving the states incentives to address the problem, but the Republicans did not seem convinced.

Falling Short on Coverage

On the issue of coverage of the 50 million uninsured Americans, the Republicans had the least to offer. Congressman Boehner’s plan, according to the CBO, would only cover 3 million uninsured, and the Republicans did not take issue with this number. Rep. John Barrasso (R-WY), a physician, claimed that he had taken care of patients regardless of their insurance status, but free treatment by doctors does not seem like a viable solution. He also asserted that we have the best health care system in the world and that Canadian politicians fly here for treatment. In response, President Obama asked how this helped uninsured Americans.

Republicans did observe that half of the coverage expansions in the legislation will come through expanding Medicaid, and Medicaid is a troubled program, paying providers inadequately and bankrupting the state and federal governments. The Democratic response was that Medicaid is better than nothing. There was also disagreement as to whether the federal government needed to define the “essential benefits” that insurance must cover, with the Republicans seeing this as an unwarranted extension of federal authority and restriction on choice. The Democrats responded that minimum standards are necessary for health insurance, just as they are for food or drugs, and pointed out that the Federal Employees’ Health Benefit Program, which covers all Members of Congress, is governed by federal minimum standards.

The Republicans claimed repeatedly that public opinion polls show that the American people don’t like the Democrats’ plan, but the President noted that those same polls show that Americans support the separate elements of the plan. Democrats also observed that the public has been misled by Republican characterizations of the Democrats’ plan. Senator McCain also called on President Obama to remove pork provisions from the legislation, which the President said would be fine with him.

Areas of Agreement?

In his conclusion, the President stated that he had seen areas of agreement and disagreement between the Democrats and Republicans over the course of the day. He felt that there was room for agreement about the need for insurance market reforms, sale of health insurance over state lines, the use of exchanges, perhaps even for medical malpractice. He also acknowledged that basic philosophical differences separated the parties, which probably could not be bridged. Insuring 30 million more Americans is going to cost money, and delivery system reform is going to be difficult. Starting over is not an option, however. The President affirmed that he wants to work with Republicans, and would be willing to wait a month, perhaps six weeks, if necessary to reach agreement. But he did not rule out passing the legislation by a majority vote if the Republicans were not interested.

Although I was initially skeptical about the value of this exercise, it struck me in the end as useful. I doubt many Americans sat through the whole six hours, but if they did, they got a pretty good picture of what the Democrats are proposing and why the Republicans disagree with it. Whether or not those Americans who did not sit through it will get an accurate picture of what transpired from the media is, of course, another question. I did come away from the day, however, believing that the time for further debate is over, and it is now time to get the job done. I, for one, hope the votes are there to do it.

Categories: Health Care Policy

Health Care Summit: Half-Time Report

Thu, 02/25/2010 - 15:26

Editor’s Note: This is the first of 2 posts from Tim Jost on the summit. Part 2 looks at budget deficit, Medicare, malpractice, and possible areas of agreement.

The health care summit has now been underway for almost 3 hours. President Obama established in his opening statement what he hoped would come of the summit, which was to reach agreement on areas of commonality in the need for health care reform. The President, as well as a number of the Democratic speakers, has stressed these commonalities. The message is, of course, we both have the same goals and our bill meets these goals, so what is the problem?

The Republicans are having none of it. They showed up to reject the Democratic bill and present their own alternatives. They came heavily armed with facts and figures (some of them plausible, some not), and are in a constant attack mode. By and large this attack has to do with substance, although in some instances, notably John McCain’s speech, it is an attack on process as well. They see the bill as a Washington takeover of the health care system, and they are vehemently opposed.

The Democrats are by and large not engaging these attacks. Rather they are telling stories about how their constituents are suffering under the current health care system, and, like the President, stressing how their legislation embraces Republican ideas. It is a pity that they are not more aggressively engaging the Republican claims, because they could convincingly do so.

The Republicans, for example, repeatedly come back to the issue of malpractice, a theme that plays well in the United States where the public has long since accepted as a fact that malpractice and consequent defensive medicine are major cost drivers. David Camp noted that the Congressional Budget Office concluded that the Republican changes in malpractice law, which basically make it harder for injured people to sue, would save $50 billion over 10 years. What he did not say was that this is a half a percent of the total costs over that period, two days of health care costs per year. He threw out larger figures from other sources, but these figures are not only contrary to unbiased research in this area, but also are belied by the fact that California and Texas have already adopted the Republican reforms and are not experiencing health care costs dramatically lower than the rest of the country. Where was McAllen again?

Interstate Insurance Sales, Association Health Plans, And High-Risk Pools

Interstate sales of health insurance, another Republican proposal, are fine, and are encompassed in the Democratic bill, but subject to consumer protection regulation. You cannot simply buy auto or homeowners insurance from any state in the country, but only from insurers licensed in your own state. The same thing is true of health insurance. MEWAs for a time permitted unregulated sales of insurance and the result was serious fraud problems. As the President’s ACME insurance example shows, just because something calls itself an insurance company doesn’t really mean it will be there when you need it. State insurance commissioners oppose unregulated interstate sales because they are a recipe for disaster.

Association health plans already exist in many states, and are offered by the Republicans as an alternative to the exchanges. But association plans can freely cherry pick the best risks, leaving higher-risks in the nongroup pool, driving up costs. They make insurance cheaper for the healthy, but much more expensive for those who really need it. High risk pools exacerbate this problem by putting all of the high risks in one, very expensive, pool. They have been around for decades but have not made a serious dent in the problem of the uninsured. The exchange solution, building bigger pools and getting everyone in them is a far superior solution.

Medicare Spending: Much Is Wasted … But None Should Be Cut?

Senator McConnell claimed that one third of Medicare expenditures are wasted and that 20% are consumed by fraud. Leaving aside the issue that these fraud statistics are simply not plausible, and that fraud also is a serious problem in the private insurance sector, the fraud claim ignores that dozens of pages of fraud prevention provisions in the Democratic bill (many of them Republican ideas) and the additional provisions in Obama’s proposal. The greatest irony, however, is that the claim that one third of Medicare expenditures are wasted was followed by strident opposition to cutting any Medicare expenditures for securing the program’s future and funding other needs. If there is waste in Medicare, why not go after it in a targeted way, which is what the Democrats’ bill does. It is a shame, however, that the Democrats did not make this point more forcefully.

Insurance Premium Rates

Perhaps the most substantive disagreement between the parties was over what each plan does to insurance rates. Let’s first get some things straight. First, the Senate bill clearly and absolutely does grandfather in both existing individual and employer plans. Some regulations would apply to these plans over time, but not the essential benefits provisions. Second, the Senate bill does not regulate the benefits provided by employer or large group health plans. Third, the Senate bill does not affect HSA’s except to increase penalties for withdrawal of funds for non-medical purposes. It does limit contributions to FSAs, but since when did anyone see “use-it-or-lose-it” FSAs as a cost-control strategy?

The Republicans are right, however, to point out that the CBO projects that health premiums in the nongroup market will go up under the Democrats bill. What no one mentioned is that after the subsidies are applied, they will go down dramatically for most people. Also the CBO projected that premiums would go down in the nongroup market under the Republican bill.

The reason why the premiums go up under the Democratic bill is because the coverage is richer and more higher-risk people are covered. One must remember that the vast majority of those going bankrupt from health care costs are in financial trouble because their coverage is inadequate to provide financial security. There is also growing evidence that the underinsured are not getting adequate health care. The Democratic bill would put a floor under coverage. The CBO evaluation of the Republican bill, on the other hand, notes that it will reduce premiums by covering more low and fewer high risk people and by reducing the scope of coverage. More uninsured, more underinsured.

The Real Question

This poses a real difference between the proposals. Do Americans want better insurance coverage, and are they willing to see some tax increases to get it? Do we want to see everybody covered, regardless of health status? Or would we rather have cheaper policies that cover less and that are not available to those with preexisting illnesses, but pay less in taxes (and keep Medicare expenditures high even if the money is wasted)? This is the question the debate needs to frame more clearly.

Categories: Health Care Policy

Should We Be Able To Buy Insurance Across State Lines?

Wed, 02/24/2010 - 10:50

I live in Texas. Right now, the only health insurance I can buy is insurance regulated under Texas law. But if bills before Congress (most notably, one sponsored by Arizona Republican Congressman John Shadegg), are enacted, I would be able to buy insurance regulated, say, by the laws of Virginia, or the laws of Delaware, or 47 other states.

Proponents claim this would greatly increase competition. Opponents claim it would undermine “consumer protections.” I think both claims are mainly wrong. I would not expect the number of insurance companies trying to sell me insurance in Dallas, Texas to change at all. And if I am worried about consumer protections, I can continue to buy Texas-regulated insurance, just as I did before.

In fact, far from losing consumer protections, I would gain access to all sorts of protections I do not now have. Specifically, I would be able to choose among 50 different regulatory regimes. And because market prices (premiums) would reflect the different regulatory costs, I could weigh cost against benefits in selecting the regulatory regime that best fits my needs.

What Matters To Consumers?

Let’s run through a few things that a rational consumer should care about. One is guaranteed renewability and how well that is enforced. I don’t want an insurer to be able to cancel my policy or jack up my premium just because I get sick.

Dispute resolution is another issue. If I don’t agree with a coverage decision my insurer makes, what procedures are in place to make sure I get a fair hearing and an objective resolution? How difficult is this to do? How long does it take?

Every state has mandated health insurance benefits. These are laws requiring insurers to cover services ranging from acupuncture to in vitro fertilization and providers ranging from chiropractors to naturopaths — and there are considerable differences among the states. Although often described as “consumer protections” in every legislative hearing I have ever attended, it is the special-interest providers (rather than patients) who are pushing for these laws.

Still, I might be concerned about a change in my plan benefits in future years. So if I want to make sure I am always covered by chiropractic services, maybe I will want a regulatory regime that requires it.

Then there are a set of technical issues that are hard for a normal consumer to understand, but that can be summarized and explained by Consumer Reports or some other independent body. If the state regulates premiums, insurance forms, or loss ratios (percent of premium spent on benefits), after-the-fact audits are better than pre-approvals — by which regulatory inertia can keep markets from quickly meeting consumer needs. Also, insurance company audits should be paid for by the regulator (not the insurer), so that regulators are not tempted to needlessly impose costs.

Promoting Competition Among Regulators

Competition among 50 regulatory regimes would have beneficial effects both on regulators and insurers. Regulatory regimes that impose high costs and create few benefits would soon see everyone avoiding them. In time, they would have to change or discover they have no insurance left to regulate. And once customers start focusing on the non-price aspects of insurance, insurers will have enhanced incentives to compete on those features.

Remember the phrase, “You’re in good hands with Allstate”? The advertisement asks consumers to think about how they are treated at the time claims need to be paid. I don’t recall ever seeing a health insurance company boast about its claims-paying prowess. But that would become normal if health insurance were sold in a national marketplace.

Which brings us back to the claim of the proponents. I would not expect to see more competitors. I would expect to see more competition, however, in those aspects of insurance that are today handled almost exclusively by regulators.

Eliminating “Private Sector Socialism”

One thing that would not survive 50 state regulatory regime competition is guaranteed-issue and community rating in the individual market. In the six states that impose such requirements the vast majority of people who are relatively healthy are overcharged so that the small percent who are sick can be undercharged. This form of private sector socialism would quickly dissolve, as the healthy sought cheaper insurance under other regulatory regimes.

This would be a good outcome for healthy people because lower premiums would encourage the uninsured to buy insurance. But would people with pre-existing conditions (who remain in shrinking pools with rising per capita costs) be unfairly burdened? The solution that would face the least political resistance would be to exempt these six states from the proposal, unless they opt in. But a better solution would be for states to find more rational ways of subsidizing the care of high-cost patients.

Overall, University of Minnesota economists Steve Parente and Roger Feldman estimate that cross-state purchasing of health insurance would induce 12 million more people to obtain health insurance. That number would double if tax subsidies for health insurance were equalized — thus insuring 80% of the number of uninsured people the Senate (ObamaCare) health bill aims to insure — without any net cost to the federal government.

Categories: Health Care Policy

The President’s Health Reform Proposal: Other Provisions

Mon, 02/22/2010 - 18:10

Editor’s Note: Timothy Jost, the author of the post below, analyzed the insurance and revenue provisions of the President’s Proposal for Health Care Reform in an earlier post.

Public debate concerning the pending congressional health reform legislation has largely focused on insurance reforms, which were discussed in my first post on the president’s latest reform proposal. But the health insurance reform provisions make up only one title and one-fifth of the 2,400-page Senate bill on which the final reform will undoubtedly be based, if reform happens at all. The remaining provisions of the legislation address a wide range of health reform issues—indeed, most of the topics that health reform must deal with to be comprehensive (and perhaps some that could better have been left to a later time). The House bill addresses each of these issues with comparable, though seldom identical, provisions. This post analyzes the President’s Proposal for Health Care Reform as it affects the topics addressed by these provisions.

I discussed these provisions of the Senate bill in earlier blog posts analyzing the original Senate bill and the manager’s amendment to the Senate bill. An excellent analysis of these provisions by Karen Davis and others can be found at the Commonwealth Fund website, which also includes a tabular summary of the Senate bill’s health systems reform provisions. Detailed analyses of Medicare and Medicaid provisions of the bill are available on the Kaiser Family Foundation site.

Medicaid Expansions

Of all of the reforms found in the last four-fifths of the bill, the Medicaid expansions are the most important for extending access to care and are the most integrally related to the insurance reforms of Title I. Under current federal law and the law of most states, Medicaid eligibility is not based on poverty alone; an applicant must usually also be over sixty-five, disabled, blind, a child, or the parent of a child. These categories go back to the 1930s, when social welfare assistance was extended only to the “worthy poor.”

The Senate health reform legislation would, effective 2014, extend Medicaid assistance to all U.S. citizens with a modified adjusted gross income of less than 133 percent of the poverty level, currently $14,404 for an individual and $29,327 for a family of four. (By comparison, a forty-hour-a-week job paying the minimum wage for fifty-two weeks a year would currently gross $15,080.) The newly eligible population would be offered a benefits package similar to that available through the exchanges to the general nongroup population. The House would have expanded Medicaid to citizens earning up to 150 percent of the poverty level, but the President’s Proposal adopts the Senate’s 133 percent eligibility level. The proposal would, moreover, eliminate income disregards currently applied by the states, so the eligibility expansion would be even less generous than it would appear at first glance (although it would leave a 5 percent income disregard for certain Medicaid eligibility determinations).

The CBO projects that Medicaid expansions would cover an additional 15 million Americans, increasing the Medicaid population to 50 million. Moreover, a recent Rand study estimates that an additional 9 million Americans, 38 percent of those remaining uninsured under the Senate bill, would be eligible for Medicaid but would not be enrolled. These persons would be afforded a level of financial security by the legislation, since they would in most instances be signed up for Medicaid by health care providers if they required expensive medical care. The Senate legislation also extends the CHIP program through 2019, and funding for it through 2015. The Medicaid expansions and CHIP extension are essential to undergird the insurance reforms of Title I, since they ensure coverage to those Americans who are simply too poor to participate in the reformed insurance market.

The Medicaid expansions, however, present a serious problem. Historically, Medicaid has been funded jointly by the federal and state governments, with the federal government funding at least half of the cost of the program, but considerably more in lower-income states. Medicaid is a countercyclical program, with enrollment expanding during recessions just as state revenues are plummeting. The states are currently in terrible financial shape, and Medicaid is one of their greatest burdens. Recognizing that the states are in no position to expand Medicaid coverage, the Senate bill provided for 100 percent federal funding for expansion populations for 2014 to 2016, with federal funding settling eventually at a rate between 82.3 percent and 95 percent. CHIP funding is increased by 23 percentage points, effective October 2015.

The President’s Proposal would extend 100 percent federal funding to the states for the Medicaid expansion population further, through 2017. It would also provide 95 percent funding for 2018 and 2019, and 90 percent for 2020 and subsequent years. It would eliminate Nebraska’s “Cornhusker” kickback, one of the most derided compromises in the Senate bill, while increasing by 8 percent federal matching rates for states that have already expanded Medicaid coverage to adults with incomes below 100 percent of the poverty level, beginning in 2014.

The President’s Proposal only begins to solve the problems currently affecting Medicaid. One of the greatest of these is inadequate provider payment levels. In most states, Medicaid pays providers significantly less than Medicare, which in turn pays less than private insurance. The House bill would have provided federal funding to increase payments for primary care providers up to Medicare levels, but the Senate bill does not. The President’s Proposal follows the Senate bill.

Medicare Reforms

The Senate bill devotes over 500 pages to the Medicare program, significantly more than it spends on insurance reforms. The legislation is dense and complex, but basically it is intended to achieve four goals: 1) reducing increases in and restructuring payments for some providers to help finance the rest of the reform initiatives; 2) authorizing experiments with new approaches to provider payments, to move away from fee-for-service and limited prospective payment schemes and toward payment schemes that pay for quality and that afford providers more flexibility to improve their performance; 3) improving benefits, particularly in coverage for preventive services, drug coverage in the “donut hole,” and coverage for services in rural areas; and 4) creating an new Independent Advisory Board to rationalize and depoliticize Medicare cost control efforts.

The President’s Proposal would make two major changes in the Medicare provisions of the Senate bill. First, it would begin to fill the “donut hole,” the current gap in Medicare pharmaceutical coverage that affects Medicare beneficiaries when they exceed the initial coverage limits but have not yet reached the catastrophic coverage threshold. The Senate bill provides a 50 percent discount for certain drugs in the donut hole, and so presumably does the President’s Proposal. The Senate bill also increases the donut hole threshold by $500 for 2010. The President’s Proposal replaces this with a $250 rebate for beneficiaries who hit the donut hole. It would then phase out coinsurance in the donut hole from the current 100 percent level to the 25 percent level that now applies below the threshold, thus eliminating the donut hole by 2020.

Second, the President’s Proposal would reduce payments for Medicare Advantage (MA) plans, which currently cost 14% more than traditional Medicare to cover the same beneficiaries. Both the House and Senate bill currently reduce MA payments, but in different ways. The House bill phases MA plan payments down to fee-for-service levels, while the Senate bill changes to a bidding model of payment. The President’s Proposal claims to adopt elements of both approaches, but seems to rely primarily on moving payments toward benchmarks related to fee-for-service costs, with adjustments for quality and enrollee satisfaction. The proposal would also reduce MA payments to adjust for coding patterns in MA plans that have raised payments more rapidly than actuarial analysis would suggest is warranted, given enrollee health status. The MA payment cuts are intended to serve as a major source of funding for additional expenditures found elsewhere in the legislation.

Prevention, Wellness, Public Health, and Workforce Initiatives

The House and Senate bills contain a host of prevention and wellness initiatives. These include eliminating cost-sharing for evidence-based preventive services in Medicare, providing extra funding to states that eliminate preventive services cost-sharing for Medicaid, and requiring non-grandfathered private insurance policies to eliminate cost-sharing for preventive services. The legislation also includes grants to smaller employers and to state and local governments to implement and evaluate wellness programs.

The most important improvement that the President’s Proposal makes in this area is to expand funding for community health centers over the next five years, from the $7 billion provided by the Senate bill to $11 billion (which is still less than the $12 billion provided by the House bill). It would also eliminate cost-sharing for preventive services in grandfathered plans after 2018.

There is a widespread belief that our health care workforce must be expanded and refocused, in order to care for the millions of additional Americans who will have health coverage under the health reform legislation. The House and Senate bills contain a number of initiatives to strengthen the health care workforce, focusing in particular on education and training. Professions receiving particular attention are primary care physicians; nurses; public health workers; general, pediatric, and public health dentists; geriatric care providers; and mental health educators. The President’s Proposal does not add to or change these provisions.

Fraud and Abuse Provisions

Title VI of the Senate bill combines under the general heading of “Transparency and Program Integrity” a variety of provisions that address fraud and abuse, nursing home improvements and quality, and conflict of interest disclosures; many of these provisions are also found in the House bill. The President’s Proposal adds a number of fraud and abuse initiatives taken either from the President’s FY 2011 Budget Proposal or from Republican proposals. These proposals are described on the White House Web site and are only listed here.

They would:

1) Create a comprehensive Medicare and Medicaid sanctions database, to be overseen by the HHS Inspector General;

2) Require registration and background checks of billing agencies and individuals and strengthen exclusion authority;

3) Open up the health care integrity and protection data bank to quality control and peer review organizations, and to private plans that are involved in federal health care programs;

4) Hold Medicare administrative contractors liable for payments made to excluded individuals or entities or for denied claims;

5) Strengthen oversight of community mental health centers;

6) Limit bankruptcy discharges for fraudulent health care providers and suppliers;

7) Enhance real-time data review to identify fraudulent payments;

8) Increase sanctions for illegal acquisition and distribution of Medicare or Medicaid beneficiary identification numbers or billing privileges;

9) Study the use of universal product numbers for selected items and services paid for by Medicare;

10) Improve state monitoring of high-risk billing activity to identify worrisome patterns of drug prescribing and utilization;

11) Apply extrapolation of error rates to MA plans to recoup overpayments;

12) Increase the authority of MA contractors to conduct medical reviews; and

13) Coordinate CMS and IRS investigations and enforcement to target high-risk provider types in high-vulnerability areas.

Pharmaceutical Innovation and the CLASS Act

Title VII of the Senate bill provides for FDA approval of “biosimilars,” generic biologics. The House bill places limits on so-called “pay for delay” settlements in litigation between brand-name and generic drug manufacturers that keep generics of the market, behavior that the Federal Trade Commission estimates costs consumers $35 billion per decade. The President’s Proposal declares anticompetitive and unlawful agreements in which a generic drug manufacturer receives anything of value from a brand-name drug manufacturer and in which the generic drug manufacturer agrees to limit or forego research, development, marketing, manufacturing, or sales of the generic drug. This presumption against the legality of the agreement can be overcome only if the parties to such an agreement provide clear and convincing evidence that the procompetitive benefits of the agreement outweigh its anticompetitive effects. The FTC is given authority to enforce the prohibition. The President’s Proposal would also delay the effective date of the therapeutic discovery credit in the Senate bill.

Finally, Title VIII of the Senate bill establishes the Senator Kennedy’s CLASS Act program, to help Americans save for the purchase of community living assistance services and support when they lose the capacity to function independently. The House bill contains similar provisions. The President’s Proposal makes unspecified changes in the Senate bill to “improve the CLASS program’s financial stability and ensure its long-run solvency.”

Categories: Health Care Policy

The President’s Health Reform Proposal: Insurance And Revenue Provisions

Mon, 02/22/2010 - 16:06

Editor’s Note: Timothy Jost analyzes the insurance and revenue provisions of the President’s Proposal for Health Care Reform in the post below. In a second post, Jost analyzes the other provisions of the proposal.

On Monday, February 22, the White House posted the President’s Proposal for Health Care Reform. Although the proposal was posted as “a prelude to the February 25 health care summit between Democrat and Republican congressional leadership and the president, it is not a mere ideas piece or discussion draft. Rather, it is essentially the outline of a budget reconciliation bill that—in tandem with HR 3590, already enacted by the Senate—would complete the task of comprehensive health care reform when adopted by both Houses. All of the provisions of the President’s Proposal arguably relate to the revenues and outlays of the federal government and should pass muster under the Senate reconciliation rules.

As widely expected, the bill seems to reflect negotiations between House and Senate leadership that took place in January, prior to the Massachusetts Senate bombshell, intended to split the difference between the House and Senate bills. While those negotiations were presumably comprehensive, however, the President’s Proposal addresses only issues that can be resolved through reconciliation. It does not, for example, change the Senate bill’s abortion language. It also tends to follow more closely the Senate’s approach than the House’s, even on issues arguably amenable to reconciliation. It does not, for example, include a public plan, sides with the Senate on state exchanges rather than a national exchange, and adopts the Senate’s 133 percent ceiling for Medicaid eligibility rather than the House’s 150 percent.

The position of the White House, of course, is that it is merely putting out a proposal to debate with the Republicans. Indeed, in the press conference accompanying the release, White House staff stated that Republican fraud and abuse ideas had been incorporated into the President’s Proposal. Republican proposals amenable to adoption through reconciliation could, of course, be added to or form the basis of modification to the President’s Proposal. Republican proposals that cannot be adopted through reconciliation could be voted on separately at a later date, perhaps as part of a bipartisan package to amend parts of the current legislation after it is adopted by Congress. The president’s approach of merely putting out reconciliation language is, however, politically realistic. It should be clear to everyone that simply starting over with a clean slate is not politically feasible at this point. A year’s work has gone into the pending legislation, and this Congress has neither the time nor the good will to do it all over again.

Insurance Regulation Changes

Assuming that the president’s proposals are intended to amend the Senate bill, how would they change it? Most media attention to date has been focused on Title I of the Senate bill, the provisions of the bill intended to improve the affordability and accessibility of private health insurance. This post focuses on the insurance provisions of the President’s Proposal as well as its revenue provisions. My next post will discuss Medicare, Medicaid, and other provisions of the proposal.

Title I of the Senate bill includes a host of provisions that tighten regulation of health insurance, particularly in the nongroup and small group market. The President’s Proposal would go further in couple of respects. First, it would increase oversight of premium increases at the federal and state levels. The original Senate bill provided for federal and state review of unreasonable premium increases, while the manager’s amendment to the Senate bill permitted the states to take into account excessive and unjustifiable premium increases in deciding whether or not to allow insurers access to the exchanges. Responding to dramatic and widely publicized premium increases in California and other states, the proposal would go further and allow the Department of Health and Human Services or the states to review rate increases and to require insurers to lower their premiums or provide rebates if increases were determined to be unreasonable. About half of the states reportedly now have authority for prior approval of rate hikes, but this proposal would strengthen this authority and supplement it with federal authority. It would also create a new national Health Insurance Rate Authority that would, according to a report in The New York Times, generate an annual report on the reasonableness of insurance rate increases.

Second, the President’s Proposal would extend the regulation of grandfathered plans. Under the House and Senate bills, individual and group policies that existed at the time of the adoption of the law would not have been subject to the new law. The Senate manager’s amendment extended a few provisions of the new law to grandfathered plans, including disclosure and medical loss ratio requirements. The President’s Proposal would go further in regulating grandfathered plans, requiring them immediately to cover adult dependents to age 26, prohibiting rescissions, strengthening the appeals process, and extending state rate review. After 2014 grandfathered plans would also become subject to the annual and lifetime limit bans, the preexisting condition exclusion prohibition, and the prohibition against discrimination for highly compensated individuals, and after 2018 they would be required to cover preventive services. In essence, grandfathered plans would become subject to most of the consumer protections in the bill, except for the underwriting prohibitions.

Affordability Subsidies and Mandates

Title I of the Senate bill also provides tax credits to help lower- and middle-income Americans afford health insurance in the nongroup market, an individual mandate to ensure that those who can afford health insurance accept the responsibility to buy it, penalties for employers whose failure to insure employees leaves them dependent on federal subsidies, and tax credits to help small employers insure employees. These provisions are incorporated into the President’s Proposal in modified form.

The House bill premium subsidies tend to be more generous to lower-income Americans, while the Senate bill is more favorable to middle-income families. The President’s Proposal sticks closer to the Senate than the House bill, but it marginally increases subsidies for Americans under 200 percent of the poverty level and, surprisingly, for families whose income is between 300 percent and 400 percent of the poverty level as well. It also increases the cost-sharing subsidies for families with incomes under 250 percent of the poverty level more than the Senate bill would, although across the board the cost-sharing subsidies in the President’s Proposal remain less generous than in the House bill. Tables showing how the premium subsidy tax credits and reduced cost sharing would change can be found here.

More concretely, The New York Times illustrates the changes as follows:

Under the president’s plan, a family earning about $88,000 a year would pay … about $8,380, not including out-of-pocket costs, such as co-payments or deductibles. Under the Senate bill, such a family could have paid $8,643 a year in premiums and under the House bill as much as $10,584 a year.

Under the president’s plan, a family earning $22,050 would have to pay $441 in annual premium costs compare to $331 under the House bill. And a family earning $33,100 would have to pay up to $1,324 a year in premiums . . . compared to a maximum of $993 under the House bill.

Both the House and Senate bills require individuals not otherwise covered by employee-based coverage or a public program to purchase health insurance. For the nongroup market to function, healthy as well as unhealthy individuals and families must purchase insurance. Once health status underwriting is outlawed, this will become even more essential. The House bill imposed a percentage-of-income penalty on uninsured persons who refused to purchase insurance, while the Senate imposed the higher of a flat dollar amount or a percentage-of-income penalty. The President’s Proposal adopts the Senate’s approach, but it reduces the flat dollar amount (from $495 to $325 in 2015, and $750 to $695 in 2016), while it raises the percentage-of-income penalty (from .5 percent to 1 percent in 2014, 1 percent to 2 percent in 2015, and 2 percent to 2.5 percent, the House bill level, in 2016 and thereafter). As in the House bill, the penalty would not apply to persons with income below the tax filing threshold (currently $18,700 for a married couple), but also, following the Senate bill, it would exempt persons who would have to pay more than 8 percent of their income to purchase insurance.

Like the Senate bill (and unlike the House bill), the President’s Proposal does not include an employer mandate but rather imposes a penalty on employers who do not offer insurance (or do not offer adequate insurance) and whose employees end up receiving public subsidies. As in the original Senate bill, the mandate does not apply to small employees (with fewer than 50 employees), but the proposal also excludes from the penalty calculation the first 30 workers of an employer (so that a firm with 51 workers only pays a penalty based on 21 workers). The assessment on a firm that does not offer insurance, but that has employees who received subsidized coverage through an exchange, would increase, however, from $750 per full-time employee to $2,000 (which is still less than half the average employer’s contribution for health insurance in 2009). The President’s Proposal also eliminated penalties for employers that impose waiting periods for coverage eligibility, but caps waiting periods at 90 days. As in the original Senate bill, the proposal contains $40 billion in tax credits for small businesses to cover their employees, beginning upon enactment.

Additional Revenues

Although the President’s Proposal has not yet apparently been scored by the CBO, White House staff stated at the press conference that the increased premium tax credits and cost-sharing reductions, as well as the cost of Medicaid funding enhancements discussed in my next post, would increase the cost of the Senate bill from $871 billion to about $950 billion. This cost would be partially offset by cuts in Medicare Advantage payments beyond those found in the original Senate bill. The increased individual and employer mandate penalties should also generate significant revenue. However, the bill also requires additional tax revenue.

The House bill depended largely on a tax increase for individuals earning more than $500,000 and families earning more than $1 million. The Senate bill depended on a variety of taxes, most importantly a 40 percent excise tax on high-cost health plans—the so-called “Cadillac plan” tax. The President’s Proposal claims to take the Senate approach, but it modifies that dramatically and includes a significant tax increase for high-income taxpayers.

The tax on high-cost health plans has been widely supported by health economists, who believe that the tax subsidy for employee health benefits has resulted in an inefficiently high level of health insurance. Supporters of the tax contend that excessively generous insurance has resulted in inadequate cost sharing that blinds employees to the true cost of health care, leading to overconsumption. Taxing health benefits would, according to this line of reasoning, not only raise revenue but also reduce costs.

Other health policy analysts, however, have challenged this reasoning. They contend that high-cost health policies are more expensive primarily because they cover older and less healthy workers of employers in areas where health care costs are high. Little of the variation in health insurance costs is attributable to health policy design. Unions have been particularly vocal in their opposition to the excise tax, but in fact union health benefits plans are not notably more generous than nonunion plans, and the tax would fall on many more nonunion than union employees. House and Senate negotiations in January had reportedly reached an agreement to delay imposition of the tax on union plans, an arrangement that was denounced in some quarters as a special deal for the unions.

The President’s Proposal delays the implementation of the high-cost health plan tax for everyone from 2013 to 2018, to give employers and employees time to adapt. It also increases the threshold level from $8,500 to $10,200 for individuals, and from $23,000 to $27,500 for families. These amounts would be increased by only 1 percent above the CPI per year, however, which would make them far less generous in 2018 than they are now. But the proposal also states that “to the degree that health care costs rise unexpectedly quickly between now and 2018, the initial threshold would be adjusted upwards automatically.” Adjustments would also be made to accommodate firms whose health care costs are higher due to the age or gender of their workers, while dental and vision benefits would not count toward the taxable amount. As in the Senate bill, high-risk occupations would also be favored by higher thresholds. The end result is a tax that is far more equitable, but also that will raise far less revenue and have less of an impact, for good or ill, on employment-related insurance coverage.

The biggest source of additional revenue in the President’s Proposal is an increase in taxes on high-income taxpayers. Following the original Senate bill, the proposal increases the Medicare Hospital Insurance tax for single people earning over $200,000 a year and couples earning over $250,000 by .9 percent to 2.35 percent, with the additional income going to the Medicare HI trust fund. In addition, however, a 2.9 percent tax (equal to the employer’s and employee’s combined share of the current HI tax), would be imposed on these taxpayers for income from interest, dividends, annuities, royalties, and rents (other than income derived in the ordinary course of a trade or business that is not a passive activity). This tax would be credited to the Supplemental Medical Insurance trust fund. In this respect the proposal resembles the House’s bill more closely than the Senate’s.

Additionally, the President’s Proposal would follow the House bill in denying eligibility under the biofuels tax credit for certain paper or pulp processing byproducts, and in increasing penalties on tax shelter arrangements that lack economic substance. The proposal would increase taxes on brand-name pharmaceuticals by $10 billion, but it delays the tax imposed on health insurers until 2014 and exempts from that tax certain nonprofit insurers and VEBAs. Finally, the proposal delays the medical device manufacturer fee found in the Senate bill to 2013 and converts it to an excise tax.

My next post will examine the remaining provisions of the President’s Proposal.

Categories: Health Care Policy

Briefing: Medicare Spending And Chronic Disease

Sun, 02/21/2010 - 17:19

There will be a briefing on Tuesday, February 23, 2010, from 9:00 to 10:00 a.m. at the National Press Club in Washington, D.C., to discuss the findings of a study on Medicare cost drivers published February 18 on the Health Affairs Web site. The event will be sponsored by the Peter G. Peterson Foundation.

Speakers will include the Hon. David Walker, President and CEO of the Peterson Foundation, and Kenneth Thorpe, Ph.D., the lead author of the Health Affairs paper and the executive director of Emory University’s Center for Entitlement Reform. The moderator will be Mary Rubino, a senior editor at Health Affairs.

For more information or to RSVP, contact Katherine Klein at (202) 727-8954 or kklein@apcoworldwide.com.

Categories: Health Care Policy

Health Affairs Briefing: Child Obesity – The Way Forward

Sun, 02/21/2010 - 16:16

“America is guilty of child abuse,” writes Health Affairs Editor-In-Chief Susan Dentzer in the March 2010 issue of the journal, devoted to combating child obesity. The issue examines the childhood obesity epidemic in the United States, analyzing causes of the growing problem and proposing the best available solutions for healthier future for America’s children.

On March 2, 2010, Health Affairs will welcome policy experts at a briefing to discuss the child obesity epidemic in a series of panel discussions. Speakers will include: William H. Dietz, Director of the Division of Nutrition, Physical Activity, and Obesity, Centers for Disease Control; and Gopal K Singh, HRSA/Maternal and Child Health Bureau, U.S. Department of Health and Human Services.

WHEN: Tuesday, March 2, 2010, 8:30 am – 2:30 pm

WHERE: National Press Club [Metro Center], 529 14th St. NW, 13th Floor, Washington, DC 20045

RSVP: RSVP for this event online.

Among the topics to be addressed:

What are current trends in childhood obesity in the U.S.?
What is contributing to the problem?
What solutions can be implemented to build a healthier future for America’s children?
What roles should federal, state and local governments; schools; businesses; and families and parents play in combating childhood obesity?

Background

Child obesity is becoming increasingly prevalent in the United States, with obesity rates more than tripling over the last 30 years. Today, one in three children is either overweight or obese. The consequences could be devastating. Obesity contributes to a variety of chronic and other diseases, including cardiovascular disease, diabetes, gallbladder disease, obstructive sleep apnea, and certain types of cancer. Recent studies have shown that spending on hospitalization, emergency room and outpatient visits, and prescription drugs increases for obese and overweight children. There is also research demonstrating that children who are overweight or obese are more likely to repeat a grade in school than their peers.

This briefing is sponsored by the Robert Wood Johnson Foundation.

Health Affairs will offer live Twitter updates from the event on HA_Events at #HAobesity.

Categories: Health Care Policy

Chronic Conditions Now Drive Medicare Spending Increases

Fri, 02/19/2010 - 18:01

An article published yesterday by Health Affairs finds that the causes of Medicare spending growth have changed dramatically over the past two decades. Twenty years ago, most of the increases were due to inpatient hospital services, especially for heart disease, but recent annual increases are the result of outpatient treatment of chronic conditions such as diabetes, arthritis, hypertension, and kidney disease, report researchers from the Rollins School of Public Health at Emory University in Atlanta.

Lead author Kenneth Thorpe and colleagues analyzed data about disease prevalence and about level of and change in spending on the ten most expensive conditions in the Medicare population from 1987, 1997, and 2006. Among the key findings: heart disease ranked first in terms of share of growth from 1987 to 1997. However, from 1997 to 2006, heart disease fell to tenth, while other medical conditions – diabetes the most prevalent – accounted for a significant portion of the rise. Furthermore, the authors postulate that increased spending on diabetes and some other conditions results from rising incidence of these diseases, not increased screening and diagnoses.

Conclude the authors: “The changing mix of medical conditions driving the rise in Medicare spending had consequential effects. More than half of the beneficiaries are treated for five or more chronic conditions each year. System fragmentation means that chronically ill patients receive episodic care from multiple providers who rarely coordinate the care they deliver, and chronic disease management programs are notably absent in traditional fee-for-service Medicare. As Congress, the administration, providers, insurers. and consumers debate reshaping the U.S. health system, they must address these changed health needs through evidence-based preventive care.”

The data for the study were drawn from the 1987 National Medical Expenditure Survey (NMES), and the 1997 and 2006 Medical Expenditure Panel Survey (MEPS).

Categories: Health Care Policy

Health Wonk Review Is Up

Fri, 02/19/2010 - 17:21

Over at medicaidfirstaid, Brady Augustine hosts the latest edition of the Health Wonk Review. Brady provides the best in recent health policy blogging, along with Doctor Phil, John Stewart, and Kermit the Frog (all of whom would definitely liven up next week’s televised health policy session at Blair House).

Categories: Health Care Policy

Global E-Health Is Focus Of Health Affairs Briefing

Thu, 02/18/2010 - 18:14

Modern information and communications technology, or e-health, has already significantly transformed health care in the developed world. The way in which in e-health has also begun to transform health care in the developing world, and the potential for e-health to vastly expand in low- and middle-income countries, was the subject of a National Press Club briefing held Tuesday in Washington, D.C., by Health Affairs. Video and handouts from the briefing will be available soon on the Health Affairs Web site

In welcoming attendees, Health Affairs Editor in Chief Susan Dentzer cited important existing uses of e-health technologies around the world, such as the use of cell phone-based technologies to track receipt of HIV/AIDS medications in rural clinics in Rwanda. “These things are happening, none of them are imaginary or futuristic, but the potential of all of these technologies is much, much greater,” said Dentzer.

The briefing featured several authors from a cluster of articles on global e-health in the February Health Affairs issue, as well as other e-health experts. The Rockefeller Foundation supported the briefing and publication of the articles, which grew out of a 2008 conference in Bellagio, Italy, sponsored by the Foundation.

“This issue has a growing momentum,” said Ariel-Pablos-Mendez, a Managing Director of the Rockefeller Foundation. “In the 2008 Bellagio e-health ‘Call to Action,’ government, donors, industry, researchers, and civil society pledged to raise the profile of e-health and to promote the globalization of its benefits. The February issue of Health Affairs significantly contributes to this cause and to a better understanding of the complex multifaceted issue of e-health.” Pablos-Mendez also noted that the February Health Affairs issue marks another milestone in the journal’s increasing coverage of global health issues.

A primary theme of the conference was the need for rigorous evaluation of different uses of e-health. “As the old Scottish engineers might have said, ‘That’s all very well, but does it work?” Scotsman Hamish Fraser, Director of Informatics and Telemedicine at Partners in Health, and Assistant Professor of Medicine at Harvard Medical School, observed wryly.

Fraser related the findings of a systematic review of evaluations of e-health implementations in developing countries. He and colleagues Joaquin Blaya and Brian Holt found evidence supporting several types of e-health uses, including improving communications between institutions, such as getting information from laboratories to clinicians in remote areas; assisting in ordering and managing medications; monitoring and detecting patients who might abandon treatment; and improving the timeliness and quality of data collection using mobile devices.

Other Briefing Highlights

William Hersh, professor and chair of the Department of Medical Informatics & Clinical Epidemiology in the School of Medicine at Oregon Health and Science University, spoke about the challenges of building health informatics workforces in developing countries. In this area, “there is little data that we know about best practices: they’re not published well, we don’t know the right types of people to train,” Hersh observed, adding that ”we can’t just train people in technology; they need to understand health care, organizational issues, and management – a whole variety of topics.” He also stressed the need to provide informatics professionals in the developing world with skills that complement the cultures and health systems in their home countries.

Hersh’s paper in Health Affairs lays out a model for assessing workforce needs and creating solutions appropriate to local needs in developing and developed countries. In his talk, Hersh highlighted the American Medical Informatics Asssociation’s “Ten by Ten” program, premised on the idea that there should be one physician and one nurse in every hospital trained in informatics. The program started in the United States but has expanded to include international students and now has reached 500 people across Latin America through a Spanish language version. He highlighted AMIA’s global partnership, which seeks to build informatics capacity in low-resource settings, and he commended the Rockefeller Foundation for its support of programs like the National Institute of Health’s Fogarty Center’s informatics and global health program.

Ticia Gerber painted a picture of a vigorous global e-health universe, where innovations are emerging from many different sources, including developing countries themselves, such as Paraguay and Belize. But she also lamented that stakeholders too often end up reinventing the wheel, unaware of ongoing e-health efforts elsewhere that would be applicable to their countries.

Gerber discussed efforts to better organize and disseminate e-health knowledge, such as those at the World Health Organization, where she works as a Senior Program Officer in the Health Metrics Network. WHO is working to develop a “policy toolkit” for health ministers in the developing world. One element of this is a “policy landscape” describing ”what exists in terms of health information systems policy … in developing countries.” That leads into the next step of identifying critical questions and challenges, Gerber said. She added that the WHO is forming groups of global leaders on topics such as governance, confidentiality, capacity building, and data stewardship, to explore what consensus cross-border policies in these areas might look like.

“Most importantly, we’re creating an interactive resource center that countries, donors, and companies can access and see what’s happening across the world. They can search it by issue, by type of legislation, and by geography,” Gerber said. She expressed the hope that the policy landscape would be out in about 4 months, and she suggested that developing the resource center would take roughly two years.

Walter Curioso, Research Professor at the Universidad Peruana Cayetano in Peru and Affiliate Assistant Professor at the University of Washington, discussed the field of mobile health, or “m-health,” the use of cell phones and other portable devices in e-health applications. Curioso emphasized the importance of “South to South” collaborations, in which developing nations learn from each other.

To provide a sense of the potential for m-health in developing countries, Curioso pointed out that 80 percent of Peruvians have cell phones. He discussed the use of very inexpensive cell phones to track adverse events among Peruvian sex workers receiving medications to fight sexually transmitted diseases.

Charles Jaffe, Chief Executive Officer of Health Level 7, discussed the imperative of ensuring the interoperability of electronic health information generated by different sources. The issue of interoperability is discussed in an article in the February Health Affairs volume by Ed Hammond, Christopher Bailey, Philippe Boucher, Mark Spohr, and Patrick Whitaker. Hammond and his colleagues discuss five priority areas for achieving interoperability in health care applications: a patient identifier, semantic interoperability, data interchange standards, core data sets, and data quality.

Categories: Health Care Policy

Informal Caregiving By And For Older Adults

Tue, 02/16/2010 - 13:17

Editor’s Note: For more on informal caregivers and related issues, see Bridging Troubled Waters: Family Caregivers, Transitions, And Long-Term Care and other articles in the January issue of Health Affairs, titled Advancing Long-Term Services & Supports.

The primary focus of this analysis is to examine trends and key findings for caregivers of persons 50+, with an emphasis on the older caregivers. We use the National Alliance for Caregiving (NAC) and AARP’s national surveys of informal caregivers conducted in 2009 and make selected comparisons with the 1997 and 2004 NAC/AARP surveys. Although each survey consists of a unique sample, there are questions that are consistent across the three surveys and an operational definition of “caregiver” that is used in the screening to ensure that respondents are representative of the same caregiving population.

The 2009 NAC/AARP study reveals a few trends that are both consistent with the caregiving literature and a departure from this literature. We observe an increasing number of men included in the respondent groups across the three studies, a trend that is consistent with the literature. Despite the increase of men who report that they are providing care, the majority of informal care continues to be the work of women.

The percentage of caregivers caring for individuals over 85 years of age has increased across all three surveys. Parent care continues to be the primary caregiving situation for mid-life caregivers with 70% of the caregivers between the ages of 50 and 64. While caring for a spouse continues to be the most commonly reported care situation for those over 75 years of age, the 2009 study suggests that a good number of people in this age group are involved in caring for a friend or non-relative (20%), a parent (20%) or a sibling (18%). This finding is somewhat surprising and is likely a factor of older adults relying on peers for the help they need.

The levels of “burden of care” — a proxy for care intensity based on hours and type of care provided — observed for older caregivers are higher than that for younger caregivers and consistent with what we would expect to see for older individuals who are providing intense care to another person. It is striking to see, however, that the older caregivers are the least likely to have another unpaid person helping them. The older caregivers, however, are reporting respite service and transportation service use more frequently than younger caregivers.

A Detailed Look At The Survey Results

Table I displays selected demographic and care situation characteristics for the three sets of respondents. The average age of the 2009 respondents was 50 years, older than 1997 and 2004 respondents; average age of 46 and 48 respectively. Although the majority of respondents were women, about one-third of the respondents were men in 2009. This is consistent with other studies that suggest the proportion of male caregivers for older adults was increasing.

The percentage of respondents who report being employed while providing care have remained fairly stable across all three studies – ranging from 73% in 2004 to 77% in 1997. Similarly, the percentage of those reporting that they lived with the person they were helping was, relatively stable ranging from a high of 22% in 2004 to a low of 20% in 2009. Average care hours tended to decrease across the three surveys, with respondents reporting an average of 23 hours a week in 1997, 22 hours in 2004, and 19 hours a week in 2009.

What has changed over the course of these three surveys is the proportion caring for someone over the age of 85, increasing from approximately a quarter of the care recipients to one-third.

Table I: Characteristics of Respondent Caregivers and Care Situation

1997 (n=1509) 2004 (n=1022) 2009(n=1437) Average Age 46 48 50 Women 73% 63% 67% Married/Partnered 62% 57% 59% Employed While Caregiving 77% 73% 74% AverageDuration of Care 5 years 4 years 4 years Care Recipient
Age 75+
Age 85+
64%
24%
55%
25%
63%
30% Number Hours of Care Weekly 23 hours 22 hours 19 hours Co-resident with care recipient 21% 22% 20%

Table II shows the percentage of women within each of the age categories. Although women continue to dominate the caregiving population, there has been an increase in male caregivers in the past two decades. Among the caregivers over the age of 65, nearly a third of the caregivers are men.

Table II: Percentage of Caregivers Who Are Women, by Age Group

Caregiver Age 1997 Survey 2004 Survey 2009 Survey 18-49 years 71% 62% 66% 50-64 74% 65% 68% 65-74 77% 66% 70% 75+ 73% 57% 65%

Working Caregivers

Table III illustrates the employment status of caregivers broken down by age across the three studies. The data suggests that the pattern of employment across all age groups and the three studies have remained stable. Approximately one-third of the caregivers between 65 and 74 years of age reported being employed by providing care; and about one-fifth of caregivers 75 years and older reported being employed.

Table III: Percentage of Age Category Employed by Survey Year

Caregiver Age 1997 2004 2009 18-49 87% 83% 83% 50-64 75% 75% 75% 65-74 35% 37% 37% 75+ 20% 17% 17%

The work effects of older caregivers were modest when compared to the self-reported work effects of younger caregivers. The majority of employed caregivers under the age of 65 reported having to leave work early or come in late as a result of caregiving, with the largest group reporting this effect being those between the ages of 50-64 (53%). About 50% of the caregivers between the ages of 18-49 reported these work effects with a bit more than a third (34%) of those over 65 reporting the same.

Taking a leave of absence to provide care has negative effects for the caregiver as her or his career is disrupted and lifetime earnings diminished if, as is the usual case, the leave is unpaid. Table IV compares the ages of those reporting a leave of absence to provide care across the three studies. While we might expect caregivers who are 65 years or older to leave the workplace rather than take a leave of absence, we observe that, in the 2009 survey there was an increase in the percentage of caregivers 65+ reporting they were or had taken a leave in order to provide care.

Table IV: Percentage of Age Category Reporting Leave of Absence by Survey Year

Caregiver Age 1997 2004 2009 18-49 12% 16% 17% 50-64 8% 17% 17% 65+ 7% 6% 11%

Level of Burden of Care

The level of “burden of care” has been calculated since the 1997 survey using a scale from 1 to 5 based on the number of hours of care provided on a weekly basis, the number of Activities of Daily Living (ADL) support provided by the caregiver and the involvement of caregivers in helping with the Instrumental Activities of Daily Living (IADL). Table V displays the level of burden for our selected age groups for the study conducted in 2009.

TABLE V

The data suggest that the caregivers age 65 and over are the most likely to have the highest burden of care. Older caregivers are disproportionately represented in highest level of “burden of care” – Level 5. In contrast, only 8% of caregivers between the age of 18-49 were included in this group. The weekly hours of care provided increases with the age of respondents: caregivers 18-49 report an average of 14 hours a week, 50-64 report 16 hours , 65-74 report 19 hours a week and those 75+ report 31 hours a week, a statistical difference between age groups.

To better understand this pattern of care levels, we examine the care recipient relationships, the use of formal services and the availability of other informal caregivers who could provide help. Table VI displays the key care recipient relationships by age group. At first glance it might appear that the burden levels observed for the old-old respondents were a function of spousal caregiving – a care situation which carries the most risk for adverse outcomes related to health and work effects. In the 2009 sample, 31% of those over 75 were caring for a spouse, including partners or companions. This contrasts with mid-life caregivers (50-64) among whom only 5% reported spousal care and most (70%) were providing help to parents.

More interesting was the fact that 20% of the old-old caregivers were helping a friend and 16% were helping a sibling. Research suggests that about 15% of the caregivers in the US are providing help to a friend rather than a relative. The fact that we see a higher percentage among the old-old helping a friend, and an almost equal number caring for a sibling is a surprising finding and one that bears further study.

TABLE VI

The use of formal services increased with the age of the caregiver as shown in Table VII. In the 2009 survey, the percentage of respondents reporting use of a respite service was only 5% among those caregivers who were 18-49, 13% among the 50-64 year olds, 14% among 65-74 year olds and 23% among those 75+. Similarly, the use of a transportation service for the care recipient increased with age from 25% of those between 18 and 49 reporting this use, 33% between 50-64, 30% aged 65-74 and 43% among those 75+.

TABLE VII

Levels of burden are influenced by both the availability of formal services and other friends or relatives who provide help and support to the caregiver. Table VIII displays the extent to which respondents across the age categories report that they received no help from an unpaid, informal source.

TABLE VIII

Older adults, those over 75 years of age, are the most likely to report they have no help from a friend, relative or other informal source in their caregiving responsibilities. Over the three study periods, it was the older caregivers – 65 to 74 years olds and those over 75+ reporting they were not receiving help. The pattern among the 2009 respondents shows an increase in those between the ages of 65 and 74 reporting no help and a slight increase in the younger caregivers who were going it alone. The large percentage of 75+ caregivers reporting no informal help in 2004 is likely an artifact of the sample and the small sample size for the 75+ respondents (46 in 2004, 69 in 2009).

TABLE IX

Caregiver Age 1997 Survey 2004 Survey 2009 Survey 18-49 years 930 62% 550 54% 646 45% 50 – 64 392 25% 330 32% 585 41% 65 – 74 131 9% 96 9% 137 10% 75+ 41 3% 46 5% 69 5%

Conclusion

Policy makers and health providers may benefit from understanding that caregiving is a dynamic activity that is ongoing across the lifespan and, depending on the age and health status of the caregiver, has important implications for the overall well-being of both the care recipient and the care provider. Much has been written about family caregivers but too often we think of them in a stereotypical way – middle-aged, working women juggling competing responsibilities. Age, gender and the complexity of the care situation itself combine to create a heterogeneous array of policy and practice challenges that is not amenable to a simple solution or approach.

These caregivers are the front line of support for millions of Americans with chronic care needs and the default provider of care when affordable and appropriate care and services are unavailable. In our aging society, it is wise to remember that this default provider role can be difficult if not impossible for an old-old caregiver and we are likely to see an increasing numbers of old caregivers in the future.

Categories: Health Care Policy

Vascular Discussion Forum

Status

Health Affairs Blog

Death Of A Sales Job (A Three Act Ploy)

HA Blog Top Ten For February

Latest Edition Of Health Wonk Review Is Up

A Pilot Program For Overweight Children Yields Results

Audio Of Child Obesity Briefing Is Available

Study Showing Rise In Snacking By Children Generates Discussion

Health Affairs Policy Briefs Examine Child Obesity

Child Obesity: Health Affairs Explores Strategies For Combating Epidemic

Lessons From The Health Care Summit

Health Care Summit: The Conclusion

Health Care Summit: Half-Time Report

Should We Be Able To Buy Insurance Across State Lines?

The President’s Health Reform Proposal: Other Provisions

The President’s Health Reform Proposal: Insurance And Revenue Provisions

Briefing: Medicare Spending And Chronic Disease

Health Affairs Briefing: Child Obesity – The Way Forward

Chronic Conditions Now Drive Medicare Spending Increases

Health Wonk Review Is Up

Global E-Health Is Focus Of Health Affairs Briefing

Informal Caregiving By And For Older Adults