We’re getting used to the ACA.

When I was a young violin student I had to change violin sizes at various times as I grew.  Each time felt funny, and each time my teacher would say  “You’ll get used to it”.  The Affordable Care Act, i.e ACA, i.e Obamacare, is now hated by fewer people.  Only 43% of Americans oppose it, down from 53%.  Pundits are saying this is because the recent open enrollment period went smoothly.  That may be true, but if we take a lesson from history we can see that slow acceptance of the ACA is to be expected.  We’ve gotten used to it.

Take, for example, the New Deal.  The New Deal was a set of laws enacted in the wake of the Great Depression.  These laws resulted in policies and institutions such as the FDIC, the criminalization of child labor, the Fair Labor Standards Act that established the 40 hour work week, and Social Security.  Most people today would consider much of the New Deal to have been a pretty good idea.  But that was not the case in the 1930s when these laws were passed.  Rich people didn’t like it.  Republicans didn’t like it (they thought the Social Security Act smacked of socialism.  Funny, huh?).  Conservatives thought there was too much infringement on individual rights.  A third of the public didn’t like it, as judged from the 1936 election.  Doomsday predictions claimed that the legislation would take away human rights, create too much big government, and ruin the constitution.  Some would still argue that these predictions came true to some extent, but no one wants a repeal of child labor laws, and Social Security is now a political third rail.

In the case of the ACA, the opposition has been remarkably similar.  Infringement on individual rights, states rights, big government, socialism, unconstitutionality, all these accusations have been thrown at the ACA.  Additionally we have been told that the ACA would bankrupt the government, limit physician choice, and establish death panels.  Some of these claims are still under review.  But health care spending has gone down, more people have access to health care, and no death panels have materialized.

Parts of both the New Deal and the ACA either didn’t work or were deemed unconstitutional.  But some parts stayed, and eventually became part of life in America.  People got used to it.  Just as people are getting used to the ACA.

As Congressional Republicans are acutely aware, it is much easier to prevent something from happening than it is to take it away once it has happened. This fact is based in the human tendency to give much more weight to loss than gain.  We see this in end-of-life discussions, where doctors find it is more painful for families to decide to remove life support than to decide not to institute it.  Such tendencies can be positive or negative.  At work it is well known that once a new rule gets instituted we’re stuck with it; a rule, once made, is virtually impossible to get rid of, even if it doesn’t have the desired effect.  Standardized testing in public schools is here to stay too, even though such testing has been shown to be a poor measure of real learning.  On the other hand, a rule that works and makes sense, like a seat belt law, will also never go away, and eventually people get used to it and lives are saved.  Once people got used to Social Security it became impossible to take it away.  Once people get used to having insurance it will eventually become impossible to take it away.

Once something becomes status quo people tend to forget what they were so worried about.

 

Heeeer’s Brad!

Thanks to our Dear Leader for the link to the Republican’s health reform proposal, cutely called PCARE. Professor Wright is the expert and will look through it carefully and give you the real scoop.  I’ll be the opening act.  I’ve read through it, and there are some good things in it, although you have to skip the rhetoric spouted in the first few paragraphs of every section. To wit: “Despite promises that Obamacare would lover health care costs, costs continue to skyrocket for patients, families, taxpayers, and businesses.”  Actually, the Kaiser Family Foundation says that Medicare spent $1000 less per person last year, and is projected to remain steady at 14.5% of the federal budget and 3% of GDP.  Non-partisan this treatise is not.

The good:

1. There is a proposed provision for extending health insurance policies across state lines.  This would certainly help equalize coverage quality and could promote competition.  It is worker-friendly and makes sense.  Medicare is already nationwide, although the private insurance companies that actually provide a lot of the policies are not.  So, OK.  I wonder, though, since as I point out below the plan lays an awful lot of the responsibility for all of this stuff on the states.

2. The republicans like health care savings accounts, or HSAs (personal responsibility and all that) and would like to expand this option.  Great as long as you have two coins to rub together at the end of the month.

3. They want to keep the coverage for kids under their parent’s plan ’til age 26.  I guess that one polls well.

4. Tort reform.  Amen.  Caps on non-economic damages and limitations on attorney’s fees.

5. Transparency.  “…health insurance plans would be required to disclose covered items, drugs, and services, any plan limitations or restrictions, potential cost sharing, the actual cost of services (my boldface), the claims appeal process, as well as the providers participating in the plan.”  Some of this is already required, but some real information about cost would be welcome.

The not-so-good:

1. The plan throws out the rule that insurance companies cannot charge elderly patients more than 3 times what it charges a young person.  This is considered “too restrictive” and the new proposal ups the number to 5 times. This is supposedly better because premiums would go down for millions of Americans.  That it will also go up for millions of Americans is not mentioned.

2. The proposal seems to throw the ball back into the state’s courts.  States can opt out of the coverage for kids under age 26, they can adjust the amount the elderly pay in comparison to the elderly, re-using the high-risk pool idea within states, and making the states negotiate the terms of cross-border agreements.  Perhaps most oddly, it asks the states to designate health plans that would be the default coverage for people who don’t choose a plan.  Wait, weren’t most states perfectly happy to let the federal government set up the health insurance exchanges?

3. The republicans also really like using tax credits, which I think have already been tried. Many times.

4. Here’s the part that makes me nervous.  I quote:

“Under our plan, no one can be denied coverage based on a pre-existing condition.  To help consumers with pre-existing conditions our proposal would create a new ‘continuous coverage protection’.  Under this new protection, individuals moving from one health pan to another could not be medically unwritten and denied a plan based on a pre-existing condition if they were continuously enrolled in a health plan. This new consumer protection helps incentivize responsible behaviors by encouraging consumers to keep their health coverage.”

Those italics are not mine.  People with pre-existing conditions who have been uninsured would supposedly get a grace period in the form of a one-time enrollment period in which they could not be denied for a pre-existing condition.  So people who are not “responsible” (here read “poor”) aren’t entitled to this so-called consumer protection.  I could be wrong about this, but I need a much better explanation about why the ACA’s rule that you can’t turn anyone down for a pre-existing condition at any time is so bad.

So there you go!  The real health policy expert will now take the podium…

 

The Most Interesting Man Revolutionizing The Health World

He wrote his first world-renowned book at the age of 26. On weekends he recites love poems (ghazals) on Voice of America. He casually – and humbly – references his more than 70 patents that range from aging wine to chewing gum to bioreactors to air scrubbing systems at his infamous Chicago wine parties. And his mustache rules his twitter feed. In 2013 he was awarded the Star of Distinction, the highest civil award by the Government of Pakistan, for his inventions that are making significant impact in developing countries. He has written over 50 books, well over 100 research papers, and hundreds more articles in the field of science, philosophy, rhetoric, poetry and religion, drawing thousands of hits per day on his blog. Dr. Sarfaraz Niazi might just be the most interesting man in the world, but he is certainly the most interesting man pursuing biosimilars in the United States.

Throughout his career his driving principle has been to make things simpler. He did this while at Abbott Labs, as a former tenured professor at the University of Illinois at Chicago (UIC), in developing countries, and presently in his independent career at Therapeutic Proteins International, LLC (TPI) where he is working on biosimilars – or “copies” of current biologic pharmaceuticals that are about to lose their patents. Although only 17 biosimilars have been approved to date worldwide, though none in US, Dr. Niazi and TPI have nine in the pipeline to transform the entire market.   According to photographer Steve Huff, Dr. Niazi is, “An amazing man, in fact the most interesting man in the world!”

Flexibility Is Key To Innovation

When asked his advice to other inventors in a recent interview, Dr. Niazi explained his philosophy that, “You should never get enamored by your thoughts. If the idea does not solve a problem or move the quality of life farther, there are many more things to be invented.” With that mentality, he is filing two products this year alone, similar to Amgen Inc.’s $6 billion molecule white blood count product, due to its expiring patent in the cancer market. Next year, the two molecules he plans to take to market are similar to AbbVie’s expiring $12 billion product Humira.

With movement like that, it’s no wonder Dr. Niazi claims that the U.S. Food and Drug Administration (FDA) is his “friend.”Nevertheless, he notes extreme complications with the rolling submission model, which can cost up to $4 million per submission in fees alone. Additionally, the four levels of the FDA’s “analytical similarity” benchmarking can be troublesome if one has a new biologic entity. This benchmarking, however, allows scientists and the FDA to work together in a predictable, step-wise fashion to move products to market quickly that have fingerprint-like similarity to existing US-licensed biologic products.

Dr. Niazi’s strategy is to create an analytical and clinical equivalent to biologics with expiring patents, which is preferred even over a Phase 3 clinical trial. By doing this, the cost of production is reduced drastically and the speed of development increases by 2-3 times. Dr. Niazi estimates an overall reduction in production costs for his biosimilars of up to 50% or higher compared to market competitors.

By being flexible, his products are proving to be bio-revolutionary.

Can The United States Catch Up?

Additionally, thanks to the Affordable Care Act (ACA), a shorter licensing path for lower-cost versions of cell-derived drugs is now possible, giving inventors like Dr. Niazi another pathway for approval and distribution.

While he claims that the ACA will not reduce health costs, he does believe that independent shocks to the health market will. By this, he believes that making biosimilars easier, faster, cheaper and better translates directly into his mission of making all things simpler. Further, cost-effectiveness in the US and European Union (EU) can directly convert into worldwide distribution and scalability that is safe.

Although a friend of the FDA, Dr. Niazi is not hesitant to note the tough decisions US-based companies face to stay in the states. Having FDA approval carries weight around the world, but the financial and regulatory burden can be great for inventors and business owners. In contrast, he asserts that the EU has moved ahead of the rest of the world, with the most established and advanced regulatory framework for the authorization and marketing of biosimilars, which has since been adopted by the World Health Organization (WHO).

Additionally, Dr. Niazi says that it is difficult to raise money in the US. Venture capitalists and corporate investors are less likely to take risk and have notoriously poor track records with the health sector

Investing In The Windy City

In 2003, the TPI founder committed that his work and company would stay in Chicago.  He believed that from creation to manufacturing and testing to going to market, that TPI would excel in the Midwest due to Chicago’s health care ecosystem, experts and manufacturers.

Through a focus on creating “generic equivalents,” Dr. Niazi is proving that TPI can be wildly successful in the Midwest, and further, that in the same way generics revolutionized how people access pharmaceuticals, biosimilars can revolutionize the way those around the world access lifesaving treatments.

As his biosimilars enter the market with FDA approval, the ability of Dr. Niazi to impact the entire health sector grows because his biosimilars can be substituted for its reference product without provider or patient intervention. However, the FDA has not yet finalized these guidelines, and only 17 biosimilars have been approved internationally to date, of which none are by the FDA.

Ultimately, with numerous billion-dollar biologics coming off patent over the next six years, and the exorbitant cost for specialty drugs, the nine biosimilars TPI has in the pipeline stand to make a huge impact in the health sector. While Dr. Niazi could be doing many interesting things these days as an international man of mystery, he has devoted his research, time and energy to bringing high quality, cost-effective treatments to the US, and beyond. So long as he maintains his wine parties and poetry readings, its certain no one will complain.

 

Profiles In Courage

The kerfuffle over the “doc fix” took a truly courageous turn yesterday in the United States House of Representatives.  I will review the general idea of the doc fix but Todd Zwilich today on NPR’s The Takeway gave a fantastic and hilarious take on the history of this money hole, also known as the SGR.  In 1997 Congress passed the balanced budget act, which required them to at least appear to be balancing the federal budget.  But they couldn’t really so the found a big expenditure, medicare, and did a sort of retro-accounting move.  They decided that sometime in the future, say, 2014, the medicare payment system would have to be reset and doctors would take a pay cut of, say, 24%.  The took the 24% and added it to the budget for 1997 and wallah!  Balanced budget.  Todd Zwilich calls this “the worst kind of shell game accounting” that Congress has ever come up with.  Tom Coburn (R, Oklahoma), who is a doctor himself, calls the whole thing “funny money”.

OK, so partisanship being what it is, the big push to “fix” the SGR, which is a bipartisan initiative, is going nowhere because the Rs and the Ds can’t decide on how to get the $180 billion it would take.  So they needed to pass a patch, a 1-2 year measure to postpone this big pay cut.  John Fleming (R, Louisiana), also an MD, acknowledged that “no one wanted to vote for it, and no one wanted to vote against it.”  So what did they do, these poor congressmen, so that no one had to come down on either side, thus endangering their chances for re-election?  I’ll paraphrase Zwilich:

Eric Cantor (R, Virginia), the House Majority Leader, literally ran out of an office, onto the floor of the House, up to Steny Hoyer (D, Maryland), had a quick conversation, and presto!  The bill was passed, without anyone having to soil their hands by voting for it.  When the Representatives got to the floor themselves, they were surprised to find the whole thing over with.  Now, I have no idea what murky vagaries of House Rules makes this possible, but I do know that our brave congressmen at least had the grace to look slightly embarrassed.

Now the bill (to pass the one year patch, in case I’ve lost you)  goes to the Senate.  The Senate must vote on it by Monday, which is when the last patch expires.  Docs, don’t make your boat payment quite yet.  Unless Senators are braver than Representatives, or have the same murky rules, you might be 24% in the hole by Tuesday.

 

 

Health IT Thrives With New Startup Companies

As the health insurance exchanges opened for enrollment just days ago, the federal government, including the President and the Department of Health and Human Services (HHS), had to acknowledge that it was not technologically ready. The IT infrastructures by which individuals tried to sign up for health insurance crashed and were unavailable throughout the first day and the weeks after. Those same sights were supposed to track enrollment, but proved to not be as well tested and far more expensive than originally anticipated. However, despite the shortages and disappointments with government IT readiness for exchange websites, there was a surge in US-based startup companies that demonstrated just how innovative and forward thinking technology can be in the health care arena. Nine new companies, all curated through BluePrint Health were introduced at that same time three weeks ago on “Demo Day,” and were ready to show the new frontier of health care, and how to transform care delivery through technology.

Health IT Incubators Driving Innovation

Blueprint Health is an accelerator program geared towards health care companies that want an intensive three-month mentorship to help find customers and capital, and learn from leading industry experts. The companies that are selected for the program range from individuals with a clever value proposition to well-established organization leaders that have existing customers, investors and are generating significant revenue, but with new ideas. According to Doug Hayes, a Principal at BluePrint Health, “We are seeing an acute need for innovation at the seed stage of the health care ecosystem. With top-down changes in regulations and quickly shifting incentive structures, the most successful companies will be those who can nimbly adapt.”

He asserts that what makes BluePrint successful is that it is, “uniquely positioned to attract, identify, and support the entrepreneurs that fill the gaps of service left in the wake of massive industry changes.” The accelerator program promotes the mindset that new businesses should not have to focus exclusively on fundraising. Hayes says, “Building a company is extremely difficult, and a founders’ time is best spent on customer and product development, not fundraising.” With that mentality, BluePrint does not use many pre-established filters when evaluating the near 1,000 applications it receives each year, but instead concentrates on business models.

The nine particular startup companies that were cultivated during the summer of 2013 range from Healthify, which focuses on creating platforms that connect and standardize medical homes to treat social needs to Board Vitals, an organization that improves the testing system of our nation’s providers. Each of these new businesses gives hope to innovators and entrepreneurs.

The Companies

Artemis

Artemis is a health care analytics firm specializing in benefit claims. With employers spending billions of dollars on health care, benefits managers need more information than the historical, once a year paper reports of the past. With the Artemis platform, benefit managers have graphical, real-time updates for claims and assessments. The creators claim that that deploying its tactics not only saves money for organizations, but also heads off future costs through prevention and determination of key cost drivers.

Board Vitals

Board Vitals brings together publishers, universities, and top physicians into a single digital platform for medical specialty education, with pass rates that are 10% higher than the national average. According to co-founder, Dan Lambert, “Content is continually voted up and down, meaning that the very best material comes to the top and outdated or incorrect content is voted out.” His partner, Andrea Paul added that their aggressive, but attainable, goal is to have materials for 20 of the 35 specialties in 2014.

CredSimple

The founders of CredSimple created a system to make the mandatory credentialing of physicians cheaper and more efficient. According to co-founder Garry Choy, at present, credentialing takes two to three months per physician and hospitals spend millions a year on the routine, but inefficient process. CredSimple uses an impressive 214 data sources to verify credentials, saving all provider parties time and resources, with downstream positive implications for entire hospital systems.

Genterpret

Pharmaceutical companies strive to gain pricing power and market share using genetic information about how patients respond to drugs. Genterpret, started by two system biology PhDs, links genetics to drug responses in one-third of the time (six months) of previous genetic testers. The faster turn-around time and vast outreach program created by the founders suggests that the Genterpret technology can soon be applied to thousands of diseases, improving health outcomes and saving money.

Healthify

After years of working in Baltimore health clinics, the creators of Healthify joined forces to start a company that addresses social needs such as food insecurities to improve health in communities. Medicaid spending on medical homes averages about $15 billion, much of which is spent on social needs. The data collected by Healthify will become vital as medical homes and accountable care organizations begin to address social needs as integral to overall health and well being.

ReferBright

ReferBright helps health practitioners with digital marketing in a world full of medical advertisements. The goal, according to the founders, is to improve outreach and referral rates for various kinds of professionals. Additionally, the automated system makes updating personal information easy for practitioners and makes vetting of practitioners easy for hospitals, knowing the information on ReferBright has been inspected and verified.

SpotMe Fit

According to co-founder, Jarrod Wolf, SpotMe, “allows employers to reward their employees for attending any fitness facility, running in races, or for using fitness apps and devices. When the barrier to incentives are removed–like eliminating paperwork and providing immediate rewards–and employees are given the flexibility to choose how they engage in fitness, then program participation rates skyrocket.” This focus on wellness and fitness programs is to improve health outcomes and lower health costs through incentives, monetary and physical.

Staff Insight

The premise of Staff Insight is to increase workforce productivity, specifically through hospital leadership being able to understand and staff facilities to the optimal levels. The company aims to use real-time dashboard to identify staffing levels in units, test baseline productivity, set new benchmarks for productivity and ultimately save revenue for facilities by optimizing productivity. The founders claim that early adopters have already seen a two to four percent increase in productivity.

WellTrackOne

WellTrackOne conducts a Medicare-approved personal assessment that hospitals can use to track patient data and identify potential risk factors. To lessen the administrative burden and disruption to the workflow, WellTrackOne claims that it can integrate all electronic health records, from multiple systems to improve data and health outcomes.

The Future Of Health Technology

Despite the federal governments success in getting support from professional athletic organizations and celebrities like Jennifer Hudson, the technological infrastructure just wasn’t ready for consumer usage. In contrast, Doug Hayes says that a key reason BluePrint startups were ready on Demo Day is due to the mentor community and outreach.

He claims that a by-product of their focus on business models and portfolio is that it, “includes many enterprise solutions. The long sales cycle and disparate channels within health care makes enterprise sales an especially tough nut to crack. However, our experience within enterprise and our mentor community, 150 strong, makes us especially well positioned to help founders sell into large payers, provider networks, pharma, and other enterprise customers.

 

Mental Health Loses Funding As Government Continues Shutdown

In the months leading up to World Mental Health Day, DC has been shaken by a series of violent events that ended with innocent lives lost and our country’s mental health services called into question. During this same time period, Washington, DC has been consumed by a government shutdown, with lawmakers and policymakers trying to determine how to rein in our country’s financial burdens and overspending. Unfortunately, as federal and state governments look to cut budgets at every turn, mental and behavioral health services are often on the chopping block first. Financial cuts, compounded with US stigma often applied to mental health troubles and disparate access to services across the county, mean that those who need services most are often those left without proper care.

August though October brought DC into the spotlight for many reasons, the saddest of which is the violence that was covered by mass media as two shootings occurred. In one case, Aaron Alexis, a 34-year-old, perpetrated a mass shooting that left 12 people dead, in Washington’s Navy Yard. Previous to the shooting, it was reported that Mr. Alexis was treated at the VA for mental health issues including sleep disorders and paranoia, but had not lost clearance.

Miriam Carey, also 34, reportedly had an unhealthy obsession with the White House when she drove her car into the White House gates and led police on a chase around DC before being killed. Although she had no reported psychosis or supposed violent intent, it was noted in the months leading up to the incident she believed that the President had beenstalking her and might have suffered from postpartum depression. When killed by authorities on Pennsylvania Avenue, she had her 18-month-old child in the car.

Budget Cuts

Although societal stigma and knowledge of where to access behavioral and mental services are often barriers to care, budget cuts continue to make seeking care more difficult. Whether this be through decreases in available services, lack of providers due to poor reimbursements or less preventative actions in communities, the impact of mental health funding shortages is great. According to the National Alliance on Mental Illness, “increasingly, emergency rooms, homeless shelters and jails are struggling with the effects of people falling through the cracks due to lack of needed mental health services and supports.”

In the last five years, significant budget cuts have befallen mental health programs and services. From 2009 to 2011, states cut mental health budgets by a combined $4 billion- the largest single combined reduction to mental health spending since de-institutionalization in the 1970s. In Chicago alone, state budget cuts combined with reductions in county and city mental health services led to shutting six of the city’s 12 mental health clinics. These closures, along with other public and private center closures in Chicago, have eliminated vitally needed services, especially on the south and west sides where they are indispensable.

Threats of sequestration in 2013 had a significant impact on people’s ability to access mental health services and programs, including children’s mental health services, suicide prevention programs, homeless outreach programs, substance abuse treatment programs, housing and employment assistance, health research, and virtually every type of public mental health support. The Substance Abuse and Mental Health Services Administration(SAMHSA) claimed it alone would be cutting $168 million from its 2013 spending, including areduction of $83.1 million in grants for substance abuse treatment programs.

Consequences

Despite the need to balance budget and make all health care services more efficient, many argue that society has better long-term outcomes if more federal and state dollars are allocated to mental and behavioral health care. This includes preventative services as well as mental health testing and treatment.

Because individuals with untreated mental illness often find themselves in emergency rooms, homeless shelters and prisons, the societal cost of prevention and treatment may be exponentially less than funding those other outlets and catchment areas. This is especially true in the case of children, who face cycling in and out of the system throughout their lives if left untreated.

These costs can be exceptionally large over the lifetime given that the National Institute of Mental Health (NIMH) estimates that two-thirds of children with lifetime mental health problems never receive treatment. This takes substantial emotional and financial tolls on individuals and families, as well as the broader society. However, programs that address the mental health needs and provide services for youth show better outcomes in health and education that carry over the lifetime. For example, in the University of Chicago’s Crime Lab, therapy is being used to curb youth violence, especially amongst those with behavioral and mental health care needs.

Additionally staining on the mental health care system is that during times of recession and budget cuts the caseload for mental health actually increases. It has been estimated that during this most recent recession, the caseload of community mental health services alone has increased almost 50 percent. This increase has most notably been seen in the Native American community, where suicide prevention is an essential part of the cultural health care demands.

Everyone Benefits

The NIMH contends that one in 17 people suffer from a “seriously debilitating mental illness,” we as a society are accountable for ensuring that those in need have resources for care. Not only does access to quality mental and behavioral health care ensure that individuals are being properly treated, but that America as a whole saves money and resources caring for those in need in other, more expensive settings. It may further prevent violent acts like those in DC from happing.

On this World Mental Health day think about the ways in which access to and support of mental and behavioral health care can be improved in your community.

 

Four More Years of Health Reform

While the last news I saw this morning before leaving the house still had Florida as “too close to call,” the outcome in that state has become irrelevant, with Obama securing enough votes in the electoral college (303 at last count) and claim another term as President of the United States. Importantly, Obama also won the popular vote by about 2.5 million votes. While the contest was close until the end, and our nation clearly remains divided, I am thankful that we do not find ourselves confronting the legitimacy question that can arise when the winner of the electoral college loses the popular vote. (Think Bush v. Gore.)

So, what awaits us in Obama’s second term? Well, I think it’s clear what needs to be done: More action needs to be taken to improve the nation’s economy. The Obama administration has made some gains in this area with the stimulus and the auto bailout, but there is more work to be done. For me, the question is: Will the Republicans in Congress work with him at all? For four years they’ve played obstructionist politics, with the goal, one would assume, of creating a one-term president and capturing the White House in 2012. That’s why none of them voted for the Affordable Care Act, why they refused to vote on the President’s jobs bill, and why they pushed our country to the brink of default by playing games with the debt ceiling. All of these things were done not because they were the best for our country, but because they were the worst for the President. And, in spite of that, Obama was able to prevail.

This morning, we now know that the Affordable Care Act, better known as “Obamacare,” will have the opportunity to be fully implemented in 2014. We know that tens of millions of Americans without health insurance will soon have affordable coverage. We know that there will soon be an option for individuals to shop for health insurance in a more transparent and competitive system of health insurance exchanges, with a government-sponsored option among the available choices. And we know that our nation’s elderly and disabled will continue to depend on Medicare, rather than facing the possibility of being given a voucher to go out and shop for coverage on their own.

This election has given us four more years of health reform. In that time, perhaps the public will warm to the program the way they have grown to love Medicare and Social Security. Perhaps we’ll see some real improvements in health and health care. Perhaps this will be the impetus for additional reform efforts in the future. But we’re not out of the woods yet. Republicans still control the House, while Democrats cling to a narrow majority in the Senate. It is possible that, through the budget process, Republicans can interfere with the implementation of the Affordable Care Act. It is even possible that, if they make large gains during the 2014 mid-term elections, they could find themselves in the position to repeal the ACA by overriding President Obama’s veto. And, while I hesitate to bring it up so soon, there’s 2016, when we will once again elect our President. Obamacare will only have been fully implemented for a couple of years, and if the economy hasn’t fully recovered, you can bet that the rhetoric of repeal and replace will be on full display. But, for the moment, we can breathe a little bit easier, knowing that we just bought Obama–and Obamacare–a little more time.

 

Who, Exactly, Does Congress Represent?

The following post was authored by Wright on Health blogging partner, Nicole Fisher.

2012 has been quite a year for those in the world of health policy. We’re only three-fourths of the way through and we’ve seen incredibly nasty Affordable Care Act battles, a monumental Supreme Court decision and are still working hard before the upcoming tough and divisive presidential election. Despite all the hours we spend buried in HHS data and fighting our wonky skirmishes in OpEds, every now and then we are confronted by the remarkable and often misinformed rhetoric of politicians. It is at those times we must take a step back and contemplate the big picture of health policy and the impact, or lack thereof, of our work on those making policy decisions.

The past few months have sadly shown us just how bad politicians in particular can be at understanding their constituents, science and health (and, some would argue, how the world works in general). Granted, not all gaffes and misinformation are as bad as Tom Akin’s assertions about “legitimate rape”, but with each day it appears that another piece of the Affordable Care Act becomes political fodder or another state finds that it can’t make ends meet for the fiscal calendar and programs need to be cut. Many of these tough decisions are directly related to health care and health policy. But when we hear ignorance publicly being touted by those elected to represent us we have to ask, just whom, exactly, does Congress represent?

The easy answer: old, white men.

Although I would never argue that we need any form of required representation based on gender, race, ethnicity or religion, it is important to look at the trends of those making decisions on our behalf.

Out of 541 Congressional seats, there are exactly 93 filled by women (or 17.2 percent of the Members). There are presently eight percent, or exactly 43 African Americans, with none being elected to Senate. Hispanics and Latinos combined in Congress are 31 strong, with only two in Senate. Twelve Members in total are Asian or Native Hawaiian/other Pacific Islander. The only American Indian (Native American) serves in the House.

Here is a current breakdown of your 112th Congress:

House of Representatives
-Republicans: 240
-Democrats: 197
-Vacancies: 4
-Number of Women: 76
-Number of African Americans: 43
-Number of Hispanic or Latinos: 29
-Average Age: 57
-Average Time In Office: 10 years (5 terms)

Senate
-Republicans: 47
-Democrats: 51
-Independents: 2 (Caucus with Democrats)
-Number of Women: 17
-Number of African Americans: 0
-Number of Hispanic or Latinos: 2
-Average Age: 62
-Average Time In Office: 11.5 years (2 terms)

It should be no surprise to anyone then that those making health care and health policy decisions on our behalf not only do not represent us, they don’t necessarily relate to us or use the same working knowledge of the world that we do. While there are plenty of older, white men who make well informed, thoughtful decisions about health care and minority health, it is important to stop and reflect as health care recipients, voters and for some of us advisors, that the people we are electing and advising are not the same people they are representing.

 

Why Does John Boehner Want To Increase The Deficit?

We’re in an election year. The economy is less than ideal. The best strategy the GOP can take to win big in 2012 is to say “You’ve had your chance and it didn’t work.” The slogan they’ve been lampooning–“Change we can believe in”–seems to have become their new battle cry. Okay. Fair enough. I’m willing to hear them out. What, pray tell, are the Republicans proposing to do that will make things better for America and its people?

Well, for starters, there’s the important issue of making sure that the wealthiest Americans stay that way. Now, I’m not talking about those people you know who are living quite comfortably. I’m talking about that select group of Americans who are so uber-wealthy that they could, if they felt like it, pay enough money to the right people and take advantage of the right legal loopholes to buy your neighborhood and kick you out of your house against your will. Okay, that might be a bit hyperbolic, but not by much.

The reason, we are told, that the super-rich must continue to receive such preferential tax treatment despite the fact that our nation’s deficit threatens the entire country’s economy, is because these are America’s job creators, and what Americans need more than anything right now are jobs. That, my friends, is called “trickle-down economics” and it hasn’t worked……well…..ever. Warren Buffett is pretty clear on the fact that he is incredibly rich, and that he isn’t in a position to put a dent in the unemployment problem, which is why he wants the wealthiest Americans to stop catching so many breaks and start giving back.

But I’m willing to accept the GOP’s premise here for the sake of argument. Let’s take the raising of increased tax revenue off the table. If we do that, there are only two options left: Cut spending, or fail to reduce the deficit. Republicans and Democrats both agree that we need to reduce the deficit, and we all know how rare bipartisan agreement on anything is these days, so I think it’s safe to say that Republicans should pursue a strategy to cut spending. And, indeed, that’s what they’ve been talking about–and in many ways trying to do. Take health care. Hey seniors, remember that Medicare program you love so much and don’t want government to get involved with? Republicans have proposed that the program be fully privatized and replaced with a voucher system. I hope they decide to write you a big enough check to pay for the care you need. There is little doubt that it will cut spending, but it will also cut your benefits.

Surely it’s better than “Obamacare” you say? That’s why the GOP has promised to repeal and replace the Affordable Care Act if–and this is the catch–you vote for them in November. That’s right, America. Vote for them first, and then keep your fingers crossed that they’ll follow through. After all, it’s not like politicians ever fail to fulfill their campaign promises. I mean, the GOP is doing its part to show how committed they are to the idea. They’ve voted to repeal the ACA 33 times since it was enacted. It hasn’t gone anywhere, but hey, they tried. But I digress. The point is that repealing the Affordable Care Act will be a step in the right direction. It will keep the Democrats’ hands off your Medicare, so that Republicans can destroy that program later, and it will cut costs. Deficit problem solved. Except for one thing. The Congressional Budget Office just wrote a nice letter to Speaker of the House John Boehner explaining that repealing the Affordable Care Act will actually increase the federal deficit by $109 billion over the next decade. As Rick Perry would say, “Oops.”

So, when you head to the polls this November, ask yourself why, if Republicans are so intent on reducing the deficit, they intend to repeal a law that would do just that? Why, in fact, would they insist on preserving tax cuts on the wealthiest Americans and passing a bill that will not only dismantle improvements to our health care system for the most vulnerable Americans, but actually raise the federal deficit in the process? I mean, it’s one thing for fat cat Republicans to cut benefits for the poor to save money. Now they’re actually talking about cutting benefits for the poor to spend money. It doesn’t make sense. But then again, if it gets you to vote for them, it doesn’t have to.

 

IPAB

Contrary to the title, the IPAB is not a new Apple product. Rather, it is the “Independent Payment Advisory Board” created by the Affordable Care Act to solve the problem of ever-increasing Medicare spending. In people’s worst nightmares, the IPAB is a death panel that will make decisions about how to ration health care for the elderly and disabled. Images of 15 people sitting in a room handing out death sentences flash through the minds of the anti-government crowd. Of course, nothing could be further from the truth, as the IPAB has no authority to limit benefits, increase beneficiaries’ out-of-pocket costs, or otherwise alter the Medicare program in any way that would “ration” care.

So, what can the IPAB actually do to promote slower spending growth in Medicare? They can suggest legislation, that’s what. Legislation that, for example, would reduce or alter the way in which payments are made to providers. It’s debatable if the recommendations from IPAB will work to actually control spending. What’s not up for debate is whether action will be taken, and that’s what I’m most pleased about.

You see, I hear often from family and friends about how Congress “never does anything” and how we should “vote the whole sorry bunch out and start from scratch.” It doesn’t seem to matter which party is in power, either. Congressional disapproval knows no party affiliations. And this isn’t just a trend among my social circle. Americans generally disapprove of the job Congress is doing. The IPAB puts an end to that, and here’s how:

Starting in 2013, the chief actuary of the Centers for Medicare and Medicaid Services (CMS) will report both a projected and a target Medicare growth rate for the next five years. If the projected growth rate exceeds the target growth rate, IPAB is tasked with making recommendations to bring things in line. These recommendations are formally submitted to Congress as proposed legislation. In the past, this is where progress ceased to occur, but no longer.

With the ball in Congress’ court, the options are straightforward. Congress may either enact the legislation recommended by IPAB, introduce and enact its own legislation that achieves the same cost savings as the recommendations from IPAB, or fail to act. If Congress fails to act, however, the secretary of the Department of Health and Human Services must implement IPAB’s recommendations, which cannot be overruled by either the executive or the judicial branches. In short, when Medicare spending increases too rapidly, something will be done to address it, even if Congress fails to act.