Expanding Insurance May Not Mean Long Lines and Trouble Seeing the Doctor

When health reform made it on the agenda in 2008-9, it took almost no time to hear the old familiar line that government-run health care will mean rationing, with crowded waiting rooms and the dreaded prospect of it taking months or years to get seen by the doctor or have an important surgery performed. It didn’t matter when Brits and Canadians chimed in to say “Actually, it’s not like that here at all.” Americans succumbed to the combination of logic and fear. The logic is apparent: If more people have the ability to go to the doctor, and there isn’t suddenly a corresponding increase in doctors, then either doctors are going to have to see more patients in less time (potentially reducing quality), or patients are going to have to wait to be seen (and we don’t like to wait). Given my parenthetical explanations in the preceding sentence, do I even need to elaborate on the fear aspect?

There’s just one important question: Is that really what will happen? This is where the good folks at Harvard who do health policy and health services research are so lucky. In Massachusetts, which basically implemented ObamaCare at the state level years before ObamaCare came into being, we have a nice policy laboratory to investigate this question. That’s precisely what Karen Joynt and colleagues did, as they report in a recent article in Health Services Research.

The very short version of what they did is this: Using Medicare data, they looked to see if people with chronic diseases like diabetes and hypertension had fewer outpatient visits to the doctor after the Massachusetts health reform was enacted, compared to the number of visits they had before the reform. They also looked at some quality metrics in the same way. That is, did the patients get the treatments we know they are supposed to get? And they also looked at health care costs. The cool thing about this is that they were able to use patients in other New England states that didn’t have health reform as controls. That means that their study design is really able to attribute any changes they see in Massachusetts above and beyond what they see elsewhere in New England to the health reform in Massachusetts.

The very short version of what they found is this: There was no decrease in health care visits or health care quality in Massachusetts because of health reform, but there was an increase in costs. Now, there are some limitations to what they did, but the authors acknowledge these nicely. The biggest issue is that Massachusetts had a low rate of uninsured persons to begin with, so their health care system was less flooded with newly insured than other places–like Kentucky–might be thanks to the ACA. The other big issue is that the study only examined the Medicare population age 65 and up, so we have no idea if the under-65 disabled Medicare population and everyone else may have experienced issues getting seen by a doctor. Still, despite these limitations, the study offers a ray of hope that our health care delivery system is responsive enough to adapt to an increase in demand without making us suffer lengthy waits to be seen for outpatient care, and that the ACA may well end up doing more good than harm.

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An Engineering Feat Gives Hearts Extra Life

With the release of their new HeartAssist5 heart pump, ReliantHeart is making real-time, personalized feedback possible for the millions of Americans suffering from heart failure. The new technology allows for real-time, remote monitoring of implantable devices, years of added life for patients, and flexibility to travel without a physician nearby. With a staggering projected 46% growth in heart failure by 2030, advances in heart failure innovation are on the forefront of changing medical treatment, policy, device research and physician reimbursements. Further, with heart failure and disease disproportionately affecting minorities in the US, advances in length and quality of life could be huge strides for medical equality.

Heart Failure In America

Approximately 7.5 million people in the United States currently suffer from heart failure, a figure that is increasing over time as more people survive heart attacks and various other heart conditions. According to the Heart Failure Society of America, an estimated 400,000 to 700,000 new cases of heart failure are diagnosed each year, with deaths averaging 250,000 annually, more than double since 1979. Even worse, an estimated one half of heart failure patients die within five years of diagnosis and 20% within the first year.

With a waiting list for heart transplants at an overwhelming 3,736 at publication, and less than 2,500 hearts donated annually, the need for a bridge between heart failure and transplant is literally life and death.

LVADs

Left ventricular assist devices (LVAD) are implantable heart pumps that were created to temporarily support patients with advanced heart failure as the bridge between diagnoses and transplant. However, with new scientific advancements, LVADs are becoming a long-term tool for improving heart function without transplant.

The right ventricle pumps blood to the lungs, but the left ventricle is responsible for pumping blood to the rest of the entire body, making it much more susceptible to failure. Therefore, LVADs have been the focus of most modern research to prolong and improve life saving implants.

Patient-Centered Care

Reliant’s system acts like your car’s dashboard. “If a patient’s pump has any sign of a challenge, like dehydration or low flow, the remote monitoring system signals the change to a data-collection center that notifies the transplant center as well as the individual,” ReliantHeart CEO Rodger Ford says. This is what makes the HeartAssist5 unique; at the first sign of a problem the right people are notified immediately.

Essentially, if the engine light goes on, the heart center and patient are notified to get the engine checked.

He also notes that the patients can set monitors to send text message notifications, thus making changes in blood flow, speed and power truly personalized. Individual blood flow is collected and transmitted every 5 minutes, making one’s own body the standard comparator.

The greatest importance to Founder and CTO Bryan Lynch is his ability to use his background as an engineer to, “Get involved in a project where you can actually see how you saved a life. While the docs and nurses are the real lifesavers, we give them the tool to make it possible.” He continues that it is vitally important for engineers and innovators to gain a patient-centered approach to get a real reduction in cost burden and improve quality of life.

Sailesh Saxena, CFO, continues highlighting the patient focus of the company by telling about the origination of the design of the VAD pack. “Bryan and I used to go to Schlotsky’s Deli ($BUNZ) for lunch,” he said, “and we used to see this man wearing a coat although it wasn’t cold out. Bryan noticed immediately that he was attempting to hide an LVAD controller and batteries. Well, this happened more than once, and we recognized that he was always concealing the VAD controller. So we decided that we needed to create a unique insert so that our LVAD control system could slip right into a Louis Vuitton ($LVMH) or Gucci ($GUC) bag unnoticed. It’s the small things that make the patient feel like we understand what they really want.”

Expanding The Geography Of Care

Remote monitoring, like other methods of telemedicine, is a key to expanding the geography of health care. “As technology matures, with the help of remote monitoring, the cardiologist and patient will feel safer with greater distances between them,” says Saxena.

This growth in telemedicine as a whole, and specifically in heart care, has major implications for the Centers for Medicare & Medicaid Services (CMS) as well as health care policy and reform. Because CMS is beginning to assign reimbursements and penalties based on patient outcomes instead of traditional fee-for-service metrics, it will become more and more important to have reimbursements reflect remote monitoring and its likely benefits.

Reimbursement codes also need to be reworked to genuinely target geographic discrepancies in care, which are fundamentally important for transplant centers. However, at present, CMS is slowly beginning to take growth rates of heart implants seriously based on the agency’s continued increases in payments, including their slight variations in geographic differences.

An Engineering Feat

In a recent study, researchers found that platelets flowing through the HeartAssist5 are exposed to significantly lower cumulative shear stress levels than in competitive devices tested. Ultimately, this means that the ReliantHeart product allows for what the CTO calls “a more physiologically normal cardiac output, including the pulse.”

What Bryan means is that people with failing hearts have low blood flow throughout the body, which is why they are so sick. When an LVAD is implanted, patients return to a more normal flow, but they also need blood flow that is as natural as possible. With the HeartAssist5, blood is not damaged and any pulse that the recovering heart produces is naturally transmitted to the body.

The LVAD and heart now work together to help the patient recover.

Although there are two other continuous flow LVADs on the market (THOR and HTRW), the ReliantHeart team claims their careful design capitalizes on working with the natural ventricle to the benefit of the patient, almost like a gym trainer for your heart.

Their “implantable flow probe” is also a revolutionary aspect of the HeartAssist5. This ultrasonic probe measures the blood flow from the LVAD in real-time providing critical feedback that is a one-of-a-kind technology providing data that makes the aforementioned remote monitoring so valuable. Ford says this ability to see patient-specific trends remotely in real time not only helps all patients improve quality of life, but the longevity of the HeartAssist5 creates a life support system, far beyond the “bridge” that the LVAD was originally created to be.

So this month, for American Heart Month, think about what innovation really is. It might be the ability to prolong and add quality of life for individuals and families across the nation, to share more time with loved ones.

 

NFL Players Host Concussion Summit Week Before Super Bowl, Despite Ongoing Litigation

Real innovation is often driven by those who think outside the box; those who take the obvious and make it an actionable reality. The week leading up to Super Bowl XLVIII, a group of entrepreneurs created a unique and transformative meeting of the minds. At the Coalition for Concussion Summit (#C4CT), Brewer Sports International and Amarantus BioScience Holdings, Inc. joined forces at the United Nations’ (UN) New York headquarters to bring scientists, biotech companies and professional athletes together, with the goal of building awareness and advancing scientific and medical opportunities for traumatic brain injury (TBI), chronic traumatic encephalopathy (CTE) and concussions. Add in the weight of immediate policy implications of the National Football League facing litigation for not properly informing or protecting players and Northwestern University’s football team attempting to unionize in hopes of improving athlete’s rights, and a perfect storm is created to demand change. Collectively, the week of the Super Bowl developed into an ideal time, location and platform for changing standards of health care and promoting developments in mental medical care that are patient-centric.

NFL Litigation

In the months preceding the 2014 Super Bowl, the NFL and the NFL Players Association (NFLPA) found themselves in a heated battle over the allegations that the NFL withheld information from the players about the depth and breadth of research indicating that concussions, memory loss and memory deterioration are linked. The NFL has since agreed to a $765 million settlement, which was recently denied by Judge Anita Brody who claims that the in the suit, “not all retired NFL football players who ultimately receive a qualifying diagnosis, or their related claimants, will be paid.”

While that decision is pending, more lawsuits are beginning to surface from individual players. Last Tuesday, former Detroit Lions running back Jahvid Best sued the NFL and helmet maker Riddell, claiming that concussion problems contributed to ending his career early

However, according to Robert Griffith, a 13-year veteran of the league, it doesn’t take a career-ending hit to significantly impact long-term functioning. “Guys suffer the same symptoms even after a few years in the league, including, sleep deprivation, depression, mood swings, addictions and self worth problems.”

The same week of the Super Bowl, the Northwestern University football team also dropped a bomb on the sports world, despite efforts from the National Collegiate Athletic Association (NCAA) to curb player concussions. The team wants to change the way university’s view, treat and educate student athletes, claiming more players’ rights are needed. This comes in tandem with a more than two-year long effort by several college players to sue the NCAA for failing to protect student athletes from concussions. An irony, pointed out by Chris Nowinski, author and former professional wrestler with World Wrestling Entertainment (WWE), who noted that “We have pitch counts for shoulders, even in high school, but we don’t have hit counts.”

Health Policy at the Forefront

When the NFL, the United States’ most powerful sports league, is on the hot seat for neglecting players’ mental and physical health, it is only a matter of time before public outrage requires policy change. Not only does the NFL itself have the ability to change health policy for the better, but the trickle down impact could save many young athletes around the country the trauma that current and past players have suffered.

Ultimately, a new standard of care is possible in the near future. Because, as Jermichael Finley told me, “100% or 50%, it doesn’t matter how one steps on the field. It isn’t if you get hurt, it’s when you’ll get hurt.” Further, as one conference goer attested, “We are speaking on the floor of the United Nations about brain trauma. This has never before been possible.”

With that in mind, researchers and clinicians such as Andrew Maas, MD, PhD, Robert Stern, PhD, Kim Heidenreich, PhD and Jay Clugston, MD came together with patients and biotech companies to discuss the current state of trauma, neuroscience, degenerative diseases, sports medicine and public policy.

Meeting Of The Minds

Despite the exorbitant power of the NFL, surprisingly little has been done to advance the conversation between athletes and the scientists who work diligently to understand and protect our brains. Until now.

As the nation’s best football players ascended upon New York and New Jersey, Brewer Sports International and Amarantus BioScience Holdings, Inc. gathered a room full of athletes and scientists to educate one another and discuss the real world of traumatic brain injury, concussions and memory loss.

“As a former NFL player, I am passionate about making strides to improve the health and safety of my fellow professional athletes, both former and current,” said Jack Brewer, CEO of Brewer Sports International. “Instead of pointing fingers, we have put together a world class panel of researchers to discuss TBI-induced neurodegeneration and CTE with those directly affected by and equally passionate about the cause as we strive to enhance awareness and work to find viable treatments.”

Gerald Commissiong, President and CEO of Amarantus reinforced the originality of the idea saying that, “The true innovation in #C4CT lies in bringing all of the stakeholders on the concussion issue into one forum. Conferences that are medical in nature almost always overlook key groups such as patients, caregivers and advocates. By allowing patients to be part of the process, we are creating a paradigm shift that we hope will galvanise the broader community into action.”

Brain Function

Despite Super Bowl caliber athletes having athletic abilities that are superior to most, the brains and vulnerabilities of these athletes are comparable to all others. The impact of one hard hit or one concussion can disrupt brain function forever. A point that resonates with Mixed Martial Arts (MMA) fighters as well. Just yesterday, boxing rivals met on Capitol Hill with Senators to support efforts of the Cleveland Clinic in studying brain health. They were backed by more than 400 of their peers who wanted to maintain their profession, but ensure that the future is brighter for other athletes.

Even veteran players such as Clinton Portis assert that he does not have regrets about his career but that he, “will not let my sons play contact football until at least high school,” due to the limited research that exists on TBI and concussions.

Those downstream effects, many at the summit contend, are highly linked to neurodegeneration, memory loss and long-term functioning. However, this is exceptionally hard to prove given how hard apples-to-apples comparisons are of brain damage and functioning. This association is further limited by the ability to compare impact enumeration and force due to the small sample size that are athletes.

Events such as the Coalition for Concussions Summit are becoming imperative to change health policy. When organizations, individuals, researchers and policymakers cannot fight the battle alone, it takes a meeting of the minds to advance a message. Hopefully, assembling key stakeholders to address health care problems will become a norm to improve health and care in the US.

 

Is Your Doctor Lying To You?

The doctor-patient relationship, like any good relationship, is built on trust. After all, the patient is naturally at the mercy of their physician in most cases, because the physician is the expert. Sure, the patient should have the ultimate say in their care, but the information they are basing their decisions on typically comes from the physician, and they must trust that what they are being told is the truth. Unfortunately, a recent study by Lisa Iezzoni and colleagues finds that doctors aren’t always so honest with their patients.

In a survey of a representative sample of physicians, more than a third of doctors fail to completely agree with the statement “Physicians should disclose all significant medical errors to affected patients.” Nearly one-in-five fail to completely agree with the statement “Physicians should never tell a patient something that is not true.” That’s right, more than 17% of doctors felt that there were times when it was okay to lie to patients.

As for their actual behavior, 11% of physicians reported rarely, sometimes, or often (in contrast to never) telling a patient something that was not true, and 55% reported rarely, sometimes, or often describing a patient’s prognosis in a more positive manner than warranted. Admittedly, the latter case could be perceived as compassionate rather than dishonest depending on the circumstances.

What are we, as patients, to make of these findings? Well, on the one hand, the truth could be even worse than the results suggest because of “social acceptability bias.” In other words, doctors know that admitting to being dishonest isn’t the “right” answer to give, so they may ironically be dishonest about reporting their dishonesty. At the same time, the framing of the results may actually be misleading. By taking four responses (never, rarely, sometimes, and often) and grouping them into two categories (never vs. not never), important information is obscured. If most of the doctors who admit to lying are in the “rarely” category, perhaps that’s not so bad. If, on the other hand, most of them reported lying “often” that’s a little scary. Unfortunately, the way the data are presented, it isn’t clear which is the case. I think it would have been better to put two responses in each category so that “never” and “rarely” were combined and compared to “sometimes” and “often.”

My sense is that doctors, like all people, sometimes lie–perhaps more often by omission rather than commission–but that we should not be too worried about the results of this survey. Don’t assume your doctor is lying to you or that they are always being honest. That’s what second opinions are for.

 

 

Would More Americans Support Health Reform If Obama Was White?

Would more Americans support health reform is President Obama was white? According to a recent study conducted by Michael Henderson of the University of Mississippi and D. Sunshine Hillygus of Duke University, the answer is yes. The researchers modeled changes in support of health reform between 2008 and 2010, and what they found was striking. According to Henderson and Hillygus, among a group who supported health reform in 2008, whites were 19 percentage points more likely than blacks to be opposed to health reform by 2010. Keep in mind that this race effect is seen after controlling for party affiliation and political ideology. It also controls for income, age, gender, education, and worry over the cost of health care. Said another way, this race effect isn’t likely to be biased by the usual suspects.

Moreover, the researchers included a measure of racial resentment, and those with the highest levels of racial resentment were 29 percentage points more likely to go from supporting health reform in 2008 to opposing it in 2010. These effects are additive. That means that whites with high levels of racial resentment are a whopping 48 percentage points more likely to switch from supporting to opposing health reform in the course of two years, compared to their black counterparts with low levels of racial resentment. That’s a big deal, to paraphrase Joe Biden for a general audience.

That doesn’t mean that people’s concerns over health reform aren’t legitimate. It’s perfectly reasonable to be opposed to an individual mandate, for example. The question opponents of health reform need to ask themselves, though, is how they would feel about the Affordable Care Act if the man who signed it into law looked like them. I don’t think opposition to reform would disappear–after all, when Clinton tried to pass reform legislation in the 1990s, it failed spectacularly–but I do think the tone of the debate would have been a little different, and I don’t think we’d be seeing the continued opposition after passage that we’re seeing now. Just look to the recent past for proof: Medicare Part D is all the evidence you need that a white President can pass a budget-busting piece of legislation without so much as a second glance from the American people. If George W. Bush had been black, perhaps America’s seniors would still be without adequate prescription drug coverage.

 

 

 

In Health Reform Polling, Even Undecideds Have Opinions

If you’re at all familiar with opinion polls, you know a few things: How the questions are asked matters; The results are always within a certain margin of error thanks to probability sampling; and there are always some people who profess to have no opinion on the question being asked. When we interpret the results of polls, it’s easy to keep the margin of error in mind, and it’s not even that difficult to assess the impact of question wording by comparing the results from differently worded polls that are asking about the same thing. No, the real challenge is figuring out what those undecideds are actually thinking. A little example shows why this can be so important.

Let’s say a poll asks respondents about their support of health reform. Now imagine two sets of results, both with a margin of error of +/- 3%.

Support Health Reform – 25%
Oppose Health Reform – 25%
No Opinion – 50%

In this case, we clearly want to know what the undecided respondents are thinking, because there are so many of them. The results simply aren’t very informative when we only know what half of people are thinking. Now, consider a case where we might be inclined to ignore this lack of opinion:

Support Health Reform – 46%
Oppose Health Reform – 49%
No Opinion – 5%

In this case, we would consider the public evenly divided on the issue, because the difference of 3% is well within our combined margin of error. We probably wouldn’t think much of the 5% with no opinion, although the reality is that how that group broke out if people were forced to choose one position or the other, could make a difference. If all 5% went to the support camp, we’d still have a statistical tie. If they broke for the opposition, the difference between the two groups would no longer overlap. The undecideds matter.

Fortunately, there’s something that researchers can do to get around this. As Adam Berinsky and Michele Margolis from MIT write in a recent issue of the Journal of Health Politics, Policy, and Law, it is possible to impute the opinions of those who profess not to have an opinion. Here’s how it works: Most people don’t answer “no opinion” to every question. So, you use their responses to the questions they did answer to match them up with other respondents who answered those questions the same way they did. Then you look at the way those people answered the question that the others expressed no opinion on. That gives you a sense of how they would have answered the question if they had done so. Make sense?

Here’s a silly example: Let’s say you asked people three questions about which foods they liked to eat. First, you ask if they like lettuce. 80% say yes, and 20% say no. Then you ask if they like cheese. 50% say yes, and 50% say no. Then you ask if they like hamburger. 40% say yes, 20% say no, and 40% have no opinion. When you look at the data, you see that the 40% with no opinion all like lettuce and dislike cheese. Others in the sample who like lettuce and dislike cheese report that they dislike hamburger (it turns out they are strict vegetarians). Therefore, it’s not a certainty, but there’s a good chance that the folks with no opinion actually dislike hamburgers. They may also be vegetarians who answered no opinion because they felt the question wasn’t relevant to them, for example. Make better sense? Good.

 

Do Appointment Reminders Work?

If you’ve been to the doctor in the last few years, you’ve probably gotten one a phone call reminding you from your doctor’s office reminding you of your upcoming appointment. These calls usually come from 1 to 3 days prior to your scheduled appointment. Sometimes a member of the front office staff speaks to you in person. Other times you get an automated “robo-call.” And, while I’ve never experienced it, many providers are now contacting patients with reminders sent to their cellphones as text messages.

I’ve always found these reminders annoying, because I generally keep my appointments, but for the physicians, anything that helps to avoid missed appointments is a way to improve efficiency. After all, a physician’s day littered with missed appointments isn’t much different than a plane flying with empty seats. The phone call reminders are known to produce results, but if text messages are equally effective, they would be preferable, because they’re generally cheaper to send out than paying someone to make calls. But the big question is: Do these text message reminders work?

The answer, according to a meta-analysis appearing in the latest issue of Health Services Research, is a resounding yes. The study looked only at text message reminders, and synthesizing results from 18 separate studies, they found that text message reminders increased the likelihood of appointment attendance by nearly 50%. That’s a big effect. The only thing that’s concerning is who won’t be reached if providers migrate to text message reminders over telephone calls. Cellphone use is widespread, but there are pockets of people–the elderly, those in areas without cell coverage, etc.–that would stand to forget their appointments more often, because they don’t have a cellphone. Of course, if things get really bad, it will be the folks without cellphones who come out ahead.

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What If The Supreme Court Strikes Down the Individual Mandate?

Any ruling by the Supreme Court on the constitutionality of the Affordable Care Act’s controversial individual mandate isn’t likely for at least another several months, but it’s worth thinking about what might happen after the case is decided. The first scenario is easy: If the Court upholds the mandate, the ACA goes forward as planned to the continued objections of many conservative Americans and politicians. The second scenario is less clear: If the Court finds the mandate unconstitutional, do they find it severable from the rest of the law? If not, they’ll strike the whole ACA down. This seems like the least likely outcome. If, on the other hand, they do invoke severability, the ball is back in the White House’s court. The decision at that point would be whether or not health reform can be successful without the individual mandate.

The concern here is the death spiral first described by Nobel Prize-winning economist Joseph Stiglitz. In essence, if we don’t require everyone to buy insurance, then insurance will be disproportionately purchased by the sick, making it more expensive and leading many to discontinue coverage in a continuous cycle that drives the price higher and higher until no one can afford insurance any more and the system collapses. By contrast, getting everyone into the pool is seen as the only way to keep costs down and maintain the insurance system. So the question is: What happens if the Supreme Court strikes down the individual mandate? Does the Obama adminsitration wash its hands of health reform, proclaiming that it can’t be done without the individual mandate because costs will rise too rapidly and the insurance system will collapse, or does it forge onward and see what happens?

Option one is the safe bet if you believe that a bad status quo is better than a potentially worse change, but it’s absolutely terrible politics. It would be admitting defeat on one of the defining aspects of the Obama presidency. Moreover, it would have tremendous negative implications for the future of health reform initiatives generally. Option two looks good politically for all of the opposite reasons, but it could destroy the health insurance market and hurt Americans in the process. That’s bad leadership. While such action might lead to the type of catastrophic collapse necessary to precipitate true change, it would be incredibly painful.

New evidence suggests, however, that the pain might not be as great as many–myself included–fear. John Sheils and Randall Haught of the Lewin Group ran a simulation model to see what might happen to coverage and costs if reform went forward as planned with the exception of the individual mandate. Remember, the concern is that fewer people would be covered and health insurance premiums would increase. What they found is that, yes, compared to estimates under health reform with an individual mandate, health reform without the individual mandate would mean fewer people would be covered and insurance premiums would increase, but things would still be better than if we did nothing at all.

How much better? Well, without reform, they estimate that 51.6 million Americans would be uninsured. With reform, that number drops to 20.7 million. With reform, but without the mandate, their estimate stands at 28.5 million. Not too shabby. As for premiums, the authors estimate that eliminating the individual mandate will mean a 12.6% increase. Not a welcome increase, but not necessarily the kiss of the death spiral.
That said, other estimates by the Congressional Budget Office and MIT health economist Jonathan Gruber have not been as optimistic. The CBO expects that axing the individual mandate will mean 16 million fewer insured persons and a premium increase between 15 and 20%. Gruber puts the figures at 24 million fewer insured and premium increases on the order of 27%. Because of the sheer volume of people involved and the uncertainty of their decision making processes, it’s really hard to know who’s calculations are the most reasonable.

What you can count on is this: If the Court finds the individual mandate unconstitutional, the White House will have more actuaries and health economists crunching numbers than you can imagine. These latest results from Lewin suggest that even if the Court says no to the individual mandate, it shouldn’t necessarily mean the Obama adminsitration should give up on health reform.

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How Many Uninsured Will Medicaid Cover After Health Reform?

One of the major components of the Affordable Care Act is the extension of Medicaid eligibility to all citizens and legal residents who earn below 133% of the federal poverty level. As of 2011, that is approximately not a lot of money. Prior to the ACA, Medicaid eligibility was contingent on satisfying both income eligibility and categorical eligibility criteria, the former meaning you had to be poor and the latter meaning you had to be the “right” type of person to qualify. For example, poor pregnant women qualified, poor childless adults did not. Prior to the ACA, people who thought Medicaid was a program for poor people were only partially right. Fortunately for these people, without having to change their thinking, the implementation of the ACA will make them right. Medicaid will now be for everyone who is low-income. It’s much simpler and makes more sense, but the big question is: How will it work?

We already know that there are a number of people eligible for Medicaid coverage currently who are not enrolled in the program. It stands to reason, then, that when more people become eligible, some fraction of them will not enroll. How many do enroll will be important for many reasons: covering these folks was a major goal of health reform, newly insured individuals will need more doctors to care for them, and all of this will have an effect on health care costs. It would be helpful if we could anticipate–if not predict–the future, which is exactly what the Congressional Budget Office and the Centers for Medicare and Medicaid Services have tried to do. The problem is that they appear to be using two different crystal balls.

The CBO says that 16 million will gain coverage, while CMS says 18 million. Somebody’s wrong. My hunch is that it’s CMS, because they assume that 97% of newly eligible people will enroll in Medicaid. That seems awfully high to me. It also seems high to some health economists at Harvard who have the next best thing to a crystal ball: a simulation model. Benjamin Sommers, Katherine Swartz, and Arnold Epstein have a paper coming out in Health Affairs that considers all of the major factors that will determine how many people will be eligible and how many will enroll and calculates these estimates under a variety of assumptions that range from conservative to bold. According to their model, about 13.4 million people will newly enroll in Medicaid because of the ACA. However, using different assumptions, they come up with a 95% confidence interval that ranges from 8.5 million to 22.4 million people. That, folks, is a pretty large amount of uncertainty. The good news is that more people will be covered. The bad news is that we really won’t know how many until happens, which means we won’t be able to do too much planning ahead.

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Four Types of Hospitals

Today I want you to try out a thought experiment with me. Imagine that you were asked to rate hospitals according to the quality of care they provide and how much the care they provide costs. Then, imagine that you were asked to select a group of hospitals that should serve as the model for all hospitals in the country. In other words, with regards to quality and cost, you are trying to identify the “best” type of hospital. Which hospital or group of hospitals would you select as the best?

Well, you might consider creating a two-by-two table that contained all the possible combinations of quality and costs. So you’d have low quality, low cost hospitals; low quality, high cost hospitals; high quality, low cost hospitals; and high quality, high cost hospitals. Clearly, high quality is preferable to low quality, right? So the first two groups are clearly not the best. And, as far as cost goes, less is more, so the best hospitals are those in the high quality, low cost group, right? Well, it depends on who’s deciding.

The government, for example, loves the idea of high quality, low cost hospitals, because they provide maximum benefit at minimum expense. Such facilities could hold the key to enormous cost savings in health care. It turns out, though, that patients actually express a preference for the high quality, high cost hospitals. This according to a recent study by Ashish Jha, John Orav, and Arnie Epstein. The authors identify different levels of nurse staffing as explaining this patient preference. They don’t come right out and say it, but it seems that above a certain point, having more nurses on staff does nothing to improve quality of outcomes, but does improve patient satisfaction. In short, American hospital patients are paying to be pampered. If insurance didn’t foot so much of the bill, I wonder how much our preferences would change.

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