Tag Archives: Medicaid

Healthcare: It’s complicated

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http://www.theactuary.com/features/2017/07/its-complicated/

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It has been a little over seven years since the US began implementing healthcare reform at the national level, following the passage of the Patient Protection and Affordable Care Act (ACA), also known as Obamacare. However, the future of the law’s programmes has never seemed more uncertain now that the United States House of Representatives has passed legislation repealing and replacing many of the ACA’s key provisions.

While the ACA and the proposed replacement legislation are fundamentally different in their approaches to financing and regulating healthcare, they do have one thing in common: both are extraordinarily complicated.

Actuaries have had a front-row seat as healthcare reform has unfolded, and they are in a unique position to help address the challenges our complex system presents – whether that involves setting premium rates, calculating reserves, or just trying to explain healthcare policy to their Facebook friends. After all, actuaries were working to promote the financial stability of our complex healthcare system long before the ACA came along.

Even so, one might ask: Why is the American healthcare system so complicated? Does it have to be that way? Most stakeholders acknowledge that our current system has room for improvement, although opinions vary widely on what to do about that. In part, the complexity of our system is rooted in our history.

The healthcare system that we have today wasn’t formed in one fell swoop. Instead, it has been stitched together gradually over the past century by policymakers working to meet the challenges of their times. For example, the prevalence of employer-sponsored insurance was at least partly driven by price-wage controls implemented by the federal government in the 1940s during the Second World War, together with very favourable tax treatment. When the employer-sponsored market began to flourish, healthcare coverage became unaffordable for the non-working population – in particular, low-income workers, seniors, and disabled individuals – and the Medicare and Medicaid programmes were born. Currently, healthcare in the US is provided and funded through a variety of sources:

  • Employer-sponsored insurance – either self-funded by the employer or insured through a carrier
  • Individual major medical insurance – currently subsidised by the federal government for many individuals under the ACA
  • Medicare, Medicaid, and military health coverage – subsidised by federal and state governments and increasingly administered by privately managed care organisations
  • Other – for instance, the Indian Health Service, care provided to correctional populations, and uncompensated care provided to the uninsured.

 

It’s therefore not surprising that the policies being proposed today are an attempt to fix the problems we currently face, such as expanding access to affordable healthcare, reducing the cost of healthcare, or improving the quality of care received by patients.

However, our system has evolved in such a way that trying to implement a solution is like trying to solve a Rubik’s Cube – it is hard to make progress on one side without introducing new problems into other parts of the puzzle. For a Rubik’s Cube, successful solvers focus on both the local and global picture, and sometimes must make short-term trade-offs to achieve a longer-term solution. Unfortunately, the short-term nature of political pressures make it difficult to implement longer-term strategies for healthcare. Yet, we see many areas where actuaries can be instrumental in addressing the challenges presented by our complex healthcare system.

Complex times call for complex models

The ACA made sweeping changes that impacted almost every source of coverage listed above. The most profound changes, besides the expansion of Medicaid coverage, were the changes made to the individual and small employer health insurance markets. These already small markets were fractured into several separate pieces (grandfathered business from before the ACA became law, ‘transitional’ business issued before 2014, and ‘ACA-compliant’ business issued in 2014 and beyond). The only constant has been change, with many regulatory changes occurring each year (often after premium rates were set by insurers) and with the stabilisation programmes intended to mitigate risk during this time of change often paradoxically increasing uncertainty. This led some to question whether these markets were inherently too unpredictable to be viable, whereas others felt that the markets were finally starting to stabilise before the election changed everything.

Besides predictability problems caused by regulatory or political factors, two challenges facing health actuaries during these transitional years have been (1) the lag between when market changes are implemented and when data on policies subject to the new rules becomes available, and (2) the difficulty in predicting consumer behaviour in reaction to major changes in market rules such as guaranteed issue and community rating. How many of the uninsured would sign up? How price-sensitive would members be when they renewed their coverage each year? How will changes in other sources of coverage (such as Medicaid expansion) impact the individual market? How will potential actions by competitors affect an insurer’s risk?

Despite the daunting nature of these challenges, actuaries have, out of necessity, found ways to try to address them. For example, faced with the data lag problem, they explored ways to augment traditional claim and enrollment data with new data sources such as marketing databases or pharmacy history data available for purchase. Such sources can be used to develop estimates of the health status of new populations not previously covered by an insurer. Many actuaries also developed agent-based stochastic simulation models that attempted to model the behaviour of consumers, insurers and other stakeholders in these new markets. Such models continue to be used to evaluate the potential outcomes of future changes to the healthcare system, and will probably be essential should efforts to repeal and replace the ACA prove successful.

Information problems: what is a rational actor to do?

Most goods and services in the US have a price tag that consumers can use to ‘shop’ for the option that they feel gives them the best value for their dollar. Healthcare is different. If you ask how much a healthcare service will cost in the US, the answer is “it depends”. List prices such as billed charges for hospitals and physicians and average wholesale prices for pharmaceuticals are increasingly meaningless, given the enormous contractual discounts and rebates that typically apply. The same service may have wildly different prices depending on who is paying for it, and prices may not correlate well with either the clinical value the service provides to the patient or the actual cost to the healthcare provider who renders it. Layered on top of this complex foundation are the often arcane policy provisions that determine a member’s ultimate cost for a claim.

Moreover, even if a patient can determine the cost of treatment at different healthcare providers, making an informed choice often requires clinical knowledge the average person is unlikely to possess. Also, many of the most costly services are non-discretionary and often emergent in nature. In other words, even if a consumer wanted to shop they would be hard-pressed to do so.

All of this means that it is exceedingly hard for various stakeholders – patients, doctors, even insurers – to know the true cost of a service at the point of care, much less manage it. Yet a lot of effort has been spent in trying to better align cost incentives for providers and patients. Past efforts have often used crude methods, such as high deductibles paired with health savings accounts, to create incentives. Current efforts such as value-based insurance designs, which vary cost sharing based on a patient’s clinical profile, use more nuanced approaches to encourage patients to use high-value care. Moving from fee-for-service to value-based payment models for reimbursing healthcare providers has been a focus of both private and public payers in the US.

While such initiatives show promise, they come at the price of even more complexity – and it isn’t always clear that this price is worth paying. The proliferation of more complex benefit designs and provider contracting arrangements can exacerbate the price transparency problems that existed even in the relatively simple fee-for-service world.

Actuaries are well equipped to help insurers, providers and consumers navigate these waters. For example, repricing healthcare claims in an equitable way using actuarial techniques, such as comparing reimbursement rates with a standard fee schedule, is

an efficient way for providers and payers to evaluate cost levels consistently across contracts that may use very different reimbursement methodologies.

Actuaries also have a role to play in developing tools to support clinicians and consumers in understanding the financial dimensions of their healthcare decisions.

Technology: the cause of, and solution to, all our cost problems?

For better or worse, Americans seem determined to seek technological solutions to our health problems, even when lifestyle changes in diet and exercise habits might be just as effective.

Technological advances drive a significant portion of healthcare cost increases, and while many do result in profoundly valuable new therapies, some provide only marginal benefit over existing options at a significantly higher cost. Finding ways to leverage our love of technology to achieve health outcomes more cheaply would be a worthy goal, and one where an actuary could make a difference. Work to use machine learning (for example, in radiology), smarter medical devices, and other data-intensive methods to improve healthcare are still in their infancy, but show promise. From a policy perspective, actuaries could assist in designing novel approaches toward rethinking the incentives for clinical innovation, such as linking payment for new therapies to their clinical value relative to alternatives.

Will the US ever change its relationship status with healthcare from “it’s complicated” to something less ambiguous? In the near term, the answer seems to be “no.” But perhaps we can hope that – with a little help from actuaries – even a complicated relationship can be a good one.

Hospital group comes out against new ObamaCare repeal effort

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Hospital group comes out against new ObamaCare repeal effort

Hospital group comes out against new ObamaCare repeal effort

America’s Essential Hospitals announced its opposition to a new ObamaCare repeal and replace bill, warning of cuts and coverage losses.

The group, which represents hospitals that treat a high share of low-income people, said it is opposed to a last-ditch bill to repeal ObamaCare from Sens. Bill Cassidy (R-La.), Lindsey Graham (R-S.C.), Dean Heller (R-Nev.) and Ron Johnson (R-Wis.).

Dr. Bruce Siegel, the group’s president and CEO, said in a statement the bill “would shift costs to states, patients, providers, and taxpayers.”

“Further, by taking an approach so close to that of the earlier House and Senate plans, it’s reasonable to conclude it would have a similar result: millions of Americans losing coverage,” he added.

America’s Essential Hospitals is one of the first major health groups to come out in opposition to the bill. Most have not yet weighed in on the measure, which was only introduced on Wednesday.

Many are also skeptical of the bill’s chances, but it appears to be gaining at least some momentum.

Cassidy told reporters Friday that he thought the bill had the support of 48-49 senators, just shy of the needed 50. Still, the effort faces long odds and a fast-approaching procedural deadline of Sept. 30.

America’s Essential Hospitals was one of the most outspoken opponents of the earlier repeal bills, along with other hospital groups. Many doctors groups were also opposed and many insurers eventually weighed in against provisions to change ObamaCare pre-existing condition rules.

Following the ACA Repeal-and-Replace Effort, Where Does the U.S. Stand on Insurance Coverage?

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http://www.commonwealthfund.org/publications/issue-briefs/2017/sep/post-aca-repeal-and-replace-health-insurance-coverage

Image result for the commonwealth fund

 

Conclusion and Policy Implications

The findings of this study could inform both short- and long-term actions for policymakers seeking to improve the affordability of marketplace plans and reduce the number of uninsured people in the United States.

Short-Term

The most immediate concern for policymakers is ensuring that the 17 million to 18 million people with marketplace and individual market coverage are able to enroll this fall.

Congress could take the following three steps:

  1. The Trump administration has not made a long-term commitment to paying insurers for the cost-sharing reductions for low-income enrollees in the marketplaces, which insurers are required to offer under the ACA. Congress could resolve this by making a permanent appropriation for the payments. Without this commitment, insurers have already announced that they are increasing premiums to hedge against the risk of not receiving payments from the federal government. Since most enrollees receive tax credits, higher premiums also will increase the federal government’s costs.9
  2. While it appears that most counties will have at least one insurer offering plans in the marketplaces this year, Congress could consider a fallback health plan option to protect consumers if they do not have a plan to choose from, with subsidies available to help qualifying enrollees pay premiums.
  3. Reinsurance to help carriers cover unexpectedly high claims costs.10 During the three years in which it was functioning, the ACA’s transitional reinsurance program lowered premiums by as much as 14 percent.

The executive branch can also play an important role in two ways:

  1. Signaling to insurers participating in the marketplaces that it will enforce the individual mandate. Uncertainty over the administration’s commitment to the mandate, like the cost-sharing reductions, is leading to higher-than-expected premiums for next year.
  2. Affirming the commitment to ensuring that all eligible Americans are aware of their options and have the tools they need to enroll in the coverage that is right for them during the 2018 open enrollment period, which begins November 1. The survey findings indicate that large shares of uninsured Americans are unaware of the marketplaces and that enrollment assistance makes a difference in whether people sign up for insurance.

Long-Term

The following longer-term policy changes will likely lead to affordability improvement and reductions in the number of uninsured people.

  1. The 19 states that have not expanded Medicaid could decide to do so.
  2. Alleviate affordability issues for people with incomes above 250 percent of poverty by:
    1. Allowing people earning more than 400 percent of poverty to be eligible for tax credits. This would cover an estimated 1.2 million people at an annual total federal cost of $6 billion, according to a RAND analysis.11
    2. Increasing tax credits for people with incomes above 250 percent of poverty.
    3. Allowing premium contributions to be fully tax deductible for people buying insurance on their own; self-employed people have long been able to do this.
    4. Extending cost-sharing reductions for individuals with incomes above 250 percent of poverty, thus making care more affordable for insured individuals with moderate incomes.
  3. Consider immigration reform and expanding insurance options for undocumented immigrants.

In 2002, the Institute of Medicine concluded that insurance coverage is the most important determinant of access to health care.12 In the ongoing public debate over how to provide insurance to people, the conversation often drifts from this fundamental why of health insurance. At this pivotal moment, more than 30 million people now rely on the ACA’s reforms and expansions. Nearly 30 million more are uninsured — because of the reasons identified in this survey. It is critical that the health of these 60 million people, along with their ability to lead long and productive lives, be the central focus in our debate over how to improve the U.S. health insurance system, regardless of the approach ultimately chosen.

Uninsured Rate In U.S. Falls To A Record Low Of 8.8%

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Uninsured Rate In U.S. Falls To A Record Low Of 8.8%

Three years after the Affordable Care Act’s coverage expansion took effect, the number of Americans without health insurance fell to 28.1 million in 2016, down from 29 million in 2015, according to a federal report released Tuesday.

The latest numbers from the U.S. Census Bureau showed the nation’s uninsured rate dropped to 8.8 percent. It had been 9.1 percent in 2015.

Both the overall number of uninsured and the percentage are record lows.

The uninsured rate has fallen in all 50 states and the District of Columbia since 2013, although the rate has been lower among the 31 states that expanded Medicaid under the health law. California’s rate was 7.3 percent in 2016, less than half of its 17.2 percent rate in 2013.

“California has shown that the Affordable Care Act is working to expand health coverage and provide new patient protections,” said Anthony Wright, executive director of Health Access California, a consumer advocacy group. “While many thought our nation’s rising uninsured rate was unsolvable, the advancement in California shows that if policymakers and the public are united in trying to make reform work, we can do big things.”

The latest figures from the Census Bureau effectively close the book on President Barack Obama’s record on lowering the number of uninsured. He made that a linchpin of his 2008 campaign, and his administration’s effort to overhaul the nation’s health system through the ACA focused on expanding coverage.

When Obama took office in 2009, during the worst economic recession since the Great Depression, more than 50 million Americans were uninsured, or nearly 17 percent of the population.

The number of uninsured has fallen from 42 million in 2013 — before the ACA in 2014 allowed states to expand Medicaid, the federal-state program that provides coverage to low-income people, and provided federal subsidies to help lower- and middle-income Americans buy coverage on the insurance marketplaces. The decline also reflected the improving economy, which has put more Americans in jobs that offer health coverage.

The dramatic drop in the uninsured over the past few years played a major role in the congressional debate over the summer about whether to replace the 2010 health law. Advocates pleaded with the Republican-controlled Congress not to take steps to reverse the gains in coverage.

The Census numbers are considered the gold standard for tracking who has insurance because the survey samples are so large.

Among the states, the lowest uninsured rate last year was 2.5 percent in Massachusetts and the highest was 16.6 percent in Texas, the Census Bureau said. States that expanded Medicaid had an average uninsured rate of 6.5 percent compared with an 11.7 percent average among states that did not expand, the Census Bureau reported.

More than half of Americans — 55.7 percent — get health insurance through their jobs. But government coverage is becoming more common. Medicaid now covers more than 19 percent of the population and Medicare nearly 17 percent.

Hospital Impact—The only thing clear about healthcare policy is the continued lack of clarity

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http://www.fiercehealthcare.com/hospitals/hospital-impact-only-thing-clear-about-healthcare-policy-continuing-lack-clarity?utm_medium=nl&utm_source=internal&mrkid=959610&mkt_tok=eyJpIjoiWldFeE1XUXlPRFE0TlRneCIsInQiOiJ5dzRsZ1IwekxcL2FMZnN3NkJIOHZGbnpNV1RPcmtMNmdPd1MwV0RLUXNBSXl6QzJnK0s0NktPVzBLOUtRRjF1K0puZzZMZG95dERnN2VUcVRpeForakRVZVJsXC9GWllyU1g1Rk9ZY2pERVRQcjVyT1wvQkMycXdobjd5UnNKa2p3NiJ9

Executive looking out window

For healthcare leaders, it’s discouraging that federal policy decisions seem to be made at the last minute without much planning or consideration of unintended consequences.

I spent my Labor Day vacation in Monterrey, California, watching the waves crash into the sand and wondering what the future of healthcare will look like in the coming months and years. Some clarity is emerging that we have not seen in the past, and I feel comfortable making some observations and predictions:

  • Congress will not revisit the repeal and replacement of the Affordable Care Act before the end of the year. It is simply dealing with far too many other issues—passing a budget, raising the debt ceiling, approving disaster aid for Harvey and Irma, not to mention its desire for tax reform—that lawmakers must address.
  • While the Senate HELP committee is attempting a bipartisan effort to shore up the ACA, the issues listed above will make it almost impossible for such a law to be passed during this session.
  • The leadership of the Department of Health and Human Services ideologically opposes the very concept of the ACA and is also responsible for implementing the law. The tension between those two facts will lead to confusion and uncertainty for those of us in healthcare.
  • The passage of the ACA changed the terms of debate around healthcare reform. Granting health insurance to more than 20 million Americans has now shifted public opinion so that a solid majority believes the federal government should ensure that its citizens have insurance.
  • The ACA is not failing, but going forward it can be undermined without congressional action.

As a former anatomic pathologist, I am always interested in postmortem examination of failures, and the failure of Republicans to repeal the ACA ranks high in any list of stunning political disasters. Pundits have identified several possible causes:

  • Republicans never had a clear replacement plan or goal.
  • Taking away benefits from 22 million Americans is politically unpopular.
  • The ACA was not in a “death spiral.”
  • The president did not exert necessary leadership to get GOP senators to support his unpopular position.
  • Republican governors who had expanded Medicaid did not support the effort.
  • Organized opposition to repeal led to most Americans not supporting repeal.

Autopsy results always arrive too late for those of us who are still alive, and it is more important for those of us in healthcare to interpret the mixed messages coming out of HHS and Congress so that our organizations can continue to care for patients under the current system.

HHS seems willing and eager to let states experiment with healthcare reform. Alaska has received approval for $323 million over five years to subsidize insurance carriers and stabilize its individual ACA marketplace. Iowa is likely to receive approval for a radical 1332 waiver approach to healthcare reform in the Hawkeye state, and other states are preparing waiver submissions.

Meanwhile, HHS actions that seem to undermine the ACA include refusing to guarantee cost-sharing reduction subsidies to insurance companies and slashing the budget to support ACA enrollment for 2018. HHS recently announced advertising budget cuts of 90% for 2018 and the navigator program cuts of 40%.

A recent study—detailed in a post on The Incidental Economist blog—compared Kentucky ACA enrollment under a Democratic governor who supported advertising and a Republican governor who cut advertising. It found that lack of TV advertising led to 450,000 fewer page views on the ACA website and 20,000 fewer unique visits to the enrollment website.

ACA supporters, meanwhile, have recently put together a private enrollment campaign for 2018 to fill in the gap created by HHS decisions, Axios reported.

Last week, the Senate HELP Committee heard from state insurance commissioners and governorsabout ideas to stabilize the ACA marketplaces. They include:

  • Funding the cost-sharing reduction subsidies to insurance companies.
  • Facilitating reinsurance programs.
  • Expanding the ACA 1332 waiver programs to let states innovate.
  • Funding enrollment activities such as advertising and navigator programs.

Although health policy experts largely support these recommendations, it is hard to see how such a divided Congress could pass such proposals. Even if such legislation were approved, it would likely come too late to impact health insurance company decisions for 2018.

So, as of early September, we are left with the ACA continuing to be the law of the land, but with those in charge of the federal government not entirely supporting its success. Healthcare organizations have difficulty caring for patients when the rules keep changing and when clarity is hard to come by. It is also discouraging that decisions seem to be made at the last minute without much planning or consideration for unintended consequences.

That said, we still need to keep taking care of patients. My advice is to:

  • Continue to prepare for the transition from fee-for-service to value-based payments, but be aware that the Trump administration might slow down this process.
  • Continue to cut unnecessary costs.
  • Continue to improve the measurable quality of the care you give.
  • Participate in efforts in your individual states to innovate through waiver programs.
  • Collaborate with your physicians who are confused by all the uncertainty.
  • Keep up to date with the frequent changes that nobody can predict.

 

 

There’s one Obamacare repeal bill left standing. Here’s what’s in it.

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https://www.washingtonpost.com/graphics/2017/politics/cassidy-graham-explainer/?utm_term=.c90e0ce41aa2

Image result for cartoon dilbert beating a dead horse

After a dramatic series of failed Senate votes in July, there’s one repeal-and-replace plan for the Affordable Care Act left standing. Trump is pushing for a vote, per Politico, and John McCain has announced his support, but the bill has yet to gain significant traction.

The proposal, crafted by Sens. Bill Cassidy (R-La.), Lindsey O. Graham (R-S.C.) and Dean Heller (R-Nev.), essentially turns control of the health-care markets over to the states. Rather than funding Medicaid and subsidies directly, that money would be put into a block grant that a state could use to develop any health-care system it wants. It also allows states to opt out of many ACA regulations. “If you like Obamacare, you can keep it,” Graham has said, using a common nickname for the health-care law. “If you want to replace it, you can.”

In reality, that may not be true. The Medicaid expansion and subsidy funding would be cut sharply compared to current spending, going to zero in a decade.

 “You can’t actually keep the same program if your federal funding is being cut by a third in 2026,” said Aviva Aron-Dine, a senior fellow at the left-leaning Center on Budget and Policy Priorities. And even putting aside the cuts, she said, the block grant structure would fundamentally change the health-care landscape. “[Funding] is capped, so it wouldn’t  go up and down with the economy,” when fewer or more people become eligible for subsidies.

Republicans contest this. The drop in funding “gives strong incentives for the states to be more efficient with their program,” said Ed Haislmaier, a senior fellow at the conservative Heritage Foundation. That is, states may be able to maintain the ACA structure and regulations as long as they streamline operations.

If the streamlining turns out to be insufficient, the cuts would hit liberal states the hardest, according to a report by the Center for Budget and Policy Priorities. This is largely because they tend to be the biggest spenders on health care: They’ve expanded Medicaid and aggressively signed people up for marketplace coverage. They have the most to lose.

 On the whole, Aron-Dine says, “This is a lot more similar to the [Senate repeal bill] than different. All of them end with devastating cuts to marketplace subsidies, Medicaid, and weakening of consumer protections.”

Haislmaier agreed, pointing out the Cassidy-Graham plan was originally intended as an amendment to the Senate bill.

Here’s the nitty gritty of what would change, compared to the ACA and the Senate plan that failed in July:

Who would need to be covered

Under the Cassidy-Graham plan, the mandates would be eliminated at the federal level. States could choose to keep the measure, replace it or get rid of it completely.

How they would pay for coverage

The federal health insurance subsidies that help most people with ACA marketplace plans afford their coverage would change. This bill would shift those subsidies to the state-level, so people in some states may see their subsidy scaled back or eliminated.

Proposed changes to Medicaid

The bill would restructure Medicaid and decrease its funding. That would make it very difficult for states to maintain the Medicaid expansion.

 

Medicaid fueling opioid epidemic? New theory is challenged

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http://abcnews.go.com/Health/wireStory/medicaid-fueling-opioid-epidemic-theory-challenged-49540513

Image result for assigning blame

An intriguing new theory is gaining traction among conservative foes of the Obama-era health law: Its Medicaid expansion to low-income adults may be fueling the opioid epidemic.

If true, that would represent a shocking outcome for the Affordable Care Act. But there’s no evidence to suggest that’s happening, say university researchers who study the drug problem and are puzzled by such claims. Some even say Medicaid may be helping mitigate the consequences of the epidemic.

Circulating in conservative media, the Medicaid theory is bolstered by a private analysis produced by the Health and Human Services Department for Sen. Ron Johnson, R-Wis. The analysis says the overdose death rate rose nearly twice as much in states that expanded Medicaid compared with states that didn’t.

Independent experts say the analysis misses some crucial facts and skips standard steps that researchers use to rule out coincidences.

Johnson has asked the agency’s internal watchdog to investigate, suggesting that unscrupulous individuals may be using their new Medicaid cards to obtain large quantities of prescription painkillers and diverting the pills to street sales for profit. Diversion of pharmacy drugs has been a long-standing concern of law enforcement.

“These data appear to point to a larger problem,” Johnson wrote. “Medicaid expansion may be fueling the opioid epidemic in communities across the country.” He stopped just short of fingering Medicaid, saying more research is needed.

But if anything, university researchers say Medicaid seems to be doing the opposite of what conservatives allege.

“Medicaid is doing its job” by increasing treatment for opioid addiction, said Temple University economist Catherine Maclean, who recently published a paper on Medicaid expansion and drug treatment. “As more time passes, we may see a decline in overdoses in expansion states relative to nonexpansion states.”

Johnson is a conservative opponent of “Obamacare” who backed GOP efforts to curtail the Medicaid expansion. Wisconsin officials have urged him to push for changes in the health law to ensure the state wouldn’t be penalized for rejecting federal dollars to expand Medicaid.

Trump administration officials, including Health Secretary Tom Price and Seema Verma, head of the Centers for Medicare and Medicaid Services, have strongly criticized Medicaid, saying the program doesn’t deliver acceptable results.

Price’s agency would not answer questions about the analysis for Johnson, and released a statement instead.

“Correlation does not necessarily prove causation, and additional research is required before any conclusions can be made,” the statement said.

Translation: Just because something happens around the same time as something else, you can’t assume cause and effect. The statement said the administration is committed to fighting the opioid crisis.

Medicaid is a federal-state program that covers more than 70 million low-income people, from newborns to elderly nursing home residents and the disabled. Thirty-one states have expanded Medicaid to serve able-bodied adults, while 19 have not. The expansion went into effect in January, 2014, and the most recent national overdose death numbers are for 2015.

That leaves researchers with just a small slice of data. Both sides agree more research is needed.

Still, some patterns are emerging.

Prescriptions for medications used to treat opioid addiction in outpatient settings increased by 43 percent in Medicaid expansion states compared with states that didn’t expand, according to Maclean’s research with Brendan Saloner of Johns Hopkins Bloomberg School of Public Health. That indicates Medicaid is paying for treatment.

Maclean and Saloner also found another piece of the puzzle: Overdose death rates were higher to begin with in states that expanded Medicaid.

That’s important because it suggests that drug problems may have contributed to state decisions to expand Medicaid. States such as Ohio with high overdose rates might have wanted to leverage more federal money to help fight addiction

Maclean and Saloner looked at deaths from overdoses and fatal alcohol poisoning from 2010-2015, starting well before the Medicaid expansion. The HHS analysis for Sen. Johnson missed that underlying trend because it started with 2013 data.

When Gov. John Kasich, R-Ohio, talks about why he expanded Medicaid, “it has a lot to do with mental health and substance use disorders,” said Republican labor economist Craig Garthwaite of Northwestern University’s Kellogg School of Management.

Garthwaite finds the claim that Medicaid expansion fueled drug deaths “fundamentally flawed.”

Still another problem with the Medicaid theory is that it lumps all drug overdoses together. But illicit drugs — heroin and fentanyl — have been driving surges in deaths since 2010. A Medicaid card doesn’t provide access to illegal drugs.

“It’s worrisome because this is the type of numerical evidence that’s used to propose bad policy,” Garthwaite said.

Maclean, who reviewed the HHS analysis, said it seemed to rely on raw numbers without controlling for a range of differences among states, a standard technique.

Some researchers see hints that Medicaid expansion may be helping to mitigate the overdose epidemic.

Vanderbilt University economist Andrew Goodman-Bacon and Harvard’s Emma Sandoe drilled down to the county level in an informal analysis. From 2010 through 2015, counties with the largest insurance coverage gains experienced smaller increases in drug-related deaths than counties with smaller coverage gains.

More research is needed to provide conclusive evidence.

Relying on faulty research is “dangerous,” said Maclean. “It can lead to bad policies and people’s lives are at stake here.”

 

Data-Driven Policy Making In An Age Of Anecdotes: What Happens When A Foundation Creates A Policy Center?

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http://healthaffairs.org/blog/2017/08/31/data-driven-policy-making-in-an-age-of-anecdotes-what-happens-when-a-foundation-creates-a-policy-center/

An image of the Nashville skyline.

Why would a health foundation create a public policy research center?

The Healing Trust, in Nashville, Tennessee, has funded a wide variety of health-related service and advocacy organizations in Middle Tennessee. But in 2014, we asked them what additional support we could give to these organizations engaged in policy and advocacy work. One priority quickly rose to the top: timely, high-quality, and nonpartisan research and analysis on public policy issues critical to our community.

Tennessee has several prominent academic institutions with respected researchers in this field, but an independent and nonpartisan public policy research center simply did not exist. We began to explore this idea, using research to vet different business models for similar centers in other states. Ultimately, we decided to incubate this new policy center inside our foundation before spinning it off into a separate and independent nonprofit organization.

Aiming to create a true community resource, The Healing Trust worked with the Nelson Andrews Leadership Center to engage eighty stakeholders in an intense, three-day, co-design process. A core group of participants then spent another three months hammering out the details. This collaborative process established community buy-in and developed the road map for everything from staffing needs and board composition to the policy center’s mission, name, and brand.

Inspired and encouraged by the community’s engagement, The Healing Trust board committed $2.5 million over five years as seed funding to launch the Sycamore Institute.

Lessons Learned Through Launching The Center

What has the foundation learned through launching the Sycamore Institute, and why should philanthropy think about supporting policy research?

Ability to respond quickly in a rapidly changing policy environment: The Sycamore Institute has only been fully staffed for about six months—a period that includes one full legislative session in Tennessee and months of head-spinning debate in Congress over health reform. Yet, in that short time, our foundation’s investment has shown a solid return in the form of more than thirty reports, policy briefs, and blog posts about health policy and budget issues affecting Tennessee. As an independent public policy research center, the Sycamore Institute has the ability and agility to weigh in on rapidly evolving topics like how health reform efforts in Congress could affect our state.

Educating policy makers, the public, the media, and nonprofit partners: No matter where one stands on the political spectrum, we can all agree on the value of helping public officials make better-informed decisions. “Public Policy 101s” like how health insurance markets work and the nuts and bolts of Medicaid are just as important as analysis of specific legislation like the American Health Care Act. Our governor, administrative agencies, and legislators at the state and federal levels have already used the Sycamore Institute’s work to better understand key issues and communicate with their constituents.

These resources are equally valued by our foundation’s other grantees, who have become (1) even more knowledgeable about policy issues that affect their missions and (2) better equipped to engage with policy makers, the public, and other potential funders.

And in an era of shrinking newsrooms, the Sycamore Institute also provides important context and unbiased information to journalists covering health and fiscal policy. In very short order, the institute has become a trusted source for media outlets across Tennessee.

Unexpected Challenges

What were some of the unexpected challenges faced in launching a nonpartisan policy center?

Hiring the right leader: Hiring the right person to lead the Sycamore Institute proved more challenging than expected. The Healing Trust initially focused on candidates with backgrounds in policy research, but the collaborative design process we used shifted our focus to people with leadership experience who could launch a start-up and cultivate a diverse board. (Political, professional, geographic, and cultural diversity were all important criteria for the board.) Going back to the drawing board, our hiring committee interviewed new candidates and ultimately hired an experienced nonprofit executive director with an advanced degree in public policy.

Hiring the right staff: Building a staff with the ability to conduct high-quality research and analysis in-house and communicate about it to interested stakeholders was another challenge. Fully staffing the Sycamore Institute with an executive director, policy director, research analyst, and communications director took fourteen months—just in time to hit the ground running for the 2017 session of the Tennessee state legislature.

Recruiting a bipartisan board: To maximize and broaden the Sycamore Institute’s impact, the design shop showed we needed a bipartisan board committed to supporting nonpartisan work. The board’s balance of Republicans, Democrats, and political independents has been critical to building relationships with policy makers on both sides of the aisle. A balance of skill sets, diversity, and leadership potential is also key. With both the Sycamore Institute and its original board members based in the state capital, Nashville, recruiting additional board members from other regions of Tennessee remains a top priority.

Advocacy or analysis? Another question we wrestled with early on was where to draw the line. The primary goal of founding the Sycamore Institute was to fill a void of credible, independent, and nonpartisan analysis of policy issues in Tennessee. But should the organization go a step further to offer conclusions and recommend specific policies? Ultimately, the board and executive director decided that the Sycamore Institute would not advocate for specific policies, reasoning that doing so could hurt its credibility as a trustworthy source of politically neutral information.

Concluding Words

Building and maintaining health and well-being, which are complex issues, demand significant public and private resources. In Tennessee, as in most states, health care and education are the state’s top two budget priorities. The Sycamore Institute is dedicated to understanding and explaining the state budget and existing and proposed laws that affect the health and well-being of Tennesseans. Its information has already enabled citizens, policy makers, nonprofit agencies, foundations, media outlets, service providers, and others to understand better the fiscal and human impact of pending policies, giving stakeholders a nonpartisan and informed stake in the process and the outcomes.

Special Report—How to fix the Affordable Care Act

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Click to access FierceHealthcare-HowtofixtheAffordaleCareAct.pdf

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As Congress prepares to get back to business, the industry is holding its collective breath to see if healthcare reform will fall off the agenda. It’s pretty clear that rushing through repeal, replace or repair legislation or letting the Affordable Care Act fail isn’t the answer. In this special report, FierceHealthcare’s editors—experts on the business of healthcare—outline ways to fix the nation’s healthcare system.

Sutter will shift 10,000 Anthem Medi-Cal enrollees to community health centers

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http://www.sacbee.com/news/local/health-and-medicine/article167900272.html

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In Sacramento and Placer counties, roughly 10,000 adult Medi-Cal enrollees with Anthem Blue Cross are learning this summer that Sutter’s primary-care doctors will no longer see them.

Instead, those patients are being shifted to primary-care doctors at community health centers such as Sacramento’s WellSpace Health or Auburn’s Chapa-De Indian Health, said Dr. Ken Ashley, the medical director for primary care at Sutter Medical Group. He said the change in providers will allow the patients to access more services.

“Some of the things that the (community health centers) can provide with the funding that they are receiving are things that sometimes we struggle to find for our Medi-Cal patients, things like optometry and dental, behavioral medicine,” Ashley said. “I feel like these patients are finally going to receive things I could not provide as their primary-care doctor. I’m OK with our partners helping to take care of these patients.”

Sutter, Dignity Health, UC Davis and other providers have all contributed funding and expertise to expand the network of community health centers, more formally known as federally qualified health centers.

The so-called FQHC’s have long been the primary-care delivery network for uninsured, low-income people across the country, but Sacramento did not have a strong network of the centers until the Affordable Care Act set aside funding to help them grow to meet the needs of an expanding Medicaid population.

That flood of new patients has swamped many primary-care providers and has made it harder for all patients to get appointments through commercial providers, Ashley said. Meanwhile, in meetings with the leaders of local FQHC’s, he and other leaders were hearing how those organizations had expanded services, lengthened hours and had capacity for more patients.

About a year ago at one of the meetings, Ashley said, all the attendees began to feel that, if they could shift Anthem’s adult Medi-Cal enrollees, they would improve the health of the primary-care delivery system for a broad set of customers.

“We’ve been having a difficult time getting all our patients in at the time they would like, where they would like,” Ashley said. “This is one more step to try to help allow the rest of the community to help us take care of all these patients.”

Jonathan Porteus, the CEO of Wellspace Health, also leads the Central Valley Health Network, a group of health centers up and down the Central Valley that manage almost 3 million visits a year. He said that Anthem began earlier this year investigating whether the FQHC’s truly had the capacity to absorb the adult Medi-Cal patients served through Sutter.

“We were notified – we being the federally qualified health centers – that this change was coming and that there was a keen interest to make sure that it was smooth, that people would not be left without access,” Porteus said. “The wisdom of Sutter and others has been to help our region have a network of federally qualified health centers, a true blanket of care for the first time ever. This is one of the early tests.”

Porteus said he knows that people have questions about whether the quality of care at his centers is on par with what they would receive from primary-care doctors. He said he welcomes those questions because they give him an opportunity to tell the WellSpace story.

“The Joint Commission, which is the accrediting body that accredits hospitals and shuts them down if they don’t think they’re good enough, has accredited us to be a patient-centered medical home, has accredited all our behavioral health,” Porteus said. “This is a standard many of our commercial colleagues in this community don’t have. If you went into some of these primary-care practices and asked them if they had Joint Commission accreditation for ambulatory care, they will tell you ‘no.’”

There will unquestionably be upheaval in this process for both doctors and patients, Ashley said.

Sutter’s pediatricians will continue to provide primary-care to Medi-Cal-enrolled children covered by Anthem Blue , and the insurer’s Medi-Cal enrollees also still will be able to access Sutter specialists. Sutter primary-care doctors will continue to see anyone on Regular Medi-Cal recipients whose medical providers are paid directly by the government.