Category Archives: Preventive medicine

CBO Projections for Impact of the GOP’s ACA-Repeal Plans on Healthcare Coverage and Premiums

At 1:30 AM, January 12, 2017, the Senate passed a budget resolution to repeal the Affordable Care Act (ACA), with a party-line vote (51-48). A budget resolution needs only  a simple majority to pass and thus represented the Republican Party’s quickest avenue to repeal the ACA. Congressional Republicans are pursuing a plan that would repeal parts of the law in early 2017 via budget reconciliation (see below for which parts), but may delay enacting a new system for up to three years (i.e. they plan to defund the ACA’s key coverage provisions, but delay a replacement).

On January 17, 2017, the nonpartisan Congressional Budget Office (CBO) released a report on how ACA repeal would affect health insurance coverage and premiums. The CBO assumed the repeal plan would be similar to that adopted by Congress in 2015 (sponsored by Congressman Tom Price, Donald Trump’s nominee for secretary of Health and Human Services, and vetoed by President Obama). The bill Congress passed did not contain policies intended to replace the ACA, presumably because a consensus did not exist on what form such an alternative should take. It is unlikely that supporters of ACA repeal will have agreed on an alternative before voting on repeal. Based on the 2015 legislation, the CBO report assumes that the forthcoming reconciliation legislation will do the following:

  • repeal
    • the individual mandate penalties
    • after a delay of two years, the premium tax credits and Medicaid expansions
  • leave intact the ACA’s insurance reforms (cannot be amended through reconciliation under the Senate’s reconciliation rules)–including
    • essential health benefit
    • actuarial value requirements
    • limitations on health status underwriting
    • limitations on pre-existing condition exclusions
    • rating requirements that allow premiums to vary only based on age, geographic locations, and tobacco use (and not on sex).

 

CBO Projections of Impact on Health Insurance Coverage:

If Congress does not repeal the ACA’s insurance reforms (listed above):

  • 2017: No immediate dramatic effect because premium increases would already be established and enrollment set
  • 2018: 18 million people would become uninsured, including 10 million fewer enrollees in the nongroup (or individual) insurance market, 5 million fewer with Medicaid coverage, and 3 million fewer with employment coverage.
  • 2020: (following repeal of the Medicaid expansions and premium tax credits): 27 million will have become uninsured
  • 2026: 32 million will have become uninsured (23 million fewer nongroup market enrollees, 19 million fewer covered by Medicaid, and 11 million more enrolled in employer coverage)
  • These increases would be due to a combination of people dropping coverage because it was no longer mandated and to insurers abandoning the nongroup market and increasing premiums because of adverse selection concerns.

If Congress does repeal the ACA’s insurance reforms (listed above):

  • 2026: 59 million would be uninsured; 21 percent of the population.

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CBO Projections of Impact on Health Insurance Coverage:

  • 2018: insurers would increase premiums by 20 to 25 percent
  • 2018: insurers in some areas would leave the nongroup market in anticipation of further reductions in enrollment and higher average health care costs among enrollees who remained after the subsidies for insurance purchased through the marketplaces were eliminated. As a consequence, roughly 10 percent of the population would be living in an area that had no insurer participating in the nongroup market.
  • 2020: nongroup market premiums would increase by 50 percent relative to current law projections and about half of the population would live in states with no insurer participation in the nongroup market
  • 2026: nongroup market premiums would double and three-quarters of the population would live in states with no insurers in the nongroup market. Fewer than 2 million people would have nongroup market coverage.

The Urban Institute has released a similar Report on the Implications of Partial Repeal of the ACA through Reconciliatioin December 2016, using the same 2015 bill as the model for the 2017 reconciliation bill repeal.

The key effects of the passage of the anticipated reconciliation bill are as follows, quoted verbatim from the report’s Abstract:

  • The number of uninsured people would rise from 28.9 million to 58.7 million in 2019, an increase of 29.8 million people (103 percent). The share of non-elderly people without insurance would increase from 11 percent to 21 percent, a higher rate of uninsurance than before the ACA because of the disruption to the non-group insurance market.slide2
  • Of the 29.8 million newly uninsured, 22.5 million people become uninsured as a result of eliminating the premium tax credits, the Medicaid expansion, and the individual mandate. The additional 7.3 million people become uninsured because of the near collapse of the non-group insurance market.slide1
  • Eighty-two percent of the people becoming uninsured would be in working families, 38 percent would be aged 18 to 34, and 56 percent would be non-Hispanic whites. Eighty percent of adults becoming uninsured would not have college degrees.
  • There would be 12.9 million fewer people with Medicaid or CHIP coverage in 2019.
  • Approximately 9.3 million people who would have received tax credits for private non-group health coverage in 2019 would no longer receive assistance.
  • Federal government spending on health care for the non-elderly would be reduced by $109 billion in 2019 and by $1.3 trillion from 2019 to 2028 because the Medicaid expansion, premium tax credits, and cost-sharing assistance would be eliminated.
  • State spending on Medicaid and CHIP would fall by $76 billion between 2019 and 2028. Also, because of the larger number of uninsured, financial pressures on state and local governments and health care providers (hospitals, physicians, pharmaceutical manufacturers, etc.) would increase dramatically. This financial pressure would result from the newly uninsured seeking an additional $1.1 trillion in uncompensated care between 2019 and 2028.
  • The 2016 reconciliation bill did not increase funding for uncompensated care beyond current levels. Unless different action is taken, the approach will place very large increases in demand for uncompensated care on state and local governments and providers. The increase in services sought by the uninsured is unlikely to be fully financed, leading to even greater financial burdens on the uninsured and higher levels of unmet need for health care services.
  • If Congress partially repeals the ACA with a reconciliation bill like that vetoed in January 2016 and eliminates the individual and employer mandates immediately, in the midst of an already established plan year, a significant market disruption would occur. Some people would stop paying premiums, and insurers would suffer substantial financial losses (about $3 billion); the number of uninsured would increase right away (by 4.3 million people); at least some insurers would leave the non-group market midyear harming consumers financially.
  • Many, if not most, insurers are unlikely to participate in Marketplaces in 2018—even with tax credits and cost-sharing reductions still in place—if the individual mandate is not enforced starting in 2017. A precipitous drop in insurer participation is even more likely if the cost-sharing assistance is discontinued (as related to the House v. Burwell case) or if some additional financial support to the insurers to offset their increased risk is not provided.

The Urban Institute’s report concludes:

This scenario does not just move the country back to the situation before the ACA. It moves the country to a situation with higher uninsurance rates than was the case before the ACA’s reforms. To replace the ACA after reconciliation with new policies designed to increase insurance coverage, the federal government would have to raise new taxes, substantially cut spending, or increase the deficit.

Retail Urgent Care Clinics Do Not Decrease Emergency Department Visits

A study published online today in Annals of Emergency Medicine (“Association Between the Opening of Retail Clinics and Low-Acuity Emergency Department Visits”) demonstrated that, contrary to expectations, retail clinics had little effect on rates of low-acuity visits to nearby emergency departments (EDs). This contradicts the popular theory that retail clinics would reduce ED visits.  A 2015 report “Building a Culture of Health: The Value Proposition of Retail Clinics“, found that consumer use of retail clinics was rising, with consumers citing convenient hours/location and perceived lower cost as the main reasons for choosing retail clinics for care. Another study projected that 13% to 27% of US ED visits could be treated in retail clinic settings, with an estimated cost savings of $4.4 billion.

However, this theory did not align with the new study’s findings. During the study period (2007-2012), the number of retail clinics grew from 130 to nearly 1,400 in the 23 states studied. During the same period, the rate of retail clinic penetration – in other words, the proportion of each ED’s catchment area that overlaps with a 10-minute drive radius of a retail clinic – more than doubled (8.1 to 16.4).

In the 2,053 emergency departments in these states, more retail clinics did not correlate with fewer low-acuity ED visits; however, increased retail clinic density did correlate with a slight reduction in the subset of low-acuity visits, albeit only among the privately insured. As an example, for an ED with 40,000 annual visits and 50% private insurance, there would be approximately 8 fewer visits per year for each 10% increase in retail clinic density.

 

The accompanying editorial offers three theories as to why retail clinics increase health care use:

  1. They meet unmet demands for care. The demand for episodic acute care often exceeds the supply of physicians or facilities in many communities, and retail clinics attempt to meet this need.
  2. Motivations for seeking care differ in EDs and retail clinics. A patient who might otherwise not seek care for a cough would stop by the neighborhood retail clinic but would not invest the time and travel to schedule an appointment with their medical home or risk a long ED wait.
  3. Groups of people who are more likely to use EDs for low-acuity conditions–particularly patients withMedicaid and ED super-users–do so because they have little access to other types of care, including retail clinics. Retail clinics follow the money–they locate in affluent areas in which few Medicaid patients live. Also, Medicaid plans often do not cover retail clinic use.  ED superusers commonly have Medicaid insurance and infrequently live in affluent neighborhoods, and often have complex medical/mental health conditions that cannot be cared for in retail clinics.

As an ED physician, my primary concern is that these clinics introduce added fragmentation into an already fragmented health care system. I treat many patients who have sought care for an illness from 1-2 different retail clinics in the past week, without seeing their regular doctor, and then end up in my ED with no record (other than the patient’s recollection) of what happened at those clinics and why. I do my best to reconstruct the story–the antibiotics given for the sore throat on Monday at one retail clinic where they did not check a strep test, followed by a visit to a second retail clinic on Wednesday for the ongoing sore throat where they sold them different antibiotics from the co-located pharmacy and where they did check a strep test and some type of blood test that were both negative–and make a coherent decision based on guessing why each retail clinic did what it did and how the patient is today.

A second concern is illustrated by my patient anecdote. Retail clinics tend to compete with primary care providers for patient business, and, in so doing, they prescribe more antibiotics to meet patients’ expectations.

If patients continue to vote with their feet, using convenient retail clinics in lieu of their primary care providers, my hope is that we find a way to better integrate them into the healthcare system so that we are all working collaboratively to best serve the patient.

 

Two most common pediatric migraine medications no more effective than placebo

Neither of the two drugs used most frequently to prevent migraines in children–amitriptyline and topiramate–is more effective than a placebo, according to results of the Childhood and Adolescent Migraine Prevention (CHAMP) trial published this week in The New England Journal of Medicine. The investigators found no significant differences in reduction in headache frequency or headache-related disability in childhood and adolescent migraine with amitriptyline, topiramate, or placebo over a period of 24 weeks.

The active drugs were associated with higher rates of adverse events. One child on topiramate attempted suicide. Three taking amitriptyline had mood changes; one told his mother he wanted to hurt himself, while another wrote suicide notes at school and was hospitalized.screen-shot-2016-10-28-at-4-01-47-pm

Migraine headaches are common in children. Up to 11 percent of 7- to 11-year-olds and 23 percent of 15-year-olds have migraines.

Medical ecology: tending the microbiome

Today, the Obama administration announces the new National Microbiome Initiative, intended to create scientific tools, discoveries and training techniques related to the human microbiome, the 100 trillion microbes that live in the human body. Tending the human microbiome may help in the treatment of infections, as well as disorders that would seem unrelated to microbes, including obesity and diabetes.

The microbiome represents the only organ that can be replaced without surgery,” said Jo Handelsman, a microbiologist at the White House. “Just by eating differently, taking drugs, exercising and other things, you can have fairly immediate effects on your microbiome and your health, if we only knew how.”

Microbiome research also has important public health implications. New research, for instance, suggests that much of the world’s childhood malnutrition arises not from a lack of food, but from problems with children’s intestinal microbiomes caused by poor sanitation.India-Sanitation-web-Artboard_1

The Minimum Wage and the Social Determinants of Mental Health

A new study in Health Economics shows a temporal association between Britain’s minimum wage law and substantially improved mental health of the low wage workers benefitting from the policy.

Source: The Minimum Wage and the Social Determinants of Mental Health

Should Doctors Undergo Opioid Prescribing Risk Training?

Earlier this week, an advisory panel recommended that the Food and Drug Administration require doctors who prescribe painkillers s to undergo training aimed at reducing misuse and abuse of the medications. The New York Times notes:

It is the second time since 2010 that an F.D.A. panel has recommended expanding safety measures for painkillers. But the training plans instituted about four years ago are voluntary, and data shows that under half of the doctors targeted by the effort have completed the training.

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Despite the rising opioid-related death rate since the initial FDA panel’s initial recommendation in 2010, the panel strongly recommended training physicians. Given the amount of training we all underwent in preparation for US cases during the most recent Ebola epidemic, the physician training for this pandemic, far more deadly on our shores, seems both feasible and urgent.

More evidence-concordant FDA guidelines increase access to mifepristone

As covered in the New York Times, this week the Food and Drug Administration relaxed the guidelines for taking mifepristone (Mifiprex, formerly RU-486), a pill that induces abortion, reviving one of the most contentious issues of the abortion debate. The change brings the directions for taking the drug, mifepristone, in line with what has become standard medical practice in most states: reducing t31abortion-articleLargehe dosage to 200 milligrams from 600 milligrams, decreasing the number of visits a woman must make to a doctor to two from three, and extending the period when she can take the pill to 10 weeks of pregnancy from seven weeks.

Medication-induced abortions are increasingly common–accounting for a quarter of all abortions in 2011 according to the most recent figures from the Guttmacher Institute–and thus limiting their access has been a target of the anti-abortion movement. In some states, they have succeeded in passing laws restricting use of mifepristone, including requiring medical professionals who administer the drug to be licensed physicians, rather than nurses or physician assistants and requiring the prescribing doctor to be present with the patient when she puts the medication in her mouth. Laws requiring physicians to adhere to the FDA guidelines on the label have also passed in Arkansas, Oklahoma, and Arizona, but have been blocked by court order. Several states required that physicians adhere to the FDA guidelines which used to be based on a regimen for mifepristone developed in Europe in the late 1980s. In this week’s action, the FDA updated their regimen to reflect newer evidence supporting a simpler regimen that has been shown to be just as effective while using less medication, resulting in fewer side effects and requiring fewer visits to the provider.