Health Policy

A Supreme Day - In Photos

July 3, 2012

On Wednesday, June 27th my roommate convinced me that we should give up the comfort of our intern-housing beds for the cold hard concrete of justice and the company of other "Supreme nerds," waiting in line to witness the historic ruling on the ACA.  I'm usually not that compulsive, and I resisted at first. After some powerful persuasion, I eventually consented to go.  Interning here in DC this summer has presented me with many invaluable opportunities, but none has been as amazing as what awaited me next morning.  I owe my roommate a big "Thank you" for not succumbing to my stubbornness.

You could feel the excitement in the air.  Most of us were students or recent graduates, interns or nearby residents. Many didn't sleep that night, choosing instead to stay up night sharing opinions and speculations. Some finally succumbed to exhaustion.

We woke up in a sea of cameras. At 5:00 AM there were more camera crews set up than at 10:00am on Monday, when the Arizona case was released.  

As the morning wore on, I found myself constantly mulling over what might happen inside that beautiful building later that day. This would be among the most important, far-reaching cases of my lifetime.  

Politically I have always found a bit of both sides in myself.  With conservatives, I share concerns about the growing powers of government.  I was wary of the expansion of power that upholding the mandate would grant to Congress's interpretation of the Commerce Clause. (Yes--I was concerned about the broccoli argument.)

On the other hand, as I have learned more about the Affordable Care Act, it has become more and more appealing.  As a future physician I love the patient protections and expanded access that the health care law provides.  I also believe that sometimes the spirit of the law is more important than the letter of the law.

I hoped for a ruling that satisfied my views on both ends of the spectrum.  

While we waited inside I talked with a political science major from Johns Hopkins University.  When I asked her how she would respond to someone who believes that the ACA violates the Constitution she told me about her "Comparating Constitutions" class.  

"Under the United States Constitution, the government would not be violating its duty if it just sat back and did nothing," she said.  "Other countries' constitutions  have specific provisions written in them that forbid the government from doing nothing.  They have to provide certain services. Because of this, they are much more welcoming of big social changes like health care reform." When I asked if she advocates amending the constitution to have such duties she said, "Well, that's so long and difficult."

Her attitude surprised me.  In effect, she was saying, "Yeah, I realize there are limits in our Constitution, but they shouldn't get in the way of doing what society believes is right." 

Eventually we were shown upstairs to a room with small lockers where we were told to leave all electronic devices and other personal items.  From there we were directed to the courtroom where we waited and whispered for half an hour. Despite my profound lack of sleep, as soon as the Justices walked in a surge of adrenaline flooded my body.  No one but this relatively small group of people I was sitting with would ever witness these words uttered out of Justice Roberts's, Ginsburg's and Kennedy's mouths.  It was amazing to think that I was watching history before anyone else.  

The mandate was found unconstitutional under the Commerce Clause, but constitutional under the taxing power, and the rest of the law stood with it. (The Court did overturn the expansion of Medicaid as coercive, but the only part that was actually removed was the threat of removing all Medicaid funding for states that choose to opt out of the expansion.) I don't think there was a soul there who saw what was coming. As for me, I was elated! Upholding most of the ACA meant that meaningful health care reform would continue, and the check on the Commerce Clause abated my fears of growing Congressional power. Both of my concerns had been addressed.

I was surprised, however, by the "strike-the-whole-thing-down" position taken by the four justices who wrote the dissent.  As I see it, there are many parts of the ACA that are completely constitutional. The opinion of the dissenters seemed to be the mirror opposite of the opinion I had heard from the political science student just an hour earlier. According to the dissent's view of Congress's taxing and spending power, "the Court has long since expanded that beyond ... taxing and spending for those aspects of the general welfare that were within the Federal Government's enumerated powers." They cited "the Department of Education, the Department of Health and Human Services, [and] the Department of Housing and Urban Development" as "sizeable federal Departments devoted to subjects not mentioned among Congress' enumerated powers, and only marginally related to commerce."

In other words, they were saying, "Yeah, these agencies are solving pressing problems, but they extend beyond Congress's constitutional powers." Under similar logic, they argued that the whole Affordable Care Act should be struck down.

Picture:  Associated Press

After the Court finished the rulings, and the term, we were quickly ushered outside.  

Michelle Bachman was on a loudspeaker in the middle of the Tea Party crowd, insisting that since the justices had failed it now falls to the voters to repeal Obamacare.  She was drowned out, at times, by boos and chants of "Four more years" by people holding "we love Obamacare" and "stand up for women's health" signs.

 I stopped to ask a woman holding a "Protecting Our Care" sign what she thought about the ruling.  She was happy, of course, that the law had been upheld.  I followed up by asking her what she thought about Justice Roberts' ruling that the mandate doesn't stand under the Commerce Clause yet does stand under the taxing power.  She gave me a confused look and said, "I don't know what you're talking about."  Caught off guard, I awkwardly ended the conversation as I came to a profound realization:  most of these people here don't care about the specifics.  They're not here to find out how all the details play out.  

I would venture a guess that nearly everyone there that day would very comfortably identify themselves with one of two groups: those for limited government or for social justice.  In each group, as long as their ends are met, the details aren't important.  The limited government crowd wanted the law overturned--despite the fact that our health care system is on life support and millions don't have access to care.  The social justice crowd was elated by the ruling--regardless of its implications for the federal government's power.

In contrast to these groups, Court's job is only to determine whether the law in question is Constitutional--nothing more, nothing less.  As Justice Roberts put it, "we possess neither the expertise nor the prerogative to make policy judgments. Those decisions are entrusted to our Nation’s elected leaders, who can be thrown out of office if the people disagree with them." 

In that sense, it seems like this discussion--between two parties who care more about the ends than the means--is sort of out of place in front of the institution that is primarily concerned with the means. It was precisely the means, the details, that allowed me to feel like the day had been a win-win. By knowing the specifics of the law and the case against it, I felt like I was the only one reveling in a two-sided victory!

If the limited government crowd would have paid a little more attention to the details they may have found a silver lining in their defeat--the ruling on the Medicaid provision could end up being a major limit on federal power over the states, and some liberal bloggers have been complaining that the Court's ruling has "gutted the commerce clause."

Instead of examining the ruling, the groups were too busy volleying taglines. When this type of one way discussion takes place and people disregard the details, they tend to talk past each other.  The result is conflicting, often embarrasing, messages...

...like this:    

...or polls like this (CBS News/NY Times):  

And yet, while it might not always make sense, we have a long tradition of protesting in front of the Supreme Court.  I'm not suggesting that should end. Nor am I suggesting that we need to avoid the use of hyperbole to get one's point across.  Sometimes it can be entertaining.

But, are the two positions really irreconcilable? Can we fix the health care system and still keep limits on governmental power?  I believe we can, and I believe that is what we saw last Thursday.

Politics will continue to play on, speculations about Justice Roberts's reasoning will continue, but if we want to get things done we need to stop talking past each other, care enough to see what the other side has to offer, and build off our common ground.  

In the coming months and years, health care reform must continue. The ACA, though a good step forward, is far from a complete solution to the health care crisis. We have some tough questions ahead of us involving the quality and cost of care. Solving these problems will require our meaningful dialogue and thoughtful consideration of the details.

And by considering the details we may just discover, like I did, that solving problems doesn't have to be one-sided. We can find a middle-of-the-road solution that covers everyone's needs. That way, no one has to feel like they are "left out in the open."

The Supreme Court has Ruled on the ACA

June 28, 2012
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After a tense last two weeks of the term, the Supreme Court has handed down its ruling for the cases challenging the Affordable Care Act (Florida v. Department of Health and Human Services, Dep't of Health and Human Services v. Florida, and National Federation of Independent Businesses v. Sebelius). The court voted 5-4 to uphold the entirety of the law, under a different justification than many people expected.  Here's the link to the opinion (majority opinion by Chief Justice Roberts; concurrence by Justice Ginsburg, dissent by Justice Kennedy):  http://www.supremecourt.gov/opinions/11pdf/11-393c3a2.pdf. Please be patient if the opinion doesn't load right away--the Court's servers tend to get overwhelmed. The decision is also uploaded as an attachment on this post (on the right side of the page).

If you need a refresher on what the cases are about, here's our pre-oral argument summary, and our post-argument comments.

We're going to take our time reading the opinion, because we want to give you the our best analysis of what this means for the law, the health insurance and delivery system reforms already in progress, and the problems of unnecessary care and healthcare waste in general. We'll be back soon with our thoughts. In the meantime, follow us on Twitter (@NewHealthDialog) for immediate reactions!

The Number of the Day and ER alternatives

June 26, 2012
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The number of the day is 222—the international dialing code for Mauritania.  More interestingly, 222 is the number of nationwide ER visits per minute in 2011, according to the 2007 Emergency Department Summary from the National Hospital Ambulatory Medical Care Survey (NHAMCS). Across the year that amounts to “116.8 million ER visits or 39.4 visits per 100 persons.”

Last Monday the Alliance for Health Reform held a Briefing addressing this topic: "The Right Care at the Right Time:  Are Retail Clinics Meeting a Need?" The briefing was sponsored by the Alliance and WellPoint, Inc. to examine the question of whether urgent care clinics and retail care clinics (together called convenient care clinics) are meeting a need in the health care system. The panelists at the event included physicians from WellPoint, RAND Health, and the American Academy of Family Physicians (AAFP). The president of the trade association for retail clinics, the Convenient Care Association, was also on the panel. The conclusion of everyone present was that convenient care clinics are meeting a need. In a broader sense, their findings also presented a strong case for a reinvestment in and retooling of the primary care system, as a whole.

The use of emergency departments has been on the rise for many years. Contrary to popular belief, a Senate hearing reported that the main increase in traffic is not due to increased utilization by uninsured patients. Instead, the largest increase has been seen in those with private insurance.  The report also listed that "physician office visits have increased at an even higher rate than emergency department visits." They suggest that the concurrent increase in ER visits reflects a growing increase in demands for ambulatory care services, and that some of that demand is spilling over into the ER.

Urgent care clinics, like NextCare Urgent Care, and retail care clinics, like CVS’s “Minute Clinic,” are perfectly poised to benefit from this spillover (and the numbers show that they have).  They are open more hours than primary care offices, and cost less than the emergency rooms.  Granted, if you suddenly lose feeling on the left side of your body and start to slur your speech you are not going to stop to consider this dilemma, but ERs across the country already see a steady stream of people who are not in such life or death situations (ask any ER doc).  In fact, one of the panelists pointed out that nearly 25% of ER visits could be safely seen at other sites.  For the working single mom, whose daughter developed a fever of 101 on Saturday night, a quick Sunday morning visit to the nearest urgent care clinic will no doubt be preferred over an expensive 4 hour long ordeal at the ER.  And their transparent prices make it a feasible option for the cost conscious patient.

Rick Kellerman, former president of the American Academy of Family Physicians (AAFP), was the panelist representing traditional family physicians. As one might expect, family physicians initially felt threatened by the convenient care movement—especially by retail clinics, which are usually staffed with physician assistants or nurse practitioners. While many of their concerns (fragmentation of medical care, decreased care coordination, “medicalization of symptoms”) persist to this day, Kellerman said that the AAFP eventually told their members that they needed to wake up to the demands of their patients: “If you don’t like retail clinics, change the way you practice.” Subsequently, many physicians responded by offering changes such as extended hours, open appointments for call-ins, “quick clinics” for walk-ins with minor problems, and group appointments for chronic disease management. Many of these doctors have embraced the movement by partnering with clinics in order to get referrals or becoming supervisors of clinics. In forming such partnerships, these physicians are offering their patients a way to get setting of care that hopefully will combine the cost-consciousness and convenience of an urgent care clinic with the benefits of a long-term doctor-patient relationship and better-coordinated care.

While disagreements remain, the facts show that convenient care clinics are increasingly common, while the number of medical students going into family medicine is decreasing.  The convenient care movement has flourished in part because the status quo in health care is failing.  Regardless of what happens to the Affordable Care Act in the upcoming days, policy makers need to work toward a solution to the primary care problem—a solution that includes both convenient care clinics and traditional primary care. Everyone--primary care docs, retail and urgent care clinics, ER docs, and patients can benefit from making sure people are treated in the right place at the right time

If you want to find out more, here’s a link to the materials from the briefing.

A Market-based Case for the ACA

June 20, 2012
Waiting for Robbo

The Supreme Court will soon pass down their decision on the most hotly-contested and highly influential policy decisions in recent years:  the Affordable Care Act (ACA).  As CNN has put it, this is "an issue that affects every American."  If fully implemented, the ACA is projected to extend coverage to millions of Americans—a huge victory for universal coverage advocates.  It has also received opposition from those who claim that it represents an unprecedented intrusion of government into the free market.  But free market lovers also have reasons to cross their fingers that the ACA will be upheld in its entirety.  Here's why:

1.  The ACA is market friendly: The ACA is among the most market driven universal health care proposals that has, to date, been tried in other universal health care systems around the world—beat only, perhaps, by the Swiss model.   Ezra Klein shares this view:  “I think conservatives would be smart to embrace the Affordable Care Act structure…giving private insurance a central role in those markets and leaving us with a health system that looks more like Switzerland than like Canada.”  

Many free market advocates point to the fact that our current insurance structure is the problem—patients are shielded from the costs of their medical care, so market forces don't play into their choices.  The ACA will, to some extent, level the playing field in that area.  The creation of state insurance exchanges, with minimum coverage requirements, demystify the health care shopping process, allowing patients to compare apples to apples and buy a plan based on the best value.  Unlike systems in other countries, where government officials negotiate prices, this will force insurance companies to compete for your business, pushing them to provide the best service at the cheapest price.  As Austin Frakt puts it, "That's, essentially, competitive bidding."   The ACA allows the private markets to stay in the game, increases competition, and buys us more time to tinker with free market solutions to escalating costs.

2.  Inaction will kill us:  Inaction—the very thing that the anti-ACA legal case claimed the government is trying to regulate—is the thing that will bring us down.  The rising cost of health care is unsustainable and represents, according to the bipartisan Social Security Advisory Board, "perhaps the most significant threat to the long-term economic security of workers and retirees."  If something isn't done, we will be spending one of every five dollars on health care by 2020.  Imagine the jobs that could be created if we weren't paying so much to the health care system!  (And no: more health care jobs are not always a good thing!)

Some sort of major health system reform is coming in the next decade or two, regardless of how the Supreme Court rules.  As a nation we will soon come to the point when we have to decide if we want to keep spending a fifth (or a fourth? a third?!) of our paychecks on health care. We can either willingly enter the realm of 21st century health insurance (like the rest of our industrialized buddies), or we can have our tattered economic carcass dragged there when our ever-burgeoning health care costs squash other economic activity.  Fast forward fifty years to when more than a third of our GDP--one third of all economic activity--goes to pay for health care.  At that point, public and market pressure will force the government to move to contain costs, and it's hard to imagine they'll do anything 'market friendly.'  Then will free market advocates look back, longingly, to a time when we could have had a health care system with maximum free market involvement?  

We are waiting with bated breath to see how the court will rule.  Regardless of what happens, one group will bemoan the end of the world and another will throw a party.  Free market advocates should think twice about where they would be most comfortable.

Mass. Has Too Many Hospitals for Its Own Good

  • By
  • Shannon Brownlee,
  • New America Foundation
June 15, 2012 |
Take a walk down practically any major thoroughfare in the city of Boston, and you’ll be hard pressed to go more than a few blocks without running into a hospital. The cities of Cambridge and Boston have nine hospitals and medical centers between them, and a whopping two dozen hospitals are packed into the greater Boston metropolitan area.
 
Knowing that state-of-the-art medical help is always close at hand is probably a comforting feeling. But it shouldn’t be.

The Number of the Day

June 12, 2012

The number of the day:  11%

That's right, kiddos.  The number of the day is 11%--the probability of randomly picking Grumpy if Snow White, the Seven Dwarves, and Prince Charming all sit down for tea... or, in this case, the 11% of people in the US, according to the CDC, who are taking five or more prescribed medicines. 

You read that right.  One in nine Americans is taking five or more prescription drugs.  In the medical world we call that "polypharmacy," and it makes the doctor's job a lot harder. Each new medicine that is introduced into your body increases the chance of drug-drug interactions with undesirable side effects. While practitioners receive extensive training on how these drugs interact and which ones not to combine, there still remains a risk associated with polypharmacy. The more possible interactions, the more likely it is that a doctor might miss one. That becomes even more likely when the evidence on drug interactions can be flawed, incomplete, or falsified. Having so many people on so many drugs is practically begging for errors to happen.

Such a suggestion is made by Jeanne Lenzer in a recent article published in the BMJ.  Lenzer cited a report from the Institute for Safe Medication Practices (ISMP) which "calculated that in 2011 prescription drugs were associated with two to four million people in the US experiencing serious, disabling, or fatal injuries, and 128,000 deaths."

Leading this pack of oft-misused drugs are anticoagulants like warfarin, which the authors report "prevents ischemic strokes in approximately 1% of high risk patients a year, but causes major bleeding in an estimated 3%."  Other harm-causing drugs include an antibiotic (levofloxacin); a cancer drug (carboplatin) and a hypertension drug (lisinopril).

Numbers like 11% suggest that we need to re-evaluate the safety and effectiveness of many "standard" practices.  Numbers like 11% contribute to the staggering 128,000 deaths associated with prescription drugs--that's 10 times the number of people killed in drunk driving accidents each year.  It's not surprising, then, that ISMP calls prescribed medicines "one of the most significant perils to human health resulting from human activity."  We have Mothers Against Drunk Driving, but maybe it's time for Mothers Against Profligate Prescription.

Why Americans Need Bloomberg's Big Gulp Ban

  • By
  • Shannon Brownlee,
  • New America Foundation
June 4, 2012 |

Last week, New York city mayor Michael Bloomberg announced a plan to ban sales of sugary beverages larger than 16 ounces. The ban would apply to both bottled soda and fountain drinks containing more than 25 calories per eight ounces, but would exempt alcohol, fruit juice, or any beverage that’s at least half milk. That means that the city’s 20,000 restaurants, coffee shops, food carts, movie theaters, and stadiums will no longer be able to sell empty calories in supersize portions.

Drinks "gigantic enough for a small marine mammal to do laps in."

June 4, 2012
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New York Mayor Mike Bloomberg's most recent public health proposal, to limit sugary beverages to 16 ounces in restaurants, theaters, food carts, and stadiums, has provoked a bit of controversy.

OK, that might be an understatement. The reaction has included furious opposition people claiming this is the nanny state run amok, applause from anti-obesity groups, and a fair amount of confusion over what, exactly, the policy will accomplish. Ta-Nehisi Coates, blogging at The Atlantic, asked for more information on how it might work, so here's the rationale: There is extensive evidence from psychology and behavioral economics that people respond to larger portions by eating more. The classic experiment in the field was run by Cornell researcher Brian Wansink: his team gave random sets of subjects either large or small buckets of popcorn, and tested how much they ate during a movie. People with larger buckets ate over 30% more than people with smaller buckets. The effect persisted even when they ran the experiment with  popcorn that was two weeks old: while subjects agreed that the popcorn didn’t taste good, they still ate it, and larger buckets still made people eat more.

The main thing that the ban could accomplish is to help people who just want a soda with lunch drink less of it. There are hundreds of thousands of people in New York every day who get a soda at lunch, and don't really care about how big it is. They want enough to wash down their pastrami on rye.  Those people will be perfectly content with 16 ounces instead of 24, and they'll probably end up drinking less because of the change. By drinking just a few ounces less a day, they can cut a few hundred calories out of each week. That adds up.

The size limit isn't the only option that might work to reduce soda consumption--Bloomberg pushed for a soda tax at the state level in 2010, but it died in the legislature--but nor is it as random as it initially appears. If it's enacted (which it probably will be: the Mayor has solid control over the Board of Health), it has a real chance to do some good.

And now, a collection of the reporting and opinions expressed so far:

Our own Shannon Brownlee has a piece up at TIME Ideas laying out the fast-food economics that created half-gallon sodas in the first place. http://ideas.time.com/2012/06/04/why-americans-need-bloombergs-big-gulp-ban/

Former New York Times restaurant critic Frank Bruni has an excellent take: with nearly a third of our adult population obese and facing serious health consequences, we're beyond the point of gentle nudges. There is a crisis, and Bloomberg is on the right track. This piece also provided the title of this post. http://www.nytimes.com/2012/06/03/opinion/sunday/bruni-trimming-a-fat-city.html

Sarah Kliff, on the Washington Post's Wonkblog, places this policy in the context of Mayor Bloomberg's other innovative public health efforts, many of which have spawned imitators across the country. http://www.washingtonpost.com/blogs/ezra-klein/post/mayor-mike-bloomberg-public-health-autocrat-a-brief-history/2012/06/04/gJQArSJbDV_blog.html

Molly Ball at The Atlantic points out that Bloomberg is perhaps uniquely able to push policies like these: he's a lame duck with no concern about re-election or his popularity, but he remains powerful and doesn't have to get cooperation on this from the city council. http://www.theatlantic.com/politics/archive/2012/06/mike-bloomberg-doesnt-care-what-you-think/258001/

And finally, Jon Stewart finds himself in the painful position of agreeing with a Fox News commentator. http://www.thedailyshow.com/watch/thu-may-31-2012/drink-different

The Global Obesity Bomb

  • By
  • Charles Kenny,
  • New America Foundation
June 4, 2012 |

New York Mayor Michael Bloomberg was in the headlines last week for his proposal to ban soft drink servings over 16 ounces. It’s the latest front of his war against obesity, which kills 5,000 residents in the city each year. (The mayor is the founder of Bloomberg LP, which owns Bloomberg Businessweek.)

The U.S. is a heavyweight champion in fat. It has the most obese population of any industrialized nation. About two-thirds of all adults in the country are overweight and one-third are fully obese, according to the World Health Organization.

The End of an Era

May 29, 2012

It’s the end of an era in modern medicine. House is no more.

The Fox show House ended last week. It was entertaining, but as far as health policy is concerned, we’re not sorry to see it go. The main character (Dr. Gregory House, played by Hugh Laurie) exemplifies the kind of “cowboy doctor” too many patients have come to expect. The cowboy doctor rides in on a lab result and offers a brilliant diagnosis, saves the patient’s life, and rides off into the sunset, never to be heard from again. It’s the dominant image of heroic doctors in television. Even Hawkeye Pierce, the caring Army surgeon in M*A*S*H whose demeanor is the polar opposite of House, saw his patients in one-off interactions before sending them home or back to the front.

For most of us, though, that’s an entirely unrealistic portrait of medicine. Our interaction with doctors is usually about trying to stay healthy and avoid problems, or managing long-term, chronic diseases like diabetes, heart disease, obesity, cancer. We need doctors who will listen to us, who can explain things clearly, and who we’re comfortable telling our concerns. Chronic disease management makes for lousy TV, but in recent years it has become the dominant kind of problem doctors and patients face day to day.

That's not our only quibble with Dr. House. In addition to being a cowboy, he's not much of a diagnostician. Through the magic of scripted TV he somehow manages to stumble on the treatment that saves the patient, almost by accident. He practices what I call “spaghetti on the wall”  medicine—as in, “throw the spaghetti on the wall and see if it sticks.”  He diagnoses his patients' rare illnesses by throwing treatments at patients and seeing what happens—often causing significant harm in the process. That's just bad medicine, and it isn’t something that doctors should do lightly. To us, House isn't a hero, he's a hazard, a catastrophe waiting to happen. Blinded by his own pain, he's indifferent to the suffering he causes through his reckless, unscientific, non-evidence based treatment decisions.

But there’s one point in House’s favor: he works with a team—and that team actually talks to each other. Unfortunately, that’s as unrealistic as the rest of the show. There are only a few hospitals and medical practices (Virginia Mason, in Seattle, comes to mind, and the Mayo Clinic in Rochester, Minnesota) where communication among providers is very good. In most places, the ball gets dropped between the hospital and primary care doctor and home, or even between different specialists in the same hospital.

Maybe one day TV will produce a more realistic version of medicine, but beware: it won't be the clean-cut single interactions we saw in House, or any of the other medical dramas out there. It'll be messy, and it'll be ambiguous: something a lot more like The Wire than Marcus Welby, M.D.

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