Health reform implementation

The Nebraska State Board of Education this month rebuffed a request from Gov. Dave Heineman (R) to support a direct repeal of the Democrats' new healthcare reform law.

Instead, Board members passed a much tamer resolution that registers their opposition to "unfunded mandates" without ever mentioning healthcare at all — a change that's being cheered by children's welfare advocates wary of efforts to pit children's health coverage against their education funding.

The episode began late last month, when Heineman sent a letter to state education leaders — including the members of the State Board — warning that the Medicaid expansion in the new healthcare reform law represents a threat to education funding, and therefore to education jobs. 

"The future of education is at stake," Heineman wrote. "Don't sit on the sidelines. I strongly urge you to support the repeal of the recently enacted federal health care law."

Heineman also touted the results of a new study — performed by Milliman, Inc. at the request of the governor's office — indicating that the Medicaid expansion would cost Nebraska between $526 million and $766 million over the next decade. 

"The results are potentially devastating to the state's budget," Heineman wrote. 

In response, State Board members last week considered a resolution calling for "the repeal of the unfunded Medicaid mandates contained in the [reform law]." The draft resolution also urged a replacement of the law "with alternatives that will not burden the states with unfunded mandates that threaten their fiscal stability."

It didn't fly. 

Instead, the State Board drastically reworked the language to exclude any references to Medicaid, the reform law or healthcare at all. The final version called on state officials "to oppose unfunded mandates and to protect the resources necessary for the provision of high quality education."  

It passed last Thursday by a vote of 7 to 0. 

Following the vote, Heineman issued a statement — all of 26 words long — applauding the board for "stating clearly and unequivocally that education is Nebraska’s top funding priority." 

Yet some children's welfare advocates say the victory is theirs. 

"We won in Nebraska," said Bruce Lesley, president of First Focus, a Washington-based children's welfare group.

Last week, Lesley had written to Nebraska's State Board, asking how the Medicaid expansion — all of which will be paid by the federal government through 2016 — could pose an immediate threat to education coffers.  

"It is simply unsound for anyone to threaten the budget for education spending in 2011 based on estimated spending on healthcare in 2017 and beyond," he wrote.

The episode wasn't lost on Sen. Ben Nelson. The Nebraska Democrat issued a statement last week slamming Heineman for using "misinformation to intimidate groups involved in all aspects of our children’s health, safety and education, pitting one against the other."

"What I’m hearing from Nebraskans," Nelson said, "is they don’t want this kind of divisive politics to be played."

The Department of Health and Human Services has released guidance for health plans seeking a waiver from the healthcare reform law's restrictions on plans' ability to place annual limits on essential health benefits.

The new law creates temporary restrictions on health plans starting Sept. 23. But the law also allows the annual limits to be waived "if compliance ... would result in a significant decrease in access to benefits or a significant increase in premiums."

The guidance, quietly issued Friday, applies only to plan years beginning between Sept. 23, 2010, and Sept. 22, 2011. The waiver is only valid for one year, and plans must reapply annually "in accordance with future guidance from HHS."

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Rekindling the debate over medical malpractice: A group of researchers this week estimated that the annual cost related to medical liability is $55.6 billion — or 2.4 percent of the nation's healthcare spending. 

The figure includes payouts to patients who sue for malpractice; costs racked up as doctors practice defensive medicine to avoid lawsuits; administrative costs, including lawyer fees; and the costs related to lost work time.

The report, published Tuesday in Health Affairs, is certain to catch the eyes of Capitol Hill Republicans, who have long pushed for Congress to take up malpractice reform, including a cap on "pain and suffering" awards surrounding malpractice cases.

Democrats have countered that malpractice is a vital recourse for injured patients which, anyways, isn't contributing much to the nation's skyrocketing healthcare tab. The authors of the study said both sides are exaggerating their case.

“Physician and insurer groups like to collapse all conversations about cost growth in health care to malpractice reform, while their opponents trivialize the role of defensive medicine,” Amitabh Chandra, a co-author of the study and professor of public policy at Harvard’s Kennedy School of Government, said in a statement. "Our study demonstrates that both these simplifications are wrong — the amount of defensive medicine is not trivial, but it’s unlikely to be a source of significant savings."

The researchers are quick to concede that their cost estimate for defensive medicine — which they peg at $45.6 billion per year — is shrouded in "considerable uncertainty."

Still, they also note the value of having hard numbers to inform lawmakers as they continue their struggle to rein in the nation's astronomical healthcare spending.

“We cannot debate the potential for medical liability reform to bring down health care costs in any meaningful way without realistic cost estimates,” said Michelle Mello, the lead author and professor of law and public health at the Harvard School of Public Health.

"Some of the numbers bandied about in policy discussions were quite imaginative and we wanted a more defensible estimate."

Still plagued by a lack of primary care docs: More and more patients are rushing to the emergency room — not to their primary care doctor — for acute care—treatment, according to yet another Health Affairs report published this month. 

Twenty-eight percent of patients suffering acute symptoms — including fever, chest pain and stomach pain — went to the ER between 2001 and 2004, the researchers found. The trend is due largely to the dearth of available primary care doctors, combined with a lack of patient access to those physicians after-hours. 

"Primary care doctors have packed schedules and their offices are typically closed in the evenings and on weekends," Stephen R. Pitts, the lead author and an associate medical professor at Emory University School of Medicine, said in a statement. "Too often, patients can’t get the care they need, when they need it, from their family doctor."

Earlier in the year, Sen. Ron Wyden championed a provision of the new healthcare law allowing states to ignore certain requirements in the law — even the individual insurance mandate — as long as they create alternative systems pre-approved by the White House. 

This week, the Oregon Democrat explained (again) the thinking behind that provision. 

"When it comes to health policy, what works best for people in Tampa Bay, Florida, doesn't always work as well for the residents of Coos Bay, Oregon," Wyden writes Friday in the Huffington Post. "For states to really be empowered to be innovative the federal government has to be willing to give states a little leeway to implement their own approaches. 

"A state, for example, will struggle to offer a public option on its exchange if it has to follow the exact standards of the federal law that doesn't provide for one. And, of course, no state-based approach — no matter how innovative — can work if everyone who participates in the state program gets fined by the federal government for failing to comply with the federal mandate."

Under the Democrat's reform law, Wyden's waiver provision doesn't kick in until 2017. But the Oregon Democrat is already fighting to expedite that launch date, to 2014. 

"The reason for this," Wyden writes, "is that it's a lot less cost effective for states to implement their own approaches in 2017 if they also have to pay to implement the federally mandated approach in 2014."

Donald Berwick, head of the Centers for Medicare and Medicaid Services (CMS), is fighting back this week against Republican attacks on the new healthcare law.

Responding to recent GOP claims that the Democrats' reforms are a threat to Medicare, Berwick said Friday that, on the contrary, the healthcare law has made the program "stronger than it has been in years."

"It's no illusion to the seniors and people with disabilities who will pay less for prescription drugs, to the millions of Medicare beneficiaries who will have preventive care and check-ups covered without paying co-pays, or to the people who will be protected from fraud and abuse," Berwick writes in a Washington Post op-ed. "Under the act, Medicare is stronger than it has been in years, and seniors will get new benefits. That's no illusion; that's progress."

The comments are a direct response to another opinion piece penned last week by Michael Leavitt, head of the Health and Human Services Department (HHS) under former President George W. Bush. Also writing in the Post, Leavitt charged that the new healthcare reform law "has weakened" Medicare. 

"Worse," Leavitt wrote, "its changes create the perception of progress, making it more difficult to pursue the reforms that would put Medicare on sound financial footing so future generations of seniors will benefit."

The "perception of progress" was a reference to a recent projection from Medicare's trustees that healthcare reform will extend Medicare's solvency through 2029 — 12 years longer than predicted last year before the law was passed. 

Critics, including many Republicans, say that the math is illegitimate because it "double-counts" the savings generated under the bill, applying those funds both to extending the program and to extending coverage to the uninsured.

Berwick this week says that charge is "inaccurate and oversimplifies what is really going on." 

Rather, he argues, new savings and revenues under the law will go toward extending Medicare's trust fund, and any funds not needed immediately will be invested in Treasury bonds.

"These dollars are used to help cover other investments, such as expanding health coverage to 34 million uninsured people," he writes. "Later, when the trust fund needs to cash in its Treasury bonds, they are repaid, with interest."

Those are rules, he noted, "that Republican and Democratic administrations have used for decades."

Berwick also takes on the critics who claim that cuts to the Medicare Advantage (MA) program — under which the government pays private insurers to cover Medicare patients — threaten patient care.

The CMS chief notes that the Medicare Payment Advisory Commission has for years found that Medicare spends much more on MA patients than those in the traditional program — "without yielding measurably better health outcomes."

A part of those subsidies go to cover the marketing, salaries and other administrative costs at the for-profit companies, leading critics to wonder why the MA program exists at all.

"The new law eliminates these unwarranted subsidies," Berwick writes, "and, for the first time, financially rewards Medicare Advantage health plans that do a better job of providing quality care."

Berwick ends with a final jab at his GOP critics.

"I share Michael Leavitt's belief in the seriousness of the challenges before us," he says, "but I do not share his pessimism."

A prominent children's welfare advocate is calling on Nebraska education leaders to resist an appeal from Gov. Dave Heineman (R) to help Republicans repeal the new healthcare reform law.

Heineman's request, says Bruce Lesley, head of First Focus, creates tensions between health and education programs that could ultimately damage both.

"Educators should not be asked to make a 'Hobson’s Choice' of voting for improving the education of children by harming their healthcare or vice versa," Lesley wrote Wednesday in a letter to members of Nebraska's State Board of Education. "I urge you to either oppose or table all efforts that would pit the educational and healthcare needs of children against one another." 

Last week, Heineman wrote to Nebraska education leaders warning that the reform law's Medicaid expansion would erode funding for education programs.

"Don't sit on the sidelines," Heineman lobbied. "I strongly urge you to support the repeal of the recently enacted federal healthcare law."

Heineman's office last month issued a report estimating the reform law's Medicaid expansion will cost Nebraska up to $766 million over the next decade — a much higher projection than those crunched by other analysts, including Nebraska's health department. 

Lesley is quick to note that the federal government, under the reform law, will pick up the entire tab of the Medicaid expansion through 2016 — a timeline leading to the question of how the provision could pose an immediate threat to the state budget.

"It is simply unsound for anyone to threaten the budget for education spending in 2011 based on estimated spending on healthcare in 2017 and beyond," Lesley said.

Full repeal of the reform law, the First Focus president added, would also eliminate a long list of children's health benefits that could diminish the students' performance in the classroom. 

"If you vote to repeal healthcare reform in its entirety, then you would be voting to reimpose pre-existing exclusions on children with cancer, diabetes or other illnesses," Lesley wrote, "to reimpose annual and lifetime limits on what insurance will cover for children, cutting funding for healthcare prevention efforts for children, and to increase the number of uninsured children in this country.

"Children need to be both healthy and educated in order for our nation to compete in the world’s global economy."

The popular diet drug Meridia increases the risk of heart attacks and strokes in patients with pre-existing heart conditions, according to a report published Wednesday in The New England Journal of Medicine. 

The study arrives just weeks before a Food and Drug Administration (FDA) panel will meet to examine the safety risks associated with Meridia, which is manufactured by Abbott Laboratories.

Although the FDA in January issued a warning that Meridia shouldn't be taken by those with heart conditions, Wednesday's findings have added fuel to the argument from consumer groups that the drug should be banned altogether — a step taken by European health officials in January.

Sidney Wolfe, director of health research at consumer advocacy group Public Citizen, said Wednesday’s report comes as "no surprise." 

"Cases of otherwise unexplained heart attacks in young Meridia users had been reported to the FDA" going back to 2002, Wolfe said in a statement.

Editorialists at The New England Journal of Medicine are also supporting a Meridia ban.

"It is difficult to discern a credible rationale for keeping this medication on the market," they wrote in an editorial accompanying the findings. 

Flu vaccines for healthcare professionals are an ethical responsibility that should be mandatory, infectious disease experts are arguing this week.

In a paper published Tuesday, the Society for Healthcare Epidemiology of America (SHEA) recommends that all healthcare workers — even students, volunteers, contractors and those without direct patient contact — receive annual flu shots as a condition of their employment. Only workers known to react adversely to the vaccine should be excepted, SHEA argues. 

“Healthcare providers are ethically obligated to take measures proven to keep patients from acquiring influenza in healthcare settings," SHEA President Neil Fishman said in a statement. 

"Mandatory vaccination is the cornerstone to a comprehensive program designed to prevent the spread of influenza which also includes identification and isolation of infected patients, adherence to hand hygiene and cough etiquette, the appropriate use of protective equipment, and restriction of ill healthcare personnel and visitors in the facility."

The report — published in the latest edition of the Infection Control and Healthcare Epidemiology journal — won the quick endorsement of the Infectious Diseases Society of America (IDSA).

“The scientific evidence shows significant reductions in the risk of influenza in both acute and long-term care settings as a result of strong immunization policies and programs,” said IDSA President Richard Whitley. “Vaccination of healthcare personnel saves patients’ lives and reduces illness."

The issue drew headlines last year amid an outbreak of the H1N1 flu. A survey conducted by the RAND Corporation during that pandemic found that, despite the severity of the outbreak, almost 40 of healthcare workers had no plans to get a flu shot. 

The survey is indication, Fishman and Whitley argue, that voluntary vaccination programs simply don't work well enough.

About two dozen businesses associated with high-profile opposition to the healthcare reform law are taking advantage of a provision that helps pay for their retirees' medical bills, according to a review of federal records by The Hill. The Department of Health and Human Services on Tuesday announced that almost 2,000 employers and unions have been accepted into the $5 billion Early Retiree Reinsurance Program, with more applications pending.

The application by Koch Industries of Kansas immediately raised eyebrows because its principal owners — Charles and David Koch — have been high-profile opponents of healthcare reform and bankrollers of the Tea Party movement.

But a state-by-state review of approved applicants reveals that more than a dozen members of the board of directors of the U.S. Chamber of Commerce have also been accepted into the program. The Chamber has been a leading foe of the law.

"We’re pleased the Affordable Care Act is delivering much-needed relief to businesses that provide coverage for their retirees," said an administration official.

The Chamber members include: 

• Pfizer, PepsiCo, New York Life Insurance Company, Eastman Kodak and IBM of New York; 
• Rolls-Royce North America, the Norfolk Southern Corporation and the Altria Group of Virginia;
• UPS and Southern Company of Georgia;
• John Deere and Navistar of Illinois;
• AT&T and the Fluor Corporation of Texas; 
• U.S. Airways of Arizona;
• Entergy Services Inc. of Louisiana;
• The Dow Chemical Company of Michigan;
• Anheuser-Busch of Missouri;
• FedEx Express of Tennessee;
• CUNA Mutual Group of Wisconsin;
• And Pepco Holdings Co. of Washington, D.C.

Being members of the Chamber's board of directors doesn't mean the companies agree with all of its stances. Pfizer, for example, has been a vocal proponent of the law and even gave its CEO Jeff Kindler a raise in salary and bonuses after it passed, according to CBS News and other reports.

The possible 2012 White House contender signed an executive order restricting his state's involvement in the healthcare reform law.