After reading a variety of news sources that predicted what might be next in healthcare for 2017, I decided to take a further dive into the specifics of the Republican healthcare proposals (RHCP). The next step in healthcare will likely include parts from Paul Ryan's "A Patients' Choice Act," Tom Price's "Empowering Patients First," the healthcare portion of the Republican's plan "A Better Way," and statements from President Trump.
One popular component of these plans is high-risk pools (HRPs). In this summary, I try to examine what it might mean for patients and the future state of healthcare.
Regarding High-Risk Pools
Prior to the Affordable Care Act (ACA), insurance policies sold on the individual market were medically underwritten. That means health insurance companies evaluated individuals' health status, health history and other risk factors such as pre-existing conditions, to determine price and coverage for policies. For example, a person with high blood pressure (HBP) on medication could purchase insurance on the individual market. However, the insurance would not cover conditions related to any illness that continued or developed from high blood pressure, since it was a pre-existing condition.
Since the ACA took effect in 2014, health insurers have been prevented from denying medical coverage or charging unfairly high premiums to people with pre-existing health conditions. The effect has been that insurers are leaving the exchange markets and complaining that sicker people are buying plans and healthier people are not. This leaves insurers with the burden of not enough revenue to cover health costs. Specifically, an estimated 19 million "young invincibles" have not signed up for health insurance.
To remedy the problems of insurers leaving the exchange market, stabilized insurance prices and increased access to affordable insurance for individuals and families, some conservatives and Republicans want to fund high risk pools. Their proposals include taking the sickest people out of the commercial market and putting them into "separate, tax-subsidized, high-risk plans." On the other hand, Dean Clancy, a former senior health policy advisor to congressional Republicans and the George W. Bush administration, called high-risk pools "targeted welfare." There are definitely mixed feelings on the matter by many people.
For insurers and healthy people, the HRPs seem like a reasonable approach to stabilize health insurance prices. What is the cost? If the HRPs are not adequately funded and do not provide the health care that patients need, it will result in sicker people becoming even sicker, higher utilization of emergency rooms, health disparities and tax payers consistently footing an ever increasing healthcare bill. The Ryan plan proposes federal funding of $25 billion over 10 year while Price's plan proposes $1 billion over 3 years.
Viability is a huge question regarding high risk pools. We have some historical data because some states have had or still have HRPs. A December 2014 Commonwealth Fund study concluded that the pools are:
In addition to the above, a small number of states limited enrollment in high-risk pools to control costs to the states. Even with limited enrollment, in 2011 net losses for 35 state high-risk pools were over $1.2 billion, or $5,510 per enrollee, on average. States financed these pools by revenue sources such as tobacco taxes and hospital assessments. Paul Ryan has proposed guaranteeing universal access to healthcare, but it's unclear how the government will pay for these high-risk pools. Health savings accounts (HSAs) have been part of the solution, but for high-risk pools with HSAs are not going to be nearly enough to help individuals and families cover medical expenses.
To conclude, although we have historical data on what has happened with high-risk pools, some successful and some not so successful. Without knowing exactly who will make up these pools, how the pools will be funded and where the money will come from, I am not very optimistic about saying this option is better than a "Medicare for all" which insures everyone and spreads the risk in a practical way. As of December 2016, Republicans have not been clear on which of the current ACA tax/revenue streams they will repeal or keep.
In a subsequent posting, I intend to continue discussion on this topic.
One of the books I’m reading right now is called “The Other” by Wes Moore. It chronicles the story of two men with the same name, similar backgrounds, growing up fatherless in a Baltimore neighborhood. I was drawn to this story, because I often engage in discussions about “choice” and why some of us end up choosing the wrong path and how much empathy is deserved. In the book, How Will You Measure Your Life, (see summary here) my favorite section is “Staying Out of Jail.” The chapter begins with a quote from C.S. Lewis, “The safest road to Hell is the gradual one- the gentle slope, soft underfoot, without sudden turnings, without milestones, without signposts.”
Earlier today, I finally decided to answer one of those “No Caller ID” calls (the wrong path). My phone has been ringing off the hook with these calls. Just as I suspected, it was a democratic volunteer calling to ask me to donate into a fund to support gun control and background check legislation. Because I didn’t want to get up from the couch (NYC had a mini snow storm and I was feeling very cozy in the depths of my loveseat) to get my wallet, I told her that I didn’t have any money to donate (don't judge me). Then, she kindly persuaded me to give a reduced amount and told me some statistics about how many people are killed by gun violence in the US. The passion in her voice was convincing and she mentioned Gabby Giffords. I got up and donated…
After the phone call, I started to think about Hadiya Pendleton, a special young woman whose life was tragically cut short on January 29, 2013. She was a 15-year-old girl from Chicago, Illinois who was shot and killed in a park, just after taking her final exams. Her story sparked national attention, even in the flurry of murders that happen in Chicago, because she had just performed at President Obama’s inauguration and First Lady Michelle Obama attended her funeral. There is a Facebook page dedicated to Hadiya, R.I.P Hadiya Pendleton with over 193K likes, a hashtag #wearorange to demonstrate against gun violence, and a foundation in her name, Hadiya's Promise, to inspire people to work for peace and put down guns.
I often question why Hadiya's story resonated with me so much. Even now, I find this difficult to write. However, I realize that just like the similarities of the two men in Wes Moore's story, Hadiya's life was my own. When I was 15-years-old I lived in the midwest and attended Roosevelt High School in Des Moines, Iowa. I hung out with friends in the park after final exams, played sports, gave my parents a few headaches and enjoyed walking to Godfather's Pizza or Breugger's Bagels. Although, violent crime is not rampant in Des Moines like it is in Chicago, we know that violence can happen anywhere.
Gun violence in the United States is a public health crisis, especially where children are concerned. According to the Brady Center to Prevent Gun Violence, 18,000 children and teens are injured or killed each year due to gun violence. In NYC, I rarely watch the local news because it used to depress me to hear about the constant acts of violence. Then, there are the national news stories: 9 yr old accidentally shoots her gun instructor, 1-year-old boy was accidentally shot by his sister, and 5-year-old accidentally shoots his 4-year-old brother...
In addition to these tragedies are the mass shootings, from Sandy Hook to Charleston to Orlando. Many Americans, including me, thought that these horribly tragic events would spur our representatives to some sort of action, to finally come together in a nonpartisan way and create some legislation to help ensure these events would never happen again. I was quite surprised by the response from the NRA and others after Sandy Hook, and I knew then, this country had a long way to go before creating some commonsense reforms around gun violence.
The AMA has recently adopted a policy on gun violence declaring it "a public health crisis," and will lobby to overturn legislation that prevents research in this area. But, this is not the first declaration of its kind. In 1993 the journal Health Affairs published an article on gun violence that stated, "The current epidemic of violence in America threatens not only our physical health but also the integrity of basic social institutions such as the family, the communities in which we live, and our health care system."
In public health, we know there are many factors that spur gun violence. We also know we are a long way from preventing deaths due to gun violence and dealing effectively with the persistent impact this violence has had on our society. However, we can take action and support organizations like Hadiya's Promise and the Brady Center that are doing great work in the fight against gun violence.
Everyone is making 2017 healthcare predictions for the new year; from individuals and their diet and exercise plans, hospitals and payers focusing on their relationships and the financial industry speculating which healthcare stocks will outperform which other healthcare stocks. Below, I've pulled from the best lists ranging from marketing, finance, and consulting. There is plenty of speculation to go around in this $3 trillion-dollar industry. What are your predictions? Agree or Disagree with these lists?
Bullet points pulled from the website articles, click on the links to read more.
1. Forbes: 9 Healthcare Predictions for 2017
2. Beckers: 5 Healthcare Predictions for 2017 - Behavioral analytics, patient personas & more
3. Bernard Health Blog: Healthcare Predictions for 2017
4. Health IT Outcomes: 4 Healthcare Industry Predictions for 2017
**5. Fortune: Why Drug Costs will keep Rising in 2017
6. PWC: Medical Cost Trend: Behind the Numbers 2017
7. PM360: 10 Predictions for How the Healthcare Industry will Change in 2017
8. Philips: Top 5 HealthTech Predictions for 2017
9. Fidelity: 2017 Outlook: Healthcare
10. Tsahia's 3:
I'll tell you a secret that only my very best friends know, I love reality TV! Well not all reality TV but the stories about the American experience that deliver insight into closed societies like Escaping Polygamy and Leah Rimini: Scientology and the Aftermath. Aside from those shows, I love travel shows and almost anything on HGTV. When I was younger, I loved MTV's The Real World and Cops. I can still here that infamous tune, bad boys, bad boys, what you gonna do, what you gonna do when they come for you...
However, there is one show that makes me cringe, but I watch it ...sort of like how I watch Alien or Prometheus... it's the documentary series, Beyond Scared Straight on A&E. The show details an intense day long journey of troubled young people whose parents have sent them jail. The visit includes inmates and corrections officers screaming at them until they realize jail is not the place to be. Parents visit their children in jail and talk to them through phones separated by glass barriers. At the end of the day, it is up to a judge (and the consent slip) to determine if they go home or have to spend the night. Usually, the adolescents are crying and have been through enough trauma, realizing their mistakes (if only temporarily) and are apologizing profusely to their parents, professing all of their wrongs and how they will be made right.
Why do I watch this show when the only thing scarier to me than American jail is foreign jail? To think these young people would have behavior that leads them to this place is a wonder to me. In the US, there are nearly 2.3 million people in prison, and over 200k are women. As a person, passionate about public health, for me, this show sheds light into the missing stories of what happens in prison and what leads some young people on the path to incarceration. Whether or not the method of the program - one which conveys bullying from the officers and inmates, threats of beat downs and rape juxtaposed to gentler counseling sessions, to "get through" to rowdy young people is correct; it certainly shows that BOTH a shock experience coupled with mentoring from the officers can turn lives around. The officers and inmates do not coddle or mince words, the experience is a real American jail - single cell, overcrowded, locked down, terrible food, aggressive inmates, lots of handcuffs, and tough corrections officers.
Is this the right way to rehab young people gone rogue - stealing, disrespecting their parents, fighting, drinking, drug use, etc.? I don't know. One might argue that this treatment is warranted by the terror created for families dealing with these situations. Often, the family who brings the children to the jail program are mothers, usually in a single parent household. When the viewer gets a glimpse into the homes, we see families broken apart by having other relatives in jail, poverty, lack of resources and other surrounding influences such as gang violence and drug dealing.
The show crosses racial and gender barriers, but one thing seems common for most of the families: poverty. One might argue that this show targets low income families in an attempt to exploit them, but no parent wants to see their child in prison, and this program is often a last resort. Can we or should we deal with bad behavior by a visit to prison? Will this combat the long-term issues related to poverty, crime in the surrounding area, trauma, depression, and the social determinants of health? How can we do better?
In the US, the David Lynch Foundation offers meditation programs in schools to reduce stress and violence, as we know many children live in these environments of poverty, fear, and trauma. The mediation program is having a profoundly positive effect on children and school environments. Children should also have regular visits to a general practitioner (GP). A GP can identify issues of concern and refer out to psychologists and other mental health professional to provide counseling services - but, if children and parents do not have access to a GP, it's less likely that they will have access to mental health counselling. In addition, communities and law enforcement can offer second chances to offenders by creating a "continuum of care" by referring juvenile offenders to various treatment programs, but with the ability to stay connected to their family and community.
Unfortunately, second chances don't often come around like they do on Pitbulls & Parolees, another show I love, that features the Villalobos Rescue Center, where both pitbulls and parolees can have a second chance. Outside of the US, Norway's, recidivism rate is 20% compared to approximately 75% in the United States. Why? In countries, such as Norway and Rwanda, societies believe reconciliation, education and rehabilitation are superior to a revolving door of incarceration. Even after the Rwandan genocide in 1994 where some 800,000 people were slaughtered, the government realized that it did not have the capacity to incarcerate every criminal, so it began an unheard-of process of reconciliation using gacaca courts, which has ultimately led it to economic prosperity and relatively low crime rates, especially violent crime. In all countries, the path to incarceration can always be reduced. It will be interesting to see where the US falls over the next 5 to 10 years.