Beyond Medicine: The Road From Health Insurance To Health

By Katherine Gergen Barnett, M.D., and Lauren Taylor, MPH, M.Div

Now that as many as 6.4 million low- and middle-income Americans across 34 states have health insurance as a result of the Affordable Care Act, it’s worth asking this question: When does health insurance turn into actual health?

It’s a legitimate question because the impact of health insurance on health has been shown to be less impressive than we might wish. At least one study out of Massachusetts, for instance, has demonstrated reductions in mortality associated with insurance status, while other studies out of Oregon show only modest reductions in mental health disease burden. So how much health have we really gained nationwide from the ACA’s insurance expansion? It remains to be seen.

In the meantime, it may be time to turn our collective attention to a slightly different question: Where else in Americans’ lives might we find more substantive ways to improve health?

The Blue Cross Blue Shield of Massachusetts Foundation recently released a report which might help answer some of these questions. Researchers, led by Elizabeth H. Bradley, Ph.D., of the Yale School of Public Health, reviewed available literature on the health improvements and cost reductions associated with interventions beyond the scope of traditional medical care. The authors point to the strong evidence that increased investment in selected social services — housing support, nutritional assistance, case management for low-income families, children with asthma and seniors — as well as various models of partnership between health care and social services can offer substantial health benefits and reduce health care costs for targeted populations.

 In other words, the research demonstrates that when these interventions are targeted at high-cost, high-need patients, the results can make a huge difference in people’s lives, and also save the system money.

As a longtime primary care physician working in an urban hospital, my patients (often underserved families) confirm this empirical evidence. Here’s just one example:

The mother of a family has been coming to me for years. Her body and medical chart are riddled with multiple diagnoses: high blood pressure, chronic pain, anxiety, depression, high sugars and obesity, for which she takes numerous medications. Her life was chaotic — homeless with two young girls, a constant state of fighting in shelters, hyper vigilance for her girls’ safety and a state of depression that was only getting darker. Her girls also started getting their care through me and though they were more resilient in this state of constant flux and stress, their own lives were slowly falling apart in the long shadows of their mother’s mental illness. As a physician, it was hard to know where to start to get this family back to better health. As a mother myself and a public health advocate, I knew I had to start with the mother and her primary concerns.

And so in every visit we addressed her housing issues — filling out form after form, making calls and writing letters — alongside her other medical issues. Last year, she came in elated. She finally had secured housing. The next several visits were a flurry of pictures — new bedrooms and her smiling girls. But far beyond the pictures, there was a transformation. My patient started seeing a therapist again, taking her psychiatric medications, exercising and taking better care of her body. Her daughters also came to see me in the months that followed and it was if they were plants in the sun, finally growing back into their girlhoods. The oldest was just starting to dream about college. And though I am not naïve enough to think that their secure housing will make their health consistently good, it shifted the landscape entirely. Enough that they were able to start taking care of their lives and each other.

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What The Supreme Court Ruling On Obamacare Means: A Student’s Perspective

By Marina Renton
CommonHealth Intern

As a public health major at Brown University, I’ll admit I’m biased: When the King v. Burwell decision was handed down this week, I was absolutely elated. The decision felt exactly right to me; people were not going to lose their health care coverage, and more might even have the chance to gain it.

But the case is complicated, so to really understand the take-home messages, I consulted a couple of health care policy experts.

One is Ira Wilson, professor of Health Services, Policy and Practice at Brown University, who taught my “Health Care in the United States” class last semester.

The other is Michael Doonan, assistant professor at the Heller School for Social Policy and Management at Brandeis and executive director of the Massachusetts Health Policy Forum

Their responses are lightly edited:

MR: What background do we need to understand the Supreme Court decision?

IW: One of the core tenets of health care reform is that people who can’t afford insurance get subsidies so that they can buy it.

The ACA:

• Reforms insurance by doing things like preventing denials due to pre-existing conditions. So it requires that insurance do certain things that it hasn’t always done in the past.

• Requires that everybody get insurance. That’s the individual mandate, and that was covered in the 2012 challenge and then upheld in the 2012 case.

• Requires that affordable insurance be available to everyone. And this King case threw into question that third leg of the stool, as it were. Or at least it brought it into question for the states that, rather than deciding to develop their own exchange, used a federal one. So without this, the entire framework for health care reform in those states that have a federal exchange begins to fall apart. And as we know because we’ve seen lots of articles about estimating how many people would lose insurance if those subsidies were taken away (estimates were in the six million range), it would have a devastating impact on people who are now insured who would lose it.

What does the ruling say about Obamacare?

MD: If the Supreme Court had ruled against the government and said that the subsidies could not be available in the 34 states that have federally run exchanges, it might not have been the death of Obamacare, but it certainly would have put it on life support. So this decision is really critical in helping root and solidify the Affordable Care Act. And the more it gets rooted in each of the states, the harder it’s going to be to repeal.

IW: So this actually was a 6-3 decision, not a 5-4 decision. And it does seem to me the fact that both Justice Roberts and Justice Kennedy — who were the two that one might have imagined might have been on the other side of this issue — came down on the side of upholding these subsidies is a bit of a statement.

What if the ruling had gone the other way?

MD: Think about Texas. Now, in Texas, there are about 1.1 million people who are enrolled in that exchange, that marketplace. Well, 90% of them — over 900,000 people — are receiving those subsidies, and they could have lost their insurance.

And it’s not only important that people lose their insurance, which is the most critical thing, but hospitals would see many, many more uninsured patients. So even people adamantly opposed — I think that even Republican governors who are opposed to this are secretly saying, “Oh my gosh; thank goodness.” This would have caused them a tremendous, tremendous burden, because they would have seen more uninsured.

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Lingering Health Law Questions Jon Stewart Wants Answered

By Georgia Feuer
Guest Contributor

Last week Jon Stewart hosted Secretary of Health and Human Services Kathleen Sebelius on The Daily Show. During the interview, he kept returning to the same question: Why was the piece of the Affordable Care Act that requires businesses to provide health insurance delayed for one year, but the piece requiring individuals to obtain health insurance (the “individual mandate”) was not delayed?

In her answer, Sebelius mentioned that there are subsidies and tax credits available to individuals starting in 2014 and also that the so-called “employer mandate” affects a very small number of businesses. The employer mandate only applies to businesses with 50 or more employees. Only 5% of businesses have 50 or more employees, and most of these companies already offer insurance.

Screen shot 2013-10-14 at 1.11.38 PMBut Jon Stewart was not satisfied with her answer, and that is because she did not give the whole answer. The real reason why the individual mandate cannot be delayed is that it is too crucial to the success of health care reform. To understand why, let’s suppose that getting health insurance was, in fact, voluntary. Then the people who would be most motivated to purchase health insurance are those who are sick. Continue reading

Commentary: A Not-So-Rosy View Of Mass. Health Reform

By Josh Archambault
Guest Contributor

Hundreds of healthcare journalists will be attending the Association of Health Care Journalists’ (AHCJ) conference in Boston this week to hear from many speakers with rose-colored ideas about both our Romneycare law and a brand new state cost-control law. Yet all is not well in the Commonwealth. State officials now predict “extreme premium increases” for many small businesses under Obamacare.

In a letter to federal regulators the day after Christmas 2012, a perfect day to bury news, Massachusetts officials floated the idea of obtaining a waiver from the Affordable Care Act (ACA) out of fear of the premium spikes. Yet, recently finalized federal regulations slammed the door on that flexibility. Many small companies justifiably feel sick over the decision.

Josh Archambault of the Pioneer Institute (Courtesy of JA)

Josh Archambault of the Pioneer Institute (Courtesy of JA)

The small business community has been paying more for health insurance since the commonwealth’s 2006 reform merged sicker individuals into the same risk pool. The legislature has also added to costs by passing 12 additional mandated benefits since then, a cost borne completely by small companies and individuals.

Now the future looks even bleaker for small business. Not only will their highest-in-the-nation premiums go up because of these new regulations, but they will be paying on average $8,000 per family, per plan more in taxes over the next ten years. That translates into employers and consumers in Massachusetts paying $213 million in 2014 and $3 billion more over the next decade.

Conference speakers will be sure to mention that the Connector was created to help small companies obtain competitively priced insurance, and other states will experience this benefit in the exchanges required under the federal law. Only one problem, the rhetoric doesn’t match reality in Massachusetts. Continue reading

What To Know About Massachusetts’ First-In-Nation Health Cost Law


Massachusetts Governor Deval Patrick, a Democrat and pal of President Obama, hasn’t signed the sweeping, 350-page health care cost-cutting bill yet — but he says he will soon. (Expect a celebratory, bells-and-whistles bash, a la Mitt Romney at Fanueil Hall in 2006, signing health insurance reform legislation that would become a model for Obama’s national health overhaul.)

When the new bill does become law, the Bay state will be the first in the country to attempt to slow rising health care costs through numerous strategies including tethering the growth in health care spending to the state’s overall economy, moving away from fee-for-service payments to doctors and more heavily managing and coordinating medical care.

After the bill passed earlier this week, Representative Steven M. Walsh, a Democrat and House Chair of the Joint Committee on Health Care Financing, who has shepherded the legislation, underscored the consumer’s perspective. “The passage of today’s bill is all about seeing our health care system through the eyes of the patient. We have the highest quality medical system in the nation and the highest percentage of health care coverage, yet it is a struggle for families to afford their health insurance premiums. This legislation focuses on increasing efficiency and cutting costs within our system, while enhancing the quality of care that our patients receive and empowering them to make the best personal health decisions.”

Even if you don’t live in Massachusetts, many of these changes — in some form or another — will likely be coming to your state or doctor’s office too. We’re still digesting all the details and implications. But here’s an early snapshot of five things you might like to know:

1. Try Not To Get Sick In The First Place

Prevention and wellness are a priority in the new Massachusetts cost-cutting plan. If you lead a healthy lifestyle and try to care for your body through diet, exercise, not smoking, good attitude (when possible) etc. you can spend more time away from the doctor and out of the hospital thus saving the system money and just generally making life better. Under the Mass. plan, there’s $60 million for a prevention and wellness trust fund to boost such efforts. There are also tax credits for small businesses that run wellness programs.

2. The Cost Of Care

Speaking of budgeting, there will now be even greater pressure on your doctor, hospital or hospital system to save money. That means you will have to start thinking much more about how much your health care costs. Under the Mass. plan, hospitals and doctors will have to cut their rate of growth by about half. You, as the patient, may experience this in various ways, for instance, fewer non-critical tests, procedures and imaging Continue reading

She’s Gotta Have It: 8 ‘No-Cost’ Women’s Health Services Now Available

Alan O’Rourke/flickr

Liz Pugh, 23, is a recent college graduate with a job at a nonprofit AIDS advocacy group and financial independence for the first time in her life. Every month she shells out $15 or so of her modest salary for a co-pay on her birth control pills. But no more. The next time she runs out to the pharmacy to resupply, there will be no additional cost. “I am relieved,” she said. “to see that $15 co-pay gone.”

On August 1, insurers for the first time in history were required to start providing women with a set of basic preventive health services — not just birth control — for no extra fee. Though contraception and some of the other newly covered services, such as breast feeding support and equipment, have received most of the media and political attention, the new coverage spans a range of screening, counseling and other health services for women of all ages.

The new provisions fall under the federal Affordable Care Act and, according to Dr. Paula Johnson, Chief of the Division of Women’s Health at Brigham and Women’s Hospital in Boston, “represent a paradigm shift from a health care system built on diagnostic treatment of disease toward a foundation of disease prevention and wellness promotion.”

Johnson is a member of the Institute of Medicine Committee on Women’s Health Preventive Services — the group that recommended the new services be covered — and Executive Director of the Connors Center for Women’s Health and Gender Biology at the Brigham. She says that “cost has been a significant barrier for women” in accessing these basic medical services, and the new requirements “will allow women to get the preventive care that they need without the financial worry.” Moreover Johnson says, having these eight new services covered by insurers “raises the bar for preventive care for women,” and will ultimately strengthen the bond between doctors and patients.

Here, Johnson summarizes the 8 services women with private health insurance will now have access to without cost-sharing, and why these tests and services are vital for overall health:

1. Well-woman visits: Half of women delay or avoid well-woman preventive services due to cost barriers. Continue reading

Heavyweights Propose Top Health Care Cost-Saving Strategies

(Tax Credits/flickr)

Frankly, I’d prefer crashing a dinner party with these guys to reading their insightful, timely (but, let’s face it, a little dry) paper in the August 1 issue of The New England Journal of Medicine titled “A Systematic Approach To Containing Health Care Spending.”

Still, the piece by these health policy luminaries (including Ezekiel Emanuel, M.D., Ph.D., Stuart Altman, Ph.D., Donald Berwick, M.D., M.P.P., David Cutler, Ph.D., Tom Daschle, B.A., Arnold Milstein, M.D., M.P.H., John D. Podesta, J.D., Uwe Reinhardt, Ph.D., Meredith Rosenthal, Ph.D., Joshua Sharfstein, M.D., and Peter R. Orszag, Ph.D., among others) is worth reading, as it lays out numerous smart strategies for cost-saving and quality improvement as part of the medical journal’s election 2012 coverage. The piece also comes, coincidentally, as Massachusetts approves its own first-in-the-nation health cost savings plan, with many similar strategies. Continue reading

I'll Have What She's Having: ‘No-Cost’ Women’s Health Services Start Today

By Dr. Paula Johnson
Guest Contributor

August 1, 2012 marks the first time in history that insurers will be required to provide women with a set of core women’s health preventive services without cost-sharing. These services are part of the Affordable Care Act’s (ACA) robust plan of preventive care for women across the lifespan and represent a paradigm shift from a health care system built on diagnostic treatment of disease toward a foundation of disease prevention and wellness promotion.

Dr. Paula Johnson, Chief of the DIvision of Women’s Health, Brigham and Women’s Hospital

Unfortunately, not all U.S. women will benefit from the new system of care. With June’s Supreme Court ruling, some states may refuse to expand Medicaid to millions of our country’s poorest women, many of whom are near elderly, depriving them of access to preventive services available to Medicaid recipients and a better chance at a healthy life.

Let’s be clear that the preventive health services available under the ACA will allow women to become healthier and help reduce cost. Prior to reform, more than half of U.S. women were not up-to-date on recommended preventive health services, a fact not surprising given the growing epidemic of chronic illness among women that is costly, at an estimated $466 billion per year, yet preventable.

The new preventive services available to women with private insurance include:

Well-woman visits: Half of women delay or avoid well-woman preventive services due to cost barriers. Continue reading

Report: States That Most Need ACA Medicaid Cash Likely Won’t Take It

An update on which states are most likely to opt out of the Medicaid expansion under the newly-energized Affordable Care Act tells a sad story. The states that most need the federal money to cover their poor, sick residents are the ones most likely to snub it, according to a report in The Incidental Economist.

The Advisory Board (see their map above) says these five states won’t participate in the expansion of the federal program:

Florida: Gov. Rick Scott (R) said, “Florida will opt out of spending approximately $1.9 billion more taxpayer dollars required to implement a massive entitlement expansion of the Medicaid program.” In addition, the governor said the state will not establish an insurance exchange (Pear, New York Times, 7/2).
Louisiana: In an interview on NBC’s “Meet the Press,” Gov. Bobby Jindal (R) said, “Every governor’s got two critical decisions to make. One is do we set up these exchanges. And, secondly, do we expand Medicaid. And, no, in Louisiana, we’re not doing either one of those things” (Barrow, New Orleans Times-Picayune, 7/2). Continue reading

Bulletin: Individual Mandate Survives As A Tax, 5-4 Ruling Upholds ObamaCare

Chief Justice John Roberts Saves The ACA. Who knew?

Read the full opinion here.

So, the mandate is constitutional. Chief Justice Roberts joins left of court. Medicaid provision is limited but not invalidated, says Scotusblog.

Bottom line: “The entire ACA is upheld, with the exception that the federal government’s power to terminate states’ Medicaid funds is narrowly read,” says Scotusblog. “Roberts saved the ACA.”

Amy Howe blogs: “The money quote from the section on the mandate: Our precedent demonstrates that Congress had the power to impose the exaction in Section 5000A under the taxing power, and that Section 5000A need not be read to do more than impose a tax. This is sufficient to sustain it.”

Howe: “The Court holds that the mandate violates the Commerce Clause, but that doesn’t matter b/c there are five votes for the mandate to be constitutional under the taxing power.

(Thank you Scotusblog!)

More from Kennedy’s dissent, from Scotusblog: “In opening his statement in dissent, Kennedy says: “In our view, the entire Act before us is invalid in its entirety.”

For a laugh between all this serious talk, check out tumblr’s “When Scotus Upheld ObamaCare.”

Amy Howe summarizes the ruling in plain English:

The Affordable Care Act, including its individual mandate that virtually all Americans buy health insurance, is constitutional. There were not five votes to uphold it on the ground that Congress could use its power to regulate commerce between the states to require everyone to buy health insurance. However, five Justices agreed that the penalty that someone must pay if he refuses to buy insurance is a kind of tax that Congress can impose using its taxing power. That is all that matters. Because the mandate survives, the Court did not need to decide what other parts of the statute were constitutional, except for a provision that required states to comply with new eligibility requirements for Medicaid or risk losing their funding. On that question, the Court held that the provision is constitutional as long as states would only lose new funds if they didn’t comply with the new requirements, rather than all of their funding.

Howe notes Roberts’ rationale for his opinion here:

From the beginning of the Chief’s opinion: “We do not consider whether the Act embodies sound policies. That judgment is entrusted to the Nation’s elected leaders. We ask only whether Congress has the power under the Constitution to enact the challenged provisions.”

The New York Times front page declares: Victory For Obama