Primer prepares reporters for Supreme Court review of health reform
Back in 2009, when critics of what was then a health reform bill, not a health reform law, muttered about legal challenges to the constitutionality of the individual mandate, a lot of people in the health policy world didn’t take it all that seriously. Sure, they thought the law would be attacked in court, but there was skepticism that the legal scholars on the other side would be able to mount a legally powerful, consistent argument that would put the law, or at least key sections of the law, in jeopardy.
They were wrong. The attorneys who oppose the law, including Randy Barnett and Paul Clement, made powerful arguments. The lower courts – and some intellectually influential appellate judges – have divided. Now it’s up to the Supreme Court.
To help you cover the extraordinary six hours of arguments over three days (without a television feed), we’ve done a tip sheet and resource guide. We asked legal writer T.R. Goldman to address five questions:
- Is the individual mandate’s “minimum coverage provision” that requires most people to obtain health insurance constitutional?
- If not – will the court strike the whole law down, or just certain sections (”severability”)?
- What role does Medicaid expansion play in the legal case?
- Can the court decide on the constitutionality of the mandate now, or under the Anti-injunction Act does it have to wait until mandate penalties are imposed in 2015?
- What are some tips for health reporters trying to cover this - particularly those covering from afar?
And on that last point – the bottom line is “Don’t assume anything.”
“The working assumption of many court watchers is that at least five Justices will vote to uphold the mandate’s constitutionality,” Goldman said. “There’s really no way to know, however, what the court will do.”
One last tidbit – not strictly health-relevant perhaps but interesting. In the 19th century, the oral arguments lasted for days – and attracted a crowd of spectators (before ESPN!)
Final thought – if you think the Supreme Court ruling is going to put an end to the controversy … You’re probably wrong.
Joanne Kenen (@JoanneKenen) is AHCJ’s health reform topic leader. If you have questions or suggestions for future resources, please send them to joanne@healthjournalism.org.
Women’s health and the ACA: Look beyond contraception
If you have been listening to the contraception debate in Washington (sort of hard to avoid, isn’t it?), you may be under the impression that preventive health for women equals contraception. Or contraception equals women’s preventive health. (We’re putting aside, for the purpose of this post, the debate about religion, conscience and the role of government).
The Senate has defeated one bid to overturn the administration rule requiring employers to provide an insurance plan with first-dollar coverage of birth control, and it’s not clear what the House will do. But the issue is likely to percolate in Washington, state legislatures and the courts for some time to come.
The health reform law, and the regulations being developed to implement it, has a far more expansive definition of prevention and what it means for women’s health. Here are more details on the new regulations and a tutorial from Kaiser.edu. According to the new women’s preventive health rule, new health plans must cover, without cost-sharing, a lot more than the pill:
- well-woman visits;
- screening for gestational diabetes;
- human papillomavirus (HPV) DNA testing for women 30 years and older;
- sexually-transmitted infection counseling;
- human immunodeficiency virus (HIV) screening and counseling;
- FDA-approved contraception methods and contraceptive counseling;
- breastfeeding support, supplies, and counseling; and
- domestic violence screening and counseling.
These requirements will go into effect in August (with another year allowed to finalize how the religious exemptions will work). Grandfathered plans won’t have to follow the new rule, while they maintain their “grandfather” status. Over time, many health plans will go through changes that will mean that they will no longer be “grandfathered.” Then they too will have to follow the new regulations.
Of course, more women will get these benefits, simply because more women will be insured. Approximately one in five women of reproductive age is currently uninsured. Most of them will get coverage, including preventive services, starting in 2014 whether through Medicaid, through subsidized coverage in the exchanges or by buying coverage. Right now, coverage of maternity benefits is spotty on the individual insurance market, but the plans in the health exchanges will cover it.
The law also requires many other preventive services – some free – for men, women and children. They have not gotten much attention in the polarized birth control debate.
The conversation (and press coverage) about the contraceptive rules have included lots of misinformation about abortion. Politicians who misstate policy don’t help, but reporters need to know what the law does and does not do.
The health law does not mandate abortion coverage and this preventive health rule does not change that. In fact, states under health reform have the explicit ability to limit abortion coverage in policies sold in state exchanges and several have already taken action to do precisely that. Plans that do cover abortion in the exchange will have to wall that off in a way to keep it apart from the federal subsidies.
Joanne Kenen (@JoanneKenen) is AHCJ’s health reform topic leader. If you have questions or suggestions for future resources, please send them to joanne@healthjournalism.org.
A few more stray but relevant facts:
According to the Kaiser.edu materials, about two-thirds of women aged 15 to 44 use contraception – and do so for about 30 years.
Most employer-based insurance plans do cover contraception, though there are often co-pays. Among large employers, more than 80 percent cover contraception.
Federal Medicaid dollars do not cover abortion under the Hyde Amendment (except for rape, incest or when the life of the mother is in danger) – although some states use their own money to cover abortion in some circumstances. But Medicaid does cover contraception. In fact, Medicaid pays for more than 70 percent of publicly financed family planning services.
And Title X funds family planning clinics (created in 1970 under the Nixon presidency). According to HHS, about 5 million women and men get family planning services through more than 4,500 community-based clinics. Someone with religious objections to providing contraceptives for employees is indirectly paying for Medicaid birth control coverage – and indirectly for the tax subsidies of employer-sponsored insurance – just as we all pay taxes that fund some things we agree with and some we don’t.
States responsible for health insurance exchanges for small businesses
Most of us know that in 2014, states will open health insurance exchanges (or the federal government will run a backup exchange for them) But actually states are running two exchanges – one for individuals and one for small businesses, known as Small Business Health Options Program (SHOP) exchanges.
To the consumer, they may look the same, and people may access them through the same website. But states have the option of keeping them separate (which is what most states are planning as of now) or of merging them. The February edition of Health Affairs (which AHCJ members can get access to) has a series of articles on the SHOP exchanges, and there’s a summary on the Health Affairs blog.
Some of the articles re-examine the conventional wisdom about the fiscal rational for keeping SHOP and individual exchanges separate. There’s also a one-hour webinar supported by the Commonwealth Fund on Feb. 22 that looks more closely at the role the exchanges will have in covering small businesses – and how these new insurance markets may eventually prove attractive to larger businesses as well.
Joanne Kenen (@JoanneKenen) is AHCJ’s health reform topic leader. If you have questions or suggestions for resources, please send them to joanne@healthjournalism.org.
Essential component of reform will require more staff, training
When we think about the growing demands health reform will place on community health centers (assuming that we are thinking about community health centers at all – and we should be) we tend to think about the shortage of primary care doctors in underserved communities, and the increasing numbers of soon-to-be-insured patients needing such care.
Joanne Kenen (@JoanneKenen) is AHCJ’s health reform topic leader. If you have questions or suggestions for future resources, please send them to joanne@healthjournalism.org. According to the National Association of Community Health Centers, about 20 million patients get their primary health care needs at more than 8,000 U.S. locations. I’ve seen various projections of how that will grow under health reform (depending on fun ding and other factors) but the NACHC says it could double, to 40 million, within another five years.
There’s another aspect to the community health center workforce – one that, frankly, I had never thought about until I got a release about a set of grants a few weeks ago from a small foundation that focuses on community health. The clinics don’t just need doctors and nurses. They need people who can just run the places – who can make appointments and keep records, and do the coding and billing, and handle the health IT, and do health outreach in the community, and the case management. And they need people who speak a bunch of languages and be culturally sensitive. In other words, they need all kinds of people who can do the work necessary for these clinics to become effective “medical homes.”
So the RCHN Community Health Foundation recently announced grants of about $150,000 to $200,000 each to five very different community health groups, in five quite different settings. (On the foundation’s home page you can find links to some of the coverage it has gotten.)
- Aaron E. Henry Community Health Services Center, Clarksdale, Miss.
- Charles B. Wang Community Health Center, New York
- Penobscot Community Health Care, Bangor, Maine
- Seattle Indian Health Board, Seattle
- Wai’anae Coast Comprehensive Health Center, Wai’anae, Hawaii
The details vary, but they are developing training programs (which can be done during the work day), partnerships with local schools, community and four-year colleges, internships, outreach to potential entry-level workers who hadn’t thought of this career path, worker retention programs – with an eye both toward their own needs, their workers’ future advancement, and job creation in their communities, including veterans. In some cases, they will be designing their resources and programs with a clear eye toward having them spread, to be available and useful to other clinics, other communities.
Chances are, you won’t be covering these five specific clinics. But the challenges these grants are aimed at exist everywhere and are ripe material for covering:
- How are clinics in your areas preparing – not just expanding physically (there was a lot of money in the 2009 stimulus package for that), but how are they expanding in other, qualitative dimensions?
- Have they begun the transition to medical homes?
- Have they installed electronic medical records? (They are doing so at a faster pace than many more resource-rich practices.)
- Who is working for them?
- How are they being trained – and retained – for the coming changes in the delivery and financing of health care?
You – and your reader, listeners, and viewers – may be quite surprised by some of the innovative, change-embracing answers.
Share some health reform humor with your Tweetheart #healthpolicyvalentines
Who says health reform can’t make you laugh?
In case you have been living in a Twitter-free cave somewhere in Antarctica, you have probably seen #healthpolicyvalentines (and its half cousins #hospitalvalentines and, in a sad commentary on our times, #budgetvalentines).
It’s been going on since last week and reading it is the most fun we’ve had wasting time in quite a while. Some of the entries are not suitable for a family journalism blog (Sam, that bit about your benefit package?) but here are a few of our favorites. Go waste some time on your own, you won’t regret it.
There are dozens and dozens more – many very funny. It can be hard to make your Twitter feed go all the way back to when it began last week, but it’s worth struggling with that “load” feature. I would include more but I have to go tweet my thanks for name brand roses now (I would have been happy with generics).
For more:
Berwick shares thoughts on media coverage of health care, reform
Filed under: Government, Health care reform, Health journalism
Don Berwick has worked with reporters as part of his jobs at the Institute for Healthcare Improvement and, most recently, at the Centers for Medicare and Medicaid Services.
Berwick appeared at a Newsmaker Briefing at Health Journalism 2011. (Photo: Len Bruzzese)
Having left CMS in December, Berwick agreed to share his thoughts with AHCJ President Charles Ornstein about media coverage of CMS, health reform and his tenure.
Among other things, Berwick says, “There weren’t a sufficient number of longer in-depth analyses of what really was going on and what were the pros and cons of the choices the government, and our nation, are making.”
He also talks about what he calls the “great communication paradox around the Affordable Care Act” - the lack of understanding and explanation of the law.
Among his tips for reporters:
- Explore the “more care is better care” myth
- Medicaid is vulnerable and crucial and can’t get enough coverage
- Stay away from the three-minute soundbite
- Don’t simply repeat “nonsense”
Experts offer story ideas for covering health reform
Filed under: Health care reform, Health journalism
More than 30 attendees heard local experts sketch the particular challenges and issues presented by the Affordable Care Act in California in the latest “Implementing health reform in the states” panel, hosted by AHCJ’s San Francisco Bay Area chapter on Wednesday night at the San Francisco Chronicle.
The panel, one of a series sponsored by AHCJ, the Alliance for Health Reform and the Robert Wood Johnson Foundation, began with an explanation of exchanges and what’s happening with their implementation (or lack thereof) around the country by Larry Levitt of the Kaiser Family Foundation.
He posed some story ideas, such as: How vigorously will the states promote enrollment through the exchanges? What sort of variations to the ACA might emerge once states have the ability to ask for waivers in 2017?
Kim Belshe, a board member of the California exchange, and Marian Mulkey of the California HealthCare Foundation discussed the California scene, with lots of detail, touching on the state’s large undocumented immigrant population, the challenge of getting people enrolled (since the law of the land is now “performance” – which means maximum participation), new opportunities for medical professions, such as nurses, to fill gaps in care delivery, and how to ensure coordinated care during the transition period to exchanges so no patient is harmed. This is the accountability part of the ACA, and needs thought and new procedures, Belshe stressed.
Belshe noted that Medicaid (Medi-Cal) is the foundation of reform, a subject which reporters sometimes overlook. Both she and Mulkey noted that California is a national pacesetter when it comes to reform implementation - a story idea in itself.
The session was moderated by Ed Howard, executive vice president of the Alliance for Health Reform.
On Tuesday night, a similar briefing was held at the University of Southern California, featuring Walter Zelman, Ph.D., a professor and director of health science at California State University-Los Angeles; Daniel Zingale, senior vice president of the Healthy California program at The California Endowment; Anthony Wright, executive director for Health Access, a California health care consumer advocacy coalition; and Deborah Crowe, the health care and biotechnology industry reporter for the Los Angeles Business Journal. Howard, of the Alliance for Health Reform, moderated the session.
Zelman posed a number of questions about reform, mostly about exchanges. To a reporter from Orange County, he suggested a story about the origin of the individual mandate – an idea championed by Republicans early on, he noted, and opposed by Obama and many Democrats. To a question about accountable care organizations and bundling, he suggested stories about how fee-for-service medicine is anything but dead.
Wright offered a look at what’s happening in Sacramento, including a hearing held just a few hours before the briefing.
Zingale mentioned the importance of prevention, and how the ACA encourages prevention. He too pointed out how nonprofits in the state can team up with reporters to educate people about the ACA. He said that the more people know about the law, the better they like it.
From a reporter’s perspective, Crowe offered several practical story ideas that reporters can start writing about today.
John Gonzales of the California HealthCare Foundation Center for Health Reporting wrote about the panel and Michelle Levander of the California Endowment Health Journalism Fellowships program offers some of the story ideas mentioned by the panelists.
Special thanks to Colleen Paretty, chair of the Bay Area chapter, and Bill Erwin, of the Alliance for Health Reform, for contributing details about the panel discussions for this post.
Investigation delves into Wash.’s prescription drug problem
Filed under: Aging, Children, Europe, Government, Health care reform, Health data, Health policy, Hot Health Headline, Pharmaceuticals, Public health, Public records
Everything time we think prescription drug abuse stories have peaked, something comes along to push the story further. This time, InvestigateWest’s Carol Smith sets herself apart by starting from square one and clearly explaining the origins and dimensions of Washington’s particularly nasty drug issues, tracing back each facet of the problem to its source and spotlighting what makes the Evergreen State unique.
Washington has been one of the hardest hit states in the country, in part because of aggressive prescribing practices. That, coupled with lack of oversight of doctors who over-prescribe, has led to the spectacular run-up in the number of deaths from prescription overdoses.
The backdrop for her work is an epidemic that shows no signs of abating, despite a recently implemented state law Smith calls “a bold attempt to reduce overdose deaths by launching the first-ever dosing limits for doctors and others who prescribe these medicines.”
Prescription drug abuse is at epidemic levels throughout the state, and elsewhere in the country, despite lawmakers’ attempts to get a grip on it. Washington now has one of the highest death rates in the nation. Deaths from prescription drug overdoses in this state have skyrocketed nearly twenty-fold since the mid-1990s, and now outstrip those from traffic accidents.
Why caused it to leap so quickly? Smith tracks down several key tipping points. “There’s plenty of blame to go around for what caused the epidemic,” she writes. “Aggressive marketing of opiates by drug companies, nonexistent tracking of overprescribing, lack of insurance coverage for alternative treatments for pain, and demand by patients for quick fixes, to name a few.”
She drills down into many of those causes, with my personal favorites being two key origin stories:
- How marketing by OxyContin maker Purdue Pharma led to relaxed guidelines for chronic pain treatment and a “1999 law specified ‘No disciplinary action will be taken against a practitioner based solely on the quantity and/or frequency of opiates prescribed,’” both of which helped cause a jump in prescriptions.
- How “the rise in the death rates of Medicaid patients tracks along with the state’s cost-saving decision to move many of its poorest residents to the cheapest, most potent pain reliever available: Methadone.”
See the upper right-hand sidebar for more stories from the six-month investigation.
Article looks at reform concepts put into practice
Filed under: Health care reform, Hot Health Headline
Here’s a recent story that touches on a whole lot of themes in health reform – without getting bogged down in a lot of jargon. Value-based purchasing. Evidence-based medicine. Shared decision-making.
Jackie Crosby of the Minneapolis Star-Tribune writes about how a Minnesota insurer, HealthPartners, has introduced a new approach for patients with low back pain. Before they get surgery, they have to get a consult on nonsurgical alternatives.
Joanne Kenen (@JoanneKenen) is AHCJ’s health reform topic leader. If you have questions or suggestions for future resources, please send them to joanne@healthjournalism.org. If they still opt for surgery, they can have it. But the thinking is (based on what other health systems have learned) that many will opt for physical therapy and rehabilitation once they learn more about the pros and cons, risks and benefits, of all their options.
“Patients can still see a surgeon if they wish. But after this visit, they’ll be better informed about all of their options, and can make decisions more aligned with their own values,” the story quoted Dr. Thomas Marr, HealthPartners’ medical director of clinical relations as saying.
“In general, it’s a bad thing when the doctor and patient can’t determine the treatment without interference from the insurance company or the government,” spine surgeon Jeffrey Dick was quoted as saying. But this is an exception, he said. Surgery is appropriate for only about one out of eight low back pain patients he sees. Getting them into appropriate care from the start can save money – not to mention years of lingering back pain.
“These aren’t HealthPartners criteria,” he added. “These are treatment algorithms for low-back pain that we all should be following – but maybe haven’t been by all practitioners.”
The story also noted how HealthPartners is working with stakeholders and monitoring patient reaction and satisfaction to minimize criticism and misunderstandings.
So what are those health reform themes?
Value-based purchasing – loosely translated – is paying for what works.
Evidence-based medicine is what it sounds like – and the evidence is that a lot of back surgery is unnecessary. Sounds simple but it’s not always practiced – even in those cases where the evidence is strong. Sometimes it’s even derided as “cookbook medicine.” Financial incentives are certainly one big impediment: surgeons, hospitals, etc., make money from procedures that may not always be the best choice for the patient. Practice patterns – how physicians are taught and what’s done in the medical culture of a given hospital or community – play a role. And patients often want treatments they don’t need because they don’t understand that it’s not necessary, or they think surgery is a reliable quick fix.
Some researchers exploring medical decision-making have found that physicians are a lot more likely to talk about why to have a certain procedure, including back surgery, than why not. Clinicians and researchers are beginning to develop models for “shared decision-making” and there’s even a bit of language in the health reform law to promote it.
So are there programs like this rolling out in your local hospitals or health plans? We’d like to hear more. It will be interesting, too, to watch how people react to the HealthPartners and similar ventures. Will patient/beneficiary attitudes begin to change? Will they come to understand that more isn’t always better? Will they be glad to find out they really don’t need surgery? Or will there be a backlash about choice and control. The answer may depend on whether patients feel the decision is shared, or imposed.
Share your thoughts on database design for tracking pharma payments to doctors
Filed under: Government, Health care reform, Health data
Curtis Brainard of Columbia Journalism Review reminds reporters that their input is needed on the design of a federal database that will track payments from drug and device makers to doctors.
Investigations and databases, such as Dollars for Docs by Propublica, have revealed payments to doctors who had been accused of professional misconduct, had been disciplined or lacked credentials. Researchers have found evidence that payments can influence doctors’ treatment decisions (PDF).
Provisions in the Affordable Care Act mean that companies will have to report such payments to the Centers for Medicare & Medicaid Services, which will post the data on a public website. CMS has asked for “comments on how to structure this Web site for ultimate usability.”
There are a number of ways to submit your comments, detailed in this Federal Register announcement. Comments must be received by 5 p.m. EST on Feb. 17.
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