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Obamacare and CAM

Practitioners of so-called “complementary and alternative medicine” currently enjoy a certain measure of government largesse in the form of state laws mandating coverage of their services by private health insurance plans. The federal Patient Protection and Affordable Care Act (often referred to as the Affordable Care Act, or “ACA,” and sometimes as “Obamacare”) has the potential of putting a significant dent in this forced coverage of pseudoscientific health care.

All states require private health insurers to cover certain health care services by law. These mandates can be in the form of requirements that specific health care services or treatments be covered, that certain providers be covered, or that certain populations be covered.

Mandates are ubiquitous, inconsistent among states and costly. One insurance industry trade group calculates that there are currently 2,262 separate state mandates. Some are supported by clear evidence of benefit, such as immunizations and mammograms. Others, unfortunately, require coverage of “CAM” services, such as acupuncture and chiropractic. (In fact, acupuncture is typically not covered by small group plans unless required by state mandate.) Whether beneficial or not, all agree that these mandates increase premium costs to the consumer, most estimated to be from less than one percent to five percent of premiums, depending on the mandate. Chiropractic coverage, for example, can vary from state to state, from limiting the insured to a specific number of visits per year all the way to requiring chiropractors to be covered on par with medical doctors.

The ACA’s effect on state mandates

The ACA is nothing if not complicated, but bear with me. Under the ACA, all health insurance plans sold to individuals and small businesses must cover “essential health benefits” (EHBs). This includes plans sold on the state-run exchanges, where certain individuals (including those who wouldn’t otherwise have access to health insurance) can purchase insurance. The ACA requires these plans to cover:

  1. Ambulatory patient services
  2. Emergency services
  3. Hospitalization
  4. Maternity and newborn care
  5. Mental health and substance use disorder services
  6. Prescription drugs
  7. Rehabilitative and habilitative services and devices
  8. Laboratory services
  9. Preventive and wellness services and chronic disease management
  10. Pediatric services, including oral and vision care

Congress left it up to the U.S. Department of Health and Human Services (HHS) to further define “essential health benefits” within these broad categories. The individual states will continue in their role as health insurance regulators, although they must now operate within the parameters of the ACA. As mentioned, state functions include management of the ACA-mandated health insurance exchanges, where federal subsidies are available to assist those who cannot afford the premiums. Importantly, the ACA prevents federal subsidies from paying for state mandates which exceed EHBs, as defined by HHS. States will be required to pick up the tab for the extra cost of non-EHB mandates themselves. This is a huge disincentive for states to keep mandates that do not fall within the EHB definition.

Institute of Medicine recommendations

How HHS defines EHBs will be critical step in ridding the private health insurance system of CAM. To help decide what EHBs should include, HHS turned to the Institute of Medicine

to recommend a process that would help HHS do two things: 1) define the benefits that should be in the EHB, and 2) update the benefits to take into account advances in science, gaps in access, and the impact of any benefit changes on cost. . . . The charge of the [IOM] committee specifically was not to decide what is covered in the EHB but rather to propose a set of criteria and methods that should be used in deciding what benefits are most important for coverage.

Two summaries of the IOM’s recommendations indicate that, if followed by HHS, those recommendations could go a long way in eliminating pseudoscience from insurance coverage. In one summary, the IOM stated that “only medically necessary services should be covered” and that the benefit package “needs to be based on credible evidence of effectiveness.” In a second report summary setting forth specific EHB criteria, the IOM included these salient features under the topic heading “Criteria to Guide EHB Content on Specific Components:”

The individual service, device or drug for the EHB must:

Be safe – expected benefits should be greater than expected harms.

Be medically effective and supported by a sufficient evidence base, or in the absence of evidence on effectiveness, a credible standard of care is used.

Demonstrate meaningful improvement in outcomes over current effective services/treatments.

Be a medical service, not serving primarily a social or educational service.

Be cost effective, so that the health gain for individual and population health is sufficient to justify the additional cost to taxpayers and consumers.

In addition, the IOM included as criteria under the topic, “Criteria to Guide Methods for Defining and Updating the EHB:”

Methods for defining, updating, and prioritizing must be:

Transparent. The rational for all decisions about benefit design, and changes is made publicly available. . . .

Sensitive to value. To be accountable to taxpayers and plan members, the covered service must provide a meaningful health benefit. . . .

Responsive to new information. EHB will change over time as new scientific information becomes available. . . .

Data driven. An evaluation of the care included in the EHB is based on objective clinical evidence and actuarial reviews.

If you find this less than a perfect recipe for the delivery of science-based medicine, it is nevertheless a vast improvement over the current system of state mandates, where coverage is too often based on the lobbying efforts of special interest groups. If these strictures are implemented, we should see the eventual elimination of coverage for acupuncture and a good bit of chiropractic and naturopathy. At the very least, if coverage decisions are transparent, those decisions which fudge on the evidence will be sitting there in plain view, open for criticism.

HHS on EHBs

HHS has yet to issue regulations (which would be legally binding) defining exactly what “essential health benefits” are, but some guidance has been issued so that the states can begin setting up their health insurance exchanges. Unfortunately, HHS has opted for a system which retains state mandates, at least for now, and fails to fully implement the IOM’s recommendations. HHS decided that states can formulate the minimum requirements for a health insurance plan by choosing, within certain limits, an existing health plan offered in their state as a benchmark. All insurance plans offered on the exchanges and in the individual and small group markets must be “substantially equal” to the benchmark plan.

For 2014 and 2015, states can choose benchmark plans subject to state mandates. Because benchmark plans define what EHBs are for a particular state, the state mandates would automatically be within the definition of EHBs if a private insurance plan is chosen. This is essentially a run-around of the requirement that the federal government not pay for state mandates.

However, there is room for optimism. Starting in 2016, HHS will revisit the benchmark issue and has the option of excluding any particular state mandate from EHBs. This means that if a state chose a benchmark plan which included state mandates, the state would have to pick up the tab for the cost of those benefits axed by HHS. Given the fiscal situation of states, it is highly unlikely they will continue to mandate coverage for benefits they must pay for through premium subsidies for those who cannot afford to purchase insurance via the exchanges.

As the ACA matures, there is even greater potential for elimination of CAM. One of the primary missions of the Affordable Care Act is to make health insurance, well, more affordable. To the extent plans are larded with ineffective CAM treatments that do not improve outcomes they defeat the purpose of the ACA. Fortunately, the ACA requires HHS to periodically review and update EHBs, using, among other criteria, changes in medical evidence and scientific advancement. So, finally, the government will be legally required to look at the evidence in determining what benefits must be covered by private health insurance.

According to HHS, private insurers will be required to look at the evidence as well.

Under the benchmark framework, we note that the provision of a ‘substantially equal’ standard would allow health insurance issuers to update their benefits on an annual basis and they would be expected on an ongoing basis to reflect improvements in the quality and practice of medicine.

Finally, HHS said that the “benchmark approach” isn’t the last word in determining EHBs. It intends to propose a process of evaluation of this initial system. Again, changes in medical evidence and scientific advancement are a legally mandated part of this evaluation.

California implements the ACA

Let’s see how the ACA is playing out in California. California Senate Bill 951 and the similar Assembly Bill 1453, both of which define the EHBs for California under the ACA, are moving through the state legislature. Both peg EHBs to a Kaiser Foundation small group HMO. The original bills included specific services which must be covered by plans, including acupuncture and chiropractic services. However, the bills in their current form exclude specific coverage mandates.

While most consumer health groups lauded the plan, or were at least optimistic, guess who was complaining about lack of coverage? According to California Healthline, “representatives for the chiropractic industry . . . worried that those services weren’t adequately included among the essential benefits.” And, according to a legislative committee report, the California Chiropractic Association opposed Senate Bill 951 unless it was amended, asking that the Legislature reexamine the possible choices for an EHB plan to select one that includes chiropractic benefits. (It is not clear to me whether the benchmark Kaiser plan totally excludes chiropractic coverage or substantially limits it.)

As well, “The Council of Acupuncture and Oriental Medicine Association write they are pleased to see SB 951 recognize acupuncture as an EHB, but they are concerned SB 951 will only apply to acupuncture for treatment of pain and nausea.” This is so even though acupuncture doesn’t work, but it’s a step in the right direction.

Thus, even though states, at this point, need not base coverage decisions on actual evidence, at least one state (and a large one at that) has voluntarily chosen to limit coverage of two CAM providers. Let’s hope this is a trend.

Summary

In sum, the ACA requires that individual and small group health insurance policies cover “essential health benefits,” which the Department of Health and Human Services is working to define. HHS has turned to the Institute of Medicine for advice, which, if taken, will require that EHBs be both cost effective and evidence based as determined through a transparent process. This should eventually severely curtail or eliminate legally required coverage of “CAM” practices. If state legislatures mandate non-ESB coverage, such as “CAM” practices, those states will be required to absorb the additional cost in subsidies for people who can’t afford premiums.

In the interim, states can choose benchmark plans on which all individual and small group policies must be based. Mindful that keeping costs down is essential to the success of the health insurance purchasing exchanges required by the ACA, states are more likely to choose benchmarks which offer no-frills benefits. If California’s experience is any indication, efforts will be made to curtail, if not eliminate, CAM from essential benefits packages during this interim period.

As cost considerations and evidence-based decisions take hold in the coming years (if all goes as planned and the ACA remains law), we should see CAM providers eliminated or, at the least, more severely curtailed in health insurance coverage. Perhaps I am being overly optimistic, but the mechanisms are certainly in place for this to happen. And since you and I pay for CAM coverage through increased premiums, it will be an economic benefit to us all.

 

Posted in: Acupuncture, Chiropractic, Legal, Politics and Regulation, Science and Medicine

Leave a Comment (72) ↓

72 thoughts on “Obamacare and CAM

  1. Perhaps I am being overly optimistic, but the mechanisms are certainly in place for this to happen. And since you and I pay for CAM coverage through increased premiums, it will be an economic benefit to us all.

    Ugh. This post is possibly the worst attempt ever to “apologize” for horrible Obamacare.

    I’ll kindly excuse myself from the rest of this thread. I’ve found there’s a rather high concentration of liberals, etc, on the internet and for the most part I absolutely cannot stand their mindset.

  2. drfisher says:

    I really don’t see this as a liberal/conservative issue. As a dentist and small business owner whose health insurance costs have gone through the roof I will welcome the day when my premiums do not help perpetuate quackery. To me this is a great move to become scientifically and fiscally responsible in the area of health care. Now, if the teeth could be recognized as a part of the body by insurers….

  3. milkybar251 says:

    @Skepticalhealth

    Are we reading the same quote? To me it reads as a tentative, ‘Hooray! CAM could be pushed further to the fringes’.
    Oh and if all you’re only finding is liberals you’re not looking very hard.

    My impression of the ACA is it’s better than what you have now. ie. more people get necessary healthcare.

    If it makes you feel better the NHS is being slowly posioned with false choice and privatisation :-(

  4. rork says:

    Thanks for this article. Much talk about ACA everywhere, but sensible info is scarce.
    With or without ACA, these choices still need making.

  5. cervantes says:

    A lot of people know they’re supposed to hate the ACA, so they do, but they don’t know why they’re supposed to hate it. In fact they don’t even know what’s in it. I suspect “Skepticalhealth” is in that category.

  6. CarolM says:

    I don’t see what’s to stop national CAM associations from lobbying Congress and HHS over the mandates. And, sadly, there are CAM nuts on both ends of the political spectrum. On the right it’s a “liberty” issue and on the left it’s I don’t know what..sheer gullibility? Not to mention greed.

  7. windriven says:

    “it is nevertheless a vast improvement over the current system of state mandates, where coverage is too often based on the lobbying efforts of special interest groups. If these strictures are implemented, we should see the eventual elimination of coverage for acupuncture and a good bit of chiropractic and naturopathy.”

    You can’t be serious. Are you actually of the opinion that the feds are more immune to ‘the lobbying efforts of special interest groups’ than are the states?

    I will confidently predict* that, in the hands of legislators and regulators, sCAM will become fully woven into ACA. People (voters) like it and believe in it – and that trumps science and evidence in a great many minds. The quack lobby will marshal their forces and spread around cash. Where is the lobby in opposition? Does SBM have a K street connection that I don’t know about? If so, where do I send my check?

    *A few of the most bizarre forms of quackery may get sacrificed on the altar of sausage-making but acupuncture, chiro, etc. are safe and snug in their beds.

  8. windriven says:

    @cervantes

    “In fact they don’t even know what’s in it.”

    And whose fault is that? Did the president sell his eponymous program? Did (then) Speaker Pelosi? How about Harry Reed? Or even Secretary Sibelius?

  9. Jann Bellamy says:

    @Skeptical Health:

    The purpose of this post is not to evaluate the entire ACA, only that small portion of it which may hold some hope for ridding the private health insurance system of CAM. I think all of us who support science-based medicine can applaud that effort.

    @windriven:

    I too fear that the CAM lobbyists will try to gut these provisions but hope that they will be met by the considerable resources of the insurance industry, which is under more pressure than ever to keep premiums affordable. The insurance industry has a great deal of self interest in ridding the system of state mandates and will push back against anything that reintroduces protected classes of coverage (like CAM) back into the system.

  10. cervantes says:

    Sadly windriven, I must agree with you that Obama, the administration, and the Democrats in congress did a very poor job of explaining and defending the ACA. In fact they seemed to prefer not to talk about it until recently. I have discussed the matter here.

  11. lilady says:

    Well I’m a liberal…so I hope I don’t offend anyone here.

    Why is anyone against a Federal law, that has the potential to insure 30 million Americans, who are presently uninsured or uninsurable; disabled kids, those with preexisting medical conditions and those who have complicated medical conditions that have already reached their lifetime medical insurance “cap”?

    Since the beginning of the Obama presidency, the Republican party leadership and far-to-the right fringe groups have made universal health care their target…indeed their only target…to make Obama a one-term president and to gain control of both houses of Congress.

    While it is true that some Conservatives, Republicans, Democrats and Liberals all have their own “pet” CAM treatments…it is only the far-to-the-right groups and Republicans who have fostered the ideas of *Big Government*, *Big Pharma* and *Big Crooked AMA* which will take away a patients right to chose.

    -Remember Sarah Palin’s “Death Panels”?

    -Remember the disingenuous sight of *GOGs* (Greedy Old Geezers) on Medicare or Medicare/Medicaid picketing with placards “Keep Big Government Out Of My Healthcare”?

    So which groups aren’t part of the vast Big Government/Big Pharma/Big AMA Complex? Why, it is the chiros, the acupuncturists, the homeopaths/naturopaths, the unregulated supplement manufacturers…who have only the patient’s bests interests in mind (sarcasm).

    Was the Democratic leadership remiss when they didn’t promote universal health care? You bet they were…because to do otherwise, could very well have cost them their seats in Congress and in the Senate.

    I too, find the complicated ACA difficult to understand…made even more difficult by the political rhetoric from both sides of the aisle. I rely on analyses by political pundits, but I also frequently view these websites to see how the ever-changing political dialogues actually stand up with the Affordable Care Act as it stands now:

    http://factcheck.org/

    http://www.politifact.com/

  12. @cervantes, thank you for being the prime example of why these threads are pointless to comment in. You both insulted me and spoke condescendingly to me without cause.

  13. BobbyG says:

    I was inspired by the SCOTUS ruling to write and record a song about it.

    http://EpistemicHairball.blogspot.com

    ;)

  14. mousethatroared says:

    SkepticalHealth
    “I’ll kindly excuse myself from the rest of this thread. I’ve found there’s a rather high concentration of liberals, etc, on the internet and for the most part I absolutely cannot stand their mindset.”

    HeHe, this is kinda like that commercial were the girl calls her boyfriend to give him the silent treatment…

  15. WilliamLawrenceUtridge says:

    Kinda seems like this should be the place where we can discuss and reach a point of either agreement, or agreeing to disagree.

    SkepticalHealth, why don’t you like the ACA? What are your objections? Are they moral, fiscal, political, libertarian, medical or otherwise? Do you think a fully-public option would be superior? As a Canadian I don’t feel any particular attachment to any position, but I can give you an opinion from the perspective of someone with a public health care option.

  16. Pneumonium says:

    @SkepticalHealth, I’m not sure how you took what was said to be an apology for “Obamacare.” The summary paragraphs obviously stated that Jann is hoping that the HHS will conclude that cost effective evidence based treatments should curtail or eliminate CAM coverage. At that point if states want to support CAM then the costs would fall on the states. This statement is not liberal or conservative nor is it an apology.

  17. cervantes says:

    Ah, but skepticalhealth, I did have cause. This is what YOU wrote, to which I was responding:

    “Ugh. This post is possibly the worst attempt ever to “apologize” for horrible Obamacare.

    I’ll kindly excuse myself from the rest of this thread. I’ve found there’s a rather high concentration of liberals, etc, on the internet and for the most part I absolutely cannot stand their mindset.”

    Now who insulted people, and condescended to them, without cause? If there is something you don’t like about the ACA, just tell us what it is. Don’t begin with a gratuitous ad hominem attack on everyone who comments here, entirely omitting any substance.

    Projecting are we?

  18. lilady says:

    I wonder if skepticalhealth, is also against Medicare…which after all is a type of “universal health care”. Every worker and dependent of workers, is eligible for coverage for Part A, which is free of premiums, upon reaching age 65. Part B is health care provider coverage and Part D is drug coverage. Both Part B’s and Part D’s premiums are based on the retiree’s income. A large portion of the costs of providing these all these coverages come from the Medicare “taxes” that are paid from current workers.

    http://www.medicare.gov/Publications/Pubs/pdf/11579.pdf

    Here’s another *wrinkle* about the gap coverage that most Medicare recipients purchase. Those retirees depended on continued health care coverage (paying the full premium), through their employees…in order to get the benefit of the large “group rate”. Many of the large corporations are now booting retirees out of the group health plan…in order to lower the overall premium for them and their employees.

    Lots of luck, trying to secure a gap policy for yourself…if you have a pre-existing medical condition (simple well-controlled hypertension or expensive cancer care)…or the insurance underwriter considers a 65 year old to be “high risk”.

  19. nwtk2007 says:

    @skeptical – I am wondering what your true opinion of Obamacare is as a physician (you I mean).

    Will some 80% of doctors quit because of it? It is a good thing or a bad thing? Will it put bureaucrats in control of you and your practice?

    You hear a lot of bad stuff about it so I’m curious how the scientific docs see it as a whole. I’m neither a lib nor a gun tot’in bible banger, just curious about how ya’ll see it.

  20. nwtk2007 says:

    Also, how is it gonna be worse than it is now with healthcare as it is , essentially under insurance control?

  21. windriven says:

    @WilliamLawrenceUtridge

    “I can give you an opinion from the perspective of someone with a public health care option.”

    I for one would like to hear your thoughts. Back in the early 80′s when DRGs were first seeing broad implementation I gave some speeches to industry groups about the likely impact. At that time I used some news stories out of Toronto and the real life story of my Canadian father-in-law who died while waiting for his name to come up for a CABG under OHIP to illustrate that government control over health care did not always bring unalloyed good tidings.

    But nearly 30 years have passed since then and Canada spends substantially less per patient on health care than does the US – and has excellent health care metrics. In fact Cuba, which spends less than $600 per capita on health care is in basically the same league in gross metrics as the US which spends on the order of $7500 per capita. Clearly, America has some things to learn.

  22. windriven says:

    @lilady

    “A large portion of the costs of providing these all these coverages come from the Medicare “taxes” that are paid from current workers.”

    Do you understand that this is a serious problem for Medicare in the US and for a variety of more or less socialized medicine schemes in European countries facing the same demographic dilemma? The aging population is growing faster than the working population that pays for their care. Further, the per capita cost of delivering that care continues to rise faster than the inflation rate.

  23. lilady says:

    @ Windriven: Yes, I’m aware of the Medicare fiscal problems…especially with Part A…which is a “pay as you go” system and funded exclusively through Medicare taxes paid by current workers and/or their employers (if they are not self employed) through the Health Insurance Trust Fund. The Medicare taxes that I paid into the system for years are already spent by older retirees. During hard economic times with high unemployment the Health Insurance Trust Fund is underfunded. Parts B, C and D are funded by the policyholder and by general revenues from the Federal government.

    http://www.fas.org/sgp/crs/misc/RS20946.pdf

    You’ll notice I disparaged Palin’s “Death Panels” remarks. I am absolutely for reimbursing family physicians for discussions with patients about end of life decisions and discussing advance directives with close family members.

    I despise older people who divest themselves of assets to provide for their heirs…and to make themselves eligible for Medicaid-funded nursing home care, when many of these people can well afford Long Term Care Insurance. Not everyone who is on Medicare is a “greedy old geezer”…many of us, including me and my husband have LTC insurance. We have been paying the premiums ($ 4000 yearly) for the past twenty years.

    Why haven’t all the States and the Federal Government offered incentives for people to purchase LTC insurance? New York State provides an income tax credit for 20 % of the costs of the premiums.

    In case you haven’t read my postings before, I’m all for eliminating health insurance coverage for quack treatments, that include chiropractic, acupuncture, homeopathy, naturopathy and every other flavor of the week CAM/ALT *treatments*. Every time they get a toehold in a hospital setting and every time a hospital touts “holistic care”…their crappy treatments are legitimized.

  24. PJLandis says:

    “Will some 8[3]% of doctors quit because of it?”

    That’s not an accurate number…
    http://www.slate.com/blogs/weigel/2012/07/09/about_that_83_percent_of_doctors_hate_obamacare_so_much_they_might_quit_poll.html

    Slate is pretty liberal, but the analysis is pretty solid. So, 83% of the 4% of doctors who respond to faxed surveys from an organization that believes “PPACA is the Destruction Of Our Medicine” might quit because of the Affordable Care Act. And if you read some of the survey responses, most of these doctors were apparently ready to quit well before this law went into place.

  25. PJLandis says:

    For those who haven’t been sickened by the liberal mindset apparently on display, here’s a good overview of The Patient Protection and Affordable Care Act, otherwise known on the streets as Obamacare;

    http://www.reddit.com/tb/vbkfm

  26. mousethatroared says:

    @pjlandis – great link! thanks.

  27. WilliamLawrenceUtridge says:

    @windriven

    I for one would like to hear your thoughts. Back in the early 80′s when DRGs were first seeing broad implementation I gave some speeches to industry groups about the likely impact. At that time I used some news stories out of Toronto and the real life story of my Canadian father-in-law who died while waiting for his name to come up for a CABG under OHIP to illustrate that government control over health care did not always bring unalloyed good tidings.

    But nearly 30 years have passed since then and Canada spends substantially less per patient on health care than does the US – and has excellent health care metrics. In fact Cuba, which spends less than $600 per capita on health care is in basically the same league in gross metrics as the US which spends on the order of $7500 per capita. Clearly, America has some things to learn.

    My perspective (which is anecdotal) is informed by a couple things. I’m young(ish), I eat a diet that probably goes beyond what any recommendations exist for intake of fruits and vegetables, I exercise regularly and my job has very good health insurance. So I generally don’t have much need for a doctor and when I do I pay very little out of pocket.

    That being said, I have experienced good and bad things about Canadian health care. The good – visits to the doctor have to date cost me nothing. Walk-in clinics are pretty common, free with my health card and deal with minor complaints quite easily, requiring nothing more than time to wait. My parents and grandparents have medical issues. All have been able to see doctors about them, and have had several operations that cost nothing. All have complained about some of the doctors they’ve seen, but have been able to switch doctors without pentalty. All the doctors and receptionists I’ve had to deal with have been patient and polite, I never felt rushed or unwelcome. Despite restrictions on “one complaint per visit” my doctor has, in addition to my presenting complaint, answered questions and provided advice on unrelated minor issues without making any noise (and leaves my file open for me to read when he’s not in the room). Even with insurance, the medications I’ve needed to buy have been pretty cheap, I could have paid for them out of pocket with no trouble. Pretty much everyone I’ve known who has had to go to emergency care has experienced triage (so minor complaints wait a long-ass time) but actual emergencies are dealt with, for free, as emergencies and treated immediately. I had a friend whose wife developed cancer and he had nothing but praise, effusive praise at that, for how well they were treated and the virtually seemless transition from service to service all the way from diagnosis to surgery to post-op chemo. His one complaint was the lengthy, horribly stressful gap between a biopsy and a diagnosis of cancer, but after that diagnosis, treatment was fast and as easy as can be expected.

    The bad – finding a doctor is reputedly difficult (I found one rather easily, but my ever-wise spouse suggested he was willing to take me on because I was young(ish) and in good health) but there has been much bragging at the provincial level about efforts to increase the number of family doctors. Getting an appointment with your regular doctor can be an issue, waiting up to a month for an appointment. I had to see a specialist (is a general surgeon a specialist? A non-GP anyway) recently and that took three months for the initial appointment (but because of a cancelation the actual procedure was within a week). Some doctors are dicks, but that’s universal. Talking to friends and family, seeing specialists is the bottleneck – long waits before appointments and follow-up care. Pathologists are apparently in short supply. Every so often I’ll read a news story discussing public coverage for CAM (or more recently the MS liberation procedure debacle) but fortunately the provincial government canceled coverage for chiropractors and the like a couple years back (I was seeing a chiropractor at the time and was a student, my cost per visit went from $10 to $14 I believe).

    All of this is mostly invisible in terms of cost. I pay taxes, health care comes out of taxes, but no user fees (or at least so minor I don’t notice them). I routinely ask after appointments “that’s it?” and the only reason I pull out my wallet is to put my health card back in. Health care is politically a pretty big deal, lots of time spent discussing cost, access, if our system is failing or not, private versus public versus mixed systems. There’s lots of grousing but overall, I at least am quite satisfied. I can’t claim to be anything close to even an informed consumer, but Joseph Heath makes arguments for universal health care in Filthy Lucre that I found convincing (primarily that universal coverage costs a lot overall, but per-capita is much cheaper than private insurance).

    So, overall, I’m a huge fan of universal health care. It’s not without problems, and I am in a very lucky position, but I’m quite grateful that if I break a limb or develop a bunion, treatment is available essentially for free. I don’t understand the US preoccupation (and apparent pride though perhaps that’s just the vocal minority being vocal) with avoiding a health care system. Yes, the US does have the best care in the world…for the wealthy. I’m not wealthy, so I’m really, really happy that I pay for health care through taxes. Seriously, I’m baffled – you can pay for health care through insurance premiums (and they’ll do their best to screw you over) or you can pay for a public option through taxes. Or you can go bankrupt due to a car accident or pregnancy. For that matter, I like paying taxes because it gives me (in addition to health care) roads to walk on, libraries, sewage treatment, police officers, fire departments and all the other common goods which private industry would not deliver or do so badly. But Canadians don’t seem to have the reaction to taxes that Americans do.

    Denialism over at Scienceblogs had a series of posts on this topic and I read them with great interest. Here’s the one for Germany, I’m too lazy to look for the rest but he’s got a tag for the topic. Right now the bottom couple on the first page are entries about other countries. Don’t think Canada is there.

  28. windriven says:

    @lilady

    “You’ll notice I disparaged Palin’s “Death Panels” remarks. I am absolutely for reimbursing family physicians for discussions with patients about end of life decisions and discussing advance directives with close family members.”

    “Death Panels” are a fact of life now. Medicare and almost all private sector insurers have limits to coverage including limits on total expenditures. A frank public discourse – if such a thing is even possible in a body politic that has cleaved so sharply into into teams – about mortality is a necessary if insufficient component of real reform.

    Real “Death Panels” are probably not a bad idea if properly constituted. Let’s say that we divide health care into routine care which would include most surgeries, obstetrics and so forth and extreme care which would include intractable late stage carcinomas, non-routine and multiple organ transplants, and so forth. There might be a specific pool of funds for extreme care and a system – perhaps modeled on the organ transplant system – to allocate those funds. A young mother with stage 3 breast cancer would merit more resources than a 60 year old smoking alcoholic with esophageal cancer. There could even be a market for supplemental insurance to fund extreme care for individuals who don’t want to take their chances with the system.

    The fly in this particular ointment is that medical has progressed as it has in part because we have been willing to spend close to a fifth of GDP on health care and that has fueled innovation and funded the often circuitous path to working out the kinks of a given therapy. What might have been extreme care 20 years ago would be routine care today. How do we bring health care spending under control without smothering innovation?

  29. WilliamLawrenceUtridge says:

    Echoing mousethatroared, PJLandis’ reddit summary of PPACA is very readable and relatively short, compared to War and Peace anyway (assuming it’s accurate, I haven’t read the original document).

  30. windriven says:

    @WLU

    Thanks for your thoughts on the Canadian model. Perhaps much has changed.

    For what little it is worth, I see some real benefits to universal care, at least universal first tier care. As you may or may not know, we don’t have uninsured people dying like flies here from appendicitis and broken bones. The care gets delivered but in the least efficient manner possible. Hospitals then jack up rates for everyone else to cover that care. Having universal coverage would regularize that health care delivery and remove a good deal of fear and uncertainty from the lives of people not fortunate enough to have quality health insurance. And it forces everyone with an income to contribute (though this might seem a negative to young and healthy people who would rather use that money to buy a home or start a family).

    But the US government has a poor track record managing large entitlement programs; it is so very easy to give now and worry about paying for it later. The classic programs of Social Security and Medicare are good examples. SS started as a safety net for widows and orphans and has grown to become a program that touches the lives of all Americans. Legislators have known for decades that the demographic feces were going to hit the fan but have simply kicked the can down the road hoping, on supposes, that the problem would become a crisis until they were retired from office. No one argues that Social Security as a basic concept is a bad thing. But rational people have good reason to question the breadth of the program and its financing; essentially its management by our elected leaders.

    Which brings us back to health care. The immediate problem is not the 30 million uninsured; that is more a symptom than a cause. The problem is providing quality basic health care to a nation of 350 million without spending twice what other nations spend on a per capita basis.

  31. PJLandis says:

    “But rational people have good reason to question the breadth of the program and its financing; essentially its management by our elected leaders.”

    PPACA isn’t a government healthcare system like Medicare/Medicaid, it requires that everyone purchase insurance from private actors. I often find that people don’t understand that point.

  32. WilliamLawrenceUtridge says:

    @windriver

    Thanks for your thoughts on the Canadian model. Perhaps much has changed.

    Probably the last 15 years or so there has been a lot of noise made about the Canadian health care system. For some reason it’s seen as a point of national pride (because no other country has a health care system? I dunno why). I haven’t been following it with anything like attention, but I’ve noted headlines talking about reduced wait times, increased funding, things like that. Definite effort has been made and money spent on improving things, though I can’t personally say I’ve noticed a difference (again, health, good insurance, minimal contact so I’m more likely to think things are great).

    In a lot of ways, Canadian identity is defined in opposition to American. Since you don’t have a health care system, we’re extra proud of ours. Our beer is better than yours (no idea, I don’t drink beer). We’re self-effacing, you’re loud. Nonsense stereotypes like that. As a Canadian who tries to be cold-blooded about things, I’d rather we compared ourselves to Northern Europe.

    Immigration does seem to be less of a bugbear here than Scandinavia though, probably because we lack a coherent identity other than “clean and bland”. There’s a pretty good joke – what’s the difference between Canada and yogurt? Yogurt has culture. AHHAHAHAHA! Put that in your touque and smoke it!

    I’ve said it before, but I’ll repeat it – I think a universal health care system is a fantastic thing. I think the vocal and somehow moral opposition to it in the US is hystrionic and bizarre. If PPACA becomes a reality, I bet 20 years from now you’ll wonder what you were fussing about.

  33. marcus welby says:

    Thanks to the Canadian input. They provide quality care for half per capita to what we do in the states, and we currently have 50 million with no insurance, another estimated 50 million with underinsurance, and medical bankruptcies at an unconscionable rate. The PPACA reforms will help a little but will not control costs, as there is not a single proven cost control method included. As mentioned above, the mandate for healthy young gamblers to buy policies they think they don’t need, while sending profits to private for-profit entitities, is troubling. A dysfunctional system with 31% overhead will now surely go to 35% waste, and will fail due to continuing rise in costs. With Canada’s single payer system as a model, like most of the developed world, we could save an estimated 400 billion a year and every one of us would have better health coverage than we have now, with the tools for true cost control (global budgets, etc.) and true comparative effectiveness, which would eliminate almost all CAM. Former NEJM editor Marcia Angell says best to get to that state by lowering the eligibility age for Medicare 10 years at a time, while funding the system with progressive income taxes, instead of the outdated method now in use. Might be less disruptive that way.

  34. windriven says:

    @PJLandis

    “PPACA isn’t a government healthcare system”

    WLU and I were talking about Canadian-style healthcare which is. That said, my arguments about government control vis-a-vis PPACA doesn’t change. You may purchase from a private sector insurer but the Feds determine what must be covered. To swing the conversation back to quackery, there is nothing to prevent, say, Sen. Harkin from trading a vote on defense appropriations for a mandate that homeopathy coverage be included.

  35. windriven says:

    @marcus welby

    I never understood why Rep. Pelosi didn’t go with a single payer system from the start. PPACA was passed over strident Republican opposition so it doesn’t hold water that the decision was a sop to bipartisanship. I’ve become cynical I guess but I suspect there is more to that decision than meets the eye.

    But let me ask you this: as a physician would you be willing to accept more assertive ‘best practices’ limitations to the way you practice? I for one think this is a fine idea but then I’m not a physician.

  36. windriven says:

    @WLU

    “Immigration does seem to be less of a bugbear here than Scandinavia though”

    I served on the board of directors of a Swedish company for some years and observed firsthand the transition from warm and welcoming to borderline xenophobic. When Swedes were largely all … native Swedes the cradle to grave social system worked very well. There was a shared cultural imperative not to game the system.

    Immigrants generally had different values and were also more likely to depend heavily on social safety nets while they acclimated – a process that can take a generation or two. Swedes saw demand for services and the costs of providing them skyrocket.

    I don’t know why this hasn’t become more of an issue in Canada but I will say that some Canadians of my acquaintance were privately vocally prejudiced against Italians in the 70s and East Asians (Pakistanis and Indians) today.

    And if you want to know about beer I’ll meet you in Portland, OR – known far and wide as Beervana :-)

  37. marcus welby says:

    @windriven: of course all of us physicians will have to eventually accept more central control and rationing (there, I used the R word) since medical costs are going up in every country. Best to ration fairly on basis of what works and what is cost-effective, not on ability to pay and political special interest pressure, which is what we do now.

    As to Pelosi, et al. I blame it mostly on Rahm. I think he saw that the hugely funded opposition of insurance and drug interests could be defanged by offering them millions more policies and pills to sell, and promising not to demand a volume discount (which Obama had promised to do while campaigning), perhaps gaining corporate campaign allies for the next election. Disgusting outcome, in my opinion.

  38. evilrobotxoxo says:

    @windriven: they tried to go with single-payer (e.g. “the public option”), but I think they had to cut it out because a few of the conservative Democrats wouldn’t go for it. Also, you commented about the relationship between innovation and total health care costs, but medical research is funded through mechanisms that are largely disconnected from the provision of routine clinical care. Also, the actual number of dollars spent on research is a tiny, tiny fraction of health care-related spending.

    @Marcus Welby: I think most people agree that a single-payer system would be more efficient, and as a physician (who does mostly research), that would be my personal preference. However, it’s not entirely clear how PPACA will affect costs, and although I agree it doesn’t include anything that’s proven to lower costs, it’s plausible that simply extending coverage is enough to lower them. That’s counterintuitive, but the basic idea is that the vast majority of health care dollars are spent in hospitals, not the outpatient setting. The US has de facto universal coverage at the inpatient level because hospitals can’t turn away people who are sick enough to require hospitalization. But we don’t have universal coverage at the primary care level to keep people out of hospitals. I don’t think there’s any evidence that extending primary care coverage will help prevent hospital admissions, but there have been studies showing that excess admissions are the single largest factor driving increased health care costs in segments of the US vs. demographically-matched segments of other countries. And I think that the anecdotal experience of most doctors in the US matches this. So we’ll see, I guess, if it makes any difference.

  39. windriven says:

    @marcus welby

    I wish we would all use the R word freely. Medical care here and everywhere is a limited resource. There likely will always be rationing of medical care. I fully agree that we should ration fairly and intelligently.

    Nice analysis with Emanuel as the deus ex machina in the health care debate. Makes a lot of sense.

  40. Scott says:

    I don’t think there’s any evidence that extending primary care coverage will help prevent hospital admissions, but there have been studies showing that excess admissions are the single largest factor driving increased health care costs in segments of the US vs. demographically-matched segments of other countries.

    One factor opposing the proposition that this will make much difference is the (anecdotal) propensity of Americans to go to the ER because we don’t want to wait a couple days to see the PCP.

  41. windriven says:

    @evilrobotxoxo

    “medical research is funded through mechanisms that are largely disconnected from the provision of routine clinical care. ”

    I was speaking more of the the evolution of clinical care, that is, trying the untried, perfecting the imperfect, and so forth. It seems intuitively true that the less freedom of action clinicians have the slower the evolution of clinical care will be. In any large enterprise it is easy to fall into organizational stenosis: we’ve always done it this way so we’ll always do it this way.

  42. Linda Rosa says:

    Thanks for this essay; it straightened me out on several points. In a class I am auditing on ACA now, the instructor claims that, at the rate we’re going, in a couple three decades the US health care budget will become half of the country’s GDP. That means that we are headed for financial armageddon and there are going to be huge pressures to reduce health care expenditures.

    Won’t any plan that a state initially peg its EHBs to include, by force of law, all of that state’s standing mandates for CAM coverage? Where can they get around these?

  43. JMB says:

    Prior to ACA, the decision about medicare/medicaid coverage for a procedure was based on recommendations of a scientific panel given to the office of the director of medicare (CMS). Scientific evidence has long been a factore in CMS decisions about coverage for a procedure. That is why we had the USPSTF prior to the ACA. The ACA creates several more panels, and changes the name of the USPSTF. Ostensibly, the new panels will operate without political oversight, and are free to make decisions about funding of coverage without exposure to political (voter) pressures.

    I am not sure how much CAM medicare/medicaid currently covers. Here is a website that you can check for a given state. Feel free to correct me, but I don’t think there is very much coverage for CAM in CMS. States are much more variable in how they approach CAM.

    The gottcha in the ACA is how it changes hospital reimbursement, and makes patient satisfaction scores a significant determinant in hospital reimbursement. Satisfaction is important, but trying to please every patient is not a good thing. Obviously, you don’t want to please the drug addict seeking opiods for a headache, but your satisfaction scores will go down. An SBMer won’t want to provide homeopathy to a patient asking for it, but the satisfaction scores will decrease. An SBMer won’t want to provide antibiotics for a minor non strep sore throat, but the satisfaction scores will suffer.

    So what will the net effect of the ACA on CAM be? Will the scientific panels really be free to make decisions based on evidence free from political pressure? The scientific panels previously reporting to the CMS were largely free of political pressure. Will the financial incentives to keep the patient happy mean give the patient what they want, instead of what the evidence says that they need?

    Only time will tell. But I doubt that medicare covered much CAM before the ACA.

    In regards to the argument about retiring doctors, it’s all in how you spin the numbers. If you look at doctors in private practice age 50 and over, I would suspect that 80% will retire within 10 years if ACA is not repealed or modified. Either way, there will be a significant expansion of nurse practitioners and physician assistants because of the looming doctor shortage, and the delay in addressing the shortage. A large percentage of US citizens won’t be able to keep their doctor.

    In regards to the metrics used to compare healthcare systems, life expectancy reflects population habits as much as quality of care. Recent increases in US Life expectancy can be attributed to the drop in smoking prevalence in the last 20 years. It is predictable that because of the drop in smoking prevalence, the US life expectancy will continue to increase for the near future.

    http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=13089

    I am sure someone in the future will claim the improvement in life expectancy is due to the ACA.

    Doctors aged 50 and over were trained in a system in which nearly all teaching hospitals were “safety net hospitals”. In return for receiving state and federal aid for training doctors, the hospital had a charter to treat patients regardless of their ability to pay. We have all seen the triumphs, failures, and abuses of the system. It is clear to any physician with that experience that universal health insurance does not equal universal healthcare. The public perception that if you were uninsured and poor you wouldn’t receive healthcare was overblown. I am sure that any physician in the 50+ age group, or any hospital administrator could give an example of an uninsured poor patient who received over $500000 in top quality healthcare.

    The public discussion leading up to the passage of the ACA really ignored the amount of care currently delivered for uninsured patients. Why not expand the training of physicians and expand the safety net that still exists?

    One advantage of our broken system is that it provided healthcare options for poor unisured patients that weren’t available in some of the universal health insurance countries. An uninsured patient in any state in the US was more likely to have a life saving helicopter transport for trauma than a patient with universal healthcare in Canada in the province of Quebec (at least until recently). An uninsured woman where I work will typically wait no more than 4 weeks between an abnormal mammogram and the institution of treatment, thanks to charitable organizations (qualifying for medicaid usually takes longer, but that wait is a political decision). I’ve heard stories of women waiting 3 months just for the biopsy (or sometimes, just the further imaging) in other countries with “more compassionate” health care systems. There are far more patients in the US over the age of 80 receiving cancer surgery, pacemakers, automatic defribillators, and renal dialysis.

    That is not to say that our health system is the best, the best health system is that which meets the expectations of its populace. I am just arguing that the choice of metric really reflects agendas of those writing the report. We are dealing with diverse, complex systems.

    The US health system needs reform. The ACA really only addresses health insurance reform. Universal health insurance does not equal universal health care. If doctors are going to address the health needs of the aging population in the US, we need something different… efficiency (more time spent actually delivering the care, rather than more time recording it for policy wonks in the beltway who want to look over our shoulders), and more doctors.

  44. weing says:

    @JMB,

    Well said. I don’t really expect the ACA to save money and bring down the costs to other countries as long as the following remains true.

    “There are far more patients in the US over the age of 80 receiving cancer surgery, pacemakers, automatic defribillators, and renal dialysis.”

  45. marcus welby says:

    @JMB: thanks for useful perspective. Correct about our dysfunctional system. Lifestyle choices are far more important than healthcare access: lifestyle probably about 55%, healthcare access about 15%, but the anxiety associated with being a parent of a child or spouse who is faced with a decision regarding forgoing care due to unaffordability is excruciating, and although the safety net often saves emergency situations, the followup and treatment for chronic conditions is fragmentary without the ability to pay.
    There are some good features of the ACA reforms: expansion of Medicaid coverage for millions with no coverage (assuming this is allowed to occur in one’s state), coverage of some young people under their parent’s or parents’ policy until age 26, some money for community health centers, requirement that most insurers must spend at least 80% of premium dollar on healthcare (over 1000 waivers have evidently been granted to get around this, including several states in entirety), preexisting conditions guaranteed insurability, etc. and finally, single payer is now on the table and a part of the discussion.

  46. Jann Bellamy says:

    @ JMB: “I am not sure how much CAM medicare/medicaid currently covers.”

    Medicare covers chiropractic manipulation to “correct subluxations.” Of course, the chiropractic subluxation does not exist, so the whole concept is fraudulent. There are limitations on payments so that supposedly no payments will be made for “maintenance care,” the chiropractic concept that regular check ups for subluxations and their correction are necessary to maintain health. (A fraud within a fraud, if you will.) Despite this limitation, the Office of Inspector General of the Dept. of Health and Human Services has issued two reports detailing payments for suspected “maintenance care,” costing Medicare millions of dollars. The second report, which references the first, is here: http://oig.hhs.gov/oei/reports/oei-07-07-00390.pdf.

    Medicaid in some states pays for chiropractic (including for children), although I can’t find the reference right now.

  47. windriven says:

    @JMB

    Great comment.

    “The public discussion leading up to the passage of the ACA”

    There really wasn’t much public discussion leading up to passage. There was lots of demagoging on both sides but little meaningful discussion.

    “Why not expand the training of physicians and expand the safety net that still exists? ”

    That physician supply wasn’t addressed (or even considered so far as I can tell) borders on incredible. But the safety net that currently exists relies on a terribly inefficient delivery system. As you point out there is already de facto universal coverage; we do not have people dying in the streets of appendicitis. But routine care is less available and critical care can leave the uninsured or under-insured bankrupt. My strong libertarian impulses would normally label financial ruin a fitting consequence for not carrying insurance. But the cost of health insurance is astronomical and flatly unaffordable for some.

    Health care is a limited resource. The issues are: how are we going to allocate this resource and how can we expand the resource to make it less scarce? All of this without breaking the budget.

    PPACA doesn’t really address either of these.

  48. Jann Bellamy says:

    @ Linda Rosa: “Won’t any plan that a state initially peg its EHBs to include, by force of law, all of that state’s standing mandates for CAM coverage? Where can they get around these?”

    Yes, if the state uses a private insurance plan subject to state mandates as its benchmark, state mandates will be included. However, HHS has issued only guidance on this, not regulations, which would have the force of law. As it develops regulations, HHS may drop use of the benchmark or modify it. In addition, HHS said it will review how the benchmark is working and may eliminate some state mandates.

  49. JMB says:

    @Jann Bellamy

    I wouldn’t claim to have studied the literature in detail, but I believe for the specific application of spinal manipulation to the relief of low back pain associated with muscle spasm, the trials have shown greater effectiveness than placebo, and equivalent response compared to muscle relaxants. So I do think there is science based chiropractic practice, although a science based chiropractic practitioner will disavow vertebral subluxation. Any of the authors here can correct me on the evidence (I’m getting lazy about references), but I think medicare reimbursement for chiropractic procedures is restricted to very specific applications. I don’t know if Sam Homola is still part of this blog.

    In regards to safety net structure that remains in place, I had a friend who devoted herself to charitable care and established a clinic. She was able to establish the charitable clinic using federal funds. To the best of my knowledge, such funding will be discontinued in a few years (I think one of the few amendments to the ACA was to increase the overlap of funding of safety net clinics and the ACA). However, she expects to be put out of business by the ACA because 20 to 30% of here patients will obtain insurance, and there is no way a solo practitioner can afford the computer upgrades and additional personnel training required (or for that matter, the transition to ICD10, even if the ACA is repealed).

    My former office had participated in federally funded safety net. The administrative overhead was less than half of the cost of dealing with medicaid. In fact, we once made a reasonable request to our medicaid representative. We asked if we could just provide certain types of xray exams at no charge, because our reimbursement from medicaid did not cover the administrative overhead of billing the procedure. That would also reduce administrative costs on the government side. We were told we had to submit a bill, that we could not just do the exam for free. Therefore, we had to lose money for participating in medicaid (although we never stopped participating).

    Originally, health insurance was all purchased individually. Employers started offering health insurance as a perc. The government then stepped in and gave businesses tax deductions for providing health insurance. Then the individual policy market tanked, because it was more expensive (and number in the insurance pool is critical for spreading risk). People who became seriously ill often couldn’t work and lost their jobs and insurance. Insurance quants saw a good way to increase profitability, and preexisting conditions became an issue. If government had not given tax deductions to business for providing health insurance (and had just given everybody a tax deduction for buying insurance), how different our healthcare system would now be.

    The government also prevented clinics and hospitals from publishing their prices, which paved the way for outrageous pricing.

    Having experienced such debacles in government control of medicine, it is hard to agree to more government control of medicine (if other countries have success, part of the reason is that they don’t have to deal with US bureaucracy and politicians).

    My solution instead of the ACA… let all individual purchasers of health insurance purchase insurance through the federal employees plan (with no rejection due to preexisting conditions). That way they start out with a large (the largest) pool of members to reduce the rise in premiums. No messing with individual freedoms, no forcing the taxpayer to subsidize sex offenders getting Viagra for erectile dysfunction. If they don’t want to purchase insurance, they still have medicaid (but most states will have to double their taxes to pay for the expansion of medicaid, after initial federal support is withdrawn). Price controls could also replace half of the CMS bureaucracy (and with the federal insurance option, negate the 100 million dollar expansion of the IRS) and cut administrative overhead. Better yet, resurrect the safety net that existed in the 1980′s and train more doctors.

  50. JMB says:

    Funding for the safety net has long been a feature of federal and state programs. Funding has dwindled. The ACA is the first federal law to completely defund it (I think the funding continued for 5 more years, enough to get through another election). Of course, who knows what’s really in the law, it was passed before anyone really could digest the thousands of pages of legalese. I am relying on what my friend told me, and the press reports on extention of funding for community health clinics.

  51. JMB says:

    I should qualify my statement about medicaid causing states to raise their taxes. Louisiana received a large amount of additional funding for medicaid. Consequently, the medicaid expansion won’t require raising Louisiana state taxes. It took six pages to spell out Louisiana in the bill, and the special consideration for Louisiana became known as the “Louisiana purchase” of the ACA (the democratic senator from Louisiana was reluctant to vote for the ACA).

    In the recent Supreme court decision, the part of the law that allowed the federal government to withdraw all funding for a state’s medicaid plan if they refused expansion of medicaid, was struck down.

  52. PJLandis says:

    “SEC. 10503 ø42 U.S.C. 254b–2¿. COMMUNITY HEALTH CENTERS AND THE
    NATIONAL HEALTH SERVICE CORPS FUND.”

    Is that what your looking for? It’s page 929 in my PDF. It doesn include funding through 2018, but I’m not sure that’s any indication they intend to defund the program, unless there’s other information, because that’s a standard way to include funding in bill (always subject to later adjustment or cutting).

    And I was surprised there wasn’t any mention of the Patient-Centered Outcomes Research Institute, a non-profit started under PPACA to do what the UK’s National Institute for Health and Clinical Excellence does for the UK.

    http://en.wikipedia.org/wiki/Patient-Centered_Outcomes_Research_Institute

    I’ll repeat the Reddit link, and I could quibble some of the descriptions but none are grossly misleading and everyhing is cited directly to the act if you have doubts but overall it’s better than the TOC of the actual law.

    “If government had not given tax deductions to business for providing health insurance (and had just given everybody a tax deduction for buying insurance), how different our healthcare system would now be.”
    I was wondering the same thing when I took a course in tax law; and not just health insurance, overall we should stop using the tax system to manipulate people and focus on raising revenue.

  53. BillyJoe says:

    Michelle: “..this is kinda like that commercial were the girl calls her boyfriend to give him the silent treatment…”

    Hmmm, real life imitates art. Except that I’m doing the calling as well.
    I’ve sent her Christmas, New Year and birthday greetings, and a Chocolate Egg at Easter. A few weeks ago when I sent her an email pointing out a serious typo on her website, she corrected it without acknowledgement.
    Should I give up?

  54. JMB says:

    @PJLandis
    Thanks for the correction. The discussion that I had heard was that the final bill was amended to lengthen coverage for the safety net system, the community health centers. I was under the impression that the politicians didn’t think funding of the safety net system was still necessary, because they were going to provide insurance for all.

    In the safety net hospitals I worked in, uninsured poor patients would eventually be signed up for medicaid. However, because of bureaucracy, it would often take several months for them to be accepted into medicaid. Medicaid would never pay for medical care delivered before they were accepted. Because of the delay in coverage, the safety net system was very important in providing care.

    In the lay press, Medicaid is included in the safety net system. It is part of the safety net system, but has the issues of delay in obtaining coverage and reimbursement so low most facilities lose money taking care of medicaid patients. Here is a recent lay press article that mentions what I call a safety net hospital (Jackson).

    http://www.nytimes.com/2012/07/13/health/policy/in-florida-a-fight-brews-over-governors-vow-to-opt-out-of-medicaid-expansion.html?pagewanted=2&ref=health

    In that article there is a statement that the poor uninsured patients might have to wait more than a year for advanced testing. That wait has been described in recent years for the patients receiving universal coverage in other countries. Part of my argument is that the efforts of our healthcare community serving poor uninsured patients has been misrepresented in the rhetoric surrounding the ACA. They have to endure greater waits than insured patients, but so do insured patients in countries with more cost controls on healthcare.

    I also think there were many good initiatives prior to the ACA attempting to reduce and control costs. One of the better that I had read about (but never worked in) was the Oregon state initiative. They used an evidence based approach to rank procedures for cost effectiveness. Politicians would then vote on the amount of funding for medicaid, aware of how far down the list they were providing funding for. CAM wasn’t funded by that mechanism. Voters could then remove politicians from office for either raising taxes too much, or funding healthcare too little. But the national politicians have divested themselves from such responsibility (which may be a good thing on the national level). However, I never had personal experience working in Oregon, so I don’t know how that initiative worked out.

    In my office (I was just one of several partners), we had less administrative overhead working with the uninsured safety net patients (or for that matter the uninsured patients) because we had a negotiated price, and patients arrived with a voucher for payment. No complicated registration process, no complicated computerized submission of bills to medicaid including all of the information they wanted to receive (but never appeared to have used).

    In the county I working in, one of the orthopedists tried to set up a community clinic staffed by volunteer physicians (including specialists) to provide free care on a regular basis. We were willing to support it (we supported other charity clinics with free or reduced rate exams). However, I think malpractice concerns sank it (yes the state had good Samaritan protections, but various court rulings had weakened the protections).

    Getting back on the subject of the posted article, mechanisms have existed prior to the ACA to limit funding to only science based medicine. Whether or not the ACA strengthens those mechanisms remains a matter for subsequent observation. Based on interpretation of the bill, it should strengthen SBM. The unknown factor weight is how patient satisfaction role in reimbursement could weaken it.
    Patients want unnecessary CAM, diagnostic procedures, and treatments.

  55. mousethatroared says:

    @BillyJoe – you lost me there…

  56. Jann Bellamy says:

    @ JMB: “but I think medicare reimbursement for chiropractic procedures is restricted to very specific applications”

    It is limited to “treatment by means of manual manipulation of the spine . . . to correct a subluxation . . . ,”
    42 USC Sec. 1395x(r), so the entire premise is based on a falsehood. It is possible that chiropractors who reject the subluxation might use manipulation for back pain and get reimbursed by Medicare, but I presume, based on the statutory language, they will have to claim they are correcting a subluxation. You are correct that there is some evidence for use of spinal manipulation for back pain. It is a legitimate therapy used by physical therapists as well. Manipulation to correct a subluxation is a sham. Chiropractors use the word “manipulation” in two ways — (1) to describe the legitimate physical therapy, using it the same way a physical therapist would, and (2) as a synonym for “adjustment,” a “therapy” to treat the chiropractic subluxation.

  57. JMB says:

    @Jann Bellamy

    Thanks for the correction. Medicare coverage for chiropractic treatment may not be as restricted as I thought. I did find this information supposedly from CMS, authored in Oct 2011 that implies that Medicare is still covering spinal manipulation for spinal subluxation.

    https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Chiropractic_Services_Booklet_ICN906143.pdf

    There have been some scientific panel reports on CAM under the ACA. Unfortunately, they exhibit the same weakness of EBM that lead to this Blog suggesting SBM could correct EBM’s weakness in ability to reach negative conclusions about CAM.

    Here is a report listed on the ahrq (Agency for Healthcare Research and Quality of the American government, Department of health and human services)


    More data from long term and large head to head trials with sufficient duration of CAM
    treatments and trials comparing CAM treatment to other widely used active treatments (e.g.
    comprehensive physiotherapy) reporting clinically relevant and validated outcomes (e.g. pain
    intensity, disability, direct and indirect costs, utility of conventional care, and adverse events) are
    needed for definitive conclusions.
    Future studies should control for or examine the influence of treatment dose/duration, care
    provider-(e.g. certification, years of experience) and population-specific variables on treatment
    effect estimate.

    Document dated Oct 2010

    http://www.ahrq.gov/downloads/pub/evidence/pdf/backpaincam/backcam2.pdf

    Sounds like the Cochrane Collaboration!

    I am afraid that in spite of the sound of the law, if EBM without SBM corrections rule the scientific panels, then CAM will continue to be funded, because EBM will only ask for more studies to be completed. Of course, defunding CAM would be one of the ways to cut the cost of healthcare in this country without reducing quality, but I have yet to see progress on that issue.

    The question I have asked before is; are they willing to cut back some services knowing the evidence will predict an increase in mortality, but then fail to cut back on treatments known to be ineffective? If the government argues that we can’t afford to pay for a pacemaker to extend the life of an 85 y/o for an average of 3 months, and that we can provide universal health insurance because of such cutbacks in medicare, then they damn sure should not provide funding for CAM in that health insurance (or Viagra for sex offenders)!

  58. PJLandis says:

    JMB…I wasn’t trying to correct you per se, just cite to the actual law which I know is kind of daunting and time-consuming (although searching in PDF helps a lot. Honestly, there is less to read in the law about most issues than in your average news article.

    And there are provisions for states to enact their own legislation and initiatives, but most of that is going to be pretty vague until some regulations are promulgated or some state tries to qualify for the provision.

    “They have to endure greater waits than insured patients, but so do insured patients in countries with more cost controls on healthcare.”
    Are those wait times really comparable? The uninsured patient is waiting no matter what, and may not even qualify for the safety-net, right? Not only that but I’m assuming they’re less likely to seek treatment until late in the game. If everyone is insured, hopefully it will increase preventative care or at least earlier intervention even with wait times, and I would assume there is some mechanism to advance the most needy in those waiting lists.

    Anyway, I’m cautiously optimistic about the law. And I think it’s better that it passed, and then get’s amended in the future, than to wait for a better law; this issue has been active since the 70′s (probably earlier), it’s about time something happened.

  59. PJLandis says:

    And I mentioned the Patient-Centered Outcomes Research Institute (PCORI) above, see their website and search for “integrative” and it returns some interesting results (http://www.pcori.org/about/governance-and-leadership/).

    PCORI is one of the organizations that will be deciding what is considered “essential health benefits,” and they are definitely interested in researching CAM. It also calls for a “State-licensed integrative health care practitioner” as one of the Board Members (1 of 17) and an expert panel with an integrative health expert as appropriate.

    (TITLE IV—PREVENTION OF CHRONIC DISEASE AND IMPROVING PUBLIC HEALTH…Subtitle A—Modernizing Disease Prevention and Public Health Systems…SEC. 4001.) NATIONAL PREVENTION, HEALTH PROMOTION AND PUBLIC HEALTH COUNCIL. This council will be part of HHS, and it’s mandate calls for evidence-based reccomendations, but all it goals at least mention integrative care.

    And under Subtitle B—Innovations in the Health Care Workforce…SEC. 5101. NATIONAL HEALTH CARE WORKFORCE COMMISSION: “doctors of chiropractic…licensed complementary and alternative medicine providers, and integrative health practitioners” are included a list of healthcare providers.

    Anyway, that’s what I got just doing a PDF search of the law.

  60. JMB says:

    @PJLandis
    I still appreciate the more reliable information than what I have presented.

    From my perspective, I have seen the state and federal government dismantle the medical education system as the safety net for uninsured poor. That approach provided an increase in the number of trained physicians, and much lower debt for the graduating physician, as well as high quality free medical care. Then, after the government withdrew the support, the press lambastes the healthcare system for not providing care to poor uninsured patients. In fact, it still does, in spite of the withdrawal of government support.

    So the government quietly withdraws support for the safety net, the health insurance industry loses money on the stock market and raises premiums, and now we have to completely revamp the healthcare system? The system needs reform, I personally haven’t seen the US government increase the cost effectiveness of healthcare delivery. If the government can’t reduce costs by increasing cost effectiveness, the only alternative for reducing costs is to reduce the quantity or quality of healthcare delivered.

    I don’t share the optimism because I think our politicians are deceptive, journalists are either foolish or blinded by an agenda, and the public hasn’t been able to have a reasonable discourse (nobody knew what was in the bill when they voted on it)?

    In regards to wait times for procedures for uninsured poor patients in the US versus insured patients in other countries… that is a study I would really welcome. Occasionally a published study (either scientific or for public review) will mention the wait time. Many public reports have the goal in significantly reducing waiting times, and I think there has been significant improvement.

    Here is a reference from the NHS in the UK to the maximum allowed waiting time between referral to a specialist, and the beginning of care by the specialist — 18 weeks. That is not the average wait time, but apparently you can’t complain about the length of wait until that time has passed.

    http://www.nhs.uk/choiceintheNHS/Rightsandpledges/Waitingtimes/Pages/Guide%20to%20waiting%20times.aspx

    I don’t know for sure how that relates to the length of time between identification of a mammogram abnormality, and institution of breast cancer treatment. That is just a topic I have experience with.

    Anecdotal information suggests in our community at least, an uninsured poor woman will receive a biopsy and definitive treatment prescription (timing of procedures may vary based on the nature of the tumor, nature of the planned surgery surgery, radiation therapy, and chemotherapy). in less than 8 weeks on average. A public review in the province of Ontario, Canada showed a decrease in average wait times from 21 weeks to 20 weeks between 2001 and 2006.

    https://www.cancercare.on.ca/cms/One.aspx?portalId=14473&pageId=14903

    There are many other countries that report a shorter delay.

    Either way, a real study of health care provided to uninsured patients would have resulted in better public discourse than the pathetic characterization that if you are uninsured, you can’t get healthcare in the US. The press did report on a study of longevity, but the study had no adjustments for prevalence of smoking. The sound bytes so often repeated in the media and in public comments was, “Uninsured don’t have access to healthcare”, and, “The US is the only developed country that does not provide healthcare for all of its citizens”. Instead, the more accurate statement would be that 1. uninsured patients have to wait longer for appointments in charity clinics than insured patients with a primary care physician. 2. Uninsured patients tend to seek healthcare for non emergent problems in the ER. This increases ER crowding. More unnecessary tests are performed on these ER patients because the high liability facing ER physicians increases defensive medicine practices. Charity clinics provide more cost effective care than the ER.

  61. Geekoid says:

    @windriven – “Are you actually of the opinion that the feds are more immune to ‘the lobbying efforts of special interest groups’ than are the states?”
    Yes. Divide and conquer. Its is substantially to get what a lobbyist wants on a state level then it is on a federal level.

    Death panels was coined to refer to talking to people about the end of life choice. Nothing more.
    i.e. DNR

  62. Geekoid says:

    @JMB :

    “(nobody knew what was in the bill when they voted on it”
    No, people who did n’t read it didn’t know what was in it. Some of us red the damn thing because basing an opinion without reading up is poor form. If you didn’t read it, then how cans you form a thoughtful opinion? You can’t.

    “1. uninsured patients have to wait longer for appointments in charity clinics than insured patients with a primary care physician.”

    A) Charity clinic aren’t available everywhere
    B) Waiting longer can mean worse illness or death.
    C) They aren’t health care, there more like last ditch non emergency treatment.
    D) The do not provide numerous other option proper health care

    ” 2. Uninsured patients tend to seek healthcare for non emergent problems in the ER.”
    Which is another reason for creating a universal healthCARE system.

    ” Charity clinics provide more cost effective care than the ER.”
    yes, but funding for charity clinics is fickle. As I said earlier, there not everywhere.

  63. JMB says:

    @Geekoid

    I think you should forward to comments on reading the bill to members of the US Senate and House of representatives. I agree that you should not present yourself as an expert on the law when you have not read the entire law. Certainly, a legisltor should not vote on a law they have not read. I wasn’t presenting myself as an expert on the law (and I welcomed corrections). I was primarily discussing how the safety net system used to provide universal healthcare, a point that was lacking in the public discussion.

    I apologize that my comments were so long that you misunderstood them. You are arguing against me using the same major point I was making about the safety net system. I said that government had decreased funding for safety net clinics/hospitals since previous levels. That is why they are not as readily available. I was advocating using the tax dollars headed for the ACA to be reinvested in the safety net system. The safety net system had the significant benefit that more healthcare providers could be educated. With more healthcare providers, people with insurance can find a provider rather than going to the ER. In my experience that I discussed, the administrative overhead of medicare/medicaid was greater than safety net programs. I can say that because I have worked as a provider for the programs (in private practice and academic medicine). Do you have experience contrary to mine?

    What happened in Massachusetts with universal health insurance?
    “But, according to a report from the Division of Health Care Finance and Policy, expanded coverage may have contributed to the rise in emergency room visits, as newly insured residents entered the health care system and could not find a primary care doctor or get a last-minute appointment with their physician.”
    http://www.boston.com/news/local/massachusetts/articles/2010/07/04/emergency_room_visits_grow_in_mass/

    What specifically did I say about the ACA that was incorrect in your reading of 2000 pages? Frankly, I was mostly bemoaning the fact that the government was abandoning the safety net system, and the poor quality of the public discussion on the ACA. One more comment from my experience before you answer. You don’t really know how the law will effect the healthcare system until many directives are published in the federal register by the administrative branch, CMS publishes directives (another administrative branch), and some court decisions are made by the legislative branch. I often find it amazing how certain verbage in the law is translated to regulation in the federal register or CMS directives. Court decisions are more easily traced to the verbiage of the law, but tend to be slower in piling up.

    The discussion pertinent to the lead article of the blog was whether the verbiage of the law would cut down on funding for CAM. A reading of the law by an attorney suggests that it should result in reduced funding for CAM. CMS directives that have been released after passage of the ACA, and published studies by one of the scientific government panels, suggests that it may not result in decreased funding of CAM.

  64. elburto says:

    As a British citizen I knew something was up with JMB’s little “uninsured Americans get better care than people get under universal health coverage” claim.

    Not only is it absolute bollocks, but I didn’t even have to look far to find it. TWO paragraphs under the 18 week piece:

    Patients with urgent conditions such as cancer and heart disease, will be able to be seen and receive treatment more quickly. For example, you have the right to be seen by a specialist within a maximum of two weeks from GP referral for urgent referrals where cancer is suspected.

    We get it, you’re invested in the current system and anxious about change, but outright lies? That just nullifies any point you may have had.

    Does the NHS have it’s faults? Many. Is it preferable to the current US system and the ACA? For now, yes. It also isn’t the only healthcare route available. Fully comprehensive private plans, with pre-existing conditions covered, can be had for as little as £40 a month. They cover everything but GP care, often in settings that make average hospitals in the US look like the tents in MASH.

    It’s common for the NHS to contract out cancer care to these private hospitals. This is at no cost to the patients. In my local area the regional breast cancer care centre is based in a small private hospital set in beautiful grounds, with lovely facilities and a flexible appointment schedule. My mother has two friends who are breast cancer survivors, they feel that the calm, pleasant environment made treatment seem much less stressful. The longer, more flexible visiting hours meant that they weren’t alone.

    If you want to compare the US system with the UK system, well, it helps to know what the UK system is.

  65. elburto says:

    Argh. The italics should have ended directly after the bold.

  66. JMB says:

    @elburto

    You misquoted me.

    This is what I said, “In regards to wait times for procedures for uninsured poor patients in the US versus insured patients in other countries… that is a study I would really welcome.” I would welcome that study because of the misrepresentation of available healthcare for uninsured patients in the US in public discussions. I am well aware of the variation in wait times in different countries. The NHS has worked on wait times for decades, and has had significant success. Other countries have not achieved as much success.

    I also said, “One advantage of our broken system is that it provided healthcare options for poor unisured patients that weren’t available in some of the universal health insurance countries.” The healthcare option I discussed was helicopter transport, the comparison was to the Quebec province of Canada in recent years. Quebec province has recently added helicopters to its fixed wing transports.

    I would agree that the NHS is preferable to the ACA. But I would prefer full funding of the safety net system (to include teaching hospitals), and other significant reforms to our system over the NHS. I think that would better meet the expectations of the USA public. But I will quote myself again, “That is not to say that our health system is the best, the best health system is that which meets the expectations of its populace. “

  67. elburto says:

    @JMB – from the horses mouth:

    Here is a reference from the NHS in the UK to the maximum allowed waiting time between referral to a specialist, and the beginning of care by the specialist — 18 weeks.[1]
    That is not the average wait time, but apparently you can’t complain about the length of wait until that time has passed.
    [link]

    I don’t know for sure how that relates to the length of time between identification of a mammogram abnormality, and institution of breast cancer treatment.[2] That is just a topic I have experience with.

    Anecdotal information suggests in our community at least, an uninsured poor woman will receive a biopsy and definitive treatment prescription (timing of procedures may vary based on the nature of the tumor, nature of the planned surgery surgery, radiation therapy, and chemotherapy). in less than 8 weeks[3] on average.

    [1] For non-urgent referrals such as fertility treatment, dermatology, orthopaedic problems etc.

    [2] It doesn’t relate at all, because, as is mentioned directly under the non-urgent referral guidelines, suspected cancer (among other serious issues) is dealt with under the TWR – two week rule. Patients must see the relevant specialist and be sent for further investigations within two weeks.

    That makes [3] null and void as an attempted criticism of UHC, because you deliberately misquoted referral guidelines for cancer.

    My father’s GP was recently concerned about some respiratory symptoms he was having. As dad is 78 the GP wanted to rule out lung cancer. The referral was put in at 5pm on the Monday. The consultant’s receptionist called at lunchtime on Tuesday with an appt. for the day after.

    By the time two weeks had passed he’d been diagnosed with COPD, started treatment, and had a follow-up with his GP, where the consultant was on speakerphone.

    We live in a tiny, one-doc village. The beauty of a centralised system means that we get the same care as people in urban and suburban areas. The wheezing pensioner gets the same treatment as the city lawyer who’s coughing up blood.

    The NHS want to spot potential cancers as early as possible, purely because stage 1 and 2 malignancies are cheaper to deal with. People who disingenuously quote referral policies, to imply that potential cancer patients are sat around terrified for months before ever receiving treatment, in order to portray the ‘horrors’ of socialised healthcare, are something I come up against over and over again.

    Whether it’s: the hardcore libertarians with their “I’m alright, stuff everyone else, you’ll take my taxes from my cold dead hands” mantra, the “Why should I care if anyone else gets sick? Can’t afford insurance? Tough!” crowd, or those stupid enough to be campaigning against their own interests, the Medicare and Medicaid recipients who denounce socialised medicine as evil; one thing stands out time and again. None of them have even a semblance of recognition of a social contract with their fellow citizens. The last few years, of protesting against affordable care for all, have proven that. Optimum health should be a right, especially in a wealthy, developed nation.

  68. JMB says:

    @elburto

    Thanks for quoting me correctly.

    I specifically stated That I did not know wait times in the NHS for breast cancer treatment after identification of an abnormality on the screening mammography. I then compared wait times in my experience working for uninsured patients to a published article for a province in Canada. Our healthcare system has been compared to many other countries, not just the NHS.

    Now please note that in the preceding paragraph I stated that, “Occasionally a published study (either scientific or for public review) will mention the wait time. Many public reports have the goal in significantly reducing waiting times, and I think there has been significant improvement.”

    Now this is a reference from the OECD discussing wait times observed in different countries. It is a report from 2003, and wait times have changed since, but the discussion of the costs and factors of reducing waiting time is still relevant. It does not report data on waits for breast cancer diagnosis/treatment.

    http://www.oecd.org/dataoecd/24/32/5162353.pdf

    So the NHS has done well, which is one of the reasons I think it is better than the ACA. The ACA is not recreating the NHS in the USA.

    Advocating tax increases to support the safety net hospitals and clinics is not a libertarian stance.

    You disingenuously quoted me the first time. I specifically said I did not know how that NHS policy related to breast cancer diagnosis/treatment. That was not disingenuous.

  69. windriven says:

    @Geekoid

    “Yes. Divide and conquer. Its is substantially [easier] to get what a lobbyist wants on a state level then it is on a federal level.”

    I don’t think you have spent much time working with politicians on either state or federal levels.

    Congress is powered by cash to a greater extent than are the various state legislatures. That is not to say that lobbyists and the cash that gets them access aren’t ubiquitous on the state level, but it is the B team of lobbyists and B money as well. The A team (or should it be K team?) is in Washington. So are the A bucks. And when you get your legislation it applies to the nation, not just to Rhode Island.

    For an interest to pursue a national objective through the states it has to convince 50 state legislatures and 50 state senates; a daunting task. When you think of this in terms of science based medicine versus quackery it should be clear that quackery has the upper hand. Where are the lobbyists and cash machines pushing to eliminate quackery? Who leads the SBM lobby in Kansas or Florida or Oregon? But each of these states likely has associations of chiropractors and acupuncturists and maybe even homeopaths who have a vested interests. Even many mainstream medical centers (to say nothing of medical schools) have departments of quackery.

    I share the frustrations of many of the bloggers and commenters here. But it is one thing to be on the right side of an issue and quite another to be on the winning side.

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