Future of the ACA in the Trump Administration

We now know that Rep. Tom Price has been tapped by Pres. Elect Trump to head the Department of Health and Human Services. This answers, in part, one of the questions raised by a PHS 795 student in commenting on a Health Affairs blog piece on the future of the ACA:

I’d like to point out, as the author does too, that Trump never actually refers to The Patient Protection and Affordable Care Act, just “Obamacare.” I think the fact that he doesn’t (or  can’t?) actually name the legislation is telling. The ability to talk about legislation in a specific and clear way is important, and will have implications for what happens next. If President Elect Trump can’t point to specific provisions to repeal either he’ll be unsuccessful in repealing anything, or he’ll create a mess of our health care system by derailing and defunding all of the new structures, federal offices, funding streams, and policy mechanisms that PPACA put in place.  I think this piece does an excellent job of outlining scenarios and showing that political leadership really matters. It really matters who control Congress. It matters who President Trump selects as his Sec. of Health and Human Services (as well as other cabinet positions).  Trump will almost certainly have enormous, and probably painful, impacts on the health system. And while interesting as a policy experiment, these changes will affect peoples’ lives in ways we probably can’t yet understand. 

 http://healthaffairs.org/blog/2016/11/09/day-one-and-beyond-what-trumps-election-means-for-the-aca/

Race, Class and Maternity

A PHS 795 student offers insights on an interesting article published on ebony.com:

I would like to share the next article with the rest of the class: http://www.ebony.com/wellness-empowerment/black-mothers-health-matters#axzz4OAcQXgss

I think “Black maternal health matters” is a great article for this class because it problematizes what we understand as the access to health and how it is mediated by class, race and gender. As we learned in professor Jacob´s lecture on health care disparities, this article shows that the physical and legal access to health is not enough to ensure the appropriateness of health care within socially disadvantaged communities as African-American women in this country. This article discuss the importance of race as a stressor that affects maternal health, and as a barrier for black women´s access to the resources needed to sustain their and their children´ best health. What can public health practitioners do in order to achieve equity in health care? How important is a reproductive justice framework in our practice?

An election day observation: health disparities may affect electoral outcomes…

A thought-provoking find from PHS 795 student Edward Vargas:

Dear all: In spirit of elections and health….Below is a paper by two colleagues ya’ll might find of interests that focuses on the impact of racial mortality differentials on political participation in the US.  They find that, “premature deaths among blacks have had a significant impact on the racial composition of America’s electorate and, during the study period, may have been a key influence on several state election outcomes. State level findings suggest that our estimated effects could have had political potency at the national level, as well, given that the predicted reversal of specific senate elections would have changed the controlling party in the Senate from 1986 to 2002.”

 

Black Lives Matter: Differential Mortality and the Racial …

www.ncbi.nlm.nih.gov

Excess mortality in marginalized populations could be both a cause and an effect of political processes. We estimate the impact of mortality differentials between …

Health Affairs on the “New Era of Health Equity”

A PHS 795 student comments on a piece in the most recent issue of Health Affairs outlining the history of major policy initiatives on health equity in the US:

 a Ushering In The New Era Of Health Equity

healthaffairs.org

Ushering In The New Era Of Health Equity | At the intersection of health, health care, and policy.

The author first outlines the  3 “eras” of health equity in the US. The first came in 2001 with the IOM’s Crossing the Quality Chasm and the book  Unequal Treatment, which highlighted the presence of disparities. The second era started with the passage of the ACA and the new emphasis on access to care, and attempts to achieve the Triple Aim. Finally, the third era is here, in part because of the passage of MACRA (Medicare Access and CHIP Re-Authorization Act, which he calls the best ABC of health yet—an acronym with in an acronym).

Interestingly, some of the alternative payment and delivery mechanism are reproducing disparities. ACO are less likely to recruit doctors who take care of minority patients and MIPS (merit-based incentive programs) are less likely to exist in minority communities.Betancourt argues that in order to achieve equity in the third era, we have to ensure that some patients are not benefiting from reforms more than others. 

This article highlighted many of the themes discussed in Dr. Dugoff and Dr. Jacob’s lectures. It is interesting to examine who has access to alternative payment models, the impact on both the quality of care they have access to and their subsequent health outcomes. As we’ve talked about in class, even where health outcomes are improving, health disparities persist. This article makes it clear that access to health insurance/ providers is not enough to end health disparities. Given how much care delivery is changing, access to these new innovative models may make a huge difference in both outcomes and either perpetuating or combatting health disparities.

Something to think about as we kick off OE4. (for the non-health policy nerds, today is the beginning of the 4th open enrollment period for the ACA marketplaces) 

Measuring the impact of England’s public smoking ban on infant mortality

A PHS 795 student draws our attention to a quasi-experimental study examining the impact of England’s comprehensive public smoking ban on infant birth weight and mortality. Although it is true that an interrupted time series design is relatively weak, the magnitude of this intervention as a nationwide policy and the strength of the biological mechanisms connecting maternal smoking to these outcomes gives a whole lot of weight to its conclusion (why it was published in a high impact journal like Nature). Our student writes:

In July 2007, England passed a nationwide, comprehensive smoking ban. Since then, virtually all work and public places have been smoke-free. A few studies have looked at the positive impacts of this on adult health, in terms of direct smoking as well as second-hand smoke.

This research article from 2015 uses a quasi-experimental design to look at the effect of England’s smoke-free legislation on perinatal survival. As we’ve learned in this class, exposures during early stages of the life course can have the biggest impacts on lifetime health. This study looked at death certificates for all births between 1995 and 2011: over 52,000 stillbirths and over 10 million live-births were examined. They found the smoking ban caused a near-immediate reduction in stillbirths, low birth weight, and neonatal mortality for the study group.

Despite being one of the largest studies to investigate this topic, there are some inherent limitations to this type of analysis. How does the experimental design used here relate to the quasi experimental methods discussed with Dr. Remington? Are there other experimental designs that might be reasonable to examine the relationship between smoking bans and health benefits?

Balancing nurse practitioners and physicians to improve primary care access

In a recent PHS 795 lecture, UW Health ACO chief Dr. Jonathan Jaffery discussed the importance of ensuring that health care providers are spending their time “practicing at the top of their license.” A PHS student notes that availability of supervisory physicians is serving as a barrier to nurse practitioners in “filling the primary care gap.” They write:

This article discusses the ongoing demand for primary care physicians. Despite efforts in the past few years to increase the number of primary care physicians, and the demand is increasing as more Americans get health coverage through the ACA. They used match data to track the number of new primary care physicians and nurse practitioner graduation rates. The number of nurse practitioners (NPs) has greatly increased but the number of primary care physicians isn’t keeping up with the number of new NPs, and since there are many regulations around the type of work and amount of supervision needed for NPs, it inhibits NPs from filling the primary care gap. There are still 10 states that limit the number of NPs physicians can supervise, which means that some states cannot make use of all of the available NPs because there aren’t enough primary care physicians to oversee the NPs. The article mentions that in order to meet the goals of the “Triple Aim” health care system approach, we need to make it possible for all providers to provide the maximum care that their licenses permit.

The changes implemented by the ACA (both insurance and delivery reform) cannot be fully realized unless we can change the policies and regulations limiting the roles of health care providers and improve incentives to work as primary care providers. In Jaffery’s class lecture, he spoke about how the aspect of health care that needs the most improvement is routine and preventative care. We need more primary care physicians and NPs to not only catch up to the increasing demand for primary care services, but also to improve primary care and make primary care more accessible.

 a Primary Care Workforce: The Need To Remove Barriers For Nurse Practitioners And Physicians

healthaffairs.org

Primary Care Workforce: The Need To Remove Barriers For Nurse Practitioners And Physicians | At the intersection of health, health care, and policy.

“Poor kids who do everything right don’t do better than rich kids who do everything wrong…”

Reinforcing cycles and feedback loops are part of the “systems approach” to describing phenomena — an approach that underlies many of the most interesting conceptual frameworks in population health. In class, we’ve seen clues about how poor maternal health can influence child health and development, which can lead to generation-spanning cycles of poor health. Social mobility is key to breaking free from these health disparity “traps.” A PHS 795 student draws our attention to an article from the Washington Post (with a rather attention-grabbing headline) about a self reinforcing cycle of social economic status and educational attainment. They write:

Often times, there is a large focus on the reinforcing cycle of inequity that low socioeconomic status (SES) families and individuals are caught in. An example of this cycle involves a low SES infant being born with the higher likelihood of health problems/ vulnerabilities, being raised in high stress environment, going to a school with lower quality education, engaging at risky health behaviors at a younger age, having less access to social capital and opportunities for employment or education, not having the resources in engage in healthy behaviors, and then experiencing worse health outcomes while receiving lower quality care when illnesses occur.

What often gets neglected in discussions of inequity is the reinforcing cycle of privilege experienced by high SES individuals. The existence of this cycle can reinforce inequities experienced by low SES communities by creating a silo of privilege that the low SES communities struggle to break into.

In this article, an example silo of privilege is presented in the context of the academic world. Despite better academic performance compared to poor performing, high SES students, low SES students encounter multiple hurdles that interfere with improving their SES.

 a Poor kids who do everything right don’t do better than …

www.washingtonpost.com

America is the land of opportunity, just for some more than others. That’s because, in large part, inequality starts in the crib. Rich parents can afford …

 

Male contraception and the pleasure deficit

One of the most thought-provoking lectures of this semester so far has been from Prof. Jenny Higgins, who introduced us to the concept of the “pleasure deficit” – that research on the use of contraception for birth control and disease prevention cannot ignore the important role of sexual satisfaction. In class, we noted that the pleasure deficit may extend to better understanding other interventions to improve healthy behaviors, such as exercise or healthy eating – which involve individual perceptions of pleasure or displeasure from such activities. A PHS 795 student draws our attention to an article and YouTube video about factors underlying the lack of parity in male birth control options. They write:

Dr. Higgins’ lecture has renewed my interest in male birth control options. I’m including an article from 2011 WIRED about Vasagel. It does reinforce the pleasure deficit, discussing that it is difficult to develop hormonal birth control that doesn’t impact male libido, without discussing the sexual side effects of female birth control that has been on the market for years. Truth be told, I feel like I’ve been hearing about Vasagel-like products for over 10 years, but we haven’t gotten any closer to parity in male contraceptive options. MTV’s feminist vlogger Laci Green rightly asks why this is the case, and offers some intriguing ideas. I feel that the pleasure deficit is part of a larger issue in which women are asked to assume both the responsibility and health and sexual side effects of contraception.

https://www.wired.com/2011/04/ff_vasectomy/

https://www.youtube.com/watch?v=qUlQiELaR7M

Pop Health dissemination via music video…

A PHS Student notes the powerful message of hip hop artist Macklemore’s single “Drug Dealer.” They write:

Macklemore, an influential hip hop artist, has unveiled his addictive personality using music as an outlet. In his latest single, Drug Dealer, he etches a powerful landscape – one filled with prescription and over-the-counter drugs that percolate through the walls of our healthcare system. The aim of Drug Dealer is bringing to surface the abuse of prescription (and over-the-counter) drugs. Earlier in the semester we discussed socioecological models on health and how Scott, once a respected nurse/caretaker, was driven to a lifestyle dependent on drugs. Under the guidance of John Mullahy, we also considered health as a consumer product. Given that prescription drugs are a product of healthcare and are intended to improve health, they are a health good – a unit of health that you can just pluck off of the shelf and buy. Macklemore (and many other victims of addiction), however, brings forward an idea that we haven’t covered about health resources in 795: there’s such a thing as too much of a health good. The salience of this idea raises so many questions: how do we address the consumption of these drugs? How should their access by addressed? Should their tax rates be increased? Should drug management be more intensive and more engaged? Where’s that crystal ball when you need it?

Here’s a link to Macklemore’s single:
https://www.youtube.com/watch?v=Gps0LQq3uEo

Medical-Legal Partnerships — a new paradigm for health care?

A PHS 795 student introduced me to the concept of Medical Legal Partnerships (MLPs), which integrate health services with the delivery of legal services (including help with, for example, housing code violations, domestic violence interventions, application for public health insurance,  etc) in addition to health care services. Our student writes:

The community health center I worked at the past 2 years, was working on putting together the infrastructure to have their own medical legal partnership. As a future physician, I think this type of collaboration is essential to addressing health disparities.

This article [medical-legal-partnerships] looks at how health care is changing. “For too long, society has ignored the extent to which social determinants of health (SDH)—the conditions in which people live, learn, work, and play—are inextricably woven into and affect individual and population health.” The social determinants make improving the health of an individual and the health of the population too great of a challenge for a physician in a short clinic visit. There are too many factors influencing the health and wellness of populations. Health professionals can only address and treat what a patient presents in the clinical setting. But when the ailment would be treated more effectively with a change in the patient’s home environment or social situation, how does the physician or health professional make that recommendation or change that environment?

One-way health professionals are working to address social determinants of health are through Medical Legal Partnerships (MLP). MLPs bring together the ability to treat health conditions of physicians with the ability to address legal needs of lawyers. In a medical legal partnership, the physician would “write a prescription” to the partnering lawyer stating the need for legal intervention. From here the lawyer, can proceed with legal action until the situation is resolved.

MLPs can work to address legal issues such as housing, healthcare access, citizenship, domestic issues, and any other situation that is causing a negative impact on the patient’s health.

The situation of every person is different, and for some, simply changing apartments or pursuing legal action on their own is not feasible. Patients may feel intimated, threatened, or unable to stand up for themselves due to a host of barriers, and MLPs provide people the opportunity and support to improve their health free from these barriers.