What Can We Expect from a Trump Presidency?

A week after the presidential election, many Americans are wondering what a Trump presidency means for them.  More specifically, what does it mean for their health insurance? Three days after the election, more than 300,000 people have selected plans from the Exchanges.  The Exchange is the online marketplace where consumers can compare and buy individual health insurance plans.  However, an increase in premiums coupled with a Republican majority House, Senate, and White House places the Affordable Care Act (ACA) in jeopardy.  On the campaign trail, President-Elect Trump has called the ACA “unworkable.” However, in recent interviews, he has favored continued coverage for children on their parents’ insurance policies and prohibits discrimination for those with pre-existing conditions.

Dismantling the ACA
There are a few ways Republicans could dismantle the ACA.  First, Republicans can repeal the Act in its entirety.  This method of dismantling the ACA would require a 60-vote majority in the Senate. Further, this method is subjected to filibusters by Democrats, thus delaying voting.  As a general matter, this method seems highly unlikely given the Republicans hold 54 seats in the Senate.” The second way Republicans could dismantle the ACA is through a method called budget reconciliation.  Budget reconciliation would create revenue related challenges for the implementation of ACA.  For example through the budget reconciliation process, Republicans could remove premium tax credits for consumers. This method only needs a simple majority and does not have a filibuster option.  Budget reconciliation has a greater likelihood of undoing parts of the ACA.  However, this process would take at least two years for substantial change to affect consumers.

The New Plan
This leads to our next question, what do we replace the ACA with? President-Elect Trump hasn’t provided the public with substantial policy changes, however we can look towards the Republican’s plan entitled, A Better Way, to identify what may happen. There are three changes we can reasonably anticipate.  First, we can reasonably anticipate changes in Medicaid. Due to Medicaid expansion, the federal government covers about 90% of the costs related to covering childless adults.  A Better Way promulgates shifting to block grants for the states. This invariably means that states would receive lower funds and therefore may have to reduce coverage and may adopt plans similar to those seen in Indiana. In Indiana, Medicaid participants are required to pay into accounts in order to benefit from Medicaid. The amount could be as low as a dollar, but participants must pay into the program.  Additionally, it requires participants to pay copays, which can cost up to $25. These measures support the concept of individual responsibility.

The second substantial change we can anticipate is a decrease in coverage options. Currently, essential benefits require plans to offer specific coverage such as, maternity care, birth control, preventive screenings, and mental health. Republicans will most likely remove or decrease what some considered an essential benefit. This of course is in an effort to make coverage more affordable, but at the determinant of quality.  The third substantial change we can anticipate is the use of high risk pool plans. High risk pool plans cover individuals who have been locked out of the market by pre-existing conditions. However, traditionally, the premiums for those in high risk pool plans were twice high as those individuals who are healthy.

Although we are unclear about what will happen on January 20th, we can anticipate substantive changes. Republicans promulgate to make changes on day one of Trump’s Presidency and Democrats will have to act in defiance or work with the Trump administration to salvage parts of the ACA.

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The VA Proposes a New Rule to Combat Wait Times-Will it Help?

The U.S. Department of Veterans Affairs (VA) has an infamous reputation for providing poor service to U.S. Veterans. Stories of veterans failing to receive adequate care for serious illnesses, or even dying while waiting for care, are ubiquitous. The situation erupted in 2014 when whistleblowers revealed that records of deceased veterans had been changed or physically altered to hide how many people died while waiting for care at the Phoenix VA hospital. “Deceased” notes on files were removed so veterans would not be counted as having died while waiting for care, but that was only one situation in one hospital.

Take, for instance, the story of Barry Coates. Mr. Coates was having excruciating pain and rectal bleeding in 2011. He went to several VA clinics and hospitals in South Carolina trying to get help. Eventually, a VA hospital diagnosed him with hemorrhoids, prescribed simple pain medication, and told him he might need a colonoscopy. As the pain worsened, Mr. Coates begged VA officials for colonoscopy, but found himself on a waiting list. Finally, about a year after complaining to his doctor about the pain, Mr. Coates got a colonoscopy where doctors discovered a cancerous tumor about the size of a baseball. Mr. Coates underwent chemotherapy for his Stage 4 cancer, but it was too progressed. Mr. Coates passed away in January 2016.        

Responding to these scandals, Congress and the VA came up with a solution—the Veterans Choice Program. Veterans Choice was a $10 billion program that was supposed to give veterans a card that would let them see a non-VA doctor if they were more than forty miles away from a VA facility, or they were going to have to wait longer than thirty days for a VA provider to see them. This solution hasn’t seemed to work. Wait times have gotten worse, and compared to early 2015, there are 70,000 more appointments that took vets at least a month to be seen. While the VA says there has been a massive increase in demand for care, it seems the problem has more to do with the way Veterans Choice was set up. The program is confusing and complicated, and veterans and doctors don’t understand it.

To address these continued problems, the VA proposed a new rule that would expand the scope of practice of advanced practice registered nurses (APRNs) who work for the agency. Under the proposed rule, the VA said it intends to expand the pool of qualified healthcare professionals who are authorized to provide primary healthcare and other services to the full extent of their education and abilities without the clinical supervision of physicians.

More than sixty organizations, including veterans’ groups, healthcare professional organizations, and eighty Democratic and Republican members of Congress, have voiced support for the proposed rule. For example, the American Nurses Association released a letter in support of the proposal consistently reiterating that the proposal is in line with best practice recommendations. There have also been studies that have shown that granting nurses greater authority would have significant benefits such as achieving healthcare cost savings and increasing access to care. However, support has not been unanimous. For instance, the American Medical Association released a statement saying it was disappointed by the VA’s “unprecedented proposal,” and that the rule would significantly undermine the delivery of care within the VA.

If the VA does implement this proposed rule, it could become a leader in the occupational licensing arena and spur state governments to follow suit. Currently, a majority of U.S. states limit what nurse practitioners can do, requiring them to work under the direct supervision of a doctor and prohibiting them from prescribing drugs. One thing is certain—the VA needs to take substantive steps to address the problems that have been rampant for years. Perhaps, this proposed rule is a step in the right direction.

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California’s New Regulation to Reduce Work Place Violence in Health Care

During the last week of October, the State of California’s Occupational Safety and Health Administration (Cal/OSHA) approved regulations to protect health care workers from workplace violence.  These regulations are being heralded by many in the healthcare community, as setting a standard and were passed unanimously by Cal/OSHA. These regulations are seen by the nurses’ unions and many in the health care community as a step towards alleviating a problem that does not get much attention- violence against healthcare workers.

U.S. Occupational Safety and Health Administration  found in a study done between 2002-2013, that healthcare workers were four times more likely to be the victims of serious work place violence than other workers in private industry.  The study found that 21% of registered nurses and nursing students reported being physically assaulted and over 50% of the same group reported being verbally abused in a 12-month period. The Center for Disease Control and Prevention (CDC) also did a study on occupational traumatic injuries among health care workers. The study took reported data from 2012-2014 and found that nurses’ assistance and nurses are most vulnerable to injury and the number of reported incidents rose steadily over the two-year period of the study. As alarming as these numbers are, they may not even reflect the whole story because such injuries often go unreported or under-reported. OSHA’s report states this might be due to certain cultural factors in the health care industry. The report states:

“caregivers feel a professional and ethical duty to ‘do no harm’ to patients. Some will put their own safety and health at risk to help a patient, and many in healthcare professions consider violence to be ‘part of the job.’  Healthcare workers also recognize that many injuries are caused by patients are unintended, and are therefore likely to accept them as routine or unavoidable. Another consideration is unwillingness among healthcare workers to stigmatize the perpetrators due to their illness or impairment.”

The push for action in California came after the tragic death of Donna Gross, a psychiatric technician working at Napa State Hospital. Donna was murdered by a patient while working at the hospital in 2010.

The regulation hopes to lower work place violence in private health care facilities, by requiring such facilities to implement a Workplace Violence Prevention Plan.  The regulation requires health care facilities to implement a plan in writing that evaluates risks to workers. It also calls for the facilities to provide greater training and easier reporting for its employees. The regulation also requires facilities to identify and evaluate patient-specific risk and assess visitors or other persons who are not employees. The regulation also requires facilities to provide procedures for post-incident response and investigation. The post-incident evaluation includes identifying all employees involved, making available individual trauma counseling, conducting a post-incident debriefing, and reviewing whether appropriate corrective measures under the plan were effectively implemented. If plans are not implemented and protocols are not followed leading up to or following an incident, Cal/OSHA can give a citation to the facility.

There has been little discussion so far on how these new regulations will affect patients.

These regulations are a first step in helping to reduce an epidemic of workplace violence that has long permeated the health care profession, but got little attention.

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The New Tobacco Rule: Increasing Awareness and Decreasing the Dangers.

Many people already know that tobacco products such as cigarettes are injurious to their health, which is why they falsely believe that electronic cigarettes and cigars are a healthier substitute. In an effort to curtail this misconception, FDA has issued a new regulation on tobacco.

The FDA has been regulating tobacco since 2009. As of August 8, 2016, they have finally extended the rule to electronic cigarettes, cigars, hookah and other products that fit within the rule. The FDA’s authority has expanded, but it is for the protection of the public health. Part of the new regulation requires that tobacco manufacturers list all of the ingredients on their products by 2017. The new rule requires health warnings on “roll your own tobacco”, newly regulated tobacco products and cigarette tobacco. Free samples are also no longer permitted. The FDA will now be able to review all new tobacco products not yet in the market, which will ultimately help the FDA deal with misleading statements; thus, consumers will be correctly informed of what they are buying. Manufacturers will have to list their ingredients 90 days before the product is in the market. The rule has also prohibited sellers from selling to youths under eighteen, and consumers must now show photo identification.

A growing amount of teenagers have been using electronic cigarettes, otherwise known as e-cigarettes, because they believe that it is healthier than cigarettes. The data from the National Youth Tobacco survey indicated that 73 percent of teens believe e-cigarettes are less harmful than cigarettes. This perception is dangerous for youth because the e-cigarette actually delivers the same, if not more, nicotine than a conventional cigarette. Researchers have stated that this perception is related to their use of such products. But unfortunately, as noted by lead researcher Dr. Stephen Amrock, “children who use e-cigarettes than those who do not go on to use traditional cigarettes.” Hopefully, the new rule will increase youths’ awareness and decrease their misconceptions on alternative tobacco products.

As the new rule seeks to improve public health, it also causes a stir amongst businesses in the industry. Some business owners complain that they do not have the financial resources to comply with the regulations. The most concerning part is the “impossible pre market tobacco approval (PTMA) requirement” for products not on the market at that time. Businesses want a new date for new products, because under the current law, they argue, most products will be forced off the market. Business owners are currently reaching out to Congress in the hopes of changing the date for PTMA.

The new rule impacted businesses in the tobacco industry but it is necessary to combat the misconception on “safer” tobacco alternatives. As a result, the rule will help consumers and the vulnerable youth become more aware of their health, and the threat tobacco poses to it.

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Election 2016: High Stakes & High Premiums

Open enrollment for the Federal Exchanges is right around the corner and soon many Americans will be heading to the Exchanges for affordable healthcare options.  In an effort to increase access to care, the Exchanges provide subsidies for those unable to cover the full cost of premiums based on their percentage below the poverty level. The Affordable Care Act (ACA) has made great strides in providing care to those who normally would not have been able to receive coverage. However, this year highlights an unintended group of people with issues of access to care; those who pay full price. The Obama administration has confirmed a 22% average increase in premiums in 2017. Fortunately, families and individuals who qualify for subsidies through the Exchanges, will not feel the brunt of the increase. However, those who pay full price will have to prepare for the abrupt increase.

The rise in premiums is especially troublesome for residents in states such as Georgia and Tennessee. Blue Cross Blue Shield of Georgia, which is the only plan that covers the whole state, premiums will increase by 21%. Further, Georgia’s Humana plan is expected to increase by 67.5%.  BlueCross BlueShield of Tennessee anticipates a 62% premium increases and Cigna with an 46% increase. Insurers attribute the rise in premiums to a sicker population.  The ACA introduced an influx of new consumers who were costlier than anticipated. Outpatient spending continues to be the largest driver of premium increases. Contrary to belief, prescription drugs only account for 14.3% of premium increases which is down from 17.7% in 2015. The Center for Medicare and Medicaid Services has promulgated that there are many individuals who are eligible for subsidies on the Exchanges but have not taken advantage of the benefits. However, due to more costly than anticipated patients, insurers have left the Exchanges.  Thus, leaving potential users with fewer options for coverage and forcing many to change doctors based on network coverage.

As the Obama Administration comes to a close, the next president will have to address the rise of premiums especially for those who pay full price. Thus far, both presidential candidates have suggested solutions to help reduce the rise in premium costs. Donald Trump’s proposal includes allowing individuals to buy insurance across state lines and allowing payments toward healthcare premiums to be tax deductible. Additionally, he suggests working with states to establish high-risk pools for individuals who fail to have continuous healthcare coverage. Hillary Clinton proposes increasing premium tax credits in the Exchanges so that individuals and families do not pay more than 8.5% of their income on health insurance premiums. Further, she suggests creating a public option plan with states willing to do so and giving the Secretary of Health and Human Services the authority to modify or block unreasonable health insurance increases in states that do not have the authority. With the election less than two weeks away, we will soon see how the new administration will address the unintended consequence of rising premiums especially for those who pay full price.

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