Monthly Archives: April 2016

Customers Brought on by ACA Reforms Sicker, More Costly According to Blue Cross and Blue Shield Association Report

On March 30th, the Blue Cross and Blue Shield Association released a report on their study of those who were newly insured in the private market thanks to ACA reforms – and found that they were sicker, and costlier, than previous enrollees. The report was used by Blue Cross and Blue Shield to explain the premium increases they have asked for, and which many insurance commissioners have approved.  Those offering Blue Cross plans are also asking for certain other aspects of the ACA, such as special atypical enrollment periods, to disappear so that insurance companies can better control when and who signs up for coverage.  It should be no surprise that Blue Cross and Blue Shield companies should want increased premiums and more predictable enrollment periods – 23 of those companies reported a collective $1.9 billion decline in earnings in the first three quarters of 2015 as a result of their inclusion in the ACA national exchanges.

The report analyzed health insurance for 4.7 million Americans across all 50 states that were newly enrolled in 2014 and 2015.  One aim of the study was to find out if the ACA provisions not allowing insurance companies to disqualify people for pre-existing conditions in fact resulted in a sicker group of insureds.  The study found, in fact, newly enrolled insureds had higher rates of high blood pressure, diabetes, depression, coronary artery disease, H.I.V. and hepatitis C.  Diabetes and hepatitis C, in particular, were found to be twice as common among new enrollees, and H.I.V. was more than three times as common.  However, even Blue Cross and Blue Shield recognized that the prevalence of these diseases will shrink in new enrollees as those diseases are treated or even prevented through the insureds’ new healthcare options.  Programs to prevent and treat diseases more effectively are already paying dividends as such programs see fewer hospital admissions, readmissions, and hospital infection rates.  Blue Cross and Blue Shield is using the report not only to justify its premium increases, but to espouse the need for better care management such as making sure those with chronic diseases continue to take their medicine, or that people take advantage of preventative care, like flu shots,  to prevent illnesses that require more expensive treatments.

Another aim of the report was focused on costs and medical service usage.  Among new enrollees, visits to doctors and other medical professionals was 26 percent higher and hospital admissions rates were 84 percent higher.  The increased medical service usage the study observed may also be a result of the policies being more comprehensive, another requirement for private marketplace policies under the ACA.  It could also be the result of new enrollees having put off medical care and making up for it upon being enrolled, which could mean the service usage could flatten out over time.  On the whole, medical costs for new enrollees were 19% higher than employer-based group members in 2014 and 22 percent higher in 2015.

However, increased cost, usage, and pre-existing condition prevalence may be a sign that the ACA is working.  Administration officials, for example, have stated that these figures are signs that healthcare is now reaching vulnerable populations that it had not before, which was the intent of the ACA.  Although costly, the ACA reforms have decreased the number of uninsured citizens and helped close the health insurance gap between lower and higher income Americans.

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‘Fetal Anesthesia’

On March 29, 2015, SB 234 was signed into law making Utah the first and only state in the nation to require that doctors administer anesthesia or analgesic for women who are undergoing abortions at 20 weeks and later in order to prevent fetal pain. In 2015, Montana Governor, Steve Bullock, vetoed a very similar measure.

Those in favor of the law say that the regulation prevents fetuses from suffering during abortions. However, at the center of the debate in the legislature was the scientifically disputed notion that a fetus can feel pain during the procedure. Doctors in Utah and across the United States say there is no proof that fetuses are able to feel anything at that point in the pregnancy. Literature reviews from the Journal of the American Medical Association and the American Congress of Obstetricians and Gynecologists state that fetal pain is unlikely before the third trimester which begins at 28 weeks. Doctors opposing the law further say that sedating a woman during an abortion procedure puts the woman at risk for complications, and that it will interfere with the relationship between a physician and patient.

Senator Curt Bramble, the bill’s sponsor and a CPA with no known medical background, says the purpose of the bill is to protect those who have no voice. Bramble, who originally wanted to ban abortions after 20 weeks, further says that if abortions are going to be at all legal, then doctors must take steps to alleviate pain to the unborn child. However, an OB-GYN and abortion provider in Utah, Dr. Leah Torres, has since emailed the governor because she does not understand what the law is requiring her to do. As ‘fetal anesthesia’ does not exist in standard medical practice, the law does not specify how doctors are supposed to administer anesthesia or analgesic in these situations. When the Montana Legislature proposed a similar law, which was later vetoed, physicians asked similar questions as those doctors were also unsure what exactly was being asked of them.

How safe is anesthesia for the mother? There are three main types of anesthesia: local, regional, and general, though the Utah legislature did not specify which type or how it should be administered. Doctors tend to avoid general anesthesia except in cases where they find it to be absolutely necessary. Dr. Esplin, a Utah doctor who testified at the committee hearing for this law, said, “women having abortions will either be placed under general anesthesia – meaning they’re unconscious and hooked up to a breathing tube – or sedated with a heavy dose of narcotics.” Those opposing the law say that not only is there no benefit for the woman in administering an anesthetic, but it adds an additional risk to the woman’s health.

Based on inconclusive evidence, women in Utah are now mandated to undergo anesthesia to have an abortion at 20 weeks and later, where previously, women were given a choice whether or not they wanted to be anesthetized. Fetal pain is a complicated and controversial topic in science, but the ability to feel pain at that specific point in gestation is, for now, unproven. In absence of scientific evidence proving fetal pain, perhaps such a bill is simply another way to limit abortion access for women.

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First Ever Liver and Kidney Transplant Between an HIV Positive Donor and Recipient

On March 30th, doctors at Johns Hopkins announced that they have successfully completed the first liver and kidney transplant from an HIV positive donor. The surgeries were completed a couple of weeks ago and both patients are doing well, one has already gone home and the other is expected to go home soon. The liver and kidney came from the same HIV positive donor and each organ went to two separate HIV positive recipients. The transplant marks the first successful HIV-to-HIV transplant in the United States; similar transplants, however, have been performed in South Africa.

Johns Hopkins is the first U.S. hospital to gain approval from the United Network for Organ Sharing, a non-profit organization that manages the federal government’s organ transplant system. The approval is a big victory for the surgeons, infectious disease specialists, and the HIV advocates who spent years lobbying the federal government to allow the transplants. Since 1988, when Congress amended the National Organ Transplant Act, HIV positive individuals have been banned from becoming organ donors.  The amendment was a response to the AIDS crisis in the 1980s when HIV almost certainly led to AIDS and then death. However, HIV is now a manageable chronic disease and not the fatal public health crisis that it was in 1980s. It was not until the HIV Organ Policy Equality Act (HOPE Act) was passed in 2013 that medical professionals were allowed to begin researching the possibility of a HIV-to-HIV organ transplant.

The HOPE Act and the recent success at Johns Hopkins will give those who are HIV positive a better chance at getting an organ transplant. Prior to the HOPE Act, HIV positive individuals could be organ recipients, but viable organs were being wasted because they came from individuals who were HIV positive. A study conducted before the passage of the HOPE Act estimated that 500-600 individuals infected with HIV could donate organs annually, possibly saving 1,000 lives every year.

There is approximately 122,000 people on the transplant list at any given time and there is a consistent shortage of donors. Although many people who need organs die on the transplant list, individuals with HIV are particularly vulnerable and die even faster than their HIV negative counterparts. HIV-to-HIV organ transplants will benefit both people who are HIV negative and HIV positive. Allowing the transplants will enable HIV positive individuals to get much needed organs faster by utilizing good organs that had previously wasted. It will also benefit people who are HIV negative by shortening the transplant waiting list.

This has all been made possible by the passage of the HOPE Act and the work done at Johns Hopkins. Medical professionals at Johns Hopkins hope to share the protocols they developed with other transplant centers around the country, so that the procedure will benefit many more nationwide.

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