Category: Blog

How the NFIB v. Sebelius Ruling Will Increase the Amount of Uninsured under the ACA

In a March 2012 report, the Congressional Budget Office (CBO) estimated that by 2022, the Patient Protection and Affordable Care Act (ACA) would reduce the number of nonelderly people without health insurance by 33 million, leaving another 27 million still uninsured.  A significant part of that 33 million included the 17 million more people the CBO estimated to qualify for Medicaid by 2022 under the ACA.  They had not previously qualified because the ACA increased the eligible income to those making up to 138% of the Federal Poverty Level.  This increase in eligibility would have been implemented by making all federal Medicaid dollars given to the states contingent on states increasing the pool of eligible individuals.

On June 28th, the Supreme Court ruled in National Federation of Independent Business v. Sebelius, however, that the federal government could not withhold current levels of Medicaid funding to force the Medicaid expansion.  Instead, it could only withhold the additional funds it planned to give out, making the Medicaid expansion optional state-by-state.

Based on the Sebelius ruling, the CBO reworked its estimates in a July 2012 report that concluded, because of the Supreme Court ruling, six million fewer people would qualify for Medicaid than previously estimated. Of those six million, however, an additional three million would qualify for the new exchanges.  Therefore, the net loss of insured people thanks to the Supreme Court ruling was three million.  In updating their numbers, the CBO did not attempt to guess which states would or would not expand their Medicaid program, but attempted to “reflect an assessment of the probabilities of different outcomes…and are, in their judgment, in the middle of the distribution of possible outcomes.”

These figures are being discussed again because of a June 2013 study by HealthAffairs, which did attempt to guess state-by-state who would be expanding their Medicaid programs and its affect on the uninsured.  They note that, after the Supreme Court decision, 14 states had announced their intent to opt-out of the expansion, six were undecided, three were leaning against the expansion, and two were leaning toward the expansion.  They found that if all currently undecided states opted in, 29.8 million people would remain uninsured by 2016 (compared to 26 million people uninsured according to the CBO by the same year).  That number would rise to 31 million if all of the undecided states opted out.  They also note that around 80% of those uninsured would be US citizens, and no matter which way the undecided states go, 4.3 million children and 1 million veterans would likely remain uninsured.

As of a September 17, 2013 a report by the Advisory Board Company found that the number of undecided and not participating states had increased. They found 15 (up from 14) states firm in opting out of expansion, seven (three) leaning against expansion, five (six) undecided or exploring an alternative model, four (two) leaning towards expansion, and overall 20 (25) firmly participating.  Therefore, the percentage of states that could be opting out has increased from 34-46% to 44-54% of states.  This will in turn increase the number of uninsured people.  As the merits of the ACA continue to be debated on Capitol Hill in light of the budget debate, and more states become firm in their plans to opt-in or opt-out of the Medicaid expansion, the number of those who are ultimately uninsured could rise and continue to undermine the goal of universal health care.

 

Plan B May Be Over the Counter Now

A US federal judge ruled on April 5th that Plan B and emergency contraceptives be made available to minors without the need of a prescription.

Prior to the Obama Administration’s 2011 decision to restrict access for anyone under the age of 17, the Food and Drug Administration recommended that Plan B be made available without a prescription for all women of any age. Judge Edward R. Korman determined that there was no reason to restrict access, even to minors, because Plan B is “among the safest drugs sold over the counter.”

Although the decision to restrict access was likely an attempt to avoid angering religious groups who claim the drug is an abortifacient, science shows that the drug prevents implantation on the uterine wall. A woman is not considered pregnant until the fertilized egg has implanted itself in her uterus’ wall.

Women still face the common problems of buying the drug: Pharmacists sometimes lie and claim even adults need a prescription, refuse to sell to men, or refuse to sell at all.

Komen’s decision will appeal to the Second Circuit, which is one of the most liberal in the country.

NYC Ban on Soda Won’t Happen After All

Justice Milton Tingling struck down Mayor Bloomberg’s ban on large soda drinks, calling it “arbitrary and capricious”.

The ban was an attempt to improve the health of NYC citizens, after seeing obesity rates rise from 18% of adults in 2002 to 24%. The ban was championed by Bloomberg and approved by the Board of Health in September, 2012. Justice Tingling wrote that the power to create the ban belonged to the elected City Council, and not the Board of Health appointed by the mayor.

According to city Health Commissioner Dr. Thomas Farley, obesity-related illnesses cost the city about $2.8 billion a year.

Businesses faced costs associated with the change that they would not be compensated for – reprinting menus, changing bottles and labels, and movie theaters in particular were concerned about losing soda sales that account for 20% of their profits.

Breast Pumps For All, But Not Necessarily The Best

The ACA requires insurance companies to provide new mothers with breast pumps and other equipment that is necessary to help them breast feed.

Unfortunately, the law doesn’t specify the type or quality of the breast pumps to be provided, so the companies (with doctors’ recommendations) get to decide. This issue leads to whether a company will provide a manual or an electric pump.

The benefits of an electric pump over a manual pump are several: they’re high-powered and can simulate a nursing child, while manual pumps can be weak, clumsy, and cumbersome for a working mother to use. They take more time to pump than an electrical pump.

The costs are also considerably different, when a high-end electric pump coming in at around $300, and a manual pump costing as little as $35.

Surprise Benefit of Obamacare: Less Spending

On March 7th, Kathleen Sebelius of Health and Human Services announced that there has been a slowdown in medical spending since the implementation of the Affordable Care Act.

Obamacare, Sebelius said, is due the credit for increased efficiency and slowed medical spending growth.

“The health care law’s push for coordinated care and paying for quality rather than quantity is putting downward pressure on medical costs, the article reports,” Sebelius wrote in a blog post. “It’s improving the way health care providers do business, and that’s good news for patients.”

Sebelius cited a USA Today study that found the ACA’s cost-control measures are working.

Competing Nurse Ratio Laws Face Off in D.C.

[caption id="" align="alignleft" width="200"]nursing law Nursing Students Prepare for Care Services, Courtesy: Vlastimil[/caption]

Federal, state, and local governments regulate many aspects of health care. However, it is physicians, nurses, and other health professionals that provide care directly to patients.  The ever growing demands of an aging population have led to overfilled hospitals, struggling to avoid turning away patients, with some nurses caring for five or more patients at any given time.  As a result, there has been considerable debate over the past few years as to whether or not such a workload can be detrimental to patients.

This debate has recently been renewed by the Council of the District of Columbia.  The “Patient Protection Act of 2013” (Leg. No. B20-0101), presented by Council Chairman Phil Mendelson and cosponsored by eight other Council Members,[i] sets strict nurse-to-patient limits depending on the type of hospital setting in which a patient is treated.  For example, an operating nurse would only be permitted to care for one patient at any given time, while a non-trauma emergency department nurse or a medical/surgical nurse could only cover a maximum of four patients.

This proposed legislation is based on a similar framework created by the California state government in 1999 and put into force in 2005.  That system has been touted as a “landmark” law by National Nurses United (NNU), a nursing union.  While NNU points to California as glowing proof for the need for state-mandated limits on nurse staffing ratios, the evidence is not so clear.

A California HealthCare Federation study of various nurse-sensitive indicators in California hospitals suggests that despite significantly increased costs, there is little positive effect on patient care.  The study found that between 1999 (when the legislation was passed) and 2006, the rates of pneumonia death and failure to rescue steadily declined, yet the rates of post operative sepsis, deep vein thrombosis, and pressure ulcers increased.  The study concluded that most of the indicators they measured “do not appear to have been directly affected by the increase in RN staffing.”[ii]  On the contrary, the authors found that some hospital staff members reported experiencing difficulties in meeting both staffing requirements and requirements that nurses take mandatory breaks during the day,  that emergency department wait times had increased, and that in some rare cases ambulances were being diverted to other hospitals in an effort not to break the ratio requirements.

The American Nursing Association (ANA) lists California as the only state to require minimum nursing ratios for all nursing units at all times.  Instead, most of the states listed have laws requiring individual hospitals to have committees, comprised of nurses and administrators, that set ratios based on the specific needs of the patients on that unit.  These laws let the health care professionals decide what is appropriate for the patients under their care.  Notably, the California law cited by the NNU only required that the California Department of Public Health establish and enforce ratios, but the law itself did not take on the task of mandating specific ratios, as the D.C. proposed legislation does.

The ANA supports a model where the nurses themselves are involved in creating unit-specific staffing plans.  This model is similar to competing D.C. legislation put forth by Council Member Mary M. Cheh, representing D.C.’s Ward 3.  The “Nurse Safe Staffing Act of 2013” (Leg. No. B20-011) calls for each hospital in Washington D.C. to create a committee comprised of at least 55% direct-care registered nurses, with at least one patient care nurse from each unit,[iii] which will be tasked with setting hospital-wide nurse-to-patient ratios.  The ratios set by the committee must “[b]e based upon input from the registered nurse staff of the hospital who provide direct patient care or their exclusive representatives,”[iv] standing in stark contrast to the Mendelson bill, which puts the job of determining what is best for patients solely in the hands of politicians.[v]

Given that the ANA and the D.C. Hospitals Association reject such strong requirements, the loudest voice in support of the proposed legislation is the NNU nursing union.   Their Uniform National Professional Standards largely match the proposed Mendelson bill.  However, certain provisions buried in the legislation may point to an additional goal.  Despite the stated goal of patient protection, section 6(h)(4) of the Mendelson bill states that a “hospital (or an individual representing [a hospital]) shall not in any way interfere with the rights of nurses to organize, bargain collectively, and engage in concerted activity under section 7 of the National Labor Relations Act.”[vi]  (Emphasis added).

The D.C. Council should strongly consider the difference between the Mendelson and Cheh bills.  The Mendelson bill calls for local politicians to determine how many patients a nurse can care for, based only on the general nature of a hospital unit.  The Cheh bill puts that decision in the hands of the very healthcare professionals who provide direct hands-on patient care.  The nurses working in a hospital unit, caring for patients 24 hours a day, 7 days a week, 365 days a year, are in a far better position to decide on staffing levels than politicians.  In an era of personalized medicine, local politicians should not use the broad brush of legislation to make generalized decisions in place of nurses and healthcare administrators.

[i] This bill was introduced by Council Members Mendelson, Barry (Ward 8), Evans (Ward 2), Grosso (At-Large), Orange (At-Large), Alexander (Ward 7), Bonds (At-Large), Graham (Ward 1), and McDuffie (Ward 5), and it was co-sponsored by Council Member Wells (Ward 6).

[ii] Joanne Spetz, et al., Assessing the Impact of California’s Nurse Staffing Ratios on Hospitals and Patient Care, California HealthCare Foundation at *7 (Feb. 2009).

[iii] Nurse Safe Staffing Act of 2013 § 3(c)(1)(a-d).

[iv] Nurse Safe Staffing Act of 2013 § 3(d)(1).

[v] The Mendelson bill does require each hospital unit to create a committee to review staffing measures. However, the committee is only permitted to impose restrictions which are more stringent than those laid out by law.  Patient Protection Act of 2013 § 4(b)(1).  For example a medical/surgical unit committee could decide that the mandated 4 patients to 1 nurse is not sufficient, and the committee could then set the ratio to 3 patients to 1 nurse, but it could not change it to 5 patients to 1 nurse.

[vi] Patient Protection Act of 2013 § 6(h)(4).