The Handiest Girlie Of All

Medical Documentery 200 years of Medicine

This 45-minute documentary explores three remarkable stories of medical progress that have taken place over the course of the long history of NEJM.  In 1812, we had no understanding of infectious disease, surgery was unsanitary and performed without anesthesia, and cancer was unrecognized. Two centuries later, this film tells the story of research, clinical practice, and patient care, and of how we have continued to get better over the last 200 years

 

 

Getting Better is a short documentary that explores three remarkable stories of medical progress: Cancer, HIV/AIDS, Surgery. The film looks at the role of researchers and clinicians, of patients, their families and their advocates, and how information is translated into action. It is the story of research, clinical practice and patient care, and how we have continued to get better over the last 200 years.

In 2012 the New England Journal of Medicine celebrates 200 years of publishing practice - changing medical advances. NEJM brings together a global community, from researchers to clinicians, to improve the health of people around the world. The 200th anniversary of NEJM honors all who contribute to this mission.

 NEJM

Senate Passes Cuomo's Bill Creating State Agency to Police for Disabled Care

ALBANY NY

The State Senate unanimously passed Gov. Andrew M. Cuomo’s legislation to protect developmentally disabled and mentally ill New Yorkers on Wednesday, but some high-profile advocates have been unnerved by what they perceive as flaws in the bill. Assembly Democrats have said that they intend to pass the bill, but will negotiate some changes before the legislative session ends on June 21.

The centerpiece of the governor’s legislation will create a new state agency — the Justice Center for the Protection of People With Special Needs — with prosecutorial powers, giving it authority concurrent with local district attorneys to bring cases against those who abuse people with special needs. The Cuomo administration contends that the new agency would provide vulnerable populations with a dedicated force of investigators and prosecutors who can handle often-complicated cases involving victims who in many cases cannot speak.

The biggest concern among some advocates is that the legislation would continue to give a state agency primary control over reports of abuse and neglect, leaving outside law enforcement and district attorneys beholden to the state’s good faith and competence. They believe that local law enforcement agencies would not be given enough direct access to information under the new system.

Many advocates have a deep distrust of the state, which has for decades failed to adequately monitor lapses in care.

“This program will make this system more dangerous and give the state more power to cover up abuse and neglect,” said Michael Carey, an outspoken advocate whose son Jonathan died while in state care five years ago. He said the legislation would “keep vital cases and information from the police and district attorneys, which will continue to violate the constitutional rights of the disabled.”

Joshua Vlasto, a spokesman for the governor, countered: “The entire purpose of the Justice Center and the special prosecutor/inspector general is to ensure that every case is pursued, even if local officials do not want to pursue it.”

Mr. Carey said he would prefer that caregivers be trained to call 911, even in instances of psychological abuse, including times when workers call developmentally disabled individuals by derogatory names, an approach administration officials view as impractical. The legislation does require that any report of an incident that “may constitute a criminal offense” be forwarded to law enforcement. But while that language seems broad, similar language already in state law has been frequently ignored in the past.

Mr. Vlasto said, “The Justice Center’s 24/7 hot line will be a far more comprehensive resource for reporting every level of abuse and neglect than 911.”

He said hot line attendants would be trained to report cases needing immediate attention to the police, while members of the center could follow up on less severe cases.

That kind of judgment call concerns Mr. Carey, who also believes the administration is doing too little to prevent abuse before it happens. He has pushed a number of proposals, including installing cameras in group homes, placing tight limits on overtimeto reduce worker fatigue and increasing staff sizes.few advocates are as hostile to the legislation as Mr. Carey, but others also see flaws.

 

Bridgit M. Burke, the director of the Civil Rights and Disabilities Law Clinic at Albany Law School, said she was concerned that a new nonprofit group being set up to monitor the state’s handling of vulnerable populations would have little access to documents related to abuse and neglect, according to the legislation’s fine print.

“Over all, I think there are a lot of positive things, but I am also very concerned and therefore would encourage people not to vote for it right now, the way it is,” she said.

Cuomo administration officials aid they believed that federal laws would ensure that the new nonprofit agency, which would be federally financed and which is being created at the urging of federal regulators, would have access to documents.

The governor has said passing the legislation is his highest priority over the remainder of the legislative session. On Wednesday, he traveled to Syracuse to promote the bill.

“If we are in charge of caring for human beings with special needs, they are going to get the best treatment we can get them,” Mr. Cuomo said in remarks to reporters. “They are certainly not going to be abused in our care, not while I’m governor.”

He has rallied more than a hundred groups behind him, though many are nonprofit providers of services to disabled people who are regulated by the state.

The administration’s proposal comes in response to articles in The New York Times last year describing widespread problems in the care of people with developmental disabilities. The state had been transferring abusive employees from group home to group home, abuse cases were rarely referred to the police, and employees with criminal records were hired.

Executives of nonprofit groups caring for disabled people have also been reaping seeven-figure compensation packages, in some cases. The Cuomo administration announced Wednesday the details of a new regulation to limit the amount of state aid that could be used for executive pay.

 

New York Times

Medicaid Unconstitutional? New England Journal of Medicine explains

Although the media and the U.S. public focused primarily on the minimum-coverage requirement, or individual mandate, during the recent oral arguments in the challenges to the Affordable Care Act (ACA) before the Supreme Court, the most important issue before the Court may well be the constitutionality of the ACA's Medicaid expansion. There are potential alternatives to the minimum-coverage requirement, but a finding that the Medicaid expansion is unconstitutional could threaten all federal spending programs that set minimum participation standards. Indeed, as Justice Stephen Breyer observed during the oral argument, if the plaintiff's argument is accepted, then “Medicaid has been unconstitutional since 1964.”

The ACA expands Medicaid to cover all adults under 65 years of age who have an income below 138% of the federal poverty level. The federal government will pay 100% of the cost of this expansion for 2014 through 2016, phasing down to 90% by 2020. But states must cover the newly eligible population in order to receive any federal Medicaid funding.

The 26 Republican governors and attorneys general bringing the ACA lawsuit claim that the expansion is unconstitutional because they are being “coerced” into expanding their Medicaid programs under threat of losing all federal Medicaid funding. Their argument is grounded in statements made in two earlier Supreme Court cases speculating that financial inducements that the federal government offers states to participate in federal–state programs “might be so coercive as to pass the point at which `pressure turns into compulsion.'” No federal court has ever declared a law unconstitutional under this coercion theory, and it was rejected by the lower courts in this case.

Paul Clement, arguing for the plaintiffs, contended that the Medicaid expansion is coercive because the states must choose between accepting expanded coverage and losing all federal Medicaid funds, that the lost funding would be enormous, and that if states don't participate in Medicaid, their poorest population will be unable to comply with the ACA's minimum coverage requirement. He also asserted that federal taxes for funding the expansion would leave states incapable of funding an alternative program if they chose not to participate. Solicitor General Donald Verrilli responded that the federal government has always retained the right to change Medicaid and that earlier expansions have also required states to accept new responsibilities or lose funding. States remain free not to participate, he argued, but have no vested right to keep the program unchanged. Virtually all Medicaid-eligible persons would be exempt from the minimum-coverage penalty. Finally, most state Medicaid spending today covers optional benefits and populations, and the expansion's terms allow continued flexibility.

The Court's four liberal justices seemed unconvinced by Clement's arguments, pointing out that the federal government is not extracting money from states to pay for the expansion, since state residents are also independently subject to federal taxes, and that previous mandatory Medicaid expansions would also be unconstitutional under the states' theory. The more conservative justices seemed sympathetic to the states and to Clement's claim that, realistically, no state could withdraw from Medicaid, although Chief Justice John Roberts also recognized that the states bear responsibility for the current situation because they have willingly participated in federal spending programs since the New Deal. Justice Anthony Kennedy seemed to think that the key lay in the question of whether a state can be accountable to its citizens for a program it has no control over, but he recognized that this line of inquiry might not lead to a workable standard for deciding when coercion is present. Justice Breyer contended that any decision to withdraw Medicaid funding from a state that rejected the expansion would be judicially reviewable.

There was no clear sign that the Court is prepared to strike down the Medicaid expansion, but what would it mean if the Court held it unconstitutional?

The biggest losers would be the 16 million to 17 million Americans who are expected to gain Medicaid coverage under the 2014 expansion and the millions more who will be eligible should they have medical emergencies. Medicaid is not perfect — low provider payments limit access to care. But Medicaid beneficiaries are more likely than the uninsured to receive care, and after adjustments for health status, they have better outcomes.Medicaid will continue to be a lifeline.

Striking the Medicaid expansion would also mean a huge loss for U.S. health insurers. Most of the newly eligible population is likely to be enrolled in private managed-care plans that contract with Medicaid agencies. One amicus brief in the Supreme Court case concluded that insurers will receive $356 billion in revenue from the Medicaid expansion over the next 10 years — almost as much as they expect to gain from both the ACA's minimum-coverage requirement and tax credits.

Hospitals would also lose. Six hospital associations, representing virtually all U.S. hospitals, filed an amicus brief in support of the expansion.If the Medicaid expansion is rejected, hospitals will continue to provide uncompensated care for uninsured Americans who would otherwise receive Medicaid. ACA cuts in Medicare payments to hospitals, coupled with enhanced obligations for tax-exempt hospitals, make the Medicaid expansion even more vital. ACA provisions allowing hospitals to make presumptive determinations of Medicaid eligibility will further reduce their uncompensated-care burden — if those provisions remain in place.

Although many physicians forgo Medicaid participation, many — particularly hospital-based and clinic-based physicians — depend on Medicaid. In 2013 and 2014, Medicaid will pay 100% of the Medicare payment level for primary care services, dramatically increasing revenue for primary care physicians who accept Medicaid patients.

Paradoxically, another loser if the expansion is stricken would be the states, 13 of which filed an amicus brief in support of the expansion. A number of states have already expanded their Medicaid programs and expect fiscal relief if the expansions are upheld. Additional states would be relieved of billions of dollars in uncompensated care burdens.

As the oral argument ended, Justice Ruth Bader Ginsburg asked Clement if the states would accept a remedy blocking the expansion only in the objecting states, were the Court to find the expansion unconstitutional. Clement agreed. This solution would mitigate the damage caused by a ruling for the states but would not address the greatest threat posed by such a ruling.

Most cooperative federal programs — addressing not only health care but also transportation, education, welfare, community development, and environmental problems — involve conditional federal grants to the states. All these programs are subject to litigation if the states win this case. The Court's establishing the coercion theory as an active legal doctrine would threaten the ability of the federal government to work with the states to address national problems. Holding the expansion unconstitutional could eliminate federal–state cooperative programs. The ramifications of such a ruling could far exceed those that might follow from the invalidation of the minimum-coverage requirement.

NEJM

States seek to curb exorbitant Drug Costs Incurred by Patiants

Insurance now pays most of the price of the costly drug William Addison, 7, Victoria Kuhn’s son, takes for uncontrollable bleeding.

The hemophilia drug that saves 7-year-old William Addison from uncontrolled bleeding costs $100,000 a year. His family’s insurance pays virtually all of it.But his mother, Victoria Kuhn, says she is terrified that the insurance company may start requiring patients to pay as much as a third of the cost of the drug. “I don’t know where we’d find $30,000,” said Ms. Kuhn, who lives in Falmouth, Me.

A collection of empty bottles from William’s medicine, which costs $100,000 a year, at his home in Falmouth, Me.

Spurred by patients and patient advocates like Ms. Kuhn, lawmakers in at least 20 states, from Maine to Hawaii, have introduced bills that would limit out-of-pocket payments by consumers for expensive drugs used to treat diseases like cancer, rheumatoid arthritis, multiple sclerosis and inherited disorders. 

Pharmaceutical companies would also benefit from such legislation because high co-payments discourage patients from taking their medicines. The pharmaceutical giant Pfizer has been helping the legislative drive behind the scenes, even drafting some of the bills, according to legislators and patient advocates.

The bills aim to counter efforts by health plans to reduce the amount they pay for expensive medicines by making the patients pay a percentage, typically 20 to 35 percent, of the cost.

While some insurers have said the laws are unnecessary because of the federal health care law, backers say the state bills would supplement the federal law and take effect before 2014, when most of the federal law is to become operative. They say too much uncertainty remains about how the federal law will work and whether it will survive the challenge before the Supreme Court.

New York State passed the first law prohibiting such high patient payments in 2010. Vermont enacted a one-year moratorium that lasts until July 1. Maine’s governor, Paul LePage, signed a bill into law on Monday that would set a yearly cap on patient payments for such expensive drugs. Hearings on similar bills were held last month in Connecticut and Rhode Island. Delaware’s Health Care Commission just finished a study on the matter. And a bill that would cover all states was recently introduced in the House by David McKinley, a West Virginia Republican.

Insurance companies are pushing back, so some bills are dying, as in Washington State, or being watered down, as was the one in Maine. The insurers argue that reducing payments by users of the expensive drugs would raise premiums for everyone else.

“There’s no free dollars in the mix here,” Melvin N. Sorensen, a lobbyist for insurers, said at a hearing in the Washington State Senate in late January.

The controversy centers on so-called specialty drugs, a somewhat imprecise term that generally encompasses products that can cost tens or even hundreds of thousands of dollars a year.

Such drugs account for only 1 percent of total drug use, but 17 percent of drug spending by private insurers, according to IMS Health.

And costs are soaring as more such drugs come to market and as manufacturers raise prices. In 2010, spending on specialty drugs jumped 17.4 percent, compared with only 1.1 percent for other drugs, according to Medco Health Solutions, a pharmacy benefits manager that merged this month with Express Scripts.

Insurers typically encourage patients to use less expensive drugs by classifying products into tiers with successively higher co-payments, like $10, $30 and $50. Generic drugs are usually in the lowest tier, preferred brand-name drugs in the second tier and other brand-name drugs in the third.

But some insurers are now putting specialty drugs into a fourth tier of their own with extra high co-payments, or even co-insurance, in which the patient pays a percentage of the drug cost.

About 14 percent of workers with insurance are in plans that have four or more tiers, up from 7 percent in 2008, according to the Kaiser Family Foundation’s 2011 survey of benefits.

Patient advocates say that for some diseases, like multiple sclerosis, none of the drugs are inexpensive, making it impossible to avoid the high out-of-pocket costs unless people stop taking their medicine and endanger their health.

That discriminates against people with certain diseases, they say, and contravenes the whole idea of insurance, which is to help people pay for costly medical problems.

Mark Merritt, president of the Pharmaceutical Care Management Association, which represents pharmacy benefit managers, said the real problem was the price of the drugs. The legislation, he said, was an effort by the pharmaceutical industry to “turn a pricing problem into a coverage issue.”

Sharon Treat, executive director of the National Legislative Association on Prescription Drug Prices, an organization of state lawmakers, said that was a drawback of the bills. Insulating patients from the cost of their drugs, she said, “gives the drug companies a free ride to charge as much as they want.”

Still, Ms. Treat, a Democratic legislator in Maine, supported the bill in her state. And patient advocates say that while insurance is regulated, there is little they can do about drug prices.

Drug companies often help patients with their co-payments, but patient advocates say those programs do not solve the entire problem.

While pharmaceutical trade groups have expressed opposition to specialty tiers, Pfizer, which sells drugs for cancer, hemophilia and other diseases, has vigorously pushed the legislation, though it generally does not testify publicly.

“I was approached by a lobbyist from Pfizer with the original language,” said Stacey Allen Fitts, the state representative who introduced Maine’s bill. He said patient groups contacted him only afterward.

State Representative Cale P. Keable, a Rhode Island Democrat, and state Senator Joshua Green, a Democrat in Hawaii, said a Pfizer lobbyist provided or suggested language for the bills they introduced.

Bryon Wornson, vice president for public affairs in Pfizer’s specialty care business unit, said the company was working “in partnership with the patient groups,” adding, “I don’t think we are doing anything that is not fully transparent.”

The state bills — which would not apply to employers that insure themselves since their plans are not regulated by states — take various approaches.

New York’s law basically prohibits a fourth tier. At the time the legislation was enacted, no insurer in the state had a fourth tier, and it is not clear whether any would have started one had the law not been enacted.

Maine’s bill initially prohibited specialty tiers. The law as enacted allows them, but sets a limit of $3,500 a year for patient co-insurance payments for drugs,

Louisiana and Texas both enacted laws last year that do not limit out-of-pocket drug costs, but prohibit insurers from raising them in the middle of a contract year.

Some state bills, like one introduced recently in California, and one that died in Washington, take the same approach as the federal law, but would have it apply earlier. The federal law requires insurers, starting in 2014, to cap total yearly out-of-pocket costs, including for drugs, at about $6,000 for an individual and $12,000 for a family.

That is still a lot for many patients, though some say it would be better than nothing.

“At least I can go, ‘O.K., this is the maximum it’s going to cost my family,’ ” said Heidi Barrett of Mukilteo, Wash.

She and her four children have psoriatic arthritis and her husband has ulcerative colitis. Three family members combined use about $13,000 worth of the drug Remicade, which is used to treat both conditions, each month. Because of a change in her husband’s insurance, the family will have to pay 10 percent of the drug’s cost starting next year.

“I don’t know what we’re going to do,” she said.

New York Times

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• Multiple Sclerosis Treatment Options (answers.com)
• Novartis Gilenya Patient Develops Rare and Fatal Brain Disease (inquisitr.com)
• Rheumatoid arthritis linked to irregular heart rhythm (eurekalert.org)
• Canada's private sector insurers to share drug costs (ctv.ca)

Super Committee Cuts Could Lead to Worse Health for Gay and Transgender Americans

Health Programs for All Groups Must Be Protected

Sen. Patty Murray (D-WA), co-chair of the Joint Select Committee on Deficit Reduction, walks through the Capitol in Washington, Tuesday, November 15, 2011.

 

The ongoing budget and deficit reduction negotiations carry far-reaching consequences for every American. But further capping or cutting funding for vital health programs such as Medicare, community health centers, and Medicaid place populations that already face disparities in health and access to health care, including gay and transgender Americans,* under even greater threat.

 

Heavy cuts to health care entitlement programs and health programs funded by discretionary spending would put these populations at serious risk of losing assistance essential to their well-being. Many gay and transgender people, like other Americans, rely on entitlement programs such as Medicare and stand to benefit substantially from the expansion of Medicaid and other provisions of the Affordable Care Act.

 

Most importantly, further cuts to discretionary spending threaten to undermine the national health infrastructure that protects the health of all Americans and that is critical to closing the disparities that affect the lesbian, gay, bisexual, and transgender population.

 

This column explores several possible paths the budget negotiations could take and what potential cuts to both mandatory and nondefense discretionary spending may mean for gay and transgender Americans.

 

The Center for American Progress recommends that cuts to discretionary spending and entitlement programs be minimal and balanced by the kinds of significant revenue increases that will truly help eliminate the deficit and responsibly balance the budget.

 

The budget landscape

 

As part of a broader deal to raise the nation’s debt ceiling earlier this summer, Congress passed the Budget Control Act to rein in the growing budget deficit. The BCA cuts $900 billion from the federal budget over the next 10 years by placing caps on defense and nondefense discretionary spending. The act also created the Joint Select Committee on Deficit Reduction, popularly known as the budget “super committee,” to identify additional deficit reduction measures that total at least $1.2 trillion.

 

These measures may include cuts to both mandatory and discretionary spending. Mandatory spending accounts for 59.5 percent of the total federal budget and includes the three largest federal entitlement programs: Social Security, Medicare, and Medicaid. Discretionary spending accounts for 35.2 percent of the total federal budget and Congress must annually reappropriate funds for programs supported by discretionary funds. Twenty percent of these funds go toward defense spending, with the remaining 15 percent supporting programs that range from the National Institutes of Health and the Veteran’s Health Administration to the FBI and the Environmental Protection Agency.

 

The bipartisan super committee must agree on its proposal by November 23 of this year. Both the House and the Senate will consider the proposal in a simple up or down vote, with no possibility for amendment. While it remains unclear what deficit reduction measures the committee will finally recommend, three potential outcomes can occur.

 

First, if the committee fails to develop a proposal, or if Congress fails to pass it, then automatic cuts known as sequestration will occur starting in January 2013 across certain areas of mandatory spending and across most areas of discretionary spending. Sequestration will require a 2 percent cut to funding for Medicare, with Medicaid remaining untouched, and across-the-board cuts of $1.2 trillion to discretionary spending.

 

Under this scenario, some estimate that 194,000 health-care-related jobs would be lost and that thousands of Medicare beneficiaries would see their coverage affected.

 

Alternately, the committee could reach an agreement that meets the $1.2 trillion minimum. Though such a “grand deal” would avoid sequestration, this scenario could result in the largest cuts to essential health programs that rely on government dollars.

 

The committee does not have a legal limit on where it can make cuts, meaning that it can slash funding for Medicaid and other vital programs administered by the Department of Health and Human Services, including the community health center program, prevention and wellness initiatives, medical research, and various provisions of the Affordable Care Act.

 

In the third alternative, the committee reaches a deficit reduction deal that does not meet the $1.2 trillion threshold. In this case, automatic cuts in Medicare and discretionary spending would still be triggered, and programs that are protected from sequestration, such as Medicaid, could face cuts under the terms of the proposal itself.

 

What has been proposed so far

 

Super committee members from both parties offered proposals that include large cuts to discretionary spending along with both Medicare and Medicaid. Democrats proposed a plan that slashes $400 billion from Medicare, $75 billion from Medicaid, and $1.3 trillion in discretionary spending while increasing revenue by $1.3 trillion. Republicans, on the other hand, offered up a proposal that cuts $500 billion from Medicare and $185 billion from Medicaid, with $1.2 trillion more in discretionary cuts and only $40 billion in revenue increases. The Republican cuts to Medicare rely much more heavily on increasing premium costs for beneficiaries than the Democratic plan.

 

Overall, both of these plans are much more inclined than previous proposals to cut spending rather than increase revenues. In summer 2011 the bipartisan Gang of Six introduced a plan that cut Medicaid and Medicare combined by $500 billion and cut discretionary spending by $1.1 trillion, but it also raised revenue by $2 trillion. In December 2010 the Simpson-Bowles Commission, also known as the deficit commission or the National Commission on Fiscal Responsibility and Reform, cut Medicare and Medicaid by $400 billion and discretionary spending by $1.3 trillion but increased revenues by $2.2 trillion.

 

Why does all this matter for gay and transgender health?

 

The super committee’s unprecedented power, either through action or inaction, to affect the nation’s budget puts numerous health programs that provide health care services and other benefits to millions of Americans, including many gay and transgender people, at risk of serious cuts.

 

Gay and transgender communities most at risk include families with children and gay and transgender people who are doubly marginalized in American society, such as gay and transgender people of color, those living in poverty, immigrants, homeless youth, elders, and those with disabilities.

 

Though there are no data currently collected on how many gay and transgender people rely on programs such as Medicaid, Medicare, and community health centers, they likely benefit from these programs at least in proportion to their heterosexual and nontransgender counterparts, if not more so.

 

The Williams Institute’s most recent findings conservatively estimate that at least 3.5 percent of American adults are gay, lesbian, or bisexual, and at least 0.3 percent are transgender. Of the more than 100 million adults receiving direct assistance from government-funded health care programs, we can therefore estimate that at least 4 million of these beneficiaries are gay or transgender. Because LGBT people are more likely than the general population to live in poverty and often do not have access to private insurance coverage through their own or a partner’s employer, the actual number relying on these programs is probably much higher.

 

The super committee’s actions regarding mandatory spending will thus significantly affect the health of gay and transgender Americans. Gay and transgender older adults who, like other older Americans, rely on Medicare, may have their access to care limited by cuts to Medicare provider reimbursements under the sequester.

 

What’s more, the Affordable Care Act will expand Medicaid eligibility up to 133 percent of the federal poverty level, which will allow the program to serve many more gay and transgender adults. But this change will not happen until 2014—and in the meantime, the super committee may decide to cut funding to the Medicaid program. This would destroy the very foundations on which one of the most important provisions of the Affordable Care Act is to be built, potentially depriving an estimated 16 million Americans of an opportunity to gain health insurance coverage.

 

Beyond Medicare and Medicaid, the situation is even worse for programs funded by nondefense discretionary spending, including many promising initiatives under the Affordable Care Act and HHS programs that address health disparities and reach out to underserved communities.

 

Cuts to the funding that supports these programs would severely threaten the ability of HHS and its partners around the country to address the disparities in health status and access to health care that affect gay and transgender individuals, families, and communities.

 

Programs and initiatives at risk include:

 

• Data collection by HHS on sexual orientation and gender identity that would allow gay and transgender disparities to be identified and effectively targeted
• Biomedical and behavioral research on HIV prevention and treatment at the Centers for Disease Control and Prevention and the National Institutes of Health
• Primary, preventive, and other direct health care services through community health centers, which will serve an estimated 40 million Americans by 2015, including many gay and transgender people and their families
• Mental health services that help gay and transgender youth and adults cope with depression and other consequences of bullying and discrimination
• Substance abuse prevention and treatment programs, including tobacco cessation programs that work to reduce high rates of smoking among gay and transgender people
• Programs that support out-of-home gay and transgender youth, who comprise up to 40 percent of the homeless youth population in the United States
• Efforts by the Office of Minority Health to address the staggering disparities that affect gay and transgender communities of color

 

Though the funding for these programs may be discretionary, the programs themselves should not be.

 

The super committee has yet to offer up a viable plan, despite a looming deadline, and the outlook for our nation’s health is grim. The Budget Control Act already imposed caps on discretionary spending, and any further cuts either under the sequester or contained in a super committee deal would decimate the ability of these vital programs to protect and promote the health of our nation’s most vulnerable communities, including gay and transgender Americans.

Moreover, we can ill afford cuts to Medicaid and Medicare as long as 50 million Americans remain uninsured, and particularly in the years when the first baby boomers are turning 65.

The super committee must resist the urge to take a cuts-only approach without raising any significant additional revenue. Otherwise, it threatens to sacrifice our nation’s future health for short-term political gain.

Kellan Baker is the LGBT Health Policy Analyst at American Progress. Zach Britt is an intern with LGBT Progress.

*In this column, the term “gay” is used as an umbrella term for people who identify as lesbian, gay, or bisexual.

Center for American Progress

Related articles

• Deficit: No deal is better than a bad deal (csmonitor.com)
• Budget wars: Cut, cut and cut some more (money.cnn.com)
• The Supercommittee Is Probably Going to Fail. So What Happens Next? (swampland.time.com)
• The Supercommittee Is Probably Going to Fail. So What Happens Next? (swampland.time.com)

Have Pre-Existing Condition? A New Coverage Option for the Uninsured by 2014

If you have had a hard time finding health insurance because of a pre-existing condition or if you’ve been turned down for insurance coverage and feel like you’re out of options, you’re not out of luck.

You may now be eligible for a new government program – the Pre-Existing Condition Insurance Plan –created by the Affordable Care Act.

This transitional program is available for children and adults in all 50 states and the District of Columbia who have been locked out of the health insurance market because of a pre-existing condition. In 2014, Americans – regardless of their health status – will have access to affordable health insurance when the nation transitions to a new marketplace.

Under this new program, you’ll receive health coverage for a wide range of medical benefits including physician services, hospital care and prescription drugs. All insurance benefits are available to you – even to treat a pre-existing condition. You won’t be charged a higher premium because of your medical condition and your eligibility is not based on your income. Like standard health insurance plans, you may be required to pay a monthly premium, a deductible and some cost-sharing expenses. Premiums may vary depending on where you live, your age and which plan you choose.

 

The Pre-Existing Condition Insurance Plan is already getting results that are changing the lives of Americans across our nation who don’t have health coverage and need medical care. James H., who lives in Texas, was diagnosed with brain cancer in 2010. Shortly after his diagnosis, James’ insurance company cancelled his coverage, claiming that his cancer was a pre-existing condition. James knew that his lack of coverage was a death sentence. Fortunately, James was able to join the Pre-Existing Condition Insurance Plan in Texas and is now receiving the medical treatment he needs.

Cathy A., who lives in Ohio and is a small business owner, has Systemic Lupus which has required very little treatment over the years, but she has consistently been denied health insurance because of her medical condition. Cathy noted that “without me working and paying the bills, my firm would close.” After enrolling in the Pre-Existing Condition Insurance Plan in Ohio, Cathy now has the peace of mind she deserves, and she doesn’t have to worry about the financial instability that goes with being uninsured.

These stories are just a snapshot of what we’re hearing from people across the nation who are participating in the Pre-Existing Condition Insurance Plan – just one of many new initiatives resulting from the health care reform law that are helping Americans across the nation.

To qualify, you must: be a citizen of the United States or reside here legally, have been without health coverage for at least six months before applying and have a pre-existing condition or have been denied insurance coverage because of your health.

Each state may use different methods to determine whether you have a pre-existing condition and whether you have been denied health coverage. To find out more about the Pre-Existing Condition Insurance Plan, including eligibility, plan benefits and rates and how to apply, visit http://www.pcip.gov/. Choose “Find Your State” and select your state from the United States map or from a drop-down menu for details.

You can also call a toll-free line at: 1-866-717-5826 (TTY 1-866-561-1604) to get more information. The PCIP Call Center is open 8 A.M. to 11 P.M. Eastern Time.

Blog.gov

For exsample I  went through the options at Health Care .gov

EXSAMPLE

For WA State I was disabled, my health care also would need to serve Special needs (wheelchairs,scooters ect) and my age.6 options came up

Explore these options:

1.	Medicaid		Medicaid provides coverage for low income children, families, the elderly, and people with disabilities. Pregnant women may qualify with higher incomes.
2.	Medicare		Medicare covers people 65 and over and certain people under 65 with a disability, and people with end-stage renal disease.
3.	Health Insurance Through Work		You may be eligible for coverage through work – your job or your spouse’s.
4.	Health Insurance Plans for Individuals & Families		If you do not have job-based or other coverage, you may want to buy a policy from a private insurer.
5.	Pre-Existing Condition Insurance Plan (PCIP)/High Risk Pool		You may qualify for a pre-existing condition insurance plan or a high risk pool, which helps people who have a hard time getting insurance find coverage.
6.	Finding Care You Can Afford		There may be local facilities that provide free or reduced-cost care, whether you’re insured or   depends on your income.

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Obama administration drops part of healthcare law

The CLASS program to provide long-term-care insurance will not be implemented because it wouldn't be financially sustainable, says the Department of Health and Human Services. 

The Obama administration will not implement a new program to provide Americans with long-term-care insurance, abandoning a controversial part of the healthcare overhaul the president signed last year.

The move will not affect other parts of the sweeping law, including preparations for a major expansion of health insurance coverage starting in 2014, according to administration officials.

But the decision to give up on what was once touted as a key benefit of the law marks a major retreat for the administration and a vindication for critics who have voiced doubt about the promises that Democrats made as they fought to enact the law last year.

It also struck a blow at a long-cherished goal of consumer advocates and liberal Democrats, especially the late Sen. Edward M. Kennedy, who championed a government entitlement to help elderly Americans pay for home care or a nursing home.

In a letter to senior Democrats and Republicans on Capitol Hill, Secretary of Health and Human Services Kathleen Sebelius said such a benefit remained crucial.

But she said the program envisioned in the healthcare law — Community Living Assistance Services and Supports, or CLASS — couldn't have been structured to collect enough in premiums to remain solvent.

"For 19 months, experts inside and outside government have examined how [the Department of Health and Human Services] might implement a financially sustainable, voluntary and self-financed long-term-care insurance program under the law," Sebelius wrote. "But despite our best analytical efforts, I do not see a viable path forward for CLASS implementation."

Republican critics of the CLASS program urged even more aggressive action to eliminate the benefit.

"Simply setting aside the program for the near term is not enough," said Sen. John Thune (R-S.D.). "Repeal is the only solution to ensuring American taxpayers will not be on the hook in the future for this disastrous entitlement."

Rep. Frank Pallone Jr. (D-N.J.), a leading proponent, criticized the administration's decision and pledged to work to revive the program.

"The Obama administration is simply wrong," he said. "This is too important to give up."

Kennedy, Pallone and many consumer advocates pushed for the long-term-care program amid evidence that few Americans have private insurance for long-term care. Many elderly Americans face tens of thousands of dollars in bills for home care or for stays in nursing homes, which are not covered by Medicare, the federal program for the elderly and disabled.

Nursing home stays are covered by the Medicaid program for the poor. But in order to qualify for aid, seniors have to spend down their resources, only to then become a burden on the government.

Advocates for a new entitlement — including AARP, the Alzheimer's Assn. and the National Council on Aging — argued that this situation could be avoided if workers paid a portion of their paycheck into a long-term-care insurance program so they could draw on its benefits when they got old.

As Democrats crafted the healthcare law, early budgetary projections from the nonpartisan Congressional Budget Office estimated that because workers could start paying into the CLASS program for five years before benefits became available, it would show a positive balance for years, helping to offset the overall cost of the healthcare law.

That was welcome news to Democrats, who were struggling to find ways to show that the law wouldn't widen the deficit.

But there were also early warnings that the CLASS program would not be sustainable over the long run.

Because the program is voluntary, younger, healthier workers would be less likely to sign up than older, sicker ones.

That could create a destructive cycle in which premiums would have to rise to pay out higher benefits, in turn driving away even more healthy workers and pushing premiums even higher.

Administration officials predicted just such a scenario.

"This imbalance … would cause the program to quickly collapse," Kathy Greenlee, the program administrator, concluded in a memo to Sebelius.

Greenlee predicted that premiums for the program could have cost $391 a month, or even as much as $3,000 a month, for a benefit that paid out only about $50 a day.

Administration officials have not proposed an alternative. Nor, in the current partisan environment, does it appear likely that lawmakers will fix the program.

In her letter to congressional leaders, Sebelius warned that by 2020, an estimated 15 million elderly Americans will need some kind of long-term care, with few having insurance.

"Without insurance coverage or the personal wealth to pay large sums in their later years," she wrote, "more Americans with disabilities will rely on Medicaid services once their assets are depleted, putting further strain on state and federal budgets."

LA TIMES

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Autism treatment benefits could be jeopardized by federal health law provision

Autism treatment advocates have won one legislative battle after another since 2007, most recently in California, which sent a bill to the governor this month mandating that insurers cover the disorder. Now more than half the states have such requirements, but that success could be in jeopardy as federal officials set new national standards for health coverage.

Insurers and employers argue that the laws increase health costs, because treatment is often expensive and lasts years. But the advocates have prevailed by using federal data showing a growing number of children with the disorder, compelling stories about middle-class families struggling to afford treatment and testimony from celebrity parents of children with autism, including former pro football stars Dan Marino and Doug Flutie.

However, a provision in the 2010 health overhaul law gives the federal government authority to define “essential benefits” that will be offered on the health insurance exchanges, or marketplaces, to individuals and small businesses starting in 2014. If states mandate a benefit but it isn’t on the federal list, the states would be responsible for the cost of the coverage.

As a result, autism benefits and dozens of other state-required benefits, covering services and conditions such as infertility, acupuncture and chiropractic care, could be at risk. By the end of September, the Institute of Medicine is scheduled to recommend criteria the Department of Health and Human Services should use in determining the essential benefits package. HHS is expected to announce its decision by the end of the year.

“We do think states will be under enormous pressure to repeal benefits” not deemed essential, said Stephen Finan, senior director of policy for the American Cancer Society’s Cancer Action Network. The society is concerned that the benefits package will not include all the cancer screenings that it has recommended.

“It will be a new day,” said Amanda Austin, a lobbyist for the National Federation of Independent Business, which typically fights new insurance mandates because the costs will lead to higher premiums.

HHS faces a difficult balancing act: The more comprehensive the benefits package, the more it would cost insurers and their customers. Taxpayers would pay more, too, because the law provides government subsidies to help millions of people afford coverage.

Most of the state laws covering autism require insurers to pay for behavioral analysis as well as physical and occupational therapy. These services can cost tens of thousands of dollars a year, although many states put dollar limits on coverage.

Autism encompasses many disorders from mild to severe that can affect a child’s behavior and ability to communicate. Applied behavioral analysis (ABA)  typically involves one-on-one counseling to teach children how to behave or act in different situations. Although parents and many clinicians consider it the most effective therapy for children with autism, the results are mixed in peer-reviewed research.

Insurers typically oppose state benefit mandates, saying that they reduce their ability to control costs and that the cost of autism coverage gets passed on to all their customers through higher premiums. In addition, insurers argue that autism is a development disorder that is best addressed by the educational system, not the medical system.

Parents worry the essential-benefits provision could reopen the debate over covering treatment for autism and spark another showdown with insurers.

“Fear runs through my mind,” said Ann Rounseville of Newton, Mass., whose son Luke, 4, has been able to get speech, occupational and behavioral therapy because of the insurance benefit that started this year.

“Without this coverage, he would not be getting any of the extra therapy he needs,” said Rounseville, estimating the Massachusetts law has saved her family more than $10,000 since May.

Stuart Spielman, a lobbyist for Autism Speaks, the New York-based group that has led the push for coverage laws, said he is confident HHS will include autism because the federal law lists behavioral health treatment in its broad outline of what should be considered essential. The law also spells out the need for emergency services, hospitalization, maternity care, prescription drugs and prevention.

It’s unclear how HHS will decide what to deem an essential benefit. The agency could declare a broad list of categories of treatments and services essential and leave the specifics to the states.

At the state level, autism treatment advocates have argued that the problem is too big — and too expensive for families — not to be covered by insurers. They also say providing treatment to young children can save money in the long run by reducing the later need for institutionalized care.

The state mandate laws typically only affect about half of people with health coverage because they do not apply to self-insured employers, typically large companies.

According to the federal Centers for Disease Control and Prevention, one in 110 American children have been diagnosed with autism spectrum disorder, including one in 70 boys. A Harvard University study in 2006 found that, on average, the annual care for a person with autism runs about $29,000 for medical costs and $38,000 for non-medical costs, such as special education, camps and child care.

The mandates have been a way for states to be doing something on a major issue without money coming out of the state treasury,” said Jack Pitney, professor of American politics at Claremont McKenna College in California. “It’s a cost borne by insurance companies who are not an object of a great deal of public affection.”

 

WashingtonPost

 

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FACTBOX-U.S. health advocates seek deficit protections

With U.S. President Barack Obama poised to unveil his deficit reduction planMonday, healthcare consumer advocacy groups are calling for policy changes that
would extend Medicare to the middle-aged and lower prescriptiondrug costs.

Following are some of the deficit-cutting ideas that the groups would like to see Obama and the congressional ``super committee'' consider on behalf of Medicare and Medicaid beneficiaries, and others who rely on federal health carespending.
Medicare is the federal health insurance program for the elderly and disabled. Medicaid is the federal-state health insurance program for the poor.


MEDICARE

* Lower the eligibility age for Medicare to 55 so that
younger, healthier people who typically need less care and
fewer services can add revenue to the program through premiums
and other charges;

* Allow the U.S. health secretary to use Medicare's
negotiating power with pharmaceutical companies to lower the
cost of prescription drugs;

* Stop paying private insurers who run Medicare Advantage
plans on behalf of the government more money than the cost of
traditional Medicare;

* Include a drug benefit in traditional Medicare services
from hospitals, nursing homes and doctors to save money from
the program's lower administrative costs;

* Extend drug rebates from the Medicaid program for the
poor to people eligible for both Medicaid and Medicare;

* Fully fund the patient reform and healthcare
affordability measures contained in the Affordable Care Act
such as payment bundling and accountable care organizations;

* Avoid further cost-shifting to Medicare beneficiaries,
who already spend a substantial part of their income on health
expenses;

 

MEDICAID

* Endorse the Medicaid maintenance measure in the
Affordable Care Act, which requires states to ensure that the
program adequately serves low-income populations and sets the
stage for expanding Medicaid coverage to uninsured people with
relatively higher incomes in 2014.

* Avoid program cuts that would reduce funding for people
in nursing homes, eliminate access to healthcare for children
and limit options for people with disabilities;

* Reject proposals that shift costs to states and
beneficiaries, such as a reduction in federal matching funds;

* Reject proposals that could change Medicaid into a
federal block grant program, including cuts or caps on
spending;

* Seek to control Medicaid costs by endorsing sections in
the Affordable Care Act that help to extend healthcare coverage
to the uninsured through measures such as premium tax credits
for individuals and small businesses;

* Expand access to home and community-based services for
people in nursing homes;

* Avoid cuts to Medicaid programs that focus on prevention
and better quality of care, which could lead to complications
or reliance on emergency room visits, further boosting
healthcare costs;

 

PRESCRIPTION DRUGS

* Reduce the period of time that pharmaceutical companies
can maintain patents on brand name biologic drugs before
generic versions become available;

* Prohibit pay-for-delay agreements that allow brand name
patent holders to delay the arrival of generic alternatives in
the healthcare marketplace;

* Establish a framework for the safe, legal importation of
lower-priced prescription drugs from abroad;


GENERAL HEALTHCARE:

* Avoid funding cuts for the U.S. Centers for Disease
Control and Prevention; the Environmental Protection Agency and
the National Institutes of Health;

* Maintain funding for federal research and prevention
programs including chronic disease research and genomic
research of cancer cases;

* Fully fund the Prevention and Public Health Fund created
by the Affordable Care Act to promote better diet and exercise,
limit tobacco use and maintain early detection and treatment
services;

* Expand the National Breast and Cervical Cancer Early
Detection Program to cover all eligible women who need cancer
screening services including mammograms and Pap tests.

LA TIMES

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(Saving Medicaid) Vice President Biden announces over $2 billion in anti-waste measures

 

WASHINGTON –

At the White House today, Vice President Biden convened a cabinet meeting to discuss waste reduction at federal agencies as part of the administration’s Campaign to Cut Waste. The vice president announced a new initiative to fight waste in Medicaid that is estimated to save taxpayers over $2 billion, unveiled new efforts to track state progress in reducing improper unemployment insurance payments, and directed each Cabinet secretary to undertake a waste and efficiency review that will target unnecessary, wasteful, and inefficient federal spending.

“Today’s announcements on cutting waste in Medicare, Medicaid and Unemployment Insurance shows that we can make our government more efficient and responsible to the American people,” said Vice President Biden.  “If we’re going to spur jobs and economic growth and restore long-term fiscal solvency, we need to make sure hard-earned tax dollars don’t go to waste.”

Joined by Health and Human Services (HHS) Secretary Kathleen Sebelius, the vice president discussed a new initiative to fight waste and fraud in Medicaid that will save taxpayers an estimated $2.1 billion.  HHS today released its final rule for the Medicaid Recovery Audit Contractor Program, a waste-cutting program created by the Affordable Care Act. HHS projects the program will save $2.1 billion over the next five years, of which $900 million will be returned to states.  The new program is based on the successful Medicare Recovery Audit Contractor program, which the vice president announced has already recovered nearly $670 million to date in 2011 – increasing the taxpayer dollars recovered by nearly 800 percent compared to 2010.

“Today we are building on an already successful program that targets improper payments in our health care programs and recovers those dollars, making Medicare and Medicaid more reliable and responsible,” said HHS Secretary Kathleen Sebelius. “We simply can't afford to see even one penny of our health care dollars wasted and expanding this program will help us reach that goal."

The vice president also unveiled new Labor Department efforts to reduce improper Unemployment Insurance payments and hold states accountable for progress as part of the administration’s comprehensive efforts to crack down on waste, fraud and abuse. Department of Labor Secretary Hilda Solis joined the vice president to discuss the department’s next steps in combating these improper payments:

• A New Transparency Initiative to Make It Clear Where States Stand: The Department of Labor is launching a new effort to clearly show every state’s performance on improper payments.  The agency unveiled an online map that will show citizens their state’s payment errors, which types of problems are driving its error rate, and the steps it has taken to address its rate.
• Comprehensive Turnaround Plans for High Priority States: DOL has identified six high priority states -- Virginia, Indiana, Colorado, Washington, Louisiana, and Arizona -- based on their high rate of improper payments. DOL is working with these states to ensure they develop a comprehensive turnaround plan to reduce their improper payments. In addition, high-performing states will be paired with these states to offer guidance and aid as the plans are developed and implemented.  High priority states will be subject to additional monitoring and technical assistance until they achieve an improper payment rate under 10 percent and sustain that performance for at least six months.
• New Awards to States to Automate and Improve Unemployment Insurance Data Collection:  The Department of Labor today awarded nearly \ 92 million to 42 states to implement waste-cutting initiatives and improve the Unemployment Insurance program, including upgrading technology systems to more accurately collect data and process claims. 

These steps build on other efforts to address improper payments the administration launched earlier this year.

“The Unemployment Insurance system is a unique partnership between the federal government and the states. States bear the responsibility of operating an efficient and effective benefits program, but as partners the federal government must be able to hold them accountable for doing so,” said Secretary Solis. “These new measures, demonstrate our commitment to working closely with states to ensure the integrity of the system, turnaround underperforming programs and save taxpayer dollars.”

Finally, as part of efforts to cut waste and inefficient spending, the vice president asked the Cabinet to report back on wasteful and inefficient agency spending on travel, auto fleets, publications, and office equipment and supplies, from cell phones to software, or in any other areas identified by agencies. 

The vice president highlighted the Department of Homeland Security’s Efficiency Review as a model effort. Since 2009, the agency has identified more than $1 billion in cost avoidances and implemented 30 efficiency initiatives across the agency – from buying software licenses in bulk to using government offices for meetings instead of renting private space.  As a result of these savings and other ongoing efficiency initiatives, the agency’s 2012 budget request included more than $800 million in reductions.  As he did with the Recovery Act, the vice president called on secretaries to be personally involved in these reviews, and will hold cabinet members personally responsible for the performance and results of the process.

“Over the last two years, we have made an unprecedented commitment to efficiency in order to support frontline operations by building a culture of fiscal discipline and accountability throughout the department,” said Secretary Napolitano. “Through the Department of Homeland Security’s Efficiency Review, we’ve taken a hard look at how we do business, and identified ways to maximize the effectiveness and efficiency of limited taxpayer dollars we receive.”

As part of the launch of the Campaign to Cut Waste in June, the president asked the vice president to take on a new role holding the Cabinet accountable for cutting waste in their agencies – part of the administration’s ongoing effort to make government more efficient and responsive to the American people. The vice president will hold regular Cabinet waste cutting meetings and is working closely with Office of Management and Budget Director Jack Lew and the administration’s Chief Performance Officer Jeffrey Zients to root out waste across the agencies and make government work for America’s families.

“We have made great strides in the last two years – shrinking contract spending for the first time in 13 years, identifying $3 billion in cost reductions from information technology projects across government, and getting rid of property we no longer need,” said Lew. “Particularly now in these challenging fiscal times, it is critical that each and every member of the Cabinet take personal ownership of aggressively rooting out waste and being vigilant stewards of taxpayer dollars.”

 

HHS.GOV

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