Aaron E. Carroll's Blog, page 129

Don’t Assume That Private Insurance Is Better Than Medicaid

The following originally appeared on The Upshot (copyright 2017, The New York Times Company). It was coauthored by Aaron Carroll and Austin Frakt.

As we recently wrote, it’s better for patients to have Medicaid than to be uninsured, contrary to critics of the program. But is having Medicaid, as those critics also say, much worse than having private insurance?

This idea has become a talking point for conservatives who back big changes to Medicaid, as the Senate health bill proposes. The poor would benefit simply by being ushered off Medicaid and onto private insurance, they write.

But it’s far from proven that Medicaid is worse than private insurance. A lot depends on what kind of insurance is compared with Medicaid, and how they are compared.

Many studies that measure Medicaid against private insurance suffer from the same flaws that compare Medicaid with being uninsured. They’re terribly confounded, and can show only associations, not causation. People with private insurance are healthier and wealthier than those on Medicaid, and in ways not fully controlled for in statistical analyses. These factors almost certainly predispose someone on Medicaid to have worse outcomes than someone with private insurance.

Perhaps the most convincing way to compare Medicaid and private insurance would be with a randomized controlled trial that pits them head to head. No such trials exist. Recall that the Oregon Medicaid study randomly offered, via a lottery, the opportunity for low-income adults to enroll in Medicaid. It did not have another study arm that offered private insurance.

But we do have a decades-old trial that looked at varying levels of cost-sharing: the RAND Health Insurance Experiment. This is relevant because one substantial difference between Medicaid and most private coverage is the level of cost-sharing. Medicaid is nearly free. Most private coverage comes with deductibles and co-payments.

The RAND study randomly assigned 2,750 families to one of four health plans. One had no cost-sharing whatsoever — kind of like Medicaid. The other three had cost-sharing (money people had to pay out-of-pocket for care) at levels of 25, 50 or 95 percent — capped at $1,000 at the time, which is about an inflation-adjusted $6,000 today. This level of personal liability acts like a deductible, making the plan with a 95 percent level of cost-sharing comparable to a “Bronze” plan on the Affordable Care Act’s exchanges today.

The RAND study found that the more cost-sharing was imposed on people, the less health care they used — and therefore the less was spent on their care. The study also found that, over all, people’s health didn’t suffer from lower health care use and spending.

Lower spending and no decline in health — these are the results that everyone cites to justify increased cost-sharing, and to justify shifting people from Medicaid to private plans with high deductibles.

But the results of the RAND study, like so much in health care, are complicated. A deeper dive into the data shows that people decreased their consumption of necessary health care in equal measure to unnecessary health care. As a rule, people are terrible discriminators of what care is needed and what’s not. Since most people under the age of 65 are healthy, even in the RAND study, that doesn’t matter much.

But even if most people are healthy, some are not (and particularly those on Medicaid). In the RAND study, poorer and sicker people — exactly the kind more likely to be on Medicaid — were slightly more likely to die with cost-sharing.

Free care also resulted in improvements in vision and blood pressure for those with low income. As an influential 1983 New England Journal of Medicine paper put it: “Free care does make a difference.”

One limitation of the RAND study is its age. It took place between 1971 and 1982. There have been no studies of cost-sharing to rival it since. Still, the best recent evidence we have is that giving free care to poorer and sicker people improves health and saves lives. It is reasonable to conclude that switching them to a plan with high cost-sharing (even a private plan) would do the opposite.

Some of the more recent studies were nicely summarized in a paper by Katherine Swartz for the Robert Wood Johnson Foundation’s Synthesis project. She found that increased cost-sharing for low-income populations was associated with a shift toward more costly services, like increased emergency room visits because people skipped taking their drugs. She also found that increased cost-sharing affects poor people differently than everyone else, confirming RAND’s findings. A more recent study found that enrollment in plans with high deductibles led to reductions in necessary care, which would have consequences for the poor and sick.

Austin wrote previously herehow increased cost-sharing may lead people to take fewer drugs for their high cholesterol, hypertension and diabetes. In his first Upshot column, Aaron wrote that parents delay taking their children for asthma treatment when cost-sharing rises.

Even small premiums can lead to problems. A $10 increase in monthly Medicaid premiums was followed by a 6.7 percent reduction in Medicaid and coverage of CHIP (Children’s Health Insurance Program) for people just above the poverty line.

Unquestionably, private coverage can work very well for many people. Take us, for instance. The insurance that we each have from our employers is probably better for us than Medicaid would be. Though these plans come with cost-sharing, we have incomes that can handle it. Our plans cover things that Medicaid often does not, like dental checkups.

Our plans have great networks, and they reimburse well for the care we receive. Just like Medicaid enrollees, we also receive support from the federal government, which waives tax collections on dollars contributed to premiums. That tax break is higher than the cost of Medicaid in many cases.

We’re also relatively healthy and would probably be fine on any plan (unless and until our health deteriorates).

But because our plans require considerable cost-sharing, even Medicaid enrollees would struggle on them. More important, neither House nor Senate repeal and replace bills offer poor Medicaid enrollees plans as generous as ours.

The Senate’s health care plan, for example, would offer much less generous plans. A 64-year-old woman with an income of $11,400 would face a deductible of at least $6,000. For her, such a plan is not better than Medicaid; it is most likely much worse if she is also sick. Because of the deductible, the care she’d need would be financially out of reach.

A recent paper in Health Affairs documented that outcomes in Arkansas, which allowed poor people to buy private plans on the exchanges, were similar to those in Kentucky, which expanded access to poor people through Medicaid. But those private plans came with significant cost-sharing subsidies, which would be stripped away by the Senate’s bill. Even so, the evidence did not suggest that the private coverage of Arkansas was better than the public coverage of Kentucky.

There are certainly private plans for poor and sick Americans that are better than Medicaid. But plans with very high cost-sharing — which are the ones being offered in Congress as A.C.A. replacements — are not among them.

The most influential health care studies, according to Twitter

In an interview, a journalist asked me for the health care studies with greatest policy influence. I said the RAND Health Insurance Experiment and the Oregon Medicaid Study. I added there are certainly more worthy to be named, but this is not a thing my brain does so readily.

And so I put it to Twitter:

Please @ me the health care studies you think most influenced debate and/or policy. (Preferably a link but enough of cite to find OK too.)

— Austin Frakt (@afrakt) July 10, 2017

The replies overwhelmed me, so I asked if anyone would compile them for a post. Nisarg Patel, a DMD Candidate at Harvard University and delivery system innovation researcher at Boston Children’s Hospital, obliged. (He’s on Twitter @nxpatel).

Below is the list, in no particular order. Just so you can debate these and add more, comments open for one week. (I won’t be going back to Twitter to pull in more replies there, so if you want yours in the TIE record you’ll have to add them here.)

***

National Research Council. America’s uninsured crisis: consequences for health and health care. Washington, DC: The National Academic. 2009.

Baicker K, Staiger D. Fiscal shenanigans, targeted federal health care funds, and patient mortality. The quarterly journal of economics. 2005;120(1):345-86.

Kane TJ, Orzsag P, Gunter DL. State fiscal constraints and higher education spending: The role of Medicaid and the business cycle. 2003.

Blumberg LJ, Buettgens M, Holahan J, Garrett B, Wang R. State-by-State Coverage and Government Spending Implications of the Better Care Reconciliation Act. 2017.

McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristofaro A, Kerr EA. The quality of health care delivered to adults in the United States. New England journal of medicine. 2003;348(26):2635-45.

Baicker K, Taubman SL, Allen HL, Bernstein M, Gruber JH, Newhouse JP, Schneider EC, Wright BJ, Zaslavsky AM, Finkelstein AN. The Oregon experiment—effects of Medicaid on clinical outcomes. New England Journal of Medicine. 2013;368(18):1713-22.

Wagnerman K, Alker J, Hoadley J, Holmes M. Medicaid in Small Towns and Rural America: A Lifeline for Children, Families, and Communities. 2017.

Arrow KJ. Uncertainty and the Welfare Economics of Medical Care. The American Economic Review. 1963;53(5): 941-973

Summers LH. Some simple economics of mandated benefits. The American Economic Review. 1989;79(2):177-83.

Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health affairs. 2008;27(3):759-69.

Barnett ML, Sommers BD. A National Survey of Medicaid Beneficiaries’ Expenses and Satisfaction With Health Care. JAMA Intern Med. Published online July 10, 2017. doi:10.1001/jamainternmed.2017.3174

Sommers BD, Gawande AA, Baicker K. Health Insurance Coverage and Health—What the Recent Evidence Tells Us. New England Journal of Medicine (2017).

Frean M, Gruber J, Sommers BD. Disentangling the ACA’s coverage effects—lessons for policymakers. New England Journal of Medicine. 2016;375(17):1605-8.

Luntz F. The Language of Healthcare 2009. Politico.

Wasserman J, Manning WG, Newhouse JP, Winkler JD. The effects of excise taxes and regulations on cigarette smoking. Journal of health economics. 1991;10(1):43-64.

Ridley DB, Grabowski HG, Moe JL. Developing drugs for developing countries. Health Affairs. 2006;25(2):313-24.

Marmot M. Social determinants of health inequalities. The Lancet. 2005;365(9464):1099-104.

Nelson A. Unequal treatment: confronting racial and ethnic disparities in health care. Journal of the National Medical Association. 2002;94(8):666.

@afrakt

Private insurance isn’t always better than Medicaid

Austin and I have a new column up on The Upshot today. We’ll post it here in its entirety on Friday, per our routine, but it’s important for you to go read it today before the new Senate bill is likely released tomorrow. A new talking point is that while Medicaid may be better than being uninsured (what people used to say), it’s certainly far, far worse than private insurance.

We take that apart over at the NYT. Go read it.

@aaronecarroll

I’ll have that maternity leave that she’s having

David Brooks has a theory about the cause of rising American social inequality. Well-off parents invest more money and time in their children.

Over the past generation, members of the college-educated class have become amazingly good at making sure their children retain their privileged status. They have also become devastatingly good at making sure the children of other classes have limited chances to join their ranks.

How they’ve managed to do the first task — giving their own children a leg up — is pretty obvious… Over the past few decades, upper-middle-class Americans have embraced behavior codes that put cultivating successful children at the center of life. As soon as they get money, they turn it into investments in their kids.

Upper-middle-class moms have the means and the maternity leaves to breast-feed their babies at much higher rates than high school-educated moms, and for much longer periods… [and] to spend two to three times more time with their preschool children than less affluent parents.

Brooks then makes some remarks about informational barriers between social classes. He somehow misses that there is a simple policy that would help reduce the class difference in the time that American parents invest in their children. We could give every family, not just those with means, a paid leave when they have a newborn child.

It’s a straightforward way to invest in children and nearly every developed country other than the US does it. In Canada, families get 55% of a parent’s income for a year, up to a maximum, when you have a newborn (it’s not a ‘maternity’ leave, because the father can take it, or you can split it between spouses).

Giving everyone a year with their infant won’t make all children equal. However, there is considerable evidence that early childhood is of great importance for children’s health and development and that paid maternity leave contributes to better child health.

We may not know how to tear down psychological barriers between social classes. However, we know how to give parents more time to raise young children.

@Bill_Gardner

Health Plans That Nudge Patients to Do the Right Thing

The following originally appeared on The Upshot (copyright 2017, The New York Times Company).

As health care costs rise, Americans are increasingly on the hook to pay more for their care. This trend is more than just annoying — asking consumers to pay more for everything deters many from getting the care they need. What would happen if, instead, health plans offered more generous coverage of high-value care, but less generous coverage of those services that provide little or no health benefit?

This idea is known as value-based insurance design. Though not widespread, V-BID is not new. It was pioneered nearly 20 years ago by Dr. Mark Fendrick, a physician and professor at the University of Michigan, and Michael Chernew, a Harvard economist. (“Value” in V-BID plans is usually set according to longstanding measurements of quality established by decades of study of medical records.)

In his own practice, Dr. Fendrick feels as if standard insurance is working against him and his patients. “They are deeply concerned about the amount they have to pay out of their own pockets for the things I beg them to do,” he said. “It makes no sense that they pay the same co-payment for a lifesaving drug to treat diabetes or cancer, as for a drug that makes toenail fungus go away.”

This may be changing. The Affordable Care Act includes a V-BID provision, eliminating cost-sharing for more than 100 preventive services, such as vaccinations and cancer screenings. It’s endorsed by four committees of medical experts.

Many large employers and state governments are going further, reducing cost-sharing for high-value care and medications to treat chronic illnesses, like depression and heart disease. This year, the Centers for Medicare and Medicaid Services began a five-year test of value-based design that permits Medicare Advantage plans in seven states to reduce cost-sharing and enhance benefits for enrollees with designated chronic conditions. Bipartisan legislation has been introduced in the House and Senate to expand the program nationwide.

In 2018, the Department of Defense will pilot a V-BID program that reduces cost-sharing for high-value medications and services, trying to improve the care and outcomes for American military personnel.

Does value-based insurance work? The Medicare Advantage and Department of Defense programs will tell us more, but experience with commercial V-BID programs suggests it’s a promising approach.

Several studies show that value-based “carrot” programs — those that help patients with chronic illnesses stay out of the hospital by reducing cost-sharing for high-value medications — increases medication use, at least modestly. Of course, if patients are paying less for medications, someone else — employers and health plans — pick up that part of the tab.

But making high-value drugs less expensive can offset other health care spending. One study of 6,000 heart attack patients compared one group that received their drugs free with those whose regular insurance had co-payments of $10 to $25. Patients receiving free drugs increased their use of them — and the additional insurer drug costs were offset by a decrease in hospital procedures.

Another study, of reduced cost-sharing for diabetic medications, showed that patients took their medication more regularly and used other, costly services less. Emergency department visits dropped 36 percent, and hospitalizations fell 13 percent.

Value-based programs need not focus exclusively on drugs. In 2010, I.B.M. encouraged greater use of primary care by eliminating cost-sharing for primary care visits. A study of the effect on children found increases in primary care visits and vaccinations, and decreases in expensive emergency department and specialist visits.

In 2011, Connecticut started the Health Enhancement Program for state employees, which required participants to obtain high-value primary and chronic disease preventive services — like screenings, physical examinations and other guideline-based services — and lowered cost-sharing for them. The use of those services and medications for chronic conditions increased, while emergency department use decreased during the program’s first two years.

Though programs like these improve patients’ health and quality of life, they don’t necessarily save money. That’s the finding of a large programby Blue Cross Blue Shield of North Carolina. In 2008, the insurer reduced cost-sharing for hypertension, hyperlipidemia, diabetes and congestive heart failure medications for more than 700,000 policy holders. Their overall health care spending remained comparable to that of similar patients insured by other plans that did not use a value-based design.

“For the most part, V-BID isn’t a way to save money,” Mr. Chernew said. “What it can do is shift health care use from lower- to higher-value care.” In doing so, it can also provide more financial protection for people who have regular need for maintenance medications and care.

If reducing cost-sharing for high-value care is the “carrot” approach, increasing it for low-value care is the “stick.” Though less common, stick approaches have been tested, too. A program by a large public employer in Oregon raised cost-sharing for sleep studies, upper gastrointestinal endoscopies, advanced imaging services and certain types of overused procedures, like surgery for back pain. Although clinically appropriate circumstances exist for each service, copayments were raised $100 to $500 only for those specific situations where their use was deemed not medically necessary.

An evaluation demonstrated that consumers responded to these higher out-of-pocket costs. Targeted services fell by about 12 percent over all, though some fell more than others. For example, sleep studies and low-value surgery use fell by about 20 percent. But advanced imaging use fell by only 7.7 percent.

It may be inevitable that health insurance comes with cost-sharing. But there’s no reason it can’t be applied in ways that also help patients do the right thing, nudging them toward high-value care and decreasing incentives to pursue low-value care.

@afrakt

Preventing hospitalizations from nursing homes is harder than it looks

I applaud the publication of negative studies. From JAMA Internal Medicine, “Effects of an Intervention to Reduce Hospitalizations From Nursing Homes: A Randomized Implementation Trial of the INTERACT Program“:

Importance: Medicare payment initiatives are spurring efforts to reduce potentially avoidable hospitalizations.

Objective: To determine whether training and support for implementation of a nursing home (NH) quality improvement program (Interventions to Reduce Acute Care Transfers [INTERACT]) reduced hospital admissions and emergency department (ED) visits.

Design, Setting, and Participants: This analysis compared changes in hospitalization and ED visit rates between the preintervention and postintervention periods for NHs randomly assigned to receive training and implementation support on INTERACT to changes in control NHs. The analysis focused on 85 NHs (36 717 NH residents) that reported no use of INTERACT during the preintervention period.

Interventions: The study team provided training and support for implementing INTERACT, which included tools that help NH staff identify and evaluate acute changes in NH resident condition and document communication between physicians; care paths to avoid hospitalization when safe and feasible; and advance care planning and quality improvement tools.

Main Outcomes and Measures: All-cause hospitalizations, hospitalizations considered potentially avoidable, 30-day hospital readmissions, and ED visits without admission. All-cause hospitalization rates were calculated for all resident-days, high-risk days (0-30 days after NH admission), and lower-risk days (≥31 days after NH admission).

We’d like to reduce hospitalizations from people who live in nursing homes, by keeping them from getting sick or hurt. The INTERACT program was designed to do just that. It supported and trained nursing home workers in identifying and evaluating issues in residents in nursing homes, communicating with doctors, and implementing quality improvement. Nursing homes were randomized to this or usual care. The main outcome of interest was hospitalizations, avoidable hospitalizations, readmissions, and ED visits.

Eighty-five nursing homes with 281 752 person-months were included in the analysis. There was no significant change in the number of hospitalizations in the intervention group versus the control group. There was no significant change in readmissions, ED visits, or any of the sub-analyses of hospitalizations. There was a small, but statistically significant reduction in avoidable hospitalizations, but once they applied a Bonferroni correction, it was no longer significant.

Let’s talk about that for a second. When you do a lot of statistical tests on a lot of potential outcomes, you increase the chance that something will be “significant” by chance alone. When that’s the case it’s good practice to apply a correction to account for that. Since they had six outcomes, the Bonferroni correction reduced the p-value threshold from 0.05 to 0.008. The result (as p=0.01) was no longer significant. Good for them. For more information on significance and p-values, I encourage you to watch our Healthcare Triage episodes on the subject here and here.

We all want to improve the care in nursing homes and prevent hospitalizations and ED visits, if possible. This trial showed a pretty big intervention didn’t work. Let’s acknowledge that and try to do better, instead of doing the same things over and over again. It may take more investment. Sometimes good things cost money.

@aaronecarroll

Needed: Core Quality and Outcome Measures for Pediatric Health

Checklists and other quality measures are critical in protecting patients and improving the quality of health care. Unfortunately, many physicians and other clinicians find the burden of documentation overwhelming.

David Blumenthal and J. Michael McGinnis argue that part of the problem is that we have too many measures.

Not only are many measures imperfect, but they are proliferating at an astonishing rate, increasing the burden and blurring the ability to focus on issues most important to better health and health care. Measures of the same phenomenon also vary in specification and application, leading to confusion and inefficiency that make health care more expensive and undermine the very purpose of measurement, namely, to facilitate improvement. Not uncommonly, a health care organization delivering primary care to a typical population is asked to report and collect hundreds of measures aimed at dozens of conditions.

With Kelly Kelleher, a pediatrician at Nationwide Children’s Hospital, I have been working with a group of child health experts to develop a parsimonious set of core quality and outcome measures for children’s health care. We describe this effort in JAMA Pediatrics. We’re part of a larger National Academy of Medicine effort. They have proposed a core measure set for adults. We argue, however, that because children are different, we need a distinctively pediatric set of quality and outcome measures.

We need a measure set for children because the goals of children’s health care are different from that of adults, children face different health risks, and the context of children’s health care is different.

The goal of health care—well-being—has a different meaning across the life span. For children, it is building the physical, cognitive, and social foundations for adult capabilities in addition to enhancing their current state. The specific health needs of children can change rapidly as they pass through developmental stages. Thus, a pediatric measure set must find a careful compromise that is sensitive to development without excessively expanding the number of measures.

Similarly, children face different health risks. Because children are mostly healthy, subclinical precursor states of adult health problems get insufficient attention. Preventive care is therefore underemphasized, leading to health problems in adulthood. For example, adolescents being overweight and obese is strongly associated with adult cardiovascular mortality.

Finally, children’s risks are different because many of the diseases and risks for children are environmental or neighborhood-influenced. Children are more sensitive to socioenvironmental factors and depend more on support for their health and care than adults. Thus, detailed measures that capture the socioenvironmental circumstances in the community are essential.

There’s lots to do and we’re looking for your good ideas.

@Bill_Gardner

The research on malpractice and nursing homes

This is the second post in a series on a proposed CMS rule that would eliminate an Obama-era ban on pre-dispute arbitration for nursing home residents. For the intro, see here.

By penalizing injury-causing negligence, tort law is supposed to deter negligent conduct. That’s one of the reasons (but not the only one) that CMS originally moved to ban nursing homes from insisting on pre-dispute arbitration: by reducing the threat of malpractice, arbitration clauses could compromise patient safety.

Now, mandatory arbitration doesn’t eliminate the malpractice threat. Arbitration is an alternative forum for resolving claims, albeit one that stacks the deck in nursing homes’ favor. Plus, not all arbitration agreements will stand up in court. Sometimes, a judge will find that the resident wasn’t competent to waive her rights to sue.

Without a doubt, however, arbitration clauses reduce nursing homes’ financial exposure and thus any deterrent effect associated with potential litigation. But how big is that reduction? Is it big enough to matter?

To answer that question, we’d ideally look at studies that examine whether a shift to mandatory, pre-dispute arbitration caused a dip in nursing home quality. But no one’s done that research, at least to my knowledge, perhaps because it’s tough to get a handle on how frequently nursing homes insist on arbitration clauses.

That doesn’t mean we’re out of luck, though. There’s a bunch of research on whether malpractice risk is associated with nursing home quality. If that research suggests that the deterrent effect is big, more arbitration might well be bad for patient safety. If the deterrent effect is small, it might not make of a difference.

So what does the research tell us? In 2011, an important study in the New England Journal of Medicine concluded that nursing homes with more quality deficiencies, and more serious deficiencies, were more likely to be sued for negligence. But the difference was small: “Nursing homes with the best deficiency records faced about a 40% annual risk of one or more claims, as compared with 47% among homes with the worst deficiency records.”

From this, it looks like there’s only so much a nursing home can do to mitigate its liability risk. Even it improves, it’ll get sued about as often as it used to. “Such weak discrimination,” the researchers wrote, “may subvert the capacity of litigation to provide incentives to deliver safer care.”

Another 2011 study, this one in the Journal of Health Care Finance, reached a similar conclusion. It found that nursing homes in Florida with more registered nurses per resident paid less in response to malpractice claims, which jibed with earlier studies. But the study still couldn’t pick up a statistically significant connection between deficiencies and malpractice payments. Nor could this study from 2004.

All of these studies, moreover, suffer from a common problem. They tell us which nursing homes are more or less likely to be sued, but they can’t tell us directly whether malpractice risk actually influences a nursing home’s choices about staffing levels and quality. A 2013 study in Health Services Research tried to avoid the problem by exploiting variations in the background rate of malpractice in different geographic areas. In line with earlier research, the study found that “while a deterrence effect exists, it is small, concentrated among a subset of nursing homes, and unlikely to lead to widespread improvements in quality.”

In short, the research suggests that tort law matters, but only on the margins. If that’s right, then mandatory arbitration may not raise substantial safety concerns.

Now, these studies aren’t the final word. Reported deficiencies are only proxies for overall quality; it’s possible that the malpractice threat makes nursing homes attentive to unmeasured but important aspects of quality. Plus, the research pretty consistently shows that having more registered nurses (but not nursing aides) reduces malpractice risk. In the absence of litigation exposure, nursing homes might well hire fewer registered nurses, with unfortunate consequences for quality.

Most importantly, the studies can’t and don’t address the systemic, long-term risks of an industry-wide practice of substituting mandatory arbitration for civil litigation. In particular, the research doesn’t capture whether the secrecy of arbitration may make it easier to sweep the endemic quality problems in the nursing home industry under the rug. I’ll turn to that question in my next post.

@nicholas_bagley

Healthcare Triage: Reduce Crime AND Save Money – Treat Addicts Instead of Punishing Them

Substance abuse and addiction are terrible for addicts health, and they’re really tough on family and friends. Addiction also drives up the violent crime rate, and the rate of property crime. This week on Healthcare Triage, we look at research on how diverting addicts to treatment programs has a positive effect on crime rates.

Special thanks to Austin, from whose Upshot column this episode was adapted.

@aaronecarroll

What should we do about children’s health coverage?

Back in May, I was on a panel at the Pediatric Academic Societies to discuss health care reform, kids, and the future. After that panel, David Rubin wrote a post over at the Health Affairs blog summarizing his thoughts on what needed to be done.

Most of the people there were either pediatricians, or pediatric-focused, and, of course, we were all pulling our hair out at how little of the conversation nationally focuses on kids or families. So much of our discussion focuses on adults, and then when they’re done talking about them, they turn to the elderly. Medicaid and CHIP cover something like two in five children and Medicaid, even before the expansion, covered one-third of births, and those births produce kids. I’ve written before about how employer-sponsored coverage for kids has been eroding. I shouldn’t need to remind any readers of this blog that proposals for Medicaid in Republican bills come with severely decreased funding in the future.

David has some suggestions for focus:

CHIP reauthorization: While the AHCA works its way through Congress, some may not have noticed that CHIP funding expires this fall. Without re-appropriation, more than 8 million children may lose coverage immediately. States are already sounding alarms; they have been unable to project their CHIP budgets for next year. The immediacy of the CHIP re-appropriation debate in Congress offers a “NOW” opportunity to stake a new way forward and present pragmatic solutions to strengthen children’s insurance, embracing the realities that have reshaped the family insurance market.

Guarantee of essential health benefits: The most critical issue arising from any children’s insurance plan today, whether in the employer-sponsored or public insurance market, is the promise of a set of health standards to all children regardless of their insurance. The House-passed AHCA proposes removing the requirement of federally guaranteed essential health benefits from all plans. Should this become law, states will have the choice of whether or not to provide these benefits. So, one solution for protecting children is to require these states to provide families access to a CHIP plan that meets a comprehensive and standard set of federally legislated and guaranteed essential benefits, such as vision, developmental, and behavioral health screenings.

Private market reforms: Beyond essential benefits, it may be time to address the affordability and quality of dependent coverage on the employer-sponsored and exchange markets. We may need stronger caps on deductibles as a proportion of income, and limits to exorbitant cost-sharing for child dependents. Furthermore, prohibitions of narrow networks—or the increase of cost-sharing for enrollees who seek out-of-network services—in the pediatric market would go a long way to ensuring that families have critical access to pediatric subspecialty care should their children develop cancer, diabetes, or other debilitating illnesses. While narrow networks may work in the adult health care arena, they are not nimble for families whose children have special health care needs and require specialists based solely in children’s hospital networks that may be tiered out in such plans. All told, the private market is not working for families, and if Congress wishes to halt the migration of families onto public insurance, they may need to hold employers and commercial insurers responsible for their own contributions to crowding families out of that market.

Go read the whole thing. And remember it when people say that no one has any plans.

@aaronecarroll