The Healthcare Policy Podcast ® Produced by David Introcaso

Listen NowConsidering the debate over the past five months about repealing the ACA (and more generally reforming the Medicare program via premium support),  it is worth remembering that approximately 55% of non-elderly Americans, or 155 million, still receive their health care coverage via their employer.   In addition, as of 2016 the ACA requires employers with over 50 employees to either offer health benefits or face a financial penalty.   The question remains what is the future of employer based insurance coverage, both for employees and retirees) if, for example, the ACA's "employer shared responsibility" provision and/or the employer tax exclusion (addressed in the ACA by the so called "cadillac tax") is repealed. During this 25 minute discussion Mr. Gelband briefly describes ERIC's mission/work, identifies what methods large employers are using to continue to offer employee coverage, how retiree coverage is being addressed, how employers are incenting providers to deliver quality care, ERIC's view of much debated HRAs (Health Risk Assessments) and wellness programs and his organization's position on the employer tax exclusion.  (Listeners may recall I interviewed Dr. Joe Antos last August 5th on the tax exclusion.)Mr. James Gelfand is Senior Vice President of Health Policy at ERIC where he works to develop and advance public policies to support the ability of employers to design and administer health plans.   Previously, Mr. Gelfand was the Director of Federal Affairs at the March of Dimes Foundation.   Prior to, he served as Associate Director for Luntz Global Partners.  He served on Capital Hill as Counsel to Senator Olympia Snowe, on the Senate Small Business Committee and to Senator Tom Coburn.   Mr. Gelfland also was for four years a lobbyist for the US Chamber of Commerce.   Mr. Gelfand received his JD from the George Washington University Law School and his undergraduate degree from Northwestern. For more information on ERIC go to: http://www.eric.org/. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit www.thehealthcarepolicypodcast.com

Listen Now As former DHHS Secretary Louis Sullivan wrote in support of this work, "Mary Otto brings history, policy and painful personal realities together in this compelling and engaging book about our nation's highly preventable epidemic of oral disease.  Teeth should be read by every policy maker and health professional who believes we can and must ace to reduce the current barriers to dental care."  (Listeners of this podcast may be also interested in related interviews with Burton Edelstein, DDS, from April 2013 and my interview with the American Dental Association's Dr. Marko Jujicic from January 2016.) During this 22 minute conversation, Ms. Otto discusses the impetus for her work, i.e., the 2007 death of a 12-year old Maryland resident, Deamonte Driver, from an abscessed tooth, she discusses efforts to integrate oral health with overall physicial health, the problems of substantial racial/ethnic disparities in oral health in light of the industry's increasing financial interests in provided cosmetic dentistry, the battle between dentists and mid-level providers, e.g., dental hygienists, over the latter's efforts to improve oral health primary and secondary prevention and the possibilities for improved oral health coverage moreover for adults under both Medicare and Medicaid.   Ms. Mary Otto is the oral health topic leader for the Association of Health Care Journalists.  She began writing about oral health at The Washington Post, where she worked for eight years covering social issues, including health care and poverty.  Ms. Otto is a resident of Washington, DC.  Ms. Otto's volume is available via Amazon at: https://www.amazon.com/Teeth-Beauty-Inequality-Struggle-America/dp/1620971445.   A review of her work appeared in the March 23rd issue of The New York Times, at: https://www.nytimes.com/2017/03/23/books/review/teeth-oral-health-mary-otto.html?_r=0.   An executive summary of Surgeon General David Satcher's 2000 report, "Oral Health In America," noted during this conversation, is at: https://www.nidcr.nih.gov/datastatistics/surgeongeneral/report/executivesummary.htm.  This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit www.thehealthcarepolicypodcast.com

Listen NowIn mid-January the CDC abruptly canceled a three-day "Climate and Health Summit" the Center had been planning for months.  The meeting was intended to discuss public health risks caused by the climate crisis and steps being taken to reduce the emissions of carbon dioxide and other greenhouse gases or its adverse consequences on human health.   (It was speculated the meeting was canceled because the CDC did not want to run afoul of the incoming president who has repeatedly called climate change a “hoax” perpetrated by the Chinese.)   The American Public Health Association (APHA) and others however went ahead and held a one-day meeting on February 16 titled,"Climate and Health" at the Carter Center in Atlanta.  The meeting was keynoted by former Vice President Al Gore.   Dr. Jonathan Patz, the Director of the Global Health Institute at the University of Wisconsin-Madison, was one of the meeting's organizers and participants.    During this 24 minute conversation Dr. Patz discusses how the meeting came about and what was accomplished, e.g., he summarizes the afternoon's panels that discussed what's being done to reduce green house gas emissions.  He also discussed how to better involve the professional medical community  and how to effectively communicate the reality of the climate crisis. Dr. Jonathan Patz is the Director of the Global Health Institute at the University of Wisconsin-Madison.  He is a professor and the John P. Holton Chair in Health and the Environment with appointments in the Nelson Institute for Environmental Studies and the Department of Population Health Sciences.  For 15 years, Dr. Patz served as a lead author for the United Nations Intergovernmental Panel on Climate Change (or IPCC)—the organization that shared the 2007 Nobel Peace Prize with Al Gore.  He also co-­chaired the health expert panel of the U.S. National Assessment on Climate Change, a report mandated by the Congress.  Dr. Patz has written over 90 peer-reviewed articles, a textbook addressing the health  the health effects of global environmental change and co-edited the five volume Encyclopedia of Environmental Health (2011).  He has been invited to brief both houses of Congress and has served on several scientific committees of the National Academy of Sciences.  Dr. Patz served as Founding President of the International Association for Ecology and Health.  He is double board-­certified, earning medical boards in both Occupational/Environmental Medicine and Family Medicine.  He received his medical degree from Case Western Reserve University (1987) and his Master of Public Health degree (1992) from Johns Hopkins University.A webcast of the February 16 meeting is at: https://www.climaterealityproject.org/health.  Listeners are particularly encouraged to listen to Vice President Gore's 30 minute keynote address.  For more information concerning the Medical Society Consortium on Climate and Health go to: https://medsocietiesforclimatehealth.org/.Since I mention during the discussion the Obama administration's 2016 "The Impacts of Climate Change on Human Health in the US: A Scientific Assessment," a review of the paper is, again, at: http://altarum.org/health-policy-blog/nature-bats-last-a-warming-earth-will-exact-adverse-health-effects-but-our-responsibilities-are.    This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit www.thehealthcarepolicypodcast.com

Listen NowOver approximately the past decade the health care industry has become increasingly committed to financially incenting physicians and other clinicians, or tying performance to reimbursement.  Commonly termed "pay for performance"(P4P), these arrangements are increasingly employed in the Medicare (i.e., under the Medicare Access and CHIP Reauthorization Act, or MACRA) and Medicaid programs and by commercial insurers, most notable accountable care models and bundled payment arrangements.   One might assume because P4P models are now common there is research evidence that demonstrates they are effective in, again, improving care quality, patient outcomes and lowering spending growth.  That is not the case.  For example, a systematic review published by Cochrane in 2011 found "there is insufficient evidence to support or not support the use of financial incentives to improve the quality of primary health care."  Among other examples, for all the attention the Massachusetts' Alternative Quality Contracts (AQCs) have received since they were launched in 2009, it remains unclear if they have reduced spending or spending growth.   Because P4P models have not proved out, payers and providers, for example, England's National Health Service and in the US the integrated, 12 hospital system, Geisinger Health, have substantially reduced incentive payments or are returning to paying providers straight salaries.            During this 27 minute conversation, Professor Soumerai discusses his interest in the P4P topic, describes P4p arrangements, summarizes his and others' review of the research evidence relative to the effectiveness of P4P arrangements and suggests model designs that may be more effective.  Stephen B. Soumerai is Professor of Population Medicine at Harvard Medical School and Harvard Pilgrim Health Care Institute.  He also co-chairs the Statistics and Evaluative Sciences concentration within Harvard University’s health policy Ph.D. program.  Dr. Soumerai recently served as International Trustee for the Canadian Health Services Research Foundation.  Dr. Soumerai has published more than 250 original scientific articles in leading scientific journal, such as the New England Journal of Medicine and the Journal of the American Medical Association.  He is well known nationally and internationally for his work on the impacts of health policies and methods to improve the quality of medical practice.  He frequently advises Congress, state legislatures and federal and international agencies on the design of drug cost containment, coverage and quality-of-care policies, evidence-based health policy and his research has been used extensively to support expanded economic access to medications in Medicaid and Medicare. He is the recipient of numerous honors including numerous article of the year awards from national and international scientific societies, named lectureships, and is the recipient of the Everett Mendelsohn Excellence in Mentoring Award from the Harvard University Graduate School of Arts and Sciences.Professor Soumerai's 2015 and 2016 CDC articles noting in this discussion are at: https://www.cdc.gov/pcd/issues/2015/15_0187.htm and https://www.cdc.gov/pcd/issues/2016/16_0133.htmA summary of these works can be found at: http://www.vox.com/the-big-idea/2017/1/25/14375776/pay-for-performance-doctors-bonuses This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit www.thehealthcarepolicypodcast.com

Listen NowLate today, or within a few hours after this interview was completed, the House Republicans proposed ACA repeal or reconciliation legislation.  The legislation includes repealing Medicaid expansion under the Affordable Care Act (ACA).  More specifically, House Republicans propose repealing the  federal enhanced match rate for eligible beneficiaries on December 31, 2019 though states can keep the enhanced match rate for those Medicaid eligible before January 1, 2020 but only for those that do not have a break in Medicaid eligibility for more than one month after that January 1, 2020..  Moreover, the proposed legislation would reform federal Medicaid funding by creating a per capita cap model starting in 2020.  This means federal funding would be benchmarked to 2016 for the five Medicaid enrollee categories: the elderly; blind and disabled; children; non-expansion adults; and, expansion adults.  Year- over-year federal spending increases would be pegged to the medical care component of the Consumer Price Index (CPI).   While there is not yet a Congressional Budget Office (CBO) score for the proposed legislation, that's schedule for mark up on Wednesday, estimates by the Center for Budget and Policy Priorities (CBPP) project that if the 32 states that expanded Medicaid coverage under the ACA wanted to keep it, the cost to these states would be approximately $280 billion over the next decade.  CBPP also estimates that per capita caps will  increase the state's share of Medicaid costs, excluding expanded coverage, by another $280 billion also over 10 year budget window.   During this 25-minute interview, Executive Director of the National Association of Medicaid Directors (NAMD), Matt Salo, discusses the mission of NAMD, his understanding of House Republican legislation to fundamentally reform the Medicaid program, the challenges with either Medicaid block grants or per capita caps, and other related policy issues the NAMD is working to resolve.  Mr. Matt Salo has served as Executive Director of NAMD since 2011.  NAMD is a non-partisan association representing all 56 of the nation's state and territorial Medicaid Directors.    Prior to NAMD, Mr. Salo spend 12 years at the National Governors Association where he  worked to forward the Association's health and human services policy agenda.   Prior still Mr. Salo worked for five years as a health policy analyst at the American Public Human Services Association.   Mr. Salo also spent two years as a substitute teacher in the Alexandria, VA public school system. Mr. Salo holds a BA in Eastern Religious Studies from the University of Virginia.For more on the NAMD go to: http://medicaiddirectors.org/For more on House ACA repeal or reconciliation legislation go to: https://energycommerce.house.gov/hearings-and-votes/markups/markup-committee-print-and-h-res-154https://waysandmeans.house.gov/event/markup-budget-reconciliation-recommendations-repeal-replace-obamacare/ This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit www.thehealthcarepolicypodcast.com

Listen NowIn his recent work, The Case Against Sugar, Gary Taubes argues not all calories are alike.  Sugar, or the consumption of sugar, causes elevated levels of insulin, or hyperinsulenema, and high levels of insulin drives fat accumulation.  Rather than obesity causing diabetes, Taubes argues, hyperinsulinemia causes both.   That there's been an 800% increase since 1960 in the consumption of sugar and approximate doubling of diagnosed cases of diabetes since 1990 cannot be a coincidence.  (Per the CDC, over the past 25 years the age-adjusted prevalence of diabetes increased by ≥50% in 42 states and by ≥100% in 18 states.)   Not only does sugar consumption drive the diabetes epidemic, Taubes argues it can also be correlated to hypertension, cancer, stroke and dementia.        During this 35 minute conversation Mr. Taubes discusses the impetus for the book, sugar's relationship to elevated insulin levels and obesity and diabetes, the problem/s with the accepted belief that a "calorie is a calorie," the FDA's determination that sugar is GRAS (Generally Accepted as Safe), the role the Sugar Association has played in encouraging and defending sugar's consumption, the difficulty in scientifically proving sugar consumption is correlated to diabetes, hypertension and cancer among other prevalent serious and fatal illnesses, how much sugar do we consume and how much is too much, or how much sugar can we tolerate safely.    Mr. Gary Taubes is the co-Founder of the Nutrition Science Initiative, and a science and health journalist. He is the author of Why We Get Fat and Good Calories, Bad Calories. Gary has been a contributing correspondent for the journal Science since 1993, and has contributed articles as a freelancer to The Atlantic Monthly, The New York Times Magazine, Esquire, Slate, and numerous other publications.  His 1997 book, Bad Science was a New York Times Notable Book and a finalist for the Los Angeles Times Book Awards.  He is the only print journalist to be a three-time winner of the National Association of Science Writers Science-in-Society Journalism Award.  He is the recipient of a Robert Wood Johnson Foundation Independent Investigator Award in Health Policy Research.  Gary received his B.S. in physics from Harvard University, his M.S. in engineering from Stanford University, and his M.S. in journalism from Columbia University.For more information on The Case Against Sugar go to: http://www.penguinrandomhouse.com/books/213737/the-case-against-sugar-by-gary-taubes/9780307701640/.To learn more about the Nutrition Science Initiative go to: http://nusi.org/.  This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit www.thehealthcarepolicypodcast.com

Listen NowThis past November, voters in seven states legalized marijuana either for medical or for recreational use.  Twenty-nine states have now legalized cannabis for medicinal use (and of these eight, along with the District of Columbia, for recreational use).   Despite growing state legalization, the debate concerning marijuana's health effects continues.  Recently, the National Academy of Sciences (NAS) published an extensive scientific review of research literature published since 1999 to reach nearly 100 conclusions about its therapeutic benefits including in the treatment for chronic pain in adults, chemotherapy-related nausea and vomiting and Multiple Sclerosis-related spasticity.  Despite state approval and demonstrated health benefits, at the federal level, marijuana is still classified as a Schedule I controlled substance (along with, e.g., heroin), and its use illegal.  Mr. Paul Armentano is the Deputy Director of NORML, the National Organization for the Reform of Marijuana Laws.  He is also a faculty member at Oaksterdam University in Oakland, California.  His is the author of over 200 publications including more than a dozen contributions to textbooks and anthologies.  His most recent book-length work is, The Citizen's Guide to State-by-State Marijuana Laws (2015) and he is co-author of the 2013 volume, Marijuana is Safer: Why Are We Driving People to Drink?  Mr. Armentano was the principle investigator for the defense counsel in US v Schweder, the first federal evidentiary hearing since 1973 to challenge the constitutionality of cannabis as a Schedule I controlled substance.  He also served as an expert in a successful Canadian constitutional challenge, Crown v. Allard, preserving qualified patients right to grow cannabis at home.   Among other awards Mr. Armentano was the 2013 Freedom Law School Health Freedom Champion of the Year.  The National Academy of Sciences' report, The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research is at: http://nationalacademies.org/hmd/reports/2017/health-effects-of-cannabis-and-cannabinoids.aspx.For more information regarding NORML go to: http://norml.org/. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit www.thehealthcarepolicypodcast.com

Listen NowWhile there is evidence noise-induced hearing loss among adolescents has increased due to the use of smartphones and other mobile devices, the evidence to date is not compelling or is still the subject of scientific debate.  Nevertheless, noise induced-hearing loss is a legitimate concern and therefore a topic in need of health education to combat, particularly since exposure is frequently voluntary, the consequences are cumulative and because the effects typically do not manifest until years later. Already, it is estimated 12 to 15 percent of school age children have some hearing deficits attributable to noise exposure and in adults, 15 percent of 26 million Ameeicans between the ages 20 and 69 have noise induced hearing loss.  The consequences can be significant.  In children, for example, hearing loss can delay language development, reduce educational achievement, produce social isolation and compromise quality of life.   During this 21 minute conversation Dr. Battey discusses the effects of being deaf, the physiological causes of deafness, the evidence for noise induced hearing loss and moreover the impetus for the NIDCD's "It's a Noisy Planet" and the educational program's goals, targeted audiences, activities and success or impact to date.  Since 1998 Dr. James Battey has served as Director of the NIH's NIDCD.  Previously he served as the Institute's Director of Intramural Research.   He has also served as an Investigator and Section Chief at the NIH's National Cancer Institute and the National Institute of Neurological Disorders and Stroke.  Dr. Battey received his undergraduate degree in physics at the California Institute of Technology and his MD and Ph.D. in biophysics at Stanford University School of Medicine.  He did his residency training in pediatrics also at Stanford and did postdoctoral training in genetics at Harvard Medical School. For information concerning NIDCD's "It's a Noisy Planet" go to: https://www.noisyplanet.nidcd.nih.gov/.For a review article concerning noise induced hearing loss among children, see, for example, Robert V. Harrison, "The Prevention of Noise Induced Hearing Loss in Children," International Journal of Pediatrics (2012) at: https://www.hindawi.com/journals/ijpedi/2012/473541/.  This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit www.thehealthcarepolicypodcast.com

Listen NowOn any given day US prisons and jails hold between 80,000 and 120,000 men, women and children in solitary confinement.   A significant percent of these individuals enter solitary with a mental disease and a similar percent of those held in isolation for extended periods of time develop severe psychiatric illnesses that include self amputation and suicidality.  (US prisons and jails constitute the largest psychiatric hospitals in the country.)  The UN Special Rapporteur on Torture and Other Cruel, Inhuman or Degrading Treatment and Punishment, Juan E. Mendez, has concluded solitary confinement for more than 15 days constitutes torture.  In Hell is a Very Small Place, Voices from Solitary Confinement," edited by Jean Casella, James Ridgeway and Sarah Shourd, 16 former and current solitary confinement inmates discuss their experience in solitary and  two physicians and three professors (in law, political science and philosophy) discuss its physical and psychological effects and legal justification. During this 32 minute conversation, Ms Casella provides an overview of Hell Is a Very Small Place.  She explains why inmates are placed in solitary confinement, for how long and describes conditions under confinement.  She provides an overview of the psychological effects of solitary noted by contributing authors Dr. Stuart Grassian and Dr. Terry Kupers.  She addresses whether solitary confinement constitutes torture, explains how inmates attempt to keep their sanity, explains to what extent private sector profit making contributes to the practice and discusses what continued progress, if any, may be made under a new, incoming administration. Ms. Jean Casella is co-director of Solitary Watch, a web-based watchdog project that investigates, documents, and disseminated information about solitary confinement in US prisons and jails.  Prior to co-founding Solitary Watch in 2009, Ms. Casella managed several mission-driven book and magazine publishers including Thunder's Mouth Press and the Feminist Press.  Jean's writing has appeared in The Nation, Mother Jones, The Guardian, Al Jazerra, and other publications and media outlets.  The Hell is a Very Small Place anthology edited was published by The New Press in February.  For her work on solitary confinement, Jean was awarded a Soros Media Fellowship in 2012. For more information concerning Hell Is a Very Small Place go to: http://thenewpress.com/books/hell-very-small-place.The UN Special Rapporteur's report is at: http://solitaryconfinement.org/uploads/SpecRapTortureAug2011.pdf. For another physician's review of solitary confinement, see, for example, Dr. Atul Gawande's essay titled,"Hellhole," in the March 30, 2009 issue of The New Yorker.  At: http://www.newyorker.com/magazine/2009/03/30/hellhole.  This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit www.thehealthcarepolicypodcast.com

Listen NowWith the election of Donald Trump Congressional Republicans are poised to repeal the Affordable Care Act (ACA) within the first 100 days of the 115th Congress via the budget reconciliation process.  (At some future date they are pledging to draft ACA replacement language or legislation.)  The expectation is repeal would have an effective date of 2018 or 2019, or after the mid-term Congressional elections.  However, many if not most health policy experts agree the simple act of repeal would cause such instability state insurance marketplaces would collapse long before repeal would, legally, go into effect.  Congressional Republican leadership is also promising to move major Medicare, via premium support and major Medicaid legislation, via block grants or per capita caps, though the upcoming Congress.       During this 23 minute conversation Chris Jennings discusses whether, and moreover how if at all, Congressional Republicans can repeal the ACA with an out-year effective date without fatally damaging state insurance marketplaces, the likely consequences of a simple repeal (without replace), when and how will Republicans will replace the ACA and whether that effort would garner any Democratic interest or support, what substantively explains Republican opposition to the current law and what might Republican leadership do to reform the Medicaid program and its likely effects.Chris Jennings is currently Founder and President of Jennings Policy Strategies, a DC-based policy firm where he consults with foundations, purchasers and other aligned stakeholders on policies to ensure higher quality, more affordable health care for all Americans.  Previously, Mr. Jennings served as Deputy Assistant for Health Policy to President Obama and for eight years as White House Health Care Adviser to President Clinton.   Prior still he served for a decade in the US Senate for Senators Glenn, Pryor and Melcher where he worked on Medicaid CHIP, HIPAA, PDUFA, major Medicare reforms in the 1997 Balanced Budget Act and related work concerning long term care, prescription drug coverage, rural healthcare and other related issues.  Chris has been a campaign adviser to six Democratic presidential campaigns and is a frequent contributor on health reform issues to the New England Journal of Medicine and numerous other scholarly journals, periodicals and newspapers.    This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit www.thehealthcarepolicypodcast.com