In the wake of the defeat of the Republicans’ effort to legislate repeal or replacement of Obamacare, considerable commentary has focused on the options for proceeding to deal with the resulting state of the healthcare insurance marketplace.

Bipartisan Healthcare Moves in the House and Senate

Politico was the first to report that a centrist coalition of 40 House Democrats and Republicans—the Problem Solvers Caucus—has developed a set of Obamacare market stabilization fixes. Tops on the list is a proposal to fund the ACA’s cost-sharing subsidies that reduce low income out-of-pocket costs. President Trump has maintained the subsidies on a cliff-hanging month-to-month basis all the while threatening to abolish them as part of an Obamacare “implosion” strategy. Other key provisions of the centrist proposals: an increase in employer mandate coverage requirements from 50 to 500 employees and a statutory federal fund for states to use to reduce premiums for extremely high cost medical needs.

On the Senate side meanwhile, signs of some bipartisan moves to shore up the Obamacare marketplace came in the form of an announcement by Senate Health, Education, Labor and Pensions Committee Chairman Lamar Alexander (R-Tenn.) that the committee will begin work in September “to stabilize and strengthen the 2018 health insurance market.” His announcement was quickly greeted with praise from the Democrats’ senior member of the committee, Sen. Patty Murray (Wash.).

Recommendations for Future of Medicaid

Two former CMS administrators—Democrat Andy Slavitt and Republican Gail Wilensky—joined in an opinion piece to urge a set of recommendations regarding the future of Medicaid. The authors—emphasizing the successes and vital place of Medicaid in the healthcare system—propose a series of measures designed to make Medicaid a more outcomes-based program, including improved Medicaid financing, and the assurance of access to care.

Medicaid recipients will certainly applaud such moves, according to a new national survey of Medicaid enrollee satisfaction with their health care. Researchers at the Harvard T.H. Chan School of Public Health report that enrollees enjoyed good access to physicians, while few noted any barriers to accessing care due to their Medicaid insurance.

Stabilize Cost Sharing and Keep Individual Mandate

ACA expert Timothy S. Jost, writing in a Commonwealth Fund article, calls for enactment of a mandatory appropriation to cover the cost-sharing reduction reimbursements through 2020. “The cause of this crisis is no secret. Insurers and insurance regulators have repeatedly pointed to the regulatory uncertainty driving insurance withdrawals and premium increases.” Jost also issued a call to keep the individual mandate in place until Congress can devise a credible replacement. “The ACA’s individual mandate penalty is too small, was phased in too slowly, and has not been adequately enforced, but for the time being it is all we have to encourage healthy people to enroll in coverage. Until someone comes up with a better solution it should be left in place.”

Possible Executive Branch Steps Against ACA

Whether any such efforts move forward will require the support of a thus far very hostile administration. In recent Sunday talkshow appearances HHS Sec. Tom Price has continued to speak in terms of ACA destruction rather than rehabilitation. Writing in a New York Times article, Haeyoun Park and Margot Sanger-Katz identified six independent executive branch steps—both in progress and possible—that can further that objective: weakened enforcement of the individual mandate (in progress), state Medicaid work requirement waivers (in progress), withdrawal of advertising and outreach support (in progress), less generous premium tax credits (proposed), failure to pay future cost-sharing subsidies (possible), and marginal redefinition of essential health benefits (possible).

Socioeconomic Disparities Reduced in Healthcare Access

Amid the turmoil surrounding the ACA, some indications of its positive impact came by way of two published articles. In the first, Boston University authors found strong evidence that the Act reduced socioeconomic disparities in healthcare access. Writing in Health Affairs, the authors conclude that “in the first two years of full implementation, the ACA improved health care access for Americans in low income households, people who are not college graduates, and the unemployed. The law’s Medicaid expansion was responsible for about half of these gains. The ACA was associated with a substantial (but incomplete) narrowing of socioeconomic disparities in access, particularly in states that expanded Medicaid.”

ACA Is Not a Job Killer

In a second paper, published by the National Bureau of Economic Research, the authors argue that the ACA, contrary to some pre-enactment projections, was not a job killer. According to the lead researcher, Mark Duggan, quoted in the Wall Street Journal, the findings instead “weakened one of the arguments against the ACA; the law doesn’t look like it hurts the economy. Data from the first two years of the law’s implementation suggests that, in the aggregate, any labor supply effects of the ACA have been modest.”

Individual Market Is Stabilizing

Kaiser Family Foundation researchers, revisiting an earlier analysis using more current data, have concluded that “early results from 2017 suggest the individual market is stabilizing and insurers in this market are regaining profitability. Insurer financial results show no sign of a market collapse. First-quarter premium and claims data from 2017 support the notion that 2017 premium increases are necessary as a one-time market correction to adjust for a sicker than expected risk pool. Although individual market enrollees appear, on average, to be sicker than the market pre-ACA, data on hospitalizations in this market suggest that the risk pool is stable on average and not getting progressively sicker as of early 2017. Some insurers have exited the market in recent years, but others have been successful and expanded their footprints, as would be expected in a competitive marketplace.”

Far-Reaching Medicare Changes in House Committee FY18 Budget

Not all the recent Congressional healthcare action was directed at Obamacare. The House Budget Committee approved the FY18 budget blueprint “Building a Better America,” which, while assuming passage of the now defunct repeal legislation, envisions some far-reaching Medicare changes, including implementation of a premium support system. “Under the premium support system, Medicare beneficiaries would pick from a list of federally certified plans to best suit their needs. The government would make a payment directly to the insurers to cover the cost of that plan. Coverage would be guaranteed, and traditional Medicare would always be available for those in the program for future generations. It would operate in a manner similar to Medicare Advantage, Medicare part D and employer sponsored insurance which most people are familiar with.”

Bipartisan Legislation to Support Family Caregivers and Strengthen Elder Abuse Prevention

Two legislative area that continues to show some bipartisanship: family caregiving and elder abuse. On July 27 New Mexico Democratic Representative Michelle Lujan Grisham and Florida Republican Representative Ileana Ros-Lehtinen introduced legislation to create a Care Corps demonstration program designed to provide support for family caregivers and help meet the growing demand for the care of aging and disabled Americans. The demonstration will place volunteers in communities to work with seniors and individuals with disabilities who need extra support to live independently. In exchange volunteers will receive health insurance and other benefits such as tuition assistance. “Seniors want to remain in their homes and they want control over their own health care,” Representative Grisham said. “Most of all, they want to remain as independent as they can, for as long as they can. The same is true for individuals with disabilities. Care Corps will allow them to keep that independence. Unfortunately, we’re facing high costs, along with a shortage of direct care workers, which results in the lack of access to these important services, especially for middle-class families. A national care corps will help build the workforce, while building intergenerational relationships that allow seniors and young people to learn from each other.”

In a second bipartisan display, August 1 saw Senate passage of a widely supported bill (S.178) that would increase protections for elders suffering various forms of abuse, including fraudulent telephone solicitation schemes that have received widespread media attention. As summarized in the Judiciary Committee’s report accompanying the bill, “The Elder Abuse Prevention and Prosecution Act, S. 178, seeks to promote a more coordinated, effective response to elder abuse and financial exploitation. The bill includes provisions to promote justice for victims, such as mandatory forfeiture in elder abuse cases, increased training of federal investigators, and the designation of at least one federal prosecutor in each judicial district to handle cases of elder abuse and exploitation. The bill also includes requirements to promote greater data collection, coordination, and information sharing by federal officials.”

NIH/NIA Research Budget for FY19 Targets Alzheimer’s and Related Dementias

Research aimed at achieving effective prevention and treatment of Alzheimer’s disease has received an important boost with the presentation of the National Institute on Aging’s FY19 research budget proposal. The proposal is slated for fast-track consideration under federal rules that provide for certain items to proceed without modification through the traditional budget process.

Published research results in July covered a range of issues pertinent to patient care and family caregiving.

Employers Agree Caregiving a Top 10 Employee Benefit Priority

From the Northeast Business Group on Health and AARP came the results of a survey indicating that “caregiving is among the top 10 employee health and wellness benefits priorities for most employers, and most employers agree that in the next five years, caregiving is going to become an increasingly important issue among employees.” Just over half of respondents believed it to be commonplace for employees to spend up to 20 hours per week in a caregiving role. “Family caregiving is an issue that affects the vast majority of us,” AARP Chief Advocacy and Engagement Officer Nancy LeaMond observed. “We are either caregivers now, have been in the past, will be in the future, or will need care ourselves.”

Hospital Patients Use iPads to Track Their Health Data

The Washington Post’s Hayley Tsukayama reports on an Apple-Cedars-Sinai Medical Center undertaking in which “the hospital is offering some patients the option to check out iPads during their stay for free, to provide more insight into their own health. The Cedars-Sinai pilot, which began last year, is limited but has helped improve communication between doctors and patients, hospital staff said. So far, only people who have heart conditions, and women who have just given birth have been able to participate. The hospital chose those patients because they are two types of patients who tend to want a lot of real-time data, and quickly. Patients have used the iPads to address a common gripe: finding a better way to keep track of all the practitioners in the seemingly endless rotation that takes care of them. The patients also viewed their own health data, such as their heart rates and their glucose readings, and learned what those vitals mean. And they can also watch or read educational materials about their procedure from the iPad through the hospital’s app, which can make it easier for nurses to know and mark what the patient has reviewed.”

Stroke Nurse Navigators Assist Patients and Family Caregivers

Yale New Haven Hospital stroke patients face a daunting road to recovery and rehabilitation. They are now receiving some much needed assistance from “stroke nurse navigators,” a role described by West Hartford news reporter Ed Stannard. The specialized nursing team provides services to patients and caregivers from the initial evaluation to post discharge phases of stroke treatment. “When a patient is going from rehab to home, I think there is a lot of fear,” stroke navigator Kaile Neuschatz said. “It’s very scary. Family caregivers have concerns about physically caring for the patient including giving medications. We explain the process of stroke recovery care and that it’s usually longer than we want. Every patient is different. Sometimes a daughter will need to cry on your shoulder and we have the time to offer that support.”

Surgical Updates in Real-Time for Families

Another example of employing new mobile technology in the pursuit of improved family involvement in patient care is described in a study emanating from the Orlando Health Arnold Palmer Hospital for Children. There, clinicians have developed a mobile application to provide real-time updates of surgical procedures to families in the waiting room. As reported in the New England Journal of Medicine Catalyst, “the use of a mobile application to communicate in real time from the operating room enhances the family experience and improves satisfaction. Physicians and nurses report that this method of updating the family is more efficient, reliable, valuable, and enjoyable than the traditional phone call.”

Post-Surgical Confusion and Emergency Hospitalizations Study Reveals Potential for Cognitive Decline

Two studies reported in July emphasize the potential impact of post-surgical confusion, as well as emergency hospitalizations on cognitive decline in older adults. In the first, researchers at Rush University Medical Center found that “those who have nonelected hospitalizations and who have not previously been diagnosed with dementia had a rapid decline in cognitive function compared to the prehospital rates. By comparison, people who were never hospitalized and those who have elected hospitalizations did not experience the drastic decline in cognitive function. These findings have important implications for the medical decision-making care of older adults. While recognizing that all medical procedures carry some degree of risk, the study implies that planned hospital encounters may not be as dangerous to the cognitive health of older patients as emergency or urgent situations.”

In the second study, Mayo Clinic researchers concluded that postoperative delirium (POD) in elderly patients led to a significant risk of subsequent cognitive impairment. “Our main finding is that elderly patients who are cognitively normal at a detailed assessment performed before surgery and who experience clinically evident postoperative POD are more likely to develop mild cognitive impairment or dementia subsequently compared with those who do not experience such delirium. These findings suggest that elderly surgical patients who experience postoperative delirium should receive extended neurocognitive follow-up as they might be at increased risk for cognitive dysfunction.”

Mortality Rates Not Increased for Cardiac and Pneumonia Patients Under ACA Readmission Reductions

Hospital readmissions continue to serve as the focus of research findings. On the positive side, Yale cardiologist Kumar Dharmarajan and colleagues set out to determine whether thirty-day hospital readmission reductions associated with the Affordable Care Act had the unintended consequence of increasing mortality after hospitalization. The answer, based on a review of 5 million Medicare fee-for-service hospitalizations for heart failure, acute myocardial infarction, and pneumonia from 2008 to 2014: While readmissions have declined, mortality rates have not increased.

Patient Involvement and Discharge Instruction Reduce Hospital Readmission

The extent to which patient involvement in care decisions and the receipt of written discharge instructions affects hospital readmission was examined by Canadian researchers in a study published in the Patient Experience Journal. After reviewing a variety of communication discharge elements, the authors conclude that the patient involvement and instruction factors were most related to the reduced risk of readmission. “Patients who reported always not being involved in their care decisions had 34% higher odds of readmission, compared with those who reported some degree of involvement. Additionally, patients who reported that they did not receive written information about what symptoms or health problems to look out for after leaving the hospital had 24% higher odds of readmission. Interestingly, not being involved in one’s care and not receiving written discharge information had a cumulative effect with those respondents having 54% higher odds of readmission.”

Problematic Communication Gaps Between Doctors and Home Healthcare Nurses

From the University of Colorado comes a finding that major communication gaps between doctors and home healthcare nurses exist and may be contributing to patient errors and hospital readmissions. As reported by Science Daily, researchers, using home health nurse focus groups, emphasized that communication breakdowns can have consequences for patients. “These are some of our most fragile patients, most are over 65, and more seamless communication is needed. The study cited frequent discrepancies in the medication list, confusion over who was responsible to write patient care orders, inaccessible hospital records, and resistance from clinical staff for accountability. As one focus group participant put it, ‘As a general rule I’ve been told  not to contact the hospitals. I actually got in trouble for contacting the hospital trying to find out, get more information, trying to track a doctor down. [And] the communication between the hospital and the primary care providers is just as bad as it is for us because the PCPs don’t have the information.’”

Coordinated Care and Beyond: The Future of Chronic Care Event From Alliance for Health Policy

Improving care for patients with complex, chronic conditions was the focus of an Alliance for Health Policy event that is now available for viewing on AHP’s website. Three panels examined future trends in chronic care, coverage and chronic care, and the future of integrated care for complex chronic conditions.

Fragmented Healthcare System Impacts High Need Patients and Their Caregivers Most

How to care for “high need patients”—people with multiple and often interconnected medical, social, and behavioral health needs—is the subject of an article by physician Dave Chokshi in the JAMA Forum. The article references a variety of resources emerging in recent years to address the needs of approximately 12 million patients who have three or more chronic conditions as well as functional limitations, such as difficulties with self-care. “The size of that patient population also approximately maps to the oft-cited 5% of patients who account for half of national health spending. In some ways, focusing on this group is common sense; it derives from the venerable notion of ‘triage’ in medicine. Yet our healthcare system does not effectively triage the slower moving emergencies of chronic conditions, including mental illness and addiction. Sadly, the fragmentation that plagues the healthcare system as a whole is felt most acutely by high need patients and their caregivers.” Chokshi calls attention to a number of recent additions to the toolbox of approaches to the challenges these patients pose, including: a National Academy of Medicine publication, a Commonwealth Fund-Peterson Center report on improving Medicare policies toward high need patients, and state initiatives using Medicaid and family caregiver projects to advance integrated medical and social services.

Universal Health Coverage: Arguments in Favor

Against the backdrop of the fight over Obamacare’s future, two sets of authors seek to put the debate in the broader context of the overall state of the American healthcare system. Writing in Health Affairs, Walter McClure, Alain Enthoven, and Tim McDonald make the case for universal health coverage. In so doing they take aim at both left and right sides of the political spectrum. “Universal health coverage is a wise public investment. Done right it will return far more to our national prosperity than it costs in tax dollars. Sickness is costly. It shrinks the workforce and makes it less productive. Good health, like education, expands the workforce and makes it more productive. One reason other countries have better health than the United States at substantially less cost is because they cover everyone starting at birth. Good, inexpensive prenatal and infant care makes healthy children, and healthy children make healthier, less costly adults. The left must recognize that universal coverage requires serious cost-containment incentives on both patients and providers. In its zeal to get everyone covered, and its unwarranted confidence in government controls, the left has consistently failed to include these incentives so far. For its part, the right should stop fighting universal coverage and recognize it for the shrewd and crucial public investment it is, and make sure that it gets done right this time, including strong means and incentives for patients to choose providers who are better for less.

In similar fashion Commonwealth Fund authors, drawing upon the Fund’s annual ranking of the US healthcare system as last among high income countries, conclude that the US “could achieve the best-performing healthcare system in the world by undertaking coordinated efforts to address a number of challenges. Ensuring universal and adequate health insurance coverage; strengthening primary care; reducing administrative burden; and reducing income related disparities by strengthening behavioral health and social service supports would go a long way toward improving the health of the US population. These foundational changes can increase prevention, minimize delayed diagnosis and delayed or ineffective treatment, and ensure that people can be more effective at managing their own health. Not only would these improvements reduce mortality amenable to healthcare, over the long run they might well reduce the use of very expensive acute care “rescue” services, thereby reducing spending.”

Hospital Charity Care Dwindles While Maintaining Tax Exempt Status

In a lengthy investigative report, Politico’s Dan Diamond concludes that “a decade after the nation’s top hospitals used all their advertising and lobbying clout to keep their tax exempt status, pointing to the vast givebacks to their communities, they are seeing their revenue soar while cutting back on the very givebacks they were touting. The result is that the nation’s top seven hospitals, as ranked by U.S. News & World Report, collected more than $33.9 billion in total operating revenue in 2015, the last year for which data was available, up from $29.4 billion in 2013, before the ACA took full effect, according to their own financial statements and state reports. But their spending on direct charity care—free treatment for low income patients dwindled from $414 million in 2013 to $272 million in 2015. To put that another way: The top seven hospitals’ combined revenue went up by $4.5 billion per year after the ACA’s coverage expansions kicked in, a 15% jump in two years. Meanwhile, their charity care—already less than 2% of revenue—fell by almost $150 million per year, a 35% plunge over the same period.”

SNFs to Address 30-Day Readmission Rates

Most of the attention with respect to 30-day readmission reductions has thus far focused on hospital discharges. In October 2018, however, Medicare will begin imposing penalties on skilled nursing facilities for failing to curb readmissions from the SNF back to a hospital. The result, as reported by Modern Healthcare’s Kristen Schorsch, is an emerging effort by both hospitals and SNFs to address the readmission situation. “As of October 2018, Medicare will withhold 2% of all payments to skilled nursing facilities, which they can earn back by having a readmission rate likely no more than 20%, experts say. Worried about losing out, some facilities, like St. Paul’s House in Irving Park are investing in unique approaches. Dr. Dheeraz Mahajan, St. Paul’s medical director, embeds a team of doctors and nurses to keep close tabs on patients in what he calls a high acuity unit. A year ago St. Paul’s readmission rate was 23%. The rate has been steadily declining, then dropped to 10% after the unit launched in January.” 

‘Against Medical Advice’ Hospital Discharges Not Uncommon

A.M.A.—against medical advice —is the topic of a New York Times post by Paula span: “The Patient Wants to Leave. The Hospital Says No Way.” Span offers both research findings and anecdotal insights into a phenomenon gaining increasing attention. “Why would an older person essentially discharge himself from a hospital, defying a physician’s recommendation and signing a daunting form that acknowledges he is leaving against medical advice? Such events happen more commonly than one might think. Though A.M.A. discharges occur far more frequently in younger patients, a recent study analyzed a large national sample from 2013 and found that 50,650 hospitalizations of patients over age 65 ended with A.M.A. discharges. ‘Reasonable people can disagree about whether a patient needs to stay one more day for an additional scan,’ Span quotes hospitalist Dr. Cordelia Stearns. ‘Fuller conversations about why patients want to leave might yield less contentious solutions, including outpatient treatment, home visits or drugs taken orally at home instead of being administered intravenously.’ Dr. Stearns once saw a pet cockatoo brought to a patient’s room to dissuade him from checking out. ‘Let’s see if we can come up with an alternative plan,’ Dr. Stearns said. ‘A lot of the time we can. We’re doctors, not jailers.’”

Recent Articles Addressing End-of-Life Care

End-of-life care produced several noteworthy pieces in July. Dina Keller Moss used the Health Affairs blog to describe her valiant and ultimately successful effort to facilitate her mother’s passing away on her own terms. Faced with her 89-year-old mother’s often-expressed wish to avoid extensive end-of-life interventions, on the one hand, and a colorectal surgeon’s contrasting push to operate on a cancerous mass, Moss finally found the path to palliative care that provided her mother with six satisfying and pain-free final months. “I’ll never understand why the option of hospice with palliative care was not presented to us early in my mother’s hospital stay, given her very clear statements of her wishes when she was first told of the existence of the mass. It was only when we finally said the seemingly magic words—we would like to confer with a palliative care doctor—that we learned that my mother’s wishes could in fact be granted. I shudder to think about what might happen to people who are less persistent or do not know what to ask.”

“It Takes a Squad to Care for an Elder” is the story of one family’s formation of a squad that fell in line like soldiers to care for a beloved family member when she couldn’t care for herself. “The old African proverb,” writes author Sherri Williams, “says it takes a village to raise a child. My experience showed me it takes a squad to care for a dying elder.” Williams goes on to quote Jon Radulovic of the National Hospice and Palliative Care Association: “Squad care is critical at the end of life because it’s often a time when families find themselves alone. “Friends and folks who usually keep in touch are afraid of what they will say. They’re afraid of doing something wrong so they stay away. At the end of life isolation often becomes a very serious problem for people. The fear of the situation from those friends and other folks in the community can be a big part of it.”

In a poignant remembrance of his mother’s final days, the Washington Post’s Steven Petrow depicts a phenomenon that at first appeared frightening, but which is often the manifestation of “nearing death awareness.” “Last summer, six months before my mother died, I walked into her bedroom, and she greeted me with a tinny hello and a big smile. She then resumed the conversation with her mother—who had died in 1973. ‘Where are you?,’ Mom asked, as though Grandma, a longtime Fifth Avenue milliner was on one of her many European hat buying junkets. As I stood there dumbstruck Mom continued chatting—in a young girl’s voice no less—for several more minutes. Was this a reaction to medication, a sign of advancing dementia? Or was she preparing to ‘transition’ to wherever she was going next?” Petrow quotes Rebecca Valla, a Winston-Salem, North Carolina psychiatrist: “Those who are dying and seem to be in and out of this world and the next one often find their deceased loved ones present, and they communicate with them. In many cases the predeceased loved ones seem to the dying person to be aiding them in their transition to the next world.” One evening Petro concludes, “I made a simple dinner: spaghetti with store-bought marinara sauce and a bright green leafy salad. Mom had pretty much stopped eating by this point but she made a show of trying her best. After dinner I helped her back to bed where she exclaimed: ‘How did you know?’ How did I know what? I asked. ‘That was exactly how I wanted my funeral to be,’ Mom replied. ‘You invited all my favorite people and the food was just what I would have ordered.’ Mom was beaming. Six weeks later she passed—pasta and salad were on the menu at her service.”

Statement on Senate Action on Repeal of Affordable Care Act from FCA Executive Director Kathy Kelly

Friday, July 28, 2017 — Last night, the current version of the Republican-led repeal and replace of the ACA—the Healthcare Freedom Act—failed by a dramatic vote cast by Senator John McCain joining with the stalwart opposition of Senators Susan Collins and Lisa Murkowski. These three Republican Senators voted with the Democrats to halt efforts to disrupt the current healthcare policies of the Affordable Care Act (ACA) that have extended healthcare and community-based long-term care to millions more Americans. We would like to thank Senators Collins, McCain, and Murkowski and the 48 Democratic Senators for standing with American families, children, adults with disabilities, and older adults with chronic health conditions in support of expanded healthcare across the country.

2017 Rosalinde Gilbert Alzheimer’s Disease Caregiving Legacy Awards: Applications Accepted Now!

FCA, with support from The Rosalinde and Arthur Gilbert Foundation, is pleased to oversee the 10th annual Rosalinde Gilbert Innovations in Alzheimer’s Disease Caregiving Legacy Awards — now accepting applications until Monday September 11, 2017, 5 p.m. (Pacific Time). The program promotes strengthening caregiving for people with Alzheimer’s disease, and encourages innovation in this field by both recognizing and rewarding the efforts of those who lead the way in addressing the needs of Alzheimer’s disease caregivers. One $20,000 award will be given in each of the following categories: Creative Expression, Diverse/Multicultural Communities, and Policy and Advocacy. View FCA’s online scrapbook of previous Caregiving Legacy Award winners, 2008–2016.

• Supporting Family Caregivers of Persons with Urinary Incontinence
• University of Wyoming - Caregiving Relationships Study
  

• Investigating general psychological well-being in primary caregivers of patients with Major Depressive Disorder
• Improving medication adherence in older people with dementia through a technological design
• Caregiver to Ill, Wounded or Disabled Veterans