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Health Policy, In the News, Medicine and Society, Public Health

On King v. Burwell and the survival of the Affordable Care Act (and an unexpected birthday present)

On King v. Burwell and the survival of the Affordable Care Act (and an unexpected birthday present)

5362318849_dd1527d632_zToday is my birthday – and the Supreme Court (or, at least, two-thirds of it) just gave me, most people who follow health policy, and millions of now still-insured Americans a present: King v. Burwell.

There’s a lot to say about this decision, but I want to focus on three things: the strength of the conflicting substantive arguments, the possible internal Court dynamics that resulted in the majority and dissenting opinion, and a guess at some deeper meanings of the case for the future of health care in America.

On the substance, this is a case that really could have gone either way. The idea that the Court should apply the words as written, no matter how silly, has precedent in the Court’s history; so does the idea that the Court should try to interpret laws in ways that make them work as intended. The majority — at the end, Chief Justice John Roberts’s opinion — does recognize this conflict; the dissent, from the more textualist end of the Court, rejects the idea of a tension. The majority has it right in the sense that sometimes the Court applies the words as written, sometimes it requires interpretation, and that both are legitimate responses to cases – both are within the culture of legal interpretation that the Court has included over the last two-and-a-quarter centuries.

I do think the Court could have legitimately gone the other way, though I think it would have been foolish and harmful, to the country and even to the conservatives who will now bemoan this outcome. I am glad they did not. I prefer judges who try, when the law – or more accurately its interpretative culture – will allow them to, to make things work in a sensible way. The dissent’s position would have upended a major government program and harmed millions of people for a technicality – like a ticky-tack penalty or foul call deciding the Super Bowl or the World Cup. The Court could have done that, but it would have been wrong.

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Health Policy, In the News, Medicine and Society, Public Health

Supreme Court upholds Affordable Care Act with a 6-3 vote

Supreme Court upholds Affordable Care Act with a 6-3 vote

Supreme Court picUpdated 4:07 PM: “Obamacare lives to fight another day,” writes David Studdert, ScD, a core faculty member at CHP/PCOR and an expert in health law, in a Stanford Law School blog post. In his piece, he offers more legal details of the ruling.

***

Updated 1:51 PM: Stanford law professor Hank Greely, JD, has this to say:

Today is my birthday – and the Supreme Court (or, at least, two-thirds of it) just gave me, most people who follow health policy, and millions of now still-insured Americans a present: King v. Burwell

I do think the Court could have legitimately gone the other way, though I think it would have been foolish and harmful to the country and even to the conservatives who will now bemoan this outcome. I am glad they did not. I prefer judges who try, when the law – or more accurately its interpretative culture – will allow them to, to make things work in a sensible way. The dissent’s position would have upended a major government program and harmed millions of people for a technicality – like a… foul call deciding the Super Bowl or the World Cup.  The Court could have done that, but it would have been wrong…

What does it mean about the future of Obamacare? Well, I think it means the Supreme Court is done with it, at least with its fundamental, life or death issues.

Greely will expand on these thoughts in a longer piece on Scope later today.

***

Updated 12:45: Mello goes into detail on the ruling in a just-published Stanford Law School blog post.

***

Updated 11:51 AM: Stanford’s Laurence Baker, PhD, who has done extensive research on the economic performance of the U.S. health-care system, has also weighed in, saying, “This ruling, affirming the intent of the Affordable Care Act, is a relief for millions of Americans who have gained coverage under the law. It also provides important stability for insurers and the health-care system more broadly, avoiding what would have been tumultuous disruption in health-insurance markets in many states. We can now turn full attention back to the important work of improving health-insurance markets and expanding coverage, from which this court case was such a distraction.”

***

Updated 11:04 AM: Some thoughts now from Stanford health economist Jay Bhattacharya, MD, PhD, a core faculty member at the Center for Health Policy and the Center for Primary Care and Outcomes Research (CHP/PCOR):

Today’s Supreme Court ruling preserves the Obama administration’s implementation of the ACA’s subsidy scheme to all qualified people (between 133 and 400 percent of the poverty line). The Supreme Court essentially ruled for the status quo.

Had the plaintiffs won the case, such subsidies would only have been legal in states, like California, that have established their own insurance exchange (or marketplace). The immediate effect of the ruling, then, would have been to eliminate federal subsidies for the people living in states without a state-established insurance exchange. Families with income between 133 and 400 percentof the poverty line in such states who purchased their insurance through a federally-established exchange would have had to pay the full costs of their insurance premiums. This would have made insurance unaffordable for many of these families.

The ruling would not have directly affected people who get insurance through their employers or through the government in some other way, such as through Medicare (health insurance for the elderly and disabled) or through Medicaid (health insurance for the poor).

It is difficult to imagine, had the ruling gone the other way, that it would be a stable political equilibrium for people in one state to be eligible for federal subsidies, while similar people in another state to be not eligible. There would have been a lot of pressure on Democrats and Republicans at both state and federal levels to reform Obamacare, and either reestablish the subsidies or make some other arrangement to make insurance affordable. With the Supreme Court ruling the way it did, there will be substantially less impetus or desire for the reform of Obamacare, especially on the Democratic side.

***

Updated 10:45 AM: Stanford’s Michelle Mello, JD, PhD, professor of law and of health research and policy, has just provided her insight on the ruling, which she said offered strong claims by both sides:

The Court was profoundly influenced by its desire to avoid an interpretation of the law that would defeat Congress’s purpose in passing it. That purpose was to create a functional market through which individuals could buy insurance… The Court found it “implausible” that Congress intended for States that opted not to set up their own Exchanges to suffer the foreseeable, well-understood consequence of a “death spiral.”

The spiral occurs because without the tax credits, a very large proportion of the people who would otherwise be required to buy insurance get exempted from the individual mandate because the insurance cost exceeds a set amount of their income. That means too few people — and in particular, too few healthy people — buying insurance now… People know they can buy insurance later when they get sick. Their decisions to do so push premiums up for everyone, and the adverse selection makes the market unsustainable…

The trio writing in dissent could hardly have shown greater disgust with the majority’s approach. They disputed the majority’s threshold claim that the four little words were ambiguous — and everything that followed from it. The length and complexity of the majority’s justification for its holding, they claimed, is just proof that (once again) the justices are contorting the law in order to achieve a political objective — upholding the Affordable Care Act…

But on balance, I think the majority got it right in pointing to the well-understood consequences of withholding tax credits as evidence that Congress didn’t intend the reading the challengers urged. The decision is on firm legal ground, and to public-health advocates, is an enormous relief.

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Global Health, Health Disparities, Health Policy, Stanford News

Rosenkranz Prize winners devoted to innovative health care in developing countries

Rosenkranz Prize winners devoted to innovative health care in developing countries

African girls studyingMarcella Alsan, MD, PhD, knows that the division of labor among men and women starts at a young age in the developing world.

“Anecdotally, girls must sacrifice their education to help out with domestic tasks, including taking care of children, a job that becomes more onerous if their younger siblings are ill,” Alsan, a core faculty member at the Center for Health Policy/Center for Primary Care and Outcomes Research (CHP/PCOR) within the Freeman Spogli Institute of International Studies, recently told me.

More than 100 million girls worldwide fail to complete secondary school, despite research that shows a mother’s literacy is the most robust predictor of child survival. So Alsan is analyzing whether medical interventions in children under 5 tend to lead their older sisters back to school. She’ll compile data from more than 100 Demographic and Health Surveys covering nearly 4 million children living in low- and middle-income countries. The surveys ask about episodes of diarrhea, pneumonia and fever in children under 5 and record data on literacy and school enrollment for every child in the household.

“My proposed work lays the foundation for a more comprehensive understanding of how illness in households and early child health interventions impact a critical determinant of human development: an older girl’s education,” Alsan, the only infectious-disease trained economist in the United States, said.

Alsan is one of two winners of this year’s Rosenkranz Prize for Health Care Research in Developing Countries, awarded by CHP/PCOR. Her Department of Medicine colleague, Jason Andrews, MD, is the other recipient of the $100,000 prize, which is given to young Stanford researchers to investigate ways to improve access to health care in developing countries.

In the current scientific climate, most National Institutes of Health grants go to established researchers. The Rosenkranz Prize aims to stimulate the work of Stanford’s bright young stars – researchers who have the desire to improve health care in the developing world, but lack the resources.

While Alsan is researching how older girls in poorer countries are impacted by the health of their younger siblings, Andrews is focusing his attention on cheap, effective diagnostic tools for infectious diseases.

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Global Health, Health Policy, Medicine and Society, Public Health, Stanford News

The battle against big tobacco hits the classroom

The battle against big tobacco hits the classroom

4822770407_f1a230b06c_bIn Malawi, children as young as five years old work in tobacco fields. Here, in the Silicon Valley, five-year-olds compete to attend top preschools. Stanford communications major Minkee Sohn highlighted that dramatic contrast with a parody video, “Fresh Recruits,” for a new Stanford anthropology class. Taught by Matthew Kohrman, PhD, the class, “Smoke and Mirrors in Global Health,” aimed to raise awareness about the global tobacco industry and was the subject of a recent Stanford News article.

Simply acknowledging that “smoking is bad for you” is no longer enough to halt tobacco’s spread. As noted in the piece, the tobacco industry remains a powerful global force and produces three times as many cigarettes as it did during the smoking heyday in America in the 1960s; it’s also the source of millions of preventable deaths. Kohrman encouraged his students to develop original communication strategies and to take on hard-hitting issues, such as the use of underage labor.

For their final projects, Kohrman’s class presented a slew of web-based videos, exposés and written critiques exploring little known facets of the global tobacco industry, including:

  • Chinese academia’s involvement in the tobacco industry
  • Philip Morris’ use of child labor in Africa
  • South Korea’s flawed approaches to tobacco control

Overall, Kohrman, an associate professor of anthropology, deemed his experimental class a “great success.” The course uncovered many little-known aspects of global tobacco, and taught students to “understand the sociocultural means by which something highly dangerous to health such as the cigarette is made both politically contentious and inert.”

Alex Giacomini is an English literature major at UC Berkeley and a writing and social media intern in the medical school’s Office of Communication and Public Affairs.  

Previously: A call to stop tobacco marketing, Cigarettes and chronographs: How tobacco industry marketing targeted racing enthusiasts and How e-cigarettes are sparking a new wave of tobacco marketing 
Photo by Jo Naylor

Health Costs, Health Policy, Medicine and Society, Orthopedics, Research, Stanford News

When physicians work together, costs can rise

When physicians work together, costs can rise

97187153_16040f08b7_zOnce upon a time, patients received care from a local doctor, who usually worked alone or with a few partners. Now, most physicians belong to large practices, which have standardized procedures and costs.

These mergers have been greeted warmly by regulators and the public, who believe that larger groups can take advantage of economies of scale. But these alignments could also give physicians greater bargaining power with insurers, a move that could push costs up, according to a new study by Stanford researchers.

Eric Sun, MD, an instructor of anesthesiology, perioperative and pain medicine, working with senior author Laurence Baker, PhD, investigated the fees charged by orthopedic surgeons for knee replacements between 2001 and 2010. They also ranked how concentrated physicians’ health-care markets scored on a commonly used index.

They found that physicians’ fees in markets with a high concentration of physician groups rose $168 compared to fees in the least concentrated markets — a jump of 7 percent.

The research has implications for the Affordable Care Act, which encourages physicians to join alliances. “The point is not to say that consolidation is a bad thing,” Sun concluded in our press release on the study. “But as we think about encouraging these kinds of mergers, we really want to weigh the costs against the benefits.”

The study appears in the June issue of Health Affairs.

Previously: Health-care policy expert Arnold Milstein weighs in on Medicare’s plan to prioritize “value over volume”, Steven Brill’s Bitter Pill and What’s the going rate? Examining variations in private payments to physicians
Photo by Waldo Jaquith

Health Disparities, Health Policy, In the News, Medicine and Society, Women's Health

Report: Health-care industry needs to focus on women

Report: Health-care industry needs to focus on women

16755600997_ca15a76fcf_zThe health-care industry needs to pay much more attention to women. That’s the argument laid out in a recent piece on MedCity News, which shared findings of a survey (.pdf) from the Center for Talent Innovation. That report shows that women make the majority of health-care decisions but are inadequately equipped to do so, and it calls on health-care companies, which are increasingly oriented towards consumers, to bridge that gap.

According to the survey, which included more than 9,200 respondents from the U.S., U.K., Germany, Japan, and Brazil, 94 percent of women make decisions for themselves and 59 percent make decisions for others; when working moms are considered separately, 94 percent make decisions for others. And yet, 58 percent of these decision makers lack confidence in their decision making.

The report says this is due to “three profound famines”: lack of time, lack of knowledge, and lack of trust. Seventy-seven percent of women don’t know what they need to do to stay healthy; 62 percent lack the time. Only 38 percent of working mothers passed a “health literacy quiz,” and the report showed that women are unlikely to trust online information (31 percent), their insurance companies (22 percent), or pharmaceutical companies (17 percent).

The report suggests that health-care companies need to understand women in the context of their family and career responsibilities, which is quite different from standard male-based “life stage analysis.” Moreover, they need to understand that women think about health more broadly than freedom from illness and health risks. Fully 79 percent said that health means “having spiritual and emotional wellbeing,” while 77 percent called it “being physically fit and well rested.”

An excellent place to start change is the management structure of health-care companies, the report suggests. Despite being the “CMOs” (Chief Medical Officers) for their families, women are underrepresented in other “C-level” roles in these companies:

We find that, while the health-care industry employs a large number of female professionals, their ideas, insights, and capabilities haven’t been fully supported, endorsed, and promoted. Without women in power, women’s ideas don’t get the audience they deserve, because… leaders only see value in ideas they personally relate to or see a need for.

MedCity news writer Nina Ruhe sums up another area for improvement. “Doctors, insurance companies and pharmaceutical companies can start instilling trust in women again by letting them know exactly what they should know in regards to their personal health and the health of their families,” she writes.

Health Policy, In the News, Patient Care, Stanford News, Technology

Exploring electronic health reminders’ effect on quality of care

Exploring electronic health reminders' effect on quality of care

It’s not every day that the director of the National Institutes of Health blogs about your research. But that’s the day that David Chan, MD, PhD, assistant professor of medicine, recently had when NIH Director Francis Collins, MD, PhD, highlighted his work.

Chan, a core faculty member at the Center for Health Policy/Center for Primary Care and Outcomes Research, is exploring the impact of electronic health record reminders on the quality of primary care. He received an NIH Early Independence Award last year for his work in this area.

Collins writes:

Is 5 too few and 40 too many? That’s one of many questions that… Chan is asking about the clinical reminders embedded into those electronic health record (EHR) systems increasingly used at your doctor’s office or local hospital. Electronic reminders, which are similar to the popups that appear when installing software on your computer, flag items for healthcare professionals to consider when they are seeing patients. Depending on the type of reminder used in the EHR—and there are many types—these timely messages may range from a simple prompt to write a prescription to complex recommendations for follow-up testing and specialist referrals.

More details on Chan’s work can be found in the full post.

Beth Duff-Brown is communications manager for the Center for Health Policy and Center for Primary and Outcomes Research.

Previously: A new tool for tracking harm in hospitalized childrenAutomated safety checklists prevent hospital-acquired infections, Stanford team finds and Can sharing patient records among hospitals eliminate duplicate tests and cut costs?

Cancer, Dermatology, FDA, Health Policy, In the News, Public Health

Experts call on FDA for a “tanning prevention policy”

Experts call on FDA for a "tanning prevention policy"

6635416457_a62bfeb09d_zIndoor UV tanning beds are known carcinogens that are responsible for many cases of skin cancer, which is the most commonly diagnosed form of cancer in the U.S. A recently issued Call to Action to Prevent Skin Cancer from the U.S. Surgeon General states that “more than 400,000 cases of skin cancer [8% of the total], about 6,000 of which are melanomas, are estimated to be related to indoor tanning in the U.S. each year” while “nearly 1 out of every 3 young white women engages in indoor tanning each year,” making indoor tanning a serious public health issue.

In a JAMA opinion piece published yesterday, Darren Mays, PhD, MPH, from the Georgetown University Medical Center‘s Department of Oncology, and John Kraemer, JD, MPH, from Georgetown’s School of Nursing and Health Studies, argued that the FDA needs to step up its regulatory approach and restrict access to this technology – due to its limited therapeutic benefits and known damaging effects.

In 2011, California was the first state to ban access to indoor UV tanning beds to minors. The authors assert that “state-level policies restricting a minor’s access to indoor tanning devices are effectively reducing the prevalence of this cancer risk behavior among youth,” but argue that regulation at the federal level is in order:

Like tobacco products, a national regulatory framework designed to prevent and reduce indoor tanning could reduce public health burden and financial costs of skin cancer. …from a public health perspective the indoor tanning device regulations are not commensurate to those of other regulated products that are known carcinogens with very little or no therapeutic benefit.

However, the likelihood of this regulation taking place is questionable:

FDA did not leverage its authority last year to put a broader regulatory framework in place, which could have included a national minimum age requirement and stronger indoor tanning device warning labels… Critical factors seem to be aligning for such policy change to take place, but additional momentum is needed to promote change at a national scale. The US national political environment makes more expansive regulation by either FDA or Congress seem unlikely in the near future.

The authors concluded with a call for organizations other than governments to help build momentum on toward a “national indoor tanning prevention policy.” For example, they said, universities could implement “tan-free” campus policies similar to the “tobacco-free” campaign.

Previously: More evidence on the link between indoor tanning and cancers, Medical experts question the safety of spray-on tanning productsTime for teens to stop tanning?, Senator Ted Lieu weighs in on tanning bed legislation and A push to keep minors away from tanning beds
Photo by leyla.a

Cancer, Health Policy, In the News, Public Health, Women's Health

Health hazards in nail salons: Tips for consumers

Health hazards in nail salons: Tips for consumers

3044578995_fe5151de75_zAfter exercise class the other day, my friend asked if I wanted to grab coffee and get our nails done. With nail salons on what seems like every block, having a manicure or pedicure is as easy as grabbing a latte. You don’t need an appointment and you’re done in less than an hour.

But this convenience comes at a cost. A recent investigative report in the New York Times exposed the not-so-bright side of nail salons. The articles have raised awareness of poor working conditions and health risks, and they’ve generated a vigorous public dialogue.

“It got people talking and that’s a good thing,” said Thu Quach, PhD, MPH, a research scientist at the Cancer Prevention Institute of California and research director at Asian Health Services.

An epidemiologist, Quach has spent much of her career studying harmful chemicals in nail care products and their health impacts on nail salon workers, a vulnerable workforce that is mainly comprised of low-income immigrants. In research studies she has conducted over time, Quach identified symptoms commonly experienced by salon workers, including dizziness, rashes, and respiratory difficulties, and more serious reproductive health effects and cancer.

“Unfortunately, the risks associated with chronic, long-term exposure to chemicals used in nail products have been little studied,” Quach said. “We know workers are exposed every day and their health is at risk – this is an important focus of my ongoing research.”

The California Healthy Nail Salon Collaborative (CHNSC), convened through Asian Health Services, educates salon owners, workers and consumers about health and safety issues, and advocates for stronger protections for all. Quach, who has been a CHNSC member since its inception, works closely with other members to address worker health and safety using an integrated approach of community outreach, research, and policy advocacy to address health and safety. The CHNSC has worked at the local, state, and federal level to promote changes.

Encouraging counties and cities to adopt the healthy nail salon program is a first step in their local approach. Participation is voluntary and to date three counties and one city have committed: Alameda, San Francisco, San Mateo, and Santa Monica. These counties provide training and formal recognition for salons that participate. Santa Clara has the program in the works and many salons throughout the state participate in healthy initiatives on their own.

In addition to local municipalities taking action, some manufacturers have stepped up to omit the “toxic trio” – dibutyl phthalate, toluene and formaldehyde – from their formulations. But despite rising awareness of the health hazards posed by these chemicals, many products still contain them and there is no regulatory oversight.

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Biomed Bites, Clinical Trials, Health Policy, Videos

The mathematics of clinical trials: A career

The mathematics of clinical trials: A career

Welcome to Biomed Bites, a weekly feature that introduces readers to some of Stanford’s most innovative researchers.

Math was Philip Lavori‘s first intellectual love. After earning his PhD in mathematics at Cornell University, Lavori spent his time solving tricky calculations. But the disconnect between the world of pure mathematics, and the messy outside world where people were living and dying started to bug him.

“It soon became obvious to me that I would have enormous interest in doing research that would have direct benefits to human beings,” Lavori says in the video above.

He began offering his skills as a consultant to physicians, where he discovered a new intellectual love.

“I’ve found the problems that arose in the design of clinical trials were problems that I could attack with my mathematical skills…. That quickly led to an entire career.”

Now Lavori is chair of the Department of Health Research and Policy, and he co-directs the Stanford Center for Clinical and Translational Research and Education (Spectrum).

Learn more about Stanford Medicine’s Biomedical Innovation Initiative and about other faculty leaders who are driving biomedical innovation here.

Previously: Survey confirms that small number of U.S. adults, children participate in research studies, A faster, better, cheaper clinical trial (electronic record system not included) and Re-analyses of clinical trial results rare, but necessary, say Stanford researchers

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