Daily Health Policy Report

Friday, August 30, 2013

Last updated: Fri, Aug 30

KHN Original Reporting & Guest Opinion

Health Spending And Fiscal Battles

Health Reform

Coverage & Access

State Watch

Health Policy Research

Editorials and Opinions

KHN Original Reporting & Guest Opinion

A Reader Asks: I Get Coverage Through My Estranged Husband. Can I Choose To Go To The Marketplace?

Kaiser Health News consumer columnist Michelle Andrews offers caution about the financial implications of that switch (8/30). Read the question and answer.

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Florida Is No. 2 In Nation For Rate Of Uninsured

The Miami Herald's Daniel Chang, working in partnership with Kaiser Health News, reports: “Florida has the nation’s second-highest rate of uninsured residents younger than 65 — a total of about 3.8 million people, or about 25 percent of the state’s population, including more than 500,000 younger than 19, according to U.S. Census data released Thursday” (Change, 8/30). Read the story.

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Group Health Omits Abortion Coverage From Plans Sold On State Exchange

The Seattle Times' Carol M. Ostrom, working in partnership with Kaiser Health News, reports: “Group Health Cooperative will not cover abortion in its individual health-insurance plans being offered through the Washington state marketplace put in place by the Affordable Care Act, but says women who buy them will be able to access the service without paying more. Group Health said it made the decision not to include the coverage because of murky regulations about how it would have to account for federal money in plans that offered abortion” (Ostrom, 8/30). Read the story.

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Capsules: IRS Ruling On Same-Sex Couples Has Implications For Health Law; HHS Will Allow ‘Unbanked’ People To Use Prepaid Debit Cards On Exchanges; Americans Have Low Health Insurance Literacy; Covered California Launches $80 Million Ad Campaign

Now on Kaiser Health News’ blog, Mary Agnes Carey reports on the IRS ruling: “The decision from the Treasury Department and the Internal Revenue Service means that the income of legally married same-sex couples will be considered in determining eligibility for enrollment in the health law’s Medicaid expansion and for subsidies to purchase coverage in the law’s online marketplaces, or exchanges” (Carey, 8/30).

Sarah Varney reports on the Department of Health and Human Services decision to let “unbanked” people used prepaid debit cards to pay for insurance: “At the urging of advocates for low-income consumers, the Obama administration said Wednesday that it is moving ahead with a rule requiring health plans accommodate households that do not have traditional bank accounts. One in four of the uninsured eligible for federal insurance subsidies does not have a bank account, according to a report released earlier this year by the tax preparation firm Jackson Hewitt” (Varney, 8/29).

Also on the blog, Marissa Evans reports on a survey examining public understanding of health coverage buzz words: “Premium, deductible, copay, all basic health insurance terms many Americans don’t understand, according to a recent poll. More than half could not correctly define at least one of these common financial terms related to health insurance, according to poll results released by the American Institute of CPAs” (Evans, 8/29).

And, KPCC's Stephanie O'Neill, working in parnership with KHN and NPR, reports on Covered California's new ad: "Officials at Covered California — the Golden State’s health insurance marketplace – are placing a big bet on advertising to lure people to get health insurance. With a campaign boosted by $80 million from the federal government, they’ll tell people about the Affordable Care Act and encourage uninsured citizens to buy health insurance" (O'Neill, 8/30). Check out what else is on the blog.

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Political Cartoon: 'Out Of Steam?'

Kaiser Health News provides a fresh take on health policy developments with "Out Of Steam?" by Eric Allie.

Here's today's health policy haiku:


Can wedded bliss last
long once you have to sort out
insurance choices?

If you have a health policy haiku to share, please send it to us at http://www.kaiserhealthnews.org/ContactUs.aspx and let us know if you want to include your name. Keep in mind that we give extra points if you link back to a KHN original story.

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Health Spending And Fiscal Battles

White House, GOP Senators Throw In The Towel On Budget Talks

Over the past weeks, the Republicans had moved away from the kind of "grand bargain" sought by the president, which would have combined higher tax revenues with cuts to programs like Medicare. Republicans said the talks had yielded "no common ground."

The New York Times: Talks To Avert A Fiscal Crisis In The Fall End With No Result
Over the past weeks, the Senate group — which called itself the “sounding board” — had moved away from the kind of “grand bargain” Mr. Obama had sought, which would combine higher tax revenues and changes to social programs like Medicare to produce trillions of dollars in deficit reduction. Instead, they aimed simply to replace the automatic across-the-board cuts known as the sequester over the next eight years with other budget changes. Mr. Obama, in his most recent budget plan, had accepted $200 billion in sequester savings over eight years, and both sides appeared ready to leave in place small cuts to entitlement programs in the sequester legislation (Weisman, 8/29).

The Washington Post: White House, Republican Senators Give Up On Budget Talks
The end of the talks comes just over a week before Congress is to return from its summer break to confront a series of imminent deadlines, including the risk of a government shutdown Oct. 1 and potential default on the national debt a few weeks after that. … Through multiple meetings with White House Chief of Staff Denis McDonough, Deputy Chief of Staff Rob Nabors and Budget Director Sylvia Mathews Burwell, the group discussed a range of options, including a “grand bargain” that would involve a complete restructuring of Medicare, according to people familiar with the meetings, who spoke on the condition of anonymity to describe the private talks. The group also discussed a smaller deal that would replace much of the remaining sequester savings — about $500 billion over the next eight years — with narrower reforms to Medicare, Social Security and other ­mandatory-spending programs, such as farm subsidies (Montgomery, 8/29).

The Associated Press/Washington Post: Republican Senator Says Budget Talks With White House Officials Yield ‘No Common Ground’
But the budget talks have always split over Obama’s insistence that any reduction in programs such as Social Security or Medicare be accompanied by tax increases or closed loopholes for the rich that would generate more revenue. Obama did win more than $600 billion in tax increases over 10 years on wealthier taxpayers earlier this year and Republicans have said they would not cede more (8/29).

The Wall Street Journal: Budget Talks Fail To Bridge Divide
Republicans have offered to replace the bulk of the sequester cuts—$518 billion over eight years—with other, more targeted cuts to Medicare, Medicaid and other entitlement programs, according to a GOP official familiar with the discussions. They offered to raise revenues to reduce the deficit, the official said, but not, as the White House wanted, to replace the sequester (Hook, 8/29).

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Health Reform

White House Readies Major Health Law Push

The strategy will feature the president, as well as first lady Michelle Obama, Vice President Joe Biden and Jill Biden, appearing in key states over the next six months to encourage people to enroll in new coverage options. Politico also looks at how former President Bill Clinton will be part of the effort to sell the American public on the overhaul.

Politico: President Gearing Up For Major New Obamacare Push
Three years after signing Obamacare into law, President Barack Obama finally looks eager to talk about it. The White House is mapping out a strategy to deploy the president, First Lady Michelle Obama, Vice President Joe Biden and Jill Biden in what will be their most coordinated effort yet to sell Obamacare, senior administration officials said (Budoff Brown, 8/30).

Politico: The Obama-Clinton Health Care Bond
Bill Clinton will attempt again next week to do for Obamacare what has long eluded its namesake: Cut through the political noise and change the perception of a law much of the public doesn’t like or understand. His speech at Clinton’s presidential library in Arkansas Wednesday is a continuation of the relationship that benefited the former and current president in the 2012 campaign. It’s a role Clinton has played before on behalf of the Affordable Care Act, which is rooted in the failed effort by he and his wife, Hillary Clinton, to pass comprehensive health care reform two decades ago (Haberman and Millman, 8/30).

Meanwhile, labor unions appear to be making progress in getting the administration to address their health law concerns -

The Wall Street Journal: Labor Official Sees Progress On Health-Law Concerns
Unions are making some progress in getting the Obama administration to address their concerns about the new health law, and Labor Secretary Tom Perez is playing a central role, AFL-CIO President Richard Trumka said Thursday. "We've been working with the administration to find solutions to what I think are inadvertent holes in the act. I'm hopeful that we'll get something done in the very near future," Mr. Trumka said at a breakfast with reporters sponsored by the Christian Science Monitor (Trottman, 8/29).

The Fiscal Times: Why Organized Labor Is Organizing Against Obamacare 
But Obama is also getting blasted these days from an unexpected quarter: Major labor groups instrumental in helping the president win a critical second term are charging that Obamacare is undercutting existing union-sponsored health insurance programs and even encouraging employers to cut workers’ hours. This is the latest bizarre wrinkle in the unfolding political drama over Obama’s signature program for extending health insurance coverage to millions of uninsured Americans (Pianin, 8/30).

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Calif. Releases Ads For Insurance Marketplace; Aetna Leaves N.Y. Exchange

Many of the California advertisements will be in Spanish to persuade consumers unfamiliar with the law to sign up, the Los Angeles Times reports. Meanwhile, Aetna did not give many details about its decision to not compete in New York's exchange.

Los Angeles Times: California Unveils Ads For New Health Insurance Market
The state faces the daunting challenge of trying to reach more than 5 million people who are uninsured or don't receive health insurance at work. Now officials are preparing to advertise on television and radio, in print and online — much of it in Spanish — to persuade consumers unfamiliar with the federal health law to sign up. The state is purposefully avoiding Hollywood stars in its opening sales pitch. Instead, the state's ads revolve around people worrying about getting care and paying their medical bills in hopes that those stories will counter persistent political attacks and widespread confusion about the Affordable Care Act (Terhune and Gorman, 8/29).

Reuters: Aetna Pulls Out Of Another Obamacare Health Exchange
Aetna Inc has decided not to sell insurance on New York's individual health insurance exchange, which is being created under President Barack Obama's healthcare reform law, the fifth state where it has reversed course in recent weeks. The third-largest U.S. health insurer has said it is seeking to limit its exposure to the risks of providing health plans to America's uninsured, but did not give details about its decision to pull out of specific markets. ... Aetna and its newly acquired Coventry Health unit, a low-cost provider that caters to individuals and Medicaid beneficiaries and provides private Medicare policies, still have applications to sell coverage in 10 states, based on publicly available information (Humer, 8/29).

In other state exchange news -

The Associated Press: Health Exchange Board Delays Vote On Plans Again
The board for the [Washington] state health exchange on Thursday once again delayed a vote on approval of 31 plans proposed to be part of the system. After previously delaying a vote last week, the board of the Washington Health Benefit Exchange voted 6-2 to delay the final vote until next Wednesday, to coincide with an already scheduled meeting to consider additional companies that are appealing exclusion by Washington's insurance commissioner (La Corte, 8/30).

Seattle Times: State Board Delays Certifying Exchange Health Plans
"We don't need to rush a vote today," Teresa Mosqueda told fellow board members. Mosqueda, legislative and policy director of the Washington State Labor Council and chairwoman of the Healthy Washington Coalition, warned that if the board proceeded with certification Thursday, some members might vote against certifying plans already approved by the state Office of the Insurance Commissioner (OIC) because they believe those that were rejected have not received a full hearing (Snow Landa, 8/29).

Kaiser Health News: Capsules: HHS Will Allow 'Unbanked' People To Use Prepaid Debit Cards On Exchanges
At the urging of advocates for low-income consumers, the Obama administration said Wednesday that it is moving ahead with a rule requiring health plans accommodate households that do not have traditional bank accounts. One in four of the uninsured eligible for federal insurance subsidies does not have a bank account, according to a report released earlier this year by the tax preparation firm Jackson Hewitt (Varney, 8/29).

The Associated Press: Ready Or Not, Health Law Outreach Training Begins
It wasn't easy writing the training program for the 800 outreach workers who will help Illinoisans sign up for insurance under President Barack Obama's health law. Washington was still shaping the regulations. Illinois lawmakers were still amending bills. Then the Obama administration delayed part of the law affecting some businesses. Every change meant more revisions. All the moving parts made it a challenge, but so far everyone who has taken the course has passed the test required for certification, said Elizabeth Calhoun, a University of Illinois at Chicago professor who led the effort under a $910,000 contract between the university and the state (8/30).

Also in state health law news -  

Kansas Health Institute: Kansas Lawmakers Urged To Consider Medicaid Expansion
The chief executive of one of the state's largest medical centers this week urged Kansas legislators to consider expanding eligibility for the state's Medicaid program. The original intent of the Affordable Care Act, commonly known as Obamacare, was that all states would expand their Medicaid programs effective Jan. 1, 2014 to include all adults with incomes at or below 138 percent of federal poverty guidelines (Ranney, 8/29).

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State Insurance Exchanges: Separating Fact From Fiction

Georgia Health News asks a state insurance expert to analyze premiums in the new online marketplace -- they dispute predictions of exploding premiums by Georgia's insurance commissioner. Meanwhile, the Minneapolis Star Tribune talks to people in that state's high risk insurance pool who could not buy policies in the past because of serious illnesses but who will be able to do so beginning Oct. 1.

Georgia Health News: Exploding Premiums: Real Danger Or False Alarm?
"Massive rate hikes." That's how Georgia's insurance commissioner has characterized the premiums in the upcoming state insurance exchange, being created under the federal Affordable Care Act. Commissioner Ralph Hudgens received national attention recently when he blasted the premiums in Georgia's federally run exchange, or marketplace, which will begin enrollment Oct. 1 (Miller, 8/29).

Minneapolis Star Tribune: Minnesota’s Insurance Plan Of Last Resort Nears End Of Line
Donna Devine is tired of being branded as "uninsurable" more than a decade after being treated for cancer. …Until now, Devine's only option has been to buy insurance through a state-run program that helps those with pre-existing conditions or who have been denied traditional coverage. The program, called the Minnesota Comprehensive Health Association (MCHA), serves about 26,000 residents, but it will be phased out in 2014 when insurers will be required to take all comers under the Affordable Care Act (Crosby, 8/29).

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Health Exchange Rate Shock Not So Likely, Study Finds

A study by Rand Corp. researchers concludes that predictions of sharp jumps in insurance premiums for coverage purchased through the new online insurance marketplaces may be overstated.

Bloomberg: Premium Increases Under Obamacare May Be Overstated
Predictions of sharp increases in health-insurance premiums for people getting coverage under the U.S. Affordable Care Act have been overstated and many states will see little to no change, researchers at Rand Corp. found. Out-of-pocket premiums for most individuals who buy health plans through new insurance exchanges will decline because of federal subsidies, the Santa Monica, California-based nonprofit research group said today in a report (Armstrong and Wayne, 8/29).

NPR: Study: Price Shocks On Health Exchanges Appear Unlikely
With new health insurance exchanges set to launch in just over a month, there's been a lot of chatter about how shocking the rates might be. One possibility is that adding sick people to a more comprehensive benefits package will cause premiums to soar. Last spring, the Society of Actuaries predicted an average increase of 32 percent because of to the law, which prompted an outcry from opponents of the law. But an analysis just out from the RAND Corp. reaches a very different conclusion (Rovner, 8/29).

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Health Law Subsidies Present Calculation Challenges

The Wall Street Journal reports on the challenges of calculating future income and health insurance subsidies -- both of which will have an impact on the health law's new insurance marketplaces. Meanwhile, The Washington Post reports on how executive-branch and legislative-branch employees will have different experiences with the overhaul.  

The Wall Street Journal: Subsidies for Older Buyers Give Health Insurers A Headache
But the federal subsidies that make this possible for older people are causing headaches that insurers are struggling to understand. The programs reverse a long-standing tenet of the insurance business: That riskier customers pay more. The subsidies can be far more generous to older people than younger ones, the analysis of Ohio's marketplace shows (Weaver and Radnofsky, 8/29).

The Wall Street Journal: A New Kind Of Insurance Head-Scratcher: Estimating Future Income
Under the health law, millions of Americans will face a new test of their fortunetelling skills: precisely predicting their next year's income. The federal health-care overhaul creates a potentially rich new class of benefits for people -- namely, federal subsidies they can use to buy insurance on the new marketplaces created in each state. Eligibility for subsidies is based on income (Radnofsky and Weaver, 8/29).

The Washington Post: Obamacare Affects Executive And Legislative Employees Differently
Executive-branch employees won't automatically lose their existing health coverage when they become eligible soon for the insurance exchanges forming under President Obama's health care law, according to the federal personnel office. Agency officials began driving that point home this week amid continued confusion and concerns about how the so-called Obamacare legislation will affect health-benefits for federal employees (Hicks, 8/30).

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Coverage & Access

Those In Gay Marriages Set To Receive New Federal Benefits

The federal government on Thursday issued rules on the federal benefits that gay Americans and their same-sex spouses can expect to receive. HHS said Medicare will allow all beneficiaries access to care in a nursing home where their spouse lives. A ruling from Treasury and the IRS also has implications for the health law, combining gay spouses' incomes in determining eligibility for the Medicaid expansion and subsidies to buy coverage in online marketplaces. 

The New York Times: Gay Marriages Get Recognition From the I.R.S.
Separately, the Health and Human Services Department said Thursday that Medicare would extend certain key benefits to same-sex spouses, "clarifying that all beneficiaries in private Medicare plans have access to equal coverage when it comes to care in a nursing home where their spouse lives." But federal agencies are not moving in lock step. Instead, they are creating a patchwork of regulations affecting gay and lesbian couples -- and may be raising questions about discrimination and fairness in the way that federal benefits are distributed. Medicare and Treasury officials have said they would use a "place of celebration" standard for determining whether gay couples are eligible for benefits. That means same-sex couples would receive benefits as long as they are legally married, regardless of where they live (Lowrey, 8/29).

Kaiser Health News: Capsules: IRS Ruling On Same-Sex Couples Has Implications For Health Law
The decision from the Treasury Department and the Internal Revenue Service means that the income of legally married same-sex couples will be considered in determining eligibility for enrollment in the health law's Medicaid expansion and for subsidies to purchase coverage in the law's online marketplaces, or exchanges (Carey, 8/30).

Los Angeles Times: IRS, Treasury Will Recognize Same-Sex Marriage Across State Lines
The change in policy follows the Supreme Court's decision in June overturning a key provision of the Defense of Marriage Act that barred the federal government from recognizing same-sex marriages for purposes such as insurance benefits, immigration and tax filings. … "Today's announcement is the first of many steps that we will be taking over the coming months to clarify the effects of the Supreme Court's decision and to ensure that gay and lesbian married couples are treated equally under the law," Health and Human Services Secretary Kathleen Sebelius said (Koseff, 8/29).

The Hill: HHS Expands Medicare Options For Same-Sex Couples
The Health and Human Services Department took initial steps Thursday toward complying with the Supreme Court's ruling striking down part of the Defense of Marriage Act. The HHS lifted restrictions on nursing home care for same-sex couples, which had been imposed by DOMA's definition of marriage as a union between a man and a woman (Baker, 8/29).

The Washington Post’s Wonk Blog: The IRS And Medicare Will Now Recognize Same-Sex Marriages. All Of Them.
It's still not all federal government roses for these couples. Social Security uses a place of residence rule, and has issued instructions to personnel to deny claims for spousal benefits from same-sex couples living in states where such marriages are not recognized. But the overall trend is toward a federal government that offers benefits to as expansive a set of same-sex married couples as possible (Matthews, 8/29).

Modern Healthcare: HHS Extends Equal Coverage To Same-Sex Advantage Beneficiaries In Skilled-Nursing Facilities
All beneficiaries in Medicare Advantage plans will now receive access to equal coverage when it comes to care in a skilled-nursing facility where their spouse lives, regardless of sexual orientation, HHS announced Thursday. The guidance specifies that certified married same-sex couples would be eligible for this equal coverage and care even if they reside in a state that does not legally recognized their marriage (Johnson, 8/29).

The Associated Press: Judge: VA Can't Deny Benefits To Lesbian Army Vet
A judge in Los Angeles ruled Thursday that a lesbian Army veteran and her spouse should be entitled to disability benefits given the recent Supreme Court ruling that struck down part of the Defense of Marriage Act. U.S. District Judge Consuelo Marshall said that a federal code defining a spouse as a person of the opposite sex is unconstitutional "under rational basis scrutiny" since the high court's decision allowing legally married gay couples the right to health care benefits (8/30).

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State Watch

State Highlights: Texas Bans Youth From Tanning Salons

A selection of health policy stories from Texas, Florida, South Dakota, Washington and California.

The Texas Tribune/New York Times: With Youth Tanning Law, Texas Aims to Lower Melanoma Risk
Soon, Texas will join a number of states that bar minors from tanning indoors, which experts say greatly increases the risk of melanoma in those under 18. Senate Bill 329, written by State Senators Joan Huffman, Republican of Southside Place, and Sylvia R. Garcia, Democrat of Houston, automatically became law in June without the governor's signature and will take effect on Sunday (Serrano, 8/29).

The Washington Post: Adults In The Northeast And Midwest Are Relatively Well-Insured. The Rest Of The Country Not So Much.
More than one in four Texans under the age of 65 lacks health insurance, more than any other state in the nation. Florida is next, followed by Nevada, New Mexico and Oklahoma. Those results are from a new Census Bureau report released Thursday morning detailing health insurance rates at the state and county level. The report is a fascinating read if you’re into health policy and demographics, but we found one map -- the first -- especially interesting (Chokshi, 8/29).

Kaiser Health News/The Miami Herald: Florida Is No. 2 In Nation For Rate Of Uninsured
Florida has the nation’s second-highest rate of uninsured residents younger than 65 -- a total of about 3.8 million people, or about 25 percent of the state's population, including more than 500,000 younger than 19, according to U.S. Census data released Thursday (Change, 8/30).

The Associated Press: Fla. Is No. 2 In Lack Of Health Insurance
Florida had the nation's second-highest rate of residents without health insurance with almost 1 out of 4 Floridians lacking it, according to new U.S. Census figures released Thursday. Only Texas surpassed Florida's rate of 24.8 percent of residents under age 65 without health insurance in 2011, the most recent year figures are available, the Census said (Kennedy, 8/30).

The Associated Press: Proposed Medicare Change Threatens 26 Rural Hospitals In South Dakota
Twenty-six rural hospitals in South Dakota are threatened by a federal agency’s proposal that could take away the extra payments they get for service to Medicare patients, a move that might even force some hospitals to close, a state official said. State Health Secretary Doneen Hollingsworth said the proposal is a long way from being approved, but state officials plan to fight the proposed change in the way rural facilities designated as critical access hospitals are reimbursed for care provided to Medicare patients (Brokaw, 8/29).

The Seattle Times: State To Boost Care For Medicaid Youths
In what all sides hailed as a landmark agreement, the state of Washington has agreed to fundamentally change the way it provides mental-health care to the most troubled children and youth who qualify for Medicaid.  The settlement, which calls for intensive in-home and community-based care, was reached Thursday between the state and attorneys who filed a class-action lawsuit in 2009 (Miletich, 8/30).

California Healthline: Senate Panel Moves Abortion Clinic Bill
The Senate Committee on Appropriations this week passed a bill that would change building code requirements on health clinics that offer abortion services. AB 980 by Assembly member Richard Pan (D-Sacramento) would bring licensing and building standards into line with all other primary care clinic standards, Pan said at Monday's hearing (Gorn, 8/29).

California Healthline: Big Jump In School-Based Health Centers
When California elementary, middle and high school students return to school this fall, almost 230,000 of them will have access to health care through school-based health centers. That's an increase of more than 25,000, the largest one-year jump since the California School Health Centers Association started keeping track in 2004. School-based health clinics have more than doubled in California in the past decade -- from 108 in 2002 to 226 in operation now. Another 37 California schools are in the process of opening clinics (Lauer, 8/29).

St. Louis Post Dispatch: St. Louis ConnectCare Cuts More Than Half Of Its Staff
St. Louis ConnectCare, one of the area's leading providers of outpatient specialty medical services for the poor, issued layoff notices Wednesday to more than half of its staff. The layoffs of 88 employees, from nurses to medical assistants and customer service personnel, will take effect in 60 days, said Melody Eskridge, president and chief executive of ConnectCare.

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Health Policy Research

Research Roundup: Assessing New Hospital Observation Rule

Each week, KHN compiles a selection of recently released health policy studies and briefs.

JAMA Internal Medicine: "Observation Status" For Hospitalized Patients
Hospitalized patients in the United States are increasingly placed on "observation status." The Centers for Medicare & Medicaid Services (CMS) state that observation should rarely exceed 48 hours. At our hospital, however, observation stays frequently exceed 48 hours, particularly for adult general medicine patients, as our research group recently reported in this journal. Reimbursement has not covered the costs, resulting in operating losses. After our study was completed, CMS proposed a rules change, assigning inpatient status and Medicare Part A coverage to all hospital stays of 2 midnights ("2 days") or longer, assuming medical necessity supported a 2 midnights-or-longer stay. ... We used our data to assess the implications of the proposed rules change (Sheehy et al., 8/26).

Science: Confronting the Sorry State of U.S. Health
In January 2013, the U.S. National Research Council (NRC) and Institute of Medicine (IOM) issued U.S. Health in International Perspective: Shorter Lives, Poorer Health, a stunning depiction of how, over the past four decades, the comparative health status of Americans has declined. ... President Obama recently declared that growing social inequalities are tearing at the social fabric of the nation. He must now create a National Commission on the Health of Americans charged with holding public hearings and determining vigorous steps that must be taken to address, not simply the health of those at the bottom, but the comparative status of America as a whole. There is a strong evidentiary basis for action beyond interventions at the individual behavioral level  (Bayer, Fairchild, Hopper and Nathanson, 8/29).

JAMA Pediatrics: Clinician Perspectives Regarding The Do-Not-Resuscitate Order
While data exist regarding the frequency and timing of the do-not-resuscitate (DNR) order in children, little is known about clinician attitudes and behaviors regarding this order. ... In theory, many physicians and nurses in our study believe that the DNR order should guide therapeutic decisions only during a cardiopulmonary arrest. Yet in reality, most believe that care changes beyond resuscitative interventions. ... Many physicians and nurses in our study reported that the care of a patient changes on implementation of a DNR order. ... more than half reported that care changes beyond resuscitative measures and focusing on comfort, including limitation or withdrawal of diagnostic and therapeutic interventions and, most concerning, decreased attentiveness from the clinical team (Sanderson, Zurakowski and Wolfe, 8/26).

Kaiser Family Foundation/JAMA: Visualizing Health Policy: A Short Look At Long-Term Care for Seniors
This month’s Visualizing Health Policy provides an informational snapshot of long-term services and support (LTSS) for seniors in the United States. This includes information about the number and proportion of seniors who will need LTSS because of physical and cognitive impairment, the role of unpaid family caregivers in providing the majority of LTSS, the role of Medicaid (not Medicare) as the primary payer for LTSS, the shifting of Medicaid spending from institutional-based care toward community-based care, and the fact that only 35% of US adults 40 years or older say they have set aside money for their long-term needs (Rousseau, Firth and Jankiewicz, 8/28).

Here is a selection of news coverage of other recent research:

NPR: Patients Love A Gentler Approach To Surgery, But Surgeons Balk
Surgery can be a necessary misery, endured in hope of health. But what if you took away the misery, and kept the benefits? When hospitals quit subjecting patients to prolonged fasting, nasogastric tubes, abdominal drains, and other commonplaces of surgical care, a study finds, patients feel less pain and recover faster. Women who had major abdominal surgery at the Mayo Clinic under a protocol to enhance recovery went home sooner and needed less pain medication than women who had the surgery the usual way. ... Patient care cost $7,600 less, on average, with the new protocol. The results were published in the journal Obstetrics & Gynecology (Shute, 8/27).

Medscape: Leaving Hospital Against Medical Advice Increases Death Risk
In an analysis of more than 1.9 million hospital admissions over the course of 20 years, leaving the hospital against medical advice (AMA) more than doubled the odds of 90-day mortality and 30-day readmission compared with complying with medical advice, lead author Allan Garland, MD, from the Departments of Internal Medicine and Community Health Sciences and the Manitoba Center for Health Policy, University of Manitoba, Winnipeg, Canada, and colleagues explain in an article published online August 26 in the Canadian Medical Association Journal (MacReady, 8/26).

Medscape: Pediatric Readmissions, Revisits May Not Reflect Performance
Pediatric readmission and revisit rates are less valuable for quality assessment than in adult hospitals, as few children's hospitals are high- or low-performers for condition-specific rates, according to a retrospective analysis published online August 26 in Pediatrics. "As a national way of assessing and tracking hospital quality, pediatric readmissions and revisits, at least for specific diagnoses, are not useful to families trying to find a good hospital, nor to the hospitals trying to improve their pediatric care," lead author Naomi Bardach, MD, assistant professor of pediatrics at University of California, San Francisco, Benioff Children's Hospital, said (Barclay, 8/26).

American Medical News: Men In High-Deductible Health Plans Put Off Serious Care
For men enrolled in high-deductible health insurance plans, serious events such as a kidney stone or chest pain might not be enough for them to seek emergency care, according to a study in the August issue of the journal Medical Care. ... Researchers noted a 34% reduction in visits by men for serious problems and a 21% reduction for minor to moderate issues in the year after a move to an HDHP, compared with men who remained in an HMO. Conversely, this trend was reversed the following year, with a 30% increase in hospital admissions for men in an HDHP (Phalen Tomaselli, 8/26).

MedPage Today: Patients With Prostheses Cost Medicare Less
Medicare recipients given orthotic and prosthetic devices were more likely to remain active in the community and avoid facility-based care than similar Medicare patients who didn't receive such devices, a retrospective study found (Pittman, 8/29).

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Editorials and Opinions

Viewpoints: Tying 'Social Safeguards' To Work May Not Be Best Policy; GOP Missing An Opportunity By Not Offering Alternative To Health Law; Food Makers' Health Claims 'Hard To Swallow'

Los Angeles Times: Workers Facing The Thorny Problems of Healthcare And Retirement
In May, the head of [Trader Joe's] ... sent a confidential memo to employees notifying them of changes to their health coverage, retirement program and wages. ... He pledged to reduce workers' healthcare costs 10% for the remainder of the year while the company determines its response to changes under the Affordable Care Act. ... As Labor Day approaches, it's worth noting that the challenges faced by Trader Joe's are shared by most U.S. businesses, large and small. Meeting workers' present and future social-welfare needs has become a crucial and highly complex issue as healthcare costs continue to outpace inflation and secure retirements grow increasingly out of reach for many people. These issues highlight the vulnerabilities of a system in which people's social safeguards are tied to their employment (David Lazarus, 8/29).

The New York Times: Economix: The Central Challenge In U.S. Health Policy
"Health Care Costs Climb Moderately, Survey Says" read the headline in The New York Times last week. It appears that health insurance premiums for job-based family coverage rose "only" 4 percent between 2012 and 2013, although still twice as fast as did wages (Uwe E. Reinhardt, 8/30). 

The Washington Post: U.S. Congress Set For Two Major Fiscal Fights
In some ways, the impasse has worsened since Congress and President Obama cobbled together a temporary fix to the "fiscal cliff" drama nine months ago. A promising series of meetings between Mr. Obama and a group of compromise-minded Republican senators fizzled. Sen. Ted Cruz (Tex.) and others on the GOP right launched a deeply mischievous campaign to "defund" Obamacare, the premise of which is that this is the last chance to stop the hated program and Republicans should reject any spending bill that contains money for it — even if that means shutting down the government. Never mind a Congressional Research Service paper that shows this would be futile, since Obamacare's implementation does not require new discretionary spending authority (8/29).

The Washington Post's Right Turn: Obamacare's Rotten Summer
Opponents of Obamacare should recognize how big a burden this will be for the Democrats in 2014 and 2016. But they must also take care to do nothing to muddy the waters. This is the president's baby and the Democrats' burden; let them defend it. Given how badly Obamacare has been roughed up, the temptation is great to say Republicans don't have to come up with their plan. That's bad politics and a missed opportunity. Voters want a few things (e.g. protection from rate hikes for preexisting illnesses) and will be hesitant to dump the whole thing without assurance these will remain in place (Jennifer Rubin, 8/29).

The Wall Street Journal: A Test Of GOP Resolve On ObamaCare
Republicans are busy debating what gives them the most "leverage" in their fight to get rid of Obamacare. One powerful tool, it happens, is an issue that few of them so far have wanted to talk about. The issue is the White House's recent Obamacare bailout for members of Congress and their staffs. The GOP has been largely mute on this blatant self-dealing. The party might use what's left of its summer recess to consider just how politically potent this handout is, and what—were they to show a bit of principle—might be earned from opposing it (Kimberley Strassel, 8/29). 

The New Republic: Another Story Of Obamacare Rate Shock That Isn't
Another ObamaScare article is making the rounds. This one, from National Journal, is about what people buying their own insurance will pay on the new Obamacare exchanges—and how those prices compare to what people pay when they get coverage from their employers. ... Ritger's analysis is based on a seemingly simple comparison. She looked at what people can expect to pay for insurance in the new Obamacare "exchanges," using figures from California’s new insurance marketplace, which seem pretty typical for the country as a whole. Then she looked at what people can expect to pay for employer coverage, using data on the "employee contribution" from the Kaiser Family Foundation. ... But the analysis has other, serious flaws. For one thing, the true cost of employer-sponsored insurance should include at least some portion of what the employer pays (Jonathan Cohn, 8/29).

Los Angeles Times: Medical Alerts In Sacramento
As their session draws to a close, California lawmakers are poised to approve at least two hotly disputed measures that could slow the growth of healthcare costs. One would allow nurses with advanced training to deliver more medical care, and another would open the door to less-expensive versions of pricey biologic drugs. Although the nursing bill was weakened in the face of opposition from doctors, it's still an important step in the right direction. The biologic drug measure, on the other hand, strays off course (8/30).

Los Angeles Times: Taking Physicians Out Of The Abortion Decision
AB 154, a bill in the California Legislature that would allow nurse practitioners, midwives and physician's assistants to perform some early abortions, won't be controversial with most supporters of legal abortion. But it severs a connection between abortion rights and the practice of medicine that played an important role in the Supreme Court's Roe vs. Wade decision legalizing abortion (Michael McGough, 8/29).

Los Angeles Times: Food Makers Health Claims Are Hard To Swallow
A few years ago, Kellogg Co. embarked on an ad campaign to convince parents that eating Frosted Mini-Wheats cereal would make star students of their children, with higher levels of attention and memory. "Clinical studies" — a revered term — showed that a breakfast of the cereal improved children's attentiveness by "nearly 20%," the ads said. There are studies, and then there are studies (8/30).

Bloomberg: Cancer's Primeval Power And Murderous Purpose
We think of cancer as a modern scourge, but it was here long before people walked the Earth. Only very recently, in geological time, have creatures like us evolved who think there might be something they can do about it (George Johnson, 8/28).

Forbes: Medicare Ruling Would Hurt Alzheimer's Patients
CMS has issued a draft decision that, if it were to become effective, would deny payment for a new FDA-approved PET scan technology. ... The PET scan technology empowers doctors to more accurately diagnose patients that may be suffering from hard to diagnose forms of dementia. With this more accurate diagnostic tool, doctors are better able to design appropriate treatment plans for patients. Thanks to an earlier diagnosis, the PET scan empowers patients to plan for the disease more effectively and enroll in clinical trials should they choose this option (Wayne Winegarden, 8/29). 

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Stephanie Stapleton

Andrew Villegas

Lisa Gillespie
Shefali Luthra

The Kaiser Daily Health Policy Report is published by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation. (c) 2014 Kaiser Health News. All rights reserved.