JAMA Forum: Women’s Rights Are Human Rights—Aren’t They?

Eli Adashi, MD, MS

Eli Adashi, MD, MS

So far, this summer has brought some interesting developments in the area of international women’s rights. Although precious few gains made it to the winning column, those that did were worth the wait. The common thread for these developments was Congress’s annual push-and-pull ritual in crafting the FY 2015 State and Foreign Operations Appropriations spending bill, which includes a large proportion of funding for US global health programs.

Here are some of the highlights.

Peace Corps Volunteers and Abortion Coverage

Since 1979, health coverage for Peace Corps volunteers has excluded coverage for abortions, even in the context of rape, incest, or when a pregnancy endangers a woman’s life. No other federal employees, and that includes Peace Corps employees, are similarly constrained. In a surprise move on June 24, the House Appropriations Committee approved an amendment to the House version of the State and Foreign Operations Appropriations spending bill (HR 5013) for next year, proposed by Rep Nita Lowey (D, NY), to remove this exclusion on Peace Corps volunteers in cases of rape, incest, and life endangerment.

This outcome could hardly have been anticipated. The House Appropriations Committee’s actions followed in the footsteps of its Senate counterpart, which approved a comparable measure on June 19 within the framework of its version of the spending bill (S 2499). The amendment, previously introduced as a stand-alone bill known as the Peace Corps Equity Act of 2013(S 813), was reintroduced in the Senate in May by Sen Jeanne Shaheen (D, NH). Given the bicameral consensus on this matter, all indications are that the provisions in question will be deemed exempt from further negotiation between the chambers and that coverage for abortion in the face of rape, incest, or life endangerment will in all likelihood be available to Peace Corps volunteers when the appropriation legislation is enacted into law later this year.

Global Gag Rule

The Senate version of the State and Foreign Operations Appropriations spending bill (again inspired by an amendment proposed by Sen Shaheen) also included a provision to permanently repeal the 1984 “global gag rule,” also known as the Mexico City Policy. This requires US-funded foreign nongovernmental organizations (NGOs) to certify, as a condition for receiving family planning assistance, that they would not perform or promote abortion as a method of family planning, even with funds from another source. The policy further requires US-funded foreign NGOs to refrain from providing information, referrals, or access to legal abortion and from advocating for local laws that would legalize abortion or provide access to it.

The global gag rule is currently in a state of abeyance by dint of an Executive Order by President Obama. The amendment, which would permanently repeal the policy if signed into law, was approved in the Senate committee with a significant bipartisan margin of 19 to 11.

In contrast, the House Appropriations Committee unveiled a FY15 State and Foreign Operations Appropriations spending bill that would reinstate the global gag rule. As articulated under the provision titled “Limitations on Family Planning/Reproductive Health,” the House version of the appropriation bill “prohibits funds for population planning activities or other population assistance to foreign nongovernmental organizations that promote or perform abortion, with certain exceptions.” An amendment by Rep Barbara Lee (D, CA) to strike the global gag rule from the draft version of the House bill failed on a vote of 19 to 25. If past precedent is any indication of the final outcome, any and all language applicable to the global gag rule is likely to be deleted in the upcoming conference between House and Senate negotiators, as it has under previous Democratic administrations.

United Nations Population Fund

Congress also revisited, as it does annually, the multilateral funding of the United Nations Population Fund (UNFPA) to support the UNFPA’s quest to ensure universal access to reproductive health. In this context, the House’s version of the FY15 State and Foreign Operations Appropriations spending bill included a proviso stipulating “no funds for the United Nations Population Fund.” An amendment by Rep Rose DeLauro (D, Conn) to reverse the funding ban in the draft bill was defeated on a vote of 20 to 26.

In contrast, the Senate version of the spending bill resolved that $37.5 million “shall be made available for the United Nations Population Fund” subject to the condition that the “UNFPA does not fund abortions.” While the final resolution of this intercameral disagreement is far from certain, past precedents suggest that the UNFPA will live to be funded another year.

The time frame for the enactment of the House and Senate committee–approved bills remains to be determined. However, with only a limited number of days left on the legislative calendar before the new federal fiscal year (October 1, 2014) and with adjournment planned for the 2014 midterm November elections, floor action seems unlikely. More likely than not, an interim (if unresolved) version of bill will likely be incorporated into a “continuing resolution,” until such time that a lame duck session of Congress convenes after the election.

The arcane congressional debate on the funding of international women’s health services may come across as a surreal throwback to times long gone by. It is precisely this harsh if improbable reality which prompts one to wonder all over again: women’s rights are human rights—aren’t they?


About the author: Eli Y. Adashi, MD, MS (eli_adashi@brown.edu) is a professor of medical science and the former dean of medicine and biological sciences at the Warren Alpert Medical School of Brown University in Providence, Rhode Island. A member of the Institute of Medicine, the Association of American Physicians, and the American Association for the Advancement of Science, Dr Adashi has focused his writing on domestic and global health policy at the nexus of medicine, law, ethics, and social justice. A former Franklin fellow, Dr Adashi served as a senior advisor on Global Women’s Health to the Secretary of State office of Global Women’s Issues during the first term of the Obama Administration.

About The JAMA Forum: JAMA has assembled a team of leading scholars, including health economists, health policy experts, and legal scholars, to provide expert commentary and insight into news that involves the intersection of health policy and politics, economics, and the law. Each JAMA Forum entry expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. More information is available here and here.


JAMA Forum: How Well Is the Affordable Care Act Working?

Larry Levitt, MPP

Larry Levitt, MPP

The American people are still divided in their views of the Affordable Care Act (ACA), which is perhaps not surprising given how partisan the debate has been and the fundamental ideological differences in the country about the appropriate role for government in health care, as in other spheres. There are legitimate differences of opinion about the law, just as there are about any important policy issue.

But the politics of the ACA often get confused with the question of whether the law is working as intended, whatever one may think of the wisdom of those intentions. That is largely a factual question, though facts about the ACA are often blurred when looked at through ideologically tinted lenses.

To be sure, there is still plenty that remains unknown about the ACA, and it will take years for the law to fully play out and to get a complete evidence-based reckoning of how it is working. Here, though, is my initial take on how well the ACA is accomplishing so far what it set out to do:

1. Creating an easy online process for people to get information about their health insurance options and sign up.

A centerpiece of the ACA was the creation of new health insurance exchanges (now called marketplaces) that would allow people to compare plans and easily apply for coverage and income-based financial assistance online. This, needless to say, did not go quite as planned. Most states decided not to set up marketplaces, leaving it to the federal government. Healthcare.gov, the online home for the federal marketplace, was largely nonfunctional when open enrollment began last October.

It was subsequently fixed in a widely-publicized “tech surge,” yet challenges still remain. For example, many people had information on their applications that was inconsistent with what was shown in government databases, and the process for resolving those inconsistencies has been slow. State-operated marketplaces were a mixed bag, with some (eg, California, Kentucky, Connecticut, Washington, Rhode Island) working reasonably well by most accounts, and others facing significant technological problems (eg, Oregon, Hawaii, Maryland, Massachusetts). However, even with these technological missteps, 8 million people signed up for a marketplace plan by the end of the open enrollment period, beating expectations (with at least 80% of them likely having paid their first month’s premium and actually enrolling). And, an estimated 6 million more people are enrolled in Medicaid since the third quarter of last year.

2. Making insurance more accessible.

One complaint with the individual insurance market that the ACA sought to address was discrimination against people with preexisting health conditions, who previously were either denied coverage altogether or charged higher premiums. People with expensive illnesses still face some access challenges—for example, very high out-of-pocket costs for certain specialty drugs—but in general, individuals with preexisting conditions now have no trouble getting access to insurance and they pay the same premiums as people who are healthy. This is significant because about half (49%) of adults younger than 65 years say they or someone in their household has a preexisting condition.

3. Making insurance more affordable.

This is perhaps the hardest of the ACA’s aims to sort out. In part, there is no easy answer because the effect varies so much, depending on individual circumstances. The preponderance of the evidence, however, suggests that insurance is now more affordable on average than it was before the ACA’s implementation:

  • Limits on the share of premiums that insurers can devote to administrative costs and profits have led to rebates for consumers and businesses and lower premiums than would have otherwise been the case.
  • Although there was much controversy last fall about people who experienced cancellation of individual insurance policies that didn’t include services defined by the ACA as essential or excluded people with preexisting conditions, and who then saw their premiums increase under the ACA, a recent Kaiser Family Foundation (KFF) survey of people in the individual insurance market shows that just as many people who switched to ACA-compliant plans saw their premiums decrease.
  • New federal data shows that 87% of the people signing up for coverage in the federal marketplace qualify for income-based premium subsidies that lower their average premium from $346 per month to $82, a reduction of 76%.

4. Reducing the number of Americans who are uninsured.

This is perhaps the ultimate test of whether the ACA is working as intended: Is it significantly diminishing the 48 million Americans who were previously uninsured? It will be quite some time before we have the results of large federal surveys that can be used to measure changes in the number of people uninsured. And projections from the Congressional Budget Office suggest that it will take several years for the full effects of the ACA on insurance coverage to ramp up.

But we are already starting to see signs of a decreasing number of uninsured individuals. A large tracking poll from Gallup shows that the percentage of adults who say they are uninsured is down from 17.1% in the fourth quarter of 2013 to 13.4% today. Earlier surveys from the Urban Institute and RAND also show declines. And the recent Kaiser Family Foundation individual insurance market survey shows that nearly 6 in 10 of those enrolling in health insurance marketplaces were previously uninsured.

For years we’ve debated the ACA based on hypotheticals and spin. Now, as the law is being implemented, facts are starting to enter the discussion, and that’s a welcome development. Of course, because the ACA—like any complex law—has both losers and winners, it will no doubt continue to remain controversial for the foreseeable future, even if it accomplishes what it’s supposed to.


About the author: Larry Levitt, MPP, is Senior Vice President for Special Initiatives at the Kaiser Family Foundation and Senior Advisor to the President of the Foundation. Among other duties, he is Co-Executive Director of the Kaiser Initiative on Health Reform and Private Insurance.

About The JAMA Forum: JAMA has assembled a team of leading scholars, including health economists, health policy experts, and legal scholars, to provide expert commentary and insight into news that involves the intersection of health policy and politics, economics, and the law. Each JAMA Forum entry expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. More information is available here and here.



JAMA Forum: Reading the Tea Leaves on Proposed Health Insurance Premium Hikes in a Post-ACA World

Gail Wilensky, PhD

Gail Wilensky, PhD

Health economists and other experts generally expect that consumers will pay more for health insurance premiums year after year. That’s because 1 or more of the components of premiums—the cost of medical claims, administrative costs, or profits—are usually anticipated to increase at least as fast as the rate of medical inflation.

Just how big the premium increases are likely to be each year is the great unknown—and for 2015, there are more uncertainties than usual. There’s been intense speculation about potential increases for next year’s premiums in the new federal and state insurance exchanges, partly because so little is known about (particularly regarding the health status of) those newly insured under the Affordable Care Act (ACA) and partly because of the potential political implications that 2015 premium increases might have for the 2014 midterm congressional elections.

What Do We Know Now?

Just as premium prices for 2014 varied widely, the proposed increases in premium rates for 2015 vary substantially across plans, within a state, and across states. Figures have been released for about a dozen states plus the District of Columbia. In most of the states, the health insurer with the largest number of newly insured under the ACA exchange, which frequently had offered the lowest or second-lowest premiums in their states in 2014, are proposing larger increases—either because they charged too little in 2014 or they feel they can tolerate some drop in enrollment. Plans that ended up with smaller enrollments in 2014 are requesting small increases and sometimes decreases in premiums.

Here’s a sampling of proposed increases:

Maryland. In Maryland, CareFirst, the dominant insurer in the state’s exchange in 2014, proposed a premium increase for the BlueChoice plan of almost 23%, compared with a proposed increase of 12% by Kaiser, which enrolled a relatively small number of people in 2014. Two new insurers, Cigna and UnitedHealthcare, are planning to offer plans in Maryland for 2015. Increased competition in other states has usually resulted in lower premium options being available; one would expect the same will happen in Maryland as well.

Virginia. The increases proposed for Virginia also vary significantly. Humana has proposed the highest increase (22.4%). Overall, the proposed increase in Virginia (when weighted by 2014 enrollment) is 11.7%. As in Maryland, 2 new insurers are planning to enter in 2015.

Washington: For Washington State, the weighted average increase is 9.6%.

Oregon. In Oregon, the health plan that had enrolled approximately three-fourths of the new enrollees has requested an increase of 12.5%.

District of Columbia. Most of the proposed increases for plans offered by CareFirst BlueCross, the largest insurer in the nation’s capital, range from 10% to 15%. However, the company is proposing a 25% increase for its bottom-level, catastrophic coverage plan.

What Happens Next?

The process by which health insurance rate increases are reviewed varies by state. In most states (35 states plus the District of Columbia as of 2012), prior approval is required by the insurance regulators before the insurer can raise rates. In Maryland, for example, a prior-approval state, the state’s insurance administration can ask insurers to lower their rates before it agrees to approve them. That’s what happened last year: CareFirst had initially proposed a 25% rate increase, but regulators cut the final rates by 10%—which may in part explain the large increase CareFirst has requested for 2015.

Other states may simply review rates or allow rate changes to go into effect after a certain period of time, with the state acting later if the rate is found to be unreasonable, but these types of reviews are becoming less common. Under the ACA, the Department of Health and Human Services (HHS) is authorized to review premium increases for states that are regarded as having ineffective review processes. Five states are in this category.

The ACA also authorizes HHS to review any rate increases that it regards as “unreasonable,” which the agency has defined to be increases exceeding 10%. The expectation had been that most insurers would keep their premium increase requests just below 10% to avoid HHS review—but obviously, that has not been the case for many of the proposed increases.

New Dynamics Being Played Out

Several types of responses by insurers are beginning to play out in response to the “first year” of experience with enrollees in plans offered by the health exchanges (in reality, only 2-3 months’ experience for many of the new enrollees). Some of the new entrants offering plans in the health exchanges in 2015 are some of the country’s largest insurers. Aetna, WellPoint, UnitedHealthcare, and others were deliberately very selective about the number of markets they entered in 2014, and planned to enter additional markets in 2015, when more information about enrollees was expected to be available. But most had not anticipated the size of the enrollment surge that occurred in late March nor the extension of the enrollment period to mid-April to accommodate glitches in the exchanges.

That means these insurers have less information for 2015 than they anticipated; most are submitting bids with little information on existing enrollees’ use of health care services and no information about how the enrollee numbers and mix might change with the next open enrollment period. Information reported to date indicates that the early enrollees attracted to the exchanges were sicker than average. This is not surprising, because the ACA doesn’t allow insurers to charge more for those who have a higher expected use (other than for age, and that variation is limited to a 3:1 price differential between the oldest and youngest enrollees).

Another wrinkle is that insurers are currently permitted to continue existing individual plans that do not offer the ACA’s specified “essential health benefits” (in states willing to allow this extension) until 2016. This further segmented the market, with younger and healthier enrollees likely to stay in their more limited plans. What is less clear is whether the surge of reportedly younger (and presumably healthier) enrollees who waited until late March to enroll will balance out the health status of the earlier enrollees.

Another uncertainty involves how the exchanges will affect costs related to Part D Medicare (Medicare Prescription Drug Coverage). Part D Medicare plans that propose the highest premium rate increases tend to lose enrollment to plans that have small ones, which has kept cost increases well below projections. But in the health insurance exchanges (where most plans have narrow physician networks), enrollees who switch plans are likely to lose access to the physicians in their previously held plan. On the other hand, because most people enrolled through the exchanges may not have had long-term relationships with the physicians in their plan, the barriers to switching may be lower than for other insured populations. Time will tell whether plan-switching in response to premium increases will also occur in the exchanges.


About the author: Gail Wilensky, PhD, is an economist and Senior Fellow at Project HOPE, an international health foundation. She directed the Medicare and Medicaid programs, served as a senior adviser on health and welfare issues to President George H. W. Bush, and was the first chair of the Medicare Payment Advisory Commission.  She is an elected member of the Institute of Medicine.

About The JAMA Forum: JAMA has assembled a team of leading scholars, including health economists, health policy experts, and legal scholars, to provide expert commentary and insight into news that involves the intersection of health policy and politics, economics, and the law. Each JAMA Forum entry expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. More information is available here and here.


Kidney Transplant Patients May Reap Big Benefits From Small Policy Changes

Small policy changes may help reduce geographic disparities in donor kidney distribution.  (Image: JAMA, ©AMA)

Small policy changes may help reduce geographic disparities in donor kidney distribution, a new study reports. (Image: JAMA, ©AMA)

An experimental policy that helped 2 states ease their geographic disparities in allocating donor kidneys may play a role in alleviating similar discrepancies nationwide, according to a new study.

National policy now specifies that if a donor kidney isn’t used in the donor service area that requested it, the organ then is offered regionally or nationally. The United States has 58 donor service areas, which are designated by the Centers for Medicare & Medicaid Services. Despite a 1998 rule from the US Department of Health and Human Services requiring geographic parity for kidney transplants, wait times for a donor kidney can vary among donor services areas, even those located next to each other.

In the early 1990s, however, Tennessee and Florida were allowed to implement a variance to keep kidneys available in-state before allocating them regionally or nationally. To learn whether the change alleviated geographic disparities, researchers at Northwestern University’s campuses in Chicago and Evanston, Illinois, analyzed data from the Organ Procurement and Transplant Network.

Their analysis compared geographic disparities in Tennessee and Florida for 5 years before the variances were implemented, from 1987 to 1991, and afterward, from 1992 to 2009. Comparisons with other states that didn’t implement variances were included in the study, published online today in the Clinical Journal of the American Society of Nephrology.

The investigators measured disparities with 5 indicators: kidney transplant rates, wait times for transplants, cumulative dialysis time, 5-year graft survival, and how long the kidney was chilled with a small or no blood supply. Results showed that disparities measured with those indicators decreased by 41%, 36%, 31%, 9%, and 7.5 hours, respectively, in Tennessee and by 28%, 62%, 34%, 19%, and 5 hours, respectively, in Florida.

In the comparison states—North Carolina, Pennsylvania, Wisconsin, California, New York, and Ohio—geographic disparities worsened or improvement was inconsistent from 1987 to 2009.

The study authors wrote that Tennessee and Florida have “the only [United Network for Organ Sharing ] policy variances for which actual evidence exists in support of its ability to reduce geographic disparity.”

They added that their findings are timely, as discussions are under way to restructure the kidney allocation system to reduce geographic disparities. Small changes to the existing system can lead to substantial improvements without risking unforeseen problems that may arise from more sweeping changes, such as redefining regions, the authors wrote.

JAMA Forum: A Global Epidemic in Plain Sight

Joshua M. Sharfstein, MD

Joshua M. Sharfstein, MD

The leading cause of death in Maryland among women during pregnancy and the first year after delivery is not hemorrhage, eclampsia, heart disease, cancer, or even motor vehicle accidents.

It’s homicide.

Lethal violence against pregnant and postpartum women is shocking, but in one sense not surprising. The recent mass shooting in California has shed light on a dark corner of our society, in which misogyny poses a real threat to the health of women. Intimate partner violence is a global epidemic, affecting women of every race, ethnicity, culture, age, educational level, and socioeconomic strata. In the United States, about one in four women sustain severe physical violence from a partner in their lifetime.

Such injuries, such as fractures, bruises, and lacerations are the most obvious health effects. Other consequences include depression, anxiety, posttraumatic stress disorder, asthma, chronic pain, smoking, and substance use disorders.

Both public safety and health professionals have a critical role to play in addressing this crisis.

Police Departments can assign domestic violence experts to police units, improve victims access to information, implement a standardized lethality assessment to guide response, and provide free and confidential mail forwarding for victims. Maryland has taken all these steps and has made women who are forced to leave a job because of intimate partner violence eligible for unemployment insurance. Judges and police departments must protect victims of abuse in order to keep them from becoming victims of homicide.

Health professionals at all levels, in every subspecialty, have an equally vital role. We can also save lives by identifying those at risk and helping them take action to protect themselves. Our health department in Maryland has developed a screening tool for use in emergency departments and medical offices across the state. In the last year, we have given more than 100 training sessions to health professionals and more than 1000 clinicians have pledged to use it every day.

Maryland is seeing progress, with homicides of women down from an average of 81 from 2006 to 2008 to an average of 66 from 2011 to 2013. It has helped immeasurably to have Gov Martin O’Malley make further reductions in homicides one of his top strategic goals for the state.

But there is so much more to do, in our state and every other. Just this week, in suburban Baltimore, another pregnant woman’s death is under investigation as a homicide.

The 24/7 national domestic violence hotline is 1-800-799-SAFE. It should be as integral to medical care as a stethoscope.


About the author: Joshua M. Sharfstein, MD, is Secretary of the Maryland Department of Health and Mental Hygiene. He has previously served as the Principal Deputy Commissioner of the US Food and Drug Administration and as Commissioner of Health for Baltimore. A pediatrician, he lives with his family in Baltimore.

About The JAMA Forum: JAMA has assembled a team of leading scholars, including health economists, health policy experts, and legal scholars, to provide expert commentary and insight into news that involves the intersection of health policy and politics, economics, and the law. Each JAMA Forum entry expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. More information is available here and here.



JAMA Forum: “Have You Ever Served?” The VA and the Private Sector

Diana Mason, PhD, RN

Diana Mason, PhD, RN

I’m a veteran. I served in the US Army Nurse Corps for 3 years after I graduated from nursing school, the last 2 years of which were paid for by the Army. From 1970 to 1973, I served as a lieutenant, then a captain, at Walson Army Hospital at Fort Dix, NJ, while colleagues of mine were serving in Vietnam. Now we’re all eligible for health benefits through the Department of Veterans Affairs (VA), although those who served in Vietnam have access to a higher level of benefits and priority for enrollment in the VA health system than I do. I have never used the VA health system as a patient, but by most reports, veterans in the system receive very good care.

The VA runs the largest integrated health system in the country, with a budget set by Congress. Until recently, it has received widespread acclamation as a leader in patient safety and use of electronic health records with patient access. Recent disclosures of excessive wait times for veterans to enroll in the VA health system and the administrative cover-ups and falsification of wait-time data led to the resignation of VA secretary Eric Shinseki in late May. Congress called for the resignation despite the Senate’s failure to confirm 2 of 3 open assistant secretary positions for more than a year. And Congress has also passed House and Senate versions of bills that would, among other things, increase the private sector’s involvement in the care of veterans. But the private sector may be ill-prepared to ensure better care for US veterans.

In April of this year, the VA released a report showing that, of the approximately 22 million veterans, roughly 5.7 million received treatment at a VA facility in 2013.* Only about a quarter of our veterans receive care through the VA health system. Why aren’t more using it? According to the 2010 National Survey of Veterans, 72% of veterans report being in good to excellent health and are able to carry out activities of daily living without assistance. But 42% of those who have never used VA health benefits said they didn’t know about them and 26% didn’t know how to apply.

Clearly, the VA health system would be even more overwhelmed if more veterans tried to use it. With about three-quarters of veterans either not getting health care or getting it from the private sector, the suggestion that non-VA health care clinicians and facilities play a greater role in providing care to veterans seems reasonable. But Linda Schwartz, RN, PhD, commissioner of the Connecticut Department of Veterans’ Affairs and a veteran who served as an Air Force nurse during the Vietnam War (and who, for the past 10 months, has been awaiting confirmation by the Senate as assistant secretary of the VA’s Office for Policy and Planning), has argued that the private sector may be ill-equipped to deal with the special health problems arising from veterans’ occupational and military exposures—exposures that vary according to when and where they served and what work they did. For example, veterans could have health problems arising from exposure to Agent Orange (Vietnam and Korea), contaminated water (Camp Lejeune, 1957-1987), oil-well fires and open burn pits (Iraq and Afghanistan), and radiation (“Atomic Veterans”).

The VA’s health care professionals are experts in the diagnosis and management of the consequences of these exposures. Most clinicians in the private sector are not. In fact, a 2011 online survey of community-based mental health and primary care professionals found that 56% of the respondents failed to ask patients whether they have ever served in the military or are family members of those who have served. If this is never asked, it’s easy to understand how, as Schwartz noted in her commencement address at Quinnipiac University School of Nursing in May, a veteran may be living with chronic pain or other debilitating condition arising—perhaps unknowingly by even the veteran and his or her health care providers—from a service-related injury or exposure that may be treatable if properly diagnosed.

Schwartz was instrumental in the development of an initiative of the American Academy of Nursing (disclosure: Schwartz is an academy fellow and I am the academy’s current president), in partnership with the National Association of State Directors of Veterans Affairs, called “Have You Ever Served in the Military?” The initiative seeks to raise the awareness of veterans’ health needs among clinicians in the private sector and includes materials for health care professionals that link time and site of military service, occupation, potential exposures and injuries, and relevant diagnoses. In addition, the initiative aims to embed the question “Have you ever served?” into electronic health records and include an algorithm to direct clinicians’ subsequent line of assessments.

It all begins by asking: “Have you ever served in the military?”

In May, the state of Connecticut passed Public Act 14-141, requiring, among other things, that “Whenever a person is admitted to a hospital, such person shall be asked if he or she is a veteran.”  Schwartz told the graduates at Quinnipiac about the genesis of that law. A couple of years ago she was involved in helping a veteran from Maine, a man hospitalized with a life-threatening condition while visiting his mother in Connecticut. A veterans services officer questioned the patient about his service; the officer realized that the man had been exposed to Agent Orange in the 1960s. The patient was subsequently diagnosed with non-Hodgkin’s lymphoma—a possible consequence of the exposure.

In writing this blog post, I realize that I have never disclosed to any health care provider in the past 40 years that I am a veteran. Even as a nurse, I never thought to offer the information during a health care visit. And no one has ever asked.

*Exact numbers on veterans are difficult to obtain and vary by source.


About the author: Diana J. Mason, PhD, RN, is the Rudin Professor of Nursing and Codirector of the Center for Health, Media, and Policy at the Hunter College; Professor at the City University of New York; and President of the American Academy of Nursing.

About The JAMA Forum: JAMA has assembled a team of leading scholars, including health economists, health policy experts, and legal scholars, to provide expert commentary and insight into news that involves the intersection of health policy and politics, economics, and the law. Each JAMA Forum entry expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. More information is available here and here.

Author Insights: Young Adults With Access to Parents’ Coverage Save On Health Costs

Kao-Ping Chua, MD, of Boston Children’s Hospital, and Benjamin D. Sommers, MD, PhD, of Harvard University’s School of Public Health, found out-of-pocket health care costs for young adults younger than 26 years decreased after a law went into effect that allowed most individuals in this age group to obtain health insurance through a parent’s policy. Image: Provided by Kao-Ping Chua

Kao-Ping Chua, MD, of Boston Children’s Hospital, and Benjamin D. Sommers, MD, PhD, of Harvard University’s School of Public Health, found out-of-pocket health care costs for young adults younger than 26 years decreased after a law went into effect that allowed most individuals in this age group to obtain health insurance through a parent’s policy. Image: Provided by Kao-Ping Chua

Young adults report improved health and lower out-of-pocket costs after a provision of the Affordable Care Act (ACA) went into effect in 2010 that allows individuals to obtain health insurance through a parent’s policy until their 26th birthday. Before the ACA, dependent children were often “aged out” of a parent’s plan at age 19 years, or age 22 years if they were full-time students.

Much debate has centered on whether the implementation of the ACA would help or hurt young people. Some provisions have made it easier for young adults to access insurance either through a parent’s plan or, starting in 2014, by purchasing insurance through a state or federal health insurance exchange. However, some concerns have been raised that young people may pay higher premiums to offset the health costs of older or less healthy individuals obtaining coverage through the health exchanges.

Although it’s too soon to assess how young adults are faring in the health insurance exchanges, analyses have suggested that allowing young adults to stay on their parents plan increased health insurance coverage among younger adults. An analysis appearing in today’s JAMA, by Kao-Ping Chua, MD, a pediatrician in the division of emergency medicine at Boston Children’s Hospital, and Benjamin D. Sommers, MD, PhD, of Harvard University’s School of Public Health, examined health insurance coverage, health spending, and self-reported health of adults younger than 26 years before and after the 2010. Adults aged 26 through 34 years were used as a control group. They found that adults younger than 26 years saved on out-of-pocket costs after the provision became effective and reported better physical and mental health compared with those aged 26 through 34 years, who were too old to benefit from the provision.

Chua, who is also a student in the Harvard PhD Program in Health Policy, discussed the findings with news@JAMA:

news@JAMA: Why did you decide to do this study?

Dr Chua: I decided to do the study because young adults have had the highest rate of uninsurance in the United States, leading to poorer health and a higher risk of catastrophic health costs.

Previous research showed that both low-income individuals in Oregon who gained Medicaid coverage through a lottery system and elderly adults who gained Medicare insurance have improved health. The incidence of catastrophic medical expenses also decreased for those who gained Medicaid coverage in Oregon.

news@JAMA: How do your findings add to previous research on this provision of the ACA?

Dr Chua: Ours is the first that looked at medical spending using the Medical Expenditure Panel Survey (an annual survey of US health expenditures). Other studies have looked at health insurance coverage and utilization but have not had as much detail on medical spending.

The biggest finding is that the share of all healthcare expenditures paid out-of-pocket decreased, by about 3.7 percentage points. That suggests that having health insurance is doing what it’s supposed to be doing, protecting people against the high cost of health care.

news@JAMA: Why do you think those who were eligible for coverage under the provision reported better physical and mental health?

Dr Chua: In the Oregon Medicaid expansion experiment, the authors showed that those who were selected to receive coverage reported better mental and physical health even before changes in utilization began. Just knowing you will have access may improve a person’s sense of well-being.

We only had 1 year of utilization data, so that may have made it difficult to detect small changes in utilization. Our analysis suggests that primary care use increased by 2.2%, but the finding wasn’t statistically significant. Our study may not have had the power to detect smaller differences.

news@JAMA: Your sample was predominantly (73.9%) white. Is there any reason to think the results might be different in other demographic groups?

Dr Chua: There have been other studies suggesting that certain racial and ethnic groups were more or less likely to gain coverage. But young adults of all races gained insurance. There may be differences in magnitude, but all groups gained in some way.

Our study was not powered to look at subgroups. So future research would need to address differences in health spending among racial and ethnic groups.

news@JAMA: Are there any other research questions that remain to be answered?

Dr Chua: This particular data set didn’t include objective health measures, like blood pressure readings. It would be interesting to look at the effect of this provision on objective health measures using other data sets.