JAMA Forum: What Near-Death Experience Can Tell Us About Medical Care

David Cutler, PhD (Image: Ted Grudzinski/AMA)In 2005, a survey was conducted examining how aggressively physicians treat patients near the end of life. Some 1500 primary care physicians and cardiologists were presented a scenario describing an 85-year-old man with severe congestive heart failure. The fictional patient was described as receiving maximal medications, using supplemental oxygen at home, and not being a candidate for surgery or other procedures to treat blockages in blood vessels to the heart. When the patient experiences worsening shortness of breath (a symptom of fluid accumulating in his lungs) and makes an office visit, increasing his supplemental oxygen makes him more comfortable.

The survey group was then asked “How often (always/almost always, most of the time, some of the time, rarely) would you arrange for each of the following?” The choices were

A. Allow the patient to return home and receive increased oxygen and increased diuretics (to remove excess fluid from the body)

B. Admit to the hospital (but not to the intensive care unit [ICU] or coronary care unit [CCU]) for aggressive removal of excess fluids

C. Admit to the ICU/CCU for intensive therapy and monitoring

D. Place a pulmonary artery catheter to assess the severity of heart failure and to optimize drug treatment

E. Recommend a pacemaker

F. Initiate or continue discussions about palliative care

Recently, the responses to this survey were analyzed by me, Ariel Stern, PhD; Jonathan Skinner, PhD; David Wennberg, MD, MPH. Although the data are nearly a decade old, there is no reason to think that answers today would be any different. Our analysis of these responses reveals the troubled state of American health care—as well as the possibilities.

Options A and B are less-intensive ways of managing the patient and each finds support in the literature. Three options—C, D, and E—are much more intensive but have no evidence to support them (they were not recommended in the guidelines then and are not recommended now). Option F, a palliative care discussion, is clearly warranted; half of patients like this die within a year. Thus, a physician following practice guidelines would be expected to choose A or B, plus F.

But the answers that physicians gave were far from these recommendations. One-quarter of physicians recommend 1 of the 3 most aggressive options. Only about half would likely have a palliative care discussion. Primary care physicians and cardiologists differ slightly in their answers, but not enormously so. Very aggressive treatments were supported by 22% of the primary care physicians and 28% of the cardiologists, while only 49% and 45% would have a palliative care discussion.


Cowboys vs Comforters

This issue has great import for medical spending. Based on the responses to our survey, we called the physicians who consistently advise aggressive end-of-life care not supported by guidelines “cowboys,” and those who would have a palliative care discussion “comforters.” A physician can be both a cowboy and a comforter, but empirically, few are.

Cowboys and comforters are not randomly distributed in the population, and medical spending reflects this. Medicare spending for end-of-life care is 60% more in an area where physicians are mostly cowboys than in one with few cowboys. An area full of comforters will spend 27% less. Generally, spending in this arena negatively tracks patient preferences. Patients routinely express a desire for comfort over aggressive care at the end of life.

What makes physicians become cowboys or comforters? Many physicians say that the fear of being sued for malpractice drives them to do too much. But our survey evidence does not support this theory. Although 41% of cardiologists report that they have sometimes or frequently done a cardiac catheterization because of malpractice fears, there is no correlation between the response to that question and being a cowboy. Nor is there a relation between physicians who report responding to patient expectations and being a cowboy. Some characteristics are correlated with not being a cowboy: those who are younger or who practice in larger groups are much less likely to be cowboys than other physicians.

In reality, I think there are 2 fundamental factors at work, and each is important for the future of medical care. First, although the evidence of what is appropriate may exist in guidelines and medical journals, nothing compels physicians to follow it. A cardiologist can believe he has better outcomes than the literature suggests. And if the issue comes up, “my patients are different” or “my outcomes are better” usually ends the conversation. These statements cannot be generally true or the literature would reflect that. But who can say if they are true for any particular physician?

The interesting question is why these statements are rarely challenged. Sometimes, big systems do have these conversations, which may explain why there are fewer cowboys in hospital-based and group practices. Intermountain Healthcare in Utah is famous for the idea that internal standardization can lead to better care. Even today, though, Intermountain remains the exception.

Look behind the curtain, and one sees the importance of money. Standardization generally results in a greater reduction in overused services than an increase in underused services. Thus, in a fee-for-service system, standardization results in a revenue loss. Add to this the financial and psychic costs of physician profiling (to compare practice patterns) and standardization, and it is easy to see why even the largest systems avoid it.

As the payment system changes, this calculus will change as well. In an accountable care organization (ACO), money saved by avoiding unnecessary procedures becomes surplus to the organization. The same is true for organizations accepting a predetermined bundled payment for an episode of illness. There are more than 600 ACOs in the country today, and many hundreds of institutions are receiving bundled payments. Thus, internal analysis and standardization may become significantly more frequent.


Talking About Palliative Care

Why do only half of clinicians discuss palliative care for patients at the end of life? A likely reason is that such discussions are painful and physicians naturally wish to leave them to someone else. This choice may be easy to rationalize because so many physicians are involved in patient care near the end of life. The primary care physician can say that she is not an expert in severe congestive heart failure and hence the cardiologist needs to discuss options with the patient. The cardiologist can say that the primary care physician knows the patient better and is better equipped to have the palliative care discussion. Each is right, but the outcome is still bad.

Again, what is needed is a system for seeing that such discussions take place. At institutions such as Gundersen Lutheran in Wisconsin, end-of-life conversations are routine as people age and end-of-life spending is correspondingly lower. In other areas, the conversations are avoided. Not surprisingly, the Dartmouth Atlas shows enormous variation in end-of-life care spending across the country.

But there is cause for hope: if all physicians followed the guideline recommendations, end-of-life costs would decrease by one-third, and overall Medicare costs would decrease by 15%. This outcome can be achieved without rationing: gathering data, having discussions with colleagues and patients, and setting standards would do an enormous amount.

My suspicion is that much of health care is like the case of caring for the fictional 85-year-old with congestive heart failure. No one is trying to do the wrong thing, but the consequences of unstandardized and often excessive care is wasted money and unnecessary pain. Establishing the right systems, realigning payments, and pushing for the right care can accomplish far more than many think is possible.


About the author:

David M. Cutler, PhD, is the Otto Eckstein Professor of Applied Economics in the Department of Economics and Kennedy School of Government at Harvard University and a member of the Institute of Medicine. He served on the Council of Economic Advisers and the National Economic Council during the Clinton Administration and was senior health care advisor to Barack Obama’s presidential campaign. He also was involved in the debate over the Massachusetts health reform legislation discussed here and is a Commissioner on the state’s Health Policy Commission. Heis the author of the recently published The Quality Cure, and Your Money or Your Life (2004). He tweets at @cutler_econ.

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: Tackling the Ebola Epidemic

Lawrence Gostin, JD

Lawrence Gostin, JD

The Ebola virus epidemic in West Africa is now out of control, but it shouldn’t have come to this. Ebola virus disease (EVD) is a preventable disease, but the current epidemic is challenging efforts to contain it. Previous outbreaks that have occurred since the virus was first detected in 1976 have been confined to rural areas. This time, EVD has reached the urban landscape, with people and animals congregating together. Extensive travel across land borders and by air is furthering its spread.

Why Ebola Is Out of Control

The most affected countries—Guinea, Liberia, and Sierra Leone (with recent spread to Nigeria, which currently has a dozen cases)—are ranked lowest in global development and do not have the basic infrastructure to contain the Ebola epidemic. Even with international help, it will take at least 6 months to bring the crisis under control, according to Médecins Sans Frontières/Doctors Without Borders. For now, Ebola is spreading unchecked because of such factors as fragile health systems in resource-poor countries, cultural practices, and deep-seated distrust.

Broken Health Systems

Being treated or working in a hospital in affected states is hazardous. Health professionals are the most susceptible: they typically care for infected patients without personal protective equipment and infection controls; they lack training in differential diagnosis of and treatment for EVD; and they are underpaid. Patients, too, perceive that hospitals in the affected countries are unsafe places that offer little effective treatment. Consequently, patients with Ebola-type symptoms stay away, and those who need treatment for myriad health problems—from AIDS and malaria to cancer and heart disease—remain untreated in the community.

The persistence of traditional burial and other cultural practices in West Africa also make it more difficult to contain Ebola. Loved ones come in close contact with the deceased, including ritual touching and bathing. Burial practices create the conditions for transmitting EVD, which then can be spread throughout the community. Another practice, consuming bush meat, which might include animals that are reservoirs for Ebola virus, is a traditional source of food, especially for poor Africans, providing life-sustaining protein. Women, as the traditional caregivers, are more likely to contract the virus than men.

Further challenging attempts to contain the spread of Ebola are common misperceptions, such as the belief that aid workers from medical groups were spreading the disease. Public education has been neglected and governments have curtailed accurate news reporting about the crisis. Epidemic control requires trust and an informed public, so risk communication is fundamental to controlling Ebola’s spread.

Ethical Issues

Also related to the issue of trust has been the use of scarce experimental therapies. More than 20 Ebola outbreaks have erupted in sub-Saharan Africa, yet the world was unprepared for the current tragedy, with no licensed vaccines or treatments. (This lack of readiness would not have surprised Albert Camus. As he wrote in The Plague, “Everybody knows that pestilences have a way of recurring in the world; yet somehow we find it hard to believe in ones that crash down on our heads.”)

An experimental drug called ZMapp, which has neither been proven effective nor tested for safety in humans, was available in scarce amounts and was administered to 2 US aid workers and, reportedly, to a Spanish priest. The last remaining doses have now been delivered to West Africa, but the initial perceived preference given to white foreign workers fueled a sense of injustice. Although selecting who should get the untested treatment is an agonizing choice, it’s my opinion that priority should be given to African health workers, who die of Ebola in far greater numbers than do foreign workers. In any case, it is vital that allocation decisions be made fairly and transparently. The decision to treat the foreign workers was made behind closed doors without community consultation. Going forward, high-resource countries should create public-private partnerships to ramp up development and rigorous evaluation of vaccines and treatments.

Militarization of a Disease

Adding to the distrust that hinders attempts to control the epidemic is local populations’ fear not only of Ebola but also of the militarization of the disease. Countries have erected cordons sanitaires (guarded lines preventing anyone from leaving), but are using ancient methods to enforce the quarantine. In West African hot spots, armed troops have established blockades, closed roads, and banned travel beyond the guarded perimeter.

As a result, the populace is finding it hard to obtain food and other basic necessities. Targeted travel restrictions may be necessary, but there is a smarter way to go about them, through humane care and incentives. Governments should provide people with nourishing food, health care, and psychosocial support. Transmission hot zones can’t be ignored, but neither can the needs and human rights of communities.

What Can Be Done Now? A “Health Systems Fund”

Fragile health systems are at the root of the problem, and bolstering them is a key to fighting Ebola and preventing another uncontrolled outbreak. Affected countries are unprepared for Ebola’s complexities; they are unable to provide all their people basic health services, much less the requirements of an Ebola response, including full body protective gear, specially trained health workers, isolation units, and advanced laboratory capacity with higher biosafety capabilities. Building strong health systems would rebuild the most basic community asset: trust. Looking ahead, the international community should mobilize to provide sustainable funding scalable to needs.

This crisis represents a manifest failing of the international community, particularly its wealthier members, which ought to have been generous in supporting surveillance and response capacities obligatory under the International Health Regulations (IHR). The World Health Organization (WHO), the World Bank, and the United States Agency for International Development, among others, have made notable pledges of support. But what the region needs now is an assurance that these funds will be ample and sustainable.

To address this need, I propose an emergency, and then an enduring, “Health Systems Fund” administered by WHO (with participation of local governments and civil society) and supported by high-resource countries. Considering the funding needs, an immediate (emergency) down payment of $200 million is needed for the affected countries and their at-risk neighbors. The money should be spent to strengthen health systems. Building on recent pledges of support, these additional funds could reward and motivate frontline health workers, ensure humane conditions in communities subjected to cordon sanitaire, and establish surveillance and response preparedness.

This fund would be surprisingly affordable, with this initial installment of funding representing only 1% of international health assistance. Growing the fund over time into a multibillion dollar funding channel for lower-income countries would finally make it possible to mobilize the resources envisioned in the IHR, as well as the growing global commitments to universal health coverage. Eventually, the fund might be merged with the Global Fund to Fight AIDS, Tuberculosis and Malaria into a new Global Fund for Health.

It is in all states’ interests to contain health hazards that may eventually travel to their shores. But beyond self-interest are the imperatives of health and social justice: a humanitarian response that would actually work, now and for the long term.


About the author: Lawrence O. Gostin, JD, is University Professor and Faculty Director, O’Neill Institute for National and Global Health Law, Georgetown University Law Center, and Director of the World Health Organization Collaborating Center on Public Health Law and Human Rights. His most recent book is Global Health Law (Harvard University Press).

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: Much Ado About Narrow Networks

Andrew Bindman, MD

Andrew Bindman, MD

The bumpy rollout of the health insurance coverage expansion by the Affordable Care Act (ACA) through private insurance exchanges ultimately exceeded enrollment expectations. The question is no longer whether the public will embrace these new health insurance marketplaces, but whether individuals are happy with their ability to use their new plans to access care.

In several states, there are concerns that the networks of physicians available through health plans sold in insurance exchanges are sometimes too narrow, limiting access to care and disrupting long-standing patient-physician relationships for some enrollees. The concern has surfaced mainly in the form of anecdotes, with no reliable estimate of how many individuals are negatively affected. But physician organizations have been quick to ring the alarm bell on behalf of patients and, presumably, their own self-interests.

Cost-cutting Déjà vu?

There is a striking familiarity about this concern that harkens back to the 1990s, when consumers pushed back against attempts by managed care organizations to limit their choice of physicians. In response, many health plans redirected their cost-cutting efforts away from narrow networks and focused instead on limiting benefits and finding ways to keep high-cost patients from joining their plans.

The regulatory requirements within the ACA have removed these cost-saving maneuvers by standardizing the essential benefits health plans must provide and by eliminating opportunities for health plans to select against high-cost patients. With these options constrained, it is perhaps not surprising that health plans would once again turn to narrow physician networks as a means to control costs.

Narrow networks can reduce a health plan’s cost by reducing access to high-cost services and by directing patients to physicians who accept lower payments in return for promises of higher volume. There would appear to be obvious potential for savings, as the recently released Medicare physician payment data revealed marked variation in the intensity of services and payment amounts to physicians; fewer than 2% of physicians generated 24% of the total payments. If plans are able to avoid these sorts of high-cost physicians, who are disproportionately clustered in a few specialties, there is the potential for real savings. How much might plans save by using a selective process to prevent high-cost physicians into their networks? Estimates vary, with some suggesting it could be as high as 25% of costs.

The outcry associated with narrow networks might be more muted if it were clear that networks were excluding only extreme high-cost outlier physicians and including physicians of similar or better quality who could provide the same services. Patients are particularly interested in having their regular source of primary care available through a plan’s network—and when that’s not the case, it raises concerns about the quality of all of the available physicians.

The lack of transparency about how plans decide who is in the network and who is excluded undermines the patients’ and physicians’ confidence in the process. What’s more, during the initial rollout of insurance exchanges, many of the participating plans provided consumers with misleading information about their physician networks. As a result, many individuals signed up for a plan that they believed would include their regular physician, only to find out afterwards that that was not the case.

Strength in Numbers

Physicians are attempting to outflank plans’ attempts to form narrow networks by forming groups with significant market control. By negotiating as a large group, physicians hope to prevent plans from being able to select among them to create narrow networks at lower rates. To further reinforce their position, physician organizations are encouraging legislators to pass “any willing provider” laws that would require plans to contract with any qualified physician.

Although these strategies maximize the potential for access, they provide high-cost physicians with a safe haven to continue practice as usual, which could undermine the effectiveness of health plans to control costs. What is needed are clear ground rules for how and when health plans should be allowed to narrow their networks, rules that would balance the competing interests of preserving access and quality while allowing for some cost controls. Health insurance exchanges might be a good place for establishing these rules, particularly in states where the exchange has already positioned itself as an active purchaser working on behalf of consumers.

Standards are needed for physician network adequacy, just as there have been standards established for different levels of insurance coverage (bronze, silver, gold, and platinum tiers). Such standards should address the number of physicians by specialty categories that are available on a population and geographic basis for the plan. For example, there are some rudimentary federal standards for the number of primary care and specialist physicians needed on a population basis that were derived from data in integrated health plans. These could be updated and perhaps modified to take the population’s health risk, geographic barriers, and other priorities into consideration when applying to the health plans in a particular state.

Out-of-pocket Costs

There should also be a routine assessment made of how a plan’s network affects out-of-pocket costs for its enrollees. Plans with overly narrow networks are likely to have more patients receiving care outside of the network, care that incurs higher out-of-pocket costs. Including these patient costs in the assessment of the actuarial value of a plan would result in a more honest valuation of a plan in an insurance exchange.

Insurers should also be required to be transparent in how they decide which physicians are included or excluded from a plan’s network. Physicians and consumers should be able to see the data on costs, quality, and other factors used to make network decisions so that there is both a shared understanding of how physicians are being evaluated and an opportunity to identify and correct erroneous information. If the decision is based on the performance of the physician’s group as opposed to the specific performance of the physician, that should be made explicit as well. Ideally, insurers would disseminate a clear set of performance standards that would let physicians and consumers know what physicians in a plan are expected to achieve in terms of access, costs, and quality in order to be a part of the plan’s network.

In the end, patients will decide if they are willing to accept narrow networks as a means of lowering health care costs. Although this approach failed in the 1990s, plans may have few alternatives as a means to control costs this time around. Faced with narrow networks or steep increases in premiums, patients may be willing to give up some amount of choice, particularly if they can be convinced that their plan is excluding physicians who are the true high-cost outliers and not the patients’ relatively low-cost primary care physicians.


About the author: Andrew Bindman, MD, is Professor of Medicine, Health Policy, Epidemiology and Biostatistics at University of California San Francisco (UCSF). He is the founder and Director of the University of California Medicaid Research Institute, a multicampus research program that supports the translation of research into policy.

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: Bye, Bye Employer-Sponsored Health Insurance?

Stuart Butler, PhD

Stuart Butler, PhD

The hullabaloo following the US Supreme Court’s ruling in the Hobby Lobby case has prompted a timely debate about the role of employers in providing health insurance. Some critics of the decision demand that employers be stopped from “interfering” with a worker’s insurance for certain services, such as contraception, even if the employer has profound religious objections to sponsoring such coverage. That  in turn led to efforts to pass legislation that would block privately owned firms from using religious beliefs as a reason not to provide certain features of health insurance.

Putting aside the legal technicalities, critics of the Hobby Lobby decision are right to be concerned about employers essentially controlling the health coverage of their workers. But most critics have the wrong solution.

The answer is not to start interfering with religious liberty, or engage in an arcane legal dispute about whether a private corporation is a “person,” or to strengthen mandates on employer coverage. The correct strategy is to push forward with tax reforms and other steps that would lead to the disappearance of most employer-sponsored insurance. That’s actually something both advocates of single-payer systems and conservatives should agree on.

Health economists of all stripes, as well as employers and benefits managers, recognize the notion that employers “pay for” health benefits is a myth. In truth, health insurance is just a part of an employee’s total compensation, like cash income or a payroll deduction for a 401(k) retirement plan.

Employers are not charities, and total compensation is determined by local labor market conditions. But under Internal Revenue Service (IRS) tax rules, if the employee lets his or her boss make the crucial decisions over the part of their pay involving health insurance, it becomes free of tax.

While tax-free employer-sponsored health insurance is familiar and popular, it has many problems, besides those at the center of the Hobby Lobby case. For one thing, the tax benefit is very regressive, with highly paid employees in the top brackets gaining most from the tax breaks and lower-paid workers receiving the least. That’s exactly the opposite of good public policy aimed at helping people afford insurance.

In addition, the illusion that the employer pays has long been criticized as encouraging overuse of care and fanning cost escalation. That’s a major reason why many employers have been decreasing the share of compensation paid in the form of “employer-paid” insurance, so that employees have more skin in the game in controlling costs. Add to those concerns the worry that employment-based insurance often results in “job-lock”— where a worker is reluctant to move to a better job or become self-employed”— because moving could result in a change or loss of coverage.

These problems have spurred many proposed reforms aimed at modifying the employer’s role in health insurance. The most recent is of course the Affordable Care Act (ACA). By establishing health exchanges—a mechanism widely advocated for many years—the ACA provides for some Americans an alternative platform to employment-based coverage for organizing health insurance. And by combining a cap on the tax-free status of employer-sponsored insurance with tax credits and subsidies for exchange plans, the ACA takes some steps down the road of reducing the tax bias associated with employer-controlled coverage.

But the design of the ACA falls short of what is needed. In an unwise effort to prop up the employment-based system and to contain the program’s budget cost, the ACA’s sponsors flinched from equalizing the tax breaks and subsidies for exchange plans and employer-sponsored health insurance. Yet that tax and subsidy disparity actually threatens to undermine employer-sponsored coverage in firms with many lower-paid workers. That’s because the government subsidies available for many such families enrolling in exchange plans are much larger than the tax benefits of employer-sponsored insurance , encouraging employers and workers to drop employer-sponsored insurance in favor of extra cash earnings. Meanwhile the delay of the ACA’s mandate on employers, triggered by concerns of hiring cutbacks, underscores the fact that trying to force employers to provide government-designed coverage is likely to fail.

Some have argued that employer-sponsored insurance will continue to erode, in part because of the ACA. Former Obama health advisor Ezekiel Emanuel, MD, PhD, an architect of the ACA, predicts that by 2025, fewer than 20%  of private-sector workers will have traditional employer-sponsored insurance. He could be right. Like conservative health economists, he has long criticized tax-exempt health insurance.

But rather than allow a transition to occur in a haphazard way, it would be wiser to have an open and thorough debate about the importance of moving away from employer-based insurance. Such a discussion hopefully would avoid a clumsy and likely damaging “fix” for the Hobby Lobby decision.

Back in 2007, I proposed a strategy for an orderly transition, called the Health Exchange Plan. That plan envisioned state-chartered exchanges. There would also be a cap on the tax-free status of employer-sponsored coverage, in conjunction with a refundable tax credit for lower-income families. The cap would be indexed to grow more slowly than the expected increase in employer-sponsored insurance, thereby gradually reducing the tax bias in favor of such coverage.

Importantly, the Health Exchange Plan still envisioned a continuing role for employers but not the role of picking coverage. The place of employment would continue to be where the transactions took place, with employers arranging payroll deductions for plans and helping employees sign up for plans. No doubt many larger firms would continue to offer wellness plans and take other steps to promote a healthy workforce. Some might continue to offer coverage, and would be allowed to do so, but most would transfer the control of coverage to their employees.

The result of the plan would be that the vast majority of employers would become facilitators of exchange-based coverage and no longer the sponsors or controllers of coverage. It seems to me that’s a result both Hobby Lobby and its critics would applaud.


About the author: Stuart M. Butler, PhD, is Director of the Center for Policy Innovation at the Heritage Foundation in Washington, DC, where he focuses on developing new policy ideas. Previously he served as Vice President for Domestic and Economic Policy Studies. He is also an adjunct professor at Georgetown University’s Graduate School, and serves on the board of trustees for the Convergence Center for Policy Resolution.

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: 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: 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.


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.