Boston, MA, United States (KaiserHealth) – Nearly two years after the passage of the federal health law, more than 40 percent of people say they know little or nothing about how the law will affect them, according to the Kaiser Family Foundation’s latest monthly health tracking poll, published in December. That figure hasn’t budged since April 2010, just after the law was signed.

Jonathan Gruber, an economist at the Massachusetts Institute of Technology, aims to change that with a book, “Health Care Reform: What It Is, Why It’s Necessary, How It Works,” that explains the ins and outs of the law in an innovative way: an adult comic-strip form similar to graphic novels.

Gruber was one of the architects of the Massachusetts’ health care overhaul, which included many features that appear in the federal law, and he advised the Obama administration and Congress on the Affordable Care Act. I spoke with him about his new book, which he co-authored with HP Newquist. The book is illustrated by Nathan Schreiber.

Q. What made you decide to write a book for consumers about health reform?

A. I think what really inspired me was hearing that when you polled consumers about the Affordable Care Act they were split in their support. But when you polled them about individual pieces of the law, they liked it. As an educator, you didn’t have to do any more than explain what the law did [to gain support]. It needed to be explained in a way that people understood.

Q. Why did you choose a graphic novel format?

A. The publisher approached me about doing it that way. At first I wasn’t that enthusiastic. I didn’t think it would be that effective. But the publisher said they had done a graphic novel about the 9/11 Report. My son likes graphic novels, he’s 17. He said it’s a great opportunity, it’s a great medium. When you’re on a plane and they want to teach you what to do in case of accident, they hand you a graphic. I think it was the right call.

Q. Who’s the primary audience for this book?

A. I wrote it for the person who is confused and open-minded about this bill. The person who doesn’t understand it. The two groups I really hope will read it and benefit from it are the independent voter who was inclined to like Obama and knows it’s a big, transformative bill and wants to learn more, and the disaffected Democratic voter. I’m stunned that many don’t support it.

Q. Do you think it will change any minds? Turn opponents into supporters?

A. I don’t think it’s going to change the minds of anyone who’s convinced it’s a bad piece of legislation. But it could change the minds of those who are wary and concerned.

Q. You showcase Massachusetts as an example of how health reform can work, noting that it employs some of the same elements that appear in the federal law, like the individual mandate that requires people to have insurance. What should readers be aware of about Massachusetts’ experience with health reform? Has anything surprised you?

A. I would say the point the book tries to make is that Massachusetts was successful in what it tried to do. It reduced the number of uninsured and lowered non-group insurance premiums. Premiums for individual market plans fell by 50 percent relative to national trends. The biggest surprise to me is that employer-sponsored health insurance actually went up after reform when it was falling everywhere else in the country. It speaks to the power of the [individual] mandate. People said, “Give me health insurance,” and they did.

Q. You talk about how health care reform will help Anthony, Betty, Carlos and Dinah, all of whom have different health insurance situations. But you don’t discuss what will happen to Emilio the undocumented worker, who won’t get coverage under the new law. Did you consider talking about who loses out under health reform, including the roughly 11 million illegal immigrants?

A. You hit on a great issue: Who loses out under the law. People don’t lose out. Emilio doesn’t lose out, he just doesn’t gain. A lot of people don’t gain. By design, the bill leaves a lot of people alone, including those with employer-sponsored insurance. They don’t lose but they don’t gain either. As for undocumented immigrants, there was no support to help them. Unfortunately, the law leaves them out in the cold. That was just a political reality.

Q. I know it’s a big piece of legislation and you were trying to cover a lot of ground, but I couldn’t help thinking as I read the book that in some places you oversimplified in such a way that it made the law look better than it is. Can you talk a bit about concerns some may have that you may confuse readers by making sweeping statements about the benefits of this law?

A. Certainly I wrestled a lot with where to simplify and where not to. I think I tried my best to never be misleading. At the end of the book there’s a set of references where people can go to learn more about the law. I think the truth is that most people don’t want that level of detail. It’s for people who just want to know what the heck is this bill.

Q. In the book you discuss the long-term care program created under the law, the CLASS Act, which the administration has decided not to implement, at least not at this time. Obviously, this law is changing and evolving. Depending on what happens in the next election, it could change a lot. What do you think is going to happen? Do you have any plans to update the book?

A. I am fairly confident, I think there’s a better than 50 percent chance, for the Supreme Court not to turn down the mandate, and voters not to kick Obama out of office. If both those things go that way, I think it will be an incredibly positive thing for the Democrats in 2016. It will be good for them because the law will be doing good things by then. States need to move more quickly if we’re going to implement the law smoothly. I can see it starting out roughly and being in great shape in a year or two.

My guess is I wouldn’t want to update [the book]. I haven’t really thought about that.

Please send comments or ideas for future topics for the Insuring Your Health column to questions@kaiserhealthnews.org.

– Provided by Kaiser Health News.

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United States (KaiserHealth) – Dr. Donald Berwick, who oversaw Medicare and Medicaid until earlier this month, defended the programs Monday, but said they are trapped in a U.S. health system that promotes wasteful spending and inefficient care.

“Health care is broken,” Berwick said in an interview with Kaiser Health News. “… We have set up a delivery system that is fragmented, unsafe, not patient-centered, full of waste and unreliable. Despite the best efforts of the workforce, we built it wrong. It isn’t built for modern times.”

Berwick said the 2010 federal health law is changing how doctors and hospitals are paid and deliver care though such new arrangements as accountable care organizations, which are designed to improve coordination and lower costs.

But he said it is unclear whether such efforts would produce results quickly enough to hold off critics, including most Republicans, who want to make more radical changes that would shift more of the burden to beneficiaries. “That is the central question, the nub…whether that will happen fast enough, I just don’t know.”

Despite being considered one of the foremost authorities on health quality and safety, Berwick was a controversial pick as administrator of the Centers for Medicare and Medicaid Services after Republicans accused him of supporting rationing care. Berwick denies the charge, but noted both private insurers and government programs impose limits on what they will cover.

After Republicans said they would not confirm his appointment, President Obama appointed him during a congressional recess in July 2010, which meant he could serve only for 18 months. His last day was Dec. 2.

Berwick previously led the Cambridge, Mass.-based Institute for Healthcare Improvement.

On other topics, Berwick told KHN:

• His failure to be confirmed did not affect his ability to get things done, though he would have preferred a longer term. “An agency of this size will do better with longer-term leadership commitment,” he said. Knowing his tenure could be short gave him a greater sense of urgency to achieve things, he said.
• His most challenging decisions involved state requests to cut Medicaid benefits and writing regulations to encourage doctors and hospitals to form accountable care organizations to work more closely, while not making the requirements overly burdensome.
• He criticized state efforts to limit hospital coverage for Medicaid recipients, currently under review by federal regulators. Hawaii has proposed a 10-day coverage limit on some enrollees; Arizona has proposed a 25 day limit. “It’s a nonsensical idea,” he said. “If a patient needs twenty days, the patient should get twenty days,” he said.
• Managed care done right is the best way to provide care, he said, but if states are not ready to take on the responsibility, it can lead to restrictions that prevent people from getting the care they need. Early in his career, Berwick worked for Harvard Health Plan, a nonprofit HMO based in Boston.

Berwick said he has not yet decided what to do next beyond spending more time with his family in Boston.

– Provided by Kaiser Health News.

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Washington, DC, United States (KaiserHealth) – By agreeing today to hear challenges to President Obama’s 2010 health care law, the Supreme Court set the stage for a decision — probably in late June and in the midst of the presidential campaign — that could be among its most important in decades.

The case, which will probably be argued in March on a date still to be announced, is especially momentous because it not only will determine the fate of President Barack Obama’s biggest legislative achievement but also will cast important light on the Supreme Court’s future course under Chief Justice John Roberts on issues of federal government power.

The central issue — but not the only important one — is whether Congress exceeded its constitutional powers to regulate interstate commerce and to levy taxes when it adopted the so-called “individual mandate” at the heart of the health care law.

That provision would require millions of people starting in 2014 to buy commercial health insurance policies or pay financial penalties for failing to do so.

The court also agreed to decide a challenge to the Affordable Care Act’s provision essentially requiring states greatly to expand their Medicaid spending.

The court made clear that if it decides to strike down the individual mandate or Medicaid provision, it will also decide which of the 975-page law’s hundreds of other provisions should go down too, by divining whether Congress would have wanted some or all of them to be effective even without the voided provision or provisions.

Finally, the court agreed to decide whether — as one federal appeals court ruled — the litigation surrounding the individual mandate must be deferred until 2015 because of the 1867 “Anti-Injunction Act,” which bars courts from striking down tax laws before they take effect.

The court allocated an extraordinary five and one-half hours — the most time in many decades for related challenges to a single new law — for argument on all these issues combined.

How The Case Got Here

The court’s announcement Monday centered on a challenge to the law by 26 state governments. The 11th Circuit Court of Appeals in Atlanta voted in August to strike down the individual mandate but to leave standing the rest of the health law, including the Medicaid expansion. All three of the petitions granted today involve that case.

In other action, though, the D.C. Circuit and the 6th Circuit, centered in Cincinnati, have upheld the individual mandate, with opinions supporting the Obama position by two of the nation’s leading conservative judges, the D.C. Circuit’s Laurence Silberman and the 6th Circuit’s Jeffrey Sutton.

Another appeals court, the 4th Circuit, said courts have no power to decide the individual mandate issue until 2015, when the first monetary penalties will be due for failing to comply with the individual mandate to buy health insurance. This decision held that the penalty provision is a “tax” within the meaning of the Anti-Injunction Act, as described above.

If the justices agree that the Anti-Injunction Act applies, this year’s case will be perhaps the greatest anticlimax in Supreme Court history. And, the justices’ assignment of a full hour of oral argument to this question suggests that some take this issue very seriously.

Meanwhile, the purpose of the individual mandate is to force millions of Americans to obtain health insurance — whether they want to or not — in order to offset the costs that health insurers would bear under the health care law’s requirement that they sell insurance to everyone without charging those with especially costly health problems more than healthy people.

The lower court judges who have struck down the mandate have cited as their reasoning the lack of any precedent for Congress to require people to buy a commercial product they don’t want and the government’s failure to show how — if the individual mandate is upheld — a limit enforceable by the courts could be applied to this exercise of congressional power.

As background, the two Supreme Court decisions since’37 that have struck down acts of Congress as exceeding the commerce power, one in’95 and one in 2000, stressed that Congress’ commerce power must be restrained by some principle that could be enforced by the judicial branch of government.

Defenders of the individual mandate stress other Supreme Court precedents suggesting that even economic decisions that have a tiny direct effect on interstate commerce — such as a person’s decision not to buy health insurance — cumulatively have major effects on interstate commerce and thus can be regulated by Congress.

With the court’s announcement today, none of the justices recused themselves from hearing the case. Some conservative opponents of the health care law have suggested that Justice Elena Kagan should recuse herself because of her prior work as President Obama’s Solicitor General. And some liberals have suggested that Justice Clarence Thomas should recuse himself because of his wife Virginia Thomas’s political activities opposing the health care law. But the decision on recusal is left to each individual justice and it would have been announced with today’s order.

Meanwhile, as is customary, the Court announced the grants of review with no comment or indication of the vote. Any four justices can agree to review a case. And, given the importance of the issues, with federal appeals courts divided, today’s announcement was widely expected.

Most but not all Supreme Court experts predict — some very confidently, some cautiously — that the Court will uphold the law. The Supreme Court’s four liberals are certain to uphold the law. They would need only one more vote to prevail. While Justice Clarence Thomas seems a sure vote to strike the law down, Chief Justice John Roberts and Justices Anthony Kennedy, Antonin Scalia and Samuel Alito are harder to call.

A decision in June — or before — would help make the future of health care law a central issue in the 2012 presidential campaign.

Taylor, an author and journalist, is a nonresident fellow at the Brookings Institution.

– Provided by Kaiser Health News.

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TA REACH, Cambodia (IRIN) – Cambodian efforts to contain the spread of malaria have been strengthened by a pilot project using text messaging and web-based technology.

“My work is definitely easier,” said Sophana Pich, 41, one of 184 village malaria workers (VMWs) now trained in three provinces (Kampot, Siem Reap and Kampong Cham) since the project launch earlier this year.

She typically diagnoses five to six cases of the often deadly virus each month during the rainy season between May and October.

“Before, it would take a month before this information was reported to the district health level. Now it’s instantaneous,” the mother-of-three said from her home in Ta Reach, a village of 200 households in Kampot Province, about 150km southwest of Phnom Penh.

There are close to 3,000 VMSs in 1,500 villages across Cambodia, described by many as the “foot soldiers” in the country’s fight against malaria.

As part of a larger US$22.5 million malaria containment effort launched by the government in 2009 and funded by the Bill & Melinda Gates Foundation , the volunteers receive three days of training in the early diagnosis of malaria and treatment.

In addition, they are given a bicycle, a pair of boots, a bag, a flashlight and a cooler box for medicines, as well as a small travel allowance.

Under the pilot scheme now under way, they are also given mobile phones.

Using FrontlineSMS – an open-source software enabling users to send and receive text messages with groups of people – VMSs can now report in real time all malaria cases in their villages to the Malaria Information and Alert System in Phnom Penh with a simple text message, including the patient’s name, age, location and type of virus.

That information is then disseminated to local, district and provincial health offices, with coordinates mapped on the country’s national malaria database using Google Earth.

Mobitel (Cambodia’s largest telecommunications company) provides free SIM cards and free SMSs, making the system cost-effective and easy to maintain.

“Without doubt, this is an important tool to quickly identify malaria cases and respond effectively,” explained Pengby Ngor, data manager for the Malaria Consortium , an NGO working closely with the government’s National Malaria Control Centre that helped develop the database.

“This is a pilot project which ultimately could be used throughout the country.”

That is good news for Cambodia, where malaria remains endemic; the government hopes to eliminate the disease over the next 15 years.

“We need a series of campaigns and activities so that malaria will go down towards the zero rate of malaria transmission by the year 2025,” Prime Minister Hun Sen told participants at this year’s 32nd National Health Conference in March.

Challenges

But while there is progress in that direction, including falling numbers of people getting sick or dying from malaria across much of the country, key challenges remain.

According to the Ministry of Health , the number of deaths from malaria fell by 53.8 percent in 2010 from the previous year.

At the same time, however, Cambodia has reported an increased incidence of multi-drug resistant falciparum malaria, one of four types of the disease, along parts of its 800km border with Thailand since 2009.

There health officials have expressed concern that the malaria causing parasite is becoming increasingly resistant to the most effective drug they have for treating it, Artemisinin.

“Here in Cambodia, we’ve found that the drug is less effective,” Najibullah Habib, malaria containment project manager for World Health Organization (WHO), confirmed in Phnom Penh, specifically in the area described as Zone 1.

In Cambodia, some 270,000 people live in Zone 1, comprised of Pailin Province, as well as parts of Battambang, Pursat and Kampot provinces.

Another 110,000 people live in the Thai border areas of Trat and Chanthaburi provinces.

“This is the epicentre of drug-resistant malaria,” Habib explained.

To counter that, Cambodian and international efforts are working on the ground to prevent the drug-resistant parasite from spreading elsewhere in the region, focusing on prevention, treatment and testing efforts at the village level.

“The VMWs are all over Zone 1,” the WHO official said. “They’re an essential tool.”

In 2008, prior to the distribution of more than half a million bed nets, as well as the VMW intervention, Zone 1 averaged more than 100 cases per month. Today that number is between 10 and 15.

According to WHO, in 2000, the number of treated malaria cases in Cambodia stood at 129,167 with 608 deaths. In 2010, that dropped to 56,217 and 135 deaths, down 78 percent.

About 3.3 billion people – half the world’s population – are at risk of malaria. Every year, this leads to about 250 million malaria cases and nearly one million deaths. People living in the poorest countries are the most vulnerable, the world health body says.

ds/mw

– Provided by Integrated Regional Information Networks.

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Washington, DC, United States (KaiserHealth) – This week, we address readers’ questions about health insurance coverage and costs.

My son was denied coverage on the basis that he had been drinking before going to the ER with a broken shoulder. Is drinking a legitimate reason for denial of coverage? John Johnson, Tucson, Ariz.

More From This Series Insuring Your Health

As of 2008, 36 states allowed insurers to exclude coverage for injuries related to alcohol and/or drug consumption, according to research from George Washington University’s Department of Health Policy at the School of Public Health and Health Services.

The practice dates to’47 when, as a way to discourage drinking, the National Association of Insurance Commissioners adopted a model statute that excluded coverage of alcohol-related health claims. More than 40 states and the District subsequently passed such laws.

But as the benefits of drug and alcohol treatment programs became apparent, these laws were recognized as counterproductive, since they discouraged emergency department and other medical personnel from screening people for and counseling them about drug and alcohol abuse. In 2001, the NAIC reversed course and recommended that such laws be scrapped.

My husband had a stroke in December, and the insurance reps refused to discuss his account with me because they didn’t have his signature on a form, and he couldn’t tell them over the phone it was okay to talk to me. And it is MY insurance! They said they had to follow HIPAA [the Health Insurance Portability and Accountability Act, which protects patients' medical privacy]. Is this true? Name withheld, Lawrenceville, Ga.

It’s a common misperception by health-care providers and insurers that HIPAA prohibits them from discussing patients’ medical information with family members, says Deven McGraw, director of the health privacy project at the Center for Democracy and Technology, a civil liberties group that promotes health privacy. “It’s not true; it has never been true,” she says. Unless the patient objects, such information can be shared with family members.

Advance planning documents can help avoid confusion and heartache, say experts. A living will spells out what if any measures you wish to have taken to prolong your life — being put on a breathing machine or on dialysis, for example. A health care proxy names the person you choose to make medical decisions for you in the event that you can’t do so yourself.

In addition, most states have surrogacy laws that assign decision-making responsibility to family members based on their relationship to the patient. Typically, if someone is incapacitated, state law would assign decision-making to the patient’s spouse, says Jay Horton, clinical program manager at the Lilian and Benjamin Hertzberg Palliative Care Institute at Mount Sinai School of Medicine in New York. If there is no spouse, the laws spell out who would be assigned to make decisions instead, based on their relationship to the patient.

Our doctor recommended that my husband get a preventive colonoscopy since it had been five years since his last one. The doctor found two benign polyps and removed them. Our [health] plan was to cover 100 percent for a preventive colonoscopy. Because the doctor removed the polyps during the procedure, it is now not covered. We have to pay the deductible, and the balance owed. I can assure you that many, many people will not have this procedure done (as I will not) when they are made aware of the additional costs involved. Pam Nevin, Rutherfordton, N.C.

Under the new federal health law, Medicare beneficiaries and members of new private health plans starting this year can generally receive free colonoscopies to screen for colon cancer if they meet age and other criteria.

Unfortunately, like you, others have been hit with sometimes substantial charges if a growth or mass called a polyp is discovered during a routine screening colonoscopy they thought would be free. Once a preventive procedure turns into a diagnostic procedure or other type of treatment, providers can charge you for it under the new law. According to the interim final rules: “A plan or issuer may impose cost-sharing requirements for a treatment that is not a recommended preventive service, even if the treatment

results from a recommended preventive service.”

Some experts have expressed concern that colonoscopy charges raise questions about what other newly free preventive services might incur similar hidden costs. Fortunately, it doesn’t appear that it will be a widespread problem, says Stephen Finan, senior director of policy for the American Cancer Society’s Cancer Action Network. The reason: Colonoscopies appear to be the only procedure covered under the new guidelines for free preventive care where both prevention and diagnosis happen during

the same procedure. Usually they’re separate, as when something suspicious turns up on a woman’s mammogram. In that case, a separate procedure such as a biopsy would be scheduled to diagnose the problem, says Finan. “Colonoscopy is a very unique scenario,” he says.

Got a question for Michelle Andrews to answer in a future column? khnquestions@kff.org

– Provided by Kaiser Health News.

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Melbourne, Australia (AHN) – Lack of physical exercise has long been associated with poor health, but new research suggests the act of sitting too much could be its own separate risk factor for disease.

The researchers said that health care professionals are already beginning to take action against too much sitting through educational campaigns and messages about not being sedentary at home and at the workplace.

The researchers suggested methods like height-adjustable desks at work, community entertainment venues and events considering non-sitting alternatives and community infrastructure changes to promote walking and biking instead of using motor transportation to reduce sitting time spent in cars.

A report on the study is published in the August issue of the American Journal of Preventive Medicine.

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Scientists say abnormal brain structures in the frontal lobes of cocaine users are associated with their compulsive use of the drug.

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The U.S. Food and Drug Administration announced this week that bottles of sunscreen that have SPF values between 2 and 14 will be required to come with a warning stating that the product has not been shown to help prevent skin cancer or early skin aging.

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Chronic back pain can impact more than your physical health. Find out how to manage persistent back pain and its emotional effects.

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A combination of sesame, poppy and sunflower seeds gives these breadsticks a satisfying crunch.

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