Beyond the COVID-19 Pandemic: The Urgent Need to Expand Primary Care and Family Medicine.

The COVID-19 pandemic, together with its resultant economic downturn, has unmasked serious problems of access, costs, quality of care, inequities, and disparities of US health care. It has exposed a serious primary care shortage, the unreliability of employer-sponsored health insurance, systemic racism, and other dysfunctions of a system turned on its head without a primary care base. Fundamental reform is urgently needed to bring affordable health care that is accessible to all Americans. Over the last 40-plus years, our supposed system has been taken over by corporate stakeholders with the presumption that a competitive unfettered marketplace will achieve the needed goal of affordable, accessible care. That theory has been thoroughly disproven by experience as the ranks of more than 30 million uninsured and 87 million underinsured demonstrates. Three main reform alternatives before us are: (1) to build on the Affordable Care Act; (2) to implement some kind of a public option; and (3) to enact single-payer Medicare for All. It is only the third option that can make affordable, comprehensive health care accessible for our entire population. As the debate goes forward over these alternatives during this election season, the likelihood of major change through a new system of national health insurance is becoming increasingly realistic. Rebuilding primary care and public health is a high priority as we face a new normal in US health care that places the public interest above that of corporate stakeholders and Wall Street investors. Primary care, and especially family medicine, should become the foundation of a reformed health care system.

Medicare Advantage for Most.

Policy Points Fixing the ACA requires real cost containment in addition to better subsidies. Private Medicare (Medicare Advantage) plans are uniquely empowered to control costs and deliver good care. Medicare Advantage plans should serve as the public option on the ACA Marketplace. Medicare Advantage plans can also be deployed to voluntarily raise minimum employer-sponsored benefits and contain their costs.

Long-Term Implications of Post-ACA Health Reform on State Health Care Policy.

In the midst of the COVID-19 outbreak, health care reform has again taken a major role in the 2020 election, with Democrats weighing Medicare for All against extensions of the Affordable Care Act, while Republicans quietly seem to favor proposals that would eliminate much of the ACA and cut Medicaid. Although states play a major role in health care funding and administration, public and scholarly debates over these proposals have generally not addressed the potential disruption that reform proposals might create for the current state role in health care. We examine how potential reforms influence state-federal relations, and how outside factors like partisanship and exogenous shocks like the COVID-19 pandemic interact with underlying preferences of each level of government. All else equal, reforms that expand the ACA within its current framework would provide the least disruption for current arrangements and allow for smoother transitions for providers and patients, rather than the more radical restructuring proposed by Medicare for All or the cuts embodied in Republican plans.

Making Single-Payer Reform Work for Behavioral Health Care: Lessons From Canada and the United States.

The claim is often made that the adoption of single-payer health care in the United States would result in dramatic improvement of services for people with mental health and substance use disorders. Evidence from this sector in countries with such frameworks is mixed, however, presenting both positive and negative lessons for an American audience. Focusing on Canada as an example, this article sheds light on this topic by drawing on sources in the professional and academic literature, government reports, news stories and features, and research on-site by the author. A concluding section highlights key policy issues that American single-payer advocates will need to address for meaningful reform of the behavioral health care sector.

Treatment practices for aspirin-exacerbated respiratory disease: analysis of a national insurance claims database.

BACKGROUND: Aspirin-exacerbated respiratory disease (AERD) is the triad of asthma, nasal polyposis, and sensitivity to cyclooxygenase-1 inhibitors. Treatment options include medical management, surgical intervention, and aspirin desensitization (AsaD). METHODS: AERD patients were identified using the MarketScan Database from 2009 to 2015. Patients were included using International Classification of Diseases, 9th edition (ICD-9) codes for asthma, nasal polyposis, and drug allergy. Treatments were determined by Current Procedural Terminology (CPT) codes for drug desensitization and endonasal procedures. Geographic trends and timing of interventions between those exposed and not exposed to desensitization were explored. RESULTS: A total of 5628 patients met inclusion criteria for AERD, with mean age 46 years, 60% female; 395 (7%) underwent AsaD and 2171 (39%) underwent sinus surgery. Among patients who were desensitized, 229 (58%) underwent surgery, of whom 201 (88%) had surgery prior to AsaD (median [quartile 1, quartile 3]; 61 days [30, 208] prior to desensitization). For patients undergoing surgery following AsaD (n = 46), surgery was performed a median of 302 (163, 758) days after AsaD. Nineteen patients had multiple surgeries post-AsaD with median time between surgeries being 734 days (312, 1484); 261 patients were not desensitized to aspirin but did undergo multiple surgeries, with the median of the median time between surgeries being 287 days (15, 617), which is shorter than for patients post-AsaD (p < 0.001). CONCLUSION: A very small percentage of AERD patients undergo AsaD. Patients who had AsaD underwent surgery approximately 2 months prior to AsaD. Patients who underwent AsaD experienced an increased time between surgeries compared to patients who did not undergo AsaD.

Lessons From the Long and Winding Road to Medicare for All.

Recently there has been a surge in political attention to Medicare for all, the latest chapter in a long history of conflict over national health insurance in the United States. This essay places the current Medicare for all debate in historical perspective.My aim is to illuminate past struggles over single-payer reform, explore the genesis and evolution of Medicare, and analyze the implications for contemporary health politics of the public and private insurance arrangements developed by the United States over the past century.The history of US health reform provides critical lessons for understanding the enduring appeal of single-payer models as well as the formidable political obstacles to transforming Medicare for all from an aspiration into a legislative reality.

Physical and psychosocial factors associated with depression among adults with type 2 diabetes mellitus at a Federally Qualified Healthcare Center.

PURPOSE: The purpose of this study is to examine the prevalence of depression and physical and psychosocial factors associated with depression among adults with Type 2 Diabetes Mellitus (T2DM). METHODS: The sample included 421 patients with T2DM at a Federally Qualified Healthcare Center in a southern state. The Patient Health Questionnaire (PHQ-9) was used to measure the severity of depression. RESULTS: The multiple logistic regression analyses revealed that the likelihood of depression increased as the level of pain increased and as the level of ambulation difficulties increased. The likelihood of depression increased as the number of traumatic events increased and as the number of SES-related stressors increased. Expectedly, the likelihood of depression decreased as levels of self-esteem increased. CONCLUSIONS: The findings support that health care providers developing care plans for individuals with diabetes need to include assessments and interventions that address both the physical and psychosocial needs of patients.

Lack of a substantive effect of insurance and the national US payment system on the relative distribution of surgical cases among hospitals in the State of Iowa: A retrospective, observational, cohort study.

STUDY OBJECTIVE: Our aim was to quantify the extent to which the distribution of patients among payers and changes to the payers' policies has influenced the market of surgery among hospitals in a relatively rural state. DESIGN: Retrospective cohort study. SETTING: Iowa Hospital Association data analyzed were from 2007 through 2016 for the N = 121 hospitals with at least one case performed that included a major therapeutic procedure. MEASUREMENTS: We used five categories of payer (e.g., Medicare), five categories of patient age (e.g., 18 to 64 years), and three categories of patient residence location (e.g., neither from the county of the hospital nor from a county contiguous to the county of the hospital). MAIN RESULTS: Sorting hospitals in descending sequence of numbers of surgical cases, depending on year, the top 10% of hospitals performed 58.4% to 59.2% of the cases. Increases in numbers of cases among patients with commercial insurance increased the heterogeneity among hospitals in numbers of surgical cases (P < 0.0001). However, the magnitude of the effect was very small, with an estimated relative marginal effect on the overall Gini index of only 0.9% ±â€¯0.2% (SE). Increases in numbers of cases of patients with Medicare insurance reduced the heterogeneity in numbers of cases among hospitals (P < 0.0001), but also with very small magnitude (-0.9% ±â€¯0.2%). In contrast, factors encouraging patient travel contributed to larger hospitals becoming larger, and smaller hospitals becoming smaller (3.9% ±â€¯0.7%, P < 0.0001). CONCLUSIONS: We found the absence of a substantive effect of insurance and national US payment systems on the relative distribution of surgical cases among hospitals. Anesthesia groups should focus on payer and payment reform in terms of their effects on payment rates (e.g., average payment per relative value guide unit), not on their potential effects on hospital caseloads.

Solidarity as a national health care strategy.

The Trump Administration's recent attempts to repeal the Affordable Care Act have reignited long-running debates surrounding the nature of justice in health care provision, the extent of our obligations to others, and the most effective ways of funding and delivering quality health care. In this article, I respond to arguments that individualist systems of health care provision deliver higher-quality health care and promote liberty more effectively than the cooperative, solidaristic approaches that characterize health care provision in most wealthy countries apart from the United States. I argue that these claims are mistaken and suggest one way of rejecting the implied criticisms of solidaristic practices in health care provision they represent. This defence of solidarity is phrased in terms of the advantages solidaristic approaches to health care provision have over individualist alternatives in promoting certain important personal liberties, and delivering high-quality, affordable health care.

Evolving Federal and State Health Care Policy: Toward a More Integrated and Comprehensive Care-Delivery System for Children With Medical Complexity.

Irrespective of any future changes in federal health policy, the momentum to shift from fee-for-service to value-based payment systems is likely to persist. Public and private payers continue to move toward alternative payment models that promote novel care-delivery systems and greater accountability for health outcomes. With a focus on population health, patient-centered medical homes, and care coordination, alternative payment models hold the potential to promote care-delivery systems that address the unique needs of children with medical complexity (CMC), including nonmedical needs and the social determinants of health. Notwithstanding, the implementation of care systems with meaningful quality measures for CMC poses unique and substantive challenges. Stakeholders must view policy options for CMC in the context of transformation within the overall health system to understand how broader health system changes impact care delivery for CMC.

Financial Performance of Health Insurers: State-Run Versus Federal-Run Exchanges.

Many insurers incurred financial losses in individual markets for health insurance during 2014, the first year of Affordable Care Act mandated changes. This analysis looks at key financial ratios of insurers to compare profitability in 2014 and 2013, identify factors driving financial performance, and contrast the financial performance of health insurers operating in state-run exchanges versus the federal exchange. Overall, the median loss of sampled insurers was -3.9%, no greater than their loss in 2013. Reduced administrative costs offset increases in medical losses. Insurers performed better in states with state-run exchanges than insurers in states using the federal exchange in 2014. Medical loss ratios are the underlying driver more than administrative costs in the difference in performance between states with federal versus state-run exchanges. Policy makers looking to improve the financial performance of the individual market should focus on features that differentiate the markets associated with state-run versus federal exchanges.