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Zombies Against Medicare

Medicare -- New York Times - Mon, 07/27/2015 - 12:00am
Arguments that have already been shown to be false are still used by conservatives to attack a program that has done rather well.
Categories: Elder, Medicare

Helping Patients and Doctors Talk About Death

Medicare -- New York Times - Sun, 07/26/2015 - 12:00am
Doctors soon may be reimbursed by Medicare for talking with patients about end-of-life treatments. It’s a change in policy that’s long overdue.
Categories: Elder, Medicare

Roxbury Center Targets Health Disparities In Boston’s Poorest Neighborhoods

CommonHealth (WBUR) - Fri, 07/24/2015 - 5:00pm

Whittier Street Health Center opened its community vegetable garden on June 24. (Courtesy of Chris Aduama)

By Marina Renton
CommonHealth Intern

When it comes to health in Boston, it’s hard to deny there’s a great divide across neighborhoods.

Need proof? A 2013 Boston Public Health Commission report found that, from 2000 to 2009, the average life expectancy for Boston residents was 77.9 years. But in the Back Bay, it was higher — 83.7 years — compared to Roxbury, where the average life expectancy was 74.

If you want to get even more local, you can analyze the same data by census tract, where life expectancy varies by as many as 33 years: 91.9 years in the Back Bay area between Massachusetts Avenue and Arlington Street, and 58.9 years in Roxbury, between Mass. Ave. and Dudley Street and Shawmut Avenue and Albany Street. That’s according to a 2012 report from the Center on Human Needs at Virginia Commonwealth University in Richmond.

The Whittier Street Health Center in Roxbury is trying to tackle the disparities in a very concrete way. With the launch of a new fitness club and community garden, the center is trying to make healthy food and exercise opportunities available and affordable to all, despite geography.

“What we’re trying to do is to remove those social determinants and barriers that are causing these [health] disparities,” said Frederica Williams, president and CEO of the health center.

‘If I Sweat, I’m Doing Something Right’

The fitness club and garden initiatives just launched June 27, but the Whittier Health and Wellness Institute is already drawing in community members.

Eight months ago, Wanda Elliott weighed 256 pounds. On a visit to her Whittier Street physician, she learned her blood pressure was high — high enough that she had to start taking medication. That was the wake-up call that motivated her to change her diet and start exercising.

“I was dragging,” she said.

Elliott began exercising at a local Y but joined the Whittier Street fitness club when it opened. In eight months, she has lost 52 pounds, leaving her 4 pounds shy of her 200 pound goal weight.

“I have two knee replacements, so I have to keep active every day,” she said. Trainers at the center helped her learn to use the exercise machines, and now it feels like a routine, she said.

“I feel addicted to working out. I feel like if I sweat, I’m doing something right,” she said. “From 256 to 204, I feel like a model. I can walk the runway; that’s how energized I feel now.”

Elliott is now off her blood pressure medication. She is working on making changes to her diet “slowly but surely,” drinking more water, eating more salad, and cutting back on red meat.

Josline Cespedes has been coming to this fitness club for about a week, after leaving a gym where the environment didn’t work for her. “I wanted something quiet,” she said.

Before Cespedes joined, she said, “I had a lot of health problems. My job is all day on my feet…and by the time I got home in the afternoon, I was tired, my legs were swollen.”

Now, “I have more energy,” she said. “I’m up all the time…I want to do more stuff with my kids.”

Prescription For Healthy Behavior

The Whittier Street Health Center currently serves around 28,000 residents (up from 18,000 in 2012) and hopes to reach 40,000 by 2017, president and CEO Williams said. Its patients, all living in socioeconomically disadvantaged and urban communities, are predominantly African-American and Hispanic. The center offers medical and public health programs, including primary, eye and dental care, podiatry, endocrinology, smoking cessation, mental health care, substance abuse counseling and urgent care, in addition to community education programs, Williams said.

“We believe that a significant portion of what comprises good health is our behaviors and lifestyles and, of course, access to quality health care,” she added.

The center takes an integrated, coordinated approach to providing care, “because you cannot separate a diabetic person that has depression, you cannot separate their depression from the diabetes,” Williams said. “We’re sensitive to the many social factors that hinder our residents…You have to be really patient-centered and community-centered to really get people to be engaged and activated in taking care of themselves.”

Obesity is a major issue in these communities, Williams said; only about 20 percent of adult patients and 35-40 percent of children had a healthy body mass index (BMI) in 2012. By 2017, the center hopes to be at 70 and 80 percent healthy BMI for adults and children, respectively, which would help reduce the incidence of weight-related chronic conditions, she added.

Hence the launch of the Whittier Health and Wellness Institute, including a new level of health care coordination, the wellness and fitness club and the community garden.

The fitness club, a $1.2 million investment, is over 6,000 square feet and includes the equipment you’d expect in a gym, along with space for people who need to exercise at a slower pace and studios for aerobics, yoga and Zumba classes. The center will also offer classes on stress reduction and fall prevention (for seniors).

Paging The Health Coach

A pivotal figure in the fitness club is the health coach, a nutritionist and fitness trainer who will work with patients to develop their personal goals. “They serve as the motivator,” Williams said.

Patients are referred to the fitness center via a “Prescription for Health” from their primary care physician, psychiatrist or other clinician at Whittier. Thus, a fitness regimen becomes incorporated into a patient’s medical record, and physicians can track clinical outcomes at the same time, to get clearer information about the effects of increased exercise.

“Your doctor will see the information and track how you’re doing…what type of progress you’re making,” Williams said. “And after your first visit with the health coach, they will work with you to develop your self-management goals.”

Fitness club membership for Whittier Street Health Center patients costs $10 per month; the fee is meant to encourage accountability, Williams said. Members of the community who don’t frequent the health center are permitted to join as well.

The fitness club is “not going to be a moneymaker,” Williams said. The membership fees aren’t enough to fund its operation. About half the money to build and equip the facility came from grants, and the other half from the Whittier Street Health Center’s operating funds. To keep the club open, they will have to raise money through annual fundraisers and additional grants.

Community Garden

In addition to addressing the physical fitness of community members, the center wants to address their nutrition.

“We are in a food desert. People don’t have easy access to affordable fresh fruits and vegetables,” Williams said.

That’s where the community garden, managed by a nutritionist, comes in. Patients of the health center can help tend their own plots. The produce grown in the garden — including tomatoes, peppers and cucumbers — will be given away to community members when they attend a nutritionist-led cooking demonstration, Williams said.

The goal is that patients who benefit from the fitness club and community garden will take their newfound self-management skills back to their communities, Williams said.

“We’re looking to not only impact the patients we serve, we’re looking to impact their immediate and extended families, their friends and their neighbors, and we envision that ultimately this will contribute to wellness and fitness in this community,” Williams said.

As part of its Boston Health Equity Program, the Whittier Street Health Center has a series of outcomes it uses to measure the success of its programs, including patients getting regular checkups and improving BMI. Those clinical outcomes — for instance lowering blood pressure — will be achieved in part by individuals visiting the fitness club and community garden and making improvements in their fitness, stress level and nutrition, Williams said.

Avoiding The New Year’s Resolution Effect

A big challenge is not only getting patients to start making lifestyle changes, but encouraging their maintenance, Williams said. In other words, how do you avoid the tapering-off that follows the Jan. 1 rush to the gym?

Because health care providers coordinate the changes and track their patients’ progress, the hope is that it will be harder for the patients to stop coming back, Williams said.

If a patient receives a referral to the fitness club and they don’t come to work out within two weeks, the health coach will follow-up with him or her, Williams said. Similarly, if a patient stops showing up, someone from the Whittier Street Health Center will get in touch.

“The key for us to get people engaged and to maintain it is for us to stay connected to them,” Williams said. “Our job is to make sure we keep that connection and that excitement and empowerment and look for creative ways to keep them focused on changing their lifestyles.”

In a pilot program a couple years ago, the Whittier Street Health Center hosted Zumba classes, and around 600 people came and stuck with it, Williams said, making her feel optimistic about the fitness center’s retention rate.

While some people do stop coming regularly after an initial period of enthusiasm, “I’m just motivated to do it because I love myself,” Elliott said. “And I hate high blood pressure.”

Categories: Health Care

Medical Residents Confide Their Feelings On Performing Abortions

CommonHealth (WBUR) - Fri, 07/24/2015 - 12:10pm

Opponents and supporters of an abortion bill hold signs outside the Texas Capitol July 9 in Austin. (Eric Gay/AP)

Abortion can be hard for the patient. But it can also cause turmoil for the doctor performing the procedure.

Janet Singer, a nurse midwife on the faculty of Brown University’s obstetrics-gynecology residency program, found herself acting as a confidant in many discussions with residents about abortion.

“Over the years, when a resident felt confused, overwhelmed or thrilled about something to do with abortion care, they often came to me to discuss it,” she says.

Tricky questions continued to arise: Where does life actually begin? How do doctors’ personal beliefs play out in their clinical care? And, what’s really best for mothers?

(KateLMills/Flickr)

Singer thought the general public would benefit from hearing more about the complexities of the young doctors’ experiences. So she asked four residents to write about their feelings about abortion training and services, or as one resident characterized it: “one of the most life-changing interventions we can offer.”

These personal stories are published in the July issue of the Journal of Obstetrics and Gynecology, headlined: “Four Residents’ Narratives on Abortion Training: A Residency Climate of Reflection, Support, and Mutual Respect.”

I asked Singer to offer a bit more background on the project, and here, edited, is her response, followed by some excerpts from the residents’ narratives:

Janet Singer: The abortion debate in the U.S. is so divisive, making everything seem black and white; but the real life experiences of doctors and women are much more complex. I am a nurse midwife and though personally committed to increasing access to abortion services, I believe that abortion is not a black and white issue. I speak openly about my personal beliefs with the obstetric residents I work with.

My thinking about the grey areas surrounding abortion care are the result of many conversations with colleagues and residents. One came to me overwhelmed on a day when she had done a late-term abortion and then been called to an emergency C-section for a fetus/baby just a week further along.

She needed to talk about how overwhelming it felt to try to decide where the cusp of life was, why it was OK to take one fetus/baby out of the womb so it wouldn’t live and one out so it might. 

Following that conversation, a few of us decided to form a resident abortion providers support group so that the residents getting abortion training would have a safe space to talk about the complexity of abortion. At the same time, I started checking in, informally, with each resident during their abortion training block. I gave the resident an opportunity to talk — no agenda, no judgment, just a forum for exploring how they were feeling in their new role as abortion provider.

Some had little to say, but most were pondering big questions about what they were doing, why, how it affected them, how satisfied they felt. Conversations on this charged issue occur frequently among the residents. The residents who chose not to get abortion training also revealed the struggles they faced — feeling like they weren’t offering comprehensive care to their patients or realizing they had to rely on colleagues to take care of this part of reproductive health care. And both groups had to confront the fact that the political rhetoric their side used just didn’t fit the coworkers they loved and respected. The pro-choice group knew that their pro-life colleagues weren’t “women haters.” And the pro-life group knew their pro-choice colleagues weren’t Hitlers.  Each group was working from conscience, truly doing what they thoughtfully believed in.

I asked three residents — one committed to doing abortions, one who got training but was deeply conflicted about it, and one who had decided not to get training — if they would write about their experiences. We came up with a set of guiding questions and I told them not to censor, but just to spill. They poured their hearts out. The pro-life resident ended up doing one abortion — a late one because he understood the woman’s plight and that the fetus was unlikely to survive.

After that, I decided we needed one more voice from someone who would never do an abortion, so we added a fourth resident.

The narratives revealed that the clear distinction between being pro-life and pro-choice often breaks down when one is faced with the real-life prospect of caring for pregnant women. (Though, as it happens, three of the four narratives are by men.) We hoped our writing would open a new dialogue about abortion, one that acknowledges the complexity of the issue.

Here are a few excerpts:

Resident 1:

When I started residency, I was open to the possibility of providing terminations. I was and remain uncertain about when life begins, and I used to hope that a deeper understanding of fetal development might help me make such a decision empirically. Over the course of internship, I came to understand embryonal development as a fluid yet constant march toward being human in which an embryo at 6 weeks is an entirely distinct entity from an anatomically formed fetus 2 months later. Unfortunately, this acquired knowledge has failed to help me fully define my position.

Increasingly, I have found myself caught up in an endless array of rhetorical questions. Is there not a more profound difference between 10 and 20 weeks than between 20 and 30? If my first task as a physician is to do no harm, how can I justify harming a fetus? I do not pretend to know the answers to these questions, but given what I perceived to be an abyss of ambiguity, I chose not to provide elective terminations. Our program director supported my choice, saying, “If anyone makes you feel uncomfortable about that choice, I need you to tell me right away.”

Discussions with co-residents have helped me consider the individual woman who has the courage to request an abortion. Since opting out, I have realized that my line of thinking has been feto-centric at best and over-intellectualized at worst. Nonetheless, in the absence of a clear moral understanding of abortion, I can only do no harm.

Resident 2:

At the start of residency, I was not sure if I was ready to perform elective terminations. I realized that the lion’s share of my reluctance was driven by “what would my mom think of me?” I struggled with my own faith, and with what God would think.

On my third-year obstetrics clerkship in medical school, I had my first experience with abortion in a patient with severe preeclampsia at 20 weeks of gestation. There was no provider in the city who felt adequately trained to perform an abortion at this gestational age, and I remember feeling helpless as we watched the patient get sicker. Twenty-four hours passed while a provider was flown in from out of state.

The woman’s clinical condition improved shortly after the procedure. When I was wavering about opting in for abortion training, I thought of this patient many times…One particular conversation with a senior resident was instrumental in my decision to participate in the abortion training. She explained that, for her, abortion is not “black and white”; it is not a “feel-good” procedure, but it changes the course of a patient’s life. It was so helpful to know that my apprehension was normal. That affirmation, along with my desire to gain gynecologic experience, gave me the confidence to pursue abortion training.

I was nervous about my first day at Planned Parenthood. I envisioned protesters chanting and throwing objects at me. After my first morning of early abortions, we performed an 18-week termination. Seeing the fetus on an ultrasound scan and then watching it as we did the procedure really shook me to the core. I thought maybe I had made the wrong choice, and I could not stop thinking about what my family would think if they knew what I had done.

Later that week we had an informal gathering of residents who had struggled with abortion training. It became apparent that others shared similar feelings. Many of us felt more comfortable with early abortions and struggled with second-trimester cases. Regardless of whether we performed abortions or not, it had to do with patient care and, in this case, our patients are the mothers. After listening to the struggles of fellow residents, I convinced myself to return to the clinic.

There, I soon realized how powerful it was to be able to comfort and assure such vulnerable patients. I began to frame my interventions at the clinic as life-changing for women.

Resident 3:

Although I might not always understand an individual woman’s choices, if she feels that she cannot be a parent for whatever reason, I will support her in that decision. I see little role for my personal values in the shared decision-making process.

The truth is that being involved in this work scares me. I am fearful of the violence and taunting that protesters have inflicted against providers. Assaulting providers in the name of “protecting life” disgusts me, especially because abortion is legal. This fear for my family and me has affected my interest in pursuing a family planning fellowship.

Abortion is a necessary procedure that I feel morally obligated to make available to my patients. The future of this service hinges on our society’s ability to support its practice, prevent undesired pregnancy, and ensure the safety of abortion providers. I have worked through my own internal struggles, but these broader societal issues will shape how I practice in the future. Participating in abortion services has left me fulfilled and honored, and I consider the provision of this care a privilege.

Resident 4:

I am a Born Again Christian, and I believe that life begins at conception. I believe that since I do not have the power to create life, I do not have the power to take it. I am proud of my choice and do not apologize for it, but that was not always the case.

I love obstetrics and gynecology — the breadth and depth, the bonds between patients and providers, and the lifelong relationships that are formed. However, I once heard someone say that an ob-gyn who did not provide terminations was not offering their patients the best, most complete care. Initially I shrugged this off as her opinion and deemed it irrelevant to me and to what my practice would become. But as I replayed that statement in my mind, I began to wonder, would I be providing the best care to my patients if offering terminations conflicted with my personal beliefs and passions? Would my patients feel judged and unsupported if I told them that I could not provide a service that they needed? Could I be truly impartial in my counseling?

Categories: Health Care

Law Library Summer Interns 2015 – Pic of the Week

In Custodia Legis - Fri, 07/24/2015 - 9:00am

[left to right] Antonio Ortiz, Lucy Jones, Jourdan Douglas, Faith Hamby, Wyatt Smith, Allegra Chilstrom, Julia Heron, Genevieve Horchler, Timothy Byram, Pamela Oliver, Nasiruddin Nezaami, Genevieve Claveau. [Photo by Donna Sokol]

The Law Library benefits every year from the energy and enthusiasm of our summer interns!  We had another large group of interns this year, and many of them recently convened for the traditional group photo.

This year, international interns hailed from Afghanistan, Canada, China, and Ireland.  We welcomed students from University of Washington, North Carolina Central University, University of Montreal, Tulane University Law School, and Washington Ireland Program.  We had representatives from the metropolitan Washington, D.C. region, as well!

We will be sad to see them go but hope they fondly remember their time at the Law Library.  (Starting this fall, we’ll have a right and proper Reading Room to show our future interns!)

Categories: Research & Litigation

First Edition: July 24, 2015

Kaiser Health News - Fri, 07/24/2015 - 6:55am
Categories: Health Care

Choosing How We Die

Medicare -- New York Times - Fri, 07/24/2015 - 12:00am
A new federal rule could help patients decide on care at the end of their lives.
Categories: Elder, Medicare

The Hutchins Center Explains: The Medicare Trustees Report

Brookings Institute -- Medicare - Thu, 07/23/2015 - 4:15pm

Editor's Note: This post originally appeared on the Up Front blog as part of the "The Hutchins Center Explains" series. 

The trustees of Medicare, four government officials and two private citizens, issue detailed annual reports on the current and projected finances of the Medicare health insurance program for the elderly and disabled. The report, which looks 75 years into the future, incorporates the latest thinking of actuaries on trends in Medicare spending.

What's new in the July 2015 report?

Not much in the near term. The Trustees did make some technical adjustments to their long-run model that lowered projected Medicare spending, but these adjustments only affect the projections from 2041 on. By 2088, this adjustment amounts to a bit less than 1 percent of GDP.

What does the report say about the trajectory of Medicare spending over the next ten years?

Medicare spending is projected to rise from 3.5 percent of GDP in 2014 to 4.3 percent in 2024, with the increase mostly attributable to increased enrollment as the baby boom generation turns 65.

Adjusted for inflation, spending per beneficiary rises an average of just 2% per year—about the same pace as per capita GDP growth—as reimbursement cuts under the Affordable Care Act (ACA) continue to restrain spending.

What about over the long–run?

In the longer run, the Trustees project Medicare spending to increase sharply as a share of the economy, rising from 3.5 percent of GDP in 2014 to 6 percent by 2089.

The rise in spending between 2014 and 2035 is largely driven by increased enrollment. From 2036 to 2089, spending is projected to rise primarily due to growing per-beneficiary costs.

The Medicare problem doesn't look so bad. What happened?

The Trustees have dramatically lowered their projections of long-run Medicare expenditure growth. In 2009, for example, the Trustees projected that Medicare spending would reach 11.2 percent of GDP by 2080—compared with just 6 percent in this year's report. The change in the spending outlook is attributable to the effects of the ACA on provider reimbursements and a much slower rate of increase in actual Medicare expenditures since 2009. Excess cost growth in Medicare—the difference in the growth rates of per beneficiary spending and per capita GDP—is now expected to be quite low relative to historical averages.

So is the Hospital Insurance (Part A) trust fund still projected to be depleted?

Yes, in 2030—the same as in last year's report. Medicare Part A (hospitals) is funded by payroll taxes. Because Medicare enrollment is increasing at a much faster pace than the labor force, even with relatively slow per beneficiary spending growth, outlays are still expected to outpace revenues. Part B of Medicare (doctors) and Part D (drugs) are financed by premiums and by general revenues.

What is the Illustrative Alternative Scenario, and why do the Trustees include it?

The Trustees offer an "illustrative alternative" to their baseline scenario intended to highlight the trajectory of Medicare spending under a hypothetical legislative alternative in which parts of the ACA are repealed. The Affordable Care Act included provisions that lowered the annual increases in provider reimbursements. Before the ACA, payments were to be updated each year by an amount equal to the growth of input costs (hospital wages, etc.); after the ACA, the payment update equals the growth of input costs less the rate of increase in economy-wide productivity. In addition, physician reimbursement updates were cut as part of the recently enacted "doc fix" (the Medicare Access and CHIP Reauthorization Act of 2015). The Trustees believe that, unless the health care sector manages to become much more productive over time, these payments will be too low to ensure that Medicare beneficiaries continue to have good access to health care providers. As a result, they hypothesize that future Congresses might choose to override them. Under this alternative, Medicare spending rises to 9.6% percent of GDP, about 50% higher than in the baseline scenario.

The question of whether the ACA updates are sustainable is a contentious one and depends very much on one's view of health care productivity growth. (For more on this issue, see Louise Sheiner's recent presentation.)

How do the Trustees' estimates compare with CBO's?

The Trustees and CBO have similar projections for spending over the next ten years, but they have very different methodologies for projecting Medicare spending growth in the long run. In particular, the Trustees assume that Medicare spending will rise more slowly than private health expenditures, while CBO assumes that Medicare spending will rise more rapidly. As a result, their projections diverge sharply as the horizon is extended, with CBO projecting Medicare expenditures to be more than twice as high as a share of GDP by 2089.

How much stock should I put into any of these long-term projections?

Not much after the first ten years or so. Long-term projections are inherently uncertain, and healthcare spending is particularly difficult to predict. Whether or not the recent slowdown in health expenditures will persist, the pace of technological progress in the medical field, and the effectiveness of the Affordable Care Act's cost-saving measures can all have large impacts on long-run medical spending, but are nearly impossible to accurately predict. The wide differences between the Trustees' and CBO's projections highlight the enormous uncertainty of long-term health spending projections.

Who are the Trustees and how do they get appointed?

The board of trustees is a six-member body made up of four government officials—Treasury Secretary Jack Lew, Labor Secretary Thomas Perez, Health and Human Services Secretary Sylvia Mathews Burwell, and Acting Commissioner of Social Security Carolyn Colvin—along with two trustees appointed by the President and confirmed by the Senate as representatives of the public—Charles P. Blahous III and Robert D. Reischauer.

Authors         
Categories: Elder

The Hutchins Center Explains: The Medicare Trustees Report

Brookings Institute -- Medicare - Thu, 07/23/2015 - 4:15pm

The trustees of Medicare, four government officials and two private citizens, issue detailed annual reports on the current and projected finances of the Medicare health insurance program for the elderly and disabled. The report, which looks 75 years into the future, incorporates the latest thinking of actuaries on trends in Medicare spending.

What's new in the July 2015 report?

Not much in the near term. The Trustees did make some technical adjustments to their long-run model that lowered projected Medicare spending, but these adjustments only affect the projections from 2041 on. By 2088, this adjustment amounts to a bit less than 1 percent of GDP.

What does the report say about the trajectory of Medicare spending over the next ten years?

Medicare spending is projected to rise from 3.5 percent of GDP in 2014 to 4.3 percent in 2024, with the increase mostly attributable to increased enrollment as the baby boom generation turns 65.

Adjusted for inflation, spending per beneficiary rises an average of just 2% per year—about the same pace as per capita GDP growth—as reimbursement cuts under the Affordable Care Act (ACA) continue to restrain spending.

What about over the long–run?

In the longer run, the Trustees project Medicare spending to increase sharply as a share of the economy, rising from 3.5 percent of GDP in 2014 to 6 percent by 2089.

The rise in spending between 2014 and 2035 is largely driven by increased enrollment. From 2036 to 2089, spending is projected to rise primarily due to growing per-beneficiary costs.

The Medicare problem doesn't look so bad. What happened?

The Trustees have dramatically lowered their projections of long-run Medicare expenditure growth. In 2009, for example, the Trustees projected that Medicare spending would reach 11.2 percent of GDP by 2080—compared with just 6 percent in this year's report. The change in the spending outlook is attributable to the effects of the ACA on provider reimbursements and a much slower rate of increase in actual Medicare expenditures since 2009. Excess cost growth in Medicare—the difference in the growth rates of per beneficiary spending and per capita GDP—is now expected to be quite low relative to historical averages.

So is the Hospital Insurance (Part A) trust fund still projected to be depleted?

Yes, in 2030—the same as in last year's report. Medicare Part A (hospitals) is funded by payroll taxes. Because Medicare enrollment is increasing at a much faster pace than the labor force, even with relatively slow per beneficiary spending growth, outlays are still expected to outpace revenues. Part B of Medicare (doctors) and Part D (drugs) are financed by premiums and by general revenues.

What is the Illustrative Alternative Scenario, and why do the Trustees include it?

The Trustees offer an "illustrative alternative" to their baseline scenario intended to highlight the trajectory of Medicare spending under a hypothetical legislative alternative in which parts of the ACA are repealed. The Affordable Care Act included provisions that lowered the annual increases in provider reimbursements. Before the ACA, payments were to be updated each year by an amount equal to the growth of input costs (hospital wages, etc.); after the ACA, the payment update equals the growth of input costs less the rate of increase in economy-wide productivity. In addition, physician reimbursement updates were cut as part of the recently enacted "doc fix" (the Medicare Access and CHIP Reauthorization Act of 2015). The Trustees believe that, unless the health care sector manages to become much more productive over time, these payments will be too low to ensure that Medicare beneficiaries continue to have good access to health care providers. As a result, they hypothesize that future Congresses might choose to override them. Under this alternative, Medicare spending rises to 9.6% percent of GDP, about 50% higher than in the baseline scenario.

The question of whether the ACA updates are sustainable is a contentious one and depends very much on one's view of health care productivity growth. (For more on this issue, see Louise Sheiner's recent presentation.)

How do the Trustees' estimates compare with CBO's?

The Trustees and CBO have similar projections for spending over the next ten years, but they have very different methodologies for projecting Medicare spending growth in the long run. In particular, the Trustees assume that Medicare spending will rise more slowly than private health expenditures, while CBO assumes that Medicare spending will rise more rapidly. As a result, their projections diverge sharply as the horizon is extended, with CBO projecting Medicare expenditures to be more than twice as high as a share of GDP by 2089.

How much stock should I put into any of these long-term projections?

Not much after the first ten years or so. Long-term projections are inherently uncertain, and healthcare spending is particularly difficult to predict. Whether or not the recent slowdown in health expenditures will persist, the pace of technological progress in the medical field, and the effectiveness of the Affordable Care Act's cost-saving measures can all have large impacts on long-run medical spending, but are nearly impossible to accurately predict. The wide differences between the Trustees' and CBO's projections highlight the enormous uncertainty of long-term health spending projections.

Who are the Trustees and how do they get appointed?

The board of trustees is a six-member body made up of four government officials—Treasury Secretary Jack Lew, Labor Secretary Thomas Perez, Health and Human Services Secretary Sylvia Mathews Burwell, and Acting Commissioner of Social Security Carolyn Colvin—along with two trustees appointed by the President and confirmed by the Senate as representatives of the public—Charles P. Blahous III and Robert D. Reischauer.

Authors         
Categories: Elder

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