Why Did the ACA Co-Op Program Fail? Lessons for the Health Reform Debate.

The ACA created a new type of nonprofit health insurance entity, the "Consumer Operated and Oriented Plan" ("co-op"). Most of the newly created co-ops soon lost money, and only 4 of the original 23 remain. We interviewed key stakeholders and conducted in-depth case studies of 3 of these co-ops. We discovered that politicians and regulators made it unlikely the program could succeed, that most of the co-ops did not have the management capacity to overcome these political obstacles, and that even those with good managers lacked the needed fiscal resilience. We also considered lessons suggested for those proposing a newly created "public option." The main one is that a successful public option requires a supportive political environment, strong management, and significant fiscal capacity, none of which comes easily. A better route may be a quasi-public option in which the government subcontracts the operation of its newly created plan to a private firm. Although it is uncertain whether federal regulators have the capacity to hold such private for-profit firms accountable, pragmatism suggests that a combination of public-sector regulation and private-sector implementation may be the most direct path toward a US version of affordable universal coverage.

Racial Differences in Extremity Soft Tissue Sarcoma Treatment in a Universally Insured Population.

BACKGROUND: In prior reports from population-based databases, black patients with extremity soft tissue sarcoma (ESTS) have lower reported rates of limb-sparing surgery and adjuvant treatment. The objective of this study was to compare the multimodality treatment of ESTS between black and white patients within a universally insured and equal-access health care system. METHODS: Claims data from TRICARE, the US Department of Defense insurance plan that provides health care coverage for 9 million active-duty personnel, retirees, and dependents, were queried for patients younger than 65 y with ESTS who underwent limb-sparing surgery or amputation between 2006 and 2014 and identified as black or white race. Multivariable logistic regression analysis was used to evaluate the impact of race on the utilization of surgery, chemotherapy, and radiation. RESULTS: Of the 719 patients included for analysis, 605 patients (84%) were white and 114 (16%) were black. Compared with whites, blacks had the same likelihood of receiving limb-sparing surgery (odds ratio [OR], 0.861; 95% confidence interval [95% CI], 0.284-2.611; P = 0.79), neoadjuvant radiation (OR, 1.177; 95% CI, 0.204-1.319; P = 0.34), and neoadjuvant (OR, 0.852; 95% CI, 0.554-1.311; P = 0.47) and adjuvant (OR, 1.211; 95% CI, 0.911-1.611; P = 0.19) chemotherapy; blacks more likely to receive adjuvant radiation (OR, 1.917; 95% CI, 1.162-3.162; P = 0.011). CONCLUSIONS: In a universally insured population, racial differences in the rates of limb-sparing surgery for ESTS are significantly mitigated compared with prior reports. Biologic or disease factors that could not be accounted for in this study may contribute to the increased use of adjuvant radiation among black patients.

EU regulation of blood donation and the importation of blood and blood products / La regulación comunitaria de la donación de sangre y la importación de hemoderivados / La regulació comunitària de la donació de sang i la importació d'hemoderivats

The European Union recommends unpaid blood donation because it deems this to be the safest way of collecting blood and the best way of respecting the dignity of the donor as well as certain ethical principles relating to the availability of human-origin products. However, the risk of suffering shortages of blood has led EU law to authorize the importation and consequent circulation across EU territory of blood from countries where the law allows donors to be paid. This paper analyses the inconsistency this represents and mentions the alternative of blood donation becoming a civic duty. This would allow the necessary amounts of blood to be collected in a more consistent way for EU regulation than the situation as it currently stands

La Unión Europea recomienda la donación no remunerada de sangre por considerar que este tipo de donación es el método más seguro para obtener sangre y sustancias derivadas de la misma, y el que mejor respeta la dignidad del donante así como algunos principios éticos relativos a la disposición de productos de origen humano. Sin embargo, el riesgo de sufrir escasez de sangre y de otros hemoderivados, ha hecho que el Derecho comunitario autorice la importación, y consiguiente circulación por el territorio comunitario, de productos sanguíneos provenientes de países en los cuales la ley permite remunerar a los donantes. Ante esta situación, se analiza la incoherencia que supone y se alude a la alternativa de que la donación de sangre sea considerada un deber cívico a cargo de los ciudadanos, lo que permitiría obtener las cantidades necesarias de sangre y derivados de forma más coherente y menos problemática para la regulación comunitaria que la situación en la que se encuentra en la actualidad

La Unió Europea recomana la donació no remunerada de sang per considerar que aquest tipus de donació és el mètode més segur per a obtenir sang i substàncies derivades d'aquesta, i el que millor respecta la dignitat del donant així com alguns principis ètics relatius a la disposició de productes d'origen humà. No obstant això, el risc de sofrir escassetat de sang i d'altres hemoderivats, ha fet que el Dret comunitari autoritzi la importació, i consegüent circulació pel territori comunitari, de productes sanguinis provinents de països en els quals la llei permet remunerar als donants. Davant aquesta situació, s'analitza la incoherència que suposa i s'al·ludeix a l'alternativa que la donació de sang sigui considerada un deure cívic a càrrec dels ciutadans, la qual cosa permetria obtenir les quantitats necessàries de sang i hemoderivats de forma més coherent i menys problemàtica per a la regulació comunitària que la situació actual

Estimating a Change from TRICARE to Commercial Insurance Plans.

Introduction: We estimate the effect on health care spending of an option to change TRICARE. Under the option, which is based on a proposal made by the Military Compensation and Retirement Modernization Commission (MCRMC), most beneficiaries could choose from a range of commercial health networks instead of the current TRICARE plans. Military treatment facilities would become network providers under the commercial plans. Materials and Methods: We used data from the Department of Defense (DoD) to estimate the cost of providing the current health care benefit to working-age retirees and their dependents and survivors, and active duty family members. We then adjusted those data to estimate what the private insurance premiums would be for those groups. Greater details about the methodology can be found in earlier work by the Congressional Budget Office. Because payments by TRICARE to physicians and hospitals are tied to payments made by Medicare, we used the information from studies that compare Medicare payment rates to rates paid to doctors and hospitals by private insurance to estimate what it would cost private insurers to provide approximately the same level of care, with adjustments to account for the higher out-of-pocket costs that beneficiaries would pay under the option. We also made adjustments to account for the possibility that many beneficiaries would decrease their use of the MTFs in favor of private providers, which could increase the overall costs of DoD. We then estimated that increasing the cost sharing to a level found in popular civilian plans would lower overall demand for services by about 10% for military retiree households and about 18% for active duty family members. Results: We estimated that DoD would pay subsidies to retain about half of the excess capacity created by beneficiaries switching their care from MTFs to the private sector. Evaluated at the midpoint of the ranges, the net effect on DoD's budget would be approximately $0, we estimate, but costs could fall in a likely range from about $3 billion in annual savings to about $3 billion in annual costs. Thus, the MCRMC estimate of $3.2 billion implicitly assumed that no excess capacity would be retained by MTFs. In 2031, under current law, the average retiree family is expected to cost the federal government about $24,100 (in 2017 dollars) and that family's out-of-pocket costs are expected to amount to about $1,900. The option would reduce the government's costs for the average retiree family to $23,500, but retiree families could see their out-of-pocket costs rise to $7,500 per year. Conclusion: This article outlined a method of identifying two particular sources of that uncertainty: the extent to which people will receive care outside of MTFs and the extent to which the MTFs can adjust to reductions in demand. For one particular option, we demonstrate that the potential savings from changing the system depends on increasing the share of costs paid by beneficiaries - particularly working-age retirees - and on DoD's ability to reduce excess capacity in the system.

Community health insurance as a catalyst for uptake of family planning and reproductive health services: the Obio Cottage Hospital experience.

Health service delivery in the Niger Delta region of Nigeria has suffered many setbacks. Community participation may help break the barriers limiting access to health services, especially those associated with family planning and reproductive health services. This is a two-year review of family planning and reproductive health services records offered by the Obio Cottage Hospital from the onset of the Community Insurance Scheme (2010-12). Since the inception of the Community Insurance Scheme, there has been an increase in the uptake of family planning methods of more than 50%; 1,274 women in 2011 vs 3,140 in 2012. An increase in number of women seeking reproductive health services was also observed. The Community Health Insurance Scheme (CHIS) at the Obio Cottage Hospital provides evidence for expansion, as seen in the improvement in patronage for family planning and reproductive health services.

Integrating personal medicine into service delivery: empowering people in recovery.

OBJECTIVE: Illness management and recovery strategies are considered evidence-based practices. The article describes how a web-based application, CommonGround, has been used to support implementation of such strategies in outpatient mental health services and assess its impact. The specific focus of this article is Personal Medicine, self-management strategies that are a salient component of the CommonGround intervention. METHOD: With support from counties and a not-for-profit managed care organization, CommonGround has been introduced in 10 medication clinics, one Assertive Community Treatment (ACT) team, and one peer support center across Pennsylvania. Methods include analysis of data from the application's database and evaluation of health functioning, symptoms, and progress toward recovery. RESULTS: Health functioning improved over time and use of self-management strategies was associated with fewer concerns about medication side effects, fewer concerns about the impact of mental health medicine on physical health, more reports that mental health medicines were helping, and greater progress in individuals' recovery. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Using Personal Medicine empowers individuals to work with their prescribers to find a "right balance" between what they do to be well and what they take to be well. This program helps individuals and their service team focus on individual strengths and resilient self-care strategies. More research is needed to assess factors that may predict changes in outcomes and how a web-based tool focused on self-management strategies may moderate those factors.

Impact of medical loss regulation on the financial performance of health insurers.

The Affordable Care Act's regulation of medical loss ratios requires health insurers to use at least 80-85 percent of the premiums they collect for direct medical expenses (care delivery) or for efforts to improve the quality of care. To gauge this rule's effect on insurers' financial performance, we measured changes between 2010 and 2011 in key financial ratios reflecting insurers' operating profits, administrative costs, and medical claims. We found that the largest changes occurred in the individual market, where for-profit insurers reduced their median administrative cost ratio and operating margin by more than two percentage points each, resulting in a seven-percentage-point increase in their median medical loss ratio. Financial ratios changed much less for insurers in the small- and large-group markets.

Feasibility of community-based health insurance in rural tropical Ecuador.

OBJECTIVE: The main objective of this study was to assess people's willingness to join a community-based health insurance (CHI) model in El Páramo, a rural area in Ecuador, and to determine factors influencing this willingness. A second objective was to identify people's understanding and attitudes toward the presented CHI model. METHODS: A cross-sectional survey was carried out using a structured questionnaire. Of an estimated 829 households, 210 were randomly selected by two-stage cluster sampling. Attitudes toward the scheme were assessed. Information on factors possibly influencing willingness to join was collected and related to the willingness to join. To gain an insight into a respondent's possible ability to pay, health care expenditure on the last illness episode was assessed. Feasibility was defined as at least 50% of household heads willing to join the scheme. RESULTS: Willingness to join the CHI model for US$30 per year was 69.3%. With affiliation, 92.2% of interviewees stated that they would visit the local health facility more often. Willingness to join was found to be negatively associated with education. Other variables showed no significant association with willingness to join. The study showed a positive attitude toward the CHI scheme. Substantial health care expenditures on the last illness episode were documented. CONCLUSIONS: The investigation concludes that CHI in the study region is feasible. However, enrollments are likely to be lower than the stated willingness to join. Still, a CHI scheme should present an interesting financing alternative in rural areas where services are scarce and difficult to sustain.