How funding to house #MentallyIll, #Homeless is a financial gain, not drain

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A director of a supportive housing center in Bronx, New York, talks with a resident and case worker in December 2015.
Bebeto Matthews/AP

Carol Caton, Columbia University Medical Center

As Congress considers the federal budget proposal for fiscal year 2018 to reduce funding for services to poor and homeless Americans, programs with proven cost-effectiveness should not be on the chopping block. One such program is supportive housing for homeless people with severe mental illness. The Conversation

Supportive housing, funded and coordinated by several different federal agencies and nonprofits, provides homeless people who have severe mental illness with housing coupled with treatment and support services. There is no increase in net public cost compared to street and shelter living.

While it may appear that paying for supportive housing is a drain on the federal budget, research has shown that ending homelessness for the severely mentally ill saves taxpayers money.

Because funding comes from several different agencies, it is hard to know specifically from the president’s budget plan how deep the cuts to supportive housing could be. Yet we do know that the president has proposed cuts in funding to Housing and Urban Development by 13 percent and to Health and Human Services by 19 percent. Both these agencies provide significant funding for supportive housing.

I research mental illness and homelessness. Cutting funds to house the homeless would cost us more money than it would save.

Supportive housing and the homeless mentally ill

Since the 1980s, homelessness has plagued cities and towns across the country. Today, more than a half-million people in the U.S. are homeless. One in every three homeless people suffers from a mental illness, which is often compounded by multiple health problems and substance abuse.

The homeless mentally ill are likely to remain undomiciled and without treatment for long periods of time. This brings a high social and economic cost to society. Disabled by mental illness and unable to work, these individuals have little hope of exiting homelessness without public assistance.


Beset with extreme poverty and disability, their inability to work renders them heavily dependent on the largesse of government agencies for disability income, housing support and health care.

The challenges facing homeless people in general are daunting. Security, privacy and creature comforts are in short supply. The daily burden of being homeless involves finding ways to assuage exhaustion and hunger, and to sidestep the violence and victimization that regularly occurs in life on the streets. An estimated 14 to 21 percent of homeless people are victims of crimes, compared to about 2 percent of the general population.

Supportive housing, started in the early 1980s, has shown to make a big difference. Unlike the temporary respite provided by crisis shelters, it provides access to permanent housing, mental health treatment and support from mental health professionals to guide the adjustment from homelessness to stable residence in the community.

Supportive housing tenants must have a behavioral health condition that qualifies them for a federal disability income. Residents pay one-third of the cost of rent and utilities with their disability income (about US$733 per month). The balance is covered by a housing subsidy provided through private or governmental sources. In some cases, eligibility for a housing subsidy is based on duration of street and shelter living.

The numbers tell the story

In concert with the federal plan to “End Chronic Homelessness in Ten Years,” supportive housing has helped to reduce chronic homelessness by 35 percent between 2007 and 2016.

At an annual cost ranging from $12,000 to nearly $20,000 per unit, permanent supportive housing is expensive, but it is substantially less than the annual cost of a stay in a homeless shelter, jail or prison, or psychiatric hospital.

Some of the funding comes from the federal government, including from the Department of Housing and Urban Development’s Continuum of Care and from Section 8 housing subsidies. The Department of Health and Human Services and the Department of Veterans Affairs also provide funding.

States including New York, California, Washington and Connecticut have helped to fund housing for people with mental illness, as have some city and county governments.

Other sources of funding include low-income housing tax credits, private foundations and charitable donations to nonprofit housing providers. The Affordable Care Act Medicaid expansion program provides Medicaid reimbursement for services provided to individuals in supportive housing.

And the winner is…everyone

Controlled trials conducted in the United States and Canada have found the majority of people who have had access to supportive housing remain housed for a year or more, showing greater housing stability than that among comparison subjects. In addition, individuals in supportive housing not only stayed longer but also had a reduction in subsequent homelessness and decreased use of emergency departments and hospitals.

Cost offset studies show that supportive housing leads to less use of costly public services.

A landmark analysis of administrative data from multiple public service systems examined the impact of supportive housing placement on 4,679 individuals and their use of the public shelter system, public and private hospitals, and correctional facilities. The study found that persons placed in supportive housing experienced significant reductions in use of homeless shelters, hospitals and time incarcerated. In fact, public service cost reductions following housing placement nearly offset the cost of the housing itself.

Significantly, supportive housing is nearly half the average cost per year of $35,578 for a chronically homeless person. Part of the reason is that stable housing resulted in a shift in service use from expensive crisis services to less costly community-based care.

Strong and compelling evidence indicates that supportive housing is a “win-win” for both the homeless mentally ill and the holders of the public purse. It offers people with mental illness safe and adequate housing and greater access to treatment, essential elements in their recovery. And it can lead to greater cost-efficient use of public services.

Currently there are not nearly enough supportive housing units to house the thousands of individuals with severe mental illness who are currently unstably housed or are at risk of falling into homelessness.

It would not make economic sense to cut funding for a cost-effective intervention that provides a solution to homelessness. Rather, what we need now is the public will to bring supportive housing to scale so that the most fragile among us might achieve stable residence in the community. They, too, deserve the opportunity for personal fulfillment and involvement in mainstream society.

Carol Caton, Professor of Sociomedical Sciences (Psychiatry and Public Health), Columbia University Medical Center

This article was originally published on The Conversation. Read the original article.


How a travel ban could worsen doctor shortages in US hospitals and threaten primary care

Exam room in a rural Alabama hospital. Brynn Anderson/AP
Exam room in a rural Alabama hospital. Brynn Anderson/AP

John Burkhardt, University of Michigan and Mahshid Abir, University of Michigan

The Ninth Circuit Court of Appeals in San Francisco on Feb. 9 upheld the restraining order on President Trump’s immigration ban. A key argument used by the States of Washington and Minnesota was the negative impact of the ban on higher education, but an important corollary is the impact on medical care in the U.S. While the world waits for a final decision on the matter, potentially from the Supreme Court, it’s worth looking carefully at the potential ramifications of the ban.

Regardless of the ultimate ruling, the travel ban has already had significant consequences for people from the seven targeted majority Muslim countries and American citizens. Doctors are among those people directly affected – and that has big implications for health care delivery in U.S. hospitals, particularly those in rural America and inner-city safety net hospitals.

Physicians who are citizens of these nations who were traveling outside the country at the time of the ban have been detained or refused access to the U.S.

Larger-scale, lasting effects of a ban on the graduate medical education system are likely to be even more severe and may further strain an already overstretched health care system and affect the care of communities across the U.S. Indeed, the president of the American Medical Association already has written a letter to the Department of Homeland Security, explaining how the ban could affect those who are already underserved by limiting doctors from other countries.

As physicians involved with educating and training the next generation of doctors, we see dire consequences for health care delivery in our country if the travel ban is reinstated.

A looming deadline

Even though the ban has been temporarily lifted, the timing could not be worse for international applicants hoping to train in the U.S. While new resident physicians typically begin on July 1, the match process that allots positions occurs much sooner. On Feb. 22, residency program directors must submit their rank list of which applicants they would like to have in their program.

Dr. Shane Prejean examines a patient at a Baton Rouge, Louisiana hospital as medical students look on. The area has a dire physician shortage.
Gerald Herbert/AP

Therefore, without clear signs that travel for foreign applicants will be possible by July, program directors who want to protect their training program from staffing shortages may decide against ranking these applicants. The loss of a single incoming class of international medical graduates will significantly decrease the number of residents in training and physician capacity in hospitals and health care systems across the U.S.

Graduates from outside the United States constitute 26 percent of the U.S. graduate medical training. These foreign medical graduates usually fill resident training positions that are left vacant after medical schools match U.S.-based students to residency programs.

Therefore, foreign graduates typically do not take spots away from graduates of American medical schools, but instead provide medical care in hospitals that will otherwise be understaffed. These include rural hospitals around the country, where it is especially hard to recruit physicians, and safety net hospitals serving the poor.

Primary care could be threatened

Even if all current residency positions could be filled with U.S. medical school graduates and eliminate the need for any additional resident physicians from outside the U.S., the projected demand for physicians in the near future will still not be met.

Physicians in graduate medical education provide a significant proportion of all health care in the U.S., with teaching hospitals accounting for 40 percent of charity care (US$8.4 billion annually) and 28 percent of Medicaid hospitalizations. Without sufficient residents to care for patients, teaching hospitals are ill-equipped to maintain this role for the poorest patients and may not continue to meet this critical societal need.

Physicians who are both foreign-born and U.S.-born and trained outside the country constitute more than a quarter of all practicing physicians in the U.S.

Dr. Ammar Hashim, born in Iraq, is the chief operating officer for several clinics in Houston.
Pat Sullivan/AP

While the country of origin of these doctors is not often reported on a country-by-country basis, a recent interview with the Association of American Medical Colleges reported 260 physicians in training were from the seven targeted nations last year.

Expanded travel bans could dramatically increase that number as, between 2008 and 2010, 16 percent of these international medical graduates taking a required licensing exam were from Middle Eastern countries.

A drop in primary care providers

These international physicians also disproportionately work in primary care fields that are the hardest hit by the ongoing U.S. physician shortage crisis.

Currently, primary care programs have 50 percent of their residency slots filled by nonallopathic students and international medical graduates, whose absence could cripple primary care capacity.

Having a primary care doctor leads to increased access to care, reduced emergency department visits, decreased hospitalizations and improved management of chronic conditions, and decreased acute care utilization can lower overall health care spending. Similarly, general surgery has seen a 13 percent decrease in U.S. graduates in the specialty; however, this shortcoming has been buffered by influxes of international medical graduates. Delays in scheduling operative cases have also been associated with increased health care costs, making adequate numbers of surgeons another cost containment strategy.

Without international physicians entering the graduate medical education workforce, it would require substantial changes to maintain the current level of physician staffing in health care systems, such as replacing physicians with midlevel providers which may further inflate health care costs.

While physician shortage is a challenge for many communities across the U.S., the pain will not be distributed equally among all Americans.

Minority and low socioeconomic status patients are more likely to suffer from increased physician shortages, are most likely to be impacted by increased wait times to get care, and stand to lose the benefit of having a primary care doctor that has also shown to confer benefits to at-risk populations.

President Trump’s immigration ban has the potential for immediate ramifications for the hospital and health care system workforce in the U.S. Long term, decreases in the number of international medical graduates in training will result in fewer primary care physicians and general surgeons, just as the country is likely to need more.

This immigration policy can have significant adverse impacts on health care delivery and the health of Americans. These consequences should be critically considered in related immigration and travel ban policy decisions moving forward.

The Conversation

John Burkhardt, Lecturer, University of Michigan and Mahshid Abir, Assistant Professor, Department of Emergency Medicine, Director of the Acute Care Research Unit, University of Michigan

This article was originally published on The Conversation. Read the original article.

Communities plagued by uninsurance also suffer from breakdowns in trust, social connection

Applicants for insurance wait in Richmond, California in 2014. Eric Risberg/AP file photo.
Applicants for insurance wait in Richmond, California in 2014. Eric Risberg/AP file photo.

Tara McKay, Vanderbilt University

Dismantling the Affordable Care Act (ACA) without a replacement plan is projected to increase the nation’s uninsured population by 18 million in the first year after repeal and by 32 million in 2026, according to recent estimates by the Congressional Budget Office (CBO). As lawmakers and the American public consider repealing portions of the ACA, it is an important time to reflect on what limiting access to health insurance might mean for Americans and their communities. If a repeal occurs, not only individuals, but also their communities, could be affected.

Whether we like it or not, health insurance affects our lives in significant ways. Sometimes these effects are very direct, determining whether we can afford to see a doctor when we need to. At other times, health insurance affects us in less direct ways by shaping whether providers hire that extra nurse or relocate to a wealthier area of town.

One of the things we’ve paid a lot less attention to is whether the effects of health insurance go beyond things like health and costs to shape other aspects of our social lives. My new study with Stefan Timmermans of UCLA addresses this gap by examining the consequences of uninsurance for cohesion and trust in Los Angeles communities during the 2000s.

Using longitudinal data from the Los Angeles Family and Neighborhood Survey (L.A. FANS), we find that people living in communities with lower levels of insurance are less likely to feel connected to and trust their neighbors, even after controlling for several other neighborhood and individual factors that might affect people’s perceptions of and engagement with their communities.

We also test whether broader access to health insurance through a policy like the ACA could strengthen communities over time. This analysis demonstrates that people’s perceptions of their neighbors and communities improve as more people gain access to insurance in their community.

Consequences beyond health care

How does this work?

When large groups of people don’t have health insurance, this places unique financial and organizational strains on individuals, providers and health care markets. Research demonstrates that a lack of access to health insurance negatively affects health, health care access and quality, utilization of preventative services and out-of-pocket costs for the uninsured.

These effects also frequently spill over to the insured, negatively affecting the health and out-of-pocket costs for people living or receiving care alongside large groups of uninsured. Such spillovers come about as providers try to lower their exposure to a large uninsured population by reducing, dropping or redistributing staff and services that are disproportionately used by the uninsured, such as emergency care.

These provider strategies also go on to affect access to health care, quality of care and trust in health care providers for everyone living in a community, not just the uninsured.

Given the particular pressures that uninsurance places on individuals, providers and health care markets, it’s not surprising that we find the consequences of uninsurance go beyond health and health care.

We specifically measured the consequences of living in a community with high levels of uninsurance on residents’ reports of social cohesion, or their feelings of trust, mutual obligation and reciprocity toward their neighbors. Moving from a community where almost everyone has health insurance to one where more than half are uninsured results in a 34 percent decrease in residents’ perceptions of social cohesion in their community, we found.

We tested many possible explanations for this decrease, including differences in the composition of these communities over time, but this result is persistent. There is a social cost for communities that carry a larger burden of uninsured. This 34 percent difference in social cohesion is a substantial difference that has important consequences for other individual and community outcomes pertaining to health, political engagement and more.

New tensions created in communities

There are two primary ways that a lack of health insurance might affect communities.

First, in battles over state and local budgets, attempts to cover the uninsured through the redistribution of new or existing funds may run into political barriers or be forced to compete with other public services such as education and law enforcement. These battles can create competing interests and goals within a community that contribute to the breakdown of social cohesiveness, trust and reciprocity among community members over time.

In case studies of programs intended to expand coverage to the uninsured in Birmingham, Alabama, and Alameda County (Oakland), California, debates around the provision of care for the uninsured became even more contentious because they intersected with racial and class divides that have historically limited access to insurance and health care institutions among African-Americans and Latinos. Sometimes, community institutions, like churches and schools, are able to develop their own programs to support the uninsured, with varying success.

Second, within communities, higher out-of-pocket costs to the uninsured and their families can exacerbate social and economic inequalities which promote class differentiation, social distance and community disengagement.

Uninsured people in Tennessee wait for the arrival of President Obama to speak about expansion of Medicaid in that state.
Mark Humphrey/AP

Importantly, some uninsured individuals feel this status very acutely, as an indicator that they don’t belong or matter to the broader community or society. When the uninsured do seek care, they frequently report experiencing poorer-quality care, discrimination and depersonalization, which they view as an assault on their personal dignity.

Taken together, these indirect pathways suggest that lack of access to health insurance matters not only for health and costs, but also for the cohesiveness and resilience of communities.

Can policies like the ACA strengthen communities?

Where local and state governments have made a concerted effort toward including marginal populations into the health care system, as in San Francisco and Massachusetts, we see promising results. Lawmakers, providers and patients are motivated by the importance they place on connectedness, collaboration and feelings of a shared fate.

In our study, we specifically look at how communities might have changed if an ACA-type expansion in insurance coverage had occurred in Los Angeles County during our survey period (2001 and 2007) using a difference-in-difference estimation. This technique takes into account trends in how feelings of trust and reciprocity among community members would have changed during this time period anyway, even without expanding access to health insurance.

To do this, we use individuals’ reports of their actual health insurance status when they were reinterviewed in 2007-2008 by L.A. FANS and estimate who would become eligible for Medicaid and for California state and federal subsidies to buy insurance in the individual marketplace under 2014 ACA eligibility criteria.


We then used these estimates to see how residents’ feelings of trust and reciprocity might have changed if they and their neighbors had gained access to health insurance coverage under an ACA-type expansion in 2007.

We find that the differences between high insurance and low insurance communities on perceptions of social cohesion are significantly smaller when we impose an ACA-type intervention, suggesting that such an intervention could significantly improve individuals’ perceptions of social cohesion in their communities.

It is not yet clear how a repeal of ACA will affect communities. A repeal may undo any gains that communities have experienced over the past few years in terms of increased trust and reciprocity. These changes may take some time to be felt or may be very pronounced if individuals who stand to lose access to insurance through a repeal feel they are being singled out for exclusion.

What we do know is that prior to the implementation of the ACA, a lack of health insurance substantially undermined communities. As health policies increasingly contend with larger issues of social and economic inequality, we expect that health policies such as the ACA – and whatever comes next – will continue to have important consequences for communities that need to be considered alongside effects on health and costs.

The Conversation

Tara McKay, Assistant Professor, Vanderbilt University

This article was originally published on The Conversation. Read the original article.

Dengue Virus Antibodies May Worsen A Zika Infection

Revellers at a carnival in Sao Paulo wear mosquito masks in a reference to the Aedes aegypti mosquito, which can spread dengue and Zika on February 4, 2016. Paulo Whitaker/Reuters
Revellers at a carnival in Sao Paulo wear mosquito masks in a reference to the Aedes aegypti mosquito, which can spread dengue and Zika on February 4, 2016. Paulo Whitaker/Reuters

Sharon Isern, Florida Gulf Coast University

The World Health Organization declared in November that Zika was no longer a public health emergency of international concern.

That doesn’t mean concern over Zika is over, but now that a link between Zika and microcephaly has been established, it is viewed as a long-term problem, which requires constant attention.

While researchers have concluded that Zika infection can cause microcephaly and other birth defects such as eye damage in newborns, there are still many unanswered questions about the virus.

Earlier Zika outbreaks in Africa and Asia were gradual, continuous and associated with mild clinical outcomes, but the Zika outbreaks in the Pacific in 2013 and 2014 and the Americas in 2015 and 2016 have been explosive. They have been associated with severe disease, including birth defects in newborns and Guillain-Barre, a condition that can cause temporary paralysis in adults. Scientists are trying to figure out why.

I study flaviviruses, which include Zika and dengue, at Florida Gulf Coast University. Like other flavivirus researchers, I am turning to dengue to better understand Zika. Dengue, a close relative of Zika, is regularly found in places like Brazil, and is spread by the same mosquitoes, Aedes aegypti.

My colleagues and I wanted to find out whether having immunity to dengue from an earlier infection could make a Zika infection worse.

Aedes aegypti mosquitoes can transmit both Zika and dengue viruses.
AP Photo/Felipe Dana, File

A brief history of Zika

Zika was first isolated in Uganda in 1947. For decades Zika infections in humans were sporadic. Perhaps cases of Zika went underreported, since its symptoms were similar to other fever-causing diseases and most cases are asymptomatic.

By the 1980s, Zika had spread beyond Africa and had become endemic, or habitually present, in Asia. Many individuals living in these regions may be immune to the virus.

The first reported Zika outbreak outside of Africa and Asia occurred in the Pacific, in Micronesia, in 2007. To our knowledge there were no associations with microcephaly or Guillain-Barre reported at the time.

Zika transmission in the Pacific wasn’t reported again until 2013, when French Polynesia experienced an explosive outbreak. In 2014 further outbreaks were reported in New Caledonia, Easter Island and the Cook Islands. When French Polynesia experienced another outbreak in 2014, there were reports of Zika being transmitted to babies, most likely in utero, and complications associated with Guillian-Barre in adults.

Map showing countries affected by the Zika virus.

By early 2015 the virus had spread to the Americas, and the first confirmed case of locally acquired Zika in the region was confirmed in May 2015 by Brazil’s National Reference Laboratory. The Pan American Health Organization reports that Zika virus transmission had occurred in over 48 countries or territories in the Americas, with 177,614 confirmed cases of locally acquired Zika in the region, over half a million suspected cases, and 2,525 confirmed congenital syndrome associated cases with Zika infections as of Dec. 29.

Why did Zika start to cause explosive outbreaks? And why did it start to cause more health problems?

Dengue a common connector

A few factors might explain. For instance, perhaps the difference may lie in the age of the person exposed to Zika.

If children are infected before they reach puberty, they become immune and cannot pass Zika along to their children. And in parts of the world where Zika is endemic, people are more likely to have been exposed and become immune while young.

The scenario we’ve seen in the Americas is different. Since Zika had not been reported in the region prior to 2015, people, including women of child-bearing age, had never been exposed to the virus. However, this doesn’t explain why certain people develop severe disease, whereas others do not.

Dengue virus is endemic many parts of Asia, Africa and the Americas, infecting up to 100 million people globally each year. And the areas of the Pacific and the Americas that experienced explosive Zika outbreaks have two things in common: they had not been exposed to Zika before and dengue is endemic. And dengue may provide a clue to why Zika has caused severe disease in these new outbreaks.

Could a prior dengue infection make Zika worse?

When a person is infected with a particular virus for the first time, the immune system springs into action, producing antibodies to destroy it. The next time a person encounters that virus, the body produces those antibodies again to fight back, preventing illness. This is called immunity.

There are four different kinds of dengue virus, called serotypes. Antibodies produced during infection with one dengue serotype confer lifelong immunity against only that particular serotype. If a person is infected with another serotype later on, the antibodies from the earlier infection will bind to the new virus type, but can’t prevent it from infecting cells.

Instead, the bound antibodies can transport the viruses to immune cells that are normally not infected by dengue. In other words, if a person is infected with one serotype of dengue and then gets infected with another serotype, the antibodies from the previous infection then make the new serotype infect cells that it otherwise wouldn’t. Then the virus can reproduce to very high numbers in these cells, leading to severe disease. This process is called antibody-dependent enhancement, or ADE.

Zika virus is closely related to dengue and has been shown to undergo ADE in response to other flavivirus antibodies. Zika virus antibodies in turn have been shown to have a similar effect on related viruses. And other researchers have shown that preexisting immunity to Zika can enhance dengue virus disease severity in animals.

A digitally colorized electron microscope from the CDC shows the Zika virus, in red.
Cynthia Goldsmith/CDC via AP

My lab studied the African strain of the Zika virus in 2015 before the connection with microcephaly was known.

Our results, posted in April to bioRxiv, a preprint server for biology, showed that antibodies from a prior dengue virus infection greatly enhanced Zika virus production in cell culture. Other groups have since independently verified our work. And, as we found in a more recent study, the same results hold true with a strain of Zika isolated in Puerto Rico by the CDC.

Our findings suggest that preexisting dengue virus antibodies may enhance Zika virus infection in patients, potentially making the infection more severe.

However, this correlation needs to be confirmed in the clinic. We do not know how many people infected with Zika in the outbreaks in the Pacific and in the Americas had prior dengue infections. But since the virus is endemic in those areas, it is possible that some people may have been infected with dengue before they were infected with Zika.

Zika’s spread may become limited

Like dengue and other mosquito-borne viruses, Zika spread is seasonal, and outbreaks occur when mosquitoes are abundant. As the United States heads into winter and South America heads into summer, what can we expect with regard to Zika and dengue and disease severity?

As more and more people acquire immunity to Zika, its spread will be limited to those who have never been exposed. Given enough time, new infections will be limited to the young. As long as infections occur prior to child-bearing years, microcephaly in newborns should not be a concern.

If these studies hold true in the clinic, cocirculation of Zika and dengue could increase the severity of both viruses. Vaccines to protect against Zika, and dengue for that matter, would need to be designed carefully so that vaccination with one does not enhance a natural infection with the other virus.

Public health emergency or not, there is still much to be learned about Zika virus and its associated consequences.

The Conversation

Sharon Isern, Professor of Biological Sciences, Florida Gulf Coast University

This article was originally published on The Conversation. Read the original article.

As Republicans Ready to Dismantle ACA, Insurers Likely to Bolt

The Capitol Building as seen in Washington, D.C., Thursday, Dec. 8, 2016. AP Photo/Pablo Martinez Monsivais
The Capitol Building as seen in Washington, D.C., Thursday, Dec. 8, 2016. AP Photo/Pablo Martinez Monsivais

J.B. Silvers, Case Western Reserve University

There’s a joke among insurers that there are two things that health insurance companies hate to do – take risks and pay claims. But, of course, these are the essence of their business!

Yet, if they do too much of either, they will go broke, and if they do too little, their customers will find a better policy. This balancing act isn’t too hard if they have a pool sufficient to average out the highs and lows. I speak with some experience as the former CEO of one of these firms.

Employee-sponsored insurance has fit this model fairly well, providing good stability and reasonable predictability. Unfortunately, the market for individuals has never worked well.

Generally, this model forces insurers to take fewer risks so that they can still make money. They do this by excluding preexisting conditions and paying fewer claims. In such a market, fewer people are helped, and when they are able to get insurance, they pay a lot more for it than if they were part of an employee-sponsored plan.

The Affordable Care Act changed all of this. Companies were required to stop doing these bad things. In exchange for taking on substantially more risk of less healthy patients, they were promised more business by getting access to more potential customers.

The federal government offers subsidies to help pay the premiums for consumers whose income falls below a certain level. The law also stipulates that all people must be covered, or they face a penalty. This so-called individual mandate also guaranteed business for the insurance companies, because it led healthy people into the risk pool.

To entice insurers into the market, the ACA also offered well-established methods to reduce risk. For example, it built in protections for insurers who enrolled especially sick people. It also provided back-up payments for very high-cost cases and protected against big losses and limited big gains in the first three years.

These steps worked well in establishing a stable market for Medicare drug plans when this program started under President Bush in 2006. Competition there is vigorous, rates are lower than estimated and enrollees are satisfied. In other words, the market works well.

President Bush speaks on his Medicare Prescription Drug Benefit plan at the Asociacion Borinquena de Florida Central, Wednesday, May 10, 2006, in Orlando, Florida.
AP Photo/Pablo Martinez Monsivais

Congress did not honor the deal

But when the time came to pay up for risk reduction in the Obamacare exchanges, Congress reneged and paid only 12 percent of what was owed to the insurers. So, on top of the fact that the companies had to bear the risk of unknown costs and utilization in the start-up years, which turned out to be higher than they expected, insurers had to absorb legislative uncertainty of whether the rules would be rewritten.

It is no wonder that this year they have dramatically increased premiums, averaging 20 percent, to compensate for the extra risk they didn’t factor into the original lower rates. In contrast, underlying health costs are rising at about 5 percent.

Is the ACA here to stay? In this June 25, 2015 file photo, demonstrators cheers after the Supreme Court decided that the Affordable Care Act (ACA) may provide nationwide tax subsidies.
AP Photo/Jacquelyn Martin, File

Repeal and replace?

And now comes the reality of the “repeal and replace” initiatives from the Republicans. If the uncertainty of this market was large before with the ACA, it is almost unknowable under whatever comes next. Thus the initial exit of some latecomers, including United Healthcare, and undercapitalized minor entrants, such as nonprofit co-ops, is almost certain to become a flood of firms leaving the exchanges. They have little choice since the risks are too large and the actuarially appropriate rates are still not obvious given the political turmoil and changing rules.

Some in Congress seem to think that passing the “repeal” part immediately but delaying its implementation for two or three years will somehow leave everything as it is now. But this naïve notion misses the fact that the riskiness of the Obamacare individual insurance exchange markets will have been ramped up to such a level that continuing makes no sense.

Even if a company reaches break-even in the “delay” years, it will lose when the repeal is effective. If the premium subsidies now available to lower-income enrollees go away immediately and the mandate to sign up for an insurance plan disappears, then the number of people purchasing individual policies on the exchanges will drop like a rock. In fact, it is clear that even debating this scenario is likely to be self-fulfilling, since insurers must decide on their participation for 2018 by the late spring of 2017. Look for many to leave then.

But what will happen in 2018? The homepage for as seen in October 2016.
AP Photo/Pablo Martinez Monsivais, File

When risks are too high, just exit

It is easy to leave a market when things look bad. The health plan I oversaw, although top-rated by JD Powers, was losing huge amounts when I took over. Part of the turnaround we put into place was to withdraw from a number of counties where most of the losses were occurring. The same will be the case in the ACA exchanges.

It is easy to predict that this induced uncertainty from Congress will effectively kill the exchanges even if it delays the implementation of repeal. As a result, all of the individuals who have benefited from coverage and subsidies will lose out. They will either not be able to gain insurance because of a preexisting condition, or they will not be able to afford the higher premiums.

When they leave the market, it is also easy to guess that the political and economic price will be substantial in terms of patient access, provider uncompensated care costs and employment in the health sector – a major job creator. It is hard to predict these costs, but they could be into the billions of dollars. And, the health of millions could be jeopardized.

Is there any way out of this dilemma for those who don’t like Obamacare? Clearly the first principle, since all of the solutions suggested rely on private insurers, is to reduce the level of risk for them – the opposite of what we are doing now! Even House Speaker Paul Ryan’s proposals rely on private firms which will be loath to trust the game they are asked to play because of the dramatic changes to the rules.

If we want them to continue to do the good things required by the ACA, we can’t make it so uncertain. What this means is that the mechanisms designed to reduce risk and a stable set of operating arrangements must be reaffirmed as core principles of all reform and replace efforts. This shouldn’t be hard for market-oriented Republicans, if they can leave behind their political baggage. Blind talk of repeal with no clear way to build confidence among the private insurers, which will be needed in the replace phase, leads to market failure.

Like the dog that finally caught the car it had been chasing and doesn’t know what to do, what comes next for the administration and Congress is not clear. But we shouldn’t fool ourselves to think it will be easy or painless. Otherwise, it may be that the great experiment trying to establish a viable market for individual insurance – ironically long a conservative objective – will end in the chaos of what came before.

The Conversation

J.B. Silvers, Professor of Health Finance, Case Western Reserve University

This article was originally published on The Conversation. Read the original article.

How To Know When Holiday Drinking Is Hurting Your Brain

Holiday drinking brings good cheer, but it also could be a sign of problem drinking.
Holiday drinking brings good cheer, but it also could be a sign of problem drinking.

Jamie Smolen, University of Florida

For many, the holidays are indeed the most wonderful time of the year. Families and friends come together and enjoy food, good cheer – and, often, alcohol.

Commercially speaking, alcohol and the holidays seem to be made for each other. Alcohol can be a quick and easy way to get into the spirit of celebration.

And, it feels good. After two glasses of wine, the brain is activated through complex neurobiochemical processes that naturally release dopamine, a neurotransmitter of great importance.

When the dopamine molecule locks on to its receptor located on the surface of a neuron, or basic brain cell, a “buzz” occurs. It is often desirably anticipated before the second glass is empty.

This image shows an illustration of a man drinking a pint of beer, indicating how the body metabolizes alcohol and the organs that this alcohol affects.
Wellcome Images via Flickr, CC BY-NC-ND

There are those, however, who drink right past the buzz into intoxication and, often, into trouble. For them, the brain starts releasing the same enjoyable dopamine, no different than what happens in the casual drinker’s, but it doesn’t stop there. A compulsion to binge drink can result.

As someone who has studied alcohol use disorder for over 15 years and who has treated thousands of patients who have it, I think it’s a major, yet often poorly understood, public health problem. Our culture seems to be moving beyond the point of labeling those with opioid addictions as “weak,” and I hope we can do the same for those with alcohol use disorder, too, which is more widespread than people may appreciate. Excessive drinking accounted for one in 10 deaths among working-age adults in the United States.

Moving beyond judgment

Although alcohol can feel as though it is relieving stress, it contributes to 88,000 deaths in the United States each year. That is more than double the number of people killed by heroin and opioid prescription drug overdose, another major public health crisis, in 2014.

In addition, more than 66.7 million Americans reported binge drinking in the past month in 2015, according to the recent report on addiction by the surgeon general.

The consequences to the individual and the family are staggering, affecting physical and mental health, an increased spread of infectious disease, reduced quality of life, increased motor vehicle crashes and abuse and neglect of children, to mention a few.

Scientific study of the brain has helped explain binge drinking even if it may be hard for family and friends to understand. It’s defined as drinking five or more drinks for men and four for women on the same occasion on at least one day in the past 30 days.

Binge drinking is a medical condition. It happens through no fault of the individual, who is victimized by the comparative malfunction of the pleasure circuits in the brain. This causes the drinker to want more and more alcohol. Brains of binge drinkers have a disease, acknowledged by the American Medical Association since the 1950s, yet binge drinkers are often vilified.

Americans typically want to know and are willing to make some lifestyle changes out of fear and common sense when it comes to diseases such as heart disease, obesity and cancer. We as a society are not quite at the same point with substance abuse disorders, but researchers are desperately trying to bring that same willingness for prevention and treatment to substance use disorders.

Science understands the cause well enough to explain it and treat it so that lives can be saved and spared the devastating consequences for the millions who suffer with these conditions, their families and communities. This has become an urgent matter of national importance for scientists and medical practitioners.

The three stages of addiction

The alcohol addiction process involves a three-stage cycle: Binge-Intoxication, Withdrawal-Negative Affect, and Preoccupation-Anticipation.

It begins in the neurons, the basic type of brain cell. The brain has an estimated 86 billion of these cells, which communicate through chemical messengers called neurotransmitters.

Neurons can organize in clusters and form networks or circuits in order to perform specific functions such as thinking, learning, emotions and memory. The addiction cycle disrupts the normal function of some of these networks in three areas of the brain – the basal ganglia, the extended amygdala and the prefrontal cortex.

The disruptions do several things that contribute to continued drinking. They enable alcohol or drinking-associated triggers (cues) which lead to seeking alcohol. They also reduce the sensitivity of the brain systems, causing a diminished experience of pleasure or reward, and heighten activation of brain stress systems. Last, they reduce function of brain executive control systems, the part of the brain that typically helps make decisions and regulate one’s actions, emotions and impulses.

These networks are critical for human survival. Unfortunately for the binge drinker, they become “hijacked,” and the bingeing continues even after the harmful effects have begun.

Because binge drinkers’ brains feel intense pleasure from alcohol, there is a powerful motivation to binge drink again and again. What may begin as social binge drinking at parties for recreation can cause progressive neuro-adaptive changes in brain structure and function. The brain is no longer well enough to function normally. It’s getting sick. Continued partying can transition into a chronic and uncontrollable daily pattern of alcohol use. These maladaptive neurological changes can persist long after the alcohol use stops.

Your brain on alcohol

During the Binge-Intoxication Stage, a part of the brain called the basal ganglia rewards the drinker with pleasurable effects, releasing dopamine, the neurotransmitter responsible for the rewarding effects of alcohol and creating the desire for more.

With continued bingeing, the “habit circuity” is repeatedly activated in another part of the basal ganglia called the dorsal striatum. It contributes to the compulsive seeking of more alcohol. This explains the intense desire (craving) which is triggered while a binge drinker is driving by a favorite bar and can’t resist pulling in, even after a promise to go directly home after work.

During the Withdrawal-Negative Affect Stage, there is a break from drinking. Because the reward circuit has a diminished ability to deliver a dopamine reward, there is far less pleasure with natural (safe) experiences – such as food and sex – compared to alcohol.

During abstinence from alcohol, stress neurotransmitters such as corticotropin-releasing factor (FRC) and dynorphin are released. These powerful neurochemicals cause negative emotional states associated with alcohol withdrawal. This drives the drinker back to alcohol in order to gain relief and attempt to reestablish the rewards of intoxication.

Regions of the brain are affected differently by alcohol.
Surgeon General’s Report on Addiction

After a period of abstinence from alcohol, which may last only hours, the drinker enters the Preoccupation-Anticipation Stage. This involves the prefrontal cortex, where executive decisions are made about whether or not to override the strong urges to drink. This part of the brain functions with a “Go system” and “Stop system.”

When the Go circuits stimulate the habit-response system of the dorsal striatum, the drinker becomes impulsive with a craving and seeks a drink, perhaps even subconsciously. The Stop system can inhibit the activity of the Go system and is important especially preventing relapse after being triggered by stressful life events.

Brain imaging studies show that binge drinking can disrupt the function in both the Go and Stop circuits. This interferes with proper decision making and behavioral inhibition. The drinker is both impulsive and compulsive.

An illness that can be treated

There is good news, as scientific evidence shows that this disorder can be treated.

The FDA has approved three medications for treatment that should be offered whenever appropriate. There is well-supported scientific evidence that behavioral therapies can be effective treatment. This includes recovery support services, such as Alcoholic Anonymous.

Most importantly, it is important to know that alcohol use disorder is a brain disorder causing a chronic illness. It is no different from diabetes, asthma or hypertension. When comprehensive continuing care is provided, the recovery results improve, and the binge drinker has the hope of remaining sober as long as lifelong treatment and maintenance of sobriety become a dedicated lifestyle choice.

The Conversation

Jamie Smolen, Associate Professor of Medicine, University of Florida

This article was originally published on The Conversation. Read the original article.

The Potential Costs of Tom Price as HHS Secretary

Rep. Tom Price as he arrives at Drumpf Tower on Nov. 16, 2016. , in New York. AP Photo/Carolyn Kaster
Rep. Tom Price as he arrives at Drumpf Tower on Nov. 16, 2016. , in New York. AP Photo/Carolyn Kaster

Miranda Yaver, Yale University

President-elect Donald Trump has repeatedly vowed to “repeal and replace Obamacare.” A logical question is: With what? The announcement of Rep. Tom Price (R-Ga) as Trump’s nominee for secretary of health and human services provides some answers.

Unlike other Republican critics of the Affordable Care Act (ACA), Price, an orthopedic surgeon, has offered many replacement plans of unmatched detail. His Empowering Patients First Act was 242 pages long. It offers a market-based vision for American health care, restricting government involvement.

His plan, however detailed, lacks specifics about what will happen to the 20 million or so who gained insurance coverage under the ACA. This includes people who have preexisting conditions and those who rely on Medicaid, the federal-state program that provides insurance to poor children, pregnant women of a certain income level as well as the disabled and blind under 65.

Price’s policies could also limit access to care for children, women and for many people of all ages with chronic and mental illnesses.

As a scholar of American policymaking, I hope to shed some light on Price’s plan.

What would Rep. Price do as head of the Department of Health and Human Services?
AP Photo/Alex Brandon, File

Children’s coverage could be jeopardized

One of the main pillars of Price’s plan is tax credits based on age to individuals who wish to buy health insurance in the private market. Importantly, this proposal assumes that those who are younger will also be healthier, thus requiring less coverage.

However, there has been a rise from in the prevalence of chronic illnesses among children, from 12.8 percent in 1994 to 26.6 percent in 2006.

Also, incidence of type 2 diabetes and teen depression has increased. Mental health conditions often have an age-of-onset in the teens and 20s. Yet both age groups are allotted the lowest tax credits in the Price plan, and more children from lower- and middle-income households may struggle to obtain needed coverage.

In 2007, Price voted against the reauthorization of the State Children’s Health Insurance Program (SCHIP), a program founded in 1997 that provides medical care to about eight million low-income children, at a total cost of about US$13 billion. It has been cited as instrumental in reducing the number of uninsured children from 10.7 million in 1997 to 6.6 million in 2012.

Application for CHIP.
J. David Ake via AP

Medicaid could be rolled back

Lower-income children are not the only lower-income group likely to suffer under Price’s proposal.

Currently, federal and state governments share the cost of Medicaid, with 32 states having adopted the Medicaid expansion that was called for under the ACA. An ACA repeal would eliminate expansions of Medicaid and the Children’s Health Insurance Program (CHIP) – which together cover approximately one in five Americans – and replace it with Medicaid block grants that the federal government provides to the states.

This would slow the growth annual rate of spending on Medicaid from its current level of 7 percent to 3 percent, according to the Congressional Budget Office. The CBO also estimated a reduction in Medicaid spending by $1 trillion over 10 years.

But The Medicaid programs that Price seeks to restrict not only are more cost-effective in the long run to administer – with the Robert Wood Johnson Foundation estimating that Medicaid coverage expansion reduced hospitals’ uncompensated care by 21 percent, with states saving in costs of caring for the uninsured – but have had demonstrably positive health outcomes for vulnerable populations. For example:

A study in the public health journal Health Affairs suggested that outpatient medical appointments increased 29 percent, while preventable hospitalizations fell 48 percent in the aftermath of a new new public insurance program in Wisconsin in 2009.

Also, The Kaiser Family Foundation reported in 2016 that Medicaid expansion under the ACA not only reduced the uninsured rates of those states, but in many cases improved access to care and utilization of some physical and behavioral health services. Similarly, an Urban Institute report on outcomes related to Medicaid showed greater access.

Those with preexisting conditions could lose out

In the aftermath of meeting with President Obama, Trump indicated some interest in preserving the provision that people cannot be denied insurance coverage for preexisting conditions.

This is challenging, however. Insurers’ ability to guarantee coverage regardless of preexisting conditions works in tandem with the ACA’s mandate that all individuals enroll in at least some level of coverage. The purpose of this was to bring healthy patients into the risk pool.

Price’s plan would prevent insurers from denying coverage based on preexisting conditions, but at a price. His plan would allow insurers to charge consumers up to 150 percent of standard premiums. This would apply if consumers do not maintain continuous coverage for at least 18 months. Thus, if someone becomes unemployed and unable to afford coverage in between jobs, he or she could be left without insurance.

Such a marked premium increase could in some cases be devastating, especially for those with chronic conditions. The Centers for Disease Control and Prevention estimated in 2012 that about half of the American population (117 million) had at least one chronic health condition, and one in four adults has two or more chronic health conditions. Seven of the top 10 causes of death are chronic diseases.

Mental health treatment could suffer

Within the context of preexisting conditions, it is worth emphasizing also that the CDC estimate focused on behavioral and not mental health, the diagnosis of which would also constitute a preexisting condition.

Yet about 16.1 million Americans had a major depressive episode in the past year, which does not include milder forms of depression, or other behavioral health conditions such as anxiety or psychotic disorders. Indeed, about one in five American adults will struggle with mental illness in a given year.

The ACA provided a marked expansion in access to care for mental and behavioral health by requiring that most individual and small group plans and all marketplace plans provide mental health benefits. The repeal of the ACA leaves the state of mental health care very much in question. It renders particularly vulnerable those who have capitalized on the ACA’s access to mental health coverage and in doing so, accumulated preexisting conditions.

Planned Parenthood South Austin Health Center is seen in Austin, Texas on June 27, 2016.
RIlana Panich-Linsman/Reuters

Women’s health could be harmed

In his first term in Congress, Price cosponsored the Right to Life Act, which sought to extend 14th Amendment personhood to a fertilized egg and thus limit abortions. This did not make exceptions for pregnancies resulting from rape or incest, and it did not consider the health of the woman.

Price did not simply vote for legislation to defund Planned Parenthood (HR 3134 in 2015); he cosponsored it.

The defunding of Planned Parenthood could limit care to women, given that it provides contraception, STD testing, cancer screenings and prenatal care. Increased contraceptive use has been the main reason for a dramatic decline in teen pregnancies in recent decades.

Women in urban areas can obtain contraceptive care from many sources in urban areas, but Planned Planned Parenthood is the sole provider in one fifth of 491 counties surveyed in 2010. And in two-thirds of those counties, Planned Parenthood clinics served at least half of the women who obtained contraceptive care from safety-net health centers.

Who is empowered?

After the American Medical Association endorsed Price, an open letter signed by over 5,000 physicians challenged the endorsement.

The empirical evidence in favor of the programs that he seeks to scale back or eliminate altogether should temper his eagerness to overhaul the Affordable Care Act.

Such tempering is not yet apparent. How Senate Democrats and moderate Republicans – perhaps those in states that accepted and benefited from Medicaid expansion – respond to Price in the looming confirmation battle may provide some answers to who is empowered first under Price’s leadership.

The Conversation

Miranda Yaver, Lecturer in Political Science, Yale University

This article was originally published on The Conversation. Read the original article.