Medicaid's Future: What Might ACA Repeal Mean?

Issue: Republicans in Congress are expected to repeal portions of the Affordable Care Act (ACA) using a fast-track process known as budget reconciliation.Goals: This issue brief examines how repeal legislation could affect Medicaid, the nation's health care safety net, which insured 70 million people in 2016.Findings and Conclusions: Partial-repeal legislation that passed Congress but was vetoed by President Obama in 2016 offers some insight but new legislation could go further. It could repeal the ACA's Medicaid eligibility expansions for adults and children but also roll back other provisions, such as simplified enrollment and improvements in long-term services and supports for beneficiaries with disabilities. Additionally, the Trump Administration could expand use of demonstration authority to introduce deeper structural changes into Medicaid, such as eligibility restrictions tied to work, required premium contributions and lock-out for nonpayment, annual enrollment periods, and coverage limits and exclusions. Together, these changes would have far-reaching implications for Medicaid's continued role as the nation's safety-net insurer

How will Texas’ Affordable Care Act Implementation Decisions Affect the Population? A Closer Look

The Affordable Care Act (ACA) gives states two key choices: Whether to expand Medicaid to cover poor uninsured adults; and whether to establish a state Exchange. No population stands to gain more from these choices than residents of Texas, who experience the nation’s highest uninsured rate. National estimates show that by not expanding Medicaid, the state has foregone coverage for 1.5 million people. County‐level estimates show that in 249 out of 254 counties, the proportion of uninsured adults exceeds 20 percent of the total adult county population. In 31 counties, the proportion of low income uninsured adults exceeds 60 percent of all low income adult county residents. Because Texas has chosen not to establish a state Exchange, its residents are vulnerable to a decision by the United States Supreme Court in King v Burwell that strikes down premium subsidies in states such as Texas, whose elected leaders have decided to rely on the federal Exchange. Should the Court eliminate subsidies in federal Exchange states, an estimated 1 million residents could face the immediate loss of affordable health insurance. County‐level estimates show that in 56 counties, 1 in 25 residents or more could be left without access to affordable coverage. The combined effects of not expanding Medicaid and the potential impact of King v Burwell will hit Texas’ health care system hard. County‐level estimates show that prior to implementation of the ACA, 38 counties experienced hospital annual uncompensated care levels of $50 million or greater, and 4 counties showed losses greater than$200 million. Texas’ failure to adopt the Medicaid expansion, coupled with the loss of premium subsidies as a result of a decision against the government in King would reverse the progress that has been made in reducing the number of uninsured Texans. Furthermore, hospitals could find that the demand for charity care actually rises, as thousands of previously‐insured people with serious health conditions turn to their hospitals for help. A landmark research study presented to the United States Supreme Court in King by public health Deans and the American Public Health Association documents the relationship between increased health insurance and reduced adult mortality. This research shows that for every 830 adults who gains health insurance, one fewer adult will die annually from preventable causes. This means that of the more than 2 million people potentially adversely affected by Texas’ decisions not to expand Medicaid and to rely on the federal Exchange, approximately 2400 Texans could die annually from preventable causes, with thousands more unable to manage serious health condition

Streamlining Medicaid Enrollment: The Role of the Health Insurance Marketplaces and the Impact of State Policies

In addition to expanding eligibility for Medicaid, the Affordable Care Act reformed the program's enrollment process, with the health insurance marketplaces playing a central role in the reforms. State-based marketplaces determine Medicaid eligibility, but federal regulations give states using the federal marketplace a choice either to allow the marketplace to make Medicaid eligibility determinations or to limit its role to assessing and referring applicants to the state Medicaid agency. This issue brief examines Medicaid enrollment data and finds that states that establish their own marketplaces realize higher Medicaid enrollment. In states that use the federal marketplace, Medicaid enrollment is higher when states have the marketplace determine eligibility. These findings underscore the importance of states' marketplace decisions regarding Medicaid enrollment

Improving Community Health through Hospital Community Benefit Spending: Charting a Path to Reform

A new report recommends that the Trump administration take action to revise existing Internal Revenue Service policies governing community benefit spending by tax-exempt hospitals in order to encourage greater hospital involvement in activities that can improve health on a community-wide basis.Research increasingly shows the outsize importance of healthy communities to population health. Affordable and safe housing, safe and welcoming neighborhoods, access to nutritious food, strong child development programs and quality education together can lead to better health outcomes. Hospitals themselves have recognized the health impact of these broader social, economic and environmental conditions and as well as the value of their involvement in activities aimed at improving social conditions.Building on longstanding policies regarding tax exempt hospitals and community benefit spending, the report shows the incoming Trump administration can encourage greater hospital involvement in community-wide health by adopting a more flexible regulatory standard on what constitutes a community benefit. Produced by researchers at the George Washington University's Milken Institute School of Public Health (Milken Institute SPH), the report identifies a series of steps that the IRS can take, working in collaboration with public health experts drawn from across government and private institutions and organizations, to modify existing community benefit policies to encourage greater population health activities. Such a change would be wholly consistent with hospitals' own community health needs assessments (CHNAs), which focus on high-priority community health needs that extend beyond clinical health care

Access to comprehensive perinatal services among pregnant women enrolled in both Medi-Cal and Covered California: aligning and integrating care

Medi-Cal-enrolled women who are pregnant are entitled to coverage for enriched pregnancy-related care under Medi-Cal’s Comprehensive Perinatal Services Program (CPSP), a national landmark in the care and management of pregnant women with elevated health risks due to their low economic status. This entitlement applies to all pregnant women enrolled in Medi-Cal, including women who also are enrolled in subsidized health plans purchased through Covered California. The task that jointly faces Medi-Cal and Covered California is how best to align these two sources of pregnancy care financing in order to achieve a central goal of SB 857 – ensuring that dually enrolled pregnant women continue to have full access to CPSP-level treatment. With roots in California’s acclaimed Obstetrical Access demonstration program, the CPSP program does not simply provide additional coverage. CPSP effectively alters the standard of care available to pregnant women facing elevated health and social risks by establishing a provider network certified and overseen by the California Department of Public Health and qualified to provide CPSP-level care. This care is furnished in a fully integrated manner, through treatment teams comprised of clinicians, social workers, health educators, nutrition counselors, and other health professionals. By contrast, California’s essential health benefit regulations, which define the scope of coverage to which Covered California enrollees are entitled, do not specify either a range of maternity benefits comparable to those available through CPSP, or access to a provider network possessing the comprehensive treatment capabilities of CPSP providers. A review of health plans sold through Covered California reveals that these plans offer the standard level of maternity care expected from traditional commercial insurance. The care they offer, as described in their benefit summary materials, contains none of the special social, nutritional, enabling, or behavioral services available through CPSP, nor is there mention of special treatment standards that fully integrate a broader range of services into highly integrated care programs. The absence of this higher standard of care is not surprising, since Covered California is designed to reflect the commercial insurance market. This fact also explains the legislative intent behind SB 857 – to ensure that women enrolled in both Covered California plans and Medi-Cal and receiving pregnancyrelated care continue to have full access to the services and benefits of the CPSP program. Two options exist for aligning and integrating the CPSP program and Medi-Cal coverage with Covered California for dually eligible women. The first is to specify CPSP providers as “essential community providers” and direct health plans to extend network membership to all CPSP providers in their service areas. This approach might be combined with special payment incentives to plans that provide additional risk adjustments related to the treatment of pregnant women at higher health risk. Plans would pay CPSP providers for the standard maternity care they furnish and that are part of women’s Covered California coverage, and Medi-Cal would pay an enhancement to CPSP providers for the additional care they furnish. The California Department of Public Health would continue to maintain certification and oversight responsibilities for CPSP providers. The benefit of this model is that it would fully integrate CPSP providers into plan networks, thereby easing referral arrangements, especially for the treatment of underlying and diagnosed medical conditions. The limitation is the regulatory direction over plan network composition. A second option would be to treat CPSP providers as covered out-of-network care. Medi-Cal would pay providers as it currently does and seek repayment from Covered California plans up to the level of payment for standard maternity care. The strength of this model is the absence of greater regulation of 3 plan networks, while the limitation is the lesser level of integration of CPSP into broader health plan coverage and care through Covered California

Medicaid Payment and Delivery Reform: Insights from Managed Care Plan Leaders in Medicaid Expansion States

Issue: Managed care organizations (MCOs) are integral to Medicaid payment and delivery reform efforts. In states that expanded Medicaid eligibility under the Affordable Care Act, MCOs have experienced a surge in enrollment of adults with complex needs.Goal: To understand MCO experiences in Medicaid expansion states and learn about innovations related to access to care, care delivery, payment, and integration of health and social services to address nonmedical needs.Methods: Interviews with leaders of 17 MCOs in 10 states that have seen large Medicaid enrollment growth and have undertaken payment and delivery reforms.Findings and Conclusions: MCO leaders regard their ability to enroll and serve the Medicaid expansion populations as a signal achievement. They have focused on identifying and helping high-risk populations and addressing the social determinants of health. MCOs are testing value-based payment strategies that link payment with performance and are increasingly focused on engaging patients in their care. Leaders report common challenges: setting appropriate payment rates; managing members whose needs differ from traditional Medicaid beneficiaries; ensuring access to specialty care; and effectively implementing payment reform and practice transformation. All point to the need for a stable policy environment and a strong working relationship with state Medicaid agencies

Multimodal Treatment Eliminates Cancer Stem Cells and Leads to Long-Term Survival in Primary Human Pancreatic Cancer Tissue Xenografts.

Copyright: 2013 Hermann et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.PURPOSE: In spite of intense research efforts, pancreatic ductal adenocarcinoma remains one of the most deadly malignancies in the world. We and others have previously identified a subpopulation of pancreatic cancer stem cells within the tumor as a critical therapeutic target and additionally shown that the tumor stroma represents not only a restrictive barrier for successful drug delivery, but also serves as a paracrine niche for cancer stem cells. Therefore, we embarked on a large-scale investigation on the effects of combining chemotherapy, hedgehog pathway inhibition, and mTOR inhibition in a preclinical mouse model of pancreatic cancer. EXPERIMENTAL DESIGN: Prospective and randomized testing in a set of almost 200 subcutaneous and orthotopic implanted whole-tissue primary human tumor xenografts. RESULTS: The combined targeting of highly chemoresistant cancer stem cells as well as their more differentiated progenies, together with abrogation of the tumor microenvironment by targeting the stroma and enhancing tissue penetration of the chemotherapeutic agent translated into significantly prolonged survival in preclinical models of human pancreatic cancer. Most pronounced therapeutic effects were observed in gemcitabine-resistant patient-derived tumors. Intriguingly, the proposed triple therapy approach could be further enhanced by using a PEGylated formulation of gemcitabine, which significantly increased its bioavailability and tissue penetration, resulting in a further improved overall outcome. CONCLUSIONS: This multimodal therapeutic strategy should be further explored in the clinical setting as its success may eventually improve the poor prognosis of patients with pancreatic ductal adenocarcinoma

Kinetics of Eotaxin Generation and Its Relationship to Eosinophil Accumulation in Allergic Airways Disease: Analysis in a Guinea Pig Model In Vivo

Challenge of the airways of sensitized guinea pigs with aerosolized ovalbumin resulted in an early phase of microvascular protein leakage and a delayed phase of eosinophil accumulation in the airway lumen, as measured using bronchoalveolar lavage (BAL). Immunoreactive eotaxin levels rose in airway tissue and BAL fluid to a peak at 6 h falling to low levels by 12 h. Eosinophil numbers in the tissue correlated with eotaxin levels until 6 h but eosinophils persisted until the last measurement time point at 24 h. In contrast, few eosinophils appeared in BAL over the first 12 h, major trafficking through the airway epithelium occurring at 12–24 h when eotaxin levels were low. Constitutive eotaxin was present in BAL fluid. Both constitutive and allergen-induced eosinophil chemoattractant activity in BAL fluid was neutralized by an antibody to eotaxin. Allergen-induced eotaxin appeared to be mainly in airway epithelium and macrophages, as detected by immunostaining. Allergen challenge of the lung resulted in a rapid release of bone marrow eosinophils into the blood. An antibody to IL-5 suppressed bone marrow eosinophil release and lung eosinophilia, without affecting lung eotaxin levels. Thus, IL-5 and eotaxin appear to cooperate in mediating a rapid transfer of eosinophils from the bone marrow to the lung in response to allergen challenge

CSL–MAML-dependent Notch1 signaling controls T lineage–specific IL-7Rα gene expression in early human thymopoiesis and leukemia

Notch1 activation is essential for T-lineage specification of lymphomyeloid progenitors seeding the thymus. Progression along the T cell lineage further requires cooperative signaling provided by the interleukin 7 receptor (IL-7R), but the molecular mechanisms responsible for the dynamic and lineage-specific regulation of IL-7R during thymopoiesis are unknown. We show that active Notch1 binds to a conserved CSL-binding site in the human IL7R gene promoter and critically regulates IL7R transcription and IL-7R α chain (IL-7Rα) expression via the CSL–MAML complex. Defective Notch1 signaling selectively impaired IL-7Rα expression in T-lineage cells, but not B-lineage cells, and resulted in a compromised expansion of early human developing thymocytes, which was rescued upon ectopic IL-7Rα expression. The pathological implications of these findings are demonstrated by the regulation of IL-7Rα expression downstream of Notch1 in T cell leukemias. Thus, Notch1 controls early T cell development, in part by regulating the stage- and lineage-specific expression of IL-7Rα

Differential Disclosure Across Social Network Ties Among Women Living with HIV

Women’s disclosure of their HIV serostatus across social network ties was examined in a sample of women living in Los Angeles (n = 234), using multivariate random intercept logistic regressions. Women with disclosure-averse attitudes were less likely to disclose, while women with higher CD4+ counts were significantly more likely to disclose, regardless of relationship type. Relative to all other types of relationships, spouses/romantic partners were greater than four times more likely to be the targets of disclosure. Women were more than 2.5 times more likely to disclose to a given network member if that target provided the woman with social support. Social network members whom women believed to be HIV-positive were more than 10 times more likely to be the targets of disclosure. The implications for how social roles and social identities are manifest in these results are discussed, including the implications such an interpretation has for future prevention research