CHIP (and not the kind you eat)

An update from my first blog post in November about new issues for Obama's administration.I noted that expansion of SCHIP would likely be expanded.  Well, hooray, it was!

CHIPRA, H.R. 2:

CHIP, the state-administered Children's Health Insurance Program was signed into law by President Obama on February 4th, 2009 and will take effect April 1, 2009.  The important act, formally, H.R. 2: Children's Health Insurance Program Reauthorization Act (CHIPRA) of 2009 renews coverage of health insurance for 7 million children and expands it to 11 million children through 2013.  

Brief History:

CHIP was originally authorized in 1997 for ten years, ending in 2007.  Twice in 2007, it was passed by Congress to be vetoed both times by President Bush.  Stopgap legislation was passed by Congress to extend the program for 18 months, ending in March 2009.  

The act amends title XXI of the Social Security Act.  It was introduced on Jan 13, 2009, passed in the House Jan 14, passed in Senate Jan 29, and signed by Obama on Feb 4.  The program will cost $32.8 billion and is paid for with an increase in tobacco taxes ($.62 rise in cig. tax).  

CHIPRA Provisions:

Some key notes about CHIPRA:  

1) States are allocated funds to pay for the program based on projected trends.  

2) New tools, using Express Lane Eligibility, were created to increase enrollment for the the already-eligible-but-not-enrolled uninsured children.  There is also $100 million allocated for grants to promote outreach and enrollment into CHIP and Medicaid.

3) Eligibility rules were changed to: 

       a) limit states (whom still have the ultimate power on income eligibility) from covering above 300% FPL (would then get Medicaid matching rate instead of SCHIP) 

       b) pregnant women can be covered, 

       c) parents (and childless adults) will not be given new SCHIP coverage and eventually phased out the program/moved to a new grant

       d) the 5-year waiting period for legally-residing children and pregnant women has been removed.  

4) There is also a quality initiative to develop evidence-based quality measures for children in SCHIP and to improve the reporting of quality data by the states.  Hooray! Also, $20m for projects on HIT for kids, $25m for projects to prevent childhood obesity, and MACPAC committee to review payment rates (like Medicare's MEDPAC). 

5) Increased access to dental benefits (re: Deamonte Driver death-see links below)

6) Mental health parity!!  I'll have to write another story soon on this topic as I'm pretty excited about the broader legislation passed (and I wrote a 25 page paper for Managed Care on this topic).  However, CHIPRA says that mental health services now must be covered as equally as physical health services.  (Finally getting toward that 1948 WHO definition of health, encompassing physical, mental, and social well-being---and I digress...again).

Side Note #1:  

Lisa Dubay, one of my Professors at Johns Hopkins, was an instrumental player in the SCHIP reauthorization and was present at Obama's signing of the act into law.  She shared photos with us in class.  Her profile can be found here:  http://faculty.jhsph.edu/Default.cfm?faculty_id=1657.

Side Note 2: 

Formerly known as State Children's Health Insurance Program (SCHIP), CHIP, CHIPRA, and SCHIP are roughly synonymous.  

Side Note 3:

For more information about Deamonte Driver, the boy who died due to a tooth infection that spread to his brain, see the links below:

http://www.washingtonpost.com/wpdyn/content/article/2007/03/02/AR2007030200827.html

http://abcnews.go.com/Health/story?id=2925584

A new version of "Social Medicine" (as in in "Social Network Medicine")

Feeling sick?  Need to see a doctor?  Get out your laptop.  Not to look up the location or phone number of a doctor's office, but to "e-visit" your doctor.  

One Brooklyn, NY based physician practice is transforming medical practice and seeing patients through online visits with social networks.  "Hello Health" offers visits with your doctor through instant messaging (IM), video chats, or for extra fees, a personal home visit.  Patients enroll on their website (link below), do a one-time in person visit, pay a monthly fee of $35, and then pay for the type of visit they wish thereafter (video, home, IM, etc).  There are already 300 patients, and the company has only existed for less than a year.  A second practice is opening in the West Village, NYC.  

This new model does come with risks--such as the protection of patient's electronic health records (EHR) and quality of care for patients (ensuring standards of care).   Also, if allowed to use video to see your patient, doctors and patients don't have to be in the same city, state, or country.  So, the practice of medicine raises issues in various geographical licensure issues.  These issues will have to be addressed with the new health care delivery model.

However, there are no more wait times.  Simultaneously "tweet" your friends and your doctor, while sitting around at home.  As long as you have the internet (and some spare money--not yet covered by insurance), you have access to a doctor.  And imagine the worker productivity changes--instead of missing a 1/2 day to a full day of work (and vehicle mileage), you can take a 20 minute break from work to have a video visit with your doc.  That sounds appealing.

Social networks--facebook, twitter, myspace, etc--are on the rise.  Should the delivery of medical care join the social network revolution?  

Article in Health Affairs:

http://content.healthaffairs.org/cgi/reprint/28/2/361

"Hello Health's" website:

https://www.hellohealth.com/main/index.html

CNN story on Hello Health:

http://www.cnn.com/2009/HEALTH/01/15/ep.trends.in.ehealth/index.html

I vote for patient safety.

Medical-device technology firms should not be putting patients at risk (via the oops--we didn't know--non-disclosure of risks on our devices).  See the link to the story from yesterday's NEJM editorial from Curfman, Morrissey, & Drazen; http://content.nejm.org/cgi/content/full/360/15/1550.  

Where is the compromise between the free market/business enterprise and FDA regulation?  It better not be on on the risks of the public's health.  I for one, vote for patient safety.

Obama & Health Care: Most Likely Outcomes

Obama has some hefty challenges awaiting him in the White House for sure.  The rough economy and war overseas will have to be immediate priorities in January.  Health care reform is also in that list of top priorities.  Last week, Johns Hopkins School of Public Health (JHSPH) held their 4th event in the Universal Healthcare Series, "Moving Toward Universal Healthcare:  Alternative approaches to reform in the US."  Harvard's Dr. David Himmelstein was among the speakers, whom pointedly noted that we've had plenty of opportunities for reform, which have failed (think Clinton's 1992 effort and many multiple state attempts).  He pointed out that now is our opportunity for reform.  

In today's issue of The Lancet, Nellie Bristol discusses Obama's plans for our country and the world's health (Obama's plans for US and global health care).   Many project the following are most probable and feasible Obama's immediate administration:  reversal of Bush's ban on stem cell research, expansion of State Children's Health Insurance Program (SCHIP), reversal in "Mexico City policy" (aka global gag rule), and the establishment of a comparative effectiveness group (similar to UK's National Institute for Health & Clinical Excellence).  

To expand on probable immediate actions, Obama is likely to remove some of the restrictions Bush placed on stem cell research (to only use existing stem-cell lines).  Secondly, SCHIP was vetoed by Bush last year after approval from both houses of Congress.  Most likely coverage will be expanded by $35 billion to $60 billion (paid by cigarette taxes).  Children make up 20% of the US uninsured population (Kaiser Foundation).  Expansion of SCHIP appears likely.  Next, the Mexico City policy (global gag policy) requires NGOs to agree to neither "perform nor actively promote abortion as a method of family planning in other nations."  It was enacted by Reagan in 1984, overturned by Clinton, and put back into place by Bush.   Finally, the comparative effectiveness group would look at evidence-based medicine and the Medicare system for physician reimbursements to give guidelines for clinical practice.  

What will be the long-term results though?  Will we move away from employer-based health insurance?  Will we cover all Americans?  Will we have better preventive care and can we improve health outcomes with new policy reform?  How much will we spend on global health, when the US needs the health improvement also?  

It's certainly an interesting time to be near Washington DC and in the field of Health Policy & Management.  Be sure to advocate and put full pressure on local representatives to push for health care reform (there is also currently a $1m media campaign targeted at newly elected officials to "keep their promises" for health care reform).  

If we don't reform US health care now, (when) will we?