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The House Republican Plan

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                    [post_content] => House Republicans recently released  a new plan to replace Obamacare. It's hard to say exactly what effects it would have because the plan is more of an outline without legislative language or many details. Even so, today I take a look at the evidence we have about the likely effects of the key parts of the outline. I try to be fair, acknowledging that the Republican goal for health reform is fundamentally different than what the Democrats tried to achieve with the ACA's passage seven years ago. The point isn't to cover as many people, but to reduce the role of the federal government and government spending in health care. So for each component I describe a pro and a con, why the House Republicans like the idea and why opponents don't.

1) Medicaid block grants

Pro – Medicaid is now the single largest budget item in most states, accounting for more than a quarter of all state expenditures. This is of great concern to state leaders trying to get a handle on their budgets so they will have enough money for other things like transportation and education. Of course, when you factor in how much of this money comes from the federal government, states are really spending more like 17% of their own funds on Medicaid. But that is still a lot of money that they have very little control over. Republicans also don't like that the federal government effectively writes a blank check to states for Medicaid, with very little ability to reduce spending. The federal burden has only increased with the ACA's promise to pay at least 90% of the costs of enrollees in the expansion population. Block grants would solve these problems by giving states a fixed amount of money to spend on Medicaid. The federal government would no longer be a blank check and states would have greater flexibility on how to spend the federal dollars they receive for Medicaid. Graph of Expenditures by Function from the NASBO State Expenditure Report Con – There are three primary ways that states can reduce spending on Medicaid as they try to manage a block grant they receive from the federal government: 1) reduce the number of people enrolled in the program, 2) make the benefits less comprehensive, and 3) pay health care providers less for their services. Any of the three would lead to decreased access to care for vulnerable people who cannot afford another option.

2) Health savings accounts

Pro – Individuals are able to set aside money, often tax-free, to be used at their discretion to pay towards health care expenses. Unused money rolls over to subsequent years, meaning that people who manage their health savings account well can accumulate a nice balance. The theory goes that because people have a larger stake, they will be more cost conscious and not spend as much and health care costs will be contained. There is insurance that kicks in after a large deductible is paid from the HSA, and the premium is relatively low because the deductible is so high. Con – People save money in an HSA by delaying and deferring care. That is fine as long as the care they are delaying is unnecessary, but it leads to bad health and financial outcomes if they are delaying necessary or preventative care. One of the major criticisms of Obamacare is the large number of plans sold on the exchange with high deductibles. It would therefore be ironic if one of the major coverage components of the ACA replacement plan was explicitly based on the idea of high deductibles.

3) High risk pools

Pro – Its harder for me to find the pro here. I guess high risk pools are better than nothing for people who are pushed out of an ACA plan but can't get insurance another way because of costs or pre-existing conditions. Con – high risk pools face actuarial math that doesn't add up by trying to pool the sickest and least insurable people together. Analysis by Jean Hall published by the Commonwealth Fund shows that they are 1) extremely expensive to administer, 2) prohibitively expensive for consumers, with very high premiums and deductibles, and 3) offer limited coverage, often with annual and lifetime caps. We are talking about deductibles as high as $25,000 and yearly coverage limits of $75,000. Once again, it would be ironic if high risk pools are touted by opponents of the ACA as the way forward. Technically these people will have coverage, but it won't be very good and won't protect them from medical debt.

4) Age-based tax credits

Pro – Right now the ACA gives tax credits to people between 100-400% of the federal poverty level so that they can purchase insurance. The tax credit is on a sliding scale based on income so that people with less money receive the greatest help. The House Republican plan would change this so that everyone receives a tax credit, regardless of income. The amount would be based on age so that older people, whose health care costs are presumably more expensive, would receive more than younger people. As Margot Sanger-Katz of the NY Times points out, this means that multi-millionaire Secretary of State Rex Tillerson would receive the same level of help as another 64 year old living in poverty. This approach would be simpler to administer and would eliminate an incentive that younger people might have faced to not work harder and earn for fear that they would receive less help. Con – The 64 year old living in poverty has much greater need than Rex Tillerson. Young people often don't make enough money to make up the difference between the tax credit and the cost of coverage. Without the requirement that everyone be covered, many young people will likely gamble by foregoing insurance. This hurts them when they get sick and weakens risk pools, driving up costs for everyone else. As I wrote two weeks ago, the metric we should be using to evaluate alternatives in the debate over health reform is not whether a plan solves all problems, but whether it leaves us with a better set of problems. You can decide for yourself, but I think the evidence shows that the House Republican plan leaves us with a worse set of problems. Feature image: Ron Cogswell, House of Representatives Building and the East Portico of the U.S. Capitol – Washington (DC) January 2013, used under CC BY 2.0/cropped from original Graph from the NASBO State Expenditure Report [post_title] => The House Republican Plan [post_excerpt] => PHP Editor-in-Chief David K. Jones looks at the pros and cons of the key parts of the House Republican plan outline to replace Obamacare. [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => house-republican-plan [to_ping] => [pinged] => [post_modified] => 2017-09-01 23:11:11 [post_modified_gmt] => 2017-09-02 03:11:11 [post_content_filtered] => [post_parent] => 0 [guid] => http://www.publichealthpost.org/?post_type=bu_news&p=1242 [menu_order] => 0 [post_type] => bu_news [post_mime_type] => [comment_count] => 0 [filter] => raw ) [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [view] => BUPHP_Post_View Object ( [multipage] => [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [extra_args] => Array ( ) [owner] => [_trigger_error:WPLib_Base:private] => 1 )

PHP Editor-in-Chief David K. Jones looks at the pros and cons of the key parts of the House Republican plan outline to replace Obamacare.

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Evidence vs. Alternative Facts

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                    [post_content] => Let's be honest – every president is selective about which truths they highlight. But the level of misrepresentation by the Trump administration in its first month far exceeds anything we have seen before. If we can't trust Kellyanne Conway and Sean Spicer on crowd sizes how can we take anything they say about policy seriously? The debate over health reform is so complex that the average American will not be able to sift through their statements to decide for themselves what is true and what isn't. A recent survey showing that 1 in 3 Americans do not know that Obamacare is the same thing as the Affordable Care Act epitomizes the challenge of having an informed debate about health reform.

Evidence on a Postcard

A friend of mine recently hosted a party in which guests wrote facts about the ACA, the immigration executive order, and climate change on the back of 800 postcards. The postcards were then sent to someone in Wisconsin who mailed them to Speaker Paul Ryan from a post office in his district. My friend even went through the trouble of specially ordering Wisconsin postcards with pictures of cows and cheese on the front. This is a creative act of protest reminiscent of some of the most effective actions undertaken by the Tea Party. In late 2011, Wisconsin Governor Scott Walker was under enormous pressure to return a federal grant his administration had received to create a health insurance exchange as part of implementing Obamacare. Activists mailed him hundreds of envelopes filled with strings to symbolize the dangerous strings they believed were attached with grant money from the Obama administration. Activists also collected enough signatures to trigger a recall election, forcing him to campaign again just two years after winning office. Within two days of these signatures being submitted, Governor Walker announced he was returning the grant money. There is some evidence that Republicans in Congress are getting nervous about the level of engagement they are seeing from ACA supporters. Leaked audio from the recent Republican retreat makes it clear that there is not yet consensus on what to replace the ACA with if it is repealed. In fact, Republicans are starting to talk more now about "repairing" the ACA rather than repealing or replacing it. The most recent ideas floated by the Trump administration include fairly modest changes such as increasing the ratio between what insurance companies can charge older and younger enrollees from 3:1 to 3.49:1. My friend asked me to provide a short list of facts about the ACA that guests at her party could put on the back of the postcards they mail to Speaker Ryan. I unfortunately could not respond in time to help her, but below is a list of short talking points about what I would have said.

Here is the best and most recent evidence we have about the ACA

1) The ACA has without question reduced the number of people without health insurance. The exact number depends on how you count the uninsured, but by every measure the number has dropped dramatically since the ACA fully went into effect in 2014. According to Gallup, 17.1% of U.S. adults lacked insurance at the end of 2013. By the end of 2015 this was down to 11.9% and in 2016 this dropped to 10.9%. The CDC estimated that the uninsured rate dropped to around 9% in early 2016. These are dramatic and unprecedented changes affecting millions of people. The changes vary dramatically throughout the country depending on choices made by individual states, with the uninsured rate remaining very high in many states that have resisted the ACA. 2) A recent poll - by Fox no less - shows that 50% of Americans have a favorable opinion of the ACA. Donald Trump's favorability number in the same poll was 42%, meaning that [ictt-tweet-inline]Obamacare is more popular than President Trump.[/ictt-tweet-inline] 3) Repealing the ACA would give a tax cut to the wealthiest 400 households in the country that is larger than the combined financial assistance that 800,000 people in 20 states receive as part of the ACA. 4) Donald Trump's campaign proposals to repeal and replace the ACA (to the extent there was one) would be costly and result in millions losing coverage. He has since promised that everyone would be covered with lower premiums and deductibles. He hasn't said how he would do that either, but Trump's campaign plan costs $550 billion over 10 years and results in 21 million more uninsured. 5) One of the biggest criticisms against Obamacare recently was the 25% average premium increase for exchange plans. This is alarming if the trend continues, but should be placed in context. Analysis by Loren Adler and Paul Ginsburg at Brookings shows that premiums are lower than we expected them to be at this point and lower than they would be without Obamacare. Don't forget to factor in the tax credits. Most consumers experienced a change of 0% in the premium they paid for 2017 compared to year before. 6) There is a low level of competition in some state exchanges. In many states there is only one insurance company selling plans. This undermines the whole premise of an exchange that competition will benefit consumers by driving down prices. I have written before about why this criticism is somewhat disingenuous, but this is nevertheless an important issue that needs addressing. 7) ACA plans provide good coverage. Plans sold on the exchange are more comprehensive than what most people in the individual market would have been able to purchase otherwise. But there is a worrisome trend towards increasingly high deductibles. One analysis suggests that 90% of enrollees in exchange plans have deductibles greater than $1,300 for an individual and $2,600 for a family. The ACA has cost-sharing reductions to mitigate this problem, but there is still a significant burden on low-income populations. 8) Hospitals spend $7.4 billion less on uncompensated care because more people have insurance. The drop is estimated at $5 billion in states that expanded Medicaid and $2.4 billion instates that did not. 9) ACA repeal could lead to tens of thousands of preventable deaths. Estimates range from 20,000 to 36,000 per year. This is a very hard number to predict, but the underlying point holds that taking away insurance will leave many people vulnerable. I unfortunately can't link to the Council of Economic Advisers report to President Obama on this in December 2016 because it was taken off the White House's page. 10) The effects of the ACA on businesses is complex, but most businesses have not dropped employer-sponsored coverage as predicted. Many employers dislike or are apprehensive about the ACA, but more than anything they want stability. The law is not perfect. Changes need to be made. But as political scientist Frank Thompson has written, the right criteria for evaluating reforms is not whether they solve all problems, but whether they leave us with a better set of problems than we would otherwise have. The ACA passes that test. Feature image: Gage SkidmoreKellyanne Conway speaking at the 2016 Conservative Political Action Conference (CPAC) in National Harbor, Maryland, used under C BY-SA 2.0 license/cropped from original.  800 Postcards photo used with permission.  [post_title] => Evidence vs. Alternative Facts [post_excerpt] => David K. Jones gives us ten facts and the most recent evidence we have about the ACA. 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David K. Jones gives us ten facts and the most recent evidence we have about the ACA.

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We Need Good Reporters

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                    [post_content] => Public Health Post profiles health policy journalists and the work that they do. Here, Michael Stein spoke with Dan Diamond, the author of POLITICO Pulse and creator of PULSE CHECK, a podcast that features weekly conversations with some of the most interesting and influential people in health care. Michael caught up with Dan in between coming off the air on NPR and interviewing a Congressional leader. Here's the second half of their conversation.

MDS: What’s your sense from where you’re sitting, how this election has changed the public appetite for journalism? We live in this new media world of lies and misinformation, and since you’re a serious writer, how does this change your job?

DD: That is the question of the moment with all of my colleagues. I read two stories yesterday that are at the poles of this. One written by Margaret Sullivan, the brilliant public editor for the New York Times, now a columnist for the Washington Post. She had a headline that was something like, 'Journalists are now facing the hellscape of the Trump years where lies are going to be manifold, where attacks on the press are going to be incredibly strong, where people don’t trust these institutions.' I thought there was a lot of truth to that article.

Then my colleague, and kind of a hero to me, Jack Shafer, the longtime media columnist at Slate and elsewhere and now Politico, wrote a story that said, basically, [ictt-tweet-inline]'It’s springtime for journalism.'[/ictt-tweet-inline] There are so many targets, there’s so much need for journalism now. There had been this widespread outpouring of people standing up and saying we need good reporters; in many ways, Trump has been a gift. I think there is truth to both sides.

I have never been as attacked for writing fairly standard, mundane stories about health care and the economy. I was getting horrible comments via email and on social media, but at the same time I've never had a moment where I thought my journalism could matter more.
 ‘It’s springtime for journalism.’ There are so many targets, there’s so much need for journalism now.  
And  it’s very hard to know what will happen until we get into the actual Trump administration, because we’ve been in this weird inter-regnum. I could see it going in a very good way where journalists are holding the administration to account and being celebrated for it and I can see it going in an awful way where the administration gets angry and locks down on journalists, and Peter Thiel, an ally of the Trump administration, launches some crusade and things kind of go the wrong way. Hard to say for sure right now, but everyone is aware of the opportunity and the potential peril. Featured image: OPEN DAYSRoundtable with Journalists, Roundtable with Journalists - 07 October 2013. EU OPEN DAYS 2013 #euopendays Belgium - Brussels - October 2013 © European Union. Photographer : Patrick Mascart. Used under CC BY-NC 2.0 license/cropped from original.  [post_title] => We Need Good Reporters [post_excerpt] => In the coming weeks, Public Health Post will be profiling health policy journalists and the work that they do. Michael Stein profiles Politico's Dan Diamond. [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => need-good-reporters [to_ping] => [pinged] => [post_modified] => 2017-09-01 22:58:30 [post_modified_gmt] => 2017-09-02 02:58:30 [post_content_filtered] => [post_parent] => 0 [guid] => http://www.publichealthpost.org/?post_type=bu_news&p=990 [menu_order] => 0 [post_type] => bu_news [post_mime_type] => [comment_count] => 0 [filter] => raw ) [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [view] => BUPHP_Post_View Object ( [multipage] => [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [extra_args] => Array ( ) [owner] => [_trigger_error:WPLib_Base:private] => 1 )

In the coming weeks, Public Health Post will be profiling health policy journalists and the work that they do. Michael Stein profiles Politico’s Dan Diamond.

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Trump, the ACA, and Women’s Health

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                    [post_content] => The health of women in the United States is in the hands of President Trump and the Republican-controlled Congress. On the campaign trail, Trump vowed to repeal and replace the Affordable Care Act (ACA) by partnering with Congress to “create a patient-centered health care system that promotes choice, quality, and affordability.” However, repealing the ACA poses a serious threat to the health care in America. As of 2016, the Health Insurance Marketplaces, Medicaid, and other ACA provisions expanded health insurance coverage to 20 million Americans, and a record number of Americans enrolled in health plans from Health Insurance Marketplaces for 2017. Women are particularly vulnerable to the effects of repeal.

One way the ACA is improving women’s health is through nondiscrimination policies and access to affordable, quality health plans. No woman can be denied health insurance because of her gender. In 2016, 6.8 million women and girls selected health plans from the Health Insurance Marketplaces. The uninsured rate among women aged 18 to 64 decreased by 44%. The ACA also extended preventive services without co-pays or deductibles to 55.6 million women, and 8.7 million women received insurance for maternity services. Another 65 million women are protected from discrimination or higher premiums because of pre-existing conditions. Despite these expansions in coverage, cases like Burwell v. Hobby Lobby, which allows family-owned corporations to cite religion to deny ACA-mandated contraception coverage, limit women’s access to health care.

Repeal

Republicans have control of both chambers of Congress, but are eight seats shy of a filibuster-proof 60-vote majority in the Senate. As a result, Democrats will be able to stop Republicans from passing a law that fully repeals the ACA. But Republicans have already begun to lay the groundwork to use the budget reconciliation process to get rid of the ACA’s coverage expansions. This is a parliamentary tactic that allows bills with a clear budgetary impact to pass the Senate with a straight majority of 51 votes. Only 20 budget reconciliation bills have become law since 1980, but they have included some of the most consequential legislation of the last 20 years, including Bill Clinton’s welfare reform and the George W. Bush tax cuts. Republicans have already used reconciliation to repeal parts of the ACA, though their bill did not become law because of President Obama’s veto last January. Democrats are not in a position to criticize Republicans for using reconciliation to repeal major parts of the ACA given that this is how they passed the law in the first place. It is clear that Republicans can pass a bill repealing the ACA. It is far from clear, however, whether they can simultaneously pass a replacement. Many don’t think they need to because they can simply delay the date by which their repeal will go into effect. They hope that a compromise on what comes next will become possible in a few years because enough parts of the law will fall apart by that point and there will be intense pressure on Democrats to cooperate.

And Replace?

Repealing the ACA would increase the number of uninsured women, limiting access to quality, affordable health plans. The extent of the impact will depend on what is ultimately enacted. One approach Trump and Ryan have proposed is expanding the use of Health Savings Accounts (HSAs). According to Timothy Jost, HSAs would primarily benefit the wealthy because tax deductions do not proportionately benefit low-income families compared to high-income families. Jost also notes that Republicans have proposed replacing the ACA with fixed dollar tax credits, but these credits would not cover the cost of health care as much as the current ACA health plans. [ictt-tweet-inline]Replacing the ACA health plans with HSAs might disproportionately affect low-income women[/ictt-tweet-inline] if this approach mostly benefits the wealthy.
Replacement proposals should continue non-discrimination policies that prohibit insurers from denying a woman coverage because of her gender, as well as ensure access to quality, affordable plans with preventive and maternity services.  
Trump has shown a willingness to keep some parts of the ACA, like a provision extending coverage to individuals on their parents’ health plans until the age of 26 and a provision protecting individuals with pre-existing conditions. He should add women’s coverage to that list. Republicans are likely to target federal funding for Planned Parenthood. This would significantly decrease access to services like cervical cancer prevention, breast cancer screenings, pelvic exams, endometriosis treatment, and Pap and HPV tests, among others. But this does not mean Republicans cannot support parts of the ACA that maintain access for women. Pace and colleagues found that the ACA improved consistent use of the oral contraceptive pill among women because it eliminated cost sharing, which lowers rates of unintended pregnancy. Replacement proposals should continue non-discrimination policies that prohibit insurers from denying a woman coverage because of her gender, as well as ensure access to quality, affordable plans with preventive and maternity services.

Secretary Price & What Comes Next

The nomination of Georgia Congressman Tom Price to lead the Department of Health and Human Services has enormous implications. He is an avid opponent of the ACA, having introduced replacement plans to Congress each year since its enactment. Just as Kathleen Sebelius and Sylvia Burwell played major roles as HHS Secretary in defining what the ACA actually accomplishes, what the ACA’s repeal legislation actually means will in large part hinge on Price’s interpretation and influence. Even before the ACA is repealed, Price could undercut major parts of the law by refusing to enforce regulatory requirements. The Obama administration is defending challenges to the ACA in court, but Price and the Trump administration could stop defending the lawsuits, allowing the plaintiffs to win. These include contraceptive cases like Zubik v. Burwell, which the Supreme Court recently returned to lower courts after religious groups challenged the ACA’s mandate to provide insurance coverage for contraception to employees. Considering Price and Trump’s vow to dismantle the ACA, it is difficult to imagine “a patient-centered health care system” that serves women and “promotes choice, quality, and affordability” for women. Featured Image: Gage Skidmore, Donald Trump speaking at CPAC 2011 in Washington, D.C., used under CC BY/cropped from original.
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The health of women in the United States is in the hands of President Trump and the Republican-controlled Congress.

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LGBT Nigerians Navigate Antigay Laws to Mitigate HIV

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                    [post_content] => The Criminal Code Act of 1916 and the Same-Sex Marriage (Prohibition) Act of 2014 criminalize homosexual acts, same-sex marriage, attending a same-sex marriage and LGBT advocacy in Nigeria. Nigeria is one of only two African governments to ban LGBT advocacy, and Nigerian anti-gay laws penalize LGBT organizing, though 37 African nations outlaw homosexual acts.

NoStrings NG, a Nigerian LGBT media organization, is launching a social media campaign to engage health providers with the local LGBT community to improve access to LGBT-friendly health services. The campaign shares stories from health providers and LGBT Nigerians living with HIV/AIDS to describe homophobia’s effect on HIV transmission.

“[ictt-tweet-inline]NoStrings actually serves not just the community, but also tries to shape perceptions around LGBT-related issues[/ictt-tweet-inline] more especially because a whole lot of people are looking up to the mainstream media as a source for information,” said Mike Daemon, NoStrings NG project coordinator. “We try to correct certain notions and impressions people have about LGBT-related issues.”

Criminalizing Advocacy for LGBT Health

NoStrings NG partners with LGBT-friendly NGOs, which consult with health providers and HIV-positive Nigerians willing to share their stories on social media. “You can’t come out officially [or] publicly because of the anti-LGBT law that we have,” said Daemon. “There’s a problem because if you identify or if there is something about you that suggests to people that you’re gay, then you could be arrested.” [caption id="attachment_828" align="aligncenter" width="800"] Nigeria is one of seven nations where homosexual acts are punishable by death (The Wall Street Journal).[/caption] “One has to have a strong standing [in the LGBT community] in order to [support] such organizations in a homophobic country like Nigeria,” wrote one Nigerian online supporter, speaking anonymously. The Same-Sex Marriage (Prohibition) Act of 2014 expanded the Criminal Code Act of 1916 to not only ban same-sex relations, but also to prohibit LGBT advocacy and to restrict organizations from providing health and social services to LGBT Nigerians. After its enactment, 38% of Nigerian men who have sex with men (MSM) reported fear of seeking health services compared to 25% of Nigerian MSM before its enactment. “That has been a major problem more especially because there is a certain part of the law that tends to criminalize organizations working towards helping individuals living with HIV,” Daemon said. Nigeria reduced its HIV/AIDS prevalence from 5.8% to 4.1% between 2001 and 2010, though the HIV prevalence among Nigerian MSM increased from 13.5% to 17.4% between 2007 and 2010. Nigerian MSM transmit 10% of new HIV infections in the country. “It’s quite difficult for LGBT persons to access their drugs, and sometimes getting to trust [health providers] is another problem because a whole lot of people are suffering from internalized homophobia,” Daemon said. Daemon understands how moving these clandestine conversations from the ground to social media, where the Nigerian government monitors advocacy less attentively, shapes LGBT organizing and LGBT health. “We have quite a limited number of LGBT organizations catering for HIV-infected LGBT persons in the country currently, and most of them are actually on the ground [supporting the Nigerian LGBT community],” Daemon said.
NoStrings NG introduced the social media campaign to improve LGBT visibility online and access to LGBT-friendly health services, which might serve as a model for other LGBT organizers advocating in homophobic contexts.  

A Safe, Queer, Online Space

NoStrings NG uses its website, podcasts, Facebook and Twitter to advance LGBT representation and HIV/AIDS online. The Nigerian online supporter notes how [ictt-tweet-inline]NoStrings NG’s social media campaign offers a safe, queer, online space for LGBT Nigerians[/ictt-tweet-inline]. “It gives the LGBT Nigerians better coverage, and it helps indirectly to reduce bigotry,” the ally wrote in an email. “It is safe because people of the community are free to express themselves without discrimination or bigotry. It gives them an assurance that they are not alone facing challenges due to their sexuality.” “Options are limited for LGBT persons because a whole lot of the time they have other health issues that they would like to talk about,” Daemon said. “They need an organization that is completely friendly.” NoStrings NG introduced the social media campaign to improve LGBT visibility online and access to LGBT-friendly health services, which might serve as a model for other LGBT organizers advocating in homophobic contexts. “The project is trying to explore why this is wrong [and] the negative things that these laws are doing to individuals in terms of people wanting to test and the fear of exposure,” Daemon said. Featured Image: Ian Cochrane, Lagos DSC04208 Nigeria, used under CC BY/cropped from original [post_title] => LGBT Nigerians Navigate Antigay Laws to Mitigate HIV [post_excerpt] => Nigeria's NoStrings NG is launching a social media campaign to improve access to LGBT-friendly health services. [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => lgbt-nigerians-navigate-antigay-laws-mitigate-hiv [to_ping] => [pinged] => [post_modified] => 2017-09-01 23:08:34 [post_modified_gmt] => 2017-09-02 03:08:34 [post_content_filtered] => [post_parent] => 0 [guid] => http://www.publichealthpost.org/?post_type=bu_news&p=814 [menu_order] => 0 [post_type] => bu_news [post_mime_type] => [comment_count] => 0 [filter] => raw ) [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [view] => BUPHP_Post_View Object ( [multipage] => [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [extra_args] => Array ( ) [owner] => [_trigger_error:WPLib_Base:private] => 1 )

Nigeria’s NoStrings NG is launching a social media campaign to improve access to LGBT-friendly health services.

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Public Health without a Budget: Budget Crisis in Illinois

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                    [post_content] => Illinois gained notoriety as the only state in the U.S. to spend fiscal year 2016 without a state budget and the first state to go a whole year without a budget in close to a century. A profound impasse between the newly elected Republican Governor Bruce Rauner (staunchly pro-business and anti-tax) and the Democratic-led state legislature (broadly pro-government spending and pro-union) led to a budget stalemate which has yet to be meaningfully resolved.

The combatant sides produced a stopgap budget on June 30, 2016, the final day of the fiscal year, which provided some funding for the first half of the 2017 fiscal year. However, the temporary budget fix funds only some state obligations, at less-than-full levels, leaves the resolution of fundamental differences on budgeting for further debate before the expiration of the short-term budget at the end of December 2016, and fails to clarify how, to whom, and how much funding will be distributed to desperate recipients of state funds.

The stopgap budget may be too little too late for many health service, mental health, and social service organizations. The inability to rely on state funding in the near future may keep many organizations from re-expanding services which were cut during the previous year’s impasse. For instance, when state funding dropped off, Rape, Advocacy, Counseling, and Education Services (RACES) in Urbana, Illinois, gradually reduced services over the course of 11 months, going from multiple professional staff providing counseling, advocacy, outreach, training, and crisis response down to a single, part-time staff member coordinating trained volunteers to provide crisis intervention and advocacy. While RACES may receive some funds (although this is unclear) under the temporary budget, the extreme uncertainty about continued funding is a barrier to rehiring staff or re-expanding services which might then have to be cut again almost immediately.
As the length of the Illinois budget impasse extends, public health officials have noted significant concerns, from the elimination of long term programs to the potential for a preventable illness outbreak to “a major dismantling of human services and public health infrastructure.”  
  In addition to non-profit agencies like RACES, many local and state organizations rely heavily on state funds which are missing or reduced due to the budget impasse. Local health departments often provide essential public health services using state funds, including immunizations, health inspections, and prevention efforts. As the length of the Illinois budget impasse extends, public health officials have noted significant concerns, from the elimination of long term programs to the potential for a preventable illness outbreak to “a major dismantling of human services and public health infrastructure.” Whether or not such drastic effects occur, [ictt-tweet-inline]the Illinois budget impasse has had significant short and long-term impacts on public health organizations[/ictt-tweet-inline] and the health of the people of Illinois. In the short term, the state’s most vulnerable citizens, who rely on state-funded public health and social service resources, are being underserved by critical programs like autism services, child care subsidies, and mental health services. In the long term, rebuilding agencies like RACES, decimated by the lack of funds, will take extraordinary commitment to recouping the financial and social capital. Further, vulnerable citizens may face ongoing or lifelong health consequences. Children who don’t receive immunizations when local public health agencies reduce their outreach will face ongoing risk of disease. Families who could not access immigration services, funding for which was specifically frozen, may have missed critical opportunities to connect with community health programs. Many more examples exist, but [ictt-tweet-inline]the takeaway from the ongoing Illinois budget impasse is that state funding is the lifeblood of public health[/ictt-tweet-inline] in the daily lives of American citizens. Withholding funding has clearly had catastrophic effects, and the continued uncertainty about funding in the future has lessened the benefit of the temporary funding relief provided by a stopgap budget. Essential public health programs and organizations – defined expansively to include social service and community health programs – should be funded with ongoing, automatic appropriations. The lesson to policymakers from Illinois’s disastrous experience is to provide clear and trustworthy plans to support consistent public health programs, regardless of political issues around other funding questions. Featured image: Illinois State Capitol by Daniel X. O'Neil, can be reused under the CC BY license/cropped from original [post_title] => Public Health without a Budget: Budget Crisis in Illinois [post_excerpt] => Illinois gained notoriety as the only state in the US to spend 2016 without a state budget and the first state to go a year without a budget in close to a century. [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => public-health-without-budget-budget-crisis-illinois [to_ping] => [pinged] => [post_modified] => 2017-09-01 22:56:52 [post_modified_gmt] => 2017-09-02 02:56:52 [post_content_filtered] => [post_parent] => 0 [guid] => http://www.publichealthpost.org/?post_type=bu_news&p=684 [menu_order] => 0 [post_type] => bu_news [post_mime_type] => [comment_count] => 0 [filter] => raw ) [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [view] => BUPHP_Post_View Object ( [multipage] => [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [extra_args] => Array ( ) [owner] => [_trigger_error:WPLib_Base:private] => 1 )

Illinois gained notoriety as the only state in the US to spend 2016 without a state budget and the first state to go a year without a budget in close to a century.

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Student Essay Contest: Dear Paul Ryan…

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PHP is thrilled to announce its first student essay contest. The assignment is to imagine you are writing directly to House Speaker Paul Ryan. How do you convince him to make public health a priority as he considers new health reform legislation? What policy or policies do you recommend he enacts? The ideal responses will be engaging, provide compelling evidence, and speak to the current political realities. 

The top three finalists will be published on PHP and the winner will receive $250. There is a strict 1000 word limit. References should have embedded hyperlinks rather than a bibliography at the end. Each submission should also include 3 tweets (not counted against the word limit) that would be used to promote the post and attract attention from Speaker Ryan and other policymakers. The deadline for submissions is Monday January 2, 2017The winning posts will be published the week of Donald Trump’s inauguration, starting on January 16, 2017

Only students (at any level: undergraduate, masters, doctoral) during the 2016-2017 school year are eligible. This includes people graduating in December 2016. You do not have to be in a school of public health. Email Melissa Davenport with any questions: davenpor@bu.edu

Summary

What: Student essay contest Question: Imagine House Speaker Paul Ryan will read your post. How do you convince him to make public health a priority in 2017? What policy or policies do you recommend he enacts? Why? Prize: $250 and publication on Public Health Post Eligibility: Anybody who is a student during the 2016-2017 school year Word limit: 1000 words, plus 3 tweets (not counted against word limit) Deadline: Monday January 2, 2017, by 12:00 midnight EST  Submit essay to: Melissa Davenport at davenpor@bu.edu. Indicate your school and expected date of graduation at the top of  the essay.  

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PHP is thrilled to announce its first student writing contest. The assignment is to imagine you are writing directly to House Speaker Paul Ryan. How do you convince him to make public health a priority as he considers new health reform legislation?

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20 Questions for President Trump

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                    [post_content] => The last six and a half years have been uncharted territory in our nation's century-long debate over health reform. For the first time the fight was about how to implement an attempt at near-universal coverage rather over what this plan should look like and what could win enough support in Congress. The Affordable Care Act (ACA) has survived major political, legislative, and legal tests, including dozens of repeal votes, two Supreme Court decisions, the 2012 presidential election, and state-level resistance.

I was outside the Supreme Court on June 25, 2015 when the King v. Burwell decision was released. I was there the moment activists switched their signs from saying "Don't you dare take my care" to "The ACA is here to stay." I wrote that we could finally say with some certainty that they were right, the law is here to stay. They were wrong. I was wrong.

Donald Trump's victory throws the future of health reform into complete chaos. He will take office in January 2017 with Republican majorities in the House and Senate. President Trump, Speaker Ryan, and Senate Majority Leader McConnell have all made repeated promises to get rid of Obamacare. They will face enormous pressure to follow through with their threats of repeal. Approximately 21 million people are projected to lose insurance if they follow through with their initial proposals.

[caption id="attachment_543" align="alignnone" width="700"]aca-here-to-stay Outside the Supreme Court on June 25, 2015. Photo by author. Featured image by Tom Lohdan.[/caption]

The first step to figuring out where to go from here is understanding what decisions are on the horizon. [ictt-tweet-inline]Here are my first 20 questions about health reform under the Trump administration[/ictt-tweet-inline], in no particular order:

1. [ictt-tweet-inline]Will Republicans follow through with repealing the ACA?[/ictt-tweet-inline] It is one thing to make threats when there is no chance they will come to pass. Where will health reform fit in the constellation of issues President Trump promised to focus on such as immigration and the economy?

2. If they decide to move forward with repeal in the first year—as I fully expect them to do—what will this look like? The details matter greatly. Will this be a mostly symbolic gesture to appease the conservative base without upsetting interest groups and taking away people's insurance, or will this be a more comprehensive overhaul of the ACA?

3. [ictt-tweet-inline]Will legislation to repeal the ACA include specifics about what to replace it with or will these be two separate conversations?[/ictt-tweet-inline] The history of health reform clearly shows that it is very hard to gain consensus on the details even if there is agreement on the broad goals. It will be much harder to pass repeal legislation if Republicans have to agree on what comes next.

4. I expect they will target the individual mandate. What will they do to combat the likely adverse selection problems that will lead to weakened risk pools and increased premiums increases?

5. Will they try to keep popular parts of the law such as allowing children to stay on their parents' plans until age 26 or banning insurance companies from excluding people because of pre-existing conditions?

6. Will Republicans re-claim ownership of policy ideas they supported before they became part of Obamacare, such as using tax-credits to subsidize the purchase of private insurance through state-based health insurance exchanges?

7. Would they repeal the ACA's coverage expansions across the board or use a federalism approach similar to the ACA which gives states flexibility to opt-in to keeping things like the Medicaid expansion and insurance exchanges?

8. What does a repeal timeline look like? How long will insurance companies, states, and consumers have to adapt before the coverage expansions are phased out?

9. What effect will all this uncertainty have on the current enrollment period for the exchanges?

10. What will state leaders do? In particular, what will leaders do in the states that have expanded Medicaid but voted for Trump, including Arizona, Michigan, and Pennsylvania? Will they fight to keep the federal money coming into their state or will they support ending the expansion?

11. Will we finally see a voter feedback effect in which the 20 million people who stand to lose insurance mobilize and fight against the ACA's repeal? We have not seen this in Kentucky where Governor Bevin has undone the state's exchange and is trying to remove or scale back the state's Medicaid expansion.

12. What happens to all the current and future negotiations over Medicaid 1115 waivers? Will the Trump administration halt conversations? Will they be more permissive and allow things like work requirements which the Obama administration has rejected?

13. Will any state try a 1332 waiver? If so, how will the Trump administration respond?

14. Assuming block grants are part of the ACA replacement plan, what does this actually look like? What will this mean for states and beneficiaries?

15. This a crucial stage in the dramatic movement away from fee for service to alternative payment models. Will the Trump administration continue in this direction or shift course entirely?

16. What is the future of Accountable Care Organizations?

17. [ictt-tweet-inline]What happens when the Children's Health Insurance Program (CHIP) expires on September 1, 2017?[/ictt-tweet-inline] Will the bipartisan coalition that has supported CHIP further erode? Check out these articles in NEJM and Health Affairs that Jon Oberlander and I wrote about CHIP politics as it stood earlier this year.

18. Will Donald Trump follow through with his early campaign promises to allow Medicare to negotiate pharmaceutical prices?

19. [ictt-tweet-inline]Will public health emerge as a health reform issue that can transcend the partisan divide?[/ictt-tweet-inline] In other words, will leaders be able to move beyond the fights over insurance coverage to focus on non-partisan population health issues such as maternal and infant mortality?

20. What does the future look like for federal funding for research on health services, medical care, and social sciences through AHRQ, NIH, and NSF?
                    [post_title] => 20 Questions for President Trump
                    [post_excerpt] => Donald Trump's victory throws the future of health reform into complete chaos. Here are my first 20 questions about health reform under the Trump administration.
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Donald Trump’s victory throws the future of health reform into complete chaos. Here are my first 20 questions about health reform under the Trump administration.

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Pascal’s Wager & Obamacare Politics

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                    [post_content] => Open enrollment for the ACA's health insurance exchanges began today. Our most recent databyte (by PHP fellow Jon Gang, available here) highlights that 40% of counties in states relying on healthcare.gov will only have one insurance company offering plans. That means many people buying private insurance through the ACA won’t have much choice about what plan to select. This undermines the whole premise of the exchanges, that prices would stay low because plans would compete with each other for business.

There are reasons to be concerned about the long-term health of the exchanges if this trend continues and also reasons to believe things are not as bad as critics contend. However, [ictt-tweet-inline]some of the outcry over limited competition is disingenuous[/ictt-tweet-inline] since this is the outcome opponents seemed to have hoped for. Many have done more than simply stand back and predict problems. They are actively working to undermine the law and make failure a self-fulfilling prophecy.

Democrats Own Obamacare

Conservative opposition to the exchanges is ironic given that this was a policy idea specifically included in the ACA to win support from Republicans and moderate Democrats. This was “conservative means to liberal ends” because coverage would be expanded through private insurance and with the principles of marketplace competition. This was not the liberal ideal many on the left held out for in the 70s and 90s when they rejected moderate plans by Richard Nixon and Bill Clinton. There were lots of reasons to believe compromise on the exchanges was possible. Republican governors in Massachusetts and Utah had already created exchanges. Paul Ryan’s alternative to the ACA included health insurance exchanges. The elimination of the public option and the elevation of the Senate bill creating state-based exchanges rather than stronger national control was seen by Democrats as further attempts to win broad support. But that didn’t happen as Republicans decided to oppose the ACA en masse. Not a single Republican voted for the final bills. Re-branding the law as Obamacare, they made it clear that President Obama and his fellow Democrats had full ownership. If it failed, it was his/their fault. They believed that doing everything they could to make sure the law failed would help them win big in 2010 and 2012.

State-Level Opposition

At first it didn’t seem that the strictly partisan politics surrounding the ACA’s enactment would filter down to state-level planning about health insurance exchanges. The law contained a threat that any state refusing to set up their exchange would lose control to the federal government who would do it for them. Even as 26 states were suing the Obama administration over the individual mandate and the Medicaid expansion, every state except Alaska and Minnesota accepted a million dollars federal grant to begin exploring how to set up an exchange.
Some of the outcry over limited competition is disingenuous since this is the outcome opponents seemed to have had hoped for. Many have done more than simply stand back and predict problems. They are actively working to undermine the law and make failure a self-fulfilling prophecy.  
I have conducted more than 200 interviews with policymakers and stakeholders at the state and federal levels about how states reacted to the choice of whether or not to create an exchange. Seventeenth century French philosophy doesn’t come up often in my research on health reform politics, but [ictt-tweet-inline]one bureaucrat in Nebraska likened the Obamacare decision facing conservative states to Pascal’s Wager[/ictt-tweet-inline]. In his mind, conservative leaders had to decide whether they believed the ACA would survive legal and political challenges (similar to Pascal’s question of whether God exists). If yes, then it would be better to comply with the exchanges, retaining control and taking as much federal money in the process – just as Pascal concluded that the upside of eternity in heaven outweighed the alternative and so the safe approach is to believe in God. With this in mind, it is therefore amusing that another analogy a handful of conservatives used to defend creating a state-based exchange is “It is better to work with the devil you know.” (Click here for an article I co-authored more fully exploring the Pascal's Wager analogy). The breakdown in the Pascal’s Wager analogy is that he presumably had no control over whether God exists, though conservative opponents believed they could bring down the law if they resisted strongly enough. I have written a book (expected 2017) about how opponents worked to undermine the national reform through state-level attacks. The Tea Party and other opponents were remarkably effective at defeating the traditionally dominants interest groups in many states.

Mississippi

[ictt-tweet-inline]Mississippi is a case study in what could have been for the exchanges[/ictt-tweet-inline]. More insurers likely would have participated in the exchange had the state followed through with retaining control. Insurance Commissioner Mike Chaney took it upon himself to create the state’s exchange when legislation failed. He is a Republican who opposed the ACA, but he believed it would be better for the state to retain as much control over regulating its insurance market as possible. Commissioner Chaney is independently elected instead of appointed by the governor and so believed he could move forward without the governor’s support. He created an advisory committee that met every month and included the state’s major insurers. They got very close to launching, including building a website that stood up very well under pre-launch testing (making the initial failures of healthcare.gov doubly ironic in Mississippi).   [caption id="attachment_467" align="alignnone" width="700"]mike-chaney MS Insurance Commissioner Mike Chaney. Photo by Raeley Stevens. Featured image by Lance Cheung.[/caption] Governor Phil Bryant eventually blocked him as Tea Party opposition to the exchange grew. The Obama administration reluctantly sided with Governor Bryant, saying it was not feasible to operate a successful exchange if the governor refused to cooperate. The advisory committee fell apart and most of the major insurers backed out, deciding they didn’t want to participate if they didn’t have a voice in planning or a direct connection to the regulators. Commissioner Chaney was then left scrambling to convince insurers to remain so that each part of the state would have at least one plan available. It is impossible to know what would have been different had Mississippi stuck with plans to run its own exchange. More insurers likely would have participated at the outset, but maybe they would have struggled and eventually pulled out. Maybe we would be in almost the same situation we are in now. But maybe not. The Mississippi story is a window to how things could have played out across the country if opponents had not been so hell-bent on blocking the law. When you read criticism from opponents of the ACA that the exchanges are not working as well as predicted, remember that this is what they wanted and that they have worked very hard for this. [post_title] => Pascal's Wager & Obamacare Politics [post_excerpt] => Mississippi is a case study in what could have been for the exchanges. Insurers were willing to participate until conservative leaders & Obamacare politics got in the way. [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => pascals-wager-obamacare-politics [to_ping] => [pinged] => [post_modified] => 2017-09-01 23:07:28 [post_modified_gmt] => 2017-09-02 03:07:28 [post_content_filtered] => [post_parent] => 0 [guid] => http://www.publichealthpost.org/?post_type=bu_news&p=461 [menu_order] => 0 [post_type] => bu_news [post_mime_type] => [comment_count] => 0 [filter] => raw ) [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [view] => BUPHP_Post_View Object ( [multipage] => [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [extra_args] => Array ( ) [owner] => [_trigger_error:WPLib_Base:private] => 1 )

Mississippi is a case study in what could have been for the exchanges. Insurers were willing to participate until conservative leaders & Obamacare politics got in the way.

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