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Last Build Date: Mon, 27 Feb 2017 16:30:18 +0000


From Machine-Readable Provider Directories, A Preview Of A Revolution

Mon, 27 Feb 2017 16:30:18 +0000

Amidst recent and anticipated changes in health insurance markets, there has been a growing trend towards increased transparency of provider networks. An important part of this effort is the implementation of standardized, machine-readable provider directories. By enabling the aggregation of provider information and plan comparisons as never before, these directories permit researchers and regulators to advance what we know about health plan provider networks, including to what extent providers in those networks report that they are accepting new patients. This advance in network information and transparency comes at an important time—as policymakers consider new balances between regulatory requirements, product diversity, and consumer choice. Background: Concerns with Provider Networks and Directories With the establishment of health insurance exchanges in 2014, health insurers faced increasing pressure to narrow their commercial plan provider networks. Studies led by health economist Daniel Polsky and Janet Weiner and the consulting firms Avalere and McKinsey documented the “narrowness” of many of these networks. There are good reasons why health insurers chose to do this, including cost savings and the desire to drive business toward the providers that most effectively serve the unexpectedly sick and higher-cost populations that enrolled in these plans. Medical Loss Ratio-required rebates for high administrative costs forced insurers to look at the costs of maintaining providers that serve few plan members. Further, the exchange shopping experience, which, to date, allows consumers to compare plan cost sharing while providing scant information in most states on quality and number of providers, further incents the narrowing of networks. Studies suggest that narrow networks are not inherently bad. For example, research conducted by Simon Haeder et al. in Health Affairs and JAMA , in 2015 found no quality differential between narrow and broader network plans in the California market. Nonetheless, consumer advocates and some regulators remain worried by the trend toward narrow network health plans. Heading into 2014, United HealthGroup and Anthem, to name just two, whittled-out certain hospitals and physicians from their Medicare Advantage and new Health Insurance Exchange networks. Although the insurers continued to meet regulatory network adequacy standards, these moves generated critical media coverage and queries from state insurance commissioners and members of Congress. Government watch-dogs were dispatched, and by the end of 2015, the Department of Health and Human Services (DHHS) Inspector General, the California State Auditor, and the Government Accountability Office had all issued unflattering reports on Medicaid and Medicare Advantage provider networks. Their studies suggested patterns of inaccuracies with reported provider networks, long appointment times in the Medicaid program, and gaps in oversight of provider networks in the Medicare Advantage program. Recent CMS provider directory oversight activities suggest continued widespread directory inaccuracies that prompted the agency to issue 21 warning letters. As of March 2016, six lawsuits were filed by enrollees against health plans claiming that they were misled into selecting plans based on incorrect information in the plan’s provider directory (one of these cases recently settled for $15 million). A year ago, the National Association of Insurance Commissioners finalized a new model Network Adequacy Model Act. While the model does not have legal standing, it serves as a best practice for states to consider. Since that time, a handful of states — including Colorado, Georgia, Maryland, Ohio, and Connecticut — have passed laws or promulgated regulations establishing new or higher standards for health plan provider networks; a little more than half of the states were already conducting network reviews in keeping with much of the model act. Meanwhile, the Centers for Medicare & Medicaid Services (CMS) warned of additional oversight o[...]

Don’t Ease Resident Work Hour Restrictions

Mon, 27 Feb 2017 16:00:06 +0000

One evening in May, 1999, when I was an intern, I fell asleep at the wheel driving home from a 36-hour shift at the hospital. Drives like that occurred not infrequently in those days, and I had developed techniques to fight off fatigue. Singing at the top of my lungs was one. Opening my car window wide to the brisk Chicago winds was another. Sometimes I had to combine one or both of these with a third, literally prying open an eyelid with one hand while steering with the other. I am embarrassed to reveal today how poor my judgment was then. How could I have taken such risks, endangering not only myself but others as well? I have no excuse, only a feeble explanation: I longed for the semblance of a normal life outside the hospital, and on that particular occasion I was supposed to meet friends for pizza. My defenses gave way upon arriving first in line at a red light. I drifted off, and, relaxing my foot off the brake pedal, drifted out. I was awakened when my car, a Honda hatchback, seemed to explode. I had been struck by the first two vehicles in cross-traffic, an Audi and a Jaguar. The Honda was totaled, but thankfully I was the only person hurt. For the last 27 years I have suffered from a chronic irritability of the muscles of my neck, for which I am grateful. These spasms are better than being dead, and are a substantial improvement over the flaring agony I used to suffer several times a year for a week at a time. A Step Backward on Residency Hours The memory of this accident has returned with the news that the Accreditation Council for Graduate Medical Education (ACGME, the body that regulates medical residencies) will vote in February on a new proposal to loosen restrictions on resident duty hours (see the Health Affairs Blog post by the Chief Executive Officer of ACGME, Thomas Nasca, MD). The restrictions in question, which did not exist when I was in training, limit consecutive work-hours for first-year residents to 16, and more senior residents to 24. The new proposal would allow residents at all levels to work up to 28 consecutive hours and, in a Kafkaesque twist, would require training programs to provide 24-hour access to mental health services in order to deal with the resulting depression and anxiety. How can it be anything other than reckless for physicians at any level to work more than 24 or even 16 consecutive hours? Is there any other profession, much less one upon which the lives and health of others are so dependent, that has a similar expectation of its workers? The background of this issue is well known. Throughout most of the history of modern American medical training, residency was brutal, with 36-hour days alternating with one to three 12-hour ones. Indeed, post-graduate trainees are called “residents” because they used to reside in the hospital, there being no reason for them to have a dwelling elsewhere. In the aftermath of the 1984 Libby Zion case, in which the death of an 18-year-old woman in New York City was attributed to the exhaustion of the residents taking care of her, work hour restrictions were adopted by the State of New York. Starting in 2003 the ACGME required similar restrictions as a condition of accreditation nationwide. Problems with the ACGME Proposal The proposal now before the ACGME to relax these restrictions is modeled after conditions tested in the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) Trial, published in The New England Journal of Medicine in 2016. The FIRST trial randomized 117 general surgery training programs to either the 2003 or the proposed new guidelines. The main findings were that relaxation of work hour restrictions had no measurable impact either upon the incidence of patient death or serious complications, or upon resident perceptions of well-being. But as large as this study was, it was statistically powered to detect differences greater than only 13 percent between the groups, thus limiting its potential to identify uncommon but potentially significant adverse patient events. An even greater l[...]

A Look At Republican Intentions? Diving Into The Leaked ACA Replacement Bill

Sat, 25 Feb 2017 14:44:13 +0000

On February 24, 2017, a draft House reconciliation bill was leaked to the media. Although I have not seen any claims that it is not authentic, it is dated February 10 and may not be the most recent draft. I have also not seen any assertion that the Congressional Budget Office has concluded an analysis of the bill and found its budgetary consequences to be acceptable to the bill’s sponsors. The draft is, however, consistent with statements that Republican leadership have recently made about their legislative program. Because the draft is the best information we have about the House Republican leadership’s proposals, I offer a summary of its major provisions. What The Bill Does Not Do First, it must be emphasized what the bill does not do. It does not repeal the ACA. Indeed, it only repeals particular sections of the ACA, such as its taxes, mandates, Medicaid expansion and subsidies. And some of these it only does after 2019. It does not appear to repeal most of the ACA’s insurance reforms, such as the requirements that health plans cover preexisting conditions; not health status underwrite; meet actuarial value requirements; cover adult children up to age 26; not discriminate on the basis of race, nationality, disability or sex; cap out-of-pocket expenditures; and not impose lifetime or annual limits. It does not touch the ACA’s Medicare reforms or cuts. It is replace, but not repeal. Medicaid Much of the bill is focused on changes to the Medicaid program. It ends the ACA expansion for low-income adults and essential health benefit requirements as of the end of 2019, as well as the ACA’s presumptive Medicaid eligibility provisions and disproportionate share hospital payment reductions. The bill establishes a per-capita cap approach to funding state Medicaid programs beginning with fiscal year 2019. The per-capita cap provisions are lengthy and complicated and I will leave it to others more expert on Medicaid than myself to explain them. Federal payments to the states through Medicaid or any other program for Planned Parenthood would be prohibited. High-Risk Pools: The State Innovation Grant and Stability Program The bill would establish a “State Innovation Grant and Stability Program,” beginning in 2018. States could use funding from this program for a variety of initiatives such as high risk pools, reinsurance programs, programs to subsidize providers for direct provision of care or to reduce cost sharing, or programs to promote access to preventive services. Beginning in 2020, states would have to apply for the funding, but an application would be deemed approved within 60 days of submission if not acted on and, once an application is approved, it would be deemed reapproved each year through 2026. It is not wholly clear how the funds would be distributed before 2020, but apparently no application is necessary. The bill would appropriate $15 billion for the program for calendar years 2018 and 2019, and $10 billion a year for the following calendar years through 2026. The money would be allocated among the states using a formula that is based for 2018 and 2019 on relative marketplace participation and premium costs for each state, and thereafter based on the percentage of residents of states that are below some income threshold or uninsured. (The formula for 2018 and 2019 might favor states that did not expand Medicaid because individuals with incomes between 100 and 138 percent of the poverty level would be in the exchanges rather than on Medicaid). States would have to match the federal contributions at a rate initially set at 7 percent for 2020, increasing to 50 percent by 2026. Continuous Coverage Requirement A continuous coverage requirement in the individual and small group markets would begin with plan year 2019, or 2018 for special enrollments. Premiums would increase by 30 percent for twelve months for individuals who had a gap in creditable coverage of at least 63 continuous days during the preceding 12 months (or, for people leaving depende[...]

Syrian Doctors And The American Dream: Practicing Medicine In A New Immigration Landscape

Fri, 24 Feb 2017 17:06:15 +0000

Becoming a physician is a lifelong dream for many. Having the opportunity to train in the United States is also a deeply held ambition for countless aspiring doctors around the globe. We are living out that dream. We came to the U.S. from Syria, a war-torn country in the Middle East, with the same goal: to attain highly specialized training at the best U.S. institutions. We had the idea that the U.S. had the best medical and research universities and hospitals in the world. Later, when we all made it here and started our journeys, our experiences came to confirm our initial impressions. Many great countries are on the frontiers of science, technology, and medical practice. However, the United States stands out from the crowd in that it attracts individuals with great passion for and high skills in what they do. Indeed, being a hub for the brightest and most talented minds has contributed immensely to U.S. strength in so many domains and for more than two centuries. Some of us came into the U.S. more than a decade ago while others only a few years ago. All of us, however, share the profession of medical practice and research. We have studied and worked at some of the nation’s most reputable institutions across the U.S. We all have a strong passion and drive in different fields of biomedical, translational, and clinical research. Many of us also provide medical care for many patients across clinical disciplines. Some of us also provide that patient care in underserved areas. Syria was one of the countries specified in President Trump’s January 27 executive order (EO) on immigration. This EO was issued to protect the U.S. and Americans from potential terrorists. It detailed a ban on legal immigrants as well as non-immigrant visas from seven countries for 90 days, a 120-day ban on admitting refugees, and an indefinite ban on admitting refugees from Syria. For days after the order was announced, any individual with a legal visa from these countries was prevented from entering the United States regardless of their qualifications, skills, or expertise. The executive order drew rapid litigation and on February 3, a federal judge temporarily prohibited the government from enforcing the order on equal protection grounds and due process guarantees. The Trump administration, however, has signaled it intends to rewrite the order, and on February 21 it issued new directives to the Department of Homeland Security to deport unauthorized immigrants. This will likely not be the final say on the matter, however, and the potential for blocking immigrants and refugees from Syria and other Middle Eastern countries from coming to the U.S. is still very real. This EO had grave ramifications for thousands of people holding legal status and visas all across the U.S., those flying in, and those who were outside. It also had great personal impact on many of us, our families, friends, and colleagues. From our experience, we believe that the order’s impact would be deeply felt across the medical professions. Any ban citing a person’s national origin, religion, race, or ethnicity is very counterproductive to keeping and attracting international expertise into the U.S. health care system. Even before the EO, Syrian medical students and graduates who wanted to continue their training in the US faced significant obstacles. For example, International Medical Graduates must first receive a visa to come to the US in order to be present for the USMLE Step2 CS exam as well as for interviews, both of which are necessary to be matched with a residency program. In September 2016, we conducted a brief survey of 106 Syrian medical students and graduates currently applying to be matched with a US residency program. Of our survey participants, more than 50 percent had to apply twice or more to be approved for a visa to the US and some even had to apply five times or more. What is more, all of them also had to visit a US embassy outside of Syria in order to apply for tha[...]

Behind The CMS Spending Projections: Assumptions, Challenges, And Lessons

Fri, 24 Feb 2017 15:18:13 +0000

The health spending statistics and forecasts from the Centers for Medicare and Medicaid Services (CMS) Office of the Actuary are central to health policy evaluation. The current release, which provides actual numbers from 2015 and uses them to update projections for spending for the next decade, is no exception. Economist Tom Getzen has shown that these forecasts tend to be quite accurate, and have become more accurate over time. Since 1997 the mean absolute deviation (MAD) between forecast and actual growth in the first projected year is just 0.9 percentage points. Three years out, the MAD rises to 1.3 percentage points. (Mean absolute deviation is the average of the absolute value of the difference between forecasted and actual spending. Put more colloquially, it is the average size of the mistake.) As good skeptical economists (i.e. curmudgeons), we wonder if this accuracy reflects superior modeling techniques or merely reflects a slow but predictable evolution of health spending. We decided to see how well we could do using a simple possible forecast based solely on the prior year’s growth. Before we report on how we did, some institutional detail is useful. First, bear in mind that the recent CMS release contains 2015 data that is used to predict spending that already happened in 2016 (i.e., we do not yet know how much we spent last year). Second, the forecasts are not adjusted for overall inflation, which fortunately has been quite tame for the past two decades. This helps explain the impressive recent performance of the CMS forecasts — since 2001 the MAD between the forecast and actual growth in the first projected year is just 0.6 percentage points. (Any differences between this and Tom Getzen’s earlier work are because we are only focusing a more recent time period.) Our naïve forecasting model—based on a regression in which we forecast future spending based solely on prior year’s growth—also does well, with an MAD of 0.9 percentage points (note 1). Exhibit 1 provides a more detailed comparison among actual spending and the two forecasts. The Exhibit confirms that CMS bests our simplistic approach. But how much better is CMS doing? Our MAD may be 50 percent larger, but the 0.3 percentage point difference is small relative to the 5.9 percent average spending growth. Perhaps, if we were to factor in basic macroeconomic conditions, such as labor market growth (which CMS largely ignores but we have previously shown affects both private and Medicare spending growth), our simple forecast would have equaled or outperformed CMS. The Difficulties Of Accounting For Macroeconomic Trends It is not our intention to play Monday morning quarterback and we are not here to criticize CMS. It is often difficult to outperform naïve forecasts based on trends, and predicting health care trends is no exception, as there are too many moving parts for anyone to substantially outpredict the trend line. Take, for instance, the relationship between the macro-economy and health care spending. Our prior research shows that abrupt changes in macroeconomic conditions will produce abrupt parallel changes in health spending. But predicting macroeconomic shocks is perhaps more perilous than predicting health spending. Moreover, it is difficult to be certain which aspects of the macroeconomy should form the basis of health spending forecasts. In most recessions, gross domestic product (GDP) is a good predictor of health spending. But in the last recession, GDP recovered quickly while labor market participation did not, and the latter proved to be a more reliable predictor of health spending. CMS could not have predicted the onset or depth of the Great Recession or foreseen changes in the relative usefulness of different macro-economic indicators. Do The CMS Spending Forecasts Really Assume Unchanging Laws? CMS has baked into their methods another obstacle to accurate forecasting by assuming that there will be no [...]

Administration Allows States To Extend Transitional Policies Again

Thu, 23 Feb 2017 21:20:12 +0000

On February 23, 2017, the Centers for Medicare and Medicaid Services released an insurance standards bulletin allowing states once again to extend the life of “grandmothered” or transitional health insurance policies to policy years beginning on or before October 1, 2018, as long as the policies do not extend beyond December 31, 2018. These plans will continue to be exempt from most of the ACA’s insurance reform provisions which otherwise became effective on January 1, 2014, including the ban on health status underwriting; the guaranteed availability and renewability requirements; the essential health benefits, annual out-of-pocket limit and actuarial value requirements; the ban on preexisting condition exclusions; and the requirement that all individual and small group market plans of an insurer be part of a single individual or small group risk pool. Background To understand the guidance, some background is needed. The Affordable Care Act contained a “grandfather clause” promising, in the words of President Obama, that “if you like your health care plan, you can keep your health care plan.” The promise, however, was very specific: Nothing in this Act (or an amendment made by this Act) shall be construed to require that an individual terminate coverage under a group health plan or health insurance coverage in which such individual was enrolled on the date of enactment of this Act (March 23, 2010). It was a standard grandfather clause, such as can be found in many statutes, providing essentially that the statute had prospective operation. It was not a general promise that if, at any point in the future, a consumer found a health plan that he or she liked, it could be kept forever. Of course, the statue raised the question of what exactly was the coverage that could be kept. The clause was clear that a grandfathered plan would have to conform to some new ACA requirements, such as covering adult children up to age 26 or dropping lifetime limits, but it was also clear that grandfathered coverage could be renewed and that new dependents or employees could be added to the plan. But it what other ways could coverage change and remain grandfathered? It would seem obvious that if an individual was insured through a health plan, and that plan radically changed its cost-sharing, benefits, or premiums, it would no longer be the same plan. One of the first rules to be promulgated following the enactment of the ACA defined when a plan was grandfathered. It basically allowed grandfathered plans to make moderate changes in cost-sharing or employer premium contributions, but recognized that major changes in cost sharing, premium contributions, or benefits would in fact change the coverage into different coverage, ending grandfathering and subjecting the new coverage to the requirements of the ACA. As of 2016, about one quarter of covered employees remained in grandfathered plan. However, it became widely believed that the “if you like your health plan, you can keep your health plan,” applied not only to plans in which individuals were enrolled in 2010, but rather plans in which people were enrolled in 2013, or perhaps at any time in the future—in part because President Obama repeated variants of the line during the 2012 campaign. As it became clear that many of the ACA’s insurance reforms would go into effect on January 1, 2014, people began to realize that they would lose the coverage that they had obtained since 2010 but before the end of 2013, and would have to obtain ACA-compliant coverage. In many instances the ACA-compliant coverage would be more comprehensive and have lower cost sharing, and most importantly would cover sick as well as healthy people, and would thus cost more. Many people apparently believed, or were led to believe, that the original promise of the ACA should allow them to keep their 2013 coverage. On November 14, 2013, facing political pressure from mi[...]

Withdrawal Of Guidance On Bathroom Access Raises Questions For Gender Identity Protections Under ACA

Thu, 23 Feb 2017 17:03:20 +0000

On February 22, 2017, the Departments of Education and Justice issued a statement withdrawing the Obama administration’s guidance that required schools to permit access to sex-segregated facilities (bathrooms and locker rooms) based on gender identity. The Trump administration statement said that the Obama Administration guidance had not contained extensive legal analysis explaining how it was consistent with Title IX, which prohibits sex discrimination, and that the Trump administration intends to offer “due regard for the primary role of the States and local school districts in establishing educational policy.” The statement obviously calls into question the Trump administration’s position on the Affordable Care Act section 1557 nondiscrimination regulations released in the spring of 2016, which prohibit discrimination based on gender identity. The February 22 statement itself has no immediate and direct effect, however, on the 1557 rule. The Trump administration statement withdraws and rescinds a Department of Education guidance document. Guidance is promulgated without notice and comment rulemaking and can be withdrawn by subsequent guidance, but the 1557 rule was promulgated through rulemaking and can only be withdrawn by subsequent rulemaking, with notice and comment. Moreover, section 1557 can be enforced by private litigation independent of the regulation. Separate regulations prohibit discrimination based on gender identity by qualified health plan insurers, by insurers in the individual and small group markets, and in the marketing of coverage in the individual and small group markets. Moreover, at least 18 state insurance departments have issued bulletins prohibiting insurer discrimination based on gender identity or insurer refusal to cover gender transition services. Nevertheless, a Texas district court entered a nationwide injunction against the section 1557 rule gender identity discrimination prohibition at the end of December. In late January, that court set a briefing schedule on a motion by civil liberties groups to intervene and ordered the United States to answer the complaint by March 1. The HHS Office of Civil Rights has announced that it will not be enforcing the gender identity discrimination prohibition while the injunction remains in effect. The February 22, 2017 guidance suggests that HHS files may not defend the 1557 rule prohibition and that the government will not appeal the preliminary injunction. ACA section 1557 incorporates Title IX’s sex discrimination prohibition. The HHS regulation was based on judicial decisions holding that sex discrimination includes discrimination based on gender identity. The Supreme Court is currently reviewing a Fourth Circuit decision upholding and applying the Obama administration’s earlier guidance in a Title IX school bathroom access case in Gloucester County School Board v. G.G. At least two federal district courts have stayed section 1557 litigation claiming gender identity discrimination by hospitals pending the Supreme Court’s decision. Also on February 22, the Department of Justice informed the Supreme Court of its decision to withdraw the school bathroom access guidance. As the Fourth Circuit relied at least in part on the earlier guidance in deciding the case, the Supreme Court could send the case back to the lower court for further consideration given the administration’s change in position. It could also, however, decide whether in fact the earlier guidance was correct, and whether Title IX does in fact prohibit gender identity discrimination. That decision would likely finally determine the fate of the gender identity discrimination prohibition in the section 1557 rule. [...]

Reading The Fine Print: Do ACA Replacement Proposals Give States More Flexibility And Authority?

Thu, 23 Feb 2017 14:00:03 +0000

State officials have been heartened by statements from incoming Congressional leadership and the new President that states will gain greater authority and autonomy over their health insurance markets than they have had under the Affordable Care Act (ACA). For example, President Trump’s executive order on the ACA called for giving states “more flexibility and control to create a more free and open health care market.” Similarly, leading members of Congress have said, for example: “States, not the federal government, should have the primary responsibility for health policy,” and suggested that their replacement plans for the ACA will give “power back to the states.” But do the specifics of the plans support these statements? In fact, the fine print in some plans to replace the ACA would take away state authority over health insurance benefit design, premium rates, marketing, and consumer complaint resolution. A close examination of these proposals shows they would turn upside down a longstanding principle of federal-state regulation of insurance, which provides that the states should be the primary source of health insurance oversight and consumer protection, with the federal government only stepping in to set minimum standards or fill gaps. The Federal-State Framework for Insurance Regulation Individual market health insurance has historically been regulated at the state level, with minimal federal involvement. States regulate insurance company solvency and business practices, plan premium rates and benefit design, and are the cop on the beat if a consumer has a complaint or a provider can’t get his or her bills paid. Over time, and in response to concerns about gaps in state insurance regulation, Congress has instituted a patchwork of federal minimum standards that apply across all states. Federal laws such as the 1996 Health Insurance Portability and Accountability Act (HIPAA), the 1998 Women’s Health and Cancer Rights Act (WHCRA), and the 2008 Mental Health Parity and Addiction Equity Act (MHPAEA) established nationwide rules to expand the accessibility and comprehensiveness of health insurance coverage. States could, and did, enact stronger protections. In 2010 Congress enacted more sweeping reforms through the ACA to address continued significant shortcomings in coverage access, affordability, and adequacy. On the eve of the ACA, close to 50 million people were uninsured and millions more were covered but lacked basic consumer protections to ensure their coverage met their health care needs. However, the implementation of the ACA’s reforms continued to rely on the longstanding federal-state regulatory partnership, largely deferring to the states for enforcement of these federal standards, and several states have maintained or enacted standards that exceed the federal minimum. Most states elected to retain their role as the primary regulators of insurance and enforce both federal and state protections (note 1). At a minimum, most states continue to ensure that companies have sufficient financial reserves, review proposed premium rate increases, confirm that plans deliver on promised benefits, identify and stop fraudulent marketing tactics, and work to resolve consumer complaints. New Efforts to Preempt State Authority In spite of lip service to state authority and flexibility over insurance, pending proposals to replace the ACA, such as Speaker Ryan’s “A Better Way” plan, Health and Human Services’ Secretary Price’s “Empowering Patients First Act,” and Senator Paul’s “Obamacare Replacement Act,” would actually preempt much of that authority. They do so through two key provisions: (1) the sale of insurance across state lines and (2) individual association health plans or “insurance pools.” A federal law to encourage the sale of insurance “across state lines” would authorize an out-of[...]

Health Affairs Web First: Mexico’s Sugar-Sweetened Beverage Tax Shows Results

Wed, 22 Feb 2017 22:09:13 +0000


In 2012 studies showed that the prevalence of overweight and obesity in Mexico had reached 70 percent among adults and 30 percent among children. In an effort to combat the obesity epidemic, Mexico implemented a 1 peso per liter excise tax on sugar-sweetened beverages at the beginning of 2014.

A new study, released by Health Affairs as a Web First, estimated changes in beverage purchases in Mexico for 2014 and 2015. The authors, M. Arantxa Cochero, Juan Rivera-Dommarco, Barry M. Popkin, and Shu Wen Ng, found that purchases of taxed beverages (carbonated and noncarbonated sugar-sweetened beverages) decreased 5.5 percent in 2014 and fell an additional 4.2 percentage points to 9.7 percent in 2015. Households at the lowest socioeconomic level showed the largest decreases in purchases of taxed beverages for both years (9.0 percent decrease in 2014 and 14.3 percent in 2015). The authors also found that purchases of untaxed beverages (diet sodas, unsweeted carbonated and uncarbonated waters, juices, and dairy and substitute dairy products) increased 2.1 percent during the study period. These results contrast with industry reports of a decline in the effect of the tax after the first year of its implementation.

To compare consumer behavior before and after the tax took effect, the authors used store purchase data for 6,645 Mexican households from January 2012 to December 2015; the data came from Nielsen’s Mexico Consumer Panel Services.

“At the global level, findings on the sustained impact over two years of taxes on the beverages in Mexico may encourage other countries to use fiscal policies to reduce the consumption of unhealthy beverages along with other interventions to reduce the burden of chronic diseases,” the authors conclude.

Cochero and Rivera-Dommarco are affiliated with the National Institute of Public Health in Mexico; Popkin and Ng are with the University of North Carolina, Chapel Hill.

This study, which was supported by Bloomberg Philanthropies, the National Insitute of Health, the Robert Wood Johnson Foundation, and the Carolina Population Center, will also appear in Health Affairs’ March issue.

Should Government Officials Be Held Responsible For Failing To Protect Health?

Wed, 22 Feb 2017 14:04:22 +0000

Editor’s note: This post is part of a series stemming from the Fifth Annual Health Law Year in P/Review event held at Harvard Law School on Monday, January 23rd, 2017. The conference brought together leading experts to review major developments in health law over the previous year, and preview what is to come. In May 2016, President Barack Obama observed that Flint, Michigan’s water crisis arose from a “culture of neglect” and the belief “that less government is the highest good no matter what.” The crisis, which developed after the city’s unelected emergency manager switched the water supply from the Detroit Water System to the highly corrosive Flint River, caused dangerously high blood lead levels in many of the city’s children, as well as an outbreak of Legionnaire’s disease. Property values plummeted and the state and federal governments were forced to spend hundreds of millions of dollars to mitigate the problem. Now as a new President who has promised to improve the nation’s infrastructure settles into office, the question remains: Will the culture of neglect, especially regarding the health of poor people of color, continue? The answer may depend upon whether the law recognizes the protection of public health as not only a source of governmental power, but also as a duty for which officials may be held responsible. Granting Extraordinary Powers To Public Health Officials The protection of public health is among the most ancient and widely accepted governmental functions. Even before the adoption of the Constitution, cities and states enacted a wide variety of laws designed to safeguard public health. In one of its most important early opinions, the Supreme Court recognized that the Constitution left the states with the authority, known as the police power, to undertake such measures. Over the next 200 years, Americans have granted extraordinary powers to public health officials. For example, state and federal laws grant public officials wide-ranging authority to isolate and quarantine individuals to prevent the spread of dangerous diseases such as Ebola. These powers, and their limits, have occupied the field of public health law for decades. Yet far less attention has been paid to the question of whether officials can be held accountable when they fail to exercise the authority that is granted to them. Nor has much consideration been given to whether government officials can be held legally responsible when their own actions jeopardize public health. The Flint water crisis raises these critical issues. The dearth of attention to the duties of public health officials stems in part from the Supreme Court’s clear rejection of any federal constitutional right to protection by the state. Less noticed is that rights to public health protection are similarly weak or absent in state constitutional, statutory, and common law. Michigan courts, for example, have cited federal due process cases in rejecting a state constitutional right to public protection. In addition, the Michigan Tort Claims Act confers absolute immunity on the highest executive officials in any jurisdiction, effectively shielding the Governor, mayors, and emergency managers from tort liability for their failure to protect health, or even for actions taken that harm health. Lower level officials may be held liable, but only if their actions constitute gross negligence. Other state courts have relied on common law notions to reject a tort duty to protect, even in the face of legislation permitting suits against the government. To be sure, statutes sometimes create specific obligations to protect public health. In the case of Flint, the most relevant statute is the federal Safe Drinking Water Act (SDWA). The Copper and Lead regulations issued under that Act requires large public water syst[...]