Do voters really care about health care reform?

In April of last year, the Atlantic told readers that this question would be “the most decisive question” of the upcoming 2016 presidential election: “Will you take away my health insurance?” On February 2, 2016, the House of Representatives, voting mostly along party lines, failed to override President Obama’s veto of the latest attempt to repeal the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) in the form of the Restoring Americans’ Healthcare Freedom Reconciliation Act (H.R. 3762). Yet, while attacks on reform efforts are usual rhetoric for Congressional Republicans as well as most of the GOP presidential candidates, a recent study by the Kaiser Family Foundation shows that voters’ interest in health reform as an issue in the presidential primary race is not as strong as some had predicted. Does this mean that voters do not care about health reform as much as we thought? Further, will this trend continue once the primaries are over and the Republican and Democratic candidates go head-to-head?

Kaiser study

A Kaiser Tracking Poll released in January of 2016 revealed that the ACA does not “rank highly as an issue for voters in the presidential primaries.” While the general cost of health care ranked as the third most important issue—with 28 percent of voters stating that that issue would be “extremely important” to their presidential vote—the ACA specifically ranked eighth overall, with 23 percent of respondents stating it was extremely important to their vote. Other issues ranking above the 2010 health reform were terrorism (38 percent), the economy and jobs (34 percent), the federal budget deficit (28 percent), and gun control (27 percent). Moreover, when respondents were asked to choose the single most important issue in the presidential race, only 4 percent chose the ACA.

CNN poll

A less specific question asked in a recent CNN poll ranked health care in general as the third most important issue in the election. When asked how important, on a scale of extremely important to not that important, a list of issues would be in the upcoming election, 35 percent stated health care would be extremely important, 41 percent said it would be very important, and 18 and 6 percent considered it moderately important or not that important, respectively. The poll also revealed that only 39 percent of respondents were aware of President Obama’s recent veto to the ACA-repealing legislation and that opinions are steady and almost evenly split when it comes to satisfaction with the ACA, with 44 percent having an unfavorable view and 41 percent favoring the reform.

Candidates’ opinions

Current Republican front-runners for the presidential nomination, including Senator Ted Cruz (R-Texas), Senator Marco Rubio (R-FL), and Donald Trump, have expressed their intentions to repeal the ACA, if elected. Yet, there is no one replacement plan that all the candidates agree on. While Cruz and Rubio both voted in favor of the recent attempt to repeal the ACA through H.R. 3762, Trump’s views on the reform have been vague. Beyond “bashing the current law” and promising that “everybody’s going to be taken care of” and “the government’s [going to] pay for it,” Trump’s particular stance on health reform is unknown. The lack of a solid position on this issue for the popular candidate has GOP leaders concerned.

On the Democratic side, while former Secretary of State Hillary Clinton has promised to make general improvements in health care costs, she supports a continued implementation of the ACA. Her sole democratic opponent, Bernie Sanders (D-VT), has indicated that, if elected, he intends to pursue replacing the ACA with a “Medicare for all” single payer system.

As the votes for and against the override of the President’s veto of H.R. 3762 show, it appears that support for health care reform is split between party lines. However, in terms of the current presidential candidates, the views on health care reform are not as uniform. Because of the unique circumstances of the current presidential primaries, it may not be clear to what extent health care reform will be a major deciding issue for the race until the primaries are over and the Democratic and Republican nominations are decided.

Highlight on Vermont: New all-payer model grows out of state Medicaid budget crisis

For months, Vermont has been struggling with how to pay for its Medicaid program as reported costs have far outstretched allotted budgets. Instead of reducing benefits for all of the newly insured enrollees in Vermont’s health care programs, Governor Peter Shumlin announced a new payment system entirely, one that he claims will transform its health care system from one that rewards fee-for-service, quantity-driven care to one that rewards quality-based care that focuses on keeping Vermonters healthy.

All payer model. This new all-payer model is described by Shumlin as an agreement between the state and CMS that enables the three main payers of health care in Vermont–Medicaid, Medicare, and commercial insurance—to pay for health care differently than the traditional fee-for-service reimbursement. In an all-payer model, Vermonters will continue to have the same choice of providers as they have today under Medicare, Medicaid, and commercial insurance. Benefits will not be reduced and by changing the payment structure, Medicare beneficiaries may have access to, and coverage for, new services not currently covered by Medicare.

In Vermont’s proposal, the all-payer model will require commercial insurers and Medicaid to pay the same way Medicare will be paying for health care under its Next Generation program. All involved payers will approach health care payment to accountable care organizations in a common way and all payers will provide doctors and other health care professionals the flexibility they need to lead health care delivery change. Maintaining the same set of rules, standards, and methods of payment across payers will drive efficiencies in the system. The all-payer model builds off current federal and state health care reform efforts that have value-based payment components.

Outlined to the public on January 25, 2016, Shumlin and the Green Mountain Care Board released an outline or term sheet detailing the new all-payer system. The state is focusing on three main health goals: increasing access to primary care, reducing the prevalence of chronic diseases, and addressing the substance abuse crisis. The term sheet lays out plans to curb expenses by setting a 3.5 percent spending target and 4.3 percent spending cap, with a commitment that “Medicare will grow more slowly in Vermont than nationally.” These financial targets, the term sheet notes, are based on health care services in Vermont’s Medicare, commercial, and Medicaid shared savings programs today, mostly hospital and physician services.

“From Day 1, reforming the way doctors and other medical providers are paid has been a priority of my administration,” Gov. Shumlin said. “This is the only way we will curb the rising cost of health care that gobbles up money faster than Vermonters can make it. Today is the beginning of the rubber hitting the road on cost containment. Our success will mean better health outcomes for Vermonters and the end to health care costs rising faster than our economic growth.”

Investments in infrastructure. To curb spending, Vermont is planning to incorporate old and new ways of making health care more affordable. By investing in the state’s current infrastructure, Shumlin plans to expand the Services and Supports at Home (SASH) program, which already has a track record of saving money while keeping seniors in their home and out of hospitals. Another program Vermont intends to continue with is Medicare participation in the Blueprint for Health, Vermont’s nationally recognized initiative transforming primary care, which has also already demonstrated success. The state also proposes to add Medicare participation in the Hub and Spoke opiate addiction treatment program.

The state is currently in the process of finalizing negotiations of the terms of the all-payer model with the federal government. The information and terms released by Vermont do not represent the final state plan.

Supreme Court sets March date for contraceptive mandate arguments

The Supreme Court has set a 90-minute hearing on March 23, 2016, for the seven cases challenging the Patient Protection and Affordable Care Act’s (ACA) (P.L. 111-148) contraceptive mandate. The challenges seek a decision from the Supreme Court overturning the ACA requirement that non-profit groups take action to opt out of the mandate, allowing them to benefit from the blanket exclusion granted to churches and other religious institutions (see Supreme Court will hear 7 challenges to contraceptive mandate, Health Reform WK-EDGE, November 10, 2015).

Non-profits challenge

At issue is whether the contraceptive coverage mandate and its accommodation process, which requires the filing of additional paperwork stating objections to the provision of contraceptives, violate the Religious Freedom Restoration Act (RFRA) (P.L. 103-141) by forcing religious nonprofits to act in violation of their sincerely held religious beliefs, when the government has not proven that the compulsion is the least restrictive means of advancing any compelling interest. The accommodation itself, the organizations argue, is a substantial burden on their religious exercise.

The Supreme Court will rule on whether the mandate and the accommodation violate the RFRA, but refused specifically to hear claims under the RFRA and the First Amendment that the government discriminated between those allowed an exemption and those not.

ACA implementation

The March hearing before the Supreme Court highlights the challenges found in implementing the contraceptive mandate. Despite these challenges, the ACA provision for contraceptive coverage has already directly benefited millions of women who use contraceptives by decreasing their total out-of-pocket spending on contraceptives.

According to researchers at Washington University in St. Louis, prior to the ACA, high initial costs were barriers to women using highly effective contraceptive methods such as intrauterine devices (IUDs) and implants. Cost also affected adherence to commonly used refillable methods such as oral contraceptive pills, the contraceptive patch, or the vaginal ring with recurring prescription co-payments previously required.

The researchers noted that the provision for contraceptive coverage has the potential to substantially improve public health. Access to contraception without financial barriers reduces unintended pregnancies and births, which in turn can improve maternal and infant health.

PCORI approves $70M for patient-centered research

What is the most effective way to treat chronic migraines while preventing medication overuse? Would motivational text messages from a doctor’s office help diabetes patients better manage their conditions? What is the optimal dose of aspirin to prevent heart attacks and strokes? The answers to those questions may soon be available, thanks to the Patient-Centered Outcomes Research Institute (PCORI) Board of Governors, which approved $70 million in awards for nine, patient-centered research projects for various conditions ranging from asthma to breast cancer.


PCORI is an independent, non-profit organization established by section 6301 of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148). It funds research to provide patients, caregivers, and clinicians with information to make better-informed health care decisions. PCORI has dedicated over $1.2 billion to research funding.

Pragmatic Clinical Studies

Five of the research projects were awarded funding as part of PCORI’s initiative to support pragmatic clinical studies (pragmatic studies), which are aimed at producing results that are relevant to a broader range of patients and care settings and that are easy to adopt. The studies are conducted in more routine clinical settings rather than in specialized research centers and use study participants that are similar to typical patients.

All of the pragmatic studies work with national advocacy organizations, professional associations, payers, and other key stakeholders to design and implement their studies so as to speed up the dissemination and application of the results.

Breast Cancer

One of the newly approved pragmatic studies will compare treatment options for individuals diagnosed with ductal carcinoma in situ (DCIS), which is an early stage, localized type of breast cancer. The study will examine whether women who undergo active surveillance have the same invasive cancer rate as those who undergo traditional treatments, such as surgery and radiation. It will also compare the mastectomy rate, survival endpoints, and quality of life endpoints between the two groups.

Chronic Migraines

Another study seeks to find an effective treatment for sufferers of chronic migraines who overuse their medication. The study will look at two methods of treatment, and determine whether an early discontinuation of overused medication combined with migraine prophylactic therapy is more effective than continuing the overused medication during the therapy.

“We’re strongly committed to supporting large-scale projects that will provide patients and those who care for them with the useful, authoritative evidence they need to make the better-informed health and health care decisions,” said PCORI Executive Director Joe Selby, MD, MPH.

Clinical Data Research Networks

PCORI also awarded $6.7 million to three Clinical Data Research Networks (CDRNs) that are members of PCORnet, which is the organization’s initiative to establish a national, patient-centered clinical research network. The award will help the CDRNs study how population-targeted health policies and interventions impact complications, risks, and disparities relating to type II diabetes. The projects will be part of the new, Natural Experiments Network (NEN), which is collaboration between PCORI, the Centers for Disease Control and Prevention, and the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health. The research projects are aimed at assisting policy makers and community leaders prioritize policies so as to prevent diabetes.

Additional Studies

The PCORI Board also approved $5.2 million in funding for a study that will examine whether motivational text messages or diabetes wellness coaches more effectively assist African-American patients in managing uncontrolled diabetes.

A study that seeks to identify the optimal dose of aspirin to prevent heart attacks and strokes in heart disease patients also received $3.8 million. The award will fund expanded trial activities and will recruit patients who have no Internet access. It is estimated that finding optimal aspirin doses could save thousands of lives.

PCORI notes that all of the awards were approved pending review by its staff and the issuance of formal award contracts.