I met a young man last week who lost his job in December of 2009, and despite his best efforts, still hasn’t found another. He told me he had excellent health benefits through his previous employer, but rarely needed to use them. He described himself as a typical young and healthy patient – going in for routine cleanings at the dentist’s office and seeing a primary care physician for nothing worse than a bad cold. Given this, losing his health insurance was not at the top of his worry list when he lost his job.

That is, not until he became sick and had to be transported to the emergency department in an ambulance.

Without insurance, although his ambulance ride lasted just 15 minutes and his visit with the attending physician less than 20, his medical debt from that one incident will last many years.

This young man is just one of the over 1.2 million people in Michigan – over 50 million in the U.S. – who lack health coverage. Hearing his story reminded me that those big numbers are more than statistics describing a population. Those numbers are made up of individuals – people we know, work with, our own families, even – whose health and financial security is at risk every day they are uninsured.

And thousands have lost their jobs during the economic downturn, which usually means losing access to health care coverage. Many thousands more work in low-wage jobs with no benefits and can’t afford to purchase health coverage. And too many times, even when people are employed and have coverage, medical expenses have driven families into bankruptcy.

The young man I talked to last week said he is now trying desperately to find some type of coverage so he can follow up with a physician and get the drugs he needs to manage his condition. Even though he has little or no income, as an able-bodied male with no dependent children he does not currently qualify for Medicaid.

In her April 19, 2010 blog post[CHRT BLOG POST TITLED “ADVANCING SOCIAL JUSTICE AND EQUITY:”], Marianne Udow-Phillips describes the history of the Medicaid program, originally intended to cover certain categories of low-income people: mainly children, pregnant women, people with disabilities, and those over age 65 living in nursing homes. Because of this “categorical” eligibility, being poor alone does not qualify one for Medicaid, leaving many low-income individuals out of this public insurance program. And outside of Medicaid and other smaller state-based and local public programs, there aren’t many other options for low-income individuals to get consistent and affordable care.

In 2014, the Affordable Care Act will change this picture for the first time in U.S. history by eliminating categorical eligibility and expanding Medicaid eligibility to all non-elderly citizens and resident immigrants who are below 139 percent of poverty. In Michigan, 686,600 uninsured individuals under the age of 65 meet this income standard today. The Medicaid expansion will open up coverage for millions in the U.S. who have limited or no access today.

With millions of individuals potentially entering Medicaid rolls in 2014, states and communities should be planning now to support these individuals and connect them with the health care system. Federal, state and local communities must also address how to fund the Medicaid program and allocate resources so that the influx of new patients will have access to medical care, not just an insurance card. A loss of a job in the U.S. should never again mean loss of health.

It is my hope that in fifty years, when the history books, blogs, and articles are written about health care and health reform in the U.S., stories like the one I heard last week will be just that. Stories from the past.

In November 2010 we released an issue brief on the cost of prematurity in Michigan. In that issue brief we noted that in 2008/2009, Blue Cross and Blue Shield of Michigan spent a total of more than $46 million on preterm infants in the first year of life. The average cost of medical care for a preterm baby in its first year of life was almost $42,000, compared to just over $4,000 for a full-term infant. In 2007, the March of Dimes published similar national numbers that set the medical cost of a preterm birth at $49,000.

The cost of prematurity is of considerable concern, and so are the health consequences. Data in our issue brief and elsewhere highlight the relationship between prematurity, infant mortality, and developmental delays.

Finding treatments that can mitigate the risk of prematurity is clearly desirable, both to individuals and society at large.

And, indeed, such treatments exist. In 1956, the FDA approved a drug called Delalutin, developed by Squibb for another purpose and later shown to reduce prematurity. Squibb withdrew this drug from the market in 1999, for business – not safety – reasons.

Since that time, patients have been able to obtain the drug from pharmacies that compound it themselves under the label “17 OHP.” But not all pharmacies compound drugs, so individually compounded drugs are somewhat less accessible than drugs produced by pharmaceutical manufacturers.

Because of the accessibility issue, the March of Dimes pushed the FDA to classify 17 OHP under the orphan drug statute to give pharmaceutical manufacturers more incentive to produce it.

On June 25, 2010, the FDA published a notice that because Delalutin was withdrawn from the market for reasons not related to safety, it would therefore authorize an abbreviated new drug approval (ANDA).

According to the FDA notice, “ANDA applicants must, with certain exceptions, show that the drug for which they are seeking approval contains the same active ingredient in the same strength and dosage form as the ‘listed drug,’ which is a version of the drug that was previously approved. ANDA applicants do not have to repeat the extensive clinical testing otherwise necessary to gain approval of a new drug application (NDA). The only clinical data required in an ANDA are data to show that the drug that is the subject of the ANDA is bioequivalent to the listed drug.”

In other words, compared to the cost of a new drug discovery, the cost of ANDA approval would be fairly minimal.

On February 4, the FDA gave an exclusive contract to K-V Pharmaceuticals for the drug Makena (essentially the same drug as Delalutin) under the “orphan drug” provision. This approval gives K-V exclusivity on production of the drug for seven years.

The 20-week cost of treatment using 17OHP is about $300 – a true boon to women at risk of having a repeat premature birth, and a clear cost savings to society.

So, what is the cost of Makena? The wholesale price first published by K-V for 20 weeks of treatment was $29,000.

That’s right: $29,000 for Makena – essentially the same drug as 17 OHP but at 100 times the cost.

What does that cost difference mean to society? Some have estimated the number of women that could benefit from this drug at 139,000 women each year. The cost of treating all 139,000 women using 17 OHP would be $41.7 million per year, with a potential total medical cost savings of $519 million. In contrast, the cost of treating all these women with Makena would be $4 billion – a net increase in costs to society!

Rarely in the world of health policy does one see such a strong and clear public policy debacle: a law intended to increase the availability of drugs could result in reduced access for patients and increased cost to society. The New England Journal of Medicine and a number of consumer advocates exposed this pricing in articles framed as the “unintended consequences” of the orphan drug law.

Since the New England Journal article, K-V has been feeling the heat. First, the company offered “hardship relief,” and to subsidize copays for this drug (a great marketing strategy but nothing that brings down the unnecessary cost to society, or addresses the fact that employers would still be picking up the bill, making health care coverage unaffordable for some). Unhappy patients started a Facebook page entitled, “Shame on You, K-V Pharmaceutical and CEO Greg Divis.” Now Senators Sherrod Brown and Amy Klobucar are demanding federal hearings.

On March 30, the FDA announced that despite KV’s request, it would not take enforcement action against pharmacies that continued to compound 17 OHP. The next day (April 1), K-V lowered the cost of the drug from $1,500 to $690 per treatment (no, truly – not an April Fool’s joke). That brings the cost of a course of treatment “down” to $13,800 – now, only 50 times higher than the cost of the compounded drug!

This is not the only instance of this kind of pricing in the pharmaceutical world. It just happens to be extremely clear cut and getting the kind of visibility no one in this business wants. Ultimately, there is a much bigger issue here about the laws and regulations around pharmaceutical pricing: laws intended to promote drug discovery that have now become anti-competitive and, in too many cases, turned into protectionism.

So, when we talk about ways to reduce the rate of increase in health care spending and improve health at the same time, Makena and K-V should be the case study we remember!

Well, the polling data are in! And, the results: people are just as confused about health reform today as they were when it passed a year ago; maybe, more so. In fact, 22 percent of those polled by the Kaiser Family Foundation believe health care reform has already been repealed and another 26 percent aren’t sure.

How could it be that one year after health reform was passed and dozens of provisions have already gone into effect that 48 percent aren’t sure if it has been repealed and 53 percent are still confused about what it is (the exact same percentage as the day the Affordable Care Act was passed)?

Democrats believed that once they had passed health reform, people would like it. They knew there would be some difficulty protecting the law from attack (since the big provisions don’t go into effect until 2014), so they front-loaded the Act with provisions they thought would be very popular: beginning to close the “donut hole” in Medicare drug coverage (including $250 checks for seniors, summer 2010); eliminating pre-existing condition clauses for children; allowing young adults to stay on their parent’s health plans even if they are not dependents or in school; ending lifetime limits on benefits, and establishing high risk pools for those who have had a hard time finding coverage.

And, indeed, people like all these things. But, polling data also show that even though people like these things, they don’t associate them with health reform.

How could this be and what does it portend for the future?

One theory is that the administration and the health reform advocates have done a poor job of communicating about the ACA, and that is certainly true.

But, another theory might be that the very attributes that enabled health reform to be passed in the first place made it a challenge to communicate and embrace.

The reality is that the Affordable Care Act is a complex piece of legislation and a compromise from the beginning: it embraces all sorts of ideas without fundamentally altering the existing, confusing, confounding structure of health care in this country.

While there are some things about American health care that will simplify over time, the truth is that the ACA keeps intact the public/private mix of health insurance, the many different health plans, and the multiplicity of avenues into the system.

Indeed, diagrams put forward by various opponents of health reform look like Rube Goldberg designs precisely because the ACA builds on the current non-system, filling in gaps rather than creating something entirely new. The political watchword in the 2008 campaign was to fix health care with a “uniquely American approach,” and the American approach to health care was already as complicated – and sometimes, convoluted – as anything Rube Goldberg could have imagined.

So, yes, communication about the Act has been poor. But when it is the goal of some to confuse and mislead about something that is already complex, it is not surprising that most Americans are as confused today as they were when health reform was passed.

Does the confusion mean that health reform has been ineffective or is doomed to be repealed?

No, and perhaps at least in part, for the same reasons that it is so confusing to so many. That is, undoing something as fragmented and decentralized as the American approach to health care is hard to do! Much has been put in motion over the past year, and more will be done in the year ahead. And with each change made by providers and states and health plans and consumers to implement provisions of the Act, forward momentum builds and becomes harder and harder to stop.

So, what is so significant about the one year anniversary? Maybe, nothing. But just maybe, the passage of time – in and of itself – is what’s significant.

Of course…only time will tell.

The Affordable Care Act uses a number of terms that could never have been field tested by a marketing team. One that is very confusing to most people is the term “essential benefits” – a concept key to the way health insurance exchanges will work and the health benefits people will actually get under health reform.

Health insurance exchanges will offer benefit packages to individuals and small businesses that meet certain tests. Fundamentally, four packages will be offered through the exchange: bronze, silver, gold, and platinum. Another package will be offered to those under 30 – the “young invincibles” – essentially providing catastrophic care.

In the four packages, the exchanges must offer health benefits meeting a certain actuarial equivalent, i.e., the package must be priced to limit out-of-pocket costs for “essential benefits” to a target percentage. The bronze plan provides coverage for 60 percent of the cost of the essential benefits; silver 70 percent, gold 80 percent, and platinum, 90 percent. And, of course, premiums will vary according to the breadth of coverage.

Given that these percentages are tied to the concept of essential benefits, the definition of essential benefits is pretty important. The law provides some broad guidance here by listing the categories that need to be included in essential benefits. Specifically included are:

• Ambulatory patient services
• Emergency services
• Hospitalization
• Maternity and newborn care
• Mental health and substance use disorder services, including behavioral health treatment
• Prescription drugs
• Rehabilitative and habilitative services and devices
• Laboratory service
• Preventive and wellness services and chronic disease management
• Pediatric services, including oral and vision care

The law also says the scope of benefits must be comparable to that typically offered in employer health plans; it must also meet a few additional requirements (such as non-discrimination against certain groups of individuals and balance between different benefit types). But the law steers clear of defining essential benefits in detail or proposing to replicate benefits in existing programs such as Medicare or Medicaid. Here, the framers of the ACA intentionally tried to avoid some of the controversy the Clintons got into when they included 61 pages of benefit descriptions in their health reform proposal.

The law did, however, ask the Institute of Medicine to help the Secretary of Health and Human Services (HHS) define essential benefits. The Institute of Medicine has convened a panel to help them do that by summer– timed to be close to the spring target for regulations on health insurance exchanges. The panel held one meeting in January to begin its work; a second meeting was held the first week of March.

The essential benefits provision of the law is likely to receive at least as much comment and debate as the recent discussion on the Medical Loss Ratio. The National Association of Insurance Commissioners (NAIC) was assigned to make recommendations to the Secretary of HHS on the technical definition and application of the Medical Loss Ratio. In April 2010, HHS asked for this definition to be completed by June 2010. On June 1, the NAIC said that date was not achievable. Hundreds of comments and much active lobbying later, the NAIC made its final recommendations to HHS on October 21, 2010, almost five months after the requested date (but well within the timeframe specified in the law).

The definition of essential benefits will go through the same lively process. In fact, the debate over essential benefits might be even more heated. Once people understand what essential benefits are, every consumer and provider who cares about particular services will want to be heard. For example: should such benefits cover chiropractic services, autism spectrum disorder, eating disorders, fertility services, podiatry services? The public hearings and comments will be passionate.

Jonathan Gruber has advised the IOM panel to start by being conservative: every benefit that is added makes the premiums more expensive (and therefore less affordable) and it is very hard, if not impossible, to take benefits away later.

But whether or not the panel – and ultimately, the Secretary of HHS – will be able to be conservative is a real question. Politically, it is easier to be more comprehensive when it comes to benefits than to limit the scope of coverage.

Economically, Jonathan Gruber is no doubt right. How this issue comes out come June will say a lot about how people actually experience health reform on the ground – and, how complex tradeoffs really get made.

Despite the “Strum und Drang” over health care reform in Congress these days, there is actually some interesting bipartisan activity occurring. While the stridency on health care reform often gets the most notice, the bipartisan activity offers some hope that challenging problems can move forward in a constructive way.

Not surprisingly, this activity is taking place principally in the Senate and between two senators who have worked together and on health care for a long time: Ron Wyden, Democrat of Oregon, and Charles Grassley, Republican of Iowa. They are sometimes joined by Scott Brown, Republican of Massachusetts. Wyden, Grassley and Brown came together over the proposal embraced by President Obama to accelerate the time line to permit state flexibility in health care reform. Now, Senators Wyden and Grassley are both interested in bills that would require transparency of Medicare provider data: a very good idea.

Medicare has one of the largest health care databases in the country: a true treasure trove of information for health care researchers and others. Senator Grassley says he was inspired to introduce the idea of more transparency of Medicare data after the Wall Street Journal and Center for Public Integrity sued and were given limited access to Medicare data. The suit was necessary because of a 1979 injunction that prohibited the federal government from releasing financial information about physicians. The injunction resulted from a legal challenge mounted by the Florida Medical Association to stop the Carter administration from publishing Medicare related physician earnings.

As a result of the data mining that was done from the limited information received by the Wall Street Journal, suspected gaming of Medicare was identified and some possible fraud exposed. Indeed, one physical therapist whose data was reported by the Journal has now been indicted for fraud.

The American Medical Association argues that this information should be kept confidential because physicians have a right to keep their financial information private. But, why would this be so when they are receiving funding from the federal government? After all, the request is not to release all data on physician incomes: only on the amount provided by Medicare. Salaries for teachers and public employees of all kinds and levels are routinely made public. If the AMA’s argument about right to privacy holds any water, why wouldn’t that same right apply to other individuals who receive public dollars?

The fact is that when someone receives public dollars, they should be accountable to the public. That principle should apply to physicians as it does to other public employees. Accountability has long been argued as the reason to make public sector employee data widely available. And public accountability has an important role in the wise use of public dollars. Making the Medicare provider database available could help achieve many important public goals. Such data would provide researchers and policy analysts the opportunity to study health care trends in easily accessible ways, to not only identify potential fraud (a useful outcome in and of itself) but also to identify quality and care management improvement opportunities – something that could benefit patients and medical care overall.

Having access to the Medicare database should not and does not need to jeopardize patient information. Patient information can be protected while at the same time enabling a detailed review of provider practices. Such an approach is commonly adopted whenever Medicare makes its data available to health care researchers. The Wyden/Grassley approach would simply make such uses easier and more widely available. What a radical and good idea! If approaches like this can move forward in a bipartisan way, there is a real possibility the Affordable Care Act can be truly strengthened and given an even better chance of meeting the goals of improving access, enhancing quality of care, and moderating health care cost trends.

Ah, what a great outcome that would be!

The Affordable Care Act is a complicated law, in part because it builds off the current health care system to achieve some far reaching goals: significantly expanded access to care and control over the rate of cost increase. Though some describe the Act as a federal takeover of health care, in fact, much of the law is to be carried out in the states, with considerable state discretion over the design of many provisions.

One point of discretion that they don’t have, however, is on who/how people are covered, at least before 2017.

The Affordable Care Act specifies who is covered and through what mechanism. That is, all those below 133 percent of poverty must be covered by Medicaid and most of those with higher incomes who are not yet Medicare-eligible must be covered by an employer or purchase health insurance on their own. States are allowed to opt out of these provisions in 2017 if they can demonstrate they can cover, in a different way, at least as many people as would be covered by the Affordable Care Act.

Additionally, effective with the signing of the law on March 23, 2010, Congress prohibited states from reducing Medicaid coverage – or making it more difficult to enroll – in the run up to the 2014 expansion (except for individuals with incomes higher than 133 percent of poverty that states were covering on a voluntary basis). Similarly, states cannot cut coverage for children in the Children’s Health Insurance Program (CHIP) through 2019, when children with CHIP get rolled into the health reform provisions.

Of course, Congress passed these provisions last year, when many believed the economy would improve sooner and to a greater degree than it has to date. The language was also passed before the last election, when many state legislatures and governors’ offices changed hands.

In addition to the budget challenges they face due to broader trends in the economy, many new governors and legislators ran on tax cutting platforms. For every state today, Medicaid is among the top spending components of the state budget, and even though the Medicaid expansion in 2014 will be funded to a significant level by the federal government, there will be some increase in costs to states as Medicaid expands over time.

There is quite a debate over the cost of that expansion. Within a 10 year time horizon, Republicans on the Senate Finance and House Energy and Commerce panels estimate the cost at $118 billion, while the Congressional Budget Office’s score marks the cost at almost half that amount. Looking at a five year horizon, the Urban Institute, the Lewin Group, and the Medicare actuary actually show a net savings to states.

Of course, all of these projections are entirely variable depending their underlying assumptions, and those assumptions can be affected by philosophy as well. That is, whether or not one supports the Affordable Care Act may influence which projections one believes.

So, it is not surprising that in January, 33 governors/governors-elect – all members of the Republican Governors Association – sent a letter to federal leaders asking that the mandates on states be revisited.

Specifically, many of these governors would like Medicaid converted from an entitlement program to a block grant (similar to what happened in welfare reform in 1996). Those who are in support of the Affordable Care Act are entirely opposed to this change, convinced that many who are poor will lose coverage as a result, and the Obama administration has said that it will not support such a change.

At the National Governors Association in the first week of March, however, President Obama did offer an olive branch, suggesting that the opt out provision for states could be moved up from 2017 to 2014 as long as states could show that they would cover at least as many people under their own programs as would be covered under the Affordable Care Act. However, within hours after the President indicated his support for more flexibility in the law, many opponents of the law were calling this approach “dead on arrival.”

So, where will all this end up? Clearly the states are – and must be – big players in making health reform successful. If the current debate among state leaders is any indication, however, the state/federal relationship will be sorely challenged in many states over the next several years.

In 1995, the Centers for Disease Control (CDC) launched a major initiative to reduce the overuse of antibiotics. While many people think that taking an antibiotic for viral infections is either beneficial or benign, the CDC knew that the overuse of antibiotics was leading to a significant increase in infections that were drug resistant.

National efforts like the CDC’s, along with local efforts like the Michigan Antibiotic Resistance Reduction Coalition (MARR), focused significant resources on pediatricians and families to educate practitioners and consumers about the dangers associated with overuse of antibiotics. While many people seem to have heard of these concerns, data we are releasing today[CHRT ANTIBIOTIC PRESCRIBING] show that the overuse of antibiotics continues to be a major problem in Michigan, particularly in some parts of the state.

Our issue brief notes that between 2007 and 2009, antibiotic prescribing increased in Michigan for children covered by Blue Cross and Blue Shield of Michigan (BCBSM). Of particular concern is an increase in the percentage of antibiotics prescribed for children that are considered “broad spectrum” – from 44.9 percent of perscriptions in 2007 to 46.4 percent in 2009. Compared to narrow spectrum antibiotics, which are specifically targeted at particular infections, broad spectrum antibiotics are “heavy hitters” – those that should be reserved for difficult to treat infections. High use rates of broad spectrum antibiotics are of concern because when these drugs are no longer effective, there are few, if any, alternative treatments.

That is the precisely the problem in the treatment of MRSA (Methicillin-resistant Staphylococcus aureus). MRSA is a bacterial infection that is highly resistant to many antibiotics. The CDC estimated that in 2005, MRSA was responsible for more than 94,000 infections and almost 19,000 deaths in the US. That’s more than those caused by AIDS in that same year.

Using a broad spectrum antibiotic when a narrow spectrum antibiotic would work is considered a misuse of the drug. The overuse of antibiotics in general is also a serious contributor to antibiotic resistance. In particular, the use of antibiotics for viral infections is of major concern. In 2009, almost 22 percent of children covered by Blue Cross and Blue Shield of Michigan who had an upper respiratory infection received an antibiotic. This is better than statistics we have from 20 years ago, but since antibiotics don’t improve outcomes in upper respiratory infections, still too high. Infections can be tested to determine whether they are viral or bacterial, but only 56 percent of children who received an antibiotic received the appropriate test in advance of the prescription.

Use of antibiotics to treat viruses was also evident in adults. For example, most cases of bronchitis are viral in nature and yet in 2009, 77 percent of BCBSM-covered adults with bronchitis were given antibiotics.

Our data also show considerable geographic variation in the use of antibiotics in Michigan. For example, more than 62 percent of BCBSM-covered children in West Branch were prescribed antibiotics for upper respiratory infections compared to only a little more than 10 percent in Holland. Overall, southeast Michigan had lower rates of antibiotic use and more appropriate prescribing than the rest of the state. For children, parts of the state that had high overall use also had high rates of use of antibiotics for viral infections. And, regions with a high rate of use of antibiotics for viral infections also had a lower rate of testing for bacterial infections prior to prescribing antibiotics. So, it does appear that the high use areas of the state are also using these medications less appropriately than the low use areas.

More needs to be done to change this picture. With all of the focus on high tech medicine and complex diseases like cancer and heart disease, we often forget that there are many – far too many – deaths that are preventable in low tech and conservative ways. We can all be part of this solution. Too much medical care – that is, care that is it not needed or higher tech than needed – isn’t good for you. We need to remember: when it comes to medical care, more is not necessarily better.

Many people search websites for information about their health concerns. But, there are many health oriented websites to choose from and consumers don’t always have good ways to sort out the information they are reading. For example, the New York Times magazine ran a small but significant story on the difference between WebMD and the MayoClinic websites. The Times reported on the hearings on WebMD held by Senator Chuck Grassley of Iowa. In those hearings, the connection between WebMD and pharmaceutical manufacturers was documented in some detail. And, the advice given on that website seems shaped by that connection – directly promoting pharmaceutical treatments to those searching for insights into their medical conditions.

The pharmaceutical industry has long been criticized for seeming to focus more on marketing than research and development. And, indeed, the industry has done an excellent job at marketing their products. For decades, the pharmaceutical industry has been a top performer when evaluated on profit margins. In 2008, the industry had the third highest return on revenues at 19.3 percent (after network communications and Internet services), according to data published on Fortune Magazine’s website. Medical products and equipment were next at 16.3 percent. In contrast, in the same year, pharmacies and other health services had a three percent return, medical care facilities, 2.4 percent, and health insurance and managed care, 2.2 percent.

The industry hasn’t done anything wrong in achieving these margins: they have succeeded within the financial and regulatory structure in the US. And, there is no question that pharmaceutical products have made a huge difference in the quality of life and longevity of many people. But, there have also been serious questions raised and studies done on the balance between marketing and research and development.

The National Institutes of Health have become so concerned about the lack of new drugs in the pipeline that they have announced that they will be starting their own drug development center. With $1 billion in funding, the new National Center for Advancing Translational Sciences is designed to spark new research. And while $1 billion in funding for drug research is a relatively small number compared to the almost $46 billion spent by the industry on drug development in 2009, it is nonetheless a significant statement by the NIH.

While there is much debate on the exact amount being spent by the pharmaceutical industry on marketing, there is no question that the industry spends a lot. Indeed, some researchers believe that the industry spends more on marketing than on research and development.

All of which brings us back to the New York Times’ article about health websites. As I said, as a whole, there is nothing that the pharmaceutical industry is doing that isn’t within the rules of what they are permitted to do. And, whether or not those rules should be changed – rules related to patents, direct to consumer advertising, pricing and regulation – is a topic for another post.

What is extremely important, however, is for consumers to be aware when they are being marketed to and when they are getting impartial, unbiased information. Unfortunately, in today’s world of searches on the web, that is not always clear. So, before taking medical advice verbatim from a website, it would be well to read the fine print about sponsors, advertisers, and conflict of interest policies enforced by the site. In other words, don’t stop at researching your medical conditions: research your websites, too.

One year ago, the New York Times reported on a series of serious medical errors that had occurred during the administration of Intensity Modulated Radiation Therapy, or IMRT. IMRT is a relatively new technology that uses sophisticated equipment to deliver high doses of radiation to very specific areas of the body, while sparing normal tissue. When administered correctly, IMRT can reduce the toxic effects of radiation therapy and allow higher doses than traditional radiation therapy. However, when this highly targeted beam misses its target due to a medical error, the results can be catastrophic.

The attention generated by the Times article has led to some promising steps in the past year toward better radiation safety in oncology practice. The American Society for Therapeutic Radiation and Oncology (ASTRO) released a six point plan outlining the steps the professional society was going to take to improve safety. And many facilities, including University of Michigan Health System, have made information about the safety procedures they use for radiation therapy available to the public.

Experts agree that accurate and transparent error reporting is necessary to help improve IMRT safety. Error registries allow facilities to learn from each other, and enable systematic study into the factors that allow errors to occur. Some states have been very successful in achieving high rates of error reporting, but what leads to that success is not clear. For example, the state of New York has an error reporting rate 16 times Michigan’s rate.

Michigan has not yet taken the kinds of steps implemented in New York. In Michigan, facilities are only inspected every four to five years, and there are no statewide requirements for safety and quality assurance procedures. Short of stronger regulation in Michigan, approaches like those taken by the University of Michigan Health System could improve safety for IMRT patients and give providers better tools for quality improvement.

Heather Kofke-Egger is a health policy consultant at the Center for Healthcare Research and Transformation (CHRT). She supports CHRT’s public information and policy research activities. She served as one of the primary researchers on The Price of Care, a series of policy reports on health care costs in Michigan. Her current work includes research on preventable readmissions and appropriate use of healthcare services.

Since the January 31 decision by the Florida court that struck down the entire Affordable Care Act as unconstitutional, there has been endless speculation about what the court ruling means and what will happen next. Some Attorneys General who were party to the lawsuit have asked for an expedited decision by the Supreme Court on the constitutionality of the law; others have argued that Judge Vinson’s decision in Florida gives the states all the rationale they need to suspend implementation of the law in its entirety. The Senate held a vote on February 2 on the Republican proposal to repeal the law and not surprisingly, the repeal vote lost, 47 to 51 (Republicans voted unanimously for repeal). What is lost in all this focus on the legal and political strategy (especially: the theatrics) around the Affordable Care Act is what American consumers, businesses, and health care entities are actually saying about the law.

The message from consumers is actually clearer and different from that often presented in the debates in Congress. Despite what some took as the message of the 2010 election, most in the public actually do not want to see the Act repealed per se. A Kaiser poll conducted in January noted that 43 percent want to repeal the law (more than half of those want to replace it with a Republican alternative) while 47 percent do not want it repealed (indeed, more than half of those actually want it made stronger than it is). An even larger percentage of those polled (62 percent) are opposed to defunding the law should it stay in place.

There are, however, components of the law that are unpopular, most notably, the individual mandate (with 76 percent holding an unfavorable view). But, other elements closely tied to the mandate (elimination of preexisting condition clauses, recisions and the like) are extremely popular.  An example of that public view can be seen in New York Times coverage of the Florida decision, reporting on those fearful the ban on lifetime limits on health care coverage may go away.

The business view on the Affordable Care Act is particularly interesting. Some business groups have been quite vocal in their complete opposition to the Act. Most notably, the U.S. Chamber of Commerce and the National Federation of Independent Businesses (representing small businesses) have strongly supported repeal. Groups representing large businesses, however, have not. The Business Roundtable has not called for repeal. And, most notably, the National Business Coalition has actively opposed repeal. As quoted by David Wessel in the January 13 Wall Street Journal, Helen Darling, the Executive Director of the National Business Coalition on Health (and a former Republican staffer) notes that if businesses understood the Affordable Care Act, they would not support repeal. Indeed, her quote is quite powerful. She says, “I don’t think we’ll get a better solution in the U.S. in our lifetime. If it gets repealed, or gutted, we’ll have to start over and we’ll be worse off.”

And, then there is the health care industry – a group that will be dramatically affected by the law. Well, another interesting picture emerges there: according to the February 2 Wall Street Journal, health care entities are by and large moving forward on implementation of the law despite the two court decisions that have raised constitutional concerns about the law. And, indeed, health care investors are seeing the law as having benefits for most health care businesses as more people get health coverage and benefits are broadened.

The picture that emerges from these perspectives is that repeal is not the answer. Rather, the focus should be targeted on certain elements of the law (see “the Affordable Care Act and the Courts” for a discussion of an alternative to the mandate).

What is the path forward? The process through the courts will continue, ending up in the Supreme Court. We can only hope, however, that regardless of what happens in the courts, over the next few months, the focus in Congress turns to how to make this law work – and work better than currently designed – and moves away from the currently unhelpful discussion about an outright repeal.