Physician Associations Oppose Rescission of DACA; Call on Congress to Enact Legislation to Continue Program

Several national and state physician organizations issued statements today opposing the rescission of the Deferred Action for Childhood Arrivals (DACA) program, and calling on Congress to enact legislation that would continue the program:

American Medical Association 

American College of Physicians 

American Academy of Pediatrics

California Medical Association

The Association of American Medical Colleges also issued a statement in support of DACA.




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97 Percent of Deferred Action for Childhood Arrivals (DACA) Recipients are Employed or Pursuing Higher Education

A recent study conducted by Tom K. Wong from the University of California San Diego, United We Dream, National Immigration Law Center, and Center for American Progress reports that 97 percent of recipients of Deferred Action for Childhood Arrivals (DACA) status are either employed or pursuing higher education. The online survey was conducted in August 2017 and had over 3,000 respondents. This is the largest and most recent study about the current employment and educational status of the nearly 800,000 DACA recipients.

91 percent of the DACA recipients responding to the survey are currently employed. Among respondents age 25 and older, the employment rate jumps to 93 percent. After receiving DACA, 69 percent of respondents reported moving to a job with better pay; 54 percent moved to a job that “better fits my education and training”; 54 percent moved to a job that “better fits my long-term career goals”; and 56 percent moved to a job with better working conditions. Higher wages are not just important for recipients and their families but also for tax revenues and economic growth at the local, state, and federal levels.

At least 72 percent of the top 25 Fortune 500 companies – including Walmart, Apple, General Motors, Amazon, JPMorgan Chase, Home Depot, and Wells Fargo, among others – employ DACA recipients.

5 percent of respondents started their own business after receiving DACA. Among respondents 25 years and older, this climbs to 8 percent. The rate of starting a business among Americans as a whole is 3.1 percent, meaning that DACA recipients are outpacing the general population in terms of business creation.

45 percent of respondents also are currently in school. Among those currently in school, 72 percent are pursuing a bachelor’s degree or higher. 36 percent of respondents 25 years and older have a bachelor’s degree or higher. Importantly, among those who are currently in school, a robust 94 percent said that, because of DACA, “I pursued educational opportunities that I previously could not.”

Updated: The Department of Homeland Security announced today that has rescinded the DACA program, phasing it out over the next six months. This action puts pressure on Congress to enact legislation that would continue the program.

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8 Governors Issue Bipartisan Proposal to Strengthen Affordable Care Act

Eight governors in key states – Republicans John Kasich from Ohio and Brian Sandoval from Nevada, Democrats John Bel Edwards from Louisiana, John Hickenlooper from Colorado, Tom Wolf from Pennsylvania, Terance McAuliffe from Virginia, and Steve Bullock from Montana, and Independent Bill Walker from Alaska – have issued a bipartisan proposal to strengthen the Affordable Care Act (ACA).

The governors call for both Congressional and executive actions to stabilize the health insurance marketplaces, to support both health plans in providing and individuals in accessing affordable health insurance through those marketplaces, and to continuing to provide flexibility to states for innovation within the requirements of the ACA. Many of these proposals have broad support among both health care providers and consumer advocates, although not all of them were included in the House and Senate bills to “repeal and replace the ACA” that ultimately stalled in the Senate in July.

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Oregon Health Authority Transformation Center: Opportunities for Oregon’s Coordinated Care Organizations to Advance Health Equity

This report summarizes the work to date and identifies future opportunities for Oregon’s Coordinated Care Organizations (CCOs) to advance health equity as part of their health system transformation activities.

CCOs are obligated to identify and pursue opportunities to advance health equity in several ways. Three of the eight transformation plan areas in their Oregon Health Authority (OHA) contracts require CCOs to meet their diverse members’ cultural and linguistic needs and to reduce racial and ethnic disparities. These obligations include:

  • Assuring that communications, outreach and member engagement are tailored to cultural, health literacy and linguistic needs.
  • Assuring that the culturally diverse needs of members are met, including cultural competence training, provider composition that reflects member diversity, and certified traditional health workers and traditional health workers composition reflecting member diversity.
  • Developing a quality improvement plan focused on eliminating racial, ethnic and linguistic disparities in access, quality of care, care experience and outcomes.

In addition, CCOs have been measuring and reporting their performance on more than 30 health care quality measures. OHA has reported statewide CCO performance on those quality measures, stratified by race and ethnicity (and, more recently, by disability and mental health diagnosis), as part of its accountability to CMS and to the public. These stratified data highlight the continuing racial and ethnic disparities in health care access and outcomes among Oregon’s diverse CCO members.

Finally, there are robust requirements for CCOs to engage the diverse communities that they serve by conducting community needs assessments and by developing and implementing community health improvement plans (CHPs) responsive to the identified community needs. Many of these community needs go beyond health care and highlight the social determinants of health fundamental to advancing health equity. CCOs have invested significant efforts and financial resources in the communities they serve through these CHPs, including addressing social determinants of health that support health equity.

The OHA Transformation Center supported tailored technical assistance to all 16 of the CCOs on health equity from March through November 2016. These health equity consultations identified and documented many activities and innovative ideas to advance health equity that Oregon’s 16 CCOs are implementing. Among the lessons learned from the CCOs about how to advance health equity are the following:

  • Create a CCO-wide plan to advance health equity
  • Use each CCO’s own data to identify and prioritize disparities
  • Partner with diverse members and communities served
  • Engage clinics and providers
  • Build and sustain a diverse workforce
  • Integrate equity into health system transformation
  • Be accountable for advancing health equity.

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This work was highlighted at a session at an Innovation Cafe in May 2017:

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National Academy of Medicine: Effective Care for High-Need Patients

The National Academy of Medicine has published a report on effective care for high-need patients, highlighting the opportunities for improving outcomes, value, and health. In the U.S., 1% of patients account for more than 20% of the nation’s health care expenditures, and 5% account for nearly half of the nation’s spending on health care.

Significantly, the report does not identify high-need patients based solely on medical conditions but proposes a taxonomy that embeds social risk factors, behavioral health factors, and functional limitations to identify high-need patients. Patients would first be identified through a clinical assessment, with follow-on assessment of behavioral health issues and social services needs to determine the specific type of services are required. For example, key behavioral health factors most likely to affect care delivery decisions include substance abuse, serious mental illness, cognitive decline, and chronic toxic stress. Key social risk factors include low socioeconomic status, social isolation, community deprivation, and house insecurity.

Accordingly, groups of high-need patients would include:

  • Children with complex needs: have sustained severe impairment in at least four categories together with enteral/parenteral feeding or sustained severe impairment in at least two categories and requiring ventilation or continuous positive airway pressurea tinuous positive airway pressure
  • Non-elderly disabled: under 65 years and with end-stage renal disease or disability based on receiving Supplemental Security Income
  • Multiple chronic conditions: one complex condition and/or between one and five noncomplex conditions
  • Major complex chronic conditions: two or more complex conditions or at least six noncomplex conditions
  • Frail elderly: over 65 years and with two or more frailty indicators
  • Advancing illness: other terminal illness, or end of life

The report reviewed over a dozen models of care and identifies the following care attributes of successful models of care of high-need patients:

  • Assessment: multidimensional (medical, functional, and social) patient assessment
  • Targeting: targeting those most likely to benefit
  • Planning: evidence-based care planning
  • Alignment: care match with patient goals and functional needs
  • Training: patient and care partner engagement, education, and coaching
  • Communication: coordination of care and communication among and between patient and care team
  • Monitoring: patient monitoring
  • Linking: facilitation of transitions

And here are the delivery features of successful models of care:

  • Teamwork: multidisciplinary care teams with a single, trained care coordinator as the communication hub and leader
  • Coordination: extensive outreach and interaction among patient, care coordinator, and care team, with an emphasis on face-to-face encounters among all parties and colloca- tion of teams
  • Responsiveness: speedy provider responsiveness to patients and 24/7 availability
  • Feedback: timely clinician feedback and data for remote patient monitoring
  • Medication management: careful medication management and reconciliation, particularly in the home setting
  • Outreach: extension of care to the community and home
  • Integration: linkage to social services
  • Follow-up. Prompt outpatient follow-up after hospital stays and the implementation ofstandard discharge protocols

An executive summary and summary of key points are available. In addition, a two-page summary of characteristics of successful models of care for high-need patients also is available.



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Health Care Payment Learning & Action Network: “Refreshed” Alternative Payment Model Framework

The Health Care Payment Learning & Action Network (LAN) has issued a “refreshed” white paper updating its framework for Alternative Payment Models (APMs). The updates bring the framework into alignment with the APMs recognized by the Centers for Medicare and Medicaid Services in the Quality Payment Program being implemented as a result of the Medicare Access and Children’s Health Insurance Program Reauthorization Act (MACRA) and emerging recommendations from the Physician-Focused Payment Model Technical Advisory Committee. The updated framework also recognizes the role of integrated health care finance and delivery systems in APMs.

Link to Original Source

The LAN also has produced a one-page summary and a fact sheet about the updated framework:

Link to Original Source

Link to Original Source

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Congressional Budget Office: Terminating Cost-Sharing Reductions Would Increase Health Insurance Premiums by 25% and Increase the Federal Deficit by $194 Billion

The Congressional Budget Office has estimated that the threatened termination of cost-sharing reductions for low-income Americans purchasing health insurance through the health insurance marketplaces established by the Affordable Care Act would increase premiums by 20% next year and by another 5% by the year 2020. President Donald Trump has threatened terminating these federal subsidies at the end of this calendar year. Ironically, rather than saving federal dollars, the termination would actually increase the federal deficit by $194 billion over the next ten years because more Americans would need and become eligible for the ACA’s federal health insurance premium reductions.

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National Quality Forum: Request for Comments on Draft Report on Healthcare Disparities Measurement

The National Quality Forum (NQF) has released a draft report, A Roadmap to Reduce Health and Healthcare Disparities through Measurement. The report was developed by NQF Standing Committee on Disparities, and was funded by the Centers for Medicare and Medicaid Services Office of Minority Health. The report proposes four steps for reducing health and healthcare disparities through performance measurement:

  • Step 1: Prioritize disparities-sensitive measures
  • Step 2: Identify evidence-based interventions to reduce disparities
  • Step 3: Select and use health equity performance measures
  • Step 4: Incentivize the reduction of health disparities and achievement of health equity.

For Step 1, the Committee revised prior criteria for prioritizing disparities-sensitive measures:

  • Prevalence: how prevalent is the condition among populations with social risk factors? what is the impact of the condition on the health of populations with social risk factors?
  • Size of the disparity: how large is the gap in quality, access, and/or health outcome between the group with social risk factors and the group with the highest quality ratings for that measure?
  • Impact of the quality process: how strong is the evidence linking improvement in performance on the measure to improved outcomes in the population with social risk factors?
  • Ease and feasibility of improving the quality process (actionable): is the measure actionable among the population with social risk factors?

For Step 2, the report highlights the importance of identifying and implementing interventions at multiple levels: the patient and family level, provider level, organization level, community level, and policy level.

For Step 3, the report identified five domains for health equity performance measurement:

  • Collaborate and partner with other organizations or agencies that influence the health of individuals
  • Adopt and implement a culture of equity
  • Create structures that support a culture of equity
  • Ensure equitable access to healthcare
  • Ensure high-quality care within systems that continuously reduce disparities

For Step 4, the report identifies four strategies to incentivize the reduction of disparities:

  1. Implement health equity measures
  2. Incentivize health equity through payment reform
  3. Support organizations that disproportionately serve individuals with social risk factors
  4. Develop and implement demonstration projects with rigorous evaluation partnering with equity researchers

Comments are due on August 21, 2017 and may be submitted through the NQF website.


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Congressional Budget Office: Health Care Freedom Act Would Result in 16 Million Americans Losing Health Insurance

The Congressional Budget Office (CBO) has swiftly issued its estimate of the impact of the just released Senate Health Care Freedom Act. The CBO maintains its prior estimate that by 2026 (after 10 years), 16 million Americans would lose their health insurance under the bill. That impact would be immediate, with 15 million Americans losing their health insurance next year. The CBO also maintains its prior estimate that average health insurance premiums in the individual marketplaces would increase 20%.

However, the CBO now estimates that the federal budget deficit reduction from the bill over ten years would be over $135 billion, which is over the $133 billion target (from the House’s American Health Care Act).

So it now appears that the bill will meet the requirements for a budget reconciliation bill that will only requires 50 votes for passage (with any 50-50 tie to be broken by Vice President Mike Pence).

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Text of Senate Health Care Freedom Act (“Skinny Repeal”)

Here (finally), is the text of the 8-page Senate Health Care Freedom Act, the misnamed “skinny repeal” of the Affordable Care Act (ACA). This would be the final Senate bill to be voted on to repeal and/or replace the ACA.

The bill includes the defunding of Planned Parenthood and the expansion of ACA section 1332 waivers that the Senate parliamentarian has ruled would require 60 votes rather than the 50 votes required for a budget reconciliation bill.  There have been some changes to these provisions so it is unclear how the parliamentarian would rule now.

It also is not clear that the bill contains sufficient federal deficit reduction provisions to meet the requirements for a budget reconciliation bill; if it doesn’t reduce the deficit by $133 billion (the amount of deficit reduction in the bill that the House passed), it also will require 60 votes. An earlier estimate was that this bill would only reduce the deficit by $78 billion.

The Congressional Budget Office (CBO) has previously estimated that, by 2026 (after 10 years), the repeal of the individual mandate alone would result in 16 million Americans losing their health insurance and average health insurance premiums in the individual market increasing by 20%.

If the Senate passes this bill, it is so different than the American Health Care Act passed by the House that there would be a House-Senate conference committee convened to reach agreement on a common bill to send back to the House and Senate. This will drag out the repeal and replace process out for additional months. Or there is speculation that the House would simply agree to this Health Care Freedom Act as the least common denominator and get the bill to President Trump for enactment.

The Health Care Freedom Act would:

  • Repeal the individual mandate
  • Repeal the employer mandate through 2025
  • Delay the ACA’s tax on medical devices for 3 years
  • Increases the limits on contributions to Health Savings Accounts
  • Cut off federal funding to Planned Parenthood for one fiscal year
  • Defund the Prevention and Public Health fund
  • Provide additional funding for community health centers for one fiscal year
  • Expand the ACA section 1332 waiver so that states could ignore many of the ACA’s requirements for health insurance, such as ensuring a list of essential health benefits; however, a waiver would have to maintain coverage for the same numbers of state residents; the bill now provides $2 billion for states to support such waivers

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