Presidential Proclamation Now Restricts Entry from Chad, Iran, Libya, North Korea, Somalia, Syria, Venezuela, and Yemen

President Donald Trump has issued a presidential proclamation based on Executive Order 13780, changing the list of countries from where admission of immigrants and non-immigrants will be restricted. The countries on the immigration and travel restrictions list are now Chad, Iran, Libya, North Korea, Somalia, Syria, Venezuela, and Yemen. Chad, North Korea, and Venezuela have been added to the list and Sudan has been removed from the list (Iraq was on the list under the first Executive Order 13769 issued in January, but not on the list under Executive Order 13780, and was not on the list discussed in this presidential proclamation). The new restrictions on nationals from Chad and North Korea apply broadly but the new restrictions on Venezuela only apply to certain government officials and their families. There also have been changes on the breadth of restrictions on immigration and travel from the countries that remained on the list.

The proclamation describes the review of immigration and national security issues in each country by the Departments of Homeland Security and State, as well as national intelligence agencies, about which countries should be on the list. The proclamation clarifies that existing approved visas will still be honored and that the restrictions on the new countries would become effective on October 18, 2017.

Based on this latest presidential action, the U.S. Supreme Court has cancelled the oral argument that had been scheduled for October 10 on the U.S. government’s appeals of two federal court of appeals injunctions against the implementation of Executive Order 13780. Instead, the Court requested briefing on how this presidential proclamation impacts those injunctions and also requested briefing on whether the injunctions related to section of Executive Order 13780 that temporarily suspended the admission of refugees for 120 days, would be moot by the end of October. Notably, the presidential proclamation does not address the ban on refugee admissions. These supplemental briefs are due October 5.

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Kaiser Family Foundation: 35 States Would Receive Less Federal Funding for Medicaid Under Graham-Cassidy

The Kaiser Family Foundation has issued this analysis of the state-by-sate impact of the bill proposed by Senators Lindsey Graham and Bill Cassidy to repeal and replace the Affordable Care Act (ACA), concluding that 35 states and the District of Columbia would receive less federal funding for their Medicaid programs. Overall, there would be a reduction of $107 billion in federal funding to the states.

Because of their larger state populations and their expansions of Medicaid and health insurance marketplace coverage under the ACA, the states of California, New York, and Pennsylvania would lose the most federal funding under the Graham-Cassidy proposal. In contrast, because they declined to expand Medicaid and only have limited increases in health insurance coverage through the ACA, the states of Texas, Georgia, Tennessee, and Mississippi would gain the most federal funding under the proposal.

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Congressional Budget Office: Graham-Casssidy Proposal Would Result in Millions of Americans Losing Their Health Insurance

The Congressional Budget Office (CBO) has released this preliminary analysis of the proposal by Senators Lindsey Graham and Bill Cassidy to repeal and replace the Affordable Care Act (ACA), concluding that millions of Americans would lose their health insurance coverage under the bill. The CBO explains:

“The reduction in the number of insured people relative to the number under current law would result from three main causes. First, enrollment in Medicaid would be substantially lower because of large reductions in federal funding for that program. Second, enrollment in nongroup coverage would be lower because of reductions in subsidies for it. Third, enrollment in all types of health insurance would be lower because penalties for not having insurance would be repealed.”

Since the bill shifts significant responsibility to the states for designing their Medicaid programs through block grants, and for their health insurance marketplaces with much more flexibility to change the current national standards established by the ACA, the CBO has not had the time to analyze or estimate the impacts on these complex, potential state-level decisions. For example, the CBO could project that states that have expanded Medicaid under the ACA are more likely to try to use both their Medicaid programs and their health insurance marketplaces to maintain coverage for those currently insured, including establishing state-based subsidies for premiums and cost-sharing. However, states may be limited in what they can do because the amount of federal funding for Medicaid under the new block grants and for their health insurance marketplaces is capped and limited.

Considering the caps on federal Medicaid funding and the limited amount of federal assistance for the marketplaces, the CBO does preliminarily conclude that the number of uninsured will increase, that the average amount of health insurance premiums will increase, and that the scope of health insurance benefits will decreases (since states can waive the “essential health benefits” required by the ACA).

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Here is the text of the proposed bill analyzed by the CBO (at least two other versions of the bill have been circulated):

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Since this bill would use the federal budget reconciliation process to repeal and replace the ACA, it must be voted on before the end of this year’s federal fiscal year, or this Saturday September 30. Republican Senators Rand Paul, John McCain, and Susan Collins have announced their opposition to the proposal, which means that whether the Senate even votes on the bill this week remains uncertain.

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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.

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

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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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