Changing views on Halbig/King: the case of PPS 165 at Duke

Much has been written about the Halbig/King litigation that the Supreme Court on Friday agreed to hear. The case centers on the question of whether federal subsidies can flow to persons who purchased coverage in states with federally facilitated exchanges (I’m not going to try for comprehensive link round up). I have nothing to add on the merits of the case. I write to report drastic changes in what Duke undergraduates (mix of frosh, soph and pre-med kids) taking my class at Duke University (PPS 165, Introduction to the U.S. Health Care System) have thought about it over the past 3 Fall terms (2012, 2013, 2014).

I assigned the identical memo prompt all 3 semesters. The goal was to get them to look at the text of the law and the IRS regs and decide what they thought; it is an assignment in making a decision and writing persuasively. I provided little to no discussion of the issues prior to their writing. The breakdown of student views across the 3 semesters were as follows (No means a conclusion that tax credits cannot legally flow to persons buying in a federally facilitated exchange; yes means they are allowable):

In defense of football

I don’t write to defend domestic violence, drug abuse, denigration of women, or the many other ways in which professional football players misbehave. I don’t write to defend what I consider to be the unjust withholding of money from college players. And I don’t write to defend lack of transparency and not paying for the health needs of players injured while playing.

I do write to defend the game of football, as it was played yesterday in a middle school game in Durham, N.C. I loved playing middle school and high school football, and I now have the privilege of being a volunteer assistant coach with my son’s team, who won the game 14-12. The other team easily could have won and both played well and hard. No parents misbehaved. The refs did a good job. And no one got seriously hurt. Continue reading “In defense of football”

Mismatch between patient preferences and what Medicare covers

I have a new paper with Duke and NIH colleagues out this week (early online) in the Journal of Clinical Oncology (full pdf:JCO-2014-Taylor) that demonstrates gaps between the stated preferences of Medicare beneficiaries with cancer and their caregivers about what Medicare should cover, and what the benefit package actually covers. The gaps we highlight show beneficiaries and caregivers allocating finite resources toward now-uncovered benefits that broadly speaking are designed to maximize quality of life:

  • unrestricted cash  (some level chosen by 46%)
  • home based long term care (52% choose a level far beyond what home health would cover)
  • concurrent palliative care (45% chose a level beyond the current hospice benefit; such care without having to unelect curative treatments)

Continue reading “Mismatch between patient preferences and what Medicare covers”

Hospice enrolling well patients to kill them?

The online headline of the WaPo’s latest on the Medicare hospice benefit (in fairness to the author, they typically don’t have control over headlines; but the article itself has such competing themes, it would be hard to figure out the headline):

Lethal doses: the dangers of hospice care

The hospice industry is booming, but concerns are rising about treatments for patients who aren’t near death.

If you stopped at the headline, and sub-headline you would get several ideas:

  • Hospice is enrolling patients who aren’t dying
  • Lethal doses of medicines are being given, meaning either euthanasia or homicide is occurring (depending upon the state there is no legal difference between the two)
  • Hospice is booming, presumably due to enrolling and then killing patients who aren’t dying

Continue reading “Hospice enrolling well patients to kill them?”

Paying college players-cost of attendance stipends

The Raleigh, N.C. News and Observer had a front pager yesterday on the changes that are coming to college sports regarding paying players. There are so many issues, and so many questions, but a key one is understanding a key University concept, “the cost of attendance (COA).” Duke University’s COA for 2014 is shown below:


Continue reading “Paying college players-cost of attendance stipends”

Ruling Against the NCAA

A federal judge ruled against the NCAA in the so-called Ed O’Bannon case, opening the way for players to share in licensing revenue (the use of their image and likeness on TV, etc) above the cost of attending college (what can be covered by a scholarship). The most consequential points:

In a 99-page opinion, U.S. District Judge Claudia Wilken issued an injunction that will prevent the NCAA “from enforcing any rules or bylaws that would prohibit its member schools and conferences from offering their FBS football or Division I basketball recruits a limited share of the revenues generated from the use of their names, images and likenesses in addition to a full grant-in-aid.” Wilken said the injunction will not prevent the NCAA from implementing rules capping the amount of money that may be paid to college athletes while they are enrolled in school, but the NCAA will not be allowed to set the cap below the cost of attendance. (my emphasis)


The injunction will also prohibit the NCAA from “enforcing any rules to prevent its member schools and conferences from offering to deposit a limited share of licensing revenue in trust for their FBS football and Division I basketball recruits, payable when they leave school or their eligibility expires,” Wilken wrote. Her injunction will allow the NCAA to set a cap on the trust fund at less than $5,000 in 2014 dollars for every year an athlete remains academically eligible to compete. The money would be payable to athletes upon expiration of their athletic eligibility or graduation, whichever comes first. She ruled schools could offer lower amounts of compensation if they want, but they can’t “unlawfully conspire with each other in setting these amounts.”

Continue reading “Ruling Against the NCAA”

Avik Roy’s health reform proposal

Avik Roy released a health reform proposal yesterday, published by the Manhattan Institute (full pdf). I am not going to go all post-modern literary critic on this (only deconstruct), in part because a lot of it lines up nicely with things I have been writing about/calling for over the past few years, in search of a political deal that could move the policy ahead. For example, I called for replacing the individual mandate and federalizing the dual eligibles and buying low income persons into exchanges in December of 2010! (these are “cousins” of what Avik proposes). My more fully fleshed out “next step health reform” version came in my book in 2011. Again, it is not hard to imagine a deal between what Avik and I wrote.

Perhaps most importantly is the tone, that acknowledges that policy deals are available. However, politics have been standing in the way.

As Avik puts it:

One of the fundamental flaws in the conservative approach to health care policy is that few—if any—Republican leaders have articulated a vision of what a market-oriented health care system would look like. Hence, Republican proposals on health reform have often been tactical and political—in opposition to whatever Democrats were pitching—instead of strategic and serious.

Continue reading “Avik Roy’s health reform proposal”

Duke University Renames Charles B. Aycock Dorm

Duke University will announce today that it is renaming Charles B. Aycock Dorm to its original name-East Dormitory (it was changed to Aycock in 1911). Aycock has long been known as “the education Governor” and there was great expansion of compulsory education during his tenure (1900-04). Aycock’s name also graced a prominent N.C. Democratic Party fundraiser (the Vance/Aycock Dinner) until 2011 when they removed it due to the white supremacist views of Governor Aycock.

I grew up in Goldsboro, N.C., near the birthplace of Charles B Aycock, and he is easily the most famous person ever from Goldsboro/Wayne County (he is one of two North Carolinians honored with a statue in the U.S. Capitol). Continue reading “Duke University Renames Charles B. Aycock Dorm”

Pre-Fund VA health benefits?

Michael Cannon and Christopher Preble have an interesting suggestion in the New York Times-pre fund Veterans benefits via private insurance

We propose a system of veterans’ benefits that would be funded by Congress in advance. It would allow veterans to purchase life, disability and health insurance from private insurers. Those policies would cover losses related to their term of service, and would pay benefits when they left active duty through the remainder of their lives.

To cover the cost, military personnel would receive additional pay sufficient to purchase a statutorily defined package of benefits at actuarially fair rates. The precise amount would be determined with reference to premiums quoted by competing insurers, and would vary with the risks posed by particular military jobs.

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North Carolina Senate Budget on Medicaid

The N.C. Senate released its budget, and the key Medicaid section starts on page 91. A few highlights and some questions and comments:

  • Section 12H.1.(b) stops the movement toward a regionalized “Medicaid ACO reform approach” that was the direction that the Executive branch (NC DHHS) had been moving, and is really back toward the Governors initial plan, which I labelled as ‘unworkable’. But, the phrasing below about full-risk capitated plans and provider led and non provider led plans is quite vague, so might really encompass Medicaid ACOs. I don’t know if the language is trying to be coy, or if they don’t really appreciate the nuance under the labels.
  • Section 12H.1.(a) would move Medicaid out of NC DHHS and into an independent agency (first sentence below). The execution of such a move is key, but I actually think this is a pretty good idea.
  • Section 12H.1.(a) also has some generalities that are difficult to judge without lots more details. There is *massive* amounts of health policy in lines 16-21

SECTION 12H.1 .(a)It is the intent of the General Assembly to transfer the
14 Medicaid and NC Health Choice programs to a new state entity that will define a new, more
15 successful direction for the programs and that will be able to focus more clearly on the
16 operation of the programs. Specifically, the Medicaid program shall move away from
17 unmanaged fee -for-service towards a system that manages care. To that end, Medicaid shall
18 include all dimensions of care for a recipient through full-risk, provider-led and
19 non-provider-led, capitated health plans. Such full-risk capitated health plans shall include all
20 aspects of care, without exceptions, so that the State will bear only the risk of enrollment
21 numbers and enrollment mix

Continue reading “North Carolina Senate Budget on Medicaid”