The dust is still settling from the election—we have some state-level results to report and some speculation about what the new administration will mean for healthcare nationally.
Overall, the measures we identified as related to palliative and end-of-life care before the election fared well: 7 passed; 2 rejected; 1 removed from the ballot prior to the election due to invalid signatures (details below).
Notably, Arkansas, Florida, North Dakota, and Montana all approved medical marijuana, bringing the total to 20 states. (At the same time, Maine, Massachusetts, Nevada, and California approved recreational marijuana.)
The physician-assisted death proposition passed in Colorado, which joins Oregon, Washington, Vermont, and California in offering the option. Voters there, however, overwhelmingly rejected an amendment to establish a state healthcare system, and Montana voters rejected a bond measure to establish a state authority to make research grants to develop therapies and cures for brain injuries and neurological diseases.
With the surprise win for Donald Trump of the presidency, healthcare in general is headed for a time of uncertainty and turmoil. One of Trump’s signature campaign issues was to repeal and replace Obamacare, although specifics from him on the replacement have been thin. Just over the past several days, news reports have suggested that Trump is considering trying to preserve key features of Obamacare, while others suggest that the law will be repealed “on Inauguration Day.” Even in the case of a wholesale repeal pundit comments offer reassurance that effects would be phased in and unlikely to impact beneficiaries of subsidized policies until 2018. This “repeal but delay” scenario seems to be gaining steam, though not without its own chaotic effects.
In a recent presentation at the Hospital Quality Conference in San Diego, healthcare “futurist” Ian Morrison, PhD, offered predictions for what changes might be in the offing under a Trump administration, including major structural changes in the Affordable Care Act (and likely a changed name), an end to mandated participation by individuals and corporations, elimination or reduction of the tax on so-called “Cadillac” health plans, establishment of state-administered high-risk pools for people with pre-existing conditions, reduced federal subsidies for middle- and low-income and Medicaid beneficiaries, more state discretion and control over Medicaid spending (and thus more variability from state to state in benefits and services), and less regulation of insurance. Biggest implications for hospice in these changes is potential for Medicaid hospice benefits to be reduced or cut in states exercising additional discretion over spending and services.
Of course, there’s a great deal more to Obamacare, and healthcare reform generally, than “just” the insurance exchanges and Medicaid expansion, which might more directly affect palliative and end-of-life care. A healthcare policy announcement Thursday on Trump’s transition website www.greatagain.gov has some in the palliative care community concerned that Trump policies may result in a roll-back of support for advance care planning, advance directives, and patient choice in decisions around life-sustaining treatment—possibly even a resurgence of the “death panels” rhetoric and resistance. Another concern is the potential dismantling of Medicare as a system and its currently robust benefits, including hospice.
While Trump’s policy statements are vague, Paul Ryan’s conservative agenda is much more specific, and likely to significantly inform reform legislation. Although hospice is not mentioned once in the detailed policy paper, Ryan’s A Better Way agenda includes expanding Medicare Advantage programs, repealing the Medicare Independent Payment Advisory Board, combining Medicare Parts A and B, and abolishing the Center for Medicare and Medicaid Innovation (CMMI). Among many other programs, the CMMI administers the Medicare Care Choices Model, allowing concurrent curative and palliative care, which has – or had – another four years to run. Ryan’s agenda also suggests largely or wholly privatizing Medicare, moving away from direct payment for services and more toward premium support, or significantly reducing coverage.
Policies may be significantly shaped, too, by who is appointed as Secretary of Health and Human Services. In the running right now: Newt Gingrich (House Speaker in the 1990s), Bobby Jindal (former Louisiana Governor and presidential candidate), Rick Scott (current Florida Governor), and Richard Bagger (VP Celgene Corporation and former New Jersey State Senator). Ben Carson (neurosurgeon and presidential candidate) was under consideration but has taken himself out of the running. All these candidates have at least some healthcare administration or policy development in their backgrounds: Gingrich, after leaving the House, founded and chaired the Center for Health Transformation. Bagger, an attorney, has served as house counsel for Horizon Blue Cross Blue Shield of NJ and lobbyist for Pfizer. Celgene is a global biopharmaceutical company developing drugs and treatments for cancer and immune system disorders. In his mid-twenties, Bobby Jindal served as Secretary of the Louisiana Department of Health and Hospitals, and later, in the George W. Bush administration, as advisor to the U.S. Secretary of Health and Human Services. In the 1990s, Rick Scott was a cofounder of Columbia Hospital Corporation, which later merged with Hospital Corporation of America to form the largest for-profit health care company in the country.
A podcast for members from the National Hospice and Palliative Care Organization last week, however, took the view that with the new administration, Congress, and HHS Secretary, impacts on hospice were likely to be more in the nature of a “gear shift” than the “seismic shift” others are anticipating. Hospice, they noted, enjoys bipartisan support and that its “friends and champions” of both parties are “going to be back” next year. Even with anticipated changes in the Secretary of Health and Human Service and among some appointees to CMS, many longtime career personnel will remain in place. NHPCO’s message? Keep calm and carry on.
Finally, expansion of physician aid in dying laws may well hit speed bumps, because of the changed tone at the top and because of significant shifts to the right in state governments. As a result of last week’s election, four states shifted to full control (both legislative chambers and the Governor’s office) by Republicans, bringing the total to 24. In another 7 states, Republicans control both chambers of the legislature, though not the Governor’s office. While physician aid in dying has support from both parties, Republican-controlled legislatures and Governors have generally been less friendly to the issue. That said, Compassion & Choices has announced plans to pursue expansion, targeting Maryland, Minnesota, and New York.
Results of Ballot measures:
Issue 6, Arkansas Medical Marijuana Amendment of 2016 – PASSED (53–47%)
Issue 7, Arkansas Medical Cannabis Statute – REMOVED FROM BALLOT 10/27/16 DUE TO INVALID PETITION SIGNATURES.
Proposition 56, Tobacco Tax – Increase – PASSED (63–37%)
Amendment 69, State Healthcare System – REJECTED (79–21%)
Proposition 106, Colorado End of Life Options Act – PASSED (65–35%)
Amendment 2, Medical Marijuana Legalization – PASSED (71–29%)
I-181, Bonds to Fund Biomedical Research Authority – REJECTED (58–42%)
I-182, Medical Marijuana Initiative – PASSED (58–42%)
Question 4, Medical Equipment Sales Tax Exemption Initiative (a.k.a. Medical Patient Tax Relief Act) – PASSED (72–28%)
Measure 5, Medical Marijuana Legalization Initiative (a.k.a. North Dakota Compassionate Care Act) – PASSED (64–38%)
Palliative Care on the Ballot: A Roundup of Issues Related to Palliative and End-of-Life Care on Statewide Ballots, November 8, 2016
In all the contention leading to the November 8th election, the topic of healthcare has not been much discussed and palliative care not at all. In several states, however, important issues relevant to palliative and end-of-life care are up for consideration. Medical marijuana is big this year, on the ballot in four states (and recreational marijuana in five). Physician-assisted death is on the ballot in Colorado, having failed to pass the state’s legislature in 2015 and 2016. Colorado also has a single-payer state-run health payment system on the ballot, and other states are raising taxes on tobacco, removing them from medical equipment, and floating bonds to fund research. And North Dakota is giving "Compassionate Care" a whole new meaning!! Here’s a roundup; links will take you to specific language and pro/con discussions:
Issue 6, Arkansas Medical Marijuana Amendment of 2016, and Issue 7, Arkansas Medical Cannabis Statute: to legalize medical marijuana. The two measures differ in details and in implementation: Issue 6 as a state constitutional amendment and Issue 7 as an initiated state statute. If both pass, the one with the larger number of votes will take effect. Issue 6 charges the state Department of Health to define patient eligibility and health conditions that qualify for medical marijuana use. Issue 7 details specific conditions and symptoms, including intractable pain.
Proposition 56, Tobacco Tax Increase: increases tax on tobacco and tobacco products, including electronic cigarettes, to fund various initiatives including primary care and emergency physician training; cancer, cardiovascular and lung disease research; and to continue funding for other tobacco tax-supported programs.
Amendment 69, State Healthcare System: Authorizes a state tax increase, assessed from payroll and income taxes, totaling $25 billion to establish a state-administered healthcare payment system (ColoradoCare) to fund, as primary or secondary payment source, a defined set of healthcare services for all Colorado state residents. Services include “palliative and end-of-life care.” Relationships between ColoradoCare and other payers including Medicare and Medicaid are detailed in the full text of the amendment.
Proposition 106, Colorado End of Life Options Act: Creates statute establishing a legal framework under which competent, terminally ill patients with a prognosis of 6 months or less may request and receive a prescription for lethal medications for the purpose of ending their lives. Process steps are similar, though not identical, to similar statutes in Oregon and California.
Amendment 2, Medical Marijuana Legalization: a state constitutional amendment to allow physicians to prescribe marijuana to eligible patients with specific conditions, including cancer, ALS, HIV/AIDS, Parkinson’s, and others.
I-181, Bonds to Fund Biomedical Research Authority: establishes a state authority to oversee and review grant applications to promote development of therapies and cures for brain diseases and injuries and mental illnesses, including Alzheimer’s, Parkinson’s, brain cancer, dementia, traumatic brain injury and stroke by Montana biomedical research organizations.
I-182, Medical Marijuana Initiative: amends an initiative approved by voters in 2004, which had been hobbled by a repeal attempt and veto of the repeal. Allows prescription of marijuana to patients with debilitating medical conditions, including cancer, HIV/AIDS, and others, that produce wasting, chronic pain, nausea, seizures, or other conditions defined by the state. This measure includes PTSD in the qualifying conditions.
Question 4, Medical Equipment Sales Tax Exemption Initiative (a.k.a. Medical Patient Tax Relief Act): state constitutional amendment to exempt from sales and use tax durable medical equipment, oxygen delivery equipment, and mobility-enhancing equipment prescribed by licensed health care provider.
Measure 5, Medical Marijuana Legalization Initiative (a.k.a. North Dakota Compassionate Care Act): creates state statute to legalize use of marijuana by eligible patients with debilitating medical conditions, including cancer, AIDS, hepatitis C, ALS, and others.