Health Policy Updates: December 23 2017

The individual mandate – viewed by many as an essential component of the ACA/Obamacare in order to maintain insurance market stability – was officially repealed this week with the passage of the GOP tax bill. Health Affairs has compiled a list of resources discussing the possible implications of mandate repeal.

According to health policy expert Timothy Jost:

“The CBO, in its most recent analysis of the individual mandate repeal proposal, projected that repeal would result in four million more uninsured by 2019, 13 million more by 2027. Repeal would increase premiums in the individual market by 10 percent or more in most years…But the repeal of the individual mandate penalty will not by any means bring an end to the ACA. The numbers who lose coverage will likely be much smaller than the CBO estimates.”

This week, everyone was talking about a Lisa Rosenbaum opinion piece in the NEJM. Discussing the “Less is More” movement within medicine aimed at reducing wasteful and low-value care, she makes the argument that sometimes this mindset goes too far, and there is often a case to be made for “More is More.”

“But the less-is-more mantra may dominate policy discussions partly because of the sheer visibility of waste…Unfortunately, it’s not clear that we have evidence-based knowledge about how to eliminate waste safely.”

My take? I fully agree with her summary that “sometimes less is more, sometimes more is more, and often we just don’t know.” But I take issue with the characterization that the “Less is More” philosophy currently has the upper hand and is running the show. The US health care system is still a fundamentally More is More entity, despite a growing number of voices that wish to change that. Rather than bringing balance to The Force by swinging the pendulum back towards the More is More side of things, I think we still have a long way to go towards reducing waste.

A great article in the NYTimes this week, examining the potential harms of cancer screening in elderly populations.

The FDA’s approval of bosutinib this week for the first-line therapy of CML is emblematic of the types of new drugs we are getting in oncology. In the BFORE trial, bosutinib was better than the standard-of-care (imatinib) in terms of how fast it clears cancer cells from the body (the surrogate outcome of “major molecular response”). However, there was no evidence that this translated to clinically meaningful endpoints, such as overall survival. So, we now have another drug available for CML, which will be more costly than imatinib (which is now available generically), but without any evidence of superiority. Should oncologists use it?

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