Nutrition education is lacking in most health professions education — either isn’t incorporated, exists in the context of specific disease-related diets, or glosses over the concept of nutrition and diet. Honestly, it’s understandable considering how much knowledge needs to be conveyed and learned — especially in medical school, the only health profession I can speak to personally. But, just as I’ve written before about the need to incorporate more health policy education, it’s time to also offer more discussions about nutrition and the vast impact of society and policy on the “what” and “where” people eat. [Also just as important is proper education on eating disorders. This post from my friend Clare of Fitting it All In is a great overview about caring for individuals with eating disorders.]
Obesity is common, costly, and poses serious health risks. So let’s start with some numbers to get our bearings about why this topic warrants our attention:
On a short study break, a classmate and I were discussing how the public health and health policy courses we took in graduate school influence our view of the healthcare system as medical students. It was the most productive form of procrastination (nerding out about public health and health policy) but it was also supremely frustrating to talk about all the problems in the healthcare system. The ACA was such a monumental step forward and now it seems like we’ve taken many steps back–only 34 states have expanded Medicaid, states are implementing work requirements for Medicaid, and Congressional Republicans have tried to repeal the ACA dozens of times with no real replacement or effort to fix the provisions that aren’t working well.
Only one more day stands between me and freedom from anatomy! Although, as our awesome lecturers have reminded us, anatomy is a key component of the actual practice of medicine. If you don’t know cardiac anatomy, how can you listen to the various valves of the heart, one of the most basic exams in clinical medicine?
Since histology ended a week ago, most of my time has been spent with a Netter’s atlas in the anatomy lab learning the cranial nerves and all their innervations. My free time consists of going to the grocery store and maybe an episode of The Office before bed. But there is one recent JAMA article that I did take a moment to read and feel needs to be shared.
It’s 7am and I’m sitting in bed with too many beverages (coffee, water, smoothie–gotta get those leafy greens in) and too many tabs open (embryology review, TeamRads, Twitter, and multiple newspaper homepages). And oh yeah, my second anatomy exam is this afternoon.
But what I’m actually stressing about how thousands of low-income Arkansas residents no longer have Medicaid coverage.
On June 29, 2018, the D.C. federal district court issued a ruling in Stewart v. Azar, a lawsuit brought by a group of Kentucky Medicaid beneficiaries challenging the Secretary of HHS’s approval of a Section 1115 Medicaid waiver that imposes work requirements, monthly premiums up to 4% of income, coverage lockouts, and other provisions on Kentucky’s Medicaid program that could lead to a loss of coverage for 95,000 enrollees. The judge ruled that HHS Secretary Azar violated the Administrative Procedures Act (APA) in approving the waiver by not adequately evaluating whether the requirement that beneficiaries log 80 hours a month of “work and community engagement” furthers the objectives of Medicaid.
In early 2017, CMS Administrator Seema Verma and former HHS Secretary Tom Price sent a letter to governors promoting more flexibility in the design of state Medicaid programs with 1115 waivers to refocus the program on the “truly vulnerable.” Republicans argue that social service programs, such as Medicaid, disincentivize work and favor imposing work requirements as a condition of receiving benefits. The Obama Administration did not allow states to pursue work requirements, which are predicted to make it a serious challenge for low-income individuals and families to retain Medicaid coverage.
We’ve already covered how Medicaid benefits are structured–mandatory versusoptional–and the partnership between the federal government and the states in administering the program. But did you know that states can apply to the Secretary of Health and Human Services to waive certain requirements of Medicaid? Medicaid has not always been successful at serving its diverse and medically-complex population, including eliminating barriers to access and quality care and an inadequate focus on long-term health outcomes. Thus, federal law gives the Secretary of HHS the authority to grant Section 1115 waivers, also known as “Demonstration Project” waivers. [“1115” is the section of the Social Security Act that outlines the purpose and scope of these waivers.]
Bundled Payments. Dual Eligibles. Managed Care. These terms–along with other insurance jargon–are responsible for describing everything from how providers are paid for services rendered to who is eligible for certain insurance benefits.
The incredible folks over at the Association of State and Territorial Health Officials (ASTHO) compiled a 48 page glossary to help facilitate conversations about Medicaid between medical professionals and public health practitioners. We think this resource can be used to learn about a dozens of important, everyday terms that medical students should know should keep in mind! Here’s just a snippet of what ASTHO has put together:
Medicaid is jointly administered by the Centers for Medicare and Medicaid Services (CMS) and individual state Medicaid agencies. CMS is an agency within the Department Health and Human Services (HHS), which in turn is overseen by the President. CMS sets program parameters, provides policy guidance, and approves waivers excusing states from certain requirement. CMS issues guidance on eligibility, enrollment, medical assistance, coverage, provider participation, provider payments, cost-sharing, and a host of other policy issues related to the program.
In turn, each state creates a uniform, state-wide medical assistance program that is embodied in a federally-approved state plan. The state agencies are free to make choices within the parameters set by the federal government, often through waivers or creative programming.