Category: Uncategorized

CNN's Money Blog has an interesting map outlining who loses out under Obamacare.  You can look at it here: http://politicalticker.blogs.cnn.com/2013/07/25/who-loses-out-under-obamacare/.

When you look at it you will see Missouri squarely within the non-expansion states, a decision estimated to affect 4.9 million uninsured Americans nationwide.  But there's more to the story than that, of course, and you may drill down into the demographic characteristics of those who make up the majority of uninsured individuals at less than the 138% federal poverty level of ACA Medicaid expansion, to see who really loses out on the decision not to expand Medicaid.

You can see these numbers presented graphically at the website of the Kaiser Commission on Medicaid and the Uninsured: http://kff.org/disparities-policy/issue-brief/the-impact-of-current-state-medicaid-expansion-decisions-on-coverage-by-race-and-ethnicity/.

What do we learn? Nearly six in ten uninsured Blacks at less that 138% FPL reside in states not moving forward with Medicaid expansion at this time. This compares with four in ten uninsured Hispanics and four in ten uninsured Whites and just about one quarter of uninsured Asians in these low income groups. This is another way of illustrating that the decisions of Texas, Florida, and Georgia not to expand Medicaid under the ACA will disproportionately harm African Americans. So much press coverage focuses on the state by state head count, when it might more usefully focus on the total population head count.

Maybe a glance at the first map already told you this, if you know anything about the demographics of non-expansion states. But maybe seeing the differential skewed not just by income but by race helps to clarify just who wins and loses here. For that matter, a population-oriented analysis shows who really benefits here as well.

 

 

Missouri Governor Nixon has signed into law a Missouri bill requiring that ACA Navigators be licensed by the Missouri Division of Insurance.  I am still wondering: "Licensed as what?" since the infrastructure to license these top level federally funded guides to Missouri's federally operated exchange is not in place.

In politics — as in the rest of life –  timing is everything.  If no Missouri  state health insurance Navigator licensing infrastructure is in place as of the  date of signing, will emergency state insurance regulations be necessary in order for Navigators to be in place when ACA enrollment opens on October 1st?  If not, who will perform the Navigator function in Missouri? Might we find volunteers in the already licensed but explicitly precluded from the Navigator role by federal law group known as for-profit commercial health insurance brokers?

This could get interesting. I think of these last attempts to derail an ACA insurance counseling system designed to promote direct purchase of health insurance as the revenge of the disintermediated.

Now it is official that, after only one year, nine Medicare Pioneer accountable care organizations — among those who did not produce savings in their first year in the program — will leave the Pioneer ACO program for the Medicare Shared Savings Progam ACO model. Modern Healthcare reported it, CMS put its own spin on it, and the blogosphere has lit up with speculation.

What can we conclude after one year? 

Very very little about health care finance that we did not already know — health care provider compensation in the United States is premised  on some very entrenched principles, not the least provider insulation from cost and price among them.  Turns out, these entrenched principles are difficult to change. But even some of the departing Pioneer ACOs slowed health care cost growth somewhat. Slowing it enough to generate savings and enough savings to incite provider appetite for assuming both upside and down-side risk is another, longer term, project.

We might also tentatively conclude that it is easier to change provider behavior on quality than it is on cost.  A number of the departing Pioneer ACOs had significant — albeit short term– success in meeting quality benchmarks such as lowering risk-adjusted hospital readmission rates and improving  diabetes care. This is also not unexpected. Health care is likely to grow more expensive before it gets cheaper under the ACA.

Why the rush to try and draw conclusions after one year of Pioneer ACO experience?

We are an impatient people.  This is our virture and our vice. Whitman was correct. We are a resistless restless people.

Let's try not to draw too many firm conclusions too soon from a program just born.

Here's the ICMTR's charge:

http://www.senate.mo.gov/MedicaidTransformation/simr-charge.htm

It is interesting to see the reduction of fraud and abuse first and foremost in the ICMTR's charge.  There is much that can be done on this.

Missouri, for instance, does not allow whistleblowers to file qui tam (private attorney general proceedings) proceedings under the state false claims act — robbing the state statute of the strongest potential enforcement mechanism it might have in lean prosecutorial budgetary times. The statute's hostility to qui tam standing also renders  Missouri ineligible for important cooperative cases and recoupment with the federal government, because the state statute does not meet the stringency standards for such bonuses.

This one has been kicking around for some time. Missouri attempted to enact a buttressed  false claims act in 2011.  H.B. 374 included a qui tam provision and an anti-retaliation provision, and mirrored the language of the FCA.The bill did not pass before the legislature adjourned that session.

I wonder if fiscal watchdogs will line up to support another attempt at Missouri false claims act reform.

David Rivkin and Elizabeth Foley have a vivid Op-Ed in the June 19, 2013 Wall Street Journal. Titled: "An ObamaCare Board Answerable to No One" the piece begins by singling out the Independent Payment Advisory Board (IPAB) as the ACA's "new beast, with god-like powers."  They then offer "a vivid illustration of the extent to which life-and-death medical decisons have already been usurped by governmennt bureaucrats" — the Sarah Murnaghan transplant case.

But, IPAB hasn't been formed yet. IPAB, even once formed, will have no individual utilization review decision power — the ACA leaves this power where it has vested for some time now, in the hands of commercial insurance company utilization review schemes. No such review exists for government funded insurance. What, then, could Rivkin and Foley be talking about when discussing Secretary Sebelius's decision to maintain two separate lung-transplant lists: one for children and one for adults? Will IPAB be in charge of the difficult decisions that must be made about organ transplant availability?

Organ transplant availability is a sorry mess in the United States, a morass of  easily-gamed conflicting lists, rules, and programs. You can learn more about the gaming of an overwhelmingly de-centralized system here: http://www.npr.org/blogs/money/2012/05/29/153914790/who-decides-whether-this-26-year-old-woman-gets-a-lung-transplant  Interestingly, it is not the government that has made it so chaotic.

Now, maybe you didn't know these things.  And maybe some of the readers of the Wall Street Journal didn't know these things.  But I am going to guess that David Rivkin and Elizabeth Foley could have found these things out with some research.  Maybe the Wall Street Journal's fact checkers could have helped them out.

But then the Op-Ed would have to have taken on IPAB's defects on its own terms.

 

Wonkblog's Sarah Kliff and others have begun to consider whether it is necessarily in a gay couple's best financial interest, under the ACA, to be married. She posts that individuals who may qualify for premium supports and subsidies through the exchanges or even expanded Medicaid eligibility may combine their incomes into a household where neither spouse is entitled to such subsidies or expanded Medicaid eligibility.  Without ever acknowledging that these same marital disincentives may also exist for heterosexual couples — the way the federal tax code systematically punishes two relatively high wage earner marital households springs to mind — she talks about assessing the "financial interest" of a gay couple.

I do think that same sex couples contemplating marriage will have some serious financial and estate planning considerations to address,  but they should extend far beyond the immediate concern of health care premium supports under the ACA and extend all the way to Medicare eligibility.  The financial implications of marriage — in theory (and for significant demographic cohorts — in reality)  a lifetime commitment  — actually merit both a short term analysis and a long term analysis.

A short term analysis might look at eligibility for family based coverage under a spouse's employer sponsored health insurance plan.  This is a good time to remember that employers are not required to offer family coverage under the ACA.  A private employer may meet its play or pay obligation, in short, by offering individual coverage under an employer sponsored commercial plan.  A spouse of any gender would then be pushed to the exchanges, Medicaid, or their own employer's insurance plan. If the spouse's employer also offers only individual coverage, then any children of the household will be pushed to Medicaid, Medicaid extension programs, or the exchanges themselves.

Mind bogglingly complex to contemplate each member of a single household enrolled in a different insurance plan? Yes. A concern peculiar to same sex couples contemplating marriage? No.

A longer term analysis might look at social security eligibility and its handmaiden, Medicare eligibility. Depending upon how a family organizes its wage income production, a spouse may qualify for a more generous benefit under the breadwinner's work record than under their own, particularly if labor force attachment has been attenuated by family or other responsibilities.  But you don't get to claim social security retirement under the employment record of a spouse of an extremely brief marriage.

Remaining unmarried to qualify for ACA premium support while planning to marry in the future for spousal social security benefits and Medicare eligibility, in short, may be inconsistent approaches. At the very least, questions of timing must be considered.

Yes, affordable health insurance coverage matters here and now beyond words. Medicare coverage during your peak health care consuming years matters too, for most Americans.

Each couple will need to do the math for themselves with so many individually relevant variables in the mix: work record, ages at marriage, anticipated retirement ages, likely income trajectories. But it won't be as simple, for many, as determining how best to attain premium supports under the ACA or to attain expanded Medicaid eligibility — as pressing as those needs are for many.

 

Yesterday, it was reported that California Insurance Commissioner Dave Jones  has issued a statement recommending that Anthem Blue Cross not be allowed to sell in Covered California's health insurance exchange for small businesses. Insurance Commissioner is an elected Constitutional office in California, so Dave Jones is certainly entitled to have his say, but his decision to single out Anthem — in light of a reported three consecutive premium hikes his office had deemed unreasonable — merits more thought for multiple reasons including what it can teach us about exchange operation, what it can teach us about state regulation of insurance, and what it means to promote consumer welfare by protecting fair competition in the exchanges.

The first thing Dave Jones' statement teaches us is that he does not, as Insurance Commissioner, control access to the opportunity to sell in the structured health insurance marketplace the ACA calls an exchange.  Covered California's own governing authority does that.  But Dave Jones knows that, so why expend the effort? The answer relates to the fact that California's exchange is not a completely open one. Not only must a company want to sell health insurance inside the exchange (and meet the statutory and regulatory requirements related to things like minimum essential benefits), a company must be permitted to do so.  And California has chosen not to make its marketplace completely open to any ready, willing, and able seller.  As I have discussed earlier, this is, in part, reflective of a decision to attempt to lower the cost of exchange sold products by limiting access to the exchange marketplace.

What has this got to do with state regulation of insurance? One way to view Dave Jones' decision to speak out from his bully pulpit against Anthem's participation in the small business exchange is to see it as an effort to promote price transparency in health insurance products and as part of an effort to breed some price sensitivity into California's taxpayers. It is Anthem, after all, that chose to announce a 10.6% rate hike in January, a 10.5% rate hike in March, and a prospective rate hike of 7.6% effective July 1st of this year.  Another way to see Commissioner Jones' decision is as an attempt to do indirectly, through public shaming, what California's state specific health insurance law and regulations will not allow him to do directly — tell Anthem that their rate hikes may not go forward. You see, California, gives its Insurance Commissioner a few valuable things: authority to review medical loss ratios, authority to investigate proposed rate hikes though not necessarily derail them, and a bully pulpit.  By current calculation, Dave Jones has attempted to use all three in his office's struggles with Anthem.

Perhaps the most interesting aspect of all of this is the cry of "unfair competition" and "unfair to consumers" from the sellers of health insurance products and from representatives of the business community that purport to represent the inerests of small business that would like to purchase health insurance products that will have increased in cost almost 30% in a six month period. The argument is that these Anthem products are popular in the small business market and that consumers (unclear whether this is understood as employers or the ultimate health care consumers — employees) are being deprived of choice if the exchange is not open to Anthem for small business products.

Fair competition law exists to protect consumers. How can it help us here? First, your perspective on this may depend upon whether you think employers are the consumers of health insurance plans or whether you think the consumers in need of protection are the ultimate consumers of the health insurance involved — employees.  Second, it may be that the open exchange model has visceral appeal as pleas to increase the number of vendors in the health insurance marketplace almost always do. "If we only had more sellers…" and then you fill in the blank. Finally, it may be that the more competitive marketplace may involve levels of competition: first you compete to be able to sell, then you compete against those in the selling arena, then you enter perhaps a second or third round of competition in a sort of reverse auction format.

Both models can lay claim to the laurel wreath of free and open competition. So, it is not just as easy as it might seem to be to claim: let anyone sell, the market will sort it out.  Actually, health insurance markets are notoriously distorted for any number of reasons but chief among them would have to be that the buyer on one level (the employer) is not the consumer (the employees).

If we are to continue to have a health care system funded — in significant part — by employer selected and sponsored health insurance (and that is the insurance framework of the ACA), then the clarion call for free and open perfect competition in health insurance markets rings more than a little hollow.  That ship has sailed.

Instead, we can watch California and others attempt to promote their own versions of competition in highly distorted markets. And watch I will. If Dave Jones is able to use his bully pulpit to attempt to police health insurance costs in the exchange, it will be an object lesson to other states.

But noone gets to claim a monopoly on the "fair competition" mantle in this dispute.  It is not that simple but, then, it rarely is.

It  was H.L. Mencken who said: "For every problem there is an answer that is clear, simple and wrong."

[Here is a slightly edited version of my remarks at today's panel on NFIB v. Sebelius, Medicaid, and Health Care Federalism — a panel discussion at the annual meeting of the American Society of Law, Medicine, and Ethics.]

My remarks today on NFIB, Medicaid, and Federalism are
focused on the re-invention of Medicaid – by which I mean both the re-invention of Medicaid
originally contemplated by the ACA as well as the re-invention effectuated by
the Supreme Court.  And so I tip my
hand to reveal my perspective that it is not the ACA that is reinventing
Medicaid so much as it is the Supreme Court that is reinventing Medicaid. 

 

In acknowledgement of the ACA’s drafters'  bold attempt to re-invent
Medicaid by essentially federalizing it,  while so much of the country’s attention was focused on the arguably
less significant individual mandate provisions and accompanying insurance
market reforms, and the Supreme Court’s equally bold decision to reign in the
Secretary’s enforcement authority, I title these remarks: The Medicaid Gamble: Will Medicaid Survive the ACA?

 

From my perspective, the attempt to expand Medicaid
without building in a fall back provision (say, the equivalent of a federally
facilitated exchange for a non-exchange building state) was a tremendous
gamble, particularly in light of 
the now documented evidence that public support or disdain for  exchange implementation and Medicaid
expansion tracks highly ideological voting patterns making those correlates for the individual mandate seem mere partisan affairs by comparison. Not only were we, as students of the ACA,  focused on the wrong provisions of the ACA — when considering transformative power — we mismeasured the ideological force of the Medicaid expansion.  

 

I propose, in my limited time, to address three aspects of
health care federalism or health care reform implementation power struggles  that I think are particularly  pressing in light of Medicaid’s current vicissitudes:

 

1.     What’s
up with coercion? As Sara Rosenbaum phrased it so pithily yesterday, the
weaponizing of the coercion doctrine and the implications of that for Medicaid
going forward deserve some of our time. But my angle on coercion has to do
with the history of Medicaid’s origins.

 

2.     The
second is the battle being waged between the federal government and the states
over who, if anyone, should expand Medicaid.  I
want to say a few words about the battle being waged over what political unit,
within a state, should shoulder the burden of expanding Medicaid. This is a battle being waged in California.

 

3.     My
third and final topic will focus on a consideration of what will likely occur
in non-expansion states come January
1, 2014. And, I offer a few observations on what will likely occur in expansion states come January 1, 2014.

 

 

 

FIRST:

 

The immediate challenge before the states will be to
determine whether Medicaid expansion under the ACA is gift or Trojan Horse. And that determination may take a while.  Those of you familiar with the rollout of original Medicaid,
know that this takes time. 
Although 11 states were all in on original Medicaid  by 1967, New York was kicking around
legislation that  same year calling
for Medicaid’s repeal. Still, 8 more states were onboard by 1970, almost all
participating within four years, though Arizona (the final hold out) was not
onboard until 1982. I will note that Texas considered exiting the Medicaid
program as recently as 2011. But they did not. I  am still uncertain which way that cuts on the coercion
analysis.

 

Given Arizona Governor Brewer’s relative haste to be all in
on Medicaid expansion this time out of the gate, I have been wondering if there
are lessons that may be learned from Arizona’s  journey to participation in original Medicaid.  I 
discern three possible lessons:

 

Lesson # 1 
The cost of uncompensated care – however you slice and dice it – is  a budget buster. Arizona’s interest in
original Medicaid participation seems to have roughly correlated with the
exponential growth in indigent care costs born by the state (rising from $50 M
in 1974 to $125 M in 1980).  Although these numbers seem almost unbearably quaint by our standards, this represented significant money to Arizona in the 1970's and 1980's.  Mind you that Arizona, in the
mid-1960’s was insulated from the indigent care costs of some its poorest
citizens because those same individuals were  then eligible for free or reduced price care through the
federally funded Indian Health Service. So, let that be part B of the first
lesson: cost shift to the federal government where ever you can and for as long
as you can while you sort  this
out.

 

Lesson #2 When all was said and done, financial
exigency coupled with the argument that Arizonans were still taxed for the
program in which they chose not to participate, seems to have ruled the day.

 

 

Lesson #3  Arizona, to this day, operates what it describes as its
state Medicaid program under a section 1115 waiver originally bargained in the
1980’s.  I can find no mention of federal funding on the front page of Arizona's Medicaid web portal. 

 

Maybe these lessons are old
hat.  Maybe better historical grist
is to be found in the 1997 rollout of the CHIP program, you say?  Then you could look at the work of Ian
Hill at the Urban Institute. Perhaps. But we may want to reach back beyond
CHIP’s rollout and analogize to a rollout that – unlike CHIP—does not allow states
to impose waiting lists or impose enrollment limits to curb costs.  This is what makes the ACA Medicaid
expansion a gamble, in part, — neither of these options are available.

 

Ultimately, chastened by the cost of
uncompensated indigent care, Arizona came onboard with original Medicaid.  And, Arizona’s governor at least, does
not seem eager to be a poster child for “health care reform done right, outside
the ACA.”

 

At one point there were other
fleeting candidates for that role but the interest, now, has coalesced around
“health care reform done right, inside the

ACA.” Arkansas is the current
leading contender, though HHS’s provisional approval of a premium support
program or privatized Medicaid expansion won’t really mean much until we see
what the actual terms of the plan are. 
What we do know – as Sidney Watson so ably outlined yesterday —  “cost effectiveness” (the sina qua non
of Medicaid premium support programs) may be in the eye of the beholder,
especially in light  of the recent
invitation to the states to apply for 1115 waivers that broaden that phrase to
include incorporating imputed savings from reduced churning in the non-privatized Medicaid eligible
population and in the invitation to factor into the analysis reductions  in commercial insurance rates offered in the exchanges as products of increased
competition. 

 

I don’t know what “cost
effectiveness” will mean anymore, though I do think it will be interesting to
try to calculate whether the value of increased insured lives in some state
exchanges will enhance insurance rate competition and, arguably, benefit all
exchange purchasers, not just Medicaid premium funded purchasers.  The antitrust scholar in me would like
to see that. Because if the CBO is even close to accurate that it will cost the
federal government $6,000 a year to cover another individual American under
Medicaid expansion but $9,000 a year to cover the same individual (with the wrap
around coverage and premium subsidies necessary to make the commercial
insurance “Medicaid-like”), there are going to have to be some mighty
interesting offset calculations ahead. 

 

 

SECOND

 

While much of our attention is
directed at the federalism arena sparring between the states and the federal
government, I think not enough attention has been paid to the sparring between
and among political units within the states over the Medicaid expansion. 

 

Take California, for example.  For several decades, California has
worked hard at unwinding its statewide safety net. The full story would talk
about county by county variable standards for public assistance or the
incredible inconsistency with which MediCal applications were processed in
California but today I just want to focus on the state’s forcing (dare I say
coercing?) of the counties to assume responsibility for medical indigents.  Seen from one perspective, California
has perfected devolving the apparatus of the welfare state to the political
unit closest to community life. 
Seen from another perspective, unevenly burdened counties (particularly
those with high populations of uninsured Californians or undocumented
Californians such as the 198,000 undocumented individuals living in San Diego
County alone, roughly 6.5% of the total population) stagger under county
indigent expenses that only serve to emphasize the truism that California is
simultaneously our richest state and our poorest state. 

 

This means that, for Medicaid
expansion to be funded in California, the counties will have to transfer money
to the state. Fearful of bankrolling Medicaid expansion for the working poor
while still being left to serve the merely poor and definitively undocumented,
the counties are hanging tough. 
And that is what all the newspaper coverage about the Gov. Brown’s
negotiations with the counties to fund Medicaid expansion have been about.
Nicole Huberfeld has spoken, with dismay, of the state “ownership” of
Medicaid.  County "ownership" of
Medicaid anyone?

 

THIRD:

 

What will happen on January 1,
2014?

 

In some places, the bridge to
January 1, 2014 is already being built – not just the obvious example of
Massachusetts, but  groups like the 500,000 early Medicaid enrolled (wait for it — wait for it — on a county by county basis) in
California for example.

 

In October of 2013, the exchanges
will open– whatever forms they take – the navigators, non-navigator assistance
personnel, and just about every other insurance counselor you know — including yourselves — needs to be
braced for the biggest outpouring of those in need of insurance counseling we
may ever see in our lifetimes.  I do not see this as
a failure of the ACA in particular except insofar as it is health care reform grafted on our byzantine health insurance system. 
We are all of us woefully unprepared to understand our  health insurance system and the
complexity of selecting the appropriate insurance products for ourselves. Think
the rollout of Medicare Part D, only cubed.

 

But the real confusion will mount
when Medicaid expands in some places and not in others. The American public is
not aware that a mere state line may separate them from government funded
health insurance.  When this does
begin to percolate into public consciousness we will have a natural experiment
in border effects.  Conventional
wisdom is that, but for certain very specific disease groups, Americans do not
migrate to attain health insurance. If there ever were a fact pattern to test
that truism, I believe we’ve found it.

 

The confusion may likely peak when so many newly insured — as they did in Massachusetts — decide they are ready for their closeups.  By this, I mean the real gamble of the ACA may have been that we have sufficient provider supply to serve all of the newly insured. Our self-manufactured primary care provider shortage as well as our shortage of Medicaid accepting specialty physicians may show us up as the biggest gamblers of all on January 1, 2014.

 

Closing

 

All of this makes me want to know what  the cicadas will think about
health care reform and  Medicaid expansion the next time they arise?  ]Well, if we’re talking those  synchretized 17 year cycle East Coast
cicadas – I haven’t a clue. But if we’re talking the Missouri Brood Cicadas –
on a three year cycle (but split into three evenly sized non-synchretized
broods, so that one brood is always singing in the trees), I am confident
Medicaid expansion will be back before the Missouri legislature again next
session and possibly the session after that. 
Like Missouri Brood Cicadas, we just can’t stop ourselves.

 

 

 

 

 

 

 

 

 

I keep getting asked what I think about the anticipated health exchange prices published by Covered California in this past week. After noting that Oregon, Washington, and other states also have some version of their anticipated exchange purchase premiums up for different markets, I tell people I am not surprised.

You see, California's numbers are coming from a state where health insurance is relatively robustly regulated on the state level.  Significantly, California's small employer market (the market whose expected premium data was released this week) already requires insurers to issue policies to all comers. The risk pool for California's small employer market already mirrors — to a certain extent — the characteristics of the post-ACA small employer market. 

Does this fact mean the failure of sticker shock to materialize is any less real? No. 

Does this fact mean that sticker shock (if that term includes premium increases prompted, in part, by a mandated increased richness of insurance products offered to a wider scope of insurance seekers) is not quite possibly still ahead elsewhere? No again.

Yes, I am looking at you Missouri.

I also note that the California's "active purchaser model" of exchange development may well have played a significant role here.  Insurers must compete to sell through the California exchange, unlike some states where all may sell in exchanges that are, essentially, clearinghouses.( Note that the federally facilitated exchanges will be open exchanges)

This means I also had the contrarian reaction to last week's announcement that United Health Care, Aetna, and Cigna are all sitting out the first round of Covered California sales in certain product markets. That is what it means to have an active purchaser model exchange in a state with a robustly state regulated insurance market — some insurers (in this case relatively small players in California's individual market) will choose to watch and learn from the sidelines before calculating whether they can play in the pool.  This is good news. If we can learn anything from California's past– the too rapid expansion of certain ill-conceived insurance products in the the 1990's followed by hasty market retreat at the price of considerable insurance market dislocation shortly thereafter — it is this:  that the announcement that the pool is open may not mean that everyone should jump in at once.

By now, many of you will have read Angelina Jolie's powerful op-ed in the New York Times outlining her decision in February of this year to begin a series of surgeries (double mastectomy, eventual removal of her ovaries,etc.) as part of her effort to live with the BRCA gene mutation. If you haven't, you may read it here:http://www.nytimes.com/2013/05/14/opinion/my-medical-choice.html. And you might even follow up on the incredible outpouring of comments from readers at the same site.

I am not certain second-guessing Angelina Jolie on this is a worthwhile enterprise, but should you care to do so, she has been remarkably forthcoming on her treatment decisions at: http://www.pinklotusbreastcenter.com/. 

Not every American woman is as wealthy or well-informed about the BRCA gene mutation and about what their health insurance might think about this genetic mutation — particularly at the time, like Angelina Jolie, when a woman is asymptomatic. 

The path to the identification of the breast cancer type one susceptibility protein began in 1990 with the recognition that such a protein might exist and the 1994 actual identification and cloning of the protein.  Angelina Jolie, seem from this perspective, is a fortunate woman to live in a time when she can look the BRCA gene mutation in the eye. Although her mother, Marcheline Bertrand, knew what was killing her by the time she died in 2007, she probably never faced the choices before her daughter now.

The capacity to search for genetic evidence of likely future disease has been difficult for our health insurance system to digest.  In a system traditionally based on insurance underwriting designed to reward the insurers best skilled at sorting the sick from the well and the currently-well from the likely-to-become-sick, the advance of this kind of gene testing has been revolutionary. 

Various statutory and regulatory attempts have been made to protect the genetically forecast-to-be-sick, such as the Genetic Information Nondisclosure Act of 2008 ("GINA") but, even then,  most of the focus was on protecting gene information confidentiality and not on addressing the fears of women concerned about the insurance implications of being tested for BRCA1 and, later, BRCA2. Such fears have driven a  number of women appropriate for the testing to forego it. You can read about one study that tried to quantify this here: http://cebp.aacrjournals.org/content/11/1/79.full.

I think of these women, and not Angelina Jolie, when I note that testing for the BRCA gene mutation, after appropriate screening, is included as a covered preventive service under the ACA. You can find the the Center for Consumer Insurance Information and Oversight ("CCIO") discussing counseling, screening, and testing for BRCA here: http://cciio.cms.gov/resources/factsheets/aca_implementation_faqs12.html This combined with constraints of pre-exisiting condition exclusions found in the ACA, should increase the number of women identified, counseled, and tested for BRCA gene mutations– whatever they decide to do now or later with the information.

So, here's to Angelina Jolie for telling her story in a straightforward, honest, and even graceful manner.  Grace is playing the cards you are dealt in life, after all.  As for the rest of us who are not independently wealthy movie stars, here's to the ACA's attempt — through a science-based determination to identify high value preventive services that should be available to as many as possible — to give those among us with the BRCA gene mutations an opportunity to live with grace as well.