The Benefits of Standardized Asthma Care

December 20, 2015  |  General  |  No Comments



Asthma is a common childhood condition. Some estimates are that around 10% of all children have it. The incidence has been steadily increasing for many years, but some recent data suggest the burden of the disease in children may have leveled off over the past couple of years. That’s encouraging, but the number of children with asthma is still huge. The best way to think of asthma is that of an exaggerated reaction of the small airways in the lungs to common irritants, making them constrict and reduce airflow. These include viral infections, environmental triggers, and poorly understood things intrinsic to the individual. There is a strong familial tendency to developing asthma. Additionally, some things predispose to it, including sedentary lifestyle and obesity.

A big push in pediatric practice over the past decade or so has been to try to keep kids with asthma out of the hospital. This can be accomplished by a good asthma care plan for the family to use when a child’s symptoms get worse. Another key component is a team approach to managing this chronic disease. Asthma is the most common preventable reason for a child to be admitted to the hospital. A recent report from the American Academy of Pediatrics shows how effective these care plans can be.

The investigators looked at 3,510 children with asthma treated over the years at Primary Children’s Hospital in Utah. The notion was to see if increased compliance with asthma control measures by the family would reduce the number of hospital admissions. That turned out to be the case, significantly so. Interestingly, one of the biggest problems for the research project was to get physicians to accept and go along with the best current evidence-based information about how to manage asthma. I’m actually not surprised by this. Asthma management has changed over the years and current best practice is not what I was taught years ago. Things change, but many physicians don’t.

The key for any parent who has a child with asthma is to have a clear understanding of exactly what to do if your child has worse breathing problems. Many visits to the hospital could be headed off if all parents had such a plan, as well as a resource person to call if the plan is not working.

The credentialing process for physicians is still a chaotic mess

December 8, 2015  |  General  |  No Comments

I posted about this last year when I was once again wading through physician credentialing. I recently had occasion to do it again because I’m helping out a friend at a new hospital, and, if anything, the process is even worse.

Everyone wants to be sure their physician is competent and appropriately trained. The way this is done is through credentialing. A new applicant for privileges to practice at a hospital or other healthcare facility fills out an application and submits a curriculum vitae that details when and where a physician trained and the certifications obtained, such as specialty boards, and a work history (if any). Copies of key documents — medical degrees, residency certificates, and the like — accompany the application. The applicant also provides the names of professional references who can attest to competency. Also required are declarations that the applicant has never been fired (or asked to resign) from a medical job for competency issues. The applicant also must also swear to a long list of other things. These include not being a drug addict (who would answer yes to that?), a convicted felon, or to have been disciplined for questionable or illegal activity. A committee then reviews the application and grants (or not) privileges to practice medicine at that facility.

Before the committee grants privileges, however, all the information gets verified. This makes perfect sense because, regrettably, there are more than a few documented instances of people embellishing or even outright lying on their applications. I have been on enough selection committees to know that folks occasionally stretch the truth. Flagrant examples of this occasionally make the news. The job of credentialing departments is to check up on all this. Interestingly, in the example I just linked to, the guy hoodwinked all the verifiers; it was only picked up later by accident.

It gets more complicated because not just hospitals and healthcare facilities want their practitioners credentialed. All of the people who pay the bills, such as insurance companies and the government — Medicare, Medicaid — want to make sure they are paying legitimate costs to legitimate practitioners. So they have their own credentialing departments, all different in how they do things. A typical physician has to be credentialed by every single one of the payers covering every single one of his or her patients. That can mean a dozen payers or more. So, for example, besides having privileges at the hospitals at which I practice, my background is verified by all the people who pay the bills for my patients. And believe me, the requirements of all these entities are not the same and all have their own sheaf of forms to fill out and supporting documents to submit.

This situation cries out for a central clearing house for credentialing information. Some examples of this exist, such as this one, if nothing else because collecting all this information is tedious and expensive. Credentialing departments at many facilities are getting larger all the time. Credentialing is also a major industry, with overwhelmed facility credentialing staffs farming out the process to outside contractors. The problem is that, in our disorganized healthcare “system,” no facility or entity wants to surrender the right to collect their own data in their own way. Attempts to institute a more global process, at least in my experience, have simply added another layer of bureaucracy to slog through. The convenience, or even the sanity, of the physicians wrestling with this unholy mess is not their concern. For physicians like me, who practice at several hospitals in different parts of the country with little overlap in who the regional payers are, the expense and hassle of it all are large. And even when you think you’re done, you’re not: many entities require frequent updates, often meaning a whole new application. One that I deal with demands this every three months.

Okay — rant over. But what prompted this was my agreeing recently to help out some people for a few weeks at a new hospital. I’m now four months into the credentialing “process.” During that time I’ve dealt with three separate organizations, none of which communicate with each other. I’ve worn out my fax machine submitting extraneous document after document. Nearly every day my email inbox has strident demands for still something else IMMEDIATELY! If I hadn’t promised my time to people I like, I think at this point I would just say: no, I’m done — good luck.

I’ve been practicing medicine for over 35 years. For my first job I just showed up for work. People checked that I had graduated from medical school, done a residency, and passed my exams, but that was about it. I realize physicians have to some extent brought all this on ourselves by a few of us scamming the system over the years or just lying. I recall a case some years ago of a physician lying about a five year gap in his work history, a gap that turned out to be because he was serving time in prison for third-degree murder. (I looked for a link to this incident but couldn’t find one — it most likely was pre-Google.)

Anyway, I think this credentialing mess has got to get better organized somehow. We need a central authority of some sort, accepted by all. The current trajectory is unsustainable. Healthcare is expensive enough, and all this adds many millions to the total costs for little benefit.


Reducing salt in processed foods would save many lives

November 29, 2015  |  General  |  No Comments

The link between salt intake and high blood pressure has been known for decades. That’s why, if you have high blood pressure, your doctor will tell you to reduce your salt intake. The reason is that excess salt makes your body retain more water. And more water in your circulation means more fluid in your vascular pipes, making the pressure in the pipes higher. That’s also why one of the first line treatments for high blood pressure is a diuretic, a drug that makes your kidneys release more water into the urine. It’s one thing to put down the salt shaker and also reduce (or eliminate) your consumption of salty snacks. But there is a hidden source of salt we often don’t think about — the salt in processed foods. When you are cooking raw food you control how much salt you add.  But you are not in control of how much salt is in processed foods, such as prepared things you might get in the frozen food section or out of a box. Food companies add quite a bit of salt to these since the perception is that doing so makes the foods tastier. Do they need to do that? How much different would foods taste if they didn’t? A recent study gives some answers to those questions.

The research was published in a recent edition of the British Medical Journal. The investigators used a national survey database to look at changes in the incidence of high blood pressure, stroke, and heart attacks over the past decade and found improvements in all of these. There are several possible explanations, including better treatment for these conditions. However, the investigators also had access to urinary salt values in many patients. The improvement particularly in blood pressure correlated with lower salt consumption. Of note, since 2003 the amount of salt in processed foods has been gradually reduced in the United Kingdom. Overall salt consumption fell by 15%. It is reasonable to conclude that at least part of the reduction in cardiovascular disease they observed was because of this salt reduction.

Although it would be difficult to accomplish, I don’t see any reason such improvements couldn’t be carried out in the USA. From everything we know, particularly high blood pressure is a long-term killer, and most people with it don’t know they have it because blood pressure needs to become very high before a person has any symptoms that would bring them to the doctor.

Overdiagnosis: how our compulsion for diagnosis may be harming children

October 17, 2015  |  General  |  No Comments

A recent article in the journal Pediatrics is both intriguing and sobering. It is intriguing because it lays bare something we don’t talk much about or teach our students about; it is sobering because it describes the potential harm that can come from it, harm I have personally witnessed. The issue is overdiagnosis, and it’s related to our relentless quest to explain everything.

Overdiagnosis is the term the authors use to describe a situation in which a true abnormality is discovered, but detection of that abnormality does not benefit the patient. It is not the same as misdiagnosis, meaning the diagnosis is inaccurate. It is also distinct from overtreatment or overuse, in which excessive treatment is given to patients for both correct and incorrect diagnoses. Overdiagnosis means finding something which, although abnormal, doesn’t help the patient in any way.

Some of the most controversial, and compelling examples of overdiagnosis come from cancer research. Two of the most common cancers, prostate cancer for men and breast cancer for women, run smack into the issue. It is certainly generally true early diagnosis and treatment of cancer is better than late diagnosis and treatment . . . usually, not always. A problem can arise when we use screening tests for early cancer as a mandate to treat them aggressively when we find them. The PSA (prostate-specific antigen) blood test was developed when researchers noticed its value went up in men with prostate cancer. From that observation is was a short, but significant leap, to use the test in men who were not known to have cancer to screen for its presence. The problem is at least two-fold. There is overlap between cancer and normal, and many small prostate cancers do not progress quickly. Since the treatment for prostate cancer is seriously invasive and has several bad side effects, the therapy may be worse than the disease, especially in older men who will likely die of something else first. You can read more about the PSA controversy here. There are similar questions about screening for breast cancer; you can read a nice summary here. The controversy has caused fierce debates.

Children don’t get cancer very often, but there are plenty of examples of overdiagnosis causing mischief with them, too. The linked article above describes several common ones. A usual scenario is getting a test that, even if abnormal, will not lead to any meaningful effect on the child’s health. Additionally, an abnormal test then typically leads to getting other tests, which can lead to other tests, and so on down the rabbit hole. I have seen that many times. As the authors state:

Medical tests are more accessible, rapid, and frequently consumed than ever before. Discussions between patients [or their parents] and providers tend to focus on the potential benefits of testing, with less regard for the potential harms. Yet a single test can give rise to a cascade of events, many of which have the potential to harm.

This is kind of a new frontier in medicine, and the issue grows larger as the huge number of diagnostic tests we have mushrooms every year. For a parent, a good rule of thumb is to ask the doctor not just what the benefits of a proposed test are, but also the risks. Importantly, ask what the doctor will actually do with the result. We are prone to think more information is always a good thing, but that clearly is not the case. And never, ever get a test just because you (or your doctor) are merely curious.


California ends personal belief and religious exemptions for childhood vaccinations

October 7, 2015  |  General  |  No Comments

California has recently ended most exemptions from childhood vaccinations. Only exemptions for medical conditions remain, and such exemptions must be certified by a physician. The requirement applies to children attending elementary or secondary school, as well as day-care centers; home schooled children are not included. A recent editorial in the New England Journal of Medicine reviews the politics behind passage of the new law.

Clearly the recent outbreak of measles in the state played a large role in convincing the legislature to pass the law. That, plus the progressive fall in the percentage of children vaccinated. Epidemiological research has shown that when the percentage of the population that is vaccinated falls below a certain number, what is termed herd immunity no longer functions. That concept is that, if the great majority of the population is immune to a disease, the few who are not are protected by the overall rarity of the infection. The particular threshold for herd immunity varies with the disease, but it is usually in the neighborhood of 80-95%. The more infectious the disease, the higher the percentage of immune people needs to be to prevent spread. If sufficient herd immunity can be maintained for long enough, the disease can actually be eradicated. Thus far only smallpox and rinderpest (a disease of cattle) have been eliminated in this way. Perhaps the purest example of the importance of herd immunity is whooping cough, or pertussis. The people most prone to contract severe, even lethal infection are small infants. Yet they cannot begin to get the vaccine (it takes several doses) until they are several months old because it doesn’t work before that age. They are entirely dependent upon not encountering older persons who have the disease.

In my view, vaccine requirements are lawful applications of the state’s interest in public health. Adults have a right to do whatever they like to their bodies (although not their children’s) as long as their actions don’t affect others. In the case of vaccines, not participating in maintenance of herd immunity has significant and potentially serious effects on the health of others.

More here.

Cerebral palsy is generally not related to events occurring around the time of birth

September 15, 2015  |  General  |  No Comments

Cerebral palsy is an old term, and an imprecise one. It refers to a heterogenous group of lifelong movement disorders that derive from problems in the brain. Although it is generally related to the motor system, it is often accompanied by intellectual deficits, seizures, or sensory issues. It affects about 2 out of every 1,000 children.

Cerebral palsy has many causes, but for many years it was assumed that many, even most cases originate from things that happen around the time of birth, some sort of birth injury. I was taught that 40 years ago in medical school and pediatric residency. It was assumed that the most common injury was the result of interruption of oxygen delivery to the infant’s brain during labor or delivery, termed birth asphyxia. Several minutes of insufficient oxygen is well known to cause brain injury, both in this setting and in many other ones. This assumption is probably the principal reason for the invention and then the huge increase in invasive fetal monitoring over the past decades. The notion was that by closely watching the infant’s heart rate and other things during labor, potential problems could be identified. Once a baby in trouble was identified, a rapid delivery by emergency surgery, cesarian section, would rescue the baby before any damage could occur.

Not surprisingly, the increase in monitoring also led to a large increase in the proportion of babies delivered by cesarian. Better safe than sorry, ran the reasoning. There certainly are multiple conditions and situations when cesarian is life-saving, both to the infant and the mother. But most experts agree that we have overused cesarians and there have been recent initiatives to limit them to situations in which they are actually needed.

There is another thing to consider. If cerebral palsy is mostly related to injuries occurring during labor and delivery, then the dramatic increase in the proportion of babies delivered by cesarian should have reduced the number of children who develop the condition. A very useful recent study examines this question, and goes on to review what we know about the causes of cerebral palsy. It begins with this very instructive graph:

The author’s interpretation is succinct:

The increasing proportions of both elective and emergency Cesarian deliveries since 1980 have not been accompanied by any change in the proportion of live births with cerebral palsy.

So what is going on here? Why have we made no progress in reducing the number of children with cerebral palsy? In the remainder of the article the authors review what we know about causes of the disorder. They conclude that only a small minority of affected children suffer birth injury as a cause. For most, it is much more complicated.

The article reviews the many conditions we know are associated with cerebral palsy. A key observation is one we’ve known for many years: other birth defects, ones not affecting the brain, occur more frequently in children with cerebral palsy. Poor fetal growth is also correlated with it. There is also clearly a genetic component; children who have a sibling with cerebral palsy have a 10-fold higher risk of developing it themselves. Premature birth is a well-known risk factor, although this particular article is about babies born at term, on time.

The bottom line is that things are complicated, and the more we learn the more complex the entity we term cerebral palsy becomes. Although clearly children who experience severe birth asphyxia are at high risk, the majority of cases are not the result of birth injury. This conclusion has significant medical-legal implications, since obstetricians are frequently sued by families of affected children, even when the events around the time of birth were routine or nearly so. Fetal monitoring data are often pointed to, even though such data have never been shown to be predictive of cerebral palsy. The author’s final conclusion is apt:

In the past, assumptions about an asphyxial cause of cerebral palsy have led to an increase in surgical deliveries, harmed maternal services, and blinkered research. It is now evident that in advantaged countries, most cases of cerebral palsy in term or near-term neonates must have other explanations.

From my perspective it appears that the thing we call cerebral palsy is probably the final common pathway to how the fetal brain responds to a wide variety of stresses, most of which occur long before birth.


Reading to your children has demonstrable positive effects on their brain development

August 13, 2015  |  General  |  No Comments

The beneficial effects of stimulating a child’s brain have been known for decades, at least in general terms. That is to say, children who have been regularly played with, read to, and generally interacted with by adults have a great advantage over those children who did not receive these things. The key period for this appears to be up to the age of three years. For an example of this sort of research see here, whose authors conclude:

Child development was strongly associated with socio-economic position, maternal schooling and stimulation.

General observations like this demonstrate how mental growth is entangled with the effects of socioeconomic status. Children who are economically disadvantaged encounter many problems that affect cognitive development, such as poorer nutrition, more chaotic home life, and emotional stress. Any solid information on the effect of stimulation, and of what kind, would help us sort out the relative importance of these various things. Now we some fascinating recent data about that issue.

A recent study used functional magnetic resonance imaging (fMRI) to examine just what reading to a child does to the child’s brain. The reason to examine reading in particular is that literacy and language skills correlate  with later achievement. As the investigators state:

Disparities in home cognitive environment during childhood can have dramatic impact on achievement and health. Parent-child reading has been shown to improve certain emergent literacy skills, though its effect on the brain has not yet been shown.

So a big question here is precisely what does mental stimulation, particularly reading, do to a child’s brain? Can we document what is happening between the ears? Now we have some information about that. The investigators did fMRI scans on children to identify what regions of the brain reading activated. What they found was this (from the American Academy of Pediatrics summary):

Results showed that greater home reading exposure was strongly associated with activation of specific brain areas supporting semantic processing (the extraction of meaning from language). These areas are critical for oral language and later for reading. Brain areas supporting mental imagery showed particularly strong activation, suggesting that visualization plays a key role in narrative comprehension and reading readiness, allowing children to “see” the story. This becomes increasingly important as children advance from books with pictures to books without them, where they must imagine what is going on in the text.

It is important that these observations held up even after controlling for socioeconomic status. I should note that this research is reported in what we term abstract form — the complete details are yet to be published. It also has not been confirmed (as far as I know) by other investigators yet. Even with these caveats, finding a physical locus in the brain for complicated mental events is exciting stuff.

There is a footnote to this research that goes back to the Baby Einstein controversy in 2007. If you didn’t know, the Baby Einstein products were videos whose authors claimed were educational in the sense of improving learning and brain development in infants and toddlers. The company was sued for false advertising claims and the Disney Corporation (the owner) paid out refunds to those who had bought them. More about that controversy here. Research published in 2007 actually showed regression of language in children who watched a lot of these videos. So how can we square that with the experience of reading to your child being good for the brain?

I have no data to offer about this, but I suspect the difference between putting your child in front of a TV and reading to him or her is the personal interaction that accompanies reading.


How placebo and nocebo effects work

July 18, 2015  |  General  |  No Comments

All physicians are familiar with what is called the placebo effect: the improvement in a patient’s symptoms after receiving a treatment that has no known effect on the particular disease. I was taught that statement could be further refined to state: improvement in a patient’s symptoms after receiving a treatment that has no known biological effect on the particular disease. The standard example is a “sugar pill.” That’s an important distinction, but it’s also clearly wrong; improvement in symptoms is obviously a biological effect, no matter the mechanism. The placebo effect is evidence of the complex interactions between mind and body because symptoms, by definition, are things perceived by the brain and cannot be specifically measured. Placebo effects are perception. They do not, for example, shrink tumors, cure asthma, or control diabetes.

The placebo effect is a key reason why, as much as possible (sometimes it isn’t), we study patient response to new treatments using a placebo arm in randomized, controlled trials. These are studies in which a patient is randomly chosen to receive either the new drug or something presumed biologically to have no effect on the particular disease. Neither the patient nor the investigator knows which one the patient is getting until after the trial is over. (Some trials compare a new treatment with an existing one — that’s a different topic.) The placebo effect is when a patient receiving the inert substance, the sugar pill, experiences an improvement. How big is the effect? Sometimes it can be as high as 30% of patients. This is why a placebo group is so important for studying disorders in which subjective symptoms are the essence of the disease, such as migraine headaches. There is no objective test one can do to assess improvement; it is all patient-reported.

How does the placebo effect work? There is a wonderful and highly understandable discussion of this in a recent edition of The New England Journal of Medicine. The article is only a couple of pages long and well worth a read. There is also a good podcast accompanying the piece. The bottom line is that clearly the placebo is not really an inert substance in the sense of doing nothing. It is doing something to the patient’s perception of symptoms, often by using known pathways of neurotransmitters in the brain. From the article:

Moreover, recent clinical research into placebo effects has provided compelling evidence that these effects are genuine biopsychosocial phenomena that represent more than simply spontaneous remission, normal symptom fluctuations, and regression to the mean.

The authors describe a fascinating example of how the placebo effect can play a role in a complex disorder like asthma. In asthma we can measure air flow as the patient breathes; that is, we can get an objective measure of how severe a patient’s problem is. The patient typically feels short of breath, and the degree of reduction of airflow correlates with that symptom. But feeling short of breath is a subjective thing. It comes from the brain. I have seen both patients in severe subjective distress with only modest reduction in airflow and patients surprisingly comfortable with very decreased objective numbers. There is a significant subjective component to asthma. This has been demonstrated by giving an placebo breathing treatment to an asthmatic and then showing that, as expected, there is no improvement in airflow. Yet the patient may experience an impressive improvement in perceived breathing symptoms.

There is also another side to the coin, what is called the nocebo effect.

 . . . the psychosocial factors that promote therapeutic placebo effects also have the potential to cause adverse consequences, known as nocebo effects. Not infrequently, patients perceive side effects of medications that are actually caused by anticipation of negative effects or heightened attentiveness to normal background discomforts of daily life in the context of a new therapeutic regimen.

Here is an example. Patients in randomized controlled trials do not know if they are receiving the placebo or not. But just in case they are receiving the real drug they are informed of possible side effects. Interestingly, 4 – 26% of patients in the placebo groups in such trials stop their participation because of these perceived adverse effects. This is the nocebo effect.

One of the most fascinating aspects of this is that there appear to be genetic predispositions among people for experiencing a placebo effect. This is an area of active research. The authors’ conclusion is a good one, I think:

Of course, placebo effects are modest as compared with the impressive results achieved by lifesaving surgery and powerful, well-targeted medications. Yet we believe such effects are at the core of what makes medicine a healing profession.

The placebo effect has always been a part of medicine. Patient’s perceptions of their physician’s compassion have long been known to be important. Really, until quite recently in medicine the placebo effect was all physicians had to offer. And it’s not a bad thing. I think it explains the modest improvements reported by some patients receiving a wide variety of what we call these days alternative therapies, such as homeopathy.

Anyway, the essay is a good review of this fascinating subject, and I recommend it to you.

Half of children may not be drinking enough water

June 30, 2015  |  General  |  No Comments

Adequate hydration, getting enough water, is vital to good health. After all, we’re mostly made of water — about 60% of our bodies is water. Our bodies are quite good at hanging on to most of this water. Our skin holds nearly all of it inside, for example. But we do lose water through what we call obligatory or insensible losses. Some is lost through our skin, such as through sweating. A fair amount is lost through our breath, since the air we breathe out is fully humidified. Our kidneys also lose water through urine. Even though these organs are very, very good at conserving water, they still need to manufacture a minimal amount of urine to keep good function. So we need to take in water every day. There is some water in food, of course, more in some foods than in others. But the bulk of our daily water needs come from drinking.

How much water do we need every day? A good general rule is that an average adult male needs around 3 liters (about 3 quarts) per day and an average adult woman requires 2.2 liters. Of course that is just the baseline. If you are doing something that increases water loss, such as moderate or severe exercise, you need additional water on top of the basal amount to make up for what you are losing. What about children? On a per weight basis children generally need more. We have some simple calculations we use to determine what we call their maintenance fluid need: 100 mL/kg for the first 10 kg of body weight, 50 mL/kg for the next 10 kg body weight, and 20 mL/kg for every kg after that until the child is adult sized. That works out to about 1 liter/day for a 10 kg (22 pound) child, 1.5 liters/day for a 20 kg (44 pound) child, and 1.9 liters for a 40 kg (88 pound) child. Again, that’s just the baseline; you need to add more for activity.

Our thirst mechanism is a key way we regulate our water, but both adults and children can take in less than their requirement but not get too thirsty if the deficit is not much. Yet that water deficit can still be significant. Chronic, mild dehydration makes you feel generally unwell, something probably all of us have experienced. For example, if you’ve been out and about most of the day and feel a bit lethargic — maybe you have a mild headache as well. Then you drink a tall glass of water and within a few minutes feel much better.

An interesting recent research study asked the question if children are, on average, as hydrated as we would recommend. They used data from the National Health and Nutrition Examination Survey, which spanned the years 2009-2012, and involved over 4,000 children between the ages of 6 – 19 years. The study was a powerful one because it didn’t just ask parents how much fluid their children drank; it measured the osmolality of the urine, which indicates how concentrated the urine is. The body normally makes urine more concentrated if it is trying to conserve water because the person isn’t drinking much.

The results were interesting. The authors found that just over half of all children were not optimally hydrated. They weren’t dehydrated, that is to say sick, but their urine osmolality was higher than what we would recommend. The authors also calculated that around 8 ounces of additional water (about 350 mL) would be sufficient to bring the average school age child up to the recommended amount. That’s the size of a standard kitchen glass of water.

The take home message for me is to offer your children plenty of water at meals and make sure they take water with them when they go to various activities, especially sports.

CBO finds that 19 million would lose their health insurance if the ACA is repealed

June 19, 2015  |  General  |  No Comments
[This is important. It was written by Phil Galewitz and republished (by permission) from Kaiser Health News (KHN), a nonprofit national health policy news service.]

Repealing the federal health law would add an additional 19 million to the ranks of the uninsured in 2016 and increase the federal deficit over the next decade, the Congressional Budget Office said Friday.

The report is the first time CBO has analyzed the costs of the health law using a format favored by congressional Republicans that factors in the effects on the overall economy. It is also the agency’s first analysis on the law under Keith Hall, the new CBO director appointed by Republicans earlier this year.

CBO projected that a repeal would increase the federal deficit by $353 billion over 10 years because of higher direct federal spending on health programs such as Medicare and lower revenues. But when including the broader effects of a repeal on the economy, including slightly higher employment, it estimated that the federal deficit would increase by $137 billion instead.

Both estimates are higher than in 2012, the last time that the CBO scored the cost of a repeal.

The latest report from the nonpartisan congressional watchdog and the Congressional Joint Committee on Taxation comes just days before the Supreme Court is expected to rule on the health law’s premium subsidies in the nearly three dozen states that rely on the federal marketplace. Such a ruling would cut off subsides to more than 6 million people and be a major blow to the Affordable Care Act. It could also boost Republican efforts to repeal the entire 2010 law, which would likely face a presidential veto.

Last week, President Barack Obama said nearly one in three uninsured Americans have been covered by the law—more than 16 million people.

The CBO said repealing the health law would first reduce the federal deficits in the next five years, but increase them steadily from 2021 through 2025. The initial savings would come from a reduction in government spending on the federal subsidies and on an expanded Medicaid program. But repealing the law would also eliminate cuts in Medicare payment rates to hospitals and other providers and new taxes on device makers and pharmaceutical companies.

The CBO projected that repeal would leave 14 million fewer people enrolled in Medicaid over the next decade. Medicaid enrollment has grown by more than 11 million since 2013, with more than half the states agreeing to expand their programs under the law.

By 2024, the number of uninsured would grow by an additional 24 million people if the law is repealed.

In 2012, the CBO projected repealing the health law would increase the federal deficit by $109 billion over 10 years.  It said the higher amount in Friday’s report reflected looking at later years when federal spending would be greater.

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