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Secretario Price declara estado de emergencia de salud pública en Puerto Rico y las Islas Vírgenes de EE. UU. a causa del huracán Irma

HHS Gov News - September 08, 2017

Tras las declaraciones de emergencia en Puerto Rico y las Islas Vírgenes de EE. UU. por parte del Presidente Trump, el secretario del Departamento de Salud y Servicios Humanos, Dr. Tom Price, declaró hoy la emergencia de salud pública en Puerto Rico y las Islas Vírgenes de EE. UU. a medida que el huracán Irma avanza en su trayectoria por el Caribe. Además, tomó medidas para otorgar a los beneficiarios y proveedores de atención médica de la red de los Centros de Servicios de Medicare y Medicaid (CMS) dependientes del HHS mayor flexibilidad para la atención de situaciones de emergencia.

“Con la inminente llegada del huracán Irma a Puerto Rico y las Islas Vírgenes de EE. UU., el HHS se prepara para ayudar a nuestros compatriotas, y estamos haciendo todo lo necesario para garantizar el acceso a los servicios de atención médica y al apoyo que necesiten”, expresó el Secretario del HHS, Dr. Tom Price. “Estamos movilizando recursos para cubrir las necesidades de atención médica inmediatas y para estar preparados para las consecuencias a largo plazo. Estamos haciendo todo lo que está a nuestro alcance para sostener el acceso a la atención para los beneficiarios de Medicare y Medicaid con apoyo a los hospitales y otros centros de atención médica que forman parte de esos programas, a fin de que puedan prestar servicios de atención médica en tiempo y forma a tantas personas impactadas por la tormenta como resulte posible”.

Además de aumentar la flexibilidad para la prestación de los servicios y la asistencia para beneficiarios de los CMS, HHS ha asignado un grupo de 70 personas a las áreas afectadas para ayudar a las autoridades locales y estatales a planificar y responder a las necesidades médicas de sus comunidades, y hay personal adicional a disposición en caso de necesidad.

La declaración de emergencia sanitaria en Puerto Rico y las Islas Vírgenes de EE. UU. está en línea con declaraciones similares en Texas y Luisiana que el Secretario Price firmó para ayudar a los residentes afectados por el huracán Harvey. El Secretario Price actúa en virtud de la autoridad que le confieren la Ley de Salud Pública y la Ley de Seguridad Social.

Estas medidas y flexibilizaciones tienen vigencia en forma retroactiva al 5 de septiembre de 2017.

Hay información de salud y seguridad con relación al huracán Irma disponible en:

Podcast: ‘What The Health?’ Welcome Back, Congress. Now Get To Work.

Kaiser Health News:HealthReform - September 08, 2017

The Senate this week launched hearings on both the fate of the individual insurance market and the future of the Children’s Health Insurance Program (CHIP), which is set to expire at the end of September. Still in the mix on Capitol Hill is one possible last-ditch effort to “repeal and replace” the Affordable Care Act.

But with Congress quickly wrapping up much of its “must-do” legislation, it’s not clear how or when these issues will be tackled, says a panel of experienced health care journalists in this week’s episode of “What the Health?” Julie Rovner of Kaiser Health News, Joanne Kenen of Politico, Margot Sanger-Katz of The New York Times and Mary Agnes Carey of Kaiser Health News discuss the return of Congress and bipartisan efforts to shore up the individual health insurance market for 2018.

Plus, for “extra credit,” the panelists recommend their favorite health stories of the week they think you should read, too.

Julie Rovner: NPR’s “Pets Deserve Evidence-Based Medicine, too, says the SkeptVet” by Ingfei Chen.

Joanne Kenen: Slate’s “You Shouldn’t Fast Before Surgery,” by Marina Kamenev.

Margot Sanger-Katz: Stat’s “IBM pitched its Watson supercomputer as a revolution in cancer care. It’s nowhere close,” by Casey Ross and Ike Swetlitz.

Mary Agnes Carey: KHN’s “Vital Health Officials You’ve Never Heard Of: Insurance Commissioners In The Hot Seat,” by Julie Appleby.

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcher or Google Play.

Guess Who Pays The Price When Hospital Giants Hire Your Private Practitioner?

Kaiser Health News:Insurance - September 08, 2017


MOUNTAIN VIEW, Calif. — When Dr. Sarah Azad followed her mother into the field of obstetrics eight years ago, she thought she’d be in private practice for the rest of her career. At the time, independent practices abounded in Silicon Valley.

“From the time we were young, my mom’s patients loved her. She was a part of their lives. That’s just always how I’ve seen medical care,” she said.

But over the past decade, she’s watched as doctor after doctor sold their practice and went to work for one of the large hospital systems in town. Today, Azad runs one of the last remaining independent OB-GYN practices in Mountain View.

The number of physician practices employed by hospitals increased by 86 percent from 2012 to 2015, according to a study conducted by Avalere Health for the Physicians Advocacy Institute, a health policy-focused nonprofit.

Perhaps nowhere has the trend been more pronounced than in Northern California.

This KHN story also ran in the Los Angeles Times. It can be republished for free (details).

As large hospital systems like Sutter Health, Stanford Medicine and UCSF Medical Center gobble up doctor practices, they gain market muscle that pushes costs upward. It’s a key reason why Northern California is now the most expensive place in the country to have a baby.

A study published this week in Health Affairs found that large doctor practices, many owned by hospitals, exceed federal guidelines for market concentration in more than a fifth of the areas studied. But the mergers are typically far too small for federal antitrust authorities to notice.

“When you have less competition, prices go up,” said Martin Gaynor, a health care economist at Carnegie Mellon University. “If you’re an insurance company and you don’t reach an agreement with Sutter, then you have a hard time offering an attractive insurance product because it’s so big and pervasive. So you don’t have the same negotiating power, and Sutter can extract higher prices.”

In the San Francisco Bay Area, the reimbursement rate for a vaginal delivery is two to four times higher for physicians who work for large hospital systems than for those who are independent, according to a Kaiser Health News analysis. The news organization examined claims data provided by Amino, a health cost transparency company, plus results from medical cost calculators available from certain employers to help workers comparison shop.

The extra money for physician services goes to the hospital system, and doctors, now on salary, might take home no more than before. Although switching from independent practice spares OB-GYNs the considerable hassles of negotiating with insurers and running an office, doctors say the lion’s share of the benefit goes to hospital systems — not to physicians or patients.

In Northern California, Sutter, Stanford and UCSF all mentioned quality as a reason why their physician prices are higher, and it might seem intuitive that integrating care among disparate physicians leads to better care.

“Sutter Health-affiliated doctor groups consistently rank among California’s highest performers,” Dr. Jeffrey Burnich, senior vice president at Sutter Health Medical and Market Networks, wrote in an email. In the long run, “by improving care quality and efficiency, we reduce costs.”

But in general, research suggests bigger is not necessarily better.

Fewer patients of small physician-owned practices, for example, are admitted to the hospital for preventable conditions than those of large hospital-owned practices, according to a 2014 study published in Health Affairs. A report from the National Academy of Social Insurance showed that the integrated delivery networks of large hospital systems have raised physician costs without evidence of higher quality. And a recent paper, also published in Health Affairs, found that high-price physician practices, which cost at least 36 percent above average, had no better quality than low-cost practices.

“All of the evidence that we see shows that the quality in these larger systems is the same or worse,” said Kristof Stremikis, associate director for policy at the Pacific Business Group on Health, which represents employers that provide health insurance.

A Personal Connection

On a sunny day this spring, Azad walked into her patient’s room wearing a colorful headscarf. Just weeks from her due date, Ruby Lin sat on the end of the exam table holding her belly. The two women greeted each other like old friends.

“Hi! You look great,” Lin told Azad.

“Thanks — I’m not where I hoped I’d be,” Azad replied, rolling her eyes and touching her stomach. The doctor gave birth to her fourth child just months earlier and hadn’t lost the “baby weight” she wanted to yet.

Dr. Sarah Azad examines patient Ruby Lin in Mountain View, Calif. Azad’s mother was also an obstetrician. (Jenny Gold/KHN)

This was Lin’s second baby with Azad as her doctor. “I get very nervous about seeing doctors and especially OB-GYNs, and Dr. Azad is the only one I’m comfortable with,” said Lin.

This sort of well-established, personal relationship is Azad’s favorite part of being a doctor, and she considers it a hallmark of independent practice. At the larger practices owned by hospital systems, she said, patients may be more likely to have the doctor on call deliver their baby rather than the obstetrician whom they’ve grown to know over months.

But Azad says running a medical practice in one of the most expensive parts of the country is getting harder. “Rent goes up 3 percent per year. Water and utilities went up 18 percent last year alone. But seven years later, [the insurers] are still paying me the same amount, despite any efforts to negotiate.”

At first, Azad tried reaching out to the insurance companies directly to ask for higher rates. They refused even to meet with her, she said. Then she hired a consultant to negotiate on her behalf. Nothing worked.

“One insurance contract responded saying, ’You don’t even have 2 percent of market share. Basically drop our contract or not — it doesn’t affect us,’” she said. Another insurer told her they couldn’t raise her rates because they had to pay too much to the larger health systems in town, she said.

Independent doctors in the Bay Area are reimbursed, on average, a median $2,408.45 for a routine vaginal delivery, which includes prenatal and postnatal visits, according to the Kaiser Health News analysis of Amino claims data.

That compares with $5,238.13 for the same bundle of services for Stanford physicians and $8,049.84 for doctors employed by University of California-San Francisco.

Health data company Amino provided KHN with median billing amounts for Bay Area obstetricians. KHN used a Medicare provider database to determine where each doctor worked. In cases where the doctor’s employment status was unclear, a reporter retrieved the information by calling the health system or physician directly. KHN then calculated the average median billing amount for a routine vaginal birth for each health system.

The Amino database did not contain many claims from doctors employed by Sutter, so KHN also reviewed OB-GYN charges on several insurers’ online cost estimators. The review found that obstetricians employed by Sutter Health are reimbursed about three times more for the same service than independent doctors, or about $6,452 for a vaginal delivery.

Many doctors are mystified as to why prices vary so dramatically — independent or not.

Same Office, Same Pay

After nearly a quarter-century in independent practice, OB-GYN Ken Weber sold his practice to Stanford, where he now works. His office is in the same place, across the street from Azad. Both physicians admit patients to the same local hospital.

But insurers now pay about twice as much for his services as before.

He still makes the same amount, he said. Stanford’s health system gets the rest.

“It doesn’t make sense to me from the insurance company’s standpoint, because they’re losing all these doctors to the bigger groups and having to pay more. And if they just had negotiated with us fairly, I think we could come to some middle ground,” Weber said.

Weber said he hung on to his independent practice as long as possible, but he grew increasingly frustrated. “It’s hard to know that you’re doing the same work someone else does at Sutter or Stanford or wherever,” yet insurers are paying more for patients to see the other person, he said.

Nonetheless, there have been some real benefits to selling his practice, he added: He no longer has to worry about dealing with billing or maintaining compliance with the new electronic health record regulations.

For their part, the big Bay Area hospital systems caution against oversimplifying the many factors that go into paying for obstetrical care. A Stanford spokeswoman, Samantha Dorman, said the health system incurred significant costs when it integrated new provider groups. For instance, many were not yet on electronic health records and needed updated equipment. Dorman added that Stanford reduced physician charges a few years ago to be more in line with other practices.

A UCSF spokeswoman said that just looking at physician reimbursement rates was misleading because while the system charges more for physician services, it charges less for other hospital services. Overall, she said, their costs are competitive.

For its part, Sutter suggested it was not accurate or fair to judge physician price discrepancies on online cost calculators. According to Burnich of its Medical and Market Networks service, the rates provided are inconsistent and often out-of-date.

The agreements between hospitals and insurers have “gag clauses” barring either party from divulging rates. The bottom line, for many patients, is that it’s almost impossible to determine either the cost or the value of the various health care providers available to them. This is particularly problematic for patients with high-deductible plans, who may be on the hook for a significant portion of those costs.

Meanwhile, the type of consolidation that Azad has witnessed in Northern California is spreading quickly throughout the country, and it is extremely difficult to reverse.

The most consolidated places like Northern California, Pittsburgh and Boston have become a “poster child of what not to do,” said economist Gaynor of Carnegie Mellon. “We should look at places that have consolidated and think about how to avoid that.”

Kaiser Health News correspondent Sydney Lupkin contributed to this report.

Meningitis B Vaccine’s High Price Tag Poses A Health Care Conundrum

Kaiser Health News:Marketplace - September 08, 2017

Four years ago, when meningitis B, an extremely rare but potentially lethal form of the infection, sickened a small number of college students at Princeton and the University of California-Santa Barbara, there was no vaccine against the disease sold in the U.S. Despite its availability abroad, it had never been licensed in the country due to its limited marketability.

Scientific evidence supporting an absolute need to immunize against meningitis B still falls short. The risk of contracting it is smaller than that of being involved in a car crash.

But the headlines prompted by those 13 campus cases — which resulted in one death and one double amputation — helped reshape the financial prospects for a vaccine.

Today, two brand-name vaccines, both with price tags of more than $300, are widely advertised on television and touted as a smart investment for parents who love their college-bound kids.

This KHN story also ran in The New York Times. It can be republished for free (details).

“As moms, we send our kids out into the world, full of hope,” says a mother in the ad for Bexsero, sold by pharmaceutical giant GlaxoSmithKline, as her son loads up the car to go off to college.

Says another voice, “And we don’t want something like meningitis B getting in their way.”

Analysts expect the two vaccines to generate annually at least hundreds of millions of dollars in global sales.

As new crops of students head to college, some physicians and other industry experts, though, are growing uneasy about the role of marketing in leveraging parental fears to sell the MenB vaccine — as well as ever more expensive vaccines that prevent quite rare illnesses. A complete Bexsero series costs $320; a competing vaccine, Trumenba, costs $345.

“Parents believe their children are susceptible to this terrible condition, and [drugmakers] use that fear to get parents to take action,” said Adrienne Faerber, a lecturer at the Dartmouth Institute for Health Policy and Clinical Practice who researches drug marketing.

The advertising, especially when coupled with news coverage, puts parents in a quandary left unresolved by federal vaccination guidelines and university requirements.

The Centers for Disease Control and Prevention recommends doctors consider the meningitis B vaccine for people ages 16-23 on an individual basis. This recommendation — ranked as a category B — is not as universal as the approach applied to illnesses such as measles or human papillomavirus vaccines or even the “quadrivalent” vaccine for meningitis A, C, W and Y, which all students must get.

Meanwhile, insurers generally cover it as part of preventive care. Still, most universities don’t require the vaccine but simply list it as an option for families to consider.

The resulting messages can confuse parents.

“There is perhaps, with all the marketing and advertising, some bending of the truth, and perhaps a little bit of creating fear — again recognizing that meningitis disease is a very severe disease,” said William Moss, a professor at Johns Hopkins Bloomberg School of Public Health who specializes in vaccines and global children’s health. “[The risk] is not a large enough problem to warrant routine vaccination.”

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In recent years, drugmakers’ interests have begun to expand beyond the relatively cheap, broadly used immunizations — such as a tetanus shot or the children’s hepatitis A vaccine — to new, much pricier ones for less common infections.

These newer treatments have the potential to transform what’s long been a less lucrative side of drug production, manufacturing vaccines, into a major cash cow. But since the newer vaccines are regarded as less crucial than, say, preventing measles — and are often not required — marketing has become a big part of the sales equation.

Bexsero and its competitor, Trumenba, offer clues into how this scenario plays out.

Both vaccines got accelerated approval by the Food and Drug Administration in 2015 and 2014 respectively, following the Princeton and UCSB outbreaks.

Meningitis B does not spread readily from person to person. It requires close physical contact, like kissing or sharing utensils. It can be fatal but is treatable with antibiotics if caught early. Caused by the B serogroup of the meningococcal infection, it tends to appear in rare-scatter, slowed, self-limited outbreaks on college campuses. The standard meningitis vaccine doesn’t prevent it.

After new cases at Princeton and UC-Santa Barbara kept appearing over many months, the CDC arranged for an emergency import of Bexsero. All students on those campuses got the shots, and there were no more cases.

Now the drugmakers are urging all parents to be proactive. Last year, Pfizer put more than $21 million into paid advertisements for the vaccine, according to figures kept by Kantar Media, a firm that tracks multimedia advertising. GlaxoSmithKline put in just about $79,000.

Those figures don’t account for other efforts such as meningitis awareness and ongoing social media campaigns done by GlaxoSmithKline, a “substantial effort” that “wasn’t cheap,” said Sriram Jambunathan, who heads GlaxoSmithKline’s meningococcal franchise in the United States. They also don’t include Pfizer’s investments in similar activities.

Already, industry analysts forecast Bexsero could bring in global revenue north of $1 billion per year by 2022. Trumenba is expected to earn Pfizer $880 million by that time.

But the industry’s gain may come at the expense of efficient health care spending and inflated consumer concern.

First, there’s the relative rarity of meningitis B. The CDC has estimated fewer than 300 cases occur in the United States per year, and some medical experts interviewed suggested the number may be closer to 50 or 60.

“As a mom, I would say, if my kid got this disease, and I had had the opportunity to prevent it, and I didn’t, I would kill myself,” said Martha Arden, a practicing physician and the medical director of Mount Sinai Adolescent Health Center’s school-based health program in New York City. “But the odds are small. It’s much more dangerous to send a kid out skiing than it is to not give the vaccine.”

Jambunathan said the price tag is warranted given the resources needed to bring Bexsero to market. Similar vaccines, he added, are comparably priced, and firms won’t necessarily want to develop these pharmaceuticals if they aren’t sure they can recoup their investment.

For parents who opt for the vaccines, there are caveats. Researchers don’t know, for instance, how long its immunity lasts. Many noted it also doesn’t cover all strains of the infection, so its efficacy in the United States is uncertain (there are different strains in different parts of the world).

And the cost of vaccination, while substantial, isn’t immediately felt by consumers because the treatment usually is covered without having to pay out-of-pocket. But the price tag may contribute to increasing premium costs.

In a world where there already aren’t enough health care dollars to address every possible harm, many experts noted, other health concerns might be a smarter investment.

Still, the price tag might not cause parents to blink. “When it’s your child or one case you know about, suddenly the health economic arguments feel difficult to have,” Jambunathan said.

KHN’s coverage of prescription drug development, costs and pricing is supported in part by the Laura and John Arnold Foundation.

For Low-Income Drug Users, Medi-Cal Offers A Fresh Start

Kaiser Health News:Madicaid - September 08, 2017

Breann Johnson stopped using heroin on Mother’s Day this year, determined to end her 13-year addiction. Days later, she began three months of residential treatment in Riverside, Calif. — all paid for by California’s Medicaid program.

Johnson, who has two young sons, said other inpatient drug rehab programs had refused to accept Medicaid, and she knew outpatient care would not be enough to break her habit.

“I couldn’t stop,” said Johnson, 28. “With my drug, you are either sick all day or you have to do it to make yourself feel better.”

As the opioid epidemic burns a path of devastation through communities across the nation, California is leading the way in revamping treatment for low-income residents like Johnson. Before this year, the state’s Medicaid program, known as Medi-Cal, covered only limited and episodic care. Now, it pays for a much broader range of treatment including expanded access to medications, inpatient beds, individual therapy and case managers.

Use Our ContentThis KHN story can be republished for free (details).

The five-year pilot project, which gives the state flexibility in its use of federal money, was approved in 2015 by the agency that oversees Medicaid. The California project officially started earlier this year. Virginia, Massachusetts and Maryland also have federal permission to expand drug treatment for Medicaid members. Other states, including West Virginia and Michigan, are seeking it.

California’s drug rehab overhaul makes it easier for Medi-Cal members to get care and improves their chances of long-term recovery, state health officials said. It also aims to reduce costs by decreasing use of emergency rooms and hospitals and keeping drug-addicted enrollees out of jail and out of the child welfare system.

“It is such a dramatic change to our substance abuse field,” said Marlies Perez, chief of the substance use disorder compliance division at the state Department of Health Care Services. “We turned off one system one day and turned on a whole new system the next.”

Health officials and service providers say that with the federal waiver they are finally able to address addiction as a chronic disease. Instead of simply getting short-term outpatient care, Medi-Cal beneficiaries can receive ongoing treatment from detoxification through recovery, tailored to their specific needs.

“The old traditional way was a rather canned approach to recovery,” said Bruce Copley, director of the Department of Alcohol and Drug Services in Santa Clara County.

The state does not yet know how much the changes will cost, because the program is open-ended: Anyone eligible for the services in the participating counties can receive them. In previous years, the state has spent about $180 million annually on drug rehabilitation for Medi-Cal beneficiaries. Perez said the state is only beginning to receive bills and is hoping to prove to the federal government that the changes will actually reduce overall costs related to substance abuse.

Drug rehab providers still fear for the future of Medicaid given the ongoing debate over health care in Washington, said Tom Eby, clinical director of Whiteside Manor, a nonprofit residential treatment center in Riverside. If his clients lost their Medicaid coverage — or the federal government ended California’s drug rehab program — it could imperil the progress being made, Eby said.

“It would go back to what it was, with these folks dying on the street,” he said.

Thirty-eight of the state’s 58 counties have joined California’s Medi-Cal pilot. Riverside and San Mateo started in February. Other counties, including Los Angeles and San Francisco, have come on board since.

The big increase in the availability of residential care is a significant aspect of the program, since it could reduce the chance of relapse or overdose for those with severe addictions. Previously, Medicaid did not cover treatment in inpatient rehab facilities with more than 16 beds. That resulted in long waiting lists. Inpatient stays typically were paid for by the county, a private insurer or the person being treated.

In Riverside County, Medi-Cal recipients used to wait more than two months for a bed. Now, many of them get one in a day or two, according to Rhyan Miller, the county’s substance abuse services program administrator.

At MFI Recovery’s women’s center in Riverside, known as A Woman’s Place, residents now have access to a licensed vocational nurse, a driver to take them to appointments and a discharge planner. They can stay 90 days (with a possible 30-day extension) and longer if they are pregnant.

Breann Johnson (left) and Brittany Stearns arrived at A Woman’s Place in Riverside on the same day in May, both determined to get sober. The women, who are both on Medi-Cal, are making plans to go to a sober-living facility after leaving the center. (Anna Gorman/KHN)

Johnson said she was grateful to get in without a long wait. If she hadn’t, the Riverside woman said, “I would either be on the streets or dead.”

Brittany Stearns, another resident, said her parents had paid $48,000 for an earlier stay at a private residential treatment center to treat opioid addiction. When she relapsed three years later, the 32-year-old Palm Springs resident knew her parents wouldn’t pay for it again.

“I needed help,” said Stearns, whose 2-year-old daughter, Molly, lives with her at the center. “If Medi-Cal didn’t pay for this, I am afraid to think about where I would be.”

Johnson and Stearns both completed their residential treatment and are now getting follow-up outpatient care.

Perez, of the health care department, said that although the project is scheduled to run five years, the state does not intend to return to the old way of doing business. It hopes to persuade the federal government to continue allowing spending flexibility. “This is already impacting not only Medi-Cal but other individuals who are receiving substance abuse disorder services,” she said.

That’s because clinics have made sweeping changes to meet the new Medi-Cal requirements for participation, including the recruitment and training of new employees. Counties are also now using guidelines set by the American Society of Addiction Medicine — another condition of participation.

When the new program started, thousands of people called in to a substance abuse line for screening and referral, said Miller of Riverside County. That was up from fewer than 200 calls the previous month.

“We didn’t expect this,” he said. “It has been absolutely crazy. The sheer numbers of calls completely overwhelmed and also excited us.”

At Whiteside Manor, director Ron Vervick said the additional reimbursement from Medi-Cal enabled him to hire more counselors, drivers, nurses and intake workers. Many of the residents at Whiteside are homeless and mentally ill. In the past, he said, they didn’t get the care they needed.

Kendall Jenkins sought treatment at Whiteside Manor in Riverside after years of heavy drinking and using methamphetamines, heroin and pills. He was relieved when he heard that Medi-Cal would cover his stay at the inpatient drug rehabilitation center. (Anna Gorman/KHN)

One resident of Whiteside Manor, Kendall Jenkins, sought treatment in early May after years of heavy drinking and drug use that included heroin, methamphetamines and pills — “anything I could get my hands on.” A former college golfer and hotel valet, Jenkins, 30, was homeless off and on, and spent stretches living in his car. He recently left the facility, found work at a hotel and is staying in a sober-living home nearby.

Jenkins said that when he learned Medi-Cal would cover his stay at Whiteside, he felt relieved. He was able to participate in individual counseling and group therapy and said the center “saved my life.”

Though he still thinks a lot about using heroin, he knows where he would end up if he did.

“It’s not worth it,” he said. “I know I can do this.”

KHN’s coverage in California is funded in part by Blue Shield of California Foundation.

5 Governors Press Congress For Fast Bucks To Secure Obamacare Market In 2018

Kaiser Health News:HealthReform - September 07, 2017

Sen. Lamar Alexander (R-Tenn.) has a problem — and not much time to solve it.

The chairman of the Senate Health, Education, Labor and Pensions (HELP) Committee wants to turn the page on the divisive health debate of this summer. He’s been working with the panel’s top Democrat, Patty Murray (D-Wash.), to craft a bipartisan bill aimed at shoring up the individual health insurance market.

Alexander has been looking at a proposal that would please Democrats (and insurance companies) by funding contested subsidies that help moderate-income policyholders pay their out-of-pocket health costs. To please Republicans, he has been pushing a plan to give states more flexibility to set up “reinsurance” pools that would help bring down premiums by limiting insurer exposure for the most expensive patients.

And he has to get the job done with only a handful of legislative days in September before insurers must make final decisions on 2018 coverage.

Alexander may have an impossible task ahead of him if his committee’s hearings over the past two days are an indication.

Use Our ContentThis KHN story can be republished for free (details).

A bipartisan succession of state governors and insurance commissioners told the committee that there is no time for them to get their own reinsurance programs up and running in order to stabilize the market. What would help in the short term, they said, would be for the federal government to step in and do it — temporarily. “For the first year, you’re going to have to have the federal government help on that,” said Gov. Bill Haslam (R-Tenn.).

But a clearly frustrated Alexander said at the end of Thursday’s hearing that he couldn’t pass that kind of bill. “To get a Republican president, House and Senate to vote for just more money isn’t going to happen in the next two or three weeks,” he said.

That, however, did not convince the governors, who said this money was essential in stabilizing the markets.

“One of our great challenges is to get more people participating in the system; a reinsurance pool is one of the best ways to do that,” said Gov. John Hickenlooper, a Democrat from Colorado.

He and Haslam were echoed by Massachusetts Gov. Charlie Baker and Utah Gov. Gary Herbert, both Republicans; and Montana Gov. Steve Bullock, a Democrat.

Reinsurance provides money to insurers for the sickest and highest-cost consumers. Governors testified that reinsurance would lower premiums, thereby bringing young, healthy people into the risk pool and providing stability to the marketplace.

Alexander has been a proponent of states setting up their own reinsurance pools by applying for exemptions from the Affordable Care Act’s rules to innovate in their markets. So-called Section 1332 waivers are permitted as long as they don’t cost the federal government more money or cover fewer people. He asked in his opening remarks if there was a way to reform the clunky 1332 process to allow states to create their own reinsurance pools.

“Whether it’s reinsurance or an invisible high-risk pool or a stabilization fund — we need to think about what the state share of that should be,” Alexander said.

As written, the health law makes it impossible for states to get waivers for reinsurance pools that could be up and running in time for 2018 enrollment. The waivers require state legislation and six-month waiting periods for final federal approval. The ACA created a federal reinsurance program that ran for three years, expiring in 2016.

Bullock said the federal reinsurance pool lowered premiums by 10 to 15 percent in 2014.

Sen. Maggie Hassan (D-N.H.), a former governor of her state, supported using federal dollars to help states set up their reinsurance programs.

“At least some of the seed money should come from the feds, because the feds are going to save money if they put in place a reinsurance program and premiums go down,” Hassan said.

Without reinsurance, the federal government’s costs for premium subsidies will rise as premiums increase.

But Sen. Chris Murphy (D-Conn.) said it was unlikely that a federal reinsurance program would be ready in time to affect 2018 premiums.

“I think we’re on a really tight time frame,” Murphy said after the hearing. “Whatever enthusiasm exists in the Senate for a federal reinsurance program might not exist in the House.”

Every governor in attendance also advocated for the extension of cost-sharing reduction payments to insurers for at least two years. Those payments, estimated at $10 billion for 2018, reimburse insurers for discounts given to low-income consumers. They are being funded on a month-to-month basis by the Trump administration.

Some Republican senators have denounced both cost-sharing payments and reinsurance as “insurance company bailouts,” but both the governors and the insurance commissioners told the committee that funding them is essential to keep insurers participating in the Obamacare marketplaces next year and prevent a spike in premiums.

Two more HELP Committee hearings are set for next week, on Tuesday and Sept. 14 — the first with health care experts and the second with a mixed panel including doctors and patient advocates. Alexander said Thursday that he wants to reach a consensus about stabilizing the individual health market by the end of next week and pass legislation before the end of September. That is when insurers need to submit their 2018 rates to state insurance regulators.

National survey reveals the scope of behavioral health across the nation

HHS Gov News - September 07, 2017

The Substance Abuse and Mental Health Services Administration’s (SAMHSA) latest National Survey on Drug Use and Health (NSDUH) report provides the latest estimates on substance use and mental health in the nation, including the misuse of opioids across the nation. Opioids include heroin use and pain reliever misuse. In 2016, there were 11.8 million people aged 12 or older who misused opioids in the past year and the majority of that use is pain reliever misuse rather than heroin use—there were 11.5 million pain reliever misusers and 948,000 heroin users.

“Gathering, analyzing, and sharing data is one of the key roles the federal government can play in addressing two of the Department of Health and Human Services’ top clinical priorities: serious mental illness and the opioid crisis,” said HHS Secretary Tom Price, M.D. “This year’s survey underscores the challenges we face on both fronts and why the Trump Administration is committed to empowering those on the frontlines of the battle against substance abuse and mental illness.”

Nationally, nearly a quarter (21.1percent) of persons 12 years or older with an opioid use disorder received treatment for their illicit drug use at a specialty facility in the past year. Receipt of treatment for illicit drug use at a specialty facility was higher among people with a heroin use disorder (37.5 percent) than among those with a prescription pain reliever use disorder (17.5 percent).

The report also reveals that in 2016 while adolescents have stable levels of the initiation of marijuana, adults aged 18 to 25 have higher rates of initiation compared to 2002-2008, but the rates have been stable since 2008. In contrast, adults aged 26 and older have higher rates of marijuana initiation than prior years. In 2016, an estimated 21.0 million people aged 12 or older needed substance use treatment and of these 21.0 million people, about 2.2 million people received substance use treatment at a specialty facility in the past year.

Rates of serious mental illness among age groups 26 and older have remained constant since 2008. However, the prevalence of serious mental illness, depression and suicidal thoughts has increased among young adults over recent years. Among adults aged 18 or older who had serious mental illness (SMI) in the past year, the percentage receiving treatment for mental health services in 2016 (64.8 percent) was similar to the estimates in all previous years.

“Although progress has been made in some areas, especially among young people, there are many challenges we need to meet in addressing the behavioral health issues facing our nation,” said Dr. Elinore McCance-Katz, Assistant Secretary for Mental Health and Substance Use. “Fortunately there is effective action being taken by the Administration and U.S. Department of Health and Human Services with initiatives to reduce prescription opioid and heroin related overdose, death, and dependence as well as many evidence-based early intervention programs to increase access to treatment and recovery for people with serious mental illness. We need to do everything possible to assure that those in need of treatment and recovery services can access them and we look forward to continuing work with federal and state partners on this goal.”

“Addiction does not have to be a death sentence – recovery is possible for most people when the right services and supports in place, including treatment, housing, employment, and peer recovery support,” said Richard Baum, Acting Director Office of National Drug Control Policy. “The truth is that there’s no one path to recovery because everyone is different. And frankly, it doesn’t matter how someone gets to recovery.  It just matters that they have every tool available to them, including peer recovery support and evidence-based treatment options like medication-assisted treatment for opioid addiction.”

NSDUH is a scientific annual survey of approximately 67,500 people throughout the country, aged 12 and older.  NSDUH is a primary source of information on the scope and nature of many substance use and mental health issues affecting the nation. SAMHSA is issuing its 2016 NSDUH report on key substance use and mental health indicators as part of the 28th annual observance of National Recovery Month.  Recovery Month expands public awareness that behavioral health is essential to health, prevention works, treatment for substance use and mental disorders is effective, and people can and do recover from these disorders.

The complete findings for the NSDUH report issued today are available on the SAMHSA web site at:

To view the live webcast please visit The webcast will be shown from 9:00 – 10:30 am.

HHS Secretary Price declares public health emergency in Puerto Rico, U.S. Virgin Islands due to Hurricane Irma

HHS Gov News - September 07, 2017

Following the lead of President Trump’s emergency declarations for Puerto Rico and the U.S. Virgin Islands, Health and Human Services Secretary Tom Price, M.D., today declared a public health emergency in Puerto Rico and the U.S. Virgin Islands as Hurricane Irma continues its track in the Caribbean. In addition, he has taken action that gives HHS’ Centers for Medicare & Medicaid Services’ (CMS) beneficiaries and their healthcare providers and suppliers greater flexibility in meeting emergency health needs.

“As Hurricane Irma bears down on Puerto Rico and the U.S. Virgin Islands, HHS stands ready to help our fellow Americans and do all we can to ensure they have access to the healthcare services and support they need,” said HHS Secretary Tom Price, M.D. “Assets are being mobilized to address both immediate healthcare needs and prepare for long-term challenges. We are doing everything in our power to maintain access to care for those with Medicare and Medicaid by supporting the ability of hospitals and other healthcare facilities that participate in those programs to provide timely care to as many people impacted by the storm as possible.”

In addition to increasing the flexibility in providing services to, and assistance for, CMS beneficiaries, HHS has deployed approximately 70 personnel to affected areas to help state and local authorities plan and respond to communities’ medical needs, and additional staff is on standby to assist.

Today’s declaration of public health emergencies for Puerto Rico and the U.S. Virgin Islands follows similar emergency declarations for Texas and Louisiana that Secretary Price signed to help residents affected by Hurricane Harvey. Secretary Price acted under his authority in the Public Health Service Act and Social Security Act.

These actions and flexibilities are effective retroactively to September 5, 2017.

Public health and safety information for Hurricane Irma can be found at

HHS mobilizes medical staff and supplies to support response to Hurricane Irma

HHS Gov News - September 07, 2017

Anticipating significant impacts from Hurricane Irma, currently a category 5 hurricane, as the storm approaches U.S. territories and states, the U.S. Department of Health and Human Services (HHS) pre-positioned medical support personnel near potentially impacted areas and alerted additional medical and public health teams to be ready to deploy into affected areas.

“Hurricane Irma is an especially powerful storm, and as the focal point for federal medical and public health support, we stand ready to assist states and U.S. territories in meeting local health needs when this hurricane hits,” said HHS’ Assistant Secretary for Preparedness and Response Dr. Robert Kadlec. “A storm of this magnitude threatens the safety and health of everyone in its path, and I urge residents to be prepared for the possible health effects that come along with it.”

U.S. Secretary of Health and Human Services Tom Price, M.D., spoke with Puerto Rico Governor Ricardo Roselló, U.S. Virgin Islands Governor Kenneth Mapp and Florida Governor Rick Scott on Tuesday to inform them about HHS’ efforts to prepare for the storm and assist their local responses if needed.

Federal personnel and equipment are provided at the request of state or territory officials. To ensure that HHS is positioned to fill requests immediately from affected states and territories, the department pre-positioned incident coordination staff and equipment in Puerto Rico and Georgia. These teams will oversee response activities in Puerto Rico, the U.S. Virgin Islands, or Florida.

HHS also dispatched a Disaster Medical Assistance Team (DMAT) from the National Disaster Medical System to Puerto Rico, and pre-positioned two DMATs in Georgia to deploy quickly into areas impacted by Irma. DMATs consist of medical professionals and support personnel from private sector who are called into federal service during disasters to help local officials meet the overwhelming need for medical care after storms.

HHS alerted four additional DMATs to be ready to deploy if needed. Three teams of U.S. Public Health Service Commissioned Corps personnel also stand ready to assist.

To aid state and territory officials in preparing for potential health impacts, HHS makes emPOWER data available to public health officials in Puerto Rico and Florida. This data shows the number of Medicare beneficiaries in each potentially impacted area who rely on any of 14 types of life-maintaining and assistive equipment, ranging from oxygen concentrators to electric wheelchairs, as well as data on the number of people who rely on dialysis, oxygen, and home health services. These citizens are among the most vulnerable in their communities and most likely to need life-saving assistance in prolonged power outages.

If needed, HHS can establish Federal Medical Stations (FMS) capable of providing care for to up to 250 patients at a time. HHS set up and staffed an FMS at a convention center in Houston following Hurricane Harvey. The Department also can mobilize additional medical supplies and equipment, including pharmaceuticals, as needed to aid the local medical response.

Information on health safety tips before and after the hurricane will be provided by HHS’ Office of the Assistance Secretary for Preparedness and Response and will be available at

Critical updates are available at:

ASPR - @PHEgov

HHS - @HHSgov

CDC  - @CDCgov

Secretary Tom Price, M.D. - @SecPriceMD

Lawmakers Debate How Much Wiggle Room To Give States In Health Care

Kaiser Health News:HealthReform - September 07, 2017

One of the few things that Republicans and Democrats broadly agree on is that states should have some flexibility to experiment with different ways to pay for and deliver health care.

But they disagree — strongly — on how much. In fact, Republicans don’t agree with one another on this, and that dissent helped sink efforts this summer to “repeal and replace” the Affordable Care Act. Bridging these divides will help determine the success of a bipartisan effort in the Senate this month to help shore up the individual health insurance market.

“I’ve always said not all the wisdom is going to be in Washington,” said Sen. Ron Wyden (D-Ore.), the ranking Democrat on the powerful Finance Committee. “Progressive and conservative folks are going to say ‘we can do better.’”

The federal health law includes a provision that allows states to alter some of its rules if they can think of a better way to provide health care to their residents. These are known as “Section 1332 waivers,” bookmarking where they are located in the health law.

This KHN story also ran in Stat. It can be republished for free (details).

But the law strictly limits how far states can go with their experiments. It includes what are known as “guardrails.” Those limits, said Nicholas Bagley, a health law professor at the University of Michigan, “are to prevent states from undermining the Affordable Care Act goal to provide people with comprehensive coverage.”

The waivers were designed “so blue states can experiment with blue state solutions, and red states can experiment with red state solutions,” said Bagley. “But to do so and stay within the guardrails is really difficult.” For example, he said, “you can reallocate the money, but you can’t reallocate it to create losers.”

At issue is whether to broaden authority for states by revising or eliminating the “guardrails” intended to protect patients and the federal government.

Wyden, who authored the 1332 language in the ACA, is skeptical. Under the current rules, he said, “states can make changes that make health care better. But they can’t go out and make health care worse.”

It is clear that Republicans in Congress want changes to the provision. The repeal-and-replace bill that passed the House and all those considered in the Senate included some expansion of state authority to waive protections included in the health law. Bagley said the bills “would have essentially given carte blanche to states to come up with ACA alternatives without any regard to the guardrails” other than the one prohibiting additions to the federal deficit.

And Sen. Lamar Alexander (R-Tenn.), chairman of the Senate Health, Education, Labor and Pensions (HELP) Committee, who is working on a bipartisan bill, said Wednesday that “Democrats will have to agree to something — more flexibility for states — that some are reluctant to support.”

So is there a compromise between Democrats who want to maintain the protections and Republicans who want states to have a freer hand?


David Anderson of Duke University said one possible source of agreement would be to streamline the federal approval process, starting with the guidance issued by the Obama administration in 2015 that critics said was too restrictive.

Under the rules set by the ACA, states can use waivers to adjust things like the structure of premium assistance to those with low and moderate incomes or the individual and employer requirements to have and offer coverage. But those changes must meet four key standards: States continue to provide equally comprehensive coverage to at least the same number of people, with no higher out-of-pocket costs and without costing the federal government more than it would spend under the provisions of the ACA.

The rules around the waivers also make it hard to accomplish a truly comprehensive overhaul of a state’s health care system, as states can’t use them to reach the place where most of the money funding that system comes from: tax breaks for employer-provided insurance and the federal Medicare program. Workers don’t pay taxes on the value of employer-provided insurance, which is estimated to cost the federal Treasury some $260 billion in income and payroll taxes 2017.

“If you want to reshape your state health insurance market, you’ve got to be able to grab onto the employer market or Medicare, and you can’t” using the waiver procedure, Bagley said.

States also cannot use Section 1332 to change provisions of the Medicaid and Children’s Health Insurance Program, although they can submit simultaneous waivers to each program under separate Medicaid waiver authority in the law.

So far, only two states — Hawaii and Alaska — have won federal approval for 1332 waivers under the health law.

Hawaii has had its own system for providing health coverage based on an employer requirement for coverage since the 1970s. The state’s waiver allows it to use money allocated to help small businesses afford coverage in different ways.

Alaska’s waiver, which was approved this summer, involves a “reinsurance” plan that will help spread the costs of the state’s sickest patients more widely. “By removing high-cost conditions from the risk pool, the benefits of the [reinsurance program] are shared by the entire individual health insurance market,” Lori Wing-Heier, head of the state’s insurance department, told the HELP Committee on Wednesday. In its first year, the program dropped proposed premium increases from 40 percent to “just over 7 percent,” Wing-Heier said.

Minnesota has applied for a waiver similar to Alaska’s, and approval is expected. Earlier this spring, the Department of Health and Human Services specifically invited states to apply for waivers of that type.

Other states, though, are working on proposals that would make more comprehensive changes. Iowa, for example, wants to dramatically redistribute the money available, with bigger subsidies for the middle-class customers and smaller ones for those with lower incomes. The state says that would help draw more customers into the marketplace so that the risk pool is healthier and the premiums for everyone would decrease. It would also eliminate the help lower-income people get to pay their out-of-pocket medical costs, such as deductibles and copayments.

“The Iowa waiver on its face pretty brazenly ignores the guardrails,” said Bagley.

Oklahoma, which is seeking a waiver for its own reinsurance program, is also working on a plan that would make major changes, including encouraging people to purchase insurance with higher deductibles along with a health savings account.

Part of the difficulty with the waivers is the number of hoops states must jump through to win approval, including passing legislation, seeking public comment and holding hearings around the state.

And those are not even the biggest problems, state officials say. “The part that is stifling states right now is the six-month waiting period before they receive final approval,” Alaska’s Wing-Heier told the Senate panel.

Teresa Miller, former Pennsylvania insurance commissioner, agreed at the Senate hearing, saying, “The current process is very cumbersome.”

Anderson of Duke University said one key possibility to add flexibility would be to loosen the requirement that state changes not add to the federal deficit. “Maybe they could allow for deficit neutrality over the course of the waiver rather than year by year,” he said, in which case experiments that cost money to begin with but save over time would be allowed.

Wyden said he is willing to look at any ideas to make the waivers easier to use.

But he added that the popularity of state “reinsurance” waivers that are lowering premiums shows the waiver provision is working as intended. And, he said, if GOP members try again to roll back coverage using the waiver provision “they’re going to have to roll over me, then they’re going to have to persuade people” that it meets the 1332 requirements.