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Updated: 5 hours 21 min ago

Calif. Leads Nation In Pushing Back Against Trump Administration Health Policies

April 20, 2018

These days, when the federal government turns in one direction, California veers in the other — and in the case of health care, it’s a sharp swerve.

In the nation’s most populous state, lawmakers and other policymakers seemingly are not content simply to resist Republican efforts to dismantle the Affordable Care Act. They are fighting to expand health coverage with a series of steps they hope will culminate in universal coverage for all Californians — regardless of immigration status and despite potentially monumental price tags.

The Golden State embraced the health care law early and eagerly, and has more to lose than any other state if the ACA is dismantled: About 1.5 million Californians purchase coverage through the state’s Obamacare exchange, Covered California, and 3.8 million have signed up for Medicaid as a result of the program’s expansion under the law.

While other states are making efforts to preserve the ACA and expand coverage, California stands out by virtue of its ambition and size, economic clout, massive immigrant population and liberal bent.

Its health care resistance movement is broad and includes Attorney General Xavier Becerra, who has made a sport of suing the Trump administration. He is currently leading a coalition of 15 states, plus the District of Columbia, against a Texas-based lawsuit that seeks to strike down the ACA.

Even Covered California, the ACA marketplace, has jabbed at the feds. During the most recent enrollment period, which ended in January, it preserved its three-month sign-up window while the federal government cut the enrollment period in half for states that rely on the exchange. Covered California also deployed a monster advertising budget of $45 million to encourage enrollment, while the federal government slashed its ad dollars to $10 million.

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California’s activism could be contagious, said Linda Blumberg, a fellow at the nonprofit research institution the Urban Institute.

“California has been in the forefront” on a lot of health policy issues, she said. To the extent that it is successful, she said, “that helps not only the state of California itself but other states as well.”

Since last year, the federal government has allowed some states to impose work requirements on Medicaid recipients; promoted temporary health plans that have fewer consumer protections than Obamacare insurance; and, most recently, adopted a rule allowing states to lower the percentage of premium dollars that insurers are required to spend on medical care.

In response, California lawmakers are debating bills that would prohibit work requirements in Medi-Cal, the state’s version of Medicaid; ban the sale of short-term plans in the state; and increase the percentage of insurance premiums that must go toward consumers’ care.

“Look at what we’ve done in women’s issues, climate change, protecting immigrants. … That’s just the kind of thing we do. Health is no different,” said state Sen. Ed Hernandez (D-West Covina), the head of the Senate Health Committee and author of several proposals.

Four pending bills in California would provide some consumers with state-funded financial help to supplement federal subsidies created by Obamacare. One such proposal could cost the state about $500 million initially.

“We continue to move forward and push the envelope, now more than ever,” state Sen. Ricardo Lara (D-Bell Gardens) told a room full of physicians recently in Sacramento. Lara, a candidate for state insurance commissioner, is carrying a bill that would offer full Medicaid benefits to a group that’s never been covered before: adults who are in the country illegally.

“We not only play defense, but we want to make sure we’re more proactive,” he said.

California’s efforts to cover unauthorized immigrants under Medi-Cal predate the Trump administration. Achieving it now would represent not only a significant expansion of coverage within the state, but also a direct challenge to the federal government, which has made a point of cracking down on immigrants.

Critics point out that this spirit of defiance does not represent all Californians.

“We have some crazy things happening here,” said Sally Pipes, president of the conservative Pacific Research Institute. “Nobody talks about how to pay for these. Well, you pay for it in increased taxes.”

Sara Rosenbaum, a professor at the Milken Institute School of Public Health at George Washington University, said it’s no secret that President Donald Trump doesn’t like California — and that the feeling is mutual.

While she believes his administration might try to punish the state for its defiance, California will nonetheless persist in its campaign to defend the ACA and expand coverage.

“I’m sure [federal officials] can try to do a million things to make the state’s life miserable,” she said. “They can jerk it around on the federal Medicaid payments. … But I just think this, too, shall pass.”

It’s not clear whether the pending legislative proposals will succeed. Assuming any of the bills make it through the legislature, their fate lies with Gov. Jerry Brown, a Democrat known for fiscal conservatism.

“If the past is any indication, it seems unlikely that bills with sizable and uncertain ongoing costs will move forward,” said Shannon McConville, a researcher at the Public Policy Institute of California.

California is not alone in resisting health care policies put forth by the Trump administration. Other states, including Maryland and New Jersey, may establish state-based penalties for not having insurance — a response to Congress’ decision to kill the federal Obamacare penalty starting in 2019.

But California’s approach, characteristically, is different.

“Rather than use the stick, use the carrot,” said Hernandez. His bill would target $500 million from the state’s general fund to help some income-eligible Californians pay their premiums or out-of-pocket medical costs. This assistance would supplement the federal financial aid for those on the Covered California exchange.

The Senate Health Committee approved the bill last week.

The Congressional Budget Office estimates that about 4 million people nationwide will become uninsured when the tax penalty for not having insurance goes away. In California, the number would be about 378,000, according to a recent Harvard University study.

Three other bills would offer state-based financial aid to different groups of consumers, including those who make too much money to qualify for federal tax credits but still struggle to pay their premiums.

The biggest potential budget-buster of them all is a proposal to establish a single-payer health system, which was pulled from consideration last year, largely because of its eye-popping price tag: $400 billion annually.

Advocates for universal health care aren’t giving up, though some have shifted their strategy to moving piecemeal toward universal health care in lieu of a massive single-payer bill.

“There are individual steps that we can still take to expand coverage to various populations that are falling through the cracks,” said Gerald Kominski, director of the UCLA Center for Health Policy Research.

One of those populations, and a large one, is immigrants living without authorization in the country.

Lara is not the only legislator with a proposal to extend full Medi-Cal coverage to income-eligible adult immigrants without legal status. State Assemblyman Joaquin Arambula (D-Fresno) has introduced a separate bill that would do the same. Arambula’s measure made it through the Assembly Health Committee on Tuesday, and Lara’s bill passed the Senate Health Committee earlier this month.

Of the nearly 3 million Californians without insurance, about 58 percent are currently ineligible for full Medi-Cal benefits or Covered California insurance because they’re not in the country legally.

California must “lead the nation in bold and inclusive polices” that support the health of all communities, said Arambula, who is an emergency room doctor.

In 2016, the state extended full Medi-Cal benefits to all children, and now more than 200,000 undocumented kids are enrolled. It’s not clear how much it would cost to cover undocumented adults, but last year, the state budgeted $279.5 million for the children. Adults are generally more expensive to cover.

All of these measures, successful or not, add up to a campaign of defiance.

“It’s a signal that California is willing to fight very hard, on multiple fronts … to protect certain values and policies,” McConville said. “This shows we’re not willing to go backwards on that.”

Podcast: KHN’s ‘What The Health?’ Nothing In Health Care Ever Goes Away

April 19, 2018
Sarah Jane Tribble

Kaiser Health News


Read Sarah Jane's Stories Joanne Kenen



Read Joanne's Stories Margot Sanger-Katz

The New York Times


Read Margot's Stories Paige Winfield Cunningham

The Washington Post


Read Paige's Stories

Congressional Republicans have struck a decidedly different tone when talking about the Affordable Care Act, and the Democrats have introduced a new Medicare expansion bill.

Meanwhile, states are talking about Medicaid expansion, and a federal court’s ruling on Maryland’s proposal to battle drug price-gouging sends shock waves nationwide. Both chambers of Congress have been busy introducing legislative fixes for the nation’s opioid epidemic with lawmakers promising that legislation will land this spring.

This week’s panelists for KHN’s “What the Health?” are Sarah Jane Tribble of Kaiser Health News, Joanne Kenen of Politico, Margot Sanger-Katz of The New York Times and Paige Winfield Cunningham of The Washington Post.

Among the takeaways from this week’s podcast:

  • In the upcoming election season, the tables may be turned: Democrats likely will spend more on health care ads than Republicans.
  • Democrats think that this congressional campaign season they can effectively target vulnerable Republicans by focusing on the GOP’s support for repealing and replacing the Affordable Care Act.
  • Republicans, on the other hand, predict they have a winning argument with their repeal of the unpopular requirement that people get insurance or pay a penalty. Campaigns likely will also point to the party’s efforts to encourage more flexible — but perhaps less protective — coverage options, such as association and short-term health plans.
  • Two Democratic senators, Jeff Merkley of Oregon and Chris Murphy of Connecticut, introduced a bill this week that would allow individuals who haven’t yet reached 65 and small businesses to buy into the Medicare program. It would also substantially increase subsidies for people buying ACA marketplace plans.
  • Democratic efforts to expand the population that can use Medicare could hit opposition from two key groups: health care providers, such as hospitals and doctors, who object to the lower reimbursement, and seniors, who may be afraid that resources could be stretched too thin.
  • Medicaid expansion advocates in some conservative states seek to follow Maine in getting the issue on the ballot, but those efforts in very conservative states, such as Utah and Idaho, face immense obstacles.
  • Despite a court last week throwing out Maryland’s new law on drug pricing, other states are moving forward on efforts to bring more transparency to what consumers are charged for their prescriptions.
  • Lawmakers are scurrying to push through Congress efforts to help fight the nation’s opioid epidemic. One measure, by Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.), is expected to be marked up next week. Rep. Greg Walden (R-Ore.), the head of the House Energy and Commerce Committee, says his panel will bring a bill to the floor by Memorial Day.
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Plus, for “extra credit,” the panelists recommend their favorite health stories of the week they think you should read, too.

Joanne Kenen: The New York Times’ “How Profiteers Lure Women Into Often-Unneeded Surgery,” by Matthew Goldstein and Jessica Silver-Greenberg

Margot Sanger-Katz:’s “A ‘Breakthrough in Organ Preservation’: Study Shows Keeping Livers Warm Helps Preserve Them for Transplant,” by Eric Boodman

Paige Winfield Cunningham: The Washington Post’s “Science Hinted That Cancer Patients Could Take Less of a $148,000-a-Year Drug. Its Maker Tripled the Price of a Pill,” by Carolyn Y. Johnson

Sarah Jane Tribble: The Washington Post’s “‘One Last Time’: Barbara Bush Had Already Faced a Death More Painful Than Her Own,” by Steve Hendrix

Additional Reading

Sanger-Katz recommended two stories during the opioid discussion. Here are the links to those, too:

Reason’s “America’s War on Pain Pills Is Killing Addicts and Leaving Patients in Agony,” by Jacob Sullum

Harper’s “The Pain Refugees: The Forgotten Victims of America’s Opioid Crisis,” by Brian Goldstone

To hear all our podcasts, click here.

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

Great Weekend Reads From KHN

April 13, 2018
The Friday Breeze

Newsletter editor Brianna Labuskes, who reads everything on health care to compile our daily Morning Briefing, offers the best and most provocative stories for the weekend.

Happy Friday! Welcome back to The Friday Breeze, where I (KHN’s newsletter editor) wade through hundreds of health articles from the week so you don’t have to.

Health certainly was not at the top of mind for this week’s news cycle (what with the House speaker announcing he would not seek re-election and a raid here or there), but there were still some stories that are worth the read. Here’s what you need to know.

Following on the heels of Minnesota’s success, states are starting to eye publicly funded reinsurance pools (which essentially protect insurers when they’re hit with an unexpectedly high claim) as an answer to stabilizing the health law marketplace. But in the era of tight budgets, states have only so much money to throw at the problem. Also, a comprehensive look at where exchanges stand after the past couple topsy-turvy months.

The growing popularity of retail clinics and urgent care centers (as well as low pay and long hours for the physicians themselves) are nudging the traditional primary care doctor toward extinction. Physicians are worried all these mergers and movement in the industry are a slippery slope. What’s next, asks one: “Are Aetna patients going to be mandated to go to a CVS MinuteClinic?”

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Over in pharmaceutical land, the once-powerful industry’s rare defeat in the “doughnut hole” battle with Congress doesn’t speak well of its current clout on the Hill. And, believe it or not, there are some arguing that certain drug prices are too low.

In the war on opioids, you won’t get far without hearing about naloxone. It’s been a lifesaver for thousands, and the surgeon general just last week urged Americans to start carrying it. But it has its flaws, it’s expensive and, right now, there aren’t any realistic alternatives. Scientists want to change that.
Use our content This story can be republished for free (details).
And drug distributors are about to be summoned to Congress in a move some are likening to the tobacco executive hearings in the 1990s.

There were a few things out of the states to keep an eye on from this week: the California bill that would let the state set certain health prices (like hospital stays); how beliefs on single-payer are coming to define the California gubernatorial race (in a microcosm of the Democratic Party); and the fact that not one patient has utilized D.C.’s aid-in-dying law.

In the miscellaneous file of smart, funny or insightful reads from the week: a heartbreaking dive into the crisis facing black women and their babies; juicy takeaways from a book on Theranos (including how staffers would “get disappeared” by the company’s mysterious No. 2); the thousands of vacancies the VA just can’t seem to fill (because there aren’t enough HR people to do the hiring); and the lawyer who’s at the center of the battle over young immigrants seeking abortions.

Have a fantastic weekend (but not too fantastic, because apparently one extra glass of wine a day takes 30 minutes off your life). And make sure to let us know what you think of the Friday Breeze.

Podcast: KHN’s ‘What The Health?’ It’s Nerd Week

April 12, 2018
Julie Rovner

Kaiser Health News


Read Julie's Stories Stephanie Armour

The Wall Street Journal


Read Stephanie's Stories Sarah Kliff


Read Sarah's Stories Paige Winfield Cunningham

The Washington Post


Read Paige's Stories

The Trump administration this week issued the rules governing next year’s Affordable Care Act insurance marketplaces, and they make some potentially large changes that could result in higher premiums and fewer benefits.

Meanwhile, states are going different ways in addressing the health insurance markets in their states in response to the federal activity. And House Speaker Paul Ryan announced his retirement — leaving an intellectual void among House Republicans when it comes to health care.

This week’s panelists for KHN’s “What the Health?” are:

  • Julie Rovner of Kaiser Health News
  • Stephanie Armour of The Wall Street Journal
  • Sarah Kliff of
  • Paige Winfield Cunningham of The Washington Post

Among the takeaways from this week’s podcast:

  • The federal rules for the ACA’s marketplaces could dramatically alter how state regulators determine what plan benefits must be covered.
  • Those rules also change some conditions allowing people to qualify for exemptions to the requirement to have coverage — and they make those exemptions retroactive to 2017. So, some people who opted not to buy insurance and paid a penalty for 2017 may be able to file for refunds from the government.
  • Insurance companies are concerned about a number of the new provisions, including those that might drive healthy consumers away from the marketplaces and alter how insurers are compensated for having unusually high numbers of expensive customers.
  • An announcement from the White House this week said the administration is hoping to extend the work requirements that some states are seeking for Medicaid to other safety-net programs.
  • California and Maryland are among the states looking at ways to shore up their individual insurance markets in light of the changes being made at the federal level. Email Sign-Up

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‘Bill of the Month’

This month, NPR’s Alison Kodjak talks about a case of two CT scans — identical, except one cost 33 times more than the other.

Send Us Your Medical Bill

Do you have an exorbitant or baffling medical bill? Join the KHN and NPR’s Bill-of-the-Month Club and tell us about your experience. We’ll feature a new one each month.

Submit Your Bill

If you want to submit a bill for the Bill of the Month series, here is the form.

And if you have an emergency room bill you’d like to share for this project, here’s that form.

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

Julie Rovner:, “Toe Ointment, a $937 Bill, and a Hard Truth About American Health Care,” by Sarah Kliff.

Stephanie Armour:, “The Drug Pricing Contract Express Scripts Doesn’t Want You to See,” by Bob Herman.

Sarah Kliff:, “Why Scott Gottlieb Is the One Trump Official Everybody Seems to Like,” by Julia Belluz, German Lopez and Dylan Scott.

Paige Winfield Cunningham: Kaiser Health News, “How A Drugmaker Turned The Abortion Pill Into A Rare-Disease Profit Machine,” by Sarah Jane Tribble.

To hear all our podcasts, click here.

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

The Friday Breeze

April 06, 2018

Happy Friday! Welcome to the inaugural edition of KHN’s Friday Breeze. As the newsletter editor at Kaiser Health News, I read hundreds of health stories a week, and I’m here each Friday to sum up the more important ones — interesting reads, news that will have lasting impact, unique takes on the big problems in the industry. I wade through them so you don’t have to.

So here’s what you need to know from this week.

The big news is that the official enrollment numbers for the health law came in, and despite the gloom and doom predictions from the fall, they’re only slightly down from last year. (We already knew this, but now it’s official!) The “list price” on premiums are up, but because of a weird glitch with how subsidies now work (since President Donald Trump cut off payments to insurers) a lot of people are actually paying less. That seems dandy now, but experts are worried about the lasting ramifications of what’s known as “silver loading” (aka more people buying into that middle tier and ending up with free or very cheap plans). While things are working well at the moment, some warn there’s a reckoning coming. Meanwhile, Democrats hope a different kind of reckoning is coming with the midterms. Here are some of the top stories:

There was a lot of movement on the opioid crisis this week: from the surgeon general making a rare public health advisory that loved ones of those with an addiction should be carrying anti-overdose medication in the same vein as learning CPR; to studies linking looser marijuana laws and less opioid prescriptions; to Food and Drug Administration chief Scott Gottlieb imploring the “internet ecosystem” to step up to curb the tide of illegal drugs. We’re also going to see a lot of focus on the issue in Congress as lawmakers work toward a package they want to get to the floor in May — which would give both sides a win they could talk up in the fall while campaigning for the midterms.

In industry news, the potential merger between Walmart and Humana is making people nervous — namely, hospitals that are still reeling from other proposed acquisitions and new major players entering the landscape.

Over in pharmaceutical land: Some are worried that the China tariffs could contribute to the already daunting problem of skyrocketing drug prices; and check out this fascinating profile on two men who crisscross the country and leave higher prices in their wake.

If you haven’t been following Stat’s coverage of the National Institutes of Health-alcohol story, you’re missing out. An investigation revealed that NIH researchers were wooing the alcohol industry to fund a study that showed the benefits of moderate drinking. But the reporters have continued to dig deeper and have found more layers of ethical complexity.

Although the story has been resolved, I want to flag BuzzFeed’s investigation into Grindr sharing its users’ HIV statuses with outside companies. The app decided it would no longer provide that data, maintaining that the furor around it was a “misunderstanding of technology.” Either way, it shines a light on the vulnerabilities of putting health care information into public forum-esque apps.

And some other news to watch out for: Despite voters OK’ing Medicaid expansion, Maine’s governor is refusing to apply for federal funding, insisting that lawmakers figure out a way to pay for it; a look at how an office that deals with refugees has become a battleground for abortion; in California, it’s the single-payer-or-bust die-hards versus the realists who want to see incremental steps toward universal coverage; and movement on both gay-conversion bans and physician-assisted death in state legislatures (both issues have been gaining traction this year).

Finally, just in case you were worried about last week’s ruling that coffee in California has to come with a cancer warning, public experts say go ahead and continue to drink up. And let us know what you think about the Friday Breeze here.

Have a great weekend!

Timeline: Despite GOP’s Failure To Repeal Obamacare, The ACA Has Changed

April 05, 2018

Congress in 2017 failed to “repeal and replace” the Affordable Care Act. But the health law has been changed in many other ways over the past year and a half. Some changes were made by Congress, some by President Donald Trump and his administration and some by state officials. Here is a timeline of the most consequential events that have shaped the health law:

Jan. 20, 2017:

(Chip Somodevilla/Getty Images)

On his first day in office, Trump issues an executive order to “minimize the unwarranted economic and regulatory burdens” of the health law. It includes instructions to agencies to “exercise all authority and discretion available to them to waive, defer, grant exemptions from, or delay the implementation of any provision or requirement of the Act that would impose a fiscal burden.”

The same day, officials at the Department of Health and Human Services begin removing information on how to sign up for coverage from the website, even though enrollment for 2017 policies lasts until the end of the month.

Jan. 26, 2017:

HHS officials abruptly pull funding for outreach and advertising for the last days of 2017 enrollment. That is usually when healthier people traditionally enroll. Some of the advertising and outreach continues, but that’s largely because it is too late to cancel advertising purchased and scheduled by outgoing Obama administration officials.

One former Obama-era official later estimates nearly a half-million fewer people enrolled as a result of the cuts to outreach and advertising.

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Reversing an Obama administration plan, the Internal Revenue Service says it won’t start rejecting returns that don’t indicate whether a taxpayer had health insurance.

Feb. 15, 2017:

The Trump administration proposes new rules, backed by the insurance industry, cutting the 2018 open enrollment period in half and making it more difficult for people to buy insurance outside that six-week window. Insurers say the rules would reduce the number of people who “game the system” by waiting until they need care to sign up for coverage. These rules are finalized in April.

March 7, 2017:

U.S. House Speaker Paul Ryan, a Republican from Wisconsin (center) holds up a copy of the American Health Care Act while House Majority Leader Kevin McCarthy from California and Rep. Greg Walden, (R-Ore.) listen during a news conference on March 7, 2017. (Zach Gibson/Bloomberg via Getty Images)

House Republicans introduce a repeal-and-replace bill: the American Health Care Act.

March 13, 2017:

HHS Secretary Tom Price sends a letter to each state saying the department is eager to help leaders unleash state innovations for the insurance marketplaces to “alleviate the burdens” of the ACA. He says HHS is eager to see ideas from the states for bringing down premium prices through new insurance pools that would help cover the costs of high-risk enrollees.

The Congressional Budget Office estimates the GOP bill would result in an additional 24 million people being without insurance by 2026. It also predicts that premiums would go down for younger people and rise dramatically for older people under changes envisioned in the bill.

March 15, 2017:

Surprise! Despite Trump’s cutoff of enrollment advertising and outreach, the final tally of marketplace enrollment during the open season shows numbers fairly close to the previous year.

April 12, 2017:

Efforts in the House to advance the AHCA stall as it becomes clear Republicans don’t have the votes. Trump, trying to revive the repeal effort, threatens to cut off the ACA’s cost-sharing reduction payments (CSRs) that help some low-income marketplace customers pay for out-of-pocket expenses in an effort to get Democrats to the negotiating table.

May 4, 2017:

President Donald Trump stands in the Rose Garden on May 4 after House Republicans mustered just enough votes to pass their health care bill. (Andrew Harrer/Bloomberg via Getty Images)

The House narrowly passes the American Health Care Act, its version of a “repeal and replace” measure for the health law, but the bill has no support in the Senate. Despite that, Trump says at a celebration in the White House Rose Garden that not only was the House bill “a great plan,” but also, of the underlying health law, “it’s dead. It’s essentially dead.”

June 6, 2017:

The uncertainty about the fate of the ACA is having an impact on the market. Anthem pulls out of Ohio, becoming just the latest in a long list that included Humana, Aetna, Wellmark in Iowa and Blue Cross and Blue Shield of Kansas City.

June 7, 2017:

A screenshot from YouTube of an HHS video, part of a series that detailed the problems people are having with the Affordable Care Act.

HHS launches a series of videos on its YouTube channel detailing the problems people are having with the Affordable Care Act.

June 22, 2017:

In an effort to pass the bill before the July Fourth recess, Senate leaders release their bill to overhaul the ACA: the Better Care Reconciliation Act (BCRA). It would cap Medicaid spending, repeal the taxes that pay for ACA benefits and let states waive consumer protections in the health law.

June 26, 2017:

The CBO says the new Senate bill would result in 22 million more uninsured by 2026 and increase premiums initially, but lower them in the long run.

June 27, 2017:

The Senate fails to take up its health care bill before leaving for the Fourth of July holiday.

July 13, 2017:

A revised version of the BCRA is released, including an amendment from Sen. Ted Cruz (R-Texas) that would let insurers offer plans that don’t meet some ACA provisions and would provide more money for opioid treatment and allow the use of money in health savings accounts to be used to pay premiums.

July 16, 2017:

Senate Majority Leader Mitch McConnell (R-Ky.) delays the Senate vote on the health care bill until Sen. John McCain (R-Ariz.) returns from surgery for brain cancer.

July 20, 2017:

The CBO updates its estimate of the revised BCRA, saying it would result in 22 million more uninsured people by 2026 and would lower premiums, but that would be because the plans would likely cover fewer services, so people who use health care would pay more on average. And older people could be hit particularly hard.

July 25, 2017:

The Senate approves a procedural motion to take up BRCA 2.0, by a vote of 51-50, with the just-returned John McCain casting the decisive vote.

July 28, 2017:

Sen John McCain (R-Ariz.) leaves the Senate Chamber after a vote on a stripped-down, or “skinny repeal,” version of Obamacare reform on July 28. McCain was one of three Republican senators to vote against the measure. (Zach Gibson/Getty Images)

As the week wears on, it becomes clear none of the leading proposals can garner enough votes. A last-ditch effort called a “skinny repeal” is the last bill standing. It is little more than a shell to keep negotiations going with the House. Still, it would repeal the individual and employer mandates for coverage and give broad authority to states to waive key sections of the ACA. The CBO says it would have resulted in 16 million more people without insurance in 2026 and premium increases of 20 percent. But in a moment of high drama around 2 a.m., McCain, who dramatically voted to let the debate proceed earlier in the week, became the deciding vote to end the effort.

July 29, 2017:

Trump threatens to stop funding the cost-sharing reduction (CSR) payments. These reimburse insurers for discounts that they are required by the ACA to offer to some low-income exchange enrollees to help them afford deductibles and other out-of-pocket costs. The payments were the subject of a lawsuit filed by the House against the Obama administration, with the House charging that Congress had not provided a specific appropriation and therefore the administration was making the payments illegally.

Aug. 2, 2017:

Sens. Patty Murray (D-Wash.) and Lamar Alexander (R-Tenn.) (Mark Wilson/Getty Images)

With the partisan fight seemingly over, Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.) announce they will work together on a bill to stabilize the individual market.

Aug. 11, 2017:

An early look at insurance premiums for 2018 suggests much variation but somewhat lower increases than seen for 2017. It also suggests less competition as large insurers exit the market.

Aug. 14, 2017:

HHS officials make clear that they will not be working with local groups on enrollment efforts for the sign-up period starting Nov. 1.

Aug. 31, 2017:

HHS officials announce that the advertising budget will be cut 90 percent for the coming enrollment season and programs that provide help to people signing up will be cut by 41 percent. Officials tell reporters on a call that the programs are ineffective and people are already aware of the health law logistics, something public opinion polls suggest is not the case.

Sept. 22, 2017:

(Illustration created using iStock)

During a conference call with community groups, HHS officials announce the federal enrollment website will be shut down for as long as 12 hours every Sunday except one during the six weeks of open enrollment. Officials say the time is needed for site maintenance, although such maintenance took far less time during the Obama administration.

Sept. 26, 2017:

The last chance for a partisan vote on the ACA repeal-and-replace effort ends with a whimper as Sens. Lindsey Graham (R-S.C.) and Bill Cassidy (R-La.) announce they cannot get 50 votes for their bill that would effectively take most of the federal funds in the ACA and turn them over to states in the form of block grants. Sens. Collins, McCain and Rand Paul (R-Ky.) all come out against it.

Sept. 27, 2017:

Trump officials instruct HHS regional directors and staff not to participate in state events to promote enrollment. An HHS official tells BuzzFeed that enrollment events “are organized and implemented by outside groups with their own agendas, not HHS.”

Sept. 29, 2017:

Oklahoma withdraws its request for a waiver from federal rules that would have allowed the state to create a “reinsurance” program that it estimated could have reduced premiums in the state by more than 30 percent. The proposal followed Price’s April letter inviting states to seek changes, and state officials said they had been led to believe a waiver was forthcoming. But it failed to materialize. State officials say the delay would keep the program from launching in time for the 2018 plan year.

Earlier, Trump administration officials said Minnesota could institute a similar program, but that the state was also going to lose nearly $370 million in funding for a separate health law program serving those with low incomes. Other states that are ultimately frustrated by the waiver process include Iowa and Massachusetts.

Oct. 12, 2017:

During the day, Trump signs an executive order pushing federal officials to make it easier for people to purchase insurance that does not meet the regulatory standards of the Affordable Care Act.

(DigitalVision Vectors/Getty Images)

Late that night, he follows through on his threat to cut off the cost-sharing reduction payments to insurers. “The bailout of insurance companies through these unlawful payments is yet another example of how the previous administration abused taxpayer dollars and skirted the law to prop up a broken system,” says a statement from press secretary Sarah Huckabee Sanders.

State regulators respond by adding the lost payments to premiums of “silver” plans that determine premium subsidies. The result is that insurers get the money anyway, and most consumers eligible for premium help are held harmless or pay less.

Nov. 1, 2017:

Open enrollment begins for 2018 coverage. (Although, for the first time, enrollment will last only six weeks. In the previous year, the window was 12 weeks.)

Nov. 14, 2017:

The Senate moves to eliminate the penalty for not having health insurance — the so-called individual mandate — as part of its tax cut bill.

Dec. 1, 2017:

Sen. Collins says she has been promised a vote on the bill from Sens. Alexander and Murray and the bill she introduced with Sen. Bill Nelson (D-Fla.) before the end of the year in exchange for her vote for the tax bill.

Jan. 4, 2018:

The Department of Labor proposes a rule to expand the availability of “association health plans” that allow small businesses to band together to purchase health coverage that does not have to abide by some consumer protections.

Jan. 22, 2018:

Sen. Collins’ promised vote does not happen before the end of 2017, nor are the bills included in the spending bill to reopen the government following a brief shutdown in January. Aides say they will come later.

Feb. 20, 2018:

(Illustration created using Getty Images)

The Trump administration proposes to loosen restrictions on “short-term” health plans that consumer advocates fear will fail to protect consumers from serious medical bills and could destabilize the individual insurance market by pulling healthy people out of insurers’ risk pools.

March 21, 2018:

The final spending bill of the year comes and goes — without Collins’ promised votes.

April 3, 2018:

The Centers for Medicare & Medicaid Services reports that about 11.8 million people bought 2018 coverage on the ACA’s federal and state-based exchanges during the shortened open enrollment period — and 27 percent of them were considered new consumers.

Podcast: KHN’s ‘What The Health?’ Alive And Limping: ACA In The Age Of Trump

April 05, 2018
Julie Rovner

Kaiser Health News


Read Julie's Stories Joanne Kenen



Read Joanne's Stories Alice Ollstein

Talking Points Memo


Read Alice's Stories Margot Sanger-Katz

The New York Times


Read Margot's Stories

A lot has happened to the federal Affordable Care Act in the past year and a half. In this special episode of KHN’s “What the Health?” the panelists dissect the changes made to the health law, how it has affected the politics and policy around health care, and what to watch for going forward.

This week’s panelists are:

  • Julie Rovner of Kaiser Health News
  • Joanne Kenen of Politico
  • Margot Sanger-Katz of The New York Times
  • Alice Ollstein of Talking Points Memo

Among the takeaways from this week’s podcast:

  • The Affordable Care Act may have taken some body blows since President Donald Trump was sworn in, but it has surprised many people by showing a good bit of resilience.
  • The congressional Republicans’ inability to agree on a path for partial repeal of the ACA showcased that the party — which had over seven years made the law a focus of their opposition — had no unified vision of what type of health policy it wanted.
  • Two key factors that worked against the Republicans’ efforts to repeal the ACA were the public’s desire to keep the law’s protections for people with preexisting conditions and to maintain the current Medicaid system, the state-federal health insurance program for low-income Americans.
  • Unable to upend the law through a partial repeal, the administration is seeking to make some changes to regulations about the law and may accomplish some Republican goals such as doing away with overregulation of the market and allowing people buying their own insurance to find cheaper and less involved plans. But, of course, they come with fewer protections, too.
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Here is Julie Rovner’s video about the budget reconciliation process.

Here is Julie Rovner’s timeline of ACA changes and major events, dating to President Trump’s election: Timeline: Despite GOP’s Failure To Repeal Obamacare, The ACA Has Changed

The panelists will be back with the latest news and “extra credit” stories next week.

To hear all our podcasts, click here.

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

Don’t Get Tripped Up By The IRS’ Tweak To Health Savings Accounts

April 03, 2018

It’s tax time, and this week I answered questions from readers about the penalty for not having health insurance as well as changes to health savings accounts. I also discuss health insurance coverage options for a reader’s parents who are immigrants and green card holders.

Q: I heard that health savings account rules would be loosened under the new spending bill passed by Congress last month. Did that happen?

No. In fact, the standards have become slightly tighter this year.

In recent years, members of Congress from both parties have supported expanding eligibility for health savings accounts and how the money in them can be spent, among other things. To date, though, those proposals haven’t become law.

Health savings accounts, which are linked to high-deductible health plans, continue to multiply. In 2017, there were 22 million accounts totaling more than $45 billion in assets, an increase of 11 percent in the number of accounts over the previous year, according to Devenir, a firm that offers advice on HSA investments.

Money deposited in HSAs is tax-deductible, grows tax-free and can be used without owing tax to pay for medical expenses. Advocates promote the plans as a way to help consumers play a larger role in controlling their health spending and say that the tax advantages help people afford care.

The Internal Revenue Service announced last month that the maximum amount individuals with family coverage could contribute to their health savings accounts would actually be reduced slightly from their previously announced limit for 2018. The maximum contribution for people with individual coverage in 2018 remains $3,450.

The $50 family coverage contribution reduction, from $6,900 to $6,850, is pretty small change. It happened because the federal government altered the way it calculates inflation adjustments to the contribution limits.

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But ignoring the new limit could create headaches for people who have already made the maximum HSA contribution for the year based on the $6,900 figure, said Roy Ramthun, president of HSA Consulting Services. If you don’t ask the bank that handles your HSA to return the $50 plus any earnings that have accrued before the next tax season, your taxable income will be off by that amount, plus you’ll be on the hook for a 6 percent penalty for exceeding the maximum contribution allowed.

That’s not going to amount to a lot of money, but there’s more than financial pain to consider, Ramthun said. “Do you really want to give the IRS a reason to come find you?”

Q: I didn’t have health insurance for one month last year, in January 2017. Do I owe a penalty for not having health insurance when I file my taxes this spring?

If you were uninsured for only one month in 2017, you won’t owe a penalty. People can be uninsured for up to three consecutive months during the year without triggering a tax penalty for not having coverage, said Tara Straw, a senior policy analyst at the Center on Budget and Policy Priorities.

This year, for the first time, the Internal Revenue Service won’t accept electronically filed tax returns unless filers report whether they had health insurance all year, were exempt from the requirement or will pay a penalty for not having had coverage. Tax refunds that are due with paper returns that don’t have this information may be delayed, according to the IRS.

In your case, you’ll file Form 8965 with your tax return to report a short-term coverage gap and claim an exemption from the coverage requirement. Your employer — or your insurer, if you purchased coverage on your own — will send a form to the IRS stating that you were covered for the other 11 months, Straw said.

Those penalties — $695 or 2.5 percent of your household income, whichever is greater — are also in force for 2018 coverage. But starting next year, you won’t owe a penalty no matter how long you may be uninsured. The tax reform law eliminated the penalty for not having health insurance in 2019.

Q: What health insurance options are available for my parents, who are seniors who worked in India and are now retired in the United States with green cards? 

Depending on their situation, people like your parents who are legally entitled to reside permanently in the United States have a number of options.

From your description, it’s unclear whether they live on their own or with you. If you claim them as dependents on your taxes, you might consider adding them to your own health insurance plan, said Shelby Gonzales, a senior policy analyst at the Center on Budget and Policy Priorities.

Assuming your parents haven’t worked for at least 10 years in the United States, they’re probably not eligible for premium-free hospitalization coverage under Medicare, the federal health insurance program for people age 65 and older, Gonzales said. If they’ve lived in the States for at least five years and their income and other resources meet state eligibility guidelines, however, they could qualify for Medicaid, the federal-state program for low-income people.

If they don’t qualify for either government health program, they could consider buying a health insurance plan on the state marketplace or through a broker.

If they buy a marketplace plan, they could be eligible for premium subsidies if their income is less than 400 percent of the federal poverty level (about $66,000 for a couple in 2018), said Gabrielle Lessard, a senior policy attorney at the National Immigration Law Center.

Please visit to send comments or ideas for future topics for the Insuring Your Health column.

Americans Have Mixed Feelings About The ACA’s Future — But Like Their Plans

April 03, 2018

Use Our Content This story can be republished for free (details). Most Americans are happy with the insurance they buy on the individual market, yet those same people think the markets are collapsing before their eyes.

A poll by the Kaiser Family Foundation, released Tuesday, found that 61 percent of people enrolled in marketplace plans are satisfied with their insurance choices and that a majority say they are not paying more this year compared with last year’s premium costs.

Yet, more than half of the overall public — 53 percent — also think the Affordable Care Act’s marketplaces are “collapsing.” (Kaiser Health News is an editorially independent program of the foundation.)

Experts have warned that some policy actions supported by the Trump administration would undermine the market, including repealing the penalty for going without insurance and giving people the option to buy short-term plans. Such plans are often less expensive but cover fewer benefits. They are not automatically renewable, and insurers are able to charge people with medical conditions more — or exclude them altogether.

But only about one-fifth of people who obtain coverage on the individual market were even aware that the mandate penalty had been repealed as of 2019, according to the poll. It is still in effect this year.

Nine in 10 enrollees said they would still buy insurance without the penalty, and 34 percent said the mandate was a “major reason” they chose to buy insurance at all.

“They may have been prompted to buy the coverage in the first place because of the mandate,” said Sabrina Corlette, a professor at Georgetown University’s Health Policy Institute. “But now that they’ve got it, they clearly value it.”

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Most of the people who buy plans because they don’t get coverage through work or the government, 75 percent, said they bought insurance to protect against high medical bills, and 66 percent said peace of mind was a major reason.

In February, President Donald Trump eased some of the restrictions on short-term insurance plans, allowing them to cover people for 12 months instead of three.

Critics worried this alternative would draw people away from traditional insurance plans and weaken the individual market. According to the poll, though, only 12 percent of respondents buying on that market said they’d be interested in buying one of the short-term plans.

Georgetown’s Corlette cautioned that these numbers could change when people are faced with an actual choice next open enrollment season.

“If you look at how these things are marketed, your average consumer will not be able to tell that these products are any different from a traditional health plan,” she said.

Most people said they didn’t face a premium increase this year. Thirty-four percent said their premiums were “about the same” as last year and 23 percent said they actually went down.

That’s not surprising, said Joseph Antos, a resident scholar at the conservative American Enterprise Institute who follows the health industry. Many consumers saw their premium subsidies rise too.

Thirty-five percent of people said one of the major reasons they bought insurance was because government subsidies made it affordable.

The subsidies that people receive, Antos noted, went up to offset the premium increase in many cases, especially if consumers took the advice of experts and shopped around for coverage.

“They’re buying because they feel they need insurance and that their net premiums and deductibles add up to something they’re willing to buy,” Antos said.

The poll was conducted Feb. 15-20 and March 8-13 among 2,534 adults. The margin of sampling error is +/-2 percentage points for the full sample, +/-7 percentage points for all non-group enrollees and +/-9 percentage points for marketplace enrollees.

Kaiser Health News senior correspondent Julie Appleby contributed to this report.

Podcast: KHN’s ‘What The Health?’ VA Secretary Out, Privatization In?

March 29, 2018
Julie Rovner

Kaiser Health News


Read Julie's Stories Anna Edney



Read Anna's Stories Sarah Kliff


Read Sarah's Stories Alice Ollstein

Talking Points Memo


Read Alice's Stories


David Shulkin, the secretary of Veterans Affairs, was fired Wednesday night by President Donald Trump. To replace him, Trump will nominate his White House physician, naval Rear Adm. Ronny Jackson. Shulkin, however, is not going quietly. He took to The New York Times op-ed page to claim he was pushed out by those who want to privatize VA health services for profit.

Meanwhile, two more states, Iowa and Utah, passed legislation that would sidestep some of the requirements of the Affordable Care Act. Iowa wants to allow the sale of health plans that cover fewer benefits — or restrict coverage for people with preexisting health conditions. Utah wants to expand Medicaid to those higher up the income scale — but not as high as prescribed by the ACA.

This week’s panelists for KHN’s “What the Health?” are Julie Rovner of Kaiser Health News, Anna Edney of Bloomberg News, Sarah Kliff of and Alice Ollstein of Talking Points Memo.

Among the takeaways from this week’s podcast:

  • If Shulkin is right that the administration is keen on privatizing the VA, would it move to something akin to the Medicaid managed-care systems that many states have set up?
  • Veterans groups haven’t yet shown their cards on whether they think Jackson is a suitable choice to replace Shulkin.
  • Iowa is poised to allow farmers groups to offer health plans that could sidestep some of the consumer protections in the federal Affordable Care Act, such as requiring that preexisting conditions be covered. Tennessee has a program similar to what Iowa is implementing, and some consumer groups have complained it pulls healthy individuals out of the ACA marketplace and drives up premiums for those who remain.
  • Utah’s request for a federal waiver so that it can offer a Medicaid expansion program to people earning up to 100 percent of the federal poverty level — and not the 138 percent included in the ACA — will show whether the Trump administration has a different standard than the Obama administration. Obama officials rejected partial Medicaid expansion requests.
  • Sen. Elizabeth Warren (D-Mass.) introduced a bill that offers provisions to help middle-income customers buying insurance on the ACA marketplace. But it suggests Democrats are still not sure what is the best health care strategy heading into the midterm elections. Send Us Your Medical Bill

    Do you have an exorbitant or baffling medical bill? Join the KHN and NPR’s Bill-of-the-Month Club and tell us about your experience. We’ll feature a new one each month.

    Submit Your Bill

New Segment: ‘Bill Of The Month’

This month, Shefali Luthra talks about the case of the $1,500 tube of toenail fungus cream and how patients can never be too careful in asking how much a prescription will cost.

If you want to submit a bill for the “Bill of the Month” series, here is the form.

Several other news outlets are reaching out to patients to crowdsource some health stories. If you’re uninsured and you want to share your story with Bloomberg News, here’s where you can do that.

And if you have an emergency room bill you’d like to share for this project, here’s the form.

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

Julie Rovner: Bloomberg News’ “Why Some Americans Are Risking It and Skipping Health Insurance,” by John Tozzi.

Anna Edney: Kaiser Health News’ “As Trump Targets Immigrants, Elderly Brace To Lose Caregivers,” by Melissa Bailey.

Alice Ollstein: The Brookings Institution and the University of Southern California’s “Do States Regret Expanding Medicaid?” by Mark Hall.

Sarah Kliff: Kaiser Health News’ “Reporter’s Notebook: The Tale Of Theranos And The Mysterious Fire Alarm,” by Jenny Gold.

To hear all our podcasts, click here.

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

Poll: Americans Aghast Over Drug Costs But Aren’t Holding Their Breath For A Fix

March 23, 2018
Use Our Content

This Kaiser Health News story can be republished for free (details).

More Stories To Republish

The recent school shootings in Florida and Maryland have focused attention on the National Rifle Association’s clout in state and federal lobbying activities.

Yet more than the NRA or even Wall Street, it’s the pharmaceutical industry that Americans think has the most muscle when it comes to policymaking.

A poll from the Kaiser Family Foundation found that 72 percent of people think the drug industry has too much influence in Washington —outweighing the 69 percent who feel that way about Wall Street or the 52 percent who think the NRA has too much power. Only the large-business community outranked drugmakers. (Kaiser Health News is an editorially independent program of the foundation.)

Drug prices are among the few areas of health policy where Americans seem to find consensus. Eighty percent of people said they think drug prices are too high, and both Democrats (65 percent) and Republicans (74 percent) agreed the industry has too much sway over lawmakers.

Democrats were far more likely than Republicans — 73 vs. 21 percent — to say the NRA had too much influence.

The monthly poll also looked at views about health care. Americans may be warming to the idea of a national health plan, such as the Medicare-for-all idea advocated by Sen. Bernie Sanders (I-Vt.). Overall, 59 percent said they supported it, and even more, 75 percent, said they would support it if it were one option among an array for Americans to choose.

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Americans are far more concerned with lowering prescription drug prices, though they don’t trust the current administration to fix the problem. Fifty-two percent said lowering drug costs should be the top priority for President Donald Trump and Congress, but only 39 percent said they were confident that a solution would be delivered.

“There’s more action happening on the state level; what we are finding is they’re not seeing the same action on the federal level,” said Ashley Kirzinger, a senior survey analyst for KFF’s public opinion and survey research team. “They’re holding the president accountable as well as leaders of their own party.”

Overall, at least three-quarters of people don’t think Democrats and Republicans in Congress, as well as the Trump administration, are doing enough to bring costs down.

Twenty-one percent reported that they didn’t trust either party to lower prices, up from 12 percent in 2016. And, unlike other health-related policy questions such as repealing the Affordable Care Act or creating a national health plan, the poll does not find a partisan divide on this perception.

Passing legislation to lower drug prices was at the top of the list of the public’s priorities, making it more important than infrastructure, solving the opioid epidemic, immigration reform, repealing the ACA or building a border wall.

Looking ahead to the 2018 midterm elections, 7 percent reported that creating a national health plan was the “single most important factor” for how they would vote in 2018. However, 7 in 10 said it is an important consideration, and 22 percent said it is not an important factor at all.

The poll found that support for the federal health law fell this month, from February’s all-time high of 54 percent to 50 percent in March. Opposition moved up slightly from 42 to 43 percent.

The poll was conducted March 8-13 among 1,212 adults. The margin of sampling error is +/-3 percentage points.

Clash Over Abortion Hobbles A Health Bill. Again. Here’s How.

March 21, 2018

The Affordable Care Act very nearly failed to become law due to an intraparty dispute among Democrats over how to handle the abortion issue. Now a similar argument between Democrats and Republicans is slowing progress on a bill that could help cut soaring premiums and shore up the ACA.

At issue is the extent to which the Hyde Amendment — language commonly used by Congress to prohibit most federal abortion funding — should be incorporated into any new legislation affecting the health law.

Republicans generally want more restrictions on abortion funding. Democrats generally want fewer. Here’s a guide to the history of the current impasse:

What Is The Hyde Amendment?

The Hyde Amendment, named for Rep. Henry Hyde (R-Ill.), an anti-abortion crusader who died in 2007, prohibits federal funding of abortion in Medicaid and several other health programs run by the Department of Health and Human Services. Current exceptions allow for funding in cases of rape, incest or “where a physical condition endangers a woman’s life unless an abortion is performed.”

But the Hyde Amendment is not permanent law. Rather, it has been included every year since 1977 as a “rider” to federal spending bills. Hence, its exact language changes from time to time. The rape and incest exceptions, for example, were not included in the annual HHS spending bill from 1981 to 1993. During that time, the only exception was for abortions required to save a pregnant woman’s life.

Hyde-like language has been added to other annual spending bills over the years, so federal abortion funding is also now forbidden in private health insurance plans for federal employees, women in federal prisons, those in the Peace Corps and women in the military, among others.

Over the years, Democrats have worked, unsuccessfully, to eliminate the Hyde Amendment, charging that it unfairly harms low-income women who cannot afford to pay for abortions. Proposed elimination of the language was included in the Democratic Party’s 2016 platform.

Republicans have tried, also so far unsuccessfully, to write the Hyde funding prohibitions into permanent law. “A ban on taxpayer funding of abortion is the will of the people and ought to be the law of the la

nd,” said then-House Speaker John Boehner (R-Ohio) in 2011.

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How Did The Affordable Care Act Deal With Federal Abortion Funding?

Republicans in both the House and Senate unanimously refused to support the Affordable Care Act when it passed Congress in 2010. Even without their backing, abortion remained a huge hurdle.

In order to pass the bill over GOP objections, Democrats needed near unanimity among their ranks. But the Democratic caucus at the time had a significant number of abortion opponents, particularly those representing more conservative districts and states. In order to facilitate the bill’s movement, House and Senate leaders agreed that the health bill should be “abortion-neutral,” meaning it would neither add to nor subtract from existing abortion restrictions.

That proved difficult. So difficult that to this day there is disagreement about whether the law expands or contracts abortion rights.

Democratic sponsors of the bill were buffeted by appeals from women’s groups, who wanted to make sure the bill did not change existing coverage of abortion in private health insurance; and from abortion opponents, led by the United States Conference of Catholic Bishops , who called the bill a major expansion of abortion rights.

The bill passed the House in 2009 only after inclusion of an amendment by Rep. Bart Stupak (D-Mich.), a longtime opponent of abortion. That bill included a government-sponsored health plan and Stupak’s provision would have made the Hyde Amendment a permanent part of that plan. The amendment also banned federal premium subsidies for private health insurance plans that offered abortion as a covered service, although it allowed for plan customers to purchase a rider with non-federal money to cover abortion services.

The Senate bill jettisoned the government-sponsored plan, so no restrictions were necessary on the abortion issue. And it was the Senate plan that went forward to become law. Still, differences remained over how to ensure that subsidies provided by taxpayers did not go to private plans that covered abortions.

In the upper chamber, a compromise was eventually reached by abortion-rights supporter Sen. Barbara Boxer (D-Calif.) and Sen. Ben Nelson (D-Neb.), who opposed abortion. Nelson was the final holdout on the bill, which needed all 60 Democrats then in the Senate to overcome unanimous GOP opposition. The Boxer-Nelson language was a softening of the Stupak amendment, but still allowed states to prohibit plans in the ACA’s insurance marketplaces from covering abortion.

In addition, President Barack Obama agreed to issue an “executive order” intended to ensure no federal funds were used for abortions.

In the end, both sides remained unhappy. Abortion opponents wanted the Hyde Amendment guarantees in the actual legislation rather than the executive order. Abortion-rights backers said the effort constricted abortion coverage in private health plans.

And both sides are still unhappy. According to the Guttmacher Institute, a reproductive health research group, 26 states have passed legislation restricting abortion coverage in any plan sold through the ACA’s insurance exchanges.

Another 11 states have passed laws restricting abortion coverage in all private insurance sold in the state. Nine of those states allow separate abortion “riders” to be sold, but no carriers offer such coverage in those marketplaces, according to a 2018 analysis by the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

Three states — California, New York and Oregon — require nearly all insurance plans to provide abortion coverage, according to the National Women’s Law Center.

What Abortion Provisions Do Republicans Want To Add To The Latest Health Bill?

The issue for 2018 is a bipartisan bill that seeks to “stabilize” the individual insurance market and the ACA’s health insurance exchanges by providing additional federal funding to offset some recent premium increases. Some options include restoring federal subsidies for insurers who cover out-of-pocket costs for very low-income customers and setting up a federal reinsurance pool to help insurers pay for very expensive patients.

But once again, the abortion debate threatens to block a consensus.

Many Republicans are dubious about efforts to shore up the health law. They still hope its failure could lead to a repeal they were unable to accomplish in 2017.

Even some who say they are sympathetic to a legislative remedy want to add the permanent Hyde Amendment language that was left out of the final ACA, although included in Obama’s executive order.

That is “not negotiable for House Republicans,” a spokeswoman for House Speaker Paul Ryan (R-Wis.) told The Hill newspaper. The White House has also endorsed a permanent Hyde Amendment.

But Sen. Patty Murray (D-Wash.), who has been negotiating the insurance bill for the Democrats, calls any additional abortion restrictions “a complete nonstarter” for Democrats.

With Some Republican Support, Virginia Edges Closer To Medicaid Expansion

March 16, 2018

Virginia is among 18 states that have not expanded Medicaid under the Affordable Care Act. But this year, the state legislature is closer to enacting expansion than it has been in the past, and the issue will be the sticking point as the legislature goes into a special session next month to hash out its budget.

Republican Del. Barry Knight from the Virginia Beach area calls it “the 800-pound gorilla in the room.” He’s one of more than a dozen Republicans who voted to include Medicaid expansion in the House budget — along with a work requirement — this year.

It’s a big shift in the House position on the issue and comes after 15 seats flipped to Democrats in the so-called blue wave of last November’s election, which also saw the election of Democratic Gov. Ralph Northam.

“On the big-picture issues, I think it was a reawakening and a call to look at things from a different perspective,” said Republican Del. Chris Peace, from the Richmond area, who also voted in favor of expansion.

A December poll showed that over 80 percent of likely Virginia voters support an expansion.

“I think the House heard that message, loud and clear. I think the Senate still needs to listen a little bit,” Northam said.

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The state Senate still has a strong bulwark against expansion, led by Senate Majority Leader Tommy Norment, who represents the Tidewater area in southeastern Virginia. Norment has come out against the House Republicans who want to expand. He reminds them that, despite a slim margin, Republicans are still in charge and could stop Medicaid expansion.

“I do think that the House of Delegates is waiting for that moment of lucidity and epiphany to realize that their majority is 51 to 49,” Norment said.

But opposition to President Donald Trump has energized Democratic voters, said Bob Holsworth, a former political science professor at Virginia Commonwealth University. He said he thinks expansion has a greater chance this year.

It could pass in the Senate, he said, because of a potential wildcard: Republican Sen. Emmett Hanger, from mostly rural central Virginia. Hanger has expressed support for some form of Medicaid expansion, and has a track record of voting independently, said Holsworth.

“What Hanger has said that’s very interesting … is that if he decides to support some version of Medicaid expansion, he says, ‘There are a number of other Republicans who are going to go over with me,'” said Holsworth.

However, Hanger said he isn’t happy about a tax on hospitals that has been incorporated into the House’s budget to help pay for the state’s share of expansion costs. The tax accounts for about three-quarters of the over $400 million Medicaid-related gulf between House and Senate budgets.

If legislators don’t come up with a budget that includes Medicaid expansion, Northam has a Plan B. He said he’ll introduce an amendment to add it back into the budget. In the amendment process, the lieutenant governor, Democrat Justin Fairfax, gets a vote if the Senate ties. Fairfax said he’d be happy to vote to expand coverage to up to 400,000 low-income Virginians.

“There are so many people that we can help, and we have the means to do it if we expand Medicaid. We just have to have the political will to do it,” Fairfax said.

Medicaid expansion in Virginia would especially benefit low-income adults without children.

“An adult who does not have children can have zero income — can be totally impoverished — and they cannot get Medicaid,” said Jill Hanken with the Virginia Poverty Law Center.

And a family of three with a total income of about $10,000 doesn’t qualify for Medicaid, she said.

“It’s hard to explain to them that they don’t have a choice, they’re not eligible for Medicaid,” she said, and they’re not eligible for subsidies for insurance on the exchange, so health insurance is out of reach. “And the reason is because Virginia hasn’t expanded Medicaid,” she said.

The special session begins April 11. The state needs a budget agreement by June 30 to prevent a government shutdown.

This story is part of a reporting partnership with NPR, local NPR member stations and Kaiser Health News.

Podcast: KHN’s ‘What The Health?’ Rocky Road Ahead In Congress For Insurance Market Bills

March 15, 2018
Julie Rovner

Kaiser Health News


Read Julie's Stories Joanne Kenen



Read Joanne's Stories Alice Ollstein

Talking Points Memo


Read Alice's Stories

Paige Winfield Cunningham

The Washington Post


Read Paige's Stories Congress is barreling toward a March 23 deadline to finish work on a bill to fund much of the federal government for the remainder of the fiscal year. That bill is also supposed to include separate legislation aimed at stabilizing premiums for individuals who buy their own health insurance. But the legislation is being slowed by a number of policy disputes, including ones related to abortion.

Meanwhile, the Department of Health and Human Services has told Idaho that it cannot authorize insurance plans that specifically violate the Affordable Care Act. And a new study shows — again — that while people in the U.S. use about the same amount of health services as people in other wealthy countries, Americans pay far higher prices for those services.

This week’s panelists for KHN’s “What the Health?” are Julie Rovner of Kaiser Health News, Paige Winfield Cunningham of The Washington Post, Joanne Kenen of Politico and Alice Ollstein of Talking Points Memo.

Among the takeaways from this week’s podcast:

  • Washington Sen. Patty Murray, who is leading the Democrats’ efforts on stabilizing the individual insurance market, may have the upper hand for the long term. Some Democrats think that recent special elections show that voters care more about preserving the benefits of the health law than undermining it.
  • Republicans, too, could gain with a stabilization bill because studies suggest the efforts could help lower premiums, which would be especially pronounced among people who earn too much to get federal subsidies to help pay their premiums.
  • With Congress having failed to defund Planned Parenthood in legislation last year, HHS seems to be trying to rework the federal family planning program to minimize the group’s participation. But, so far, the administration has not gone as far as it could have.
  • The saga in Idaho is continuing — at least, that’s what Idaho officials suggest. Despite a letter from federal officials saying the state must obey the Affordable Care Act, Idaho officials say the matter is not yet settled because the changes they are suggesting for the insurance market are better than what the Trump administration is promoting.
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Plus, for “extra credit,” the panelists recommend their favorite health stories of the week they think you should read, too.

Julie Rovner: Journal of the American Medical Association’s “Health Care Spending in the United States and Other High-Income Countries,” by Irene Papanicolas, Liana R. Woskie and Ashish K. Jha.

Joanne Kenen: The New York Times’ “Museums Fight the Isolation and Pain of Dementia,” by Farah Nayeri.

Alice Ollstein: Kaiser Health News’ “Medicaid Is Rural America’s Financial Midwife,” by Shefali Luthra.

Paige Winfield Cunningham: CNN’s “The More Opioids Doctors Prescribe, The More Money They Make,” by Aaron Kessler, Elizabeth Cohen and Katherine Grise.

To hear all our podcasts, click here.

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No-Go For Idaho: Back To The Drawing Board On State-Based Health Plans

March 09, 2018

No, you can’t.

That’s what federal officials told Idaho regulators and the state’s governor late Thursday regarding the state’s plan to allow insurers to sell health plans that fall short of the Affordable Care Act’s requirements.

But the letter from the Trump administration letter did offer an alternative: Tweak your plan a bit to make them qualify as “short-term” policies. These alternatives — which are exempted from ACA rules, including those barring insurers from rejecting people with preexisting medical conditions — offer coverage for a limited time.

“On the one hand, they’re saying they’re going to enforce the ACA,” said Sarah Lueck, a senior policy analyst at the Center on Budget and Policy Priorities. But, the Health and Human Services Department also seems to say, “if you want to roll back protections for people with preexisting conditions, we have some ideas for you,” she added. “And that concerns me.”

Idaho’s approach, announced in January, would have allowed insurers to offer “state-based” insurance plans that did not include some of the law’s consumer protections. A few weeks later, Idaho Blue Cross jumped in with five “Freedom Blue” state-based plans it hoped to sell.

Regulators in other states were watching the Idaho situation. Its move was viewed either as a brazen effort to flout federal law or an innovative attempt to stabilize the market. Regardless, it meant the Trump administration had to take position: Enforce the ACA or look away.

Here are four key takeaways from the decision and how it may play elsewhere.

1. States and insurance carriers can’t ignore federal law.

Although the letter commended Idaho’s effort to “address the damage” caused by the ACA, it said the proposed state-based plans would violate at least eight of its provisions, including its ban on setting annual or lifetime caps, charging sick people more than those considered healthy or excluding coverage for preexisting conditions.

Thursday’s letter noted that if such plans were sold in Idaho, insurance carriers might face significant financial penalties. Experts said they would be surprised if insurers wanted to take that risk.

“It’s one thing for the state to take on CMS, but quite another for carriers,” said Jan Dubauskas, general counsel for the IHC Group, which sells short-term health insurance nationally. “When I heard that, I thought, ‘This is the end for state-based plans.’”

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But Idaho Gov. Butch Otter, a Republican, was upbeat, saying the letter from Centers for Medicare & Medicaid Services Administrator Seema Verma “was not a rejection of our approach” but “an invitation … to continue discussing …  what can and cannot be included in state-based plans.”

And late Friday, Idaho Blue Cross issued a statement expressing disappointment with the CMS letter, but still echoing Otter’s willingness to move forward.

The timetable going forward is not immediately clear, although both federal regulators and state officials say they are willing to talk about alternatives. Getting new short-term plans on the market would also require insurers to consider their options, modify the plans and come up with new premium rates.

2. Short-term plans get another boost.

Dubauskas and others said the Idaho decision could increase interest in short-term plans.

Such policies have been sold for years, meant as a stopgap for people between jobs. They’re less expensive than ACA plans, mainly because they can reject people with health conditions or exclude coverage for such conditions and have other limitations. Most of the plans don’t cover mental health and substance abuse treatment, few cover maternity care, and some don’t include prescription drug coverage. They generally can’t be renewed, meaning consumers must reapply and answer medical questions each time their policies expire.

The Obama administration, fearing that short-term plans would suck relatively healthy people out of the ACA market, limited them to 90-day terms. The Trump administration, however, has proposed allowing short-term plans to last for up to a year. These final rules aren’t expected for at least another two months.

Ironically, Idaho Insurance Director Dean Cameron had in January promoted the more robust “state-based” plans — like those the Blues insurer wanted to sell — as an alternative to short-term coverage.

After getting the CMS letter, he told the Idaho Statesman newspaper that short-term plans might be easier for the Trump administration to handle legally but could cause consumers more problems than what Idaho had proposed.

Critics fear that consumers will buy such plans without understanding their limitations.

“They might think it’s health insurance like they’re used to, but it’s really not, it’s really very bare-bones,” said Lueck.

3. State reactions will vary widely, creating different rules around the country.

Even if the Trump administration proposal to extend short-term coverage to a full year is finalized, states can set stricter rules.

A handful of states already do.

New York and New Jersey require many of the same rules as the ACA, but insurers wont’ sell short-term plans there.

Four states — Arizona, Michigan, Minnesota and Oregon — limit the length of the plans to 185 days, according to a survey by the Commonwealth Fund and researchers at Georgetown University.

“A small group of largely blue states have some regulation [of short-term plans], but not very many,” said Sabrina Corlette, a research professor at Georgetown University’s Health Policy Institute. “It’s possible that if this rule is finalized we will see more states start to step up and regulate short-term markets.”

Conversely, lawmakers in other states may promote short-term coverage as a lower-cost alternative to the ACA, although people with preexisting conditions may not be able to buy such plans.

“Politically, short-term plans have some appeal because lawmakers can say now there’s a cheaper option out there,” Corlette noted.

4. The increased emphasis on short-term plans could increase premiums. 

Actuaries fear that short-term plans — or state-based plans like those rejected in Idaho — would help drive up costs for people who remain in more comprehensive ACA coverage.

That’s because younger and healthier people might be tempted to drop their ACA coverage, leaving a remaining pool of those who are older, sicker and costlier. That, in turn, drives up premiums — affecting millions of Americans who don’t receive subsidies and already struggle to pay.

But just how many people will jump to new, short-term coverage?

The Trump administration has estimated that about 100,000 to 200,000 people with existing ACA coverage would make the shift, while other experts suggest higher numbers.

Christopher Condeluci, a benefits attorney, said it’s unclear which estimates are correct.

The real issue to keep in mind, he said, is that an increasing number of people who don’t get subsidies are already choosing to either forgo coverage or pick an alternative, such as short-term plans.

“People are voting with their feet,” he said. “That cannot be overlooked.”

A Health Plan ‘Down Payment’ Is One Way States Try Retooling Individual Mandate

March 09, 2018

As President Donald Trump and congressional Republicans tirelessly try to dismantle the Affordable Care Act, a number of states are scrambling to enact laws that safeguard its central provisions.

The GOP tax plan approved by Congress in the last days of 2017 repealed the ACA penalty for people who fail to carry health insurance, a provision called the “individual mandate.” On Jan. 30, in Trump’s first State of the Union address, he claimed victory in killing off this part of the health law, saying Obamacare was effectively dead without it.

But before that federal action kicks in next year, some states are enacting measures to preserve the effects of the mandate by creating their own versions of it.

Maryland is on the cutting edge with legislation moving through both chambers of the Statehouse.

“We’ve been just struggling since Trump became president with how to protect the ACA in our state,” said Vincent DeMarco, president of the Maryland Citizens’ Health Initiative, a nonprofit organization that has been instrumental in pushing the measure.

Proposals have been discussed or advanced in at least nine states, including California, Washington and Connecticut, and the District of Columbia.

Creating an individual mandate is just one way that states — generally blue states where Democrats control the legislature — seek to ensure what many lawmakers view as key advances made by the ACA don’t disappear.

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They’re looking to one another as test cases to see how state-level legislation can either buttress or alter the ACA, according to Trish Riley, the executive director of the National Academy for State Health Policy.

“One state will try one approach, others will try it,” Riley said. “It’s an experiment, and an important one.”

Time is short, since most states have limited legislative calendars and are fast approaching the deadlines for insurers to file their 2019 rate plans.

Passing and implementing these kinds of measures will be tough, said Sabrina Corlette, a research professor at Georgetown University’s Health Policy Institute. But “I think there’s still a window of opportunity for states to do something and have an impact on 2019 premiums,” she said.

Maryland’s Take On The Individual Mandate

Maryland’s effort began last April when the state legislature created the Maryland Health Insurance Coverage Protection Commission “both in response to and in anticipation of efforts at the federal level to repeal and replace the ACA,” according to a report by the state’s legislative services department and the commission itself.

The commission, chartered for three years, is charged with studying how federal action could affect the state’s health insurance market and Medicaid program and offering recommendations to mitigate any negative impacts. The panel began meeting months before the Maryland General Assembly started its 90-day session in January.

Based on the commission’s initial recommendations, Sen. Brian Feldman and House Del. Joseline Peña-Melnyk introduced the Protect Maryland Health Care Act of 2018, which lays out a framework for preserving an individual mandate in the state.

The federal individual mandate was put in place to make sure that younger, healthier people joined the insurance risk pool, helping to stabilize the market. The idea is that those relatively healthy customers help cover the insurers’ costs for sicker customers’ care, which keeps premium costs manageable for everyone.

The Congressional Budget Office estimated that 13 million people nationwide would become uninsured without the individual mandate. Some will choose to go without insurance or will not be able to find an affordable plan. Insurers could opt to leave local markets because they could not make money covering only sick patients.

Feldman said insurers and health care experts testified before the commission that Maryland’s insurance exchange would collapse in 2019 if the state didn’t act.

“Because of uncertainty at the federal level, it’s going to be up to states in this arena to pick up the slack and to enact legislation that responds to that uncertainty,” he said.

The federal mandate imposed a tax penalty on people who could afford to but chose not to buy insurance, depositing the money in a general Treasury fund.

In Maryland, the penalty fee will effectively be used, according to advocates, as a “down payment” on an insurance policy.

Beginning in 2020, if someone indicates on their taxes that they’re uninsured, the state would use the fine, plus any tax credits from the federal government, to buy an insurance plan for them.

Maryland would match its residents only with plans that cost nothing more than the fine plus the federal subsidy. So, if such a plan isn’t available in a person’s area, the state will hold on to the money in an interest-bearing account until the next open enrollment season. Then, the person has another chance to buy insurance. If at this time they don’t purchase a plan, the state will deposit the money into an insurance stabilization fund.

Politics And Policy On The Ground

Maryland is fertile ground for such health care experiments. The ACA remains popular within the state. Polling commissioned by DeMarco’s group puts the law’s support at 62 percent.

In addition, about 52 percent of Marylanders favored a state-based individual mandate, to make up for the federal provision that was repealed.

Democrats control the general assembly, but Gov. Larry Hogan, a Republican, has not offered a specific position on the issue — rather, he alluded to health reform efforts in his State of the State address. “Let’s develop bipartisan solutions to stabilize [health insurance] rates,” he said.

Ed Haislmaier, a senior research fellow at the Heritage Foundation, expressed skepticism about whether this approach will make a difference. The people who are targeted, he argued, are younger, healthier and generally lower-income. They don’t have insurance because they don’t want it, he suggested.

Jason Levitis, a senior fellow at Yale Law School’s Solomon Center for Health Law and Policy who has been instrumental in helping states craft their own versions of the individual mandate, warned that Maryland’s approach could face administrative challenges.

States that follow an approach more closely modeled after the federal mandate, he said, will have an easier time implementing it because regulators have already had five years of experience enforcing it.

Still, Levitis praised the Maryland plan: “There’s something attractive about the idea there, that you put this money … towards coverage.”

And a sampling of state proposals highlight a common theme.

“All the mandate efforts are based on the federal one,” Levitis said. “The variations are what you put on top, [how states] individually keep track of the money people pay and use it for health care services.”

He pointed to Connecticut as an example. It has two bills pending in its legislature — one that closely mirrors the federal mandate, but with slightly lower fines, and another in which the fines would be deposited into health savings accounts for the individuals.

In New Jersey, a Senate panel advanced a two-bill approach this week that would collect a fee from residents who opt against buying health insurance. These fines would then be used to help pay the health care claims of people who are catastrophically ill.

In the District of Columbia, a health care working group recommended an individual mandate nearly identical to the federal one. The plan would require City Council and congressional approval to become law.

Washington state has convened a group to study how to enforce a mandate, and no legislation has been introduced yet in California.

Meanwhile, Maryland officials also hope to learn from the experiences of other states.

For instance, lawmakers in Maryland are considering the creation of a state-based, basic, low-cost health plan as well as a fund to help insurers cope with the burden of very high-cost patients.

These efforts also come from the work of the commission.

Stan Dorn, a senior fellow with the pro-Obamacare group Families USA, said Maryland “had the foresight to see threats coming and to try to be proactive about it.”

Podcast: KHN’s ‘What The Health?’ HHS Leaders Take To The Stump

March 08, 2018

Three of the top officials of the Department of Health and Human Services — Secretary Alex Azar, Food and Drug Administration Commissioner Scott Gottlieb and Centers for Medicare & Medicaid Services Administrator Seema Verma — were out in force this week. All made major public appearances in an effort to reset the department’s agenda. In the wake of the failed congressional effort to “repeal and replace” the federal Affordable Care Act, the administration officials said they plan to focus on lowering the costs of health care and giving states and consumers more power.

On Capitol Hill, Congress is nearing the next deadline to finish legislation aimed at keeping the government running. But disputes remain over funding for health programs and over separate legislation that could be added to the “must-pass bill” aimed at stabilizing the individual insurance market.

This week’s panelists for KHN’s “What the Health?” are Julie Rovner of Kaiser Health News, Anna Edney of Bloomberg News, Margot Sanger-Katz of The New York Times and Joanne Kenen of Politico.

Among the takeaways from this week’s podcast:

  • As Congress looks at a federal reinsurance program to help stabilize the individual insurance market, there’s an interesting irony: The effort would require new funding that Republicans are hesitant to commit to the Affordable Care Act’s marketplaces, but at the same time the program would be much like the high-risk pools that the GOP has been touting.
  • It’s not yet clear if the recent round of high-level public outreach from HHS signifies a change in the administration’s health policies, but the strategy is very different than that under former chief Tom Price.
  • The latest big-name consolidation in health care — Cigna’s announcement that it is buying Express Scripts — also suggests that insurers are looking to reduce costs by getting rid of the drug industry middlemen.
  • Arkansas received approval this week to implement work requirements for some people receiving Medicaid benefits. It’s the latest sign that this is a policy priority for the administration. Email Sign-Up

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

Julie Rovner: NPR’s “Miracle Of Hemophilia Drugs Comes At A Steep Price,” by Jenny Gold of Kaiser Health News.

Joanne Kenen: The New York Times’ “A ‘Bright Light,’ Dimmed in the Shadows of Homelessness,” by Benjamin Weiser.

Margot Sanger-Katz:’s “America’s Opioid Crisis Has Become an ‘Epidemic of Epidemics,’” by Ella Nilsen.

Anna Edney: The New York Times’ “The Price They Pay,” by Katie Thomas and Charles Ornstein.

To hear all our podcasts, click here.

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Congress Races The Clock In Quest To Bring Stability To Individual Insurance Market

March 02, 2018

Congress is running out of time if members want to come up with legislation to stabilize the individual insurance market.

While Republicans and Democrats still feud over the fate of the Affordable Care Act, a bipartisan group of senators and House members has been working since last summer on measures to keep prices from rising out of control and undermining the individual market where people who don’t get insurance through work or the government buy policies.

They hope to attach a package of fixes to what should be the year’s final temporary spending bill, due in late March.

The lawmakers are up against not just the legislative clock, but also the insurance companies’ timeline. Insurers have until summer to decide if they want to continue to sell policies in the ACA marketplaces, but many start making preliminary decisions as early as April.

In the absence of congressional action, insurers say premiums will go up in 2019 due to the uncertainty — raising costs for consumers and the government.

It is by no means clear whether any package could gain the votes needed in the House and Senate. Most Republicans are loathe to be seen “fixing” Obamacare, although opinion polls clearly show they will be blamed for problems with the law going forward.

The bipartisanship extends beyond Capitol Hill. Last week five governors (three Democrats, one Republican and one Independent) released a blueprint for a health system overhaul that includes several of the stabilization ideas under consideration in Congress.

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About 18 million people buy their own policies, both inside and outside the ACA insurance marketplaces.

Lawmakers are looking at two primary fixes, although they could be combined.

One, pushed by Sens. Susan Collins (R-Maine) and Bill Nelson (D-Fla.), is called “reinsurance.” It is a way to guarantee the insurance companies do not face large losses. The idea is that if insurers don’t have to worry about covering the expenses for their highest-cost patients, they can keep premiums lower for everyone.

The ACA actually had a temporary reinsurance program from 2014 to 2016. It was intended to help insurers get started in a market where sick people were able to buy their own insurance for the first time. Prior to the law, most insurers did not cover many people with preexisting health conditions. If they did, it was at an extremely high cost.

Since the federal program ended, several states, including Minnesota and Alaska, have adopted, with some success, their own reinsurance programs in an attempt to hold premiums down.

The other proposal, negotiated by Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.), would guarantee insurers federal reimbursement for so-called cost-sharing reduction subsidies. Those are discounts that the ACA requires insurers to provide to their lower-income enrollees to help reduce their deductibles and other out-of-pocket costs. President Donald Trump cut off federal reimbursement of those payments in October.

Senate Majority Leader Mitch McConnell (R-Ky.) pledged to Collins in exchange for her vote on the GOP tax plan in December that he would support bringing both bills to the floor for debate.

That has not happened, although in a statement, Collins said she is “continuing to have productive discussions” with Senate and House leaders about both bills.

Meanwhile, a lot has changed, including new questions about whether the fixes would work.

For starters, state insurance regulators managed to find a workaround for Trump’s sudden cancellation of the federal cost-sharing payments. Most states allowed insurers to offset the loss of these funds by increasing the premiums for the “silver” level plans that determine how much help enrollees get to pay those premiums. So the increases end up being paid by the federal government anyway, through higher premium subsidies. The result is that most people who get government help pay the same (or, in some cases, less), while insurers are effectively being paid back for the discounts, albeit through a different mechanism.

That means, however, if the cost-sharing reduction payments were reinstated for 2018, as the original legislation called for, insurers would have to give the excess money back to the government.

Analysts agree that would only add to the confusion.

Restoring the federal payments for this year, said Joseph Antos of the conservative American Enterprise Institute, “does not lower premiums this year, so it does absolutely no good to the average person.”

Some advocates have suggested that Congress should guarantee the payments for 2019 and 2020. But Antos said that “also makes no sense, because the insurers would then think ‘Are we going to go through this again?’”  They might raise premiums even more to make up for the uncertainty.

Antos  — and many other analysts — agree that restoring or creating a new reinsurance program would likely do more to control premium increases.

Reinsurance “will protect premiums for the people who are actually most subject to them,” said Sherry Glied, a former Obama administration health official now at New York University. She was referring to those in the individual market who do not get government help and have been footing large premium increases for the past several years. That’s because having protection against the largest bills would allow insurers to lower premiums across the board.

Then there are the political considerations.

Many Republicans in Congress have called the cost-sharing reduction payments in particular a “bailout” to the insurance industry, and are resistant to reinstate the payments.

Republicans seem more amenable to the idea of reinsurance, because they consider it a type of “high risk pool,” which they have been pushing for years. House Speaker Paul Ryan said at an event in Wisconsin in January that “I think there might be a bipartisan opportunity there to get risk pools, risk mechanisms.”

But Republicans have made clear they want something in return for what could be considered a “fix” to the health law they despise.

Health and Human Services Secretary Alex Azar was careful to say in a meeting with reporters last week that the Trump administration has no formal position yet on the stabilization efforts.  But, he said, “I think it would need to be part of an entire set of reforms there that we would want to see.” That would likely include more flexibility for states to opt out of some of the health law’s coverage requirements.

The delay has made Democrats more demanding, too. The repeal of the ACA’s penalties next year for people who don’t have insurance has changed the situation dramatically, said Sen. Murray.

“As I have made clear, the bipartisan bill I originally agreed on with Chairman Alexander will not make up for this latest round of Republican health care sabotage,” she said in a statement. “In fact, there are changes that now need to be made to our bill to ensure it meets its intended goals of keeping premiums down and stabilizing markets.”

But while Congress decides if it will take action, insurers are warning that doing nothing will lead to still higher premiums.

Premium rates for a “benchmark” silver plan could rise by 27 percent in 2019, the Blue Cross Blue Shield Association said earlier this month.

Congressional action on reinsurance and cost-sharing, the association predicted, would help push premium rates 17 percent below this year’s levels.

“Health plans are looking for certainty in the market,” said Justine Handelman, senior vice president in the association’s policy shop.

Ideally, Congress would include the funding in measures adopted in February or March, said Handelman, who spoke with reporters during a briefing at the association’s Washington, D.C., headquarters: “Most plans are filing premium rates by April.”

Kaiser Health News senior correspondent Julie Appleby contributed to this story.

Podcast: KHN’s ‘What The Health?’ The ACA Heads Back To Court. Again.

March 01, 2018

Twenty state attorneys general filed another lawsuit challenging the constitutionality of the Affordable Care Act this week. They charge that when Congress added a provision to the December tax bill that eliminates the tax penalty for not having health insurance, the entire health law was invalidated. Attorneys general were also part of the unsuccessful effort to strike down the law in 2012.

Meanwhile, a key Democratic think tank, the Center for American Progress, has released a health overhaul proposal that tries to bridge the divide among Democrats between the Affordable Care Act and a “Medicare for All” single-payer proposal. Will Democrats get on the same page on health care? Or will they end up as split as Republicans?

This week’s panelists for KHN’s “What the Health?” are Julie Rovner of Kaiser Health News, Sarah Kliff of, Margot Sanger-Katz of The New York Times and Joanne Kenen of Politico.

Among the takeaways from this week’s podcast:

  • If the lawsuit brought by 20 states this week against the Affordable Care Act were to get to the Supreme Court, it would likely be several years down the road, and it’s not clear that the court would still look like it does now.
  • The divide among the states over health policy is growing again and perhaps taking the country back to pre-ACA days.
  • Some Democrats are beginning to wonder if the ACA can work long-term and is resistant to Republican efforts to sabotage it. But they have not yet settled on a plan for a future health care policy that will avoid an intra-party civil war. Email Sign-Up

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

Julie Rovner: California Healthline’s “Health Care Revamp At The L.A. County Jails,” by Anna Gorman.

Joanne Kenen: The Atlantic’s “What Are Active-Shooter Drills Doing To Kids?” by James Hamblin.

Margot Sanger-Katz: BuzzFeed News’ “The Inside Story Of How An Ivy League Food Scientist Turned Shoddy Data Into Viral Studies,” by Stephanie M. Lee.

Sarah Kliff: BuzzFeed News’ “Passengers Who Call Uber Instead Of An Ambulance Put Drivers At Risk,” by Caroline O’Donovan.

To hear all our podcasts, click here.

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

Tens of Thousands of Medicaid Recipients Skip Paying New Premiums

March 01, 2018

When Arkansas lawmakers debated in 2016 whether to renew the state’s Medicaid expansion, many Republican lawmakers were swayed only if some of the 300,000 adults who gained coverage would have to start paying premiums.

This “skin-in-the-game” provision — endorsed by conservatives in Washington and in many statehouses — is designed to make Medicaid recipients value their government health insurance more and lead healthier lives.

It’s “to encourage more personal responsibility,” Arkansas Gov. Asa Hutchinson told reporters in 2016. “We want to incentivize better, healthy living.”

Yet few enrollees are paying the $13 monthly premiums, which apply only to Medicaid recipients whose earnings surpass the poverty level. In 2017, just 20 percent of the 63,000 Arkansas enrollees paid. Medicaid enrollees in Arkansas don’t lose coverage for lack of payment.

Arkansas is not the only state where Medicaid recipients who gained coverage under the Affordable Care Act disregard the new premiums. Tens of thousands of Medicaid enrollees in four other states that added premiums during the past four years— Indiana, Michigan, Iowa and Montana — have also opted not to pay, according to state records.

Under the ACA, states received millions of federal dollars to cover everyone with incomes under 138 percent of the federal poverty level (about $16,700 for an individual today). Previously, Medicaid mainly covered only low-income children, disabled adults and parents.

Premiums, which are routine obligations in private health insurance and Medicare, were not a part of Medicaid until that expansion in 2014. In these five states, conservative lawmakers were hesitant to expand the federal-state program unless they secured fees from nondisabled adults.

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Kentucky has received approval to add premiums in 2018.

“We believe the premiums are important to prepare these beneficiaries for what would be required of them if they move up the economic ladder and get coverage through an employer or the federal marketplace,” said Arkansas Medicaid spokeswoman Amy Webb. “It’s a small amount, especially considering the benefit they are receiving. Under an employer or at the marketplace, they would lose their coverage for failure to pay.”

Advocates for Medicaid say it is not surprising that significant numbers of Medicaid enrollees fall behind on their payments.

“Premiums are a financial barrier for low-income people, even if you are working,” said Rich Huddleston, executive director of Arkansas Advocates for Children and Families. Even the state’s $13 monthly premium is burdensome. “Families have to make tough choices every day about whether they buy food, pay the electric bill, their rent, or pay premiums.”

Still, the experience in the five states shows converting conservatives’ “skin-in-the-game” mantra into practice has many administrative challenges.

Michigan requires Medicaid enrollees with incomes over the poverty level to pay 2 percent of their income in monthly premiums, though the amount could be decreased if they engage in so-called healthy behaviors, such as getting a flu shot or trying to quit smoking.

A survey of enrollees last year in Michigan found nearly 88 percent said the amount they had to pay was “fair,” and 72 percent said they agreed that they would “rather take some responsibility to pay something for their health care than not pay anything.”

But from January through August last year, fewer than half of Michigan Medicaid recipients who owed a premium — about 77,000 of 175,000 — paid it.

And premiums were not the only new obligation that many of these enrollees are failing to meet. The state’s Medicaid expansion also required them to fill out a health risk assessment form with their doctor and promise to improve their health. In return, members could lower their premiums or gain a $50 gift card.

Of the 900,104 beneficiaries who have been enrolled in Medicaid for at least six months, 19 percent have completed this chore, according to state records.

For most enrollees this is voluntary. But enrollees with incomes above 100 percent of the poverty level could lose Medicaid coverage if they don’t fill out the form to attest they will try to improve their health. Michigan particularly is getting tough: Last month it mailed letters to 13,550 beneficiaries informing them that they failed to meet this requirement and there will be consequences. They will be moved off Medicaid and will have to choose a private plan on the Obamacare insurance marketplace or will be automatically enrolled in one in June.

Dr. Renuka Tipirneni, a researcher with the University of Michigan Institute for Healthcare Policy & Innovation, said it’s unclear if these enrollees will be worse off in the private plans since many will get subsidies to help cover their premium costs. But they may face a larger cost-sharing portion or have to change doctors.

She was surprised by how few people paid their premiums, given the survey findings. “Many people want to pay and want to say they are contributing, but what is the reality of their circumstances?” she asked. The lack of a penalty for not paying, she added, could be a factor.

Michigan officials last year also sent 68,000 Medicaid enrollees who owed premiums a notice that they would garnish any state income tax refunds or lottery winnings. That led about 7,000 recipients to pay. The state last year collected premium money from 19,400 through their tax refunds and another 59 from their lottery winnings, according to a state report.

Arkansas officials also plan to intercept state tax refunds to recoup unpaid premiums, but not until 2019.

Other states have mixed records on collecting Medicaid premiums, according to state reports:

  • In Indiana, about 25,000 Medicaid recipients were kicked off the program from the fall of 2015 to October 2017 for failure to pay — or more than 1 in 3 who owed premiums. The payments range from $1 to $27. Indiana is the only state to lock enrollees out of Medicaid for six months for failure to pay the premium for two months in a row — and about 10,000 recipients fell into that category in 2016. Kentucky recently received federal permission to add a similar lockout provision this year.
  • Iowa disenrolled more than 14,000 Medicaid enrollees from January 2016 to September 2017 for failure to pay a $10 monthly Medicaid premium, though they could re-enroll at any time. More than 40,000 Medicaid enrollees with incomes over 50 percent of the poverty level were subject to a premium in September 2017 and about three-quarters of them had not paid nor completed a health risk assessment form that would have waived the fee.
  • Montana’s Medicaid program dropped 2,884 adults with incomes over the poverty level from coverage in 2017 for failing to pay a premium. The state charges 2 percent of the enrollee’s monthly income. Montana allows those dropped to re-enroll at any time without paying.