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Updated: 13 hours 35 min ago

California’s ACA Rates To Rise 8.7% Next Year

July 19, 2018

Premiums in California’s health insurance exchange will rise by an average of 8.7 percent next year, marking a return to more modest increases despite ongoing threats to the Affordable Care Act.

The state marketplace, Covered California, said the rate increase for 2019 would have been closer to 5 percent if the federal penalty for going without health coverage had not been repealed in last year’s Republican tax bill.

The average increase in California is smaller than the double-digit hikes expected around the nation, due largely to a healthier mix of enrollees and more competition in its marketplace. Still, health insurance prices keep growing faster than wages and general inflation as a result of rising medical costs overall, squeezing many middle-class families who are struggling to pay their household bills.

The 8.7 percent increase in California ends two consecutive years of double-digit rate increases for the state marketplace.

“It’s not great that health care costs are still increasing that much, but the individual market is not sticking out like a sore thumb like it has in other years,” said Kathy Hempstead, senior adviser at the Robert Wood Johnson Foundation. “It’s falling back to earth.”

The future may be less bright. An estimated 262,000 Californians, or about 10 percent of individual policyholders in and outside the exchange, are expected to drop their coverage next year because the ACA fines were eliminated, according to the state. Peter Lee, executive director of Covered California, warned that the exodus of healthier consumers will drive up insurance costs beyond 2019 — not just for individual policyholders but for California employers and their workers.

“We are paying, in essence, a surcharge for federal policies that are making coverage more expensive than it should be,” Lee said in an interview. “There will be more of the uninsured and more uncompensated costs passed along to all of us.”

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Critics of the Affordable Care Act say it has failed to contain medical costs and left consumers and taxpayers with heavy tabs . Nearly 90 percent of Covered California’s 1.4 million enrollees qualify for federal subsidies to help them afford coverage.

Foiled in its attempt to repeal Obamacare outright, the Trump administration has taken to rolling back key parts of the law and has slashed federal marketing dollars intended to boost enrollment. Instead, the administration backs cheaper alternatives, such as short-term coverage or association health plans, which don’t comply fully with ACA rules and tend to offer skimpier benefits with fewer consumer protections.

Taken together, those moves are likely to draw healthier, less expensive customers out of the ACA exchanges and leave sicker ones behind.

Nationally, 2019 premiums for silver plans — the second-cheapest and most popular plans offered — are expected to jump by 15 percent, on average, according to an analysis of 10 states and the District of Columbia by the Avalere consulting firm. Prices vary widely across the country, however. Decreases are expected in Minnesota while insurers in Maryland are seeking 30 percent increases.

In California, exchange officials emphasized, consumers who shop around could pay the same rate as this year, or even a little less.

Christy McConville of Arcadia already spends about $1,800 a month on a Blue Shield plan for her family of four, opting for “platinum” coverage, the most expensive type. Her family doesn’t qualify for federal subsidies in Covered California.

She’s worried about further increases and doesn’t want to switch plans and risk losing access to the doctors she trusts. “We’re getting right up to the limit,” McConville said.

Amanda Malachesky, a nutrition coach in the Northern California town of Petrolia, said the elimination of the penalty for being uninsured makes dropping coverage more palatable. Her family of four pays almost $400 a month for a highly subsidized Anthem Blue Cross plan that has a $5,000 deductible.

“I’ve wanted to opt out of the insurance model forever just because they provide so little value for the exorbitant amount of money that we pay,” said Malachesky, who recently paid several hundred dollars out-of-pocket for a mammogram. “I’m probably going to disenroll … and not give any more money to these big bad insurance companies.”

Covered California is aiming to stem any enrollment losses by spending more than $100 million on advertising and outreach in the coming year. In contrast, the Trump administration spent only $10 million last year for advertising the federal exchange across the 34 states that use it.

Also, California lawmakers are looking at ways to fortify the state exchange. State legislators are considering bills that would limit the sale of short-term insurance and prevent people from joining association health plans that don’t have robust consumer protections.

However, California hasn’t pursued an insurance mandate and penalty at the state level, which both health plans and consumer advocates support. New Jersey and Vermont have enacted such measures.

Lee said it’s up to lawmakers to decide whether a state mandate makes sense.

David Panush, a Sacramento health care consultant and a former Covered California official, said some lawmakers may be reluctant to push the idea, even in deep-blue California.

“The individual mandate has always been the least popular piece of the Affordable Care Act,” he said.

Despite the constant uncertainty surrounding the health law, many insurers nationally are posting profits from their ACA business and some plans are looking to expand further on the exchanges.

In California, the same 11 insurers are returning, led by Kaiser Permanente and Blue Shield of California. Together, those two insurers control two-thirds of exchange enrollment. (Kaiser Health News, which publishes California Healthline, is not affiliated with Kaiser Permanente.)

The Covered California rate increases are fairly uniform across the state. Premiums are climbing 9 percent across most of Southern California as well as in San Francisco. Monterey, San Benito and Santa Cruz counties faced the highest increase at 16 percent, on average.

The rates are subject to state regulatory review but are unlikely to change significantly. Open enrollment on the exchange starts Oct. 15.

The ACA’s expansion of coverage has dramatically cut the number of uninsured Californians. The proportion of Californians lacking health insurance fell to 6.8 percent at the end of last year, down from 17 percent in 2013, federal data show.

This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California Health Care Foundation.

States Attacking ACA Would Suffer Most If Preexisting Conditions Shield Gets Axed

July 17, 2018

If the Affordable Care Act’s protections for people with preexisting medical conditions are struck down in court, residents of the Republican-led states that are challenging the law have the most to lose.

“These states have been opposed to the ACA from the beginning,” said Gerald Kominski, a senior fellow at the UCLA Center for Health Policy Research. “They’re hurting their most vulnerable citizens.”

Twenty Republican state attorneys general and governors challenged the constitutionality of the ACA in federal court in February. Last month, U.S. Attorney General Jeff Sessions and the Department of Justice made the unusual decision not to defend key portions of the law against this legal challenge.

The states’ lawsuit argues that because Congress eliminated the Obamacare tax penalty for not having insurance coverage, effective next year, the entire law is unconstitutional. By extension, the suit calls on federal courts to find the health law’s protections for people with preexisting conditions unconstitutional — and Sessions agrees.

Nine of the 11 states with the highest rates of preexisting conditions among adults under 65 have signed onto the lawsuit to strike down the ACA, according to data from insurance companies and the U.S. Centers for Disease Control and Prevention. The 2015 data, the most recent available, were analyzed by the Kaiser Family Foundation in 2016. (Kaiser Health News, which produces California Healthline, is an editorially independent program of the foundation.)

Those who support the lawsuit contend that there are other means of protecting people with preexisting conditions.

“If a court strikes down the constitutionality of the ACA, there are ways to repeal and replace without Arizonans with preexisting conditions losing their coverage,” said Katie Conner, a spokeswoman for Arizona Attorney General Mark Brnovich.

Conner said her boss, who is party to the lawsuit, believes preexisting conditions should “always be covered.” In Arizona, more than 1 in 4 adult adults under 65 have a preexisting condition, according to the data.

The state with the highest rate of adults with preexisting conditions is West Virginia — 36 percent of those under age 65. That means that about 1 in 3 of them could have a hard time buying insurance through the individual marketplace without the ACA protections.

The office of West Virginia Attorney General Patrick Morrisey, who joined the legal challenge against the ACA, declined to comment. But a spokesman for Morrisey’s re-election campaign told PolitiFact last month that “help should be provided to those who need it most, including those with preexisting conditions.”

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Plaintiffs in the lawsuit “are paying lip service to these critical protections for people, but they are in fact engaged in a strategy that would get rid of those protections,” said Justin Giovannelli, an associate research professor at Georgetown University’s Center on Health Insurance Reforms. “Frankly, it’s hard to square what they’re saying on the one hand and what they’re arguing in the courts on the other.”

According to a poll released in June, also by the Kaiser Family Foundation, three-quarters of Americans say that maintaining protections for people with preexisting conditions is “very important.” This includes majorities of Democratic, Republican and independent voters.

Before the health law was adopted, insurance companies routinely denied coverage to millions of people with preexisting conditions who purchased insurance through the individual marketplace. If they didn’t deny coverage outright, some health plans charged consumers exorbitant premiums, or offered policies that excluded coverage for pricey conditions. (Although many people got insurance through their employers or public plans that covered preexisting conditions, they could have been left vulnerable if their employment status or other circumstances changed.)

The ACA ended those practices.

Common conditions that led insurance companies to deny coverage included high blood pressure, cancer, obesity, diabetes and depression, among many others. Some people were denied for having acne, asthma or for being pregnant.

The KFF analysis estimated that at least 27 percent of adults under 65 — more than 50 million Americans — had at least one preexisting condition that would have jeopardized their coverage pre-ACA. The foundation said its estimates were an undercount because some diseases that insurers cited when declining coverage are not in the survey data. Also, each insurance company set its own rules and conditions for denials, making accurate counts of those who could be affected hard to nail down.

Less precise estimates by other researchers and the Department of Health and Human Services show that up to half of all adults under age 65 have at least one preexisting condition.

This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California Health Care Foundation.

In Florida, Midterm Elections Hold Faint Hope For Medicaid Expansion

July 16, 2018

Can the deep-red Florida Statehouse follow Virginia and expand Medicaid?

Highly unlikely anytime soon, many state political analysts say.

It’s been three years since the Florida legislature last debated — and overwhelmingly rejected —Medicaid expansion under the Affordable Care Act.

Republicans — who have controlled the governor’s office and both legislative chambers for nearly all of the past two decades — have shown no interest since then in pursuing the policy that would make about 660,000 uninsured adults eligible for the government insurance program for the poor.

While Democrats are expected to gain Statehouse seats in the midterm election, it’s unlikely they can capture enough to make a difference. That’s especially true in the House, where the GOP holds a 76-41 majority, with three seats vacant. Six GOP House members don’t even face an opponent.

“I don’t see Medicaid expansion having much of a chance,” said Carol Weissert, Florida State University’s chair of civic education and political science. “It’s a combination of the political reality on the ground, and I don’t see a huge push for it around the state.”

While health care is typically a big issue in retiree-heavy Florida, gun laws and education are likely to play heavy on voters’ minds this fall following the February massacre at Marjory Stoneman Douglas High School in Parkland, Fla., where 17 people were killed.

Susan MacManus, a political science professor emeritus at the University of South Florida in Tampa, said one “long shot” for the Democrats’ fall election prospects is a growing percentage of younger voters. They tend to be more supportive of expanding Medicaid, she said.

Although Election Day is still more than three months away, expansion proponents are unlikely to pull off a repeat of what happened in the Virginia House of Delegates election last November, Weissert said. Democrats there captured 15 GOP seats and came within one vote of controlling the assembly.

That shock helped persuade a few GOP lawmakers to join Democrats to push Medicaid expansion through a legislature that had staunchly rebuffed it for four years. Many freshman Virginia Democratic lawmakers campaigned on this issue and other measures that would make health care more accessible.

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About 400,000 people in Virginia are expected to gain coverage from expansion.

Florida is one of 17 states that have not expanded Medicaid since 2014, and only Texas has more residents who could benefit. An expansion would drop Florida’s uninsured rate from 15.7 percent to nearly 11, according to the nonpartisan Urban Institute.

Republican leaders in Florida have cited various reasons for opposing this step. They say the state can’t afford it. They assert that Florida can’t trust the federal government to pay for at least 90 percent of costs for the newly eligible. They also argue that Medicaid coverage should not go to nondisabled adults because the state is straining to cover children, pregnant women and people with disabilities.

In looking at the issue in the gubernatorial races, the good news for expansion proponents is that Gov. Rick Scott, a Republican who opposed the health law and briefly supported Medicaid expansion then opposed it, is leaving office.

Scott is running for the U.S. Senate against incumbent Democrat Bill Nelson.

While the leading Democratic candidates for governor back expansion, the top Republican candidates, including state agriculture Commissioner Adam Putnam and U.S. Rep. Ron DeSantis, are firmly against it. The state’s primary election is Aug. 28.

But if a Democrat could gain the governorship, it would at least give Medicaid advocates some negotiating leverage, said MacManus.

“A Democratic governor could have some influence on the legislature down the road,” she said.

Gregory Koger, professor of political science at the University of Miami, said the party not controlling the White House usually does well in midterm elections and expects Florida Democrats to benefit. President Donald Trump’s low approval ratings, he added, should also help them.

Although the odds are long, he said, the GOP’s failure to repeal the health law last year in Congress might sway some Republicans in the state legislature to vote for expansion, particularly if the plan included a work requirement for those gaining coverage.

“That could give Republicans political cover,” Koger said.

Florida voters seeking expansion will not be able to follow Maine’s lead on a voter referendum on Medicaid until at least 2020.

Maine’s successful 2017 voter referendum ignited interest in other states, including Utah, Nebraska and Idaho, where voters are expected to address the measure in the fall.

Jonathan Schleifer, executive director of the Fairness Project, which is directing the ballot initiatives, said there wasn’t enough time this year to launch an effort in Florida.

“It was premature to do in Florida because we needed a larger runway for the work,” he said. “It would have been impossible to put together that many signatures.”

Schleifer said he sees strong public support for expanding Medicaid and hopes that after more states approve the ballot referendum it will make it easier to accomplish in the Sunshine State.

Podcast: KHN’s ‘What The Health?’ ACA Under Fire. Again.

July 12, 2018
Julie Rovner

Kaiser Health News


Read Julie's Stories Julie Appleby

Kaiser Health News


Read Julie's Stories Anna Edney



Read Anna's Stories Margot Sanger-Katz

The New York Times


Read Margot's Stories

Democrats in the Senate are gearing up to fight President Donald Trump’s nominee to the Supreme Court, U.S. Circuit Judge Brett Kavanaugh. They argue he is not only a potential threat to abortion rights, but also to the Affordable Care Act.

Meanwhile, the Trump administration continues its efforts to undermine the workings of the Affordable Care Act. This week, officials announced a freeze on payments to insurers who enroll large numbers of sicker patients, and another cut to the budget for “navigators” who help people understand their insurance options and enroll for coverage.

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

Julie Rovner of Kaiser Health News

Margot Sanger-Katz of The New York Times

Anna Edney of Bloomberg News

Julie Appleby of Kaiser Health News

Among the takeaways from this week’s podcast:

  • One reason Democrats are rallying around the health issue rather than the abortion issue is that there is more unity in their caucus over health than abortion. Also, the two key Republican senators who support abortion rights — Sen. Susan Collins (R-Maine) and Sen. Lisa Murkowski (R-Alaska) — also voted against GOP efforts to repeal the Affordable Care Act last year.
  • The Trump administration’s action on risk-adjustment payments sent yet another signal to insurers that the federal government does not necessarily have their backs and is willing to change the rules along the way.
  • The Trump administration says it wants to cut to payments for navigators because they are not cost-effective. But the navigator money does not come from taxpayers or government sources. It is paid from insurance industry user fees. These funds also go to support ACA advertising — which has also been cut. However, the user fees have not been reduced. In theory, reducing these fees could provide savings that could be passed on to consumers.
  • After being called out on Twitter by Trump, drugmaker Pfizer this week announced it would delay some already-announced price increases on about 100 of its drugs. It is worth noting that the president used his bully pulpit and gained some success. The six-month delay will mean that consumers will not experience an increase in cost at the pharmacy for at least that time period. But it still raises questions.
  • The Trump administration worked to block a World Health Organization resolution to promote breastfeeding. But while this seemed a clear case of promoting the interests of infant formula companies over public health experts, there was pushback from some women who say they are unable to breastfeed and feel stigma when they opt for formula instead. On the other hand, formula can be dangerous in developing countries without easy access to clean water.
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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: Politico Agenda’s “The One Big Winner of the Obamacare Wars,” by Joanne Kenen

Julie Appleby: The New York Times’ “Doctor, Your Patient Is Waiting. It’s a Red Panda,” by Karen Weintraub.

Anna Edney: Politico’s “CMS Quit Test of Pricey Cancer Treatment Amid Concerns Over Industry Role,” by Sarah Karlin-Smith and David Pittman

Margot Sanger-Katz: HuffPost’s “Trump Administration May Be Preparing A New Obamacare Sabotage Effort,” by Jonathan Cohn

To hear all our podcasts, click here.

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

Outrageous Or Overblown? HHS Announces Another Round Of ACA Navigator Funding Cuts

July 12, 2018

The Trump administration’s decision Tuesday to slash funding to nonprofit groups that help Americans buy individual health insurance coverage sparked outrage from advocates of the Affordable Care Act. Using words like “immoral” and “cold-hearted,” they saw it as the Republicans’ latest act of sabotage against the sweeping health law.

But as the ACA’s sixth open-enrollment period under the health law approaches in November, the lack of in-person assistance is unlikely to be a disaster for people seeking coverage, insurance and health experts say.

“I think alone it will have a very small impact on enrollment for 2019,” said William Hoagland, a senior vice president with the Bipartisan Policy Center in Washington.

But combined with other recent actions by the Trump administration, the decision sets a negative tone, Hoagland said.

“It does send a signal of course that the administration is not promoting enrollment,” he said.

The Centers for Medicare & Medicaid Services announced it is cutting money to the groups known as navigators from $36 million to $10 million for the upcoming 45-day enrollment period.

This reduction comes a year after the Trump administration decreased navigators’ funding by 40 percent from $62.5 million — and cut advertising and other outreach activities.

CMS Administrator Seema Verma said the navigators that operate in the 34 states that use the federal marketplace — including many health and religious organizations — were ineffective and had outlived their usefulness.

She pointed out that they helped with fewer than 1 percent of enrollments in 2017 — though she counts navigators as “helping” only if consumers sign up in their presence.

CMS also notes that after last year’s navigator funding was reduced, the overall enrollment in Obamacare plans increased slightly (when counting people who paid their first month’s premiums) to 10.6 million people.

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Florida Blue, an insurer that enrolls among the largest number of Obamacare consumers nationwide, said it won’t miss the help from the federally funded grass-roots helpers.

“Given our large and unique distribution-channel strategy of utilizing our retail centers along with our telesales efforts, our dedicated field agents and our direct in-market enrollment efforts, we do not depend on navigators to enroll ACA members,” said spokesman Paul Kluding.

Greg Fann, a fellow with the Society of Actuaries, said the role of navigators has been overstated.

“I am a numbers guy, and what really matters to people are the numbers and price of the coverage,” he said. Nearly 9 in 10 people buying coverage on the ACA exchanges qualify for federal subsidies based on their incomes, and the amount those subsidies rose last year because of an increase in silver-plan premiums.

The navigators, Fann added, were needed more in 2013 and 2014 when the marketplaces were in their first years and millions of people who hadn’t bought insurance before were considering the health law’s new options.

Insurers and brokers, Fann said, should step in to make up for navigator funding.

Don’t count on it, said Steve Israel, a Boynton Beach, Fla., insurance agent and past president of the Florida Association of Health Underwriters. He said most independent brokers want nothing to do with ACA plans because insurers have cut their commissions. “We’ve been sending people to navigators,” Israel said.

Some states that operate their own marketplaces, however, are continuing to invest in these grass-roots aides.

Covered California, for example, is holding its navigator funding steady, dedicating $6.5 million to navigators in this year’s budget.

That’s more than half of what is investing in navigators in 34 states.

California has 1.5 million people in Obamacare plans, second highest in the nation behind Florida, which has 1.6 million.

Death By 1,000 Cuts? 

Trump spent his first year in office trying to repeal the health law and came within one vote in the U.S. Senate of achieving that goal. Immediately after Sen. John McCain (R-Ariz.) cast the deciding vote to block the dramatic repeal effort, Trump implored Republicans to let the law disintegrate.

“Let ObamaCare implode, then deal,” Trump tweeted on July 28, 2017.

But his administration has not stood idly by.

The Republican-controlled Congress in December passed a law that next year will eliminate the requirement that most Americans have insurance, a move likely to drive healthier people out of insurance market and lead to higher prices for those who are left.

Just last week, CMS said because of a pending lawsuit it was suspending a program created by the law to even out the burden on health insurers whose customers are especially unhealthy or sick. That could take millions of dollars away from some insurers, causing them to hike prices or abandon markets.

The Trump administration also issued new rules to try to make it easier for individuals and small businesses to buy health plans that cost less than ACA coverage because they cover fewer medical services. These plans would bypass the law’s protections that prevent companies from charging higher prices to women, older people and those with preexisting medical conditions.

Critics deride such plans as “junk insurance.”

CMS now wants the navigators to promote these policies in addition to steering people toward ACA-compliant plans and Medicaid.

This adds to the concern about the lack of navigator funding.

The availability of such new types of coverage will increase consumer demand for specially trained navigators, said Elizabeth Hagan, a senior consultant with Transform Health, a consulting firm.

She said the problem with reducing consumer assistance is not so much that fewer people will buy coverage but that people will buy policies that don’t fit their needs.

Jodi Ray, who leads the University of South Florida’s navigator program — the largest one in the state — said her staffers do much more than help with enrollment. They also help consumers file appeals with insurers.

“This is how health care disparities are exacerbated — we will be put in the awful position of pitting populations that need assistance against each other in order to prioritize how we can use the resources,” she said.

California Healthline reporter Ana B. Ibarra contributed to this report.

Democrats Rally Against Threats To The ACA To Block Trump’s Supreme Court Nominee

July 10, 2018

Senate Democrats, who are divided on abortion policy, are instead turning to health care as a rallying cry for opposition to President Donald Trump’s Supreme Court nominee.

Specifically, they are sounding the alarm that confirming conservative District Court Judge Brett Kavanaugh could jeopardize one of the Affordable Care Act’s most popular provisions — its protections for people with preexisting health conditions.

“Democrats believe the No. 1 issue in America is health care, and the ability of people to get good health care at prices they can afford,” said Senate Minority Leader Chuck Schumer (D-N.Y.).

The Kavanaugh nomination, he added, “would put a dagger” through the heart of that belief.

Democratic senators spent Tuesday trying to connect the dots between potential threats to health care and Trump’s high court pick.

“President Trump as a candidate made it very clear that his priority was to put justices on the court who would correct for the fatal flaw of John Roberts,” said Sen. Chris Murphy (D-Conn.) on the Senate floor Tuesday. Chief Justice Roberts was the decisive fifth vote to uphold the ACA in a key case in 2012. “[Republicans’] new strategy is to use the court system to invalidate the protections in the law for people with preexisting conditions,” Murphy said.

Murphy — and many of his Democratic colleagues — are referring to a case filed in Texas in February by 20 Republican state attorneys general. The AGs charge that because the tax bill passed by Congress last year eliminated the tax penalty for not having health insurance, it rendered the entire health law void.

Their reasoning was that Roberts based his opinion upholding the ACA on Congress’ taxing power. Without the tax, the AGs argue, the law should be held unconstitutional.

The Trump administration, which would typically defend the ACA because defending federal law is part of what the Justice Department is tasked to do, opted to follow a different course of action.

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In a response filed in June, political appointees in the department said eliminating the penalty should not invalidate the entire law. But it should nullify provisions that prevent insurers from refusing to sell insurance to people with preexisting conditions or charging them higher premiums.

If this argument were to be upheld by a newly reconstituted Supreme Court, the health law would be dealt a serious blow.

The lawsuit, however, is only in its earliest stages. And many legal scholars on both sides doubt it will get very far.

In an amicus brief filed with the court in June, five liberal and conservative legal experts who disagreed on previous ACA cases argued that both the Republican attorneys general and the Justice Department are wrong — that eliminating the mandate penalty should have no impact on the rest of the law.

Their position is rooted in something called “congressional intent.” When a court wants to invalidate a portion of a law, it usually also has to determine whether Congress would have considered other aspects of the law unworkable without it.

But that is not a problem in this case, the legal experts argued in their brief. “Here, Congress itself has essentially eliminated the provision in question and left the rest of a statute standing,” they wrote. “In such cases, congressional intent is clear.”

The merits of the lawsuit notwithstanding, the issue works well for Democrats.

For one thing, the health law’s preexisting condition protections are among its most popular parts, according to public opinion polls.

And unlike abortion, defending the health law is something on which all Senate Democrats agree. That includes some vulnerable senators in states that voted for Trump in 2016, including Sens. Joe Manchin (D-W.Va.), Heidi Heitkamp (D-N.D.) and Joe Donnelly (D-Ind.). None are strong supporters of abortion rights. But all have stood firm against GOP efforts to take apart the Affordable Care Act.

Manchin, for example, said in a statement about the nomination, “The Supreme Court will ultimately decide if nearly 800,000 West Virginians with preexisting conditions will lose their health care.”

Manchin’s opponent in November is Republican Attorney General Patrick Morrisey. He is one of the officials who filed the suit against the health law.

Listen: Health Insurers Struggle With Sudden Freeze On ACA Payouts

July 10, 2018

Chad Terhune, a senior correspondent at California Healthline and Kaiser Health News, discussed the latest move by the Trump administration and the potential impact in California with A Martinez, host of the “Take Two” show on Southern California Public Radio.
Can’t see the audio player? Click here to download.

Health insurers and Covered California officials are facing another curveball from the Trump administration on the Affordable Care Act that could rattle the insurance market.

Over the weekend, Seema Verma, administrator for the federal Centers for Medicare & Medicaid Services, said she was suspending a $10 billion program that helps stabilize the insurance markets created under the health law.

She said the “risk-adjustment” payments and collections had to be halted in response to a New Mexico court ruling in February that said elements of the program were flawed. Another court in Massachusetts had upheld the program in January.

The risk-adjustment program doesn’t involve taxpayer money. Instead, the federal government collects money from some insurers that enrolled healthier patients and then transfers money to other insurers who had sicker enrollees.

Because the Affordable Care Act requires insurers to accept all people regardless of their medical history or preexisting conditions, architects of the law created the risk-adjustment program to prevent insurance companies from cherry-picking the healthiest people.

Nationally, insurance industry officials quickly denounced the Trump administration’s move and warned that the decision would drive up premiums.

The news comes at a critical time for the Covered California exchange, which was set to announce rates for 2019 this month. State officials indicated that decision could be delayed to allow more time to assess the situation.

There have been winners and losers in risk adjustment. Blue Shield of California has been a major beneficiary since Covered California and other ACA exchanges launched in 2014.

The San Francisco insurer received $582 million in risk-adjustment compensation for its participation in the individual market in 2014-2016, the second-highest amount nationally. It stood to receive an additional $556 million for 2017 alone, according to federal data released Monday. But that payout is now frozen.

Meantime, other insurers in California, such as Kaiser Permanente and Molina Healthcare, regularly owed money under the federal program. (Kaiser Health News is not affiliated with Kaiser Permanente.)

For years, Molina and other insurers have complained that the risk-adjustment program unfairly rewarded many Blue Cross Blue Shield plans that had excess administrative costs and higher premiums.

Blue Shield, the second-largest insurer on the Covered California exchange, declined to comment on the suspension of risk adjustment. Instead, the insurer referred to a statement from the Blue Cross Blue Shield Association.

“Without a quick resolution to this matter, this action will significantly increase 2019 premiums for millions of individuals,” the trade association said.

Critics said it was just the latest example of the Trump administration undermining the ACA and harming consumers who purchase individual policies. California Insurance Commissioner Dave Jones said the “Trump administration has just taken another step to sabotage the nation’s health insurance market.”

The Republican-led Congress failed last year to repeal and replace the ACA. However, Republican lawmakers and the Trump administration have made a series of moves intended to weaken the health law, such as halting subsidies that covered some consumers’ out-of-pocket costs and eliminating the penalty for not having insurance.

This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California Health Care Foundation.

Podcast: KHN’s ‘What The Health?’ Whither Work Requirements?

July 05, 2018
Julie Rovner

Kaiser Health News


Read Julie's Stories Stephanie Armour

The Wall Street Journal


Read Stephanie's Stories Anna Edney



Read Anna's Stories Joanne Kenen



Read Joanne's Stories

A federal District Court judge in Washington, D.C., has — for now — blocked Kentucky’s proposal to add a work requirement for much of its adult Medicaid population. The decision, while far from final, is likely to prompt lawsuits from advocates in other states where the Department of Health and Human Services has approved similar proposals.

Also this week, HHS released updated enrollment information about those purchasing health insurance in the individual market. Despite efforts by the Trump administration and Republicans in Congress to depress enrollment by cutting outreach and canceling federal payments to insurers, the number of people who actually paid their first month’s premium was up slightly in 2018, compared with 2017.

This week’s panelists for KHN’s “What the Health?” are: Julie Rovner of Kaiser Health News, Stephanie Armour of The Wall Street Journal, Anna Edney of Bloomberg News and Joanne Kenen of Politico.

Among the takeaways from this week’s podcast:

  • While the overall number of people buying coverage in the health law’s exchanges rose, the number of people not getting help with their premiums fell for the third-straight year. While some consumers may have found other coverage (through Medicare or jobs), rising premiums have been a problem.
  • The court decision blocking Kentucky’s Medicaid work requirement does not necessarily preclude other states’ work requirements from going forward. But the decision is likely to spark lawsuits in those states that have already had their work programs approved by HHS.
  • The window for bipartisan action on health care costs on Capitol Hill has closed. The Justice Department’s decision to join the state attorneys general lawsuit on preexisting conditions was likely the last straw. Issues surrounding coverage of preexisting conditions will now likely dominate the political discussion leading up to the midterm elections this fall.
  • Two things worth noting from the month of June. First, the recent court decision on risk-corridor payments to insurers seems to be a significant blow to the industry. Also, the Trump administration announced a major reorganization of Cabinet-level agencies. Although this is a common step for an administration, and something that rarely moves beyond “pie-in-the-sky” discussions, this one seems to be encapsulating the debate about the safety-net and social welfare programs.

Read the latest on the Bill of the Month series:

“Father’s And Son’s Injuries Lead To The Mother Of All Therapy Bills,” By Stephanie O’Neill.

If you have a medical bill you’d like NPR and KHN to investigate, you can submit it here.

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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: Kaiser Health News’ “Unlocked And Loaded: Families Confront Dementia And Guns,” by JoNel Aleccia and Melissa Bailey

Stephanie Armour: NPR’s “Rising Cost of PrEP to Prevent HIV Infection Pushes It Out of Reach for Many,” by Shefali Luthra and Anna Gorman

Anna Edney: The New York Times’ “Emergency Rooms Run Out of Vital Drugs, and Patients Are Feeling It,” by Katie Thomas

Joanne Kenen: The Washington Post’s “College Students Are Forming Mental-Health Clubs — and They’re Making a Difference,” By Amy Ellis Nutt

To hear all our podcasts, click here.

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Texas Clinics Busting Traditional Silos Of Mental And Physical Health Care

July 05, 2018

AUSTIN, Texas — Kerstin Taylor fought alcohol and substance abuse problems for two decades. She periodically sought help through addiction and psychiatric treatments to stay sober, but she continued to relapse.

That unrelenting roller coaster, and the emotional and mental fallout, left her with little energy or resources to take charge of her overall health. Taylor, 53, has asthma and doctors told her she was at risk of developing diabetes.

“I wasn’t doing anything to help myself,” she said about her physical health.

Then an opportunity to get coordinated mental and physical health care services helped turn life around for Taylor, who also lives with bipolar and obsessive-compulsive disorders.

Until recently, health care professionals, in general, treated the mind and body separately and cared for them under different systems. That meant someone like Taylor, who relies on public transportation, had trouble getting to referrals for physical care at locations far away from her psychiatric appointments. That made follow-ups unlikely.

In 2012, Integral Care in Austin offered Taylor a holistic approach, with access to physical health care and a program to manage chronic disease, on top of her regular psychiatric care. Many of the services were available either at the clinic or in her home, and one case manager would help Taylor handle it all.

The seamless care made a big difference, Taylor said, because her recovery depends on addressing all aspects of her health, not just her mental state.

“With chronic-disease [management], resting well, good nutrition, that’s a full package right there,” Taylor said. “It has really built me up to be a better woman.”

Now she has her own efficiency apartment in south Austin and plans to volunteer for a local animal charity. She walks regularly with a chronic-disease case manager and has taken courses to learn how to cook healthful food on a budget.

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Efforts to provide integrated care are spreading, especially in public health clinics.

It developed partly out of the realization that untreated mental health conditions negatively affect patients’ physical health, thus costing the system more money.

And in 2010, the Affordable Care Act established a mandate to give parity to mental health services.

A desire to reduce costly emergency room visits also is driving the trend.

A 2007 survey conducted by the Agency for Healthcare Research and Quality indicated that 1 in 8 emergency room visits were related to a mental health or substance abuse diagnosis. Those patients were also more than twice as likely to be admitted to the hospital during that visit.

Over the past decade, the federal government has bet on integrated care to help relieve the problem. From 2009 to 2015, the Substance Abuse and Mental Health Services Administration (SAMHSA) awarded 187 grants worth over $162 million to implement integrated care models.

The Centers for Medicare & Medicaid Services also is investing in integrated care. A 2013 report by SAMHSA found that Medicaid is the largest single payer for mental health services, and nearly a quarter of the inpatient hospital stays covered by the program were for mental health and substance abuse issues.

In Texas, 64 of the state’s 73 federally qualified health centers offer some mental health services, according to data from the Health Resources and Services Administration. That’s a jump from just 36 clinics over a decade ago.

Integrated health care is “fundamental” to achieving state goals such as reducing suicide rates, lowering incarceration rates for people with mental health issues and developing a savvier mental health care workforce, according to the state’s behavioral health strategic plan.

Learning To Be Flexible And Multitask

Austin’s CommUnity Care is a federally qualified health care clinic that serves mostly low-income and uninsured patients in several locations around the city. Pediatrician Tracy Lama-Briseño sees the benefits and challenges of integrated care there every day.

She said the average person would be surprised to learn how many young children and teens deal with mental health issues.

“We do have some pretty young kids that start to present at an early age with symptoms of anxiety or sadness,” she said. “Parents separating … the loss of a loved one. All that can be pretty confusing to a young child.”

Lama-Briseño’s clinic sees about 23,000 medical patients per year, approximately 1,700 of whom use mental health services.

Sometimes the boundaries of responsibility can get blurred between mental and physical health care, she said. “I feel like I do a little bit more social work than I would like,” she said. “But in the end, it’s about taking care of the kids and the families.”

Addressing mental health in primary care gives access to people who might never seek it out, but it also opens the door to additional responsibilities for Lama-Briseño. For instance, CommUnity Care administers a two-question depression screening to every new patient older than 12 and repeats it for existing patients once a year. The results can prompt further action.

Lama-Briseño describes how her young patients can come in for one thing, like an earache, and then the visit turns into something completely different. She said it all happens quickly.

“You can’t say ‘OK, make another appointment,’” she added. “It has to be, you know, dealt with then and there. And so I definitely had to learn how to be flexible and sort of multitask.”

Lack Of Mental Health Specialists

One of the challenges for the integrated model is recruiting mental health professionals. Approximately 1 million adults statewide have a “serious mental illness,” according to the Texas Health and Human Services Commission, and more than 80 percent of Texas’ 254 counties don’t have enough mental health professionals to care for patients.

The Department of State Health Services also reports that the majority of counties, especially in the western half of the state and in the Panhandle, have no practicing psychiatrists.

“My concern, actually, is that we don’t have a big enough pipeline to fill these jobs that are gonna be available,” said Neftali Serrano, executive director of the Collaborative Family Healthcare Association, an advocacy group for integrated care.

Serrano likened the problem to trying to build a plane while flying it. The health care system can’t just stop, so people need to be trained in this new way so that, as integrated care becomes more common, they’ll be ready to work, he said.

“This is not just about plopping a mental health professional in a primary care setting,” he said. “It takes … a certain kind of behavioral health professional, and well-trained physicians and nurse practitioners and [physician assistants] to do this work well.”

Buy-in from primary care doctors is another piece to the complicated puzzle of integrated care. While surveys show many support integrating mental health professionals with primary care, some lack the incentive to change their practices.

Dr. Ernest Buck is chief medical officer of Driscoll Health Plan, which serves mostly kids and families on Medicaid in a highly rural area that spans 26,000 square miles from south of San Antonio all the way down to Brownsville. Buck said most practices in his network aren’t willing to bring on a therapist.

“It’s hard to start a new model where a physician’s practice could be put at risk, particularly at Medicaid rates,” which tend to be lower than private insurance plan payments, he said.

Also, many primary care doctors simply weren’t trained to work this way — collaboratively, on a team with mental health professionals.

Bill Tierney, head of Population Health at the University of Texas-Austin’s Dell Medical School, said that when he was a practicing family doctor he rarely worked with mental health professionals.

“For 15 years, I practiced with no mental health support,” he said. “If I sent [patients] to the mental health clinic, I didn’t know whether they got there. They had a separate information system, I couldn’t see how they were being treated, and patients often didn’t want to go to see the shrink.”

Despite U.S. Court’s Ruling, Medicaid Work Requirements Advance In Other States

July 02, 2018

The fallout from Friday’s federal court ruling that struck down the Medicaid work requirement in Kentucky was swift.

The decision by Judge James Boasberg immediately blocked Kentucky from enacting the provision in Campbell County, which had been set to start Sunday and roll out statewide later this year.

Within 36 hours, Kentucky Gov. Matt Bevin, a Republican, eliminated vision and dental benefits to nearly 500,000 Medicaid enrollees, saying the state could no longer afford it.

Meanwhile, Arkansas, New Hampshire and Indiana are moving ahead with the implementation of their versions of a Medicaid work requirement. It is not clear how or if Boasberg’s ruling invalidating the Trump administration’s approval of Kentucky’s plan affects these states.

Arkansas is implementing its requirement this summer while New Hampshire and Indiana plan to phase in their rules beginning In January.

Virginia health officials say they still plan to seek federal permission to enact a work requirement but it isn’t needed in order to expand Medicaid eligibility on Jan.1.

Virginia lawmakers approved Medicaid expansion in June with the condition the state apply for federal permission to include the new mandate.

“We remain focused on the work necessary to ensure that new health coverage for Virginia adults is available beginning on January 1, 2019,” Dr. Jennifer Lee, director of the Virginia Department of Medical Assistance Services, said in a statement. “Developing a waiver is a separate and ongoing process, as described in the final state budget.”

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Virginia Medicaid is in discussions with the U.S. Centers for Medicare & Medicaid Services about its waiver, which has not yet been submitted.

Many Republican lawmakers in Virginia voted to expand Medicaid only after it was assured new enrollees would have to work or do volunteer service.

Dr. Scott Garrett, a Virginia House member from Lynchburg, Va., said he was under the impression the bill signed in June by Virginia Gov. Ralph Northam, a Democrat, meant the Medicaid expansion would begin only with a work requirement in place.

“The intent of the General Assembly … was that you could not do one absent the other,” he said.

Garrett, a Republican, said he long opposed plans to add 400,000 adults to Medicaid because of cost concerns. He said requiring these enrollees to work or do volunteer service would make them healthier and improve their well-being.

Patricia Boozang, senior managing director for Manatt Health, a consulting firm, said she is not surprised states are moving ahead with work requirement plans regardless of the court ruling, which was specific to Kentucky.

She said the decision would cause the Trump administration to review the pending applications more closely so they could withstand a judicial review.

The federal court said Health and Human Services Secretary Alex Azar did not adequately take into account how many people would lose coverage for the work requirement and did not prove such a provision would improve enrollees’ health.

“It’s going to be challenging for them to make the case that health and well-being is going to be improved by the [work requirement] waiver,” she said.

In Arkansas, some Medicaid enrollees face a Thursday deadline to register their status — that they worked, did volunteer service in June or meet one of the state’s many exemptions.

“The ruling does not have an immediate effect on Arkansas’ work requirement,” said spokeswoman Marci Manley.

Advocates for low-income people are weighing whether to file lawsuits to stop the work requirement in other states that have won federal approval.

“We have … partnerships with state legal advocates in these states and are exploring enforcement and litigation options with them,” said Jane Perkins, legal director of the National Health Law Program, which filed the suit on behalf of Medicaid enrollees in Kentucky to block the work requirements.

Judge Blocks Kentucky Medicaid Work Requirement

June 29, 2018

[UPDATED at 5:30 p.m. ET]

A federal judge on Friday struck down a Trump administration decision allowing states to force low-income adults to work to qualify for Medicaid.

The 60-page ruling, which is likely to be appealed, was hailed by advocates for the poor. But it could limit the number of states expanding Medicaid under the Affordable Care Act.

“The Secretary never adequately considered whether [the work requirement] would in fact help the state furnish medical assistance to its citizens, a central objective of Medicaid,” wrote Judge James Boasberg. “This signal omission renders his determination arbitrary and capricious.”

Boasberg also noted that “the Secretary never provided a bottom-line estimate of how many people would lose Medicaid with Kentucky HEALTH in place. This oversight is glaring, especially given that the risk of lost coverage was ‘factually substantiated in the record.’”

The case has been closely watched because work has never been a condition for receiving health coverage through Medicaid.

“Today’s decision is disappointing,” said Seema Verma, administrator of the Centers for Medicare & Medicaid Services. “States are the laboratories of democracy and numerous administrations have looked to them to develop and test reforms that have advanced the objectives of the Medicaid program. The Trump administration is no different.”

The administration is now reviewing its legal options, she said.

The ruling by the U.S. District Court immediately blocks Kentucky from moving ahead with implementing its work requirement, which was scheduled to begin its rollout Sunday.

“Even a temporary implementation of Kentucky HEALTH could cause serious harm,” Boasberg wrote in his decision.

Critics of the work requirement applauded the court’s finding, saying that it reinforced and emphasized Medicaid’s mission.

“Medicaid is about health insurance. Period,” said Frederick Isasi, executive director of Families USA, a consumer advocacy group that supported the health law. “And policies that make it harder for people to get health insurance run counter to the program’s purpose.”

Judy Solomon, vice president of the left-leaning Center on Budget and Policy Priorities, agreed, calling the decision “a big victory.” She said this work requirement rejection should apply to the other states looking to implement it.

Those on the other side of the issue took a different view.

“It’s a setback, but I would not call it a blow,” said Angela Rachidi, a research fellow with the conservative American Enterprise Institute. She said she believes that the ruling will affect only Kentucky and that other states will move forward with the same provision, which could illicit other lawsuits.

“Today’s decision is clearly erroneous and should be reversed swiftly,” said Jonathan Ingram, vice president of research at the Foundation for Government Accountability, which favored the work requirements and opposes the health law.

Kentucky Gov. Matt Bevin, a Republican, had threatened to scale back the health program if the courts rejected the mandate, a move that could leave hundreds of thousands of low-income adults without coverage.

Kentucky was the first of four states that won federal approval this year to advance a work requirement, a historic change in the federal-state program’s 53-year history. The others are Arkansas, Indiana and New Hampshire. It’s unclear if this federal court ruling invalidates the other states’ work requirement plans.

“This is a big roadblock for the four states looking to implement these already approved waivers,” said Matt Salo, executive director of the National Association of Medicaid Directors. “The court decision acknowledged that there will be appeals, and I suspect this may well end up at the Supreme Court eventually.”

Seven more states have applications pending with the federal government: Arizona, Kansas, Maine, Mississippi, Ohio, Utah and Wisconsin.

Kentucky’s program would have required nondisabled adults each month to participate in 80 hours of work, job training, education or other volunteer service to remain covered. Those failing to meet the requirement can regain coverage the month after they complete 80 hours of community engagement in a 30-day period or by taking a state-approved health literacy or financial literacy course.

Those exempted include pregnant women, full-time students, primary caregivers of a dependent and beneficiaries who are considered medically frail or have an acute medical condition that would prevent them from complying.

State officials estimate about 200,000 adults would have to comply with the new work requirements by year’s end.

Critics say the work requirement would lead many low-income people to lose their health coverage, and with it their access to care. They note Kentucky’s own projections show that 95,000 Medicaid enrollees would fall from the rolls within five years. They fear such a directive could have a chilling effect on people signing up for Medicaid or make it harder for people to qualify.

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About 500,000 adults were added to Medicaid in Kentucky after the state in 2014 expanded coverage to everyone with incomes below 138 percent of the federal poverty level, or about $16,700 for a single adult.

Adding a work requirement has been seen in some states as a way to give political cover to Republicans, who after initially resisting the expansion decided to pursue it.

The Republican-controlled Virginia legislature in May approved expanding Medicaid contingent on such a policy. Trump administration officials said the work requirement gives low-income adults an incentive to enter the workforce. Proponents argue that working or doing community service would improve enrollees’ health.

States that are implementing the policy have exempted large swaths of people, such as those who are pregnant, going to school, getting treatment for opioid addiction, taking care of a sick relative or suffering from a medical condition that prevents them from working.

Critics argue that people need Medicaid to get healthy so they can work. The work requirement, they add, was unnecessary because the large majority of Medicaid enrollees already work or go to school or care for a relative.

A Kaiser Family Foundation report estimated just 6 percent of adult Medicaid enrollees would be affected because they either already work or meet one of many exemptions. (Kaiser Health News is an editorially independent program of the foundation.)

But the idea has strong public backing. About 70 percent of Americans said they support states imposing a work requirement on nondisabled adults, according to a Kaiser Family Foundation poll last year.

Advocacy groups filed the lawsuit against the federal government and Bevin on behalf of 16 Kentucky Medicaid recipients. They claim the work requirement violates the 1965 law establishing Medicaid because it would reduce low-income people’s access to health care.

The decision also overturned the entire Kentucky Medicaid waiver approved by the Trump administration in January, saying that “preserving the status quo — including plaintiffs’ continuity of coverage — is appropriate.”

Under Kentucky’s plan, premiums would range from $1 a month for people with little or no income and up to $37.50 a month.

Those above the poverty line who fail to pay would be locked out of coverage for six months and must pay past-due premiums to regain coverage.

Those below the poverty line who don’t pay would have their reward accounts for receiving vision and dental benefits docked.

Heather Hahn, a senior fellow at the nonpartisan Urban Institute, said the ruling was important because it focused attention on the purpose of Medicaid, but she warned this was only the first battle in the legal war over the future of the program.

“There is a lot of momentum for work requirements, and I would expect people to try other avenues to move them forward,” she said.

Gov. Bevin filed a countersuit against those same 16 Medicaid recipients in a federal court in Frankfort, Ky., to uphold the work requirements and other provisions.

The Kentucky Hospital Association and the Kentucky Association of Health Plans filed briefs supporting Bevin in Frankfort while dozens of scholars representing some of the nation’s most prestigious schools of public health are backing the Medicaid recipients in the Washington case.

A decision is pending in the Frankfort lawsuit.


Podcast: KHN’s ‘What The Health?’ Justice Kennedy Retires. Now What?

June 28, 2018
Julie Rovner

Kaiser Health News


Read Julie's Stories Rebecca Adams

CQ Roll Call


Read Rebecca's Stories Alice Ollstein

Talking Points Memo


Read Alice's Stories Margot Sanger-Katz

The New York Times


Read Margot's Stories

The retirement of Supreme Court Justice Anthony Kennedy has triggered a political earthquake in Washington, as Republicans see a chance to cement a conservative majority and Democrats fear a potential overturn of abortion rights and anti-discrimination laws, and even — possibly — challenges to the Affordable Care Act. Kennedy has been the deciding vote in dozens of cases over his long career on the high court, mostly siding with conservatives but crossing ideological lines often enough that liberals see him as the last bulwark against challenges from the right to many policies.

The Supreme Court made other health news this week, ruling that California cannot require anti-abortion “crisis pregnancy centers” to post signs informing women of their right to an abortion and telling them that financial help is available.

This week’s panelists for KHN’s “What the Health?” are Julie Rovner of Kaiser Health News, Rebecca Adams of CQ Roll Call, Alice Ollstein of Talking Points Memo and Margot Sanger-Katz of The New York Times.

Among the takeaways from this week’s podcast:

  • Kennedy’s retirement will put all eyes on the Senate, where Republicans have a slim majority but have also changed the rules to allow confirmation with only 51 votes instead of the usual 60.
  • The fight over Kennedy’s replacement is likely to galvanize both Republicans and Democrats, but also put in the hot seat the two Republican female senators who have supported abortion rights — Susan Collins of Maine and Lisa Murkowski of Alaska.
  • This week’s primaries again put the spotlight on Democratic support of single-payer health proposals, as Alexandria Ocasio-Cortez upset the fourth-ranking Democrat in the House in New York and former NAACP head Ben Jealous won the Democratic nomination for governor in Maryland. But while Democrats have made clear that health is their top issue for the coming campaign, they have so far managed to paper over their intraparty differences on incremental versus wholesale change.
  • The California legislature could vote on a measure as soon as Thursday that would gut efforts by municipalities to put in place soda taxes. If it passes, it will mark a change in momentum away from the success of these measures across the country. The soda industry took a page from the tobacco companies in executing this plan.
  • The controversy surrounding the Trump administration’s immigration policy that separates children from their parents at the border continued to be a flashpoint this week. Health and Human Services Secretary Alex Azar was questioned about it on Capitol Hill during a hearing about drug pricing. Congressional Republicans find themselves in a difficult position. Many don’t want to defend the administration, but there doesn’t seem to be an avenue by which to move forward either.

To hear all our podcasts, click here.

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ACA Protections For Sick Patients Still Popular Despite GOP’s Efforts To End Them

June 27, 2018

Even as many Republicans continue to back a repeal of the Affordable Care Act, a majority of GOP voters want to retain a core consumer protection of the law that prohibits insurers from denying care or charging more to people with histories of health problems, according to a poll released Wednesday.

The requirement that insurers treat people with preexisting conditions the same as those with pristine health histories allowed the law to expand coverage to millions of previously uninsurable people starting in 2014.

But the Trump administration has refused to defend it in a legal challenge against the law brought by 20 Republican state attorneys general. The administration called for the protections guaranteeing coverage to be nullified.

The poll from the Kaiser Family Foundation showed 7 in 10 people think insurance companies should not be permitted to deny coverage because of a person’s medical history or charge them higher rates. Support for the preexisting conditions provision included 58 percent of Republicans. (Kaiser Health News is an editorially independent program of the foundation.)

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As the 2018 congressional elections near, Democratic and independent voters identify health care as “the most important issue” for candidates to discuss. Support for the provision is especially strong among households where someone has a preexisting condition. But it remains a second-tier priority for Republican voters, according to the poll, nearly tied with immigration and behind the economy and jobs. Nearly 6 in 10 Republican voters place a priority on a candidate’s support for repealing the health law.

There is more partisan agreement on President Donald Trump’s proposal to require that drugmakers publish list prices for their drugs in television commercials. Three-fourths of the public support the idea.

Those drug ads are ubiquitous on TV, and 14 percent of people who said they saw an ad said they had talked with a doctor about the specific medicine, the poll found. More than half said the physician gave them the drug and 48 percent said they discussed the cost of the medicine with the doctor.

The poll was conducted June 11-20 among 1,492 adults. The margin of error is +/-3 percentage points for the full sample.

‘You Can’t Have Perfection’: Lawmakers Who Forged ACA Look Back

June 27, 2018

Former Sens. Max Baucus (D-Mont.) and Chris Dodd (D-Conn.) and former Reps. Henry Waxman (D-Calif.) and George Miller (D-Calif.) and retiring Rep. Sander Levin (D-Mich.) led the five key committees that pushed the Affordable Care Act toward its passage in 2010.

They joined Kaiser Health News’ Julie Rovner during a session at the annual Aspen Ideas Festival in Colorado to discuss the partisan battles over the ACA, how their efforts in Congress differed from an earlier effort by the Clinton administration to revamp health care, and the problems that arose because they couldn’t get a bill through Congress to make corrections to the ACA.

They note the high price their party paid for implementing the law and the deep disagreement it sparked in the country about the role of government.

The former lawmakers agreed that they don’t think the law is perfect or meets all their hopes. While the bill generated intense opposition from conservatives during its initial debate, they said, they felt they could not give up. Their efforts to revamp health care were the foundation that future generations can build on, they said.

Thinking About An Association Health Plan? Read The Fine Print

June 26, 2018

If you own a restaurant, plumbing company or other small business, you may be intrigued by the expected expansion of association health plans under a new rule that got a stamp of approval from the Trump administration last week.

Will they meet your needs? Save you money?

Those are important questions for small businesses and self-employed people who struggle to buy affordable insurance for themselves and their workers.

Federal officials said the new rule would help level the playing field for these businesses, giving the kind of flexibility on benefits and leverage to negotiate with providers that large companies may have.

When announcing the policy on June 19, President Donald Trump said it would “result in very low prices, much more choice, much more freedom, including in many cases new opportunities to purchase health insurance. You’ll be able to do this across state lines.”

But detractors say the plans may not provide the full protection that workers need, plus the changes likely will drive up costs in the regular individual and small-group markets, where people who need comprehensive coverage would be forced to seek insurance.

Critics also point to “the long history of fraud and scams and insolvencies” for these plans, said Timothy Jost, emeritus professor of law at Washington and Lee University in Virginia.

“I think consumers are going to be in for a pretty wild ride,” Jost said.

Here are some details about what association health plans could mean for you.

Q: What are association health plans and what did the administration change?

Association health plans (sometimes called AHPs) allow small businesses to band together to buy insurance. Some plans have been in place for years, and those plans can continue to operate after the new rule takes effect. But the Trump administration’s regulation loosens the rules for additional plans to enter the market, allowing more small businesses, including individuals who work for themselves, to join these plans.

In contrast to earlier AHPs that generally required the association’s members to share an economic or other common purpose beyond enrolling in health insurance, new AHP members can be connected by geography alone or by business and professional interests. And under the new rule, providing members with insurance can be the main purpose of the association health plans.

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Q: When will the plans be available?

The new rule will be phased in starting in September. It’s uncertain how soon after that date plans will be offered.

Q: The ACA added some popular protections, including requiring plans to cover preventive care without charging consumers anything out-of-pocket and allowing people to keep their kids on their plan until they reach age 26. How will these provisions be handled under association health plans? 

Those provisions still apply to association health plans.

Q: How are preexisting medical conditions handled in the new rule?

Association health plans that are established under the new rule won’t be allowed to discriminate against individuals if they’re sick. But that doesn’t necessarily mean that people with preexisting medical conditions won’t encounter roadblocks in finding affordable, comprehensive coverage.

In the final rule, the administration lays out a variety of circumstances that could affect affordability. For example, an association plan could charge companies that employ construction workers higher premiums than firms that are in the hospitality business. The rule also allows plans to charge different rates based on gender, age and location.

Q: Will the plans cover a broad range of benefits?

It’s unclear. Association health plans are intended to make health insurance more affordable for small businesses in part by giving them the same kind of flexibility that large companies have in choosing which benefits they offer.

Flexibility may have a downside, though. AHP insurers don’t have to include the 10 “essential health benefits” that are required under the health law for plans in the individual and small-group market, typically companies with fewer than 50 employees. They might exclude coverage for prescription drugs or rehab services, for example.

Even though they’re not required to, large companies typically provide comprehensive benefits to compete for top talent. Smaller companies with fewer resources may find it tougher to afford generous employee perks.

Association health plans that cover employers with at least 15 employees will have to offer maternity coverage — one of the ACA’s essential health benefits — under the new rule. But smaller employers could skip that requirement.

The plans have to abide by the annual maximum out-of-pocket spending limit for the essential health benefits they decide to cover, and they can’t impose annual or lifetime limits on coverage of those benefits.

But since plans don’t have to cover all the essential health benefits, those protections aren’t as meaningful, some say.

“It waters down the out-of-pocket cap protection if you don’t have essential health benefit coverage requirements,” said Sarah Lueck, a senior policy analyst at the Center on Budget and Policy Priorities.

Q: How could premiums be affected?

The new rule allows health insurers to use several factors that may provide clues that people are likely to be expensive to insure, including gender, age, industry and geography, when setting rates for employers. A company with older workers who are more likely to have chronic conditions, for example, could face higher rates — as might one that employs lots of women, who might rack up charges for maternity care. In addition, individuals within a company could be charged different premiums based on their occupation or other factors not related to their health status if the employer chooses to do so, Jost said.

Q: Who’s likely to benefit under the rule? 

Companies that have relatively young, healthy employees could fare well.

“For young men in certain low-risk industries, who are currently healthy, they’re likely to encounter a relatively low premium,” said Justin Giovannelli, an associate research professor at Georgetown University’s Center on Health Insurance Reforms.

The Blue Cross Blue Shield Association, when filing comments on the proposed rule, said association health plan premiums for women in their early 30s might be more than 30 percent higher than rates under regular individual and small-group rules. It also estimated that rates for young men of a similar age could be more than 40 percent lower than ACA rates.

Similarly, companies in some industries could see lower premiums than others, according to BCBS. Rates for engineering companies could be about 9 percent lower than what insurers would charge on the individual and small-group market, for example, while those for the taxicab industry could be nearly 15 percent higher.

Q: What if an employer offers a really skimpy plan? Are workers stuck with it?

That depends. If an employer offers coverage that doesn’t meet minimum standards, workers can shop for subsidized health insurance on the marketplace, and the employer may face penalties. (Companies with fewer than 50 workers are exempt from penalties, however.) In 2018, that means that single coverage can’t cost workers more than 9.56 percent of their entire household income and plans have to pay at least 60 percent of the cost of covered benefits. The same rules apply if an employer offers coverage through an association health plan.

Some policy experts say they’re worried that people who work for small businesses may get burned if their companies, which do not offer any plans now, start offering coverage through an association health plan. The new plan may be skimpier and more expensive than the comprehensive coverage they’ve been getting on the ACA exchange.

“Even though the AHP coverage might be skimpy, employees would no longer be eligible for subsidized coverage on the exchange,” said Katie Keith, a health policy consultant who writes frequently about health law.

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

Podcast: KHN’s ‘What The Health?’ Live from Aspen!

June 22, 2018
Julie Rovner

Kaiser Health News


Read Julie's Stories Joanne Kenen



Read Joanne's Stories Margot Sanger-Katz

The New York Times


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With President Donald Trump and Republicans in Congress stymied in their efforts to change the nation’s health care system, individual states are wrangling with public ire over price and coverage.

Two guests this week, Democratic Govs. John Hickenlooper of Colorado and Steve Bullock of Montana, have made health a priority in their states and are among the governors who have signed on to bipartisan efforts to shore up parts of the Affordable Care Act that are not working. Both governors are also among the long list of Democrats mentioned as possible presidential candidates in 2020.

Meanwhile, actions in Washington, including this week’s regulation expanding the availability of association health plans, often leave states scrambling to figure out what it will mean for their own health insurance markets.

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

Among the takeaways from this week’s podcast:

  • Both governors said they think health care will be a dominant voting issue in 2018 and 2020. They say governors are among the few who are able to work on the issue on a bipartisan basis.
  • The conservative health plan unveiled this week as a replacement for the Affordable Care Act would give states more flexibility. It also would likely pose an enormous challenge because, over time, it would reduce the amount of federal health care dollars and wouldn’t give states much time to implement their programs.
  • If a federal court in Washington, D.C., opts to throw out Kentucky’s Medicaid work requirement for nondisabled adults, expansion plans in a number of states could be thrown into disarray. Some of them, like Kentucky, say they will not keep the expansion without the work requirement.
  • Montana offered a somewhat different path to work for people who are covered under the Medicaid expansion. Eighty percent of them are working already. Instead of being punitive, Bullock said, the state made a number of support services and employment training options available and, in turn, that raised the number of those working by 9 percent.
  • Hickenlooper said that in Colorado, because the unemployment rate is below 3 percent, most of the nondisabled adults who were covered under Medicaid expansion and not working are instead caring for their children or elder family members.

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Administration Eases Way For Small Businesses To Buy Insurance In Bulk

June 19, 2018

Small employers will more easily be able to band together to buy health insurance under rules issued Tuesday by the Trump administration, but the change could raise premiums for plans sold through the Affordable Care Act’s online marketplaces, analysts say.

The move loosens restrictions on so-called association health plans, allowing more businesses, including sole proprietors, to join forces to buy health coverage in bulk for their workers.

By effectively shifting small-business coverage into the large-group market, it exempts such plans from ACA requirements for 10 “essential” health benefits, such as mental health care and prescription drug coverage, prompting warnings of “junk insurance” from consumer advocates.

Supporters say the new Labor Department rules, which the government estimated could create health plans covering as many as 11 million people, will lead to more affordable choices for some employers.

When it comes to health insurance, “the regulatory burden on small businesses should certainly not be more than that on large companies,” Labor Secretary Alexander Acosta told reporters Tuesday.

Existing rules limit association plans to groups of employers in the same industry in the same region.

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The new regulations eliminate the geographical restriction for similar employers, allowing, for example, family-owned auto-repair shops in multiple states to offer one big health plan, said Christopher Condeluci, a health benefits lawyer and former Senate Finance Committee aide.

The rules, to be implemented in stages into next year, also allow companies in different industries in the same region to form a group to offer coverage — even if the only reason is to provide health insurance.

Like other coverage under the ACA, association insurance plans will still be required to cover preexisting illnesses.

Analysts warn that because these changes will likely siphon away employers with relatively healthy consumers from ACA coverage into less-expensive trade-association plans, the result could be higher costs in the online marketplaces.

“If you have a group that is healthier than average, you might get a better rate from one of these plans, and your broker is going to come and say, ‘Hey, I can get you a better deal,’” said Dan Mendelson, president of Avalere Health, a consulting firm.

That would mean that, on balance, consumers insured through ACA small-group and individual plans could be older, sicker and more expensive, adding to years of erosion of the ACA marketplaces engineered by Republicans hostile to the law.

Loosening rules for association plans would lead to 3.2 million people leaving the ACA plans by 2022 and raising premiums for those remaining in individual markets by 3.5 percent, Avalere calculated this year.

America’s Health Insurance Plans, the largest medical insurance trade group, issued a statement saying the regulation “may lead to higher premiums” in ACA insurance and “could result in fewer insured Americans.”

Unlike ACA plans, association coverage does not have to include benefits across the broad “essential” categories, including hospitalization and emergency care.

The National Association of Insurance Commissioners previously warned that such plans “threaten the stability of the small group market” and “provide inadequate benefits and insufficient protection to consumers.”

The American Academy of Actuaries has expressed similar concerns.

Business groups praised the change, proposed in draft form earlier this year.

“We’ve been advocating for association health plans for almost 20 years, and we’re pleased to see the department moving aggressively forward,” said David French, senior vice president of government relations for the National Retail Federation.

Association plans have been around for decades, although enrollment has been more limited since the ACA’s passage. While some of the plans have worked well for their members, others have a checkered history.

In April, for example, Massachusetts regulators settled with Kansas-based Unified Life Insurance Company, which agreed to pay $2.8 million to resolve allegations that it engaged in deceptive practices, such as claiming it covered services that it did not.

The coverage “was sold across state lines and was issued through a third-party association,” according to a release from the Massachusetts attorney general’s office.

Postcard From D.C. Courthouse: Medicaid Work Requirements And Manafort

June 15, 2018

It’s probably safe to say that the scrum of reporters — noses and lenses pressed up to the glass doors of the E. Barrett Prettyman Federal Courthouse in Washington, D.C., — were not there to cover a hearing regarding Kentucky’s work requirements for some Medicaid recipients.

No, the news satellite trucks parked outside and long queue of spectators stacked up against the building where there to catch a glimpse of Paul Manafort, President Donald Trump’s former campaign chairman, who was appearing that same morning before another judge in another federal courtroom.

But while the hearing for the Stewart v. Azar case might not have generated as much buzz as Manafort’s, it has the potential to impact many more people. Kentucky itself says as many as 95,000 enrollees would likely lose coverage.

Judge James E. Boasberg acknowledged that he wasn’t presiding over the flashiest case in the courthouse.

“I guess the Paul Manafort overflow room was full so you decided to come in here,” he said.

Even so, Boasberg’s courtroom was packed, with about 65 people inside and a few others waiting outside.

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People started to line up for entry more than 90 minutes before the hearing’s 11 a.m. start. They huddled in the cream-colored hallway near its marble pillars to discuss health policy — and the Manafort scene. By 10:30 a.m., a security guard arrived on the scene to shush the assembled crowd, complaining that she could hear their chatter from “every level” of the courthouse.

Who knew Medicaid wonks were such a rowdy bunch?

There was a lot at stake, though. The case’s outcome could reverberate across the country and help determine how much authority the Trump administration has to unilaterally change Medicaid.

Medicaid is the federal-state health insurance program for low-income and disabled people. Kentucky expanded Medicaid under the Affordable Care Act, but got approval from the Trump administration this year to require healthy adults who gained that coverage to prove that they are working, volunteering or taking care of family members for at least 80 hours each month.

Three advocacy organizations sued the federal government on behalf of 15 Kentucky Medicaid recipients who said they would lose their coverage if the work requirements, and some other aspects of Kentucky’s plan, were implemented.

The crux of the argument boiled down to this: What is the purpose of Medicaid?

Ian Heath Gershengorn, the attorney arguing on behalf of the Medicaid recipients, said the Kentucky plan went too far. Instead of tweaking some things to make Medicaid better or allow it to serve more people, he argued that Kentucky was fundamentally turning it away from a program designed to improve medical access.

The main goal of the Medicaid statute, according to Boasberg, was to furnish “medical assistance” to people. How then could stripping coverage from 95,000 individuals fit that definition, he asked.

Justice Department attorney Ethan Davis said people who lost their coverage because of the work requirement would find it in the private or employer-sponsored market. Plus, the secretary of Health and Human Services had interpreted Kentucky’s plan to be consistent with Medicaid’s, he added.

Davis also said if Kentucky’s work requirements were struck down, it would discourage other states from expanding their Medicaid programs.

Boasberg said he would try to have a decision by the end of June. Kentucky’s work requirements are scheduled to go into effect July 1.

Most Texans Want State To Expand Medicaid And Help Poor Get Health Care

June 14, 2018

Texans think the Legislature should expand Medicaid to more low-income people and make health care more affordable, according to a survey released Thursday.

Researchers surveyed 1,367 Texans between March and May of this year about topics ranging from Medicaid, the Affordable Care Act, maternal mortality and the role of government in tackling health care issues.

Here are some takeaways from the survey by the Kaiser Family Foundation and the Episcopal Health Foundation. (Kaiser Health News is an editorially independent program of the Kaiser Family Foundation.)

1) Almost All Texans See A Role For The Texas Legislature

Texans overwhelmingly agree that the state should have a role in making health systems work. According to the survey, 67 percent of those surveyed said the state should have a “major role” and 28 percent said a “minor role” in health care. Only 5 percent of Texans said the state should have no role.

“A majority of Texans say that the state has an important role to play in health care,” said Elena Marks, the president and chief executive officer of the Episcopal Health Foundation. “The state is not doing enough and the state should spend more. And people also believe that the state has a role to play in increasing access to insurance.”

2) Texans Are Concerned About Maternal Deaths

When asked what the state Legislature should make a top health care priority, 59 percent of Texans said “reducing the number of women who die from causes related to pregnancy and childbirth.”

That response came in a close second to “lowering the amount individuals pay for health care” (61 percent).

Marks says she thinks a lot of this concern is probably related to media coverage around maternal mortality and that the question itself is really a “no-brainer.”

“‘You mean people are dying from pregnancy and childbirth?’” she said. “I think people may just look at that and go, ‘Well, of course you should be doing something about that.’”

3) Medicaid Expansion Is Popular

About two-thirds of Texans (64 percent) said they think Texas should expand Medicaid to cover more low-income people. Texas is 1 of the 17 states that have not expanded Medicaid under the Affordable Care Act.

Even though feelings in the state are still mixed on the ACA, the survey found that Medicaid is quite popular.

“Roughly 4 million people are covered by Medicaid in Texas, nearly three-quarters of whom are children,” according to the survey’s authors. When asked, 6 in 10 Texans said Medicaid is important to their families.

Marks said she thinks the conversation about Medicaid expansion in Texas is limiting for people seeking more insurance coverage here. She says the state should have a conversation about coming up with its own way to expand access to affordable coverage, which is a popular idea across the political spectrum.

“Let’s stop talking about Medicaid expansion and let’s start talking about expanding access to affordable health insurance coverage,” Marks said.

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4) Texans Say We Aren’t Helping The Poor Enough

Roughly two-thirds of Texans also say the state is not doing enough to make sure low-income people get the health care they need.

Respondents also think lawmakers could do more to help children (45 percent) and immigrants (41 percent) get coverage. Broken down by party, Republicans were less likely to say that the state is not doing enough to help vulnerable populations get health care services.

5) A Lot Of Texans Don’t Know Basic Facts About Health Care Here

One of the standouts in this survey is how little people know about the state’s health care system. Consistently, however, Republican respondents were more likely to be misinformed.

For example, groups asked Texans whether the state’s uninsured rate is higher compared to other states. According to the survey, 3 in 10 Texans (31 percent) correctly answer that it is higher. Broken down by party, only 24 percent of Republicans knew Texas has a larger than average share of uninsured people, while 38 percent of Democrats did.

Marks says that could explain why Republicans are less likely to say they think there are problems with the state’s health care system.

“If you think we have about the same or lower uninsured rates, then you don’t think there’s a problem unique to us that we need to solve,” she said.

Texans were also asked whether Medicaid had been expanded in the state; 51 percent of those surveyed correctly said the state had not expanded it.

According to the study’s authors, “Democrats are somewhat more likely than Republicans and independents to know that Texas has not expanded its Medicaid program” (62 percent, 43 percent, and 52 percent, respectively).

This story is part of a partnership that includes KUT, NPR and Kaiser Health News.

KHN’s coverage of women’s health care issues is supported in part by The David and Lucile Packard Foundation.

Podcast: KHN’s ‘What The Health?’ California Here We Come

June 14, 2018


Health care is a big political issue, but no place more than in California. In San Francisco last week, voters overwhelmingly approved a ballot measure upholding a ban on flavored tobacco products — over the vehement objections of the tobacco industry.

And the state’s activist attorney general, Xavier Becerra, is leading a group of Democratic officials from more than a dozen states defending the Affordable Care Act in a case filed in Texas. That is important given that the Trump administration’s Justice Department decided not to defend the law in full from charges that changes made by Congress in last year’s tax law invalidates the health law.

This week’s panelists for KHN’s “What the Health?” are: Julie Rovner of Kaiser Health News, Anna Maria Barry-Jester of, Carrie Feibel of KQED San Francisco and Joanne Kenen of Politico.

Among the takeaways from this week’s podcast:

  • Republicans and Democrats had been gearing up for a midterm election debate on who is responsible for higher health insurance costs. But that shifted last week to an argument over whether consumers with preexisting conditions should be guaranteed coverage following the Justice Department’s brief saying changes to the ACA invalidated those protections.
  • In California, there is widespread support among Democrats for a single-payer health system. But the term is somewhat amorphous. For some officials, it is a catch-all phrase that seems to suggest strong efforts with current programs to get the uninsured rate down to zero, while still keeping much of the current insurance system in place.
  • Becerra has filed a suit against Sutter Health, a giant in the hospital industry in Northern California, alleging that consolidation has resulted in anti-competitive pricing practices.
  • San Francisco’s adoption of a referendum to ban flavored tobacco products could lead other local governments to follow suit. The measure included not only products with flavors allegedly geared to young people, but also menthol cigarettes, which make up about 30 percent of the market.

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

Julie Rovner: The New York Times, “Elizabeth Warren And A Scholarly Debate Over Bankruptcy That Won’t Go Away,” by Margot Sanger-Katz.

Anna Maria Barry-Jester: The Atlantic, “Being Black In America Can Be Hazardous To Your Health,” by Olga Khazan.

Carrie Feibel: KQED, “In The Land Of Legal Weed, Drug Education Moves From ‘Don’t’ To ‘Delay,’” by Carrie Feibel.

Joanne Kenen: The Miami Herald, “She Dreamed Of Getting Plastic Surgery In Miami. Three Days Later, She Was Dead,” by Sarah Blaskey, Sonia Osorio, and Daniel Chang.

To hear all our podcasts, click here.

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