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Updated: 16 hours 21 min ago

Medicare For All? CMS Chief Warns Program Has Enough Problems Already

October 16, 2018

The Trump administration’s top Medicare official Tuesday slammed the federal health program as riddled with problems that hinder care to beneficiaries, increase costs for taxpayers and escalate fraud and abuse.

Seema Verma, administrator of the Centers for Medicare & Medicaid Services (CMS), said those troubles underscore why she opposes calls by many Democrats for dramatically widening eligibility for Medicare, now serving 60 million seniors and people with disabilities, to tens of millions other people.

“We only have to look at some of Medicare’s major problems to know it’s a bad idea,” Verma told health insurance executives at a meeting in Washington.

CMS lacks the authority from Congress to operate the program effectively, Verma said, which means it often pays higher-than-necessary rates to doctors and hospitals and can’t take steps used by private insurers to control costs.

“We face tremendous barriers to supporting and bringing innovation to Medicare, and it literally takes an act of Congress to add new types of benefits for the Medicare population,” she added.

Since Medicare was approved in 1965, Congress has held power over eligibility and benefits — largely to control spending. That has meant efforts to expand services can get weighed down by partisan politics and swayed by lobbying groups, which significantly delay changes. One example: Congress didn’t add a pharmaceutical benefit to Medicare until 2003 — decades after drugs became a mainstay in most treatments.

Advocates for seniors have called for adding vision and dental benefits for many years, but the proposals have gotten little traction because of cost concerns.

Another problem, according to Verma, is that her agency reviews less than 0.2 percent of the more than 1 billion claims that Medicare receives from providers. “That is ridiculously low,” she said.

Verma also lamented the traditional Medicare program’s limited ability to require doctors and hospitals to get prior authorization from the federal government before performing certain procedures. That process — which has been routine for decades in the private sector — can lead to higher improper payments to doctors and more fraud and abuse, she said.

Jonathan Oberlander, a professor in the department of health policy and management at the University of North Carolina-Chapel Hill, agreed with Verma that “Medicare is not always nimble, particularly in adjusting benefits,” and officials have long complained that Congress micromanages the program. Still, he added, “with a program as large and important to Americans as Medicare, it is perfectly appropriate for Congress to weigh in on the addition of new benefits, especially since taxpayers will bear the costs of those changes.”

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Verma for months has spoken out against the “Medicare-for-all” proposals pushed by Sen. Bernie Sanders (I-Vt.) and a growing chorus of Democrats. But her 35-minute address to the meeting of the trade group America’s Health Insurance Plans marked the first time she listed the litany of problems with Medicare, which she has run since March 2017.

Proponents of “Medicare-for-all” are reacting to problems caused by the Affordable Care Act, she said, and should know expanding Medicare will worsen the program’s existing challenges of controlling costs and improving care.

“But their solution is literally to do more of what’s not working,” she added. “It’s like the man who has a pounding headache, who then takes a hammer to his head to make it go away.”

Verma’s comments, however, overlooked the key leadership role that Medicare plays in the health sector, which is often emulated by private insurers, Oberlander said.

“In payment reform, Medicare has a record of being a leader and innovator,” he said. “For all of their supposed advantages, private insurers pay much higher prices than Medicare does for medical services. Verma ignores the fact that Medicare’s price regulation has produced substantial savings.”

Although Verma heavily criticized the traditional Medicare program, which covers two-thirds of enrollees, she boasted about how she and the Trump administration were running Medicare Advantage, the fast-growing alternative program that is operated by private insurers such as UnitedHealthcare and Humana.

More than 20 million Medicare beneficiaries are enrolled in these plans, which often cost members less than traditional Medicare and have additional benefits. But they generally require members to use only the plan’s network of providers.

“Medicare Advantage represents value for our beneficiaries and taxpayers,” Verma said.

She touted a 2019 CMS initiative that will for the first time allow the Advantage plans to offer supplemental health benefits that go beyond traditional dental and health services. These include adult day care, in home support services and meals.

It is “one of the most significant changes made to the Medicare program” and “will have a major impact” on improving health for plan members, she said.

But the private plans have taken a cautious approach to adding those benefits.

About 270 Medicare Advantage plans — or fewer than 10 percent of the total — agreed to offer these services next year.

At the AHIP conference on Monday, health insurance executives said they were still trying to figure out which of their members would most likely benefit from the new offerings.

“We are operating in a vacuum of good evidence,” said William Shrank, chief medical officer of UPMC Health Plan in Pittsburgh. Nonetheless, Shrank said the opportunity to offer new benefits going beyond just health care could help beneficiaries stay out of the hospital and lead healthier lives.

Verma did not mention a report last month by the Department of Health and Human Services’ inspector general that found many Advantage plans were improperly denying claims from patients and doctors.

Administration critics were quick to note that omission.

“Her intemperate attack on traditional Medicare — on which two-thirds of all beneficiaries rely and which millions value so highly” — is “striking,” said Sara Rosenbaum, a professor of health law and policy at George Washington University. As is “her utter failure to acknowledge the serious challenges in making Medicare Advantage operate fairly, which her own inspector general underscored.”

Listen: Health Care Issues Reverberate In The States

October 15, 2018

Julie Rovner, chief Washington correspondent for Kaiser Health News, joined “1A” host Joshua Johnson, Scott Greenberger, the executive editor of Stateline, and Reid Wilson, national correspondent for The Hill, to discuss health policy initiatives in the states.

Among the topics they examined are Medicaid expansion efforts, work requirements that some states are implementing for Medicaid, efforts to bring down the price of prescription drugs and programs to battle the opioid epidemic. You can listen to the discussion on the “1A” broadcast page.

Medicare Advantage Riding High As New Insurers Flock To Sell To Seniors

October 15, 2018

Health care experts widely expected the Affordable Care Act to hobble Medicare Advantage, the government-funded private health plans that millions of seniors have chosen as an alternative to original Medicare.

To pay for expanding coverage to the uninsured, the 2010 law cut billions of dollars in federal payments to the plans. Government budget analysts predicted that would lead to a sharp drop in enrollment as insurers reduced benefits, exited states or left the business altogether.

But the dire projections proved wrong.

Since 2010, enrollment in Medicare Advantage has doubled to more than 20 million enrollees, growing from a quarter of Medicare beneficiaries to more than a third.

“The Affordable Care Act did not kill Medicare Advantage, and the program looks poised to continue to grow quite rapidly,” said Bill Frack, managing director with L.E.K. Consulting, which advises health companies.

And as beneficiaries get set to shop for plans during open enrollment — which runs from Monday through Dec. 7 — they will find a greater choice of insurers.

Fourteen new companies have begun selling Medicare Advantage plans for 2019, several more than a typical year, according to a report out Monday from the Kaiser Family Foundation. (KHN is an editorially independent part of the foundation.)

Overall, Medicare beneficiaries can choose from about 3,700 plans for 2019, or 600 more than this year, according to the federal government’s Centers for Medicare & Medicaid Services.

CMS expects Medicare Advantage enrollment to jump to nearly 23 million people in 2019, a 12 percent increase. Enrollees shopping for new plans this fall will likely find lower or no premiums and improved benefits, CMS officials say.

With about 10,000 baby boomers aging into Medicare range each day, the general view of the insurance industry, said Robert Berenson, a Medicare expert with the nonpartisan Urban Institute, “is that their future is Medicare and it’s crazy not to pursue Medicare enrollees more actively.”

Bright Health, Clover Health and Devoted Health, all for-profit companies, began offering Medicare Advantage plans for 2018 or will do so for 2019.

Mutual of Omaha, a company owned by its policyholders, is also moving into Medicare Advantage for the first time in two decades, providing plans in San Antonio and Cincinnati.

Some nonprofit hospitals are offering Medicare plans for the first time too, such as the BayCare Health system in the Tampa, Fla., area.

While Medicare beneficiaries in most counties have a choice of several plans, enrollment for years had been consolidated into several for-profit companies, primarily UnitedHealthcare, Humana and Aetna, which have accumulated just under half the national enrollment.

These insurance giants are also expanding into new markets for next year. Humana in 2019 will offer its Medicare HMO in 97 new counties in 14 states. UnitedHealthcare is moving into 130 new counties in 13 states, including for the first time Minnesota, its headquarters for the past four decades.

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Extra Benefits

Seniors have long been attracted to Advantage plans because they often include benefits not available with government-run Medicare, such as vision and dental coverage. Many private plans save seniors money because their premiums, deductibles and other patient cost sharing are lower than what beneficiaries pay with original Medicare. But there is a trade-off: The private plans usually require seniors to use a restricted network of doctors and hospitals.

The federal government pays the plans to provide coverage for beneficiaries. When drafting the ACA, Democratic lawmakers targeted the Medicare Advantage plans because studies had shown that enrollees in the private plans cost the government 14 percent more than people in the original program.

Medicare plans weathered the billions in funding cuts in part by qualifying for new federal bonus payments available to those that score a “4” or better on a five-notch scale of quality and customer satisfaction.

Health plans also gained extra revenue by identifying illnesses and health risks of members that would entitle the companies to federal “risk-adjustment” payments. That has provided hundreds of billions in extra dollars to Medicare plans, though congressional analysts and federal investigators have raised concerns about insurers exaggerating how sick their members are.

A study last year found that those risk adjustments could add more than $200 billion to the cost of Medicare Advantage plans in the next decade, despite no change in enrollees’ health.

For-profit Medicare Advantage insurers made a 5 percent profit margin in 2016 — twice the average of Medicare plans overall, according to the Medicare Payment Advisory Commission, which reports to Congress. That’s slightly better than the health insurance industry’s overall 4 percent margin reported by Standard & Poor’s.

Those profit margins could expand. The Trump administration boosted payments to Medicare Advantage plans by 3.4 percent for 2019, 0.45 percentage points higher than the 2018 increase.

Betsy Seals, chief consulting officer for Gorman Health Group, a Washington company that advises Medicare Advantage plans, said many health plans hesitated to enter that market or expand after President Donald Trump was elected because they weren’t sure the new administration would support the program. But such concerns were erased with the announcement on 2019 reimbursement rates.

“The administration’s support of the Medicare Advantage program is clear,” Seals said. “We have seen the downstream impact of this support with new entrants to the market — a trend we expect to see continue.”

Getting Consumers To Switch

Since the 1960s, Mutual of Omaha has sold Medicare Supplement policies — coverage to help beneficiaries in government-run Medicare pay the portion of costs that program doesn’t pick up. But the company only briefly entered the Medicare Advantage business once — in its home state of Nebraska in the 1990s.

“In the past 10 or 20 years it never seemed quite the right time,” said Amber Rinehart, a senior vice president for the insurer. “The main hindrance was around the political environment and funding for Medicare Advantage.”

Yet after watching Medicare Advantage enrollment soar and government funding increase, the insurer has decided now is the time to act. “We have seen a lot more stability of funding and the political tailwinds are there,” she said.

One challenge for the new insurers will be attracting members from existing companies since beneficiaries tend to stick with the same insurer for many years.

Vivek Garipalli, CEO of Clover Health, said his San Francisco-based company hopes to gain members by offering low-cost plans with a large choice of hospitals and doctors and allowing members to see specialists in its network without prior approval from their primary care doctor. The company is also focused on appealing to blacks and Hispanics who have been less likely to join Medicare Advantage.

“We see a lot of opportunity in markets where there are underserved populations,” Garipalli said.

Clover has received funding from Alphabet Inc., the parent company of Google. Clover sold Medicare plans in New Jersey last year and is expanding for 2019 into El Paso, Texas; Nashville, Tenn.; and Savannah, Ga.

Newton, Mass.-based Devoted Health is moving into Medicare Advantage with plans in South Florida and Central Florida. Minneapolis-based BrightHealth is expanding into several new markets including Phoenix, Nashville, Cincinnati and New York City.

BayCare, based in Clearwater, Fla., is offering a Medicare plan for the first time in 2019.

“We think there is enough market share to be had and we are not afraid to compete,” said Jim Beermann, vice president of insurance strategy for BayCare.

Hospitals are attracted to the Medicare business because it gives them access to more of premium dollars directed to health costs, said Frack of L.E.K. Consulting. “You control more of your destiny,” he added.

Must Reads Of The Week From Brianna Labuskes

October 12, 2018
The Friday Breeze

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

Just in case our ever-decreasing anonymity in this tech-driven world hasn’t scared you enough, new studies find that within a few years 90 percent — 90 percent! — of Americans of European descent will be identifiable from their DNA. If you fall into that group, it doesn’t even matter whether you’ve given a DNA sample to one of the popular gene-testing sites (like 23andMe). Enough of your distant relatives have, so there’s a good chance you’re in the system.

Take your mind off that by checking out what you may have missed in health care this week.

The biggie, of course, was President Donald Trump’s opinion piece in USA Today about “Medicare-for-all.” (And the rebuttal from Vermont Sen. Bernie Sanders.)

Fact checkers came out in droves to comb through Trump’s arguments and found that nearly every paragraph contained a misleading statement or falsehood.

The Washington Post: Fact-Checking President Trump’s USA Today Op-Ed on ‘Medicare-for-All’

More than shedding any kind of light on the complicated topic, the back-and-forth highlights how much of a role health care is playing in the upcoming midterm elections. Each side has doubled down on its respective talking points (read: preexisting conditions and Medicare-for-all — I warned you you’d get tired of me saying that). In fact, health care is featured so heavily in ads that it trumps the topics of jobs or taxes.

The Wall Street Journal: Health Care Crowds Out Jobs, Taxes in Midterm Ads

(Side note: If you do want some light shed on Medicare-for-all and single-payer systems, check out these great pieces from KHN’s own Shefali Luthra.)

Speaking of midterms, the Democrats’ attempt to block the administration’s expansion of short-term plans (very predictably) failed, with only Maine Republican Sen. Susan Collins joining the Democrats. It was never about winning, though. What it did was force Republicans to go on record with a vote that is potentially politically dangerous in the current landscape.

Politico: Senate Democrats Fail to Block Trump’s Short-Term Health Plans

In stark contrast to the sharply partisan discourse, Trump signed two bipartisan health care measures into law this week. The bills banned “gag clauses” on pharmacists, which had prohibited them from offering consumers cheaper options. The legislation won’t directly affect drug prices, but it might mean people will pay less at the register.

The New York Times: Trump Signs New Laws Aimed at Drug Costs and Battles Democrats on Medicare

The Friday Breeze

Want a roundup of the must-read stories this week chosen by KHN Newsletter Editor Brianna Labuskes? Sign up for The Friday Breeze today.

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For the first time, premiums for the most popular level of insurance sold in the health law marketplaces have gone down. The numbers are the latest sign that the marketplace is stabilizing. (Centene’s expansion into new states is another from this week.) CMS Administrator Seema Verma touted the success, saying the news counters any accusations of sabotage. Health experts, however, said those price tags would have been even lower if not for the administration’s actions over the past year.

The Washington Post: Premiums for Popular ACA Health Insurance Dip for the First Time

The Justice Department approved CVS’ $69 billion merger with Aetna, and although the deal still needs approval from state regulators, the green light is a major hurdle cleared. The merger would reshape the health landscape and mark the end of an era for free-standing pharmacy benefit managers. The potential consolidation is just one of many in recent years in a fast-evolving industry — a trend critics worry will lessen competition and drive up prices for consumers.

The New York Times: CVS Health and Aetna $69 Billion Merger Is Approved With Conditions

Hospitals scrambled to ensure patient safety as Hurricane Michael battered Florida and Georgia this week. “It was like hell,” said one doctor who rode out the storm at Bay Medical Center in Panama City, Fla. The hurricane brought with it memories of last year’s power outages that came with Hurricane Irma and were linked to the deaths of several nursing home residents.

The New York Times: Hospitals Pummeled by Hurricane Michael Scramble to Evacuate Patients

Now that the Brett Kavanaugh battle is over and he’s taken a seat on the Supreme Court, Planned Parenthood has gone into planning mode in case anything happens to Roe v. Wade. A key component of the organization’s plan is to shore up networks in states where abortion would likely remain legal (with longer hours for clinics, for example). On the other side, abortion-rights opponents are getting primed for a new high court that’s likely friendlier to them by strategizing what cases would be best to move forward with.

NPR: With Kavanaugh Confirmed, Both Sides of Abortion Debate Gear Up for Battle

How do you fight measures to expand abortion rights in progressive states? Make it about money. A battle in Oregon illustrates a strategy that — although unlikely to be successful — gives opponents of the bills at least a hope of winning.

Politico: Oregon’s Unlikely Abortion Fight Hinges on Taxes

Holes in the court system have allowed state judges to grant full custody of migrant children to American families — without notifying their parents. Federal officials say it should never happen, but oversight of the problem is scattershot and challenging because states handle adoption proceedings differently.

The Associated Press: Deported Parents May Lose Kids to Adoption

Democrats have been vocal about what they don’t like when it comes to immigration policy. But they have a problem: a lack of cohesion within the party about the correct way forward.

The New York Times: The Democrats Have an Immigration Problem

In the miscellaneous, must-read file:

• A gripping piece takes you into the bowels of a Philadelphia neighborhood dubbed the “Walmart of heroin.” “Drug tourists” come from all over to buy the cheap, pure heroin flowing through the veins of the streets, and some never make it out. (Warning: Make sure you have some time before you start, it will suck you in completely.)

The New York Times: Trapped by the ‘Walmart of Heroin’

• Why were nursing home residents getting extremely pricey therapy in the last weeks of their lives? Bloomberg takes a closer look at these cash-strapped facilities and the questionable decisions made about patients’ rehab.

Bloomberg: Nursing Homes Are Pushing the Dying Into Pricey Rehab

• In good news from the segment of people who were too old to take advantage of the HPV vaccine, the Food and Drug Administration just approved its use for those up to age 45.

The Associated Press: FDA Expands Use of Cervical Cancer Vaccine up to Age 45

As an office of ardent dog lovers, we were distressed to hear the news that therapy dogs in hospitals are little germ machines, leaving behind happiness but also superbugs.

Have a great (hopefully superbug-free) weekend!

Podcast: KHN’s ‘What The Health?’ Falling Premiums And Rising Political Tensions

October 11, 2018
Mary Agnes Carey

Kaiser Health News

@MaryAgnesCarey

Read Mary Agnes' Stories Rebecca Adams

CQ Roll Call

@RebeccaAdamsDC

Read Rebecca's Stories Julie Appleby

Kaiser Health News

@Julie_Appleby

Read Julie's Stories Anna Edney

Bloomberg

@annaedney

Read Anna's Stories

The Trump administration announced that, for the first time, the average premium for a key plan sold on the federal health law’s insurance marketplaces will fall slightly next year. Federal officials said that changes they have made helped facilitate the reduction, but others argue that it was because more plans are moving back into those federal exchanges and making money.

The news is likely to further inflame the political debate on health care in the run-up to the midterm elections. Democrats and Republicans are battling over which party is more attuned to consumers’ needs on protections for people with preexisting conditions and affordable health care.

Meanwhile, President Donald Trump signed two bills this week that would ban efforts to keep pharmacists from telling customers that their prescriptions would be cheaper if they paid in cash, rather than using their insurance. And the Food and Drug Administration this week announced it will ease the process for drugmakers to bring some products to market.

This week’s panelists for KHN’s “What the Health?” are Mary Agnes Carey of Kaiser Health News, Rebecca Adams of CQ Roll Call, Anna Edney of Bloomberg News and Julie Appleby of Kaiser Health News.

Among the takeaways from this week’s podcast:

  • The drop in the average price for ACA plans follows a recent analysis that found insurers are regaining profitability in the individual market.
  • Democrats this week were unsuccessful in their effort to get the Senate to reverse a new policy that eased rules for short-term health plans. The administration argues that these plans help provide a more affordable option for many people, but Democrats complain that they are junk insurance because they don’t have many of the protections offered through the ACA.
  • Trump and members of Congress celebrated a rare moment of bipartisanship on health care when the president signed the two bills restricting gag orders on pharmacists. Despite the goodwill, the much-touted aim of the administration to constrain drug prices has not made much progress.
  • Health care has been a key issue in midterm campaigns, with Democrats hitting hard at their opponents to charge that the GOP would not guarantee ACA protections for people with preexisting conditions. But Republicans are fighting back with personal stories of their own health concerns — and an op-ed by the president on concerns about some Democrats’ plans to expand Medicare.
  • The new policy announced by the FDA this week will apply to complex drugs, which are drugs that are coupled with a device, such as patches or auto-injectors. The agency said it would be more flexible in reviewing materials for approving those devices.

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

Mary Agnes Carey: The Washington Post’s “Patrick Kennedy Shepherded a Major Mental-Health Bill Into Law. Ten Years Later, Big Barriers Remain,” by Colby Itkowitz

Rebecca Adams:  The New York Times’ “Migrant Children in Search of Justice: A 2-Year-Old’s Day in Immigration Court,” by Vivian Yee and Miriam Jordan

Julie Appleby: Kaiser Health News’ “Spurred By Convenience, Millennials Often Spurn The ‘Family Doctor’ Model,” by Sandra G. Boodman

Anna Edney: The New York Times’ “These Cholesterol-Reducers May Save Lives. So Why Aren’t Heart Patients Getting Them?” and “In Medical Reporting, the Impact of Patients’ Stories,” both by Gina Kolata

To hear all our podcasts, click here.

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

Obamacare Premiums Dip For First Time. Some Call It A Correction.

October 11, 2018

After two years of double-digit price hikes, the average premium for individual health coverage on the federal health law’s insurance marketplace will drop by 1.5 percent for 2019, the Trump administration said Thursday.

The announcement  marked the first time average premiums have fallen since the exchanges created by the Affordable Care Act went into effect in 2014.

It also comes during a bitter midterm congressional campaign season in which health care is a central issue following last year’s efforts by Republicans to repeal the ACA.

Administration officials claimed credit for the price drop, saying it was due to their actions to make changes to the law. Health policy experts said it was a reaction to insurers’ huge profits following hefty premium increases on plans offered this year.

The federal exchange covers about 9 million people in 39 states. The other states and the District of Columbia have their own online marketplaces and were not included in the report.

The analysis by federal officials looked at the price of the second-lowest silver plan for a 27-year-old nonsmoker on the marketplaces. Those silver plans are used by the ACA to set subsidies.

Open enrollment for 2019 runs from Nov. 1 through Dec. 15.

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Charles Gaba, a Michigan-based blogger who tracks ACA sign-ups, noted that the numbers released by the administration were just one snapshot of the marketplace.

He said premiums next year will “still be a whopping 30% higher than they were in 2017, with the vast bulk of that due specifically to sabotage actions taken by the Trump Administration and Congressional Republicans.”

Before the 2010 health law passed, it was typical for individual health insurance rates to increase yearly, largely because people needing the insurance had above-average health risks.

The health law’s marketplace was designed to allow shoppers to easily compare rates for policies that had to meet federal benefit requirements, such as covering mental health and pregnancy care.

Under President Barack Obama, insurance rates on the marketplace rose 1 percent for plans available in 2015 and 8 percent in 2016. But, just as Obama was leaving office, rates rose 20 percent for 2017 plans. Premiums for plans in 2018 soared 34 percent, following changes made by the Trump administration that included dropping subsidies paid to insurers to help cover the cost of out-of-pocket expenses they shoulder for low-income customers.

“Premiums would have dropped more on average if not for harmful Trump administration actions,” said Sarah Lueck, senior policy analyst for the left-leaning Center on Budget and Policy Priorities. She cited decisions to expand the use of plans that don’t provide all ACA patient protections and the dramatic cut in outreach and enrollment assistance for consumers.

The vast majority of consumers buying on the exchange have been shielded from rate hikes because their incomes are low enough to qualify for federal subsidies. But the marketplace price hikes have become a political lightning rod — bolstering the arguments from Trump and congressional Republicans to repeal the health law.

Administration officials said a decision they made allowing seven states to set up reinsurance programs helped insurance companies lower premiums.

Seema Verma, administrator of the federal Centers for Medicare & Medicaid Services, also pointed to new regulations allowing insurers to sell short-term policies. These policies can be renewed for up to three years and don’t have to meet federal minimum benefit rules. She said that caused carriers to drop rates on the exchange to be more competitive.

Those new plans are not yet available and are not included in the marketplace rates.

Despite the drop in prices, Verma said, premiums are still high. “To open the markets to more Americans … as well as the millions who are priced out of the market, the law needs to change,” she said.

Verma, like Trump, has repeatedly called for the health law to be repealed, but she did not repeat that call on Thursday.

During a briefing with reporters, she was asked about policy experts who say flat or declining rates for 2019 come mainly because insurers raised premiums so much in 2018 in response to Trump administration actions. She replied, “We heard a lot of predictions that didn’t turn out to be true.”

Cynthia Cox, who monitors the marketplaces for the Kaiser Family Foundation, wrote on Twitter: “One big reason insurers are lowering premiums: Individual market insurers are currently so profitable it would be hard for many companies to justify a rate increase.”

Those profits are also driving new companies into the Obamacare marketplace in several states, she said. (Kaiser Health News is an editorially independent program of the foundation.)

Cox said some efforts by the Trump administration have made the marketplace more attractive to insurers, such as cutting in half the open-enrollment period and approving some states’ reinsurance plans. That green light allows states to help insurers pay for extremely costly patients so that premiums for the overall patient pool can remain relatively modest.

Rates still vary dramatically by state. For example, average premiums are dropping 26 percent in Tennessee but rising 16 percent in Delaware.

The drop in rates is good news for people buying unsubsidized coverage — those with incomes over 400 percent of the federal poverty level, or about $49,000 for an individual.

Consumers will get less assistance this fall in shopping for exchange plans. The Trump administration cut millions of dollars in funding to the program that pays groups to work with people needing help selecting coverage.

Nonetheless, Verma said the falling premiums show the administration has been defying its critics.

“While some have publicly been accusing us of sabotage, the reality is we have been working hard to mitigate damage caused by Obamacare,” she said. “Our actions have succeeded.”

Fact-Check: Who’s Right On Protections For Preexisting Conditions? It’s Complicated

October 11, 2018

Ensuring that people with preexisting health conditions can get and keep health insurance is the most popular part of the Affordable Care Act. It has also become a flashpoint in this fall’s campaigns across the country.

And not only is the ACA, which mostly protects people who buy their own coverage, at risk. Also potentially in the crosshairs are preexisting conditions protections that predate the federal health law.

Democrats charge that Republicans’ opposition to the ACA puts those protections in peril, both by their (unsuccessful) votes in Congress in 2017 to “repeal and replace” the law, and via a federal lawsuit underway in Texas.

“800,000 West Virginians with preexisting conditions in jeopardy of losing their health care,” claimed Sen. Joe Manchin (D-W.Va.).

Republicans disagree. “Preexisting conditions are safe,” President Donald Trump declared at a rally in West Virginia for Manchin’s GOP opponent, Patrick Morrisey. Morrisey, West Virginia’s attorney general, is one of a group of state officials suing to overturn the ACA.

Who is right? Like everything else in health care, it’s complicated.

What is clear, however, is that voters want protections. Even majorities of Republicans told pollsters this summer that it is “very important” that guarantees of coverage for preexisting conditions remain law.

Here are some key details that can help put the current political arguments in perspective.

Preexisting conditions are common.

Preexisting conditions are previous or ongoing medical issues that predate health insurance enrollment. The problem is that the term is a grab bag whose limits have never been defined. It certainly applies to serious ongoing conditions such as cancer, heart disease and asthma. But insurers also have used it to apply to conditions like pregnancy or far more trivial medical issues such as acne or a distant history of depression.

The Kaiser Family Foundation estimated in 2016 that more than a quarter of adults younger than 65 — about 52 million people — have a preexisting health condition that likely would have prevented them from purchasing individual health insurance under the pre-ACA rules. (Kaiser Health News is an editorially independent program of the foundation.)

Protections vary by what kind of insurance you have.

But what protections people with preexisting conditions have depends on how they get their coverage. For that reason, it’s not right to say everyone with health problems is potentially at risk, as Democrats frequently suggest.

For example, Medicare, the federal health program for seniors, and Medicaid, the federal-state health plan for low-income people, do not discriminate in either coverage or price on the basis of preexisting conditions. The two programs together cover roughly 130 million Americans — nearly a third of the population.

The majority of Americans get their coverage through work. In 1996, Congress protected people with preexisting conditions in employer-based coverage with the passage of the Health Insurance Portability and Accountability Act, known as HIPAA.

HIPAA was intended to eliminate “job lock,” or the inability of a person with a preexisting condition (or a family member with a preexisting condition) to change jobs because coverage at the new job would likely come with a waiting period during which the condition would not be covered.

HIPAA banned those waiting periods for people who had maintained “continuous” coverage, meaning a break of no more than 63 days, and the law limited waiting periods to one year for those who were previously uninsured. In addition, it prohibited insurers from denying coverage to or raising premiums for workers based on their own or a family member’s health status or medical history.

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HIPAA was less successful in protecting people without job-based insurance. It sought to guarantee that people with preexisting conditions leaving the group market could buy individual coverage if they had remained continuously covered. But the law did not put limits on what individual insurers could charge for those policies. In many cases, insurers charged so much for these “HIPAA conversion” policies that almost no one could afford them.

The Affordable Care Act, passed in 2010, built on those 1996 protections, and specifically sought to help people buying their own coverage. It barred all health insurers from excluding people due to preexisting conditions, from charging them higher premiums and from imposing waiting periods for coverage of that condition.

While the protections were mostly aimed at the individual insurance market, where only a small portion of Americans get coverage, the ACA also made some changes to the employer market for people with preexisting conditions, by banning annual and lifetime coverage limits.

Will protections on preexisting conditions become collateral damage?

In 2017, the GOP-controlled House and Senate voted on several versions of a bill that would have dramatically overhauled the ACA, including its protections on preexisting conditions. Under the last bill that narrowly failed in the Senate, states would have been given authority to allow insurers to waive some of those protections, including the one requiring the same premiums be charged regardless of health status.

In February, 18 GOP attorneys general and two GOP governors filed suit in federal court in Texas. They charge that because Congress in its 2017 tax bill eliminated the ACA’s penalty for not having insurance, the entire federal health law is unconstitutional. Their argument is that the Supreme Court upheld the ACA in 2012 based only on Congress’ taxing power, and that without the tax, the rest of the law should fall.

The Trump administration, technically the defendant in that case, said in June that it disagreed that the entire law should fall. But it is arguing that the parts of the law addressing preexisting conditions are so tightly connected to the tax penalty that they should be struck down.

Clearly, if the lawsuit prevails in either its original form or the form preferred by the Trump administration, preexisting protections are not “safe,” as the president claimed.

Even more complicated, the protections written into HIPAA were rewritten and incorporated into the ACA, so if the ACA in whole or part were to be struck down, HIPAA’s preexisting conditions protections might go away, too.

Republicans in Congress have introduced a series of proposals they say would replicate the existing protections. But critics contend none of them covers as many situations as the ACA does. For example, a bill unveiled by several Republican senators in August would require insurers to offer coverage to people with preexisting health conditions, but not require coverage of the conditions themselves.

That hasn’t stopped Republicans from claiming that they support protections for preexisting conditions.

“Make no mistake about it: Patients with preexisting conditions should be covered,” said Wisconsin GOP Senate candidate Leah Vukmir, who is running to unseat Democratic Sen. Tammy Baldwin. Health care has been a major issue in that race, as well as many others. Yet Vukmir was recently hailed by Vice President Mike Pence as someone who will vote to “fully repeal and replace Obamacare.”

Meanwhile, Democrats who are chastising their Republican opponents over the issue are sometimes going a bit over the top, too.

An example is Manchin’s claim about the threat to coverage for 800,000 people in West Virginia. West Virginia’s population is only 1.8 million and more than a million of those people are on Medicare or Medicaid. That would mean every other person in the state has a preexisting condition. A recent study found West Virginia has a relatively high level of preexisting conditions among adults, but it is still less than 40 percent.

Podcast: KHN’s ‘What The Health?’ Some Things Old, Some Things New

October 04, 2018
Julie Rovner

Kaiser Health News

@jrovner

Read Julie's Stories Rebecca Adams

CQ Roll Call

@RebeccaAdamsDC

Read Rebecca's Stories Kimberly Leonard

Washington Examiner

@leonardkl

Read Kimberly's Stories Margot Sanger-Katz

The New York Times

@sangerkatz

Read Margot's Stories

Congress passed major health-related legislation in time for the fiscal year, which began Monday, including a broad bill to address the opioid epidemic and a spending bill for the Department of Health and Human Services. This marks the first time since the 1990s that Congress has agreed to HHS spending levels before the start of the fiscal year.

Meanwhile, the Food and Drug Administration is cracking down on teen use of e-cigarettes as well as brand-name drugmakers who work to delay generic competition (and keep drug prices high). And a new survey shows health insurance costs continue to rise for people with coverage provided by their employers.

This week’s panelists for KHN’s “What the Health?” are Julie Rovner of Kaiser Health News, Rebecca Adams of CQ Roll Call, Margot Sanger-Katz of The New York Times and Kimberly Leonard of the Washington Examiner.

Among the takeaways from this week’s podcast:

  • The package of bills addressing the opioid epidemic passed Congress on a rare note of bipartisanship. Many of the measures are designed to help prevent opioid addiction but are short on treatment options.
  • California Gov. Jerry Brown’s veto of a bill that would have required public university health centers to offer drugs used for medical abortions surprised many people since Democrats in the state often position themselves as defenders of abortion rights.
  • New data on insurance coverage shows that the percentage of employers offering plans is holding steady, despite concerns that the rate would fall once the Affordable Care Act was enacted and provided easy access. Still causing concern: the high deductibles required of patients in many of these work-based plans.
  • A federal raid on the offices of the e-cigarette maker Juul Labs signals a dilemma for FDA Commissioner Scott Gottlieb. While he once backed e-cigarettes as a way to help smokers cut back on their habit, it appears he is now concerned about their use by young people.

Rovner also interviews Alison Kodjak of NPR, who wrote the latest “Bill of the Month” feature for Kaiser Health News and NPR. It’s about a Texas radiologist who had an accident that resulted in a very expensive air ambulance ride.

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

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

Julie Rovner: Bloomberg News’ “Thousands of People’s Insurance Appeals Went to a Doctor Feds Say Is a Fraud,” by John Tozzi

Margot Sanger-Katz: The New York Times’ “In Australia, Cervical Cancer Could Soon Be Eliminated,” by Livia Albeck-Ripka

Kimberly Leonard: Politico’s “Kavanaugh’s Drinking Spotlights Trump’s ‘Abnormal’ Abstinence,” by Andrew Restuccia

Rebecca Adams: The New Yorker’s “The Comforting Fictions Of Dementia Care,” by Larissa MacFarquhar

To hear all our podcasts, click here.

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

High-Deductible Health Plans Fall From Grace In Employer-Based Coverage

October 03, 2018

With workers harder to find and Obamacare’s tax on generous coverage postponed, employers are hitting pause on a feature of job-based medical insurance much hated by employees: the high-deductible health plan.

Companies have slowed enrollment in such coverage and, in some cases, reinstated more traditional plans as a strong job market gives workers bargaining power over pay and benefits, according to research from three organizations.

This year, 39 percent of large, corporate employers surveyed by the National Business Group on Health (NBGH) offer high-deductible plans, also called “consumer-directed” coverage, as workers’ only choice. For next year, that figure is set to drop to 30 percent.

“That was a surprise, that we saw that big of a retraction,” said Brian Marcotte, the group’s CEO. “We had a lot of companies add choice back in.”

Few if any employers will return to the much more generous coverage of a decade or more ago, benefits experts said. But they’re reassessing how much pain workers can take and whether high-deductible plans control costs as advertised.

“It got to the point where employers were worried about the affordability of health care for their employees, especially their lower-paid people,” said Beth Umland, director of research for health and benefits at Mercer, a benefits consultancy that also conducted a survey.

The portion of workers in high-deductible, job-based plans peaked at 29 percent two years ago and was unchanged this year, according to new data from the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

Deductibles — what consumers pay for health care before insurance kicks in — have increased far faster than wages, even as paycheck deductions for premiums have also soared.

One in 4 covered employees now have a single-person deductible of $2,000 or more, KFF found.

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Employers and consultants once claimed patients would become smarter medical consumers if they bore greater expense at the point of care. Those arguments aren’t heard much anymore.

Because lots of medical treatment is unplanned, hospitals and doctors proved to be much less “shoppable” than experts predicted. Workers found price-comparison tools hard to use.

High-deductible plans “didn’t really do what employers hoped they would do, which is create more sophisticated consumers of health care,” Marcotte said. “The health care system is just way too complex.”

At the same time, companies have less incentive to pare coverage as Congress has repeatedly postponed the Affordable Care Act’s “Cadillac tax” on higher-value plans.

Although deductibles are treading water, total spending on job-based health plans continues to rise much faster than the overall cost of living. That eats into workers’ pay in other ways by boosting what they contribute in premiums.

Employer-sponsored group health plans, which insure 150 million Americans — nearly half the country — tend to get less attention than politically charged coverage created by the ACA.

For these employer plans, the cost of family coverage went up 5 percent this year and is expected to rise by a similar amount next year, the research shows.

Insuring one family in a job-based plan now costs on average $19,616 in total premiums, the KFF data show. The American worker pays $5,547 of that in a country where the median household income is more than $61,000.

The KFF survey was published Tuesday; the NBGH data, in August. Mercer has released preliminary results showing similar trends.

The recent cost upticks, driven by specialty drug costs and expensive treatment for diseases such as cancer and kidney failure, are an improvement over the early 2000s, when family-coverage costs were rising by an average 7 percent a year. But they’re still nearly double recent rates of inflation and increases in worker pay.

Such growth “is unsustainable for the companies I have been working with,” said Brian Ford, a benefits consultant with Lockton Companies, echoing comments made over the decades by experts as health spending has vacuumed up more and more economic resources.

For now at least, many large employers can well afford rising health costs. Earnings for corporations in the S&P 500 have increased by double-digit percentages, driven by federal tax cuts and economic growth. Profit margins are near all-time highs.

But for workers and many smaller businesses, health costs are a heavier burden.

Premiums for family plans have gone up 55 percent in the past decade, twice as fast as worker pay, according to KFF.

Employers’ latest cost-control efforts include managing expenses for the most expensive diseases; getting workers to use nurse video-chat services and other types of “telemedicine”; and paying for primary care clinics at work or nearby.

At the “top of the list” for many companies are attempts to manage the most expensive medical claims — cases of hemophilia, terrible accidents, prematurely born infants and other diseases — that increasingly cost as much as $1 million each, Umland said.

Employers point such patients to the highest-quality doctors and hospitals and furnish guides to steer them through the system. Such steps promise to improve results, reduce complications and save money, she said.

On-site clinics cut absenteeism by eliminating the need for employees to drive across town and sit in a waiting room for two hours to get a rash or a sniffle checked or get a vaccine, consultants say.

Almost all large employers offer telemedicine, but hardly any workers use it. Thirty-nine percent of the larger companies covering telemedicine now make it comparatively less expensive for workers to consult doctors and nurses virtually, the KFF survey shows.

Podcast: KHN’s ‘What The Health?’ (Almost) Live from Austin!

September 28, 2018

(From left) Julie Rovner, Joanne Kenen, Alice Ollstein and Anna Edney(Courtesy of The Texas Tribune Festival)

Julie Rovner

Kaiser Health News

@jrovner

Read Julie's Stories Anna Edney

Bloomberg

@annaedney

Read Anna's Stories Joanne Kenen

Politico

@JoanneKenen

Read Joanne's Stories Alice Ollstein

Politico

@AliceOllstein

Read Alice's Stories

President Donald Trump’s proposed rule that would make it more difficult for immigrants to gain permanent status if they use government aid programs could have a major impact in Texas, with its large immigrant population.

Texas is also ground zero for the health debate in this year’s midterm elections. Texas Attorney General Ken Paxton is the lead plaintiff in a case filed by 20 GOP state officials arguing that the entire Affordable Care Act is now unconstitutional in light of last year’s tax bill, which canceled the penalties for people who fail to obtain health insurance. The Trump administration does not agree that the whole law should fall, but says the parts protecting people with preexisting health conditions should be struck down. A federal district court judge in Fort Worth is expected to issue a decision in the case soon.

This week’s panelists for KHN’s “What the Health?,” are Julie Rovner of Kaiser Health News, Joanne Kenen of Politico, Anna Edney of Bloomberg News and Alice Ollstein of Politico. Technical difficulties prevented us from bringing you the discussion taped Sept. 27 before a live audience in Austin as part of the 2018 Texas Tribune Festival. So, the panelists, back in D.C., joined Rovner, still in Austin, for a redo Sept. 28.

Among the takeaways from this week’s podcast:

  • The latest version of the new “public charge” regulations proposed by the Trump administration could penalize immigrants who use food stamps, Medicaid, housing assistance or Medicare prescription drug subsidies. But unlike an earlier version of the proposal, it would not take into account immigrants’ use of subsidies under the Affordable Care Act.
  • With less than six weeks to go before the critical midterm elections, federal protections for people with preexisting health conditions has become the top campaign health issue in many states, in many races eclipsing concerns about prescription drug pricing and other out-of-pocket health costs.
  • As hearings continued on the nomination of federal Judge Brett Kavanaugh to serve on the Supreme Court, a three-judge appeals court panel heard arguments on a case he decided earlier this year concerning the right of minor immigrants to obtain an abortion.
  • Increases in premiums for insurance under the Affordable Care Act appear to moderating, and some states are reporting decreases for plans that start Jan. 1, 2019. The Trump administration is now trying to take credit for “fixing” the ACA’s marketplaces. However, state insurance officials have noted that premiums are moderating in spite of, rather than because of, the administration’s actions.

To hear all our podcasts, click here.

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

Threat To The ACA Turns Up The Heat On Attorney General Races

September 27, 2018

For years, congressional Republicans have vowed to repeal the Affordable Care Act. Now, in a case sending shock waves through midterm election campaigns, Republican attorneys general across the country may be poised to make good on that promise.

The case, Texas v. United States, reveals just how high the stakes are for health care in this year’s attorney general races, elections that rarely receive much attention but have the power to reverberate through the lives of Americans.

“It just shows that nothing is safe,” said Xavier Becerra, California’s attorney general, who is leading 16 states and the District of Columbia in defending the ACA in the case.

Both parties expect record-breaking fundraising for this year’s 30 contested elections for state attorneys general. Democrats aim to translate public outrage over the threat to the ACA into the votes needed to seize a handful of posts currently held by Republicans.

This will be the first major election since Republicans tore up a deal brokered with Democrats roughly two decades ago not to challenge each other’s incumbents in attorney general races. That gentlemen’s agreement acknowledged the need for attorneys general from both parties to collaborate on investigations and lawsuits.

But some of the same partisan forces that have embittered Capitol Hill have spilled into these contests. With Republicans in control of the executive and legislative branches — and close to staking their claim on the Supreme Court — Democratic attorneys general are seen as a check on Trump administration policies. Similarly, their Republican counterparts frequently took the Obama administration to court.

That pressure is likely to increase should congressional Democrats fail to win control of at least one chamber of Congress in November.

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Raphael Sonenshein, the executive director of California State University’s Pat Brown Institute for Public Affairs in Los Angeles, compared the politics invigorating state attorneys general to a bar brawl.

“Two people have a fight, and then it spills out into the street, and 20 people join in,” he said. “Everybody gets off the bench and joins the fight.”

A banner on the Democratic Attorneys General Association’s website captures their mindset, while states are busy challenging the Trump administration on issues like sanctuary cities and family separations at the border: “This office has never been more important.”

Former Vice President Joe Biden recently endorsed six attorney general candidates in races Democrats think they can win, including Ohio and Wisconsin, and the association plans to raise a record-breaking $15 million for November’s elections, said Lizzie Ulmer, a spokeswoman for the group.

By mid-June, the Republican Attorneys General Association had raised $26.6 million, continuing to break its fundraising records.

Of this year’s 30 contested attorney general races, 18 posts are held by Republicans and 12 are held by Democrats. (Another five are in play this year, but those posts are appointed by the governor or state lawmakers.)

Unlike in Congress, there is no inherent advantage to one party claiming the majority of attorneys general posts. It takes just one attorney general to file a lawsuit.

But Democratic attorneys general see themselves as a firewall against an administration and their Republican counterparts dead set on revoking many federal protections. In that arena, every lawyer counts.

That is especially the case with health care, where fights over issues like access to abortion have multiplied since President Donald Trump took office, with others liable to end up in the courts at any time.

Earlier this month, a federal judge heard arguments in Texas v. United States on the constitutionality of the individual mandate, the ACA’s requirement that all Americans obtain health insurance or pay a penalty.

Citing the law passed late last year that eliminated the penalty, the plaintiffs — a Texas-led coalition of 20 states and two individuals — argued the individual mandate was now unconstitutional. By extension, so was the rest of the ACA, they said. They asked for a preliminary injunction that could halt the sweeping ACA in its tracks — including popular provisions such as protections for people with preexisting conditions.

Ken Paxton, the attorney general of Texas, has defended his decision to challenge protections that have broad support, including among Republicans, saying he has a duty to fight laws that harm Texans and defy the U.S. Constitution.

“The least compassionate thing we could do for those with preexisting health problems is to take away their access to high-quality care from doctors of their own choosing and place them entirely at the mercy of the federal government,” Matt Welch, Paxton’s campaign spokesman, said in a statement.

But the idea that insurers would no longer have to cover those with preexisting conditions has proven explosive, offering Democrats a powerful rallying cry beyond even attorney general races. In Missouri and West Virginia, states that Trump won in 2016 but are represented by Democratic senators, the issue has followed the Republican attorneys general — Missouri’s Josh Hawley and West Virginia’s Patrick Morrisey — as they run for Senate.

“We’re wasting millions and millions of dollars of taxpayer money trying to take away preexisting condition protections not just for all Texans but all Americans,” said Justin Nelson, Paxton’s Democratic challenger, who said he would withdraw Texas from the case should he win his long-shot bid.

In Wisconsin, the Republican attorney general, Brad Schimel, has also taken a leading role in Texas v. United States, as well as a 2016 challenge to a landmark Obama administration rule banning discrimination in health care based on a patient’s gender identity, among other cases.

This year, Schimel has drawn a formidable Democratic challenger, Josh Kaul. He’s a former assistant U.S. attorney who prosecuted federal drug crimes and has promised to focus on the state’s backlog of untested rape kits and take a more aggressive approach to the opioid epidemic. “We’re not going to beat that without ensuring our efforts are targeting large-scale drug traffickers,” he said.

Experts caution a changing of the guard would not spell the end of a big case like Texas v. United States. For instance, even if Paxton were to defy expectations and lose, Texas’ legal and financial backing for the case could easily be picked up by another state.

However, the message voters would send by electing a Democratic attorney general in Texas — where no Democrat has won statewide office since 1994 — could have profound implications for Republican morale.

“Without Ken Paxton leading the charge, many Republicans may soften their opposition to Obamacare,” said Brandon Rottinghaus, a political science professor at the University of Houston.

Medicare Eases Readmission Penalties Against Safety-Net Hospitals

September 26, 2018

On orders from Congress, Medicare is easing up on its annual readmission penalties on hundreds of hospitals serving the most low-income residents, records released last week show.

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READMISSION PENALTIES BY HOSPITAL AND STATE

Medicare is penalizing hospitals that see patients return to the hospital too soon after being discharged. Medicare reduces what it pays each hospital per patient, per stay.

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Since 2012, Medicare has punished hospitals for having too many patients end up back in their care within a month. The government estimates the hospital industry will lose $566 million in the latest round of penalties that will stretch over the next 12 months. The penalties are a signature part of the Affordable Care Act’s effort to encourage better care.

But starting next month, lawmakers mandated that Medicare take into account a long-standing complaint from safety-net hospitals. They have argued that their patients are more likely to suffer complications after leaving the hospital through no fault of the institutions, but rather because they cannot afford medications or don’t have regular doctors to monitor their recoveries. The Medicare sanctions have been especially painful for this class of hospitals, which often struggle to stay afloat because so many of their patients carry low-paying insurance or none at all.

In a major change to its evaluation, the federal Centers for Medicare & Medicaid Services (CMS) this year ceased judging each hospital against all others. Instead, it assigned hospitals to five peer groups of facilities with similar proportions of low-income patients. Medicare then compared each hospital’s readmission rates from July 2014 through June 2017 against the readmission rates of its peer group during those three years to determine if they warranted a penalty and, if so, how much it should be.

The broader issue is whether medical providers that serve the poor can be fairly judged against those that care for the affluent. This has been a continuing topic of contention as the government seeks to accurately measure health care quality. It is particularly a concern in efforts to consider patient outcomes in setting pay rates for doctors, nursing homes, hospitals and other providers.

Overall, Medicare will dock payments to 2,599 hospitals — more than half in the nation— throughout fiscal year 2019, which begins Oct. 1, a Kaiser Health News analysis of the records found. The harshest penalty is 3 percent lower reimbursements for every Medicare patient discharged in fiscal year 2019. The number of hospitals and the average penalty — 0.7 percent of each payment — are almost the same as last year.

But the new method shifted the burden of those punishments. Penalties against safety-net hospitals will drop by a fourth on average from last year, the analysis found.

“It’s pretty clear they were really penalizing those institutions more than they needed to,” said Dr. Atul Grover, executive vice president of the Association of American Medical Colleges. “It’s definitely a step in the right direction.”

(Story continues below.)

Safety-net hospitals that will see their penalties cut by half or more include many urban institutions, such as Sutter Health’s Alta Bates Summit Medical Center in Oakland, Calif.; Providence Hospital in Washington, D.C.; and Hurley Medical Center in Flint, Mich. Sixty-five safety-net hospitals — including Franklin Medical Center in Winnsboro, La., Astria Toppenish Hospital in Toppenish, Wash., and Emanuel Medical Center in Swainsboro, Ga. — that had been penalized last year escaped punishment entirely this year.

Conversely, the average penalty for the hospitals with the fewest low-income patients will rise from last year, the analysis found.

Before the program began, roughly 1 in 5 Medicare beneficiaries were readmitted within a month. Hospitals were paid the same amount regardless of how their patients fared after being discharged. In fact, a readmission was financially advantageous as hospitals would be paid for the second hospital stay, even if it might have been avoidable. This story also ran on NPR. This story can be republished for free (details).

Since the sanctions began, Medicare has evaluated each year rates for readmitted patients who had originally been treated for heart failure, heart attacks and pneumonia. And it has reduced its payments to more than half of hospitals based on those rates. The evaluations have since expanded to cover chronic lung disease, hip and knee replacements and coronary artery bypass graft surgeries.

Medicare counts patients who returned to a hospital within 30 days, even if it is a different hospital than the one that originally treated them. The penalty is applied to the first hospital.

Medicare exempts hospitals with too few cases, those serving veterans, children and psychiatric patients, and critical-access hospitals, which are the only hospitals within reach of some patients. In addition, Maryland hospitals are excluded because Congress lets that state set its own rules on how it distributes Medicare money.

(Story continues below.)

In its revised method this year, Medicare distinguished hospitals that serve a high proportion of low-income patients by looking at how many of the hospital’s Medicare patients were also eligible for Medicaid, the state-federal program for the poor. American Hospital Association officials say that while they considered this an improvement, it isn’t a perfect reflection of poor patients. For one thing, they say, hospitals in states with more restrictive Medicaid coverage do not appear through this formula to have as challenging patient populations as do hospitals in states with higher Medicaid eligibility.

Akin Demehin, the association’s director of quality policy, said CMS might consider linking its records to Census records that show income and education level of patients.

“It might give you a more precise adjuster,” he said.

The hospital industry remains critical of the overall program, saying that stripping hospitals of revenue because of poor performance only makes it harder for them to care for patients.

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Congress’ Medicare Payment Advisory Commission in June concluded that the penalties from previous years successfully pressured hospitals to reduce the numbers of returning patients — and helped save Medicare about $2 billion a year.

In its analysis of the approach’s effectiveness, Congress’ advisory commission rejected some of the hospital industries’ complaints about Medicare’s Hospital Readmissions Reduction Program: that hospitals may have tried to get around the penalties by keeping patients under “observation status” and that discouraging rehospitalizations may have led to extra deaths.

The commission found that between 2010 and 2016 readmission rates fell by 3.6 percentage points for heart attacks, 3 percentage points for heart failure and 2.3 percentage points for pneumonia. At the same time, readmissions caused by conditions that do not factor into the penalties fell on average 1.4 percentage points, indicating hospitals were focusing on lowering unnecessary readmissions that could hurt them financially.

The commission wrote: “We conclude that the [penalties] contributed to a significant decline in readmission rates without causing a material increase in ED [emergency department] visits, a material increase in observation stays, or a net adverse effect on mortality rates.”

This fall, Medicare will attack the readmissions from another angle by issuing penalties on skilled nursing facilities that send recently discharged residents back to the hospital too frequently.

KHN’s coverage related to aging and improving care of older adults is supported in part by The John A. Hartford Foundation.

Podcast: KHN’s ‘What The Health?’ A Detour On A Smoking Off-Ramp

September 13, 2018
Sarah Jane Tribble

Kaiser Health News

@sjtribble

Read Sarah Jane's Stories Rebecca Adams

CQ Roll Call

@RebeccaAdamsDC

Read Rebecca's Stories Stephanie Armour

The Wall Street Journal

@StephArmour1

Read Stephanie's Stories Kimberly Leonard

Washington Examiner

@leonardkl

Read Kimberly's Stories

The Food and Drug Administration declared Wednesday that vaping among teenagers has reached “an epidemic proportion.” The agency told five major e-cigarette manufacturers that they had 60 days to find ways to keep their products away from minors.

“I use the word epidemic with great care,” FDA Commissioner Scott Gottlieb said in a Wednesday news release. “E-cigs have become an almost ubiquitous — and dangerous — trend among teens.” Yet, as the panel discusses, health advocates warned that the actions may not be strong enough.

This week’s panelists are Sarah Jane Tribble of Kaiser Health News, Stephanie Armour of The Wall Street Journal, Kimberly Leonard of the Washington Examiner and Rebecca Adams of CQ Roll Call.

They also look at Arkansas’ announcement that more than 4,000 Medicaid enrollees will be suspended for not meeting new work requirements, the Census Bureau’s announcement that the nation’s uninsured rate was unchanged last year, legislation under consideration on Capitol Hill that will affect the Affordable Care Act and efforts to stem the opioid epidemic.

Among the takeaways from this week’s podcast:

  • The FDA’s announcement on e-cigarettes appears to be a turning point on officials’ views of how to handle the issue. It was spurred by reports of dramatic growth in teen vaping. Sen. Dick Durbin (D-Ill.) recently reported that teen use has increased by 75 percent in the past year.
  • The e-cigarette industry is largely unregulated. Many brands offer a variety of sweet flavors, even though makers of traditional cigarettes are prohibited from doing that.
  • Arkansas’ move to cut adults from the Medicaid expansion program the state rolled out under the ACA is likely to be challenged in court.
  • The Trump administration has been a strong supporter of work requirements in the Medicaid program and Seema Verma, who heads the Centers for Medicare & Medicaid Services, tweeted Wednesday night after the Arkansas announcement that she was excited about the work Arkansas has done to connect beneficiaries to jobs and education.
  • The Census Bureau’s report Wednesday is the first time since the implementation of ACA coverage expansions that the national uninsured rate did not fall.
  • The Republican-led House is expected to vote soon on a package of bills that will remove or postpone more taxes in the ACA, including the penalty for employers who do not offer coverage for workers and a tax on tanning salons. It is doubtful, however, that the measure will get through the Senate this year.

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

Sarah Jane Tribble: Bloomberg News’ “The Secret Drug Pricing System Middlemen Use to Rake in Millions,” by Robert Langreth, David Ingold and Jackie Gu

Kimberly Leonard: Harper’s Magazine’s “Can Hospitals Learn to Better Treat Deaf Patients?” by Katie Booth

Rebecca Adams: The New York Times and ProPublica’s “Top Cancer Researcher Fails to Disclose Corporate Financial Ties in Major Research Journals,” by Charles Ornstein and Katie Thomas

Stephanie Armour: The Financial Times’ “Opioid Billionaire Granted Patent for Addiction Treatment,” by David Crow

To hear all our podcasts, click here.

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

In Trump’s First Year, Nation’s Uninsured Rate Unchanged

September 12, 2018

Despite Republican resistance to the federal health law, the percentage of Americans without health insurance in 2017 remained the same as during the last year of the Obama administration, according to a closely watched report from the Census Bureau released Wednesday.

However, the uninsured rate did rise in 14 states. It was not immediately clear why, because the states varied dramatically by location, politics and whether they had expanded Medicaid under the federal health law. Those states included Texas, Florida, Vermont, Minnesota and Oregon.

The uninsured rate fell in three states: California, New York and Louisiana.

An estimated 8.8 percent of the population, or about 28.5 million people, did not have health insurance coverage at any point in 2017. That was slightly higher than the 28.1 million in 2016, but did not affect the uninsured rate. The difference was not statistically significant, according to the Census report.

About 17 percent of Americans were uninsured in 2010, the year the Affordable Care Act was enacted.

The Census numbers are considered the gold standard for tracking who has insurance because the survey samples are so large.

(Courtesy of the U.S. Census Bureau)

Analysts credit the health law with helping drive down the number of uninsured. But also a factor: The proportion of people without insurance typically falls as unemployment rates decline. That’s because more people can get health coverage at work or can better afford buying insurance on their own.

The nation’s unemployment rate has generally been falling since before 2011 and was 4.1 percent for the last quarter of 2017, the lowest level since before the Great Recession began in December 2007.

Critics of the health law said the report emphasized its deficiencies. “Today’s report is another reminder that Obamacare has priced insurance out of the reach of millions of working families,” Marie Fishpaw and Doug Badger of the Heritage Foundation said in a statement. “Despite a growing economy and very low unemployment rate, the uninsured rate remains virtually unchanged.”

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But the law’s supporters instead saw the glass as half full.

“These numbers show the resilience of the Affordable Care Act,” said Judith Solomon, senior fellow at the Center on Budget and Policy Priorities. She said people still value the coverage they receive from the health law even as it’s been under attack by President Donald Trump and Republicans who want to repeal it. “It’s good news because the numbers show the strength of the ACA but bad news in that we have not seen further progress.”

Solomon expressed concern, though, about the large number of states seeing uninsured rates increase.

Uninsured rates last year ranged from a high of more than 17 percent in Texas to low of just under 3 percent in Massachusetts.

West Virginia had one of the sharpest increases in uninsured.

About 14 percent of the state’s residents were uninsured in 2013 before the ACA’s premium subsidies and Medicaid expansion began. That rate fell by nearly two-thirds by 2016. Last year, however, West Virginia’s uninsured rate crept up 0.8 percentage points to 6.1 percent, according to the Census report.

Carol Bush, who has worked as a health insurance navigator the past three years in West Virginia, expects to be uninsured by month’s end. She is losing her job amid Trump administration cuts to the Affordable Care Act navigator program.(Courtesy of Carol Bush)

Carol Bush, 58, of Elkins, W.Va., expects to lose coverage Oct. 1 because her job is ending.

It’s an unfortunate irony: Elkins has served for the past three years as a navigator helping people in her community find coverage in the health law marketplaces. Federal officials have largely scrapped that program.

The Trump administration cut funding by more than 80 percent during the past two years, saying it had no proof that navigators were helping people find coverage. Only if consumers signed up in the presence of the navigator was a session considered a success.

Bush had coverage through the University of West Virginia, which has a navigator contract that ends at the end of this month. Without employer coverage, Bush said, the cheapest insurance she could find would be about $1,100 a month. She won’t qualify for a federal subsidy to lower her premium because of her family’s income. Her husband is insured through Medicare.

Although she said she has strongly considered going without insurance because of the cost, she knows she needs it.

“In all honesty, I’ve always had some kind of health insurance, and the thought of being without it worries me,” she said. “I can’t risk getting seriously ill and incurring enormous debt at this point in my life. Peace of mind has a value too.”

Shenandoah Community Health Center, a federally funded health clinic in Martinsburg, W.Va., has started to see an increase in uninsured patients the past year, although it’s still below levels it saw before the health law’s coverage expansion began in 2014, said CEO Michael Hassing. Hassing said he believes many patients have dropped coverage, thinking the ACA’s individual mandate was repealed.

“Folks say, ‘I don’t need to have it anymore,’ and they let it go,” he said.

While the GOP failed last year to repeal the law, Congress was able to strip out one of its key features — the individual penalty for not having coverage. The vote last December eliminated that penalty starting in 2019 — meaning Americans are still required this year to have health coverage or face the consequences on their 2018 taxes.

The Remedy For Surprise Medical Bills May Lie In Stitching Up Federal Law

September 10, 2018

When Drew Calver had a heart attack last year, his health plan paid nearly $56,000 for the 44-year-old’s four-day emergency hospital stay at St. David’s Medical Center in Austin, Texas, a hospital that was not in his insurance network. But the hospital charged Calver another $109,000. That sum — a so-called balance bill — was the difference between what the hospital and his insurer thought his care was worth.

Though in-network hospitals must accept pre-contracted rates from health plans, out-of-network hospitals can try to bill as they like.

Calver’s bill eventually was reduced to $332 after Kaiser Health News and NPR published a story about it last month. Yet his experience shines a light on an unintended consequence of a wide-ranging federal law, which potentially blindsides millions of consumers.

The federal law — called ERISA, for the Employee Retirement Income Security Act of 1974 — regulates company and union health plans that are “self-funded,” like Calver’s. That means they pay claims out of their own funds, even though they may be administered by a major insurer such as Cigna or Aetna. And while states increasingly pass laws to protect patients from balance bills as more hospitals and doctors go after patients to collect, ERISA law does not prohibit balance billing.

Although Texas is one of nearly two dozen states that provide consumers with some degree of protection against surprise balance bills, those state laws don’t apply to self-funded plans.

It’s a fairly common problem. About 60 percent of workers who get coverage through their job have self-insured plans, and 18 percent of people with coverage through a large employer who were admitted to the hospital in 2016 received at least one bill from an out-of-network provider, according to an analysis by the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

Health researchers and advocates have identified a number of potential solutions that could tackle the problem at the federal or state level. The courts are another option. Yet whether these efforts are politically feasible when health care is in play as a partisan football is another matter.

Polarized views on appropriate reimbursement levels for medical services “limit stakeholders at both the federal and state level from making progress,” said Kevin Lucia, a research professor at Georgetown’s Center on Health Insurance Reforms, who has analyzed state laws that restrict balance billing.

A look at options that experts say might address the problem:

Change Federal Law

The simplest way to stop surprise bills would be through restrictions imposed by federal legislation that would apply to both state-regulated policies sold by insurers and employer-sponsored self-funded health plans, which are federally regulated.

There’s a precedent for this. The Affordable Care Act added provisions that apply to both types of plans. That law requires plans that cover dependents to allow children to stay on their parents’ plans until they turn 26, for example, and cover preventive benefits without charging patients anything out-of-pocket.

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New legislation could plug a big loophole in the ACA. The health law offered some consumer protections for out-of-network emergency care, one of the biggest trouble spots for balance billing. Not only do people sometimes wind up at out-of-network hospitals when they have an emergency, but even if they visit an in-network hospital, the emergency physicians, specialists and other providers such as pathologists and labs may not be in their health plan’s network.

The ACA limited a patient’s cost sharing for emergency services to what they would face if they were at an in-network facility. It also established standards for how much health plans have to pay the hospital or doctors for that care.

But the law didn’t prohibit out-of-network emergency doctors, hospitals and other providers, such as ambulance services, from balance billing consumers for the amounts their health plan didn’t pay.

Federal legislation could close that loophole by prohibiting balance billing for emergency services, as well as hospital admissions related to that emergency care.

Analysts at the University of Southern California-Brookings Schaeffer Initiative for Health Policy, who have suggested such a remedy, say the federal law could apply to any doctors and hospitals that participate in the Medicare program, as most do, to ensure that the effect would be widespread.

They also propose prohibiting balance billing in non-emergency situations when someone visits an in-network facility but receives care from out-of-network doctors or is referred for outpatient lab or diagnostic imaging that is outside of the person’s health plan network.

Still, the deep political scars left by the health law battles would seem to preclude any bipartisan efforts in Washington to change it.

“I’d love to see any kind of federal action,” said Loren Adler, associate director at the USC center, who co-authored the proposal. “It’s just hard to be super optimistic about anything happening in the near future.”

Revise Federal Regulations

The federal executive branch could also weigh in on fixing the problem for self-insured coverage. The Department of Labor could, for example, issue a ruling that clarifies that states can regulate provider payment, or require self-funded plans to participate in state dispute-resolution programs.

But experts say relying on regulatory changes to fix surprise bills may also be a nonstarter in this political climate.

“I don’t foresee the administration taking a hard look at the limits of its powers under the ACA,” said Sara Rosenbaum, professor of health law and policy at George Washington University.

Look To The States

More than 20 states have laws protecting consumers to some degree from surprise bills from out-of-network emergency providers or in-network hospitals if they’re covered by a state-regulated insurance policy, according to an analysis by Georgetown researchers published by the Commonwealth Fund.

State laws vary. Texas, for example, requires that consumers in HMO plans be held harmless from balance billing in out-of-network emergency and in-network situations, but consumers in PPO plans can be balance-billed.

New York’s law is more comprehensive, covering both types of plans and settings. New York protects consumers from liability for out-of-network emergency and other surprise bills, requires plans to disclose how they determine a reasonable provider payment and has a binding independent dispute-resolution process.

These laws typically don’t apply to self-funded plans, however. But that could change. A New Jersey law that went into effect last month allows self-funded plans to opt in to the state’s balance billing dispute-resolution process. If a federally regulated plan decides to participate in the state program, doctors, hospitals and labs would be prohibited from balance-billing those consumers, and any disputes will be handled through a binding arbitration process.

For self-funded employers, especially those who choose to pay their employees’ surprise bills, “this provides for a more formal structure and some relief,” said Wardell Sanders, president of the New Jersey Association of Health Plans.

There are other possibilities for addressing surprise bills at the state level, policy experts say. While states can’t regulate self-funded health plans, they do regulate doctors and hospitals and other providers.

States could simply cap the amount that providers can charge for out-of-network care, for example, or prohibit practitioners like radiologists and pathologists, who don’t deal directly with patients, from billing them for services, said Adler.

“As long as providers can charge whatever they please, the problem won’t go away,” said Adler.

Will The Courts Weigh In?

These billing disputes rarely end up in court, mainly because attorneys are hesitant to take them since there are no guaranteed attorney’s fees.

A recent Colorado case was a rare success for a patient. A jury in June sided with Lisa French, a clerk at a trucking company, who was stunned by a $229,000 balance bill for spinal fusion surgery. Saying the charges were unreasonable, the jury knocked down her share of that bill to just $766.74.

The hospital was paid nearly $75,000 by her health coverage, an amount her insurer felt built in a fair profit margin, but the hospital claimed fell short.

That raises the question at the heart of many disputes over balance billing: What is a fair price?

Hospitals argue they should get whatever amount they set as charges on their master list of prices. Attorneys for patients, however, argue that a fair price should be closer to those discounted rates hospitals accept in their contracts with insurers.

Hospitals generally refuse to disclose those discounted rates, leaving patients fighting surprise bills little information about what other people pay.

Several recent court cases — including state Supreme Court rulings in Georgia and Texas — required hospitals to provide those discounted rates, although the rulings did not say those discounted prices are ultimately what patients would owe.

Podcast: KHN’s ‘What The Health?’ Health Policy Goes To Court

September 06, 2018
Julie Rovner

Kaiser Health News

@jrovner

Read Julie's Stories Mary Agnes Carey

Kaiser Health News

@MaryAgnesCarey

Read Mary Agnes' Stories Alice Ollstein

Politico

@AliceOllstein

Read Alice's Stories Margot Sanger-Katz

The New York Times

@sangerkatz

Read Margot's Stories

A federal judge in Texas seemed sympathetic to the argument by GOP state officials that the Affordable Care Act soon will no longer be constitutional, since Congress eliminated the penalty for not having insurance. The case was filed by 18 state attorneys general and two governors.

Sixteen Democratic attorneys general are defending the health law because the plaintiff in the case — the Trump administration — agrees in part with the Republican officials. The administration argues that while the elimination of the tax penalty might not render the entire law moot, it should result in striking down the part of the law that protects people with preexisting conditions.

The case could eventually wind up at the Supreme Court, a fact not lost on Senate Democrats questioning nominee Brett Kavanaugh at his confirmation hearings this week.  Kavanaugh was also grilled on how he might vote on such an ACA case and on his stance on abortion — but he revealed little. If he wins confirmation, he may have a number of abortion-related cases to consider before long.

Among the takeaways from this week’s podcast:

  • The case being argued in federal court in Texas is putting pressure on GOP candidates in the midterm elections because Democrats are arguing that Republicans’ arguments will destroy the ACA’s protections for people with preexisting conditions.
  • Ten Republican senators say a bill they are pushing will help people with preexisting health problems if the federal court in Texas strikes down the ACA. But while the bill requires insurers to sell coverage to these people, it does not require the companies to cover treatment for those medical conditions.
  • A bill sent to California Gov. Jerry Brown would require state colleges to stock drugs for medical abortions at their health centers to make them more accessible to students. The effort points up how even after these drugs became available, their use has been widely curtailed by abortion opponents.
  • The Trump administration finally made grant awards to family planning groups that provide services under the federal family planning program. But the grants were for only seven months rather than the usual three years. Some reproductive health advocates argue that short time frame was designed to give the administration time to finalize regulations aimed at evicting Planned Parenthood from the program.

Rovner also interviews Chad Terhune, who wrote the latest “Bill of the Month” feature for Kaiser Health News and NPR. It’s about a Texas high school teacher with very good insurance who still got a six-figure hospital bill after treatment for a heart attack. You can read the story here.

Send Us Your Medical Bill

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

Submit Your Bill

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

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’ “The Last Company You Would Expect Is Reinventing Health Benefits,” by Reed Abelson

Margot Sanger-Katz: MedPage Today’s “’Death Certificate Project’ Terrifies California Doctors,” by Cheryl Clark

And: The New York Times’ “How a Supreme Court Shaped by Trump Could Restrict Access to Abortion,” by Adam Liptak

Alice Ollstein: Health Affairs’ “Medicaid Recipients’ Early Experience With the Arkansas Medicaid Work Requirement,” by Jessica Greene

Mary Agnes Carey: Kaiser Health News’ “Giuliani’s Consulting Firm Helped Halt Purdue Opioid Investigation In Florida,” by Fred Schulte

To hear all our podcasts, click here.

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

Listen: The GOP Case Against ACA’s Preexisting Condition Protections Begins

September 06, 2018

A federal judge in Fort Worth, Texas, heard oral arguments in the latest challenge to the Affordable Care Act on Wednesday. The case pits a group of 18 Republican state attorneys general and two Republican governors against a coalition of Democratic state attorneys general led by California’s Xavier Becerra.

Ashley Lopez of member station KUT in Austin reports on the first day in court, and KHN’s chief Washington correspondent Julie Rovner discusses what it all means on NPR’s “All Things Considered.”

California: A Health Care Laboratory With Mixed Results

September 05, 2018

California’s expansion of Medicaid under the Affordable Care Act enabled many low-income HIV patients to get health insurance previously denied to them. Still, those with mental health needs, who had been receiving coordinated care through a separate federal program, suddenly faced gaps in treatment, payment disputes and doctors who had little understanding of life with HIV.

A report on HIV patients is one example in a special California edition of the journal Health Affairs showing that though the state is often a national beacon in health care, some of its innovations fall short of expectations.

The Golden State was a pioneer in embracing the ACA, aiming to enhance the availability, quality and efficiency of health care. But its size and diversity — as well as the unforeseen complications of real-world implementation — have made for some messy experiments.

It is “not a well-controlled laboratory,” said Dylan Roby, an associate professor at the University of Maryland’s School of Public Health. “When you are trying to make things more efficient, there are, of course, going to be these gaps that are created.”

In the case of HIV patients, “individuals who had previously been receiving really integrated, culturally tailored services … were now having to navigate a really complicated landscape,” said Emily Arnold, associate professor at University of California-San Francisco and lead author of the HIV study.

Another Health Affairs article tracked the impact of California’s Medicaid expansion on family planning services for low-income residents. Researchers found that while it left far fewer young women uninsured, it did not boost the proportion who actually received family planning or general health care services.

(Early et al./Health Affairs)

“It was a little bit disappointing,” said Heike Thiel de Bocanegra, associate professor at UCSF and one of the study’s co-authors. “We pushed for access and enrollment and to get everybody on health insurance. Now we have to make sure that they use it and that they use it for preventive services.”

That outcome may be due in part to the fact that California had already invested in family planning services, including for low-income women, according to the study.

California’s increasingly diverse population, willingness to tackle complex health care issues and long history with integrated health care mean it “has learned a lot for itself and also has lessons for the rest of the country,” Alan Weil, Health Affairs’ editor-in-chief, said in an interview.

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Now, Weil said, people are watching California’s discussion of a single-payer health system, which the leading candidate for governor, Democrat Gavin Newsom, has made part of his platform.

The Health Affairs issue also highlights some California successes, including on maternal mortality. The death rate was rising alarmingly and “cut everyone to the core,” leading clinicians and state officials to establish quality measures and follow up on them, said Dr. Elliot Main, medical director of the California Maternal Quality Care Collaborative at Stanford University.

“The status quo was no longer sustainable,” said Main, the lead author of an article about a project to address the rising death rates.

Beginning in 2006, the public health department joined with doctors, hospitals and researchers to study the data, better understand the deaths and teach hospitals how to improve outcomes. While the U.S. maternal mortality rate got worse, California’s dropped nearly in half — from 13.1 maternal deaths per 100,000 live births, on average, for the years 2005 through 2009 to an average of seven per year from 2011 to 2013.

(Main et al./Health Affairs)

In San Diego County, hospitals and clinics tackled another killer: heart disease. Dr. Anthony DeMaria, a professor at University of California-San Diego, said the county’s biggest health care systems worked together on fighting heart disease, which continues to be the leading cause of death in California and the U.S.

They shared data and strategies, used health coaches to work with patients and collaborated with churches. Between 2007 and 2016, hospital admissions due to heart attacks dropped by 22 percent, compared with an 8 percent drop statewide.

“How many cities do you think would be able to get all the competing health care institutions to collaborate on something like this?” asked DeMaria, who co-authored a Health Affairs analysis on the effort. “In most places, it’s like porcupines mating. When they come together, they are very, very cautious.”

State health officials, the federal government and insurance plans have also worked together to improve care for chronically ill, low-income seniors who are on both Medicare and Medicaid. They are among the most expensive and complicated patients in the nation and historically have had poorly coordinated care.

California was one of 13 states to implement a pilot project intended to better integrate their medical care and other health-related services. Patients who enrolled in the pilot, known as Cal MediConnect, ultimately reported greater satisfaction with their benefits and quality of care.

At the same time, about half of the eligible participants opted out of enrollment — a significant shortcoming in the experiment.

Despite its successes, California still has significant health disparities and an uneven distribution of health care providers to help reduce them. A Health Affairs study about nurse practitioners underscores the challenge of getting these medical professionals to the populations that need them the most.

Joanne Spetz, a professor at UCSF, found that even though nurse practitioners could help fill gaps in primary care, they and the programs that train them are generally in locations that already have a relatively high number of doctors per patient.

San Francisco, for example, has multiple nurse practitioner education programs, said Spetz, lead author of the article. “That isn’t where the jobs are and where the greatest needs are,” she said.

For California’s complex health challenges, “there is no silver bullet,” said Shana Charles, assistant professor at Cal State-Fullerton. “There are still going to be issues even if you have the best of intentions.”

KHN’s coverage of these topics is supported by Blue Shield of California Foundation and The David and Lucile Packard Foundation

Surprise Medical Bills Are What Americans Fear Most In Paying For Health Care

September 05, 2018

Unexpected medical bills top the list of health care costs Americans are afraid they will not be able to afford, with 4 in 10 people saying they had received a surprisingly large invoice within the past year, according to a new poll.

The Kaiser Family Foundation poll found that 67 percent of people worry about unexpected medical bills, more than they dread insurance deductibles, prescription drug costs or the basic staples of life: rent, food and gas. (Kaiser Health News is an editorially independent program of the foundation.)

Thirty-nine percent of insured adults under age 65 said they had received a medical bill within the previous 12 months that they’d figured would be covered or that was higher than they anticipated. Half of those people said the bill was less than $500, but nearly 1 in 8 said they were on the hook for $2,000 or more.

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A quarter of people who said they received a surprisingly large bill attributed it to a doctor, hospital or other provider that was not in their insurance network. Such providers often will not accept the amount an insurer thinks a procedure or test should cost, and they bill the patient for the difference. That practice, known as balance billing, is one of the most common types of outsize charges that KHN and NPR profile in the “Bill of the Month” series.

Another poll recently conducted by NORC at the University of Chicago, a research group, found similar numbers of people had received a surprise bill. The most common charges were for a physician’s service or a lab test.

Once again, the Kaiser poll found that a majority of the public — regardless of political party — does not want insurers to be allowed to deny coverage or charge higher premiums because of someone’s medical history or health status. Both practices were standard in the health insurance industry until they were outlawed by the Affordable Care Act in 2010.

Those protections would be suspended if a group of Republican attorneys general who assert the law is unconstitutional persuade a federal court judge in Texas this week that the health law be put on hold while their case against the ACA is litigated. The ACA protections are supported by at least 86 percent of Democrats, 71 of independents and 56 percent of Republicans, the poll found.

Americans said there was plenty of blame to go around for the high cost of health care. At the top, 78 percent of the public said excessive drug company profits were a major reason health care costs are rising. That is a 7 percentage point increase from 2011 and more than any other single reason. A majority of the public also blamed waste and fraud, unnecessarily high hospital charges, excessive insurance profits and the cost of new medical technologies.

The poll was conducted Aug. 23-28 among 1,201 adults. The margin of error was +/-3 percent.

Democratic, GOP Attorneys General Square Off In Texas Showdown Over Health Law

September 04, 2018

Wednesday is looking like yet another pivotal day in the life-or-death saga that has marked the history of the Affordable Care Act.

In a Texas courtroom, a group of Republican attorneys general, led by Texas’ Ken Paxton, are set to face off against a group of Democratic attorneys general, led by California’s Xavier Becerra, in a lawsuit aimed at striking down the federal health law. The Republicans say that when Congress eliminated the penalty for not having health insurance as part of last year’s tax bill, lawmakers rendered the entire health law unconstitutional. The Democrats argue that’s not the case.

But first, the sides will argue before U.S. District Judge Reed O’Connor in Fort Worth, Texas, whether the health law should be put on hold while the case is litigated. The GOP plaintiffs are seeking a “preliminary injunction” on the law.

Ending the health law, even temporarily, “would wreak havoc in our health care system,” said Becerra in a call with reporters last week. “And we don’t believe Americans are ready to see that their children are no longer able to see a doctor or that they cannot get treated for a preexisting health condition.”

Here are five questions and answers to help understand the case, Texas v. U.S.

1. What is this suit about?

In February, 18 GOP attorneys general and two GOP governors filed the suit in federal district court in the Northern District of Texas. They argue that because the Supreme Court upheld the ACA in 2012 by saying its requirement to carry insurance was a legitimate use of Congress’ taxing power, eliminating the tax penalty for failure to have health insurance makes the entire law unconstitutional.

“Texans have known all along that Obamacare is unlawful and a divided Supreme Court’s approval rested solely on the flimsy support of Congress’ authority to tax,” Paxton said in a statement when the suit was filed. “Congress has now kicked that flimsy support from beneath the law.”

The lawsuit asks the judge to prohibit the federal government “from implementing, regulating, enforcing, or otherwise acting under the authority of the ACA.”

2. Why are Democratic attorneys general defending the law?

The defendant in the case is technically the Trump administration. But in June, the administration announced it would not fully defend the law in court.

The Justice Department, in its filing in the case, did not agree with the plaintiffs that eliminating the tax penalty should require that the entire law be struck down. But it did say that without the tax, the provisions of the law requiring insurance companies to sell to people with preexisting conditions and not charge them more should fall, beginning Jan. 1, 2019. That is when the tax penalty goes away.

The Republican attorneys general say they still believe the entire law should be invalidated, but if that does not happen, they would accept the elimination of the preexisting condition protections.

The Democratic attorneys general applied to “intervene” in the case to defend the law in its entirety. They say they needed to step forward to protect the health and well-being of their residents. The judge granted them that status on May 16.

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3. What would happen if the judge grants a preliminary injunction?

The GOP plaintiffs say the law needs to be stopped immediately, “both because individuals will make insurance decisions during fall open-enrollment periods and because the States cannot turn their employee insurance plans and Medicaid operations on a dime,” according to their brief.

But setting aside the ACA while the case proceeds “would throw the entire [health] system into chaos,” Becerra said. That’s because the ACA made major changes not just to the insurance market for individuals, but also to Medicare, Medicaid and the employer insurance market.

Even in 2012, when the Supreme Court was considering the constitutionality of the law before much of it had taken effect, some analysts from both parties predicted that finding the law unconstitutional could have serious repercussions for the Medicare program and the rest of the health care system.

In practice, however, even if Judge O’Connor were to rule in favor of the Republicans’ request to stop the law’s enforcement immediately, the decision could be quickly appealed up the line, including, if necessary, before the Supreme Court.

4. Is this case purely Republicans versus Democrats?

The case is largely partisan — with Republicans who oppose the health law arguing for its cancellation and Democrats who support it fighting to keep it in place.

But a friend-of-the-court brief filed by five law professors who disagree on the merits of the ACA said that, regardless, both the GOP states and the Justice Department are wrong to conclude that eliminating the tax penalty should result in the entire law being thrown out.

In this case, “Congress itself has essentially eliminated the provision in question and left the rest of a statute standing,” so courts do not need to guess whether lawmakers intended for the rest of the law to remain, they wrote.

5. What is Congress doing about this?

Technically, Congress is watching the case just as everyone else is. But Republicans in particular, while they mostly oppose the health law, are aware that the provisions protecting people with preexisting conditions are by far the most popular part of the ACA. And Democrats are already using the issue to hammer opponents in the upcoming midterm elections.

Last month, 10 GOP senators introduced legislation they said would maintain the ACA’s preexisting condition protections in the event the lawsuit succeeds.

“This legislation is a common-sense solution that guarantees Americans with preexisting conditions will have health care coverage, regardless of how our judicial system rules on the future of Obamacare,” said Sen. Thom Tillis (R-N.C.), the bill’s lead sponsor, in a statement.

Critics, however, were quick to point out that the bill doesn’t actually offer the same protections that are embodied in the ACA. While the health law requires coverage for all conditions without extra premiums, the GOP bill would require that insurers sell to people with preexisting conditions, but not that those policies actually cover those conditions.

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