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Updated: 19 hours 55 min ago

Need Health Insurance? The Deadline Is Dec. 15

December 10, 2018

The woman arrived at the University of South Florida’s navigator office in Tampa a few weeks ago with a 40-page document describing a short-term health insurance plan she was considering. She was uncomfortable with what the broker had said about the coverage, she told Jodi Ray, a health insurance navigator who helps people enroll in coverage, and she wanted help understanding it.

The document was confusing, according to Ray, who oversees Covering Florida, the state’s navigator program. It was hard to decipher which services would be covered.

“It was like a bunch of puzzle pieces,” she said.

Encouraged by her wife, the woman eventually opted instead for a marketplace plan with comprehensive benefits.

The annual open-enrollment period for people who buy their own insurance on the Affordable Care Act’s marketplaces ends Dec. 15 in most states. Enrollment in states that use the federal healthcare.gov platform has been sluggish this year compared to last. From Nov. 1 through Dec. 1, about 3.2 million people had chosen plans for 2019. Compared with the previous year, that’s about 400,000 fewer, or a drop of just over 11 percent.

The wider availability of short-term plans is one big change that has set this year’s apart from past sign-up periods.

Another is the elimination of the penalty for not having health insurance starting next year. The Congressional Budget Office has estimated that as many as 3 million people who buy their own coverage may give it up when they don’t face a tax penalty.  But experts who have studied health insurance enrollment say that surveys so far indicate that the penalty hasn’t typically been the pivotal factor in people’s decision on whether to buy insurance.

They also caution against reading too much into the preliminary enrollment totals.

“There typically is a surge in enrollment at the end,” said Sabrina Corlette, research professor at Georgetown University’s Center on Health Insurance Reforms. “It’s hard to know whether it will make up for the shortfall.”

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If they don’t pick a new plan, people who are enrolled in a 2018 marketplace plan may be automatically re-enrolled in their current plan or another one that is similar when the open-enrollment period ends. About a quarter of people who have marketplace plans are reassigned in this way.

Another factor that may be affecting enrollment is tighter federal funding for the health insurance navigators, like Jodi Ray in Tampa, who guide consumers through the complicated process. With fewer experts available to answer questions and help fill out the enrollment forms, consumers may fall through the cracks.

Across the country, funding for navigators dropped from $36 million in 2017 to $10 million this year. In Florida, federal funding for the Covering Florida navigator program was slashed to $1.25 million this year from $4.9 million last year, Ray said. The program was the only one to receive federal funding in the state this year.

The Covering Florida program reduced the number of open-enrollment navigators to 59 this year, a nearly 61 percent drop, Ray said. Navigators this year are available in only half of Florida counties; the organization is offering telephone assistance and virtual visits to people in counties where they can’t offer in-person help.

“It’s all we can do,” Ray said. So far, the group’s navigators have enrolled about half the number of people this year as they had last year.

It’s unclear the extent to which the Trump administration’s efforts to reduce health care costs by expanding access to short-term plans is affecting marketplace plan enrollment.

These plans, originally designed to cover people who expected to be out of an insurance plan for a short time, such as when they change jobs, can be less expensive. Unlike marketplace plans, short-term plans don’t have to provide comprehensive benefits or guarantee coverage for people who have preexisting medical conditions.

The Obama administration limited short-term plans to a three-month term. But in August, the federal government issued a rule that allowed their sale with initial terms of up to a year, and the option of renewal for up to three years.

Ten states either ban short-term plans or restrict them to terms of less than three months, said Sarah Lueck, a senior policy analyst at the Center on Budget and Policy Priorities.

Many people are seemingly not focused on their options this open-enrollment season, however. According to a recent survey, about half of adults under age 65 who were uninsured or who buy their own coverage said they planned to buy a plan for 2019. But only 24 percent of people in that age group said they knew what the deadline was to enroll in health insurance, according to the Kaiser Family Foundation’s November health tracking poll.

Must-Reads Of The Week On Health Care

December 07, 2018
The Friday Breeze

Want to read the best and most provocative stories from the week? Welcome to the Friday Breeze, where we compile them all — so you’re set with your weekend reading.

Your regular Breeze correspondent, and its creator, Brianna Labuskes, is taking a break, but we didn’t want you to be without some semblance of a report today of things you don’t want to miss in health care.

So I’ll do my best at filling in. Be kind, and check back next week for the really good stuff.

One of the biggest bits of news this week was a coughed-up blot clot from the lung. Not sure why that seemed to fascinate people. We can skip that, but feel free to look.

The Atlantic: Doctors Aren’t Sure How This Even Came Out of a Patient

A more authentic bit of news was the report that health care spending slowed in 2017. It’s still growing, mind you, but growing more slowly. That’s not terribly surprising, because it has been slowing for a number of years. What Dan Diamond over at Politico calls “slowth.” It increased 3.9 percent to $3.5 trillion, while the year before it had grown 4.8 percent. Another way to look at it: Americans spend $10,739 per person on health care. HuffPost had a nice analysis:

HuffPost: America’s Health Care Spending Keeps Rising Really Slowly. Seriously.

Read the full report here.

The New York Times attempts to explain why enrollment in Obamacare is down. Any number of things could factor in, like higher employment at places that offer health insurance, no mandate forcing people to enroll or people signing up for Medicaid. Further study may present an answer.

The New York Times: Why Is Obamacare Enrollment Down?

The Friday Breeze

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This week, the Annals of Internal Medicine retracted a 2009 paper by Brian Wasinick, the now-discredited Cornell University researcher. The half-baked paper had claimed that the recipes in the more modern editions of the classic “Joy of Cooking” cookbook had more calories than the original. The always enlightening Retraction Watch website, which tracks medical and scientific research that has been undermined, has the whole story of the delightful sleuthing that led to the debunking. (And while you are on the site, peruse all the other Wasinick papers on food research that have been rescinded.)

Retraction Watch: The Joy of Cooking, Vindicated: Journal Retracts Two More Brian Wansink Papers

One of my favorite writers on health care makes an often overlooked point about health insurance: Its goal ought to be the same as other insurance, that is, to safeguard the financial health of beneficiaries. And Aaron Carroll, who is also a professor of pediatrics at Indiana University School of Medicine, says that several studies show it does exactly that.

Read the whole piece for yourself:

JAMA Forum: Medicaid as a Safeguard for Financial Health

As a bonus on this topic, here is an academic paper surfacing this week on the effects of the Affordable Care Act on mortgage delinquencies. Spoiler: The value of fewer evictions and foreclosures is substantial compared to the cost of the ACA subsidies.

The Effect of Health Insurance on Home Payment Delinquency: Evidence from ACA Marketplace Subsidies

The Commonwealth Fund, a foundation that seeks to improve health care,  wanted to know how the Affordable Care Act affected the uninsured and the insured. As its chart that summarizes its findings issued this week shows, there was considerable movement. The main finding was the number of young adults who switched from Medicaid to individual insurance — and the other direction as well.

The Commonwealth Fund: Who Entered and Exited the Individual Health Insurance Market Before and After the Affordable Care Act?

Commonwealth also conducted a forum on “Being Seriously Ill in America,” which dealt with the financial consequences.

Forbes likes to compile those “30 under 30” lists. (I’ve long wished someone would go back and look at one of those lists from 20 or 25 years ago to see how the luminaries are doing now.) Anyway, it put together a list of people in the health care industry. Most are on the cusp of 30, which might tell you something about how hard it is to get a fast start in the industry. But one person on the honor roll is only 18. In case you were wondering, because I was, Elizabeth Holmes, the founder of the ill-fated Theranos, was on a different “40 under 40” Forbes list in 2014. We hope these folks fare better.

Forbes: 30 Under 30 in Healthcare

This article ran a while back, but I got a kick out of it and just had to mention it. It looked at prehistoric health care. Researchers will never know how much Stone Age dwellers bored their hut mates with discussions of a paleo diet, but they are learning how they performed medical procedures that appeared to have worked.

The Atlantic: Neanderthals Suffered a Lot of Traumatic Injuries. So How Did They Live So Long?

May you survive another whirlwind week of health care news, until next Friday’s breezy recap.

Podcast: KHN’s ‘What The Health?’ Is Health Spending The Next Big Political Issue?

December 06, 2018
Julie Rovner

Kaiser Health News

@jrovner

Read Julie's Stories Rebecca Adams

CQ Roll Call

@RebeccaAdamsDC

Read Rebecca's Stories Joanne Kenen

Politico

@JoanneKenen

Read Joanne's Stories Margot Sanger-Katz

The New York Times

@sangerkatz

Read Margot's Stories

The Republican-led Congress was unable to repeal the Affordable Care Act in 2017, but the Trump administration continues to implement elements of the failed GOP bill using executive authority. The latest change would make it easier for states to waive some major parts of the health law, including allowing subsidies for people to buy insurance plans that don’t meet all the law’s requirements.

Meanwhile, in states that are transitioning from Republican governors to Democrats, GOP legislators are using lame-duck sessions to try to scale back executive power and lock in some key health changes, such as work requirements for Medicaid enrollees.

And there is growing evidence that even with health insurance, patients who use significant amounts of medical care are increasingly unable to afford their share.

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

Among the takeaways from this week’s podcast:

  • The Trump administration outlined last week what type of waivers it is willing to consider for states’ ACA markets. Options include changes in who gets premium subsidies and how much they receive, and making short-term insurance plans that are not as comprehensive as current marketplace plans eligible for subsidies.
  • Any changes are likely to end up in court, as have most of the revisions that the Trump administration has proposed.
  • In Wisconsin and Michigan, Republican legislatures are seeking to restrict what the new Democratic governors can do to change GOP policies on Medicaid and challenges to the ACA.
  • A recent study has highlighted that health problems can create financial hardships well beyond the illness. For example, loss of income from a debilitating illness can make paying other bills very difficult and sometimes other family members must give up their jobs to be caregivers.

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

Julie Rovner: NBC News.com’s “FDA Approves Drug for Dogs Scared by Noise,” by Maggie Fox

Margot Sanger-Katz: The Washington Post’s “An Experiment Requiring Work for Food Stamps Is a Trump Administration Model,” by Amy Goldstein

Joanne Kenen: The Atlantic’s “The CRISPR Baby Scandal Gets Worse by the Day,” by Ed Yong

Rebecca Adams: The New York Times’ “Why Hospitals Should Let You Sleep,” by Austin Frakt

Also mentioned in this episode:

The New York Times: “1,495 Americans Describe the Financial Reality of Being Really Sick,” by Margot Sanger Katz

Kaiser Health News: “No Cash, No Heart. Transplant Centers Require Proof of Payment,” by JoNel Aleccia

CBS News: “High Cost Has Many Diabetics Cutting Back on Insulin,” by Serena Gordon

To hear all our podcasts, click here.

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

Without Obamacare Penalty, Think It’ll Be Nice To Drop Your Plan? Better Think Twice

December 05, 2018

Dana Farrell’s car insurance is due. So is her homeowner’s insurance — plus her property taxes.

It’s also time to re-up her health coverage. But that’s where Farrell, a 54-year-old former social worker, is drawing the line.

“I’ve been retired two years and my savings is gone. I’m at my wit’s end,” says the Murrieta, Calif., resident.

So Farrell plans — reluctantly — to drop her health coverage next year because the Affordable Care Act tax penalty for not having insurance is going away.

That penalty — which can reach thousands of dollars annually — was a key reason that Farrell, who considers herself healthy, kept her coverage.

Now, “why do it?” she wonders. “I don’t have any major health issues and I’ve got a lot of bills that just popped up. I can’t afford to pay it anymore.”

Farrell is among millions of people likely to dump their health insurance because of a provision in last year’s Republican tax bill that repeals the Obamacare tax penalty, starting in 2019, by zeroing out the fines.

The Congressional Budget Office estimated that the repeal of the penalty would move 4 million people to drop their health insurance next year — or not buy it in the first place — and 13 million in 2027.

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Some people who hated Obamacare from the start will drop their coverage as a political statement. For people like Farrell, it’s simply an issue of affordability.

Since Farrell started buying her own insurance through the open market in 2016, her monthly premium has swelled by about $200, she says, and she bears the entire cost of her premium because she doesn’t qualify for federal ACA tax credits. Next year, she says, her premium would have jumped to about $600 a month.

Instead, she plans to pay cash for her doctor visits at about $80 a pop, and for any medications she might use — all the while praying that she doesn’t get into a car accident or have a medical emergency.

“It’s a situation that a lot of people find themselves in,” says Miranda Dietz, lead author of a new study that projects how ending the penalty will affect California.

Dana Farrell

People like Farrell whose incomes are too high to qualify for tax credits are especially vulnerable, says Dietz, a research and policy associate at the University of California-Berkeley Center for Labor Research and Education. They must pay the entire premium themselves.

Premiums, even for a bronze plan with a deductible of more than $6,000, are enormous in some cases, she says. “The state’s done a great job of implementing the ACA,” she says, “but there are still Californians who just find insurance out of reach.”

Up to 450,000 more Californians may be uninsured in 2020 as a result of the penalty ending, and up to 790,000 more by 2023, boosting the state’s uninsurance rate for residents under 65 to 12.9 percent, according to the study. The individual market would suffer the biggest losses.

Covered California, the state health insurance exchange, predicts that enrollment in the individual market — both on and off the exchange — could drop by 12 percent next year, says agency spokesman James Scullary.

Exchange officials also blame the end of the penalty for a 3.5 percent average increase in premiums, because the departure of some healthy people from the market will lead to a sicker and costlier insurance pool.

Health insurance can be difficult to afford, but going without it is a “bad gamble,” Scullary says. Keep in mind: More than 22,000 Covered California enrollees broke, dislocated or sprained arms or shoulders in 2017, and 50,000 enrollees were either diagnosed with — or treated for — cancer, he explains.

“We know that none of those people began the year thinking, ‘This is when I’m going to break my arm,’ or ‘This is the year I get cancer,’” he says.

If you’re considering dropping your plan and risking the devastating financial consequences of an unexpected medical expense, check first to see if you can lower your premium.

“A big mistake for people is to look at the notice they get for their current health insurance and see it’s going up a lot and then throw up their hands and decide they’re going to go without,” says Donna Rosato, a New York-based editor at Consumer Reports who covers health care cost issues.

“Before you do that, look at other options.”

The most important thing to do is seek free help from a certified insurance agent or enrollment “navigator.” You can find local options by clicking on the “Find Help” tab on Covered California’s website, http://www.CoveredCA.com.

Next, see if you can qualify for more financial aid. For instance, if your income is close to the threshold to qualify for tax credits through Covered California or another Obamacare insurance exchange — about $48,500 for an individual or $100,000 for a family of four this year — check with a financial professional about adjusting it, Rosato suggests. You might be able to contribute to an IRA, 401(k) or health savings account to lower the total, she says.

Beyond that, be flexible and willing to switch plans, she advises. Consider different coverage levels, both on and off health insurance exchanges. If you’re in a silver-level plan (the second-lowest tier), you might save money by purchasing a less expensive bronze-level plan that has higher out-of-pocket costs but would protect you in case of a medical emergency.

This year, Farrell got a clean bill of health from her doctor after a round of tests. She’s nervous about being without coverage next year, but feels she doesn’t have a choice.

“It’s going to be the first time in my life I’m not going to have insurance,” she says.

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

Short On Federal Funding, Obamacare Enrollment Navigators Switch Tactics

November 30, 2018

Enrollment is down sharply on the federal health insurance marketplace this fall, and the consumer assistance groups that help with sign-ups think they know why.

They don’t have the staff to help as many customers as before because the Trump administration slashed funding. The federal government is spending $10 million this year on navigators who help individuals enroll in coverage. The government spent $36 million in 2017 and $63 million in 2016.

“We don’t have the people to provide the enrollment assistance nor to do the outreach and marketing to let people know what’s happening,” said Jodi Ray at the University of South Florida, who has overseen Florida’s largest navigator program since 2014.

Ray’s program received $1.2 million in federal funding this year, down from $5 million a year ago. Florida leads the nation in enrollment in the Affordable Care Act marketplace plans.

With less money, Ray can afford to pay only 59 navigators across the state this year, down from 152 a year ago. With fewer navigators, much of the group’s counseling is done by phone instead of in person. That complicates their job, she said, because it is much easier to talk with and show marketplace customers in person when looking at dozens of health plans with different costs and benefits.

Open enrollment in the Obamacare plans began Nov. 1 and will run until Dec. 15 for the 39 states covered by the federal exchange, healthcare.gov. The other exchanges — run by states — typically extend until the end of December or into January.

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Obamacare plans are for people without workplace or government coverage.

Nationwide, navigator groups are scrambling to make up for the loss of federal funding to ensure they can help people make sense of their health insurance options.

  • In South Carolina, the Palmetto Project has transformed into the state’s first nonprofit insurance agency. Several of its former federally funded navigators are now licensed insurance agents. In their new role, they get paid a commission on their sales and don’t have to follow Trump administration rules that encourage navigators to talk to customers about short-term plans with limited benefits. The agents can also help customers enroll in Medicaid, Medicare and off-exchange plans.
  • The Community Council of Greater Dallas, which was funded last year to help with enrollment in 56 counties, has raised money from private donors to continue serving seven counties around Dallas. But it has 25 fewer navigators, so consumers seeking help must wait three days on average, compared with less than a day last year. Across Texas, 211 of 254 counties have no federally paid navigators.
  • In Wisconsin, the organization Covering Wisconsin has raised millions of dollars from cities, counties and local United Way chapters, as well as the state Medicaid agency, to make up for the federal cuts. Even still, it will be able to provide in-person assistance in only eight counties around Milwaukee and Madison. Twenty other counties are served by telephone.
  • The Kansas Association for the Medically Underserved is relying totally on volunteers to help consumers with in-person and telephone assistance. In the past year, the association was able to use government funding to pay about 20 navigators.

Nationally, nearly 800 counties served by the federal marketplace will not have any federally funded navigators this fall — up from 127 counties in 2016, according to the Kaiser Family Foundation. (KHN is an editorially independent program of the foundation.)

Federal officials said they were not providing funds for navigators in Iowa, Montana or New Hampshire because no organizations applied in those states.

Nearly 12 million people across the country — including nearly 9 million on the federal exchange — enrolled in Obamacare plans for 2018.

At the halfway point in the six-week enrollment period, 2.4 million people chose a plan for the 2019 coverage year on healthcare.gov, the federal health insurance exchange, according to data released Wednesday by the federal Centers for Medicare & Medicaid Services. That compares with nearly 2.8 million consumers who selected their coverage through the exchange during the first 25 days last year.

Among states with the largest enrollment drops: Pennsylvania (down 25 percent from last year), Missouri (down 25 percent) and Ohio (down 20 percent).

The annual enrollment tally is being closely followed in part because 2019 marks the first year since the marketplace plans began in 2014 that Americans won’t be fined for failing to have coverage.

But consumer experts think the lack of navigator funding could end up having a bigger impact on enrollment. Caroline Gómez-Tom, navigator program manager of Covering Wisconsin, said the end of the so-called individual mandate penalty has been a “non-issue” among people seeking coverage.

“Some folks mention it, but at the end of the day they still walk away with health coverage,” she said. “The ability to have coverage at affordable prices outweighs the penalty being gone because people still see health care insurance as important to have.”

Consumers generally have a greater choice of plans for 2019 as more companies enter the individual market and existing plans expand service areas. Plus, premiums are dropping in some areas, and where they are rising the rate of increase is among the lowest in several years.

Katrina McGivern, director of policy and public affairs for the Kansas Association for the Medically Underserved, said people in rural areas of the state will have the most difficulty getting help as a result of funding cuts.

After five years of experience, she said, she is hopeful that people are figuring out how to do it on their own. Still, she added, there are always “people who need assistance to get through it.”

Is Trump Pushing Health Insurance Innovation Or An ACA Rollback?

November 29, 2018

On his first day in office, as part of his mission to dismantle the Affordable Care Act, President Donald Trump signed an order promising to give states flexibility “to create a more free and open healthcare market.”

The administration on Thursday released an official set of examples to help states flex these powers.

It is intended to roll back key elements of Obama-era requirements, which were designed to promote enrollment in ACA plans that cover a broad range of medical needs and meet uniform national standards.

Seema Verma, the Centers for Medicare & Medicaid Services administrator, said those strict rules were seen by many as burdensome, and “virtually impossible” for states to meet.

Instead, the Trump administration wants states to innovate in ways that could produce more lower-cost options, even if those alternatives do not provide the same level of financial or medical coverage as an ACA plan.

“I’m confident states will come up with ideas that will work better,” said Verma.

Still, coupled with other ongoing efforts by the Trump administration to gut Obamacare, policy experts predict the ideas would further foster a parallel market of cheaper, less robust coverage that could draw younger or healthier consumers, but drive up premiums for those who remain in ACA market plans.

“Invariably, the coverage is going to be more expensive for people who really need comprehensive coverage,” said Timothy Jost, a retired Washington and Lee University law professor who follows the ACA closely.

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One of the biggest changes signaled by the administration involves allowing states to revamp how federal subsidies are used. Currently, they are strictly targeted to lower-income Americans and are seen as key to bolstering enrollment in marketplace plans.

The Trump guidance would give states wider latitude to expand or narrow the income range eligible for subsidies, target them toward younger people or allow them to be used for less costly but skimpier types of insurance.

This would “potentially upend the subsidy structure,” said Sabrina Corlette, research professor at Georgetown University’s Health Policy Institute.

Another example would, for the first time, make federal subsidy money available to people who get job-based insurance, countering Obama-era rules that generally prohibited that. It would let states use federal dollars to fund accounts consumers could use to buy insurance or pay other health costs, such as deductibles or copayments. Employers or consumers could also add additional funds to these accounts.

Still, managing those accounts would be a large administrative expense for a state to oversee, said Corlette. “I don’t understand why a state would want to set it up,” she added.

Supporters say the examples unveiled Thursday would give consumers more control over how they choose to spend their health care dollars and the types of coverage they want to buy. They say it might also improve the markets, which are seeing declining enrollment as premiums rise.

“If states can provide larger subsidies to younger individuals to attract them to enroll, that will improve the market overall,” said Christopher Condeluci, a Washington, D.C., attorney who specializes in employee benefits and has served as the tax and benefits counsel to the U.S. Senate Finance Committee.

However, if many states follow the administration’s lead, critics say, it would bring back the days when insurance rules varied widely state by state. Consumers could end up buying skimpier plans that leave them vulnerable to high, unexpected medical bills.

While not prescriptive, the examples are designed to encourage states to innovate and apply for permission to offer more choices for consumers, so long as the proposals don’t cost taxpayers more and don’t reduce access to ACA plans, said Verma.

State proposals would still have to be affordable, comprehensive and not raise the federal deficit, she said. And CMS would pay particular attention to potential effects on low-income Americans, she added.

Reshaping The Individual Market

The administration’s examples focus on states’ health marketplaces, where insurance plans are designed for individuals who don’t get job-based coverage and small businesses. An estimated 14 million people buy their own coverage through those markets or through brokers.

Premiums in those markets have risen substantially since the law took effect in 2014, for a variety of reasons, including lower-than-expected enrollment by healthy people and actions taken by Congress and the Trump administration that removed the tax penalty for failing to have coverage, eliminated some payments to insurers and loosened restrictions on alternative types of insurance plans.

The administration’s examples add a new twist to a provision of the ACA, which gave states the option of seeking a federal waiver to develop alternative marketplace proposals.

To get one under Obamacare rules, however, states have to meet four “guardrails” established in 2015. These require states to ensure their proposals would provide equally comprehensive and affordable coverage, not result in fewer people enrolling or increased costs for taxpayers.

The examples, tapped by the administration as “waiver concepts,” build on the Trump administration guidance issued in late October to loosen those guardrails. That guidance, effective in 2020, says states have to provide access to affordable and comprehensive coverage, but will not be held to a strict tally of how many people actually enroll. So long as a state could show that equal numbers of people were buying some kind of coverage — either comprehensive ACA plans or less expensive but skimpier plans — it could pass the test.

That October announcement, and Thursday’s concepts, drew immediate criticism from ACA supporters, who said it encourages the use of subsidies to buy short-term plans, which aren’t as comprehensive as ACA coverage and can bar people with preexisting conditions.

Congressional Democrats sent a letter to top administration officials saying the process by which the changes are being made — meaning they are not following a formal rule-making process — are illegal.

“We believe this sub-regulatory guidance exceeds the Secretaries’ statutory authority,” wrote Ways & Means ranking member Richard Neal (D-Mass.) and Energy and Commerce ranking member Frank Pallone Jr. (D-N.J.). “It appears to be part of the Administration’s ideologically motivated efforts to sabotage the ACA.”

The Brookings Institution and other experts have raised similar questions and predicted a legal challenge.

“As soon as any state proceeds to go somewhere with this, there will be legal challenges,” said Jost, the law professor.

Verma pushed back against this warning, noting that the Obama administration also issued its guardrails as guidance, not a formal rule.

And, just as when the administration released its earlier guidance in October, Verma anticipated that critics would say the ideas would adversely affect people with preexisting medical conditions.

Those critics argue that anything that draws younger and healthier people out of the market will drive up costs for those who remain in ACA plans, including those with medical conditions who might be barred from buying an alternative policy, such as a short-term plan.

But Verma said that “nothing in this guidance would take away protections from people with preexisting conditions.”

Listen: Paying More For Your Health Insurance? Depends On Where You Live

November 29, 2018
https://californiahealthline.files.wordpress.com/2018/11/kalw_jordan1.mp3

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Open enrollment is underway in the sixth year of the Affordable Care Act’s insurance marketplaces, with some regions of the country experiencing unexpected drops in premiums and others weathering higher prices.

In California, premiums for plans sold through the state’s health insurance exchange, Covered California, will rise an average of 8.7 percent next year, although individual rate increases — or decreases — depend on a variety of factors, including where you live, what plan you choose and your income. Many consumers can save money by switching plans.

While open enrollment lasts through Dec. 15 in states served by the federal health insurance exchange, healthcare.gov, Californians who purchase their own coverage from Covered California or the open market will have until Jan. 15 to sign up.

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Kaiser Health News senior correspondent Jordan Rau and Trudy Lieberman, contributing editor for the Columbia Journalism Review, appeared on the San Francisco public radio show “Your Call” to discuss why premiums are so expensive, how these insurance markets have succeeded and how they have fallen short, and what consumers should look for while shopping for next year’s plans.

Rau also discussed his recent reporting on premium changes around the country, with some areas like Memphis and Phoenix seeing more insurers selling policies and rates dropping.

Podcast: KHN’s ‘What The Health?’ Reading The Tea Leaves In Blue Wave’s Wake

November 29, 2018
Mary Agnes Carey

Kaiser Health News

@MaryAgnesCarey

Read Mary Agnes' Stories Anna Edney

Bloomberg

@annaedney

Read Anna's Stories Alice Ollstein

Politico

@AliceOllstein

Read Alice's Stories Margot Sanger-Katz

The New York Times

@sangerkatz

Read Margot's Stories

This week, “What the Health?” panelists discuss, among other things, how the House Democrats’ leadership battle could affect the congressional health policy agenda.

The panelists are Mary Agnes Carey of Kaiser Health News, Margot Sanger-Katz of The New York Times, Alice Ollstein of Politico and Anna Edney of Bloomberg News.

As the post-election dust settles on Capitol Hill, the Democrats — soon to be in control of the House of Representatives — have begun the process of choosing their leadership team. How this shakes out will have a lot to do with how health policy agenda takes shape in the lower chamber.

House Democrats nominated Rep. Nancy Pelosi (D-Calif.) to retake the speaker’s gavel, but she still needs to win over more of her colleagues to secure the speaker post in January.

But all the action this week wasn’t focused on Congress. Food and Drug Administration Commissioner Scott Gottlieb unveiled a proposed overhaul of the FDA’s decades-old medical device approval process, and the Trump administration announced proposals it said would reduce Medicare prescription drug costs. Critics fear those changes could mean that some people with chronic diseases like AIDS or cancer might not have access to the drugs they need.

Among the takeaways from this week’s podcast:

  • House Democrats nominated Rep. Nancy Pelosi (D-Calif.) to retake the speaker’s gavel this week along with the rest of its leadership slate, Reps. Steny Hoyer of Maryland and Jim Clyburn of South Carolina. This is only the first step, though. The leadership positions will not be filled officially until January, when they are voted on by the full House. Although Pelosi is still wrangling for the support needed to earn her the required 218 votes, most insiders expect the Democrat’s leadership team to look much as it did the last time Democrats ruled the House chamber in 2010, when the Affordable Care Act became law. That means the House will likely be laser-focused on the necessary steps to protect the ACA. There may also be hearings on single-payer health insurance — a concept that is increasingly gaining interest and support within the caucus, and especially among some of its newest members.
  • In the background, the Texas lawsuit that could overturn the ACA’s protections for people with preexisting conditions is still pending. That decision could come any day. Keep in mind, though, that whatever the court rules, it is likely to be appealed immediately and move up the legal ladder. And, in the interim, House Democrats may still move forward with legislation to strengthen those ACA safeguards. Such a measure could get some GOP support because many Republicans seeking re-election this year said they wanted to ensure that patients with preexisting medical conditions would not lose coverage.
  • The FDA unveiled a proposed overhaul of its decades-old medical device approval system. Among its provisions, the plan includes steps to ensure that new medical devices reflect current safety and effectiveness features. Critics of the current system say it has failed to detect problems with some implants — like hip replacements that failed prematurely or surgical mesh that has been linked to pain and bleeding. The changes, if approved, could take years to implement and some might require congressional approval.
  • The Trump administration proposed a series of changes to reduce the number of prescription drugs that all Medicare drug plans must cover. The proposal focuses on drugs in six “protected classes” and involves medications such as antidepressants, antipsychotic medicines, cancer drugs and antiretrovirals to treat HIV/AIDS. Administration officials have said the proposal could cut costs for Medicare, but patient advocacy groups say it could reduce patients’ access for much-needed treatments. The proposed changes would not occur until 2020, and Congress could intervene to stop them. 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.

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Also this week, Julie Rovner interviews KHN senior correspondent Jay Hancock, who investigated and wrote the latest “Bill of the Month” feature for Kaiser Health News and NPR. It’s about a single mother from Ohio who received a wrongful bill for her multiple sclerosis treatment. You can read the story here.

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 policy stories of the week they think you should read too:

Mary Agnes Carey: The New York Times’ “This City’s Overdose Deaths Have Plunged. Can Others Learn From It?” by Abby Goodnough

Margot Sanger-Katz: NPR’s “Rethinking Bed Rest for Pregnancy,” by Alison Kodjak

Anna Edney: The Washington Post’s “Overdoses, Bedsores, Broken Bones: What Happened When a Private-Equity Firm Sought to Care for Society’s Most Vulnerable,” by Peter Whoriskey and Dan Keating

Alice Ollstein: Wired.com’s “The Science Is Clear: Dirty Farm Water Is Making Us Sick,” by Elizabeth Shogren and Susie Neilson

To hear all our podcasts, click here.

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

Under Trump, Number Of Uninsured Kids Rose For First Time This Decade

November 29, 2018

After years of steady decline, the number of U.S. children without health insurance rose by 276,000 in 2017, according to a Georgetown University report released Thursday.

While not a big jump statistically — the share of uninsured kids rose to 5 percent in 2017 from 4.7 percent a year earlier — it is still striking. The uninsured rate typically remains stable or drops during times of economic growth. In September, the U.S. unemployment rate hit its lowest level since 1969.

“The nation is going backwards on insuring kids and it is likely to get worse,” said Joan Alker, co-author of the study and executive director of Georgetown’s Center for Children and Families.

Alker and other child health advocates place the blame for this change on the Trump administration and the Republican-controlled Congress, saying their policies and actions cast a pall on enrollment.

The number of children without coverage rose to 3.9 million in 2017 from about 3.6 million a year earlier, according to Census data analyzed by Georgetown.

The overall uninsured rate for people of all ages — which plummeted from 2013 to 2016 following the health law’s implementation — remained unchanged at 8.8 percent last year.

The share of children with employer-sponsored coverage rose modestly in 2017, but not by enough to make up for the drop in children enrolling in Medicaid or getting coverage from Obamacare insurance exchanges, Alker said.

While no states made any significant gains in lowering children’s uninsured rate, nine states experienced significant increases. The biggest occurred in South Dakota (up from 4.7 percent to 6.2 percent), Utah (up from 6 percent to 7.3 percent) and Texas (from 9.8 percent to 10.7 percent).

More than 1 in 5 uninsured children nationwide live in Texas — about 835,000 kids — by far the highest number of any state.

Florida had 325,000 uninsured children last year, as its uninsured rate for that age group rose 0.7 percentage points to 7.3 percent. California had 301,000 children without insurance, though its number remained virtually unchanged, relative to the previous year.

Other states with significant increases were Georgia, South Carolina, Ohio, Tennessee and Massachusetts.

The uninsured rates for children increased at nearly triple the rates in states that did not expand Medicaid under the Affordable Care Act, according to the report. Studies have shown that children whose parents are insured are more likely to have coverage.

The uninsured rate among Hispanic children was 7.8 percent, compared with 4.9 percent among whites and 4.6 percent among blacks overall. (Hispanics can be of any race.)

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Georgetown has been tracking these figures since 2008 when 7.6 million children — or about 10 percent of kids — lacked health coverage.

Because nearly all low-income children are eligible for Medicaid or the federal Children’s Health Insurance Program, known as CHIP, the challenge is making sure parents are aware of the programs, getting them enrolled and keeping them signed up as long as they are eligible, Alker said.

Congress let the CHIP program funding lapse for several months in 2017, putting states in a position of having to warn consumers that they would soon have to freeze enrollment. Congress restored federal funding in early in 2018.

In addition, low-income families were bombarded by news reports last year of Congress threatening to repeal the health law that expanded coverage to millions. In the past two years, the Trump administration has slashed funding to Obamacare navigators to help people sign up for coverage.

Alker also pointed to the Trump administration’s September proposal, known as the “public charge” rule, which could make it harder for legal immigrants to get green cards if they have received certain kinds of public assistance — including Medicaid, food stamps and housing subsidies. Green cards allow them to live and work permanently in the United States.

OLE Health, a large health provider based in Napa Valley, Calif., that serves many immigrants, said it has seen patients disenroll from Medicaid in the past year. CEO Alicia Hardy said many have dropped coverage over fears the help could jeopardize their immigration status.

“They are afraid of being deported,” she said.

All those events could have deterred families from getting their kids covered. “The welcome mat has been pulled back and as a result we see more uninsured children,” Alker said.

She said the easiest way to change the trend would be for more states to expand Medicaid under the health law. Fourteen states have yet to do so. Though the expansion largely affects adults, as parents enroll, their children are likely to follow.

KHN’s coverage of children’s health care issues is supported in part by the Heising-Simons Foundation.

In Health Insurance Wastelands, Rosier Options Crop Up For 2019

November 23, 2018

In recent years, places such as Memphis and Phoenix had withered into health insurance wastelands as insurers fled and premiums skyrocketed in the insurance marketplaces set up by the Affordable Care Act. But today, as in many parts of the country, these two cities are experiencing something unprecedented: Premiums are sinking and choices are sprouting.

In the newly competitive market in Memphis, the cheapest midlevel “silver” plan for next year will cost $498 a month for a 40-year-old, a 17 percent decrease. Four insurers are selling policies in Phoenix, which then-presidential candidate Donald Trump highlighted in 2016 as proof of “the madness of Obamacare” as all but one insurer left the region.

Janice Johnson, a 63-year-old retiree in Arizona’s Maricopa County, which includes Phoenix, said her premium for a high-deductible bronze plan will be $207 instead of $270 because she is switching carriers.

“When you’re on a fixed income, that makes a difference,” said Johnson, who receives a government subsidy to help cover her premium. “I’ll know more than a year from now if I’m going to stick with this company, but I’m going to give them a chance, and I’m pretty excited by that.”

Across all 50 states, premiums for the average “benchmark” silver plan, which the government uses to set subsidies, are dropping nearly 1 percent. And more than half of the counties that use the federal healthcare.gov exchange are experiencing an average 10 percent price decrease for their cheapest plan.

In most places, the declines are not enough to erase the price hikes that have accrued since the creation in 2014 of the health care exchanges for people who don’t get insurance through an employer or the government.

Instead, experts said, next year’s price cuts help to correct the huge increases that jittery insurers set for 2018 plans to protect themselves from anticipated Republican assaults on the markets. Although Congress came up one vote shy of repealing the law, Trump and Republicans in Congress did strip away structural underpinnings that pushed customers to buy plans and helped insurers pay for some of their low-income customers’ copayments and deductibles. Insurers responded with 32 percent average increases.

“Insurers overshot last year,” said Chris Sloan, a director at Avalere, a health care consulting company in Washington, D.C. “We are nowhere close to erasing that increase. This is still a really expensive market with poor benefits when it comes to deductibles and cost.”

For 2019, the average benchmark silver premium will be 75 percent higher than it was in 2014, according to data from the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

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When Republicans failed to kill the health law last year, they inadvertently may have made it stronger. Insurers banked hefty profits this year, and new companies are moving in.

All these factors were especially influential in Tennessee, where the average benchmark premium is dropping 26 percent, according to a government analysis. That is more than in any other state.

In 2018, 78 of 95 Tennessee counties had just one insurer. That monopoly allowed the insurer to set the prices of its plans without fear of competition, said David Anderson, a researcher at the Duke-Margolis Center for Health Policy in Durham, N.C. “They were massively overpriced,” he said.

But for the coming year, 49 Tennessee counties will have more than one insurer, with a few — like Shelby County, where Memphis is located — having four companies competing. There, Cigna dropped the price of its lowest-cost silver plan by 15 percent. Nonetheless, it was underbid by Ambetter of Tennessee, which is owned by the managed-care insurer Centene Corp.

“We’re finally at the point where the market is stabilized,” said Bobby Huffaker, the CEO of American Exchange, an insurance brokerage firm based in Tennessee. “From the beginning, every underwriter, and the people who were the architects, they knew it would take several years for the market to mature.”

Still, the cheapest Memphis silver premium is nearly three times what it was in 2014, the first year of the marketplaces. A family of four with 40-year-old parents will be paying $19,119 for all of next year unless they qualify for a government subsidy.

“The unsubsidized are leaving,” said Sabrina Corlette, a professor at Georgetown University’s Health Policy Institute. “They are finding these premiums unaffordable.”

The landscape in Phoenix is greatly improved from when Trump visited after the federal government announced a 116 percent premium increase for 2017, as the number of insurers dropped from eight to one.

But now, three new insurers are entering Maricopa County. Ambetter, the only insurer this year, dropped its lowest price for a silver plan for next year by 12 percent and still offers the cheapest such plan.

Ambetter’s plan is still 114 percent above the least expensive silver plan in the first year of the exchanges. And none of the insurers are offering as broad and flexible a choice of doctors and hospitals as consumers had back then, said Michael Malasnik, a local broker.

Since the start of the exchanges, he said, insurers have “raised their rates by multiples, and they’ve figured out you have to be a very narrow network.”

Each plan for 2019 contains trade-offs. He said only Bright Health’s plan includes Phoenix Children’s Hospital. Ambetter’s plan includes the most popular hospital and doctor groups, but they are not as conveniently located for people living in the southeastern corner of the county, making other insurers’ plans appealing.

“Geography is the name of the game this year,” Malasnik said.

Theresa and John Flood(Courtesy of Theresa Flood)

Theresa Flood, a preschool teacher who lives outside Phoenix, said none of the plans she considered accepted her doctors, who include a specialist for her spine problems — she has had four surgeries — and a neurologist who monitors a cyst and benign tumor in her brain.

“I have to establish care with a whole new spine doctor and establish care with a whole new neurologist if I want to follow up on these things,” Flood, 59, said. “You’re going from established care to who in the heck am I going to see?”

The plan she chose would have been too expensive except that she and her husband, John, a pastor, qualified for a $1,263-a-month subsidy that will drop the cost to $207 a month. That bronze plan from Ambetter carries a $6,550-per-person deductible, so she expects she’ll still have to pay for her doctors on her own unless she needs extensive medical attention.

“It’s gone from being able to have a plan that you could sort of afford and got some benefit from, to putting up with what you can afford and hoping nothing happens that you actually have to use your insurance,” she said. “At this point, I’ll take what I can get.”

Attention, Marketplace Shoppers: Don’t Delay On 2019 Enrollment

November 21, 2018

Don’t procrastinate. Most consumers who buy their own insurance on the federal health insurance marketplace face a Dec. 15 deadline. Advocates are reminding these customers that if they miss the deadline, they may not have a plan that starts in January 2019.

Despite repeated efforts by Republicans to repeal the Affordable Care Act, it remains the law of the land, and subsidies that help bring down premiums and reduce cost sharing are still available to help people afford plans sold on the marketplaces, also called exchanges. Those plans still must provide comprehensive benefits and limit out-of-pocket costs for consumers. If you buy an exchange plan, insurers can’t turn you down or charge you more if you have a preexisting medical condition.

But Republicans did push through a major change in the law that takes effect in 2019: Consumers will no longer owe a fine if they don’t have health insurance. It’s not yet clear if that has tamped down interest, but data released by federal officials showed that the number of people who had signed up during the first two weeks of open enrollment was down by about 20 percent from a year ago.

If you’re shopping for coverage off the exchange, you’ll probably encounter ads for short-term policies, which the Trump administration is promoting and for which it has loosened the requirements. Those plans generally have lower premiums, but they are riskier buys if you get sick, advocates say. More on those plans later.

If you want to enroll in a marketplace plan, now’s the time to get cracking. Enrollment, which began Nov. 1, will close on Dec. 15 in about two-thirds of states, which use the federal exchange.

Some people who live in states that run their own marketplaces may have extra time to sign up. California’s open-enrollment period doesn’t end until Jan. 15, for example, and in New York open enrollment runs through Jan. 31. In addition, people who’ve been affected by the wildfires in California may qualify for a special enrollment period that gives them even more time, according to a spokesperson for Covered California, the state’s marketplace.

Although you may have more plans to choose from for 2019, there will likely be fewer enrollment pros on hand to help you pick the one that’s right for you. Here are some tips that may help.

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Review All Your Plan Options

If you’re already enrolled in a marketplace plan and don’t take steps to sign up during open enrollment, chances are the marketplace will automatically re-enroll you in your current plan or another one that is similar for 2019. Don’t let that happen.

Even if you like the coverage you have, it’s critical to study the details. Your plan may have essentially the same name, but there’s no guarantee that the premium, deductible and other specifics — like the list of approved hospitals and doctors — will be the same. Check to make sure it still meets your needs.

Many people will have more insurers to choose from for next year. Fifty-eight percent of enrollees will have a choice of at least three insurers in 2019, compared with 48 percent who did so this year, according to an analysis by the Kaiser Family Foundation. (KHN is an editorially independent program of the foundation.) Meanwhile, the share of enrollees with just one marketplace insurer in their area will drop to 17 percent in 2019 from 26 percent this year.

Premiums will edge down slightly for many people next year. The changes vary widely by region, but the monthly unsubsidized premium for the second-lowest-priced silver plan, called the benchmark plan because its cost is used to set the level of federal premium support, will drop by an average 1.5 percent in states that use healthcare.gov, according to the Centers for Medicare & Medicaid Services. For a 27-year-old nonsmoker, that will mean a $6 difference ($412 dropping to $406).

(Silver plans are the most popular type of marketplace plan, picking up 70 percent of the cost of covered benefits, on average. Bronze plans are less generous, paying for 60 percent, while gold plans, at 80 percent, pay a greater share of the costs.)

Keep The Benchmark Plan In Sight

Premium tax credits are available for people with incomes between 100 and 400 percent of the federal poverty level ($12,140 to $48,560 for one person, or $25,100 to $100,400 for a family of four). With more insurers competing for your business and premiums heading down in some areas, the benchmark plan may change in 2019.

If you have the benchmark plan or another one with an even cheaper premium this year, be sure to check out the benchmark plan for next year.

“If you don’t stay with [the] benchmark plan, you could get sticker shock on your premium next year,” said Sabrina Corlette, research professor at Georgetown University’s Center on Health Insurance Reforms.

That’s because your subsidy will be reduced in line with the lower benchmark plan premium, and you’ll have to cover the difference if you don’t switch plans.

Estimate Your Income Carefully

If you’re ineligible for premium tax credits because your 2018 income is too high but you think it may dip below the 400 percent poverty threshold next year, it’s a good idea to sign up for a marketplace plan rather than buy a plan outside the exchange, said Karen Pollitz, a senior fellow at the Kaiser Family Foundation.

“People in marketplace plans whose income drops into subsidy territory are eligible for a special enrollment period to sign up for a subsidized plan,” Pollitz said. “If you’re enrolled in a plan off the exchange, you won’t have that option.”

About 80 percent of people who enroll in marketplace plans qualify for premium tax credits.

To avoid giving people more in advance premium tax credits than they’re eligible for, the marketplace typically asks for additional documentation to verify income when people project that their earnings will be lower than government data sources show.

This sign-up season, the marketplaces are asking for more information from people on the other end of the income spectrum. People with incomes below 100 percent of the federal poverty level aren’t eligible for subsidies. (Lawmakers who wrote the ACA expected these low-income people to qualify for Medicaid, but some states have not expanded their programs under the health law.)

For 2019 coverage, customers who estimate their income will reach or exceed that 100 percent mark, which would qualify them for premium tax credits, will generally be asked to provide additional income information if the marketplace’s data show that their income is below that standard.

The change is supposed to help avoid fraud, but inaccurate estimates may not be intentional, said Tara Straw, senior policy analyst at the Center on Budget and Policy Priorities.

“People in that income range who are often cobbling together income from part-time jobs may not have a great estimation of what their income may be for the coming year,” she said.

Update The Marketplace With Your Personal And Plan Information

Make sure to update your income and family information in your marketplace account. Otherwise, the marketplace may make an error in calculating the amount of your premium contribution, and you could be on the hook to repay excess subsidies at the end of the year.

If, while shopping for a plan, you get a notice that you’ve been automatically re-enrolled, don’t assume the marketplace will cancel that plan when you sign up for something else. Tell the marketplace that you want to terminate that plan, or you may end up owing a month’s premium for both plans while you get it sorted out, said Straw.

Complicated Coverage Questions? Get Help Now

This year, the federal government cut funding for navigators — those groups and individuals helping people sign up for coverage on the marketplaces — to $10 million, continuing a steady whittling away of support for that program from more than $60 million two years ago.

“My advice is ‘Don’t procrastinate,’ because there is less one-on-one help available in most states,” said Corlette.

If you live in a state that runs its own marketplace, you may have an easier time finding in-person help with coverage questions. Those exchanges are generally spending significantly more on outreach and assistance than the federally facilitated exchange, according to an analysis by researchers at Georgetown University and published by the Commonwealth Fund.

You may be able to find published answers to questions on your own with Georgetown’s Navigator Resource Guide or the marketplace FAQs published by the Kaiser Family Foundation.

Approach Short-Term Plans With Extreme Caution

To make more affordable health insurance options available, the Trump administration issued a rule in August that eases restrictions on short-term plans that are less comprehensive than ACA-compliant plans. These plans generally don’t cover preexisting conditions nor benefits like maternity care or prescription drugs. They can be renewed for up to three years, but that will be at the insurer’s discretion.

Because they offer much skimpier coverage than comprehensive plans that comply with the health law, short-term plans are generally cheaper.

Any plan offered through a state exchange must comply with the ACA. But people shopping online may see noncompliant coverage featured on other sites and find it hard to distinguish ACA-compliant plans from short-term and other types of limited coverage, such as health care-sharing ministries and fixed-indemnity plans, said Corlette, who has examined these offerings.

“It’s a mishmash of stuff that falls outside of the ACA,” Corlette said.

Podcast: KHN’s ‘What The Health?’ Health Nerd Books For The Holidays

November 20, 2018
Julie Rovner

Kaiser Health News

@jrovner

Read Julie's Stories Stephanie Armour

The Wall Street Journal

@StephArmour1

Read Stephanie's Stories Anna Edney

Bloomberg

@annaedney

Read Anna's Stories Joanne Kenen

Politico

@JoanneKenen

Read Joanne's Stories

The Food and Drug Administration took some serious steps toward curbing teen use of tobacco and nicotine products this month, including proposing a virtual ban on most flavors of the liquid used in e-cigarettes.

Meanwhile, open enrollment continues for individual coverage under the Affordable Care Act and Medicare. ACA sign-ups are slightly lagging behind last year’s. It is unclear why, but it’s still early in the six-week open-enrollment period.

And the new Democratic majority in the U.S. House faces big decisions about whether to pass a “Medicare-for-all” bill when it assumes control in January. First, the coalition must choose a speaker. Rep. Nancy Pelosi (D-Calif.), whose deal-making skills as speaker were instrumental in getting the ACA passed in 2010, is facing challenges from both wings of the party, although no single candidate has emerged to try to replace her.

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

Among the takeaways from this week’s podcast:

  • Several factors may have contributed to the drop in marketplace enrollment over last year’s tally. The midterm elections may have distracted customers, the government is doing less consumer outreach, the labor market is very tight so more people may be getting coverage through work, and people will not face a tax penalty in 2019 for not having coverage.
  • There’s also another open enrollment occurring: Medicare plans. Although seniors’ coverage is not on the line, they have a wealth of choices that can be confusing.
  • In both ACA and Medicare enrollment periods, it is important for consumers to check out their choices, because the best option may have changed.
  • As the FDA weighs new rules for tobacco products, it is walking a tightrope. E-cigarettes may be an important tool for adults who are looking to wean themselves from cigarettes, but officials are wary of the thrill they may hold for young people.
  • The push among progressive Democrats in the House to pass a bill to implement a “Medicare-for-all” plan may cost the party support in the critical suburban districts that members depended on this month for victory.

Plus, for extra credit this holiday week, the panelists recommend some of their favorite health policy books:

“The Heart of Power: Health and Politics in the Oval Office,” by David Blumenthal and James A. Morone

“Bad Blood: Secrets and Lies in a Silicon Valley Startup,” by John Carreyrou

“Sick: The Untold Story of America’s Health Care Crisis — and the People Who Pay the Price” by Jonathan Cohn

“Dreamland: The True Tale of America’s Opiate Epidemic,” by Sam Quinones

“An American Sickness: How Healthcare Became Big Business and How You Can Take It Back,” by Elisabeth Rosenthal

“The Immortal Life of Henrietta Lacks,” by Rebecca Skloot

“The Social Transformation of American Medicine: The Rise of a Sovereign Profession and the Making of a Vast Industry,” by Paul Starr

To hear all our podcasts, click here.

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

Buyers Of Short-Term Health Plans: Wise Or Shortsighted?

November 20, 2018

Supporters of the nation’s health law condemn them. A few states, including California and New York, have banned them. Other states limit them.

But to some insurance brokers and consumers, short-term insurance plans are an enticing, low-cost alternative for healthy people.

Now, with new federal rules allowing short-term plans that last up to three years, agents said, some consumers are opting for these more risky policies. Adding to the appeal is the elimination of a federal tax penalty for those without comprehensive insurance, effective next year. Short-term health plans often exclude people with preexisting conditions and do not cover services mandated by the Affordable Care Act.

Colorado resident Gene Ferry, 66, purchased a short-term health plan this month for his wife, Stephanie, who will become eligible for Medicare when she turns 65 in August. The difference in the monthly premium price for her new, cheaper plan through LifeShield National Insurance Co. and the policy he had through the ACA is $650.

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“That’s a no-brainer,” said Ferry, who considers the ACA “atrocious” and supports President Donald Trump’s efforts to lower costs. “I was paying $1,000 a month and I got tired of it.”

He signed up his wife for a three-month plan and said that if she is still healthy in January, he will purchase another one to last six months. But Ferry, who is covered under Medicare, said if something happens to her before open enrollment ends — which in Colorado is in January — he would buy a policy through the exchange.

Dan Walterman, who lives in Iowa, says he chose a short-term policy for himself, his wife and their 3-year-old daughter because it was less expensive and provided the coverage he needed.(Courtesy of Dan Walterman)

There’s a lot of “political jockeying” over the value of short-term plans, said Dan Walterman, owner of Premier Health Insurance of Iowa, which offers such policies. “I think people can make their own choices.”

Walterman, 42, said he chose a short-term policy for himself, his wife and their 3-year-old daughter — at a sixth of the price of more comprehensive insurance. “The plan isn’t for everybody, but it works for me,” he said, adding that he gets accident coverage but doesn’t need such things as maternity care or prescriptions.

Essentially, short-term plans cost less because they cover less.

Some plans have exclusions that could blindside consumers, such as not covering hospitalizations that occur on a Friday or Saturday or any injuries from sports or exercise, said Claire McAndrew, director of campaigns and partnership for Families USA, a consumer advocacy group.

“People may see a low premium on a short-term plan and think that it is a good option,” she said. “But when people actually go to use a short-term plan, it will not actually pay for many — or any — of their medical expenses.”

The plans can exclude people with preexisting conditions such as cancer or asthma and often don’t cover the “essential benefits” required under the health law, including maternity care, prescription drugs or substance abuse treatment. They also can have ceilings on what they will pay for any type of care. Insurers offering such plans can choose to cover — or not cover — what they want.

“Democrats are condemning them as ‘junk plans,’ but the adequacy of the health plan is in the eye of the beholder,” said Michael Cannon, director of health policy studies for the libertarian Cato Institute. “The only junk insurance is a plan that doesn’t pay as it was promised.”

The plans originally were designed to fill brief gaps in insurance coverage for people in the individual market. When the ACA went into effect, the Obama administration limited short-term plans to three months, but the Trump administration this year expanded that to 364 days, with possible extensions of up to three years. Critics fear healthy people may abandon the ACA-compliant market to buy cheaper short-term plans, leaving sicker people in the insurers’ risk pool, which raises premiums for those customers.

But some agents said the policies may be good for healthy people as they transition between jobs, near Medicare eligibility or go to college — despite significant limitations.

“It’s hard to encourage those types of people to spend hundreds of dollars extra on a health insurance plan that they are rarely using,” said Cody Michael, director of client and broker services for Independent Health Agents in Chicago.

Michael said agents also get a higher commission on the plans, providing them with more of an incentive to sell them. But he advises clients that if they do have a chronic illness, they may face denials for coverage. “This is old-world insurance,” he said. “You basically have to be in perfect health.”

Dania Palanker, assistant research professor at Georgetown University’s Center on Health Insurance Reforms, said preexisting conditions aren’t always well understood — or well explained. A person might discover too late that, for example, they aren’t covered if they have a stroke because an old blood test showed they had high cholesterol.

But Ryan Ellis, a 40-year-old lobbyist and tax preparer in Alexandria, Va., who is considering a short-term plan for himself, his wife and his three children, said his decision will be made “very deliberately, with my eyes wide open knowing the advantages and disadvantages.”

Some agents said they offer the short-term plan as a last resort — only after warning clients that if they have an accident or get sick, they might not be able to renew their plan. That means they could be stuck without insurance while waiting for the next open-enrollment period.

“They could really be in a world of hurt,” said Colorado insurance agent Eric Smith. “This is just a ticking time bomb.”

Roger Abel, of Marion, Iowa, said he’s willing to take the risk. He has a short-term plan for his 2-year-old daughter. Abel said he pays about $90 a month for her, compared with more than $450 that he would have paid for comprehensive coverage. He and his wife have a separate policy from before the Affordable Care Act took effect.

California resident Neena Moorjani says she wanted to buy a short-term plan, but they are now banned in the state.(Courtesy of Neena Moorjani)

But Abel, who is an investment adviser, has a backup option. He said he could always start a group health plan under his company that would provide his daughter with more coverage.

Neena Moorjani, 45, said she wanted to buy a short-term plan but can’t because she lives in California, where they were prohibited under a law signed by Democratic Gov. Jerry Brown this year. Moorjani, a tax preparer in Sacramento, said she rarely gets sick and doesn’t need an ACA plan.

She decided on religious-based health coverage known as a Christian ministry plan. These cost-sharing programs use members’ fees to pay for others’ medical bills. Such programs are not regulated by government agencies and may not cover preexisting conditions or preventive care.

When California banned short-term plans, “I was really, really upset,” Moorjani said. “I wish I had the freedom to choose what health care insurance is appropriate for me.”

KHN's coverage in California is supported in part by Blue Shield of California Foundation.

Must-Reads Of The Week From Brianna Labuskes

November 16, 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.

Welcome back to the Friday Breeze! Brace yourself, because with the midterms in the rear-view mirror (psshh, the 2018 elections are so five minutes ago), lawmakers, hopefuls and sideline experts are all barreling toward 2020. (I have only just this moment realized the vast opportunity for puns we’ll see when it’s over. Hindsight being … you get it.) First, though, everyone has to make it through two years of likely gridlock with a split Congress.

So what’s on the agenda for the newly empowered Democrats?

“Health care was on the ballot and health care won.” That’s House Minority Leader Nancy Pelosi’s assessment, at least. How it shakes out is trickier.

Some of the Dems’ top priorities are related to bandaging up the health law. Their efforts will likely include forcing a vote on a bill to protect preexisting conditions; shoring up the marketplaces, possibly by helping states pay for large medical claims; and pushing to get the House to intervene in the Texas lawsuit that challenges the law’s constitutionality.

At the same time, many of the party’s 2020 contenders are going to be on the trail going hard for “Medicare-for-all,” aka the litmus test for candidates who want to woo the more progressive wing of voters. The dissonance in the party that has been brewing since MFA gained popularity is at the very least going to require some complicated political maneuvering on all sides.

One Democratic agenda item many people (including President Donald Trump) seem to agree on, though? Reining in drug prices.

The New York Times: Democrats Won a Mandate on Health Care. How Will They Use It?

Politico: California’s New Governor Embodies Democrats’ Dilemma on Single Payer

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New numbers out of Arkansas that detail just how many people have been dropped from the state’s Medicaid program since work requirements were enacted have experts increasingly alarmed. An additional 3,815 lost coverage in October for not reporting their hours, pushing the total number of people who have been affected by the state’s new requirements to over 12,000. And about 6,000 more residents are on their second strike and poised to lose coverage next month.

An outcry among health care experts prescribes the rules be suspended until officials figure out why the numbers are so startlingly high.

Modern Healthcare: Arkansas Drops 3,815 More Medicaid Enrollees Over Work Requirement

The Food and Drug Administration is cracking down on certain tobacco products and e-cigarettes that contribute to the emerging teen-vaping epidemic. But the ban on selling flavored e-cigarettes at brick-and-mortar stores (a ban that won praise when an early version of the rules was leaked) was conspicuously tempered. Stores will be allowed to sell the products if they can be kept in an age-restricted area.

The agency did come out swinging hard with a proposed ban on menthol. It could take years to enact, and the tobacco industry has hinted at a court battle, but if the ban does go through, it could have a profound effect on African-American males and young people who smoke menthol cigarettes at higher rates than other groups.

The Washington Post: FDA Unveils Sweeping Anti-Tobacco Effort to Reduce Underage Vaping and Smoking

The National Rifle Association has long been a Goliath among Davids when it comes to election spending. New numbers suggest, though, that the gun control movement may actually become a formidable foe for the political powerhouse.

The New York Times: Gun Control Groups Eclipse N.R.A. in Election Spending

It was not a friendly news week for the NRA in general. One of the organization’s tweet’s (a suggestion that doctors should “stay in their lane” on the gun debate) sparked viral outrage from providers. With the floodgates opened, stories of physicians’ firsthand experience with gun violence blanketed social media. “I see no one from the @nra next to me in the trauma bay as I have cared for victims of gun violence for the past 25 years,” tweeted one doctor (from the New York Times’ coverage). “THAT must be MY lane. COME INTO MY LANE. Tell one mother her child is dead with me, then we can talk.”

NPR: After NRA Mocks Doctors, Physicians Reply: ‘This Is Our Lane’

The wildfires continued to devastate California, with the death toll climbing to at least 63 and the number of missing people soaring to more than 600. Heartbreaking tales about elderly and young evacuees living in the harsh conditions of parking-lot tent cities serve as a reminder of just how long recovery will take after the fires are contained.

The (San Jose) Mercury News: Camp Fire: 63 Dead, 631 Missing; Second Origin Spot Probed

Los Angeles Times: Made Homeless by Flames, Camp Fire Evacuees Face Hardship, Disease And Desperation

Drug prices didn’t always used to be this bad. For a while, America was spending about what other wealthy countries did. Then something happened in the 1990s. To be fair, many factors are in play with our current pricing system, but the record number of new drugs that emerged in that decade likely set the stage for our current morass.

The New York Times: Something Happened to U.S. Drug Costs in the 1990s

Enrollment in Affordable Care Act plans was a bit slower at the start of this year’s sign-up season compared with last year’s. The reason this item appears so low in this newsletter, though, is that those numbers lack context (we, as a nation, were kind of preoccupied with a little thing called the midterms) and experts say it’s too early to call this a trend. Something to keep an eye on.

The Hill: ObamaCare Enrollment Down Compared to Last Year

Sick of medical bills? Yeah, doctors aren’t really fans of having to be debt collectors either. Especially when it comes to a patient. As premium costs shift more and more to employees, providers are no longer able to just deal with impersonal insurers and are instead having to go after the very people they’re trying to help.

Bloomberg: Doctors Are Fed Up With Being Turned Into Debt Collectors

Who in the family doesn’t get health care this year? Americans are having to make such tough decisions in an era where insurance plans can be price-tagged at more than $1,000 a month. Bloomberg offers a series that puts names and faces to the problem that has been a punch in the gut for many across the country.

Bloomberg: Soaring Health-Care Costs Forced This Family to Choose Who Can Stay Insured

As you can tell, this week was popping in terms of health news, so the miscellaneous file is going to be a bit more robust today:

Native American and Alaska Native women have been vanishing in high numbers, but the reporting on the depth and breadth of the problem is woefully lacking.

• The Associated Press: Report Cites Weak Reporting on Missing, Murdered Native Women

Who decides the parole of people who have been found not guilty by reason of insanity? In Oregon, where it’s a board that reviews the state’s cases, the balance between civil rights and safety has been praised. However, an analysis of 220 defendants found that about a quarter of them were charged with attacking others within three years of being released. And the board hasn’t changed its policies.

• ProPublica: Oregon Board Says Those Found Criminally Insane Rarely Commit New Crimes. The Numbers Say Otherwise.

So, it turns out a 150-pound pig is uncannily humanlike in organ size and function. This could go a long way in addressing our perpetual donated organ shortage.

The New York Times: 20 Americans Die Each Day Waiting for Organs. Can Pigs Save Them?

A sweeping study put a damper on all the “magical thinking” surrounding the benefits of fish oil and vitamin D.

The New York Times: Vitamin D And Fish Oils Are Ineffective For Preventing Cancer And Heart Disease

If it seems as if at least one kid in every classroom these days has a food allergy, that’s because they probably do. Could hypoallergenic food be the answer?

The Boston Globe: Allergies Change How We All Eat

A revealing series of jail conversations between Aaron Hernandez, who died by suicide in April 2017, and other football players details a grim culture of opioid abuse in the NFL.

The Boston Globe: In Jail Calls, Hernandez Discussed NFL’s Reliance on Painkillers With Former Teammates

In an era of medical malpractice suits, it feels rare to get an apology out of anyone health-related these days. But the widower of a woman who died of an asthma attack outside of a locked emergency department got one from the hospital. (It’s a tragic, yet recommended read overall.)

First lady Michelle Obama spoke candidly about her miscarriage and about how women often feel alone and isolated when it comes to fertility and pregnancy.

The Associated Press: Michelle Obama Had Miscarriage, Used IVF to Conceive Girls

Whew! Everyone was definitely busy before heading into the holidays. Speaking of, we’ll be off eating turkey next week, but will hit your inbox again on Nov. 30.

Happy holidays!

Podcast: KHN’s ‘What The Health?’ Doctors, Guns And Lame Ducks

November 15, 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 Alice Ollstein

Politico

@AliceOllstein

Read Alice's Stories

Election Day was Nov. 6, but results remain undetermined in some races at the state and federal levels. Nonetheless, it is already clear that the election could have major implications for health policy in 2019.

The current Congress is back in Washington for a lame-duck session, and while the budget for the Department of Health and Human Services is set for the fiscal year that began Oct. 1, other health bills, including ones addressing AIDS and bioterrorism, are on the to-do list.

This week’s panelists for KHN’s “What the Health?” are Julie Rovner of Kaiser Health News, Rebecca Adams of CQ Roll Call, Kimberly Leonard of the Washington Examiner and Alice Ollstein of Politico.

Among the takeaways from this week’s podcast:

  • With the political divide between a Republican Senate and a Democratic House, getting legislation passed in the next Congress may prove hard. But bipartisan support could arise for bills to protect consumers from surprise medical bills and, perhaps, to control some drug prices.
  • The House will likely spend much of its time exercising oversight responsibilities, including possible probes of the Trump administration’s policies on separating immigrant children from their parents, changes in health law rules for contraception coverage, changes in Medicaid and the administration’s decision not to defend the Affordable Care Act in a key court case.
  • Among the issues on state ballots this month was a constitutional amendment in Alabama that makes it state policy to “recognize and support the sanctity of unborn life and the rights of unborn children.” Although abortion opponents hail such “personhood” measures, they have been defeated in other states because they could impinge on infertility treatments, such as in vitro fertilization. It’s not clear whether the Alabama measure will be challenged in court because of that.
  • On the ballot in Oregon and Washington were industry-backed measures that would stop localities from instituting soda taxes. The effort failed in Oregon and passed in Washington.
  • During Congress’ current lame-duck session, members will be looking to pass an appropriations bill for parts of the government. Although HHS already got its appropriations bill, other health measures — such as the renewal of the PEPFAR global HIV initiative, grants for states on bioterrorism and pandemic planning, and changes to Medicare’s doughnut hole funding — could be added.
  • A tweet by the National Rifle Association urging doctors to keep out of the gun control debate and “stay in their lane” has provoked a furor from doctors, who say they must deal with the ramifications of a flawed policy.

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’ “When Hospitals Merge to Save Money, Patients Often Pay More,” by Reed Abelson

Rebecca Adams: The New York Times’ “Something Happened to U.S. Drug Costs in the 1990s,” by Austin Frakt

Kimberly Leonard: Harper’s Magazine’s “Discovery, Interrupted: How World War I Delayed a Treatment For Diabetes and Derailed One Man’s Chance at Immortality,” by Jeffrey Friedman

Alice Ollstein: The Incidental Economist‘s “The Trump Administration Targets the Contraception Mandate,” by Nicholas Bagley

To hear all our podcasts, click here.

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

Podcast: KHN’s ‘What The Health?’ Split Decision On Health Care

November 08, 2018
Julie Rovner

Kaiser Health News

@jrovner

Read Julie's Stories Rebecca Adams

CQ Roll Call

@RebeccaAdamsDC

Read Rebecca's Stories Joanne Kenen

Politico

@JoanneKenen

Read Joanne's Stories Margot Sanger-Katz

The New York Times

@sangerkatz

Read Margot's Stories

Voters on Election Day gave control of the U.S. House to the Democrats but kept the U.S. Senate Republican. That will mean Republicans will no longer be able to pursue partisan changes to the Affordable Care Act or Medicare. But it also may mean that not much else will get done that does not have broad bipartisan support.

Then the day after the election, the Trump administration issued rules aimed at pleasing its anti-abortion backers. One would make it easier for employers to exclude birth control as a benefit in their insurance plans. The other would require health plans on the ACA exchanges that offer abortion as a covered service to bill consumers separately for that coverage.

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 Joanne Kenen of Politico.

Among the takeaways from this week’s podcast:

  • The Trump administration’s new contraception coverage rule comes after an earlier, stricter regulation was blocked by federal courts.
  • The insurance bills that the Trump administration is now requiring marketplace plans to send to customers for abortion coverage will be for such a small amount of money that they could become a nuisance and may persuade insurers to give up on the benefit.
  • House Democrats, when they take control in January, say they want to move legislation that will allow Medicare to negotiate drug prices. But fiscal experts say that may not have a big impact on costs unless federal officials are willing to limit the number of drugs that Medicare covers.
  • It appears that both Democrats and Republicans in Congress are interested in doing something to protect consumers from surprise medical bills. The issue, however, may fall to the back of the line given all the more pressing issues that Congress will face.
  • One of the big winners Tuesday was Medicaid. Three states approved expanding their programs, and in several other states new governors are interested in advancing legislation that would expand Medicaid.

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

Julie Rovner: Kaiser Health News’ “Hello? It’s I, Robot, And Have I Got An Insurance Plan For You!” by Barbara Feder Ostrov

Margot Sanger-Katz: Stat News’ “Life Span Has Little to Do With Genes, Analysis of Large Ancestry Database Shows,” by Sharon Begley

Joanne Kenen: The Washington Post’s “How Science Fared in the Midterm Elections,” by Ben Guarino and Sarah Kaplan

Rebecca Adams: The New Yorker’s “Why Doctors Hate Their Computers,” by Atul Gawande

To hear all our podcasts, click here.

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

California’s Top Lawyer Sees Election Win As Mandate To Sustain Trump Resistance

November 08, 2018

California Attorney General Xavier Becerra has cemented his role as one of the nation’s top defenders of the Affordable Care Act, filing multiple lawsuits in the past two years to uphold key protections of the law and often clashing with the Trump administration.

Voters this week gave Becerra a clear mandate to continue that work, he said.

“Californians had a chance to register their opinion on the work that I’ve done,” Becerra told California Healthline on Wednesday, the day after voters overwhelmingly elected him to the state’s top law enforcement job — 61 percent to 39 percent over Republican Steven Bailey.

“My sense is there’s a pretty clear signal.”

Becerra has filed 44 legal challenges against the Trump administration in less than two years on cases involving immigration, birth control, health care, transgender rights, net neutrality, climate change and other issues.

Four of the lawsuits involve former President Barack Obama’s signature achievement, the 2010 federal health care law, which Trump and fellow Republicans have sought to dismantle. In one key case, Becerra is leading more than a dozen other Democratic attorneys general against a Texas-led GOP lawsuit challenging the law’s constitutionality.

“We’re defending health care protections and rights not just for the 40 million Californians, but for the 320 million Americans in the country, because the Trump administration elected to back out of their role in defending a federal statute,” Becerra said. “We stepped in and are now the lead state defending the Affordable Care Act. That’s a big undertaking.”

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Democratic Gov. Jerry Brown appointed Becerra to the top post at the state Department of Justice in December 2016 after Kamala Harris was elected to the U.S. Senate. So, Tuesday’s election was the first time that the 60-year-old Democrat, who previously served in Congress, won a statewide office.

Bailey had criticized Becerra for fighting Washington instead of focusing on California issues — not an argument that resonated with voters in a state that prides itself as the head of Trump resistance.

Becerra said he has sought to spotlight health care at the state Justice Department, creating a new “strike force” of attorneys who have expertise in health care issues.

Becerra, the son of Mexican immigrants, said he also is ready to defend California should state lawmakers decide to extend health care coverage to unauthorized immigrant adults (children already are eligible). That could spur a legal challenge and would not likely be supported by the Trump administration.

The state’s estimated 1.8 million unauthorized immigrants make up nearly 60 percent of the state’s remaining uninsured residents. Covering them is key to Democratic leaders’ goal of insuring all Californians.

Aside from tangling with Trump, Becerra also has taken on both the hospital and pharmaceutical industries.

This year, he filed a lawsuit against Sutter Health, the largest hospital system in Northern California, for anti-competitive practices, and he is investigating pharmaceutical manufacturers and the three largest opioid distributors over unlawful practices. In 2017, Becerra joined a federal lawsuit that charges six makers of generic drugs with an illegal conspiracy to increase prices for an antibiotic and a diabetes medication. All three cases are pending.

In the Sutter Health lawsuit, Becerra said evidence will show that the hospital chain overcharged for services. While he has made anti-competitiveness a priority, he would not say whether he planned similar lawsuits against other hospitals. But he didn’t rule it out.

“We’re going to be vigilant to make sure that everyone follows the law and does what they’re supposed to,” Becerra said. “If we find that there are people who are acting anti-competitively or overpricing or trying to take advantage of California health care consumers, we’ll be prepared to act.”

All of the investigations and litigation, he said, are slow-moving. He compared the process to a football game in which most of the plays yield small gains, with an endgame in sight.

“We’re looking to score some touchdowns,” he said.

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

Midterm Election Boosts Medicaid Expansion, But Challenges Remain

November 08, 2018

Medicaid — which has been a political football between Washington and state capitols during the past decade — scored big in Tuesday’s election.

Following the vote, nearly 500,000 uninsured adults in five states are poised to gain Medicaid coverage under the Affordable Care Act, advocates estimate. Three deep-red states passed ballot measures expanding their programs and two other states elected governors who have said they will accept expansion bills from their legislatures.

Supporters were so excited by the victories they said they will start planning for more voter referendums in 2020.

Medicaid proponents also were celebrating the Democrats’ takeover of the House, which would impede any Republican efforts to repeal the ACA and make major cuts to the federal-state health insurance program for low-income people.

“Tuesday was huge for the Medicaid program,” said Katherine Howitt, associate director of policy at Community Catalyst, a Boston-based advocacy group. “The overall message is that the electorate does not see this as a Democrat or GOP issue but as an issue of basic fairness, access to care and pocketbook issue. Medicaid is working and is something Americans want to protect.”

But health experts caution that GOP opposition won’t fade away.

David Jones, an assistant professor in the Department of Health Law, Policy and Management at Boston University, said ballot organizers now have a blueprint on how to expand Medicaid in states that have resisted. “I see this as a turning point in ACA politics,” he said. Still, he added‚ “it’s not inevitable.”

Medicaid is the largest government health program, insuring at least 73 million low-income Americans. Half of them are children. To date, 32 states and the District of Columbia have expanded it under the ACA. Before that law, Medicaid was generally limited to children, sometimes their parents, pregnant women and people with disabilities.

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The ACA encouraged states to open the program to all Americans earning up to 138 percent of the poverty level ($16,753 for an individual in 2018). The federal government is paying the bulk of the cost: 94 percent this year, but gradually dropping to 90 percent in 2020. States pay the rest.

GOP opposition has left about 4.2 million low-income Americans without coverage in various states.

“It’s not over until it’s over is the story of Medicaid expansion and the Affordable Care Act as the politics never ends and the opportunity for obstruction never ends,” said Jones. “But the trend overall has been to increasing implementation and increasing coverage.”

Montana Fails To Endorse Funding

Two years after President Donald Trump carried Idaho, Nebraska and Utah by double-digit margins with a message that included repeal of the ACA, voters in those states approved the ballot referendums Tuesday. Together, the states have about 300,000 uninsured adults who would be eligible for the program.

In addition, Democrats secured the governor’s offices in Kansas and Maine, which will increase the likelihood those states pursue expansion. Legislatures in both states have previously voted to expand, only to have GOP governors block the bills. Maine voters also passed a referendum in 2017 endorsing expansion, but Republican Gov. Paul LePage again refused to accept it.

Current and incoming Republican governors in Utah and Idaho said they wouldn’t block implementation of the effort if voters approved it. Nebraska Gov. Pete Ricketts said Wednesday he would follow the will of the voters but would not support paying for it with a tax increase.

It wasn’t a clean sweep, however, for Medicaid on Tuesday.

In preliminary results, a ballot issue to fund Montana’s Medicaid expansion — which is already in place and slated to expire next July — was failing. Tobacco companies had mounted a campaign to stop the measure, which would have partially financed the expansion with taxes on tobacco products.

The Montana legislature and the Democratic governor are expected to address the issue in the session that starts in January. No state has reversed its Medicaid expansion, even though GOP governors in Kansas and Arkansas have threatened to do so.

Nearly 100,000 Montana residents have received Medicaid since its expansion, twice as many as expected.

Nancy Ballance, the Republican chairwoman of the Montana House Appropriations Committee who opposed the bill that expanded Medicaid in 2015, said she is confident the state legislature will extend the program past July. But she expects the legislature to put some limits on the program, such as adding an asset test and work requirements.

“There are some people in the state who may not have disabilities but need some help to access coverage,” she said. “I think we can pass something without people having a gap in coverage. … That will be a priority.”

“It was never our intent to simply sunset the expansion and have it go away,” she said. Rather, the legislature put the sunset provision in to revisit the provision to make any changes.

Chris Jacobs, a conservative health policy analyst in Washington, D.C., said the Montana results showed that when voters are given a choice of having to pay for Medicaid expansion through a new tax they were not willing to go along.

But in Utah, voters did agree to fund their state plan by adding 0.15 percent to the state’s sales tax, just over a penny for a $10 purchase.

Fernando Wilson, acting director of the Center for Health Policy at the University of Nebraska Medical Center, said the vote on the state’s ballot question indicated many people wanted to help 80,000 uninsured Nebraskans gain coverage.

“I think it showed there was a clear need for it,” he said. The legislature likely won’t block the expansion, Wilson said, though it may try to add a conservative twist such as adding premiums or other steps.

Sheila Burke, a lecturer in health policy at Harvard Kennedy School, said voters approved Medicaid expansion not just because it would help improve health coverage for their residents but to help stabilize their hospitals, particularly those in rural areas. Hospitals have said this step helps their bottom lines because it cuts down on uninsured patients and uncompensated care.

“The broad population does see the value of Medicaid,” she said. “They saw it as a loss by their states not to accept the federal funds,” she said.

Despite the victories, Burke said, advocates should not assume other states such as Florida, Texas and Tennessee will follow suit.

“I don’t see a radical shift, but it moves us closer,” she said.

‘Fertile Ground’ For More Referendums

If advocates press for more referendums, Florida might be a tempting target. More than 700,000 adults there could become eligible, but the campaign would likely also be very costly.

Jonathan Schleifer, executive director of The Fairness Project, which financed the ballot initiatives in Maine in 2017 and the four states this year, refused to say which states would be targeted next.

The group is funded by the Service Employees International Union-United Healthcare Workers West, a California health care workers union.

“The GOP has been bashing the ACA for nearly a decade, and voters in the reddest states in the country just rejected that message,” Schleifer said. “It’s a repudiation and a tectonic shift in health care in this country.”

“There is fertile ground” for more such ballot votes, said Topher Spiro, vice president for health policy at Center for American Progress, a liberal think tank. “It is clear that public opinion is on the side of Medicaid expansion and the election results merely confirm that.”

“This will build momentum for expansion in other states,” he added.

The election results also could have consequences on efforts by states to implement work requirements for Medicaid enrollees.

New Hampshire and Michigan — which expanded the program but recently won federal approval to add controversial work requirements — could revisit that additional mandate as a result of Democrats winning control over both houses of the legislature in New Hampshire and the governor’s office in Michigan.

House Dems In New Seats Of Power Will Steer Health Policy, Attack Drug Prices

November 07, 2018

For the first time since passing the Affordable Care Act, Democrats will soon control the House of Representatives and its powerful health committees. But Republicans’ tightened grip on the Senate means those hoping for another round of dramatic, progressive reforms may be disappointed.

Empowered by voters outraged over Republican attempts to chip away at the law’s protections for the sick, Democrats owe much of their midterm takeback to health care issues. And Democratic leaders say they are ready to get back to work, this time training their sights on skyrocketing drug prices, among other policy conundrums, with a majority of House votes and a slate of new committee chairmanships in hand.

In a few weeks, House Democrats will meet to elect their leaders, including several committee chairs who will be responsible for the nation’s health care policy and spending in the coming years. Hill denizens expect those currently serving as the top Democrat on most House committees to ascend to the chairmanships, with few if any members mounting serious challenges.

Those basking in a post-“blue wave” glow would do well to temper their expectations, recalling that the Republican-controlled House had already voted 54 times to unravel some or all of the Affordable Care Act by its fourth birthday in 2014. In most cases, Democrats in the Senate and White House stopped those efforts in their tracks.

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With the Senate (and the presidency) remaining under Republican control and even fewer moderate Republicans left in the House after this election, Democrats will struggle to move legislation without Republican support. What they can do is hold hearings, launch investigations and generally unnerve the pharmaceutical industry, among other likely adversaries.

And there’s a chance they could strike a deal with President Donald Trump, whose administration is moving to crack down on drug companies.

Who are the members most likely to wield the gavels? And what will they do with that power? Here’s a look at some of the major committees that influence health policy — and the people who may lead them.

The Committee on Energy and Commerce: Rep. Frank Pallone, New Jersey

Pallone, who has served in the House for 30 years, became the top Democrat on this influential committee in 2015. Should he become chairman, he would be responsible for the broadest health portfolio in the House, which includes Medicaid, public health, insurance and drug safety. This is the committee that marked up the Affordable Care Act in 2009 (when Pallone chaired the health subcommittee) and the House Republican repeal effort in 2017.

Under the Trump administration, Pallone has touted his stewardship of bipartisan legislation reauthorizing the fees charged to manufacturers to review the safety of prescription drugs and medical devices. He has also called for hearings on “mega-mergers” like the proposed merger between CVS and Aetna and worked with other Democrats to counter Republican attempts to undermine the Affordable Care Act.

Unsurprisingly, his influence over health care issues has attracted a lot of money from pharmaceutical companies, health professionals, HMOs and other industry players. By mid-October, Pallone had received more than $945,000 in campaign contributions from  the health sector for this election, according to the Center for Responsive Politics. According to a KHN analysis, nearly $170,000 came from political action committees associated with pharmaceutical companies.

The Committee on Oversight and Government Reform: Rep. Elijah Cummings, Maryland 

Cummings could prove the pharmaceutical industry’s biggest headache come next year. Having served as the committee’s ranking member since 2011 — a post that lacks the chairman’s subpoena power — he has been champing at the bit to hold drugmakers accountable.

Shortly after Trump’s inauguration, Cummings approached him about working together to lower the cost of prescription drugs (to no immediate avail), and he has partnered with other lawmakers to demand information from pharmaceutical companies about their drug pricing strategies. Previewing what a Cummings-led committee might look like, he has even launched his own investigations into drug costs, releasing reports with his findings.

Drugmakers have wasted few campaign contributions on Cummings: He has received just $1,000 from their PACs this election, according to data analysis by KHN.

In a statement to Kaiser Health News, Cummings said Democrats would conduct “credible, responsible oversight” of the Trump administration, adding: “For healthcare, that means investigating skyrocketing prescription drug prices, actions that would threaten protections for people with preexisting health conditions, and efforts to undermine the Medicaid program.” 

The Committee on Ways and Means: Rep. Richard Neal, Massachusetts

Ways and Means oversees Medicare and influences health policy through its jurisdiction over taxes. Though Neal became the top Democrat on this committee in 2017, he has been involved in health care much longer, having played a part in the crafting of both the Affordable Care Act and the failed reform effort under the Clinton administration in 1993.

Facing a primary challenger who touted her support for “Medicare-for-all” in his deep-blue district, Neal denied that he opposes the progressive single-payer proposal. But he also said Democrats should focus on shoring up the Affordable Care Act, particularly its protections for those with preexisting conditions and caps on out-of-pocket expenses. (He won handily.)

The health sector was by far one of the top contributors to Neal’s re-election campaign this year, giving more than $765,000, according to the Center for Responsive Politics. Neal’s district includes the headquarters of several health insurers and other medical companies, which makes him a prime target for campaign contributions.

The Committee on Appropriations: Rep. Nita Lowey, New York

If chosen, Lowey would become the first woman to chair the powerful House Committee on Appropriations, holding the nation’s purse strings.

Like Neal and Pallone, Lowey was first elected to Congress in 1988, and she became the committee’s top Democrat in 2013. She has been a dedicated and effective advocate for investing in biomedical research into major diseases like diabetes and Alzheimer’s, as well as public health programs like pandemic preparedness.

She has also long championed women’s health issues, proving a vocal critic of the Trump administration’s proposed gag rule on Title X funding, among other policies. Watch for her to continue to push back on the administration’s efforts to restrict access to abortion rights.

And on the Senate side, the Committee on Finance: Sen. Chuck Grassley, Iowa?

The rumor mill favors Grassley, the Republican who has served most recently as the chairman of the Senate Committee on the Judiciary, to replace retiring Sen. Orrin Hatch (R-Utah).

Senate Republican leaders have signaled that entitlement programs like Medicare and Medicaid could use trimming and, with Republicans emerging from the midterms with a slightly bigger majority, this committee could have its hands full.

Hatch proved a friend to the pharmaceutical industry, and his war chest reflected that, taking in more than $850,000 in campaign contributions from drugmaker PACs in the past decade alone, according to a Kaiser Health News analysis. But Grassley has taken a more adversarial approach to the industry, working with a Democratic colleague last summer to pressure drug companies to list their prices in direct-to-consumer ads, for instance.

Grassley held the chairmanship from 2003 to 2006, leaving him two more years at the top, should he want it. (Senate Republican chairs may serve for only six years.) But he might choose to stay on as head of the Judiciary Committee, in which case the next chairman may be the next-most-senior Republican: Sen. Mike Crapo of Idaho.

Midterm Results Show Health Is Important To Voters But No Magic Bullet

November 07, 2018

[UPDATED at 8:15 a.m. ET]

Health care proved important but apparently not pivotal in the 2018 midterm elections on Tuesday as voters gave Democrats control of the U.S. House, left Republicans in charge in the Senate and appeared to order an expansion of Medicaid in at least three states long controlled by Republicans.

In taking over the House, Democrats are unlikely to be able to advance many initiatives when it comes to health policy, given the GOP’s control of the Senate and White House. But they will be able to deliver an effective veto to Republican efforts to repeal the Affordable Care Act, convert the Medicaid health care system for low-income people into a block grant program and make major changes to Medicare.

One likely development is an expansion of Medicaid in several of the 18 states that had so far not offered coverage made available by the Affordable Care Act. Voters in Idaho and Nebraska easily approved ballot measures calling for expansion. A similar measure was leading in Utah based on incomplete returns.

In Montana, voters are deciding if the existing expansion should be continued and the state’s expenses covered by raising tobacco taxes. In preliminary results, opponents outnumbered supporters, but key counties were not expected to release their tallies until Wednesday.

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Medicaid might also be expanded in Kansas, where Democratic gubernatorial candidate Laura Kelly defeated GOP Secretary of State Kris Kobach. The Kansas legislature had previously passed Medicaid expansion, but it was vetoed in 2017 by former GOP Gov. Sam Brownback. Kobach had not supported the ACA expansion.

And in Maine, where voters approved Medicaid expansion in 2017 but GOP Gov. Paul LePage refused to implement it, Democrat Janet Mills was victorious. She has promised to follow the voters’ wishes. LePage was not running.

In exit polling, as in many earlier surveys in 2018, voters said that health care, particularly preserving protections for people with preexisting conditions, was their top issue. But health care remained more important to Democrats than to Republicans.

Those who urged Democrats to emphasize health care this year took credit for the congressional successes. “The race for the House was a referendum on the Republican war on health care. You know it, I know it, and the Republican incumbents who shamefully tried to cover up their real record on health care and lost their seats know it,” said Brad Woodhouse of the advocacy group Protect Our Care.

But the issue was not enough to save some of the Senate Democrats in states won by President Donald Trump in 2016. Sen. Claire McCaskill (D-Mo.) was defeated by GOP Attorney General Josh Hawley, who is a plaintiff in a key lawsuit seeking to declare the Affordable Care Act unconstitutional. Sens. Heidi Heitkamp (D-N.D.) and Joe Donnelly (D-Ind.), who also campaigned hard on health care, were defeated.

Nonetheless, Sen. Joe Manchin (D-W.Va.) beat Republican Patrick Morrisey, the state’s attorney general who is also a plaintiff in the lawsuit seeking to upend the ACA.

Rep. Nancy Pelosi (D-Calif.), the leader of the House Democrats who would be first in line to take over as speaker, told supporters gathered in Washington for a victory celebration that her caucus would make health care a key legislative issue.

“It’s about stopping the GOP and [Senate Majority Leader] Mitch McConnell’s assault on Medicare, Medicaid and the Affordable Care Act and the health care of 130 million Americans living with preexisting medical conditions,” she said. She pledged that Democrats would take “very, very strong legislative action” to lower the cost of prescription drugs.

Among the many new faces in the House is at least one with some significant experience in health policy. Former Health and Human Services Secretary Donna Shalala, who ran the department for all eight years of the Clinton administration, won an open seat in Florida.

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