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Tax Bill Provision Designed To Spur Paid Family Leave To Lower-Wage Workers

January 23, 2018

Tucked into the new tax law is a provision that offers companies a tax credit if they provide paid family and medical leave for lower-wage workers.

Many people support a national strategy for paid parental and family leave, especially for workers who are not in management and are less likely to get that benefit on the job. But consultants, scholars and consumer advocates alike say the new tax credit will encourage few companies to take the plunge.

The tax credit, proposed by Sen. Deb Fischer (R-Neb.), is available to companies that offer at least two weeks of paid family or medical leave annually to workers, but two key criteria must be met. The workers must earn less than $72,000 a year and the leave must cover at least 50 percent of their wages.

If contributing at the half-wage level, a company receives a tax credit equal to 12.5 percent of the amount it pays to the worker. The tax credit will increase on a sliding scale if the company pays more than 50 percent of wages. It could go up to a maximum credit of 25 percent of the amount the employer paid for up to 12 weeks of leave.

Payments to full- and part-time workers taking family leave who’ve been employed for at least a year would be eligible for the employer’s tax break. But the program, which is designed to test whether this approach works well, is set to last just two years, ending after 2019.

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Aparna Mathur, a resident scholar in economic policy studies at the American Enterprise Institute, says the new tax credit sidesteps a pitfall for Republicans. They are wary of any legislation mandating that employers provide paid leave. The tax credit also is appropriately aimed at lower-wage workers who are most likely to lack access to paid leave, said Mathur, who co-authored a recent report on paid family leave.

But it’s not a big enticement.

“Providing this benefit is a huge cost for employers,” Mathur said. “It’s unlikely that any new companies will jump on board just because they have a 12.5 to 25 percent offset.”

That view is shared by Vicki Shabo, vice president for workplace policies and strategies at the National Partnership for Women & Families, an advocacy group, who said it will primarily benefit workers at companies already offering paid family leave. The new tax credit “just perpetuates the boss lottery,” she added.

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Heather Whaling said her 22-person public relations company probably qualifies for the new tax credit, but she doesn’t think it’s the right approach. Whaling, the president of Geben Communication in Columbus, Ohio, already offers paid leave. The company provides up to 10 weeks of paid leave at full pay for new parents. Four employees have taken leave, and by divvying up their work to other team members and hiring freelancers they’ve been able to get by.

“It is an expense, but if you plan and budget carefully it’s not cost-prohibitive,” she said.

The tax credit isn’t big enough to provide a strong incentive to provide paid leave, said Whaling, 37. Besides, “having access to paid family leave shouldn’t be luck of the draw, it should be available to every employee in the country.”

Still, the tax credit may be appealing to companies that have been considering adding a paid family and medical leave benefit, said Rich Fuerstenberg, a senior partner at benefits consultant Mercer.

By defraying some of the cost, the tax credit could help “tip them over” into offering paid leave, he said. But  “I’m not even sure I’d call it the icing on the cake,” Fuerstenberg said. “It’s like the cherry on the icing.”

Only 15 percent of private-sector and state and local government workers had access to paid family and medical leave in 2017, according to the Bureau of Labor Statistics’ National Compensation Survey. Eighty-eight percent had access to unpaid leave, however.

Under the federal Family and Medical Leave Act, employers with 50 or more workers generally must allow eligible employees to take unpaid leave for up to 12 weeks annually for specified reasons. These include the birth or adoption of a child, caring for your own or a family member’s serious health condition, or leave for military caregiving or deployment. An individual’s job is protected during such leaves.

A tax credit that can be claimed at the end of the year is unlikely to encourage small businesses to offer paid family and medical leave, said Erik Rettig, an expert on family leave policies at the Small Business Majority, which advocates for those firms on national policy.

“It isn’t going to help the family business that has to absorb the costs of this employee while they’re gone,” Rettig said.

A better solution, according to Shabo and others, is to provide a paid family leave benefit that’s funded by employer and/or employee payroll contributions. Sen. Kirsten Gillibrand (D-N.Y.) and Rep. Rosa DeLauro (D-Conn.) last year reintroduced such legislation. Their bill would guarantee workers, including those who are self-employed, up to 12 weeks of family and medical leave with as much as two-thirds of their pay.

A handful of mostly Democratic states — including California, New Jersey, Rhode Island and New York — have similar laws in place, and a program in the District of Columbia and Washington state will begin in 2020.

“We know from states that this approach works for both employees and their bosses,” Shabo said.

CHIP Renewed For Six Years As Congress Votes To Reopen Federal Government

January 22, 2018
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A brief, partial shutdown of the federal government ended Monday, as the Senate and House approved legislation that would keep federal dollars flowing until Feb. 8, as well as fund the Children’s Health Insurance Program for the next six years.

President Donald Trump signed the bill Monday evening.

The CHIP program, which provides coverage to children in families who earn too much to qualify for Medicaid but not enough to afford private insurance, has been bipartisan since its inception in 1997. But its renewal became a partisan bargaining chip over the past several months.

Funding for CHIP technically expired Oct. 1, although a temporary spending bill in December gave the program $2.85 billion. That was supposed to carry states through March to maintain coverage for an estimated 9 million children, but some states began to run short almost as soon as that bill passed.

The Georgetown University Center for Children and Families estimated that 24 states could face CHIP funding shortfalls by the end of January, putting an estimated 1.7 million children’s coverage at risk in 21 of those states.

Meanwhile, both houses of Congress had been at loggerheads over how to put the program on firmer financial footing.

In October, just days after the program’s funding expired, the Senate Finance Committee approved a bipartisan five-year extension of funding by voice vote. But that bill did not include a way to pay the cost, then estimated at $8.2 billion.

In November, the House passed its own five-year funding bill for the program, but it was largely opposed by Democrats because it would have offset the CHIP funding by making cuts to Medicare and the Affordable Care Act (ACA).

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Prospects for a CHIP deal brightened earlier this month when the Congressional Budget Office re-estimated how much the extension of funding for the program would cost. In a letter to Senate Finance Committee Chairman Orrin Hatch (R-Utah) on Jan. 5, CBO said changes to health care made in the tax bill would result in lowering the five-year cost of the program from $8.2 billion to $800 million — effectively a reduction of 90 percent.

The reason, explained CBO, is that the landmark tax bill passed in December eliminated the ACA’s individual mandate, which would likely drive up premiums in the individual market. Those higher premiums, in turn, would increase the federal premium subsidies for those with qualifying incomes. As a result, if kids were to lose their CHIP coverage and go onto the individual exchanges instead, the federal premium subsidies would cost more than their CHIP coverage.

Driving that point home, on Jan. 11, CBO Director Keith Hall wrote to Rep. Frank Pallone (D-N.J.) that renewing CHIP funding for 10 years rather than five would save the federal government money. “The agencies estimate that enacting such legislation would decrease the deficit by $6.0 billion over the 2018-2027 period,” the letter said.

That made it easier for Republicans to include the CHIP funding in the latest spending bill. But it infuriated Democrats, who had vowed not to vote for another short-term spending bill until Congress dealt with the issue of immigrant children brought to the country illegally by their parents.

Republicans, said Senate Minority Leader Chuck Schumer (D-N.Y.) on Sunday, “were using the 10 million kids on CHIP, holding them as hostage for the 800,000 kids who were Dreamers. Kids against kids. Innocent kids against innocent kids. That’s no way to operate in this country.”

Republicans, however, said it was the opposite — that Democrats were holding CHIP hostage by not voting for the spending bill. “There is no reason for my colleagues to pit their righteous crusade on immigration against their righteous crusade for CHIP,” said Hatch. “This is simply a matter of priorities.”

The CHIP renewal was not the only health-related change in the temporary spending bill. The measure also delays the collection of several unpopular taxes that raise revenues to pay for the ACA’s benefits. The taxes being delayed include ones on medical device makers, health insurers and high-benefit “Cadillac” health plans.

The bill does not, however, extend funding for Community Health Centers, another bipartisan program whose funding is running out. That will have to wait for another bill.

Update: This story was updated at 9:15 p.m. on Jan. 22 to report that President Donald Trump signed the bill.

When You Need A Breast Screening, Should You Get A 3-D Mammogram?

January 16, 2018

When I went to the imaging center for my regular mammogram last year, the woman behind the desk asked me if I’d like to get a “3-D” mammogram instead of the standard test I’d had in the past.

“It’s more accurate,” she said.

What do you say to that? “No, thanks, I’d rather have the test that gets it wrong?” Of course, I agreed.

A growing number of women are likely to face a similar choice in coming years as imaging centers across the country add three-dimensional (3-D) mammography, also called digital breast tomosynthesis, to the two-dimensional (2-D) screening women customarily receive.

What’s not yet clear is whether this newer, more expensive technology is better at catching cancers that are likely to kill. So should it be widely recommended? And who should pick up the extra cost involved?

According to the Food and Drug Administration, there were 3,915 certified mammography imaging facilities that offered digital breast tomosynthesis in January. That’s a sharp increase over the previous January, when the total was 3,011.

Some facilities have switched over entirely to 3-D imaging, but many practices have both, experts said.

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“There’s a lot of marketing pressure to offer these new machines,” said Robert Smith, vice president of cancer screening at the American Cancer Society.

Both types of tests use X-ray technology to create images of the breast. The 2-D digital mammograms that most women receive typically provide front and side images, while for the 3-D test the X-ray arcs across the breast, creating multiple images of breast tissue. The experience is the same for women, though, because both scans involve compressing the breast between two plates extending from the machine.

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Studies have generally shown that the 3-D test is slightly better at detecting cancers than the 2-D test, and women typically have to return less often to have additional images taken. But the jury is still out on whether the newer technology is any better at identifying the advanced cancers that will become lethal.

“Cancers don’t always progress and kill people,” said Dr. Etta Pisano, chief science officer at the American College of Radiology’s Center for Research and Innovation and a faculty member at Harvard Medical School. Pisano is leading a five-year clinical trial of 165,000 women that will compare the two types of screening tests to evaluate whether the new technology reduces the risk that women will develop life-threatening cancers.

“If tomosynthesis is improving the likelihood of women to survive their breast cancers, they should have fewer cancers that are more likely to kill women over the 4.5 years of screening. Since tomosynthesis caught them early, they’ll never grow up to be bad cancers,” Pisano said.

Overdiagnosis is one of the potential downsides of this technology, said Dr. David Grossman, chair of the U.S. Preventive Services Task Force. The more sensitive test picks up more breast lesions for which the clinical significance is unclear, potentially resulting in women receiving more testing and treatment they don’t need. Some research suggests the biopsy rate is slightly higher with 3-D mammograms.

In addition, some of the mammography systems require both 2-D and 3-D X-rays, which can expose women to twice as much radiation. Other systems are able to generate a 2-D image from the 3-D version with software, eliminating the extra exposure. The 2-D image is important because clusters of calcifications, which may signal breast cancer, might be easier to see on the 2-D image, said Pisano.

Under the Affordable Care Act, most health plans are required to cover preventive services that are recommended by the task force without charging patients anything out-of-pocket. The task force recommends biennial mammograms for women ages 50 to 74, but it says that there’s not enough evidence to recommend 3-D mammograms at this time.

Insurance coverage of 3-D testing has improved in recent years, but it’s not assured. The 3-D test typically costs about $50 more than a 2-D test, according to a 2015 study by Truven Health Analytics that was funded by Hologic, a manufacturer of 3-D mammography systems. Medicare also covers 3-D tests.

A growing number of states require commercial insurers to cover 3-D mammograms, including Arkansas, Texas, Connecticut, Maryland, Illinois and Pennsylvania.

My state of New York also requires coverage, without any out-of-pocket payments. Though I didn’t have to pay it, the explanation of benefits form I got from my insurer said the 3-D portion of the test added $51 to the $157 cost of the mammogram.

“Costs are high for new technologies,” Pisano said. “Maybe they are better, but we need to have evidence before we recommend it for the entire population.”

So if you’re offered a 3-D test, should you get it?

“If the examination is available at no extra cost, the data we have now tells us it has some advantages,” said Smith. On the other hand, “any woman who’s feeling stressed about the extra cost … should feel comfortable getting a regular mammogram,” he said.

Trump’s Work-For-Medicaid Rule Puts Work On States’ Shoulders

January 12, 2018
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The Trump administration’s watershed decision Thursday to allow states to test a work requirement for adult Medicaid enrollees sparked widespread criticism from doctors, advocates for the poor, and minority and disability rights groups.

Conservatives, however, hailed the change to the federal-state program for low-income people. Stephen Miller, the Medicaid commissioner for Kentucky, which received authority Friday to implement a work requirement, said the new policy will “allow states the flexibility to pursue innovative approaches to improve the health and well-being of Medicaid beneficiaries.”

Yet states considering whether to enact the controversial strategy face major hurdles. They will have to figure out how to define the work requirement and alternative options, such as going to school or volunteering in some organizations; how to enforce the new rules; how to pay for new administrative costs; and how to handle the millions of enrollees likely to seek exemptions.

Take Arizona, one of the 10 states that have applied for federal approval for a work requirement. The state must settle basic questions, including whether people would have to meet the new conditions at the time of enrollment, at the annual renewal of their Medicaid coverage or at another time.

Jami Snyder, deputy director of the Arizona Medicaid program, said a key goal for the state is to help people find jobs — not to reduce its Medicaid enrollment, which stands at 1.9 million.

“Infusing the requirement into our eligibility requirements acts as a nice incentive for enrollees in their effort to seek out employment and job training,” she said.

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But the state today doesn’t know how many of its enrollees are already employed, said Snyder.

“We are still working through all the operational details,” she explained.

Seema Verma, administrator for the Centers for Medicare & Medicaid Services, said she hopes the new work requirement will improve enrollees’ health while reducing Medicaid rolls. The policy change should help people find jobs that offer health coverage or make enough money to afford private plans, she said.

Critics expressed skepticism. They say the work requirement proposal — which was repeatedly rejected by the Obama administration on the argument it would interfere with providing health coverage — is a more subtle way to reduce the number of non-disabled adults added to Medicaid under the Affordable Care Act. That Medicaid expansion was sharply criticized by conservatives, and Republicans in Congress tried to add work requirements in their unsuccessful bid last year to overturn the health law.

“This is an effort to walk back the Medicaid expansion,” said Judith Solomon, vice president of the Center on Budget and Policy Priorities, a Washington-based research organization. CMS said states would have to test whether the work requirement improves enrollees’ health — a point Solomon ridiculed. “What health outcome will be improved if we take away health care from those not able to work?” she asked.

Dr. Richard Pan, a California state senator and pediatrician in Sacramento who sees Medicaid patients, said the idea just “doesn’t make sense.” By making it harder for people to have health insurance, “you’re going to make it less likely for them to work,” he said.

Pan, a Democrat, said the proposal would create more bureaucracy and “feeds into a fiction” that Medicaid enrollees don’t work — or don’t want to work.

More than 4 in 10 non-disabled adults with Medicaid coverage already work full time.

Despite their concerns about the change in Medicaid policy, critics of the plan acknowledge that it will touch only a fraction of the nation’s total enrollment. Solomon estimates that fewer than 2 percent of the 74 million people covered would be directly affected by a work requirement.

In addition to the large group of enrollees already working, the federal guidelines excluded children — who make up nearly half of Medicaid enrollees. Also off the hook are the more than 10 million enrollees who have a disability. Many of those left either to go to school or take care of a relative or are too sick to work.

The CMS guidelines give states wide latitude in enacting work requirements, and state rules may differ on who gets exempted from the mandate. Arizona’s proposal has one of the longest lists of exemptions, including people 55 and over, victims of domestic violence, American Indians and individuals who have experienced a death of a family member living in the same household.

It is unclear how enrollees will prove they meet such criteria or if states will use the honor system.

In comparison, Kentucky seeks to exempt children; pregnant women; primary caregivers for children or a disabled relative; people who are medically frail; and full-time students.

Emily Beauregard, executive director for Kentucky Voices for Health, an advocacy group, said one of the key exemption issues states must work out is defining who is “medically frail”— a designation that CMS said would exempt enrollees from the requirement. The federal government, however, leaves the qualifying characteristics up to states.

Before coming to Washington last year, Verma was a health consultant who worked with Indiana and Kentucky to expand Medicaid under the ACA. But in a speech to the nation’s Medicaid directors in November, Verma said adding non-disabled adults to Medicaid was a mistake for a program designed to help children, the disabled and pregnant women.

“The thought that a program designed for our most vulnerable citizens should be used as a vehicle to serve working-age, able-bodied adults does not make sense,” she said at the time.

Some Democratic-leaning states are not expected to make the change. California health care leaders dismissed the idea of imposing a work requirement on the state’s Medicaid enrollees, saying it would never come to pass.

Kevin de León, a Democrat and the leader of California’s Senate, wouldn’t comment on the proposal because he said it’s a non-starter.

“This is not an option we are considering,” said Jennifer Kent, director of the state Department of Health Care Services, which administers Medi-Cal, the state’s Medicaid program that covers about 13.5 million Californians.

Most states contract with private health insurers to run much of their Medicaid operations. Those insurers said they remain concerned that as the work mandate unfolds, their jobs might become harder because of increased churn in enrollment and administrative work. About 52 million of the 74 million Medicaid enrollees rely on managed-care companies for their coverage.

“With this guidance from CMS, it will be essential for states and stakeholders in the states — including insurance providers — to understand the details of who will be impacted by work requirements, how these requirements will be defined and administered, and how people who are impacted will be directed to new pathways for coverage and care,” said Kristine Grow, a spokeswoman for America’s Health Insurance Plans, a national trade group.

Jeff Myers, president and CEO of the Medicaid Health Plans of America, another trade group, noted that most people on Medicaid already work. He said his group is concerned work requirements could affect how the health plans operate. They will need to “see all of details from states,” he said.

Podcast: ‘What The Health?’ Should You Work For Your Medicaid Coverage?

January 12, 2018
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What The Health is going to happen in 2018? Come join us in D.C. and find out.

THE EVENT: A live taping of KHN’s “What The Health?” podcast.

WHEN: Thursday, Jan. 18, 1–2 p.m. ET

WHERE: Kaiser Family Foundation, 1330 G. Street NW, Washington, D.C.


The Trump administration this week told states they will be allowed to require some beneficiaries of the Medicaid program to work or perform community service in order to keep their health insurance — a break with long-standing policies of both Democratic and Republican administrations.

Meanwhile, the Congressional Budget Office said that renewing the Children’s Health Insurance Program (CHIP) for 10 years would actually save the federal government money, because alternative arrangements for the 9 million children now covered would be more expensive.

Plus, Paul Starr, Princeton professor and co-editor of The American Prospect, talks about his about ideas for expanding the Medicare program, if and when the political winds shift in that direction.

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

They discuss these topics as well as the prospects for quick confirmation of former Health and Human Services Deputy Secretary Alex Azar to head the department. And Rovner interviews Paul Starr.

Among the takeaways from this week’s podcast:

  • The new work policy follows efforts to add a work requirement to Medicaid eligibility. But that change came through congressional action. The Trump administration’s decision to shift policy through the executive branch could complicate its legal arguments when advocates file their promised lawsuits.
  • Despite concerns about the historic nature of the change in Medicaid requirements, many people — including many Medicaid enrollees — say they support a work mandate.
  • The Congressional Budget Office’s revisions to estimates about the cost of the Children’s Health Insurance Program appear to be breaking the logjam on funding on Capitol Hill.
  • Alex Azar, the nominee to be secretary of the Department of Health and Human Services, appears on the glide path for confirmation, with at least two Democratic senators, Heidi Heitkamp of North Dakota and Joe Manchin of West Virginia, having already announced they will vote for him.
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Plus, for “extra credit,” the panelists recommend their favorite health stories of the week they think you should read, too.

Julie Rovner:  Mother Jones’ “Go Fund Yourself,” by Stephen Marche

ALSO: The New York Times’ “You’re Sick. Whose Fault Is That?” by Dhruv Khullar.

Joanne Kenen: The New York Times’ “Baltimore Hospital Patient Discharged at Bus Stop, Stumbling and Cold,” by Jacey Fortin

Sarah Kliff: Marketplace’s “The Uncertain Hour, Episode 1: The Magic Bureaucrat,” by Krissy Clark

Margot Sanger-Katz: The Wall Street Journal’s “Trump Nominee to Lead Indian Health Services Faces Claims of Misrepresentation,” by Christopher Weaver and Dan Frosch.

To hear all our podcasts, click here.

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With CHIP Funds Running Low, Doctors And Parents Scramble To Cover Kids’ Needs

January 12, 2018

Dr. Mahendra Patel, a pediatric cancer doctor, has begun giving away medications to some of his patients, determined not to disrupt their treatments for serious illnesses like leukemia, should Congress fail to come up with renewed funding for a key children’s health program now hostage to partisan politics.

In his 35 years of practice, Patel, of San Antonio, has seen the lengths to which parents will go to care for their critically ill children. He has seen couples divorce just to qualify for Medicaid coverage, something he fears will happen if the Children’s Health Insurance Program (CHIP) is axed. He said: “They are looking at you and begging for their child’s life.”

The months-long failure on Capitol Hill to pass a long-term extension to CHIP that provides health coverage to 9 million lower-income children portends serious health consequences, with disruption in ongoing treatments.

While funding promises and estimates of dates for it disappearing vary from week to week and state to state, treatment plans for serious diseases span months into the future, leaving some doctors, like Patel, to jury-rig solutions. The challenges are particularly great for kids with chronic or ongoing illnesses such as asthma or cancer.

Dr. Joanne Hilden, a pediatric cancer physician in Aurora, Colo., and past president of the American Society of Pediatric Hematology-Oncology, said cancer patients who are worried their CHIP funding will run out can’t schedule care ahead of time.

A San Antonio pediatrician, Dr. Carmen Garza, is advising parents to be sure to keep their children’s asthma medications and other prescriptions current and fill any refills that they can so they don’t get left without vital medicines if CHIP expires.

Federal funding for CHIP originally ran out Oct. 1. In December, Congress provided $2.85 billion to temporarily fund the program. That was supposed to help states get through at least March, but it is coming up well short. The Centers for Medicare & Medicaid Services (CMS) last week said it couldn’t guarantee funding to all states past Jan. 19.

About 1.7 million children in 20 states and the District of Columbia could be at risk of losing their CHIP coverage in February because of the shortfall, according to a report Wednesday by the Georgetown University Center for Children and Families.

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A few states, including Louisiana and Colorado, plan to use state funds to make up for the lack of federal funding. But that is a drastic step, since the federal government pays on average nearly 90 percent of CHIP costs. Most states cannot afford to make up the difference and will have to freeze enrollment or terminate coverage when their federal funding runs out.

Virginia and Connecticut can promise to keep their CHIP program running only through February, officials said.

The largest states seem to be in the best shape, though even that guarantees only a few months of care. Florida, California and Texas officials said they have enough CHIP funding to last through March. New York officials said they have enough money to last at least into mid-March.

Before the short-term funding was passed in late December, CHIP programs survived on the states’ unspent funds and a $3 billion redistribution pool of CHIP dollars controlled by CMS.

Republicans and Democrats on Capitol Hill say they want to continue CHIP, but they have been unable to agree on how to continue funding it. The House plan includes a controversial funding provision — opposed by Democrats — that takes millions of dollars from the Affordable Care Act’s Prevention and Public Health Fund and increases Medicare premiums for some higher-earning beneficiaries.

The Senate Finance Committee reached an agreement to extend the program for five years but did not unite around a plan on funding.

But two key Republican lawmakers — Sen. John Cornyn of Texas, who is part of the Senate leadership, and Rep. Greg Walden of Oregon, who chairs the House Energy and Commerce Committee — told reporters Wednesday that they think an agreement is close.

Alabama and Utah are among several states unsure how long their federal CHIP funding will last, according to interviews with state officials. Part of the problem is they have not been told by CMS how it will be disbursing money from the redistribution pool. Under the pool restrictions, states with excess dollars would have to give money to states running low.

Although health care provider groups and child health advocates have for months been sounding the alarm about CHIP, the Trump administration has kept quiet, saying it’s up to Congress to renew the program.

When Marina Natali’s younger son broke his arm ice-skating last year, she did not have to worry about paying: CHIP footed all of his medical bills.

Had that accident happened this year, though, Natali, 50, of Aliquippa, Pa., might be scrambling. She cannot afford private coverage for her two children on her dental hygienist pay.

“It’s creating a lot of anxiety about not having insurance and the kids getting sick,” she said.

Without CHIP, dental hygienist Marina Natali says she couldn’t afford health coverage for her sons, 12-year-old Ciro (right) and 15-year-old Marcus. When Ciro broke his arm ice-skating last year, CHIP covered his medical bills. (Courtesy of Marina Natali)

Dr. Todd Wolynn, a Pittsburgh pediatrician, said families are reacting with “fear and disbelief” to CHIP’s uncertain future. The group practice hasn’t changed any scheduling for CHIP patients, but he said “families are terrified” about the program having to be terminated.

Pennsylvania officials sent a notice to CHIP providers in late December — who then sent it to enrollees — saying it would have to end the program in March unless Congress acts.

“These families don’t know if the rug is being pulled out from them at any time,” he said.

Dr. Dipesh Navsaria, a Madison, Wis., pediatrician and vice president of the state’s chapter of the American Academy of Pediatrics, said many parents and doctors have been told for months that Congress would firm up long-term funding for CHIP, but those promises have been dashed.

“If CHIP coverage disappears, we run the risk of kids going without care or emergency room visits going up,” he said.

Navsaria also worries that many parents will be surprised if their children are suddenly without coverage. They may not know the state-branded programs they use, such as BadgerCare Plus in Wisconsin, Healthy Kids in Florida and All Kids in Alabama, are part of the CHIP program.

Ariel Haughton of Pittsburgh said she’s upset her federal lawmakers have left CHIP in flux for her two children and millions of kids around the country. “They seem so cavalier about it,” she said.

If CHIP gets canceled by the state, she likely won’t bring Javier, 2, for his two-year checkup if nothing seems wrong. “We will have to decide between their health and spending the money on something else,” she said.

Correction: This story was updated on Jan. 12 to correct the name of an organization. Dr. Joanne Hilden is the past president of the American Society of Pediatric Hematology-Oncology, not the American Society of  Hematology-Oncology.

Trump Administration Clears Way To Force Some Medicaid Enrollees To Work

January 11, 2018
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[UPDATE: This story was updated at 12:18 p.m. ET to include additional comments from experts and officials.]

The Trump administration early Thursday initiated a pivotal change in the Medicaid program, announcing that for the first time the federal government will allow states to test work requirements as a condition for coverage.

The announcement came in a 10-page memo with detailed directions about how states can reshape the federal-state health program for low-income people.

The document details who should be excluded from the new work requirements — including children and people being treated for opioid abuse — and offers suggestions as to what counts as “work.” Besides employment, it can include job training, volunteering or caring for a close relative.

Seema Verma, the administrator of the Centers for Medicare & Medicaid Services (CMS), said the policy change is an effort to give states more flexibility. She told reporters in a call Thursday that it could lead to a decline in Medicaid enrollment.

“We see moving people off Medicaid as a good outcome because that means they do not need the program anymore and have transitioned to a job or can afford insurance,” she said. “This policy helps people achieve the American dream.”

CMS officials said they did not have any estimates on how much Medicaid enrollment would drop as a result of the policy.

Adding a work requirement to Medicaid would mark one of the biggest changes to the program since its inception in 1966. It is likely to prompt a lawsuit from patient advocacy groups, which claim the requirement is inconsistent with Medicaid’s objectives and would require an act of Congress.


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Republicans have been pushing for the change since the Affordable Care Act added millions of “able-bodied” adults to Medicaid. It allowed states to provide coverage to anyone earning up to 138 percent of the federal poverty level (about $16,600 for an individual).

The Obama administration turned down several state requests to add a work requirement.

Ten states have applied for a federal waiver to add a work requirement — Arizona, Arkansas, Indiana, Kansas, Kentucky, Maine, New Hampshire, North Carolina, Utah and Wisconsin. Officials in several other states have said they are interested in the idea.

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An HHS official, who spoke on the condition of anonymity because the official had not been authorized to discuss the developments,  said the agency may approve Kentucky’s request as early as Friday. Gov. Matt Bevin, a Republican, first sought to add such a provision in 2016. The current request would require able-bodied adults without dependents to work at least 20 hours a week.

Kentucky, which has some of the poorest counties in the country, has seen its Medicaid enrollment double in the past three years after the state expanded eligibility under the ACA.

While more than 74 million people are enrolled in Medicaid, only a small fraction would be affected by the work requirement. That’s because children — who make up nearly half of Medicaid enrollees — are excluded. So are the more than 10 million people on Medicaid because they have a disability.

More than 4 in 10 adults with Medicaid coverage already work full time, and most others either go to school, take care of a relative or are too sick to work.

Still, critics fear a work requirement could have a chilling effect on people signing up for Medicaid or make it harder for people to get coverage.

Jane Perkins, legal director for the National Health Law Program, a patient advocacy group, said a lawsuit is likely once CMS approves a state waiver.

“We believe that the work requirement is indeed a problem because it is not consistent with Medicaid’s objectives” to furnish medical assistance, she said. “Programs that assist people in finding and keeping work are effective, not programs that penalize them by stopping health insurance or blocking them from getting health coverage in the first place.”

But work requirements have strong public backing. About 70 percent of Americans say they support states imposing a work requirement on non-disabled adults, according to a Kaiser Family Foundation poll last year. (Kaiser Health News is an editorially independent program of the foundation.)

The Trump administration, along with many Republican leaders in Congress, has long supported such a move. The failed efforts in the House to replace Obamacare included a work requirement for Medicaid.

In its guidance to states, CMS said they should consider how some communities have high unemployment rates and whether enrollees need to care for young children or elderly relatives.

CMS also advised states to make work requirements for Medicaid similar than those used with food stamps to “reduce the burden on both states and beneficiaries.”

(Story continues below.)

“This new guidance paves the way for states to demonstrate how their ideas will improve the health of Medicaid beneficiaries, as well as potentially improve their economic well-being,” Brian Neale, CMS deputy administrator and director for the Center for Medicaid and CHIP Services, said in the press release.

Verma, who has said she doesn’t think Medicaid should become a way of life for people who are not disabled, said the new guidance shows how the administration is trying to give states more flexibility in running Medicaid.

“Our policy guidance was in response to states that asked us for the flexibility they need to improve their programs and to help people in achieving greater well-being and self-sufficiency,” she said.

Verma, who worked with Kentucky and Indiana on their work requirement waivers as a health consultant before joining the Trump administration, recused herself from the decision on those states’ waiver requests.

Jennifer Walthall, secretary of the Indiana Family and Social Services Administration, applauded the new CMS guidance and said she expects the state’s work requirement request to be approved “in the coming days.”

“Whether it is a job, training, volunteering, substance abuse treatment, additional education or another opportunity, becoming an active and productive member of the community is an important part of healthy living,” she said in a statement.

Giving Medicaid Enrollees Something To Smile About

January 10, 2018
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Susan Inglett’s dental coverage changed just after she got a root canal on one of her top teeth.

It was 2009, and California was in the midst of a budget crisis. To cut costs, Medi-Cal, the state’s health insurance program for low-income residents, eliminated non-emergency dental benefits for adults.

Inglett, 63, of San Diego, needed a crown for that vulnerable tooth, but the state no longer paid for them.

She couldn’t afford one on her own, so she went without it. After that, she had three other teeth pulled because the dental services that would have saved them were no longer covered.

“You end up making choices about what you can and cannot afford,” Inglett says. “If a procedure comes up and you simply can’t afford it, and it’s cheaper to yank the tooth, then you take out the tooth.”

Now, Inglett won’t have to choose between fixing her teeth and getting them pulled.

Many of the dental services cut nine years ago were restored on Jan. 1 for her and about 7.5 million adults on Medi-Cal, many of whom had to get their teeth pulled rather than repaired.

Some benefits had been partially restored in 2014, such as fillings and X-rays, but critical treatments remained uncovered, including lab-processed crowns, root canals on back teeth, treatments for gum disease and partial dentures.

Those procedures are now covered.

Medi-Cal is California’s version of the state-federal Medicaid program. All state Medicaid programs must provide comprehensive dental coverage for children, but dental services are optional for adults.

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Almost all states do provide some adult dental benefits, though the scope varies. As of May 2017, 16 states plus the District of Columbia provided extensive adult dental benefits, 17 offered limited dental benefits and the remaining 13 that covered adults did so only for emergency dental care, according to the Center for Health Care Strategies.

Four states provided no adult dental benefits at all.

During budget crises, optional adult dental benefits are among the first to be chopped, says Robin Rudowitz, associate director of the Kaiser Family Foundation’s Program on Medicaid and the Uninsured. (Kaiser Health News is an editorially independent program of the foundation.)

As economies improve, states often move to restore them, Rudowitz says. Seven states, including California, Arizona and Oregon, expanded their dental coverage in fiscal years 2017 and 2018.

But access to actual dental care is a problem for Medicaid enrollees, and a critical question looms in California now that adult dental benefits have been restored: Will there be enough dentists willing to accept the rates that Denti-Cal — Medi-Cal’s dental program — pays for them?

“The vast majority of dentists don’t accept Denti-Cal patients because they can’t afford it,” says Sigmund Abelson, associate dean for clinical affairs at University of the Pacific’s dental school.

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The school operates clinics in San Francisco and Union City that treat about 2,500 Denti-Cal patients a year, he says. Services are provided by students under the supervision of faculty.

Abelson says he believes the overall health of Medi-Cal enrollees will improve now that full dental benefits have been restored, assuming they can find participating dentists.

Oral and physical health are directly linked, and many Denti-Cal recipients suffered from preventable illnesses because they couldn’t get appropriate dental care, Abelson says.

Some ended up in emergency rooms, “many times with acute infections that could have been treated by dentists,” he says.

Patients like Inglett who are missing teeth tended to start eating more processed foods and soft foods, says her dentist, Misako Hirota, who practices in National City, just south of San Diego.

“That in itself creates a lot of other problems,” such as diabetes, obesity and high blood pressure, she says. “It’s all a vicious cycle.”

Among the treatments that were restored this month, Abelson ranks root canals and special cleanings for people with gum disease as two of the most important.

Under the previous rules, root canals on back teeth were not covered. Extractions, on the other hand, were.

Now, all teeth are eligible for root canal coverage, Abelson says.

For patients with gum disease, Denti-Cal also started covering “scaling and root planing,” which is a deep cleaning below the gum line that can help reduce infections in the mouth, Abelson says.

“Remember, your gums are holding in your teeth,” he says. “There’s no point in fixing a tooth if you have bad gums. You may ultimately lose the tooth.”

Hirota is thrilled that her patients are now eligible for partial dentures. After benefits were partly restored in 2014, enrollees could get only full dentures. That meant any remaining teeth had to be pulled before patients could qualify, Hirota says.

Having dentures “makes all the difference in the world for your confidence, and for your ability to get a job and present yourself in public,” she says.

Inglett is grateful for the changes. If the benefits had not been restored, she would have had to get more teeth pulled. “I am at the point where I would have to keep sacrificing my teeth,” she says.

Inglett already has a dentist who accepts Medi-Cal. Enrollees who don’t might have difficulty finding one.

A scathing report on Denti-Cal in 2016 by the Little Hoover Commission, an independent state oversight agency, noted that just a quarter of California dentists participate “due to its low reimbursement rates and administrative obstructions.” Finding a Denti-Cal dentist in rural counties can be next to impossible.

But state officials say they are engaged in a statewide outreach effort to recruit more dentists and have simplified the enrollment paperwork for providers.

And last year, Denti-Cal increased the rates it pays dentists for hundreds of procedures by 40 percent, a boost that was funded by the tobacco tax, Proposition 56, which voters approved in November 2016.

Hirota’s regular charge for a filling that repairs damage on two surfaces of a tooth is $130. Before the rate hike, Denti-Cal paid her $48, but that grew last year to $67.20, she says.

Hirota believes more dentists may start to accept Denti-Cal patients now, but Abelson is skeptical that the rate hikes will be enough to entice an adequate number of dentists.

To search for dentists who accept fee-for-service Denti-Cal, which is the primary service model for most of the state, visit the Denti-Cal website at or call 800-322-6384. If you live in Sacramento or Los Angeles County and have managed-care Denti-Cal, email or call 916-464-3888.

You can also call your local dental society, which likely maintains a list of dentists in the area who accept Denti-Cal. You can find your branch by visiting the California Dental Association website ( and clicking on the “About CDA” tab.

Like University of the Pacific, many dental schools accept Denti-Cal patients, Abelson says. However, they are concentrated in the Bay Area and Southern California, so they won’t be accessible to all Californians.

Running On Empty: CHIP Funding Could Run Out Jan. 19 For Some States

January 05, 2018

Some states are facing a mid-January loss of funding for their Children’s Health Insurance Program (CHIP) despite spending approved by Congress in late December that was expected to keep the program running for three months, federal health officials said Friday.

The $2.85 billion was supposed to fund states’ CHIP programs through March 31. But some states will start running out of money after Jan. 19, according to the Centers for Medicare & Medicaid Services. CMS did not say which states are likely to be affected first.

The latest estimates for when federal funding runs out could cause states to soon freeze enrollment and alert parents that the program could soon shut down.

The CHIP program provides health coverage to 9 million children from lower-income households that make too much money to qualify for Medicaid. Its federal authorization ended Oct. 1, and states were then forced to use unspent funds to carry them over while the House and Senate try to agree on a way to continue funding.

Congress extended funding on Dec. 21 and touted that states would have money to last while Congress worked on a long-term funding solution. But CMS said Friday it could only guarantee that the appropriation will be enough to fund all states through Jan. 19.

CMS said the agency is in discussions with states to help deal with the funding shortfall.

“The funding … should carry all the states through January 19th based upon best estimates of state expenditures to date,” said CMS spokesman Johnathan Monroe. “However, due to a number of variables relating to state expenditure rates and reporting, we are unable to say with certainty whether there is enough funding for every state to continue its CHIP program through March 31, 2018.”

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“States need to know whether they will need to find additional funding for children covered under the Medicaid CHIP program at a much lower federal matching rate, send letters to families, and re-program their eligibility systems,” said Lisa Dubay, a senior fellow at the Urban Institute. “Of course, the implications for families with CHIP-eligible children cannot be understated: Parents are worried that their children will lose coverage. And they should be.”

Although the program enjoys bipartisan support on Capitol Hill, the Republican-controlled House and Senate have for months been unable to agree on how to continue funding CHIP, which began in 1997.

The House plan includes a controversial funding provision — opposed by Democrats — that takes millions of dollars from the Affordable Care Act’s Prevention and Public Health Fund and increases Medicare premiums for some higher-earning beneficiaries.

The Senate Finance Committee reached an agreement to extend the program for five years but did not unite around a plan on funding.

Before the CHIP funding extension on Dec. 21, Alabama said it would freeze enrollment Jan. 1 and shut down the program Jan. 31. Colorado, Connecticut and Virginia sent letters to CHIP families warning that the program could soon end.

After the funding extension, Alabama put a hold on shutting down CHIP.

“Some states will begin exhausting all available funding earlier than others,” a CMS official said Friday. “But the exact timing of when states will exhaust their funding is a moving target.”

Bruce Lesley, president of First Focus, a child advocacy group, said Congress should have known its short-term funding plan was not enough.

“The math never worked on the patch, as it only bought a few weeks,” he said. “Congress must get this finalized before Jan. 19.”

Readers Have Bones To Pick, From Health System Flaws To Covering Pot Beat

January 05, 2018

Letters to the Editor is a periodic Kaiser Health News feature. KHN welcomes all comments and will publish a selection. We edit for length and clarity and require full names.

On Building Empathy For Patients

As a nurse practitioner for 18 years and someone who has a chronic illness, I am intimately aware of the issues that Dr. Rana Awdish brings up for improving communication between physicians and patients (“Terrifying Brush With Death Drives Doctor To Fight For Patients,” Jan. 2). I see both the nursing and medical side of patient care, and I have to say that physicians could learn a lot from nurses. Listening to patients and being a patient advocate is at the core of what nurses have been doing for a hundred years. Thankfully, society is changing and realizing that the physician is not a “god-like” figure. Physicians are nothing more than real people, ones who make mistakes and have trouble with communication and feelings, just like everyone else. I wish the journalism world would realize how the nursing perspective is what has given patients the “care” they need and seek.

— Timothy Ray, Madison, Ohio

In your excellent interview with Dr. Rana Awdish, she discusses several “system” barriers to enhancing the patient-doctor relationship – such as productivity demands, the upkeep of electronic medical records, dealing with insurance. But she seems to separate physicians from the “system.” Such separation is itself a significant barrier to the communication space that the doctor challenges her colleagues to create. Breaking down system barriers requires a system-wide effort, among physicians, nurses, aides, administration and information technology officials — even insurance carriers.

— Paul Shirilla, Traverse City, Mich.

How Hospitals Game The System

In regards to the “poor and sloppy reporting” from the Chicago hospital suing over a rating agency’s contested grade (“In Era Of Increased Competition, Hospitals Fret Over Ratings,” Dec. 11): Such scores do not reflect the quality of hospital operations. They reflect the ability of a person to write the best report. This can be compared to financial success of hospitals. The hospital that knows how to game the system — getting more money from the Centers for Medicare & Medicaid Services and insurance carriers by maximizing billing — beats the hospital that is focused on good care.

— Bob Schmidt, Atlanta

Dispense Your Words Carefully

I’m certainly not a fan of PhRMA but, in the interest of accurate reporting, Jay Hancock should choose his words more carefully (“Drug Industry Spent Millions To Squelch Talk About High Drug Prices,” Dec. 19). An organization with a $220 million budget can hardly be said to “lavish” support on a group of organizations when it spends a total of $2 million across “scores of organizations,” and the largest gift was $260,000. But the word “lavish” would be entirely appropriate when describing PhRMA’s gift of $6.1 million to the American Action Network.

— Worth Gretter, Menands, N.Y.

The woman featured in your article “Opioids After Surgery Left Her Addicted. Is That A Medical Error?” (Dec. 11) was not “addicted.” She was “drug-dependent.” Yes, the docs should have educated her better, but you ought to be technically accurate.

— Sally Satel, M.D., Washington, D.C.

Missing A Killer App Opportunity For Painkillers

In reporting on the opioid epidemic, Michelle Andrews provided insight on her personal experience being overprescribed Percocet for a minor knee injury (“Doctor’s Rx For A Stiff Knee: A Prescription For 90 Percocet Pills,” Nov. 21). She noted how electronic prescribing systems make prescribing more pills simpler than prescribing fewer, as they generate the maximum prescription — in this case, 90 pills of Percocet, a relatively strong opioid for a minor knee surgery.

An automated prescribing system based on procedures would allow more accurate pain medicine allocation, while aligning with the behavioral workflow of physicians. Why not apply the sophisticated algorithms and big data — which Silicon Valley frequently capitalizes on — to the opioid crisis, by developing user-friendly software for physicians to quickly prescribe appropriate doses according to the procedure and weight of the patient?

— Ariel Cooper, Oakland, Calif.

Docs Not Inoculated Against Runaway Vaccine Costs

Prevnar’s high price tag (“The Ratcheting Price Of The Pneumococcal Vaccine: What Gives?” Nov. 29) is only part of the problem. Its manufacturer, Pfizer, unlike other vaccine companies, refuses to offer a refund for expired doses of Prevnar if the 10-dose package has been opened (doses are in separate, prefilled syringes). So, the pediatrician who orders a large supply when Pfizer offers a couple of months’ worth at the old price then gets stuck with unused vaccine ($1,000 worth this summer for me, for having six of 10 doses left in the second package — they had early expiration dates). I’m stuck with Prevnar, but I use Pfizer’s competitors for all other vaccines now.

— PL June, M.D., Moultrie, Ga.

New Light Shed On Sickle Cell Disease

Thanks for the piece on sickle cell disease (“Sickle Cell Patients Suffer Discrimination, Poor Care — And Shorter Lives,” Nov. 6). I remember hearing stuff on TV about sickle cell growing up in the ’70s, but hadn’t heard anything since biochemistry class in college. I’d assumed that, because of the earlier attention, treatments had become so good that it was no longer an issue. I guess that was naive, given the ensuing deterioration of our health care system in general.

— Linda Wilson, Georgetown, Texas

I wanted to thank the Kaiser Health News team for writing a story about sickle cell disease. My older brother, Marqus, has sickle cell disease. The story echoed our lives and managed to capture over 100 years of discrimination.

The good news is that Marqus survived his seizures and the two of us started a nonprofit to try and improve policy efforts and quality of life for sickle cell patients. We even went to the Food and Drug Administration last year and testified about the need for drug development, ultimately aiding in the FDA approval of a sickle cell drug. Thank you for validating our cause and shedding some light on disparities for sickle cell disease.

— Ashley Valentine, co-founder and president of Sick Cells, Washington, D.C.

Help For Millennials Peering Over Insurance Cliff

Your recent article reporting that millennials are struggling to enroll in health plans (“Challenges Abound For 26-Year-Olds Falling Off Parental Insurance Cliff,” Dec. 8) profiled one young woman who found a plan after consulting a health insurance broker. More first-time enrollees should consider following her lead. Eighty-four percent of consumers who sought guidance from health insurance agents and brokers when shopping on the exchanges found them helpful — a higher satisfaction rating than any other source of assistance.

— Janet Trautwein, CEO, National Association of Health Underwriters, Washington, D.C.

Weeding Through Facts On Marijuana 

It’s interesting that the article “Teaching Teens The Perils Of Pot As Marketplace Grows” (Nov. 29) completely left out the federal study released in September 2017 showing that “in 2016, rates of marijuana use among the nation’s 12- to 17-year-olds dropped to their lowest level in more than two decades, according to federal survey data released.”

— Jason Barker, LECUA Patients Coalition of New Mexico, Albuquerque

You guys keep pushing reefer madness articles to NPR. You published an article about a teenager who was speculating that legal marijuana makes it harder to talk to teens about marijuana. Maybe instead of what some random kid thinks, look at the numbers that show usage dropping among teens.

And your article on cannabinoid hyperemesis syndrome (“Wrecked And Retching: Obscure Vomiting Illness Linked To Long-Term Pot Use,” Jan. 2) is nothing more than a scare piece. What are you afraid of, dropping opioid deaths? This condition, which is stated in the article to be rare, goes away once the person ceases use. Get with the times. Your coverage is the same old only-negative drug war nonsense.

— Chad Spratt, Austin, Texas

Maine Voters Chose Medicaid Expansion. Why Is Their Governor Resisting?

January 05, 2018

This KHN special series examines the reach and the role of Medicaid, the federal-state program that began as a medical program for the poor but now provides a wide variety of services for a large swath of America.

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Donna Wall cares for her three adult autistic children at her home in Lewiston, Maine. It’s a full-time job. Sons Christopher and Brandon have frequent outbursts, and the stress of tending to them can be overwhelming.

When her twin sons turned 18 a year and a half ago, Maine’s Medicaid program dropped her health insurance. Wall is considered a “childless adult” in Maine and other states that didn’t expand Medicaid, and so she isn’t eligible for coverage. She can no longer get her antidepressants and anti-anxiety medications. She can’t see her psychologist or a doctor to check up on a troubling spot on her eye.

She needs to stay whole, she said, for her kids.

“I’m 60 years old. Things start going wrong when you get older,” she said. “I haven’t had a Pap smear or breast exam in two years. I’m just worried something will happen to me, because who is going to take care of them? It’s a big job. If I put the boys in a home, it would cost the state a lot more to take care of them than it would be to pay my medical.”

Even on frigid, wintry nights, Wall delivers newspapers, earning $150 a week when her kids are asleep.

“I go out about 2 in the morning. And it usually takes me four to five hours,” she said. “I try really hard not to fall, but I have had a few accidents. One of them was on black ice last winter.”

At one point, Wall thought she might have broken a rib. But she stayed away from the emergency room for fear of a costly medical bill.

At least 70,000 low-income Maine residents like Donna Wall should gain Medicaid health insurance because of the ballot measure that passed last fall. Advocates collected signatures to put the question to voters, and, in November, Maine became the first state to get approval at the ballot box to expand Medicaid, passing with 59 percent approval.

But even though voters here in Maine decided to expand Medicaid, the law’s fate is unclear. Republican Gov. Paul LePage has said that opening up the program to more poor adults threatens the state’s financial stability and that lawmakers shouldn’t raise taxes to pay for it.

“You have to pay for the law,” LePage said. “It’s going to cost money. And I intend to implement it, and the Legislature is required to fund it. If they do not fund it, it will not be implemented.”

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LePage has been in power for seven years, and, because of term limits, is heading into his final year in office. He vetoed five Medicaid expansion bills passed by the Legislature before voters approved it.

Lawmakers must now pay for the new law without raising taxes or dipping into the state’s rainy day fund, he said. And he warned that the expansion could threaten services for people with disabilities and the elderly.

“When able-bodied people, who are able and should be working, choose not to work, then I don’t think it’s society’s responsibility to cover their insurance at the expense of our mentally ill, our disabled and our elderly,” he said. “We’re asking hardworking Maine families to pick up the extra tab for people who should be working, but elect not to be.”

Sara Gideon, the speaker of Maine’s House of Representatives and a Democrat, said the governor’s remarks are not true.

“Let’s start with the population of people who will actually be eligible for health insurance now,” she said. “We’re talking about people, almost 70 percent of whom are people who are actually in the workforce, who are earning a living, but not actually able to afford health care with the low income that they earn.”

Gideon said LePage must follow the law. Moreover, she is confident the Legislature will find a way to fund the state’s share of $54 million and keep its promises to the elderly and disabled.

“It’s not a choice between people, one group of people over another. It’s a false choice that this governor is trying to present. And we say, we’re not going to make that choice. It is the law. And we’re simply going to make sure that that law is implemented,” said Gideon.

For rural hospitals in Maine, the Medicaid expansion can’t come fast enough.

“Our rural hospital is struggling,” said Marie Vienneau, CEO of Mayo Regional Hospital in Dover-Foxcroft. “We don’t make money. We lost a million and a half dollars the last two years.”

Maine’s rural towns and their hospitals have been hit hard. Factories have closed and many residents have moved away. As workers lost their jobs, more uninsured patients turned to rural hospitals desperate for medical care but unable to pay. Mayo is facing financial uncertainty, and at least three rural hospitals in Maine have closed in recent years.

Deanna Chevery was laid off after 25 years when the Dexter Shoe Co. factory closed in Dexter, Maine. Now 60 years old and uninsured, she’s recovering from an addiction to pain pills prescribed by her doctor for back pain.

She overdosed five times, costing Mayo Regional Hospital more than $200,000 in unreimbursed care. Before Chevery found the charity recovery program at Mayo Regional, she said she was turned away when she sought help because she couldn’t pay.

“You can only go so many places. Nobody will take you,” said Chevery. “They don’t care if you’re crawling on the ground. I’m just fortunate Dover helps me.”

But Vienneau said the hospital cannot keep up with Maine’s growing opioid epidemic and ever-rising costs without expanded Medicaid.

“You can only go so many years in a row where your business doesn’t lose money, before you depreciate to the point that you have to start closing services, decreasing services,” said Vienneau. “And then access goes away.”

Medicaid advocates, like Maine Equal Justice Partners, are pressuring lawmakers to put the new law into effect quickly. The group has been receiving postcards from around the country congratulating them on becoming the 32nd state to expand Medicaid, and advocates in many other red states that refused to expand Medicaid are eyeing their own ballot measures, including Nebraska, Utah, Idaho, Florida and Missouri.

Patrick Willard, a senior director at Families USA, a progressive advocacy group based in Washington, D.C., said that after years of Republicans attacking the Affordable Care Act, voters are beginning to shift their views.

“What we have heard is that other states suddenly see an opportunity now to figure out a way that they can get around legislatures that have been holding this up,” said Willard.

As state lawmakers in Maine work out the details of the new law, many disagree with LePage about how much it will cost. His administration estimates the price tag will be twice what the Legislature’s nonpartisan fiscal office has projected.

If they can’t resolve the impasse, LePage said, he will take legal action, if necessary.

“We will go to court, because I know — listen, one thing that I know better than the Legislature is financial responsibility. And I have proven it over the last seven years,” said LePage.

Advocates say those who are eligible for Medicaid could enroll as early as this summer. But if there are delays, they too will sue.

Just days after our interview, Donna Wall fell during her middle-of-the-night paper route and broke her ankle. She still doesn’t have health insurance and is unsure how she will care for her autistic children and uncertain what the future will bring.

Trump Administration Rule Paves Way For Association Health Plans

January 04, 2018
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The Department of Labor on Thursday released proposed new rules that proponents say will make it easier for businesses to band together in “associations” to buy health insurance.

These rules, supporters say, will lead to more affordable choices for some small businesses and sole proprietors, likely starting in 2019.

Association coverage “should be cheaper and arguably just as comprehensive” as what many employers can now buy, 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.

Critics, though, are wary about whether the plans will provide consumers adequate protection.

“This approach allows associations to offer coverage that doesn’t have to come into compliance with all the critical consumer protections that would otherwise apply to small employers and individuals. It might not be as comprehensive,” said Kevin Lucia, project director at Georgetown University’s Health Policy Institute.

The proposal — which now faces a 60-day comment period — broadens the definition of those eligible to join or form such groups and rolls back some restrictions on association health plans set by the Obama administration.

Specifically, the rule would allow associations to be created for the sole purpose of offering insurance to members. In some cases, such associations could have members nationwide, making the insurance available across state lines.

For the first time, the rules would allow sole proprietors with no employees to join such group coverage.

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Critics fear the rules could expose consumers to coverage gaps or higher out-of-pocket costs because these plans would be classified as “large-group plans,” so they would not have to meet some ACA rules.

For example, associations would not have to include benefits across 10 broad “essential” categories of care, including hospitalization, prescription drugs and emergency care. Under the ACA, large employers were exempt from these requirements because most already met them.

They would also be exempt from an ACA rule requiring insurers to spend at least 80 percent of premium revenue on medical care.

Georgetown’s Lucia and other policy experts warned that if plan eligibility is broadened and the plans are granted exemptions from some of the ACA’s coverage rules, they might siphon off the healthiest consumers. The result could drive up costs for small employers or individuals who buy insurance through the ACA market.

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

Actuaries have made similar arguments.

Still, many ACA rules would apply to association plans, noted Condeluci. For example, plans could not reject employers based on the health status of their workers. And individual employees in a workplace could not be charged different amounts based on their health.

State authority over such plans would vary depending on whether the plans were self-insured, which exempts them from some state coverage and benefit rules, or fully insured, which means they must meet state mandates.

No matter how plans are funded, states would retain oversight of their solvency, said Condeluci.

But the proposal asks for additional comments on state regulatory authority.

States have historically had this oversight responsibility and maintained that they are best attuned to problems, concerns and consumer needs within their borders.

Whether the rule recognizes the importance of this role is a “big concern,” said Lucia. “The extent of state authority over these arrangements appears to be an evolving question for the Department of Labor.”

A GOP Go-To Health Policy

Republicans have long favored association health plans, seeing them as a way for small groups to get more clout with insurers.

One big proponent is Sen. Rand Paul (R-Ky.), who in October hinted that the Trump administration would soon move to expand access to such plans.

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

A number have had solvency problems that left consumers on the hook for unpaid medical bills, while others have been fined for misleading advertising or failing to pay benefits.

Just this April, for example, Massachusetts regulators settled with Kansas-based Unified Life Insurance Company, which agreed to pay $2.9 million to resolve allegations that it engaged in deceptive practices, such as claiming it covered services that it did not.

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

Other Key Elements

The proposed rule from the Trump administration would expand the definition of who can form and join an association.

It would allow associations to form for the sole purpose of offering insurance and enroll members from the same industry or region. “A plan could serve employers in a state, city, county, or a multi-state metro area, or it could serve all the businesses in a particular industry nationwide,” said the Department of Labor’s press release on the proposed rule.

Many such trade organizations pushed for looser rules.

“The National Restaurant Association applauds the administration for supporting healthcare options for small businesses to allow them to pool their resources to provide healthcare for their employees,” wrote Clinton Wolf, senior vice president for health insurance at the National Restaurant Association, in an emailed statement.

In allowing sole proprietors to enroll in association health plans, the proposal notes it would require such enrollees to actually be involved in an ongoing business, not merely offer a “single on-demand ride for a fee, or knitting a single scarf to be offered for sale on the Internet.”

“The rule is intended to cover genuine employment-based relationships, not to provide cover for the marketing of individual insurance masquerading as employment-based coverage,” the proposed rule says.

Children’s Insurance, Other Health Programs Funded — For Now — In Bill

December 22, 2017
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The bill passed by Congress late Thursday to keep most of the federal government funded for another month also provided a temporary reprieve to a number of health programs in danger of running out of money, most notably the Children’s Health Insurance Program, or CHIP.

Funding for CHIP technically expired Oct. 1. States have been operating their programs with leftover funds provided by the Department of Health and Human Services since then. But nearly half of the states were projected to run out of money entirely by the end of January, putting health coverage for nearly 2 million children at risk by that point.

The funding provided by Congress for CHIP — $2.85 billion — is for six months, but it is back-dated to Oct. 1, so it will run out at the end of March 2018. The program covers 9 million children across the country.

This week, Alabama announced it would curtail enrollment and renewals starting Jan. 1, and start disenrolling children currently in the program Feb. 1. On Friday, the state posted a notice on its website that those plans were now canceled. Several other states, including Colorado, Virginia and Utah, have begun the process of notifying families that their coverage could end unless Congress acts.

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The funding bill also provided a temporary reprieve for a raft of other health programs that were running out of money, most notably the nation’s community health centers, which provide basic primary care to 27 million Americans. Many centers are already freezing hiring, laying off staff and closing sites due to the uncertain funding stream from Washington.

Other health programs that were set to expire but have been funded, for now, include the National Health Service Corps, which places health practitioners in medically underserved areas, and the teaching health centers program, which trains medical residents in community health centers.

Backers of CHIP complain that short-term funding fixes are disruptive to the program.

“By failing to extend long-term funding for the Children’s Health Insurance Program, Congress falls far short of the reassurance and relief families deserve,” said a statement from the American Academy of Pediatrics.

A coalition of children’s groups, including the Children’s Defense Fund and the March of Dimes, agreed, saying the short-term funding “only causes more chaos and confusion on the ground.”

Both Republicans and Democrats strongly support CHIP, which was created in a 1997 budget bill. What they disagree on is whether its funding — expected to be roughly $8 billion over the next 10 years — should be paid for by cutting other health programs. The House in November passed a five-year renewal that would finance CHIP primarily by reducing the Affordable Care Act’s Prevention and Public Health Fund and by raising some people’s Medicare premiums. Democrats question why CHIP needs to have its funding offset while Republicans are adding $1.4 trillion to the deficit through their tax cut bill.

Bonus Tucked Into GOP Tax Bill For Those Aiming To Deduct Medical Expenses

December 22, 2017

Patients scored a victory in the tough negotiations over the Republicans’ overhaul of the tax code.

The deduction that allows people with very high medical costs to shrink their taxable income by subtracting some out-of-pocket medical expenses was a moving target during the congressional debate this fall. Some lawmakers wanted to repeal it, but people with serious illnesses or who need long-term care said that eliminating the tax break would be a serious financial blow.

Congress has come around to their way of thinking, at least for now. The tax bill passed this month preserves and expands it.

Under the new law, people whose unreimbursed medical expenses exceed 7.5 percent of their adjusted gross income can claim a deduction for those expenses in 2017 and 2018. Then it is scheduled to revert to 10 percent for everyone, said Tara Straw, a senior policy analyst at the Center on Budget and Policy Priorities, a nonpartisan research institute in Washington, D.C.

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That’s a lower threshold than current rules, which had required that people’s medical expenses exceed 10 percent of their income to take the deduction in 2017 if they’re younger than 65. For people 65 or older, the threshold already was set at 7.5 percent.

Yet even at the lower threshold, relatively few people can take the deduction because their medical expenses aren’t high enough, Straw said.

To start with, health insurance premiums for employer-sponsored coverage that many people pay for with pretax dollars generally don’t qualify, she said. “For many people, their premium is their biggest medical expense, and for most people, it can’t be deducted as a medical expense.”

In 2015, roughly 8.8 million taxpayers took the medical expense deduction, according to the Internal Revenue Service.

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The House version of the tax reform bill eliminated the medical expense deduction, setting off alarm bells among consumer advocates for seniors and others. Lawmakers initially maintained that tax breaks such as the medical expense deduction weren’t necessary because their tax bill would provide so many other overall tax benefits to families.

The Senate version of the bill included the medical expense deduction and moved the threshold to 7.5 percent, at the behest of Sen. Susan Collins (R-Maine), who was concerned about high health care costs for seniors.

For the final bill, lawmakers settled on the Senate version.

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Not-So-Happy New Year: Alabama Set To Toss Kids Off Insurance Plan Starting Jan. 1

December 19, 2017
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Citing Congress’ failure to restore federal funding of the Children’s Health Insurance Program, Alabama plans to drop 7,000 kids from coverage on New Year’s Day, the first step to shutting down coverage for everyone, state officials said Monday.

Those children, who are up for their yearly renewal in January, will not be allowed to continue in the program, and the state also plans to freeze enrollment at the same time. Then, unless Congress acts, Alabama would close CHIP for all 84,000 children on Feb. 1.

Alabama would become the first state to cut off children’s coverage since Congress failed to renew federal CHIP funding, which expired Oct. 1.

“This will be devastating for many families,” said Cathy Caldwell, director of Alabama’s CHIP program, which is marketed to families under the name All Kids.

Colorado, Virginia and other states recently began sending letters to parents notifying them that officials may soon have to curtail their CHIP programs.

Republicans and Democrats in Congress say they support the program, but they have not agreed on where to get the money to pay for it. A third of states anticipate exhausting CHIP funding by the end of January, according to a Kaiser Family Foundation report out earlier in December. (Kaiser Health News is an editorially independent program of the foundation.)

The Centers for Medicare & Medicaid Services, which oversees CHIP, has been redistributing billions in unspent funds during the past 2½ months while lawmakers work on the issue to help states keep their programs running. CMS officials Monday did not respond to requests about when those dollars would run out.

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Caldwell said Alabama estimated it would have enough money to cover claims made only through February. She said it made no sense to continue renewing coverage and adding new enrollees in January if CHIP would be ending a month later. About 7,000 children have their coverage renewed each month, she said.

Caldwell said she estimates most CHIP enrollees won’t find affordable coverage without the program. Fewer than 10 percent would qualify for Medicaid, she said, and many families would find subsidized coverage for children in the Affordable Care Act’s online marketplaces too costly because it often comes with higher premiums, copayments and deductibles.

Nationwide, CHIP covers more than 9 million kids — children typically from families not poor enough to qualify for Medicaid, the state-federal program that covers low-income people.

Income eligibility levels for CHIP vary widely among states, though most set thresholds at or below 200 percent of the poverty level, about $49,000 for a family of four. Alabama has one of the broadest eligibility levels — 317 percent of the poverty level, or $78,000 for a family of four.

Unlike Medicaid, CHIP is usually not free. Enrolled families pay an average premium of about $127 a year.

Since CHIP’s enactment, the share of uninsured children fell from 13.9 percent in 1997 to 4.5 percent in 2015, according to the Medicaid and CHIP Payment and Access Commission.

Alabama’s rate fell from 20 percent to 2.5 percent, Caldwell said.

The Republican-controlled House has voted to extend the 20-year-old program for five years and would fund it by charging richer Medicare enrollees higher premiums and taking money from a public health fund created under the ACA. The Senate has not voted, but Democrats there also refuse to tie any CHIP extension to higher Medicare premiums or siphoning money from the public health fund.

Jim Carnes, policy director of ARISE Citizens’ Policy Project, an Alabama advocacy group, said CHIP is one of the few areas of health policy in which Alabama has led the country.

“We’ve been called a shining star of the South, and this has really been a very efficient and effective program,” he said. “This will really be a huge blow.”

He said freezing enrollment and ending coverage would undo years of expanded coverage. “This sends a terrible message to families … and I can only hope that this decision [by Alabama] adds to the pressure on Congress to act,” he said.

Caldwell said the last time Alabama froze enrollment in CHIP for several months, in 2004, it took several years to convince parents that the program had reopened.

“Once we deny kids and disenroll kids, we know so many of them won’t be able to get back on,” she said.

Looking North: Can A Single-Payer Health System Work In The U.S.?

December 18, 2017

TORONTO — For Dr. Peter Cram, an American internist who spent most of his career practicing in Iowa City, Iowa, moving here about four years ago was almost a no-brainer.

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He’s part of a small cohort of American doctors who, for personal or professional reasons, have moved north to practice in Canada’s single-payer system. Now when he sees patients, he doesn’t worry about whether they can afford treatment. He knows “everyone gets a basic level of care,” so he focuses less on their finances and more on actual medical needs.

Cram treats his move as a sort of life-size experiment. As a U.S.-trained physician and a health system researcher, he is now studying what he says is still a little-understood question: How do the United States and Canada — neighbors with vastly different health systems — compare in terms of actual results? Does one do a better job of keeping people healthy?

For all of the political talk, in many ways it is still an open question.

“The Canadian system is not perfect. Neither is the United States’,” Cram said over coffee in Toronto’s Kensington Market. “Anyone who gives you a sound bite and says this system should be adopted by this country … I think they’re being almost disingenuous.”

Still, American support for government-run, single-payer health care, once a fringe opinion, is picking up momentum.

Sen. Bernie Sanders, the Vermont independent who emphasized single-payer health care in his 2016 presidential bid, helped move Canada into the U.S. spotlight.

Lawmakers in California and New York have taken steps toward such programs on a statewide level, and the concept is a hot topic in gubernatorial campaigns in both Illinois and Maryland.

In addition, polling finds doctors and patients increasingly supportive, though the percentages in favor typically drop when questions are focused on the taxpayer costs of such a system.

Although Canada spends less per person on health care than the United States does, many Canadian experts worry that growing health costs pose a serious challenge. (Shefali Luthra/KHN)

In Canada, medical insurance comes through a publicly funded plan. And, while covering everyone, Canada still spends far less on health care than the United States does: just over 10 percent of its GDP, compared with the United States’ 18 percent.

To many American advocates, Canada’s health system sounds like the answer to the United States’ challenges.

But in Toronto, experts and doctors say the United States first must address a more fundamental difference. In Canada, health care is a right. Do American lawmakers agree?

“The U.S. needs to get on with the rest of the world and get an answer on that issue before it answers others,” said Dr.


Robert Reid, a health quality researcher at the University of Toronto, who has practiced medicine in Seattle.

It’s an obvious disconnect, said Dr. Emily Queenan, a family doctor now practicing in rural Ontario. Queenan, 41, grew up in the United States and did her residency in Rochester, N.Y. By 2014, after about five years of frustrating battles with insurance companies over her patients’ coverage, she had enough. She found herself asking, why not Canada?

She moved north. Gone, she said, are the reams of insurance paperwork she faced in America. Her patients don’t worry about affording treatment.

“We have here a shared value that we all deserve access to health care,” said Queenan. “That’s something I never saw in the States.”

Sanders has pushed the discussion, with a “Medicare-for-All” bill in Congress and in a visit to Toronto this fall. It was part fact-finding mission and part publicity tour. On that trip, doctors, hospital leaders and patients painted a rosy picture where everyone gets top-notch care, with no worries about its cost to them.

Sanders and Ontario Premier Kathleen Wynne meet with doctors and patients at Toronto General Hospital. (Shefali Luthra/KHN)

“They have managed to provide health care to every man, woman and child without any out-of-pocket cost,” Sanders told reporters while speaking on the ground floor of Toronto General Hospital. “People come to a facility like this, which is one of the outstanding hospitals in Canada. They undergo a complicated heart surgery, and they leave without paying a nickel.”

It sounds idyllic. But the reality is more complicated.

While progressives tout the Canadian system for efficiently providing universal health care, the Commonwealth Fund, a nonprofit research group, puts it just two spots above the United States — which ranks last — in its health system assessment. It suggests that in timeliness, health outcomes and equitable access to care, Canada still has much to improve.

“If you deny there are trade-offs, I think you’re living in wonderland,” Cram said.

The Canadian Vibe

In Canada, everyone gets the same government-provided coverage. Provinces use federal guidelines to decide what’s covered, and there’s no cost sharing by patients.

“Come to our waiting room,” said Dr. Tara Kiran, a family doctor at St. Michael’s Hospital, in Toronto. “You will see people who are doctors or lawyers alongside people who are homeless or new immigrants. People with mental health issues or addiction issues together with people who don’t.”

But that insurance — which accounts for 70 percent of health spending in Canada —addresses only hospitals and doctors. Prescription medications, dentists, eye doctors and even some specialists aren’t covered. Most Canadians get additional private insurance to cover those.

The Canadian health care system guarantees that doctors and hospital visits are covered. But it doesn’t include a prescription drug benefit, an omission advocates are pushing to change. (Shefali Luthra/KHN)

In countries such as Britain or Germany people can opt out to buy private insurance. Canada prohibits private insurers from offering plans that compete with the government, a restriction some doctors are suing to lift. It’s not a popular view in Canada, experts said, but the implications are significant.

Here, the debate focuses more on bringing down health spending — a concern in the United States, too, but one often overtaken by politics.

Canada’s provinces put, on average, 38 percent of their budgets into health care, according to a 2016 report from the Canadian Institute for Health Information, a nonprofit organization. Canada’s single-payer system is supported by a combination of federal and provincial dollars, mostly raised through personal and corporate income taxes. (A few provinces charge premiums, which are income-based and collected with taxes.)

“We make improvements or change things only to have additional debates about other things. Those debates are constant, and they should be,” Reid said. “[But] most of what you hear in the U.S. is back to the tenor of the insurance framework, whether [they] should have Obamacare or not.”

Taxes in Canada are generally higher than in the United States. Canada, for instance, collects a levy on goods and services and also taxes wealthier citizens at a higher income tax rate.

But many here call that a concession worth making, and also note that they don’t have to pay separate premiums for health care as people in the United States do.

“We can’t have what we have if we don’t pay the taxes,” said Brigida Fortuna, a 50-year-old Toronto resident and professional dog groomer, while on her way to a medical appointment. “But you have to take care of your people. … If you don’t have good health care, you’re not going to have a good society.”

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The Trade-Offs

That said, it’s not a perfect system. Canadian health care doesn’t cover prescriptions, physical therapy and psychotherapy. And there’s the concern that Canadians wait longer for health care than would Americans with robust health coverage.

There are cases, Reid said, when cancer care in Canada is delayed enough to yield health problems. Ex-pat Cram pointed to research that suggests low-income people are likely to wait longer for medical care — which can result in worse health outcomes.

“We do have a two-tiered system,” he said. “Most know it. Few will admit it.”

Typically, experts said, people with serious medical needs will jump to the front of the line for medical care. Kathleen Wynne, Ontario’s Liberal Party premier, said the Canadian government is actively trying to improve wait times.

But so far, it’s unclear how effective that’s been. A 2017 report from the nonprofit Canadian Institute for Health Information found that wait times had dropped for hip fracture repairs. But waits for, say, MRIs and cataract surgery have actually gotten worse. Depending on their province, the average wait for cataract removal ranged from 37 days to 148 days.

Many patients, though, said the waits were a trade-off they were willing to make. Toronto-based Nate Kreisworth, a 37-year-old music composer and producer, called it an obvious choice.

“You are not going to die because you’re waiting,” he said on a recent sunny morning while walking with his dog near Kensington Market. “Better wait times for everything? Sure, why not. But as long as the major issues are being covered, then I don’t think it’s really much of an issue.”

As Fortuna put it: “If you go for a headache and someone else is going to lose their arm, of course they’re going to take care of that person. I’m OK with that, because someday that could be me, too.”

Waits aren’t the only concern, though. There’s financing — and what it would cost for the United States to implement a system like Canada’s.

Because Americans have higher expectations about what a health plan should cover, it would be more expensive to adapt a Canadian approach, said Dr. Irfan Dhalla, an internist and health quality researcher in Toronto. And the quality may differ from what they are used to.

And in Canada, “everyone gets Kmart care,” Cram said. “There’s no Neiman Marcus care.”

Of course, some amenities that drive up costs — fancier food, softer gowns or private rooms — don’t necessarily produce better results.

A 2017 study found that patients with cystic fibrosis fared better in Canada than in the United States. But on the other hand, 2015 research comparing surgical outcomes found better results in the United States than in Canada. The Commonwealth Fund’s most recent ranking places Canadian health outcomes above America’s, but only by two slots.

Even so, many Canadians said they couldn’t imagine living with an American system. It’s a question not just of efficiency, but of fairness. Kreisworth compared his experience to that of family members in the United States.

“I talk to my brother’s girlfriend who is a part-time worker who has no [health] benefits — who would just be sick and not go to the doctor because she couldn’t afford to pay,” he said. “I can’t imagine that here. It seems like — it’s so wrong. It just seems utterly wrong.”

Note: This story has been corrected to reflect that health care takes up 18 percent of the United States’ GDP, rather than 16 percent as originally reported.

Health Risks To Farmworkers Increase As Workforce Ages

December 07, 2017

This story also ran on NPR. This story can be republished for free (details). That bag of frozen cauliflower sitting inside your freezer likely sprang to life in a vast field north of Salinas, Calif. A crew of men and women here use a machine to drop seedlings into the black soil. Another group follows behind, stooped over, tapping each new plant.

It is backbreaking, repetitive work. Ten-hour days start in the cold, dark mornings and end in the searing afternoon heat.

More than 90 percent of California’s crop workers were born in Mexico. But in recent years, fewer have migrated to the U.S., according to the U.S. Department of Labor. Researchers point to a number of causes: tighter border controls; higher prices charged by smugglers; well-paying construction jobs and a growing middle-class in Mexico that doesn’t want to pick vegetables for Americans.

As a result, the average farmworker is now 45 years old, according to federal government data. Harvesting U.S. crops has been left to an aging population of farmworkers whose health has suffered from decades of hard labor. Older workers have a greater chance of getting injured and of developing chronic illnesses, which can raise the cost of workers’ compensation and health insurance.

“The slowdown is happening,” said Brent McKinsey, a third-generation farmer and one of the owners of Mission Ranches in Salinas. “You start to see your production drop, but it’s difficult to manage because there aren’t the younger people wanting to come in and work in this industry.”

After a long day hunched over, cutting and bunching mustard leaves, Gonzalo Picazo Lopez, a farmworker, said the pain shooting down his leg is acting up. Lopez has been working in the fields since the 1970s, when he crossed over from Mexico. At 67 years old, he looks timeworn, with silver hair and a white beard. Deep lines mark his face.

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As Lopez described how he carefully picks the leaves with his right hand and bunches with his left, he opened and closed his fingers with difficulty.

“In 2015 my left hand started to hurt,” said Lopez. “I went into work one morning and my hand was cold — ice cold.”

Lopez is a U.S. citizen and has Medicare. He hopes to work for almost another decade, until his wife, who is 61 and picks broccoli, can collect her Social Security.

Chronic pain is a common complaint at Clinica de Salud in Salinas. Nearly all of the patients at this community clinic are farmworkers. Many don’t have health insurance and pay what they can for medical care. Those who have immigration papers, rely on Medicaid.

Oralia Marquez, a physician’s assistant at the clinic, said older farmworkers often develop arthritis, back pain, foot infections and breathing problems from pesticides.

Many of her patients, like Amalia Buitron Deaguilera also struggle with diabetes. Deaguilera is 63. She has Medicaid for insurance, but she’s losing her vision from the disease.

“When I was working in fields,” said Deaguilera, “I never had time to take care of myself and my health.”

Workers in the fields who have diabetes often cannot take their insulin because they have no place to refrigerate it, said Marquez. And they miss doctors’ appointments during the busy harvesting seasons because many don’t get paid when they don’t work.

“Most of our patients want just something to relieve the pain and to continue working,” she said. “Most of the time they don’t ask for disability. They don’t ask for days off. They say they don’t have time to miss days.”

Field laborers often delay health care, and that can lead to serious medical problems. Compared to older whites, older Latino farmworkers are much more likely to end up in the hospital, according to researchers at the Central Valley Health Policy Institute at California State University, Fresno.

Faced with an aging and dwindling workforce, Mission Ranches’ McKinsey says farmers are trying to mechanize planting and harvesting to reduce their labor needs.

But machines can only do so much, McKinsey said. You can replace the human hand in a factory, perhaps. But out here, the fields are bumpy and the winds are strong and you need people to bring the plants to life.

States — And 9M Kids — ‘In A Bind’ As Congress Dawdles On CHIP Funding

December 04, 2017

Last week, Colorado became the first state to notify families that children who receive health insurance through the Children’s Health Insurance Program are in danger of losing their coverage.

This story also ran on NPR. This story can be republished for free (details). Nearly 9 million children are insured through CHIP, which covers mostly working-class families. The program has bipartisan support in both the House and Senate, but Congress let federal funding for CHIP expire in September.

The National Governors Association weighed in Wednesday, urging Congress to reauthorize the program this year because states are starting to run out of money.

In Virginia, Linda Nablo, an official with the Department of Medical Assistance Services, is drafting a letter for parents of the 66,000 Virginia children enrolled in CHIP.

“We’ve never had to do this before,” she said. “How do you write the very best letter saying, ‘Your child might lose coverage, but it’s not certain yet. But in the meantime, these are some things you need to think about’?”

Children may be able to enroll in Medicaid, get added to a family plan on the Affordable Care Act’s health exchange or be put on an employer health plan. But the options vary by state and could turn out to be very expensive.

If Congress reauthorizes CHIP funding, states are in the clear. But they can’t bank on it yet, and states have to prepare to shut down if the funding doesn’t come through. Virginia would have to do so on Jan. 31.

“We’re essentially doing everything we would need to shut down the program at the end of January,” Nablo said. “We’ve got a work group going with all the different components of this agency, and there are many.”

For example, they will need to reprogram their enrollment systems, inform pediatricians and hospitals, and train staff to deal with an onslaught of confused families.

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Joan Alker, who runs the Georgetown University Center for Children and Families, said most states need to give families 30 days’ notice.

“But [state officials] are hearing rumors that Congress might get this done in the next couple of weeks, and they don’t want to scare families,” she said. “States are really in a bind here. It’s very tough to know what to do.”

Colorado was the first to send out a notice, and other states are close behind. There are a handful that are starting to run out of money in December, Alker said, such as Oregon, Minnesota and the District of Columbia.

The exact deadline for when CHIP funding runs out in each state is tricky to calculate, because the amount of money each has depends on how fast a state spends it — and how much stopgap help the federal government gives them.

Some states are getting creative. Oregon just announced it will spend state money to keep CHIP running, said Alker, “and they’re assuming that Congress will pass it and they’re get reimbursed retroactively. That’s what they’re hoping.”

Texas is set to run out of CHIP funds a lot sooner than was expected just a few months ago. And there’s a big reason for that: Hurricane Harvey, said Laura Guerra-Cardus with the Children’s Defense Fund in Austin.

“Natural disasters are often a way that individuals that never had to rely on programs like Medicaid and CHIP need them for the first time,” she said.

Guerra-Cardus said that after Harvey a lot of new families enrolled in CHIP and that there was also a higher demand for services. “When there is such a traumatic event, health care needs also rise. There’s been a lot of post-traumatic stress in children,” she said.

And to help those families out, Texas officials also waived fees they usually have to pay to join CHIP. So, lately there’s been less money coming in and more money going out. Like Virginia, without reauthorization, Texas would have to shutter CHIP by the end of January.

For Amy Ellis in Alpine, Texas, that’s something she’s dreading. “Losing a lot of sleep,” she said. “Still losing a lot of sleep.”

Ellis has an 8-year-old daughter who has been on CHIP since she was born. The girl has asthma and allergies, Ellis said, and health insurance is really important because her family doesn’t make a lot of money. Her daughter’s allergy medicine is expensive.

Ellis lives in rural West Texas, nearly four hours southeast of El Paso and “three hours from the closest city,” she said.

The isolation means that Ellis doesn’t have many options other than CHIP, she said. One would be enrolling her daughter in the insurance plan she and her husband have through the Affordable Care Act marketplace, but Ellis said that would be expensive.

“It would cost $300 to $400 a month for us to add her to our plan, which would be a huge chunk of our income,” she said. “That’s our grocery money and our gas money.”

A lot of families in Texas could find themselves in the same situation if Congress doesn’t act soon, said Guerra-Cardus. “Kids with chronic or special health care needs, this is going to turn their lives absolutely upside down.”

Roughly 450,000 children are covered by CHIP in Texas. Officials say they are asking the federal government to give them money that will keep CHIP alive through February.

But because officials must give families 30 days’ notice if the program will end, families in Texas could get letters right around Christmas that say their children are losing their health insurance.

This story is part of a reporting partnership with NPR, local member stations and Kaiser Health News. Selena Simmons-Duffin is a producer at NPR’s All Things Considered, currently on an exchange with Washington, D.C. member station WAMU.

With CHIP In Limbo, Here Are 5 Takeaways On The Congressional Impasse

December 01, 2017

Two months past its deadline, Congress has yet to fund the Children’s Health Insurance Program, leaving several states scrambling for cash.

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Lawmakers grappling with the failed repeal of the Affordable Care Act allowed authorization of the program to lapse on Sept. 30. Although CHIP has always had broad bipartisan support, the House and Senate cannot agree on how to continue federal funding. And the Trump administration has been mostly silent on the issue.

CHIP benefits 9 million children nationwide and 370,000 pregnant women a year. It helps lower- and middle-income families that otherwise earn too much to be eligible for Medicaid. Like Medicaid, CHIP is paid for with state and federal funds, but the federal government covers close to 90 percent of the cost.

To keep the program going, states with unspent federal CHIP money have seen their excess sent to a handful of states running low on funds. But that is a bureaucratic band-aid; some large states are warning families they may not be able to rely on CHIP for much longer.

All told, CMS has given out $1.2 billion in redistribution dollars since October. To keep the program going would cost the federal government $8.5 billion over five years, the Congressional Budget Office estimates.

Saturday marks the 25th anniversary of Pennsylvania approving the original CHIP program, which served as a model for the national law, established in 1997. Since then, CHIP has been left in the fiscal lurch only once before. In 2007, CHIP went several weeks without funding authorization from Congress.

Here’s a quick look at what the shortfall may mean to daily life.

1. Are any kids hurting because Congress has failed to fund CHIP?

No. But states such as California will run out of money within weeks. That state alone accounts for nearly 15 percent of all children benefiting from CHIP. Without federal money, state programs could freeze enrollment or suspend operation.

2. What are states doing since Congress missed the deadline?

Most states are doing little except looking for other unspent federal funds or asking the federal government to send some unspent funds from other states. But some, such as Colorado, are sending warning letters to beneficiaries to tell them that the program could soon end and to look for alternatives. This could mean exploring the ACA marketplace for coverage or researching if a child qualifies for Medicaid.

Colorado said it has only enough CHIP funding to last through January and then the program, without federal dollars, will end.

Arizona officials announced Thursday that it will use Medicaid funding to fill in the shortage of CHIP dollars to extend the life of its CHIP program.

Virginia officials plan to send out a similar notice to parents of CHIP members by early this month.

Minnesota is keeping CHIP alive by paying the federal share with state funds.

In Oregon, Democratic Gov. Kate Brown recently said that she is ready to spend $35 million in state funds to keep CHIP running through December.

Nevada this week announced it had been approved for extra funding from the Centers for Medicare & Medicaid Services — nearly $5.7 million — which could keep CHIP alive through December and possibly January.

California, which leads the nation in CHIP enrollment, has received the lion’s share of CMS redistribution funds since October: nearly $692 million.

“Approximately 98 percent of the 1.3 million population now covered using CHIP funding would continue to receive coverage under the Medicaid program because of a legal obligation to cover them through September 2019,” said California Medicaid/CHIP spokesman Tony Cava.  “If CHIP is not reauthorized, the governor and Legislature would need to deliberate on how best to address the population no longer eligible for federal CHIP funding.”

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3. When is Congress likely to act?

Not sure. CHIP reauthorization could be included in an appropriations bill that Congress must pass to fund the government into 2018. (Congress now has funded the government through next Friday.) A “continuing resolution” bill would have to be approved by then to avert a government shutdown.

But we’re journalists, not prognosticators — and we have been wrong before. Most Capitol Hill observers expected a deal by the end of September.

4. If CHIP is so popular among Republicans and Democrats, what’s the problem?

There is little debate about its worth and value, but the momentum on CHIP was lost amid disagreements over the Affordable Care Act. The House did extend authorization with a vote —mostly along party lines — on Nov. 3. The Senate itself has yet to vote. The Senate Finance Committee on Oct. 3 approved a bipartisan bill to extend the program for five years.

The sticking point is not whether to keep CHIP running but how to raise the cash needed.The House agreed to charge higher premiums to wealthier Medicare beneficiaries, cut money from the ACA’s preventive health fund and shorten the grace period for ACA enrollees who fail to make monthly premium payments.

Like the House bill, the Senate committee bill eliminated an ACA provision to increase CHIP matching funds — to states — by 23 percent. The increased funding would continue through fiscal year 2019 and fall to 11.5 percent in fiscal year 2020. It would be cut entirely in the following fiscal year.

5. How does CHIP differ based on where you live?

CHIP income eligibility levels vary by state. About 90 percent of children who qualify are from families earning 200 percent of poverty or less ($40,840 for a family of three). CHIP covers children up to age 19. But states have the option to cover pregnant women, and 18 states plus the District of Columbia do so.

And some states call CHIP by different names. For example, it is known as Hoosier Healthwise in Indiana, PeachCare for Kids in Georgia and KidsCare in Arizona.

For Millions of Insured Americans, State Health Laws Don’t Apply

November 16, 2017

Let’s say you have health insurance through your employer and live in one of 21 states with laws protecting consumers against surprise medical bills from out-of-network providers.

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Senior Correspondent Emily Bazar’s answers consumers’ questions about California’s changing medical landscape.

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Should one of those unwanted bills land in your mailbox, you can turn to your state law and regulators for help, right?

Not necessarily.

If you’re among the millions of Americans with a category of job-based health coverage known as self-funded insurance, most state health care laws do not apply to you.

Plus, if you have an issue with your coverage, you must go through a different appeals process than other state residents with private insurance. You must seek help from a federal regulator that may — or may not — be responsive.

“We have unequal consumer protections for a big chunk of our population,” says Tam Ma, legal and policy director for the advocacy group Health Access California.
For Millions of Insured Americans, State Health Laws Don’t Apply
Nationally, 61 percent of covered workers were in self-funded plans last year, according to the Kaiser Family Foundation. (Kaiser Health News, which produces California Healthline, is an editorially independent program of the foundation.)

In California, about 5.7 million people were enrolled in such plans. Last year, the Golden State’s two health insurance regulators received more than 1,000 requests for help from consumers in self-funded plans. The departments have no authority over those plans and had to refer many of the enrollees to the U.S. Department of Labor, which regulates them.

Businesses that opt for self-funded plans — also called self-insured plans — generally pay the medical bills of their employees directly.

Under a fully insured plan, on the other hand, the employer — or an individual or family — buys coverage from a state-regulated insurance company, which assumes the financial risk. In California, fully insured plans are overseen by the state Department of Managed Health Care or the state Department of Insurance.

Large companies are more likely to self-insure. Among companies with 5,000 or more employees, 94 percent of covered workers were in self-funded plans last year, KFF data show.

More businesses — including smaller ones — are self-insuring because they can save money, says Dean Hoffman, an employee benefits consultant based in Wisconsin who specializes in self-insured plans.

One way they save is by avoiding the cost of complying with state-mandated benefits. For example, Hoffman says, for every premium dollar spent on fully insured plans in Wisconsin, about 11 cents goes toward state-mandated requirements.

“Every time you add a benefit, there’s a price associated with that,” he says.

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It might not be obvious that you’re covered by a self-funded plan. Most businesses contract with health insurance companies to administer them, pay claims and provide access to their provider networks. That means your insurance card will likely have a Cigna, Blue Shield or other familiar logo on it even if your plan is self-funded.

If you’re not sure whether your plan is self-insured, ask your human resources department.

“To the consumer, it feels no different,” says Karen Pollitz, a senior fellow at KFF. “If you work for a big company, it’s a pretty good bet you’re in a self-funded plan.”

If you are, you may feel the difference in coverage, consumer protection and grievance procedures, however. “The only consumer protections available to those folks are just what federal law provides,” Ma says.

Consider state laws relating to surprise medical bills. Among the states that have adopted various protections against such bills, Connecticut, Illinois, New York, Florida, Maryland and California have the strongest and most comprehensive measures.

But even if you live in one of these states, “you still might get hit by large medical bills” if you’re in a self-funded plan, Pollitz says.

Some self-insured businesses, however, voluntarily provide many of the same protections as state law, says Lauren Vela, a senior director at the Pacific Business Group on Health, which represents about 75 companies that self-insure nationwide.

In the case of surprise bills — from out-of-network doctors such as anesthesiologists, for instance — “a lot of employers, not all of them, would have it written into their plan that it would not be considered out-of-network,” Vela says. “No employer wants to have employees get these kinds of surprise bills.”

To handle complaints about coverage, most states have laws allowing consumers in private health plans to appeal to an independent, external reviewer chosen by the state if your plan denies a claim and you disagree, Ma says.

In self-insured plans, you are entitled to external review — but your employer chooses, hires and pays the reviewer, Pollitz says. “It’s not independent in the way that state programs are.”

Plus, your regulator, the U.S. Department of Labor, may be slow to get involved in the grievance process, Ma says.

The department “doesn’t really have the resources or the ability to protect consumers in a timely way,” she says. “It may take them a very long time to get to your case, if they do at all, compared to state-regulated plans.”

So, if you’re in a self-funded plan and disagree with a coverage decision, look at your explanation of benefits, which will describe how to appeal. You can also ask your human resources department for guidance, or your union, if one represents you.

Most experts agree that your first step will likely be to contact the customer service line on your insurance card and request a review.

If your concern isn’t resolved that way, reach out to the Employee Benefits Security Administration (EBSA) through the Department of Labor at 866-444-3272 or

EBSA “has experts who can help on this,” says Michael Trupo, a spokesman for the department, though he did not answer follow-up questions for more details.

If you don’t get your questions answered, many states have Consumer Assistance Programs that help you navigate insurance problems, including those with self-funded plans. The Department of Managed Care administers California’s program, which can be reached at 888-804-3536.

“They’ll help you file your appeal and make inquiries on your behalf,” Pollitz says. “They can be your advocate.”