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In Search Of Insurance Savings, Consumers Can Get Unwittingly Wedged Into Narrow-Network Plans

Kaiser Health News:HealthReform - November 01, 2018

As a breast cancer survivor, Donna Catanuchi said she knows she can’t go without health insurance. But her monthly premium of $855 was too high to afford.

“It was my biggest expense and killing me,” said Catanuchi, 58, of Mullica Hill, N.J.

A “navigator” who helps people find coverage through the Affordable Care Act found a solution. But it required Catanuchi, who works part time cleaning offices, to switch to a less comprehensive plan, change doctors, drive farther to her appointments and pay $110 a visit out-of-pocket — or about three times what she was paying for her follow-up cancer care.

She now pays $40 a month for coverage, after she qualified for a substantial government subsidy.

Catanuchi’s switch to a more affordable but restrictive plan reflects a broad trend in insurance plan design over the past few years. The cheaper plans offer far narrower networks of doctors and hospitals and less coverage of out-of-network care. But many consumers are overwhelmed or unaware of the trade-offs they entail, insurance commissioners and policy experts say.

With enrollment for ACA health plans beginning Nov. 1, they worry that consumers too often lack access to clear information about which health plans have “narrow networks” of medical providers or which hospitals and doctors are in or out of an insurer’s network, despite federal rules requiring plans to keep up-to-date directories.

“It’s very frustrating for consumers,” said Betsy Imholz, who represents the advocacy group Consumers Union at the National Association of Insurance Commissioners. “Health plan provider directories are often inaccurate, and doctors are dropping in and out all the time.”

These more restrictive plans expose people to larger out-of-pocket costs, less access to out-of-network specialists and hospitals, and “surprise” medical bills from unforeseen out-of-network care.

More than 14 million people buy health insurance on the individual market — largely through the ACA exchanges, and they will be shopping anew this coming month.

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Trend Appears To Be Slowing 

For 2018, 73 percent of plans offered through the exchanges were either health maintenance organizations (HMOs) or exclusive provider organizations (EPOs), up from 54 percent in 2015.

Both have more restrictive networks and offer less out-of-network coverage compared with preferred provider organizations (PPOs), which represented 21 percent of health plans offered through the ACA exchanges in 2018, according to Avalere, a health research firm in Washington, D.C.

PPOs typically provide easier access to out-of-network specialists and facilities, and partial — sometimes even generous — payment for such services.

Measured another way, the number of ACA plans offering any out-of-network coverage declined to 29 percent in 2018 from 58 percent in 2015, according to a recent analysis by the Robert Wood Johnson Foundation.

For example, in California, HMO and EPO enrollment through Covered California, the state’s exchange, grew from 46 percent in 2016 to 70 percent in 2018, officials there said. Over the same period, PPO enrollment declined from 54 percent to 30 percent.

In contrast, PPOs have long been and remain the dominant type of health plan offered by employers nationwide. Forty-nine percent of the 152 million people and their dependents who were covered through work in 2018 were enrolled in a PPO-type plan. Only 16 percent were in HMOs, according to the Kaiser Family Foundation’s annual survey of employment-based health insurance.

The good news for people buying health insurance on their own is that the trend toward narrow networks appears to be slowing.

“When premiums shot up over the past few years, insurers shifted to more restrictive plans with smaller provider networks to try and lower costs and premiums,” said Chris Sloan, a director at Avalere. “With premium increases slowing, at least for now, that could stabilize.”

Some research supports this prediction. Daniel Polsky, a health economist at the University of Pennsylvania, found that the number of ACA plans nationwide with narrow physician networks declined from 25 percent in 2016 to 21 percent in 2017.

Polsky is completing an analysis of 2018 plans and expects the percent of narrow network plans to remain “relatively constant” for this year and into 2019.

“Fewer insurers are exiting the marketplace, and there’s less churn in the plans being offered,” said Polsky. “That’s good news for consumers.”

Insurers may still be contracting with fewer hospitals, however, to constrain costs in that expensive arena of care, according to a report by the consulting firm McKinsey & Co. It found that 53 percent of plans had narrow hospital networks in 2017, up from 48 percent in 2014.

“Narrow networks are a trade-off,” said Paul Ginsburg, a health care economist at the Brookings Institution. “They can be successful when done well. At a time when we need to find ways to control rising health care costs, narrow networks are one legitimate strategy.”

Ginsburg also notes that there’s no evidence to date that the quality of care is any less in narrow versus broader networks, or that people are being denied access to needed care.

Mike Kreidler, Washington state’s insurance commissioner, said ACA insurers in that state “are figuring out they can’t get away with provider networks that are inadequate to meet people’s needs.”

“People have voted with their feet, moving to more affordable choices like HMOs but they won’t tolerate draconian restrictions,” Kreidler said.

The state is stepping in, too. In December 2017, Kreidler fined one insurer — Coordinated Care — $1.5 million for failing to maintain an adequate network of doctors. The state suspended $1 million of the fine if the insurer had no further violations. In March 2018, the plan was docked another $100,000 for similar gaps, especially a paucity of specialists in immunology, dermatology and rheumatology. The $900,000 in potential fines continues to hang over the company’s head.

Centene Corp, which owns Coordinated Care, has pledged to improve its network.

Pennsylvania Insurance Commissioner Jessica Altman said she expects residents buying insurance in the individual marketplace for 2019 to have a wider choice of providers in their networks.

“We think and hope insurers are gradually building more stable networks of providers,” said Altman.

New State Laws 

Bad publicity and recent state laws are pushing insurers to modify their practices and shore up their networks.

About 20 states now have laws restricting surprise bills or balance billing, or which mandate mediation over disputed medical bills, especially those stemming from emergency care.

Even more have rules on maintaining accurate, up-to-date provider directories.

The problem is the laws vary widely in the degree to which they “truly protect consumers,” said Claire McAndrew, a health policy analyst at Families USA, a consumer advocacy group in Washington, D.C. “It’s a patchwork system with some strong consumer protections and a lot of weaker ones.”

“Some states don’t have the resources to enforce rules in this area,” said Justin Giovannelli, a researcher at the Center on Health Insurance Reforms at Georgetown University. “That takes us backward in assuring consumers get coverage that meets their needs.”

HHS Announces the Official Opening of the Health Sector Cybersecurity Coordination Center

HHS Gov News - October 31, 2018

On Monday, October 29, the Deputy Secretary of the Department of Health and Human Services (HHS), Eric Hargan, announced the official dedication of the Health Sector Cybersecurity Coordination Center (HC3) at an official opening ceremony in the Hubert H. Humphrey building.  As part of October’s National Cybersecurity Awareness Month, and in coordination with the Administration’s rollout of the National Cyber Strategy, the opening underscores HHS’ commitment to support and improve the health sector’s cybersecurity defenses.  

“HHS is proud to work with the health community to better protect Americans’ health data and confidential information,” Deputy Secretary Hargan said.  “Today’s announcement is a recognition of the importance we place on stakeholder engagement as part of our cybersecurity work.”

The U.S. Government recognizes the importance of protecting America against cyber attacks, reaffirming in the most recent National Cyber Strategy that protecting American information networks is vital to protecting the American way of life.  The Administration has designated the Department of Homeland Security (DHS) as the lead organization to combat these threats and develop preventive strategies across the entire economy, with HHS given the role to focus cybersecurity support on information sharing within the healthcare and public health (HPH) sector.

“We believe that when a risk is shared across sectors, the only way to manage that risk successfully is to manage it collectively,” said Jeanette Manfra, Assistant Secretary for Cybersecurity and Communications in DHS.  “We know that the majority of the cybersecurity attacks that occurred over the past year could have been prevented with quality and timely information - and the heightened importance of sharing information cannot be stressed enough.  The HC3 is a vital capability for the early detection and coordination of information between the private sector and the federal government, and with cyber professionals across the federal government.”

This mission is now more important than ever with the healthcare sector reporting over 400 major breaches from 2017 to 2018. Within the HPH sector, the threats are significant and hackers covet having the potential to access sensitive medical data, damage medical equipment, secure intellectual property for financial gain, or even conduct terrorist attacks.  The HC3 provides a service to healthcare organizations that enables them to protect their assets and patients.

To address these threats to the sector, HHS has developed a “coordination center” in the HC3 to coordinate the activities across the sector and report to DHS threats, profiles, and preventive strategies.  The HC3’s role is to work with the sector, including practitioners, organizations, and cybersecurity information sharing organizations to understand the threats it faces, learn the bad guys’ patterns and trends, and provide information and approaches on how the sector can better defend itself. 

The official opening ceremony comes after extensive stakeholder consultation collaborating with partners that are all working together to defend the health sector’s information technology infrastructure and to strengthen coordination of information sharing.

The Health Sector Cybersecurity Coordination Center (HC3) is an operational cybersecurity center designed to support and improve the cyber defense of the healthcare and public health sector.  HC3 strengthens coordination and information sharing within the sector and cultivates cybersecurity resilience by providing timely and actionable cybersecurity intelligence to health organizations and developing strategic partnerships between these organizations.

Trump Rollback Of Disability Rules Can Make Doctor’s Visits Painstaking

Kaiser Health News:HealthReform - October 31, 2018

Going to the doctor’s office can feel so routine. You sit in the waiting room, fill out the paperwork, get measured and hop onto the exam table.

But medical appointments for patients with disabilities require navigating a tricky obstacle course, full of impediments that leave them feeling awkward and could result in substandard care.

Despite laws that require ramps and wider doors for access, many health care providers don’t have scales that can accommodate wheelchairs, or adjustable exam tables for patients who can’t get up on one by themselves.

Dr. Lisa Iezzoni, a professor of medicine at Harvard Medical School who has multiple sclerosis and uses a wheelchair, said she went 20 years without properly being weighed. This can result in treatment plans, and even prescriptions, based on educated guesses rather than exact information, she said.

The Affordable Care Act was set to update standards for accessible medical treatment within the Americans with Disabilities Act (ADA), which is enforced by the Justice Department. But the Trump administration stopped action on this change late last year as part of its sweeping effort to roll back regulations across the federal government.

“I was in shock when I heard that [Attorney General Jeff] Sessions’ Justice Department had pulled back on their rule-making,” said Iezzoni.

Denise Hok, 54, who lives in Colorado Springs, Colo., and uses a wheelchair, opts for home health care when possible and avoids doctors’ offices where “it feels like it doesn’t really matter if something is wrong.” When offices don’t have accessible equipment, she said, it “sends a message.”

Hok holds her 4-year-old cat, Moo.(Dougal Brownlie for KHN)

The ADA, a 1990 civil rights measure designed to prohibit discrimination against people with disabilities, requires that public places be accessible, meaning new buildings and certain commercial establishments must provide ramps, doorways wide enough for a wheelchair, handrails and elevators.

The law applies only to fixed structures, though, and doesn’t address “furnishings” unattached to buildings. At doctors’ offices, that means scales, tables, X-ray machines and other diagnostic equipment aren’t legally circumscribed.

The result is that movie theaters and laundromats have to be accessible to all people, but important aspects of the medical industry do not, said Megan Morris, an assistant professor in the department of family medicine at the University of Colorado who has studied patients with disabilities and their access to health care.

The ACA directed a federal panel, the Architectural and Transportation Barriers Compliance Board, to take steps to close this gap by issuing standards for determining what medical equipment could be deemed “accessible.” Their report was finalized in January 2017, just before President Barack Obama left office.

But the DOJ’s decision in December not to update enforcement accordingly reinforces the disparities in how people are treated, said patients and disability rights advocates.

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Paul Spotts, 58, who is paralyzed from the chest down, said his checkups are “a joke.” His doctors check his eyes and ears but they don’t put him on a scale or exam table because they can’t. They don’t know how tall he is and they rely on how much he thinks he weighs.

Patients with disabilities report feeling “icky” — as if doctors and nurses don’t want to touch them to examine them, explained Colorado’s Morris, based on her research, adding that there’s a psychological toll to being treated as an “other” by the medical system.

Spotts, who also lives in Colorado Springs and has used a wheelchair for 30 years, finds it exasperating. He spends a lot of his time during appointments explaining his medical care to doctors who don’t understand how his bladder works, what his circulation problems are or how to treat his leg spasms.

The lack of equipment mirrors a lack of physician training and sensitivity to the issue, experts said. To get at this frustration, or even the perceptions that lead to it, “we need to think more broadly: How do we equip our health care providers?” Morris said. There is “implicit bias, and they don’t realize they may or may not be treating patients with disabilities differently.”

Dealing with exam tables and scales may be the first step.

“I think that all of us want to take the absolute best care of our patients, we want to account for patient needs,” said Dr. Michael Munger, president of the American Academy of Family Physicians.

How physician practices adjust often relates to their specialty and primary patient population, not to mention the financial calculation. A small practice might balk at the $1,800-to-$5,800 price tag for an adjustable table.

Under certain conditions, [it seems as if] you don’t matter as much as someone who’s not ‘broken.’

Denise Hok

Sometimes it’s a matter of “local solutions” and workarounds, such as sending a patient to a hospital to be weighed if a small practice doesn’t have an accessible scale, Munger said. That’s easier said than done for a patient like Spotts, who would have to drive more than an hour to reach a hospital that could weigh him.

Space is also an issue, Munger said. Sometimes exam rooms simply aren’t big enough to accommodate larger tables and chairs for family members and still have enough space to maneuver a mobility device. Spotts said the rooms generally aren’t big enough, period.

Some medical systems are taking action.

The Department of Veterans Affairs has used the U.S. Access Board’s standards to adopt similar accessibility guidelines. In Colorado, Centene, the largest Medicaid insurer nationwide, adopted similar guidelines.

States are using their Medicaid programs for similar, limited efforts.

California has worked with the disability community to create a survey for Medicaid providers, finding where gaps are and creating regulations requiring accessible equipment like exam tables and scales, going so far as to create a database of which providers have them. But with the Trump administration failing to move forward, what care people with disabilities receive may depend on where they live.

Said Hok: “Under certain conditions, [it seems as if] you don’t matter as much as someone who’s not ‘broken.’”

In Swing Districts, Republicans May Pay For Having Tried To Reverse The Health Law

Kaiser Health News:HealthReform - October 31, 2018

EDGEWATER PARK, N.J. — Not long ago many voters knew little about Tom MacArthur. A low-key moderate Republican congressman in a district that twice went for Barack Obama, he burnished his reputation as the guy who worked with Democrats to help rebuild in the years after Hurricane Sandy.

Now, as he wages a bitter fight for re-election to a seat he won by 20 percentage points just two years ago, even some of his supporters have turned virulently against him. The reason? His new reputation as the turncoat whose legislation almost repealed the Affordable Care Act.

Like many Republican candidates struggling to explain how they could support protections for preexisting conditions while also supporting changes that would gut them, MacArthur has offered vague but persistent promises to shield Americans with medical conditions.

But he also wrote the Republican legislation that would have allowed states to charge those Americans higher premiums or limit what services are covered, gaining enough support for the repeal bill to clear the House last year.

As such, MacArthur’s candidacy has become a kind of Rorschach test for Republicans’ repeated attempts to repeal and otherwise undermine the Affordable Care Act — and how much candidates in swing districts will pay for those efforts.

If this New Jersey district is any indication, it could be a lot.

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Sue Coleman, 64, split her ballot in 2016, voting for MacArthur and Hillary Clinton. “I thought he was a moderate, so I voted for him,” she said. Today, she feels so angry that she arrived at a recent political event at the 45th Street Pub here wearing an unruly wig, a full beard and mustache paired with a dark suit and blood-red tie — imitating one of the congressman’s top aides who has become a familiar gatekeeper as she and others have personally lobbied MacArthur. The crowd laughed and cheered.

Earlier that day, dozens of people, most of them women, gathered in a strip mall parking lot before scattering to knock on doors on behalf of MacArthur’s Democratic challenger, Andy Kim. MacArthur “didn’t listen to the people,” said Nancy Keegan, 57, of Delran Township, N.J., as she stood with her sisters.

Some of the volunteers couldn’t help but point out that the high school across the street was where MacArthur held a nearly five-hour town hall last year that made national headlines for the irate crowd of constituents and protesters who shouted down explanations of his attempts to resuscitate the repeal effort. MacArthur has made fewer, and more limited, public appearances since then.

In a sign of the race’s power to help Democrats reclaim the House, members of Planned Parenthood, NARAL and Rep. Katherine Clark (D-Mass.) were on hand to energize the sweatshirt- and sneaker-clad crowd. While it has been about a year and a half since MacArthur bolstered the Republican repeal effort, the anger hasn’t faded. Said Susan Harper, 64, also of Delran Township and Keegan’s sister: “I don’t think that’s going away.”

MacArthur, 58, a wealthy insurance executive who has received hundreds of thousands of dollars in corporate contributions and invested millions of his own in his campaigns, is locked in “a true toss-up” this year, said David Wasserman, an editor at the Cook Political Report. Kim, 36, — a former Obama administration national security official — had raised $750,000 more than MacArthur had by the end of September.

Trump won MacArthur’s 3rd Congressional District — which spans the state from the suburbs outside Philadelphia to the tourist destinations and retirement communities of the Jersey Shore — by about 6 points. In spring 2017, as House Republicans bickered over how to repeal the health care reform law, MacArthur — then a leader of the chamber’s moderate Republican caucus — brokered a deal with far-right members. It would have allowed states to circumvent some of the law’s protections for people with medical conditions, if they set up high-risk insurance pools to help cover those patients.

Through that compromise, known as the MacArthur Amendment, the bill passed the House without any Democratic support. It later stalled in the Senate.

Less than a week later, appearing at that town hall in his district’s Democratic stronghold, MacArthur spoke of losing his 11-year-old daughter, Grace, to a rare neurological condition, a painful story he had rarely discussed in public.

The death of MacArthur’s daughter “is the very reason his constituents do not understand his actions,” said Maura Collinsgru, the health care program director at New Jersey Citizen Action, a liberal watchdog group. “How could you, having had that experience, justify your votes?”

Democrats across the country have been hitting their Republican opponents hard on the issue in light of the repeal effort and a legal effort by many Republican state attorneys general to end protections for preexisting conditions. Republicans are fighting back with promises but few plans to match. During a recent forum on a local TV station, MacArthur said: “I fought to protect preexisting conditions, and I’ve always supported that.”

The MacArthur campaign did not respond to multiple requests for an interview.

Kim, who has never held elected office, started considering whether to run when MacArthur’s compromise was released, he said. But he was convinced after doctors warned him and his wife that their unborn son was dangerously underweight.

“I told my wife that if we could get through this, and if our baby is born and he is stable, I want to do what I can to hold my representative accountable for what he did,” he said. Today, Kim said, his son is doing fine.

Kim has framed himself as the anti-MacArthur, vowing to hold in-person town halls once a month and reject corporate contributions.

Further complicating MacArthur’s re-election prospects is his vote for the Republican tax bill, which the nonpartisan Tax Policy Center said would be most damaging for New Jersey, where it estimated 10.2 percent of households would see their federal taxes increase this year. He was the only New Jersey lawmaker to support it.

Mike DuHaime, a strategist who advised former Republican Gov. Chris Christie on his 2009 campaign, said Kim is benefiting from the “historical and partisan headwinds” facing Republican incumbents in blue states like New Jersey.

“Anyone who thinks Tom MacArthur doesn’t care about those with preexisting conditions is grossly mistaken and completely unaware of the type of person he is,” he wrote in an email. “He was trying to forge progress, and when you do that, you will be criticized.”

But in a time of such intense political loyalties, it is unclear whether MacArthur’s role in trying to repeal the Affordable Care Act would be damaging enough to oust him.

“It seems to me in this election people have chosen their tribal corners and issues have less potency overall,” said Tom Moran, the editorial page editor and political columnist at the state’s largest newspaper, the Star-Ledger.

“But if there is one issue that penetrates,” he added, “it’s health care.”

Republicans’ Drive To Tighten Immigration Overlooks Need For Doctors

Kaiser Health News:States - October 30, 2018

ATLANTA — Dr. Alluri Raju, a native of India, vividly remembers how his ethnicity prompted concern and discrimination in the southwest Georgia town of Richland. Doctors there hesitated to grant the family practitioner and general surgeon privileges to the local hospital when he arrived in 1981.

“I guess they wanted to cut me off so that I wouldn’t be a competitor,” he recalled.

Yet, in the 37 years Raju has been practicing in Richland, more than 20 doctors have come and gone and he’s the only physician left — not just in Richland, but in all of Stewart County and neighboring Webster County, an area roughly half the size of Rhode Island with a population of more than 8,000.

“Today, I’m it,” he said. And his patients, he said, treat him with respect — and not as a foreigner.

Stories like Raju’s are the common thread for many immigrant doctors in the United States.

The American Medical Association said that, as of last year, 18 percent of practicing physicians and medical residents in the U.S. in patient care were born in other countries. Georgia’s percentage of foreign-born doctors is similar, at 17 percent.

Yet President Donald Trump’s focus on securing U.S. borders and restricting immigration — and the bitter arguments between the national political parties on the issue during midterm campaigns — have sown concerns about opportunities for foreign-born doctors.

Many of these doctors, like Raju, work in rural areas that are desperate to attract medical professionals. Yet those areas are often reliable supporters of Trump and his strict immigration policies. A recent national poll found that immigration is the top concern for Republican voters.

Some health care experts say Trump’s tough stance could make it harder for rural areas such as Richland to relieve critical physician shortages.

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Georgia’s Republican lawmakers have considered legislation in recent years that opponents say would have restricted the rights of some immigrants. And Republican candidates for governor here campaigned in the primary this year on cracking down on illegal immigrants, though advocates for that position say bias is not the motivation, but rather the need for border security.

Raju’s patients say they don’t see any problem in seeking care from an immigrant. Raju has been treating Willie Hawkins, a retired road worker, for 30 years, as well as his mother and his sister.

Sometimes, Hawkins said with a smile, he has to ask the nurse what the doctor just said.

“You know, he talks a little funny,” said Hawkins, 66. “But who cares?”

Maybe when Raju first came here to practice, people were a bit skeptical, Hawkins recalled. Many had never met someone from India before, he said. “But today it just doesn’t matter,” he said.

Willie Hawkins says he doesn’t care that his physician, Dr. Alluri Raju, is an immigrant.(Credit: Katja Ridderbusch)

Foreign-born doctors are vital to the national health system. The U.S. is grappling with a doctor shortage that’s expected to grow to as many as 120,000 physicians by 2030, according to the Association of American Medical Colleges.

Even now, primary care doctors are relatively scarce in certain areas of the country. Georgia has a few counties without any doctors at all, and many counties lack a pediatrician or an OB-GYN.

These immigrants help fill some of the gaps, especially in primary care, said Dr. William Salazar of Augusta University’s Medical College of Georgia, who came to the U.S. from Colombia. And rural Georgia has a higher percentage of immigrant doctors than do urban areas, said Jimmy Lewis of HomeTown Health, an association of rural hospitals mostly in Georgia.

“Foreign-born doctors go to places no one wants to go,” said Dr. Gulshan Harjee, a Tanzanian-born physician who co-founded the Clarkston Community Health Center, a free clinic serving mainly immigrants and refugees in metro Atlanta.

Patients’ Bias

Several foreign-born doctors here recalled awkward interactions with patients, occasionally experiencing bias.

“When they think you’re different, they think you’re not as smart, and think they won’t understand what you’re saying,” said Salazar. “You develop skills to overcome that.’’

But patients overall are getting used to people from other countries, he added.

Saeed Raees, a pharmacist originally from Pakistan who co-founded the Clarkston clinic, said that “you’ll run into a small minority who don’t want to be seen by a foreign-born doctor or a Muslim doctor.”

Physicians from predominantly Muslim countries face increased pressure after the Trump administration tightened its visa and immigration policies. Several doctors said that their visa applications take longer than before or are on hold, and re-entry into the U.S. after traveling was difficult.

Patients line up outside the Clarkston Community Health Center near Atlanta on a recent Sunday morning. The free clinic serves many immigrants. (Andy Miller for KHN)(Andy Miller for KHN)

Syrian-born Dr. Omar Akhras treats a political refugee from Ethiopia, Fuad Abdi Limo, at the Clarkston Community Health Center. The free clinic serves immigrants and refugees in metro Atlanta’s highly diverse DeKalb County.(Andy Miller for KHN)

Nearly half of Muslim physicians in the U.S. felt more scrutiny at work compared with their peers, and many said they experienced discrimination in the workplace, according to a study by Dr. Aasim Padela at the University of Chicago. Nearly a tenth of the physicians surveyed reported that patients had refused their care because they were Muslim.

There is also acceptance.

Dr. Buthena Nagi, a native of Libya, is employed as a hospitalist at Navicent Health in Macon. Nagi, 40, completed her residency at Morehouse School of Medicine in Atlanta in 2015. But to stay in the country she has to meet immigration criteria.

Most foreign physicians complete their residency in the U.S., typically on a student visa. To remain beyond that, U.S. immigration law requires them to practice in a medically underserved area for at least three years. Afterward, they can apply for a green card and, eventually, American citizenship.

Nagi wears a hijab — a traditional head covering for many Muslim women — with her scrubs, and sometimes patients and colleagues ask her about it.

“I then explain that this is part of my religion,” she said. “And once the dialogue kicks in, the fear dies down, and people seem to understand that I’m not an alien from outer space.”

In metro Atlanta’s highly diverse DeKalb County, about 75 percent of the patients at the free Clarkston health center are immigrants, refugees or migrant workers. Up to 30 languages are spoken there. Co-founder Harjee said she speaks “only six.”

Sameera Vadsariya, 37, said through an interpreter that she loves the services there. She was born in India and is here on a visa. She has no health insurance, so the free services are worth the long wait for treatment.

Most of the volunteer doctors at the Clarkston clinic are foreign-born, said Harjee. “This is a passion for them. They want to give back.’’

Opportunity Lost

Belsy Garcia Manrique also wants to play a role.

At age 7, she left her home in Zacapa, Guatemala, and headed north through Mexico with her mother and sister. It was a two-week odyssey — a combination of walking and driving — up to the southern tip of Texas. Her father, Felix, who had come to the U.S. two years earlier seeking political asylum, met them and drove the family to his home in Georgia.

For many years, she dreamed of being a doctor, hoping to treat Spanish-speaking patients in the parts of northwest Georgia where she was raised.

U.S. immigration policy, however, blocked her path to medical school. She was not a legal resident. Most states, including Georgia, prevented undocumented immigrant children like Garcia Manrique from qualifying for in-state tuition at public universities.

Belsy Garcia Manrique arrived in the U.S. from Guatemala at age 7. Although she didn’t have legal authority to stay here, President Barack Obama’s executive order creating the Deferred Action for Childhood Arrivals (DACA) program made it possible for her to go to medical school.(Courtesy of Belsy Garcia Manrique)

But Garcia Manrique caught a break when President Barack Obama issued an executive order six years ago that created the Deferred Action for Childhood Arrivals program. DACA offered more than 800,000 undocumented immigrants brought to the U.S. by their parents a chance to stay without fear of deportation.

From 2012 to 2016, medical schools from California to Massachusetts accepted roughly 100 DACA students, whose families hailed from Mexico, Pakistan, Venezuela and other countries. Garcia Manrique applied to nearly 40 schools. The Stritch School of Medicine at Loyola University Chicago, the first medical school to accept DACA students, was the only one that offered her admission.

Shortly after taking office in 2017, Trump rescinded DACA, a move that has become the subject of ongoing legal and political battles. If the law stands, Garcia Manrique will be allowed to stay in the U.S. But if it’s overturned, she and DACA medical trainees won’t be allowed to renew their work permits.

Garcia Manrique is finishing medical school and applying for a residency program to train in family medicine. Only two Georgia medical programs — at Emory University and Morehouse College — said they would consider a DACA recipient. She applied to both.

Of her 50 applications, Garcia Manrique received interview offers from nearly a dozen programs, including ones in Illinois, California and Washington. She hasn’t heard from the ones in Georgia.

And these days she isn’t sure if the Georgia she knew, and the Georgia she loved, is a place where she’d feel welcome.

“After a certain time of being looked down upon, being told ‘no,’ going the extra mile to get the same benefits, you get tired of that,” Garcia Manrique said. “I’ve seen many immigrants who have talent in the South move out. Why not be somewhere where you’re wanted?”

With One Hand, Administration Boosts ACA Marketplaces, Weakens Them With Another

Kaiser Health News:HealthReform - October 30, 2018

In the span of less than 12 hours last week, the Trump administration took two seemingly contradictory actions that could have profound effects on the insurance marketplaces set up by the Affordable Care Act.

First, officials issued guidance Monday morning that could weaken the exchanges set up for people who buy their own insurance. The new approach makes it easier for states to get around some ACA requirements, including allowing the use of federal subsidies for skimpier plans that can reject people with preexisting conditions.

Yet, the other move — a proposed rule unveiled Monday evening — could bolster ACA marketplaces by sending millions of people with job-based coverage there, armed with tax-free money from their employers to buy individual plans.

Both efforts play into the parallel narratives dominating the bitter political debate over the ACA.

The administration, frustrated that Congress did not repeal the law, say some critics and policy experts, is working to undermine it by weakening the marketplaces and the law’s consumer protections. Those efforts make it easier for insurers to offer skimpier policies that bypass the law’s rules, such as its ban on annual or lifetime limits or its protections for people with preexisting conditions. Congress also zeroed out the tax penalty for not having coverage, effective next year. Combined, the moves could reduce enrollment in ACA plans, potentially driving up premiums for those who remain.

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The administration and Republicans in Congress say they are looking to assist those left behind by the ACA — people who don’t get subsidies to help them buy coverage and are desperate for less expensive options — even if that means purchasing less robust coverage.

“These are people who were buying insurance before [the law] and then the rules changed and they could not buy it because they could not afford it,” said Joe Antos, a resident scholar at the conservative American Enterprise Institute. “They have been slowly dropping out of insurance coverage altogether.”

The efforts are dramatically reshaping the ACA and the individual insurance market to one that looks more as it did before the 2010 law, when regulation, coverage and consumer protections varied widely across the country.

Some states will do everything they can to keep individual markets strong and stable. Others won’t,” said Sabrina Corlette, research professor at the Center on Health Insurance Reforms at Georgetown University.

So what expectations should consumers have? Here are three key takeaways:

Protections for preexisting health problems are uncertain.

Polls show that keeping the ACA’s guarantees on coverage for people with medical problems is a top concern for Americans, and Democrats have made their defense of the health law a key part of their midterm election campaigns.

Republicans have gotten that message and even those who voted to repeal the ACA or joined a lawsuit by 20 red states to overturn it now say they want to protect people with preexisting conditions. Still, GOP lawmakers have not introduced any plan that would be as protective as the current law.

In August, the administration released a rule allowing expanded use of short-term plans, which are less expensive than ACA policies. To get those lower prices, most of these plans do not cover prescription drugs, maternity care, mental health or substance abuse treatments.

The move is unlikely to benefit people with health problems, as short-term plans can reject people with preexisting conditions or decline to cover care for those medical problems.

Under the rule, insurers can sell them starting in 2019 for up to a year’s duration, with an option to renew for up to three years, reversing an Obama-era directive that limited them to 90 days.

Administration officials estimate such plans could draw 600,000 new enrollees next year, and others have estimated the numbers could be far higher. The concern is if many healthy people in 2019 switch out of the ACA market and choose short-term plans, premiums will rise for those who remain, including those with preexisting conditions or make the ACA market less attractive for insurers.

Where you live matters more.

One of the biggest changes ushered in with the ACA was a standard set of rules across all states.

Before the law took effect, consumers buying their own coverage saw tremendous variation in what was offered and what protections they had, depending on the state where they lived.

Most states, for example, allowed insurers to reject people with medical conditions. A few states required insurers to charge similar premiums across the board, but most allowed wide variations based on age, gender or health. Some skimpy plans didn’t cover prescription drugs, chemotherapy or other medical services.

By standardizing the rules and benefits, the ACA barred insurers from rejecting applicants with medical conditions or charging them more. Women and men get the same premium rates and insurers could charge older people no more than three times what they charged younger ones.

Under the new guidance issued this week giving states more flexibility on what is offered, consumers could again see a wide variation on coverage, premium rules and even subsidy eligibility.

“It shifts pressure to state politicians,” said Caroline Pearson, a senior fellow at NORC, a nonpartisan research institution at the University of Chicago. That could play into the calculus of whether a state will seek to make broad changes to help people who cannot afford ACA plans, even if the trade-off affects people with medical conditions.

“You risk making some worse off by threatening those markets,” said Pearson. “That is always going to be hard.”

Millions more will join the “buy-your-own” ranks.

The proposed rule released Tuesday allows employers to fund tax-free accounts — called health reimbursement arrangements (HRAs) — that workers can use to buy their own coverage on the ACA marketplaces.

The administration estimates about 10 million people would do so by 2028 — a substantial boost for those exchanges, which policymakers say never hit the enrollment numbers needed to attract enough insurers and hold prices down.

John Barkett, senior director of policy affairs at Willis Towers Watson, a benefits consulting firm, said he expects employers to “seriously consider” the new market. The infusion of workers will improve options by attracting more insurers, he added.

“These people coming in will be employer-sponsored, they’ll have steady jobs,” Barkett noted, and will likely stick with coverage longer than those typically in the individual market.

Currently more than 14 million people buy their own insurance, with about 10 million of those using federal or state ACA marketplaces. The others buy private plans through brokers.

The proposed rule won’t be finalized for months, but it could result in new options by 2020.

If these workers seeking coverage are generally healthy, the infusion could slow premium increases in the overall ACA marketplace because it would improve the risk pool for insurers.

But, if employers with mainly higher-cost or older workers opt to move to the marketplaces, it could help drive up premiums.

In an odd twist, the administration notes in the proposed rule that the ACA has provisions that could protect the marketplace from that type of adverse selection, which can drive up prices. But most of the protective factors cited by the rule have been weakened, removed or expired, such as the tax penalty for being uninsured and the federal subsidies for insurers to cover lower deductibles for certain low-income consumers.

Benefits consultants and policy experts are skeptical about how many companies will move to the HRA plan, given the tight labor market. Continued uncertainty about the fate of the ACA marketplace may keep them reluctant to send workers out on their own, they say.

Health benefits are a big factor in attracting and retaining workers, said Chris Condeluci, a Washington attorney who previously worked for Sen. Chuck Grassley (R-Iowa) and served as counsel to the Senate Finance Committee during the drafting of the ACA.

“Most employers believe their group health plan will provide better health coverage than an individual market plan,” he said.

Dialysis Giant DaVita Defends Itself In Court And At The Polls

Kaiser Health News:Marketplace - October 29, 2018

It’s been a year of playing defense for DaVita Inc., one of the country’s largest dialysis providers.

A federal jury in Colorado this summer awarded $383.5 million to the families of three of its dialysis patients in wrongful death lawsuits. Then this month, the Denver-based company announced it would pay $270 million  to settle a whistleblower’s allegation that one of its subsidiaries cheated the government on Medicare payments.

But its biggest financial threat is a ballot initiative in California that one Wall Street firm says could cost DaVita $450 million a year in business if the measure succeeds.

Despite these recent hits, the company continues to rake in profits and receive favorable ratings from stock analysts. Its shares are trading at about $65 a share, only about 19 percent below a 52-week high set in January. That’s largely because DaVita controls about one-third of a growing market, health experts say.

“They don’t really have many rivals, and they perform a necessary, lifesaving service,” said Leemore Dafny, a professor of business administration at Harvard Business School. “If you’re producing something people want to buy and you’re the only one making it, people are going to buy it.”

Patients with chronic kidney failure often need dialysis to filter the impurities from their blood when their kidneys can no longer do that job.

And as Americans live longer and get heavier, more people become diagnosed with kidney disease and possibly need dialysis. In 2015, 124,114 new patients received dialysis, up from 94,702 in 2000, a 31 percent increase, according to the U.S. Renal Data System.

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DaVita is one of the largest dialysis providers in the country, operating more than 2,500 clinics nationwide. In California, the company operates 292 clinics, half of all chronic dialysis clinics in the state.

Its parent company, DaVita Inc., reported $10.9 billion in revenue last year and $1.8 billion in profits, almost all of which came from its dialysis business.

This year, company officials project the dialysis group will bring in $1.5 billion to $1.6 billion in profits. It’s a big turnaround for a corporation that could barely make payroll in 1999, when it was under review by the Securities and Exchange Commission for questionable accounting practices. Its success has largely been credited to CEO Kent Thiry, a colorful personality who has dressed up as a Musketeer and ridden a horse into corporate meetings to rally workers.

Now those big profits — generated from treating sick patients — has put a target on the company’s back, as well as that of its biggest competitor, Fresenius Kidney Care.

The Service Employees International Union succeeded this year in placing Proposition 8 on California’s Nov. 6 ballot, which would limit dialysis center commercial revenues to 115 percent of patient care costs. The ballot fight pits a well-funded industry against labor and the California Democratic Party.

DaVita declined to make anyone available for this article, but in a statement said Proposition 8 “will limit patients’ access to life-saving dialysis treatments, jeopardizing their care.”

Last year, roughly two-thirds of DaVita’s dialysis revenue came from government-based programs, such as Medicare and Medicaid. But that isn’t enough to cover its costs, according to the company’s 2017 annual report, which states that DaVita loses money on each Medicare treatment it provides. (Medicare covers dialysis for people 65 and older, and for younger patients after private insurance has provided coverage for 30 months.)

Instead, DaVita generates profits from commercial health plans, which it acknowledges pay “significantly higher” rates than government programs. The ballot measure targets those higher rates, which Dafny describes as “their bread and butter.”

The prospect of the measure passing led DaVita to delay or cancel plans to open new clinics in California despite growing patient demand, Javier Rodriguez, chief executive officer of DaVita Kidney Care, told investors on a call in May, according to the online equity research website Seeking Alpha.

A few months later, Rodriguez declined to provide a dollar amount when asked how the initiative would impact the company. Rather, he warned investors that it would become “unsustainable” for the industry to treat the estimated 66,000 dialysis patients in California, should the measure succeed.

Wall Street analysts agree that Proposition 8 would wipe out DaVita’s earnings in California, according to recent reports issued by investment firms J.P. Morgan and Baird. Passing the initiative “would be so devastating,” to the tune of $450 million a year, that DaVita “would likely walk away from the state altogether,” according to a March Baird report.

DaVita has poured $66.6 million into the opposition campaign as of Oct. 25, and rival Fresenius has contributed $33.6 million. That dwarfs $17.3 million in union contributions in support of the measure, according to campaign records filed with California’s secretary of state office.

Both Wall Street firms conclude that Proposition 8 is likely to fail, citing the industry’s massive spending and the union’s record of failure at the polls on other issues.

The company’s legal troubles don’t worry stock analysts, either; Baird’s October report on DaVita’s financial performance dedicates just two sentences to them. It notes that DaVita “is subject to numerous ongoing government investigations and inquiries, similar to most large-scale, high-profile Medicare providers.”

There are no specific references to the Colorado jury award this summer, which the company is appealing, over the death of three patients who died of cardiac arrest after treatment at DaVita clinics. Nor was there concern about this month’s $270 million settlement over Medicare billing.

That’s because those incidents are seen by investors as the cost of doing business — one-time hits that don’t affect a company’s earnings power in the future, said Matthew Gillmor, a senior research analyst at Baird.

“Almost all companies I follow, at some point, have had to pay a fine to the government,” Gillmor said.

Thiry, DaVita’s CEO, acknowledged that settlements, which aren’t good public relations, are a reality for large corporations, when The Denver Post asked him last year about the company’s previous legal battles.

“If, in a trial, you are found to be wrong on even a small part of the case, it could mean that you are excluded from Medicare, which typically would mean bankruptcy for your company,” Thiry said. “So, you are essentially forced to settle.”

Harriet Rowan of California Healthline contributed to this report.

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

That’s A Lot Of Scratch: The $48,329 Allergy Test

Kaiser Health News:Insurance - October 29, 2018

Janet Winston had a rash that wouldn’t go away.

The English professor from Eureka, Calif., always had been sensitive to ingredients in skin creams and cosmetics. This time, however, the antifungal cream she was prescribed to treat her persistent rash seemed to make things worse. Was she allergic to that, too?

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Winston, 56, who works at Humboldt State University, knew the dermatologist in her rural Northern California town was booked months in advance. So, as she often does for specialized treatment, she turned to Stanford Health Care, a nearly six-hour drive south. She hoped to finally clear up her rash and learn what else she might be allergic to — for years, she had avoided lipstick and other skin products.

Winston said that 119 tiny plastic containers of allergens were taped to her back over three days of testing. Winston ultimately learned that she was allergic to — among other things — linalool (a compound of lavender and other plants), the metals gold, nickel and cobalt, the ketoconazole cream prescribed to treat her persistent rash, the antibiotic neomycin, a clothing dye, and a common preservative used in cosmetics.

Her Stanford-affiliated doctor had warned her that the extensive allergy skin-patch testing she needed might be expensive, Winston said, but she wasn’t too worried. After all, Stanford was an in-network provider for her insurer — and her insurance, one of her benefits as an employee of the state of California, always had been reliable.

Then the bill came.

Patient: Janet Winston, 56, of Eureka, Calif., English professor at Humboldt State University

Total Bill: $48,329, including $848 for the time Winston spent with her doctor. Winston’s health insurer, Anthem Blue Cross, paid Stanford a negotiated rate of $11,376.47. Stanford billed Winston $3,103.73 as her 20 percent share of the negotiated rate.


Service Provider: Dr. Golara Honari of Stanford Health Care’s outpatient dermatology clinic in Redwood City, Calif.

Medical Procedures: Extensive allergy skin-patch testing to determine what substances caused Winston’s contact dermatitis, or skin rashes.

Winston, a professor at Humboldt State University, pores over her bill at home.(Alexandra Hootnick for KHN)

“I was grateful I had such wonderful care at Stanford,” Winston said, “but I was pretty outraged they could charge that. … No one cut into me. No one gave me anesthesia. I had partly open plastic containers filled with fluid taped to my back.”

What Gives: Medical billing analysts told Kaiser Health News that Stanford’s charges for Winston’s allergy patch test appeared excessive. They were surprised to hear that Winston’s insurer, Anthem Blue Cross, paid Stanford more than $11,000 for the treatment.

Stanford’s list price, however, is a whopping $399 per allergen.

“That charge is astronomical and nuts,” said Margaret Skurka, a retired professor of health informatics at Indiana University and a medical coding and billing consultant who advises hospitals and providers. She reviewed Winston’s bill.

The “usual, customary and reasonable” charge for testing a single allergen in the high-cost San Francisco Bay Area is about $35, said Michael Arrigo, a San Francisco-based medical billing expert witness who also reviewed Winston’s bill. “The data seems pretty conclusive that the charges in this case are inflated.”

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For the type of allergy skin-patch testing Winston received, the average charge physicians submitted to Medicare — an important data point for private insurers — was about $16 per allergen in 2016, according to Medicare payment data.

An Anthem spokesman noted that one of the insurer’s examiners did review the bill but could not say whether it received extra scrutiny because of its high cost. “We try to strike a balance between protecting affordability and providing a broad network of providers to create choices,” Eric Lail said in an emailed statement.

Winston’s case highlights how some health providers set exorbitant rates, knowing they’ll ultimately be paid a lesser amount. Patients rarely pay these rates — known as “chargemaster” or list prices — and they can generate headlines for the $100 aspirin. But such list prices, as the starting point for negotiations and discounts, do help determine the amounts insurers pay, and ultimately what patients pay as their share of cost.

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Stanford Health Care also has a lot of power in dealing with insurers like Anthem Blue Cross. The academic medical system includes hospitals and outpatient clinics across the San Francisco Bay Area as well as a number of large doctor practices in the region. That kind of consolidation and market power can raise health care prices. Insurers in the region have long grappled with Stanford’s high costs, at times withdrawing the health system from their networks. But the breadth and depth of the academic medical system — not to mention its popularity with high-end customers in the Bay Area — makes it difficult for insurers to exclude a powerhouse like Stanford from a network for long.

Some of the products that Winston’s allergy skin-patch testing revealed she can no longer use.(Alexandra Hootnick for KHN)

A study recently published in Health Affairs found that such consolidation in California has caused health care costs to spike for both patients and insurers.

Patrick Bartosch, a spokesman for Stanford Health Care, said that Winston’s doctor customized her treatment rather than using off-the-shelf patch tests. The university health system operates a large allergen bank of its own, he said.

“In this case, we conducted a comprehensive evaluation of the patient and her environmental exposures and meticulously selected appropriate allergens, which required obtaining and preparing putative allergens on an individual basis,” Bartosch said in an emailed statement.

Leemore Dafny, a Harvard University health care economist, said big health systems like Stanford’s — which owns multiple hospitals and outpatient clinics — can pressure insurers to pay big.

“Everyone wants to point fingers at the providers, but … a lot of times [insurers] roll over and pay the rates,” she said.

In other words, Stanford charged Winston’s insurer $48,000 because it could.

Janet Winston’s original bill from Stanford Health Care. The bill detailed costs of $48,329.00 for allergy skin-patch testing. Winston negotiated her share of the bill down by 50 percent.(Alexandra Hootnick for KHN)

Resolution: After some bargaining with Stanford’s billing department, Winston ultimately paid $1,561.86 out-of-pocket. She made the argument that her doctor had told her the cost per allergen would be about $100, not nearly the $400 Stanford ultimately charged her insurer.

The Takeaway: Insurers often tell patients to “shop around” for the best price and to make sure they choose in-network providers to avoid surprises. Winston did everything right and still got caught out. As a state employee, she had great insurance and Stanford was an in-network provider. Winston said her doctor warned her the test would be expensive, but she never anticipated that could mean close to $50,000. So don’t be afraid to ask for specific numbers: “Expensive” and “cheap” can have hugely different meanings in the high-priced U.S. health system.

Clearly uncomfortable with the charges, Winston’s physician advised her — in advance — to contest it with Stanford’s billing department. So she did, and Stanford gave her a nearly 50 percent discount for her coinsurance share of the bill. It never hurts to ask.

The allergy skin-patch testing Winston underwent revealed she is allergic to numerous metals and other substances, including linalool, a naturally occurring terpene alcohol in many flowers and spice plants. Winston still can handle roses from her garden, which contain linalool, but she cannot wear perfumes and cosmetic products that contain the compound.(Alexandra Hootnick for KHN)

Still, Stanford received more than $12,000 total from Winston and her insurer for allergy patch tests — a cost that is borne by insurance policyholders and taxpayers. Researchers have linked consolidation by Northern California providers such as Stanford and Sutter Health to higher health costs for the region’s consumers. A local health workers union also has taken aim at Stanford’s costs with two city ballot initiatives that attempt to rein in what Stanford and other health providers can charge patients in Palo Alto and Livermore.

“I was grateful I had so much insurance, and that it was in-network, and I could afford the [final] bill,” Winston said. “On the other hand, I thought, ‘How can they get away with this?’ Most Americans could never afford this procedure, at least at this facility, and it made me think about the grand piano in the lobby.”

NPR produced and edited the interview with Elisabeth Rosenthal for broadcast. April Dembosky, from member station KQED, provided audio reporting.

Do you have an exorbitant or baffling medical bill? Join the KHN and NPR Bill-of-the-Month Club and tell us about your experience.

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

In California, Novel Initiatives Test Cities’ Power — And Will — To Tame Health Costs

Kaiser Health News:Marketplace - October 29, 2018

At a time of mounting national anger about rising health care prices, the country’s largest union of health workers has sponsored ballot measures in two San Francisco Bay Area cities that would limit how much hospitals and doctors can charge for patient care.

The twin measures in Palo Alto and Livermore, sponsored by the Service Employees International Union-United Healthcare Workers West, take aim primarily at Stanford Health Care, which operates Stanford Hospital and Clinics, the facility with the third-highest profits in the country from patient care services, according to a 2016 study.

The union also is sponsoring Proposition 8, a statewide measure that would impose a cap on profits for dialysis clinics. Together, the state and local measures seek to draw on public outrage over sky-high medical prices. And, for municipalities, they amount to a novel and untested effort to rein in those prices through the ballot box.

“I’ve been in this field almost 50 years, and I’ve never seen a local government regulating hospital prices,” said Paul Ginsburg, director of public policy at the Schaeffer Center for Health Policy & Economics at the University of Southern California. A number of states set hospital rates in the 1970s, and two states, Maryland and West Virginia, do so today, he said.

Opponents question the legal authority of cities to regulate health care pricing, and they predict a flood of litigation against the measures if they pass. The city councils of both cities oppose the proposals, arguing that local officials with no expertise in health care costs would be required to create a new bureaucracy to regulate them.

Stanford Health Care officials say the measures could undermine quality. “It would threaten [the system’s] ability to provide top-quality health care to patients from Palo Alto and across the region,” according to a September statement from the system.

Ginsburg expressed skepticism. “Of course, you could cut rates too much and harm hospitals financially,” he said. “But if done with intelligence, you could accomplish some price reduction without harming quality.”

For the union, the ballot measures could help it gain leverage in future bargaining or organizing efforts with Stanford and other hospitals. Stanford Health Care operates the largest hospital system in both cities where the price cap proposal is on the ballot. Stanford has opened, has acquired or is building health care centers with clinics and specialty services in Emeryville, Pleasanton and Redwood City — Bay Area cities where the SEIU-UHW tried but failed to place similar price-control measures on local ballots.

But union officials say their motive is simply to rein in prices. “Stanford Health is nonprofit. They don’t pay property taxes or incomes taxes,” said Sean Wherley, an SEIU-UHW spokesman. “Taxpayers are subsidizing their operations and getting wrung out by over-the-top prices.”

Stanford and other health systems have been on a buying spree in recent years acquiring hospitals and physician practices, and this concentration of ownership has stifled market competition and further boosted prices for insurers and patients.

The Palo Alto and Livermore initiatives, which also affect other medical systems in the cities, would cap prices charged by hospitals and other health care providers at 115 percent of “the reasonable cost of direct patient care.”

And there, some experts say, lies the rub.

“What is a seemingly simple idea — limiting prices to 115 percent of ‘costs’ — is neither simple in execution, nor concept,” said Benedic Ippolito, a research fellow at the American Enterprise Institute who studies health care financing. “What costs are acceptable? How will we stop providers from increasing costs as much as possible” to compensate for the cap?

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Under the initiatives, hospitals and other medical providers would be obliged to pay back any charges above the cap each year to private commercial — but not government — insurers, and to patients who pay for their own care. They would also owe the cities a fine equal to 5 percent of the excess charges. Fines collected by the cities could be used to pay for enforcing the laws.

Stanford estimates that Proposition F, the Palo Alto measure, would reduce the health system’s budget by 25 percent, forcing it to make cutbacks and possibly end essential services, said David Entwistle, the health system’s president and chief executive officer.

Livermore would need to spend $1.9 million a year on the staff required to implement Measure U — its version of the proposal — and would likely incur another $750,000 to $1 million in legal and startup costs, according to an analysis conducted for the city by Henry Zaretsky, a health economist who has worked for the state and the California Hospital Association.

Patients in the wealthy region expect high-quality services but also can be savvy consumers and passionate voters. It is an open question whether the measures would pass.

Industry consolidation is far more pronounced in Northern California than in Southern California, according to a recent study from the University of California-Berkeley. As a result, inpatient hospital prices in the north were 70 percent higher and outpatient costs as much as 55 percent higher than in the south. The price disparities, even within the Northern California region, can be dramatic.

For instance, independent doctors in the Bay Area are reimbursed, on average, a median $2,408.45 for a routine vaginal delivery, which includes prenatal and postnatal visits, according to a 2017 Kaiser Health News analysis of claims data from Amino, a health cost transparency company. That compares with $5,238.13 for the same bundle of services for Stanford physicians (and $8,049.84 for doctors employed by the University of California-San Francisco).

The higher cost of medical care also pushes up insurance premiums for patients. Health plans purchased on the state insurance exchange were 35 percent higher in Northern California than in Southern California, the 2018 UC Berkeley study showed.

Earlier this year, California Attorney General Xavier Becerra took aim at medical industry consolidation and the high prices associated with it. He sued Sutter Health, one of the nation’s largest health systems, saying it was systematically overcharging patients and illegally driving out competition in Northern California.

To C. Duane Dauner, a former president and CEO of the California Hospital Association, the ballot proposals are “a power play by SEIU-UHW to put pressure on Stanford Health Care.” The union wants Stanford “to be neutral when they try to organize employees in Redwood City, Emeryville, Pleasanton and Livermore,” said Dauner, who heads the campaign committee opposing both measures.

Larry Tramutola, a veteran campaign consultant who is not involved on either side, agrees.

“I don’t think it has anything to do with controlling health care prices,” said Tramutola, who recently managed successful local initiatives to tax sodas and ban menthol cigarettes. “It’s about bargaining. Win or lose on this, other hospitals in other places will take notice and realize that SEIU is a formidable foe.”

Protect Our Local Hospitals and Health Care, the campaign committee opposing the measures, has raised $4.2 million so far this year. The union’s political action committee has spent $1.5 million in support of the initiatives.

California Healthline senior correspondent Barbara Feder Ostrov contributed to this report.

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

Readers And Tweeters: Are Millennials Killing The Primary Care Doctor?

Kaiser Health News:Insurance - October 26, 2018

Letters to the Editor is a periodic feature. We welcome all comments and will publish a selection. We edit for length and clarity and require full names.

Health Care Wasted On The Young

I feel Sandra Boodman’s thesis is inadequate without a historical comparison to how young people accessed health care five, 10 or 20 years ago (“Spurred By Convenience, Millennials Often Spurn The ‘Family Doctor’ Model,” Oct. 9). As a family medicine doctor practicing for 33 years, my experience is that healthy young people use medical services only for urgent care and pregnancy until they develop chronic conditions. And, as a society in general, we have become more demanding about receiving services “now.”

Why should medical care not change as our expectations change? Certainly we have the technological ability to provide a portable health record one could take from site to site to improve continuity. We also have the ability to have a single electronic medical record or shared information hub so one’s health info can be accessed by any provider anywhere.

However, demanding “now” care at any convenient site does not allow one provider to get to know a person in a way to better inform them of how that individual’s situation (emotional-social-economic) impacts their health. So, convenience has its price.

— Dr. Kevin Walsh, Ellensburg, Wash.

Family physician Ajoy Kumar of Florida led a lively debate on Twitter and, in a series of tweets, emphasized how important it is to build doctor-patient relationships early because “nobody is young and healthy forever.”

“In the first 30 years of your life, you make your habits. For the last 30 years of your life, your habits make you.” Sure, everyone looks and feels great when they are young, and while you may think it will be that way forever choices and lifestyle in adulthood creep up on you.

— Ajoy Kumar, MD, FAAFP (@ajoykumarmd) October 10, 2018

— Dr. Ajoy Kumar, St. Petersburg, Fla.

It’s not so much the new generation as it is the age group. I didn’t have a primary care physician from the time I entered university until I was 42. I also only went to the doctor when I had a particular problem to deal with. Even back then (25-30 years ago), a $200 deductible meant I could pay for insurance but could not afford to use it for anything other than a dire emergency. Of course, back then almost everything was traditional indemnity, so we all paid full-freight unless you were covered by one of the nascent HMOs (which often controlled costs by denying care).

— Brenda F. Bell, North Plainfield, N.J.

Another primary care doctor bemoaned the trend as part of a larger move away from generalized medicine:

Part and parcel with how much medicine has changed with regards to specialization and fragmentation of care . As a primary care physician for over 20 yrs, I find this trend less satisfying

— H Mitchell (@Hollyfrog88) October 10, 2018

— Dr. Holly Mitchell, Amarillo, Texas

As long as we are talking about new models for medicine, here’s a plea for “human-centered design thinking”:

The young immortals are clear about how they want to access care. Now how to support Primary Care in making the connection? Seems ripe for Human Centered Design Thinking. Spurred By Convenience, Millennials Often Spurn The ‘Family Doctor’ Model https://t.co/FNosdacs6o via @khnews

— Julie Schilz (@J_Schilz) October 10, 2018

— Julie Schilz, Northglenn, Colo.

Laryngitis On The Campaign Trail?

It isn’t surprising that health care is a priority issue for voters (“Health Care Tops Guns, Economy As Voters’ Top Iissue,” Oct. 18). After all, the chief cause of personal bankruptcy is medical bills. Nor is it surprising that voters have not heard much about health care from midterm election candidates, who know the future success or failure of the health system and their political futures depend on how they respond to voters’ top concerns. It is much safer for our political leaders to leave the administration of the health system to the insurance companies.

But, so far, private insurers have shown they are more concerned with shareholders’ concerns than patients’. The result is a fragmented, impersonal health system overrun by multiple insurance plans, each with different copays, deductibles and insurance panels — where doctors are held captive by insurers’ regulations. If we vote people into office because we believe they will respond to our needs, why are so many of them so quiet on health care?

— Dr. Edward Volpintesta, Bethel, Conn.

Metrics Show Medicaid Is True To Its Mission

Both Medicaid enrollees and taxpayers see real results from Medicaid health plans — despite contrary claims (“As Billions In Tax Dollars Flow To Private Medicaid Plans, Who’s Minding The Store?” Oct. 19). Medicaid plans are held to high standards by the states, improving health, quality and savings for millions of Americans, including children, veterans, seniors and people with disabilities.

Medicaid plans run many programs to improve patient health — driving quality, coordinating care, and helping patients stay compliant with treatment. The vast majority of every Medicaid dollar pays for care, while Medicaid plan profit margins average less than 2 percent.

Medicaid plans report metrics that are made public. Results show that insurance providers saved states about $7 billion in 2016 alone — helping states realize the highest value for their Medicaid investment. Research shows that Medicaid enrollees have access to care that is similar to those who have coverage through their jobs, and are satisfied with their coverage.

Medicaid serves nearly 75 million Americans. Insurance providers know that Medicaid must work for those who rely on it — and the hardworking taxpayers who pay for it. We are committed to working together to ensure that Medicaid is effective, affordable and accountable.

— Matt Eyles, president and CEO of America’s Health Insurance Plans (AHIP), Washington, D.C.

A tweeter reading the same story noted the outsize level of Medicaid oversight compared with that of corporate America.

For people getting healthcare via Medicaid: tight scrutiny, work requirements, etc. For corporations getting hundreds of billions (more than military contractors!), not so much. https://t.co/xMxA6BRXiL via @khnews

— Fran Quigley (@FranQuigley) October 19, 2018

— Fran Quigley, Indianapolis

Imagine No Big Pharma

I know that we are all supposed to think the pharmaceutical industry is the savior of our country and that without them life itself would not be possible. What if we instead began to think of them as just the manufacturers of medication? What if we did our own drug research (maybe researching medication to treat millions instead of medication to make millions) and collected bids from every drug manufacturer for production only? What if we used tax dollars to pay for the manufacturing of the medications, and patients had to pay only a token pharmacy fee? I wonder what that would look like.

— Dr. David Herring, Staunton, Va.

Unamusing Cartoon

The publication by Kaiser Health News of a Nick Anderson cartoon with the caption “Inadequate Mental Health Services” above a picture of a prescription bottle reading “RX for Violence” from which bullets spill forth, is both surprising and deeply disappointing (‘Alternative Treatment’? Oct. 18).

How easy it is to imply that gun violence, indeed violence of any type, is largely attributable to untreated or undertreated, mental health conditions. But the facts, which I and millions of readers have come to expect from KHN, say otherwise. Mass shootings, the thought of which this cartoon invokes, account for less than 1 percent of gun violence, and for which mental health is a factor in but a small minority of cases. And while suicides are in fact increasing, and 85% of completed suicides involve guns, this too is only a small fraction (about 2%) of gun violence in the U.S.

It would be expected that KHN editors would be familiar with the oft-cited statistic that only about 4% of all violence may be attributed to people with serious mental illness, and the fact people with mental health conditions are far more likely to fall victim to violence than to perpetuate it against others.

As a trusted source of factual news, it is shocking that Kaiser would perpetuate and reinforce the erroneous, albeit widely held belief, that mental illness (treated or not) equates to gun violence.

— Debbie Plotnick, vice president for mental health and systems advocacy, Mental Health America, Alexandria, Va. 

I appreciate the perspective that inadequate mental health services can lead to negative consequences for the individual and, ultimately, for society. However, the implied connection between mental illness and violence is unfairly stigmatizing and not supported by evidence. In addition, the use of a prescription bottle seems to suggest that medication is the prescription for “adequate mental health services,” which vastly oversimplifies the need for a range of services that should be included in an effective, comprehensive system of care. I hope that you will consider removing this cartoon from your website, as it is harmful to engaging and truly supporting people with mental health needs.

— Jenifer Urff, Northampton, Mass.

A Call For Deeper Reporting

I was disappointed by Phil Galewitz’s reporting on the negative aspects of Medicare Advantage HMOs (“Medicare Advantage Plans Shift Their Financial Risk To Doctors,” Oct. 8), although it was nice that he quoted me and that you incorporated “risk shifting” into the headline. Galewitz cites a Health Affairs report but should have mentioned years of reports by the Government Accountability Office and the Medicare Advisory Payment Commission detailing overpayments and risk analysis and overpayments. There is a big dark side to Medicare Advantage plans that patients/consumers do not understand. They think it’s all about “free” care. It is hard to sue these HMOs for medical malpractice and failure to coordinate and manage care — which is what they promise to do. Medicare Advantage needs more critical reporting.

—Dr. Brant S. Mittler, San Antonio, Texas

For a Georgia reader, the story raised more questions:

Isn't this just going to encourage doctor's to do the cherry picking now that insurance companies can't? And what happens when those patients age and have serious health issues? Will those doctors just close practices and dump those patients?

— cminmd (@cminmd) October 9, 2018

— Colleen Mahaney, Woodstock, Ga.

On Shooting Down Sky-High Bills …

We in Montana were frustrated in our process to address the balance billing issues for air ambulance, with little success (“Will Congress Bring Sky-High Air Ambulance Bills Down To Earth?” Sept. 27). But the issue arises from insurance companies inserting a coverage cap in the policy, stacking deductibles for in- and out-of-network carriers. Much about this issue is aimed at air companies. They are solely responsible for their charge practices. But insurers also share the responsibility for their decisions to put those who are insured at risk as they seek to constrain premiums by policy design.

— Bob Olsen, Helena, Mont.

… And Missing The Mark?

The Oct. 19 Facebook Live broadcast (“Facebook Live: What About Those Sky-High Air Ambulance Bills?”) failed to note critical facts and provided misinformation. Alarmingly, this may cause patients to question whether they should board an air medical flight even when their physicians or first responder requests the transport based on patient need. We’d like to set the record straight.

1. Insurance Coverage

FACT: Dr. Naveed Kahn’s insurer’s payment was far lower than the actual bill, and air medical services, like all health care providers, are required by federal law to “balance bill” the patient the remainder. Dr. Kahn’s insurance company failed to adequately cover his bill.

[Editor’s note: KHN’s coverage did not focus on the mechanics of “balance billing,” but rather the prohibitive amount of the original bill.]

2. State Regulation

FACT: States can and do regulate air ambulances. Court decisions and Department of Transportation opinions have reaffirmed states’ authority to regulate all medical aspects of air medical transportation. This includes standards and coordination of patient care, including protocols controlling which air medical operator is called to a scene. Air medical operators never self-dispatch; they are called by trained first responders and medical personnel, operating under state authority.

3. Medicare Fee Schedule

FACT: The implementation of the Medicare Fee schedule did not increase rates for air ambulance services; it changed the way air ambulances are reimbursed, increasing the rates for some and dramatically decreasing the rates for others. While the data demonstrates the industry has grown over the last 37 years, according to “An Economic Analysis of the U.S. Rotary Wing Air Medical Transport Industry”, 22 of those growth years occurred before the implementation of the Medicare Fee Schedule.

Industry growth, over a 30-year period, reflects growth in demand for air medical transport services in response to continued closures of rural hospitals and trauma centers. Air ambulances are filling that gap — more aircraft means better coverage and better outcomes.

— Carter Johnson, SOAR (Save Our Air Medical Resources) Campaign, Washington, D.C.

Gun Store Owner Marshals Voters To Expand Medicaid In Idaho

Kaiser Health News:Madicaid - October 26, 2018

BOISE, Idaho — Standing outside the gun shop she co-owns, next to her SUV sporting “NRA” on the license plate, Christy Perry pledges full support for President Donald Trump.

Christy Perry, a gun store owner in Boise and an Idaho legislator, is helping lead the campaign on a voter referendum to approve Medicaid expansion in the state. (Phil Galewitz/KHN)(Phil Galewitz/KHN)

“He’s doing a good job,” said Perry, a four-term Republican member of the Idaho legislature who has voted for a litany of conservative causes, including weakening labor unions, restricting abortion and boosting charter schools.

With those credentials, Perry hopes for another big win on Election Day — one that puts her at odds with Trump and GOP orthodoxy.

She’s helping lead the drive to persuade state voters to expand Medicaid — a central tenet of the Affordable Care Act, the 2010 law embraced by Democrats and derided by many Republicans.

Perry has been pushing for Medicaid expansion the past several years in the state legislature, but those efforts were thwarted by top House leaders. Now a ballot initiative, Proposition 2, puts the matter before Idaho voters.

Perry said Medicaid coverage is desperately needed by people struggling in low-wage jobs and the economics make sense for the state given the federal government will pay a 90 percent share. An expansion will reduce or eliminate the need for other Idaho-funded programs to help the uninsured, she said.

She said the state can’t wait any longer.

“The longer you wait, the more people die” because they miss out on care, she said.

If the push is successful on Nov. 6, about 62,000 Idaho adults would be added to the state-federal health insurance program that covers 73 million low-income Americans. It would be a major advance for Obamacare into one of the most conservative parts of the country.

Idaho is one of the remaining 17 GOP-controlled states where lawmakers have steadfastly resisted expanding Medicaid.

But voters in Idaho, Nebraska and Utah will decide next month whether to buck their political leaders and go forward with the expansion. The issue is also on the ballot in Montana, which expanded Medicaid in 2016. There, residents will decide whether to continue it past 2019.

Of those states, Idaho is arguably the least politically hospitable for Medicaid expansion. Trump carried Idaho by the largest margin — nearly 32 percentage points.

Last year, Maine became the first state to approve expanding Medicaid via a ballot referendum, although the GOP governor has stalled implementation.

Unlike Maine, where political power has been split between Democrats and Republicans in recent years, Idaho, Utah and Nebraska are solidly GOP territory.

Trump and Republican congressional leaders have vowed to repeal the health law, which made expansion possible by providing the bulk of the funding for those who qualify for new coverage.

Perry, 50, doesn’t see a problem getting Trump voters to back the expansion. She said that the Republican failure to repeal the law last year opened the door for conservative states to go forward.

“I think people here listen to that and it now falls to states to go ahead” with expansion, she said.

Supporters of the referendum were successful at garnering 70,000 signatures to put the vote on the ballot, but they face a steep challenge educating the electorate about the complexities of Medicaid financing.

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Tim Dunnagan, dean of the College of Health Sciences at Boise State University, said few Idaho voters know that most states — including neighboring Oregon and Washington — have already expanded Medicaid. Because the issue can be confusing, he said, voters may gravitate to their long-held concerns about paying more taxes and government overreach.

“There is a strong sentiment that if the federal government is involved, it is not a good thing,” he said. “There’s a fierce individualism out in the West.”

Perry and the broad coalition endorsing the referendum — including teachers, employers, county sheriffs and the health industry — seek to remind voters that they are already paying for the health law’s provisions through their federal taxes and the expansion would bring $400 million in federal funds into the state.

The expansion would cover residents with incomes below 138 percent of the federal poverty level, or nearly $17,000 a year for an individual. Currently, Idaho adults who do not have children and are not disabled are not eligible for Medicaid. Those with children can only qualify with incomes up to 26 percent of the poverty level, or $3,156 a year.

The expansion also would eliminate a gap for residents whose income is too low to qualify for government subsidies to buy private coverage but who earn too much to qualify for Medicaid.

Volunteers for Idahoans for Healthcare canvass a Boise neighborhood, talking to residents about the need for Medicaid expansion. (Phil Galewitz/KHN)

Scott Richey, of Nampa, Idaho, talks to Lauren Necochea, a volunteer for Idahoans for Healthcare, as she canvasses his neighborhood for votes on Medicaid expansion.(Phil Galewitz/KHN)

Supporters have canvassed neighborhoods across the state in recent weeks. Hundreds of volunteers use lists of registered voters and a special app on their phone to detail their results.

On a recent evening, about 20 people gathered about 10 miles east of downtown Boise, where a field organizer gave them voter lists and instructions on how to approach homeowners.

Tracy Olson, 54, a nurse turned real estate agent, and Jill Galanter, 55, a physical therapist, went to an upper-income planned community. About two-thirds of the people they met said they support expansion, and most of the rest had not heard about it. Only a couple of people said they oppose the ballot question.

In their one-minute pitch, Olson and Galanter explained the coverage gap for low-income residents and the millions in federal dollars the state can gain by expanding. They didn’t mention the ACA. That’s not an oversight, organizers said.

“Obamacare has a negative connotation here,” Perry said.

Mike Brown, 50, an engineer, told Olson he didn’t know the issue but added that his health costs have soared in recent years. He nodded as Olson explained whom the expansion would help.

“I can sympathize,” he said. They recorded him as a “leaning yes.”

Richard Rapp, 75, a retired head of the career center at Boise State University, said he will support the expansion for humanitarian reasons. “Too many people don’t have adequate coverage, and that ends up costing us all,” he said.

Organizers with Idahoans for Healthcare have been driving this green truck around the state.(Phil Galewitz/KHN)

Later that week, another volunteer, Lauren Necochea, also found support in the Nampa area, west of Boise.

Norm Holm, 67, listened to her pitch. “It makes sense to me,” said Holm, a registered Republican. “Everyone deserves a decent shot at health care.”

Asked if he knew that the Medicaid expansion is part of the ACA, Holm shook his head. “If they can’t do away with it, maybe this is a way to make it better,” he said, adding that he believes the health law has good and bad parts.

In contrast, opponents of the referendum stress how Medicaid expansion is part of what they call the “failed Obamacare.”

The Idaho Republican Party and the conservative Idaho Freedom Foundation are fighting the ballot initiative. Foundation officials say it would divert dollars that could be spent on roads and education.

“Medicaid expansion is a cornerstone of Obamacare, which has failed to cover everyone and has led to increasing health costs,” said Fred Birnbaum, vice president of the foundation.

His group plans to run radio commercials, use social media and put out flyers.

Lawmakers opposed to expanding Medicaid have argued that the state could not afford its share of the cost without having to raise taxes. Under the law, the federal government pays about 90 percent of the costs for expansion and states cover the rest.

But a state-funded report this year found it would cost Idaho relatively little — $105 million over 10 years, which includes savings from state and county funds that would no longer be needed to help the uninsured. Idaho’s budget tops $3 billion a year.

Brad Little, the GOP nominee for governor who is widely expected to win in November, said he would abide by the will of the voters.

Perry is not the only Republican state lawmaker who has come out in support of expansion, but she is one of the most prominent. Perry tried — and failed — to get lawmakers to expand Medicaid. She is not running for re-election.

“Christy is well-known among GOP women and well-liked,” said Toni Lawson, vice president of government relations at the Idaho Hospital Association, which supports the initiative. She said persuading GOP women to vote for expansion will be key to a victory.

Perry said her gun store ownership and mainstream conservative values will help gain voters’ trust on Medicaid.

“Idaho is a conservative, Christian and right-to-life state, and Medicaid expansion fits right in with our morals and values we have,” she said. “It’s about doing the right thing.”

HHS Secretary Azar Declares Public Health Emergency in US Territory Due to Super Typhoon Yutu

HHS Gov News - October 26, 2018

Health and Human Services (HHS) Secretary Alex Azar today declared a public health emergency in the Commonwealth of the Northern Marianas Islands (CNMI), a U.S. territory, due to damage from Super Typhoon Yutu. The declaration follows President Trump’s emergency declaration for the territory and gives the HHS Centers for Medicare & Medicaid Services beneficiaries and their healthcare providers and suppliers greater flexibility in meeting emergency health needs.

“We are working closely with territory health authorities, the local hospital and other healthcare facilities to save lives and protect health after this catastrophic storm,” said HHS Secretary Alex Azar. “This declaration will help ensure that our fellow Americans who rely on Medicare and Medicaid have continuous access to the care they need.”

Super Typhoon Yutu hit the islands yesterday as a category 5 storm causing widespread damage.

Before the storm, CMS also worked with dialysis centers in the CNMI to encourage early dialysis of patients and activated the Kidney Community Emergency Response Program to monitor dialysis access and needs of these facilities after the typhoon.

HHS moved more than 50 medical and public health personnel along with their caches of medical supplies and equipment into Guam, the closest large territory to the CNMI before the storm; these personnel are ready to respond to medical and public health needs that CNMI officials identify in the storm’s aftermath. Additional personnel are staged or on alert from the National Disaster Medical System and the U.S. Public Health Service Commissioned Corps.

In addition to providing basic medical care, HHS teams can assist Urban Search and Rescue teams in triaging people found, support the health department with disease surveillance, offer behavioral health support for residents and responders, and more. HHS incident managers are working with CNMI officials to determine what federal medical and public health support is needed.

To assist residents in the impacted area in coping with the stress of the disasters, the Substance Abuse and Mental Health Services Administration activated the Disaster Distress Helpline. The Disaster Distress Helpline provides immediate 24/7, 365-days-a-year crisis counseling and support to people experiencing emotional distress related to natural or human-caused disasters. This toll-free, multilingual, and confidential crisis support service is available to all residents in the United States and its territories. Stress, anxiety, and other depression-like symptoms are common reactions after a disaster. Call 1-800-985-5990 to connect with a trained crisis counselor.

Additionally, the HHS Office for Civil Rights (OCR) has guidance available for territory agencies and community organizations to help ensure equal access to emergency services and the appropriate sharing of medical information during emergencies, including how federal civil rights laws apply in an emergencyhow HIPAA laws apply in an emergency. OCR also provided a HIPAA Disclosures for Emergency Preparedness Decision Tool.

In declaring the public health emergency, in CNMI and authorizing flexibilities for CMS beneficiaries, Secretary Azar acted under his authority in the Public Health Service Act and Social Security Act. These actions and flexibilities are retroactive to Oct. 24, 2018.

Public health and safety information for Super Typhoon Yutu can be found on the HHS emergency website, https://www.phe.gov/emergency/events/2018-Severe-Storms/Pages/default.aspx.
 

What You Need to Know about President Trump Cutting Down on Foreign Freeloading

HHS Gov News - October 26, 2018

“When foreign governments extort unreasonably low prices from U.S. drug makers, Americans have to pay more to subsidize the enormous cost of research and development. . . . It’s unfair and it’s ridiculous, and it’s not going to happen any longer.” — President Donald J. Trump

The President is proposing a new Medicare model, the International Pricing Index (IPI) model, that fulfills his promise to bring down drug prices and cut down on foreign freeriding.

  • On average, Medicare currently pays 180 percent of what other wealthy countries pay for the most costly physician-administered drugs.
  • The current system lets other countries reap the benefits of American pharmaceutical investment and innovation, while the costs fall on American patients and taxpayers.

The IPI model will ensure that American patients get a more fair deal on the discounts drug companies voluntarily give to other countries, saving patients and the Medicare program billions.

  • Here is how the model will work:
    • Today’s system: Medicare sets payments for physician-administered drugs at the average sales price in the U.S. market—plus a price-based add-on fee.
    • New model: Medicare sets the payment for these drugs at a Target Price, based on the discounts drug companies give other countries.
      • With the model fully implemented, total payment for these drugs will drop by 30 percent.
      • The Target Price is 126 percent of the average price other countries pay for the drug.
      • The model incorporates a new, larger add-on fee for hospitals and doctors that is independent of prices.
  • The model would be phased in over five years, with overall savings for American taxpayers and patients projected to total $17.2 billion, with out-of-pocket savings potentially totaling $3.4 billion.
  • The model would begin in 50 percent of the country, with the opportunity to scale up over time.
  • Medicare beneficiaries not covered by the model may also see drug costs go down, because the average price used to calculate traditional Medicare reimbursement will drop.

This model delivers on the President’s promise to lower drug prices—without any restrictions on patient access.

  • We propose no changes to the Medicare benefit, just more discounts from drug companies.
  • The Trump Administration will only pursue drug pricing solutions that will protect the incentives for inventing new cures and protect patient access.
  • This free-market approach seeks the same type of discounts that drug makers already voluntarily negotiate with economically-similar countries.

The proposal would keep compensation for doctors steady, while ending a perverse incentive where they are paid more for prescribing the most expensive drugs.

  • Today, doctors and hospitals’ add-on fee is calculated as a percentage share of the drug’s price, so the provider’s revenue increases when the price of the drug rises.
  • This proposal would hold compensation steady while removing perverse incentives that drive increased cost.

What the IPI Model Means for Americans

American Patients will see lower drug prices in Medicare, lower cost-sharing for those drugs, and a more secure Medicare program.

  • A senior who receives an eye medicine that currently costs Medicare $1,800 a month but other countries just $300, would see their co-insurance drop from $4,400 a year to $900 a year after full implementation of the proposal.
  • Some Medicare beneficiaries use a drug to fight infection that currently costs Medicare $4,700 every time they receive chemotherapy. On average it costs other countries $1,100. These beneficiaries would see their co-insurance drop from over $900 every time they use the drug to under $300 after full implementation of the proposal.

American Doctors will receive steady or higher compensation from the Medicare program, and no longer have a perverse incentive to prescribe drugs with higher prices. Doctors will also be able to get out of the business of bearing the risk of buying and billing for drugs.

  • Doctors are currently paid a 4.3 percent add-on fee for drugs due to budget sequestration. This would be increased, and then held as a constant fee, independent of prices.

American Hospitals will be able to get out of the business of buying and billing for drugs, freeing up capital and attention to invest in patient care.

American Drug Distributors and Wholesalers will have new business opportunities to negotiate with drug companies and offer doctors and hospitals a wide range of convenient options.

American and Foreign Drug Companies will have to reform their business models. However, the impact to their revenue would not be enough to substantially reduce current levels of research and development, and their impact would be reduced if foreign prices were more in line with U.S. prices.

HHS Advances Payment Model to Lower Drug Costs for Patients

HHS Gov News - October 26, 2018

On Thursday, the U.S. Department of Health and Human Services, through the Centers for Medicare & Medicaid Services (CMS), announced and sought input on a new “International Pricing Index” (IPI) payment model to reduce what Americans pay for prescription drugs.

Under the IPI model, described in an Advance Notice of Proposed Rulemaking (ANPRM), Medicare’s payments for select physician-administered drugs would shift to a level more closely aligned with prices in other countries. Overall savings for American taxpayers and patients are projected to total $17.2 billion over five years.

“President Trump promised that he would bring down drug prices and put American patients first,” said HHS Secretary Alex Azar. “With this innovative approach, he is now proposing historic changes to how Medicare pays for some of the most expensive prescription drugs, securing for the American people a share of the price concessions that drug makers voluntarily give to other countries.”

“In an era where the pharmaceutical industry is pricing drugs at levels approaching a million dollars—and jeopardizing the future of our safety net programs—the time has come to fix the perverse incentives in the Medicare program that are fueling price increases,” said CMS Administrator Seema Verma. “I appreciate President Trump and Secretary Azar’s bold leadership to lower seniors’ prescription drug costs and provide relief.”

The move from current payment levels to payment levels based on international prices would be phased in over a five-year period, would apply to 50 percent of the country, and would cover most drugs in Medicare Part B, which includes physician-administered medicines such as infusions. The model would correct existing incentives to prescribe higher-priced drugs and, for the first time, address disparities in prices between the United States and other countries. Since patient cost sharing is calculated based on Medicare’s payment amount, patients would see lower costs under the model.

Physicians currently purchase the drugs that they administer to patients and receive payment from Medicare for those drugs at an amount equal to the average sales price plus an “add-on” fee. The add-on is calculated as a percentage of the average sales price of the drug.

This creates several problems. First, the dollar amount of the add-on increases with the price of the drug, which encourages prescribing higher-cost drugs. Second, Medicare accepts sales prices for Part B drugs, with no negotiation. Together, this results in higher out-of-pocket costs that burden American seniors.

The pharmaceutical industry offers deep discounts abroad while taking advantage of the payment system in Medicare Part B which drives the cost in the U.S., even though Medicare is the world’s largest drug purchaser. The IPI model would take on this issue and pay vendors for Part B drugs at a level approaching international prices.

For the first time in Medicare, the IPI model would create a system in which private vendors procure drugs, distribute them to physicians and hospitals, and take on the responsibility of billing Medicare. Vendors would aggregate purchasing, seek volume-based discounts, and compete for providers’ business, thereby creating competition where none exists today.

Under the model, instead of the current percentage-based add-on payment, physicians and hospitals would receive a set payment amount for storing and handling drugs that would not be tied to drug prices. Therefore, the IPI model would remove the financial incentive to prescribe higher-cost drugs. The model also frees physicians from having to “buy and bill” high priced drugs, which creates financial risk that jeopardizes their practice and the ability to serve their community.

The agency is considering a randomized approach to determine which geographies in the country would participate in the model. 

The IPI model would achieve several goals: 

  • Reduce costs for Medicare beneficiaries, and thereby increase adherence and access to prescription drugs. 
  • Introduce competition to the system of paying for physician-administered drugs by bringing in private-sector vendors.
  • Reduce providers’ burden and the financial risk associated with managing drug inventories, so physicians can focus on patient care.
  • Maintain financial stability for physicians while removing incentives for higher drug prices.
  • Address the disparity in drug prices between the U.S. and other countries.
  • Reduce costs to the American taxpayers and Medicare beneficiaries who fund these programs.

The ANPRM ensures an open and transparent approach with opportunity for public input. CMS will carefully review comments and is considering issuing a proposed rule for the IPI in the spring of 2019, with a potential model start in spring 2020.

For a policy brief on the ANPRM, please visit: https://www.hhs.gov/about/leadership/secretary/priorities/drug-prices/ipi-policy-brief/index.html

For a fact sheet on the ANRPM, please visit: https://www.cms.gov/newsroom/fact-sheets/anprm-international-pricing-index-model-medicare-part-b-drugs

Comments on the ANPRM will be accepted until December 31, 2018 and may be submitted electronically through the CMS e-Regulation website at: https://www.cms.gov/Regulations-and-Guidance/Regulations-and-Policies/eRulemaking/index.html?redirect=/eRulemaking

The ANPRM can be downloaded at: https://www.cms.gov/sites/drupal/files/2018-10/10-25-2018%20CMS-5528-ANPRM.PDF

OCR Launches Public Education Campaign About Civil Rights Protections in Response to the National Opioid Crisis

HHS Gov News - October 26, 2018

Today the Office for Civil Rights (OCR) at the U.S. Department of Health and Human Services (HHS) launched a public education campaign on civil rights protections in light of the president’s opioid bill signing yesterday and HHS’s ongoing efforts to combat the opioid epidemic. The campaign aims to improve access to evidence-based opioid use disorder treatment and recovery services, such as Medication Assisted Treatment, by ensuring that covered entities are aware of their obligations under federal nondiscrimination laws, including laws prohibiting discrimination on the basis of disability or limited English proficiency. In addition, the campaign seeks to educate the public about disability rights protections that may apply to persons in recovery from an opioid addiction.

Well over 100 people in the United States die from an opioid related drug overdose every day. In October 2017, President Trump and HHS declared the opioid crisis a “Public Health Emergency” and many HHS agencies have taken important steps to address drug addiction and opioid misuse. In response to this emergency, OCR is issuing materials to help educate the public about civil rights protections regarding evidence-based opioid use disorder treatment and recovery services. The campaign complements OCR’s 2017 guidance – How HIPAA Allows Doctors to Respond to the Opioid Crisis informing doctors on how they can share information to help patients suffering from an opioid crisis.

Opioid misuse and addiction is a serious epidemic with devastating consequences that affect not only individuals and their families, but also the nation’s public health and economic welfare. “Persons getting help for an opioid use disorder are protected by our civil rights laws throughout their treatment and recovery,” said Roger Severino, OCR Director. “Discrimination, bias, and stereotypical beliefs about persons recovering from an opioid addiction can lead to unnecessary and unlawful barriers to health and social services that are key to addressing the opioid crisis.”

To learn more about OCR’s commitment to fighting against opioid misuse and addiction and how federal civil rights laws protect qualified individuals with an opioid use disorder, please visit www.hhs.gov/ocr/opioids. The website also highlights OCR’s important work on ensuring that HIPAA supports accessing and sharing important health information about individuals who are in crisis due to opioid addiction.

Podcast: KHN’s ‘What The Health?’ Trump, GOP Fight Back On Health Care

Kaiser Health News:HealthReform - October 25, 2018
Julie Rovner

Kaiser Health News

@jrovner

Read Julie's Stories Anna Edney

Bloomberg

@annaedney

Read Anna's Stories Kimberly Leonard

Washington Examiner

@leonardkl

Read Kimberly's Stories Alice Ollstein

Politico

@AliceOllstein

Read Alice's Stories

With Election Day less than two weeks away, the Trump administration tried to pivot away from Democrats’ attacks that they are out to dismantle health insurance protections for people with preexisting conditions.

The administration made three health care moves over the course of the week, including addressing high prices paid by the Medicare program for drugs administered in doctors’ offices and outpatient facilities.

Officials also released a proposed regulation that could strengthen the individual insurance market — by making it easier for employers to provide workers with funds so they can purchase their own health insurance. But the third action of the week could make the individual market more unstable — by providing a route for allowing states to use federal subsidies to let healthier individuals purchase less comprehensive coverage.

This week’s panelists for KHN’s “What the Health?” are Julie Rovner of Kaiser Health News, Anna Edney of Bloomberg News, Kimberly Leonard of the Washington Examiner and Alice Ollstein of Politico.

Among the takeaways from this week’s podcast:

  • The administration’s latest salvo in the battle against high drug prices deals with Medicare Part B drugs, which are those usually given for serious diseases like cancer or arthritis and are administered in a doctor’s office or outpatient facility because they involve injections or infusions.
  • The Medicare pricing for Plan B drugs often has been criticized for driving up costs. Medicare reimburses doctors for the costs they incur, plus 6 percent. Critics suggest that percentage encourages doctors to pay a high price for their drugs and that a flat administrative fee would be less inflationary.
  • Despite a raft of statements in recent weeks by Republicans  — including President Donald Trump — that they support protecting insurance coverage for people with preexisting medical problems, few GOP candidates have articulated any measures that would effectively do that.
  • Guidance announced by the administration this week to allow states to seek waivers for their ACA insurance marketplaces would upend some of the “guardrails” designed to make sure that all plans provide a set group of benefits, including preexisting condition guarantees.
  • Another proposed policy announced this week would allow employers to begin to decouple insurance from the job by giving workers tax-free money to buy policies on the ACA marketplaces.

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

Julie Rovner: Politico’s “HHS Reviews Refugee Operations As Trump Calls for Border Crackdown,” by Dan Diamond

and:

Rolling Stone’s “The Health Department’s Christian Crusade,” by Tessa Stuart

Kimberly Leonard: Reason.com’s “Trump’s Misleading Statement on Obamacare Is a Sign That Republicans Have No Idea How to Talk About Health Policy,” by Peter Suderman

Anna Edney: The New York Times’ “Miscarrying at Work: The Physical Toll of Pregnancy Discrimination,” by Jessica Silver-Greenberg and Natalie Kitroeff

Alice Ollstein: Kaiser Family Foundation’s “50-State Survey Finds Flat Medicaid Enrollment Tied to a Stronger Economy and New Eligibility Systems”

To hear all our podcasts, click here.

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

In Days Of Data Galore, Patients Have Trouble Getting Own Medical Records

Kaiser Health News:Marketplace - October 25, 2018
Navigating Aging

Navigating Aging focuses on medical issues and advice associated with aging and end-of-life care, helping America’s 45 million seniors and their families navigate the health care system.

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Medical records can be hard for patients to get, even in this digital information age. But they shouldn’t be: Federal law guarantees that people have a right to see and obtain a copy of their medical records.

New evidence of barriers to exercising this right comes from a study of 83 leading hospitals by researchers at Yale University. Late last year, researchers collected forms that patients use to request records from each hospital. Then, researchers called the hospitals and asked how to get records, the cost of doing so, how long it would take, the format in which information would be sent and whether the entire record would be available.

Researchers didn’t disclose they were conducting an academic study; instead, they posed as a relative asking questions on behalf of a grandmother who needed her records before seeking a second opinion. Family members make such requests on behalf of older relatives every day.

Hospitals’ answers were inconsistent: In many cases, the information on forms didn’t match what researchers were told on the phone. Sometimes their answers violated federal or state legal requirements.

Notably, only 53 percent of hospitals’ forms indicated patients could get their complete records. This right was acknowledged in all the phone calls. Forty-three percent of hospital forms didn’t disclose the estimated cost of obtaining records, as required. In phone calls, all but one hospital disclosed costs, but 59 percent cited a higher-than-government-recommended fee for electronic records.

“The unfortunate truth is that the system doesn’t give patients reliable or consistent responses. And some people who work in medical records departments appear to be ignorant of the law and the rights that patients have,” said Dr. Harlan Krumholz, co-author of the study and professor of medicine, epidemiology and public health at the Yale University School of Medicine.

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Under a groundbreaking law, the Health Insurance Portability and Accountability Act of 1996 (HIPAA), patients have a right to get some or all of their medical records upon request. (Psychotherapy notes can be excluded.) Hospitals, medical clinics, physician practices, pharmacies and health insurers are required to make this information available within 30 days (sometimes a 30-day extension can be granted), at a reasonable cost and in the format that patients request (for instance, paper copy, fax, electronic copy or CD), if possible.

Research suggests that reviewing medical records can be beneficial. People are more likely to follow treatment recommendations, remember what happened at medical visits and feel engaged in their care when they have access to this information, studies indicate. Use Our Content This story can be republished for free (details).
But HIPAA requirements are often misunderstood. Jacqueline O’Doherty, a geriatric care manager with Health Care Connect LLC of Califon, N.J., encountered this last month when she tried to see records for an 80-year-old client who was being transferred from a hospital to a nearby rehabilitation facility after suffering acute respiratory distress.

Although the older woman had signed a form appointing O’Doherty as a “designated representative” — a status that should have allowed O’Doherty access to her clients’ records — a hospital nurse refused to let O’Doherty check the client’s lab results, medication list and discharge summary. It was only when an infectious-disease doctor intervened, citing the need for continuity of care, that O’Doherty was able to review her client’s records.

“It really depends on the institution, what they will and won’t let you do,” O’Doherty said.

After receiving a large volume of complaints about records’ cost and accessibility, the Office for Civil Rights of the U.S. Department of Health and Human Services, issued new guidelines in January 2016. For electronic records, the guidelines prohibit per-page charges and recommend a maximum cost of $6.50 for consumers. They also clarify patients’ right to have records sent to third parties, including family members or professionals advocating on their behalf.

Despite these protections, the forms used to request records aren’t standardized and can be confusing. Often it’s not clear what is being offered. “As a person who works in the health care system, even I had trouble understanding the forms and what I could request based on the options listed,” said Carolyn Lye, a medical and law student at Yale who did much of the legwork for the new study.

Problems may be even more common at physician practices, which often don’t have medical records departments. When GetMyHealthData, a campaign to expand access to digital health information, asked consumers about their experience, people described poorly informed or unhelpful staff, high fees, long waits and frustrating bureaucratic processes, among other barriers.

“People are being told ‘No I can’t give this to you’” because office staff, nurses and doctors “don’t know what they can or cannot do,” said Pamela Lane, vice president of policy and government relations for the American Health Information Management Association.

Electronic patient portals don’t solve the problem yet: Most contain limited information and don’t currently include a way for patients to request records such as the notes physicians take during patient visits. “We’re slowly moving in that direction, but we’re not there yet,” said Catherine DesRoches, executive director of OpenNotes, an organization devoted to making doctors’ and nurses’ notes more readily available to patients.

The government is making improved electronic access to medical records a priority through its new MyHealthEData Initiative, announced earlier this year. Full details of the initiative are not yet available. But Seema Verma, administrator of the Centers for Medicare & Medicaid Services, has repeatedly called for people with Medicare coverage to have better access to their records. In an unusual move, she spoke out on Twitter about the Yale study, calling its findings “not acceptable.”

What can people do if they encounter problems like those documented by the Yale researchers?

If your hospital or doctor’s office declines to make your records available, print out materials about your rights and use them to advocate on your behalf. “Tell staff, ‘I’m entitled to a copy of my records: This is my legal right, as explained here,’” Lane said.

A good resource is a model medical records release form created by the American Health Information Management Association last year, which people can copy and bring with them to help make their case, Lane said. A summary of your right to share medical information with family, friends or other authorized third parties can be found here.

To familiarize yourself with your overall rights, see this “Guide to Getting & Using Your Health Records” published by the government’s Office of the National Coordinator for Health Information Technology. And take a look at the “Get Your Data” section of the GetMyHealthData website, which includes a clear summary of your rights, how to request your medical records, and troubleshooting suggestions if you encounter obstacles. A helpful two-page summary is available here.

KHN’s coverage of these topics is supported by John A. Hartford Foundation and The SCAN Foundation

Booming Economy Helps Flatten Medicaid Enrollment And Limit Costs, States Report

Kaiser Health News:HealthReform - October 25, 2018

Medicaid enrollment fell by 0.6 percent in 2018 — its first drop since 2007 — due to the strong economy and increased efforts in some states to verify eligibility, a new report finds.

But costs continue to go up. Total Medicaid spending rose 4.2 percent in 2018, same as a year ago, as a result of rising costs for drugs, long-term care and mental health services, according to the study released Thursday by the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

States expect total Medicaid spending growth to accelerate modestly to 5.3 percent in 2019 as enrollment increases by about 1 percent, according to the annual survey of state Medicaid directors.

About 73 million people were enrolled in Medicaid in August, according to a federal report released Wednesday.

Medicaid, the state-federal health insurance program for low-income Americans, has seen its rolls soar in the past decade — initially as a result of massive job losses during the Great Recession and in recent years when dozens of states expanded eligibility using federal financing provided by the Affordable Care Act. Thirty-three states expanded their programs to cover people with incomes under 138 percent of the federal poverty level, or an income of about $16,750 for an individual in 2018.

Medicaid spending and enrollment typically rise during economic downturns as more people lose jobs and health benefits. When the economy is humming, Medicaid enrollment flattens as more people get back to work and can get coverage at work or can afford to buy it on their own. The national unemployment rate was 3.7 percent in September, the lowest since 1969.

The falling unemployment rate is the main reason for the drop in Medicaid enrollment, but some states have reduced their rolls by requiring adults and families to verify their eligibility. Arkansas, for example, has cut thousands of people after instituting new steps to confirm eligibility.

The brightening economic outlook for states has led many to increase benefits to enrollees and payment rates for health providers.

“A total of 19 states expanded or enhanced covered benefits in fiscal 2018 and 24 states plan to add or enhance benefits for the current fiscal year, which for most states started in July,” the Kaiser report said. “The most common benefit enhancements reported were for mental health and substance abuse services. A handful of states reported expansions related to dental services, telehealth, physical or occupational therapies and home visiting services for pregnant women.”

A dozen states increased pay to dentists and 18 states added to primary care doctors’ reimbursements for fiscal year 2019.

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Medicaid covers about 20 percent of U.S. residents and accounts for nearly one-sixth of health care expenditures. Nearly half of enrollees are children.

Overall, the federal government pays about 62 percent of Medicaid costs with state’s picking up the rest. Poorer states get a higher federal match rate.

Seventeen Republican-controlled states have not expanded Medicaid. For individuals accepted into the program as part of the ACA expansion, the federal government paid the full cost of coverage from 2014 through 2016. It will pay no less than 90 percent thereafter.

In 2018, the states’ share of spending rose 4.9 percent. This was the first full year that states were responsible for part of the cost of the expansion. States expect their spending will grow about 3.5 percent in 2019.

Robin Rudowitz, one of the authors of the study and associate director of the Kaiser Program on Medicaid and the Uninsured, said the survey found many states were using Medicaid to address the opioid crisis by expanding benefits for substance disorders and also by implementing tougher restrictions on prescriptions.

“Almost every governor wants to do something, and Medicaid is generally a large part of it,” she said.

While the Trump administration’s approval of work requirements for some adults on Medicaid has generated controversy over the past year, the report shows that states are making many other changes to the program, such as increasing benefits and changing how it pays providers to get better value.

States Explore Paths To Pay Their Share For Medicaid Expansion — Using Political GPS

Kaiser Health News:States - October 24, 2018

Last year, nearly 60 percent of Maine residents voted to expand the state’s Medicaid program — an option provided by the Affordable Care Act that would extend health insurance to tens of thousands of the state’s low-income people.

But the state’s Republican governor, Paul LePage, a longtime opponent of Medicaid expansion, has refused to implement the policy because he doesn’t want to raise taxes to pay the state’s share of the cost.

The impasse highlights how the intense political push and pull over Medicaid expansion persists even when voters bypass legislators and decide the issue directly at the ballot box. Nevertheless, four more states — Idaho, Montana, Nebraska and Utah — will give voters in November’s elections the opportunity to resolve the dispute.

“It’s always treacherous” for politicians to raise taxes, said Matt Salo, who heads the National Association of Medicaid Directors. “But there are ways around it. You can figure out ways that are politically palatable.”

When the ACA’s Medicaid expansion took effect in 2014, proponents say, it set up an enticing deal. It allowed states to cover people with incomes up to 138 percent of the federal poverty level, including childless single adults.

The federal government paid the entire cost of the new enrollees. In 2017, states were to take on 5 percent of those costs. By 2020, that amount will increase to 10 percent.

States that didn’t pursue the expansion pay as much as half the cost of coverage. And, in 2018, median eligibility for a family of four was 43 percent of the poverty level, or about $10,800. No childless adults were eligible.

So far, 33 states plus the District of Columbia have opted to expand, extending coverage to almost 12 million Americans, according to federal estimates last year. In those states, the expense ranges from tens of millions of dollars to hundreds of millions.

Rather than being a cash drain, many health policy researchers and economists note, expansion has generally boosted state economies, with higher employment, reduced state spending on health care services for the uninsured and consumer spending elsewhere that would have gone to health care.

“The state savings are so significant, they make it much more manageable,” said Adam Searing, an associate professor of practice at Georgetown University’s Center for Children and Families. “The issue of how it gets paid for — it’s still an important issue, but it’s not as front and center.”

Different approaches work for different states, Salo said, and all invite political complications.

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In Montana, voters are considering Initiative 185, a ballot question that would continue the state’s Medicaid expansion and fund it by increasing what is known as a “sin tax” on tobacco products, including electronic cigarettes.

It’s a counterintuitive double whammy in such a conservative state: persuading voters first to favor an Obamacare policy, and second to finance it with a tax hike.

By taking on cigarettes, the campaign has incurred the wrath of Big Tobacco, which has put forth more than $12 million in contributions and expenditures to fight the measure.

“Anytime you go up against the tobacco industry, you are mainly going to have them as your opponent,” said Amanda Cahill, who directs government relations for Montana’s American Heart Association chapter and is part of the “Yes on I-185” campaign.

Voters can be skittish about a tax increase, she said, but many are receptive to the campaign’s argument that it pays off in the long term.

New Hampshire took a parallel “sin tax”-type approach. It uses money from an alcohol tax to help fund expansion, a deal negotiated this year.

In Utah, voters will consider newly expanding Medicaid and funding it with a 0.15 percent increase to the state’s sales tax, though the hike would exempt groceries. Current polling suggests strong voter support. Nebraska and Idaho also have Medicaid expansion on the ballot, though they would punt the funding question to state legislatures.

Other states have tried a different strategy: shielding consumers from direct taxes and instead financing expansion through taxes on industry players that benefit from Medicaid expansion. The most notable example: hospitals. For these facilities, reducing the number of uninsured, low-income people reduces the burden of uncompensated care and improves their bottom line. Research from states that have already expanded Medicaid supports this idea.

Virginia, Oregon and Colorado already have such taxes or fees in place. (Oregon voters in January approved a tax on both health insurance and hospitals to fund expansion.)

But it hasn’t been easy. Virginia’s legislature voted this summer to expand Medicaid eligibility after failing five times. During Statehouse debates, funding was a “very significant concern,” said Michael Cassidy, president of the Commonwealth Institute for Fiscal Analysis, a Richmond-based think tank that has long supported the policy.

Proponents of expansion showed economic projections that Virginia would benefit financially, since fewer uninsured people would need state-funded health services, and the injection of federal cash would boost the state economy.

The legislature eventually approved a tax on hospitals, by garnering support from their trade group, the Virginia Hospital and Healthcare Association. But the path to approval was “quite contentious,” Cassidy said. Critics argued the cost was too great and could drive up health care expenses.

Medicaid advocates haven’t begun planning ballot initiatives for 2020 yet, but there are six states that haven’t expanded eligibility where voters could take on the question directly: Florida, Mississippi, Missouri, Oklahoma, South Dakota and Wyoming.

As political analysts have long argued, the issue isn’t entirely about funding. States can surmount that obstacle if there is political will.

“If you’re talking about why did certain states not do the expansion, the fear of the cost — while a real issue — has never been within the top three of the actual reasons why they actually didn’t do it,” Salo said. “It all has been political and ideological.”

Secretary Azar Praises President Trump’s Proposal to Create New Insurance Options

HHS Gov News - October 23, 2018

On Tuesday, the Departments of Labor, Health and Human Services, and the Treasury issued a proposed regulation that expands health reimbursement arrangements (HRAs), allowing employers to use them to make contributions toward employees’ purchase of individual-market insurance.

HHS Secretary Alex Azar issued the following statement regarding the proposal:

“Today’s announcement is another example of President Trump’s delivering on his promise to provide for more affordable healthcare options for the American people. More access to association health plans, short-term insurance, and flexible HRAs complement the work we are doing at HHS to bring down drug prices and lower the cost of healthcare services. Each of these actions is focused on empowering patients through transparency, choices, and competition.”

Read the full release on the rule: https://www.dol.gov/newsroom/releases/ebsa/ebsa20181023

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