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Gavin Newsom Is Bullish On Single-Payer — Except When He’s Not

Kaiser Health News:HealthReform - October 23, 2018

Twenty minutes before the only scheduled 2018 California’s gubernatorial debate, Lt. Gov. Gavin Newsom rolled into the San Francisco parking garage in a black SUV. Through the tinted windows, a soft overhead light slightly illuminated the front-runner’s chiseled features and slicked-back hair.

In a well-tailored blue suit and matching tie, Newsom strode to the elevator and casually leaned his tall frame against the corner, emerging on KQED radio’s third floor to banter with waiting reporters — the picture of a polished and confident front-runner.

Then, in gravelly tones, Newsom squared off with his Republican opponent John Cox, letting loose his inner wonk, delving into the weeds on all manner of issues in the Golden State. “If you’re looking for timidity, I’m not your person,” he said when asked about his temperament.

But not once did the Democratic candidate mention one of the most controversial pillars of his campaign: single-payer health insurance.

Nationally, Newsom’s support for single-payer is perhaps how he is best known — aside from his bold move as San Francisco mayor in 2004 to sign marriage licenses for same-sex couples, a prescient decision that then ran contrary to law.

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Newsom’s backing for government-run, universal coverage has often been similarly bold, but other times it has been more muted, prompting conservatives to call him too liberal and liberals to label him too skittish. That dichotomy is likely a reflection of the political challenges he will face, if elected, even in one of the nation’s bluest states.

His notable omission of single-payer in the debate earlier this month could have stemmed from a tightly choreographed format and time limitations — but his opponent’s campaign immediately jumped on him for it, calling his past effort to create universal health care in San Francisco a failure of which he should be “ashamed.”

Newsom, 51, who declined requests for an interview, has at times attempted to dampen expectations, suggesting in July to the San Francisco Chronicle that the single-payer effort could take years. In part, he was acknowledging a practical hurdle: The federal government needs to approve the move if federal dollars are to be used, and the Trump administration is flatly opposed.

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On his campaign website, however, Newsom has publicly called for single-payer coverage in California. Last year, he endorsed the amended Healthy California Act, SB 562, which called for covering every Californian, including undocumented immigrants, under one public program.

The bill stalled, in part because it was projected to cost $400 billion a year, nearly three times the general fund expenditures for 2018-19. But the California Nurses Association, which has endorsed Newsom, plans to sponsor a new bill in the coming legislative session.

Newsom’s supporters say he is committed to the effort — simply because he believes it is the right thing to do.

“There are some people who have health care coverage and others who don’t,” said Mitch Katz, director of public health in San Francisco when Newsom was mayor and an unpaid adviser to his campaign. “Everyone should be covered — for Gavin, it’s a fairness issue.”

(His opponent, Cox, dismisses the very idea. Asked earlier this year whether he supports single-payer, his answer was simple: “God, no.”)

Even some who respect Newsom’s motives see his goal as quixotic.

“I’ve followed his career and believe he is an individual of integrity who wants to advance meaningful legislation that helps people,” wrote Stanford professor and author Dr. Robert Pearl in Forbes magazine. “That said, in a state that’s currently struggling to fund its schools and rebuild its infrastructure, Newsom will likely soon realize that turning California into a single-payer state is too expensive a promise to carry out.”

Newsom commonly pulls out his health care bona fides, namely his experience as mayor of San Francisco, when the city spearheaded a unique, all-embracing health care system for city residents.

“I did universal health care in San Francisco,” said Newsom on a progressive podcast recently. “We proved it could be done without bankrupting the city. I’d like to see that we can extend that to the rest of the state.”

Healthy San Francisco is not a single-payer system — not an entirely publicly funded insurance plan. It aims for universal care by covering lower-income residents through a combination of city funds, charity care, copayments and contributions from employers. It’s not true insurance because it can’t be used outside the city.

Enrollees have access to a citywide network of preexisting safety-net hospitals and clinics. At its height, it enrolled 60,000 city residents, though enrollment plunged to 14,000 after the Affordable Care Act took effect. Today, undocumented residents make up the largest share of those on Healthy San Francisco.

Some critics on the left say Newsom took credit for Healthy San Francisco only after it was deemed a success.

“Newsom is claiming credit for something he didn’t really do and didn’t support,” said Tom Ammiano, the former San Francisco supervisor and state assembly member who was chief architect of Healthy San Francisco. “If anything, I would say he did his best to undermine it.”

While Newsom liked the idea of universal health care in San Francisco, he did not publicly support the requirement for restaurants to contribute to employees’ health benefits, according to Ammiano and others who worked on Healthy San Francisco. But the Board of Supervisors voted unanimously for Healthy San Francisco, blocking any chance for a veto, and then Newsom signed it into law.

After it passed in 2006, the Golden Gate Restaurant Association sued San Francisco, arguing unsuccessfully that forcing restaurants to chip in on employees’ benefits was in conflict with a federal law governing employee benefits. “We went to court three times, and three times we won,” Ammiano said. “Where was Gavin? He never entered that fray. He never supported it, never did anything publicly.”

San Francisco progressives, like Ammiano and others, have never cared for Newsom’s pro-business stance (Newsom has owned wine shops and numerous other small businesses with about 700 employees), or what they see as his slick persona when he was mayor from 2004 to 2011. Among some circles in San Francisco, Newsom was known as “Mayor Press Release,” meaning he had a lot of big ideas but little follow-through.

The San Francisco League of Pissed Off Voters, a progressive political organization that puts out a voter guide, called Newsom a “substanceless glad-hander” who “has been flashing fake smiles, pretending to be progressive for the cameras. … He’s a machine-politics climber who claims to fight for the dispossessed but never seems to get around to actually doing anything for them.”

But even as a vocal critic of Newsom, Ammiano said he plans on voting for him as governor. “There is no third option,” Ammiano said. “I don’t believe in not voting, and I could never do Cox.”

A governor would face numerous hurdles in fundamentally restructuring the state health care system to cover everyone, including getting buy-in from the feds and confronting opposition from insurers and others invested in the status quo.

But Newsom’s supporters say that a governor, at least, would have more authority than a mayor.

“The state has much more power over health care delivery than the county of San Francisco,” said Katz, now president and CEO of NYC Health + Hospitals. “There are many more levers when you are the governor than when you are the mayor.”

Ken Jacobs, chair of the Center for Labor Research and Education at UC Berkeley and a member of the council that helped craft Healthy San Francisco, agreed.

For instance, Newsom could push to expand Medi-Cal — the public insurance program for low-income Californians — to include undocumented immigrants, said Jacobs, co-author of Universal Health Care: Lessons From San Francisco. Also, he could prevail upon legislators to institute a state mandate for health insurance and provide state subsidies to help cover the cost.

That wouldn’t meet the definition of “single-payer” but would tap a variety of sources to pay into a system that aspires to cover everyone.

Whatever approach he takes, Jacobs said, “Gavin Newsom took the issue of health care very seriously as mayor, and I would expect him to do so as governor.”

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

Fixing Obamacare’s ‘Family Glitch’ Hinges On Outcome Of November Elections

Kaiser Health News:HealthReform - October 23, 2018

Last Christmas Eve, Justine Bradford-Trent slipped on ice, slamming to the ground. Her elbow swelled. Was it broken? She couldn’t tell.

Because Bradford-Trent was uninsured, she weighed her options. She could go to the emergency room, the immediate but more costly option. The urgent care center cost less, but it was closed for the holiday. The Idaho resident decided to wait and, once the swelling subsided, she concluded it was just a bad bruise.

Bradford-Trent, 54, knows she was lucky this time. But, because her family can’t afford health insurance, she worries about the next time something happens.

“What if … I end up with cancer or [something] like that,” she said. “I don’t want to be faced with a decision of having to make a choice: to live or die? Or do we go into debt so deeply that it’s thousands and thousands of dollars just to save me, and we’re stuck in debt for the rest of our lives?”

Although the Affordable Care Act is credited with expanding health insurance to about 20 million Americans, a small segment of the population — including Bradford-Trent — has been left behind.

The problem is called the “family glitch.” It’s deeply rooted in the health law’s weeds. And fixing it would cost taxpayers a bundle.

In the current Republican-controlled Congress — which has been more interested in dismantling the health law than building on it — such a fix is unlikely. Unlikely, that is, unless the Democrats, who have been campaigning hard for the congressional elections on health care issues, pick up enough seats to control the legislative agenda.

Under the ACA, people who meet a particular income threshold can get a federal subsidy to help buy insurance on the marketplace. One of the conditions of eligibility is that the consumer doesn’t have access to “affordable” coverage through work — that is, the employee’s share of the insurance would cost no more than 9.86 percent of the employee’s household income.

The sticky part: calculating affordability considers only the cost of insuring one family member, even if the person’s spouse and children also would be covered through that health plan. So while the cost of individual coverage might sound feasible, adding the rest of the family would quickly cause financial strain.

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For Bradford-Trent, it’s a real problem. Her husband, who works in commercial construction, makes $66,000 per year and is the family’s primary breadwinner. She’s a part-time notary public, earning “a few hundred dollars a month — not enough to pay for insurance,” she said.

His employer-based coverage alone would be a doable $172 a month. That’s well within the 9.86 percent “affordability” threshold. But to add their daughter to the plan is another $270. To add Bradford-Trent as well would add $718 more, she says — a total of $1,060. “That’s 25 percent of his take-home pay — 25 percent,” she said. “That’s astronomical.” And that doesn’t include out-of-pocket costs for any medications or procedures.

For now, they’ve chosen to buy insurance for her husband and daughter. She goes without and hopes to stay healthy.

They’ve explored other health coverage options. She is looking for a full-time job with benefits. She and her husband have considered divorcing, or moving to another state, to see if she could qualify for health coverage. They’ve even turned to the ACA marketplace in search of an individual plan for her, but those generally have a price tag north of $400 a month.

This year, Obamacare open enrollment runs from Nov. 1 to Dec. 15. The Centers for Medicare & Medicaid Services announced Oct. 11 that the cost of premiums for plans available on the federal marketplace have, for the first time, trended downward. In 2018, by contrast, the national average rate of premium hikes ran well into the double digits. (Idaho’s average 2019 increase is 5 percent, far below last year’s 27 percent hike.)

I don’t want to be faced with a decision of having to make a choice: to live or die?

Justine Bradford-Trent

Policy analysts say there is no obvious solution to the family glitch. It’s a widely recognized problem that has gotten lost in the shuffle, as it affects a relatively small number of Americans — up to about 1.8 percent of the population, or 6 million people.

“Last year there was essentially one issue, and that was all of the repeal-and-replace attempts,” said Matthew Buettgens, a senior research analyst at the Urban Institute’s Health Policy Center, who has studied the glitch. “Proposals to expand federal spending have not been active in the public debate.”

Any fix, for instance, would likely involve changing the eligibility calculation for marketplace subsidies — pegging the affordability standard to the coverage cost of the whole family rather than just an individual’s coverage. Doing so would increase federal spending by about $9 billion or $10 billion, according to estimates by the Rand Corp., a nonprofit think tank, since many more people would qualify for subsidies.

Such a change was proposed by Hillary Clinton during her presidential campaign and is now part of bills put forth by Sen. Elizabeth Warren (D-Mass.) and Rep. Frank Pallone (D-N.J.), though both bills have stalled on Capitol Hill.

But the idea could gain traction if Democrats — who are already campaigning on health care and slogans like “Medicare-for-all” — take one or both chambers of Congress.

“If you talk about what might be realistically possible if the election produces strong shocks to the system, then maybe you think, ‘Well, the Democrats have the majority in the House. Maybe Democrats and Republicans could come together on some affordability reforms,” said Jonathan Oberlander, a professor of social medicine and health policy at the University of North Carolina at Chapel Hill. “This would be an enticing part of that agenda.”

The White House says it’s taking steps to address health care unaffordability — rolling out plans such as “association health plans” and “short-term limited-duration plans” — skimpier, less regulated coverage that also cost less. That could be an option for people priced out of both employer and marketplace plans, some experts say.

“If your alternative is less affordable coverage — or none at all — they look more attractive,” said Thomas Miller, a resident fellow at the conservative American Enterprise Institute, a Washington think tank.

But other experts caution that those options leave patients vulnerable, since they can charge higher rates to people with preexisting conditions, cover fewer benefits and often have higher out-of-pocket costs. For Bradford-Trent, such plans cover too little to merit the price, she said.

For now, she feels forgotten. And hopes she won’t get sick.

“There are choices you don’t want to have to make for yourself in life because affordable health care is not available,” Bradford-Trent said.

Marketplace Subsidies May Be Option In 2020 For Plans That Skirt Obamacare

Kaiser Health News:HealthReform - October 22, 2018

States would be able to use federal funding to provide subsidies to people buying short-term health insurance policies, which typically don’t provide comprehensive coverage, under guidance released Monday by the Trump administration.

The new policy could begin taking effect in 2020. It would allow states to ask for waivers from Affordable Care Act provisions governing not only subsidies that help pay for premiums, but also the benefits insurers must include in plans offered on the federal marketplace to consumers buying their own coverage.

The announcement comes two weeks before the crucial midterm Election Day as health care tops voters’ list of concerns.

States were asking for more flexibility, said Seema Verma, administrator of the Centers for Medicare & Medicaid Services (CMS). This approach would allow the states “to provide consumers plan options that best meet their needs, while at the same time ensuring that those with preexisting conditions retain access to the same coverage as today,” she said.

Under the ACA, states can ask to reconfigure their insurance markets and rules. The Obama administration required any changes to provide the same comprehensive coverage as the health law and not result in fewer people enrolling or increasing costs for taxpayers.

Those guidelines hampered finding creative ways to expand coverage and lower costs, Verma said.

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The new guidance substantially revises those Obama-era “guardrails,” allowing waivers so long as access to comprehensive plans remains.

“The big change is they no longer have to worry about making sure that people with preexisting conditions or high health care needs maintain enrollment in comprehensive coverage,” said Sabrina Corlette, research professor at the Center on Health Insurance Reforms at Georgetown University.

“The Trump administration looks like it’s willing to aggressively test the boundaries of the law when it comes to waivers. Whether that’ll stand up in court is very much open to question,” said Nicholas Bagley, a health law professor at the University of Michigan Law School.

Under Monday’s revised guidance, CMS is changing how it defines insurance sold on the ACA marketplaces in 2020 to include short-term or association health plans. These plans don’t have to follow all the Obamacare rules for eligibility and benefits. Short-term plans, for example, don’t have to be comprehensive and can exclude people with certain health conditions or charge them higher premiums. They can leave out coverage for mental health, prescription drugs or maternity care, for example.

Under President Barack Obama, such plans were limited to 90-day terms. The Trump administration this spring said short-term plans could be sold for up to a year and gave insurers the option to renew them for up to three years.

However, they cannot be sold through the health law marketplaces in 2019 and are not now eligible for federal premium subsidies for low-income customers.

Earlier in the year, the administration also approved a rule allowing businesses to band together in “associations” to buy health insurance to offer insurance to members. Critics fear that rule could expose consumers to coverage gaps or higher out-of-pocket costs because these plans would be classified as “large-group plans” and not have to meet some ACA requirements.

The changes unveiled on Monday do not affect people who get their coverage through their jobs.

Verma is using an Obamacare provision — so-called 1332 waivers — to dramatically reshape Obamacare, a health law she has repeatedly called on to be repealed by Congress.

She insisted that none of the changes would hinder people with preexisting conditions from buying or affording coverage. That concern has proven to be a potent campaign message for Democrats.

The new guidelines could increase enrollment for consumers who forgo coverage because of cost.

Under Monday’s proposal, states could also ask to change eligibility for subsidies under the ACA, perhaps to offer bigger amounts to younger adults — not necessarily tied to their income — as a way to drive them to buy coverage, said Verma.

States have struggled to attract younger adults to buy coverage in the Obamacare marketplaces. That age group is prized because it tends to have the lowest health risks and lowest costs, which helps balance the insurers’ risk pools and keep premiums from rising.

As expected, Obamacare opponents hailed the new guidance from CMS.

“Americans should have lower costs and more choices when it comes to health care, so the Trump administration has taken a good next step with the waiver process,” said Doug Badger, a visiting fellow for the conservative Heritage Foundation. “By removing even a few Obamacare restrictions, the administration has opened the door to more patient-friendly state innovation.”

Yet the guidance also moves the country back to an era when there was wide variation in insurance rules state to state, others noted.

“The ACA was passed in 2010 because states weren’t getting the job done,” said Corlette at Georgetown. “We had a patchwork of protections at the state level, 49 million uninsured and people being denied coverage because they had preexisting conditions.”

Analysts both inside and outside the government predict that the less expensive short-term plans would draw younger and healthier people from the ACA marketplaces, thus driving up premiums for those who remain.

Estimates on how many would do so and what the total effect on premiums would be varies widely. Verma said that earlier reports done by the administration indicated there would be only a modest effect on ACA premiums by increased enrollment in short-term plans.

Corlette said that remains unclear. The effect on premiums, she said, is unknown because no state has applied yet under the new guidance.

“The hypotheticals that are permissible under this could dramatically raise premiums for people with preexisting conditions, but it’s just too early to say,” she said.

Verma said several states have come to her asking to make changes in how they sell individual insurance, although she declined on a call with reporters to name the states.

The average health insurance rates for Obamacare plans are falling by 1 percent for 2019 — its first-ever drop, CMS announced earlier this month. But Verma said rates remain too high.

“In response to numerous requests from governments, the administration is giving states the flexibility they need to increase choices and combat high Obamacare premiums,” she said.

KHN chief Washington correspondent Julie Rovner contributed to this report.

Primary Care Doctors ‘Not Doing Enough’ To Curb STDs

Kaiser Health News:Marketplace - October 22, 2018

Julie Lopez, 21, has been tested regularly for sexually transmitted diseases since she was a teenager. But when Lopez first asked her primary care doctor about screening, he reacted with surprise, she said.

“He said people don’t usually ask. But I did,” said Lopez, a college student in Pasadena, Calif. “It’s really important.”

Lopez usually goes to Planned Parenthood instead for the tests because “they ask the questions that need to be asked,” she said.

As rates of sexually transmitted infections steadily rise nationwide, public health officials and experts say primary care doctors need to step up screening and treatment.

“We know that doctors are not doing enough screening for STDs,” said David Harvey, executive director at the National Coalition of STD Directors. The failure to screen routinely “is leading to an explosion in STD rates,” he said, adding that cutbacks in funding and a lack of patient awareness about the risks make it worse.

The federal government’s Centers for Disease Control and Prevention has set guidelines for annual screening for sexually active individuals. Among them: women under 25 should be tested for gonorrhea and chlamydia, and men who have sex with men should get tested for syphilis, chlamydia and gonorrhea.

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However, testing does not always happen as recommended. For example, only about half of sexually active women ages 16 to 24 with private health plans or Medicaid were screened for chlamydia in 2015. The rate was slightly better in California.

Nationally, reported cases of chlamydia, gonorrhea and syphilis are at an all-time high, CDC data show. In one year, from 2016 to 2017, nationwide rates of chlamydia rose by 7 percent, gonorrhea by 19 percent and syphilis by 11 percent.

Rates of congenital syphilis, which passes from mother to baby during pregnancy or delivery, increased by 44 percent during that time. Nearly one-third of the congenital syphilis cases are from California. The state also saw a record number of STDs last year: more than 300,000 cases of gonorrhea, chlamydia and early syphilis among adults.

Because sexually transmitted infections are often asymptomatic, screening is essential. Untreated STDs can lead to serious health problems, such as chronic pain, infertility or even death.

“Providers and primary care providers play a crucial role in combating these rising STD rates,” said Dr. Laura Bachmann, chief medical officer for the CDC division of STD prevention. “If providers don’t ask the questions and don’t apply the screening recommendations, the majority of STDs will be missed.”

State governments don’t have enough money to combat the rising number of cases, in part because federal STD funding for them has remained stagnant, Harvey said. Last year, he said, $152.3 million in federal funding was appropriated for prevention, the same as eight years earlier.

Experts cite several reasons primary care physicians don’t routinely diagnose and treat STDs. They may worry that they won’t be compensated for providing STD services, or they may not be familiar with the most up-to-date recommendations about testing and treatment. For example, the CDC in 2015 updated the medications it recommends to treat gonorrhea.

Perhaps most commonly, many family physicians are reluctant to discuss sexual health with their patients. One study showed that one-third of adolescents had annual visits that didn’t include any discussion about sexuality.

“We’re in this situation with health care providers and patients — each waiting for the other to start [the conversation],” said Dr. Edward Hook, professor at the University of Alabama-Birmingham School of Medicine. “Doctors worry if they ask patients about their sexual history that it will somehow be offensive to them.”

Dr. Michael Munger, president of the American Academy of Family Physicians, said he remembers that his conversations around sexual health were uncomfortable at first. “There are a lot of challenging conversations you can have with patients,” he said. “But this is important. If we don’t do it, who will?”

Rob Nolan gets tested for sexually transmitted diseases every six months so he always knows his status. But he says he feels more comfortable doing so at the Los Angeles LGBT Center rather than during visits with his regular doctor. “There is a sense of shame when you are telling your doctor you might have contracted something,” he says. (Courtesy of Rob Nolan)

Rob Nolan, a writer from Los Angeles, said he gets tested every six months, but he prefers to do so at the Los Angeles LGBT Center rather than during visits with his regular doctor, who rarely asks about sexual health.

Nolan, who said he has had experience with STDs, considers the clinic’s staff to be more knowledgeable about sexual health than those at a regular doctor’s office. “They just seem specialized in it,” he said. “And there is zero shame when you are in the clinic.”

Physicians also may have other, more immediate health issues to address during the short time they have with patients. Taking a sexual history and talking about sexual health falls to the bottom of many doctors’ priorities, said Dr. Leo Moore, acting medical director of the division of HIV and STD programs for the Los Angeles County Department of Public Health.

Julia Brewer, a nurse practitioner at Northeast Community Clinic in Hawthorne, Calif., said she screens for STDs as a regular part of women’s health exams. But she said her colleagues frequently refer cases to her rather than having the conversations themselves. “The family providers are overwhelmed with diabetes and high blood pressure,” she said. Sexual health, she said, can end up being an “afterthought.”

The L.A. County public health department, which identified STDs as a key priority for the next five years, recently sent representatives to doctors’ offices to teach providers how to address sexually transmitted infections. They distributed information detailing screening recommendations, sample sexual history questions and treatment guidelines.

The Los Angeles County Medical Association also plans to get the word out to doctors through social media and other efforts. “It’s an epidemic and we have to treat it that way,” said CEO Gustavo Friederichsen. “Doctors have to feel a sense of urgency.”

Dr. Heidi Bauer, who heads the California Department of Public Health’s STD control branch, said the state also is trying to educate doctors so they will screen more routinely. The department provides both in-person and online training for doctors to learn about STDs, and publishes downloadable information with current guidelines.

At the same time, Bauer urged the federal government to make its screening recommendations more comprehensive. Outside of pregnancy, for example, there are no recommendations for routine syphilis screening for women. “We are seeing this huge re-emergence of syphilis,” she said. “We haven’t been testing and syphilis is very challenging to diagnose.”

The CDC plans to review the recommendations in the next year, Bachmann said.

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

Politicians Hop Aboard ‘Medicare-For-All’ Train, Destination Unknown

Kaiser Health News:HealthReform - October 22, 2018

After decades in the political wilderness, “Medicare-for-all” and single-payer health care are suddenly popular. The words appear in political advertisements and are cheered at campaign rallies — even in deep-red states. They are promoted by a growing number of high-profile Democratic candidates, like Alexandria Ocasio-Cortez in New York and Rep. Beto O’Rourke in Texas.

Republicans are concerned enough that this month President Donald Trump wrote a scathing op-ed essay that portrayed Medicare for all as a threat to older people and to American freedom.

It is not that. But what exactly these proposals mean to many of the people who say they support them remains unclear.

As a renegade candidate for the 2016 Democratic nomination for president, Sen. Bernie Sanders (I-Vt.) opened the door to such drastic reform. Now, with Republicans showing little aptitude for fixing an expensive, dysfunctional health system, more voters, doctors and politicians are walking through it.

More than 120 members of Congress have signed on as co-sponsors of a bill called the Expanded and Improved Medicare for All Act, up from 62 in 2016. And at least 70 have joined Capitol Hill’s new Medicare for All Caucus.

But some worry the terms “Medicare-for-all” and “single-payer” are at risk of becoming empty campaign slogans. In precise terms, Medicare-for-all means bringing all Americans under the government’s insurance program now reserved for people 65 and over, while single-payer health care would have the government pay everyone’s medical bills. But few politicians are speaking precisely.

Celinda Lake, a Democratic pollster, said, “People read into ‘Medicare-for-all’ what they want to read into it.”

For every candidate with a clear proposal in mind, another uses the phrases as a proxy for voter frustration. The risk, some critics say, is that “Medicare-for-all” could become a Democratic version of the Republican “repeal and replace” slogan — a vote-getter that does not translate to political action because there is neither agreement about what it means nor a viable plan.

“If you’re on the left, you have to have something on health care to say at town halls,” said David Blumenthal, president of the Commonwealth Fund. “So you say this and move on. That’s part of the motivation.”

Dr. Carol Paris, the president of Physicians for a National Health Program, an advocacy group, said she has fielded a number of calls from candidates asking for tutorials on Medicare-for-all.

“I’m heartened, but not persuaded” that all the high-profile talk will result in any action, she said. She worries about what she called “faux ‘Medicare-for-all’ plans” that don’t live up to the mantra.

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Polling highlights health care as a top voter concern, and pressure is building for politicians to take meaningful action that could redress the pain caused by personal health care costs that continue to rise faster than inflation.

Maybe that action would be negotiating lower drug prices or fixing flaws in the insurance system that allow for surprise medical bills and high out-of-pocket costs. Republican candidates mostly continue to bad-mouth “Obamacare” as the root of all problems in American health care (of course, it’s not), and some still push to repeal it. They tend to offer only vague assurances that, for example, they will guarantee that people with preexisting conditions can find affordable insurance — proposals that do not withstand expert scrutiny.

But more and more voters seem to think the country needs more radical change.

In polling this year, 51 percent of Americans and 74 percent of Democrats said they support a single-payer plan. Surveys suggest growing enthusiasm among doctors, too, with more than half in favor.

Yet experts suggest voter support may not withstand warnings of tax increases or changes to employer-sponsored insurance. A 2017 poll from the Kaiser Family Foundation found that support for Medicare-for-all dropped when respondents were told that their taxes might increase or that the government might get “too much control over health care” — a common Republican talking point. (Kaiser Health News is an editorially independent program of the foundation.)

Despite initial enthusiasm, Vermont’s governor let a state single-payer plan die in part because it was calculated that it would require an 11.5 percent payroll tax on businesses and a state income tax of up to 9.5 percent.

The broader goal — affordable, universal health care — could be achieved by a range of strategies. For models, we can look to nations that have generally achieved better health outcomes, for less money, than the United States.

Canada and Britain come particularly close to true single-payer. Their governments pay medical bills with money raised through taxes and have monopolistic negotiating power over prices. But after that, the systems differ.

In Canada, which is Sanders’ inspiration, the government provides health insurance for most medical needs, with no out-of-pocket costs. People can, and often do, buy a second, private plan for any unmet health needs, such as prescription drugs.

Britain goes a step further. Its government owns hospitals and employs many specialists via the National Health Service. A small private system exists, catering mainly to wealthier people seeking faster access to elective procedures.

Other countries achieve universal health care (or nearly so), but without single-payer. France and Germany have kept an insurance system intact but heavily regulate health care, including by setting the prices for medical procedures and drugs, and requiring all citizens to purchase coverage.

These more incremental options have not captured the American imagination to the same extent as Medicare-for-all. But adopting such a system would require the biggest shift, with significant implications for taxes, patient choice, doctors’ salaries and hospital revenue.

Enthusiastic politicians sometimes gloss over those consequences. For example, Liz Watson, a Democrat running in Indiana’s 9th Congressional District, suggested the impact on doctors’ income was not much of a concern, because they would see a “huge recovery” on expenses since they would no longer need to navigate the bureaucracy of insurance paperwork. But analysts across the board agree single-payer would cut revenue for doctors — many say by about 12 percent on average.

And many voters seem confused by the fundamentals. In polling by the Kaiser Family Foundation, about half of Americans said they believed they would be able to keep their current insurance under a single-payer plan, which is not the case.

Optimism without specifics carries risk, as President Barack Obama learned after promising that people wouldn’t lose their doctors under the Affordable Care Act. That promise haunted the Obama administration — it was singled out as PolitiFact’s “Lie of the Year” in 2013 and is still mocked by members of the Trump White House.

There’s also the thorny issue of how Medicare-for-all would affect the thousands of jobs at private insurers. “We have an insurance industry in Omaha, and people say, ‘I worry about those jobs,’” said Kara Eastman, a Democrat running on Medicare-for-all in Nebraska’s 2nd Congressional District. She suggested people could be retrained, saying there would have to be “repurposing of positions.”

Critics of Medicare-for-all, on the other hand, tend to exaggerate the costs of single-payer: “Denmark’s top tax bracket is nearly 60 percent!” (True, although that’s largely not because of health care.) “Doctors’ incomes will drop 40 percent!” (True, specialists in private practice would probably see pay cuts, but primary care doctors could well see an increase.)

Canadians generally pay higher taxes than Americans do — specifically a goods and services tax, and higher taxes on the wealthy. In Germany, working people pay 7.5 percent of income as a contribution toward comprehensive insurance.

But many Americans pay far more than that when you count premiums, deductibles, copayments and out-of-network charges. Estimates of the tax increases required to support a Medicare-for-all or single-payer system are all over the map, depending on how the plan is structured, the prices paid to providers and drugmakers, and the generosity of benefits.

As a politician famously noted, “Nobody knew health care could be so complicated.”

Some candidates do have clear proposals in mind. Ocasio-Cortez, for example, running for the House from New York’s 14th District, is firm: a single, government-run health plan that covers everyone with no copayments or deductibles and perhaps allows Americans to buy supplemental private coverage. It’s the Canadian approach, textbook single-payer.

But many who back Medicare-for-all are vague or open to incremental approaches, like a “public option” that maintains the current insurance structure while allowing people to buy into Medicare.

O’Rourke casts Medicare-for-all as a starting point for discussion. But he said that what matters most is “high-quality, guaranteed universal health care.” Getting there, he added, “will inevitably require some compromise” — like a public option. Notably, he has not signed on as a co-sponsor of the Medicare-for-all bill because that plan does not allow for-profit providers to participate.

Jared Golden, a Democratic House candidate from Maine’s 2nd District, says in his campaign materials that he favors “something like Medicare for all,” but he clarified that at least initially, he would argue to lower the Medicare eligibility age, a change that wonks often call “Medicare for more.”

And the Wisconsin Democrat Randy Bryce, who is running to replace Speaker Paul Ryan in the House, said he would support a public option or lowering the eligibility age for Medicare. “I don’t want to say that there’s only one way to go about it,” Bryce said.

But many other candidates — both for Congress and for governorships — who are talking “Medicare-for-all” on the campaign trail either did not acknowledge or declined multiple requests to be interviewed on the subject. They include Andrew Gillum, who is running for governor in Florida; Gina Ortiz Jones of Texas’ 23rd District; the California candidate for governor Gavin Newsom; Massachusetts 7th District candidate Ayanna Pressley; and Pennsylvania 1st District candidate Scott Wallace.

Lake, the pollster, suggested that policy details simply aren’t as relevant in a midterm year and that for now we shouldn’t expect a candidate’s support for Medicare-for-all to be anything more than a way to signal his or her values. But she suggested that will change in the run-up to 2020, adding, “When we head into the presidential election, people will probably be pickier and want more details.”

That gives politicians and voters a few years to decide what they mean and what they want when they say they support Medicare-for-all or single-payer health care. For now, it’s hard to read too much into promises.

Paris, who lives in Nashville, said she was surprised and excited to hear that her representative, Jim Cooper, a Blue Dog Democrat, had signed up as a co-sponsor of the Medicare for all bill.

“I told him, ‘I’m dumbfounded,’” she recalled.

His answer? “Don’t get too excited.”

HHS Activates Aid for Uninsured Floridians Needing Medicine after Hurricane Michael

HHS Gov News - October 19, 2018

Thousands of uninsured Floridians are eligible for no-cost replacements of critical medications lost or damaged by Hurricane Michael. This relief comes from the Emergency Prescription Assistance Program (EPAP), managed by the U.S. Department of Health and Human Services’ (HHS) Office of the Assistant Secretary for Preparedness and Response (ASPR).

The program pays for prescription medications for people without health insurance who are affected by disasters. More than 4,900 Florida pharmacies participate in EPAP, and more than 72,000 pharmacies participate nationwide.

“The Emergency Prescription Assistance Program provides vital assistance to people without insurance who rely upon certain prescription medicines to protect their health after disasters,” said HHS’ Assistant Secretary for Preparedness and Response Robert Kadlec, M.D. “I encourage citizens in Florida who can use this assistance to take advantage of it to ensure they have an adequate supply of the medicines they need.”

At no cost to uninsured patients, those needing certain prescription medications during an emergency can obtain a 30-day supply at any EPAP participating pharmacy through Nov. 15. Most prescription drugs are available.

Uninsured patients also may use the program to replace specific medical supplies, vaccines or medical equipment, such as canes and walkers, damaged or lost as a direct result of Hurricane Michael or as a secondary result of loss or damage caused while in transit from the emergency site to an emergency shelter.

EPAP provides an efficient mechanism for enrolled pharmacies to process claims for prescription medication, specific medical supplies, vaccines and some forms of durable medical equipment for eligible individuals in a federally identified disaster area.

Uninsured Floridians affected by Hurricane Michael can call 855-793-7470, to learn if their medication or specific durable medical equipment is covered by EPAP and to find a participating pharmacy or visit

HHS also has Disaster Medical Assistance Teams working alongside local healthcare providers to care for emergency department patients at damaged or overwhelmed hospitals. In addition, these federal medical teams have triaged people found by Urban Search and Rescue and provided basic medical care for residents in local emergency shelters. Since arrival, these teams have seen more than 1,500 patients.

A U.S. Public Health Service Commissioned Corps behavioral health team also is providing behavioral health support for emergency responders.

The U.S. Food and Drug Administration has information available to help citizens understand the safe use of medical products, including insulin and devices, exposed to flooding or unsafe water after Hurricane Michael. This information includes the safe use of temperature-sensitive drugs when refrigeration is temporarily unavailable.

The FDA also continues to monitor Hurricane Michael’s impact on companies that develop products the FDA regulates, including medicines, medical devices, food, and the blood supply, to help ensure safety and availability. There have been no reports of significant impacts on companies that produce critically important medical products, and no shortages of these products are expected at this time.

Centers for Disease Control and Prevention subject matter experts are working with the state health department to determine and meet any long-term public health effects of the hurricane and providing public health information such as safe clean up and preventing common post-disaster diseases.

The Centers for Medicare & Medicaid Services is providing waivers and flexibilities to assist healthcare providers and suppliers in providing necessary care and services to beneficiaries throughout the emergency.

CMS is working with the Kidney Community Emergency Response network and dialysis providers to check on the well-being of dialysis patients and reschedule their dialysis services at open dialysis facilities after the hurricane.

The Substance Abuse and Mental Health Services Administration activated its Disaster Distress Helpline, a 24/7, 365-day-a-year, national hotline dedicated to providing immediate crisis counseling for people who are experiencing emotional distress related to any natural or human-caused disaster. The Disaster Distress Helpline is toll-free, multilingual, and confidential. Stress, anxiety, and other depression-like symptoms are common reactions after a disaster. Call 1-800-985-5990 or text TalkWithUs to 66746 (for Spanish, press 2 or text Hablanos to 66746) to connect with a trained crisis counselor. The helpline has received almost 200 calls from Floridians in the past week.

HHS Secretary Alex Azar declared public health emergencies in Florida and Georgia to authorize flexibilities for CMS beneficiaries, following President Trump’s emergency declarations in those states due to Hurricane Michael. These actions and flexibilities are retroactive to Oct. 9, 2018, in Georgia and Oct. 7, 2018, in Florida.

HHS, through ASPR, leads the federal government’s public health and medical response and recovery support for states and territories after disasters. HHS works to enhance and protect the health and well-being of all Americans, providing for effective health and human services and fostering advances in medicine, public health, and social services. ASPR’s mission is to save lives and protect Americans from 21st century health security threats.

Information on disaster health and HHS actions is available on Public Service Announcements with post-storm health tips are available on

As Billions In Tax Dollars Flow To Private Medicaid Plans, Who’s Minding The Store?

Kaiser Health News:HealthReform - October 19, 2018

With no insurance through his job, Jose Nuñez relied on Medicaid, the nation’s public insurance program that assists 75 million low-income Americans.

Like most people on Medicaid, the Los Angeles trucker was assigned to a private insurance company that coordinated his medical visits and treatment in exchange for receiving a set fee per month — an arrangement known as managed care.

But in 2016, when Nuñez’s retina became damaged from diabetes, the country’s largest Medicaid insurer, Centene, let him down, he said. After months of denials, delays and erroneous referrals, he claimed in a lawsuit, the 62-year-old was left nearly blind in one eye. As a result, he lost his driver’s license and his livelihood.

“They betrayed my trust,” Nuñez said, sitting at his kitchen table with his thick forearms folded across his chest.

The current political debate over Medicaid centers on putting patients to work so they can earn their government benefits. Yet some experts say the country would be better served by asking this question instead: Are insurance companies — now receiving hundreds of billions in public money — earning their Medicaid checks?

More than two-thirds of Medicaid recipients are enrolled in such programs, a type of public-private arrangement that has grown rapidly since 2014, boosted by the influx of new beneficiaries under the Affordable Care Act.

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States have eagerly tapped into the services of insurers as one way to cope with the expansion of Medicaid under the ACA, which has added 12 million people to the rolls. This fall, voters in three more states may pass ballot measures backing expansion. Outsourcing this public program to insurers has become the preferred method for running Medicaid in 38 states.

Yet the evidence is thin that these contractors improve patient care or save government money. When auditors, lawmakers and regulators bother to look, many conclude that Medicaid insurers fail to account for the dollars spent, deliver necessary care or provide access to a sufficient number of doctors. Oversight is sorely lacking and lawmakers in a number of states have raised alarms even as they continue to shell out money.

“We haven’t been holding plans to the level of scrutiny they need,” said Dr. Andrew Bindman, former director of the federal Agency for Healthcare Research and Quality and now a professor at the University of California-San Francisco. “This system is ripe for profit taking, and there is virtually no penalty for performing badly.”

In return for their fixed fees, the private insurers dole out treatment within a limited network, in theory allowing for more judicious, cheaper care. States contract with health plans as a way to lock in some predictability in their annual budgets.

More than 54 million Medicaid recipients are now covered by managed-care plans, up from fewer than 20 million people in 2000. (In traditional Medicaid, states pay doctors and hospitals directly for each visit or procedure — an approach that can encourage unnecessary or excessive treatment.)

Already, states funnel nearly $300 billion annually to Medicaid insurers. That’s up from $60 billion a decade ago. Today’s spending is approaching what Pentagon awards annually to contractors.

Jose Nuñez says he and daughter Diana Nuñez took turns calling his Medicaid plan and waiting on hold for answers after his eye surgery was canceled twice. He waited three months for his insurer to approve the operation, he says. By that time, his retina had deteriorated and Nuñez was nearly blind in one eye.(Heidi de Marco/KHN)

Medicaid is good for business: The stock price of Nuñez’s insurer, Centene, has soared 400 percent since the ACA expanded Medicaid eligibility. The company’s chief executive took in $25 million last year, the highest pay for any CEO in the health insurance industry. In California, the largest Medicaid managed-care market with nearly 11 million enrollees, Centene and other insurers made $5.4 billion in profits from 2014 to 2016, according to a Kaiser Health News analysis.

Plans get to keep what they don’t spend. That means profits can flow from greater efficiency — or from skimping on care and taking in excess government payments.

“States are just giving insurers the keys to the car and a gas card,” said Dave Mosley, a managing director at Navigant Consulting and former finance director at the North Carolina Medicaid program. “Most states haven’t pressed insurers for the information needed to determine if there’s any return on their investment.”

Two of California’s most profitable insurers, Centene and Anthem, ran some of California’s worst-performing Medicaid plans, state quality scores and complaints in government records show. California officials have been clawing back billions of dollars from health plans after the fact.

For nearly two decades, federal officials have tried building a national Medicaid database that would track medical care and spending across states and insurers. It’s still unfinished, hampered by differing state reporting methods and refusals by some health plans to turn over data they deem trade secrets.

In July, a federal inspector general’s report accused Medicaid insurers of purposefully ignoring fraud and overpayments to doctors because inflated costs can lead to higher rates in the future.

In a report last month, the U.S. Government Accountability Office disclosed that California’s Medicaid program is unable to electronically send records justifying billions of dollars in spending, forcing federal officials to sift through thousands of documents by hand. California said it can’t share key files electronically because it uses 92 separate computer systems to run the program.

“You simply cannot run a program this large when you can’t tell where the money is going and where it has been,” said Carolyn Yocom, a health care director at the GAO.

Today, Medicaid consumes the single-largest share of state budgets nationwide at nearly 30 percent — up from less than 21 percent a decade ago — crowding out funding for education, roads and other key priorities.

“If anything, our results suggest that the shift to Medicaid managed care increased Medicaid spending,” researchers at the Congressional Budget Office and the University of Pennsylvania concluded in 2013, based on a nationwide analysis.

Industry officials insist that managed care saves money and improves care. Medicaid Health Plans of America, an industry trade group, points to a study showing that health plans nationally saved the Medicaid program $7.1 billion in 2016.

Health plans also say they can help modernize the program, created more than a half century ago, by upgrading technology and adopting fresh approaches to managing complex patients.

Getting it right has big implications for patients and taxpayers alike, but the results in many states aren’t reassuring.

State lawmakers in Mississippi, both Republicans and Democrats, criticized their Medicaid program last year for ignoring the poor performance of two insurers, UnitedHealthcare and Centene, even as the state awarded the companies new billion-dollar contracts.

In Illinois, auditors said the state didn’t properly monitor $7 billion paid to Medicaid plans in 2016, leaving the program unable to determine what percentage of money went to medical care as opposed to administrative costs or profit.

In April, Iowa’s state ombudsman said Medicaid insurers there had denied or reduced services to disabled patients in a “stubborn and absurd” way. In one case, an insurer had cut a quadriplegic’s in-home care by 71 percent. Without the help of an aide to assist him with bathing, dressing and changing out his catheter he had to move to a nursing home, according to the ombudsman, Kristie Hirschman.

“We are not talking about widgets here,” Hirschman said. “In some cases, we are talking about life-or-death situations.”

Meanwhile, the Trump administration has sent mixed signals on Medicaid oversight. Seema Verma, administrator for the Centers for Medicare & Medicaid Services, has promoted a new, nationwide scorecard and vowed to ramp up audits targeting states and health plans.

“We need to do better,” Verma said in a Sept. 27 speech to the Medicaid managed-care industry. “Medicaid has never developed a cohesive system of accountability that allows the public to easily measure and check our results.”

But consumer advocates also are concerned that Verma’s efforts to roll back “burdensome regulations” will weaken accountability overall. Many also disagree with her support of Medicaid work requirements.

Nuñez, the truck driver who lost much of his sight, is suing a unit of Centene for negligence and breach of contract. The company has denied the allegations in court filings and declined to comment further, citing the pending litigation.

Talk of requiring Medicaid recipients to work is hard for him to take. “I need my health to work,” he said. “They took that away from me.”

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

Podcast: KHN’s ‘What The Health?’ Republicans’ Preexisting Political Problem

Kaiser Health News:HealthReform - October 18, 2018
Julie Rovner

Kaiser Health News


Read Julie's Stories Rebecca Adams

CQ Roll Call


Read Rebecca's Stories Stephanie Armour

The Wall Street Journal


Read Stephanie's Stories Joanne Kenen



Read Joanne's Stories

Ensuring that people with preexisting health conditions can get and keep health insurance has become one of the leading issues around the country ahead of this fall’s midterm elections. And it has put Republicans in something of a bind — many either voted to repeal these coverage protections as part of the 2017 effort in Congress or have signed onto a lawsuit that would invalidate them.

Meanwhile, the Trump administration, eager to show progress regarding high prescription drug costs — another issue important to voters — has issued a regulation that would require prices to be posted as part of television drug advertisements.

Also this week: an interview with California Attorney General Xavier Becerra, a former member of Congress who is using his current post to pursue a long list of health initiatives.

This week’s panelists for KHN’s “What the Health?” are Julie Rovner of Kaiser Health News, Rebecca Adams of CQ Roll Call, Stephanie Armour of The Wall Street Journal and Joanne Kenen of Politico.

Among the takeaways from this week’s podcast:

  • Democrats have made health care — especially the protections for people with preexisting conditions — their central strategy in midterm campaigns. It’s an issue that the GOP did not want to be campaigning on.
  • Republicans say that despite their moves to destroy the federal health law, they would work to preserve coverage options for people with preexisting conditions. But they don’t lay out what those options would be and earlier efforts have major loopholes, Democrats point out.
  • The announcement by federal health officials this week that they want drug prices added to advertisements about the products is expected to have marginal effects because pricing is so complicated. If the federal government requires drugmakers to post their prices on ads, the manufacturers are widely expected to sue based on First Amendment issues.
  • Open enrollment for Medicare began this week and runs until Dec. 7. Medicare Advantage, the private-plan option for enrollees, is becoming increasingly popular and now covers more than a third of Medicare beneficiaries.
  • But while Medicare Advantage offers many benefits the traditional program does not — frequently including dental and foot care — a recent report from the inspector general at the Department of Health and Human Services finds that some of these plans may be wrongly denying care to Medicare patients. At the same time, Medicare beneficiaries who choose to use Medicare Advantage plans may be in for a shock if they later decide to switch back to the traditional form of Medicare. They may not be eligible at that point to buy a Medigap plan to help cover their cost sharing.

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

Julie Rovner: The New York Times’ “Is Medicare for All the Answer to Sky-High Administrative Costs?” by Austin Frakt

Stephanie Armour: The Associated Press’ “Study: Without Medicaid Expansion, Poor Forgo Medical Care,” by Ricardo Alonso-Zaldivar

Rebecca Adams: The New Yorker’s “Rural Georgians Want Medicaid, But They’re Divided on Stacey Abrams, the Candidate Who Wants to Expand It,” by Charles Bethea

Joanne Kenen: Seven Days Vermont’s “Obituary: Madelyn Linsenmeir, 1988-2018.”

To hear all our podcasts, click here.

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

HHS awards $293 million to expand primary health care workforce

HHS Gov News - October 18, 2018

Today, the U.S. Department of Health and Human Services (HHS) Health Resources and Services Administration (HRSA) announced $293 million in awards to primary health care clinicians and students through the National Health Service Corps (NHSC) and Nurse Corps programs.

“These programs connect primary care providers with the rural, urban, and tribal communities across the country that need them most,” said HRSA Administrator George Sigounas, MS, Ph.D. “In addition to providing essential medical and dental care, these clinicians are on the front lines helping to fight pressing public health issues, like the growing opioid epidemic.”

The NHSC and Nurse Corps programs build healthy communities by providing scholarships and loan repayment to health care providers in exchange for working in areas of the U.S. with limited access to care.

Currently, an estimated 13 million patients receive care from more than 12,500 NHSC and Nurse Corps clinicians. Another 1,725 primary care students are either in school or in residency preparing for future service with the Corps programs.

More than 3,600 of these NHSC members are currently providing behavioral health care services, including medication-assisted treatment and other evidence-based substance use disorder care, in high-need areas. HRSA continues to invest in expanding access to substance use disorder treatment in rural and underserved areas.

“For decades, NHSC and Nurse Corps clinicians have been caring for vulnerable patients who might otherwise go without treatment,” said HRSA’s Associate Administrator for Health Workforce, Luis Padilla, M.D. “In the midst of the current opioid crisis, these providers are again rising to the challenge, working in hard-hit communities to provide mental and behavioral health services, including substance use disorder treatment.” 

HHS awards support the following programs:

National Health Service Corps Scholarship Program ($47.1 million) provides 222 new awards and 7 continuation awards to students pursuing primary care training leading to a degree in medicine, dentistry, or a degree as a nurse-midwife, physician assistant, or nurse practitioner in exchange for providing primary health care services in areas of greatest need.

National Health Service Corps Loan Repayment Program ($142.1 million) provides 3,262 new awards and 2,384 one-year continuation awards to fully trained, licensed primary care clinicians in exchange for providing primary health care services in an area of greatest need.

National Health Service Corps Students to Service Loan Repayment Program ($19.3 million) provides 162 new awards. This program provides loan repayment assistance to medical and dental students in their last year of school in return for their choosing primary care as a practice focus and working in rural and urban areas of greatest need.

National Health Service Corps State Loan Repayment Program ($12.6 million) provides cost-sharing grants to 37 states and territories that operate their own loan repayment programs, funding 1,350 new and continuation awards.

Nurse Corps Scholarship Program ($25.1 million) provides 215 new awards and 4 continuation awards to nursing students in exchange for a commitment to work at least two years in a facility with critical shortages.

Nurse Corps Loan Repayment Program ($44.4 million) provides 544 new awards and 279 one-year continuation awards to nurses in exchange for a commitment to serve at a health care facility with a critical shortage of nurses or serve as nurse faculty at an accredited school of nursing.

Faculty Loan Repayment Program ($1.1 million) provides 23 new awards to health professions educators in exchange for serving as a faculty member in an accredited and eligible health professions school. The program also encourages participants to promote careers in their respective health care fields.

Native Hawaiian Health Scholarship Program ($900,000) provides 9 new awards and 1 continuation award to Native Hawaiian health professions students trained in those disciplines and specialties most needed to deliver quality, culturally competent, primary health services to Native Hawaiians in the State of Hawaii.

Learn more about the NHSC and Nurse Corps. Like NHSC and Nurse Corps on Facebook, follow NHSC and Nurse Corps on LinkedIn, follow NHSC on Twitter @NHSCorps, and sign up for HRSA email updates.

Secretary Azar Highlights Recognition of HHS as Top Agency for Regulatory Reform

HHS Gov News - October 18, 2018

Health and Human Services Secretary Alex Azar issued the following statement today regarding the Office of Management and Budget’s release of the Fall 2018 Unified Agenda:

“Today’s report is more evidence that HHS is delivering on President Trump’s promise to reform regulations to unleash our economy while enhancing and protecting the health and well-being of the American people. HHS was the No. 1 Cabinet agency in terms of regulatory accomplishments for Fiscal Year 2018, reducing the burden of its regulations in present-value terms by $12.5 billion.

Under President Trump’s leadership, HHS continues to remove regulatory obstacles that get in the way of providers spending time with patients or that drive up the cost of healthcare. HHS’s work on regulatory reform will continue to reflect President Trump’s deep commitment to lower cost, higher quality healthcare that puts patients, not Washington, in the driver’s seat.”

Specific regulatory reform efforts at HHS have included the Centers for Medicare & Medicaid Services burden reduction initiatives, which will produce:

  • $5.2 billion in savings from 2018 to 2021.
  • More than 53 million hours of paperwork saved.
  • 105 different clinical measures eliminated because they were unhelpful or no longer meaningful.

And Deputy Secretary Hargan’s Regulatory Sprint to Coordinated Care, which will:

  • Examine the burdens created by current interpretations of the Stark Law, the Anti-Kickback Statute, HIPAA, and 42 CFR Part 2.
  • Determine how these interpretations may be impeding care coordination, as part of Secretary Azar’s efforts to build a value-based healthcare system.
  • Engage in rulemaking to empower clinicians and other providers to coordinate and deliver value.

Other examples of regulatory reform efforts include:

  • Reforming the regulation of medication-assisted treatment providers for opioid abuse.
  • Improving regulations of individual insurance and insurance exchanges.
  • Empowering state and community partners to more efficiently deliver human services such as foster care and early childhood education.

Children’s Hospitals Again Cry For Help From Voters. But Are They Really Hurting?

Kaiser Health News:Madicaid - October 18, 2018

Back in 2004, California’s children’s hospitals asked voters to approve a $750 million bond measure to help fund construction and new medical equipment. In 2008, they asked for $980 million more. Now they’re hoping voters will agree on Nov. 6 to cough up an additional $1.5 billion.

The state’s 13 children’s hospitals treat California’s sickest kids — including those with leukemia, sickle cell disease, rare cancers and cystic fibrosis — so approving their fund-raising requests is an easy “yes” for many voters.

Despite the feel-good nature of the requests, some health care experts and election analysts question the hospitals’ multiple appeals for taxpayer money — and are warning voters to review this year’s proposal with a critical eye.

“I think it’s a misuse of the initiative process for private groups to sponsor ballot measures that are intended to benefit them exclusively,” said Elizabeth Ralston, a former president of the League of Women Voters of Los Angeles who analyzes state finance measures for the group. The league recommends a “no” vote on the measure.

Repeatedly asking taxpayers to pay for the construction of state-of-the-art facilities is not standard practice, according to critics who believe it raises questions about financial accountability — and whether the hospitals truly need some of the projects on their wish lists.

This pattern “could leave children’s hospitals with little incentive to control their costs,” said Ge Bai, a professor at the Johns Hopkins University Carey Business School, who added that each hospital should take care of itself.

The initiative, Proposition 4, needs a majority vote to pass. The 2004 and 2008 children’s hospital bond measures passed with 58.3 percent and 55.3 percent of the vote, respectively.

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The California Children’s Hospital Association said its members can’t afford to pay for their building and technology needs without help from the state’s taxpayers, who would be on the hook to pay off $1.5 billion plus interest. The state Legislative Analyst’s Office estimates that would come to $2.9 billion — or about $80 million a year over the next 35 years.

Private donations often aren’t the answer because donors frequently specify how their money should be used, said Ann-Louise Kuhns, the association’s CEO. The posh playrooms and gardens at some of these hospitals, for example, are completely funded by private donations, she said.

“We do fund-raise, we ask donors to make contributions and we issue our own debt,” Kuhns said. “But it’s hard to completely close that gap for what’s needed … without a little bit of assistance.”

The association, which sponsored the initiative, said the bond measure would help pay for construction, remodeling, equipment and seismic retrofitting at the state’s eight private, nonprofit children’s hospitals and the five that are part of the University of California medical system.

The California Health Facilities Financing Authority would have to approve the hospitals’ use of the bond money. The agency weighs whether projects would expand access and improve patient care but does not determine whether a project is necessary or prudent.

That’s up to the hospitals.

(Story continues below.)

California Children’s Hospitals

The state’s 13 children’s hospitals — eight private nonprofits and five that are part of the University of California medical system — are asking voters to approve a $1.5 billion bond measure on the Nov. 6 ballot to help them pay for construction and equipment. If the measure passes, the private hospitals will receive about three-quarters of the proceeds, or about $135 million each, regardless of their profits or losses.

Source: Hospital data come from the last financial report audited by the Office of Statewide Health Planning and Development — either 2016 or 2017. Income information for UC hospitals was not available.

The campaign in support of the bond measure — funded by the nonprofit hospitals themselves — has raised nearly $11 million this year, according to the California secretary of state’s office.

In their last financial reports audited by the state, six of the eight private, nonprofit hospitals reported annual profits ranging from $18 million to nearly $176 million. The bond issuance would provide each with $135 million, regardless of its profits or losses.

Almost three-quarters of the bond proceeds would go to the nonprofits because they have the most beds, but nonprofit hospitals already receive certain perks, Bai explained. For instance, they’re exempt from paying property taxes, as well as state and federal income taxes.

Eighteen percent would be allotted to the UC system hospitals. And the proposal would offer 10 percent in competitive grants for approximately 150 hospitals that aren’t classified as pediatric hospitals, but treat children nonetheless.

The hospitals argue they need to expand because they are facing greater demand for services, as general and community hospitals increasingly transfer their patients to them for specialized pediatric care.

Children’s hospitals also rely heavily on Medi-Cal, the state’s insurance program for low-income people, Kuhns said. Medi-Cal pays hospitals less than private insurance.

Nancy Kane, a professor in the department of health policy and management at the Harvard T.H. Chan School of Public Health, pointed out that nationwide “many children’s hospitals have the same payer mix, but manage to do this anyway without the government paying for their capital.”

Kuhns said that California hospitals also face deadlines to meet seismic safety mandates. By 2020, they must be ready to withstand a major earthquake, and by 2030, they must be deemed safe enough to continue operating after a quake.

About 28 percent of the beds in the eight nonprofit children’s hospitals do not meet the 2030 seismic standards, so significant investments must be made, she said.

Tim Curley of Valley Children’s Healthcare in Madera said the previous bond measures helped pay for a 60,000-square-foot expansion of operating rooms. If this year’s bond measure is approved, the hospital would consider renovating its laboratories and pharmacy, he said.

At the end of last year, it had just under $28 million in funds remaining from the 2008 bond, a report by the financing authority said.

Loma Linda University Children’s Hospital is still using its share of the 2008 bond to help with the construction of a nine-story tower that will house most departments and labs.

The new tower, expected to be completed by 2021, will help the children’s hospital operate independently of the rest of the medical center — which serves adults —  and meet the growing demand for space, said Scott Perryman, a senior administrator.

But Ralston, with the League of Women Voters, said Californians should consider whether the money could be better used elsewhere.

“You’re committing state money,” she said, “and that means that’s money not spent on something else” like affordable housing or aging roads.

Should voters nonetheless approve this third bond measure, Bai wonders if and when the requests for taxpayer money will stop. “There are always new things to buy,” she said.

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

Health Care Tops Guns, Economy As Voters’ Top Issue

Kaiser Health News:HealthReform - October 18, 2018

Health care has emerged as the top issue for voters headed into the midterm elections, but fewer than half of them say they are hearing a lot from candidates on the issue, according to a new poll released Thursday.

Seven in 10 people list health care as “very important” as they make their voting choices, eclipsing the economy and jobs (64 percent), gun policy (60 percent), immigration (55 percent), tax cuts (53 percent) and foreign policy (51 percent).

When asked to choose just one issue, nearly a third picked health care, according to the survey by the Kaiser Family Foundation. (KHN is an editorially independent program of the foundation.)

Still, midterm elections are traditionally a referendum on the president and his party, and that holds true this year as two-thirds of voters say a candidate’s support or opposition to President Donald Trump will be a major factor in their voting decision, the poll found.

Health care was also the top issue chosen overall by voters living in areas identified in the survey as political battlegrounds, although the results varied when pollsters drilled down to political parties. Nearly 4 in 10 Democratic battleground voters and 3 in 10 independents chose health care as their most important issue in voting for Congress.

Among Republican voters, immigration was their top issue, garnering 25 percent compared with 17 percent for health care.

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The poll results in two battleground states — Florida and Nevada — also underscored voters’ interest for keeping the Affordable Care Act’s protections for people with preexisting conditions, one of the most popular provisions in the law.

Democrats have made that a key part of their campaign, pointing to Republicans’ votes to repeal the entire law and trying to drive home the message that the GOP’s efforts would strip that guarantee.

Nonetheless, Republicans have recently sought to fight back on that issue, promising on the stump and in campaign ads that they understand the need to keep the protections and would work to do that.

Nearly 7 in 10 Florida voters said they are more likely to vote for a candidate who wants to maintain the protections for people with preexisting conditions, while 9 percent said they are more likely to vote for a candidate who wants to eliminate these protections.

In Nevada, nearly 70 percent of voters also said they wanted the ACA preexisting protections guaranteed.

In Florida, where the deadliest mass school shooting in American history took place last February, health care also was the top issue among voters. Twenty-six percent of Florida voters listed health as their top issue. The economy and gun policy tied for the second-biggest issue at 19 percent.

The shooting at Marjory Stoneman Douglas High School in Parkland, Fla., left 17 students and staff members dead, spurred massive marches around the country and stirred national debate on gun policy.

Florida is traditionally a key battleground state but more so this year with close races for the U.S. Senate and governor’s race hanging in the balance.

Nearly half of Florida voters said they are more likely to vote for a candidate who wants to expand Medicaid.

Florida is one of 17 states that has chosen not to expand Medicaid under the health law, leaving tens of thousands of its adult residents without health insurance. The Republican-controlled legislature has refused to accept millions of dollars in federal funding to extend the coverage.

Two in 10 Democratic voters in Florida said support for a candidate supporting a national health plan, or “Medicare-for-all,” is the most important health care position for a candidate to take. Andrew Gillum, the Florida Democratic gubernatorial nominee, has said he would support a national health plan.

In Nevada, which also has a key Senate battle, the poll found nearly a quarter of voters said health care was the top issue in their decisions this year, but immigration and the economy were very close behind.

Nearly a third of Democrats in Nevada said they are looking for a candidate who supports a single-payer health plan.

Just under a third of Republicans in Florida and Nevada said that a candidate’s support of repealing the ACA is the most important health issue when they vote.

The poll of 1,201 adults was conducted Sept. 19-Oct. 2. The national survey has a margin of error of +/-3 percentage points.

GOP Gubernatorial Candidate John Cox: Limit Government In Health Care

Kaiser Health News:HealthReform - October 17, 2018

John Cox stood on a presidential debate stage and told the audience that he was glad abortion wasn’t legal in 1955.

If it had been, he said, he wouldn’t have been born.

“I wouldn’t be standing here before you today. This is personal to me,” Cox said in the 2007 GOP presidential primary debate, explaining that his biological father walked out on his mother.

“My mother took responsibility for me,” he said. “She’s glad she did, and I’m glad she did.”

Cox, California’s Republican candidate for governor, frequently invoked his anti-abortion views during his unsuccessful political bids for Congress and president. He unapologetically framed himself as the anti-abortion candidate – a Christian who believes in the right to life, and whose “absolute opposition to abortion on demand” was born from his mother’s circumstances.

Cox has been less vocal about his abortion views in blue-state California, where Republicans, Democrats and independents overwhelmingly favor a woman’s right to choose. But his argument that it is an issue of personal responsibility provides a window into Cox’s thinking when it comes to health care overall: He contends that free markets, combined with people taking responsibility for their actions, ought to guide health care policy — and that government should mostly stay out of it.

His views on health care contrast starkly with those of the Democratic gubernatorial nominee, Lt. Gov. Gavin Newsom, who calls for health care coverage for all Californians, and supports the creation of a single-payer, government-run health care system financed by taxpayers. In the latest Public Policy Institute of California poll released in late September, Cox trailed Newsom by 12 percentage points among California’s likely voters, with 7 percent undecided.

As a candidate for governor, Cox has not released detailed health care positions. Nor would he agree to an interview with California Healthline to explain his views or allow those closest to him to comment.

On Monday, with less than a month before the election, Cox issued a statement following a live gubernatorial debate saying that he supports affordable health care for everyone, including those with preexisting conditions. He again failed to provide any specifics.

A review of his statements, old and current campaign websites, and interviews with previous campaign aides portrays a successful businessman who believes in limiting government in health care and in general — a political philosophy inspired by Jack Kemp’s focus on free enterprise, fiscal conservatism and family values during the 1988 presidential campaign.

Cox, who grew up in a Chicago suburb he describes as lower-middle class, became a successful tax attorney, investor and developer before getting involved in Illinois Republican politics. He didn’t do as well in that arena: He ran unsuccessfully for Congress — the House in 2000 and the Senate in 2002 — and for Cook County Recorder of Deeds in 2004 and president in 2008.

“John is a principled guy. He didn’t come from much and he did very well,” said Nicholas Tyszka, who was Cox’s campaign manager in his U.S. Senate bid. “He’s certainly more of a limited-government guy who believes if you give people an opportunity to do good things, they will.”

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Cox, 63, settled in California permanently in 2011, and now lives in the affluent San Diego suburb of Rancho Santa Fe.

He has spent much of his campaign lamenting California’s high cost of living, along with the recent gas tax increase that he is encouraging voters to repeal in November.

Cox’s mindset of limited government, combined with his conviction of personal responsibility, feeds his argument that competition is the answer to rising health care costs, high prescription drug prices and nurse shortages.

“I’ve heard him say many times health care should be run more by the free markets and the federal government should have less involvement,” said Phil Collins, a Republican county treasurer candidate in Nevada who worked on two of Cox’s campaigns in Illinois.

In Monday’s statement, Cox complained that “our current system was designed by political insiders and health care corporate lobbyists to protect their monopoly profits, not to provide decent health care at a reasonable price.”

Cox said previously that, if elected governor, he isn’t interested in defending the Affordable Care Act, and that if Congress and the Trump administration were to repeal the law, the millions of Californians who now have coverage could go into high-risk insurance pools. That could increase the ranks of the uninsured.

In the hour-long debate Monday hosted by KQED, a San Francisco National Public Radio affiliate, Newsom challenged Cox’s desire to repeal the ACA and criticized his abortion views when asked how the confirmation of Brett Kavanaugh to the U.S. Supreme Court could affect California.

“It could have a profound impact on Californians, on their reproductive rights, which you believe a woman does not have a right to choose, regardless whether or not they are raped or a tragic incident of incest,” Newsom said.

Cox, who has dodged questions about his views on abortion during the gubernatorial campaign, did so again during the debate, saying only that he would appoint justices in California who will respect the U.S. and state constitutions.

“The things I’ve seen him say are very much aligned with what we hear coming out of the Trump administration and the Republican leadership of Congress,” said Dr. Andy Bindman, a primary care doctor at Zuckerberg San Francisco General Hospital and professor at the Philip R. Lee Institute for Health Policy Studies at the University of California-San Francisco who helped draft the Affordable Care Act.

When the state legislature this year considered bills that would have opened Medi-Cal, California’s Medicaid program, to unauthorized immigrants between ages 19 and 25, as well as those 65 and older, Cox went on national television to call the Democratic plans a “freebie” and told Fox News that “our government has been grabbed by a bunch of people who believe that government is the most important thing.” The bills died in the legislature.

Cox has also criticized Newsom for advocating both a single-payer system, which he says would destroy California’s economy, and health coverage for unauthorized immigrants.

“Gavin Newsom wants to make problems even worse, by increasing the costs of health care of Californians and then rewarding those who cut in line,” Cox said in an August news release. “If we want to see how Newsom’s government health care would work, just look at the DMV.”

If elected governor, Cox said in his post-debate statement, he “will break up the health care corporate monopolies, make insurance companies compete and turn patients into consumers with power over their health care dollars.”

He declined to provide any details in response to questions submitted to his campaign.

Bindman said Cox is taking a page out of the national Republican playbook — bash the Affordable Care Act without offering solutions.

“John Cox is not talking a lot about health care other than saying what he’s against because he doesn’t have any viable alternatives that ensure people retain coverage,” Bindman said.

But over the years, Cox has made suggestions that display his confidence in free markets to solve problems. What exists now, he argued in his 2006 book, “Politic$, Inc.,” is an “illogical system” where insurance companies and government have taken over individual patient care.

The solution, Cox argued both in his book and on his website as a presidential candidate, would be to end the federal tax deduction for employee health insurance, opening the door to more competition and lower prices. Like auto insurance, consumers ought to be able to choose their own health insurance plans in a free market, he said.

The poor could benefit from a limited government voucher program, he proposed, one with incentives to save money and get preventive care, as well as health savings accounts that encourage consumers to find care at the most reasonable cost.

“Wealthier people may well have better choices, but that should be one of the awards for upward mobility,” he wrote.

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

ONC and OCR Bolster the Security Risk Assessment (SRA) Tool with New Features and Improved Functionality

HHS Gov News - October 17, 2018

Patients expect not only quality health care to keep them healthy, but also trust that their most sensitive health information will be protected from threats and vulnerabilities that could lead to the compromise of one’s health information.  An enterprise-wide risk analysis is not only a requirement of the HIPAA Security Rule, it is also an important process to help healthcare organizations understand their security posture to prevent costly data breaches.  What is an enterprise-wide risk analysis?  It is a robust review and analysis of the risks to the confidentiality, integrity, and availability of electronic health information -- across all lines of business, in all facilities, and in all locations.

The HHS Office of the National Coordinator for Health Information Technology (ONC) and the HHS Office for Civil Rights (OCR) have updated the popular Security Risk Assessment (SRA) Tool to make it easier to use and apply more broadly to the risks to health information.  The tool is designed for use by small to medium sized health care practices – those with one to 10 health care providers – covered entities, and business associates to help them identify risks and vulnerabilities to ePHI. The updated tool provides enhanced functionality to document how such organizations can implement or plan to implement appropriate security measures to protect ePHI.

ONC and OCR conducted comprehensive usability testing of the SRA tool (version 2.0) with health care practice managers.  Analysis of the findings across the user base informed the development of the content and the requirements for the SRA Tool 3.0.  ONC and OCR then conducted testing of the SRA tool 3.0 to compare the user experience in completing the same tasks presented in the first round of testing.  You’ll find the tool to be more user friendly, with helpful new features such as:

  • Enhanced User Interface
  • Modular workflow with question branching logic
  • Custom Assessment Logic
  • Progress Tracker
  • Improved Threats & Vulnerabilities Rating
  • Detailed Reports
  • Business Associate and Asset Tracking
  • Overall improvement of the user experience

Using a Windows operating system? Download the Windows version of the tool at The iOS iPad version was not updated, but the previous version is available at the Apple App Store (search under “HHS SRA Tool”).

And don’t forget to explore the SRA Tool’s website, which provides a revised User Guide to help you get started.

Remember: All HIPAA covered entities and business associates are required to conduct an accurate and thorough assessment of the potential risks and vulnerabilities to the confidentiality, integrity, and availability of electronic protected health information held by their organization.  If you haven’t conducted a recent enterprise-wide risk analysis, now is the time to download the HHS SRA Tool to help with this foundational element upon which the security activities necessary to protect ePHI are built.


The Security Risk Assessment Tool at is provided for informational purposes only. Use of this tool is neither required by nor guarantees compliance with federal, state or local laws. Please note that the information presented may not be applicable or appropriate for all covered entities and business associates. The Security Risk Assessment Tool is not intended to be an exhaustive or definitive source on safeguarding health information from privacy and security risks. For more information about the HIPAA Privacy and Security Rules, please visit the HHS Office for Civil Rights Health Information Privacy website.

NOTE: The NIST Standards provided in this tool are for informational purposes only as they may reflect current best practices in information technology and are not required for compliance with the HIPAA Security Rule’s requirements for risk assessment and risk management. This tool is not intended to serve as legal advice or as recommendations based on a provider or professional’s specific circumstances. We encourage providers, and professionals to seek expert advice when evaluating the use of this tool.

States Act To Safeguard Young Cancer Patients’ Chances To Have Children

Kaiser Health News:Insurance - October 17, 2018

When Katherine Frega was diagnosed with Hodgkin lymphoma eight years ago at age 17, she was so sick that all she could focus on was starting chemotherapy to treat her aggressive blood cancer. It was her dad who thought to ask the oncologist, “How is this treatment going to affect her ability to have children?”

The oncologist discussed the risks but stressed that Frega needed to start treatment right away.

The question of fertility is often overlooked when young cancer patients are battling a life-threatening illness. And since health insurance doesn’t typically cover fertility preservation care, patients and their families may be deterred by the cost.

But a growing number of states now require plans to cover such services when medically necessary treatment jeopardizes fertility.

In 2012, Katherine Frega had a bone marrow transplant to battle her aggressive blood cancer. Doctors told her the procedure would likely cause permanent infertility, so she had her eggs retrieved and frozen. But her insurance company wouldn’t pay for the services.(Courtesy of Katherine Frega)

Treatment for cancer and other serious conditions involves toxic chemotherapy drugs, radiation and surgery that can cause infertility in women and men.

The cost to freeze patients’ healthy eggs, sperm or embryos for future use can be a major barrier, said Dr. Eden Cardozo, a reproductive endocrinologist and director of the fertility preservation program at the Women & Infants Fertility Center in Providence, R.I. Cardozo was instrumental in getting Rhode Island’s law passed last year.

“[Patients] have to move quickly,” she said. “They don’t have time to raise funds from family and friends. They don’t have time to petition their insurance company.”

Reproductive health advocates argue that fertility preservation should be viewed as a core component of cancer care in younger people, not as an optional infertility offering. Some compare this type of coverage to the federal Women’s Health and Cancer Rights Act, which requires plans that cover a patient’s mastectomy to also provide for breast reconstruction.

New laws in Delaware, Illinois and Maryland require plans to include this benefit. The Delaware law applies to plans issued or renewed after June of this year; the requirement in the other two states starts in 2019. Connecticut and Rhode Island passed similar laws last year. New Jersey lawmakers are considering a bill, and advocates in New York plan to make another attempt after both legislative chambers passed fertility preservation bills in the last session but failed to reconcile them.

The state measures don’t apply to companies that are self-funded, meaning they pay their employee claims directly rather than buying state-regulated insurance policies for that purpose. They also don’t apply to government-funded programs such as Medicaid or the military’s Tricare program.

Although freezing sperm and embryos has been common medical practice for decades, egg freezing was considered experimental by professional groups until 2012. As the technology has improved, the need for insurance coverage has grown, said Joyce Reinecke, executive director of the Alliance for Fertility Preservation, an advocacy group for cancer patients.

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When Frega’s cancer didn’t respond to chemotherapy, her doctors recommended a bone marrow transplant in January 2012. Even if her eggs hadn’t been damaged by the chemotherapy, the transplant would likely cause permanent infertility, she was told. So Frega took hormones to stimulate her ovaries to produce more eggs, among other things, and seven were retrieved during an outpatient procedure days before her transplant.

Frega’s parents paid $10,000 for the medications and egg retrieval, a significant amount but less than what many pay. They were aided by Livestrong Fertility, a nonprofit group that provides access to discounted fertility preservation services for cancer patients who meet income guidelines.

Frega has good insurance through her mother’s employer plan. “They covered everything else, except for this,” she said. “They considered it not medically necessary.”

Cancer-free following two bone marrow transplants, Frega, now 25, is a third-year medical student at the Upstate Medical University in Syracuse, N.Y. She plans to specialize in oncology.

Between 20 and 70 percent of cancer patients experience some degree of fertility impairment, according to Cardozo in Rhode Island. Though they make up the largest at-risk group, the complication isn’t unique to cancer patients. People with other conditions such as lupus and rheumatoid arthritis who are treated with chemotherapy drugs may be affected, as may patients with conditions such as endometriosis who require surgery.

Despite the much-ballyhooed examples of tech companies like Facebook, Apple and Google that offer egg freezing as an employee perk, cryopreservation, as it’s called, isn’t a typical employee benefit.

Only 6 percent of large companies with 500 or more workers offer egg freezing for employees or their spouses, according to the 2017 annual employer survey by benefits consultant Mercer. About a quarter cover in vitro fertilization. Forty-four percent of large employers don’t offer any infertility services, the survey found.

Men face the same infertility risk when they need cancer treatment.

When Blake Hornbrook, an Army medic at Fort Campbell, Ky., had surgery to remove a cancerous testicle in the fall of 2015, he and his wife, Kelsey, were stationed in Germany. Hornbrook, then 26, looked into fertility preservation while overseas, but the annual storage fee of 1,000 euros (about $1,150) deterred the couple.

Hornbrook required a second surgery several months later to see if the cancer had spread to his lymph nodes. The couple returned to the United States and drove directly from the airport to a sperm bank in Fairfax, Va. It cost roughly $400 for the initial appointment to provide a sperm specimen and store it, Hornbrook said.

Tricare covered Hornbrook’s cancer treatment, but it didn’t pay for fertility preservation or for IVF, which he estimated cost the couple $6,500 in clinic fees. Tricare provided discounts on some of the fertility drugs.

Their daughter, Harper, was born seven months ago, and Hornbrook’s cancer remains in remission.

For young cancer patients, the cost of storing the eggs or sperm that have been preserved can add up. Even if a state has a fertility preservation law, it typically doesn’t cover those costs, Reinecke said.

The Hornbrooks pay $480 annually to store his sperm and $375 to store their remaining embryos. Frega pays $1,000 annually to store her eggs.

Frega hopes to be able to conceive naturally and knowing she has frozen eggs available is “relieving, but also anxiety-producing,” she said. If she can’t get pregnant later on, she may have to pay $10,000 or more for IVF as well. “That’s what lies ahead,” she said.

Sixteen states require insurers to offer or cover infertility services to some extent, according to infertility advocacy organization Resolve. Requirements vary: Insurers may have to cover diagnosis or testing for infertility, for example, but not treatments like in vitro fertilization or fertility medications, said Barbara Collura, president and CEO of Resolve.

Typically, state infertility coverage laws require couples to try to get pregnant for a year or two before they’re eligible for insurance coverage of IVF or other treatments.

That requirement makes little sense for patients trying to preserve their fertility before undergoing medically necessary cancer or other treatment.

“These people aren’t infertile,” said Collura. “They need to undergo some sort of intervention that is going to impair their future fertility, and what we say is that if it’s medically necessary, they should have a right to have it covered.”

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

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

Kaiser Health News:HealthReform - October 16, 2018

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Administration critics were quick to note that omission.

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

Anthem Pays OCR $16 Million in Record HIPAA Settlement Following Largest U.S. Health Data Breach in History

HHS Gov News - October 16, 2018

Anthem, Inc. has agreed to pay $16 million to the U.S. Department of Health and Human Services, Office for Civil Rights (OCR) and take substantial corrective action to settle potential violations of the Health Insurance Portability and Accountability Act (HIPAA) Privacy and Security Rules after a series of cyberattacks led to the largest U.S. health data breach in history and exposed the electronic protected health information of almost 79 million people.

The $16 million settlement eclipses the previous high of $5.55 million paid to OCR in 2016.

Anthem is an independent licensee of the Blue Cross and Blue Shield Association operating throughout the United States and is one of the nation’s largest health benefits companies, providing medical care coverage to one in eight Americans through its affiliated health plans.  This breach affected electronic protected health information (ePHI) that Anthem, Inc. maintained for its affiliated health plans and any other covered entity health plans.

On March 13, 2015, Anthem filed a breach report with the HHS Office for Civil Rights detailing that, on January 29, 2015, they discovered cyber-attackers had gained access to their IT system via an undetected continuous and targeted cyberattack for the apparent purpose of extracting data, otherwise known as an advanced persistent threat attack.  After filing their breach report, Anthem discovered cyber-attackers had infiltrated their system through spear phishing emails sent to an Anthem subsidiary after at least one employee responded to the malicious email and opened the door to further attacks. OCR’s investigation revealed that between December 2, 2014 and January 27, 2015, the cyber-attackers stole the ePHI of almost 79 million individuals, including names, social security numbers, medical identification numbers, addresses, dates of birth, email addresses, and employment information.

“The largest health data breach in U.S. history fully merits the largest HIPAA settlement in history,” said OCR Director Roger Severino.  “Unfortunately, Anthem failed to implement appropriate measures for detecting hackers who had gained access to their system to harvest passwords and steal people’s private information.” Director Severino continued, “We know that large health care entities are attractive targets for hackers, which is why they are expected to have strong password policies and to monitor and respond to security incidents in a timely fashion or risk enforcement by OCR.”

In addition to the impermissible disclosure of ePHI, OCR’s investigation revealed that Anthem failed to conduct an enterprise-wide risk analysis, had insufficient procedures to regularly review information system activity, failed to identify and respond to suspected or known security incidents, and failed to implement adequate minimum access controls to prevent the cyber-attackers from accessing sensitive ePHI, beginning as early as February 18, 2014.

In addition to the $16 million settlement, Anthem will undertake a robust corrective action plan to comply with the HIPAA Rules.  The resolution agreement and corrective action plan may be found on the OCR website at

What You Need to Know about Putting Drug Prices in TV Ads

HHS Gov News - October 16, 2018

“If we want to have a real market for drugs, why not have [companies] disclose their prices in the ads, too? Consumers would have much more balanced information, and companies would have a very different set of incentives for setting their prices.” – HHS Secretary Alex Azar

In May 2018, President Trump and Secretary Azar introduced the American Patients First blueprint to bring down prescription drug prices.

  • The blueprint laid out four strategies for solving the problems patients face: boosting competition, enhancing negotiation, creating incentives for lower list prices, and bringing down out-of-pocket costs.
  • To create better incentives for list prices, the blueprint called for HHS to consider requiring the inclusion of list prices in direct-to-consumer advertising.

Right now, drug companies are required to disclose the major side effects a drug can have—but not the effect that buying the drug could have on your wallet. Patients deserve more transparency.

HHS is now proposing to require that TV ads for prescription drugs include their list price.

  • The proposal will require direct-to-consumer television advertisements for prescription drug and biological products paid for by Medicare or Medicaid to include the list price if the list price—the Wholesale Acquisition Cost—is greater than $35 for a month’s supply or the usual course of therapy, with the prices updated quarterly.
  • The 10 most commonly advertised drugs have list prices ranging from $535 to $11,000 per month or usual course of therapy.

Many patients either pay list price or pay prices calculated based on list price.

  • 47 percent of Americans have high-deductible health plans, under which they often pay the list price of a drug until their insurance kicks in.
  • All seniors on Medicare Part D have coinsurance for certain types of drugs, which means their out-of-pocket expenses are calculated as a share of list price.
  • List prices are also what patients pay if a drug is not on their insurance formulary, and list prices help determine insurance plans’ placement of drugs on their formulary.

HHS is exploring additional ways to improve drug price transparency and inform consumer decision-making.

  • As Secretary Azar has said, “You ought to know how much a drug costs and how much it’s going to cost you, long before you get to the pharmacy counter or get the bill in the mail.”
  • Another area in need of more transparency, as laid out in the blueprint, is the opaque system of rebates, which drive list prices up and do not fully benefit patients.

HHS Secretary Azar Comments on Drug Industry Price Transparency Announcement

HHS Gov News - October 16, 2018

Health and Human Services Secretary Alex Azar issued the following statement regarding pharmaceutical companies’ announcement that they would be providing access to more information on drug prices:

“Patient empowerment and transparency are at the core of the President’s drug-pricing blueprint that was released five months ago. Our vision for a new, more transparent drug-pricing system does not rely on voluntary action. The drug industry remains resistant to providing real transparency around their prices, including the sky-high list prices that many patients pay. So while the pharmaceutical industry’s action today is a small step in the right direction, we will go further and continue to implement the President’s blueprint to deliver new transparency and put American patients first. “ 

Influential Leapfrog Group Jumps In To Rate 5,600 Surgery Centers

Kaiser Health News:Marketplace - October 16, 2018

The influential Leapfrog Group, which grades nearly 2,000 U.S. hospitals, is launching a national survey to evaluate the safety and quality of up to 5,600 surgery centers that perform millions of outpatient procedures every year.

The group now issues hospitals an overall letter grade and evaluates how hospitals handle myriad problems, from infections to collapsed lungs to dangerous blood clots — helping patients decide where to seek care.

Simple Surgeries. Tragic Results.

The new surgery center effort will focus on staffing, surgical outcomes and patient experience in facilities that are performing increasingly complex procedures and seeing more aging patients. The grades will also cover surgery centers’ closest competitor, hospital outpatient departments.

Leah Binder, Leapfrog Group’s chief executive, said she wants to fill gaps in information about same-day surgery, which employers and health plans have embraced for its lower costs.

Employers, she said, “don’t have enough information on quality and safety of that care.”

Binder said a recent Kaiser Health News/USA Today Network investigation highlighted the need for independent information about surgery centers. The investigation found that since 2013, more than 260 patients died after care at centers that lacked appropriate lifesaving equipment, operated on very fragile patients or sent people home before they fully recovered.

“Your reporting did highlight the real lack of information from the federal government and the need for us to have an independent means of reporting,” Binder said. “People are going in for surgery, and our federal government doesn’t think it’s important to tell us how it’s going. Maybe that was OK 30 years ago, but now it’s not OK.”

The news report was based on inspection reports, lawsuits and data from many states that tally patient deaths but which refuse to note where they occurred. Seventeen other states collect no data on deaths at all.

The new Leapfrog plan will start with a survey of 250 centers in 2019 and include up to 5,600 surgery centers in 2020. At that point, it will publish data on the outcomes of specific procedures, like total knee replacements, across the hospital outpatient departments and surgery centers nationwide.

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The Leapfrog Group is funded by employers and health plans that cover the health care of the half of Americans who get health benefits through their job, Binder said. The organization was founded to shed light on health care quality and safety to help consumers pick high-value providers. It plans to disseminate the new surveys through its 40 business group members that steer millions in health spending.

Bill Prentice, chief executive of the Ambulatory Surgery Center Association, an industry trade group, said he supports the move toward greater transparency. However, he said the work to determine the specific measures is still underway, and “the devil is in the details.”

Ty Tippets, administrator of St. George Surgical Center in Utah, said he welcomes what Leapfrog is doing.

“Anytime [data] is gathered and provided in a transparent, easily accessed forum — it helps empower patients,” said Tippets, who recently testified before Congress about transparency in health care.

The Leapfrog Group announcement comes as Medicare is reviewing the data it will collect to gauge the quality of surgery centers.

The agency previously asked each surgery center to report its emergency transfer rate, or how often a patient 65 or older was sent from a center to the hospital. Yet the agency only required the centers to send data for half or more of its Medicare patients.

In the current rule-making period, Medicare declared the resulting data of little value, given the minimal differences among centers’ scores. The agency proposed dropping the measure, but has not yet finalized the proposal.

Going forward, Medicare has said it will use its own billing data to report the percent of surgery center patients who seek care at a hospital in the week after a procedure.

Medicare recently announced plans to shine more light on the performance of accreditors, which play a key role in granting or denying health facilities approvals to operate. A recent KHN investigation into accreditor performance in California — the only state where the private bodies’ inspection reports are public — showed repeated lapses in oversight.

A Medicare spokesman said new reports will show how well accreditors fare when state health officials inspect the same facilities.  In recent years, Medicare has found that accreditors overlooked the majority of problems that government officials uncovered.

In September, the White House Office of Management and Budget approved another health agency’s proposal to collect and report data about the “culture of safety” in surgery centers. The Agency for Healthcare Research and Quality will ask surgery center staff about issues such as whether staff feel comfortable speaking up about patient care concerns.

The plan says summary data — not facility-by-facility data — on the survey’s results will be reported publicly.

That effort would add to the overall information the public has about surgery centers, said Dr. Ashish Jha, a patient safety expert at Harvard’s School of Public Health.

“Places that do badly on safety culture surveys tend to have worse outcomes,” Jha said. “But you can’t bank on it.”

He said the most useful data for the public would cover actual events — such as deaths after surgery, admissions to the hospital or functional status and pain three months after surgery.

“Those are the things that actually matter,” he said.

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