Seeking to Grow Market Share?

Get a FREE assessment of your CDH products —
a $3,000 value.
LEARN HOW >

Drugmakers Funnel Millions To Lawmakers; A Few Dozen Get $100,000-Plus

Kaiser Health News:Marketplace - October 16, 2018

Explore The Database Campaign Contributions Tracker

Pharma Cash To Congress

By Elizabeth Lucas and Sydney Lupkin 2:00 AM EDT

A new Kaiser Health News database tracks campaign donations from drugmakers over the past 10 years.

Before the midterm elections heated up, dozens of drugmakers had already poured about $12 million into the war chests of hundreds of members of Congress.

Since the beginning of last year, 34 lawmakers have each received more than $100,000 from pharmaceutical companies. Two of those — Reps. Greg Walden of Oregon, a key Republican committee chairman, and Kevin McCarthy of California, the House Republican majority leader — each received more than $200,000, a new Kaiser Health News database shows.

As voters prepare to go to the polls, they can use a new database, “Pharma Cash to Congress,” tracking up to 10 years of pharmaceutical company contributions to any or all members of Congress, illuminating drugmakers’ efforts to influence legislation.

The drug industry ranks among lawmakers’ most generous patrons. In the past decade, Congress has received $79 million from 68 pharma political action committees, or PACs, run by employees of companies that make drugs treating everything from cancer to erectile dysfunction.

This story also ran on Daily Beast. This story can be republished for free (details). Drugmakers’ campaign contributions have reached record-breaking levels in recent years as skyrocketing drug prices have become a hot-button political issue. By June 30, 52 PACs funded by pharmaceutical companies and their trade organizations had given about $12 million to members of Congress for this election cycle. It is unclear whether drugmakers will top their previous 10-year record of $16 million, given during the 2016 election season.

While PAC contributions to candidates are limited, a larger donation frequently accompanies individual contributions from the company’s executives and other employees. It also sends a clear message to the recipient, campaign finance experts say, one they may remember when lobbyists come calling: There’s more where that came from.

The KHN analysis shows that pharmaceutical companies tend to play the field, giving to a wide swath of lawmakers on both sides of the aisle.

The drug industry favors power. Since the beginning of 2017, drugmakers contributed to 217 Republicans and 187 Democrats, giving only slightly more on average to Republicans, who currently control both chambers of Congress. This was also the case for Democrats during the 2010 election cycle, when they controlled Congress.

As with other industries, drugmakers tend to give more to lawmakers in leadership roles. For example, Rep. Paul Ryan, a Wisconsin Republican, became speaker of the House halfway through the 2016 election cycle, prompting drugmakers to pour $75,000 more into his war chest than they had the previous cycle.

Money also tends to flow to congressional committees with jurisdiction over pharmaceutical issues that can affect things like drug pricing and FDA approval. Walden, a nine-term Republican congressman, has watched his coffers swell with help from drugmaker PACs since he became chairman of the powerful House Committee on Energy and Commerce in early 2017.

With six months to go in the 2018 cycle, Walden had already raised an additional $71,000 over the 2016 cycle — or 11 times more than drugmakers gave him a decade ago.

Asked to comment on the increase in Walden’s contributions from drugmakers, Zach Hunter, his committee spokesman, called attention to Walden’s work to lower prescription drug prices and said “no member of Congress has done more” to end the opioid crisis.

Email Sign-Up

Subscribe to KHN’s free Morning Briefing.

Sign Up Please confirm your email address below: Sign Up

Pharmaceutical company PACs also gave to dozens of other members of committees, such as the Senate Committee on Health, Education, Labor and Pensions. And they appear to target congressional districts that are home to their headquarters and other facilities.

The PAC for Purdue Pharma, the embattled opioid manufacturer, gave to only a handful of members this cycle. However, it focused much of its giving on lawmakers from North Carolina, its headquarters for manufacturing and technical operations.

This election cycle, 28 percent of lawmakers did not receive any contributions from pharmaceutical PACs.

Under federal law, corporations cannot donate directly to political candidates. Exploiting a common loophole, they instead set up PACs, funded by money collected from employees. Those PACs then donate to campaigns, which are free to spend that money as they wish on necessities like advertising or campaign events.

Campaign contributions tell only part of the story. Drugmakers also spend millions of dollars lobbying members of Congress directly and give to patient advocacy groups, which provide patients to testify on Capitol Hill and organize social media campaigns on drugmakers’ behalf.

A previous investigation by Kaiser Health News, “Pre$cription for Power,” examined charitable giving by top drugmakers and found that 14 of them donated a combined $116 million to patient advocacy groups in 2015 alone.

To learn more about how Kaiser Health News built the Pre$cription for Power database, read our methodology.

And like other industries, pharmaceutical companies wield their political power in ways veiled from the public, giving to “dark money” groups and super PACs — independent groups barred from directly donating to or coordinating with campaigns — bent on swaying lawmaking.

Brendan Fischer, who directs federal reform programs at the Campaign Legal Center, cautioned that a campaign contribution from a corporate PAC does not directly translate into a vote in the drugmaker’s favor.

“Contributions help keep the door open for company lobbyists,” he said.

KHN data editor Elizabeth Lucas contributed to this story.

KHN’s coverage of prescription drug development, costs and pricing is supported in part by the Laura and John Arnold Foundation.

Pharma Cash To Congress

Kaiser Health News:Marketplace - October 16, 2018

Every year, pharmaceutical companies contribute millions of dollars to U.S. senators and representatives as part of a multipronged effort to influence health care lawmaking and spending priorities. Use this tool to explore the sizable role drugmakers play in the campaign finance system, where many industries seek to influence Congress. Discover which lawmakers rake in the most money (or the least) and which pharma companies are the biggest contributors. Or use our search tool to look up members of Congress by name or home state, as well as dozens of drugmakers that KHN tracks.

Methodology

Kaiser Health News uses campaign finance reports from the Federal Election Commission (FEC) to track donations from political action committees (PACs) registered with the FEC by pharmaceutical companies. Totals include donations to the principal campaign committees and leadership PACs for current members of Congress. We include only donations to members for election cycles in which they hold office (even if they weren’t in office for the full cycle, in the case of special elections). Donations are assigned to the quarter in which they were given, regardless of when they are reported by the receiving committee or PAC. Exact amounts can change as amendments and refunds are reported; KHN will update the analysis quarterly. Occasionally, refunds are reported in a different cycle from the original contribution, resulting in a negative total for the cycle.

There is a legal limit to how much each PAC can give to a member of the Senate or House of Representatives: $5,000 per election (including primaries and general elections) and per committee, or $10,000 per cycle. Each cycle is two calendar years, e.g. Jan. 1, 2017-Dec. 31, 2018.

When calculating changes in contributions from one cycle to another, we compare the latest quarter in the current cycle to the same point in the previous cycle for all drugmakers and for members of the House, who run for re-election every two years. For senators, who run for re-election every six years, we compare the current cycle to the cycle six years prior. We use the ProPublica Congress API to gather some information about past and present members. We use both Open Secrets and CQ Political Moneyline to collect additional information about PACs and verify our work.

KHN’s coverage of prescription drug development, costs and pricing is supported in part by the Laura and John Arnold Foundation.

Listen: Health Care Issues Reverberate In The States

Kaiser Health News:HealthReform - October 15, 2018

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

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

TV Ads Must Trumpet Drug Prices, Trump Administration Says. Pharma Tries A Plan B.

Kaiser Health News:Marketplace - October 15, 2018


[UPDATED at 6:45 p.m. ET]

The Trump administration proposed Monday that drugmakers reveal the list prices of their medicines in television ads, effectively setting the stage for months or possibly years of battle with the powerful industry.

The proposal, released late in the day, would require pharmaceutical companies to include in its television advertising the price of any drug that cost more than $35 a month. The price should be listed at the end of the advertisement in “a legible manner,” the rule states. It goes on to explain that the price should be presented against a contrasting background in a way that is easy to read.

Related Story More Stories On Drug Costs

Health and Human Services Secretary Alex Azar, nodding to an industry proposal announced earlier in the day, said voluntary moves are not enough.

“We will not wait for an industry with so many conflicting and perverse incentives to reform itself,” Azar told the audience gathered at the National Academy of Sciences in Washington, D.C.

If approved, the proposed rule has no government enforcement mechanism that would force the companies to comply. Rather, it depends on shaming, noting that federal regulators would post a list of companies violating the rule. It would depend on the private sector to police itself with litigation.

“It is noteworthy that the government is unwilling to take enforcement action,” said Rachel Sachs, an associate professor of law at Washington University at St. Louis and expert in drug-pricing regulation. The rule might never be finalized, she added.

Email Sign-Up

Subscribe to KHN’s free Morning Briefing.

Sign Up Please confirm your email address below: Sign Up

“It will take many months if not years for this regulation to be implemented and free from the cloud of litigation that will follow it. And the administration knows that,” Sachs said.

Earlier Monday, the pharmaceutical industry trade group went on the offensive in anticipation of Azar’s speech by announcing its own plans.

“Putting list prices in isolation in the advertisements themselves would be misleading or confusing,” argued Stephen Ubl, CEO of the Pharmaceutical Researchers and Manufacturers of America, or PhRMA, the major trade group for branded drugs.

Instead, Ubl, whose trade group represents the largest pharmaceutical manufacturers on the globe, promised that pharma companies would direct consumers to websites that include a drug’s list price and estimates of what people can expect to pay, which can vary widely depending on coverage.

Drug manufacturers would voluntarily opt in to this disclosure starting next spring, he said. Ubl remained strongly critical of the White House proposal.

The Trump administration’s proposal comes weeks before midterm elections in which health care is a top voter concern. Polling from the Kaiser Family Foundation suggests most voters support forcing price transparency in drug advertisements. (Kaiser Health News is an editorially independent program of the foundation.)

The White House’s plan, which was teased in President Donald Trump’s blueprint this summer, has won praise from insurance groups and the American Medical Association.

Sens. Chuck Grassley (R-Iowa) and Dick Durbin (D-Ill.) also proposed the plan in the Senate last month, but it failed to garner enough support.

Experts pointed out a host of complications, suggesting that neither PhRMA’s approach nor the White House’s would fully explain to consumers what they’ll actually pay for drugs.

On Monday, Grassley applauded Azar’s announcement, saying it was a “common-sense way to lower prices.”

But Dale Cooke, a consultant who works with drug companies trying to meet Food and Drug Administration requirements for advertising, warned there is no reason to believe posting prices would help drive down prices.

“No one has ever explained to me why this would work,” Cooke said. “What’s the mechanism by which this results in lower drug prices?”

Even more, it could be confusing for patients, Cooke said. The proposed rule seemed to acknowledge this danger, he said, noting, “On the other hand, consumers, intimidated and confused by high list prices, may be deterred from contacting their physicians about drugs or medical conditions.”

A drug’s list price — the metric HHS wants to emphasize — often bears little relationship to what a patient pays at the drugstore. Insurance plans and pharmacy benefit managers often negotiate cheaper prices than the list price. Some patients qualify for other discounts. And often patients pay only what their copay or deductible requires at any given time.

Other consumers could be stuck paying the full cost, depending on how their insurance plan is designed, or if they don’t have coverage.

“The system is very opaque, very complicated and, importantly, there isn’t a huge relationship between list prices for drugs and what patients will expect to pay out-of-pocket,” said Adrienne Faerber, a lecturer at the Dartmouth Institute for Health Policy and Clinical Practice who researches drug marketing.

But the industry’s strategy, she said, also appeared lacking.

Under PhRMA’s plan, drugmakers would not standardize how they display their information. Where consumers go could vary on Pfizer’s website versus Merck’s to learn about the list price and the range of out-of-pocket costs. That, Faerber argued, would make it difficult for people to unearth relevant information.

PhRMA also announced it is partnering with patient advocacy groups to create a “patient affordability platform,” which could help patients search for costs and insurance coverage options.

Ubl cast their proposal as a way to address more effectively the government and public concern about drug price transparency.

Pharmaceutical manufacturers rely heavily on national advertising and together represent the third-highest spender in national television advertising, according to Michael Leszega, a manager of market intelligence at consulting firm Magna.

At certain times of day, pharmaceutical ads make up more than 40 percent of TV advertisements. And those commercials stand out because they are generally longer, with a long list of side effects and warnings the pharmaceutical industry must tag on at the end.

Those disclaimers highlight another challenge for the administration: legal action.

The rule notes its legal justification was based on the responsibility of the Centers for Medicare & Medicaid Services to ensure the health coverage programs that it administers — Medicare and Medicaid — must be operated in a manner that “minimizes reasonable expenditures.”

Sachs noted that the argument may be weak because most drugs are marketed to a wider audience than Medicare and Medicaid beneficiaries.

A body of Supreme Court decisions dictate how disclaimers and disclosures can be required, said constitutional law expert Robert Corn-Revere. He filed a “friend of the court” brief in a 2011 U.S. Supreme Court case related to commercial speech and the pharmaceutical industry.

Generally, the administration’s requirement must meet the standards of being purely factual, noncontroversial and not burdensome, Corn-Revere said.

On the question of whether requiring drug prices be listed in advertising violates the First Amendment’s free-speech guarantee, Corn-Revere said it “all comes down to the specifics.”

Ubl, when asked earlier about legal action, didn’t rule out the possibility. “We believe there are substantial statutory and constitutional principles that arise” from requiring list-price disclosure, Ubl said, adding: “We do have concerns about that approach.”

KHN’s coverage of prescription drug development, costs and pricing is supported in part by the Laura and John Arnold Foundation.

Readout of Secretary Azar’s Community Pharmacy and Patient Roundtable in Pittsburgh

HHS Gov News - October 15, 2018

Today, Health and Human Services Secretary Alex Azar and Centers for Medicare & Medicaid Services Chief of Staff Paul Mango traveled to Pittsburgh, Pennsylvania to participate in a roundtable discussion at Spartan Pharmacy. The discussion included community pharmacists and their senior patients and covered the legislation recently signed by President Trump banning pharmacy gag clauses.

This significant bipartisan achievement is one of many actions the Trump administration has taken since the President rolled out the American Patients First Blueprint to Lower Drug Prices and Reduce Out-of-Pocket Costs. Pharmacists can now always inform patients when it’s possible to pay less out of pocket for prescription drugs, in both private insurance plans and in Medicare prescription drug plans.

At the roundtable, Secretary Azar stressed the importance of patients’ asking their pharmacists if they are getting the best deal on the prescription drugs they need. He listened to the participants’ healthcare concerns and their ideas to lower prescription drug prices. Secretary Azar concluded the roundtable by thanking the participants for the robust discussion and voiced his and President Trump’s commitment to lower healthcare and prescription drug costs for American patients.

To read Secretary Azar’s full statement on the legislation banning pharmacy gag clauses, please visit: https://www.hhs.gov/about/news/2018/10/10/hhs-secretary-azar-praises-results-of-president-trumps-leadership-on-drug-pricing.html

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

Kaiser Health News:HealthReform - October 15, 2018

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

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

But the dire projections proved wrong.

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

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

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

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

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

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

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

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

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

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

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

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

Email Sign-Up

Subscribe to KHN’s free Morning Briefing.

Sign Up Please confirm your email address below: Sign Up

Extra Benefits

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

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

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

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

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

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

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

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

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

Getting Consumers To Switch

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

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

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

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

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

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

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

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

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

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

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

HHS Secretary Azar declares public health emergency in Georgia due to Hurricane Michael

HHS Gov News - October 12, 2018

Health and Human Services (HHS) Secretary Alex Azar today declared a public health emergency in Georgia due to damage from Hurricane Michael. The declaration follows President Trump’s emergency declaration for the state and gives the HHS Centers for Medicare & Medicaid Services beneficiaries and their healthcare providers and suppliers greater flexibility in meeting emergency health needs.

“We are working closely with state health authorities and private sector partners from hospitals and other healthcare facilities to save lives and protect public health after Hurricane Michael,” Secretary Azar said. “This declaration will help ensure that our fellow Americans who rely on Medicare and Medicaid have continuous access to the care they need.”

To assist state and local officials in lifesaving efforts for medically vulnerable people, HHS also provided state health officials with information on Medicare beneficiaries who rely on dialysis or use special medical equipment at home, such as oxygen concentrators, in the potentially impacted areas. For these people power outages can be life threatening within hours. CMS also activated the Kidney Community Emergency Response Program to monitor dialysis access and needs of these facilities after the hurricane.

HHS moved about 400 medical and public health personnel along with their caches of medical equipment into impacted areas, ready to respond to medical and public health needs in Florida and Georgia. An additional 300 personnel are now on alert from the National Disaster Medical System and the U.S. Public Health Service Commissioned Corps.

Some of these medical personnel are working with Florida Urban Search and Rescue teams to triage people rescued. Other HHS medical personnel are working alongside local hospital staffs in providing medical care in hospital emergency departments in Florida.

HHS teams also can provide basic medical care for evacuees at shelters, help the health department with disease surveillance, offer behavioral health support for residents and responders, and more. HHS incident managers are working with state officials to determine whether federal medical and public health support is needed in Georgia.

To assist residents in the impacted area in coping with the stress of the disasters, the Substance Abuse and Mental Health Services Administration activated the Disaster Distress Helpline. The Disaster Distress Helpline provides immediate 24/7, 365-days-a-year crisis counseling and support to people experiencing emotional distress related to natural or human-caused disasters. This toll-free, multilingual, and confidential crisis support service is available to all residents in the United States and its territories. Stress, anxiety, and other depression-like symptoms are common reactions after a disaster. Call 1-800-985-5990 or text TalkWithUs to 66746 (for Spanish, press 2 or text Hablanos to 66746) to connect with a trained crisis counselor.

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

Secretary Azar declared a public health emergency in Florida Tuesday. In declaring the public health emergencies in Florida and Georgia and authorizing flexibilities for CMS beneficiaries, Secretary Azar acted under his authority in the Public Health Service Act and Social Security Act. These actions and flexibilities are retroactive to October 9, 2018, in Georgia and October 7, 2018, in Florida.

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

Must Reads Of The Week From Brianna Labuskes

Kaiser Health News:HealthReform - October 12, 2018
The Friday Breeze

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

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

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

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

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

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

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

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

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

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

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

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

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

The Friday Breeze

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

Sign Up Please confirm your email address below: Sign Up

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

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

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

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

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

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

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

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

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

Politico: Oregon’s Unlikely Abortion Fight Hinges on Taxes

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

The Associated Press: Deported Parents May Lose Kids to Adoption

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

The New York Times: The Democrats Have an Immigration Problem

In the miscellaneous, must-read file:

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

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

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

Bloomberg: Nursing Homes Are Pushing the Dying Into Pricey Rehab

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

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

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

Have a great (hopefully superbug-free) weekend!

HHS awards $2.34 billion in grants to help Americans access HIV/AIDS care and medication

HHS Gov News - October 11, 2018

Today, the U.S. Department of Health and Human Services announced that approximately $2.34 billion in Ryan White HIV/AIDS Program grants were awarded to cities, counties, states, and local community-based organizations in fiscal year (FY) 2018. This funding through the Health Resources and Services Administration (HRSA) supports a comprehensive system of HIV primary medical care, medication, and essential support services to more than half a million people living with HIV in the United States.

“New medical advances and broader access to treatment have helped transform HIV/AIDS from a likely death sentence into a manageable chronic disease,” said HHS Secretary Alex Azar. “The Ryan White HIV/AIDS Program is an important way to ensure that these life-saving treatments reach the Americans who need them, and the Trump Administration is committed to continuing to improve the care by Americans living with HIV/AIDS receive.”

"The Ryan White HIV/AIDS Program plays a vital role in the United States' public health response to ending the HIV epidemic,” said HRSA Administrator George Sigounas, M.S., Ph.D. "These grants will help ensure that the most vulnerable Americans living with HIV/AIDS have access to life-saving care and treatment needed to improve their health quality and medical outcomes."

HRSA oversees the Ryan White HIV/AIDS Program, which is a patient-centered system that provides care and treatment services to low income people living with HIV to improve health outcomes and reduce HIV transmission among hard to reach populations. The program serves approximately 50 percent of people living with diagnosed HIV infection in the United States. In 2016, approximately 85 percent of Ryan White HIV/AIDS Program clients who received HIV medical care were virally suppressed, up from 69 percent in 2010.

"The Ryan White HIV/AIDS Program is critical to improving clinical and public health outcomes by reducing HIV transmission and serves as an important source of ongoing access to HIV treatment and antiretroviral medication," said Laura Cheever, M.D., Sc.M., Associate Administrator, HIV/AIDS Bureau. "Today people living with HIV who take HIV medication daily as prescribed and who achieve and maintain an undetectable viral load have effectively no risk of sexually transmitting the virus to an HIV-negative partner.”

Under Part A of the Ryan White HIV/AIDS Program, approximately $624.3 million was awarded to 52 metropolitan areas to provide core medical and support services for people living with HIV. These grants were awarded to 24 eligible metropolitan areas and 28 transitional grant areas with the highest number of people living with HIV and AIDS and experiencing increases in HIV and AIDS cases and emerging care needs. For a list of the FY 2018 Ryan White HIV/AIDS Program Part A award recipients, visit https://hab.hrsa.gov/awards/fy-2018-ryan-white-hivaids-program-part-a-final-awards.

Under Part B of the Ryan White HIV/AIDS Program, approximately $1.4 billion was awarded to 59 states and territories to improve the quality, availability and organization of HIV health care and support services and for the AIDS Drug Assistance Program (ADAP). Additionally, 16 states received Emerging Community grants based on the number of AIDS cases over the most recent five-year period. Thirty-three states and territories were also awarded approximately $10.5 million in Part B Minority AIDS Initiative grants. For a list of the FY 2018 Ryan White HIV/AIDS Program Part B award recipients, visit https://hab.hrsa.gov/awards/fy-2018-ryan-white-hivaids-program-part-b-grant-awards.

Under Part C Early Intervention Services (EIS) of the Ryan White HIV/AIDS Program, approximately $181.9 million was awarded across the country to 351 local, community-based organizations to provide core medical and support services to people living with HIV. Additionally, 52 organizations were awarded approximately $6.9 million in Part C Capacity Development grants. For a list of the FY 2018 Ryan White HIV/AIDS Program Part C EIS award recipients, visit https://hab.hrsa.gov/awards/fy-2018-ryan-white-hivaids-program-part-c-early-intervention-services-eis-awards. For a list of the FY 2018 Ryan White HIV/AIDS Program Part C Capacity Development award recipients, visit https://hab.hrsa.gov/awards/fy-2018-ryan-white-hivaids-program-part-c-capacity-development-awards.

Under Part D of the Ryan White HIV/AIDS Program, approximately $70.3 million was awarded to 115 local community-based organizations across the country to provide family-centered comprehensive HIV care and treatment for women, infants, children, and youth. For a list of the FY 2018 Ryan White HIV/AIDS Program Part D award recipients, visit  https://hab.hrsa.gov/awards/fy-2018-ryan-white-hivaids-program-part-d-grant-awards.

Under Part F of the Ryan White HIV/AIDS Program, approximately $68.6 million was awarded to support clinical training, oral health services, quality improvement, and the development of innovative models of care through several different programs. Approximately $8.9 million was awarded to 51 recipients through the HIV/AIDS Dental Reimbursement Program, and approximately $3.5 million was awarded to 12 recipients through the HIV/AIDS Community-Based Dental Partnership Program. For a list of the FY 2018 Ryan White HIV/AIDS Program Part F HIV/AIDS Dental Reimbursement Program award recipients and HIV/AIDS Community-Based Dental Partnership Program award recipients, visit https://hab.hrsa.gov/awards/fy-2018-ryan-white-hivaids-program-part-f-grant-awards.

Also under Part F, the AIDS Education and Training Centers Program (AETC) awarded approximately $31.2 million through 14 grants, cooperative agreements and contracts to support education and training of health care professionals, which includes a network of eight regional and two national centers. For a list of the FY 2018 Ryan White HIV/AIDS Program AETC award recipients, visit https://hab.hrsa.gov/awards/fy-2018-ryan-white-hivaids-program-aids-education-and-training-center-awards.

In addition, $25 million was awarded through the Ryan White HIV/AIDS Program Special Projects of National Significance (SPNS) Program under Part F, which supports the development of innovative models of care, informing evidence-based interventions with populations living with HIV who are significantly difficult to engage, retain in care, and achieve viral suppression. For a list of current SPNS initiatives, visit here.

Grant awards in FY 2018 also support states, cities, counties, and communities to achieve the goals of the National HIV/AIDS Strategy for the United States: Updated to 2020. These include efforts to reduce new HIV infections, increase access to HIV care and improve health outcomes for people living with HIV infection, and reduce HIV-related disparities and health inequities.

To learn more about HRSA’s Ryan White HIV/AIDS Program, visit hab.hrsa.gov. For more information about HIV/AIDS prevention, testing, treatment, and research, visit HIV.gov.

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

Kaiser Health News:HealthReform - October 11, 2018
Mary Agnes Carey

Kaiser Health News

@MaryAgnesCarey

Read Mary Agnes' Stories Rebecca Adams

CQ Roll Call

@RebeccaAdamsDC

Read Rebecca's Stories Julie Appleby

Kaiser Health News

@Julie_Appleby

Read Julie's Stories Anna Edney

Bloomberg

@annaedney

Read Anna's Stories

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

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

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

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

Among the takeaways from this week’s podcast:

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

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

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

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

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

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

To hear all our podcasts, click here.

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

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

Kaiser Health News:HealthReform - October 11, 2018

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

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

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

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

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

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

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

Don't Miss A Story

Subscribe to KHN’s free Weekly Edition newsletter.

Sign Up Please confirm your email address below: Sign Up

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Kaiser Health News:Insurance - October 11, 2018

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

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

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

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

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

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

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

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

Preexisting conditions are common.

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

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

Protections vary by what kind of insurance you have.

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

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

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

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

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

Email Sign-Up

Subscribe to KHN’s free Morning Briefing.

Sign Up Please confirm your email address below: Sign Up

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

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

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

Will protections on preexisting conditions become collateral damage?

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

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

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

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

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

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

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

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

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

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

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

Kaiser Health News:HealthReform - October 11, 2018

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

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

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

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

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

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

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

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

Preexisting conditions are common.

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

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

Protections vary by what kind of insurance you have.

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

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

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

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

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

Email Sign-Up

Subscribe to KHN’s free Morning Briefing.

Sign Up Please confirm your email address below: Sign Up

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

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

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

Will protections on preexisting conditions become collateral damage?

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

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

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

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

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

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

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

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

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

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

‘Grossly Unfair’? Widower Takes Ban On Military Injury Claims To Supreme Court

Kaiser Health News:Marketplace - October 11, 2018

Walter Daniel, a former Coast Guard officer, filed a wrongful death lawsuit after his wife died following childbirth at a military hospital in 2015, but it was dismissed based on a 68-year-old federal ruling. After two failed appeals, he petitioned the U.S. Supreme Court to allow active-duty service members to seek legal damages for medical malpractice harm the same way civilians can.(Heidi de Marco/KHN)

This story also ran on The Seattle Times. This story can be republished for free (details). More than four years after Navy Lt. Rebekah Daniel bled to death within hours of childbirth at a Washington state military hospital, her husband still doesn’t know exactly how — or why — it happened.

Walter Daniel, a former Coast Guard officer, demanded explanations from officials at the Naval Hospital Bremerton, where his wife, known as “Moani,” died on March 9, 2014.

He says he got none. No results from a formal review of the incident, no details about how the low-risk pregnancy of a healthy 33-year-old woman — a labor and delivery nurse herself — ended in tragedy, leaving their newborn daughter, Victoria, now 4, without a mom.

“There was no timeline, no records of what steps were taken,” recalled Daniel, 39, sitting in his Seattle lawyer’s high-rise office last month. “I’ve had no answers.”

Daniel, who now lives in Dublin, Calif., filed a wrongful death lawsuit in 2015, but it was dismissed, as were subsequent appeals.

The dismissals were based not on the facts of the case but on what’s known as the Feres doctrine, a 68-year-old federal ruling that bars active-duty military members from suing the federal government for injuries.

This week, Daniel is taking his quest for answers to the U.S. Supreme Court.

Email Sign-Up

Subscribe to KHN’s free Morning Briefing.

Sign Up Please confirm your email address below: Sign Up

Through his lawyer, he petitioned the high court on Thursday to amend the 1950 ruling, creating an exception that would allow service members to sue for medical malpractice the same way civilians can.

The military health system, with 54 hospitals and 377 medical clinics, serves about 9.4 million beneficiaries, including nearly 1.4 million active-duty members.

“I don’t want this to happen to any other family,” Daniel said.

The Supreme Court hasn’t considered the Feres doctrine in more than 30 years, since the 1987 case U.S. v. Johnson, where the justices ruled 5-4 to uphold the ruling. That decision drew a scathing dissent from Justice Antonin Scalia, who declared the rule should be scrapped.

Feres [v. United States] was wrongly decided and heartily deserves the widespread, almost universal criticism it has received,” Scalia famously wrote.

Since then, however, the court has refused to accept at least two petitions that would have allowed reconsideration of Feres. And chances are slim now. Of the 7,000 to 8,000 cases submitted to the Supreme Court each term, only about 80 are accepted.

But Daniel and his lawyer, Andrew Hoyal of the Luvera law firm in Seattle, insist that the circumstances of Moani Daniel’s death warrant new scrutiny.

“We thought if we’re ever going to take a shot at the Feres doctrine, this is the case to do it,” Hoyal said. “It was clear negligence. It was an awful situation. And every civilian in the country would be able to bring a lawsuit to get accountability, except for members of the service.

“She was treated differently because she had lieutenant’s bars.”

Walter Daniel, a former Coast Guard officer, holds a photograph of his wife, Navy Lt. Rebekah Daniel, known as “Moani.” She died hours after giving birth to their daughter, Victoria, at the Naval Hospital Bremerton. Daniel says he received no details about how the low-risk pregnancy of his healthy 33-year-old wife, a labor and delivery nurse, ended in tragedy.(Heidi de Marco/KHN)

 

Walter Daniel plays with daughter Victoria near their apartment in Dublin, Calif., on Sept. 27, 2018.(Heidi de Marco/KHN)

A photo of Walter and Moani Daniel sits in the living room of the Daniels’ apartment. More than four years after Moani bled to death following childbirth at a Washington state military hospital, Daniel still doesn’t know exactly how or why it happened. (Heidi de Marco/KHN)

Daniel disputes the findings of a Navy autopsy that concluded Rebekah Daniel died of “natural” causes possibly linked to an amniotic fluid embolism, a rare, hard-to-prove complication of childbirth.

Daniel claims that his wife — who worked in the maternity unit where she delivered her baby — died from botched medical care that failed to stop her from hemorrhaging nearly a third of the blood in her body.

“It was utter chaos,” he recalled. “I remember multiple towels and sponges like they were trying to soak up the blood … but it kept coming.”

Doctors failed to perform vital tests, to employ an obstetrical balloon — a standard device used to halt postpartum hemorrhage — and to start massive blood transfusions until too late, court documents claim.

Just four hours after the birth of her 8-pound, 7-ounce daughter, Moani Daniel was dead.

“I was in shock,” recalled Walter Daniel.

Capt. Jeffrey Bitterman, commanding officer of Naval Hospital Bremerton, said in an email that the circumstances of Moani Daniel’s death were “thoroughly examined in a quality review process.” The results of the review cannot be publicly released, he said, declining further comment because of pending litigation.

However, in a press release promoting the “Aloha Moani” 5K run organized in Daniel’s honor, Navy officials publicly said she died “due to a rare complication of childbirth.”

Walter and Moani Daniel, who met in Hawaii, had been married nearly a decade when she became pregnant in 2013. Moani Daniel had a son, Damien, now 19, from a previous marriage.

Moani Daniel loved her job, but she had submitted her resignation to the Navy months earlier and was set to leave the service in April 2014. Walter Daniel had accepted a job in Northern California, where he had moved with Damien to get him settled in school.

The day after his wife’s death, Walter Daniel returned to her empty apartment.

“She had all this stuff for the baby set up,” he recalled. “I’m like, ‘What the hell just happened?’ It was like a nightmare.’”

The Feres doctrine holds that active-duty members of the military cannot sue under the Federal Tort Claims Act for harm “incident to service.” The justices wanted to ensure that Congress would not be “burdened with private bills on behalf of military and naval personnel.”

They reasoned then that the military provides comprehensive relief for injuries or death of service members and their families — and that there’s no parallel with private liability because the relationship between the government and its armed forces is distinct. Later, the court insisted that a primary reason for barring such lawsuits is to maintain military discipline.

But the decision, particularly the definition of “incident to service,” has been debated fiercely for years by scholars and, at least twice, in bills before Congress.

The rule, however, has been interpreted to include not just military duty, but virtually any activity of an active-duty service member, said Richard Custin, a clinical professor of business law and ethics at the University of San Diego.

“It’s just grossly unfair,” he said. “Childbirth is not a military activity. It’s clearly not ‘incident to service.’”

Custin and other critics claim the Feres doctrine strips military members of a constitutional right to seek redress for grievances, while also allowing military hospitals and doctors to escape scrutiny for negligent care.

Military hospitals reported 545 so-called sentinel events — medical omissions or errors — from 2014 to 2017, according to Defense Health Agency data. In 2014, Naval Hospital Bremerton reported at least one case of postpartum hemorrhage or hysterectomy.

But such reports aren’t public, so Daniel doesn’t know whether his wife’s case was included in those records. A 2014 review of military health care found the rate of postpartum hemorrhage was consistently higher in military hospitals than the national average, Hoyal noted.

“What they do in the medical arena is no different than what civilian hospitals do and they should be held to the same standards as civilian hospitals and civilian doctors,” Hoyal said.

Officials with the Department of Defense declined interview requests regarding the Feres ruling.

In an email, however, an agency spokeswoman said that overturning the rule would “destroy the premise” of no-fault workers’ compensation available in the military and elsewhere. It would also “create an unsustainable inequity” between military members allowed to sue and others, such as those injured in combat, who couldn’t.

And, rather than improving military health care, overturning Feres would “compromise its effectiveness,” the agency said, noting: “No medical system is perfect.”

Custin, the law professor, said he sympathizes with Daniel, but isn’t optimistic that the court will view the case differently than other medical malpractice claims.

“What this attorney needs to do is somehow distinguish Daniel from the long line of victims that have been maligned by Feres,” he said.

Walter Daniel has been raising daughter Victoria as a single dad for four years. After the death of his wife, Moani, he left the Coast Guard and returned to college to study to become a high school teacher.(Heidi de Marco/KHN)

Hoyal intends to argue that the Supreme Court’s rulings regarding Feres have been inconsistent and irreconcilable. In decisions that followed Feres, the court rejected its own “parallel liability” argument, said Hoyal. And it has never ruled that medical decisions like those at stake in Daniel’s case would undermine military discipline.

“In short, the legal landscape has undergone a sea change since 1950,” Hoyal’s petition states. “Theories once central to Feres no longer matter. Rationales not considered in Feres are now central.”

Such an argument may well sway an increasingly conservative Supreme Court that now includes justices loyal to Scalia’s views — as well as progressives inclined to support workers’ rights, said Dwight Stirling, chief executive of the Center for Law and Military Policy, a Southern California think tank.

“The Feres doctrine does not divide the court members on your standard ideological grounds,” he said. “It tends to scramble the typical calculus.”

Walter Daniel hopes so. After raising Victoria as a single dad for four years, he left the Coast Guard, recently remarried and returned to college to study to become a high school teacher. Even as his life moves on, he said, he hopes Moani Daniel’s case will provide justice for others.

“It’s not about the Daniel family, it’s about those thousands of service members throughout the world who are affected by this rule,” he said. “That’s what our fight is for.”

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

Will Maine Voters Decide To Make Aging In Place Affordable?

Kaiser Health News:States - October 11, 2018
Navigating Aging

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

To contact Judith Graham with a question or comment, click here.

Join the Navigating Aging Facebook Group.

See All Columns

As Election Day draws near, a ballot initiative in Maine to provide universal home care is shining a spotlight on the inadequacies of the nation’s long-term care system.

The essential problem: Although most older adults want to live at home when their health starts to decline or they become frail, programs that help them do so are narrow in scope, fragmented and poorly funded.

Medicare’s home care benefits are limited to seniors and adults with disabilities who are homebound and need skilled services intermittently. State Medicaid programs vary widely but are generally restricted to people at the lower end of the income ladder. Long-term care insurance is expensive and covers only a small slice of the older population.

That leaves millions of middle-class families struggling to figure out what to do when an older relative develops a serious chronic illness, such as heart failure, or suffers an acute medical crisis, such as a stroke.

“We’re about to have the largest older population we’ve ever had, which is going to need exponentially more care than has ever been needed before. And we’re not prepared,” said Ai-jen Poo, co-director of Caring Across Generations, an organization working to expand long-term care services across the U.S.

Maine, with nearly 20 percent of its residents age 65 and older, is exploring a radical response to this dilemma that’s being closely watched by other states.

Its ballot initiative, known as Question 1, proposes that home care services be available to all residents, at no cost, regardless of income. If enacted, it would become the first such program in the nation.

Adults would be eligible for the program when they need help with at least one “activity of daily living”: walking, bathing, dressing, eating, toileting, personal hygiene, and getting in or out of bed. Services covered would include care from aides and companions; speech, physical and occupational therapy; counseling; home repairs; transportation; respite care; devices for people with disabilities; and even, occasionally, small rent subsidies.

Stipends would be granted to family caregivers. Seventy-seven percent of program funds would be directed to home care aides, in a move to strengthen this workforce.

More than 21,000 people could qualify for home care services under the new program, in addition to about 5,600 people who already receive services through Maine Medicaid and other state programs, according to the most definitive analysis to date, published last month by researchers at the University of Southern Maine’s Muskie School of Public Service.

Funding for the new program would come from a new 3.8 percent tax on wages and non-wage income that isn’t taxed by Social Security: a threshold of $128,400 per person in 2018. Between $180 million and $310 million would be raised annually, according to various estimates. The program would be fully implemented by January 2022.

The political battle over Question 1 is fierce, although no one questions the need for affordable home care for seniors and people with disabilities. In AARP’s most recent “Long-Term Services and Supports State Scorecard,” Maine ranked last in the nation on affordability of home care.

Among thousands of people affected are Rick Alexander of Blue Hill, Maine. 70, a retired school librarian, and his wife, Debbie, 64, who has multiple sclerosis.

“Since Debbie has a progressive form of MS, her needs are going to increase,” said Alexander, his wife’s sole, unpaid caregiver and a supporter of Question 1. “We brought in some paid help years back, but we couldn’t do that for very long: It’s too expensive.”

Alexander wants to keep Debbie at home as long as possible, but he worries about the physical demands and emotional consequences. “I have chronic clinical depression and periodically I go down into the dumps, a long way,” he admitted. “When that happens, it’s hard for me to motivate myself to do anything.”

Also, it’s generally accepted in Maine that something needs to be done about a severe shortage of home care aides — a problem surfacing nationwide. Each week, 6,000 hours of home care services that have been authorized aren’t delivered by Maine agencies because of staff shortages, which are particularly acute in rural areas, according to the Maine Council on Aging.

Email Sign-Up

Subscribe to KHN’s free Morning Briefing.

Sign Up Please confirm your email address below: Sign Up

Despite these areas of consensus, however, disagreements surrounding Question 1 are intense and most Maine health care and business associations oppose it, along with all four candidates for governor.

Taxes are a key point of contention. Question 1 supporters argue that a relatively small number of high-income individuals would pay extra taxes. The Maine Center for Economic Policy estimates that only 3.4 percent of people earning income in Maine would be affected, according to a September report.

Citing ambiguous language in the initiative, opponents argue that families earning more than $128,400 would also be subject to the tax hike, significantly expanding its impact. A pressing concern is that higher taxes would discourage doctors, nurses and other professionals from moving to or remaining in Maine.

“We have a workforce crisis already, and this increase — which would make our income tax rate among the highest in the country — would be a disaster,” said Jeffrey Austin, vice president of government affairs at the Maine Hospital Association.

The program is too expansive and expensive to be sustained long term, other opponents say. “We have limited public resources in Maine and those should be dedicated to the people most in need, fiscally and physically,” said Newell Augur, a lobbyist for the Home Care & Hospice Alliance of Maine and chair of the “NO on Question One/Stop the Scam” campaign.

In a statement, AARP Maine, which has not taken a stand on Question 1, expressed reservations. “Using a payroll tax to pay for HCBS [home and community-based services] is an untested policy at the local level,” it noted.

Also controversial is the board that would be established to operate the home care program. The initiative calls for nine members (three from home care agencies, three direct care workers and three service recipients) elected by constituent organizations to oversee the program.

“The board wouldn’t be accountable to the governor or the legislature, and Maine taxpayers would have no say over how their money is being spent,” said Jacob Posik, a policy analyst at the conservative-leaning Maine Heritage Policy Center.

Supporters note that an advisory committee would include state officials from multiple agencies. The board’s structure is meant to be “responsive to the people providing and receiving the care,” said Mike Tipping, communications director for the Maine People’s Alliance, a grass-roots organization that’s spearheading Question 1 and that helped pass a 2017 ballot initiative expanding Medicaid in Maine, currently tied up in the courts.

For all these policy disputes, it’s clear that Question 1 has considerable emotional resonance. “I’ve never had people cry signing a petition and tell me how much something like this would have changed their lives,” said Kevin Simowitz, political director for Caring Across Generations.

One of the people who’s spoken out publicly is the Rev. Myrick Cross, 75, of St. Patrick’s Episcopal Church in Brewer.

Cross works part time at the church so he can pay for aides that care for his 38-year-old daughter with Down syndrome and his 95-year-old mother, who has suffered from kidney disease, falls, wounds that didn’t heal and pneumonia in the past several years. “I will do whatever I need to keep them home,” he said.

Originally, Cross looked to home care agencies for assistance, but with rates of $23 to $25 per hour “that was more than I could afford,” he said. Today, three local residents provide more than 50 hours of care a week for $12 to $15 an hour.

“I’m blessed that I’m able to work and to hire all these people to keep us going,” Cross said. “But several members of my congregation are older and don’t have the family resources that we have. This would make the quality of their lives better.”

We’re eager to hear from readers about questions you’d like answered, problems you’ve been having with your care and advice you need in dealing with the health care system. Visit khn.org/columnists to submit your requests or tips.

HHS Secretary Azar Praises Results of President Trump’s Leadership on Drug Pricing

HHS Gov News - October 10, 2018

On Wednesday, President Trump signed legislation that bans pharmacy gag clauses, which prevent pharmacists from informing patients when they can pay less out of pocket for a prescription drug, in both private insurance plans and in Medicare prescription drug plans.

HHS Secretary Alex Azar released the following statement:

“This bipartisan legislative accomplishment was secured by President Trump’s historic leadership on drug pricing. The President’s drug-pricing blueprint called for ending gag clauses. Within a week of the blueprint’s release, HHS informed Medicare plans that they are unacceptable, and now Congress has responded to the President’s call by formally banning them.

“American patients should know: You can always ask your pharmacist whether you’re getting the best deal on the prescription drugs you need. This is just one step in the President’s plans to deliver better healthcare to Americans at lower prices, efforts that have already involved more action to bring down drug prices than any previous President has taken.”

HHS expands corporate partnership to protect against health security threats

HHS Gov News - October 10, 2018

A strategic partnership will expand between the U.S. Department of Health and Human Services’ Office of the Assistant Secretary for Preparedness and Response (ASPR) and Johnson & Johnson of New Brunswick, New Jersey.  The expansion will focus on the development of innovative products to combat the potentially deadly health effects of chemical, biological, radiation and nuclear threats, emerging infectious diseases and antimicrobial resistant infections.

ASPR’s Biomedical Advanced Research and Development Authority (BARDA) will manage a portfolio of products with the Johnson & Johnson Family of Companies. Through the agreement, BARDA will have joint oversight, share the cost of developing a portfolio with the Johnson & Johnson Family of Companies, help determine which products to develop, and collaborate on decisions about which products enter or leave each partnership’s portfolio.

Under the agreement, BARDA will provide more than $28 million over two years and up to $200 million over six years. The Johnson & Johnson Family of Companies also will provide a significant portion of the funding needed to bring products in the portfolio to the market.

“We are pleased to expand our partnership with the Johnson & Johnson Family of Companies to bring innovative products to the market that to help combat all types of health security threats and meet daily healthcare needs,” said BARDA Director Rick Bright, Ph.D.

The first project funded will be an early development compound that can be used for acute radiation syndrome and certain potential chemical threats. The compound has demonstrated enhanced survival and beneficial effects on blood cells that can be injured by high doses of radiation.

Although the portfolio will focus on countermeasures for radiation and nuclear threats, the agreement also allows BARDA and the Johnson & Johnson Family of Companies to collaborate on the development of a portfolio of medical products.  These products will address areas such as bleeding caused by trauma, injuries caused by chemical and emerging threats and bacterial infections. The partnership builds on a 2017 portfolio agreement with Janssen Research & Development LLC, a subsidiary of Johnson & Johnson focused on pandemic influenza antiviral drugs and vaccines.

Rather than a standard contract, BARDA entered into the agreement using other transaction authority  granted to ASPR under the Pandemic and All Hazards Preparedness Act of 2006. Although not a contract, grant or cooperative agreement, other transaction authority provides a funding and collaboration vehicle to promote innovation in technology for advanced research and development.

This partnership is the seventh ASPR has formed under other transaction authority. The other partnerships also focus on developing new products to combat chemical, biological, radiation or nuclear threats, emerging infectious diseases or antimicrobial resistant infections.

About HHS, ASPR and BARDA

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. The mission of the Office of the Assistant Secretary for Preparedness and Response (ASPR) is to save lives and protect Americans from 21st century health security threats. Within ASPR, BARDA invests in the advanced research and development, acquisition, and manufacturing of medical countermeasures – vaccines, drugs, therapeutics, diagnostic tools, and non-pharmaceutical products needed to combat health security threats.

For more about ASPR and BARDA, visit www.phe.gov/aspr. To learn more about partnering with BARDA on advanced development of medical countermeasures – drugs, vaccines and devices for emergencies – visit www.medicalcountermeasures.gov.

HHS Secretary Azar declares public health emergency in Florida due to Hurricane Michael

HHS Gov News - October 10, 2018

Following President Trump’s emergency declaration for Florida, Health and Human Services Secretary Alex Azar today declared a public health emergency in the state as Hurricane Michael makes landfall. The declaration gives the HHS Centers for Medicare & Medicaid Services beneficiaries and their healthcare providers and suppliers greater flexibility in meeting emergency health needs.

“Hurricane Michael poses a significant threat to the health and safety of those in its path,” Secretary Azar said. “These actions help ensure that our fellow Americans who rely on Medicare and Medicaid have continuous access to the care they need.”

HHS also staged approximately 125 personnel from the National Disaster Medical System and an Incident Management Team, along with caches of medical equipment in Mobile, Alabama, and Jacksonville, Florida, so these assets are available quickly to help state and local authorities respond to communities’ medical needs. HHS placed about 100 additional personnel on alert from the National Disaster Medical System and the U.S. Public Health Commissioned Corps to assist if needed after the storm.

In addition, the Office of the Assistant Secretary for Preparedness and Response (ASPR) and CMS coordinated to provide information to Florida health officials on the number of Medicare beneficiaries who rely on dialysis or use special medical equipment at home and the type of equipment, such as oxygen concentrators, in the potentially impacted areas. With this information, health and emergency management agencies can respond better, particularly after power outages, to save lives.

CMS also activated the Kidney Community Emergency Response Program to monitor dialysis access and needs of these facilities after the hurricane makes landfall. Through a CMS contract, this program provides technical assistance to End Stage Renal Disease Networks, kidney organizations, and other groups to ensure timely and efficient disaster preparedness, response and recovery for the kidney community.

To assist residents in the impacted area in coping with the stress of the disasters, the Substance Abuse and Mental Health Services Administration activated the Disaster Distress Helpline. The helpline provides immediate 24/7, 365-days-a-year crisis counseling and support to people experiencing emotional distress related to natural or human-caused disasters. This toll-free, multilingual, and confidential crisis support service is available to all residents in the United States and its territories. Stress, anxiety, and other depression-like symptoms are common reactions after a disaster. Call 1-800-985-5990 or text TalkWithUs to 66746 (for Spanish, press 2 or text Hablanos to 66746) to connect with a trained crisis counselor.

In declaring the public health emergency and authorizing flexibilities for CMS beneficiaries, Secretary Azar acted within his authority under the Public Health Service Act and Social Security Act. These actions and flexibilities are retroactive to October 7, 2018.

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

Doctors Give Medicare’s Proposal To Pay For Telemedicine Poor Prognosis

Kaiser Health News:Marketplace - October 10, 2018

The Trump administration wants Medicare for the first time to embrace telemedicine across the country by paying doctors $14 for a five-minute “check-in” phone call with their patients.

But many physicians say the proposed reimbursement will cover a service they already do for free. And the Medicare reimbursement — intended to motivate doctors to communicate with patients outside the office — could have a chilling effect on patients because they would be required to pay a 20 percent cost-sharing charge.

Medicare said the call would be used to help patients determine whether they need to come in for an appointment. But doctors and consultants said the virtual sessions could cover a broad array of services, including monitoring patients starting a new medicine or those trying to manage chronic illnesses, such as diabetes. The Medicare Payment Advisory Commission, which provides guidance to Congress, panned the proposal last month, saying it could lead to excess spending without benefiting patients.

“Direct-to-consumer telehealth services … appear to expand access, but at a potentially significant cost and without evidence of improved quality,” the commission’s chairman, Dr. Francis Crosson, said in a letter to the Centers for Medicare & Medicaid Services (CMS). “Due to their greater convenience, these services are at risk of misuse by patients or provider.”

Congress has shied away from expanding the use of telemedicine in Medicare — even as it has become commonplace among private insurers — because of concerns about higher spending. Budget hawks worry that rather than replace comparatively expensive in-person visits, extra telemedicine billings would add to them.

Lack of coverage — except in rare circumstances — means fewer than 1 percent of the 50 million Medicare beneficiaries use telemedicine services each year.

Federal law forbids Medicare from paying for telemedicine services that replace in-person office visits, except in certain rural areas. That’s why CMS called the new benefit a check-in using “virtual” or “communications technology,” said Jacob Harper, who specializes in health issues at the law firm Morgan, Lewis & Bockius.

In addition to the check-in call, CMS has proposed starting to pay physicians to review photos that patients text or email to them to evaluate skin and eye problems, as well as and other conditions. It also has proposed paying physicians an unspecified fee for consulting electronically or by phone with other doctors.

“Innovative technology that enables remote services can expand access to care and create more opportunities for patients to access personalized care management as well as connect with their physicians quickly,” said CMS Administrator Seema Verma when announcing the proposal.

Email Sign-Up

Subscribe to KHN’s free Morning Briefing.

Sign Up Please confirm your email address below: Sign Up

CMS said it hopes to enact the changes in 2019. Officials will announce their final rule after evaluating public comments on the plan.

Verma and other CMS officials say they believe the change would end up saving Medicare money by reducing unnecessary office visits and catching health problems early, before they become more costly to treat.

But in its detailed proposal, CMS acknowledges the telehealth service will increase Medicare costs. CMS said the telehealth will result in “fewer than 1 million visits in the first year but will eventually result in more than 19 million visits per year, ultimately increasing payments under the [Medicare physician pay schedule] by about 0.2 percent,” or eventually about $180 million per year. Because the change must be budget-neutral, CMS is paying for this by decreasing some other Medicare physician payments.

CMS doesn’t expect rapid adoption of the telehealth service, partly because doctors can get paid from $35 to $150 for an in-person visit. “Because of the low payment rate relative to that for an office visit, we are assuming that usage of these services will be relatively low,” CMS said in its proposal.

The virtual check-in can be conducted by physicians or nurse practitioners or physician assistants working with a doctor.

Only patients who have established relationships with a doctor would be eligible for the service. Doctors also would not be allowed to bill for the check-in service if it stems directly from an in-person visit or is followed by an appointment with the doctor, according to the CMS proposal.

Dr. Michael Munger, a family physician in Overland Park, Kan., and president of the American Academy of Family Physicians, said many doctors routinely check on patients by phone. Still, he applauded the effort to increase physician pay.

“Anytime you can tie payment to what many of us are already doing is good,” he said.

Mercy, a large hospital system in St. Louis, has been offering telehealth services even without reimbursement because it helps patients access care and lowers costs in the long run, said Dr. J. Gavin Helton, president of clinical integration at Mercy Virtual.

“We are already on this path, and this will help to continue to grow our programs and make them financially sustainable,” he said.

Still, Helton said the “check-in” fee from Medicare won’t be enough to motivate providers to start telehealth services.

He said the new reimbursement signals that Medicare wants to pay for services to keep patients well rather than just treat them while they are sick.

Other physicians were more skeptical, particularly while Medicare has also proposed reducing some fees for in-person office visits.

In a letter to CMS, Dr. Amy Messier, a family medicine doctor in Wilmington, N.C., raised concerns about the effect this could have on patients’ expenses.

“I worry about implementation of this from the patient perspective now that we are charging patients for this previously free service and they have to pay their portion of the charge,” she said.

“Patients will be less likely to engage their physician outside of the office visit and more likely to seek care face-to-face at more expense, when perhaps that visit could have been avoided with a phone call which they will no longer make because it comes with a charge,” she said.

Dr. Todd Czartoski, chief executive of telehealth at Providence St. Joseph Health in Renton, Wash., predicts most doctors won’t use the proposed telehealth service.

“It’s still easier for a doctor to go room to room with patients lined up,” he said. “It’s a step in the right direction, but I don’t think it will open the floodgates for virtual care.”

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

No More Secrets: Congress Bans Pharmacist ‘Gag Orders’ On Drug Prices

Kaiser Health News:Insurance - October 10, 2018

For years, most pharmacists couldn’t give customers even a clue about an easy way to save money on prescription drugs. But the restraints are coming off.

When the cash price for a prescription is less than what you would pay using your insurance plan, pharmacists will no longer have to keep that a secret.

President Donald Trump was scheduled to sign two bills Wednesday that ban “gag order” clauses in contracts between pharmacies and insurance companies or pharmacy benefit managers — those firms that negotiate prices for employers and insurers with drugstores and drugmakers. Such provisions prohibit pharmacists from telling customers when they can save money by paying the pharmacy’s lower cash price instead of the price negotiated by their insurance plan.

The bills — one for Medicare and Medicare Advantage beneficiaries and another for commercial employer-based and individual policies— were passed by Congress in nearly unanimous votes last month.

“Americans deserve to know the lowest drug price at their pharmacy, but ‘gag clauses’ prevent your pharmacist from telling you!” Trump wrote on Twitter three weeks ago, shortly before the Senate voted on the bills. “I support legislation that will remove gag clauses.” The change was one of the proposals included in Trump’s blueprint to cut prescription drug prices issued in May.

Don't Miss A Story

Subscribe to KHN’s free Weekly Edition newsletter.

Sign Up Please confirm your email address below: Sign Up

Ronna Hauser, vice president of payment policy and regulatory affairs at the National Community Pharmacists Association, said many members of her group “say a pharmacy benefit manager will call them with a warning if they are telling patients it’s less expensive” without insurance. She said pharmacists could be fined for violating their contracts and even dropped from insurance networks.

According to research published in JAMA in March, people with Medicare Part D drug insurance overpaid for prescriptions by $135 million in 2013. Copayments in those plans were higher than the cash price for nearly 1 in 4 drugs purchased in 2013. For 12 of the 20 most commonly prescribed drugs, patients overpaid by more than 33 percent.

Yet some critics say eliminating gag orders doesn’t address the causes of high drug prices. “As a country, we’re spending about $450 billion on prescription drugs annually,” said Steven Knievel, who works on drug price issues for Public Citizen, a consumer advocacy group. The modest savings gained by paying the cash price “is far short of what needs to happen to actually deliver the relief people need.”

After the president signs the legislation affecting commercial insurance contracts, gag order provisions will immediately be prohibited, said a spokesman for Sen. Susan Collins (R-Maine), who co-authored the bill. The bill affecting Medicare beneficiaries wouldn’t take effect until Jan. 1, 2020.

But there’s a catch: Under the new legislation, pharmacists will not be required to tell patients about the lower cost option. If they don’t, it’s up to the customer to ask.

The Pharmaceutical Care Management Association, a trade group representing pharmacy benefit managers, said gag orders are increasingly rare. The association supported the legislation. Some insurers have also said their contracts don’t include these provisions. Yet two members of Congress have encountered them at the pharmacy counter.

At a hearing on the gag order ban, Collins said she watched a couple leave a Bangor, Maine, pharmacy without their prescription because they couldn’t afford the $111 copayment and the pharmacist did not advise them about saving money by paying directly for the medicine. When she asked him how often that happens, he said every day.

“Banning gag clauses will make it easier for more Americans to afford their prescription drugs because pharmacists will be able to proactively notify consumers if a less expensive option may be available,” she said last week.

When Rep. Debbie Dingell (D-Mich.) went to a Michigan pharmacy to pick up a prescription recently, she was told it would cost $1,300. “After you peeled me off the ceiling, I called the doctor and screamed and talked to the pharmacist,” she recalled during a hearing last month. “I’m much more aggressive than many in asking questions,” she admitted, and ended up saving $1,260 after she learned she could get an equivalent drug for $40.

While the legislation removes gag orders, it doesn’t address how patients who pay the cash price outside their insurance plan can apply that expense toward meeting their policy’s deductible.

But for Medicare beneficiaries there is a little-known rule — not found in the “Medicare & You” handbook or on its website —that helps people with Medicare Part D or Medicare Advantage coverage. If they pay the lower cash price for a covered drug at a pharmacy that participates in their insurance plan and then submit the proper documentation to their plan, insurers must count it toward patients’ out-of-pocket expenses.

The total of those expenses are important because that amount affects the drug coverage gap commonly called the “doughnut hole.” (This year, the gap begins after the plan and beneficiary spend $3,750 and ends once the beneficiary has spent a total of $5,000.)

And beneficiaries don’t have to wait until the gag order ban takes effect in two years.

The Medicare rule also says that if a senior asks about a lower price for a prescription, the pharmacist can answer.

Rep. Buddy Carter (R-Ga.), a pharmacist who sponsored the Medicare gag order bill, said he wasn’t surprised by the bipartisan support for the legislation. “High prescription drug costs affect everyone,” he said.

KHN’s coverage of prescription drug development, costs and pricing is supported in part by the Laura and John Arnold Foundation.

Pages