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Maryland Offers Many Insured Men Free Vasectomy Coverage

Kaiser Health News:HealthReform - February 13, 2018

It was a well-intentioned effort to provide men with some of the same financial protection from birth control costs that women get. But a new Maryland law may jeopardize the ability of thousands of consumers — both men and women — to use health savings accounts.

The law, which took effect Jan. 1, mandates that insurers cover vasectomies without requiring patients to pay anything out-of-pocket — just as they must do for more than a dozen birth control methods for women.

But the measure may run afoul of Internal Revenue Service rules that do not include vasectomies among approved preventive services for high-deductible health plans. People with health savings accounts — which are exempt from tax liabilities — tied to those plans could no longer contribute to the savings accounts in that case.

Under the Maryland Contraceptive Equity Act, insurers generally can’t charge patients a copayment or require any other cost sharing for prescription contraceptive drugs or devices approved by the Food and Drug Administration. The 2016 law is similar to what’s required under the federal Affordable Care Act, with a twist: It adds male sterilization — vasectomies — to the list of services that are free for patients.

“While the ACA made important strides … it completely left men out of the equation,” said Karen Nelson, president and CEO of Planned Parenthood of Maryland, whose organization supported the bill.

Before the law took effect, a vasectomy at the organization’s Baltimore office would cost between $225 and $1,100, depending on someone’s ability to pay, said Nelson. Now the procedure will generally cost nothing for men in insured plans in Maryland.

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The state law doesn’t apply to companies that are “self-funded,” meaning they pay their employees’ health care claims directly rather than buying state-regulated insurance policies.

Under IRS rules, consumers making tax-free contributions to health savings accounts (HSAs) that are linked to high-deductible health plans have to pay for all their medical care until they reach their deductible of at least $1,350 for individuals and $2,700 for families in 2018. The only exception is for preventive services. The hitch for the Maryland law is that vasectomies aren’t on the IRS list of approved preventive services.

The IRS hasn’t responded to a request for clarification by Maryland Insurance Commissioner Al Redmer Jr. A bill was reintroduced this year — after it failed to pass last year — that would exempt these high-deductible plans from the state mandate to cover vasectomies before the deductible is met. Such a move would preserve the tax advantages of the HSAs linked to them.

Maryland is joining a few other states, including Illinois, Vermont and, starting next year, Oregon, that have expanded contraceptive coverage without cost sharing to include male sterilization.

Vermont’s law includes language to exempt high-deductible plans with health savings accounts. While the issue has raised concerns in Maryland, in Illinois and Oregon it hasn’t appeared to generate much attention to date, legislative analysts say.

Some advocates for extending no-cost coverage to vasectomies noted that the IRS’ list of approved preventive services specifically says that it isn’t exhaustive.

But until the issue is clarified, “the safest thing to do is not make a contribution to your HSA,” said Roy Ramthun, a Maryland resident and president of HSA Consulting Services. Ramthun helped implement health savings accounts while working for the Treasury Department during the George W. Bush administration. He stressed that the uncertainty applies only to HSA contributions made after the law became effective in 2018, not to earlier contributions. The issue doesn’t affect people’s medical coverage.

Beyond the uncertainty around health savings account contributions, Maryland’s law requiring coverage of vasectomies without cost sharing addresses a gap in men’s preventive coverage.

“There are arguments to be made that male condoms and vasectomies have preventive benefits for both women and men, in terms of [sexually transmitted infection] prevention and preventing pregnancy,” said Mara Gandal-Powers, senior counsel at the National Women’s Law Center.

Seven percent of men ages 18 to 45 have had a vasectomy, according to a 2013 study by researchers at Northwestern University. The prevalence increased to 16 percent among men ages 36 to 45. Men with higher incomes, higher education and a regular source of health care were more likely to have had the procedure, the study found.

The Maryland law doesn’t apply to the method of birth control that many men use: condoms. A bill introduced this month by state Sen. John Astle, a Democrat, would expand the law to include condom coverage.

Trump’s Budget Proposal Swings At Drug Prices With A Glancing Blow

Kaiser Health News:Marketplace - February 12, 2018
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President Donald Trump’s new budget proposal flirts with combating high prescription drug prices, but industry watchers say the tweaks to Medicare and Medicaid do little more than dance around the edges of lowering the actual prices of drugs.

The White House’s proposal, which comes after Congress passed a two-year spending deal last week, though, sets the tone for the administration’s focus on prescription drugs.

“Drug costs are a populist issue for the president,” and he’s made it clear to his staff that progress needs to be made this year, said Dan Mendelson, president of Avalere Health, a health care consulting firm.

The proposal targets billions of drug spending cuts in the federal Medicare program, which provides health care for about 60 million people age 65 and older or younger patients with disabilities, and alters drug spending in Medicaid’s safety-net program for nearly 70 million Americans.

And the sheer size of the federal government’s Medicare and Medicaid programs means any drug pricing tweaks that do get made are meaningful — just not necessarily groundbreaking.

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“The main question is, how far are they actually going to go in dealing with the underlying problem?” said Paul Van de Water, who spent nearly two decades in the Congressional Budget Office and is now a senior fellow at the Center on Budget and Policy Priorities. Most of the proposals for Medicare, for example, move money around rather than force decreased prices, Van de Water said.

Alex Azar, the newly appointed secretary of Health and Human Services, said the proposed budget supports the work his agency is already doing to reduce the high cost of prescriptions, “especially for America’s seniors.”

Just last month, the former Eli Lilly executive told Congress during his confirmation hearings that “all drug prices are too high in this country.”

Highlights from the proposals include:

— Passing on the discounts and rebates negotiated by pharmacy benefit managers, the financial middlemen between insurers and drugmakers, to seniors who buy drugs through Medicare Part D. The seniors would pay less out-of-pocket when buying their drugs but the proposal could potentially raise premiums because insurers wouldn’t be getting the discounts.

— Ensuring that low-income seniors in Medicare don’t pay for generics and capping out-of-pocket costs for beneficiaries who pass through the so-called doughnut hole, or coverage gap, and hit the catastrophic stage. Beneficiaries typically pay a 5 percent coinsurance in the catastrophic phase, but under the plan it would be decreased to zero.

— Moving some of the drugs paid for under Medicare Part B, which covers drugs administered in the doctor’s office such as chemotherapy and rheumatoid arthritis infusions, into the Part D part of the program to foster price negotiations. While the government pays sticker price for drugs under the Part B program, the Part D program allows insurers and pharmacy benefit managers to negotiate formularies.

— Creating a five-state pilot project to allow state Medicaid programs to negotiate prices with manufacturers and create their own drug formularies.

Trump entered office with blustering promises to bring drug prices “way down.” But critics have charged that the White House has failed to engage Congress on cost-cutting ideas, and that a leaked draft of an executive order last summer read like a wish list for the industry.

With the new budget, the administration is trying to recast that narrative at a time when Republicans in Congress may be willing to compromise.

“Americans want Washington to lower prescription drug prices, and our paper provides policy options that would make drugs more accessible to Americans, today and in the future,” wrote D.J. Nordquist, chief of staff for the president’s Council of Economic Advisers, in an email late Friday after the council released a 28-page report on reforming drug prices.

The CEA paper and the president’s budget come on the heels of Congress passing a spending pact Friday that includes a big benefit to Medicare enrollees at the expense of the pharmaceutical industry. The budget proposes closing the doughnut hole in 2019, a year earlier than expected.

Republicans “just showed a propensity to sort of take on the industry,” said Jayson Slotnik, a policy consultant and partner at Health Policy Strategies. And there is political upside for doing more since Republicans are concerned about this year’s November midterm elections approaching, Slotnik said: “They can run and [say] it’s something they have accomplished.”

Yet James Love, director of the nonprofit Knowledge Ecology International, said Trump’s proposals are not “insightful or original” and, referring to the council’s report, said it “could have been written by PhRMA,” the powerful D.C. lobbying firm for pharmaceutical manufacturers.

PhRMA released a statement late Monday applauding the provision to pass on rebates to Medicare beneficiaries but also raising concerns about other elements of the budget proposal, saying they would “limit access to innovative medicines.”

Experts from the academic and think-tank world said the district has seen several of these policies before. For example, the rebate and discount pass-through proposal has been a topic of discussion within the Centers for Medicare & Medicaid Services for more than a year and is already in the rulemaking process.

Another proposal that lowers reimbursement for Medicare Part B drugs that are new to the program is reminiscent of an Obama-era pilot that never got off the ground.

Tara O’Neill Hayes, who focuses on health policy at the conservative American Action Forum, said several Medicare proposals were also similar to those found in a June 2016 report by the Medicare Payment Advisory Commission. If all the Medicare proposals took effect — including one that calls for more flexibility in drug formularies — O’Neill Hayes said overall premiums could go up slightly for all Part D beneficiaries, but that would be offset by lowering out-of-pocket payments for the beneficiaries with the highest drug costs.

“You’re going to have winners and losers,” she said. “The real winners here are going to be the incredibly high-cost patients.”

Trump’s budget requires hospitals to provide a minimum level of charity care to get an additional payment adjustment under the 340B program, which requires pharmaceutical manufacturers to provide drugs at steep discounts to hospitals and clinics with a high ratio of low-income patients.

The administration lowered reimbursement amounts for hospitals earlier this year, and Mendelson at Avalere said he expects more changes.

In reviewing Trump’s budget and the council report, Allan Coukell, senior director of health programs at the Pew Charitable Trusts, said several of the proposals “have the potential to reduce out-of-pocket costs, several have the potential to increase competition within the programs and/or move people toward lower cost drugs. None of it changes the overall trajectory” of rising sticker prices.

HHS Secretary Azar Statement on President Trump’s FY 2019 Budget

HHS Gov News - February 12, 2018

Health and Human Services Secretary Alex Azar issued the following statement today on President Trump’s Fiscal Year 2019 Budget:

“The President’s budget makes investments and reforms that are vital to making our health and human services programs work for Americans and to sustaining them for future generations. In particular, it supports our four priorities here at HHS: addressing the opioid crisis, bringing down the high price of prescription drugs, increasing the affordability and accessibility of health insurance, and improving Medicare in ways that push our health system toward paying for value rather than volume.

“This budget supports the hard work the men and women of HHS are already doing toward these goals. In particular, the budget’s efforts to reduce the high cost of prescription drugs, especially for America’s seniors, are a reflection of President Trump’s deep commitment to addressing this important issue.”

The HHS Budget in Brief can be found here.

Could A Rare, Deadly ‘Superbug’ Fungus Be Gaining A Foothold?

Kaiser Health News:States - February 12, 2018

The number of U.S. patients infected with a rare but dangerous fungal “superbug” called Candida auris has climbed quickly to 200 as of Dec. 31, according to the latest figures from the federal Centers for Disease Control and Prevention.

In 2016, there were only seven cases of the multidrug-resistant infection on the national radar.

CDC first alerted American health care facilities that year to be on the lookout for the fungus, which can cause serious medical complications when it enters the bloodstream, usually through wounds, ventilators or catheters. Patients with compromised health, especially those in hospitals and long-term care facilities, are most vulnerable.

“You won’t get it riding on the subway,” said Snigdha Vallabhaneni, a CDC epidemiologist.

Most of the cases, 123, have been reported in New York. New Jersey had the second-highest tally, 48. Other states reporting infections include California, Illinois and Florida.

Candida refers to a wide variety of microorganisms in the yeast family, and some forms can live harmlessly in the body. About 20 varieties can cause infections —typically minor, such as athlete’s foot, nail fungus, oral thrush and vaginal yeast infections. Candida auris raises concern because when it enters the bloodstream it can attack organs, Vallabhaneni said. Resistant to many medications, it is difficult to treat and can result in death.

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C. auris is transmitted easily between patients through contact with contaminated surfaces or person to person. It is often misidentified because it is difficult to recognize unless specialized technology is used.

C. auris “acts much more like a bacterial superbug” than other Candida species, Vallabhaneni said.

About 40 percent of the U.S. patients who have contracted C. auris have died, according to CDC records. But since those patients had other serious medical conditions, it’s unclear how much of a role C. auris played in their deaths.

Many of the patients affected rely on medical equipment such as breathing tubes and central-line catheters that pump drugs into veins, offering an easy route for the fungus.

The CDC has begun prevention and education efforts targeted toward health care staff and the labs tasked with identifying C. auris. Much of the agency’s work has focused on improving labs’ abilities to identify the fungus, Vallabhaneni said.

Nancy Leveille, executive director of the Foundation for Quality Care at the New York State Health Facilities Association, said educational efforts by public health agencies such as the CDC and the New York State Department of Health have raised awareness. “There is attention,” she said, and that will help providers keep C. auris under control.

Anuradha Chowdhary, a professor and clinical microbiologist at the University of Delhi, was among the earliest scientists to identify the fungus in 2009.

She and colleagues recently published research showing that a certain mutation in the fungus’ genetic makeup may account for its widespread resistance to fluconazole, a common treatment for Candida infections. One promising treatment is a relatively new class of antifungal medications called echinocandins.

C. auris has been reported on five continents, in countries from the United States to Colombia to Britain. Yet the fungus’ origins aren’t easily explained.

Scientists can trace what may be C. auris’ earliest appearance to a 1996 South Korean case. But when they compare the genetic makeup of samples taken from regions around the world, they find the genes are different. It’s as if C. auris has sprouted up independently in each place.

When she first encountered it in Delhi, “I thought it was just our problem,” Chowdhary said. “I never imagined it would become so big.”

Doctors Learn How To Talk To Patients About Dying

Kaiser Health News:Marketplace - February 12, 2018

[UPDATED 2 p.m. ET on Feb. 12]

Lynn Black’s mother-in-law, who had lupus and lung cancer, was rushed into a hospital intensive care unit last summer with shortness of breath. As she lay in bed, intubated and unresponsive, a parade of doctors told the family “all good news.”

A cardiologist reported the patient’s heart was fine. An oncologist announced that the substance infiltrating her lungs was not cancer. An infectious-disease doctor assured the family, “We’ve got her on the right antibiotic.”

With each doctor’s report, Black recalled, most of her family “felt this tremendous sense of relief.”

But Black, a doctor herself, knew the physicians were avoiding the truth: “She’s 100 percent dying.”

“It became my role,” Black said, to tell her family the difficult news that her mother-in-law, who was in her mid-80s, was not going to make it out of the hospital alive. Indeed, she died there within about a week.

The experience highlights a common problem in medicine, Black said: Doctors can be so focused on trying to fix each ailment that “no one is addressing the big picture.”

Now Black, along with hundreds of clinicians at Massachusetts General Hospital in Boston, is getting trained to talk to seriously ill patients about their goals, values — and prognoses — while there’s time to spare.

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The doctors are using a script based on the Serious Illness Conversation Guide, first created by Drs. Atul Gawande and Susan Block at Ariadne Labs. Since its inception in Boston in 2012, the guide has been used to train over 6,500 clinicians worldwide, said Dr. Rachelle Bernacki, associate director of the Serious Illness Care Program at Ariadne Labs.

At Mass General, Dr. Juliet Jacobsen, a palliative care physician, serves as medical director for the Continuum Project, a large-scale effort to quickly train clinicians to have these conversations, document them and share what they learn with one another. The project ramped up in January with the first session in a series that aims to reach 250 primary care providers at the hospital.

For patients with advanced cancer, end-of-life conversations with clinicians take place a median of 33 days before a patient’s death, research shows. When patients have end-stage diagnoses, fewer than a third of families recall having end-of-life conversations with physicians, another study found.

That’s despite evidence that patients have better quality of life, fewer hospitalizations, more and earlier hospice care and higher satisfaction when they talk to doctors or other clinicians about their values and goals, according to recent research.

Dr. Thalia Krakower (right), a primary care physician, gets advice from Dr. Juliet Jacobsen, medical director of the Continuum Project at Massachusetts General Hospital in Boston, during a January training session on how to talk to seriously ill patients about their goals and values. (Melissa Bailey/KHN)

Dr. Corinne Alexander, a palliative care physician at Massachusetts General Hospital in Boston, talks to actor John Carozza, who’s playing the role of a patient with chronic obstructive pulmonary disease, or COPD, during a training session in January. (Melissa Bailey/KHN)

At a recent training session, Jacobsen gave clinicians a laminated page with scripted language to help them along. When the participants role-played with professional actors, difficulties quickly emerged.

Dr. Thalia Krakower, a primary care physician, faced an emotional “patient” whose condition was on the decline.

“I can’t imagine it being any worse,” said the patient, hanging her head in tears.

“How long should we let them be silent and sad?” Krakower asked Jacobsen. “We always step in too soon.”

Physicians let patients speak an average 18 seconds before interrupting them, research has found. Jacobsen encouraged doctors to allow more silence, and to respond to patients’ emotions, not just to their words.

The scripted conversation is quite different from what doctors have been trained to do, Jacobsen acknowledged. It doesn’t aim to reach any decision, nor to fill out end-of-life paperwork.

“For the average doctor, this might feel like you’re not getting anything done,” she said. The goal is to step back from day-to-day problem-solving and talk about the patients’ understanding of their illness, their hopes and worries, and the trajectory of their disease.

In a pilot at Brigham and Women’s Hospital in Boston, Jacobsen noted, the conversations typically lasted 22 to 26 minutes.

At another moment during role-play, Jacobsen stepped in when a doctor skipped over the section in the script where she was supposed to share prognostic information.

The topic is avoided for many reasons, Jacobsen later said: Clinicians’ schedules are crammed. They may not want to scare families with a timeline that turns out to be wrong. And they may not know what language to use, especially when the disease trajectory is uncertain.

When a doctor’s message moves abruptly from “everything’s great” to “she’s dying,” Jacobsen said, patients and their families don’t have enough time to adjust to the bad news.

To address that problem, Jacobsen’s team suggests language that helps clinicians discuss a prognosis without asserting certainty: “I worry the decline we have seen is going to continue,” or, “I worry something serious may happen in the next few months.”

After the training, Jacobsen’s team plans to follow up with doctors to make sure they are having the conversations with patients, starting with those deemed likely to die within three years.

The guide is also being rolled out at Baylor Scott & White Health in Texas, Lowell General Hospital in Massachusetts, the University of Pennsylvania and hospitals in 34 foreign countries, Bernacki said.

And Ariadne Labs has teamed up with VitalTalk, a communications training company, and the Center to Advance Palliative Care to rapidly disseminate the Serious Illness Conversation Guide across the country. They aim to train 200 trainers by June 2019, Bernacki said. (This initiative and other activities at Ariadne Labs are funded by the Gordon and Betty Moore Foundation, which also supports some of KHN’s reporting.)

Right now, she said, whether patients have these discussions depends too much on geography. “Our goal,” she said, “is for every patient with serious illness to have a meaningful conversation about what they care about, in every place.”

[Correction: This story was updated Feb. 12 to correct the first name of Dr. Corinne Alexander, pictured during a January training session.]

Podcast: KHN’s ‘What The Health?’ There’s A Really Big Health Bill In That Budget Deal

Kaiser Health News:HealthReform - February 09, 2018

The bipartisan budget deal that passed Congress this week includes enough health policy changes to keep reporters and analysts busy for months.

In addition to renewing funding for Community Health Centers for two more years, the bill extends funding for the Children’s Health Insurance Program for four years beyond the six approved last month; repeals the controversial (but never implemented) Independent Payment Advisory Board for Medicare and permanently repeals Medicare’s caps on certain types of outpatient therapy.

Also, the final enrollment numbers for individual insurance purchased under the Affordable Care Act came out this week. Spoiler: They are higher than most analysts expected.

Plus, Andy Slavitt, former acting head of the Centers for Medicare & Medicaid Services under President Barack Obama, talks about his new group, “The United States of Care.”

This week’s panelists for KHN’s “What the Health?” are Julie Rovner of Kaiser Health News, Joanne Kenen of Politico, Alice Ollstein of Talking Points Memo and Margot Sanger-Katz of The New York Times.

Among the takeaways from this week’s podcast:

  • The budget bill signed by President Donald Trump on Friday provides a lot of funding for health programs, but it also takes money away from others. It takes a big chunk of funding out of the Affordable Care Act’s Prevention and Public Health Fund and raises premiums for some wealthier Medicare beneficiaries.
  • That bill could make a number of changes to how Medicare works, including some new rules for accountable care organizations and more flexibility in telemedicine rules.
  • Trump’s proposed budget for next year, which comes out Monday, will offer a number of options to bring down drug prices. Some of them might be possible through the regulation process rather than requiring congressional action.
  • A data analysis this week of the ACA marketplace enrollment numbers points out big variations among states.
  • The panel takes on a listener’s question about the possibility that states could let insurers charge higher premiums to marketplace customers who didn’t have insurance before.
  • In the recent debate about the administration’s approval of work requirements for some Medicaid enrollees, officials often talk about “able-bodied” adults. That term has little definition and goes back to Elizabethan England. Email Sign-Up

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

Julie Rovner:, “Why a Simple, Lifesaving Rabies Shot Can Cost $10,000 in America,” by Sarah Kliff.

Alice Ollstein: The New York Times, “In Sweeping War On Obesity, Chile Slays Tony The Tiger,” by Andrew Jacobs.

Joanne Kenen: Politico, “Trump’s Controversial New Health Care Idea,” by Sarah Karlin-Smith.

Margot Sanger-Katz: Harvard Business Review, “What Could Amazon’s Approach to Health Care Look Like,” by Robert S. Huckman.

To hear all our podcasts, click here.

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


Upsurge Of Suburban Poor Discover Health Care’s Nowhere Land

Kaiser Health News:Madicaid - February 09, 2018

The promise of cheaper housing brought Shari Castaneda to Palmdale, Calif., in northern Los Angeles County, about nine years ago.

The single mom with five kids had been struggling to pay the bills. “I kept hearing that the rent was a lot cheaper out here, so I moved,” she said.

But when she developed health problems — losing her balance and falling — Castaneda found fewer care options in her new town. Unable to find local specialty care, she traveled nearly 65 miles to a public hospital in Los Angeles, where doctors discovered a tumor on her spine.

Then she had to drive nearly 75 miles to the City of Hope cancer center in Duarte, Calif., for an operation to remove the growth. The procedure left her partially paralyzed. “I walked into the hospital and I never really walked again.”

Castaneda, 58, receives Social Security disability payments and is enrolled in Medi-Cal, the state’s Medicaid program for low-income people. “There are no doctors available here,” said Castaneda. “I called every single one of them in the book, and nobody takes Medi-Cal out here.” Instead, Castaneda now sees doctors nearly 50 miles away in Northridge.

Suburbs in the United States, often perceived as enclaves of the affluent, are home to nearly 17 million Americans who live in poverty — more than in cities or rural areas — and growing demand for care strains the capacity of suburban health services to provide for them, according to a recent study in Health Affairs. Suburban areas have historically received a fraction of health funding that cities have, leaving them with inadequate infrastructure and forcing people like Castaneda to scramble for the medical attention they need.

The Health Affairs study found that about a fifth of the suburban poor are uninsured, and many who do have health insurance — especially people on Medi-Cal — either can’t find providers or must travel far for appointments.

The Affordable Care Act cut California’s uninsured rate from 17 percent in 2013 to about 7 percent last year due largely to the Medicaid expansion, which added more than 3.7 million adults to the state’s Medi-Cal rolls. But that has not ensured access to health care for millions of suburbanites, said Alina Schnake-Mahl, a doctoral candidate at the Harvard T.H. Chan School of Public Health in Boston, who was lead author of the Health Affairs study.

“That really goes against the idea that everyone in the suburbs is insured because everyone has a white-collar job with coverage,” she said.

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Coverage doesn’t equate to care even for patients with Medi-Cal, as Castaneda can attest. Before the health law, they had trouble finding doctors who would see them because of Medi-Cal’s low payment rates. That problem intensified as millions more signed up for Medi-Cal, driving many enrollees to seek services at safety-net care facilities.

Health care services in the suburbs “are not robust enough to fill the needs” of a growing low-income population, said Charlie Gillig, supervising attorney at the Health Consumer Center of Neighborhood Legal Services of Los Angeles County, which has advised Castaneda about medical transportation services under Medi-Cal.

One-half of California’s 39 million residents live in suburbs, and rates of poverty among them range from nearly 25 percent around Bakersfield, in the Central Valley, to about 8 percent in the suburbs outside San Francisco, according to an analysis by Elizabeth Kneebone, research director at University of California-Berkeley’s Terner Center for Housing Innovation and a senior fellow at the Brookings Institution. The same analysis showed that 2.7 million suburban Californians lived below the poverty line in 2016, compared with 1.9 million in major cities.

Castaneda, who uses an oversized power wheelchair, says it’s difficult — “often impossible” — to arrange for a ride in a van. Getting to the doctor has become a long, painful ordeal.

And that’s if she can even schedule a visit, said Castaneda, noting that she also faces long wait times for her doctor in Northridge, a suburb that has seen an influx of patients from poorer areas. “You can’t get an appointment when you’re sick … so I’ve just been waiting and waiting,” she said. “They told me, ‘If you get sick enough, just go to the emergency room.’”

Of course, it can also be tough to get a clinic appointment or see a specialist in cities, but in the suburbs, Gillig said, “geography exacerbates an already existing problem.”

In his recent book on the changing geography of poverty, Scott Allard, a professor of public policy and governance at the University of Washington, showed that funding for human services was as much as eight times higher in urban areas than in the suburbs.

California’s metropolitan areas have had many decades to build up massive health care systems to serve the poor, including county hospitals, federally qualified health centers and community clinics. But the current scale of suburban poverty is a recent development.

Policymakers struggle to serve the health needs of cities in eastern Contra Costa County, about 50 miles from San Francisco. In Oakley, for example, business and community leaders lobbied hard for a new health center, which opened in 2011.

“There’s a huge need out here, especially for people who are undocumented or uninsured. They don’t have anywhere else to go,” said Leticia Cazares, regional manager for La Clinica, which operates the new health center. The clinic has two doctors and a nurse practitioner to serve 3,000 patients, most of whom are on Medi-Cal.

Many of the people who visit community clinics like the one in Oakley lack insurance, either because they are undocumented immigrants or because they make too much money to qualify for Medi-Cal — or subsidized coverage under Obamacare — and can’t afford it on their own.

Alex G.’s family fits both scenarios. Her husband, Edward, and 8-year-old son — also named Alex — are U.S. citizens, but she is an undocumented immigrant. The family lives in Brentwood, a town of about 60,000 in eastern Contra Costa County.

A 32-year-old community college student who declined to give her last name for fear of deportation, Alex has applied for permanent residency — a long process with an uncertain outcome.

Her husband has “a good job” as a programmer of industrial machines. He has employer-based insurance, but it covers only him. For Alex and her son to be covered, the family would have to pay $1,200 a month. Given California’s high cost of living, “we just can’t afford to pay that,” Alex said. Her husband’s salary of $70,000 is too high for Medi-Cal or Obamacare subsidies.

Alex recently experienced sharp stomach pains and had to wait several days for a mobile clinic that parks in front of a nearby community center once a week.

Whenever her son has an ear infection or a fever, Alex takes him to the free mobile clinic. “Not having insurance, I worry all the time about him getting sick,” she said.

HHS Secretary Azar holds flu briefing with key HHS leaders

HHS Gov News - February 08, 2018

On Wednesday, February 7, Health and Human Services Secretary Alex Azar received a briefing on preparedness and response efforts for seasonal and pandemic influenza from Acting CDC Director Anne Schuchat, NIH National Institute for Allergy and Infectious Diseases Director Anthony Fauci, and Assistant Secretary for Preparedness and Response Robert Kadlec.

Also in attendance and participating were Deputy Secretary Eric Hargan, Acting AssistantSecretary for Health Don Wright, Surgeon General Jerome Adams, FDA Center for Biologics Evaluation and Research Director Peter Marks, and HHS Office of Global Affairs Director Garrett Grigsby, all of whom are participating in flu preparedness and response efforts.

Secretary Azar discussed the opportunity he has had to oversee HHS’s ongoing flu activities since coming onboard at the department, and noted that he worked with many of the public health leaders present for the briefing during his previous time at HHS.

The department has been actively monitoring and responding to this year’s especially severe flu season, which has seen hospitalizations reach the highest levels since HHS began tracking such data closely in 2010 and simultaneous high levels of flu activity in more regions of the country than usual. HHS is also continuing efforts in the U.S. and around the world to build preparedness for outbreaks of pandemic flu strains, such as H7N9.

Dr. Schuchat presented on the status of seasonal flu in the U.S. and pandemic flu around the world, including statistics on intensity of activity, hospitalizations, and mortality, as well as CDC efforts to monitor and coordinate reliable supplies of seasonal flu vaccine and flu antivirals. She noted that information about the effectiveness of this year’s seasonal flu vaccine, which is still available and recommended for almost all Americans, will be released soon.

Dr. Fauci’s briefing covered ongoing research efforts, some supported by HHS, to develop more effective seasonal and pandemic flu vaccines, including a universal flu vaccine. Dr. Kadlec covered efforts being undertaken in conjunction with the private sector, including at HHS’s Biomedical Advanced Research and Development Authority, to develop and procure pandemic flu vaccines in greater volume and with greater effectiveness.

In closing, Secretary Azar and the leaders present agreed to continue working together on this year’s ongoing prevention efforts and noted a number of issues on which to coordinate going forward.

HHS Awards Engineering Blanket Purchase Agreement to CSRA, Leidos, ManTech, and Salient CRGT

HHS Gov News - February 08, 2018

The U.S. Department of Health and Human Services (HHS), Office of the Chief Information Officer (OCIO) has awarded the third Next Generation Information Technology Services (NGITS) blanket purchase agreement (BPA) to CSRA, Leidos, ManTech, and Salient CRGT. The BPA, with an estimated value of $139 million, provides support for a full spectrum of engineering projects, platforms, and services, to include endpoint, infrastructure, networks, and security. In addition, the BPA establishes a dedicated onsite engineering test laboratory that mirrors the HHS environment to enable successful solutions development and facilitate efficient operations. Leidos won the first task order on the BPA and will provide engineering services to HHS staff divisions and a number of the smaller operating divisions.

The new engineering task order will provide engineering expertise resulting in solutions that support the HHS vision for robust, flexible, efficient, and secure information technology to increase infrastructure performance and to avoid obsolescence. According to Dan Mills, director of enterprise engineering for the Office of Information Technology Infrastructure and Operations (ITIO), “This award will provide the engineering expertise necessary to produce solutions supporting the HHS vision of robust, flexible, efficient, and secure IT.”

HHS OCIO launched the NGITS program last year to provide improved support in IT service delivery, accountability, integration of new and emerging technologies, customer service, and performance measurement of information technology for the Office of the Secretary, its 22 staffing divisions, and more than 12,000 employees. The NGITS program has also awarded BPAs in the areas of IT operations and application hosting. NGITS will award one more BPA this year for program management integration.

The NGITS program offers an improved platform to leverage technology; manage standards, consistency, and activities across divisions; and allow for better services and transparency to HHS customers. “This award provides HHS the opportunity to engineer, test, and integrate innovative technologies to further support the efforts of HHS to improve the well-being of all Americans,” states George Chambers, ITIO executive director.

The Office of the Chief Information Officer advises the Office of the Secretary and the Assistant Secretary for Resources and Technology on matters pertaining to the use of information and related technologies to accomplish Departmental goals and program objectives.

Bipartisan Senate Budget Deal Boosts Health Programs

Kaiser Health News:HealthReform - February 07, 2018
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In a rare show of bipartisanship for the mostly polarized 115th Congress, Republican and Democratic Senate leaders announced a two-year budget deal that would increase federal spending for defense as well as key domestic priorities, including many health programs.

Not in the deal, for which the path to the president’s desk remains unclear, is any bipartisan legislation aimed at shoring up the Affordable Care Act’s individual health insurance marketplaces. Senate Majority Leader Mitch McConnell (R-Ky.) promised Sen. Susan Collins (R-Maine) a vote on health legislation in exchange for her vote for the GOP tax bill in December. So far, that vote has not materialized.

The deal does appear to include almost every other health priority Democrats have been pushing the past several months, including two years of renewed funding for community health centers and a series of other health programs Congress failed to provide for before they technically expired last year.

“I believe we have reached a budget deal that neither side loves but both sides can be proud of,” said Senate Minority Leader Chuck Schumer (D-N.Y.) on the Senate floor. “That’s compromise. That’s governing.”

Said McConnell, “This bill represents a significant bipartisan step forward.”

Senate leaders are still negotiating last details of the accord, including the size of a cut to the ACA’s Prevention and Public Health Fund, which would help offset the costs of this legislation.

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According to documents circulating on Capitol Hill, the deal includes $6 billion in funding for treatment of mental health issues and opioid addiction, $2 billion in extra funding for the National Institutes of Health, and an additional four-year extension of the Children’s Health Insurance Program (CHIP), which builds on the six years approved by Congress last month.

In the Medicare program, the deal would accelerate the closing of the “doughnut hole” in Medicare drug coverage that requires seniors to pay thousands of dollars out-of-pocket before catastrophic coverage kicks in. It would also repeal the controversial Medicare Independent Payment Advisory Board (IPAB), which is charged with holding down Medicare spending for the federal government if it exceeds a certain level. Members have never been appointed to the board, however, and its use has not so far been triggered by Medicare spending. Both the closure of the doughnut hole and creation of the IPAB were part of the ACA.

The agreement would also fund a host of more limited health programs — some of which are known as “extenders” because they often ride along with other, larger health or spending bills.

Those programs include more than $7 billion in funding for the nation’s federally funded community health centers. The clinics serve 27 million low-income people and saw their funding lapse last fall — a delay advocates said had already complicated budgeting and staffing decisions for many clinics.

And in a victory for the physical therapy industry and patient advocates, the accord would permanently repeal a limit on Medicare’s coverage of physical therapy, speech-language pathology and outpatient treatment. Previously, the program capped coverage after $2,010 worth of occupational therapy and another $2,010 for speech-language therapy and physical therapy combined. But Congress had long taken action to delay those caps or provide exemptions — meaning they had never actually taken effect.

According to an analysis by the nonpartisan Congressional Budget Office, permanently repealing the caps would cost about $6.47 billion over the next decade.

Lawmakers would also forestall cuts mandated by the ACA to reduce the payments made to so-called Disproportionate Share Hospitals, which serve high rates of low-income patients. Those cuts have been delayed continuously since the law’s 2010 passage.

Limited programs are also affected. The deal would fund for five years the Maternal, Infant and Early Childhood Home Visiting Program, a program that helps guide low-income, at-risk mothers in parenting. It served about 160,000 families in fiscal year 2016.

“We are relieved that there is a deal for a 5-year reauthorization of MIECHV,” said Lori Freeman, CEO of advocacy group the Association of Maternal & Child Health Programs, in an emailed statement. “States, home visitors and families have been in limbo for the past several months, and this news will bring the stability they need to continue this successful program.”

And the budget deal funds programs that encourage doctors to practice in medically underserved areas, providing just under $500 million over the next two years for the National Health Service Corps and another $363 million over two years to the Teaching Health Center Graduate Medical Education program, which places medical residents in Community Health Centers.

Kaiser Health News correspondent Emmarie Huetteman contributed to this article.

Despite Changes That Undermined ACA Enrollment, Marketplaces ‘Remarkably Stable’

Kaiser Health News:HealthReform - February 07, 2018
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After much drama leading to this year’s open enrollment for Affordable Care Act coverage — a shorter time frame, a sharply reduced federal budget for marketing and assistance, and confusion resulting from months of repeal-and-replace debate — the final tally paints a mixed picture.

With all states now reporting, ACA plan enrollment ticked downward this year, a report out Wednesday shows, but states running their own marketplaces saw slight gains and did better than those relying on the federal exchange.

About 11.8 million Americans enrolled in 2018 coverage, down 3.7 percent from last year’s total, according to the National Academy for State Health Policy.

Open enrollment began shortly after the Trump administration sharply cut federal enrollment outreach efforts and ended a type of cost-sharing subsidy paid directly to insurers, which generally responded by raising premiums to make up for the loss.

“Despite all that, enrollment in the marketplaces across the nation was remarkably stable,” said Trish Riley, executive director of the academy, a nonprofit, non-partisan group.

Enrollment in marketplaces fully or partially run by states, for example, showed a small overall increase of 0.2 percent over the previous year, while the 34 states that rely entirely on the federal hub saw sign-ups drop by 5.3 percent, the report said.

Officials from states operating their own exchanges said their ability to make changes led to their gains.

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“We could extend our open-enrollment period, control our marketing budget and nimbly mitigate the impact of the loss of cost-sharing subsidies [to insurers], which led to a very successful open enrollment,” said Zachary Sherman, director of Rhode Island’s state-run market.

Enrollment there is up 12 percent this year, he said, with sharp increases in the number of newly enrolled and policyholders aged 18 to 34.

California, which has the nation’s largest state market with about 1.5 million enrollees, saw a 2.3 percent drop in overall sign-ups. Covered California Director Peter Lee attributed some of that to efforts by the state to encourage off-market purchases by consumers who don’t qualify for subsidies.

Marketplace plans were more expensive than those sold outside for unsubsidized consumers because California and other states asked insurers to load the premium increases stemming from Trump administration directives onto on-market plans. Those on-market price hikes were largely offset by jumps in tax credits for consumers receiving subsidies.

Despite their upbeat tone about this year’s enrollment, directors of several state marketplaces warned that 2019 looks grim.

“Just the removal of the [individual mandate penalty in Congress’ recently enacted tax overhaul] will mean premiums go up 15 percent to 30 percent or more depending on the state,” said Lee.

People who get subsidies will be largely shielded from those increases because the subsidies rise along with the premiums.

Still, the burden of higher premiums would fall on the 6 million or so people who buy their own insurance but don’t get a federal tax credit to help them purchase coverage, according to an earlier study done by Covered California. The median income of those consumers was $75,000.

The report also showed that enrollment dropped sharply in some states.

Arizona, Louisiana and West Virginia, for example, all saw enrollment falling by more than 15 percent, which may also not bode well for 2019.

Health plans are likely to raise rates there “because drops in enrollment already mean bad risk,” such as greater numbers of older or sicker members, California’s Lee warned.

Congress should act soon to mitigate those expected increases, according to the five state exchange directors who participated in a press call detailing the report’s findings, by providing funding for states to create reinsurance programs, which pay insurers for medical costs for the most expensive enrollees.

Several states, including Alaska and Minnesota, already have reinsurance programs.

Legislation to provide such funding is before Congress. While the proposals have bipartisan support – and the idea is endorsed by many health industry groups – the legislation faces opposition from some lawmakers who see it as a bailout for the insurance industry.

Allison O’Toole, the CEO of Minnesota’s state insurance marketplace, invited those who are skeptical to look at her state’s reinsurance program.

“We saw it work,” said O’Toole. “Our premium rates are flat after a number of years of steep increases. We need to talk about a long term, federally financed reinsurance program if these markets are to stabilize.”

Several states, including Rhode Island, are also looking at steps they can take independent of congressional action to prepare for next year.

One idea: the use of state penalties for people who go uninsured to replace the loss of the individual mandate’s federal tax fine. Without some kind of mandate to purchase coverage, Rhode Island estimates that premiums there could rise 50 percent over three years.

“The idea that premiums would go up at that rate is something that scares us quite a bit,” said Sherman.

Readers And Tweeters Add Two Cents On Amazon Venture To Repackage Health Care

Kaiser Health News:HealthReform - February 06, 2018

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

Unsolicited Advice For Corporate Titans

I am a retired health care consultant who has been involved in health care financing and delivery since 1973. I read with keen interest how these three titans of Industry are going to increase quality and reduce costs simultaneously with technology and effective business systems (“Expert Advice For The Corporate Titans Taking On Health Care,” Jan. 31). Well, I wish them luck. First of all, quality health care is about 60 percent technology and 40 percent art (knowledge). Secondly, experience shows you can quantify the technology, but you can never quantify the art. If you make mistakes, people die. We cannot now allow computers to make life-and-death decisions on humans. Leave that to the professionals.

— Thomas J. Garvey, Merrick, N.Y.

Big money for what exactly Alexa? A new health plan, less expensive, more effective heath care, preventive medicine, better primary care, new aproach on disease management or an ehealth provider which ends up to be a onestopshop? #eHealth #BerkshireHathaway #Amazon #JPMorgan

— Matthias Lehmphul (@zippingcoffee) January 31, 2018

— Matthias Lehmphul, Berlin

We were disappointed KHN’s “Expert Advice” did not include input from advocates for a single-payer system. So, here is an open letter to the CEOs of Amazon, JPMorgan Chase and Berkshire Hathaway.

Dear Messrs. Jeff Bezos, Warren Buffett and Jamie Dimon:

We agree with you that health care is among the greatest issues facing society today. Your tremendous resources provide a unique opportunity to advocate for a health program to benefit all Americans: a universal, single-payer system.

Mr. Buffett describes our profit-based health system as a “tapeworm,” a parasite whose survival depends on its ability to drain nutrients from the host. How did our health care system reach that sorry state?

Our nation faces a catastrophic failure on two levels. First, the market has failed to deliver affordable health care to those who need it most. More importantly, our elected officials have failed to enact the reforms that could remedy health care’s woes because they are unwilling to offend big donors from the insurance and pharmaceutical industries. Instead, they’ve nibbled around the edges with incremental reforms like the Affordable Care Act. The ACA not only failed to kill the tapeworm of profit-based health care, it fattened it up with government subsidies, fueling the twin drivers of health costs — profits and administrative bloat.

Adding one more well-intentioned layer to our labyrinthine health care financing arrangements cannot fix them. We must move to one simple, nonprofit financing system, known as single-payer or “Medicare for all.” Mr. Buffett recently said that as a nation “we can afford to do it.” Medicare for all would bring desperately needed financial stability to the lives of everyday Americans, to every unit of government, and to businesses large and small.

We urge you to meet with policy experts who have studied this problem for decades, as well as the health care professionals operating at the front lines. Physicians for a National Health Program is a 22,000-member nonprofit research and education organization that advocates for single-payer health care. Our “Physicians’ Proposal for Single-Payer Health Care Reform” is a research-based plan for expanding health coverage to all Americans while eliminating the waste and profiteering of private insurance, and the inefficiencies they inflict on doctors and hospitals.

— Carol Paris, M.D., president of Physicians for a National Health Program, Chicago

Steering Readers Wrong?

Thank you for your articles and education for our senior population. But your article “No Car, No Care? Medicaid Transportation At Risk In Some States” (Jan. 30) makes it sound as if transportation fraud is rampant. My concern is that people read stories like this, and then make up their minds that because there is too much fraud we should eliminate the benefit. Someone needs to pressure Medicaid and Medicare to explain why they are not scrutinizing claims or bumping the names up to the Social Security Death Index. If they did that, they could catch the cases in which dead people’s identities were being used.

— Linda Chavez, Claremont, Calif.

Non-emergency transportation has always been difficult to effectively carry out, especially in rural areas. But waiving the requirement just establishes another barrier to care. It will result in fewer people receiving needed services.

— ((Sheldon Weisgrau)) (@ACAResource) January 31, 2018

— Sheldon Weisgrau, director of the Health Reform Resource Project, Lawrence, Kan.

Omission On Nuclear Fission Mission

Thanks to Sarah Varney for the article bringing to national attention the important issue of securing a molybdenum-99 medical radioisotope production facility in Janesville, Wis., and the importance for national security of having one in the United States (“Inside The Global Race To Deliver A Vital Radioactive Isotope Used To Detect Cancer,” Jan. 16). The article is comprehensive and well-written, but it falls short by concentrating on one company. Other viable companies work to produce molly-99 as a commercially viable product. Some work with proven technologies that have passed FDA approval for other producers. Among them is Coquí RadioPharmaceuticals, whose CEO, Carmen Irene Bigles, is a Puerto Rican woman.

— Carene Raldiris, Miami

Their Siblings’ Keepers

Thank you so much for the article “Her Sister’s Keeper: Caring For A Sibling With Mental Illness” (Jan. 9). My sister Jody and I grew up 13 months apart with Jody in the lead. Jody had a complicated birth that led to a lack of oxygen and borderline developmental disabilities. At 30, she was diagnosed with schizoaffective disorder. So much in your article rang true for me. I lived Jean’s life as Jody lived Ruby’s. Thank you for highlighting siblings. I am now in a role to help family caregivers. So few are the siblings that I personally identify with. Thank you for such an honest, dignified and loving portrayal.

— Robin Nobling, executive director of the National Alliance on Mental Illness Davidson County, Nashville

I just want to say thank you. I, too, am the guardian for my schizophrenic sister. My life with my sister is and has been very similar to what was described in the article by Jenny Gold. After I read it, it helped me so much emotionally and gave me strength. I am not alone.

— Janet Brew, Jacksonville Beach, Fla.

Your article on caring for mentally ill siblings almost 100 percent mirrors my life. My brother has schizophrenia. He was incredibly handsome, a star athlete and an outstanding academic student. He was sweet, funny and kind. His background is so similar to Ruby’s in your story. And, selfishly, I feel robbed. I never got to have a good, fun life with my amazing brother. Of course, he never had a life, either. His disease started when he was 19 and a stellar student at Penn State (today is his 60th birthday). Please keep writing these stories. They’re important.

— Claire Gawinowicz, Oreland, Pa.

A Jaw Drop On Dropping Coverage For Hoosiers

This Twitter user weighs in on Kaiser Health News’ Feb. 1 story “Indiana Medicaid Drops 25K From Coverage For Failing To Pay Premiums.”

Health is a human right. No one should lose access to care for inability to pay. Especially those with the least.

— Erin Gilmer (@GilmerHealthLaw) February 2, 2018

— Erin Gilmer, lawyer and health and patient policy advocate, Denver

Words Ring Harshly

In the story “When Nursing Homes Push Out Poor And Disabled Patients” (Dec. 20), I find the term “wheelchair-bound” offensive. Wheelchairs liberate people. They enable people to move more freely in their environment. The label “wheelchair-bound” makes these people sound more dependent or helpless. Thank you.

— Liz Pazdral, executive director of the State Independent Living Council, Sacramento, Calif.

3-D Vs. 2-D Mammograms? No Contest

In response to your article “When You Need A Breast Screening, Should You Get A 3-D Mammogram?” (Jan. 16), the science-based answer is “yes.” Studies involving over hundreds of thousands of examinations have all shown that Digital Breast Tomosynthesis — 3-D breast cancer screening — finds cancers that are not evident on 2-D mammography. One of the more recent evaluated almost a half-million examinations and showed a major increase in cancer detection.

The death rate from breast cancer had been unchanged for at least 40 years prior to the start of mammography screening in the U.S. in the mid-1980s. Soon after, in 1990, the death rate began to fall. It continued to fall as more and more women participated in screening and as we have improved our ability to find breast cancers earlier so that today there are almost 40% fewer women dying of breast cancer each year than would have had screening not been instituted.

DBT detects 20-40 percent more cancers than conventional Full Field Digital Mammography, and reduces the recall rate (women called back from screening for additional evaluation) by 10-40 percent. These are major improvements and should be available to all women.

— Daniel B. Kopans, M.D., professor of radiology, Harvard Medical School, Boston

[Editor’s note: Dr. Kopans was part of the team that secured the first patent for digital breast tomosynthesis in 1999.]

Cut In Federal Subsidies Threatens Basic Health Programs In N.Y., Minn.

Kaiser Health News:HealthReform - February 06, 2018

Comprehensive coverage for more than 800,000 low-income people in New York and Minnesota who pay a fraction of the typical cost of a marketplace plan may be in jeopardy after the federal government partially cut funding this year.

The Basic Health Program, in which these consumers are enrolled, was created under the Affordable Care Act to provide another coverage option for people with incomes up to 200 percent of the federal poverty level ($24,280 in 2018) who would otherwise qualify for subsidized marketplace coverage. Only New York and Minnesota have set up such programs.

The funding dispute is tied to a high-profile decision by President Donald Trump to stop paying cost-sharing reduction subsidies, which reduce the deductibles and out-of-pocket costs for people in marketplace plans whose incomes are up to 250 percent of the federal poverty level (about $30,000 for one person). Money that would have paid for cost-sharing reduction subsidies also helps fund the Basic Health Program in New York and Minnesota.

These plans must be as comprehensive and affordable as marketplace plans, but for many they’re significantly cheaper, with monthly premiums of either zero or $20 in New York and up to $80 in Minnesota, along with a very small or no deductible, combined with nominal copayments.

In November, when May Brown lost her job as a produce repacker — breaking 40-pound boxes of fruits and vegetables down into 10-pound boxes for grocery stores — she lost her employer health coverage, too. On the advice of a friend, the 62-year-old signed up for MinnesotaCare this month. Her $50 monthly premium is about half what she was paying for coverage on the job.

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Brown, who lives in St. Paul, said she is pretty healthy but having this coverage gives her peace of mind.

“You never know. Life is unpredictable,” she said. “I like to have something.”

Under the Basic Health Program, the federal government is responsible for paying states 95 percent of the amount it would have paid in premium subsidies and cost-sharing reduction payments on the marketplace for these enrollees. In December, the Department of Health and Human Services notified the two states it would withhold the cost-sharing reduction portion of the payments — nearly $300 million in the first quarter of 2018, about a quarter of the total amount expected. Over the course of a year, the amount withheld will exceed $1 billion.

When it cut back on funding of the Basic Health Program, the administration cited its October decision to eliminate cost-sharing reduction payments to insurers.

Last month, the attorneys general of the two states filed suit in U.S. District Court for the Southern District of New York to restore the federal funding.

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Noting that New York’s Essential Plan, as it’s called, covers more than 700,000 low-income New Yorkers, Attorney General Eric Schneiderman said in a press release, “I won’t stand by as the federal government continues to renege on its most basic obligations in a transparent attempt to dismantle the Affordable Care Act.”

In their lawsuit, Schneiderman and Minnesota Attorney General Lori Swanson argue that, among other things, the adminstration’s decision to cut off CSR payments is procedurally flawed and violates its obligations under the health law. They want the court to restore the states’ Basic Health Program funding.

Regardless of the lawsuit’s outcome, officials in both states have offered assurances that the program is safe — for now.

In New York, Gov. Andrew Cuomo’s budget included sufficient funds to leave the Basic Health Program intact for this year.

Officials at the Minnesota Department of Human Services said in a statement, “People enrolled in MinnesotaCare should feel confident in their coverage based on current information.”

Under the health law, any state can offer coverage under the Basic Health Program. One possible reason New York and Minnesota adopted the program is because they were already covering many in the target population through Medicaid, and typically sharing the cost equally with the federal government. Under the Basic Health Program, the state’s funding responsibility drops to just 5 percent.

So what happens next year? If federal funding isn’t restored, advocates are concerned that costs may rise and coverage shrink.

“It could trigger major changes to the eligibility structure, the benefits or increases in premiums,” said Maureen O’Connell, president of Health Access MN, which helps people enroll in marketplace coverage.

Elisabeth Benjamin said she’s “really worried” about the program next year if the courts don’t order the federal government to start making payments. Benjamin, the vice president for health initiatives at the Community Service Society of New York, an advocacy group, said there’s a snowball effect as states grapple with the delayed approval of Children’s Health Insurance Program funding for low-income kids amid continued uncertainty over federal funding for community health centers.

“It’s terrifying how much the feds can do, particularly for states like New York that are so reliant on federal funding,” Benjamin said.

Community Health Centers Caught In ‘Washington’s Political Dysfunction’

Kaiser Health News:HealthReform - February 05, 2018

As lawmakers face another deadline this week for passing legislation to keep the federal government open, one of the outstanding issues is long-term funding for a key health care safety-net program.

The Community Health Center program serves 27 million people at almost 10,000 nonprofit clinics nationwide, almost all of which are in low-income rural and urban areas.

Congress has allocated $3.6 billion annually to the health centers in recent years. That represents about 20 percent of the centers’ budgets—much of the rest comes in reimbursements for services. The money, say health center advocates and directors, is critical to providing services not always covered by Medicare, Medicaid and private insurance, including mental health and substance abuse care, transportation and in-home visits.

Congress was expected to renew long-term funding for the centers on Jan. 22 when lawmakers funded, for six years, the Children’s Health Insurance Program. One in 10 kids covered under CHIP gets most of their care at a community health center.

But that agreement didn’t deal with the centers. Although federal money for the centers ran out on Oct. 1, a previous budget patch provided temporary funds through March 31.

“We are caught up in Washington’s political dysfunction,” said Carmela Castellano-Garcia, CEO of the California Primary Care Association. “These centers are a lifeline for millions of people, especially in rural areas where they may be the only health care provider for miles around.”

She said the budget impasse has already forced many centers in the state to freeze hiring, put off service expansions and tap financial reserves.

Nationwide, 20 percent of health centers have instituted a hiring freeze already, and 4 percent have laid off staff. Another 53 percent said they might lay off staff if federal funding is not forthcoming, according to a survey of community health centers by George Washington University and Kaiser Family Foundation researchers released last week. (Kaiser Health News is an editorially independent program of the foundation.)

The reasons for Congress’ delayed action on funding is not altogether clear.

“We don’t really know why,” said Dan Hawkins, senior vice president of the National Association of Community Health Centers in Bethesda, Md. “But this has gone on long enough. Centers nationwide are feeling the pain. They need stable funding to plan and operate effectively.”

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Hawkins and health policy experts speculate that the impasse is due to disagreements over both the level of funding and the number of years of funding. Democrats are reportedly pushing for five to six years, but Republicans may favor a shorter period.

Republicans are seeking reductions in other areas of the federal budget to offset health center spending. That requirement was not imposed in the past.

Staffers in the offices of Sens. Debbie Stabenow (D-Mich.) and Roy Blunt (R-Mo.), who are leading talks over health center funding, said negotiations are active and there’s agreement among members of both parties that the issue needs to be resolved as soon as possible.

Community health center leaders and patients are closely monitoring the efforts.

California has the nation’s largest network of health centers. More than 1,300 centers care for 1 of every 6 Californians — 6.5 million people. Half are enrolled in Medi-Cal, California’s Medicaid program.

“We planned to open an additional clinic this year, but we’re in a waiting mode now,” said Dave Jones, CEO of Mountain Valleys Health Centers, which operates six community clinics near the town of Redding in Northern California. The centers serve around 10,000 people each year.

Jones said they probably would have to close one of six sites if Congress reduces funding.

“The way this has gone has not been helpful at all, to say the least,” Jones said.

Anderson Valley Health Center in Boonville, Calif., faces much the same predicament. The small center treats 2,800 patients a year, 45 percent of whom are low-income farm workers.

“We planned to renovate our building this year, but we’re holding off to see what happens,” said Chloë Guazzone-Rugebregt, the center’s executive director.

Maria Soto, 72, her husband Efren, 77, get care at the Anderson Valley Heath Center in Boonville, Calif. (Esther Soto/Courtesy of Maria Soto)

Maria Soto, 72, her husband, Efren, 77, along with their six adult children and 13 grandchildren all get care at Anderson. The elder Sotos, both now retired, have Medicare. The rest of the family has private insurance or are enrolled in Medi-Cal.

“The clinic plays a very big role in our lives,” Maria Soto said. “We rely on it for all our regular care. I have no idea where we would go if it had to close down.”

Across the country, Charles Allbaugh and Paula Tomko, who run Central Virginia Health Services, said they, too, have held off on hiring staff and expanding services at their network of 16 clinics serving 43,000 Virginians, pending the outcome of the funding debate.

“Congress is playing political football with us,” said Tomko. “It’s not the way things should run.”

Jean Grutzius agreed. Her 97-year-old mother’s care is provided by one of Tomko’s clinics, near the small town of Bumpass, Va.

“Without the clinic, we’d be in real trouble,” Grutzius said. Her mother, Eleanor Ciombor, is blind and deaf, in a wheelchair, and takes multiple medicines, including for a psychiatric condition. Ciombor, who lives with her daughter, is enrolled in both Medicare and Medicaid. Her only income is $900 a month from Social Security.

“She gets great care [at the clinic,] and it costs us little,” said Grutzius, who is 75 and also living on a fixed income. “I would not be able to pay for it otherwise. I am praying the center gets the funding they need.”

The current political tussle follows a significant boost in health center funding under the Affordable Care Act (ACA). Between 2010 and 2016, that funding propelled a 50 percent increase in the number of health center sites nationwide and a 33 percent increase in the number of patients served.

Health centers were also active in signing up people for the ACA’s insurance marketplaces and for Medicaid in the states that expanded that program under the ACA.

Yet, despite growing partisan acrimony over the ACA, lawmakers voted overwhelmingly — and in bipartisan agreement — in 2015 to extend health center funding at the $3.6 billion-a-year level for two additional years.

“This is federal dollars very well spent, and $3.6 billion is hardly a big federal expenditure,” said Peter Shin, an associate professor of health policy and management at George Washington University in Washington, D.C.   “In fact, there’s a strong argument for why they should get more money.”

Shin said research shows the centers save the federal government money in the long run. They do this by providing routine primary, preventive and prenatal care that keeps people out of the hospital and prevents costly emergency room visits.

By one estimate, he said, health centers save the federal government almost $25 billion annually in deterred costs for Medicare and Medicaid enrollees.

HHS Approves New Healthy Indiana Medicaid Demonstration

HHS Gov News - February 02, 2018

INDIANAPOLIS—On Friday, U.S. Health and Human Services Secretary Alex Azar joined Indiana Governor Eric J. Holcomb to announce the U.S. Department of Health and Human Services’ Centers for Medicare and Medicaid Services approval of Indiana’s Section 1115 waiver, known as the Healthy Indiana Plan or HIP.

The waiver has now been expanded to include a requirement for work or other forms of community engagement for able-bodied, working age Medicaid enrollees, just the second such Medicaid waiver in history to include this mechanism, which has shown success in other HHS programs at moving beneficiaries from welfare to work.

The Healthy Indiana extension also includes administrative reforms as well as a new funding authority to expand treatment options for Medicaid enrollees struggling with substance abuse, including opioid addiction.

“Today’s approval is the result of the hard work of Governor Holcomb, his team, and our team at CMS, and serves as a testament to Indiana’s ongoing commitment to improving the lives of its Medicaid beneficiaries,” said Secretary Azar. “We look forward to collaborating with Indiana on this next evolution of HIP, which serves as another example of the Trump Administration’s support of state-led efforts and innovative reforms to make our HHS programs really work for Americans.”

“A decade after it launched, Healthy Indiana has become the national model for a state-led, consumer-driven healthcare program that meets citizens’ healthcare needs, provides choices and improves lives,” Governor Holcomb said. “This approval continues coverage for hundreds of thousands of Hoosiers and unlocks funding to expand resources to help people struggling with addiction.”

On January 11, CMS announced new policy guidance to support state efforts to improve Medicaid enrollee health outcomes and promote independence by incentivizing community engagement among able-bodied, working-age Medicaid beneficiaries. The policy responds to numerous state requests to test programs through Medicaid demonstration projects under which work and other types of community engagement would be a condition of Medicaid coverage for that particular population. 

Indiana’s demonstration program is the second one of its kind to be approved, following Kentucky’s on January 12.

Indiana Gets Federal Approval For Medicaid Plan That Could Slice Enrollment

Kaiser Health News:Insurance - February 02, 2018

Indiana on Friday became the second state to win federal approval to add a work requirement for adult Medicaid recipients who gained coverage under the Affordable Care Act, but a less debated “lockout” provision in its new plan could lead to tens of thousands of enrollees losing coverage.

The federal approval was announced by Health and Human Services Secretary Alex Azar in Indianapolis.

Medicaid participants who fail to submit in a timely manner their paperwork showing they still qualify for the program will be blocked from enrollment for three months, according to the updated rules.

Since November 2015, more than 91,000 enrollees in Indiana were kicked off Medicaid for failing to complete the eligibility redetermination process, according to state records. The process requires applicants to show proof of income and family size, among other things, to see if they still qualify for the coverage. Until now, these enrollees could simply re-apply anytime. Although many of those people likely were no longer eligible, state officials estimate about half of those who failed to comply with its re-enrollment rules were still qualified.

Indiana’s Medicaid expansion began in February 2015, providing coverage to 240,000 people who were previously uninsured, helping drop the state’s uninsured rate from 14 percent in 2013 to 8 percent last year. The HHS approval extends the program, which was expiring this month, through 2020.

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The new lockout builds on one already in place in the state for people who failed to pay monthly premiums and had annual incomes above the federal poverty level, or about $12,200 for an individual. They are barred for six months from coverage. During the first two years of the experiment, about 10,000 Indiana Medicaid enrollees were subject to the lockout for failing to pay the premium for two months in a row, according to state data.

In addition, more than 25,000 enrollees were dropped from the program after they failed to make the payments, although half of them found another source of coverage — usually through their jobs.

Another 46,000 were blocked from coverage because they failed to make the initial payment.

“The ‘lockout” is one of the worst policies to hit Medicaid in a long time,” said Joan Alker, executive director of the Georgetown University Center for Children and Families. “Forcing people to remain uninsured for months because they missed a paperwork deadline or missed a premium payment is too high a price to pay. From a health policy perspective it makes no sense because during that period, chronic health conditions such as hypertension or diabetes are just likely to worsen.”

Indiana’s Medicaid expansion is being closely watched in part because it was spearheaded by then-Gov. Mike Pence, who is now vice president, and his top health consultant, Seema Verma, who now heads the federal Centers for Medicare & Medicaid Services.

The expansion, known as Healthy Indiana, enabled non-disabled adults access to Medicaid. It has elicited criticism from patient advocates for complex and onerous rules that require these poor adults  to make payments ranging from $1 to $27 per month into health savings accounts or risk losing their vision and dental benefits or even all their coverage, depending on their income level.

Indiana Medicaid officials said they added the newest lockout provision in an effort to prompt enrollees to get their paperwork submitted in time. The state initially requested a six-month lockout.

“Enforcement may encourage better compliance,” the state officials wrote in their waiver application to CMS in July.

The new rule will lead to a 1 percent cut in Medicaid enrollment in the first year, state officials said. It will also lead to a $15 million reduction in Medicaid costs in 2018 and about $32 million in savings in 2019, the state estimated.

The number of Medicaid enrollees losing coverage for failing to comply with redetermining their eligibility has varied dramatically each quarter from a peak of 19,197 from February 2016 to April 2017 to 1,165 from November 2015 to January 2016, state reports show. In the latest state report, 12,470 enrollees lost coverage from August to October 2017.

The Kentucky Medicaid waiver approved by the Trump administration in January included a similar lockout provision for both failing to pay the monthly premiums or providing paperwork on time. Penalties there are six months for both measures. But the provision was overshadowed because of the attention to the first federal approval for a Medicaid work requirement.

Like Kentucky, Indiana’s Medicaid waiver’s work requirements, which mandate adult enrollees to work an average of 20 hours a month, go into effect in 2019. But Indiana’s waiver is more lenient. It exempts people age 60 and over and its work-hour requirements are gradually phased in over 18 months. For example, enrollees need to work only five hours per week until their 10th month on the program.

Most Medicaid adult enrollees do work or go to school or are too sick to work, studies show.

Indiana also has a long list of exemptions and alternatives to employment. This includes attending school or job training, volunteering or caring for a dependent child or disabled parent. Nurses, doctors and physician assistants can give enrollees an exemption due to illness or injury.

Three patient advocacy groups have filed suit in federal court seeking to block the work requirements.

Robin Rudowitz, associate director for the Kaiser Family Foundation’s Program on Medicaid and the Uninsured, said it’s difficult to gauge whether work requirements or renewal lockouts will have more of an impact on coverage.  She noted both provisions apply to most demonstration beneficiaries. (KHN is an editorially independent program of the foundation).

“Any documentation requirement could lead to increased complexity in terms of states administering the requirements and individuals complying,” she said, adding that it could result “in potentially eligible people falling off of coverage.”

Stalled Health Programs Await A Green Light On The Hill

Kaiser Health News:Insurance - February 02, 2018

With the clock ticking on the current stop-gap bill that funds the federal government through Feb. 8, Congress is steeling itself to consider another must-pass budget bill. And, once again, health care could be caught in the crosshairs.

During previous debates over government funding, it was the high-profile Children’s Health Insurance Program that went months without reauthorization and became a bargaining chip in January. That program has since been extended for six years.

But the future of a host of other programs remains unsettled. Among them, funding for the nation’s 1,400 community health centers and a delay on capping Medicare coverage of physical and outpatient therapy.

The specific provisions behind these initiatives expired last fall. Advocates now are pressing lawmakers to keep them operational by including language in the broader spending bill that must pass next week to prevent another government shutdown.

Some of the items in this eclectic legislative mix are often left to the last minute to catch a ride on another bill — known as “extenders” by Washington insiders, because they extend funding that is set to expire or delay funding cuts that would otherwise take effect.

On the surface, these efforts may sound like wonky, inside-the-Beltway machinations, but program advocates say they have real-life implications for many of the nation’s neediest patients. For them, the congressional delay is causing concern. Here are some things you should know:

The provisions are important and wide-ranging.

Renewing federal funding for community health centers is the biggest ticket item — the clinics cost $3.6 billion per year, and provide basic health care for about 27 million low-income people. Also at stake is the Maternal, Infant and Early Childhood Home Visiting Program, through which trained home visitors teach poorer, at-risk mothers healthy parenting strategies to new mothers who are deemed at-risk and have low incomes.

Another provision forestalls planned reductions put in place by the Affordable Care Act — in federal funds given to particularly vulnerable hospitals that serve a particularly high rate of low-income patients, known as Disproportionate Share Hospitals.

And yet another would prevent limits, put in place by earlier budget bills, from being applied to Medicare’s coverage of physical therapy, outpatient therapy and speech-language pathology treatment. Without action, coverage would be cut off after $2,010 of occupational therapy is provided and another $2,010 for the combination of physical therapy and speech-language pathology. Each limit would translate into Medicare reimbursement for fewer than 20 visits.

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OK, so why hasn’t Congress acted on these yet?

These are generally smaller programs that, in the past, were authorized or extended via provisions attached to larger, must-pass bills. One of the favorite vehicles was the “doc fix,” which regularly moved through Congress to make adjustments in how Medicare paid doctors. That is, until a landmark 2015 law — the Medicare Access and CHIP Reauthorization Act, or MACRA — permanently addressed physician payment.

CHIP finally got funding in the Jan. 22 federal spending deal, but the other items were left on the table. One issue, many said: They’re simply not as sexy, and the impact is harder to spot immediately.

“The problem is too much of the focus was on just one egg in the basket, and that egg got done. Now the rest of the eggs are saying, ‘What about me?’” said Rodney Whitlock, a health policy consultant and former Republican Senate staffer. “The real-world impact of not addressing those is slowly becoming problematic.”

Most of the programs aren’t politically controversial.

These programs usually pass with bipartisan support. For lobbyists and policy analysts on both sides of the aisle, that makes the funding lapse especially disorienting.

“Even things that should be easy and bipartisan are taking much, much longer and encountering much more difficulty than I think any of us would have expected,” said Eliot Fishman, senior director of health policy at the liberal advocacy group Families USA and a former member of the Obama administration. “It’s clearly a matter of political gamesmanship.”

There is some room to debate how to pay for these initiatives. But even that is limited, suggested Thomas Miller, a resident fellow at the conservative American Enterprise Institute.

“If it’s your economic interest at stake … this is an end-all and be-all. But these are not gigantic items — the consequences for the larger fiscal picture are not immense,” Miller said.

Take the therapy caps. They were first put in place as part of the 1997 Balanced Budget Act, as part of an effort to curb Medicare outpatient spending.

But in 1999, right when the caps were scheduled to kick in, pushback from physicians and patient advocates led Congress to delay their effective date. Since then, Congress, has — except for a brief lapse — kept them at bay.

This delay in funding has consequences for patients.

Stephanie Weyrauch, a Minnesota-based physical therapist concerned about the therapy caps, said she and her colleagues are already starting to ration care.

She described, for instance, a 69-year-old man who is recovering from a stroke and about halfway through his allotted therapy. He will require several more sessions later this year just for that condition, which would bring him up to the cap. If his other ailments — shoulder problems and poor blood flow – worsen, Medicare wouldn’t cover treatment.

“We have to make sure we’re doing what’s best for our patients. Sometimes that means we stop therapy early to prepare for a potential next episode,” she said.

A fix from Congress could come next week. 

Congress already provided some short-term funding for community health centers, which is “keeping the lights on,” Fishman said. But it lasts only until the end of March.

And the Maternal, Infant and Early Childhood Home Visiting Program is operating on previously allocated dollars.

In the meantime, the affected programs are struggling to plan for the future, Fishman noted. They are trying to come up with budgets and make staffing decisions without a sense of what their income will actually be.

But some people expressed optimism about what will be included in the funding bill likely to take shape in Congress next week.

“I continue to believe that when a spending deal gets worked out this train will ride along. … It is an election year,” Whitlock said. “No matter what, this is one of those where it’s got to get worked out.”

Five breaches add up to millions in settlement costs for entity that failed to heed HIPAA’s risk analysis and risk management rules

HHS Gov News - February 01, 2018

Fresenius Medical Care North America (FMCNA) has agreed to pay $3.5 million to the U.S. Department of Health and Human Services (HHS) Office for Civil Rights (OCR), and to adopt a comprehensive corrective action plan, in order to settle potential violations of the Health Insurance Portability and Accountability Act (HIPAA) Privacy and Security Rules. FMCNA is a provider of products and services for people with chronic kidney failure with over 60,000 employees that serves over 170,000 patients. FMCNA’s network is comprised of dialysis facilities, outpatient cardiac and vascular labs, and urgent care centers, as well as hospitalist and post-acute providers.

On January 21, 2013, FMCNA filed five separate breach reports for separate incidents occurring between February 23, 2012 and July 18, 2012 implicating the electronic protected health information (ePHI) of five separate FMCNA owned covered entities (FMCNA covered entities). 

The five locations of the breaches were Bio-Medical Applications of Florida, Inc. d/b/a Fresenius Medical Care Duval Facility in Jacksonville, Florida (FMC Duval Facility); Bio-Medical Applications of Alabama, Inc. d/b/a Fresenius Medical Care Magnolia Grove in Semmes, Alabama (FMC Magnolia Grove Facility); Renal Dimensions, LLC d/b/a Fresenius Medical Care Ak-Chin in Maricopa, Arizona (FMC Ak-Chin Facility); Fresenius Vascular Care Augusta, LLC (FVC Augusta); and WSKC Dialysis Services, Inc. d/b/a Fresenius Medical Care Blue Island Dialysis (FMC Blue Island Facility).

OCR’s investigation revealed FMCNA covered entities failed to conduct an accurate and thorough risk analysis of potential risks and vulnerabilities to the confidentiality, integrity, and availability of all of its ePHI.

The FMCNA covered entities impermissibly disclosed the ePHI of patients by providing unauthorized access for a purpose not permitted by the Privacy Rule.

FMC Ak-Chin failed to implement policies and procedures to address security incidents.

FMC Magnolia Grove failed to implement policies and procedures that govern the receipt and removal of hardware and electronic media that contain ePHI into and out of a facility; and the movement of these items within the facility.

FMC Duval and FMC Blue Island failed to implement policies and procedures to safeguard their facilities and equipment therein from unauthorized access, tampering, and theft, when it was reasonable and appropriate to do so under the circumstances.

FMC Magnolia Grove and FVC Augusta failed to implement a mechanism to encrypt and decrypt ePHI, when it was reasonable and appropriate to do so under the circumstances.

“The number of breaches, involving a variety of locations and vulnerabilities, highlights why there is no substitute for an enterprise-wide risk analysis for a covered entity,” said OCR Director Roger Severino. “Covered entities must take a thorough look at their internal policies and procedures to ensure they are protecting their patients’ health information in accordance with the law.”

In addition to a $3.5 million monetary settlement, a corrective action plan requires the FMCNA covered entities to complete a risk analysis and risk management plan, revise policies and procedures on device and media controls as well as facility access controls, develop an encryption report, and educate its workforce on policies and procedures.

The resolution agreement and corrective action plan may be found on the OCR website at

To learn more about health information privacy laws and health information privacy rights, please visit

To file a complaint with OCR based on a violation of civil rights, conscience or religious freedom, or health information privacy, visit us at

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Indiana Medicaid Drops 25K From Coverage For Failing To Pay Premiums

Kaiser Health News:HealthReform - February 01, 2018

As the Trump administration moves to give states more flexibility in running Medicaid, advocates for the poor are keeping a close eye on Indiana to see whether such conservative ideas improve or harm care.

Indiana in 2015 implemented some of the most radical changes seen to the state-federal program that covers nearly 1 in 4 poor Americans — including charging some adults a monthly premium and locking out some of those who don’t pay for six months.

The changes were a part of Indiana’s deal with the Obama administration to expand eligibility, adding about 240,000 Hoosiers to the Medicaid rolls under the Affordable Care Act. The controversial monthly fees and lockout provisions were spearheaded by then-Gov. Mike Pence, who is now vice president, and his top health consultant, Seema Verma, who now heads the federal Centers for Medicare & Medicaid Services. That demonstration project, known as Healthy Indiana, is up for renewal in February, and state officials seek to add work requirements similar to what CMS approved for Kentucky last month and to widen who is subject to lockouts.

With CMS expected to approve Indiana’s renewal in the coming days, much remains unknown about how well Healthy Indiana is working, such as whether it has improved the efficiency of Medicaid.

But some results are in.

About 25,000 adults were disenrolled from the program between its start in 2015 and October 2017 for failure to pay their premiums, according to state reports. Yet, state officials estimate that based on surveys of recipients, about half of those who were disenrolled found another source of coverage, most often through a job.

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During the first two years of the experiment, about 10,000 Indiana Medicaid enrollees were subject to the six-month lockout for failing to pay the premium for two months in a row. The state did not provide lockout data for 2017.

While premiums are required of all adults added under the expansion, the lockouts apply only to those with incomes from 101 to 138 percent of the federal poverty level (about $12,200 to $16,600 for an individual). Those with lower incomes — more than 80 percent of Healthy Indiana enrollees — lose their vision and dental benefits for failing to pay the premium.

Several Republican-controlled states that expanded Medicaid have followed Indiana to adopt premiums. But the Indiana model is also attracting attention from some of the 19 conservative states that are leery of expanding Medicaid. Yet the possibilities of spreading the Indiana model worry Medicaid advocates, who fear that it can lead to poor Americans missing out on care.

Joe Moser, who was Indiana’s Medicaid director when the program was instituted and is now a consultant, said the expansion is achieving many of its goals, including reduced use of hospital emergency rooms for non-emergencies and more enrollees opting for preventive services to stave off more expensive care later.

State officials promoted the monthly premiums and lockout features as a way to give Medicaid enrollees “skin in the game” so they would make better health care decisions. “The lockouts give a powerful incentive for people to continue paying for their health care,” Moser said.

The provisions were key to winning enough political support to expand Medicaid.

Susan Jo Thomas, executive director of Covering Kids and Families of Indiana, an advocacy group, said even without knowing the effect of the premiums and lockouts, the Medicaid expansion was still worth it.

“It’s literally saved lives,” she said.

“To me the lesson is, it’s been worth a try to do a demonstration project to increase access,” she added. “It would never have sold politically, if we didn’t do this. … Sometimes you have to settle for getting three-quarters of a loaf of bread rather than getting no bread at all.”

Mirroring national trends following implementation of the health law, Indiana’s uninsured rate has dropped from 14 percent in 2013 to 8 percent last year.

Now, advocates worry that the Trump administration is poised to grant Indiana a long-term extension of the Healthy Indiana expansion — and add a requirement that nondisabled adults work or volunteer 20 hours a week. The state also seeks federal permission to lock out any adults who fail — regardless of income level — to renew their coverage in a timely manner.

Those changes would “be a big step backwards,” said Joan Alker, executive director of the Georgetown University Center for Children and Families. “The problem is when people lose their coverage or get locked out, their health needs do not go away.”

In addition to those who were disenrolled, another 46,000 adults who signed up for Medicaid during 2016 and 2017 were not accepted because they did not pay their initial premium, the state reported.

These premium payments go into special health savings accounts for enrollees to cover some medical expenses. Monthly contributions, based on income, range from $1 to $27. About half of current enrollees pay $1.

Thomas said one of the biggest benefits of the state’s Medicaid expansion had nothing to do with new requirements on beneficiaries. Rather, the state’s decision to increase pay to doctors to the same rates as Medicare has resulted in many more specialists to treat Medicaid recipients and reduced access problems.

Kosali Simon, an economist at Indiana University, said there are many unanswered questions about the effect of the state’s Medicaid expansion, such as whether the added premiums make enrollees better health shoppers. And there is no evidence the Indiana strategy is more cost-efficient than traditional Medicaid, she said.

But there’s no doubt the Medicaid expansion was a good idea, she said: “If we are asking if the state did better off than having no expansion, then pretty clearly the answer is yes.”

As States Target High Drug Prices, Pharma Targets State Lawmakers

Kaiser Health News:Marketplace - February 01, 2018

It was expected to be a perfunctory statehouse meeting — three lobbyists and a legislator discussing a proposal to educate Louisiana doctors about the price of drugs they prescribe.

The bill seemed like a no-brainer in a country where even decades-old medicines can cost thousands and consumers are urged to make smart choices in buying health care. The legislation simply required pharmaceutical sales reps promoting medicines at doctors’ offices to also reveal a price.

No one expected the industry scrum that materialized.

About 10 pharma lobbyists flooded the room in Baton Rouge’s art deco state Capitol, some of them hired guns — lobbyists who’d never represented drug companies before, remembers Jeff Drozda, an insurance lobbyist at the 2016 meeting.

“The message was: We’re going to bring everything at you against these bills,” he said.

They did. Pharmaceutical Research and Manufacturers of America, the powerful trade group known as PhRMA, donated directly to more lawmakers in Louisiana than in any other state in 2016, a new IRS filing shows. When discussion of the measure reached its peak last year, the industry hired a lobbyist for every two legislators.

PhRMA spent thousands entertaining lawmakers at Baton Rouge venues such as Mike Anderson’s Seafood, specializing in shrimp-and-crab gumbo, and the Mestizo Restaurant, home of the Daredevil Margarita, lobbying records show.

“I’ve been in the legislature 10 years. I’ve never in my life seen that kind of effort,” said Kirk Talbot, a Republican who sponsored the bill in the Louisiana House.

With federal officials seemingly unwilling or unable to come up with legislation to control skyrocketing drug prices, that task is increasingly moving to the states. But so is pharma muscle and money opposing the measures, regulatory disclosures and corporate filings from the last two years show.

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State lawmakers are likely to consider drug-price transparency bills this year in Connecticut, Michigan, Oregon, Washington and New Jersey, to name just a few. Many of the measures are similar to a new California law that requires drugmakers to justify big price increases. (To fight that law, the industry hired 45 lobbying firms.)

Meanwhile, activists who backed a 2017 law enabling Maryland officials to challenge “unconscionable” price increases for generic drugs now advocate price regulation for all expensive pharmaceuticals. Policymakers in New Mexico, Massachusetts and Arizona are talking about limiting drug coverage or negotiating drug prices under Medicaid.

In Washington, D.C., PhRMA, is widely credited with stalling federal drug-price measures for years, with lobbying, advertising and political contributions.

Now states are getting a dose of the same medicine.

PhRMA set the stage in 2016 by establishing a group that ultimately spent $110 million to defeat a high-profile California ballot initiative requiring state agencies to pay no more for drugs than does the federal Department of Veterans Affairs. A PhRMA-linked group spent more than $50 million to defeat a similar ballot measure last year in Ohio.

Traditionally well represented in statehouses, PhRMA wrote checks to hundreds of legislative candidates and political action committees in dozens of states in 2016, newly available IRS filings show. So did many of its member companies, according to new data published by the Center for Political Accountability, a nonprofit that works to shed light on corporate political spending.

Merck, maker of a hepatitis C drug called Zepatier that costs $54,600 according to Truven Health Analytics, gave $19 million to PhRMA in 2016 but also gave about $500,000 to candidates and political committees in some two dozen states, sometimes in checks as small as $100, according to the CPA data, compiled from voluntary disclosures on corporate websites.

Amgen, maker of leukemia drug Blincyto, which costs $173,000 for an average treatment, according to the company, donated to more than 100 statehouse candidates in about a dozen states for the 2016 elections. Johnson & Johnson, Pfizer, Bristol-Myers Squibb and Allergan also directly or indirectly supported state candidates in 2016, CPA data show.

Pharma companies “definitely have not seen that kind of activity aimed at them at the state level before and have raised their presence to address that,” said Leanne Gassaway, top state lobbyist for America’s Health Insurance Plans, a major insurance trade group.

Few states got as much pharma attention the past two years as Louisiana, though the money spent there fell short of the tens of millions invested in swaying referenda in California and Ohio. It’s cheaper to influence scores of lawmakers than millions of voters.

I’ve been in the legislature 10 years. I’ve never in my life seen that kind of effort.

Kirk Talbot, Republican member of the Louisiana House of Representatives

Drug prices are “something that’s completely out of control,” Talbot said, adding that he gets constituent requests to rein in prescription medicine prices.

Neither Talbot, chairman of the House insurance committee, nor many others in the conservative state are moving to regulate drug prices. But he and other lawmakers saw promise in an idea from Blue Cross and Blue Shield of Louisiana, a big insurer whose premiums have been driven up partly by rising drug expenses.

The proposal, which got little news coverage even in Louisiana, would have required sales reps promoting their latest, greatest medicines to give doctors the wholesale prices at the same time. Physicians, who are largely unaware of prescription costs, might think twice about ordering $500 worth of brand-name pills when a $30 generic could deliver the same benefit, the thinking went.

The measure died in committee after the pharma lobby staged its flash mob at the 2016 meeting. When the idea came up again last spring, this time with backing from Talbot and Sen. Fred Mills, Republican chairman of the Senate health committee, the industry shifted into high gear.

Mills got “a tremendous amount of calls” on his cellphone from pharma lobbyists as well as emails and texts almost immediately after his bill landed on a legislative website, he recalled. First in line was Pete Martinez, PhRMA’s top Louisiana operative.

“I’ve had this volume” of special-interest pressure “but not the speed,” said Mills, a small-pharmacy owner from St. Martin Parish who said he sees the rising price of pills firsthand. Mills recalled phone calls from “top government affairs people” at Pfizer, “telling me the problems with this bill.”

No fewer than 84 lobbyists representing pill companies blanketed Baton Rouge at the height of the legislative session last year, state records show — the most in at least nine years.

In 2016, PhRMA gave directly to about 80 Louisiana state politicians, more than those in any other state, the IRS filing shows. PhRMA and individual drug companies have made more than $600,000 in contributions to Louisiana state and local political races in the past three years, according to campaign finance files.

Martinez did not respond to requests for an interview. At hearings in Louisiana, PhRMA argued that informing doctors of wholesale drug prices is irrelevant to patients. What matters is consumers’ out-of-pocket payment, not the rest of the cost that’s often picked up by insurance, they said.

“We are committed to engaging with lawmakers, patients and others to find solutions that actually help patients,” a PhRMA spokesman said in a statement for this article.

Proponents countered that rising total drug costs are an increasingly painful burden on taxpayers, employers, workers and everybody else who pays them indirectly through insurance plans and government programs.

PhRMA’s opposition had an effect.

Instead of making salespeople disclose prices, the legislation that lawmakers eventually passed and that Gov. John Bel Edwards signed in June requires the Louisiana Board of Pharmacy to host a website listing the information. Rather than ordering drug reps to tell doctors about the site, the act says they “may” give prescribers the internet address if they choose.

The law “is quite watered-down and basically meaningless,” said Ameet Sarpatwari, an epidemiologist and lawyer at Harvard Medical School who follows pharma laws.

Talbot says he may have lost this battle but will continue the war.

“I’m going to take another stab at it” this year, he said. “We’re on the front wave of this thing. All the states are jumping on this bandwagon.”