Tagged CMS

Must-Reads Of The Week From Brianna Labuskes

Happy Friday! Did you guys get as big a kick out of the #healthpolicyvalentines hashtag as I did? (I feel I’m talking to the right crowd here.) They’re quite delightful, including this timely one from KHN’s own Rachel Bluth: “Not even a PBM could get in the middle of our love.”

On to the news from the week.

Thursday was a somber day for many as the country marked the anniversary of the Parkland, Fla., mass shooting at Marjory Stoneman Douglas High School that left 17 dead.

On the eve of the anniversary, the House Judiciary Committee approved two bills that would expand federal background checks for gun purchases. Although the legislation faces certain demise in the Senate, it is the first congressional action in favor of tightening gun laws in years. In the votes you see echoes of a recent trend: Lawmakers are no longer treating gun control as “the third rail in politics.” The difference is stark if you look at just over 10 years ago when then-candidate Barack Obama was sending out mailers assuring voters he supported the Second Amendment.

Politico: House Democrats Make First Major Move to Tighten Gun Laws

The Associated Press: Parkland Anniversary Highlights Democratic Shift on Guns

There were too many heartbreaking anniversary stories to highlight just one, but a project worth checking out is one from The Trace, a nonprofit news organization that reports on gun violence. In the year since Parkland, nearly 1,200 more children have lost their lives to guns. The Trace brought together more than 200 teen reporters from across the country to remember those killed not as statistics, but as human beings with rich histories.

14 Children Died in The Parkland Shooting. Nearly 1,200 Have Died From Guns Since.

A handy reference: The good people at The Tampa Bay Times and the AP put together a useful list of all the gun laws that have been enacted in the country since the shooting.

Tampa Bay Times and Associated Press: Here Is Every New Gun Law in the U.S. Since the Parkland Shooting

There are some lawmakers on the Hill who are almost giddy to hold hearings on “Medicare-for-all” — and they’re not Democrats. Republicans have been struggling to find a winning stance on health care, ever since Dems’ midterm victories, which were attributed in part to their stance on the issue.

For the previously floundering GOP lawmakers, MFA is practically a gift-wrapped present that fell right into their laps. They’re confident they can frame the idea as reckless, radical and expensive, and pick off moderate voters who want to keep their insurance the way it is. Democratic leadership blasted the GOP’s calls for hearings as “disingenuous,” but MFA supporters were raring to duke it out — verbally, of course. “They think it’s going to be a ‘gotcha’ moment,” said Rep. Pramila Jayapal (D-Wash.) in Politico’s coverage. “But they have been wrong on this and continue to be wrong on it.”

Politico: Republicans Can’t Wait to Debate ‘Medicare For All’

Meanwhile, Democrats introduced legislation this week that would allow people over 50 to buy in to Medicare. The measure is much more politically palatable than MFA, and its sponsors are selling it is a realistic and incremental step in the direction toward universal coverage.

Politico: Push for Medicare Buy-In Picks Up With ’50 and Over’ Bill

Here’s something you don’t hear every day: Republicans and Democrats maybe (just maybe!) have found some common ground on the health law. As part of a package of bills to shore up the Affordable Care Act, Democrats are proposing slapping some consumer warnings on short-term plans. The hint of bipartisanship in the air, though, was limited to the advisories — Republicans were not fans of the rest of the changes proposed.

Modern Healthcare: Short-Term Health Insurance Plans May Get Consumer Warnings

Advocates deem Utah’s move to limit voter-approved Medicaid expansion as a “dark day for Democracy.” The governor and lawmakers who rushed through the restrictions to the expansion, however, say the work requirements and caps are necessary to make it sustainable for the state.

The Associated Press: Utah Reduces Voter-Backed Medicaid Expansion in Rare Move

As 2020 comes into focus, the abortion debate is definitely on the front burner for President Donald Trump, who has seized on recent controversies over so-called late-term abortions. This week, Trump and White House officials met with advocates, including Susan B. Anthony List President Marjorie Dannenfelser. While the discussions weren’t open to journalists, Dannenfelser confirmed that Trump was keenly interested in the issue. “The national conversation about late-term abortion … has the power to start to peel away Democrats, especially in battle grounds,” Dannenfelser said in The Hill’s coverage.

The Hill: Trump Offers Preview of Abortion Message Ahead of 2020

There was some movement in the agencies this week that should be on your radar:

— The Food and Drug Administration has announced it’s cracking down on the $40 billion supplement industry, especially targeting diseases that really should require medical care. Right now, that landscape is pretty much the Wild Wild West, where anything goes. And consumers don’t realize that.

The New York Times: F.D.A. Warns Supplement Makers to Stop Touting Cures for Diseases Like Alzheimer’s

— The Environmental Protection Agency has released its plan to address long-lasting toxins in drinking water. Activists were not impressed, saying the “action plan” was quite short on action.

Reuters: U.S. Unveils Plan to Control Some Toxins in Drinking Water, Sets No Limits

— The Centers for Medicare & Medicaid Services released two major proposed regulations that are meant to help ease patients’ access to their health care records. Right now, many health care providers and hospitals offer patient portals, but they often lack material such as doctor notes, imaging scans and genetic-testing data. Sometimes they’ll even charge for the data. The rules would address restrictions such as those.

The Wall Street Journal: New Rules Could Ease Patients’ Access to Their Own Health Records

In a sign of the growing awareness about the United States’ maternal mortality problem, the task force that sets the standards insurers are required to follow is expanding its guidance when it comes to depression during and after pregnancy. The U.S. Preventive Services Task Force already recommends that doctors screen pregnant women and new mothers, but the old guidelines focused on patients who were experiencing symptoms. The new advice is more proactive about addressing women who may be at risk.

The Wall Street Journal: New Mothers at Risk of Depression to Get Counseling Services, Covered By Insurance, Under New Guidelines

It’s a well-established fact that doctors have an unconscious bias when it comes to race and pain — one that leaves many minority patients undertreated and undermedicated. What’s interesting is to see how that disparity has shaped the opioid epidemic in the country — the ones that wreaked havoc on white communities.

Los Angeles Times: Why Opioids Hit White Areas Harder: Doctors There Prescribe More Readily, Study Finds

While all eyes are on the massive consolidated opioid lawsuit in Ohio that’s being compared to the Big Tobacco reckoning of the ’90s, this little case in Oklahoma might steal its thunder.

Stateline: Pay Attention to This Little-Noticed Opioid Lawsuit in Oklahoma

In the miscellaneous file for the week:

• A powerful investigation from The Wall Street Journal and Frontline uncovers the history behind an Indian Health Service doctor who was accused of molesting Native Americans yet allowed to continue practicing for decades. Where did it go wrong?

The Wall Street Journal: HHS to Review Indian Health Service After Revelations on Pedophile Doctor

• Rural hospitals are collapsing everywhere, leaving vulnerable residents stranded in health deserts. It can be devastating for towns to watch their hospitals die. Ducktown, Tenn., offers a snapshot of what’s playing out in states all across the country.

Nashville Tennessean: Tennessee Rural Hospitals Are Dying. Welcome to Life in Ducktown

• Employer-sponsored health care is often held up as the gold standard. But is it really that great?

CNN: Employer Health Plans Cover Less Than You Think, Study Finds

• I vividly remember the global fear surrounding the bird flu back in the aughts. People were panicking and countries were stockpiling medical supplies, as everyone braced for an epidemic reminiscent of the catastrophic 1918 Spanish flu. But then nothing happened. So … where’d it go?

Stat: What Happened to Bird Flu? How a Threat to Human Health Faded From View

Early numbers show that the flu vaccine is doing a pretty good job this year, so remember it’s not too late to get your shot! And have a great weekend!

Utah’s Novel Plan For Medicaid Expansion Opens Door To Spending Caps Sought By GOP

Utah this week became the 35th state to approve expanding Medicaid under the Affordable Care Act, but advocates for the poor worry its unusual financing could set a dangerous precedent and lead to millions of people losing coverage across the country.

That’s because the plan includes unprecedented annual limits on federal and state spending.

Those restrictions would be a radical change for Medicaid. Since it began in 1966, the state-federal health program for low-income residents has been an open-ended entitlement for anyone who meets eligibility criteria. State and federal spending must keep pace with enrollment.

Joan Alker, executive director of the Georgetown University Center for Children and Families, is concerned that the state and federal Medicaid funding caps can limit how many people are enrolled and what services they receive. She said no state has before tried to cap its own funding.

“This is a way for the state to look like it’s doing expansion when they are really doing very little,” she said.

If Utah’s plan is approved, Alker added, other states that have already expanded Medicaid and some that are considering it will likely seek to strike a similar deal.

Limiting spending on Medicaid has been a longtime goal of fiscal conservatives, but opposition to the idea helped blow up  Republican efforts to repeal and replace the ACA in 2017.

Also fueling criticism: The law signed by Utah Gov. Gary Herbert on Monday expands Medicaid only to people earning up to 100 percent of the federal poverty level instead of the 138 percent mark set by the ACA and approved by Utah voters in a referendum supporting expansion in November. Both the Obama and Trump administrations have refused in the past to accept that condition.

The proposal also includes a work requirement for adults who gain coverage through the expansion.

Utah’s proposal needs federal approval, and state officials said they hope to have that in time to expand Medicaid to 90,000 adults on April 1.

The state expects to adopt annual spending caps after negotiations with the Trump administration.

Congressional Republicans and President Donald Trump tried to cap federal Medicaid payments as part of their health law repeal efforts in 2017. But that move met stiff opposition from Democrats, hospital and patient advocates and some Republican lawmakers. They warned it would lead to cuts in benefits and enrollment.

Utah’s proposal to limit federal spending was necessary to get the Trump administration to approve its application to only partially expand Medicaid, the state’s top Medicaid official said.

“We were looking for a way to make our waiver more attractive to the federal government,” said Nathan Checketts, Utah’s Medicaid director.

He said the Trump administration last year was skeptical of the state’s proposal to expand Medicaid to adults with incomes below 100 percent of the federal poverty level — about $12,500 annual income for an individual — instead of 138 percent of the poverty level, about $17,000 in annual income. That’s because it would mean higher federal spending, since people earning between 100 percent and 138 percent of poverty would be eligible for federal subsidies to help pay for premiums for insurance they buy on the ACA exchange.

By capping funding at a negotiated per capita rate, the federal government could better control its spending, Checketts said.

Under Trump, the federal Centers for Medicare & Medicaid Services has not approved requests by Arkansas and Massachusetts to get the higher federal match rate for partial expansion.

CMS, Checkett added, has been open to a deal since after Election Day. “They’ve become more receptive to our request than they were last year, but there are no guarantees,” he said.

Under the proposed deal, the federal government would pay 90 percent of the costs for anyone coming into Medicaid through expansion — the rate set by the ACA. In traditional Medicaid, the state receives a 70 percent federal match.

The federal spending cap would vary based on how many people are enrolled under expansion. If the costs for covering the expansion population exceeded the federal spending cap, the state could limit how many people it enrolled, Checketts said.

The law also includes a state funding cap so Utah officials can limit enrollment if spending were to exceed the budget, Checketts said. The federal government would also have to approve a state spending cap.

“The state has to balance its budget every year, and this allows the state to align its budget and a certain amount of money to put toward this population and not any more,” he said.

If CMS does not grant the waiver for a partial expansion, the bill requires the state to establish a full expansion in 2020.

Jessie Mandle, senior health policy analyst for Voices for Utah Children, an advocacy group, said the plan is tough to swallow for advocates who have been fighting for expansion for more than six years.

“This will create more barriers and restraints to care,” she said. “This was not the way voters chose to expand.”

Utah’s plan to seek a per capita spending cap comes even though the state’s per capita Medicaid spending is among the lowest, according to a report last year by the Utah Foundation, a nonpartisan research group.

The average cost for each Medicaid enrollee in Utah was $5,326 in 2014, the most recent year for which that figure is available, the report found. That number was the 10th lowest in the United States.

Nationwide, Utah also had the lowest percentage of its population enrolled in Medicaid as of 2016, the report said.

Utah Voters Approved Medicaid Expansion, But State Lawmakers Are Balking

Utah residents may have thought they were done fighting about Medicaid expansion last November. But when Utah lawmakers opened a new legislative session in late January, they began pushing through a bill to roll back the scope and impact of an expansion that voters approved in a ballot measure.

“We voted for this on Nov. 6. We were very clear about what we wanted,” said Andrew Roberts, a spokesman for Utah Decides, the group that organized the Medicaid expansion referendum, known as Proposition 3.

The voter-approved measure would extend coverage to 150,000 uninsured people in the state.

“We are frustrated, and I think Utahns are frustrated,” Roberts said.

That frustration led his group to hire a billboard truck to drive in circles around the Capitol building and through the snowy streets of Salt Lake City and its suburbs. Signs on the sides of the truck flash phrases in LED lights, including “Support democracy. Support Utah’s vote.” A looping video advertisement urges residents to call lawmakers “who don’t respect the will of the people.”

After six years of talking about Medicaid expansion, voters approved the ballot measure on Nov. 6, with 53 percent in favor. But the issue erupted again when the legislative session started Jan. 28.

Similar legislative efforts to curtail expansion are also happening in Idaho, where voters passed a Medicaid expansion initiative in November. Sixty-one percent of voters were in favor. Idaho lawmakers are considering ways to scale that program back.

In politically and fiscally conservative Utah, legislators argue the 0.15 percent non-food sales tax that voters approved won’t be enough to pay for Medicaid expansion. So they’ll pass an expansion, but only a very limited one.

Voters “wanted Medicaid expansion, and that’s what we’re doing,” said Republican state Sen. Allen Christensen. But, he added, the voters “didn’t fill in the proper blanks. We are filling in those blanks for them. They are not obligated to balance the budget. We are.”

Christensen is leading the rollback effort in Utah. His alternative proposal, SB 96, would cap the number of individuals who would qualify for Medicaid, add work requirements and lower the annual income limit. Proposition 3 supporters had wanted the coverage available for people who made up to 138 percent of the federal poverty level, or nearly $17,000 a year. But Christensen’s bill would offer Medicaid coverage only to people who made less than 100 percent of the federal poverty level, or about $12,000 for an individual.

Making those changes would require the state of Utah to get approval for two federal waivers from the federal Centers for Medicare & Medicaid Services. Proposition 3 supporters point out that similar requests from other states have been denied.

“From the perspective of voters, I think voters have a right to be furious right now,” said Matt Slonaker, executive director of the Utah Health Policy Project, another group that has supported Medicaid expansion.

Slonaker said changing the scope of Proposition 3 would mean fewer people getting health coverage, and the state would receive less money from the federal government. He also fears it could make voters feel disillusioned.

“Why would voters ever want to pursue ballot initiatives and direct democracy if the legislature’s just going to repeal it anyway?” Slonaker asked.

While some Utah lawmakers, such as Christensen, describe being “philosophically opposed” to Medicaid expansion, much of the political debate in Utah is about how much expansion will cost, and whether the new sales tax will pay for it. Supporters point to the fiscal experience of other states.

“You should think of Medicaid expansion as no different than if you said, ‘Oh, hey, somebody’s going to go open up a factory,’” said Bryce Ward, an economist at the University of Montana, in Missoula. “And that factory is going to bring, in the case of Montana, $600 million of outside money into the state that we’re going to pay to workers here.”

Ward recently published a report on the economic impacts of Medicaid expansion in Montana during the first two years of that program. He said it brought in about $600 million dollars in new funds to the state per year. That money supported about 6,000 jobs, he added, or about $350 million in additional income for residents.

Ward said states like his also can take advantage of savings, because Medicaid expansion makes providing health care to certain groups, like prisoners, more affordable. While states do have to pay 10 percent of the cost of expanded Medicaid (the federal government covers 90 percent — a more generous “match” than traditional Medicaid), the combination of savings and economic growth meant that, in the case of Montana, the program basically pays for itself, Ward said.

“The benefits that people in Utah have is that people like me in other states have done the work trying to figure this out,” he said. “Or at least get some ballpark estimates of it.”

So far, Utah lawmakers remain unconvinced by studies like Ward’s. The bill to restrict Medicaid expansion is moving fast, and could reach the governor’s desk as soon as next week.

This story is part of a partnership that includes KUERNPR and Kaiser Health News.

Shrinking Medicaid Rolls In Missouri And Tennessee Raise Flag On Vetting Process

Tangunikia Ward, a single mom of two who has been unemployed for the past couple of years, was shocked when her St. Louis family was kicked off Missouri’s Medicaid program without warning last fall.

She found out only when taking her son, Mario, 10, to a doctor to be treated for ringworm.

When Ward, 29, tried to contact the state to get reinstated, she said it took several weeks just to have her calls returned. Then she waited again for the state to mail her a long form to fill out attesting to her income and family size, showing that she was still eligible for the state-federal health insurance program for the poor.

Mario, who is in third grade, missed much of school in December because Ward could not afford a doctor visit without Medicaid. His school would not let him return without a doctor’s note saying he was no longer infected.

In January, with the help of lawyers from Legal Services of Eastern Missouri, she was able to get back on Medicaid, take her son to a doctor and return him to school. “It was a real struggle as it seemed like everyone was giving me the runaround,” Ward said. “I am upset because my son was out of school, and that pushed him behind.”

Ward and her children are among tens of thousands of Medicaid enrollees who were dropped by Missouri and Tennessee last year as both states stepped up efforts to verify members’ eligibility.

Last year, Medicaid enrollment there declined far faster than in other states, and most of those losing coverage are children, according to state data.

State health officials say several factors, including the improved economy, are behind last year’s drop of 7 percent in Missouri and 9 percent in Tennessee.

But advocates for the poor think the states’ efforts to weed out residents who are improperly enrolled, or the difficulty of re-enrolling, has led to people being forced off the rolls. For example, Tennessee sent packets to enrollees that could be as long as 47 pages to verify their re-enrollment. In Missouri, people faced hours-long waits on the state’s phone lines to get help in enrolling.

Medicaid enrollment nationally was down about 1.5 percent from January to October last year, the latest enrollment data available from the federal government’s Centers for Medicare & Medicaid Services (CMS).

Herb Kuhn, president and chief executive of the Missouri Hospital Association, said the state’s efforts to verify Medicaid eligibility could be tied to an increase in the number of people without coverage that hospitals are seeing.

“When we see over 50,000 children come off the Medicaid rolls, it raises some questions about whether the state is doing its verifications appropriately,” he said. “Those who are truly entitled to the service should get to keep it.”

In 2018, Missouri Medicaid began automating its verification system for the state-federal insurance program for the poor. People who were identified as ineligible, for income or other reasons, were sent a letter asking them to provide updated documentation. Those who did not respond or could not prove their eligibility were dropped.

The state does not know how many letters it sent or how many people responded, said Rebecca Woelfel, spokeswoman for the Missouri Department of Social Services, which oversees Medicaid. She said Missouri Medicaid enrollees were given 10 days to respond.

Woelfel cited the new eligibility system, the improved economy and Congress rescinding the federal tax penalty for people who lack insurance as factors behind the decline in enrollment.

Missouri’s unemployment rate dropped from 3.7 percent in January 2018 to 3.1 percent in December as the number of unemployed people fell by about 17,000.

Missouri Medicaid had almost 906,000 people enrolled as of December, down from more than 977,000 in January 2018, according to state data. About two-thirds of those enrolled are children or pregnant women.

Timothy McBride, a health economist at Washington University in St. Louis who heads a Missouri Medicaid advisory board, said the state’s eligibility system has made it too difficult for people to stay enrolled. Since low-income people move or may be homeless, their mailing addresses may be inaccurate. Plus, many don’t read their mail or may not understand what was required to stay enrolled, he added.

“I worry some people are still eligible but just did not respond, and the next time they need health care they will show up with their Medicaid card and find out they are not covered,” McBride said.

Tennessee’s Medicaid enrollment fell from 1.48 million in January 2018 to 1.35 million in December, according to state data. Tennessee Medicaid spokeswoman Kelly Gunderson credits a healthy job market. The state’s unemployment rate was relatively stable last year at under 4 percent.

“Tennessee is experiencing a state economy that continues to increase at what appears to be near-historic rates, which is positively impacting Tennesseans’ lives and, in some cases, decreasing their need to access health insurance through the state’s Medicaid” program and the Children’s Health Insurance Program (CHIP), she said.

She added that the state has a “robust appeals process” for anyone who was found ineligible by the state’s reverification system.

The Tennessee Justice Center, an advocacy group, has worked with hundreds of families in the past year trying to restore their Medicaid coverage. The verification process will make “Medicaid rolls smaller and saves money, and that’s a poor way for the state to measure success,” said Michele Johnson, executive director of the nonprofit group. “But it’s penny-wise and pound-foolish” because it leads to people showing up at emergency rooms without coverage — and hospitals have to pass on those costs to everyone else.

After rapid growth since 2014, when the Affordable Care Act expanded health insurance coverage to millions of Americans, Medicaid enrollment nationally started to fall, declining from 74 million in January 2018 to about 73 million in October, according to the latest enrollment data released by CMS.

Missouri and Tennessee are among 17 states that have not expanded Medicaid under the ACA. But many of those non-expansion states nevertheless saw enrollment grow, because as people tried to sign up for insurance on the ACA exchanges, those meeting state criteria were routed to Medicaid.

McBride, the health economist, said the steep drop is especially disconcerting because most of those affected are children. Because children are eligible for Medicaid or CHIP with family incomes as high as 300 percent of the federal poverty level, or $77,250 for a family of four, he said, it’s unlikely a parent’s change in job would be enough for a child to lose eligibility.

Missouri’s 70,000-person drop in enrollment, he noted, marks the biggest single-year reduction since 2006, when the state instituted tighter eligibility levels for certain groups.

Legal Services of Eastern Missouri, which advocates for low-income residents, estimates that nearly 57,000 of those dropped from the Medicaid rolls were children, a decline that is nine times the national average.

Joe Pierle, chief executive officer of the Missouri Primary Care Association, a trade group representing community health centers, said he doesn’t think the state is doing anything “underhanded or nefarious.” Nevertheless, he’s not sure Medicaid officials did enough to reach out to people before dropping them.

“I suspect some people are falling through the cracks,” he said.

Podcast: KHN’s ‘What The Health?’ A ‘Healthy’ State Of The Union

Health policy played a surprisingly robust role in President Donald Trump’s 2019 State of the Union address.

The president laid out an ambitious set of health goals in his speech Tuesday to Congress and the nation, including reining in drug prices, ending the transmission of HIV in the U.S. during the next decade and dedicating more resources to fighting childhood cancer.

Meanwhile, in Utah and Idaho, two of the states where voters last fall approved expansion of the Medicaid health program, Republican legislatures are trying to scale back those plans.

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

Among the takeaways from this week’s podcast:

  • The Trump administration is proposing to change the drug rebates in Medicare so that consumers purchasing the medicines get more of the savings and the middlemen negotiating the deals get less. But that effort could lead to increased insurance premiums — a consequence that could have significant political repercussions.
  • Trump’s pledge to end HIV transmissions in 10 years was a bit of a surprise since the disease had not been much of a priority in earlier moves by the administration.
  • The efforts to restrict Medicaid expansion approved by voters in Utah and Idaho show the limitations of referendums and could impact a move to get a Medicaid expansion question on the Florida ballot.
  • An intriguing study this week showed that medications to treat cardiac problems saved Medicare money. The results were surprising because generally public health officials suggest that prevention is important to improve health but doesn’t necessarily save money.

Also this week, Rovner interviews KHN senior correspondent Phil Galewitz, who investigated and wrote the latest “Bill of the Month” feature for Kaiser Health News and NPR. It’s about a man with a minor problem — fainting after a flu shot — and a major bill. You can read the story here.

If you have a medical bill you would like NPR and KHN to investigate, you can submit it here.

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

Julie Rovner: NPR’s “Texans Can Appeal Surprise Medical Bills, But the Process Can Be Draining,” by Ashley Lopez

Margot Sanger-Katz: The Los Angeles Times’ “In Rush to Revamp Medicaid, Trump Officials Bend Rules That Protect Patients,” by Noam N. Levey

Anna Edney: Bloomberg News’ “Ketamine Could Be the Key to Reversing America’s Rising Suicide Rate,” by Cynthia Koons and Robert Langreth

Alice Ollstein: The Washington Post’s “’It Will Take Off Like a Wildfire’: The Unique Dangers of the Washington State Measles Outbreak,” by Lena H. Sun and Maureen O’Hagan

To hear all our podcasts, click here.

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