Tagged Health Industry

There’s Lots Of Talk About Surprise Medical Bills In Congress, But Ambulance Costs Have Been Left Out Of Conversation

Lawmakers across the country and federally have been trying to figure out the best way to address surprise medical bills. But one of the main causes of the problem –ambulance rides — isn’t in any of the proposed legislation. “If you call 911 for an ambulance, it’s basically a coin flip whether or not that ambulance will be in or out of network,” said Christopher Garmon, a health economist at the University of Missouri-Kansas City. Meanwhile, legislation in the House over the bills is unlikely to be addressed until after August recess.

How The Eastern Cherokee Took Control Of Their Health Care

CHEROKEE, N.C. — Light pours through large windows and glass ceilings of the Cherokee Indian Hospital onto a fireplace, a waterfall and murals. Rattlesnake Mountain, which the Cherokee elders say holds ancient healing powers, is visible from most angles. The hospital’s motto — “Ni hi tsa tse li” or “It belongs to you” — is written in Cherokee syllabary on the wall at the main entrance.

“It doesn’t look like a hospital, and it doesn’t feel like a hospital,” Kristy Nations said on a recent visit to pick up medications at the pharmacy. “It actually feels good to be here.”

Profits from the tribe’s casino have helped the 12,000 members of the Eastern Band of Cherokee Indians opt out of the troubled U.S. government-run Indian Health Service. They are part of an expanding experiment in decentralization, in which about 20% of federally recognized tribes in Oklahoma, California, Arizona and elsewhere have been granted permission to take full control of their health care.

For the North Carolina Cherokee, self-governance has meant adopting an integrated care model designed by Alaska Natives to deliver care that not only improves patients’ health, but also is tailor-made for the needs of the tribe. It has meant the opening of a 20-bed state-of-the-art facility in 2015 and the construction of an 18-bed mental health clinic scheduled to open in October 2020.

The hospital is a “medical home for our people,” said Casey Cooper, the hospital’s CEO who is a member of the tribe.

Half of the Indian Health Service budget is now managed by Indian tribes to various degrees. But while full control has worked out well for tribes with resources like the Eastern Cherokee, they are one of just a few bright spots in an otherwise dire medical landscape. It remains to be seen how widely this model can be applied.

“Not all tribal communities have access to the economic opportunities that we have,” Cooper said. “Some tribes are in these desolate, remote locations where there are no natural resources or economic development opportunities. I get that.”

Casey Cooper, CEO of the Cherokee Indian Hospital(Katja Ridderbusch for KHN)

Self-Governing To Change The Narrative

The U.S is legally obligated to offer health services to all members of the 573 federally recognized tribes. Yet the federal Indian Health Service, which currently provides direct care to about 2.2 million out of the nation’s estimated 3.7 million American Indians and Alaska Natives, is chronically underfunded. The current IHS budget is about $5.4 billion, yet the National Indian Health Board estimates the total level of need to be nearly $37 billion.

American Indians are more than twice as likely to get diabetes and six times as likely to get tuberculosis than the average U.S. population. Mental illness, and especially substance abuse, runs high in Indian Country. Native Americans are more likely to commit suicide than any other ethnic or racial group.

Health disparities are particularly harsh in the Northern Plains region. In the Dakotas, average life expectancy among American Indians is 20 years less than among white Americans.

“You do not have to cross an ocean to find Third World health conditions,” said Dr. Donald Warne, a professor of public health at the University of North Dakota and an Oglala Lakota tribesman. “You can find them right here, in the heartland of the United States.”

One particularly grim example is the Rosebud Indian Reservation in South Dakota. In 2015, the Centers for Medicare & Medicaid Services found safety violations at the local IHS hospital so severe that they shut down the emergency room for six months. During this time, at least five patients died en route to other hospitals located sometimes 100 or more miles away. Since then, the situation has only slightly improved.

“The Indian Health Service respects tribal sovereignty and is committed to tribal self-governance,” said IHS spokesman Joshua Barnett. “IHS recognizes that tribal leaders and members are in the best position to understand the health care needs and priorities of their communities.”

Self-governance also allows tribes to be eligible for Medicare, Medicaid, private-sector health insurance, partnerships with larger health systems and even federal grants that are designed for underserved communities — all which can be limited for the IHS.

“Generally speaking, tribally operated health care systems tend to run more efficiently, more effectively and with higher quality of care than IHS-managed systems,” said Warne.

The 155,000-square-foot, 20-bed Cherokee Indian Hospital rests on a small knoll in western North Carolina. (Katja Ridderbusch for KHN)

The hospital serves over 12,000 members of the Eastern Band of Cherokee Indians who live on the Qualla Boundary, at the foothills of the Great Smoky Mountains National Park. (Katja Ridderbusch for KHN)

Money Makes A Difference

The Cherokee Indian Hospital is lucky to be supported by a tribe that’s economically thriving due to gambling revenues, according to Cooper. The Qualla Boundary is home to Harrah’s Cherokee Casino Resort. It’s a unique situation, said Indian health expert Warne, as most reservation casinos don’t make huge profits.

The hospital’s annual budget has grown from $20 million to over $80 million within the past 17 years. The largest sources are third-party reimbursements, mostly from Medicaid and Medicare, at $27.4 million, followed by IHS contributions and tribal funding.

In 2012, the hospital decided to implement a new, patient-centered approach called the Nuka System of Care, created by the Southcentral Foundation, a nonprofit health provider owned and led by Alaska Natives. A Cherokee delegation visited a Nuka program to see how it could be tailored to their culture and health needs.

“An integrated approach is more consistent with traditional healing,” Warne said. Since “we don’t separate our physical, mental, spiritual and emotional health the way we do in modern specialized health care.”

At Cherokee Indian Hospital, patients are assigned a team, which typically includes a primary care physician or a family nurse practitioner as well as a nutritionist, a pharmacist and a behavioral health specialist.

Rebuilding their health care prompted the need for the new hospital. Gambling revenue covered most of the costs for the $82 million facility. “The old building was outdated and inefficient,” said Cooper, “a constant reminder of the paternalistically provided Indian Health Service.”

Dr. Richard Bunio, Cherokee Indian Hospital’s clinical director(Katja Ridderbusch for KHN)

The new hospital’s main concourse — called Riverwalk — tells stories from Cherokee legend through graphics of a winding river, fish and turtles inlaid in the terrazzo floor. Signs are written in English and Cherokee. A literal translation of the emergency room sign is “Get better in a hurry,” and the dental suite is “the place that gives you a big smile.”

Patients can receive dialysis, acupuncture, massage therapy and chiropractic care. The ambulance bay, surgical suite and in-patient unit are located out of patients’ view to reduce anxiety and stress.

“The building really is one big strategic tool,” Cooper said.

Nations, the patient visiting recently, remembers the old days when she and her family, many of them dealing with diabetes and some on dialysis, used to wait for hours in the former hospital, a dark space dubbed “the bunker.”

The 46-year-old said that she’d typically see different providers every visit. “And every time I would have to tell my story over and over and over.” Now, she feels somewhat accountable to her care team — and more motivated to make and keep appointments.

“Back then, if my provider had wanted me to see a nutritionist, for example, I would have probably said, ‘Whatever,’ and forgotten about it,” she said.

“We’re trying to build a relationship with our patients,” said Richard Bunio, the Cherokee Indian Hospital’s clinical director who is Canadian and married to a tribe member. He noted that Native Americans generally have suffered a lot of historical trauma, leading to deeply rooted mistrust of mainstream medicine.

By quality measures, including the widely used Healthcare Effectiveness Data and Information Set, the hospital has recently performed in the top quartile for blood pressure control, blood sugar control and several cancer screenings. Also, Cooper added that in the past four years the diabetes rate in the community has leveled.

At Cherokee Indian Hospital, patients are assigned a core team, which typically includes a primary care physician or a family nurse practitioner as well as a case manager and a scheduler. Three core teams share a nutritionist, a pharmacist and a behavioral health specialist. Pictured (left to right) are certified nursing assistant Katelynn Sides, registered nurse Nicole Dyck, family nurse practitioner Tracy Birchfield and licensed practical nurse Crissy Smith.(Katja Ridderbusch for KHN)

Could It Work Everywhere?

It is uncertain if self-governance would work for tribes such as the Rosebud Sioux or the Oglala Lakota on the Pine Ridge Indian Reservation, where geographic isolation, poverty and a lack of resources make new health care investments difficult.

“It’s a huge challenge, but it’s possible,” said Warne, adding that philanthropy or partnerships with an academic health system might help finance such projects.

Not too long ago, tribal officials from South Dakota visited the Cherokee Indian Hospital. Despite their geographic and socioeconomic challenges, Cooper said, he believes self-determination is essential for their future. “Self-determination works. Self-determination is the right thing. And self-determination is the catalyst to restoring the health of our communities.”

Yet many of the South Dakota tribal leaders remain skeptical. They are concerned that self-determination would let the federal government off the hook from its responsibility to provide health services.

Therefore, the Rosebud Sioux took a different route. Instead of just parting ways with the IHS, they sued the federal government for violating treaties. The case is pending in court.

A Conservative Group Paints Trump’s Drug-Pricing Experiment As ‘Socialist.’ Is It?

As part of its effort to curb high prescription drug costs, the Trump administration is considering an experiment that has triggered strong opposition from Americans for Tax Reform, Grover Norquist’s powerful conservative organization, which the president typically counts among his supporters.

One of the most visible elements of the group’s battle plan is a nationwide commercial, on which it has spent almost half a million dollars, according to estimates by ad tracker iSpot.tv. It has been on the air since May.

The Americans for Tax Reform’s ad begins with President Donald Trump saying, “America will never be a socialist country.”

It then quickly pivots to take aim at the administration.

“You’re right, Mr. President,” the ad continues. “But the Department of Health and Human Services is considering a plan to adopt socialist price controls from foreign countries.”

That led us to wonder if the organization’s take is an accurate description.

The ad is referring to an initiative being considered by the administration that would be part of the president’s promise to curb high drug prices. Though not expected to launch until 2020 at the earliest, it would test-drive the effectiveness of setting price limits on what the federal government pays for prescription drugs. It would tie some payments in Medicare Part B — which covers hospital and physician-administered drugs — to prices charged in other countries, mostly in Europe. The trial would be limited to brand-name medicines that are responsible for a high percentage of Part B spending.

We contacted Americans for Tax Reform to find out the basis for this claim. John Kartch, a spokesman, said “price controls themselves are socialist” and argued that they constitute a “fundamental building block of state control of the economy.”

But independent experts we spoke to said this characterization, while politically powerful, is misleading.

“Socialism,” as defined by Merriam-Webster, involves “collective or governmental ownership and administration of the means of production and distribution of goods.” In this case, the label doesn’t accurately reflect distinctions in how different countries handle drug pricing and neglects to consider important context about the American pharmaceutical market.

The International Pricing Index

HHS is still deciding which countries it might include in its “international pricing index,” or IPI. Under consideration are Austria, Belgium, Canada, the Czech Republic, Denmark, Finland, France, Germany, Greece, Ireland, Italy, Japan, the Netherlands and the United Kingdom.

Some of those nations may use strategies that could be termed “socialist.” Also on the list, though, are countries that use market-based approaches, experts said.

“Each of these countries has a complex set of decision points, and they’re not the same,” said Stacie Dusetzina, associate professor of health policy at Vanderbilt University.

In Germany, for instance, the first year a drug is on the market, the manufacturer can set its own price. After that, an independent board assesses the drug’s added clinical value, which is used to determine what the country’s nonprofit insurance plans — known as sickness funds — will pay. That, drug pricing experts said, is hardly “socialism.”

Even the “price control” phrasing is suspect, some argued.

That’s because, while the IPI countries vary in strategy, many do not dictate what a pharmaceutical company charges for a drug, said Rachel Sachs, an associate professor of law at Washington University in St. Louis who studies drug pricing. Rather, she said, they are simply saying what the national insurance plan will pay.

Some of the countries in question also maintain private insurance systems beyond the government plan. For instance, in Canada, people have options, depending on the province where they live, of various forms of public and private prescription drug coverage, which differ in generosity. Therefore, what the government pays for a drug doesn’t necessarily dictate arrangements negotiated between drug companies and other insurers.

Plus, experts said, the advertisement’s framing ignores the role the U.S. government already plays in shaping the pharmaceutical market.

Currently, Medicare Part B cannot negotiate lower prices, and it is required to cover drugs that come to market. Drug patents, meanwhile, give manufacturers monopolies over their products for a set period — and the power to charge higher prices. Together, that means the government has no bargaining power, while drugmakers can set the prices where they want.

“We really need to take a look at our own system, and it’s quite far removed from a free market,” said Ameet Sarpatwari, an epidemiologist and lawyer at Harvard Medical School, who studies drug-pricing regulations.

Some argued that incorporating the IPI into Medicare Part B payments might inject more, not less, competition into the current payment system. The administration has made this argument, too. For instance, when we contacted HHS for comment, a spokeswoman directed us to this speech by Secretary Alex Azar as well as this  December blog post, both of which outline how this approach would strengthen the U.S. bargaining position by setting Medicare’s rates more in line with those of other nations.

Finally, there’s the issue of whether the United States would actually be “adopting” strategies used by other countries. Using their prices as a reference point isn’t the same thing as importing their regulatory system.

A Broader Conversation

The “socialist price control” label is one of a few commonly deployed arguments against efforts to curb drug prices — one that’s “effective but misleading,” Sarpatwari argued.

Other claims in the advertisement — that HHS’ proposal would reduce pharmaceutical innovation and limit access to lifesaving medical treatments — are also popular attack lines.

There isn’t a good body of research to suggest this would happen. Sachs suggested that, if prices come down, there would likely be some impact on either drug access or innovation. Assessing the magnitude of those changes is difficult at best, though. And, she said, it would be balanced against people who are, under the changed system, newly able to afford treatment.

Among other challenges, experts noted, would be obtaining accurate data about what other countries pay for drugs. Another: finding a strategy to force manufacturers to accept the lower price.

But those aren’t concerns Americans for Tax Reform chose to emphasize. Given the experimental nature of what the administration is considering, they’re also issues HHS could learn from and address based on how things go, Dusetzina said.

Our Ruling

The advertisement in question claims that HHS “is considering a plan to adopt socialist price controls from foreign countries.”

HHS is weighing a strategy that would take into account prices paid in other countries to set amounts paid by the Medicare program. But the advertisement’s language — in particular, the phrase “adopt socialist price controls” — is reductive, inaccurate and misleading, experts said. These strategies do not necessarily constitute “price controls.” And while some could conceivably be viewed as “socialist,” it is inaccurate to suggest all of them are.

Furthermore, the claim ignores important context about the American drug-pricing market.

This claim contains an element of truth but ignores critical facts — and is in some cases actively misleading. We rate it Mostly False.

Must-Reads Of The Week From Brianna Labuskes

Happy Friday! As you all know, when I come across an outrageous medical mystery story I like to drag you all down with me because horrified misery loves company. This week’s offering: A man in Kentucky went into his doctor complaining of eye irritation. And what did his doctor pull out of his eyeball? That’s right! A tick. (You’re welcome.)

Quickly moving on! Here’s what you might have missed during this very hot week.

The tensions in the Democratic presidential field that have been brewing for a while erupted into verbal sparring between Sen. Bernie Sanders (I-Vt.) and former Vice President Joe Biden. The mini-war seems to be more than just your typical political posturing — both men have deep personal stakes in the issue (which, if you haven’t noticed, voters care a lot about right now). Sanders’ “Medicare for All” plan is nearly synonymous with the man himself, while Biden experienced firsthand the blood, sweat and tears it took to actually get the health law passed.

Earlier in the week, Biden dropped his own health plan, which could be summed up as the Affordable Care Act on steroids. And his promise that went along with the reveal — “If you like your plan … you can keep it” — was a blast-from-the-past that highlights all the advantages (the health law is quite popular at the moment) and pitfalls (that promise when President Barack Obama made it was ranked PolitiFact’s “Lie of the Year”) of taking this particular path.

It also nudged Biden and Sanders into a collision over their philosophical differences that played out in public at various events this week. Neither candidate pulled punches, but Sanders, in particular, had some tough words for his rival. “Unfortunately, he is sounding like Donald Trump,” he said. “He is sounding like the health care industry, in that regard.”

On that note, Sanders called on the Democratic candidates to join his pledge not to take donations from the health industry or pharma. Though he didn’t name names, it seemed to many like another jab at Biden.

Biden also took shots of his own, calling Medicare for All costly and complicated, and insinuating that those looking to get rid of the health law are no better than Republicans.

Whatever the outcome of this particular scuffle, it highlights that, in a crowded field, candidates are looking for things to set them apart. And in this particular election cycle, looks like it’s health care.

CNN: Biden Proposes Massive New Obamacare Subsidies, Public Option in Health Care Plan

The New York Times: Sanders and Biden Fight Over Health Care, and It’s Personal

Politico: Sanders Calls on Democratic Rivals to Reject Drug, Insurance Industry Donations

The New York Times: Anxious Democratic Governors Urge 2020 Field Not to Veer Too Far Left


Meanwhile, the health law faced off against an unlikely foe this week: Democrats. Lawmakers in the House delivered what is in all intents and purposes a death blow to the “Cadillac tax,” a cost-containing provision that at one point in time was looked at as crucial to the law’s success. (The Senate hasn’t voted on it yet, but Republicans are not exactly fans of the tax, so its fate seems decided.)

But as hell has not frozen over, it’s not as if the Democrats are suddenly jumping on the GOP bandwagon to dismantle the law. The tax was disliked by unions (a key constituency) and some liberal-leaning economists. Rep. Joe Courtney (D-Conn.), the author of the repeal bill, even (subtly) called it, the “Middle Class Health Benefits Tax Repeal Act.”

The New York Times: House Votes to Repeal Obamacare Tax Once Seen As Key to Health Law

As a side note, you should be following Noam Levey’s great series on the ways Americans are hurting in the wake of the high-deductible revolution.

Los Angeles Times: Rising Health Insurance Deductibles Fuel Middle-Class Anger and Resentment


The Democratic field’s fireworks over candidates’ philosophical differences weren’t the only ones on display this week. Dr. Leana Wen was ousted from her position as head of Planned Parenthood after only eight months in the role. Although there have been reports about managerial styles, Wen has hinted that the friction comes from her desire to view the organization through a public health prism. During a time when the abortion wars grow only more intense, Wen’s strategy to emphasize abortion as part of a larger part of improving women’s health felt out of step to some.

The New York Times: A Messy Exit Leaves Planned Parenthood at a Philosophical Crossroads

As if underscoring that very tension, the ousting came as the Trump administration announced that the changes to family planing funding, often called a “gag rule” by critics, would be enforced immediately, now that it has the court’s go-ahead.

The Associated Press: Trump Abortion Restrictions Effective Immediately


After a yearlong legal battle, The Washington Post and HD Media, which publishes the Charleston Gazette-Mail in West Virginia, obtained information from a Drug Enforcement Administration database that shows how 76 billion oxycodone and hydrocodone pain pills saturated the country as the opioid epidemic was gaining steam. Just six companies distributed 75% of the pills from 2006 to 2012, sending millions of pills into tiny rural towns with only a few thousand residents. The numbers reveal a trail of bright, screaming red flags that were overlooked as the country barreled toward a crisis point.

The Washington Post: Largest U.S. Drug Companies Flooded Country With 76 Billion Opioid Pills, DEA Data Shows

PBS NewsHour: The Opioid Industry Fought Hard to Keep This Database Hidden. Here’s What It Shows

There was some rare good news on the opioid front this week: For the first time since 1990, fatal drug overdoses actually fell. There are (of course!) caveats, though: Experts still see worrying trends when it comes to synthetic drugs such as fentanyl.

The Washington Post: Drug Overdoses Fell Significantly in 2018 for First Time in Decades, Provisional CDC Data Show


Everyone in Congress and the administration is really, very, extremely angry about high drug prices … and yet pharma is still racking up the wins on Capitol Hill. Stat has a great read on exactly what’s going on with the industry’s influence, and looks at a new strategy from drugmakers, who seem to be targeting a pair of vulnerable Republicans to get their way.

Stat: How Pharma, Under Attack From All Sides, Keeps Winning in Washington


In a landscape where everyone is jonesing to cut costs, why is it so breathtakingly easy to scam insurers? Some investigators estimate that fraud eats up 10% of all health care spending. Consumers’ gut reaction is that insurers would, of course, be stepping in to police these bad actors. But they don’t seem to have any desire — or, at least, not enough — to actually act. Maybe that’s because consumers are the ones getting stuck with the losses.

ProPublica: Health Insurers Make It Easy for Scammers to Steal Millions. Who Pays? You.

Speaking of, a former VA employee who was supposed to help veterans navigate insurance for their kids who had spina bifida used the position to collect millions in kickbacks, prosecutors allege.

The Daily Beast: Feds Say Former VA Employee Used Vets’ Ailing Kids to Scam Millions


A lot of very cool (or at least interesting) news came out of the Alzheimer’s Association International Conference this week. A look at highlights:

Los Angeles Times: Blood Test for Alzheimer’s Disease Moves Closer to Becoming a Reality

CNN: Lifestyle Can Still Lower Dementia Risk Even If You Have High Genetic Risk, Study Suggests

The Washington Post: Women Who Work for a Salary See Slower Memory Decline in Old Age, Reducing Their Risk of Dementia, a New Study Suggests


And in the miscellaneous file:

• What’s it like to be a Border Patrol agent? Because access to them can be tightly controlled, it’s rare to hear about their experiences. This story contains a chilling, yet fitting musing: “Somewhere down the line people just accepted what’s going on as normal.”

ProPublica: A Border Patrol Agent Reveals What It’s Really Like to Guard Migrant Children

• It’s one of health care’s biggest challenges: weaning people off the habit of going to the ER instead of a primary care doctor. Well, New York City is going to invest $100 million a year to try to do just that.

The Wall Street Journal: New York City Hopes to Ease Strain on Its Emergency Rooms

• More than 200,000 kids in Tennessee were either cut or slated to be cut from insurance because the state’s unwieldy system heavily relied on hard-copy forms.

The Tennessean: At Least 220,000 Tennessee Kids Faced Loss of Health Insurance Due to Lacking Paperwork

• Do service dogs actually help veterans with PTSD? Although there are plenty of heart-warming anecdotal stories about the benefits, doctors in the VA are hesitant to recommend them over treatment that has been shown to work because there’s little hard science on their benefits. The thing is, the VA is supposed to be doing research on it. Yet, for some reason, it’s been lagging, despite the burgeoning mental health crisis among veterans.

The New York Times: Do Service Dogs Help Treat PTSD? After Years of Research, the V.A. Still Doesn’t Know

• A look at law enforcement in Alaska, where violence against women is gaining national attention, shows that dozens of convicted criminals have been hired as cops for these communities. In one small village, every single policeman on the force, including the chief, has a criminal record of domestic violence.

ProPublica/Anchorage Daily News: The Village Where Every Cop Has Been Convicted of Domestic Violence


That’s it from me! Try to stay cool and make sure to hydrate this weekend!

UnitedHealth Reverses Course, Approves Coverage For $2.1 Million Gene Therapy For Family Racing Against Clock

Lauren Sullivan, whose 21-month-old daughter, Daryn, had been trying to appeal UnitedHealth’s initial refusal and was running out of time to receive the drug before her second birthday in October, when the drug has to be administered. The company also approved claims for three other patients. In other news, UnitedHealth beats expectations for the quarter, prompting company to boost earnings guidance.

KHN’s ‘What The Health?’: Biden Doubles Down On Obamacare


Can’t see the audio player? Click here to listen on SoundCloud.


Former Vice President Joe Biden has said if he’s elected president he would build on the Affordable Care Act rather than move to a whole new health care system, such as the “Medicare for All” plan supported by some of his primary opponents for the Democratic nomination. But his campaign’s new health plan would include many things Congress tried and failed to pass as part of the health law, including a government-run “public option” plan that would be widely available.

Meanwhile, the U.S. House voted to repeal one of the ACA’s key financing mechanisms, voting overwhelmingly to cancel the so-called “Cadillac tax,” which was set to take effect in 2022. It is a 40% excise tax on the most generous employer-provided health plans.

And it was not a good week for Planned Parenthood. The women’s health provider parted ways with its president of less than a year, Leana Wen. And the Trump administration announced it would begin enforcement of new rules for the federal family planning program that Planned Parenthood said will force it to stop participating.

This week’s panelists are Julie Rovner from Kaiser Health News, Joanne Kenen of Politico, Kimberly Leonard of the Washington Examiner and Margo Sanger-Katz of The New York Times.

Among the takeaways from this week’s podcast:

  • Biden’s health proposal seeks to lower out-of-pocket costs for many people in several ways. For example, it would make federal premium help available to all who buy their own insurance, not just those with low and middle incomes. It would also change how federal premium subsidies are determined. It would base the assistance on the cost of a gold plan, rather than the current practice of using the second lowest priced silver plan. Since gold plans are more generous, using that standard could lower the amount of deductibles and copayments people getting subsidies have to pay.
  • The ACA’s Cadillac tax has been strongly endorsed by health economists, who view it as a way to cut the amount of unnecessary care some people with generous plans seek. But many employers, consumers and labor unions don’t want to tinker with the current tax system of job-based insurance.
  • The administration’s decision to go forward with its new rules for the Title X family planning program — while critics are challenging those regulations in the courts — will have a significant effect on Planned Parenthood’s finances. But the group gets even more government money through the Medicaid program.
  • Despite two setbacks last week in the administration’s efforts to reduce drug prices, President Donald Trump is continuing to hint that he wants to go forward with a plan to tie some Medicare drug prices to what people in other countries pay for the medications.
  • Federal officials have announced that opioid deaths have declined, but it is not clear that opioid overdoses or addiction has declined.

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

Julie Rovner: The New York Times’s “Where Roe v Wade Matters Most,” by Quoctrung Bui, Claire Cain Miller and Margot Sanger-Katz.

Joanne Kenen:  Scientific American’s “Why Doctors Are Drowning in Medical School Debt,” by Daniel Barron.

Margot Sanger-Katz: Bloomberg News’ “Deadly Disease Is Treatable, But Newborn Screening Patchwork Leaves Many Vulnerable,” by Michelle Cortez.

Kimberly Leonard: The Washingtonian’s “DC Types Have Been Flocking to Shrinks Ever Since Trump Won. And a Lot of the Therapists Are Miserable,” by Britt Peterson.

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcherGoogle PlaySpotify, or Pocket Casts.

Surprise Medical Bill Legislation Takes A Step Forward, But Will It Lead To A Step Back?

The House Energy and Commerce Committee Wednesday approved its version of legislation to curb surprise medical bills.

Though this step was an important advance, there’s still a long way forward before Congress agrees on a legislative solution to this high-profile consumer concern.

These bills, the unexpected and often high charges patients face when they get care from a doctor or hospital that isn’t in their insurance network, have been the hot issue on Capitol Hill for months. Lawmakers on both sides of the aisle have been tripping over themselves to address the widely loathed problem.

One of the existential questions of the debate has been how to compensate health care providers if balance billing — which is what happens when patients are responsible for the costs not covered by their insurer — is prohibited.

The bill before Energy and Commerce originally included what’s known as “benchmarking” to set the payment amount for out-of-network doctors. So, instead of sending patients a bill for the amount that their health plans don’t pay, a doctor would be forced to accept an amount that is the average of what other doctors in the area are paid for the procedure.

This approach has been favored by groups representing employers and insurance plans but draws disdain from medical specialty provider groups. Those doctor organizations, which include specialists like emergency physicians and anesthesiologists, prefer arbitration, sometimes called “independent dispute resolution.” Under that system, both the insurer and provider would propose an amount to an independent third party, who would pick one of the two prices. The loser then pays the costs of the arbitration.

During the panel’s markup, Reps. Raul Ruiz (D-Calif.) and Larry Bucshon (R-Ind.) successfully added an amendment, which would create a “backstop” to the measure’s benchmarking approach.

Here’s how it works: The doctor’s payment would still be based on a benchmark, but if he or she thinks that isn’t high enough, the physician can appeal to an arbitrator. This backstop could be used only if the dollar amount in question is more than $1,250, and the arbitrator can consider only the complexity of the case and the quality of care.

“While I prefer the benchmark like we have in Oregon, I think it strikes a fair and necessary balance,” said the committee’s top Republican, Rep. Greg Walden of Oregon.

Though it’s a tidy compromise between the positions, it means the House bill no longer matches the primary legislation moving through the Senate, which earlier this summer gained the approval of that chamber’s Health, Education, Labor and Pensions (HELP) Committee  That bill exclusively favors benchmarking.

HELP Committee Chairman Lamar Alexander (R-Tenn.) has indicated he’s open to discussions. Other members of the panel, such as Sen. Bill Cassidy (R-La.), applauded the House action.

“The House is taking a step in the right direction,” Cassidy said in an email. “We need to end up in a place that gives patients security while having a level playing field for providers, hospitals and insurers.”

No everyone viewed the “backstop” idea as a positive step forward.

A range of stakeholders who oppose the arbitration approach because they think it will lead to higher costs over time have offered stinging criticism, some even withdrawing their support for the Energy and Commerce measure.

“We have asked Congress for one key assurance — protect us, and our employees, from being locked into government-mandated binding arbitration, which is being pushed by Wall Street-owned doctor groups,” Annette Guarisco Fildes, the CEO of ERIC, a group that represents large employers, said in a statement around five hours before the amendment was introduced in committee.

“Disappointingly, the House Energy and Commerce Committee is set to report out legislation that locks employers into exactly such a mandate,” she added.

Even groups that have been championing the independent dispute resolution approach, like the American College of Emergency Physicians, have qualms with the compromise, saying most emergency services cost less than $1,250 and won’t qualify for arbitration.

That isn’t the only hurdle ahead for the surprise bill legislation.

In the Senate, where the surprise bill provisions are part of a larger package aimed at lowering health care costs across the industry, senators have placed 10 “holds” on the legislation, meaning it can’t go to the Senate floor for a vote yet.

Still, staffers are optimistic that bill can still pass before the Senate leaves D.C. for its August recess.

Listen: Opioid Trial In Oklahoma Wraps Up

Did drugmaker Johnson & Johnson create a “public nuisance” that led to the opioid epidemic? That’s the question a state judge in Oklahoma is weighing after the country’s first trial against opioid manufacturers wrapped up Monday. The state is asking for $17 billion in damages. Jackie Fortier of StateImpact Oklahoma has covered the trial from start to finish for NPR and Kaiser Health News. This account of the seven-week trial’s closing arguments aired on NPR’s “Morning Edition” on Tuesday.

This story is part of a partnership that includes StateImpact Oklahoma, NPR and Kaiser Health News.

Health Leaders Worry About Unscrupulous Data Mongers Circling Like Sharks As Patient Records Are More Accessible

There are concerns from experts who say patients may not fully understand the privacy implications of new records apps and end up signing a lot of their information away without realizing it. Other news at the intersection of technology and health care: artificial intelligence and dental bills, telemedicine in rural areas, wireless health hazards and more.

State Highlights: Maryland Cites ‘Dickensian’ Abuse Conditions In Suit Against For-Profit Group Homes; Researchers Grapple With Problems Of Diagnosing Rat Lungworm Disease In Hawaii

Media outlets focus on news from Maryland, Delaware, New Jersey, Hawaii, Tennessee, Virginia, Connecticut, California, North Carolina, District of Columbia, New Hampshire, Missouri, Georgia, Washington, Maryland, Oregon, Colorado, Ohio, Florida and West Virginia.

Big Tobacco Leans On Proven Strategy For Waging Political Warfare: Invoking Concerns Of Black Residents To Sway Dems

When it looked like New York might pass a menthol cigarette ban, tobacco lobbyists invoked Eric Garner — a man who was killed on Staten Island by police officers enforcing cigarette regulations — in their arguments that it would disproportionately hurt black residents. The bill was set aside.

Must-Reads Of The Week From Brianna Labuskes

Happy Friday! If you want a smile after this long week, be sure to check out today’s Google Doodle. I feel like this is the right crowd to appreciate it.

Now on to what you may have missed!

The courtroom was where much of the action took place this week, from Title X funding to drug prices to opioids. But the biggest spotlight of all was on the fate of the Affordable Care Act.

The latest challenge to the health law was a long-shot case, with legal experts writing off its chances of prevailing at the start. The suit can be perfectly summed up by a question from Judge Jennifer Walker Elrod, one of the three judges who heard oral arguments on the case in New Orleans: “If you no longer have the tax, why isn’t it unconstitutional?”

Judge Kurt Engelhardt also asked why the Senate hadn’t sent a lawyer along with the House counsel to convey that the congressional intent had been to keep most of the law. “They’re sort of the 800-pound gorilla that’s not in the room,” he said.

Despite some blunt questioning, though, it’s not clear where the judges will land on the final decision. The case could end up in front of the Supreme Court right in the heart of the 2020 election cycle. Considering that the “we’re the side protecting all those popular health law provisions” argument was at least partly credited for Democrats’ blue wave in the midterms, the timing of the case could have deep political ramifications for Republicans.

The Washington Post: Appeals Judges Question Whether the ACA Can Stand Without Insurance Penalty

Politico: Long-Shot Legal Challenge Could End Obamacare During the 2020 Campaign

If the law is overturned, the far-reaching ripple effects would go far beyond politics. It’s not just that 21 million people could lose health insurance, or that the protections for people with preexisting conditions would go away or that insurers would no longer have to cover young adults on their parents’ plans. So many of the Affordable Care Act’s directives have become ingrained in daily life that it’s as if many people forget they’re tied to that hot-button “Obamacare” topic.

On that list? Calorie counts on menus, lactation rooms at work, transparency for gifts from pharma companies to doctors, YMCA courses that teach diabetes maintenance, etc., etc.

The New York Times: So You Want to Overturn Obamacare. Here Are Some Things That Would Be Headaches.

Also on that list? A wonky provision that grants HHS “innovation” authority. The reason it’s important? President Donald Trump is using that very authority (that’s part of the law he’s trying to get overturned) to make big promises on revolutionizing the kidney care marketplace.

The New York Times: Trump’s Assault on Obamacare Could Undermine His Own Health Initiatives

(Pardon my detour from the courts for a minute, but that’s an impossible-not-to-utilize segue for the other big news of the week, and I’m going to jump on it.)

Trump announced an extremely ambitious plan this week to upend the kidney care world. Currently, the marketplace relies heavily on patients getting care at large dialysis clinics, even though at-home options are both safe and cost-effective. But those big chains can pull in $24 billion a year in revenue, so I somehow doubt that they’re going to go gently into that good night. Another part of the plan would incentivize kidney donations with reimbursements for lost wages and child care to try to address the country’s shortages. (And a special shoutout to Politico for the scoop on the plan.)

The New York Times: Trump Proposes Ways to Improve Care for Kidney Disease and Increase Transplants

Politico: Trump Aims to Shake Up Kidney Care Market

And now back to our court news: Trump’s strategy to curb drug prices sustained the first of two significant blows this week when a federal judge ruled that the administration can’t force companies to put prices in their TV ads. Judge Amit Mehta dodged the tricky First Amendment debate and instead focused on HHS’ authority (or lack thereof, really) to enforce such a rule. His ruling was, essentially: Hey, high drug prices are the pits and this might be an effective tool. But HHS can’t do more than Congress has authorized.

The New York Times: Judge Blocks Trump Rule Requiring Drug Companies to List Prices in TV Ads

The second punch came Friday when the administration pulled the plug on a signature proposal to eliminate drug rebates for pharmacy benefit managers (the target du jour for ire over high prices). Policy experts had worried the rule would lead to higher premiums for Medicare beneficiaries. Insurers and PBMs were popping the champagne over the announcement, while the general consensus is that pharma companies should now be braced for (an even bigger) storm headed their way.

Stat: After Trump Pulled the Plug on Rebates, His Options to Reduce Drug Prices Narrow. And He May Need Congress


The 2020 Democratic candidates were busy bees this week:

— Sen. Elizabeth Warren (D-Mass.) announced an immigration plan that would include the creation of a DOJ task force to investigate complaints of abuse and neglect from detainees.

Politico: Elizabeth Warren Takes on Trump With Immigration Overhaul

— Sen. Kamala Harris (D-Calif.) wants to take on the epidemic of outrageous rape kit backlogs. The kits can sometimes sit in police departments, which are strained for resources, for years. Harris has some bona fide experience to back up her plan. When she was California’s attorney general, her Rapid DNA Service team said it cleared all 1,300 untested rape kits in the state’s backlog in one year and earned national recognition and grants for its efforts.

USA Today: Kamala Harris: Rape Kit Backlog Can Be Cleared at Cost of Trump Golf Trips

— Sen. Amy Klobuchar (D-Minn.) released a proposal to tackle a wide range of problems that affect Americans’ seniors, from high drug costs to Alzheimer’s research to long-term care issues.

Politico: How Amy Klobuchar Would Improve Care for Seniors

— And Sen. Bernie Sanders (I-Vt.) is hopping on a bus to Canada with a group of Americans in search of cheaper insulin. This isn’t his first time embarking on such a trip. Twenty years ago, he went north with a group of breast cancer patients with a similar goal. (That two-decade gap between the trips speaks volumes, doesn’t it?)

CNN: Bernie Sanders to Join People With Type 1 Diabetes on Canada Trip for Cheaper Insulin

As we’ve seen in recent weeks, nearly all the Democratic candidates support the idea of providing health care to people who are in the country illegally. But what exactly would that entail? For one, it would place the U.S. even further left of progressive countries who already have universal health care. Most of them have at least some restrictions in place. But experts say that not only in the long run could providing care for them save money — immigrants in the country without legal permission tend to be young and relatively healthy and underuse available care.

The New York Times: What Would Giving Health Care to Undocumented Immigrants Mean?

Meanwhile, California is charging forward to become the first state in the country to offer Medicaid coverage to residents below the age of 26, regardless of their immigration status.

The Associated Press: California OKs Benefits to Immigrants In Country Illegally


Speaking of Medicaid, New Hampshire pumped the brakes on its new work requirements following reports that more than 17,000 people (yes, you read that right) would be found to be noncompliant with the rules after its first month. The state has been making the rounds with mailings, phone calls and even a door-knocking campaign, but officials still suggest the problem is that most people aren’t aware they need to report their hours. The experience mirrors Arkansas’ (almost down to the exact number of people who would be booted) and highlights the inherent obstacles states face when putting such rules in place.

Modern Healthcare: New Hampshire Delays Its Medicaid Work Requirement


A mother whose 19-month-old daughter died after being detained by ICE spoke at a House hearing this week about reports of the inhumane conditions at the facilities. “The world should know what happened,” Yazmin Juárez said during deeply emotional testimony. The name of the hearing — “Kids in Cages: Inhumane Treatment at the Border” — set the tone and reflected the state of affairs on Capitol Hill over the issue.

The Washington Post: ‘Kids in Cages’: House Hearing Examines Immigration Detention As Democrats Push for More Information


About 20% of the nation’s hospice facilities have safety lapses that are serious enough to endanger patients. What does that look like, beyond the dry terminology of an inspector general’s report? Gangrene so bad that a patient’s leg needed to be amputated; maggots burrowing near wound openings; and unnoticed sexual assault. But the report highlights another issue: There’s not much CMS can do about all of it. It would take an act of Congress to give CMS the power to fine the industry’s bad actors.

NPR: Roughly 20% of U.S. Hospice Programs Cited for Serious Deficiencies, Inspectors Say


In the miscellaneous file for the week:

• There are lots of voices in the abortion wars these days. Many of them, though, are from white leaders — on both sides of the issue — while the unique nuances and challenges that black communities face are missing from the debate. For women of color, race is tied to abortion in a way that white advocates rarely have to contend with.

The New York Times: When ‘Black Lives Matter’ Is Invoked in the Abortion Debate

•  An alleged mix-up at a fertility clinic that resulted in a woman having two babies who were not related to either her or each other highlights the real pitfalls of human error and advanced medicine.

USA Today: IVF Couple Sues California Clinic, Alleges Babies Weren’t DNA Match

• On paper, as medical aid-in-dying laws continue to pass across the country, more Americans are gaining control over how they end their lives. The reality looks a lot different, though.

The New York Times: Aid in Dying Soon Will Be Available to More Americans. Few Will Choose It.

• A Disney Channel star’s death this week highlighted the dangers of epilepsy-linked sleep deaths. Although it is rare, SUDEP is responsible for more deaths than SIDS (sudden infant death syndrome) and yet few people have heard of it.

CNN: Cameron Boyce’s Death: How Seizures Can Kill People With Epilepsy

• A new Secret Service report on mass violence incidents reveals that two-thirds of perpetrators had made threats before the attacks.

CNN: A New Report on Mass Attacks in the US Shows Common Traits Among Assailants

• A hospital in Ohio fired 23 employees in the wake of murder charges against one of its doctors in a case related to patients’ painkiller-linked deaths. There are a lot of issues here, but of particular note is how systemic such problems can become. One medical professional might be the root problem, but, at some point, that infection can spread to many interlocking parts within a health system.

The New York Times: Hospital C.E.O. Resigns and 23 Employees Are Fired After Ohio Doctor Is Charged in Murders


And, as election season kicks up, I really don’t blame any of the candidates for grabbing the Purell. Have a great weekend!

30 States Sign $10.4M Agreement With Premera Blue Cross Over Data Breach Impacting Millions

Sensitive information, including Social Security numbers, bank account information and health data, was exposed to hackers for ten months in 2014 and 2015. “It’s horrifying to think that for nearly one entire year, a hacker had access to the sensitive health records and personal data of millions of Americans,” said Oregon Attorney General Ellen Rosenblum. The lawsuit claimed Premera knew it had security problems and failed to fix them.

KHN’s ‘What The Health?’: Could The ACA Really Go Away?


Can’t see the audio player? Click here to listen on SoundCloud.


The Affordable Care Act was back in court again this week — this time before a three-judge panel at the 5th Circuit Court of Appeals in New Orleans.

A lower court ruled last December that the entire ACA is now unconstitutional because Congress in its 2017 tax bill eliminated the tax penalty for failing to maintain health insurance. It appeared that two of the three judges — both appointed by Republicans — seemed sympathetic to the arguments made by the plaintiffs, mostly attorneys general from Republican-led states.

Meanwhile, President Donald Trump on Wednesday signed an executive order calling for major changes in how the government pays for care for people with kidney disease, including making it financially easier for people to donate kidneys.

This week’s panelists are Julie Rovner from Kaiser Health News, Joanne Kenen of Politico, Kimberly Leonard of the Washington Examiner and Alice Miranda Ollstein of Politico.

Among the takeaways from this week’s podcast:

  • Many people who have employer-based insurance and don’t get coverage from the ACA don’t realize that key protections they now enjoy come from that law. These include provisions such as allowing adult children to stay on their parents’ plan until age 26 and barring insurers from using annual coverage caps or lifetime limits.
  • The legal challenge to the ACA by conservative states is a real threat to the law, but the case could still be resolved in a wide variety of ways. It is likely, however, to be appealed to the Supreme Court at some point.
  • The Trump administration’s plan to revamp how kidney patients get care appears to have satisfied many different stakeholders and is being widely hailed — except by the two giant firms that profit from clinic-based kidney dialysis and the status quo.
  • The administration this week had two setbacks on its efforts to slow the rise in prescription drug costs. A court, ruling on procedural grounds, set aside the government’s plan to require drugmakers to add prices to television ads. Also, the administration announced it is shelving its rule that consumers get some of the rebates from drugmakers that pharmacy benefit managers negotiate for insurers.
  • The legal challenge to the administration’s rule that would restrict doctors and other health professionals who receive Title X federal family planning grants from referring women for an abortion has created chaos among those health care providers because the rules have been on and off again. But for groups supporting the right to an abortion, time is the name of the game. They hope to run out the clock and elect a different president in 2020.

Also this week, Rovner interviews University of Michigan law professor Nicholas Bagley about the latest legal threat to the ACA.

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

Julie Rovner: The Washington Post’s “Hospices Go Unpunished for Reported Maggots and Uncontrolled Pain, Watchdog Finds,” by Christopher Rowland

Joanne Kenen: The Los Angeles Times’ “Trump Officials Tell One Court Obamacare Is Failing and Another It’s Thriving,” by Noam Levey

Alice Miranda Ollstein: CNN’s “Exclusive: Joe Biden on Obamacare and Medicare for All: ‘Starting Over Would Be, I Think a Sin,’ by Eric Bradner

Kimberly Leonard: Vox’s “Why I Gave My Kidney to a Stranger — and Why You Should Consider Doing It Too,” by Dylan Matthews

And

Fox News’ “ I’m Becoming a Liver Donor for the Sister I Love, So She Can Live a Long and Healthy Life,” by Ed Henry

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcherGoogle PlaySpotify, or Pocket Casts.

Using Obamacare Funds, Trump Aims To Shift Dialysis Care To Patients’ Homes

President Donald Trump on Wednesday announced a bold plan to improve care to patients with kidney disease, which he claimed would save thousands of lives each year and billions of dollars for taxpayers.

“It could be higher if it works the way we anticipate,” Trump boasted in a 25-minute speech to dozens of kidney patients, their families and kidney care providers in Washington.

The initiative aims to dramatically increase the number of patients getting dialysis at home, rather than in costly dialysis centers, and double the annual number of kidneys available for transplants. About 100,000 Americans are waiting for a kidney transplant. Ten Americans die each day because of the shortage of organs, Trump said.

Kidney disease is the ninth-leading cause of death in the United States and accounts for 20% of annual Medicare spending, or about $110 billion, administration officials said.

Trump’s strategy centers on changing how Medicare pays doctors and dialysis centers to boost their incentives to help patients get dialysis at home and keep them healthy enough to be eligible for transplantation. This would be a far cry from the current system, which focuses on in-patient dialysis center treatment.

Dr. Mark Rosenberg, president of the American Society of Nephrology, said he was pleased that some of the new payment models offered by the Centers for Medicare & Medicaid Services have only “upside” potential for doctors. He said doctors now get paid more to see their patients at the dialysis center than at home. As a result, there is little incentive to promote home dialysis options.

“I have been a kidney doctor for 35 years, and this is the most game-changing thing ever to happen,” he said.

The authority to make such major changes without congressional approval comes from the Centers for Medicare and Medicaid Innovation (CMMI), which was created by the 2010 Affordable Care Act.

On Tuesday, the Trump administration was in a federal appeals court in New Orleans arguing the entire health law should be declared unconstitutional.

“If the law is invalidated, the Innovation Center, and all its authorities, would be eliminated,” said Nicholas Bagley, a University of Michigan law professor.

In touting the new effort, Health and Human Services Secretary Alex Azar and CMMI Director Adam Boehler spoke about how kidney disease has affected their families. Azar noted his father was on dialysis for several years before receiving a kidney transplant. Boehler said an aunt died while on dialysis.

Since 1973, all Americans with end-stage kidney disease have been entitled to coverage through Medicare.

The administration said it would expand the number of kidneys available for transplant by increasing public awareness about the need for living donors and help those who donate a kidney. Currently, their medical costs are covered but the president’s plan would provide financial assistance to cover day care and time missed from work. Trump said the initiative would also hold organ procurement organizations more accountable so that fewer usable organs are discarded.

Trump said his plan would help 17,000 additional Americans get a kidney transplant each year by 2030. The policy would also help 11,000 more Americans get hearts, lungs and livers annually.

Kidney transplants cost less than having patients spend years on dialysis, according to government figures. Dialysis treatment runs on average about $89,000 a year, while a kidney transplant surgery averages about $32,000 and post-surgery care runs about $25,000 per year. Trump estimated his plan would save families and taxpayers $4.2 billion a year. “This is a dramatic and long overdue reform,” he said.

In the United States, only about 12% of patients get dialysis at home, far lower than in other countries, Trump said. The plan calls for increasing that share to 80% by 2025.

Nichole Jefferson, 47, of Dallas, who is awaiting a second transplant to replace a transplanted kidney that is failing, said getting the treatment at home is much less taxing. She had home dialysis for four years, before her initial transplant in 2008.

“It’s great to be at home where I was more comfortable and more relaxed and the care was in my hands,” she said in an interview at the Trump event. By getting dialysis at night while she slept, she was able to work during the day and take part in family events.

She had to go to a center for the dialysis when the home dialysis stopped working. “I was depressed to be in the center tied to a chair for four hours next to people I did not know,” she said. Patients often have dialysis several days a week.

Other patient advocates applauded Trump’s plan.

“The administration’s commitment to charting a new course for kidney health will help revolutionize transplantation and dialysis and advance new innovations, therapies and treatments, which patients everywhere have been waiting on for far too long,” said Kevin Longino, CEO of the National Kidney Foundation and a kidney transplant patient.

DaVita, the Denver-based company that is the largest provider of home dialysis in the country, offered a more muted response, saying it looked forward to working with the administration. The company’s stock, which fell in recent days ahead of the announcement, rose about 5% Wednesday.

Administration officials said many aspects of their plan would begin next year. Health providers in half the country will be required to participate in one of the new payment models in which they will face some financial risk for caring for patients. Doctors and health systems will have options to take on more financial risk, which means they could make more money or lose more money based on the health of their kidney patients.

Patients, however, will continue to be able to choose their doctors and dialysis providers.

Joe Grogan, head of the White House Domestic Policy Council, said the kidney disease issue “fits in the wheelhouse of items the president likes to confront. … The current quality of outcomes are pathetic in this area.”

About half of patients on dialysis die within five years, Azar said.

Using Obamacare Authority, Trump Aims To Shift Dialysis Care To Patients’ Homes

President Donald Trump on Wednesday announced a bold plan to improve care to patients with kidney disease, which he claimed would save thousands of lives each year and billions of dollars for taxpayers.

“It could be higher if it works the way we anticipate,” Trump boasted in a 25-minute speech to dozens of kidney patients, their families and kidney care providers in Washington.

The initiative aims to dramatically increase the number of patients getting dialysis at home, rather than in costly dialysis centers, and double the annual number of kidneys available for transplants. About 100,000 Americans are waiting for a kidney transplant. Ten Americans die each day because of the shortage of organs, Trump said.

Kidney disease is the ninth-leading cause of death in the United States and accounts for 20% of annual Medicare spending, or about $110 billion, administration officials said.

Trump’s strategy centers on changing how Medicare pays doctors and dialysis centers to boost their incentives to help patients get dialysis at home and keep them healthy enough to be eligible for transplantation. This would be a far cry from the current system, which focuses on in-patient dialysis center treatment.

Dr. Mark Rosenberg, president of the American Society of Nephrology, said he was pleased that some of the new payment models offered by the Centers for Medicare & Medicaid Services have only “upside” potential for doctors. He said doctors now get paid more to see their patients at the dialysis center than at home. As a result, there is little incentive to promote home dialysis options.

“I have been a kidney doctor for 35 years, and this is the most game-changing thing ever to happen,” he said.

The authority to make such major changes without congressional approval comes from the Centers for Medicare and Medicaid Innovation (CMMI), which was created by the 2010 Affordable Care Act.

On Tuesday, the Trump administration was in a federal appeals court in New Orleans arguing the entire health law should be declared unconstitutional.

“If the law is invalidated, the Innovation Center, and all its authorities, would be eliminated,” said Nicholas Bagley, a University of Michigan law professor.

In touting the new effort, Health and Human Services Secretary Alex Azar and CMMI Director Adam Boehler spoke about how kidney disease has affected their families. Azar noted his father was on dialysis for several years before receiving a kidney transplant. Boehler said an aunt died while on dialysis.

Since 1973, all Americans with end-stage kidney disease have been entitled to coverage through Medicare.

The administration said it would expand the number of kidneys available for transplant by increasing public awareness about the need for living donors and help those who donate a kidney. Currently, their medical costs are covered but the president’s plan would provide financial assistance to cover day care and time missed from work. Trump said the initiative would also hold organ procurement organizations more accountable so that fewer usable organs are discarded.

Trump said his plan would help 17,000 additional Americans get a kidney transplant each year by 2030. The policy would also help 11,000 more Americans get hearts, lungs and livers annually.

Kidney transplants cost less than having patients spend years on dialysis, according to government figures. Dialysis treatment runs on average about $89,000 a year, while a kidney transplant surgery averages about $32,000 and post-surgery care runs about $25,000 per year. Trump estimated his plan would save families and taxpayers $4.2 billion a year. “This is a dramatic and long overdue reform,” he said.

In the United States, only about 12% of patients get dialysis at home, far lower than in other countries, Trump said. The plan calls for increasing that share to 80% by 2025.

Nichole Jefferson, 47, of Dallas, who is awaiting a second transplant to replace a transplanted kidney that is failing, said getting the treatment at home is much less taxing. She had home dialysis for four years, before her initial transplant in 2008.

“It’s great to be at home where I was more comfortable and more relaxed and the care was in my hands,” she said in an interview at the Trump event. By getting dialysis at night while she slept, she was able to work during the day and take part in family events.

She had to go to a center for the dialysis when the home dialysis stopped working. “I was depressed to be in the center tied to a chair for four hours next to people I did not know,” she said. Patients often have dialysis several days a week.

Other patient advocates applauded Trump’s plan.

“The administration’s commitment to charting a new course for kidney health will help revolutionize transplantation and dialysis and advance new innovations, therapies and treatments, which patients everywhere have been waiting on for far too long,” said Kevin Longino, CEO of the National Kidney Foundation and a kidney transplant patient.

DaVita, the Denver-based company that is the largest provider of home dialysis in the country, offered a more muted response, saying it looked forward to working with the administration. The company’s stock, which fell in recent days ahead of the announcement, rose about 5% Wednesday.

Administration officials said many aspects of their plan would begin next year. Health providers in half the country will be required to participate in one of the new payment models in which they will face some financial risk for caring for patients. Doctors and health systems will have options to take on more financial risk, which means they could make more money or lose more money based on the health of their kidney patients.

Patients, however, will continue to be able to choose their doctors and dialysis providers.

Joe Grogan, head of the White House Domestic Policy Council, said the kidney disease issue “fits in the wheelhouse of items the president likes to confront. … The current quality of outcomes are pathetic in this area.”

About half of patients on dialysis die within five years, Azar said.