Tagged HHS

Cruz Plan Gets Thumbs Up From HHS But Thumbs Down From Most Everyone Else

Contradicting the opinion of most policy experts, a draft report from the Trump administration forecasts better enrollment and lower premiums for everyone who buys their own health insurance if a controversial amendment proposed by Sen. Ted Cruz of Texas were to become law.

The draft surfaced just as Republican senators were lunching with President Donald Trump on Wednesday to talk about the next steps in the health care debate.

“The Republicans never discuss how good their healthcare bill is, & it will get even better at lunchtime,” tweeted Trump, before the group convened.

But findings from the draft report drew immediate criticism from health policy experts as opaque and misleading.

“The details get a bit dicey,” said Craig Garthwaite, director of the health care program at Northwestern University’s Kellogg School of Management. “No one I’ve talked to thinks [the analysis] is well done.”

The forecasts in a 22draft analysis by the Department of Health and Human Services are exactly opposite from what many experts forecast.

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Still, the HHS analysis did provide some insight into how HHS envisioned that the Cruz plan, part of the Senate bill that appeared to die this week, could have worked. Particularly notable: The analysis assumes annual deductibles of $12,000, which means consumers would have to pay that amount — which is far higher than allowed under the ACA — before most benefits are covered.

On Wednesday, health care developments continued to unfold at a breakneck pace, and with a zigzagging trajectory, when the Senate Budget Committee posted on its website yet another bill. This one is an updated version of the 2015 “repeal and delay” bill, which is likely the measure the Senate will consider next week if a vote to start debate succeeds.

It would repeal all of the taxes that paid for the Affordable Care Act’s benefits, roll back the expansion of Medicaid (but not cap the underlying program), nullify the requirement for most people to have insurance and rescind the financial aid for low- and moderate-income Americans.

Late in the afternoon, the Congressional Budget Office released an updated estimate of an earlier analysis concluding that the new “repeal and delay” measure could result in 32 million fewer Americans having coverage and premiums doubling by 2026. By 2020, according to CBO, “about half the nation’s population would live in areas having no insurer participating in the non-group market.” The new bill does not include the Cruz amendment, the subject of the HHS report.

Opposition to the Cruz amendment from powerful health care sectors, like the insurance industry, is cited as one reason why the Senate was unable to muster enough votes to move the whole Senate bill forward for debate this week.

Last Friday, the insurance industry trade lobby sent a harsh warning to Congress, saying the Cruz amendment “is simply unworkable in any form and would undermine protections for those with pre-existing medical conditions, increase premiums and lead to widespread terminations of coverage.”

Today, the HHS report took a very different view.

First reported in the right-leaning Washington Examiner, it forecasts far more people covered by insurance in 2024 if the Cruz plan were adopted, as compared with how many would be insured under the Affordable Care Act.

It also projects premiums would fall, both in plans that meet all the rules of the ACA, and in plans Cruz proposes, which would not have to follow the rules. The Cruz plans would have lower premiums, however, because they could come with far fewer benefits — and could reject people with medical problems or charge them more.

Insurers and actuaries said the Cruz proposal would result in a segmented market, with younger and healthier people drawn to the skimpier, less expensive plans. That, in turn, would leave older or sicker enrollees in the ACA-compliant plans, causing their premiums to spiral upward.

But the analysis by HHS shows premium costs for ACA-compliant plans would go down by more than $250 a month in 2024 when compared with what they would be under current law. The Cruz plans would be super cheap, at under $200 a month under the rosiest scenario outlined.

Experts today immediately pounced on the department’s methods — in as much as they could be determined, since the full report was not released.

(HHS did not respond to requests for comment or for the release of the full report.)

For starters, the draft report, they say, compares premiums for a 40-year-old with the “weighted average” of all people of all ages purchasing ACA plans now.

“It’s not apples to apples,” said Matt Fiedler, a fellow at the USC-Brookings Schaeffer Initiative for Innovation in Health Policy.

It cited its own “proprietary model” used to determine how many people would switch from ACA plans to the new Cruz plans, without spelling out its assumptions. Not including such details is highly unusual and makes the results difficult to analyze, said Garthwaite, adding: “There’s nothing in this that gives me any hope that the entire report will be any more accurate, complete or unbiased.”

Meanwhile, over lunch at the White House, President Trump asked senators to skip all or part of their August recess in order to work on another proposal to repeal and replace the ACA. He promised premiums that would be significantly lower, without citing details on how that would occur.

Categories: Cost and Quality, Repeal And Replace Watch, The Health Law

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Transgender Health Care Targeted In Crusade To Undo ACA

Solorah Singleton has been waiting years for breast augmentation. She doesn’t want to jinx it now, but the Philadelphia resident thinks it’s finally within reach.

Singleton, 36, was born male but identifies as female. For seven years, she has had regular hormone therapy, never seeing surgery as an option. She previously didn’t have health insurance and didn’t think she could cover the cost of the procedure out-of-pocket.

Now, that’s changed. Last summer, her home state of Pennsylvania updated its Medicaid policy to spell out coverage of care related to gender transitioning — including surgery. Soon after, employees at a local health clinic signed Singleton up. She has since received medical approval for surgery and hopes to get it done soon.

“It’s a blessing,” she said. “I’ll feel at home in my own skin.”

Her experience aligns with a larger trend that could soon lose steam. Spurred in part by anti-discrimination rules in the 2010 health law, Pennsylvania — along with 13 other states plus the District of Columbia — rewrote its Medicaid policy to clarify how it covers transition-related care. Montana, the most recent adoptee, posted its change in May. Because Medicaid, the state-federal health insurance program for low-income people, covers a disproportionately high number of transgender people compared with the general population, the potential change could heap hardship on an already embattled population.

The ACA’s non-discrimination portion, known as Section 1557, says federally funded programs that provide health care, coverage or related services cannot discriminate based on sex. The provision has been in effect since the law’s enactment and helped fuel a federal push to protect transgender people from discrimination in receiving health care services. In 2016, the Obama administration’s Department of Health and Human Services issued the final rule crystallizing that policy.

Before the ACA, Medicaid operated under its own anti-discrimination requirements. However, many state programs were vague in describing gender-transition benefits. This made it difficult for people like Singleton to understand what Medicaid covered. It also made it easier for plans to question the “medical necessity” of treatments and to issue denials.

By making it clear that state Medicaid programs could not refuse to pay for a health care service simply because the beneficiary is transgender, and suggesting greater federal attention to the matter, the Section 1557 rule pushed states to be more upfront about coverage specifics.

Singleton in her salon in west Philadelphia. (Eileen Blass for KHN)

That regulation is back in play as the Department of Health and Human Services appears to be walking back from its directive and coverage protections.

In a Texas case in which faith-affiliated health care providers argued Section 1557 required they act against their religious beliefs — which “will not allow them to perform medical transition procedures that can be deeply harmful to their patients” — a federal judge issued an injunction at the end of 2016 to block the transgender protections. HHS responded by asking the court to remand the case and stay further proceedings while it rewrites the rule. Earlier this week, the judge obliged. In the meantime, that portion of Section 1557 will not be enforced.

The rewrite is part of the administration’s overarching executive effort. HHS Secretary Tom Price and President Donald Trump have vowed to use administrative power to mitigate the health law’s policy changes, specifically those that created “regulatory or economic burdens” or that don’t match up with the current White House agenda.

“Anytime the federal government says ‘we’re not going to take civil rights seriously’ — this is a huge concern,” said Sara Rosenbaum, a professor of health law and policy at George Washington University in Washington, D.C.

An HHS spokeswoman declined to answer what impact rewriting the rule could have or how likely it is the department would scale back transgender protections, citing laws that limit disclosing “non-public information regarding rule-making.”

But if the federal government isn’t asserting a certain coverage standard for publicly funded programs, health plans can find leeway to deny claims and argue a transition-related service is not medically necessary, noted Katie Keith, an adjunct law professor at Georgetown University. She also runs Out2Enroll, an advocacy group that connects LGBTQ people with health insurance options.

The consequences can be serious. Singleton said she has known many people who want hormone therapy but have long felt uncomfortable seeking it at health clinics, because of poor experiences with insurance coverage. Their alternative: buying the drugs through illicit channels, where it’s hard to know if they’re of good quality, or even safe to use.

“If they’re trying to get themselves comfortable with their look, they’ll go to any extreme measures,” she said.

Coverage changes that, she added. “It will definitely improve health situations.”

Singleton (right) colors Aly Damian’s hair at Singleton’s salon in west Philadelphia while Damian video-chats with a family member. Like Singleton, Damian, 27, is transgender and considers Singleton her “gay mother.” (Eileen Blass for KHN)

Even with Medicaid policies explicitly guaranteeing coverage, beneficiaries still navigate plenty of red tape, said Amy Nelson, who directs patient legal services at Whitman-Walker Health, a clinic in Washington, D.C., that specializes in LGBTQ care. It has staff whose entire job is navigating insurance hurdles for people seeking transition-related care.

States that have already rewritten Medicaid policies are unlikely to rescind them, Keith said. But if HHS waters down federal protections, others may be reluctant to hop on. “It makes the state-level work much more important,” she said.

Already, lower courts are offering one path. In Minnesota, a 64-year-old resident sued the state when its Medicaid program wouldn’t cover a transition-related double mastectomy. A county judge held that denying coverage for this procedure violated the state constitution. Advocates have found similar success through legal action in Pennsylvania and New York.

A growing body of research suggests that paying for gender transition doesn’t cost state Medicaid programs much when compared with potential savings down the line that would result from preventing health issues such as long-term psychological distress. Private insurance has also moved in this direction. In 2014, Medicare — the federal program covering elderly people — lifted some restrictions on covering gender transition.

Another complicating factor: the ongoing Obamacare repeal efforts on Capitol Hill. Current GOP health plans don’t address these anti-discrimination regulations because they can include only provisions that qualify for fast-track consideration. Republicans tend to support stepping back from the law’s expansion of Medicaid, which made millions of Americans newly eligible for the program. “It’s great to have 1557 [protections], but if no one can get a health insurance plan, or get Medicaid, it doesn’t matter much,” Keith said.

Plus, those lawmakers want to restructure Medicaid, giving states more control but also limiting its funding. Experts say the change could create cost pressures that would drive states to restrict who is eligible for the program, stop covering particular services or both.

“Transgender people could be vulnerable,” suggested Harper Jean Tobin, policy director at the National Center for Transgender Equality, an advocacy group. “That is more likely if the administration is sending the message to states … that it’s OK to discriminate against transgender people.”

For patients like the ones Nelson sees at Whitman-Walker, the impact would be grim. Some, she recalled, have waited as long as 40 years to get treatment that, without Medicaid benefits, was simply unaffordable.

“They’ve been suffering silently,” she said. “Folks are thrilled to have access. But to offer it and then pull it back would be devastating.”

Categories: Medicaid, Repeal And Replace Watch, The Health Law

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