Tagged Insurance

KHN’s ‘What The Health?’: The Labor Pains Of ‘Medicare For All’

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Labor unions are divided over whether to endorse a Democratic candidate for president in 2020 — and, if so, whom to choose. Some unions are firmly behind the “Medicare for All” plans being pushed by Sens. Bernie Sanders and Elizabeth Warren. But the influential Culinary Workers Union in Nevada declined to endorse any candidate, with members worried about what might replace the generous benefits they won by bargaining away wage increases.

Meanwhile, a federal appeals court panel unanimously ruled that the Trump administration violated Medicaid law when it approved work requirements for beneficiaries in Arkansas. The ruling puts similar requirements in doubt in several other states.

This week’s panelists are Julie Rovner of Kaiser Health News, Alice Miranda Ollstein of Politico, Jennifer Haberkorn of the Los Angeles Times and Rebecca Adams of CQ Roll Call.

Among the takeaways from this week’s podcast:

  • Health care remains a top issue for voters, but candidates, eager to set themselves apart from the pack, are failing to point out the major policy differences they have with President Donald Trump. For example, at the Las Vegas debate Wednesday, no one mentioned the abortion case coming to the Supreme Court in March or the appeals court case that could invalidate the entire Affordable Care Act.
  • The Trump administration has approved Medicaid work requirements in more than a half-dozen states, with at least eight more pending. All of those state plan approvals are put in doubt by the appeals court opinion that such requirements violate the Medicaid statute.
  • Enrollment in Covered California, the state’s ACA exchange, grew by almost half a million from 2019 to 2020, the state just announced. California did many things other states did not, including extending premium subsidies higher up the income scale, reinstating the penalty for not having coverage that was zeroed out by Congress, and spending millions of dollars on outreach.
  • COVID-19, the novel coronavirus that originated in China, is complicating public health efforts way beyond that nation. U.S. firms are worried about shortages of drugs and drug ingredients that are made in China, and misinformation is spreading even more rapidly than the illness.

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

Julie Rovner: CNN.com’s “Nation’s Largest Teachers Unions Call to End Active Shooter Drills Over Fears They’re Traumatizing Students,” by Leah Asmelash

Alice Miranda Ollstein: The Washington Post’s “Trust and Consequences,” by Hannah Dreier

Rebecca Adams: The New York Times’ “The Health System We’d Have if Economists Ran Things,” by Austin Frakt

Jennifer Haberkorn: Kaiser Health News’ “Ink Rx? Welcome To The Camouflaged World Of Paramedical Tattoos,” by Cara Anthony

To hear all our podcasts, click here.

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Scalpels Out: Democrats Make Slashing Attacks On Health Care Plans

Top contenders for the Democratic presidential nomination torched one another’s proposals to reform the health care system Wednesday, as the contest to unify behind a single candidate to defeat President Donald Trump took a bitterly divisive turn.

Minutes after Tom Perez, the chairman of the Democratic National Committee, warmed up the debate audience in Las Vegas by describing the party as a spirited but unified family, most of the candidates abruptly shifted into attack mode — and not just against Mike Bloomberg, the billionaire businessman and former New York City mayor making his first, belated appearance in the ninth debate.

Fighting to regain momentum after weak performances in the Iowa caucuses and New Hampshire primary, Sen. Elizabeth Warren of Massachusetts dispatched with her opponents’ plans in brutally rapid succession.

Pete Buttigieg, the former South Bend, Ind., mayor, has offered “not a plan” but “a PowerPoint” that she claimed would leave millions uninsured, she said. Sen. Amy Klobuchar of Minnesota has a proposal that is “like a Post-It note: Insert plan here,” she quipped. And Sen. Bernie Sanders of Vermont, whose “Medicare for All” plan she initially adopted as her own, “has a good start,” but his campaign cannot stop attacking those who question how it would work, she said.

“Health care is a crisis in this country,” Warren concluded. “My approach to this is, we need as much help for as many people as quickly as possible.”

It wasn’t the only tense moment.

Sanders Angers The Culinary Workers Union

How Sanders’ Medicare for All proposal would affect unions in particular isn’t a new question. But despite strong support for the proposal from some national unions, it emerged as a flashpoint in the run-up to Nevada’s caucus on Saturday, turning the state’s prominent Culinary Workers Union against Sanders, the current frontrunner, in the 11th hour.

The union did not endorse a candidate but warned members that Sanders’ proposal could eliminate the health care coverage they have gained through years of collective bargaining, replacing it with a system that is untested and unknown.  The union then put out a statement last week saying its members had been “viciously attacked” by Sanders’ supporters over the organization’s opposition . Sanders responded by saying that, though there were some bad actors on social media, it was “not thinkable” that his supporters would attack union workers.

“Let me be very clear for my good friends in the Culinary Workers union, a great union: I will never sign a bill that will reduce the health care benefits they have,” Sanders said. “We will only expand it for them, for every union in America and for the working class.”

Klobuchar defended the “hard-working” culinary workers “who have health care plans that have been negotiated over time, sweat, and blood,” she said. “And that is the truth for so many Americans right now.”

Last summer Sanders tweaked his proposal to try to alleviate concerns from unions. Under a Medicare for All system, he said, the National Labor Relations Board would supervise unions in renegotiating contracts with employers, so that they could acquire “wrap-around services and other coverage not duplicative of the benefits established under Medicare-for-all.”

The idea, Sanders’ aides said then, was so that any savings a switch to single-payer achieved could still be passed on to workers, as increased benefits or wages.

But members of the Culinary Workers Union — and some other groups — still worry about losing the coverage they have, in exchange for something unknown.

Would that happen? Technically, yes, the health plan Nevada’s culinary workers get through their union would no longer exist. Under Medicare for All, private health plans could not sell coverage that duplicates what the government program offers.

But it’s worth noting that, in this world, culinary workers would still have generous health insurance. Sanders’ envisioned health plan is robust – he says it would cover virtually all practicing physicians and medically necessary services, with virtually no cost-sharing.

Of course, that would also depend on whether a President Sanders could muster support for his plan among skeptical members of Congress.

$100 Billion In Profits

Sanders brought up one favorite talking point twice Wednesday — his claim that the health care industry makes $100 billion a year in profits. We previously checked this claim and rated it True. The number comes from adding the net revenues in 2018 from 10 pharmaceutical companies and 10 health insurance companies. We recalculated the numbers, and they added up. Experts said it was even likely that the figure was an underestimate. 

Big Pharma Is Giving Money To Buttigieg And Others 

In another biting moment, Sanders charged that drug companies are donating to Buttigieg and other campaigns as the pharmaceutical industry profits off the current system.

We previously checked Sanders’ claim that Buttigieg was a “favorite of the health care industry” and rated it Half True. This is in part because it is actually Sanders who has received the most donations of any Democratic candidate from the entire health care sector, which includes pharmaceutical companies, health insurance industry, hospitals/nursing homes and health professionals.

But, while checking this claim we also found that Buttigieg has received donations from employees and executives of pharmaceutical and health insurance companies such as AbbVie, Aetna, Anthem, Eli Lilly and Co., Merck & Co. and Pfizer. We did not check into donations for other candidates from pharmaceutical executives. 

Do People ‘Love’ Their Insurance?

You don’t start out by saying, I have 160 million people, I’m going to take away the insurance plan that they love,” Bloomberg said just minutes into the debate, pointing out the shortcomings of Sanders’ Medicare for All plan.

It is true that Sanders’ signature health proposal would eliminate private health insurance, replacing it with a single public plan that covers everybody. That would include the roughly 160 million Americans who get employer-sponsored insurance

But Bloomberg’s argument here — that those people “love” their plans — is complicated.

When we previously checked a similar claim — that 160 million people “like their health insurance” — we rated it Half-True. Cursory polling suggests people with that coverage are mostly satisfied. 

But most isn’t all. And, experts pointed out to us then, once Americans try to use that coverage, many find it lacking. In a Kaiser Family Foundation/ L.A. Times poll, for instance, 40% of people with employer-sponsored insurance still reported having trouble paying for medical bills, premiums or out-of-pocket costs. In that same poll, about half said they skipped or delayed health care because — even with coverage — they couldn’t afford it. (Kaiser Health News is an editorially independent program of the Kaiser Family Foundation.)

And More About Warren’s Attach On  Klobuchar’s Health Plan

“Amy, I looked online at your (health care) plan. It’s two paragraphs.” Warren said.

This is highly misleading.

Warren’s campaign told PolitiFact that she was referring specifically to Klobuchar’s plan for “universal health care.” It pointed to the two paragraphs at the end of this Klobuchar campaign web page, which come under the heading “Propose legislation to get us to universal health care.” 

But that ignores most of Klobuchar’s health care plan, which she outlines in quite a bit of detail on four different web pages — a main health care policy page, a more detailed sub-page, a sub-page on prescription drugs and a sub-page on mental health.

We did a word count on the text from those four web pages, and it exceeded 6,000 words — and a lot more than two paragraphs.

PolitiFact’s Louis Jacobson contributed. 

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Obamacare A Disgrace? Biden Highlights Bloomberg’s Negative Remarks About The Affordable Care Act.

Sparring over health care during the Nevada Democratic presidential primary debate, former Vice President Joe Biden took issue with former New York City Mayor Michael Bloomberg’s record on the Affordable Care Act.

“From the moment we passed that signature legislation, Mike called it a disgrace,” Biden said, a claim he repeated another time during the debate. 

Bloomberg sought to refute that charge, arguing that he defended the law and believed it should be expanded.

It was a heated moment. Both candidates are trying to tie themselves to former President Barack Obama, who spearheaded the 2010 legislation. So we decided to dig in.

We reached out to both campaigns for comment. We didn’t hear back from Bloomberg’s campaign. The Biden campaign sent a CNN article, which cited a speech Bloomberg gave at the Dartmouth Presidential Lecture in July 2010 — just a few months after the health care legislation was passed in March. In the speech, Bloomberg called the Affordable Care Act “a disgrace.” We found a video of the speech on YouTube. 

The remarks 

In the video, Bloomberg was unsparing. 

“We passed a health care bill that does absolutely nothing to fix the big health care problems in this country. It is just a disgrace,” he said. “The president, in all fairness, started out by pointing out what the big problems were, but then turned it over to Congress, which didn’t pay any attention to any of those big problems and just created another program that’s going to cost a lot of money.”

Those aren’t standalone remarks. As recently as 2014, Bloomberg called the law “really dysfunctional” during a talk he gave at the annual meeting of SIFMA, one of the financial industry’s trade groups. 

Both times, Bloomberg was still a registered Independent — he didn’t become a Democrat until 2018.

It’s also worth noting that Bloomberg wasn’t espousing a minority view. The ACA’s approval rating was underwater until 2017, according to polling by the Kaiser Family Foundation. (KHN is an editorially independent program of the Foundation.)

Bloomberg’s response

On the debate stage, Bloomberg sought distance from those remarks, saying he is a “fan of Obamacare.”

“I wrote something supporting it either in the New York Post or the Daily News,” he said.

The op-ed he appears to be referring to — published March 27, 2017, in the New York Post — does indeed talk about the ACA. But it comes years after Bloomberg’s mayorship ended. And while words like “disgrace” don’t appear, calling the piece a “defense” of the law isn’t entirely fair.

In it, Bloomberg noted some key shortcomings — for instance, the health law left 30 million people uninsured. He also argued in support of some ideas more popular with Republicans, such as high-risk insurance pools, as a way to bring down costs.

“It’s regrettable that none of these ideas was seriously considered in the rush to repeal ObamaCare,” Bloomberg wrote at the time.

It is worth noting that Bloomberg’s current health care plan would build on the ACA, largely by increasing subsidies for people buying private insurance on the exchanges, and by installing a Medicare-like public option. (That plan is quite similar to what’s been touted by Biden himself, as well as by candidates like former South Bend, Ind., Mayor Pete Buttigieg.)

Our ruling

Biden said that Bloomberg called the ACA “a disgrace.”

Evidence supports that. And it’s not the only time Bloomberg took issue with the law — even if it is a core component of his current proposal for health reform. 

We rate this claim True.

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Sanders’ Claim That Buttigieg Is ‘Favorite Of The Health Care Industry’ Is Broad And Needs Context

As Pete Buttigieg gained momentum in the Democratic presidential primary race ― finishing second in the New Hampshire primary and a front runner in the Iowa caucuses ― he has increasingly been on the receiving end of shade from his rivals.

The campaign of Sen. Bernie Sanders (I-Vt.), for instance, distributed talking points that zeroed in on fundraising, saying “Pete Buttigieg is a favorite candidate of Wall Street and the health care industry.”

The former mayor of South Bend, Indiana, already faced criticism over his “billionaire donors,” which famously manifested during the Dec. 19 Democratic debate. It was then that Sen. Elizabeth Warren (D-Mass.) described a Buttigieg fundraiser as held in “a wine cave full of crystals.”

Sanders’ comments led us to wonder if Buttigieg really is the sweetheart of the health care industry. We asked the Sanders campaign for its evidence. Staffers pointed us to data from the Center for Responsive Politics, a nonprofit group that operates the website OpenSecrets.org and tracks money from individuals and political action committees donated to political candidates and members of Congress. The center analyzes Federal Election Commission data and sorts contributions by categories based on the economic sector from which they come.

A Deep Dive Into The Numbers

The Sanders campaign used OpenSecrets data it obtained in December 2019. But the OpenSecrets website has since been updated with fourth-quarter filings, so we couldn’t confirm the figures the campaign cited.

Instead, Doug Weber, a senior CRP researcher, pointed to the 2020 presidential race section of OpenSecrets, saying it contains the most accurate data for presidential campaign contributions. It also highlights industry contribution trends focused only on the presidential giving ― in other words, excluding contributions made to Senate campaign accounts.

We asked Weber if Sanders’ talking point about Buttigieg is true. That “depends on what you mean by ‘health care industry,’” Weber wrote in an email. OpenSecrets defines its health sector by contributions from PACs and individuals working in various health industries, he said, and “for our data, that’s our broadest definition of health care.”

Based on this sweeping categorization, Sanders is ahead of Buttigieg in health sector donations. The Vermont senator received $2,910,894, while the former South Bend mayor trailed closely behind with $2,713,038.

However, when you break down this data by industries within the health sector, Buttigieg comes out ahead of Sanders in contributions from pharmaceutical companies and also for health services/HMOs ― which includes groups like large insurance companies.

But even this point is nuanced. Former Vice President Joe Biden has received the most money of any Democratic candidate from the pharmaceuticals and health products sector if contributions from his leadership political action committee are included. Leadership PACs are committees unaffiliated with campaigns that can still receive contributions and financially support candidates.

In the health care industry categories of hospitals/nursing homes and health professionals, Sanders has received the most in dollar contributions.

When asked to clarify how the Sanders campaign is defining the health care industry, a staffer responded that “Bernie Sanders issued a pledge to not accept money from top officials of the insurance and pharmaceutical industries (as distinct from rank-and-file workers in those industries, which the aggregate data you cite deals with). He asked other candidates to do the same. Pete Buttigieg has refused to take that pledge, and has instead raised money from those top officials…These clear, demonstrable and verifiable facts makes very clear precisely what we are referring to.”

The Sanders campaign sent us a list of pharmaceutical and health insurance executives that have contributed to Buttigieg, including employees and executives from AbbVie, Aetna, Anthem, Eli Lilly and Co., Merck & Co. and Pfizer. We checked that list against the Federal Election Commission database to ensure its accuracy. In addition, the Sanders’ campaign shared an October 2019 article from Sludge, an investigative journalism outlet focused on money in politics, which estimated Buttigieg’s third-quarter health care industry donations approached $97,000.

We also checked in with the Buttigieg campaign for a response, which replied that “more than 800,000 Americans” have donated to its candidate. The campaign’s emailed statement noted that Buttigieg’s “Medicare for All Who Want It” plan draws industry attacks because the health system “will have to provide more affordable coverage and better care or they will lose customers as people enroll in the public option.”

What Does It All Mean?

It seems the Sanders’ claim is “imprecise,” said Robert Maguire, research director at the nonprofit group Citizens for Responsibility and Ethics in Washington (CREW).

“Given that the health industry itself is vast, what I assume the Sanders’ campaign … meant to say was that the more corporate aspects of the health industry ― like the pharmaceutical industry and the health insurance industry ― were funding Buttigieg disproportionately to others,” he added.

Michael Beckel, research director of Issue One, a nonprofit organization focused on transparency and enforcement of campaign finance laws, said the key to understanding this claim is that the Sanders campaign is characterizing money from the health insurance and pharmaceutical industry differently than campaign contributions from individuals, such as nurses and other health professionals.

“Rank-and-file employees in one industry don’t always express the same political preferences as executives in that industry,” Beckel wrote in an email. “Even as he’s railed against the pharmaceutical industry and insurance industry, Sen. Sanders has welcomed support from labor unions representing nurses.”

Michael Malbin, a political science professor at the University at Albany-State University of New York, also took issue with the idea that an individual giving the maximum amount of money to a campaign could sway the candidate’s policies.

“Every time election season rolls around, there are stories about individuals employed in one industry favoring one candidate over another, and it could be for whatever reason,” said Malbin. “But, you cannot make the inference from industry coding … that they are giving just for a certain economic interest. Let alone that it’s remotely enough money to drive a presidential campaign. … It’s a $2,800 maximum, for crying out loud.”

The actual composition of donors in the health category can’t be known without analyzing OpenSecrets’ full data set ― which we could not do since it’s not publicly available.

OpenSecrets does, however, analyze the percentage of small donor donations (less than $200) and large contributions for each presidential candidate. And 56% of Sanders’ contributions are from small donors, while 45% of Buttigieg’s campaign contributions come from that same group.

Our Ruling

Sanders’ use of the phrase “health care industry” in this instance is too broad to support the point he is trying to make.

According to recently updated OpenSecrets data, Sanders has received more donations from the health sector than any other 2020 presidential candidate.

However, when the broad “health sector” category is narrowed down to pharmaceutical and health insurance companies, which are two targets of Sanders’ campaign, Buttigieg is shown to have received more donations than Sanders. He has also received donations from top pharmaceutical executives ― offering evidence to support Sanders’ claim. But in specifying donations from the pharmaceutical/health products sector, Biden tops Buttigieg when factoring in contributions to Biden’s leadership PAC.

Context is also important. It’s likely a large number of Sanders’ health care contributions are from nurses and doctors as individuals. There’s no way to identify whether this support was related to the candidate’s health policies or motivated by other reasons.

Sanders’ claim has some truth to it but is imprecise. For this reason, we rate the claim Half True.

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Covered California Sign-Ups Skyrocket In Sharp Contrast To Health Exchanges’ National Numbers

Sanders’ Rift With Culinary Workers Reveals A Labor Union Civil War Over ‘Medicare For All’

Analysis: Who Profits From Steep Medical Bills? The People Tasked With Fixing Them.

Every politician condemns the phenomenon of “surprise” medical bills.

Last week, two committees in the House were marking up new surprise billing legislation. One of the few policy proposals President Donald Trump brought up in this year’s State of the Union address was his 2019 executive order targeting “balance bills.” In the Democratic debates, candidates have railed against such medical bills, and during commercial breaks, back-to-back ads from groups representing doctors and insurers proclaimed how much the health care sector also abhors this uniquely American form of patient extortion.

Patients, of course, hate surprise bills most of all. Typical scenarios: A patient having a heart attack is taken by ambulance to the nearest hospital and gets hit with a bill of over $100,000 because that hospital wasn’t in his insurance network. A patient selects an in-network provider for a minor procedure, like a colonoscopy, only to be billed thousands for the out-of-network anesthesiologist and pathologist who participated.

And yet, no one with authority in Washington has done much of anything about it.

Here’s why: Major sectors of the health industry have helped to invent this toxic phenomenon, and none of them want to solve it if it means their particular income stream takes a hit. And they have allies in the capital.

That explains why Trump’s executive order, issued last year, hasn’t resulted in real change. Why bipartisan congressional legislation supported by both the House Energy and Commerce Committee and the Senate Health Committee to shield Americans from surprise medical bills has gone nowhere. And why surprise billing provisions were left out of the end-of-year spending bill in December, which did include major tax relief for many parts of the health care industry.

Surprise bills are just the latest weapons in a decades-long war among the players in the health care industry over who gets to keep the fortunes generated each year from patient illness: $3.6 trillion in 2018.

Here’s how they came to be:

Forty years ago, when many insurers were nonprofit entities and being a doctor wasn’t seen as a particularly good entree into society’s top 1%, billed rates were far lower than they are today, and insurers mostly just paid them. Premiums were low or paid by an employer. Patients paid little or nothing in copayments or deductibles.

That’s when a more entrepreneurial streak kicked in. Think about the opportunities: If someone is paying you whatever you ask, why not ask for more?

Commercial insurers as well as Blue Cross Blue Shield plans, some of which had converted to for-profit status by 2000, began to push back on escalating fees from providers, demanding discounts.

Hospitals and doctors argued about who got to keep different streams of revenue they were paid. Doctors began to form their own companies and built their own outpatient surgery centers to capture payments for themselves.

So today your hospital and doctor and insurer — all claiming to coordinate care for your health — are often in a three-way competition for your money.

As the battle for revenue has heated up, each side has added weapons to capture more: Hospitals added facility fees and infusion charges. Insurers levied ever-rising copayments and deductibles. Most important, they limited the networks of providers to those that would accept the rates they were willing to pay.

Surprise bills are the latest tactic: When providers decided that an insurer’s contracted payment offerings were too meager, they stopped participating in the insurer’s network; either they walked away or the insurer left them out. In some cases, physicians decided not to participate in any networks at all. That way, they could charge whatever they wanted when they got involved in patient care and bill the patient directly. For their part, insurers didn’t really care if those practitioners demanding more money left.

And, for a time, all sides were basically fine with this arrangement.

But as the scope and the scale of surprise bills have grown in the past five years, more people have experienced these costly, unpleasant surprises. With accumulating bad publicity, they have become impossible to ignore. It was hard to defend a patient stuck with over $500,000 in surprise bills for 14 weeks of dialysis. Or the $10,000 bill from the out-of-network pediatrician who tends to newborns in intensive care. How about the counties where no ambulance companies participate in insurance, so every ambulance ride costs hundreds or even thousands of dollars?

These practices are an obvious outrage. But no one in the health care sector wants to unilaterally make the type of big concessions that would change them. Insurers want to pay a fixed rate. Doctors and hospitals prefer what they call “baseball-style arbitration,” where a reasonable charge is determined by mediation. Both camps have lined up sympathetic politicians for their point of view.

So, nothing has changed at the federal level, even though it’s hard to imagine another issue for which there is such widespread consensus. Two-thirds of Americans say they are worried about being able to afford an unexpected medical bill — more than any other household expense. Nearly 8 in 10 Americans say they want federal legislation to protect patients against surprise bills.

States are passing their own surprise billing laws, though they lack power since much of insurance is regulated at a national level.

Now members of Congress have yet another chance to tackle this obvious injustice. Will they listen to hospitals, doctors, insurers? Or, in this election year, will they finally heed their voter-patients?

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Surge In Enrollment As Californians Avoid Penalty, Receive State Aid

Hundreds of thousands of new enrollees signed up for 2020 coverage through Covered California, driven by new carrot-and-stick state policies that provide financial aid to help some people afford their premiums while penalizing those who don’t have coverage, state health officials announced Tuesday.

Covered California Executive Director Peter Lee said the health insurance exchange is giving consumers who remain uninsured another chance to enroll: Effective immediately, those who were not aware of the new penalty or financial aid can sign up for coverage during a special enrollment period that will last through April.

Covered California is the state’s Affordable Care Act health insurance marketplace, where eligible individuals, families and small businesses can purchase plans and may qualify for federal tax credits and/or the new state-based subsidies based on their incomes.

“This has proven the case that the Affordable Care Act, as designed and not kneecapped, works and works well,” Lee said.

The new state penalty encouraged people to check the insurance exchange, he said. The subsidies encouraged people to buy.

About 418,000 Californians newly enrolled in individual or family plans through Covered California by the Jan. 31 enrollment deadline, 41% more than last year and the highest new enrollment since 2016, according to preliminary data from the exchange.

About 1.1 million existing Covered California enrollees also renewed plans, bringing the total number of enrollees to more than 1.5 million.

On healthcare.gov, the federally run health insurance exchange, about 8.3 million people enrolled in new plans or renewed their coverage this year, down slightly from 8.4 million in 2019.

California is one of six states and the District of Columbia that require most of their residents to purchase health insurance or face a penalty. Congress eliminated the Affordable Care Act’s federal tax penalty, effective last year.

California’s penalty mirrors the federal one that was nullified. In many cases, it will amount to $695 for a single adult and about $2,000 for a family of four. But for a lot of people, the financial hit could be substantially larger.

The state projects the penalty could raise $317 million in the first year, which is intended to partially fund the subsidies. Lee said he would forgo the extra revenue if it meant people are getting covered.

“The penalty is on the books but nobody wants the money,” he said. “We want it to be an economic nudge to get people to get covered.”

People who were motivated by the penalty to shop for insurance might have found coverage cheaper than last year.

Some of the new state financial aid is available to low-income customers, but California became the first state to offer subsidies to middle-income people who make too much to qualify for the federal tax credits: people whose incomes are between 400% and 600% of the federal poverty level, or about $51,000 to $76,000 a year for an individual and $104,800 to $157,200 for a family of four. Those thresholds are too high to qualify for federal aid but low enough to make health insurance a financial burden.

The average state assistance for this group is about $500 a month, Lee said.

About 625,000 people qualified for the new state subsidies, including 32,000 middle-income enrollees, Lee said.

The subsidies vary by income, household size, location and age. Some went to low-income residents who also qualify for federal tax credits.

Evette Tsang and her husband, both insurance brokers in Sacramento, serve mostly Chinese-speaking immigrants. Her clients used their state subsidies this year to purchase more comprehensive silver-tier plans with higher premiums rather than the cheaper bronze plans with lower benefits.

“After these few years, they start to see the importance of health insurance,” Tsang said. “Before, they only wanted bronze, but now they’re going to silver.”

Deborah Kelch, executive director of the Insure the Uninsured Project, said a lot of the success of this year’s enrollment numbers was the product of an aggressive marketing campaign urging Californians who hadn’t been able to afford insurance in the past to take a second look.

“They did so much great outreach,” Kelch said. “At this stage, Covered California has a really good formula they’re using. There are TV ads, they have their bus tour, they work with community organizations.”

According to Lee, Covered California budgeted $47 million for advertising this year, including $6 million for the special enrollment period.

Despite the advertising dollars, Lee said, there still isn’t enough awareness about the penalty and subsidies, necessitating the special enrollment period through April 30.

While she wants everyone to get covered, insurance broker Tsang isn’t looking forward to the new enrollment period and the extra work it will bring. Nearly all her clients knew about the penalty, she said, and it was the No. 1 reason they signed up.

California already has a longer enrollment window than the federal government’s healthcare.gov exchange, which lasts only six weeks.

Combined with other factors, the extended period encourages higher enrollment and a better mix of healthy and sick people in the insurance pool, said Laurel Lucia, director of the Health Care Program at the Center for Labor Research and Education at the University of California-Berkeley.

“With the state mandate and the new state subsidies, we project the uninsured rate will remain flat over the next few years,” Lucia said.

That’s the important comparison, according to Lee. While new enrollment in the federal exchange has dropped by 48% since 2016, new enrollment in Covered California has been relatively stable since then, dropping by 2%.

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

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Covered California Insurance States The Health Law Uninsured

Appeals Court Shoots Down Arkansas’ Medicaid Work Requirements In Latest Legal Blow For Trump Administration

Must-Reads Of The Week From Brianna Labuskes

Happy Friday! And Happy Valentine’s Day, where we at KHN have compiled some of the best #HealthPolicyValentines from Twitter (this seems the right group for that level of wonkiness!). Check out some great ones, like this from Laura Marston:

“One vial a week
Keeps me alive
Used to cost $20
Now it’s $275.”

Now on to equally fun things, like budgets!

President Donald Trump released his proposed budget this week with only the vaguest of a health care plan mentioned. A mystery pot of $844 billion signaled deep cuts to Medicaid and subsidies under the health law. In particular, an obscure passage referred to “ending the financial bias that currently favors able-bodied working-age adults over the truly vulnerable.” Critics were scratching their heads how the released budget aligned with Trump’s promise to protect people’s coverage. “You can’t cut $1 trillion from these programs and protect the most vulnerable,” said Aviva Aron-Dine of the Center on Budget and Policy Priorities.

The Associated Press: Mystery $844B Pot in Trump Budget Signals Medicaid Cuts

The budget also calls for an almost 16% cut to the CDC (yes, the agency handling the coronavirus outbreak). But top officials say that’s because the administration wants the CDC to narrow its focus to its core mission of preventing and controlling infectious diseases and handling public health crises.

The Washington Post: Trump Budget Cuts Funding for Health, Science, Environment Agencies

Trump also wants to cut the budget for the National Institutes of Health by 6.5%. (Yes, that would affect the National Institute of Allergy and Infectious Diseases, which is working on a vaccine for the coronavirus.)

The Wall Street Journal: Trump Proposes $4.8 Trillion Budget, With Cuts to Safety Nets

Another odd little nugget in the budget: Trump wants to strip the FDA of its authority over tobacco products and create an agency within HHS solely for that purpose.

Stat: Trump Doesn’t Want the FDA to Regulate Tobacco

For a full breakdown of the budget’s details, check out our roundup here.

This week, the coronavirus strain got an official name, which is — drum roll, please —COVID-19. Although the announcement probably set off celebrations among scientists and researchers who have been driven up a wall because everyone has been simply calling it “coronavirus,” I am here to report that a day into its official designation 95% of headlines are stilling using only the generic term.

— It is, however, important to note that WHO officials were careful not to name the disease after a particular region or people so as to avoid further stigmatization surrounding any outbreaks.

Time: What’s in a Name? Why WHO’s Formal Name for the New Coronavirus Disease Matters

— As the death toll climbs in China, officials have expanded their “wartime” campaign to round up all the people who may be infected. But, as you can imagine, that is not going perfectly. Not only is it stoking tensions among an angry and scared nation whose residents aren’t happy with how the government is handling the crisis, but also it’s thrusting people who haven’t even tested positive for the virus into situations where they become vulnerable to infection.

The New York Times: China Expands Chaotic Dragnet in Coronavirus Crackdown

— Readers of The Friday Breeze know I’ve been harping on the fact that our national attention has been focused on COVID-19 even though we have only 15 (non-fatal) confirmed cases of it here and the common flu is far more deadly to us. Well, there’s a psychological basis for why we tend to panic over things that statistically are unlikely to affect us. Pretty much we can be terrible at accurately assessing risk.

The New York Times: Coronavirus ‘Hits All the Hot Buttons’ for How We Misjudge Risk

— It was a bit of a roller-coaster week with data coming out of China. At first, it seemed the cases were slowing down, but then the diagnostic criteria were tweaked, and all of a sudden we had nearly 15,000 cases added in one night.

The New York Times: Coronavirus Cases Seemed to Be Leveling Off. Not Anymore.

— CDC Director Robert Redfield said that the United States is essentially trying to buy time with its containment strategy, but it is quite likely there will eventually be person-to-person transmission of the virus here. (Which means people other than evacuees from Wuhan will start getting it.)

Stat: CDC Director: More Person-To-Person Coronavirus Infections in U.S. Likely

— And you can see how easily that could happen, given a U.S. evacuee was mistakenly released from the hospital even though she was infected with the coronavirus.

CNN: First US Evacuee Infected With Coronavirus Was Mistakenly Released From Hospital

— In an update from the cruise from h-e-double-hockey-sticks: Tensions continue to rise along with COVID-19 cases among the passengers and crew of a ship quarantined off the coast of Japan. As one health official said this week: Remember, quarantines are to keep those outside of its boundaries safe, not those within.

The New York Times: Quarantined Cruise Passengers Have Many Questions. Japan Has Few Answers.

— WHO has been heaping praise on China for its response to the crisis. And while other experts acknowledge the organization is in the tenuous position of not wanting to anger China enough that they break off relations, critics say the excessive compliments are setting a bad precedent about what a good pandemic response looks like.

The Wall Street Journal: The World Health Organization Draws Flak for Coronavirus Response

— Meanwhile, the coronavirus research filed is quite small. That’s because, despite the buzz these kinds of outbreaks create, eventually the world’s attention will be caught by a different shiny object and both the funding and interest in researching the virus will fade.

Stat: Fluctuating Funding and Flagging Interest Hurt Coronavirus Research

Supporters of Sen. Bernie Sanders (I-Vt.) got their wrists slapped by a powerful Nevada union this week for “viciously attacking” members and their families online. At the heart of the matter: The union had released information critical of Sanders’ “Medicare for All” plan. The clash put Sanders — who denounced any harassment as “unacceptable” — in an awkward spot just before the Nevada caucuses next week.

Politico: Nevada Culinary Union Lays Into Sanders Supporters After Health Care Backlash

A new survey found that even when patients plan ahead, many are still hit with surprise medical bills, especially if they receive anesthesia during a procedure. With health care spending rising again (driven by high costs like the out-of-pocket price tag for an emergency room visit), the report is a reminder that the issue is likely to be top of mind with voters come November.

Meanwhile, lawmakers well aware of that fact are moving forward with legislation that would favor an arbitration method for dealing with the surprise costs. This strategy is favored by hospitals and providers, and not embraced by insurers.

Reuters: Surprise Surgery Bills Happen Even When Patients Plan Ahead

Modern Healthcare: House Committee Advances Provider-Friendly Surprise Billing Fix

In a little bit of breaking news, a federal appellate court just shut down CMS’ approval of Arkansas’ Medicaid work requirement. The panel upheld a lower-court ruling that found the requirements arbitrary and capricious.

Modern Healthcare: D.C. Circuit Nixes Arkansas Medicaid Work Requirement

Juul has vowed time and again that it hasn’t marketed its products to teenagers. But new revelations from a Massachusetts lawsuit that the vaping company bought ads on Nickelodeon and the Cartoon Network are challenging those promises.

The New York Times: Juul Bought Ads Appearing on Cartoon Network and Other Youth Sites, Suit Claims

The VA is no stranger to controversy, but the latest bout comes at a bad time for the agency. The abrupt firing of the agency’s well-liked undersecretary in combination with allegations that VA Secretary Robert Wilkie sought to dig up dirt on a woman after she said she was sexually assaulted at a VA facility have shaken the agency just as it is preparing to launch an ambitious health plan.

The New York Times: Veterans Affairs, a Trump Signature Issue, Is Facing Turmoil Again

Meanwhile, Trump continued to downplay brain injuries sustained by troops from an Iran missile strike even as the number of cases jumped past 100.

The New York Times: More Than 100 Troops Have Brain Injuries From Iran Missile Strike, Pentagon Says

In the miscellaneous file for the week:

— It’s notoriously hard to get any gun measures passed … except these advocates seem to be having some success. Their strategy? Go hyper-local.

NBC News: How Moms Are Quietly Passing Gun Safety Policy Through School Boards

— What’s going on with the Equal Rights Amendment and why has it become a fight over abortion? Politico takes a deep dive into its history about how the battle around the amendment has shifted in the nearly 40 years since it was introduced.

Politico: How the Debate Over the ERA Became a Fight Over Abortion

— New parents eager to better balance family and work life in the only industrialized country in the world without a paid family leave policy have started bringing their babies to their offices.

Stateline: You Can Bring Your Baby to Work (But Wouldn’t You Rather Be at Home?)

— In another crushing disappointment, an Alzheimer’s drug that had sparked high hopes was the latest to fail to live up to expectations.

The Associated Press: Drugs Fail to Slow Decline in Inherited Alzheimer’s Disease

That’s it from me. And remember, if you ever feel like flexing your poetic muscles outside of Valentine’sDay, we accept haiku submissions year-round. Have a great weekend!

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Americans Are Still Paying More And More In Health Costs But Not Because Amount Of Care Is Increasing

Would ‘Medicare For All’ Cost More Than U.S. Budget? Biden Says So. Math Says No.

During the Feb. 7 Democratic presidential debate, former Vice President Joe Biden once again questioned the price tag of “Medicare for All,” the single-payer health care proposal championed by one of his key rivals, Sen. Bernie Sanders of Vermont.

Biden argued that the plan was fiscally irresponsible and would require raising middle-class taxes. Specifically, he claimed, the plan “would cost more than the entire federal budget that we spend now.”

Medicare for All’s price — and whether it’s worth it — is a subject of fierce discussion among Democratic presidential candidates. But we had never heard this figure before. It caught our attention, so we decided to dig in.

Biden’s campaign directed us to the 2018 federal budget, which totaled $4.1 trillion. It compared that amount with the estimated cost of Sanders’ single-payer proposal: between $30 trillion and $40 trillion over a decade. The math, they said, shows Medicare for All would cost more than the national budget.

But it turns out, based on the numbers and interviews with independent experts, Biden’s comparison of Medicare for All’s price to total federal spending misses the mark because the calculation is flawed.

The Numbers

Sanders has said publicly that economists estimate Medicare for All would cost somewhere between $30 trillion and $40 trillion over 10 years. Research by the nonpartisan Urban Institute, a Washington, D.C., think tank, puts the figure in the $32 trillion to $34 trillion range.

We pointed out to Biden’s campaign that comparing 10-year spending estimates to one-year budgets is like comparing apples to oranges. The campaign suggested that if you take 10 times the current federal budget, you get a figure smaller than the estimated cost of Medicare for All over that 10-year window.

That calculation would lead you to multiply $4.1 trillion by 10 to get $41.1 trillion. That result is close to the high mark Sanders set for his program’s cost but well above the $34 trillion that Urban researchers projected.

Still, that’s not the correct way to formulate a comparison, experts say. “That’s not good math,” said Marc Goldwein, the senior vice president and senior policy director at the Committee for a Responsible Federal Budget. “That’s taking a 2018 number and multiplying it by 10, whereas the $34 trillion is a 10-year number that assumes a lot of growth.”

What you would need to do is add up the Congressional Budget Office’s projected budget outlays from 2020 to 2029, and compare the sum to the Medicare for All spending figure.

So we spoke to Linda Blumberg, an institute fellow at Urban’s Health Policy Center, who arrived at the $34 trillion estimate. She ran the CBO’s numbers: The next 10 years of on-budget outlay, the government office projects, add up to $44.8 trillion.

To be clear, $34 trillion (34 followed by 12 zeros) is no small sum. It accounts for about 75% of that nearly $45 trillion budget estimate and would represent a bigger single increase to the federal budget than we’ve ever experienced, Blumberg said.

That raises one point on which Biden may have some ground. Goldwein argued that you would indeed need significant tax increases to finance the Sanders proposal.

But its price tag still would be less than the projected budget.

“If he said [Medicare for All] was as big as the current federal budget, that would be incorrect,” Blumberg said.

Goldwein looked at the numbers another way: Including interest, he found, the federal budget would consume about $55 trillion between now and 2030. Again, that’s more than what Medicare for All would cost during the same period.

Big picture: No matter how you slice Biden’s math, his numbers are off.

“If what he said was Medicare for All will cost as much as the entire rest of the budget, that would be fair,” Goldwein said. But that’s not the same thing.

Our Ruling

Biden argued that Medicare for All “would cost more than the entire federal budget that we spend now.”

This relies on faulty math. Medicare for All would certainly represent a substantial increase to the federal budget. But it would neither match nor dwarf current federal spending overall. We rate this claim False.

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KHN’s ‘What The Health?’: Live from D.C. With Rep. Donna Shalala

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

President Donald Trump’s proposed budget for the fiscal year that begins in October proposes big cuts to popular programs, including Medicaid and the National Institutes of Health. Although those cuts are unlikely to be enacted by Congress, both Republicans and Democrats are likely to use the budget blueprint as a campaign issue.

Meanwhile, several House committees this week relaunched work on legislation to address “surprise” medical bills — unexpected charges from out-of-network providers. And Congress is still trying to come to a bipartisan agreement on how to address drug prices.

Rep. Donna Shalala (D-Fla.) was the special guest for this week’s podcast, taped before a live audience at the Kaiser Family Foundation headquarters in Washington, D.C. Also joining host Julie Rovner of Kaiser Health News were Paige Winfield Cunningham of The Washington Post, Rebecca Adams of CQ Roll Call and Joanne Kenen of Politico.

Among the takeaways from this week’s podcast:

  • One surprise in the president’s budget is a proposal to move tobacco regulation out from under the Food and Drug Administration’s purview. That comes despite a law Congress passed several years ago that specifically named the FDA as the regulator for tobacco.
  • Last year, it seemed clear that Congress and the White House were determined to find a way to protect consumers from surprise medical bills. But heavy lobbying on the issue and deep fissures in pinpointing the best remedy have slowed that effort. Shalala said she thinks Congress will produce a bill this year that will be balanced so that insurers and medical providers have to compromise.
  • Shalala said that in the 21 town meetings she has held in South Florida, no one has asked about efforts to end surprise bills. Most of the health questions focus on high drug prices and out-of-pocket costs. High out-of-pocket costs have been driven by the large number of people shifted into high-deductible insurance plans.
  • Shalala also said she doesn’t expect a plan to import drugs from Canada, endorsed by the Trump administration and some states, to go forward. Drugmakers sell Canada enough medicine to cover the population there, and not consumers in Florida, she added.

To hear all our podcasts, click here.

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

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Even When Patients Plan Ahead A Significant Number Can Be Walloped By Surprise Medical Bills

Insurers Try To Avoid Trump Administration Order By Taking Price Transparency Into Their Own Hands

One Defensive Strategy Against Surprise Medical Bills: Set Your Own Terms

When Stacey Richter’s husband recently landed in a New Jersey emergency room, fearing a heart attack, she had an additional reason for alarm: a potential big bill from the hospital if the ER wasn’t in his insurer’s network.

So she took an unusual step. Instead of simply signing the hospital’s financial and treatment consent form, Richter first crossed out sections calling for her to pay whatever amount the hospital charged. She wrote in her own payment rate of a “maximum of two times” what the federal government would pay under Medicare, which is in the ballpark, experts said, of what hospitals might consider an acceptable rate.

“And then I signed it, took a picture of it and handed it back to them,” said Richter, co-president of the consultancy Aventria Health Group.

Advocates say such consent-form alterations could provide some protection from surprise bills, though there are several major caveats to this largely untested idea.

These bills — often called “balance bills” — happen when out-of-network providers charge more than insurers pay and patients are responsible for paying the balance. Lawmakers say they are considering ways to help, but legislation stalled in Congress late last year. And though some states have balance-bill laws in place, they don’t apply to many patients with job-based insurance.

Richter and other proponents say patients should look to state contract law for protection.

What few patients realize is that admission and financial forms serve as contracts detailing that the hospital will provide certain services and patients will pay for them. Those forms often specify that patients are responsible for “total charges.”

And therein lies the problem for those who find themselves at an out-of-network facility or are seen by an out-of-network provider at an in-network hospital.

In those cases, providers often bill full “charges,” which are amounts set by the providers themselves and can be several times higher than what insurers or Medicare generally pay. Privately insured patients — generally, not Medicare patients — can be held responsible for the balance.

But, by writing in their own limits, patients might have leverage in negotiations or even in courts if out-of-network payment disputes arise, or at least proof they didn’t agree to pay the total charges, say advocates and some legal scholars.

Patients who try this could still get hit with a large balance bill. But “the difference is you can say ‘I offered this, but they refused it,’” rather than signing the original agreement to pay all charges, said proponent Al Lewis, CEO of Quizzify, an employee health care education company.

He came up with the twice-Medicare benchmark, even putting suggested wording for patients to print and carry with them on downloadable wallet cards, because he says it’s an amount that’s defensible.

If a hospital later turns down “two times Medicare and it goes to court, their lawyer is going to say, ‘We could lose this thing,’” said Lewis.

Such efforts are best applied only in emergencies — where federal law requires hospitals to stabilize patients and not toss them into the parking lot — no matter their ability to pay. However, patients who refuse to sign documents or try to alter them in nonemergencies — say, at a doctor visit or for elective surgery — could be refused service.

Even in emergencies, there is no guarantee the hospital will later agree to limits proposed by patients on what it can charge for out-of-network care.

“It’s a hard argument to make if the patient changes it unilaterally,” said Ericka Adler, a partner at law firm Roetzel & Andress in Chicago, who represents physician group practices, including those who work out-of-network in hospitals. “It won’t be a valid contract unless both parties sign it.”

She has not had this happen with her hospital-based clients. But with office-based physicians in nonemergency cases, some patients have tried writing caveats onto their forms.

“We have never had trouble enforcing the terms of our original policy,” she said.

Still, some legal scholars question the premise that hospitals’ financial consent forms are themselves valid contracts. That’s because contract law requires “mutual assent,” something law professor Barak Richman said patients can’t really give because they are seldom told the true price of care upfront, before signing.

“There’s something deeply exploitive about the process,” said Richman, who studies contract law and teaches at Duke University Law School.

Al Lewis, CEO and co-founder of employee education consulting firm Quizzify, recommends that patients always carry this wallet card. It displays suggested wording that he says might help reduce the amount they could be billed for out-of-network emergency care. He emphasizes its value in emergencies because, under federal law, patients with true emergencies must be treated until stabilized, regardless of their ability to pay.(KHN Screenshot of Quizzify’s website)

Still, he noted that judges often “are far too deferential to these contracts” when disputed balance bills end up in court, especially the vague wording that patients “promise to pay all charges.”

If patients alter the wording with their own terms — so long as they agree to pay what is considered a reasonable amount — then judges may also look to that added language, said Richman.

“This is not crazy by any means,” said Richman. “To the degree that courts rely on specific language of the admission contract, then this should be a successful strategy.”

But it isn’t easy to speak up, particularly in emergencies, which are already fraught.

“I believe it would be legally effective,” said Mark Hall, a professor of law and public health at Wake Forest University. “However, it requires patients to be much more astute and well prepared than is typical in most surprise billing situations.”

Richter said she had to endure some “toe-tapping” by an impatient administrator when she insisted on a paper copy of the consent form, rather than signing on the computer pad offered.

As it turned out, there was no additional bill for her husband, who gets his insurance through his job. The couple doesn’t know if that’s because everyone who saw him was in-network, or if it was her proactive stance on the forms.

“I am one who will not be peer-pressured,” said Richter.

A real solution needs to be broader than simply individuals trying to rewrite hospital contracts, Richman said.

“No one thinks we can solve this national epidemic of surprise bills with individual court cases,” he said. “But what this does could create an awareness of what people are signing” when they receive care.

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Newsom Touts California’s ‘Public Option.’ Wait — What Public Option?

Several Democratic presidential hopefuls are pitching a federal “public option” as a way to expand health coverage and make it more affordable.

The details of their proposals vary, but the general idea is to create a government-sponsored plan that could compete with private insurance.

“We have a public option, just so folks know,” California Gov. Gavin Newsom claimed last month as he unveiled his proposed 2020-21 state budget. “It’s called Covered California.”

Hmm, really?

California does not have a public option in the way most people understand the term. According to Newsom’s definition, offering a public option simply means ensuring that consumers have choices and affordable coverage, and that health plans are held accountable, things Covered California already does, his office said.

That’s a stretch, say some health care and political experts.

Covered California “is manifestly not a public option,” said Thad Kousser, chair of the political science department at the University of California-San Diego.

Kousser theorized that Newsom may be co-opting the term to make it seem like the state is making progress toward his goal of creating a single-payer system.

But if Newsom wants to flout the term, the state should “create a public option that doesn’t involve insurance companies, and Covered California is a market to buy insurance from insurance companies,” Kousser said.

Covered California is the state-run exchange, created under the Affordable Care Act, where some individuals, families and small businesses can purchase insurance.

A public option is considered less sweeping than single-payer, a system in which health care is paid for by a single public authority. As a candidate, Newsom, a Democrat, campaigned for the creation of a single-payer program.

But that isn’t likely to happen anytime soon, for a variety of reasons. For one, the Trump administration has said it would reject any state plans to use federal dollars to implement single-payer.

At the national level, Democratic presidential candidates including former Vice President Joe Biden and former South Bend, Indiana, Mayor Pete Buttigieg have pitched public-option plans that would allow, but not require, people to buy into government-run plans similar to Medicare.

The idea is to boost competition by allowing people to choose between private plans and a government-run plan — and reduce costs.

Only one state, Washington, is implementing its own version of a public option, but other states are considering it.

Cascade Care, a hybrid system in which the state will contract with an insurer to administer a public-option plan, will debut in 2021. The state will attempt to control costs by setting payment rates at 160% of what Medicare would pay for the same service. Colorado is proposing a similar idea.

This version is different from the presidential candidates’ proposals because an insurance company will be responsible for running the public-option plan — not the government. But, ultimately, Washington will give its residents a new health insurance option, and that’s not the case in California, said Billy Wynne, chairman of the Wynne Health Group, which recently launched the Public Option Institute, a group analyzing the implementation of public-option programs.

But in California’s defense, he said, what constitutes a public option “is in the eye of the beholder.”

Peter Lee, executive director of Covered California, is also calling the exchange a public option. He argues that public-option plans assume different forms, just like single-payer or Medicare for All proposals.

On the exchange, “plans don’t compete on their own terms; they compete on our terms,” Lee said.  So, “is a public option only a government plan, or is it a public program that sets the rules of how private plans compete?”

Linda Blumberg, a health policy fellow at the Urban Institute, hazards an answer: While Covered California actively negotiates with health plans to keep premiums down, it “doesn’t quite have the spirit of a public option” because it doesn’t bear the financial risk that insurance companies do.

Newsom’s Healthy California for All Commission, which is debating how to get every Californian covered — with an emphasis on single-payer — gathered in Sacramento last month for its inaugural meeting. The commissioners briefly discussed the possibility of implementing a public option as a steppingstone to achieving universal coverage.

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But the concept didn’t get much love, and some commissioners suggested that instead of creating a public option, the state should strengthen existing public programs. One commissioner said the idea of a public option had already fizzled.

“Whatever happened to Vanilla Ice, and whatever happened to Tiny Tim and Miss Vicki? Whatever happened to public option?” asked Dr. Robert Ross, president of the California Endowment, a foundation that focuses on expanding health care access among Californians. “It just kind of went away.”

The closest thing to a functioning public option in California, under the traditional definition, may be the L.A. Care Health Plan, a public, nonprofit insurer equally available to Los Angeles County residents with Medi-Cal, the state’s Medicaid program for low-income residents, and to those who earn too much to qualify for Medi-Cal.

John Baackes, the plan’s CEO, said L.A. Care functions like the public-option plan described in the U.S. House version of the Affordable Care Act, before it was axed in the Senate. “Their definition of the public option was a public entity that did not have shareholders that would compete with commercial insurers in the individual market,” Baackes said.

L.A. Care, created to serve Medi-Cal patients, later opened to individuals and families who purchase their own insurance through Covered California or the open market.

For some time, Baackes said, the plan was the lowest-priced option in the Los Angeles area.

“Our enrollment skyrocketed because this is a very price-sensitive market, but in 2020, we were underbid by competition,” Baackes said. “To me, that’s exactly what the public option was supposed to do: put pressure in the marketplace. So I’m saying if you want to see how it works, look here.”

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

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Better Than Other Plans Or Better Than Nothing? Trump’s Claim About ‘Affordable’ Options

In his wide-ranging State of the Union address, President Donald Trump returned to a favorite theme: the cost of health insurance.

He cited the high cost of premiums for people who buy their coverage through the Affordable Care Act marketplaces and said his administration has provided new, less costly coverage.

“I moved quickly to provide affordable alternatives. Our new plans are up to 60% less expensive and better,” Trump told the lawmakers gathered at the Capitol.

So we wondered, to which new alternatives was he referring? We reached out to the White House to ask.

Spokesperson Adam Kennedy responded that the president was talking about short-term, limited-duration plans. But that got us thinking: Are they really less expensive and better? Or simply better than nothing?

First, Are They New?

They are not. As background, short-term insurance plans have been around for decades in various iterations and are generally considered a stopgap solution for people between jobs or attending school. They provide some protections, usually paying a percentage of hospital and doctor bills after the policyholder meets a deductible.

But they’ve always been a bit controversial.

Unlike the ACA plans now available, short-term plans can bar people with health conditions from enrolling or exclude coverage for specific conditions or treatments. They also offer fewer benefits — meaning they are not required to comply with the health law’s mandated essential benefits requirement.

So, for example, they don’t have to cover prescription drugs, or mental health services or substance abuse treatment — and many don’t. In addition, they can set annual or lifetime caps on benefits. Almost all exclude maternity care.

If a person develops a health condition during the coverage term, insurers can look through their medical records and, in some cases, retroactively cancel the plans — or refuse to renew the coverage at the end of the policy’s term.

The Obama administration restricted these policies, which still cannot be sold on the ACA marketplaces and do not qualify for subsidies, to a maximum coverage period of 90 days, down from the 364 days that applied previously.

The Trump administration reversed that time-limit restriction in 2018 and built on it by allowing insurers to offer policies renewable for up to three years.

Officials, including Health and Human Services Secretary Alex Azar, said at the time that these short-term plans provide an alternative but aren’t a good fit for everyone.

For instance, the Trump rules require the policies to carry a warning that they aren’t “required to comply with federal requirements for health insurance.” They also state that consumers should “check the policy carefully to make sure you understand what the policy does and doesn’t cover.”

Are These Plans Less Expensive?

The White House pointed us toward a January 2019 report produced by the Congressional Budget Office and the Joint Committee on Taxation as the source for the president’s assertion that these plans are 60% less expensive.

It quickly becomes clear that the analysis is very wonky and complex.

After all, it’s not easy to project what benefits insurers will include in short-term plans or what they will charge individuals, which can vary based on their health. Even the analysts called the estimating process “challenging.”

When it came right down to it, they hedged: Short-term plans are likely cheaper than the lowest-cost ACA plan for some consumers, but more expensive for others. For example, people who get a federal tax credit to buy ACA-compliant insurance or those who are older or less healthy would likely pay more in premiums for a traditional short-term plan, the analysts said.

Conversely, those without subsidies, especially younger or healthier consumers, might pay as much as 60% less than they would for the lowest-cost plan through the ACA, the analysis concluded. Another study, not cited by the White House but done by the conservative Manhattan Institute, also listed caveats, but more robustly defended the plans as less expensive. Premiums for short-term plans are lower — in some cases, almost half the cost — of ACA plans, it concluded.

But critics put these price tags in context. “I don’t have a reason to suspect the 60% is wrong if they’re lining them up against ACA plans, but if you’re a health plan that doesn’t cover much, it’s easy enough to offer a cheap premium,” said Sabrina Corlette, research professor and co-director of the Center on Health Insurance Reforms at Georgetown University.

So That Gets To The Question, Are They Better?

The consensus is that the coverage short-term plans provide is not better than that of ACA plans. But it could be better than going without insurance entirely.

“Why not throw another option out there?” said Doug Badger, senior fellow at the conservative Galen Institute. “You might say this plan isn’t as good as that plan, but we may both agree that having this one is better than nothing.”

He said that should be a decision made by consumers, who can weigh the pros and cons: “They know their circumstances and risk tolerance.”.

Still, it’s a gamble, as no one knows what health conditions might befall them. A plan that doesn’t cover prescription drugs may be fine the first month, but if a serious illness crops up, it suddenly has unexpected costs.

Others also note that short-term plans may have wider networks of doctors and hospitals than some ACA plans, giving consumers more options.

“In Texas, for example, you cannot buy an ACA plan that covers MD Anderson,” the cancer center of the University of Texas, said Brian Blase, CEO of Blase Policy Strategies. Blase has advised Trump on his health policy efforts. “The only way you can have such a plan that includes MD Anderson — unless you have employer coverage — is in a short-term plan.”

Again, nice to have a wide network. But there’s a conundrum. Someone with cancer — attracted to a network because it includes MD Anderson — would be rejected by most short-term plans.

That ability to reject applicants — or seriously limit coverage of their preexisting conditions — helps keep premiums down.

But those are also the main reasons experts say the plans are not better than those offered under the ACA, which bars such limits.

A preexisting condition is often defined as anything treated — or for which a “prudent person” should have sought treatment — during the previous 12 months to five years, depending on the insurer.

“If you have high blood pressure and, while on one of these plans, you have a heart attack, the plan could say that was a preexisting condition,” said Corlette.

State regulation of such plans varies widely, as do the coverage benefits and limits offered by various insurers. Some have limits listed in the fine print.

While short-term plans have been embraced by regulators in some states, nearly half of all states have moved to limit them to less than 12 months. Four — California, Massachusetts, New Jersey and New York — have barred them altogether.

Those states cite concerns about the effect on ACA premiums and the risk that consumers could be left hanging by the more limited nature of the short-term plans.

Our Ruling

Trump said these are new plans that are 60% cheaper and better.

But short-terms plans are not a new idea. Just how much cheaper they are depends on a lot of factors, experts told us. And it’s very hard to examine them in an apples-to-apples comparison with ACA plans, which cover far more and are required to accept all applicants.

Given the limitations of short-term plans, they’re not better than ACA plans for most people, because policyholders could face potentially significant financial risk — or find their treatment needs are not covered. They’re definitely not better for people who qualify for federal subsidies to buy ACA insurance, especially those at the lower end of that income range, where the subsidies are larger.

That said, a short-term plan may be better than going without coverage at all, particularly for a young or otherwise healthy person, whose income is above subsidy limits.

We rate this claim as Mostly False.

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In Fierce Debate, Democratic Candidates Expand Health Agenda Arguments

Democratic presidential candidates faced off on the debate stage for the eighth time this campaign season. Meeting in Manchester, N.H., they returned to now familiar health care themes — “Medicare for All” versus a public option, the cost of prescription drugs and other key areas they say are ripe for change.

Once again, candidates sparred over the cost of the single-payer health reform bill promoted by Vermont  Sen. Bernie Sanders. Former Vice President Joe Biden argued it would necessarily raise taxes, pointing to its estimated $32 trillion price-tag (a number supported by independent economist estimates). Sanders noted that over the next decade, the nation is projected to end up spending more than $50 trillion on health care. (That’s also borne out by evidence.)

Sen. Elizabeth Warren of Massachusetts and Sen. Amy Klobuchar of Minnesota also dove into issues related to abortion rights. Warren touted the statistic that three out of four Americans believe that Roe v. Wade should be the law. This is pretty accurate — a recent Kaiser Family Foundation poll found that 69% of Americans do not want Roe v. Wade overturned. And Klobuchar again talked about how there is overwhelming support for Planned Parenthood. We previously checked this claim.

The candidates also discussed the opioid epidemic and the shortage of substance abuse treatment beds — in New Hampshire and nationwide.

Here are some highlights and related fact checks:

You sent out a tweet just a few years ago you said ‘henceforth, forewith you are for Medicare for all for the ages.’

Sen. Amy Klobuchar, Feb. 7, 2020

The truth is I have been consistent throughout in my position on health care for every American.

Former South Bend Mayor Pete Buttigieg, Feb. 7, 2020

Klobuchar and Buttigieg, the former mayor of South Bend, Ind., sparred over his record of support for Medicare for All, the single-payer health care bill Sanders backs. Klobuchar noted that Buttigieg previously tweeted in favor of the bill and has since changed his position. Buttigieg said he has been consistent on supporting an approach that would bring health care to all Americans.

Klobuchar’s point — that Buttigieg has at least expressed support for the specific bill, and no longer does — is supported by evidence.

The tweet was posted on Feb. 18, 2018. Buttigieg wrote, “I, Pete Buttigieg, politician, do henceforth and forthwith declare, most affirmatively and indubitably, unto the ages, that I do favor Medicare for All, as I do favor any measure that would help get all Americans covered.”

Since then, Buttigieg has narrowed his stance — backing “Medicare for all who want it,” a plan he argues would also achieve universal coverage, by letting people opt into a public health plan, and offering more generous subsidies for those who purchase private insurance. (Proponents of single-payer are skeptical it would succeed.)

To be fair, even Buttigieg’s 2018 statement includes an important qualifier — he’s not tied to the plan. He favors Medicare for All, he says, as he does “any measure that would help get all Americans covered.” If you agree that his current plan would also achieve universal health care, there’s an argument that he has been consistent.

—Shefali Luthra

It would cost more than the entire federal budget that we spend now.

Former Vice President Joe Biden, Feb. 7, 2020

This is in reference to Medicare for All. We contacted Biden’s campaign, who directed us to the 2018 federal budget — $4.1 trillion — compared to the estimated $32 trillion price tag of Sanders’ single-payer proposal. But there’s a problem: That latter number is an estimate of the cost for 10 years. So putting one year of the budget against a decade of health spending is comparing apples and oranges.

And converting one year’s budget to a decade-long forecast is an economically complex proposition — it’s not so simple as just multiplying by 10.

We also ran this claim by an independent expert, who crunched the $32 trillion estimate. Linda Blumberg, an institute fellow at the Urban Institute, told us Biden’s comparison is “an exaggeration” and “overstatement.”

Certainly, she said, Medicare for All would be “a bigger increase to the federal budget than we’ve ever experienced” — more than a 70% increase, compared to the CBO’s 10-year budget estimate.

“This is an enormous increase, but it wouldn’t double” the budget, she said.

—Shefali Luthra

The health care industry makes $100 billion in profit.

Sen. Bernie Sanders, Feb. 7, 2020

This is a favorite talking point from Sanders. We double-checked the math during the last debate. It holds up — and is probably an underestimate.

The figure is derived by adding the “net revenues” as reported by the companies for 10 pharmaceutical companies and 10 companies that work in health insurance. Multiple independent economists reviewed the methodology with, and affirmed that it’s sound. In fact, the total “net revenue” — or profit — is actually around $101 billion.

The talking point doesn’t include health care’s biggest earners, though: hospitals and health systems. When you factor them in, experts previously told us, the level of profit in our system will grow significantly larger.

—Shefali Luthra

30,000 Americans a year die waiting for health care because of the cost.

Sen. Bernie Sanders, Feb. 7, 2020

The way Sanders uses this number is problematic and oversimplifies the research. When we previously fact-checked this claim, we rated it Half True.

It appears that the number comes from Physicians for a National Health Program, which cited the Oregon Health Insurance Experiment, a study that assigned by lottery some participants to Medicaid and the others remained without insurance. A year into the experiment, researchers found that the death rate differed by 0.13 percentage points between those who were on Medicaid and those who were not — though this difference was not statistically significant. If you extrapolate this number to the number of Americans who are uninsured — about 27 million — then you do get close to a figure of about 30,000 people.

However, experts said that since the difference was not statistically significant it shouldn’t be extrapolated so broadly, and it’s possible that Sanders’ number is too high. Other research does show that there is a connection between being uninsured and higher likelihood of mortality. Thousands of Americans die waiting for health care every year, but this number relies on imprecise math.

—Victoria Knight

36 million Americans last year couldn’t afford to fill a prescription, including those with insurance.

Sen. Elizabeth Warren, Feb. 7, 2020

This is true. If anything, it falls a little short.

The data comes from an estimate by the  Commonwealth Fund, a health care research and advocacy group. Researchers found that in 2018, 37 million non-elderly Americans — about 1 in 5 people — skipped a prescription because they couldn’t afford it. Some of those people had coverage. Others were “underinsured.” That means they had insurance, but it wasn’t enough to safeguard them from large medical bills.

Other data suggests it’s potentially even worse. A November poll from West Health and Gallup estimated that 58 million Americans experienced what they called “medication insecurity” in the past 12 months.

—Shefali Luthra

How about we start with what a president can do —  I love saying this — all by herself? On day one I will defend the Affordable Care Act and use march-in orders to reduce the costs of commonly used prescription drugs like insulin and HIV/AIDS drugs and EpiPens.

Sen. Elizabeth Warren, Feb. 7, 2020

On the campaign trail, Warren has often mentioned that she would use the power of the executive office to reduce prescription drug prices for drugs such as HIV medication and EpiPens. We checked it, and it is true that the president has these executive powers.

Warren has in her “Medicare for All” transition plan a pledge that she would use two legal mechanisms to achieve this goal — “compulsory licensing” and march-in rights. Compulsory licensing means the government will take over a patent if a drug’s prices are too high and create competition. There is precedent for this approach, it was done in the 1960s for cheap generic drugs and in 2001 for Ciprofloxacin during the anthrax scare. Experts said this likely couldn’t be applied to all drugs but could work for insulin and EpiPens.

March-in rights are when the government “marches in” during a public health crisis because a drug isn’t available. But, it only works for drugs in which the government holds all of the patents, such as Truvada, the HIV prevention drug. However, this mechanism has never been employed and it’s unclear whether high prescription drug prices would qualify as a public health concern. Officials at the National Institutes of Health would also have to approve this measure, and it would face significant backlash from the pharmaceutical industry.

Warren is right that the laws are in place for her to reduce prescription drug prices without the power of Congress, but it’s likely it would be difficult.

—Victoria Knight

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Must-Reads Of The Week From Brianna Labuskes

Happy Friday! In news that is technically really good and exciting but is also kind of icky: yarn made from human skin could eventually be used to stitch up surgical wounds as a way to cut down on detrimental reactions from patients. As CNN reports, “The researchers say their ‘human textile,’ which they developed from skin cells, can be used for knitting, sewing and even crochet.” My face has been stuck in the scream emoji since I read this story, so please join me. (Also for those who think neat!, make sure to check out Philadelphia’s Mutter Museum, which has a journal bound with human skin and is actually very cool.)

Now on to what you may have missed this week.

It’s that time of year! President Donald Trump gave his State of the Union address to Congress, where he declared the nation’s future to be “blazing bright.” During his speech he promised to “never let socialism destroy American health care,” encouraged Congress to send him a bill on drug pricing (to which Democrats began chanting the name of the legislation the House has already passed), and touted his administration’s push for price transparency in health care.

He also said that Democrats were trying to provide health coverage for immigrants who are in the country illegally; called for a ban on abortions that are late in term; promised to always protect Medicare; said more than 7 million people have been shifted off food stamps during his term; and took credit for a drop in health insurance premiums. Various outlets fact checked these statements — which range from completely false to misleading to true — so I’ll link to a collection of them.

Fact Checking State Of The Union: Premiums, Pre-existing Conditions, Price Transparency, And More

The New York Times: Six Takeaways From Trump’s 2020 State Of The Union Speech

Stat: Dems Interrupted The State Of The Union To Chant For Their Drug Pricing Bill

And now for the coronavirus roundup, where I sifted through hundreds of stories so you don’t have to. Before we dive in, just a reminder that there are still only 12 confirmed cases in the U.S.

— As coronavirus cases in China skyrocket past 30,000 (with 636 deaths), Chinese officials are now performing house-to-house searches in Wuhan, collecting the sick and warehousing them in quarantine centers. In the city, there’s a growing sense that the residents are being sacrificed for the good of the rest of the country. “There must be no deserters, or they will be nailed to the pillar of historical shame forever,” said Vice Premier Sun Chunlan.

The New York Times: China Tightens Wuhan Lockdown In ‘Wartime’ Battle With Coronavirus

— The death of one of the first Chinese doctors to warn about a coronavirus outbreak sent waves of grief and anger through a nation that’s growing more and more frustrated with how its government is handling the outbreak.

The New York Times: A Rare Online Revolt Emerges In China Over Death Of Coronavirus Whistle-Blower

— After a week of cases jumping by double-digit percentages, health officials still say it’s too early to declare that the virus has peaked.

The Wall Street Journal: World Health Authorities Warn Virus Hasn’t Peaked After China’s Deadliest Day

— Hundreds more Americans were evacuated from China and will be quarantined by the U.S. government. But the outrageous fact I learned this week is that those people (and their insurers) are on the hook for any medical costs that arise from being quarantined. For those who are deemed unable to afford health insurance, the government will pick up the tab but it might outsource some of those costs to programs like Medicaid when possible. The evacuees also have to pay for their flight out of China and the cost to get to their final destination when the quarantine is over.

CNN: What It Means To Be Under The Coronavirus Federal Quarantine In The US

— In what seems a bit like the start of a dystopian reality TV show, thousands of cruise passengers are being quarantined on two ships off the coast of Japan and Hong Kong. A third cruise has been turned away from multiple ports.

The Washington Post: Trapped On Coronavirus-Ravaged Cruise Ship, Diamond Princess Passengers Struggle To Keep Spirits Up

— This story is an interesting look at how the first case in the U.S. was discovered, and more broadly showcases local public health officials who are often the ones on the front lines of a new outbreak.

The New York Times: Inside The Race To Contain America’s First Coronavirus Case

— The majority of human diseases, including the coronavirus, are zoonotic, or passed from animals to humans. If you want a brief summary of some notable ones throughout history, check out this piece from WSJ that includes a shout-out to a 5,300 mummified man who, before he died from an arrow, suffered from Lyme disease.

The Wall Street Journal: Plagues From The Animal Kingdom

— Not to be all doom and gloom, it seems to be humans’ lot in life to constantly be at war with pathogens. That means even if we contain the coronavirus, there’s just another deadly pathogen waiting in the wings.

Bloomberg: Man Vs. Microbe: We’re Not Ready For The Next Global Virus Outbreak

Meanwhile, this year’s strain of the flu is hitting children particularly hard. More than half of the positive flu tests from public health labs this season have been in children and adults under the age of 25.

The Wall Street Journal: The Flu Is Hitting Children Especially Hard This Season

It might be hard to focus on anything but the results snafu at the Iowa caucuses, but advocates for disabled voters are also reporting back on how the efforts to expand access played out. The Iowa Democratic Party took strides this year to better help disabled voters participate, and for some the experience was positive. Others, however, said that reality looked a lot different than what the party’s messaging promised.

Stateline: Confusion Reigned In Iowa Caucus — Even Before The Chaotic Results

Stat: Amid Iowa Chaos, Some With Disabilities Got An Accessible Caucus Location

In theory, employers pay their workers less because part of their benefits package includes health insurance. But if the country moved toward a “Medicare for All” model, would workers see their wages increase dollar-by-dollar of what was being spent on coverage? Not necessarily.

The New York Times: Would Your Wages Rise Under ‘Medicare For All’?

Although the Trump administration’s roll-out of the “Healthy Adult Opportunity” program that would encourage states to shift toward a block-grant style of funding drew lots of attention, a little-noticed change that could lead to big cuts flew somewhat under the radar. Governors of both parties, however, are sounding the alarm that an arcane fiscal accountability rule could lead to cuts up to $49 billion a year.

The Associated Press: Trump Rule Could Lead To Big Medicaid Cuts, Governors Warn

As is often the case with bans, teenagers are already finding a way around the e-cigarette flavor restrictions that went into effect this week. The FDA only regulated reusable vaping products, but disposable pods (with flavors like pink lemonade) are widely available at gas stations and the like.

The Associated Press: FDA Crackdown On Vaping Flavors Has Blind Spot: Disposables

VA Secretary Robert Wilkie abruptly fired his undersecretary, James Byrne, this week in what he called a “simple business decision.” Wilkie was forced to defend the decision because Byrne was well-liked by the veterans community, and the loss was just the latest in a long string of turnovers at the top of the troubled agency. Some also questioned if the dismissal had anything to do with the investigation of sexual assault allegations by Navy veteran Andrea Goldstein.

The New York Times: Deputy Secretary Of Veterans Affairs Is Abruptly Dismissed

And in the miscellaneous file for the week:

— Following the recent deaths of 15 inmates, the Justice Department has opened a civil rights investigation into the Mississippi prison system, which seems to be in the grips of a violent crisis.

The New York Times: Justice Dept. Opens Civil Rights Investigation Into Mississippi Prisons

— Anonymous reporting systems that have been set up to help prevent school shootings have actually been helping combat the epidemic of suicides in teens. Schools and local officials are pouring billions of dollars into preventing the next mass attack, and yet self-harm and suicidal ideation are what students are reporting far more often than any kind of suspicious activity. Public health officials say this should be a wake-up call about the real threat to young people.

NBC News: School Tip Lines Were Meant To Stop Shootings, But Uncovered A Teen Suicide Crisis

— How do you raise kids to prepare them for the projected negative effects of climate change without causing more trauma, anxiety and depression in a generation that’s already struggling to cope with such mental health issues? It’s a fine line to walk, experts say.

The Washington Post: Eco-Anxiety Is Overwhelming Kids. Where’s The Line Between Education And Alarmism?

And that’s it from me! Have a great weekend.

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Big Tech’s Push Into Health Care Is So Last Year. Now It’s Big Retail That’s Making Waves.

Federal Officials Seek Information On Coverage ‘Guardrails’ Georgia Plans To Put In Place With Health Care Revamp

Geographical Disparities Created By Medicaid Restrictions Has Some People Crossing State Lines To Seek Care

Women Shouldn’t Get A Bill For An IUD … But Sometimes They Do

After a few months on daily contraceptive pills, Erica M. wanted something more reliable. She wanted an intrauterine device, a form of long-acting reversible contraception that doctors call one of the most effective forms of birth control. (Erica’s last name has been withheld due to privacy concerns.)

It shouldn’t have been a problem. Erica, 23 at the time, had insurance through work. Under the Affordable Care Act, most health plans must cover all methods of birth control without any cost sharing. In fact, the birth control pills she was using were fully covered — she paid nothing out-of-pocket.

But a few weeks after her June 2018 appointment, she found herself on the receiving end of an IUD bill for about $1,900. On her $9-an-hour income, that expense simply wasn’t feasible.

“I never got any indication that it wouldn’t be covered,” she said. “I found out after the fact, obviously too late to do anything about it.”

Stories like hers are difficult to track. There is little research on how often women see surprise bills for IUDs, though an analysis of private insurance claims data suggests it’s not common. For those who are slapped with a fee, though, the prices are sky-high — and growing.

Meanwhile, the Trump administration has issued rules to chip away at this contraceptive mandate, by expanding the cases in which employers can opt out of providing this coverage. Those efforts have been blocked by lower courts, and the Supreme Court has agreed to weigh in. If the administration succeeds, reproductive health experts say, that move will likely exacerbate the financial issues women like her face.

Theoretically, private health plans cover birth control with no out-of-pocket costs to patients. But there are exceptions, which are particularly relevant to the 60% of women who get insurance through an employer.

  • If your plan was “grandfathered” — meaning it was in place before the ACA took effect in 2010 and hasn’t changed since — it isn’t required to cover contraception. In 2019, about 13% of people getting insurance through work had a grandfathered plan.
  • Insurers aren’t required to cover every contraceptive product on the market. But they do have to account for one version of each birth control method, and cannot favor one method over others. (That means there has to be a hormonal IUD and a copper IUD available without cost sharing.)
  • If your employer is religious — such as a church — it is not required to provide contraceptive coverage.
  • If you work at a religiously affiliated institution, such as a university or hospital, your employer may not be required to buy contraceptive coverage, but the insurance company still has to pay for it. (This is the so-called religious accommodation.)

For almost everyone else who gets coverage through work or purchases an ACA-compliant plan, the policy should apply. However, there isn’t a clear or strong mechanism to make sure health plans that are required to cover birth control do so.

It is clear that, by and large, women now spend far less out-of-pocket on birth control than they did before the mandate. And the number of women opting for IUDs has gone up since the mandate took effect, though the number was already trending upward.

Still, the most recent research, conducted in 2014, found that insurance was inconsistent in guaranteeing full coverage of birth control options generally, and of IUDs specifically.

“This is an ongoing issue,” said Marian Jarlenski, an assistant professor of health policy at the University of Pittsburgh, who researches maternal and child health.

And the limited research means “no one knows how much of a problem this is,” said Dr. Nora Becker, a clinical fellow at Boston’s Brigham and Women’s Hospital, who has studied the contraceptive mandate’s impact.

In all likelihood, most women probably won’t get a bill for IUD insertion or a birth control prescription. Data compiled by the Health Care Cost Institute, an independent research group funded by insurers, suggested that in 2017 fewer than 5% of women had an out-of-pocket bill for the insertion.

Nevertheless, “there are definitely women out there who are still being billed inappropriately,” Becker said.

Erica worked at the time at a small religious college in Kentucky. So while the employer wasn’t required to cover birth control, her health plan still had to. She spent seven months going back and forth with her doctor, employer and insurance company before finally getting her plan to pay.

“It felt like a full-time job,” she recalled.

Patients often don’t have the time or resources to take on that kind of task.

“You may be hit by a surprise bill; you may just decide to pay out-of-pocket, not knowing there might be an appeals process; or you could go to a different clinic,” Jarlenski said.

And in those cases, the price is getting steeper.

The HCCI data didn’t indicate what patients with out-of-pocket costs ultimately paid. But it did showcase a sharp increase in what private insurance plans negotiated and then paid for IUDs over the past decade. Like much else in health care, there was wide variation in what different plans ended up paying.

From 2008 to 2017, the average payout for a Paragard copper IUD jumped from $420 to $818. In 2017, the top 90th percentile of private plans paid about $980 for the copper IUD; the bottom 10th paid $710.

“That’s a substantial difference,” said John Hargraves, a senior researcher at HCCI.

The impact may not be widely felt now, but reproductive health experts suggested it’s an issue that could grow more prevalent as the Trump administration pursues a federal rule change that would give more employers the ability to opt out of guaranteeing contraceptive coverage. Under the Trump proposal, religiously affiliated employers like Erica’s could drop coverage altogether, and the health plan she had wouldn’t still have to pay for contraception.

The change hasn’t taken effect — a federal appeals court issued a nationwide injunction last year, blocking the rule. This month, the Supreme Court agreed to hear the case. This decision marks the third time the high court has agreed to examine the contraceptive mandate, but the first case in which the deciding body will include the members nominated by President Donald Trump, Justices Neil Gorsuch and Brett Kavanaugh.

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Feds Slow Down But Don’t Stop Georgia’s Contentious Effort To Ditch ACA Marketplace

The Trump administration announced Thursday it was putting on hold Georgia’s proposal to significantly alter how that state’s Affordable Care Act insurance marketplace operates but suggested it is eager to help the state get it done.

“CMS is committed to working with states to provide the flexibility they need to increase choices for their citizens, promote market stability, and more affordable coverage,” a spokesperson for the Centers for Medicare & Medicaid Services, who declined to be identified, wrote in an email to KHN. “We are pleased to see states like Georgia take the lead in health care reform by creating innovative state based solutions.”

Federal officials in recent weeks had requested additional information from Georgia, and Republican Gov. Brian Kemp on Wednesday asked for a delay in the evaluation of a large portion of the proposal.

The state’s plan, which has drawn opposition from ACA supporters, proposes to jettison consumer access to the federal insurance enrollment website — healthcare.gov — and instead send people buying individual policies to private companies to choose coverage.

It would also cap how much is spent on premium subsidies, which could mean some consumers would be put on a wait list if they needed financial help to buy a plan. ACA subsidies are not capped in any state now.

The state’s proposal is the boldest yet under new guidelines the Trump administration issued in 2018 and 2019. Those guidelines widen the opportunity for states to try different approaches to expanding coverage and lowering costs for consumers who buy insurance themselves because they don’t get it through their job or a government program.

Georgia officials say the initiative would help drive down insurance costs — for the state and consumers — by providing more choices, permitting cheaper plans to be offered and capping financial assistance to consumers.

Last year, 450,000 Georgians enrolled in a health plan through the ACA, 88% of whom received a federal subsidy to help pay their premium.

Nationwide, 11 million people got health insurance through the marketplaces in 2019.

Ryan Loke, who handles special projects for Gov. Kemp, said state officials expected that the federal government would need more details as it reviewed the proposal. Georgia’s request “is a first in the nation approach to reforming the individual marketplace, and given the novelty to the approach — we expected that supplemental information would be required, and have worked with our federal partners to begin putting together the necessary information for their review.”

But critics in Georgia and two detailed analyses released in late January have slammed the proposal, initially submitted for federal review Dec. 23.

“If CMS were to approve this waiver in its current form, I would expect lawsuits on behalf of Georgia consumers and families,” said Laura Colbert, executive director at Georgians for a Healthy Future, a consumer group based in Atlanta that has called the proposal “terrible for Georgians.” “The proposal would encourage enrollment in substandard plans and likely cause many Georgians to lose coverage. People with preexisting health conditions would be put at risk.”

Such a lawsuit would add to the mountain of litigation surrounding the ACA, including two cases before the Supreme Court and an appeals court decision in December that threatens the entire law.

A decision favoring Georgia’s proposal would also add to the continuing high-profile political debate over the fate of the ACA.

“This is the first time a state has tried to take advantage of the Trump administration’s new approach to waivers, to implement some of the ideas the administration’s been pushing,” said Justin Giovannelli, a health policy expert at Georgetown University in Washington, D.C. “Other states and a lot of lawyers are watching closely.”

Georgia is making the request for new marketplace rules under a procedure known as a 1332 waiver. Under the law, states using such a waiver must still hew to strict rules set by the ACA.

For example, a state experiment can’t cost the federal government more money (for premium subsidies), raise costs for consumers on average, or result in fewer people gaining coverage than would be the case without the experiment.

Georgia’s proposal is in two parts. The first part seeks to establish a reinsurance program that picks up the tab for the care of high-cost patients using both state and federal funds. That allows insurers to keep costs down so they can offer lower premiums to consumers. The program, if approved, would go into effect in January 2021.

CMS says it will evaluate that part separately, with an eye toward swift evaluation and approval after a 30-day comment period. Final approval would make Georgia the 13th state to gain permission to use a reinsurance program.

Kemp has dubbed Georgia’s proposal for more far-reaching changes, starting in January 2022, the “Georgia Access Model.”

Instead of using the federal marketplace, Georgia would require consumers to enroll in coverage directly through insurance companies, brokers or private-sector websites.

At the same time, Georgia proposes to take over the administration of subsidies and cap the amount each year.

Insurers would also be allowed to sell plans that don’t comply with ACA requirements, under Georgia’s request. For example, one proposed type of plan could cover just half of a consumer’s costs for care, as opposed to the 80% to 90% levels of ACA’s silver and gold plans. Such a plan would have lower premiums but sharply higher out-of-pocket costs (such as deductibles and copays) if extensive care was needed.

Insurers and brokers would also be allowed to promote cheaper plans that don’t cover all the benefits required of current ACA plans.

Two studies released late last month concluded that Georgia’s proposal does not meet the guidelines for marketplace experiments set out in the ACA.

“There are very clear errors in Georgia’s proposal,” said Christen Linke Young, co-author of one of the reports and a fellow at the Brookings Institution in Washington, D.C. “The numbers don’t add up, and the proposal doesn’t meet the standards the ACA established. The plan would harm consumers if approved, and we don’t believe it can or should be approved.”

The second study, by the left-leaning Center for Budget and Policy Priorities (CBPP), also in Washington, concluded that Georgia’s proposal would “cause thousands of Georgians to lose coverage and … likely also leave many with less affordable or less comprehensive coverage than they would otherwise have.”

If premiums or enrollment rose by 10%, for example, CBPP calculates that Georgia would have to deny subsidies to between 15,000 and 34,000 people under the proposed cap.

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