Tagged Insurance

‘Delay, Deny And Hope You Die’: NFL’s Byzantine Rules Stymie Ex-Players Seeking Health Benefits

But Paul Scott, who worked as the NFL’s benefit plan point person, wants to change that. He’s hoping to help former players through the application process to get the disability benefits they’ve earned. Meanwhile, experts find fault in the way the University of Maryland treated football player Jordan McNair when he suffered from heatstroke, which led to his death.

Activist Investor Icahn Drops Opposition To Cigna-Express Scripts Deal After Advisory Firms Signal Their Support

Billionaire Carl Icahn had called the deal a “$60 billion folly,” but is now walking back his opposition in light of recommendations from Institutional Shareholder Services and Glass Lewis. The latter called the insurer’s offer for the pharmacy benefits manager “both strategically and financially compelling, structured in a reasonable manner from a valuation standpoint for Cigna shareholders.”

Feds Urge States To Encourage Cheaper Plans Off The Exchanges

For those who make too much money to qualify for health insurance subsidies on the individual market, there may be no Goldilocks moment when shopping for a plan. No choice is just right.

A policy with an affordable premium may come with a deductible that’s too high. If the copayments for physician visits are reasonable, the plan may not include their preferred doctors.

These consumers need better options, and in early August federal officials offered a strategy to help bring down costs for them.

The guidance is from the Centers for Medicare & Medicaid Services, which oversees the insurance marketplaces set up by the Affordable Care Act. CMS is encouraging states to allow the sale of plans outside of those exchanges that don’t incorporate a surcharge insurers started tacking on last year.

Many insurers added the premium surcharges last fall to plans sold on the individual market. It was a response to the Trump administration’s announcement that it would no longer pay the companies for the “cost-sharing reduction” subsidies required under the health law. The subsidies help cover deductibles and other out-of-pocket costs for lower-income consumers who buy marketplace plans.

Insurers typically added the cost to silver-level plans because those are the type of plans that consumers have to buy in order to receive the cost-sharing subsidies. “Silver loading,” as it’s called, added an estimated 10 percent to the cost of those plans, according to the Congressional Budget Office.

People who qualified for federal premium subsidies — those with incomes up to 400 percent of the federal poverty level (about $48,000 for one person or $100,000 for a family of four) — were shielded from the surcharge because their subsidies increased to cover the cost.

But people with higher incomes faced higher premiums. The new guidance is geared to help them.

“It encourages states to encourage silver loading only on the exchange,” said Aviva Aron-Dine, vice president for health policy at the Center on Budget and Policy Priorities.

But some analysts say they’re unsure if the new federal policy will make a difference since states have already implemented similar strategies.

Many states moved last fall to limit silver loading to plans sold on the exchanges, while allowing or, in the case of California, requiring, very similar plans to be sold off the exchanges without the extra premium charge.

Yet CMS’ endorsement of the strategy removes doubts states may have had, said David Anderson, a research associate at Duke University’s Margolis Center for Health Policy who has tracked the issue.

Eighty-three percent of people who bought a plan during the open-enrollment period for 2018 qualified for premium tax credits. The average monthly premium per subsidized enrollee was $639; after accounting for premium tax credits, however, enrollees owed just $89 on average. That amount was 16 percent lower than the monthly premium the year before.

For people who don’t qualify for premium tax credits, the picture is very different. The average monthly premium for 2018 was $522. That total was 28 percent higher than the previous year’s total of $407, according to an analysis by the Center on Budget and Policy Priorities of CMS enrollment data.

In general, federal rules require that insurers charge the same rates for identical qualified health plans that are sold on and off the exchanges. The CMS guidance suggests that the unloaded plans could be tweaked slightly in terms of cost sharing or other variables so that they are not identical to those on the marketplaces.

Tracing what type of coverage is purchased off the exchange is difficult because there is no centralized source. Consumers can buy plans directly from insurers, or they may use a broker or an online web portal. According to one such portal, eHealth, 28 percent of unsubsidized consumers on its site bought silver plans in 2018, while 42 percent bought bronze plans, whose coverage is less generous than silver plans and typically have lower premiums. Conversely, on the exchanges nearly two-thirds of people bought silver plans in 2018 while 29 percent bought bronze plans, according to federal data.

If fewer insurers add the CSR load to silver plans sold off the exchange, those plans may be more affordable next year than they were in 2018, said Cynthia Cox, director of health reform and private insurance at the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

“This makes silver plans an option for [unsubsidized] people who wanted to buy a silver plan but might have been pushed off onto a bronze plan,” she said.

Consumers who want to consider off-exchange plans have to find them first. Some experts suggest checking with insurers that are selling on the marketplace in an area, because it’s possible that they’ll also be selling plans off the exchange.

But that’s not a given. A health insurance broker can help people find and evaluate plans sold off the exchange. But experts urge consumers to stay on their toes and make sure they understand whether the plans they’re considering provide comprehensive coverage.

Starting in October, insurers can offer short-term plans with limited benefits that last up to a year.

“Differentiating between the two may not be easy, and the off-exchange unsubsidized market is the target market for short-term plans,” said Anderson.

Please visit khn.org/columnists to send comments or ideas for future topics for the Insuring Your Health column.

Feds Urge States To Encourage Cheaper Plans Off The Exchanges

For those who make too much money to qualify for health insurance subsidies on the individual market, there may be no Goldilocks moment when shopping for a plan. No choice is just right.

A policy with an affordable premium may come with a deductible that’s too high. If the copayments for physician visits are reasonable, the plan may not include their preferred doctors.

These consumers need better options, and in early August federal officials offered a strategy to help bring down costs for them.

The guidance is from the Centers for Medicare & Medicaid Services, which oversees the insurance marketplaces set up by the Affordable Care Act. CMS is encouraging states to allow the sale of plans outside of those exchanges that don’t incorporate a surcharge insurers started tacking on last year.

Many insurers added the premium surcharges last fall to plans sold on the individual market. It was a response to the Trump administration’s announcement that it would no longer pay the companies for the “cost-sharing reduction” subsidies required under the health law. The subsidies help cover deductibles and other out-of-pocket costs for lower-income consumers who buy marketplace plans.

Insurers typically added the cost to silver-level plans because those are the type of plans that consumers have to buy in order to receive the cost-sharing subsidies. “Silver loading,” as it’s called, added an estimated 10 percent to the cost of those plans, according to the Congressional Budget Office.

People who qualified for federal premium subsidies — those with incomes up to 400 percent of the federal poverty level (about $48,000 for one person or $100,000 for a family of four) — were shielded from the surcharge because their subsidies increased to cover the cost.

But people with higher incomes faced higher premiums. The new guidance is geared to help them.

“It encourages states to encourage silver loading only on the exchange,” said Aviva Aron-Dine, vice president for health policy at the Center on Budget and Policy Priorities.

But some analysts say they’re unsure if the new federal policy will make a difference since states have already implemented similar strategies.

Many states moved last fall to limit silver loading to plans sold on the exchanges, while allowing or, in the case of California, requiring, very similar plans to be sold off the exchanges without the extra premium charge.

Yet CMS’ endorsement of the strategy removes doubts states may have had, said David Anderson, a research associate at Duke University’s Margolis Center for Health Policy who has tracked the issue.

Eighty-three percent of people who bought a plan during the open-enrollment period for 2018 qualified for premium tax credits. The average monthly premium per subsidized enrollee was $639; after accounting for premium tax credits, however, enrollees owed just $89 on average. That amount was 16 percent lower than the monthly premium the year before.

For people who don’t qualify for premium tax credits, the picture is very different. The average monthly premium for 2018 was $522. That total was 28 percent higher than the previous year’s total of $407, according to an analysis by the Center on Budget and Policy Priorities of CMS enrollment data.

In general, federal rules require that insurers charge the same rates for identical qualified health plans that are sold on and off the exchanges. The CMS guidance suggests that the unloaded plans could be tweaked slightly in terms of cost sharing or other variables so that they are not identical to those on the marketplaces.

Tracing what type of coverage is purchased off the exchange is difficult because there is no centralized source. Consumers can buy plans directly from insurers, or they may use a broker or an online web portal. According to one such portal, eHealth, 28 percent of unsubsidized consumers on its site bought silver plans in 2018, while 42 percent bought bronze plans, whose coverage is less generous than silver plans and typically have lower premiums. Conversely, on the exchanges nearly two-thirds of people bought silver plans in 2018 while 29 percent bought bronze plans, according to federal data.

If fewer insurers add the CSR load to silver plans sold off the exchange, those plans may be more affordable next year than they were in 2018, said Cynthia Cox, director of health reform and private insurance at the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

“This makes silver plans an option for [unsubsidized] people who wanted to buy a silver plan but might have been pushed off onto a bronze plan,” she said.

Consumers who want to consider off-exchange plans have to find them first. Some experts suggest checking with insurers that are selling on the marketplace in an area, because it’s possible that they’ll also be selling plans off the exchange.

But that’s not a given. A health insurance broker can help people find and evaluate plans sold off the exchange. But experts urge consumers to stay on their toes and make sure they understand whether the plans they’re considering provide comprehensive coverage.

Starting in October, insurers can offer short-term plans with limited benefits that last up to a year.

“Differentiating between the two may not be easy, and the off-exchange unsubsidized market is the target market for short-term plans,” said Anderson.

Please visit khn.org/columnists to send comments or ideas for future topics for the Insuring Your Health column.

Shadowy Threesome Known As ‘Mar-A-Lago Crowd’ Have Been Silently Exerting Influence On Veterans Affairs

The Mar-a-Lago group is led by the reclusive chairman of Marvel Entertainment, Isaac Perlmutter, 75, a longtime friend of Mr. Trump’s and a member of his West Palm Beach golf club. Veterans advocates are worried that the group is going to exert pressure on new VA Secretary Robert Wilkie.

Must-Reads Of The Week From Brianna Labuskes

The next time I even hint that we’re drifting into a slow news period, feel free to remind me not to jinx things: This week was bursting with industry moves, health law attacks, midterm strategizing, and, oh yeah — an indictment.

A quick programming note before we dive into all that: The Breeze is going on hiatus as I breeze out of town for a bit. But I’ll be back Aug. 31, just as we really start heading into midterm season, so look for me again then.

Now for the news you may have missed:

This week’s swipe at the health law focused on accountable care organizations (shorthand explanation: a program that took a carrot-and-stick approach to getting hospitals, doctors and other providers to coordinate, with the end result of higher-quality, more efficient care). They were supposed to save the government billions of dollars, but data show they’ve failed to measure up to the promise, so the program is being overhauled.

The Washington Post: Trump Administration Proposes Further Dismantling of Affordable Care Act Through Medicare

Rep. Chris Collins (R-N.Y.) was charged with fraud in connection to alleged insider trading after an investigation into his ties with Innate Immunotherapeutics, an Australian biotech firm.

Politico: GOP Rep. Chris Collins Charged With Securities Fraud

If that all sounded vaguely familiar, it’s because back when then-HHS secretary nominee Tom Price was being vetted for any possible ethics violations, his connection to both Innate and Collins was put in the spotlight. And just a small plug: KHN did deep reporting on this, and you can read the stories here.

Medicare Advantage got some leverage to curb drug costs this week by way of “step therapy” (or, as it’s known to critics, “fail first”). Essentially, the private plans will be able to require that patients try cheaper versions of drugs before moving on to more expensive ones. To be clear: This is a pretty distant cry from campaign promises to let Medicare negotiate drug prices, and there’s no guarantee patients will actually see any savings from this move.

Stat: Private Medicare Plans Will Be Able to Use a New Tool to Lower Drug Costs

Would a Netflix model work for drugs? That’s what Louisiana wants to find out. Under the proposal, the state would pay a subscription-type fee to be able to cover all of its Medicaid patients who need hepatitis C treatment. Beyond the click-baity notion, though, experts warn that because drug prices are such a moving target (with some costs coming down quickly) the state may not actually save money.

Stat: Louisiana Explores a ‘Netflix’ Subscription Model for Buying Hepatitis C Drugs

For even some moderate Democrats, “Medicare-for-all” is a pipe dream involving all sorts of politically unpopular complications like trillions of dollars in government spending (the current point of contention). But on the trail, it’s a rallying cry. Gubernatorial candidates, especially, are embracing it, suggesting their states become early testing grounds for universal coverage plans that have been more rhetoric than action so far.

The Washington Post: Tossing Aside Skepticism, Democratic Candidates for Governor Push for State-Based Universal Health Care

The Hill: Ocasio-Cortez: ‘Medicare for All’ Is ‘Not a Pipe Dream’

Apart from “Medicare-for-all,” Democrats could have a winning health issue with drug prices. The problem? They can’t really coalesce behind a plan, all these “concessions” as of late are making it harder to attack the administration, and, uh, there may be a lack of interest in cutting off campaign cash this close to the elections.

Stat: Drug Prices Could Be a Winning Issue for Democrats — If Only They Had a Plan

The idea to penalize legal immigrants’ use of Medicaid has been rumbling around for a bit now, but it picked up some speed in recent days. Though it could be a winning issue for Republicans on the trail, the argument isn’t really backed up by the data. It turns out that legal immigrants are likely subsidizing native-born Americans’ health care.

The New York Times: Plan to Punish Immigrants for Using Welfare Could Boost G.O.P. Candidates

The Hill: Study: Immigrants Have Lower Health-Care Costs Than People Born in US

Buckle up, there were industry moves galore this week. I’ll try to keep it quick:  Billionaire Carl Icahn came out against Cigna’s attempts to acquire Express Scripts, saying it is (in my favorite vocab usage of the week) a “$60 billion folly”;  Rite Aid called off its (unpopular) merger with Albertsons; the American Medical Association came out against CVS’ deal with Aetna; and GM signed an exclusive deal with a health system to provide care for its workers.

The Wall Street Journal: Carl Icahn Publicly Opposes $54 Billion Cigna-Express Scripts Deal

The Wall Street Journal: Rite Aid, Albertsons Call Off Merger Amid Investor Opposition

Reuters: American Medical Association Opposes Merger of CVS and Aetna

The Wall Street Journal: GM Cuts Different Type of Health-Care Deal

If that wasn’t enough news for you, here’s my miscellaneous file: A billionaire and his PTSD clinics have become entangled in the fierce debate over VA privatization; a look at how Zika babies are faring as they grow up is sobering in the breadth of damage the virus has done; an app can warn those recovering from addiction when they’re in neighborhoods or with acquaintances that could trigger a relapse; and a medical examiner is writing to doctors personally each time one of their patients dies from an overdose — and it’s working.

ProPublica: Steve Cohen Is Spending Millions to Help Veterans. Why Are People Angry?

The Washington Post: 1 In 7 Babies Exposed to Zika in U.S. Territories Have Birth Defects, Nervous System Problems

Stat: Can An App’s Warnings to Avoid Triggers Prevent Opioid Addiction Relapses?

Los Angeles Times: Coroner Sent Letters to Doctors Whose Patients Died of Opioid Overdoses. Doctors’ Habits Quickly Changed

 —

And don’t miss one of my favorite long reads of the week (which I got sucked into while on deadline, thank you very much) about an Appalachian odyssey and a hunt for ALS genes.

Stat: Appalachian Odyssey: Hunting for ALS Genes Along a Sprawling Family Tree

Have a great weekend, all!

Podcast: KHN’s ‘What The Health?’ Coming Soon: ‘Long-Term Short-Term’ Plans

The Trump administration’s new rule allowing “short-term” insurance plans to be used for up to three years has touched off a big reaction in health policy circles. Supporters of the change say those who can no longer afford comprehensive health insurance will have the ability to purchase lesser but cheaper plans. But opponents worry that consumers who fail to read the fine print will end up with plans that won’t cover care they need.

Reaction is similarly divided over an administration rule change that will make it easier for managed-care plans participating in Medicare to negotiate the price of drugs provided in doctors’ offices or hospitals. Insurance groups call it a small but positive step; patient groups worry it will make it harder for those with serious medical problems to get the medication their doctors recommend.

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

Among the takeaways from this week’s podcast:

  • The Trump administration says its promotion of short-term health plans is designed to help people who don’t get government subsidies find more affordable health coverage and will provide some help to people who are not going to buy a plan on the federal health insurance marketplaces anyway. But the policies tend to limit many types of care, such as maternity expenses, prescription drugs and mental health issues.
  • In addition to concerns that these plans will destabilize the Affordable Care Act marketplaces, some consumer advocates say people looking at the plans don’t realize the extent to which they lack patient protections. For example, one may not cover hospital expenses if a patient is admitted over a weekend or pay for care needed for injuries if the patient was drunk.
  • As part of the administration’s effort to meet President Donald Trump’s promise to curb prescription costs, federal officials announced this week that private Medicare Advantage plans can require patients being prescribed drugs from a doctor or in a hospital to first try the cheapest drug options. But some patient advocates object, saying consumers and their doctors should be able to decide what is the best therapy.
  • The federal indictment announced this week against Rep. Chris Collins (R-N.Y.) renews questions about why a member of Congress with a large role in a biotech company was allowed to be a member of a House committee that oversees health issues. After the indictment, House Speaker Paul Ryan stripped Collins of his seat on the Energy and Commerce Committee.
  • New York Gov. Andrew Cuomo, a Democrat, surprised many people with his announcement that insurers would not be able to factor in to premium prices the expectation that fewer people will buy marketplace plans because the health law’s coverage penalties expire in 2019.

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

Julie Rovner: NPR’s “Doctors With Disabilities Push For Culture Change In Medicine,” by Elana Gordon

Anna Edney: The Atlantic’s “Women More Likely to Survive Heart Attacks If Treated by Female Doctors,” by Ed Yong

Margot Sanger-Katz: ProPublica’s “The Shadow Rulers of the VA,” by Isaac Arnsdorf

Kimberly Leonard: The Washington Post’s “A Huge Clinical Trial Collapses, and Research on Alcohol Remains Befuddling,” by Joel Achenbach

To hear all our podcasts, click here.

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

Democrats Tout $2 Trillion In Savings From ‘Medicare For All,’ But Author Of Cost Analysis Cries Foul

The Washington Post fact checks the notion that a recent working paper supports the idea that the proposal by Sen. Bernie Sanders (I-Vt.) would save $2 trillion in health care spending. To get to that number, one would need to make unrealistic assumptions, the report’s author says.

How Genetic Tests Muddy Your Odds Of Getting A Long-Term-Care Policy

This week, I answer questions from readers who are concerned about Medicare and insurance for long-term care.

Q: Can getting a genetic test interfere with being able to buy long-term-care insurance in the future? If you do get a plan, can the insurer drop you after you find out the results of a genetic test?

In general, long-term-care insurers can indeed use genetic test results when they decide whether to offer you coverage. The federal Genetic Information Nondiscrimination Act prohibits health insurers from asking for or using your genetic information to make decisions about whether to sell you health insurance or how much to charge. But those rules don’t apply to long-term-care, life or disability insurance.

When you apply for long-term-care insurance, the insurer may review your medical records and ask you questions about your health history and that of your family. It’s all part of the underwriting process to determine whether to offer you a policy and how much to charge.

If the insurer asks you whether you’ve undergone genetic testing, you generally have to disclose it, even if the testing was performed through a direct-to-consumer site like 23andMe, said Catherine Theroux, a spokeswoman for LIMRA, an insurance industry trade group.

“You need to release any medically relevant information,” she said.

Some states provide extra consumer protections related to genetic testing and long-term-care insurance, said Sonia Mateu Suter, a law professor at George Washington University who specializes in genetics and the law. But most follow federal law.

If you get genetic testing after you have a policy, the results can’t affect your coverage.

“Once the policy has been underwritten and issued, the insurer doesn’t revoke the policy if new medical information comes to light,” Theroux said.

Q: Can I switch Medigap insurance companies midway through the year? I found a less expensive policy.

It depends. Under federal law, when people turn 65 and first enroll in Medicare Part B they have a six-month window to sign up for a Medigap plan. Medigap plans pick up some of beneficiaries’ out-of-pocket costs for services under Medicare Part A, which covers hospitalization, and Medicare Part B, which covers outpatient services. During that six-month period, insurers have to accept people even if they have health problems.

If you’re still in that six-month period now and you want to switch plans, go right ahead.

But if you’re past the six-month window, under federal law insurers are required to sell you a plan only in certain circumstances, such as if you lose your retiree coverage or Medicare Advantage plan. If you don’t meet the criteria, insurers can decline to cover you or charge you more for preexisting medical conditions.

Many states have provided more robust protections, however. Three states — Connecticut, Massachusetts and New York — have year-round open enrollment and require insurers to offer coverage. And Maine requires a one-month “guaranteed issue” open-enrollment period every year.

Some states guarantee current policyholders a chance to switch Medigap plans at certain points during the year. Other states have additional qualifying events that allow people to switch Medigap plans, according to data from the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

“The first thing the person should do is check with her state insurance department to find out her rights related to buying a Medigap plan,” said Brandy Bauer, associate director at the Center for Benefits Access at the National Council on Aging. If someone decides to go ahead and switch, it is wise to sign up for a new plan before terminating your current policy, she said.

Q: I did not enroll in Medicare Part B when I turned 65 because I already have a regular plan that covers everything. I was told that the insurer would keep paying as usual, but now the company says it will pay only part and that I have to buy Medicare Part B. I didn’t want to pay for two policies. Is there anything I can do to avoid that?

From your description, it’s hard to know exactly what’s going on, but we can make educated guesses. Typically, when people turn 65, it makes sense to sign up for Medicare unless they or their spouse are working and getting health insurance from an employer. For others, at age 65, Medicare typically becomes their primary insurer and any other coverage they have becomes secondary, filling in gaps in Medicare coverage.

That’s how it generally works with retiree coverage, said Tricia Neuman, director of the Program on Medicare Policy at the Kaiser Family Foundation.

If you have an individual policy that you bought on the health insurance exchange and decide to hang on to it instead of signing up for Medicare, your premiums and other costs could be higher than they would be on Medicare, depending on your income.

But if you’re not receiving employee coverage and you don’t enroll in Medicare Part B, you could be subject to a permanent premium penalty of 10 percent for every 12 months that you could have signed up for Part B but didn’t. You could also owe a premium penalty for not signing up for a Part D prescription drug plan. (Most people don’t owe any premium for Medicare Part A, so there’s no penalty for late sign-up.)

“Without knowing more, it sounds like she should drop the [current] plan and sign up for Part B and D,” Neuman said. “But we need more information to know for sure.”

Your best move now may be to call 800-Medicare or visit your local state health insurance assistance program (SHIP) to help sort out your coverage issues.

Please visit khn.org/columnists to send comments or ideas for future topics for the Insuring Your Health column.

Once Its Greatest Foes, Doctors Are Embracing Single-Payer

When the American Medical Association — one of the nation’s most powerful health care groups — met in Chicago this June, its medical student caucus seized an opportunity for change.

Though they had tried for years to advance a resolution calling on the organization to drop its decades-long opposition to single-payer health care, this was the first time it got a full hearing. The debate grew heated — older physicians warned their pay would decrease, calling younger advocates naïve to single-payer’s consequences. But this time, by the meeting’s end, the AMA’s older members had agreed to at least study the possibility of changing its stance.

“We believe health care is a human right, maybe more so than past generations,” said Dr. Brad Zehr, a 29-year-old pathology resident at Ohio State University, who was part of the debate. “There’s a generational shift happening, where we see universal health care as a requirement.”

The ins and outs of the AMA’s policymaking may sound like inside baseball. But this year’s youth uprising at the nexus of the medical establishment speaks to a cultural shift in the medical profession, and one with big political implications.

Amid Republican attacks on the Affordable Care Act, an increasing number of Democrats — ranging from candidates to established Congress members — are putting forth proposals that would vastly increase the government’s role in running the health system. These include single-payer, Medicare-for-all or an option for anyone to buy in to the Medicare program. At least 70 House Democrats have signed on to the new “Medicare-for-all” caucus.

Organized medicine, and previous generations of doctors, had for the most part staunchly opposed to any such plan. The AMA has thwarted public health insurance proposals since the 1930s and long been considered one of the policy’s most powerful opponents.

But the battle lines are shifting as younger doctors flip their views, a change that will likely assume greater significance as the next generation of physicians takes on leadership roles. The AMA did not make anyone available for comment.

Many younger physicians are “accepting of single-payer,” said Dr. Christian Pean, 30, a third-year orthopedic surgery resident at New York University.

In prior generations, “intelligent, motivated, quantitative” students pursued medicine, both for the income and because of the workplace independence — running practices with minimal government interference, said Dr. Steven Schroeder, 79, a longtime medical professor at the University of California-San Francisco.

In his 50 years of teaching, students’ attitudes have changed: “The ‘Oh, keep government out of my work’ feeling is not as strong as it was with maybe older cohorts,” said Schroeder. “Students come in saying, ‘We want to make a difference through social justice. That’s why we’re here.’”

Though “single-payer” health care was long dismissed as a left-wing pipe dream, polling suggests a slim majority of Americans now support the idea — though it is not clear people know what the term means.

A full single-payer system means everyone gets coverage from the same insurance plan, usually sponsored by the government. Medicare-for-all, a phrase that gained currency with the presidential campaign of Sen. Bernie Sanders (I-Vt.), means everyone gets Medicare, but, depending on the proposal, it may or may not allow private insurers to offer Medicare as well. (Sanders’ plan, which eliminates deductibles and expands benefits, would get rid of private insurers.)

Meanwhile, lots of countries achieve universal health care — everyone is covered somehow — but the method can vary. For example, France requires all citizens purchase coverage, which is sold through nonprofits. In Germany, most people get insurance from a government-run “public option,” while others purchase private plans. In England, health care is provided through the tax-funded National Health System.

American skeptics often use the phrase “socialized medicine” pejoratively to describe all of these models.

“Few really understand what you mean when you say single-payer,” said Dr. Frank Opelka, the medical director of quality and health policy for the American College of Surgeons, which opposes such a policy. “What they mean is, ‘I don’t think the current system is working.’”

But the willingness to explore previously unthinkable ideas is evident in young doctors’ ranks.

Recent surveys through LinkedIn, recruiting firm Merritt Hawkins and trade publication NEJM Catalyst indicate growing support. In the March NEJM survey, 61 percent of 607 respondents said single-payer would make it easier to deliver cost-effective, quality health care.

Delving further, that survey data shows support is stronger among younger physicians, said Dr. Namita Mohta, a hospitalist at Brigham and Women’s Hospital and clinical editor at NEJM Catalyst.

But it’s unclear whether these findings reflect young doctors’ feelings about the policy or whether they are tapping in to broader frustrations with the American health system.

Much like the general public, doctors often use terms like single-payer, Medicare-for-all and universal health care interchangeably.

“Our younger generation is less afraid to come out and say we want universal health care,” said Dr. Anna Yap, 26, an emergency medicine resident at UCLA, who served as a medical student delegate to the AMA until this past June. “But how? It’s different in what forms we see.”

Younger doctors also pointed to growing concern about how best to keep patients healthy. They cited research that broadly suggests having health insurance tracks with better health outcomes.

“Medical students, I would say, are very interested in public health and improving social determinants of health — one of them being access to health insurance,” said Dr. Jerome Jeevarajan, 26, a neurology resident at the University of Texas-Houston, referring to non-medical factors that improve health, such as food or housing.

Some of the shift in opinion has to do with the changing realities of medical practice. Doctors now are more likely to end up working for large health systems or hospitals, rather than starting individual practices. Combined with the increasing complexity of billing private insurance, many said, that means contracting with the government may feel like less of an intrusion.

The debate is, at this point, still theoretical. Republicans — who control all branches of the federal government — sharply oppose single-payer. Meanwhile, single-state efforts in California, Colorado and New York have fallen flat.

Also, doctors represent only one part of the sprawling health care industrial complex. Other health care interests — including private insurance, the drug industry and hospital trade groups — have been slower to warm to catchphrases like single-payer or universal health care, all of which would likely mean a drop in income.

But increasingly physicians seem to be switching sides in the debate, and young physicians want to be part of the discussion.

“There’s tremendous potential … to be at the table if single-payer becomes a significant part of the political discourse, and create a system that is more equitable,” Pean said.

One Of Nation’s Largest Hospital Systems Agrees To $65M Settlement Over Medicare Overbilling Allegations

Prosecutors had alleged that Prime Healthcare Services unnecessarily admitted Medicare patients who were being treated at the emergency rooms of several hospitals in its system. Medicare pays more for patients who are admitted to hospitals than those who are treated as outpatients.

In Weary Post-Storm Puerto Rico, Medicaid Cutbacks Bode New Ills

SAN JUAN, Puerto Rico — Blue tarps still dot rooftops, homes lack electricity needed to refrigerate medicines, and clinics chip away at debts incurred from running generators. Yet despite the residual effects from last year’s devastating hurricanes, Puerto Rico is moving ahead with major cuts to its health care safety net that will affect more than a million of its poorest residents.

The government here needs to squeeze $840.2 million in annual savings from Medicaid by 2023, a reduction required by the U.S. territory’s agreement with the federal government as the island claws its way back from fiscal oblivion.

Overall, Puerto Rico faces a crushing debt of more than $70 billion — much of it due to the territory’s historically astronomical Medicaid expenses — on an island where the average household earns $20,000 and diabetes and hypertension are widespread.

But physicians, health insurers and former government officials say the drastic cuts demanded defy actuarial science and provide too little money to care for a population still traumatized by Hurricane Maria.

The cutbacks will give private health insurance companies the incentive to shuttle around patients with costly chronic diseases or mental illness, critics warn. And they do nothing to address the underlying fiscal imbalance at the root of Puerto Rico’s health care woes, which stem from the fact that the federal government contributes a tiny fraction of the island’s Medicaid budget, compared to what it contributes to the 50 U.S. states.

“We are rearranging the chairs on the Titanic,” said Dr. Jaime Torres, whose jurisdiction included Puerto Rico when he served as a regional director of the Department of Health and Human Services.

Already health plans have been forced to lay off social workers and nurses like Eileen Calderón, who once visited dozens of chronically ill Puerto Ricans each month, finding them specialists, supervising medicine compliance and arranging rides to doctor appointments.

“These people who have been under our service for the last four or five years, all of a sudden I have to abandon them,” said Dr. José Joaquín Vargas, chief medical adviser for VarMed, the Bayamon-based company that operated the program that employed Calderón.

Health Crippled By Debt

If Puerto Rico were a state, the federal government would pay 83 percent of Medicaid costs. (It pays upward of 70 percent of Medicaid expenses in 10 states, according to a formula that takes a state’s economy into account.) But because of a 1968 law capping the amount of Medicaid money Washington sends to U.S. territories, the federal government pays only about 19 percent, as a fixed annual payment — a so-called block grant.

In February, Congress approved $4.8 billion in additional funds to help pay the island’s Medicaid bills. But the additional payments are widely viewed as a stopgap measure; health economists say that extra money is likely to run out in September 2019, a grim estimate shared by the territory’s fiscal oversight board. That’s a federal control board established by Congress in 2016 to oversee Puerto Rico’s budget, negotiate with its creditors and help restructure at least some of the island’s debt.

Gov. Ricardo Rosselló’s administration aims to reduce Medicaid spending and improve access to care by putting an end to years of regional monopolies by private health insurance companies. The insurers have locked patients into narrow networks of health care providers. Later this year, under Rosselló’s plan, the companies will be forced to offer island-wide insurance plans and compete for customers.

“We do not have the luxury” of continuing to spend inefficiently, said Ángela Ávila Marrero, executive director of Puerto Rico’s Health Insurance Administration.

If Rosselló’s overhaul fails to achieve adequate savings — as most observers predict — drastic cuts are in the offing. Some 1.1 million Puerto Rican residents on Medicaidout of 1.6 million enrollees — are at risk of losing coverage next fall, their health held hostage to the island’s need to pay back its crippling debt.

Puerto Rico’s government effectively defaulted on more than $70 billion in debt. Economists blame a decades-long recession, a corporate tax break that ended in 2006 and reckless spending by a bloated government.

But also to blame, they say, and largely unnoticed in discussions of the debt, is Puerto Rico’s staggering Medicaid burden.

Poverty is so pervasive here that nearly 1 in 2 people qualify for public health insurance; Medicaid expenses in 2016 totaled $2.4 billion. Residents suffer from higher rates of chronic conditions like diabetes and asthma, and the percentage of people who are elderly is quickly rising.

Footing medical bills without the kind of federal assistance dispensed to states has effectively doomed the island’s fiscal health, health economists say.

Researchers of health care say that, putting aside interest on Puerto Rico’s debt, the territory’s primary fiscal deficit would have been erased had Congress paid the same share of Medicaid bills that it pays the 50 states and Washington, D.C.

“The main issue is that we are not yet a state,” said Rep. Jenniffer González-Colón, the commonwealth’s nonvoting member of Congress. The island must pay for Medicaid, she added, “with local funds that we don’t have.”

Battered Even Before The Storm

Puerto Rico’s health care system was already convulsing in September 2017 when Hurricane Maria struck. The federal government had issued warnings that the island would soon run out of additional Medicaid funds provided by the Affordable Care Act and 900,000 Puerto Rican residents would lose coverage.

Insurance companies, hospitals and physicians complained that the government was chronically late paying its bills. That frustration forced hospitals to defer maintenance and investments in new technology and fueled the exodus of thousands of physicians to the mainland in search of better incomes.

Today, Medicaid patients face long waits to see doctors on the island.

“If your kid needs a neurologist, for example, the waiting period is around six to 12 months,” said Dr. Jorge Rosado, a pediatrician in San Juan. “For a genetics specialty, it’s two to three years.”

The $4.8 billion in relief funding from Congress is propping up Medicaid while the Rosselló administration negotiates new contracts with health insurance companies and enacts other measures mandated by the fiscal oversight board. Those include a new Medicaid fraud detection system and enhanced data collection.

Little Time To Waste

Barring the unlikely passage of bills that would eliminate the cap on federal Medicaid spending in Puerto Rico, the disaster relief fund is projected to run out next fall. González-Colón also authored a bill calling for statehood, which would eliminate the federal government’s unequal treatment toward the island’s Medicaid program.

The fiscal control board established by Congress openly acknowledges the impending disaster. In an April 19 report, the board projects monthly costs per Medicaid patient will rise nearly 40 percent over the next six years, barring any changes, and that Puerto Rico “will hit a ‘Medicaid cliff.’”

Beginning this fall, Medicaid patients will be able to pick from at least four insurers, instead of being assigned to the one that had covered their ZIP code.

Puerto Rico has long capped monthly payments insurers receive for Medicaid patients regardless of how many medical services they use, a form of managed care. But the government here believes that the insurers — without their regional monopolies — will be forced to compete, offering better care and more efficient delivery. They could save money by reducing unnecessary emergency room visits or hospital stays and by negotiating discounted payment rates to providers.

The island’s government has vowed to pay private insurers extra money to care for those with expensive or chronic medical conditions. Insurers have cautiously welcomed the changes.

“I support the government on what they’re trying to do, but they didn’t price it properly,” said Dr. Richard Shinto, the president and chief executive of InnovaCare, an insurance company that sells plans in Puerto Rico.

He added, “The oversight board is fixated on cuts, but we’re never going to improve health care unless more money is put into the system.”

Government health officials argue Medicaid patients, especially those outside the San Juan metropolitan area, will gain access to more specialists, who are concentrated in the capital. But the island’s clinics and hospitals fear they will be squeezed by insurers seeking to lower costs, just as they are still reeling from hurricane-related expenses.

Hospital General de Castañer spent $5,000 every five days for gasoline to power the generators at its three sites for seven months; Health Pro Med, a community health center, spent at least $2,000 a day in added expenses, including private flights to ferry doctors to the storm-battered island of Vieques.

Many experts are skeptical that managed-care companies will hire the army of social workers and nurses like Calderón needed to trudge up hillsides, knock on doors and do the tedious work that entails solving the daily problems of poverty. Viewed through a narrow lens, with an eye for cutting expenses, such problems can seem far outside the purview of medicine.

Many people displaced by the storm haven’t yet been able to return home, and that, too, can complicate health care delivery. Carmen Ramos, executive director of Redes del Sureste, a conglomerate of 22 medical groups in Puerto Rico, says 60 percent of the letters she recently sent to patients on her mailing list were returned.

“The managed-care companies need to produce revenue,” said Victoria Sale, a senior director at Camden Coalition, a pioneer of social and health programs for the chronically ill. “That’s a setup for concern.”

Bottom line? The economic overhaul doesn’t rectify Puerto Rico’s fundamental problem — it can’t sustain its Medicaid program so long as Congress treats the territory differently than it treats states.

“Next year, we will go back to Congress demanding the funding we deserve as U.S. citizens,” said Torres. But, he added, “it’s time the local government started thinking about a Plan B.”

Must-Reads Of The Week From Brianna Labuskes

A slow health news week wrapped up with a flurry of movement over the Affordable Care Act in the past few days. As we drift into August, there are definitely a few stories to keep an eye on.

Here’s what you might have missed:

The Trump administration issued a final rule on short-term plans. (The highlights: Coverage can go for 12 months and be renewed for a max of 36 months; it doesn’t have to cover essential benefits; and there aren’t preexisting conditions protections.) Officials were surprisingly candid (“We make no representation that it’s equivalent coverage”) in acknowledging the skimpiness of these plans — which were only ever supposed to act as three-month stopgaps for people between jobs.

The New York Times: ‘Short Term’ Health Insurance? Up to 3 Years Under New Trump Policy

For Democrats in the Senate, there’s a silver lining: The move gives them an opportunity to try to force Republicans — just months before midterm elections, mind you — to go on record voting against those popular provisions that short-term plans strip away. There’s no chance such a measure would pass the House (much less be signed by President Donald Trump), but it puts their colleagues across the aisle in a tough spot.

The Associated Press: Dems Will Try Forcing Senate Vote Against Trump Health Plan

The latest attempt to unmoor the ACA is just one in a series of grenades the administration has lobbed at the health law. But premiums aren’t spiking as much this year, insurers are joining the marketplace instead of fleeing it, and public support for Obamacare is skyrocketing. Has the war been already won?

Politico: Trump’s Losing Fight Against Obamacare

And, that wasn’t the only hubbub over the health law this week. Four major cities are suing Trump, saying his multiple attempts to “sabotage” the legislation is a failure of his constitutional duty to enforce the laws of the land. (Spoiler: They’re unlikely to be successful.)

Reuters: Four U.S. Cities Sue Over Trump ‘Sabotage’ of Obamacare

Passion over HHS’ decision to separate children at the border continues to boil. The government is now making the argument that the burden of reuniting deported parents with their children should actually fall on the American Civil Liberties Union. The ACLU fired back saying that the government is the one that made the mess, and officials shouldn’t be able to foist it off now that it needs cleaning up.

Politico: Trump Administration Tells ACLU to Find Deported Parents

An eye-popping price tag for a “Medicare-for-all” proposal dominated headlines early this week, but experts are saying there’s more to that $32.6 trillion than it might seem. Essentially, the plan would actually save money in overall national health care spending, but shift it over to the government — which means higher taxes.

Modern Healthcare: Libertarian Think Tank: Providers Would Pay for Medicare for All

Rebates are being painted as the new villain in the blame game that is the conversation around lowering high drug prices. Here’s a primer on what they are — but don’t get too attached, they might not be around for long.

The New York Times: Meet the Rebate, the New Villain of High Drug Prices

Bloomberg: Secret Drug Price Rebates Will Go Away, Pfizer CEO Predicts

If that’s not enough news for you, my miscellaneous file is chock-full: New VA Secretary Robert Wilkie is planning on reassigning the officials who have been at the heart of the morale crisis plaguing the agency; Medicare could save nearly $3 billion in a single year if it were able to negotiate drug prices as other agencies can; the FDA put the companies that were selling a dangerous class of opioids in charge of monitoring abuse of said opioids — and then did little to intervene over poor prescribing practices; and the drug industry is pumping millions in charity money into those very towns that are suing the companies over their role in the opioid crisis.

The Washington Post: New Veterans Affairs Chief Plans to Reassign, Sideline Trump Loyalists Now in Power

Stat: Medicare Could Save $2.8 Billion in a Single Year if Prices Could Be Negotiated

The New York Times: F.D.A. Did Not Intervene to Curb Risky Fentanyl Prescriptions

Bloomberg: Facing Wave of Opioid Lawsuits, Drug Companies Sprinkle Charity on Hard-Hit Areas

And as if childbirth wasn’t hard enough, this woman says she had to have a C-section without anesthesia.

Have a great weekend!

WATCH: What You Should Know About The New Rule On Short-Term Health Plans

Kaiser Health News senior correspondent Julie Appleby explains on “PBS NewsHour” how the Trump administration’s approach to short-terms plans could make this form of health coverage more widely available.

But the plans also could cause premium increases for those consumers who opt for more comprehensive insurance through the Affordable Care Act marketplaces.