Tagged Legislation

For Millennials, Both Good And Bad News In Senate’s GOP Health Bill

Darlin Kpangbah receives free health insurance through Medicaid and is grateful for the coverage in case of accidents, such as when she tore a ligament in her leg a few years ago. “I feel like I’m injury-prone,” said Kpangbah, 20, who lives in Sacramento, Calif. Without insurance, she said, the injury “would’ve been huge to pay for.”

Young adults like Kpangbah were among the biggest beneficiaries of Obamacare, which helped reduce the rates of uninsured millennials to record lows and provided millions of Americans with access to free or low-cost insurance as well as maternity care, mental health treatment and other services.

Now, Senate Republicans have proposed overhauling the Affordable Care Act — a move that could help some young adults by lowering the cost of their premiums in the private insurance marketplaces but could hurt others who gained insurance through a massive expansion to Medicaid. A Congressional Budget Office analysis of the bill released Monday estimated that 22 million Americans could lose coverage under the Senate bill, which could change significantly before an expected vote before July 4.

The proposed legislation also would retain a popular Obamacare provision that allowed young adults up to age 26 to stay on their parents’ insurance. But the bill in its current form also could dramatically reduce health coverage and care for other young adults, according to the bill’s many critics, which include the American Medical Association and the American Hospital Association.

“Don’t be fooled,” said Jen Mishory, executive director of the advocacy organization Young Invincibles. “This is going to be a bad deal, particularly for the most vulnerable young people.”

Mishory said one of the biggest concerns is that states could opt out of requiring insurers to provide benefits such as maternity care, mental health care and prescription drugs — all commonly used among young adults. “You will see a lot of young people not getting the kind of coverage they need,” she said.

The proposed changes in the marketplaces, however, could make coverage more attractive to young people. The Congressional Budget Office reports that the Senate bill would result in a larger number of younger people paying lower premiums to buy private plans. The proposal would allow insurers to charge older people up to five times more than others, which could mean lower premiums for younger people.

At the same time, the Senate bill shifts the amount people who qualify for subsidies must pay toward their own premiums, meaning that people under age 40 might pay a smaller portion of their income toward coverage than they do under Obamacare.

But young adults could face other cost increases because of larger deductibles and less help with out-of-pocket expenses. Some no longer would qualify for subsidies at all, because the bill would reduce the income threshold for eligibility.

Millions of young adults have enrolled in coverage through the insurance exchanges, in part because of a coordinated push to get as many healthy, young people into the marketplace to balance out older, sicker consumers who were eager to sign up right away.

About 27 percent of the 12.2 million consumers who enrolled in health insurance through the exchanges across the nation in 2017, were 18 to 34 years old. In California, 37 percent of 2017 enrollees were in that age group, according to Covered California, the state’s insurance exchange.

Steven Orozco, who lives in Los Angeles, is among them. He, his wife and 2-year-old daughter have a plan through Covered California. Orozco, who is a real estate agent, said they are all healthy so they don’t use it often, but he has it just in case of broken arms or other unexpected health needs.

Orozco, 32, said that he is concerned about what could happen in Washington and how that might affect his coverage, which currently costs about $450 a month.

Despite potential benefits to young adults in the private marketplace, the most damaging changes under the Senate proposal would be for young adults covered by Medicaid, said Walter Zelman, chairman of the public health department at Cal State-Los Angeles.

In addition to phasing out the expansion of Medicaid, the Senate bill also would result in reduced funding for the program, he said.

“The biggest impact on young people is the dismantling of Medicaid,” Zelman said.

Since the Affordable Care Act took effect, about 3.8 million young adults have gained coverage through the expansion of Medicaid, according to Young Invincibles.

In California alone, Zelman said, hundreds of thousands of young people won’t be able to access Medi-Cal, California’s version of Medicaid, if the expansion is phased out. Zelman, who worked to enroll California State University students into health coverage under Obamacare, said that historically the highest percentages of uninsured people have been young adults, low-income residents, part-time workers and Latinos.

“Those are my students,” he said. “And, more generally, those are young people overall. … Anything that threatens [their] access to health is bad for them,” he said.

It’s unclear whether the proposed Republican overhaul would result in more or fewer young enrollees.

Uninsured Sacramento resident Sydney Muns, 27, works at a nonprofit that doesn’t offer health coverage, and she earned too much money to qualify for Medi-Cal or receive Obamacare subsidies. Muns said she hopes premiums and out-of-pocket costs will decline in the future so she can get coverage.

“It’s just not affordable,” said Muns, who faces $50,000 in college loan debt. “I don’t know anyone my age who has insurance.”

Carly Carpenter, left, and Chyneise Dailey are each on their parents’ health insurance plans, but say they will purchase their own when they have to. (Kellen Browning/California Healthline)

But Chyneise Dailey, 24, said she plans to purchase health care whether or not she is required to do so. Dailey, who works at Sacramento State, remains on her parents’ Blue Cross health insurance plan, but knows she has only a couple of years before she has to buy her own coverage.

“You never know what can happen. You get into a car accident, you’re in the ER — do you want to pay full rate or do you want to pay your copay?” Dailey said. “I’d just rather be safe than sorry.”

Under both the Senate and House plans to overhaul Obamacare, young women who go to Planned Parenthood for reproductive health and other medical services could be hurt because of a provision to ban federal funding of the organization for a year.

That concerns Niki Kangas, 35, who frequently visits Planned Parenthood clinics even though she has job-based coverage from Kaiser Permanente. (Kaiser Health News, which produces California Healthline, is not affiliated with Kaiser Permanente.) Kangas, of Sacramento, said she is “pissed off” that the Senate’s proposed bill would impose a one-year ban on federal funding to the organization, which is a frequent target for conservatives.

“I’ve used Planned Parenthood a lot, either in between jobs or sometimes it’s just more convenient than going out to Kaiser, like if I just need birth control,” said Kangas, a project manager at a design agency. “I think for people who don’t have insurance through their work that it’s a resource they depend on.”

Mary Agnes Carey, Julie Appleby and Barbara Feder Ostrov contributed to this report.

This story was produced by Kaiser Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. KHN’s coverage in California is funded in part by Blue Shield of California Foundation.

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

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Analysis: Mitch McConnell Plans to Hide Trumpcare’s Pain Until After Midterms

Senate Majority Leader Mitch McConnell is well aware of the political peril of taking health benefits away from millions of voters. He also knows the danger of reneging on the pledge that helped make him the majority leader: to repeal Obamacare.

Caught between those competing realities, McConnell’s bill offers a solution: go ahead and repeal Obamacare, but hide the pain for as long as possible. Some of the messaging on the bill seems nonsensical (see: the contention that $772 billion squeezed out of Medicaid isn’t a cut). But McConnell’s timetable makes perfect sense — if you are looking at the electoral calendar.

Here are a few key dates in McConnell’s “Better Care Reconciliation Act” (BCRA) that seem aimed more at providing cover for lawmakers than coverage for Americans:

2019: First major changes and cuts to the Affordable Care Act exchanges happen after the 2018 midterm cycle, allowing congressional Republicans to campaign on a “fixed” health system, even though Obamacare is still largely in place next year.

2019: States share $2 billion in grants to apply for waivers under a much looser process through this fiscal year. These waivers could allow insurers to sell skimpy plans that have low price tags but don’t take adequate care of people with preexisting conditions. None of those waivers has to go into effect, however, until after 26 Republican governors face re-election in 2018.

2020: Stabilization cash that makes the markets more predictable and fair for insurers flows through the congressional midterm cycle and the 2020 presidential cycle. Then it disappears. Medicaid expansion funds hold steady through this crucial political window, too.

2024: States enjoy their last few sips of Medicaid expansion cash at the end of 2023 — just as, perhaps, a second Republican presidential term is ending.

2025: The bill changes the formula for the entire Medicaid budget (not just the Obamacare expansion), dramatically reducing federal funding over time. That starts eight years and two presidential election cycles from now.

McConnell insists everything about the bill has been aboveboard and transparent.

“Nobody’s hiding the ball here. You’re free to ask anybody anything,” McConnell said on June 13.

But he and his working group did literally hide the bill from Democrats and most Republicans, crafting it behind closed doors until there was just a week left before his goal to secure a vote on it. (That timing was thrown off Tuesday with the announcement the vote was delayed, but the dealmaking is just beginning.)

Meanwhile, at least two policy details in the bill may obscure the effects for several years and make the health insurance markets look better almost immediately by giving insurers a more predictable, more lucrative market.

One is a stipulation that compels the federal government, for two years, to pay the cost-sharing reduction payments to insurance companies that President Donald Trump has threatened to end. The payments are part of the Affordable Care Act, and they flow to insurers on behalf of low-income marketplace customers to cover their out-of-pocket health expenses. Republicans had sued to stop the payments, adding considerable instability to ACA marketplaces next year. McConnell ends that uncertainty for two years.

On top of that cash infusion, the BCRA proposes a “Short-Term Stabilization Fund” that would also aim to help lower premium costs and could attract a few more insurers into counties that are sparsely covered now. It would dish out $50 billion to insurers — $15 billion per year in 2018 and 2019 and $10 billion per year in 2020 and 2021.

The money would make up for the billions that the Republican-led Congress has refused to appropriate for insurance companies under the ACA’s risk corridors program. Risk corridors aimed to offset losses for insurers whose costs were more than 103 percent of expected targets. Congress has so far paid only 12.6 cents on the dollar of those obligations and faces lawsuits from insurers that were stiffed.

In short, the two pots of money would go a long way toward addressing the instability in Obamacare created by the Republican-led Congress, but only through the next presidential cycle in 2020.

Beyond timing, the legislation’s features allow senators to make truthful arguments that disguise negative effects.

Perhaps the key claim is that the Senate bill would increase access to insurance. It might, in that insurance companies in states that waive standards would be free to offer much cheaper plans. But those plans would be cheaper because they wouldn’t cover essential health benefits or adequately cover preexisting conditions. Lower-income Americans might be able to buy a plan — possibly a $6,000 deductible for someone who makes less than $12,000 a year.

A spokesman for McConnell did not answer a request for comment. But Democrats are keenly aware of the electoral machinations in the bill.

“Everything about this legislation, from the process to the effective dates of many of the provisions, is driven by political expediency,” said Brian Fallon, a Democratic consultant and former lead spokesman for Hillary Clinton’s campaign. “Mitch McConnell only cares about getting the ‘win,’ not about the substance of the bill.”

Senate Democratic aides who spoke on background were not sure that the steps the bill takes to shore up markets for the next two elections would work when insurance companies can see what lies ahead. But they agreed the timing and short-term fixes might help McConnell twist the arms of reluctant Republican senators.

“I think it will be enormously helpful to McConnell in a room with a moderate Republican who wants to be told, ‘Hey, a lot of this stuff that’s going to happen in this bill that you’re hearing about, that’s worrisome is past your re-elect, it’s past 2018, it’s past 2020,’” one senior aide said. “‘Just vote for it, it’ll be fine, we’ll figure the rest out later.’”

Democrats said McConnell’s hide-the-ball strategy will not work with voters, and they want Republican senators to know that before they vote.

“The polling already shows that, based on the fact that they control every aspect of government, Trump and the Republicans own everything that happens from now on in the health care system,” Fallon said.

Sen. Patty Murray (D-Wash.), the top Democrat on the Health, Education, Labor and Pensions Committee who has the task of leading the arguments against the GOP bill, thinks senators will imperil their political futures if they buy McConnell’s arguments.

“Sen. McConnell is doing everything he can to persuade Senate Republicans that Trumpcare won’t be devastating for the people they serve, but the facts are that Trumpcare is going to cause families to pay more, gut Medicaid, and take coverage away from millions of people,” Murray said. “Any Senate Republican who votes for Trumpcare and believes patients and families won’t hold them accountable is being sold a bill of goods.”

Still, McConnell knows how to work a legislative calendar. Expect a July full of closed-door dealmaking with reluctant senators, leading up to maximum leverage before the August recess.

Categories: 2018 Elections, Insurance, Medicaid, Repeal And Replace Watch, The Health Law

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House Seeks To Cap Malpractice Awards As Part Of Health Care Update

Last week, a jury awarded a Pennsylvania man $620,000 for pain and suffering in a medical malpractice lawsuit he filed against a surgeon who mistakenly removed his healthy testicle, leaving the painful, atrophied one intact.

However, if a bill before the House of Representatives passes, the maximum he would be able to receive for such “non-economic” damages would be $250,000.

Non-economic damages cover losses that are hard to put a dollar amount on such as suffering, loss of a limb, pain, and loss of companionship. In addition, medical malpractice awards may include monetary damages to cover medical costs and loss of future wages. Sometimes punitive damages may be awarded as well as punishment for reckless or other harmful behavior.

The bill is part of a package of proposed reforms that supplement the American Health Care Act, the House measure to replace the Affordable Care Act that was narrowly approved in May. The Trump administration pledged to support the tort reform legislation.

Passage is far from certain. Groups across the political spectrum oppose the measure. Patients advocates say it would be unfair to seriously injured people whose lives are changed forever because of medical negligence. Many conservatives don’t embrace it either because it would impose federal standards on tort law, an area where states have traditionally determined the rules.

Michelle AndrewsInsuring Your Health

The Congressional Budget Office estimated that the bill would lower health care costs by reducing medical liability insurance premiums and the use of health care services by providers worried about being sued. This would lead to lower spending on federal health care programs and lower medical insurance liability premiums. The effect would be to reduce deficits by nearly $50 billion over 10 years.

Supporters say caps on medical malpractice awards discourage frivolous lawsuits and reduce the cost of health care because providers no longer need to practice defensive medicine.

Yet research shows that costs from medical liability make up just 2 to 2.5 percent of total health care spending.

About half of states have a cap of some sort on non-economic damages in medical malpractice cases, according to Joanne Doroshow, executive director of the Center for Justice and Democracy, a consumer advocacy organization for civil justice issues.

Under the House bill, states that have caps on non-economic damage awards could keep those in place. In states without such caps, even if the state constitution prohibits them or state courts have struck them down, the federal $250,000 cap would apply.

The case of the Pennsylvania man’s surgery is a “never event,” one that experts on patient safety say should never occur. Since that state doesn’t have a cap on non-economic damages, if the House bill had been in effect, it would limit the amount that the jury could award the patient to $250,000. The patient, Steven Hanes, 54, also was awarded $250,000 in punitive damages.

Hanes declined to be interviewed, but his attorney, Braden Lepisto, said his client was shocked to learn of the proposed cap. “He felt that the $250,000 cap was ridiculous because that amount would not compensate him for what he has gone through and will go through moving forward,” Lepisto said in an email. He added, “The reality is that there are many individuals who are injured from medical negligence who do not have ‘economic loss’ as defined by the law. Nonetheless, their lives are altered from the pain and suffering, loss of life’s pleasures, and the emotional effects of the injuries.”

The House bill would also come into play in Florida, where earlier this month the state Supreme Court struck down caps on non-economic damages in medical negligence cases because the court ruled they violate the equal protection clause of the state constitution. The House bill would supersede the state court decision and impose the cap in Florida cases.

Although the damages cap is noteworthy, other elements of the House bill also trouble consumer advocates. For example, it would establish a three-year statute of limitations following an injury for consumers to bring a lawsuit, or a one-year limit from the date that the consumer discovers or should have discovered an injury.

“Because it’s [worded as] whichever comes first, for all intents and purposes it’s one year,” said Doroshow. “That is a drastic change. Almost no state has a statute of limitations that severe.”

The bill would also set limits on the amounts that lawyers can recover in contingency fees from consumer judgments. This seemingly consumer-friendly provision could actually harm patients, said Doroshow.

Medical malpractice cases are complex and expensive to bring, she noted. “If you have a law that caps the ability of the attorney to recover from the judgment, they’ll think twice before taking a case,” Doroshow said. “It hurts the patient’s ability to have a competent attorney or any attorney at all.”

Meanwhile, some supporters of tort reform say the House bill goes about it the wrong way.

“The federal government doesn’t really have a legitimate role to play here,” said Dr. Jeffrey Singer, a general surgeon in Phoenix who is an adjunct scholar at the libertarian Cato Institute, located in Washington, D.C.

Conservatives might be relying too much on the idea of tort reform to bring down health care costs, he said.

“It’s become almost a part of the canon of people who align themselves with the market-oriented conservative reforms school,” he said. “But it should be done at the state level and we’re fooling ourselves if we think that it’ll be the magic bullet.”

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

Categories: Health Care Costs, Health Industry, Insuring Your Health, Public Health

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Winners And Losers: 40 Is Old In Senate GOP Health Plan’s Subsidy Structure

People getting subsidies to help buy health insurance would see at least three sharp changes — tied to both age and income — that could dramatically affect how much they pay for coverage if the Senate Republican health plan becomes law.

The Senate bill released Thursday would reduce the income thresholds that determine eligibility, change the amount people who receive help pay toward their insurance premiums and peg subsidies to less generous coverage.

About 85 percent of the nearly 10 million consumers who enrolled in coverage last year through federal and state marketplaces received tax credit subsidies and other types of financial assistance. Under the Senate plan, some could pay less in premium costs, but many, particularly older Americans, could see their share of payments go up. And let’s be clear — you’re old at about 40.

Incomes Eligible For Help Fall To 350 Percent Of Poverty

The Affordable Care Act provides tax credit subsidies on a sliding scale for people earning up to 400 percent of the federal poverty level — an amount that equals about $47,520 this year for individuals. Starting in 2020, the Senate bill would drop that to 350 percent, which is now an annual income of about $41,580. As a result, fewer people would qualify. To be sure, some enrollees who exceed that new income limit might lose only a small subsidy because of the way the current law is structured, but older enrollees could lose substantial amounts. The Center on Budget and Policy Priorities estimated Thursday that a 60-year-old earning just above the cutoff would lose at least $3,000 annually in subsidies.

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Age Matters

Tax credits are just one part of the picture. Under the ACA, subsidy-eligible enrollees must pay a percentage of their annual household income toward premiums, ranging from about 2 percent to just over 9.5 percent for those with higher incomes. Those amounts go up over time. The Senate bill would adjust those percentages based on age, keeping the lower limit at around 2 percent, but exceeding 16.2 percent at the highest income and age group. So if you are 39 or younger, you generally would pay smaller percentages of your income when compared with what you pay under the ACA, ranging from about 2 percent to 8.9 percent.

But once you hit 40, things change. Let’s say you earn $41,580 — 350 percent of poverty — you would pay more than 12.5 percent of your income, or $5,197, under the Senate plan. That compares with $4,029, or 9.69 percent currently under the ACA. At that same income level, percentages rise to 15.8 for those ages 50 to 59 and up to 16.2 percent of income for those 60 and up.

Aiming For Bronze: Subsidies Tied To Less Generous Coverage

The Senate would link the subsidies to plans with less generous coverage than the ACA. Subsidies under current law are pegged to a benchmark “silver” plan, which covers an average of about 70 percent of medical expenses. The Senate would peg the subsidy to the median price of a policy that covers about 58 percent of health costs, roughly equivalent to today’s “bronze” plans. Consumers pay the rest of the cost, usually through deductibles and copayments. This year, average deductibles for bronze plans were more than $6,000, while silver plans averaged $3,500, according to consumer website HealthPocket. People could still use subsidies to buy more generous plans, but the premiums would be higher.

Christopher Condeluci, who served as tax and benefit counsel to the Senate Finance Committee when the ACA was drafted, said the changes might prompt more people to buy insurance, noting that subsidies will be available to those who are under the federal poverty level, which they aren’t under current law. Younger people also might benefit by paying less toward coverage, helping boost their enrollment.

To make that happen, however, he said, the formula had to be adjusted so older people at the higher-income end of subsidy eligibility pay more.

“The current ACA discourages younger people from getting in,” said Condeluci, who expects “the older-age lobby will continue to criticize this type of proposal.”

While getting people under the poverty level covered by insurance would be a good thing, it should be done by expanding Medicaid, said Sabrina Corlette, who studies the individual insurance market as research professor at Georgetown University’s Health Policy Institute.

“It’s much more expensive for the federal government to subsidize private insurance than provide a Medicaid benefit,” said Corlette, who also doubts that many people earning less than $12,000 a year have enough saved to cover the cost of a deductible in the types of plans the Senate proposal would subsidize.

In total, the changes proposed in the Senate bill mean, Corlette said, “the subsidy buys you less and the older you are, the more you will be asked to pay.”

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

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A ‘Safe’ Space To Shoot Up: Worth A Try In California?

Tawny Biggs’ seemingly happy childhood in the northern Los Angeles County suburb of Santa Clarita, Calif., showed no outward sign that she would one day struggle with drug addiction.

As Biggs tells it, she was raised with two siblings “in a very good family” by an assistant fire-chief dad and a stay-at-home mom. Her after-school hours were filled with hockey and soccer.

But paradise was lost sometime during her late teens, when emotional problems, drugs and alcohol turned Biggs into a self-described “nightmare.” One night, when she was amped up on cocaine, her boyfriend gave her a hit of something different to help her sleep: heroin.

Before she even knew what had happened, she was addicted. Six months later, she learned she had contracted hepatitis C from a dirty needle.

Biggs, now 37, finally got sober 14 years ago. Now, she helps others get clean as an admissions coordinator at Action Family Counseling drug and alcohol treatment centers, in her hometown. Based in part on her own arduous experience, she strongly supports a controversial proposal to establish venues where adult intravenous drug users can shoot up with clean needles under medical supervision and get referrals to addiction treatment.

The only injection facility currently operating in North America is in Vancouver, Canada. Australia and several countries in Europe also have such centers.

“I think it’s a great idea,” said Biggs. “Right now, in this climate, we have to think out of the box because we’re fighting an uphill battle.”

A bill pending in the state legislature, AB 186, would authorize eight California counties — Alameda, Fresno, Humboldt, Los Angeles, Mendocino, San Francisco, San Joaquin and Santa Cruz — to test so-called “safe injection sites.”

The legislation faces tough opposition. Critics say it essentially endorses the use of illicit drugs. And it is not likely to sit well with the federal government, particularly under Attorney General Jeff Sessions, whose hard line on drugs is well-known.

Advocates argue, however, that a different approach is needed to stem the rising tide of addiction and related deaths.

Earlier this spring, San Francisco’s Board of Supervisors instructed the Department of Public Health to form a task force to make recommendations on the establishment of safe injection venues.

Nationwide, several major cities — including Seattle, Baltimore and Philadelphia — are considering such publicly sanctioned locations as a means to curb escalating heroin drug overdoses and deaths; slow the spread of infectious diseases such as hepatitis C; and help people kick their lethal habits.

Across the United States, an exploding opioid epidemic has sent overdose deaths skyrocketing and policymakers scrambling for solutions. In 2015, opioid overdoses — both from prescription drugs and from more potent and easier-to-obtain street heroin — took the lives of 2,018 Californians and 33,091 Americans, according to data from the Kaiser Family Foundation. (California Healthline is produced by Kaiser Health News, an editorially independent service of the foundation.)

“This is a medical issue, it is a brain disease, and we have to get out of our shell of thinking that these are bad people and … they have to hit bottom and then decide to pull themselves up by their own bootstraps,” said Barbara A. Garcia, director of health at the public health department in San Francisco, where 22,000 residents are known IV drug users. “That’s the pathway to death.”

Safe injection sites would go beyond existing needle exchanges by allowing drug use on the premises. Under the proposed California measure, introduced by Assemblywoman Susan Talamantes Eggman (D-Stockton), health care providers stationed at the sites would be armed with the emergency medication naloxone, which is used to help revive people from opioid overdoses.

We got to do something different. People are dying everywhere.

Cary Quashen

“What we’re talking about here is essentially a medical facility,” said Christian Burkin, a spokesman for Eggman. “This is an opportunity to take drug abuse off the streets and put it into a safe and sterile environment.”

Opponents of the measure, including many law enforcement organizations, fear such sites would only serve to normalize illicit drug use and harm local neighborhoods.

“It creates a danger for the communities that these safe consumption program sites would be located in,” said Cory Salzillo, legislative director for the California State Sheriffs’ Association. “It doesn’t require anybody to undergo treatment. … It’s just effectively: ‘Here’s a safe place for you where you can come; here’s your needle, your paraphernalia and here you go, shoot up.’”

Even if the state measure were to pass, it might face significant resistance from the federal government, since the drugs that would be injected are illegal under U.S. law, said Stanley Goldman, a criminal law professor at Loyola Law School in Los Angeles.

“So you’d have to be fairly assured that the federal government was not going to proceed against such operations before people could feel completely comfortable with participating,” Goldman said.

Cary Quashen, president and founder of the Santa Clarita rehabilitation center where Biggs works, said that while he also has some reservations, he’d be likely to support the concept as long as drug users are offered access to recovery services at the centers.

“We got to do something different. People are dying everywhere,” Quashen said. “We lose more people in this country to accidental overdoses than to car crashes and gun violence.”

Burkin noted that the proposed safe injection clinics would be restricted to areas “where they are experiencing a high rate of opioid abuse, including death.”

A 2011 study published in The Lancet found that overdose deaths on the streets surrounding Vancouver’s safe injection site dropped 35 percent in the two years after it opened, compared with the two prior years. In the rest of the city, overdose deaths dropped 9.3 percent during the same period.

Another study showed a 30 percent increase in the use of addiction treatment services associated with the opening of the Vancouver site. Studies also suggest that supervised injection facilities in Australia and Europe have reduced overdoses without an increase of drug injecting or trafficking in their communities.

“We are not supporting what people call ‘shooting galleries,’” said Garcia, the San Francisco public health director. “I don’t believe in allowing people to just sit in a room and shoot drugs with each other — that is not something I’m going to support. What I will support is how do we engage those who are using drugs to help them reduce their harm and get better and go into recovery eventually.”

Another argument in favor of supervised injection sites is financial: Two recent studies showed that a single supervised injection site would save $3.5 million a year on health care costs in San Francisco and $6 million in Baltimore.

Burkin believes that, given a chance, the safe injection pilot programs will prove their worth.

“Someone addicted to opioids who is going to come to a facility like this is someone starting on the first step toward recovery,” he said. “This is not someone who is going to ignore appeals or attempts to get them connected to services.”

Tawny Biggs agrees. If it were not for a work colleague in recovery who introduced her to a 12-step program years ago, she said, she would not have survived.

When her boyfriend gave her that first hit of heroin, she said, it didn’t seem like a big deal.

“I was thinking, ‘I can handle this,’” Biggs recalled. “Then something snapped in my brain and there became no control over needing it. I knew at that point it was either I gave up my son to my mom and shot up dope until I died, or I got some sort of help.”

This story was produced by Kaiser Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

Categories: California Healthline, Mental Health, Public Health

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Descent Into Secrecy: Senate Health Talks Speak To Steady Retreat From Transparency

Congress struggling to finish a huge budget reconciliation bill. A GOP president pushing a major overhaul of federal payments for health insurance that could transform the lives of sick patients.

Sound familiar? The year was 1986. I was a rookie health reporter on Capitol Hill and watched a Medicare bill move from introduction, to hearings, to votes in subcommittees, to full committees and then to the entire House — an operation that took months and was replicated in the Senate, before the two chambers got together to iron out their differences for final passage. Everything was published in the official Congressional Record in almost excruciating detail for everyone to see — as long as they could read really tiny type.

Since then, in three decades of reporting, I’ve had a front-row seat to Congress’ slow, stuttering retreat from such step-by-step transparency, a process known as “regular order.”

It has now culminated in the Senate GOP leadership’s top-secret process to try to write a health bill that could change the formula for nearly one-fifth of the nation’s economy, with a vote they want to cast by July 4. In fact, a GOP Senate aide told the news site Axios on Monday that no details would be forthcoming until the bill is finished, adding, “We aren’t stupid.” That means bypassing the debate that traditionally went into lawmaking, in order to achieve consensus.

The extreme secrecy is a situation without precedent, at least in creating health law. Still, it’s not hard to see how we got here — and there is plenty of bipartisan blame to go around.

Since 1986, I have chronicled the passage (and repeal) of the Medicare Catastrophic Coverage Act, the fight over President Bill Clinton’s health proposal, passage of the Medicare prescription drug bill and passage of the Affordable Care Act, in addition to a dozen budget reconciliation measures that altered health care, often in fundamental ways.

Despite promises from incoming Democratic and Republican leaders over the past decade to restore a time-honored process, regular order has not returned. In fact, not only has it become increasingly rare, but the legislative process itself has become ever-more truncated, with Congress skipping steps it deemed inconvenient to partisan ends, particularly as leaders have “end run” the committees that are supposed to do the lion’s share of legislative work.

So long as there is bipartisan agreement, regular order can still prevail. A major bill completed in 2015 to reconfigure how Medicare pays doctors was the product of 15 months of work by Democrats and Republicans in the House and Senate, and passed three committees in open session by unanimous roll call votes.
But it has become progressively — and distressingly — more acceptable to set transparency aside in lawmaking over the years.

In the 1980s, Rep. Bill Natcher (D-Ky.) routinely closed the subcommittee markup of the spending bill to fund the Departments of Labor, Health and Human Services, and Education, even when there was no particular controversy to avoid. Reporters got to see the bill for the first time at the full Appropriations Committee markup.

Markups at the House Ways and Means Committee under Chairman Dan Rostenkowski (D-Ill.) also were frequently closed to the press and public, mostly for tax bills. Still, once I personally held up a health subcommittee markup for nearly a half-hour because the vote to close the session required a majority of members present. I refused to leave until a couple of committee members could be located and brought to the room to vote in person and kick me out.

Even meetings open to the press were sometimes less than revealing. In House-Senate conference meetings, members would frequently refer to what they were talking about using numbers on notes that were not shared with the audience, including reporters. So they basically spoke in code, and if you didn’t have the key you were just out of luck.

Of course, today there are fewer and fewer formal conference committees, places the two sides hammer out their differences in the public eye. Often the final versions of contentious bills are worked out behind closed doors, often without all of the members of the conference committee. In 2003, House Ways and Means Committee Chairman Bill Thomas (R-Calif.) retreated with all the Republican conferees and two of seven Democrats into his Capitol hideaway office in a group he called “the coalition of the willing.” They wrote the final bill in secret while reporters and lobbyists stood outside in the hall for weeks on end. (Sitting in the Capitol is considered civil disobedience and is strictly forbidden.) We were there so long and got to know one another so well that on my birthday someone got all the conferees in the room to sign a birthday card for me.

The final version of that bill was the one that passed the House in the dead of night – Republicans purposely scheduled the vote to begin at 1 a.m. (on the theory it would be easier to get wavering members to vote yes if only to go home to bed). The vote didn’t end until nearly 6 a.m., after President George W. Bush reportedly got the last few members to switch, via phone calls.

In 2009, creation of the Affordable Care Act was both open and closed. There were hundreds of hearings and markups that lasted days, or, in the case of the Senate Health, Education, Labor and Pensions Committee, months. But the unsuccessful effort by Senate Finance Committee Chairman Max Baucus (D-Mont.) to bring Republicans into the fold consisted of weeks of closed-door discussions, and the Senate bill that would ultimately become the foundation of the ACA was written in Senate Majority Leader Harry Reid’s office before being debated on the Senate floor for almost a month.

We got a sneak preview of how the GOP might shepherd its health bill through in 2015, when Republicans — who by then controlled Congress — orchestrated a “dress rehearsal” ACA repeal bill that was vetoed (as they knew it would be) by President Barack Obama. The bill was prewritten by leadership, approved by the relevant House committees, passed by the House and sent to the Senate. The Senate passed it with small changes (and without committee consideration). Rather than having a conference, the amended Senate bill was then simply approved by the House and sent to Obama for his veto.

That secretive process is being reiterated now. Only this time a Republican, Donald Trump, is president and the potential for change is real. People are outraged over the lack of transparency and the loss of regular order. But both Democrats and Republicans have laid the track on which this train is rolling.

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

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