Tagged Legislation

On The Air With KHN

Kaiser Health News reporters have gone on television and radio shows in recent weeks to help explain the politics and policy at stake in the debate over a Republican plan to replace the Affordable Care Act. Catch up here on all the chatter:

Congressional Budget Office score released: 24 million Americans may lose coverage, Congress’ official scorekeeper finds. Julie Rovner, chief Washington correspondent for Kaiser Health News, describes the practical impact of the Republicans’ health care plan to “On Point” host Tom Ashbrook. (March 14)

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Health savings accounts debate revived: A crucial element of the Republican proposal, health savings accounts come with considerable tax breaks but mostly benefit the healthy and wealthy, Rovner tells “Here & Now” host Meghna Chakrabarti on WBUR. (March 13)

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Some left behind by GOP bill: Who are the winners and losers of the GOP plan? KHN senior correspondent Mary Agnes Carey explains on “Politics Inside Out” on Sirius XM Radio. (March 10)

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House health care bill would hit low-income and elderly Californians hardest: Chad Terhune, a senior correspondent for Kaiser Health News and California Healthline, discussed the House bill and how it would work in California with A Martínez, host of the “Take Two” show on Southern California Public Radio (KPCC). (March 10)

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Seismic changes to Medicaid proposed: The American Health Care Act accomplishes a long-held Republican goal of scaling back Medicaid from all except the neediest poor, Rovner tells Judy Woodruff on “PBS NewsHour.” (March 9)

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What is the American Health Care Act? Carey talks to Michael Smerconish of “The Michael Smerconish Program” on SiriusXM. Smerconish asks Carey, whom he calls the “health care whisperer,” to help listeners break down the GOP bill. Listen here. (March 9)

GOP tax credits raise cost to the elderly: Rovner talks to Judy Woodruff on “PBS NewsHour” about the impact on the individual market if the GOP plan becomes law: The criteria for tax credits shifts, with age becoming a greater factor than income. (March 8)

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How the Republican health care plan could affect you: Two days after Republicans unveil their plan to repeal and replace the Affordable Care Act, Carey joins Politico’s Dan Diamond and Susan Dentzer of the Network for Excellence in Health Innovation to discuss how the GOP plan could affect Americans on WAMU’s “1A” with Joshua Johnson. Listen here. (March 8)

American Health Care Act introduced: The day after House Republicans unveiled the American Health Care Act, Rovner discusses the legal restraints guiding what Republicans can repeal, and how, with the National Constitution Center. (March 7)

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Categories: Repeal And Replace Watch, The Health Law

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Trump’s Promise To Rein In Drug Prices Could Open Dam To Importation Laws

With prescription drug prices soaring and President Donald Trump vowing to take action, an old idea is gaining fresh traction: allowing Americans to buy medicines from foreign pharmacies at far lower prices. A new bill in Congress to allow the practice would modify previous safety standards and remove a barrier that proved insurmountable in past attempts to enable progress.

Congress came close to allowing importation through the Medicare Modernization Act in 2003, but added one firm precondition that has proved a nonstarter. The secretary of Health and Human Services had to guarantee that imported medications posed no additional risk to public safety and would save money.

“That is a fairly absolute standard and a high bar to cross,” said Elizabeth Jungman, director of public health at the Pew Charitable Trusts. Such an exacting standard — guaranteeing that no imported prescriptions posed a threat — has kept any secretary of HHS from condoning it.

In an open letter to Congress, four former commissioners of the Food and Drug Administration argue consumer drug importation remains too risky to permit. “It could lead to a host of unintended consequences and undesirable effects, including serious harm stemming from the use of adulterated, substandard, or counterfeit drugs,” they said in the letter distributed to media organizations. It was signed by Robert Califf, Margaret Hamburg, Mark McClellan and Andrew von Eschenbach, who headed the FDA at various times between 2002 through 2016.

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The recent proposal, from Sen. Bernie Sanders (I-Vt.) and such Democrats as Cory Booker from New Jersey and Bob Casey from Pennsylvania, drops that requirement. Instead, it sets up a regulatory system where Canadian pharmacies who purchase their supply from manufacturers inspected by the Food and Drug Administration would be licensed to sell to customers across the border. The bill allows not only individuals but drug wholesalers and pharmacies to buy from Canada.

After two years, HHS could allow importation from other countries that meet standards comparable to those of the U.S.

(Another bill in Congress, proposed in January by John McCain (R-Ariz.) and Amy Klobuchar (D-Minn.) focuses solely on allowing individuals to purchase from such pharmacies.)

Trump has promised that “pricing for the American people will come way down.” Last week, he had a high-profile meeting at the White House with Elijah Cummings, Peter Welch (D-Vt.) and the head of Johns Hopkins Hospital, Redonda Miller, to discuss allowing Medicare to negotiate prices on outpatient medicines. Cummings told reporters later that Trump said he supports Medicare price negotiation as well as the Sanders bill.

PhRMA, the drug industry’s trade group, has denounced Sanders’ proposal as it has others that enabled imports in the past.

“The bill lacks sufficient safety controls [and] would exacerbate threats to public health from counterfeit, adulterated or diverted medicines, and increase the burden on law enforcement to prevent unregulated medicines and other dangerous products from harming consumers,” said PhRMA spokeswoman Nicole Longo.

Surveys indicate that up to 8 percent of Americans have bought medicines outside the U.S. even though the practice is technically illegal and imported pills are subject to confiscation.

Around 45 million Americans — 18 percent of the adult population — said last year they did not fill a prescription due to cost, according to an analysis of data from the Commonwealth Fund by Gabe Levitt, president of PharmacyChecker.com, whose company helps Americans buy medications online by vetting overseas pharmacies and comparing prices for different drugs. Data compiled by the company comparing prices offered in Canada to those in New York, shows drugs are frequently three times or more as costly in the U.S. as over the border.

For example, a simple Proventil asthma inhaler costs $73.19 in the U.S. vs. $21.66 in Canada. Crestor, the cholesterol-lowering drug, is $6.82 per pill in the U.S. but $2.58 in Canada. Abilify, a psychiatric medicine, is $29.88 vs. $7.58, according to pharmacychecker.com.

Many previous bills to allow importation or to allow Medicare to negotiate prices for its beneficiaries have failed in the face of $1.9 billion in congressional lobbying by the pharmaceutical industry since 2003, according to Open Secrets. But Americans may be reaching a tipping point of intolerance. In polling just before the election by the Kaiser Family Foundation, 77 percent of Americans called drug prices “unreasonable” and well over half favored a variety of proposals to address them.

To address safety concerns, the Sanders bill institutes several new strategies. Canadian pharmacies that want to be registered to sell to Americans would have to pay a fee to pay for additional FDA monitoring. A General Accountability Office study would be required within 18 months of the final rule to address outcomes related to importation processes, drug safety, consumer savings and regulatory expenses.

Allowing people to legally import medications wouldn’t totally solve the problem of high prescription drugs, advocates say, but would be a step in the right direction. Said Levitt: “The best way for Americans to afford their meds is to enact polices here to bring the prices down here.”

KHN’s coverage of prescription drug development, costs and pricing is supported in part by the Laura and John Arnold Foundation.

Categories: Cost and Quality, Pharmaceuticals

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KHN On Call: Answers To Questions On Tax Credits, Penalties And Age Ratings

For years, Republicans in Congress have promised to repeal and replace the Affordable Care Act, claiming that its requirement for nearly everyone to buy insurance or pay a fine is burdensome and costly, and that it doesn’t give people enough flexibility to get the coverage they need.

Now that they’re in charge, the bill they’ve released as an alternative (the American Health Care Act) would effectively eliminate the requirement to buy coverage and might open up more health care choices. It’s also under fire because it may cause millions of people to lose their coverage. According to the nonpartisan Congressional Budget Office, up to 24 million more people could be without insurance by 2026 if it passes.

So what are the differences between the ACA and the GOP alternative, and what does it all mean to you and your health care? We put some of your questions from our Twitter chat (#ACAchat) earlier this month to Alison Kodjak, NPR health policy correspondent, and Julie Rovner, chief Washington correspondent for Kaiser Health News.

Many questions came in about the elimination of the requirement to buy insurance, known as “the mandate,” and how the lack of one might affect the health insurance market.

Is the mandate in the GOP bill? It won’t work if people sign up only when they are sick.

Kodjak: The mandate is technically still written into the law, but since no one will enforce it under this new bill, it’s unlikely to have any impact. In fact, the Internal Revenue Service has already issued some guidance that suggests it may not enforce the mandate very actively even now, before this bill becomes law. The result? People who think insurance is too expensive and don’t expect to need it are unlikely to sign up for a health plan.

Rovner: It’s true that the GOP bill technically preserves the mandate, but it eliminates the penalties. Instead, the bill would require those with a lapse in insurance of more than 63 days to pay an insurance premium that’s 30 percent higher for one year. Analysts say that could actually serve as a disincentive for healthy people to purchase insurance if they’ve had a break.

Can someone wait until they are sick to buy insurance, knowing that they would have to pay a 30 percent fine?

Rovner: Not exactly. There will still be standardized open enrollment periods once a year, and you will only be able to buy insurance outside of those windows if you have a life change, like moving or losing a job. But if you’re willing to wait as long as 11 months, then, yes, you can wait and buy insurance after you get sick.

Kodjak: It’s not without risk. The Department of Health and Human Services has already proposed regulations that would reduce that open enrollment period to six weeks from the current three months. So a patient may incur some health care costs while awaiting the open enrollment, and then face the 30 percent penalty when they do buy a health plan. However, if the individual has a health issue where treatment can wait, then they certainly can enroll at the correct time and then seek medical care.

We also got a lot of questions about the GOP bill’s new tax credits to help people buy insurance, and how different they would be from the structure of purchasing help in the ACA.

Explain the difference between tax credits and subsidies, and will tax credits be distributed quarterly or at the end of the year?

Kodjak: Both the ACA and the AHCA use advanceable, refundable tax credits. That means the government each month sends the tax credit amount to your insurance company.

We refer to the Obamacare financial assistance as a “subsidy” in part because the amount fluctuates and is based on your income — the idea is to limit your health costs to a specific percentage of your income. In addition, under the ACA, there are payments to insurers to help cover the copayments and deductibles of lower-income people.

Rovner: The tax credits differ in how large they are and how they are calculated. The ACA tax credits are based on income and how much insurance costs in a given area. The GOP credits, by contrast, are based primarily on age and do not vary according to the cost of insurance in an area, so in low-cost parts of the country they will go further than in very high-cost areas.

In addition, the ACA has a series of subsidies that help those with low incomes (under 250 percent of poverty; about $50,000 for a family of three) pay their deductibles and other out-of-pocket expenses in addition to the tax credits to help pay for premiums.

Why does the GOP bill provide age-based tax credits instead of income-based ones?

Kodjak: The basis for age-based tax credits is that people who are younger tend to have fewer health costs, so insurance policies are likely to be lower-priced for them than for older people.

Republicans prefer the fixed credits in part because they are cheaper, and more predictable, than the income-based credits under the Affordable Care Act. That’s because those ACA credits rise as premiums rise, giving insurers little incentive to keep their premiums low. Republicans hope that by restraining the government’s financial help to patients, insurance companies will offer cheaper policies that better match the cost of the tax credits.

Rovner: Younger adults, on average, need less health care than older adults. The ACA limited the differential in premiums for older adults to three times more than the amount charged to younger adults. The GOP bill would change that so older adults could be charged five times more. The change would make insurance less expensive for younger people, likely enticing more of them to enroll, and lowering premiums for all, at least marginally, according to the Congressional Budget Office. But it would dramatically increase premiums for older adults, particularly those aged 55-64, just under the age to qualify for Medicare.

Which brings us to this question, which represents several we received about how the AHCA appears to disproportionately penalize people ages 55-64.

Do I face a penalty for waiting to buy health insurance until I’m eligible for Medicare in three years? I’m concerned that I’ll be stuck with an expensive plan.

Kodjak: No 30 percent penalty if you wait for Medicare, but remember, if you get sick while you’re waiting, you could be in financial trouble.

Rovner: That is correct. Also, remember, if you fail to sign up for Medicare when you first become eligible at age 65, you would also pay a premium penalty. It’s 10 percent per year, forever.

Got more questions? We’ll keep answering them as the GOP bill moves through Congress. Send them to us via Twitter at #ACAchat or via email at KHNHelp@kff.org.

Categories: Repeal And Replace Watch, The Health Law

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GOP’s 3-Bucket Strategy To Repeal And Replace Health Law Is Springing Leaks

Republicans in Washington working to overhaul the Affordable Care Act say their strategy consists of “three buckets.” But it appears that all three may be leaking.

The plan to dismantle and replace Obamacare emerged after the Republican congressional retreat in late January. The first bucket is a fast-track budget bill that needs only a simple majority to pass the Senate. Because of congressional rules, however, it can only address parts of the health law that have immediate impact on federal spending.

The second consists of changes to regulations and other policies put in place by the Obama administration that could theoretically be undone by new Health and Human Services Secretary Tom Price. And the third is separate legislation that would do things Republicans have been advocating for many years, such as imposing caps on medical malpractice damages and selling health insurance across state lines.

All three are proving problematic at this point — among Republicans.

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“There is no three-phase process, there is no three-step plan,” Sen. Tom Cotton (R-Ark.) told radio host Hugh Hewitt Tuesday. “That is just political talk. It’s just politicians engaging in spin.”

“Anyone who believes in the three-step process is believing in a fantasy,” said Rep. Raul Labrador (R-Idaho) at a press conference Thursday.

The first part, the so-called budget “reconciliation” bill, is already drawing fire within the GOP, not to mention among Democrats. Conservatives, like Sen. Rand Paul (R-Ky.), derisively refer to it as “Obamacare Lite” and oppose the bill’s tax credits to help people buy insurance as a new entitlement. Moderates have been shaken by the estimate from the Congressional Budget Office that 24 million people could lose their health coverage if the bill passes.

The bill has passed through several committees, but members of the conservative House Freedom Caucus say they might be able to stop the bill from passing the House, in spite of heavy pressure from Republican leaders and the Trump administration.

“The question is: ‘Am I OK losing my election because I did the thing I promised I would do?’” said Freedom Caucus co-founder Labrador, referring to his promise to repeal the entire law. He said the answer to that question is yes: “I can live with myself if I do the things I promised I would do.”

Complaints about the bill from a several Republican senators suggest that there are more than enough GOP “no” votes in that chamber to block its passage.

Conservatives also question exactly how much of the law the administration can dismantle.

Price said at a CNN Town Hall Wednesday that he is ready to plunge into the “hundreds” of regulations and “thousands” of guidance letters issued by the Obama administration to implement the health law.

“If they hurt patients, they need to go away,” he said. “If they drive up costs, then they need to go away.”

But undoing all those rules comes with its own set of dangers.

“Step two requires us to believe that Tom Price is going to go outside the law,” Labrador said. He noted that conservatives often complain when an administration takes on authority not granted in legislation when devising rules.

“And we think the courts are not going to stop him from doing that?” Labrador asked. Reversing policy on existing law can open up new rules and regulations to lawsuits.

Cotton, in his radio interview, noted that whatever changes Price proposes are “going to be subject to court challenge, and therefore, perhaps the whims of the most liberal judge in America.”

Finally, while Republicans tend to agree on step three, the legislation that would implement their preferred policies for the nation’s health care system, there is one big hurdle: It would need 60 votes to pass a filibuster in the Senate, and getting eight Democrats to join seems highly unlikely.

“It’s not going to happen if you need 60 votes in the Senate,” said Sen. Lindsey Graham (R-S.C.) on MSNBC Wednesday.

Cotton agreed. “If we had those Democratic votes, we wouldn’t need three steps,” he said. “We would just be doing that right now on this legislation.”

Categories: Repeal And Replace Watch, The Health Law

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Do You Speak ‘Repeal and Replace’?

Have questions about the terminology being used in the debate over health care legislation? Click on the bubbles above to learn more. (Illustration by Lynne Shallcross; photo by Mandel Ngan/AFP/Getty Images)

President Donald Trump and many congressional Republicans campaigned on repealing the Affordable Care Act and replacing it with their own plan to overhaul the nation’s health care system. As the GOP develops its offering, its representatives are tossing around wonky health policy terms to describe their core strategies.

Want to know what it all means? See below for a tipsheet, then click on the thought bubbles above for easy-to-understand translations.

MEDICAID BLOCK GRANTS AND PER-CAPITA CAPS: The federal government gives states a set amount of money to pay for coverage for Medicaid recipients. This would be a shift from the current Medicaid program, where the federal government matches state Medicaid spending on a percentage basis. Learn more.

HEALTH SAVINGS ACCOUNTS: Also known as HSAs, these allow consumers to put money away on a tax-free basis as long as they use it for medical expenses. Learn more.

BUDGET RECONCILIATION: Legislative process that allows measures to pass with a simple majority in Congress. Budget reconciliation bills can’t be filibustered but must focus on provisions that have a budgetary impact. Learn more.

ESSENTIAL HEALTH BENEFITS: ACA-mandated categories of benefits that health plans must cover. They include emergency services, hospitalization and maternity care. Learn more.

INDIVIDUAL MARKET: Where people who do not have health coverage through the government or their employer purchase a plan directly from an insurer. It is sometimes called the non-group market. Learn more.

TAX CREDITS/SUBSIDIES: Financial assistance to help consumers purchase health insurance. Learn more.

HIGH-RISK POOLS: Insurance groups that cover individuals with high health insurance costs, such as people who have a past serious illness or a chronic condition. Learn more.

Visit Repeal & Replace Watch for more KHN coverage of the health law debate.

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By Law, Hospitals Now Must Tell Medicare Patients When Care Is ‘Observation’ Only

Under a new federal law, hospitals across the country must now alert Medicare patients when they are getting observation care and why they were not admitted — even if they stay in the hospital a few nights. For years, seniors often found out only when they got surprise bills for the services Medicare doesn’t cover for observation patients, including some drugs and expensive nursing home care.

The notice may cushion the shock but probably not settle the issue.

When patients are too sick to go home but not sick enough to be admitted, observation care gives doctors time to figure out what’s wrong. It is considered an outpatient service, like a doctor’s visit. Unless their care falls under a new Medicare bundled-payment category, observation patients pay a share of the cost of each test, treatment or other services.

And if they need nursing home care to recover their strength, Medicare won’t pay for it because that coverage requires a prior hospital admission of at least three consecutive days. Observation time doesn’t count.

“Letting you know would help, that’s for sure,” said Suzanne Mitchell, of Walnut Creek, Calif. When her 94-year-old husband fell and was taken to a hospital last September, she was told he would be admitted. It was only after seven days of hospitalization that she learned he had been an observation patient. He was due to leave the next day and enter a nursing home, which Medicare would not cover. She still doesn’t know why.

“If I had known [he was in observation care], I would have been on it like a tiger because I knew the consequences by then, and I would have done everything I could to insist that they change that outpatient/inpatient,” said Mitchell, a retired respiratory therapist. “I have never, to this day, been able to have anybody give me the written policy the hospital goes by to decide.” Her husband was hospitalized two more times and died in December. His nursing home sent a bill for nearly $7,000 that she has not yet paid.

The notice is — as of last Wednesday — one of the conditions hospitals must meet in order to get paid for treating Medicare beneficiaries, who typically account for about 42 percent of hospital patients. But the most controversial aspect of observation care hasn’t changed.

“The observation care notice is a step in the right direction, but it doesn’t fix the conundrum some people find themselves in when they need nursing home care following an observation stay,” said Stacy Sanders, federal policy director at the Medicare Rights Center, a consumer advocacy group.

Medicare officials have wrestled for years with complaints about observation care from patients, members of Congress, doctors and hospitals. In 2013, officials issued the “two-midnight” rule. With some exceptions, when doctors expect patients to stay in the hospital for more than two-midnights, they should be admitted, although doctors can still opt for observation.

But the rule has not reduced observation visits, the Health and Human Services inspector general reported in December. “An increased number of beneficiaries in outpatient stays pay more and have limited access to [nursing home] services than they would as inpatients,” the IG found.

The new notice drafted by Medicare officials must be provided after the patient has received observation care for 24 hours and no later than 36 hours. Although there’s a space for patients or their representatives to sign it “to show you received and understand this notice,” the instructions for providers say signing is optional.

Some hospitals already notify observation patients, either voluntarily or in more than half a dozen states that require it, including California and New York.

Doctors and hospital representatives still have questions about how to fill out the new observation care form, including why the patient has not been admitted. During a conference call Feb. 28, they repeatedly asked Medicare officials if the reason must be a clinical one specific for each patient or a generic explanation, such as the individual did not meet admission criteria. The officials said it must be a specific clinical reason, according to hospital representatives who were on the call.

Atlanta’s Emory University hospital system added a list of reasons to the form that its doctors can check off, “to minimize confusion and improve clarity,” said Michael Ross, medical director of observation medicine and a professor of emergency medicine at Emory. Emory also set up a special help line for patients and their families who want more information, he said.

The form also explains that observation care is covered under Medicare’s Part B benefit, and patients “generally pay a copayment for each outpatient hospital service” and the amounts can vary. But Ross said “this wording may be antiquated.” Medicare revised some billing codes last year to combine several observation services into one category. That means beneficiaries are responsible for one copayment if the observation stay meets certain criteria.

The new payment package also includes coverage for some prescription drugs to treat the emergency condition that brought the observation patient to the hospital, said Debby Rogers, the California Hospital Association’s vice president of clinical performance and transformation. Other drugs for that condition will be billed under Part B with separate copayments, she said.

But patients will have to pay out-of-pocket for any medications the hospital provides for preexisting chronic conditions such as high cholesterol, and then seek some reimbursement from their Medicare Part D drug plans for any covered drugs.

Yet, Ross said, most observation visits are less expensive for beneficiaries than a hospital admission if they stay a short time, which the inspector general’s report also concluded. Doctors should “front load” tests and treatment so that the decision to admit or send the patient home can be made quickly. “If you get them out within a day, they are more likely to go back to independent living as opposed to needing nursing home care,” he said.

Last summer, Judy Ehnert’s 88-year-old mother had a bad fall and broke her wrist. Following surgery, and additional complications, hospital officials told the family she would be kept for observation but she would need to go to a nursing home to recover. When the family learned what observation care meant, said Ehnert, a retired bookkeeper who lives in West Fargo, N.D., “that’s when we blew a cork.”

Then, after a few days in observation, Enhert’s mother contracted an infection and she was admitted to the hospital. “Her care was totally the same, in the same room, with the same doctor, the same nurse.” And Medicare covered her nursing home care.

“That’s what I expected at her age,” Enhert said. “I always thought that’s what Medicare was for.”

KHN’s coverage related to aging & improving care of older adults is supported by The John A. Hartford Foundation and its coverage of aging and long-term care issues is supported by The SCAN Foundation.

Categories: Aging, Health Industry, Medicare, Syndicate

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