Tagged Legislation

Must-Reads Of The Week From Brianna Labuskes

Happy Friday! Today is the day I’m going to challenge you to stretch those creative muscles and enter our Halloween Health Care Haiku Competition. Yes, it is going to be exactly as awesome as it sounds! The entries are already pouring in, check out the rules here. To kick things off, KHN’s very own talented and brilliant haiku master-in-residence Stephanie Stapleton wrote this one: “Goblins wear white coats, and not much is spookier, than the health system.”

Now on to what you might have missed this week.

Democrats packed themselves onto a crowded stage this week for what already feels like the umpteenth debate but was only the fourth or the sixth (depending if you count the two-nighters separately).

Going by the amount of heat she took, it seems safe to say Sen. Elizabeth Warren (D-Mass.) is considered by her rivals to be one of the race’s front-runners. With that spotlight, though, comes a target on her back.

South Bend Mayor Pete Buttigieg and Sen. Amy Klobuchar (D-Minn.) – who are both vying to become the alternative for former Vice President Joe Biden’s moderate voters – were particularly sharp in their demands for Warren to reckon with the costs of “Medicare for All.” The question of how she would pay for such a plan has been one she’s been managing to dodge, but her rivals tried to hold her feet to the fire on Tuesday. “At least Bernie’s being honest,” Klobuchar said at one point in reference to Sen. Bernie Sanders’ (I-Vt.) admission that the proposal will raise taxes.

FWIW: Despite being pressed to answer the direct question: “Will you raise taxes on the middle class to pay for it? Yes or no?” Warren still didn’t let herself be pinned down. Something that, the day after the debate, Biden jumped on as well.

The New York Times: Warren Draws Fire From All Sides, Reflecting A Shift In Fortunes In Race

The New York Times: Joe Biden Ramps Up Attacks On Elizabeth Warren’s ‘Credibility’

Health care is possibly the broadest (or at least one of the broader) topics that the candidates could talk about, and yet all it seems they’ve been discussing at the debates is health care coverage. Friends, you are not alone if you’re frustrated by not seeing a more diverse range of questions. Even Sen. Kamala Harris (D-Calif.) was fed-up enough to redirect the conversation toward abortion rights and reproductive health. Considering it’s such a viscerally hot-topic at the moment, the omission seems glaring.

Los Angeles Times: Kamala Harris Slams Republicans On Abortion, Says They’re Killing Poor Women Of Color

But it’s not just reproductive health that the moderators could ask about. Axios came up with at least four great questions that I think a lot of people in the field would like to have answered. Like: Many of the things that make people sick are not the fault of bad health care — they’re social factors like poverty, low-quality housing, etc. Should it be part of the health care system’s job to address them? (Hint, hint moderators.)

Axios: Four Health Care Questions For Tonight’s Democratic Debate

Don’t get me wrong, there were a few other health-related moments beyond “Medicare for All” bickering… including one of the more heated exchanges of the night. Beto O’Rourke said Democrats need to be courageous in their policies and not be scared of polls, to which Buttigieg responded: “I don’t need lessons from you on courage.”

The Wall Street Journal: Democratic Debate: The Moments That Mattered

Meanwhile, amid all this focus on “Medicare for All,” a new study counsels that there are many paths toward universal coverage—it doesn’t have to be “Medicare for All” or bust.

The Associated Press: Study: ‘Medicare For All’ Not Only Way To Universal Coverage


A big decision on the constitutionality of the health law is expected to drop sometime in the coming weeks. Although in theory, the Trump administration wants a certain outcome, if the court decides the ACA is unconstitutional, it could be a big ole headache for the White House heading into 2020. A ruling like that could not only foster confusion right around open enrollment, but also allow the Democrats to re-frame the health narrative in a way that could appeal to independent and moderate voters more than the current back and forth about “Medicare for All.”

The New York Times: How Pending Decision On Obamacare Could Upend 2020 Campaign


Rep. Elijah Cummings (D-Md.) passed away this week at 68 from complications of longstanding health problems. House Speaker Nancy Pelosi (D-Calif.) announced that she’ll be renaming her signature drug pricing policy after Cummings as he was a long-time champion of reigning in such costs.

Some might remember that it was Cummings who took Martin Shkreli, of “pharma bro” fame” to task at a hearing.

“It’s not funny, Mr. Shkreli,” Cummings said as Shkreli smirked. “People are dying, and they’re getting sicker and sicker.”

The Baltimore Sun: U.S. Rep. Elijah Cummings, Key Figure In Trump Impeachment Inquiry And Longtime Baltimore Advocate, Dies At 68

Stat: Pelosi: Democrats Will Name Marquee Drug Pricing Bill For Late Rep. Cummings


In a high-stakes, eleventh hour gambit Judge Dan A. Polster is summoning the drug CEOs involved in the massive, nationwide opioid trial to try to agree to a massive $50 billion settlement. Although the talks center around the big players involved — like AmerisourceBergen, Cardinal Health and McKesson — plaintiffs’ lawyers say they hope such a deal would have a domino effect on the remaining defendants.

Although the reports seem hopeful, those familiar with the talks say that the cities and counties are hesitant because they’re worried they’re not going to see their fair share of the money.

(This is as of press time! It’s happening today, so there could be developments depending when your read this—ah, the excitement of live news!)

The New York Times: Judge Summons Drug C.E.O.S For Talks On Sweeping Opioid Settlement

In a sea of heartbreaking stories on the opioid epidemic, this one stands out. The Washington Post took a look at West Virginia’s crisis and how court victories against drug companies aren’t really the panacea they’re sometimes made out to be.

The Washington Post: Inside West Virginia’s Opioid Battle: ‘They Looked At Us Like An Easy Target’


These two court stories feel like they happened ages ago, but really it was just last Friday post-Breeze. If you caught them happening in real time, there’s nothing to update, but I wanted to make sure I included them for anyone who wasn’t glued to their computer on a Friday evening.

The New York Times: Judges Strike Several Blows To Trump Immigration Policies

The Associated Press: US Appeals Court Skeptical Of Trump’s Medicaid Work Rules


This binge-worthy story needs no other introduction than the one ProPublica already wrote for it, so I’m going to quote them: “Welcome to Coffeyville, Kansas, where the judge has no law degree, debt collectors get a cut of the bail, and Americans are watching their lives — and liberty — disappear in the pursuit of medical debt collection.”

ProPublica: When Medical Debt Collectors Decide Who Gets Arrested

And, on a related note, if you’ve missed my colleague Jay Hancock’s coverage of UVA’s lawsuits against their patients, make sure to check out all the developments here.


Meanwhile, in the miscellaneous story file this week:

— Melody Petersen of LAT won the holy cannoli award this week with her investigation into the practice of harvesting body parts—and the coroners that go along with it. My face when reading the entirety of the article was an exact replica of the “shocked and distressed” emoji.

Los Angeles Times: In The Rush To Harvest Body Parts, Death Investigations Have Been Upended

— Deaths, poor quality of care, and other problems have absolutely plagued the Indian Health Service for years, and Native Americans are sick of it. They want to take over running their own health care system, but the task would be daunting.

The New York Times: Fed Up With Deaths, Native Americans Want To Run Their Own Health Care

— You can’t swing a cat these days without hitting some new CBD product. It seems inevitable that that kind of lucrative, thriving marketplace would draw pharma’s attention. Here’s a look at what companies are developing new drugs to tap into those profits. (PSA: but don’t actually swing any cats, please.)

Stat: These Four Companies Are Betting Big On CBD-Based Prescription Drugs

— If you want a fentanyl drug ring story that reads like a thriller, check this article out.

The New York Times: The China Connection: How One D.E.A. Agent Cracked A Global Fentanyl Ring


That’s it from me! Have a great weekend and don’t forget to get your flu shot!

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Courts Elections Health Care Costs Health Industry Insurance Medicare Pharmaceuticals Public Health The Health Law Uninsured

California’s New Transparency Law Reveals Steep Rise In Wholesale Drug Prices

Drugmakers fought hard against California’s groundbreaking drug price transparency law, passed in 2017. Now, state health officials have released their first report on the price hikes those drug companies sought to shield.

Pharmaceutical companies raised the “wholesale acquisition cost” of their drugs — the list price for wholesalers without discounts or rebates — by a median of 25.8% from 2017 through the first quarter of 2019, according to the Office of Statewide Health Planning and Development. (The median is a value at the midpoint of data distribution.)

Generic drugs saw the largest median increase of 37.6% during that time. By comparison, the annual inflation rate during the period was 2%.

Several drugs stood out for far heftier price increases: The cost of a generic liquid version of Prozac, for example, rose from $9 to $69 in just the first quarter of 2019, an increase of 667%. Guanfacine, a generic medication for attention deficit hyperactivity disorder (ADHD), on the market since 2010, rose more than 200% in the first quarter of 2019 to $87 for 100 2-milligram pills. Amneal Pharmaceuticals, which makes Guanfacine, cited “manufacturing costs” and “market conditions” as reasons for the price hike.

“Even at a time when there is a microscope on this industry, they’re going ahead with drug price increases for hundreds of drugs well above the rate of inflation,” said Anthony Wright, executive director of the California advocacy group Health Access.

The national debate over exorbitant prescription drug prices — and how to relieve them — was supposed to take center stage in recent weeks, as House Speaker Nancy Pelosi released a plan to negotiate prices for as many as 250 name-brand drugs, including high-priced insulin, for Medicare beneficiaries. Another plan under consideration in the Senate would set a maximum out-of-pocket cost for prescription drugs for Medicare patients and penalize drug companies if prices rose faster than inflation.

President Donald Trump has highlighted drug prices as an issue in his reelection campaign. But lawmakers’ efforts to hammer out legislation are likely to be overshadowed, for now, by presidential impeachment proceedings. In Nevada, health officials in early October fined companies $17 million for failing to comply with the state’s two-year-old transparency law requiring diabetes drug manufacturers to disclose detailed financial and pricing information.

California’s new drug law requires companies to report drug price increases quarterly. Only companies that met certain standards — they raised the price of a drug within the first quarter and the price had risen by at least 16% since January 2017 — had to submit data. The companies that met the standards were required to provide pricing data for the previous five years. In its initial report, the state focused its analysis on drug-pricing trends for about 1,000 products from January 2017 through March 2019.

California’s transparency law also requires drugmakers to state why they are raising prices. Over time, that information, in addition to cost disclosures, could create “one of the more comprehensive and official drug databases on prices that we have nationwide,” Wright said. “That, in itself, is progress, so that we can get better information on the rationale for drug price increases.”

But the data does not reflect discounts and rebates for insurers and pharmacy benefit managers and bears little resemblance to what consumers actually pay, said Priscilla VanderVeer, a spokeswoman for the trade group Pharmaceutical Research and Manufacturers of America. The group filed a lawsuit seeking to overturn the California legislation that has not yet been resolved.

“If transparency legislation only looks at one part of the pharmaceutical supply chain, without getting into the various middlemen like insurers and pharmacy benefit managers that ultimately determine what patients have to pay at the pharmacy counter, it won’t help patients access or afford their medicines,” VanderVeer said in an email.

State Sen. Richard Pan (D-Sacramento), a pediatrician who chairs the Senate health committee, agrees — up to a point.

“Transparency always has value,” Pan said. But policymakers need more data on how much insurers and consumers are spending on prescription drugs, he said.

And he wonders why the price of generic drugs, including those with plenty of competition, rose at higher rates.

His concerns were echoed by University of Southern California policy researchers, who recently published a study that concluded most state-level drug-transparency laws are “insufficient” to reveal the true transaction prices for prescription drugs, or where in the distribution system excessive profits lie.

“The question is, why are these prices going up? Typically, there are competing stories for that,” said Neeraj Sood, vice dean of the University of Southern California’s School of Public Policy and an author of the study. “Maybe cost of production is going up,” he said. “Maybe there’s a drug shortage, or some competitors got eliminated. This reporting of [wholesale acquisition cost] data doesn’t really tell us which of these stories is true.”

For now, California’s new data is not likely to be of much help to consumers, Pan said. But he said it might help state officials in their bid to overhaul the way the state purchases drugs for 13 million people served by Medi-Cal, the state’s Medicaid program for low-income residents. Gov. Gavin Newsom’s controversial plan to have the state, rather than individual Medi-Cal managed-care plans, negotiate directly with drugmakers would save the state an estimated $393 million a year by 2023, according to the administration.

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

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California Cost and Quality Health Care Costs Pharmaceuticals States

Extent Of Health Coverage Gains From California Gig Worker Law Uncertain

A new California law that reclassifies some independent contractors as employees, requiring they be offered a range of benefits and worker protections, will likely expand health insurance coverage in the state, health policy experts say.

But it might end up harming some workers.

That’s in part because the law, which takes effect Jan. 1, could cut two ways. While inducing many employers to extend health insurance to newly reclassified employees, it might prompt others to shift some workers from full-time to part-time status to avoid offering them health coverage, or — in the case of some small firms — to drop such benefits altogether.

Some companies might trim their workforce to limit cost increases. Benefits typically account for about 30% of total employee compensation costs, and health insurance is the largest component of that.

“I think we will see more people classified as employees over time,” said Ken Jacobs, chair of the Center for Labor Research at the University of California-Berkeley. “And that is very likely to expand the number who are offered and take coverage. But the situation is definitely fluid.”

Adding to the fluidity: Some large employers are contesting the new law. Uber, the ride-sharing app company, has said the law does not apply to its drivers and indicated it is prepared to defend its position in court. The company has joined competitor Lyft in broaching the idea of a 2020 ballot initiative to challenge the law.

California Gov. Gavin Newsom has indicated a willingness to negotiate changes and exemptions with those companies and others.

Uber did not respond to requests for comment, and Lyft declined to comment.

In addition to shared-ride drivers, the law affects construction workers, custodians and truck drivers, among others.

Some independent contractors prefer the flexibility that comes with setting their own hours, but others are eagerly eyeing health coverage.

Steve Gregg, a resident of Antioch, Calif., is among them. Gregg, 51, is uninsured and makes too much to qualify for Medi-Cal, the state’s version of the Medicaid program. He hopes to be reclassified as an Uber employee in 2020, primarily to gain access to health insurance.

“The only medical care I can really afford right now is to use an online doctor for my blood pressure medicine,” said Gregg, who typically logs 50 hours or more a week driving for Uber in the Bay Area.

Under the Affordable Care Act, companies with at least 50 full-time employees must pay a penalty if they don’t offer health insurance to those who work 30 hours or more a week.

California’s new “gig economy” law requires employers to treat independent contractors as regular employees if the work they perform is central to the core mission of the company and they operate under the company’s direction.

Several kinds of workers are exempt from the law’s provisions, however, including insurance and real estate agents, investment advisers, doctors and nurses, direct sales workers and commercial fishermen.

Jacobs said other states will closely watch what happens in California, given that some tech companies hire large numbers of independent contractors.

New Jersey, Massachusetts and Connecticut have similar labor laws on the books. Lawmakers in Oregon and Washington state are eyeing legislation akin to California’s.

Independent contractors in the Golden State are nearly twice as likely to be uninsured as regular employees, according to an analysis by UC-Berkeley’s Center for Labor Research, known as the Labor Center. From 2014 to 2016, just under 70% of workers classified as employees had employer-sponsored health insurance, compared with 32% of independent contractors, the study shows.

An estimated 1.6 million of the state’s 19.4 million workers are full-time independent contractors, according to another analysis by the Labor Center. It is unclear precisely how many contractors are “misclassified,” but sponsors of the new law, led by Assemblywoman Lorena Gonzalez (D-San Diego), put the number at around 1 million.

Whatever the exact number, employers who rely on contract workers will need to make complex health insurance decisions.

A company whose contract workers average 35 to 40 hours a week, for example, could reclassify them as employees for the purpose of complying with the new law but try to limit their weekly hours to fewer than 29, thus avoiding the ACA coverage requirement, said Dylan Roby, an associate professor of health policy and management at the University of Maryland and an adjunct associate professor at UCLA.

A large proportion of small companies that are not required by the ACA to cover their employees do so anyway, and the ones that hire independent contractors will also face hard choices.

“If they have to expand that to reclassified employees, the cost could be substantial,” said Christen Linke Young, a health insurance researcher at the Brookings Institution in Washington, D.C.

A small firm with a skilled and relatively high-wage workforce might choose to absorb the cost of expanding coverage to reclassified workers, Young said, because those workers might not qualify for subsidies to buy health insurance on their own through Covered California, the state’s ACA marketplace. Offering insurance is also a retention tool.

Other small companies, however, could choose to drop coverage altogether rather than pay the tab for newly reclassified workers.

And some might be able to place the new employees in a separate category and offer them no health benefits, or less generous ones than the existing employees get. But under federal law, an employer can do that only if the new employees are doing a different kind of work than the current ones, Young said.

Companies of all sizes can wait a year before offering new employees coverage, to establish what their average weekly hours are. That buys firms with 50 or more employees time to decide whether the reclassified workers qualify for health benefits under the ACA.

The uncertainty about how the new law will play out is sowing confusion among many independent contractors.

Vanessa Bain, a resident of Menlo Park, Calif., who works full time as a contract worker for Instacart — a same-day delivery service for groceries — worries about what her employer will do.

Bain and her family are enrolled in Medi-Cal, California’s version of the Medicaid program for people with low incomes. But she would rather get insurance through Instacart.

“What will they offer us?” Bain, 33, wonders. “If the premiums are too high or the coverage crappy, we may be better off buying it on our own through Covered California. We’ll have to see.”

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

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California Cost and Quality Health Care Costs Insurance States The Health Law