Tagged Medicaid Expansion

Biden’s ‘Incremental’ Health Plan Still Would Be A Heavy Lift

The headlines about presidential candidate Joe Biden’s new health care plan called it “a nod to the past” and “Affordable Care Act 2.0.” That mostly refers to the fact that the former vice president has specifically repudiated many of his Democratic rivals’ calls for a “Medicare for All” system and instead sought to build his plan on the ACA’s framework.

Sen. Bernie Sanders, one of Biden’s opponents in the primary race and the key proponent of the Medicare for All option, has criticized Biden’s proposal, complaining that it is just “tinkering around the edges” of a broken health care system.

Still, the proposal put forward by Biden last week is much more ambitious than Obamacare — and, despite its incremental label, would make some very controversial changes. “I would call it radically incremental,” said Chris Jennings, a political health strategist who worked for Presidents Bill Clinton and Barack Obama and who has consulted with several of the current Democratic candidates.

Republicans who object to other candidates’ Medicare for All plans find Biden’s alternative just as displeasing.

“No matter how much Biden wants to draw distinctions between his proposals and single payer, his plan looks suspiciously like “SandersCare Lite,” wrote former congressional aide and conservative commentator Chris Jacobs.

Biden’s plan is built on expanding the ACA to reduce costs for patients and consumers, similar to what Hillary Clinton campaigned on in 2016. It would do things Democrats have called for repeatedly since the ACA was passed. Among them is a provision to that would “uncap” federal help to pay for health insurance premiums — assistance that is now available only to those with incomes below 400% of the poverty level, or about $50,000 for an individual. Under Biden’s plan, no one would be required to pay more than 8.5% of their income toward health insurance premiums. The plan also proposes to make coverage more affordable to use by effectively lowering deductibles and copayments.

But it includes several proposals that Congress has failed repeatedly to enact, including some that were part of the original debate over the ACA. It also has some initiatives that are so expansive, it is hard to imagine them passing Congress — even if Democrats sweep the presidency and both chambers of Congress in 2020.

Here are some of the more controversial pieces of the Biden health plan:

Public Option

Although many of the Democratic presidential candidates have expressed varying degrees of support for a Medicare for All plan, nearly all have also endorsed creating a government-sponsored health plan, known colloquially as a “public option,” that would be available to people why buy their own health insurance. In other words, it would apply to those who don’t get insurance through their job or qualify for other government programs, like Medicare or Medicaid.

A public option was included in the version of the ACA that passed the House in 2009. But it could not muster the 60 votes needed to pass the Senate over GOP objections — even though the Democrats had 60 votes at the time.

Biden’s public option, however, would be available to many more people than the 20 million or so in the current individual insurance market. According to the document put out by the campaign, it would be available to those who don’t like or can’t afford their employer insurance, and to small businesses.

Most controversial, though, is that the 2.5 million people ineligible for either Medicaid or private insurance subsidies because their states have chosen not to expand Medicaid would be automatically enrolled in the new public option, at no cost to them or the states where they live. Also included automatically in the public option would be another 2 million people with low incomes who currently are eligible for ACA coverage subsidies but would also be eligible for expanded Medicaid.

That part of Biden’s proposal has prompted charges that the 14 states that have so far chosen not to expand Medicaid would save money compared with those that have expanded, because expansion states have to pay 10% of the cost of that new population.

Jennings, the Democratic health strategist, argued that’s unavoidable because it’s the population that needs coverage most. “If you’re not going to have everyone get a plan right away, you need to make sure those who are most vulnerable do,” he said.

Abortion

The Biden plan calls for eliminating the “Hyde Amendment,” an annual rider to the spending bill for the Department of Health and Human Services that forbids the use of federal funds to pay for abortions. Biden recently ran into some difficulty when his position on Hyde was unclear.

But the plan also calls for federal abortion funding. “[T]he public option will cover contraception and a woman’s constitutional right to choose,” said the document.

In 2010, the Affordable Care Act very nearly failed to become law after an intraparty fight between Democrats who supported and opposed abortion funding. Abortion opponents wanted firm guarantees in permanent law that no federal funds would ever be used for abortion; abortion-rights supporters called that a deal breaker. Eventually, a shaky compromise was reached.

And while it is true that there are now far fewer Democrats who oppose abortion in Congress than there were in 2010, the idea of even a Democratic-controlled Congress voting for federal abortion funding seems far-fetched. The current Democratic-led House has declined even to include a repeal of the Hyde Amendment in this year’s HHS spending bill, because it could not get through the GOP-controlled Senate or get signed by President Donald Trump.

Undocumented Immigrants

When Obama said in a speech to Congress in September 2009 that people not in the U.S. legally would be ineligible for federal help purchasing insurance, it prompted the infamous “You lie!” shout from Rep. Joe Wilson (R-S.C.).

Today, all the Democratic candidates say they would provide coverage to undocumented residents. There is no mention of them specifically in the plan posted on Biden’s website, although a campaign official told Politico that undocumented people would be able to purchase plans on the health insurance exchanges but would not qualify for subsidies.

Still, in his speech unveiling the plan at an AARP-sponsored candidate forum in Iowa, Biden did not address this issue of immigrants’ health care. He said only that his plan would expand funding for community health centers, which serve patients regardless of ability to pay or immigration status, and that people here without legal authority would be able to obtain coverage in emergencies, which is already law.

KHN’s ‘What The Health?’: Biden Doubles Down On Obamacare


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


Former Vice President Joe Biden has said if he’s elected president he would build on the Affordable Care Act rather than move to a whole new health care system, such as the “Medicare for All” plan supported by some of his primary opponents for the Democratic nomination. But his campaign’s new health plan would include many things Congress tried and failed to pass as part of the health law, including a government-run “public option” plan that would be widely available.

Meanwhile, the U.S. House voted to repeal one of the ACA’s key financing mechanisms, voting overwhelmingly to cancel the so-called “Cadillac tax,” which was set to take effect in 2022. It is a 40% excise tax on the most generous employer-provided health plans.

And it was not a good week for Planned Parenthood. The women’s health provider parted ways with its president of less than a year, Leana Wen. And the Trump administration announced it would begin enforcement of new rules for the federal family planning program that Planned Parenthood said will force it to stop participating.

This week’s panelists are Julie Rovner from Kaiser Health News, Joanne Kenen of Politico, Kimberly Leonard of the Washington Examiner and Margo Sanger-Katz of The New York Times.

Among the takeaways from this week’s podcast:

  • Biden’s health proposal seeks to lower out-of-pocket costs for many people in several ways. For example, it would make federal premium help available to all who buy their own insurance, not just those with low and middle incomes. It would also change how federal premium subsidies are determined. It would base the assistance on the cost of a gold plan, rather than the current practice of using the second lowest priced silver plan. Since gold plans are more generous, using that standard could lower the amount of deductibles and copayments people getting subsidies have to pay.
  • The ACA’s Cadillac tax has been strongly endorsed by health economists, who view it as a way to cut the amount of unnecessary care some people with generous plans seek. But many employers, consumers and labor unions don’t want to tinker with the current tax system of job-based insurance.
  • The administration’s decision to go forward with its new rules for the Title X family planning program — while critics are challenging those regulations in the courts — will have a significant effect on Planned Parenthood’s finances. But the group gets even more government money through the Medicaid program.
  • Despite two setbacks last week in the administration’s efforts to reduce drug prices, President Donald Trump is continuing to hint that he wants to go forward with a plan to tie some Medicare drug prices to what people in other countries pay for the medications.
  • Federal officials have announced that opioid deaths have declined, but it is not clear that opioid overdoses or addiction has declined.

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

Julie Rovner: The New York Times’s “Where Roe v Wade Matters Most,” by Quoctrung Bui, Claire Cain Miller and Margot Sanger-Katz.

Joanne Kenen:  Scientific American’s “Why Doctors Are Drowning in Medical School Debt,” by Daniel Barron.

Margot Sanger-Katz: Bloomberg News’ “Deadly Disease Is Treatable, But Newborn Screening Patchwork Leaves Many Vulnerable,” by Michelle Cortez.

Kimberly Leonard: The Washingtonian’s “DC Types Have Been Flocking to Shrinks Ever Since Trump Won. And a Lot of the Therapists Are Miserable,” by Britt Peterson.

To hear all our podcasts, click here.

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

Must-Reads Of The Week From Brianna Labuskes

Happy Friday! If you want a smile after this long week, be sure to check out today’s Google Doodle. I feel like this is the right crowd to appreciate it.

Now on to what you may have missed!

The courtroom was where much of the action took place this week, from Title X funding to drug prices to opioids. But the biggest spotlight of all was on the fate of the Affordable Care Act.

The latest challenge to the health law was a long-shot case, with legal experts writing off its chances of prevailing at the start. The suit can be perfectly summed up by a question from Judge Jennifer Walker Elrod, one of the three judges who heard oral arguments on the case in New Orleans: “If you no longer have the tax, why isn’t it unconstitutional?”

Judge Kurt Engelhardt also asked why the Senate hadn’t sent a lawyer along with the House counsel to convey that the congressional intent had been to keep most of the law. “They’re sort of the 800-pound gorilla that’s not in the room,” he said.

Despite some blunt questioning, though, it’s not clear where the judges will land on the final decision. The case could end up in front of the Supreme Court right in the heart of the 2020 election cycle. Considering that the “we’re the side protecting all those popular health law provisions” argument was at least partly credited for Democrats’ blue wave in the midterms, the timing of the case could have deep political ramifications for Republicans.

The Washington Post: Appeals Judges Question Whether the ACA Can Stand Without Insurance Penalty

Politico: Long-Shot Legal Challenge Could End Obamacare During the 2020 Campaign

If the law is overturned, the far-reaching ripple effects would go far beyond politics. It’s not just that 21 million people could lose health insurance, or that the protections for people with preexisting conditions would go away or that insurers would no longer have to cover young adults on their parents’ plans. So many of the Affordable Care Act’s directives have become ingrained in daily life that it’s as if many people forget they’re tied to that hot-button “Obamacare” topic.

On that list? Calorie counts on menus, lactation rooms at work, transparency for gifts from pharma companies to doctors, YMCA courses that teach diabetes maintenance, etc., etc.

The New York Times: So You Want to Overturn Obamacare. Here Are Some Things That Would Be Headaches.

Also on that list? A wonky provision that grants HHS “innovation” authority. The reason it’s important? President Donald Trump is using that very authority (that’s part of the law he’s trying to get overturned) to make big promises on revolutionizing the kidney care marketplace.

The New York Times: Trump’s Assault on Obamacare Could Undermine His Own Health Initiatives

(Pardon my detour from the courts for a minute, but that’s an impossible-not-to-utilize segue for the other big news of the week, and I’m going to jump on it.)

Trump announced an extremely ambitious plan this week to upend the kidney care world. Currently, the marketplace relies heavily on patients getting care at large dialysis clinics, even though at-home options are both safe and cost-effective. But those big chains can pull in $24 billion a year in revenue, so I somehow doubt that they’re going to go gently into that good night. Another part of the plan would incentivize kidney donations with reimbursements for lost wages and child care to try to address the country’s shortages. (And a special shoutout to Politico for the scoop on the plan.)

The New York Times: Trump Proposes Ways to Improve Care for Kidney Disease and Increase Transplants

Politico: Trump Aims to Shake Up Kidney Care Market

And now back to our court news: Trump’s strategy to curb drug prices sustained the first of two significant blows this week when a federal judge ruled that the administration can’t force companies to put prices in their TV ads. Judge Amit Mehta dodged the tricky First Amendment debate and instead focused on HHS’ authority (or lack thereof, really) to enforce such a rule. His ruling was, essentially: Hey, high drug prices are the pits and this might be an effective tool. But HHS can’t do more than Congress has authorized.

The New York Times: Judge Blocks Trump Rule Requiring Drug Companies to List Prices in TV Ads

The second punch came Friday when the administration pulled the plug on a signature proposal to eliminate drug rebates for pharmacy benefit managers (the target du jour for ire over high prices). Policy experts had worried the rule would lead to higher premiums for Medicare beneficiaries. Insurers and PBMs were popping the champagne over the announcement, while the general consensus is that pharma companies should now be braced for (an even bigger) storm headed their way.

Stat: After Trump Pulled the Plug on Rebates, His Options to Reduce Drug Prices Narrow. And He May Need Congress


The 2020 Democratic candidates were busy bees this week:

— Sen. Elizabeth Warren (D-Mass.) announced an immigration plan that would include the creation of a DOJ task force to investigate complaints of abuse and neglect from detainees.

Politico: Elizabeth Warren Takes on Trump With Immigration Overhaul

— Sen. Kamala Harris (D-Calif.) wants to take on the epidemic of outrageous rape kit backlogs. The kits can sometimes sit in police departments, which are strained for resources, for years. Harris has some bona fide experience to back up her plan. When she was California’s attorney general, her Rapid DNA Service team said it cleared all 1,300 untested rape kits in the state’s backlog in one year and earned national recognition and grants for its efforts.

USA Today: Kamala Harris: Rape Kit Backlog Can Be Cleared at Cost of Trump Golf Trips

— Sen. Amy Klobuchar (D-Minn.) released a proposal to tackle a wide range of problems that affect Americans’ seniors, from high drug costs to Alzheimer’s research to long-term care issues.

Politico: How Amy Klobuchar Would Improve Care for Seniors

— And Sen. Bernie Sanders (I-Vt.) is hopping on a bus to Canada with a group of Americans in search of cheaper insulin. This isn’t his first time embarking on such a trip. Twenty years ago, he went north with a group of breast cancer patients with a similar goal. (That two-decade gap between the trips speaks volumes, doesn’t it?)

CNN: Bernie Sanders to Join People With Type 1 Diabetes on Canada Trip for Cheaper Insulin

As we’ve seen in recent weeks, nearly all the Democratic candidates support the idea of providing health care to people who are in the country illegally. But what exactly would that entail? For one, it would place the U.S. even further left of progressive countries who already have universal health care. Most of them have at least some restrictions in place. But experts say that not only in the long run could providing care for them save money — immigrants in the country without legal permission tend to be young and relatively healthy and underuse available care.

The New York Times: What Would Giving Health Care to Undocumented Immigrants Mean?

Meanwhile, California is charging forward to become the first state in the country to offer Medicaid coverage to residents below the age of 26, regardless of their immigration status.

The Associated Press: California OKs Benefits to Immigrants In Country Illegally


Speaking of Medicaid, New Hampshire pumped the brakes on its new work requirements following reports that more than 17,000 people (yes, you read that right) would be found to be noncompliant with the rules after its first month. The state has been making the rounds with mailings, phone calls and even a door-knocking campaign, but officials still suggest the problem is that most people aren’t aware they need to report their hours. The experience mirrors Arkansas’ (almost down to the exact number of people who would be booted) and highlights the inherent obstacles states face when putting such rules in place.

Modern Healthcare: New Hampshire Delays Its Medicaid Work Requirement


A mother whose 19-month-old daughter died after being detained by ICE spoke at a House hearing this week about reports of the inhumane conditions at the facilities. “The world should know what happened,” Yazmin Juárez said during deeply emotional testimony. The name of the hearing — “Kids in Cages: Inhumane Treatment at the Border” — set the tone and reflected the state of affairs on Capitol Hill over the issue.

The Washington Post: ‘Kids in Cages’: House Hearing Examines Immigration Detention As Democrats Push for More Information


About 20% of the nation’s hospice facilities have safety lapses that are serious enough to endanger patients. What does that look like, beyond the dry terminology of an inspector general’s report? Gangrene so bad that a patient’s leg needed to be amputated; maggots burrowing near wound openings; and unnoticed sexual assault. But the report highlights another issue: There’s not much CMS can do about all of it. It would take an act of Congress to give CMS the power to fine the industry’s bad actors.

NPR: Roughly 20% of U.S. Hospice Programs Cited for Serious Deficiencies, Inspectors Say


In the miscellaneous file for the week:

• There are lots of voices in the abortion wars these days. Many of them, though, are from white leaders — on both sides of the issue — while the unique nuances and challenges that black communities face are missing from the debate. For women of color, race is tied to abortion in a way that white advocates rarely have to contend with.

The New York Times: When ‘Black Lives Matter’ Is Invoked in the Abortion Debate

•  An alleged mix-up at a fertility clinic that resulted in a woman having two babies who were not related to either her or each other highlights the real pitfalls of human error and advanced medicine.

USA Today: IVF Couple Sues California Clinic, Alleges Babies Weren’t DNA Match

• On paper, as medical aid-in-dying laws continue to pass across the country, more Americans are gaining control over how they end their lives. The reality looks a lot different, though.

The New York Times: Aid in Dying Soon Will Be Available to More Americans. Few Will Choose It.

• A Disney Channel star’s death this week highlighted the dangers of epilepsy-linked sleep deaths. Although it is rare, SUDEP is responsible for more deaths than SIDS (sudden infant death syndrome) and yet few people have heard of it.

CNN: Cameron Boyce’s Death: How Seizures Can Kill People With Epilepsy

• A new Secret Service report on mass violence incidents reveals that two-thirds of perpetrators had made threats before the attacks.

CNN: A New Report on Mass Attacks in the US Shows Common Traits Among Assailants

• A hospital in Ohio fired 23 employees in the wake of murder charges against one of its doctors in a case related to patients’ painkiller-linked deaths. There are a lot of issues here, but of particular note is how systemic such problems can become. One medical professional might be the root problem, but, at some point, that infection can spread to many interlocking parts within a health system.

The New York Times: Hospital C.E.O. Resigns and 23 Employees Are Fired After Ohio Doctor Is Charged in Murders


And, as election season kicks up, I really don’t blame any of the candidates for grabbing the Purell. Have a great weekend!