Tagged Medicaid

Podcast: KHN’s ‘What The Health?’ You Have Questions, We Have Answers

This week, KHN’s “What the Health?” panelists answered questions submitted by listeners.

Among the topics covered were what might happen to parts of the Affordable Care Act if a lawsuit now working its way through the courts succeeds in declaring the health law unconstitutional, and how Medicare and Medicaid deal with surprise medical bills from out-of-network providers.

This week’s panelists are Julie Rovner of Kaiser Health News, Jennifer Haberkorn of the Los Angeles Times, Joanne Kenen of Politico and Kimberly Leonard of the Washington Examiner.

The panel addressed questions including the following:

  • What would happen to the Medicare Part D “doughnut hole” if the entire ACA is struck down, and would newer bills, such as the Bipartisan Budget Act, which helped close the coverage gap for brand-name drugs one year early, prevent this feature of the ACA from being eliminated?
  • Will the Health Insurance Portability and Accountability Act (HIPAA) of 1996 remain if the ACA is completely overturned?
  • Since surprise medical bills aren’t allowed in Medicare and Medicaid, what happens when an anesthesiologist or contract emergency room doctor who doesn’t accept Medicare or Medicaid treats an enrolled patient? Do they take a lower rate? Does the hospital make up the difference? Why can’t this be applied to all out-of-network arrangements?
  • Statistics show that approximately 5% to 10% of the population accounts for about 50% of total health care spending. Who makes up this population? Are there any reasonable proposals to address the health of this population and perhaps reduce spending while improving outcomes?

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

Julie Rovner: Kaiser Health News’ “Lethal Plans: When Seniors Turn To Suicide In Long-Term Care,” by Melissa Bailey and JoNel Aleccia

Jennifer Haberkorn: The New York Times’ “Insurers Want to Know How Many Steps You Took Today,” by Sarah Jeong

Joanne Kenen: Vox.com’s “Walmart’s $25 Insulin Can’t Fix the Diabetes Drug Price Crisis,” by Julia Belluz

Kimberly Leonard: The [Columbia, S.C.] State’s “SC Inmate’s Baby Died in Toilet: Lawsuits Allege Rampant Medical Neglect in Prisons,” by Emily Bohatch

And, The Atlanta Journal-Constitution’s “For Some in Ga. Prisons and Jails, Diabetes Has Meant a Death Sentence,” by Danny Robbins

To hear all our podcasts, click here.

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

Podcast: KHN’s ‘What The Health?’ You Have Questions, We Have Answers

This week, KHN’s “What the Health?” panelists answered questions submitted by listeners.

Among the topics covered were what might happen to parts of the Affordable Care Act if a lawsuit now working its way through the courts succeeds in declaring the health law unconstitutional, and how Medicare and Medicaid deal with surprise medical bills from out-of-network providers.

This week’s panelists are Julie Rovner of Kaiser Health News, Jennifer Haberkorn of the Los Angeles Times, Joanne Kenen of Politico and Kimberly Leonard of the Washington Examiner.

The panel addressed questions including the following:

  • What would happen to the Medicare Part D “doughnut hole” if the entire ACA is struck down, and would newer bills, such as the Bipartisan Budget Act, which helped close the coverage gap for brand-name drugs one year early, prevent this feature of the ACA from being eliminated?
  • Will the Health Insurance Portability and Accountability Act (HIPAA) of 1996 remain if the ACA is completely overturned?
  • Since surprise medical bills aren’t allowed in Medicare and Medicaid, what happens when an anesthesiologist or contract emergency room doctor who doesn’t accept Medicare or Medicaid treats an enrolled patient? Do they take a lower rate? Does the hospital make up the difference? Why can’t this be applied to all out-of-network arrangements?
  • Statistics show that approximately 5% to 10% of the population accounts for about 50% of total health care spending. Who makes up this population? Are there any reasonable proposals to address the health of this population and perhaps reduce spending while improving outcomes?

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

Julie Rovner: Kaiser Health News’ “Lethal Plans: When Seniors Turn To Suicide In Long-Term Care,” by Melissa Bailey and JoNel Aleccia

Jennifer Haberkorn: The New York Times’ “Insurers Want to Know How Many Steps You Took Today,” by Sarah Jeong

Joanne Kenen: Vox.com’s “Walmart’s $25 Insulin Can’t Fix the Diabetes Drug Price Crisis,” by Julia Belluz

Kimberly Leonard: The [Columbia, S.C.] State’s “SC Inmate’s Baby Died in Toilet: Lawsuits Allege Rampant Medical Neglect in Prisons,” by Emily Bohatch

And, The Atlanta Journal-Constitution’s “For Some in Ga. Prisons and Jails, Diabetes Has Meant a Death Sentence,” by Danny Robbins

To hear all our podcasts, click here.

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

Hickenlooper Expanded Medicaid, Created State-Run Marketplace To Insure Nearly All Coloradans

Former two-term Colorado Gov. John Hickenlooper is a rare breed in the 2020 presidential race — he’s running as a moderate.

On health care, he supports universal coverage and boasts about Colorado’s record-low uninsured rate. But unlike many of his competitors for the Democratic nomination, he opposes “Medicare-for-all,” the single-payer federal system that would guarantee health care coverage to every American.

Hickenlooper has been making the rounds on cable talk shows and is trying to distinguish himself as a compromiser. In an interview on MSNBC’s “Meet the Press,” Hickenlooper said, “We got to almost universal coverage in health care in Colorado. We expanded Medicaid. We created one of the most innovative exchanges in the country.” His campaign website claims that “nearly 95 percent” of Coloradans currently have health care coverage.

We wondered how Colorado’s uninsured rate changed during Hickenlooper’s time in the governor’s mansion and how it compares with the rest of the country.

How Did Hickenlooper Do It?

The Affordable Care Act, or ACA, authorizes states to expand Medicaid to include health care coverage for all adults earning up to 138% of the federal poverty level. Colorado is one of 37 states that have opted to do so.

In 2013, then-governor Hickenlooper announced his proposal to expand Medicaid at no cost to the state general fund. Under the ACA, the federal government would pay for the program until 2016, after which states had to pay a portion. Hickenlooper planned to cover future expenses with cost-cutting efforts and existing revenues, including a hospital provider fee rolled out in 2009.

After Hickenlooper launched the Medicaid expansion, Colorado’s uninsured rate dropped from 14.3% in 2013 to 6.5% in 2017, according to the Colorado Health Institute.

However, about 350,000 Coloradans still don’t have health insurance — one-quarter of whom are undocumented, making them ineligible for public insurance. Also, the price of coverage continues to rise in Colorado, where people pay some of the highest premiums in the United States.

Hickenlooper saw Medicaid expansion as a step toward his goal of making Colorado the “healthiest state in America.” But he hasn’t always supported policies that could give more people health care coverage. In 2016, he opposed a ballot measure that would have created a single-payer state health care system called ColoradoCare. Then, he said he’d be open to a Trump administration-backed policy to implement a work requirement for Medicaid recipients.

How Does Colorado Compare?

Hickenlooper’s Medicaid expansion more than halved Colorado’s uninsured rate. But if a 6.5% uninsured rate counts as “almost universal coverage,” then how many other states can tout that accomplishment?

According to the Kaiser Family Foundation, Colorado’s uninsured rate positions it squarely in the upper half of the pack, with a national average uninsured rate of 9%. (It’s important to note that the Kaiser Family Foundation measured Colorado’s uninsured rate differently, pegging it at 8%. The Colorado Health Institute said its rate is slightly lower because it includes more data on children. Kaiser Health News is an editorially independent program of the foundation.)

The foundation lists 20 states with even lower uninsured rates than Colorado, including Massachusetts at 3% and Iowa at 4%.

In an email to PolitiFact, Michele Lueck, the president of the Colorado Health Institute, called Hickenlooper’s claim that “nearly 95 percent” of Coloradans currently have health care coverage a “friendly rounding error.”

Enrollment Numbers In Decline Nationwide, But Not In Colorado

About 300,000 fewer Americans bought insurance through healthcare.gov during the enrollment period in 2018 than in the previous year. Meanwhile, Colorado’s enrollment numbers were up.

The Affordable Care Act allowed states to create their own marketplaces to sell insurance plans to people who aren’t covered by their employer, Medicaid or Medicare — which includes about 8% of the total market in Colorado. Twelve states, including Colorado, run their own marketplaces.

Some credit lower enrollment across the country to the Trump administration’s policies to stymie the Affordable Care Act. It cut funding for healthcare.gov’s budget for marketing and eliminated the penalty for not having insurance.

But in Colorado, nearly 6% more people purchased a plan on Connect for Health Colorado, the state-run marketplace that operates independently of the federal government. While healthcare.gov released fewer ads and shut down weekly for maintenance, Connect for Health Colorado continued to reach out to eligible customers.

Our Ruling

Hickenlooper said, “We got to almost universal coverage in health care in Colorado.” Though Colorado is much closer to universal health care coverage than before the Affordable Care Act, hundreds of thousands of Coloradans remain uninsured and other states have even lower uninsured rates. Nevertheless, the state has an uninsured rate of 6.5%, which is close to universal coverage, as Hickenlooper said. The state achieved this by expanding Medicaid and running its own health care marketplace.

We rate the claim Mostly True.

Changes To CMS Readmission Penalties Appear Effective In Addressing Unique Challenges Of Rural, Teaching Hospitals

The changes were made to address complaints from hospitals—safety-net hospitals in particular—that they are unfairly penalized in the readmissions program because of their complex patient case mix. For rural hospitals, their average penalties are estimated to decline from $55,268 to $53,633; while average penalties for teaching hospitals will drop from $287,268 to $283,461. Other news from CMS looks at accountable care organizations and primary care accounts.

Changes To CMS Readmission Penalties Appear Effective In Addressing Unique Challenges Of Rural, Teaching Hospitals

The changes were made to address complaints from hospitals—safety-net hospitals in particular—that they are unfairly penalized in the readmissions program because of their complex patient case mix. For rural hospitals, their average penalties are estimated to decline from $55,268 to $53,633; while average penalties for teaching hospitals will drop from $287,268 to $283,461. Other news from CMS looks at accountable care organizations and primary care accounts.

Watch: Sanders Re-Ups ‘Medicare-For-All,’ Gets More Mileage On Campaign Trail

KHN chief Washington correspondent Julie Rovner appeared on two CNN programs to help explain what’s known and what’s still to be figured out about the “Medicare-for-all” plan Sen. Bernie Sanders (I-Vt.) reintroduced this week in the Senate. The plan by Sanders, who is among the front-runners in the Democratic presidential primary race, has drawn a lot of attention on the campaign trail and Capitol Hill.

Watch CNN’s “New Day” with Alisyn Camerota and John Berman.

Watch “CNN Newsroom” with Brooke Baldwin.

Podcast: KHN’s ‘What The Health’: Still More ‘Medicare-For-All’

Vermont Sen. Bernie Sanders, a presidential candidate, unveiled the 2019 version of his “Medicare-for-all” bill this week. But even more than two decades after first proposing a single-payer plan for the U.S., Sanders still has not proposed a way to finance such a major undertaking.

Congress continued to pursue its examination of high prescription drug prices this week by calling to testify both insulin makers and the drug “middlemen” known as pharmacy benefit managers.

And Idaho is following Utah in trying to scale back an expansion of Medicaid under the Affordable Care Act approved by voters last November.

This week’s panelists are Julie Rovner of Kaiser Health News, Sarah Kliff of Vox.com, Margot Sanger-Katz of The New York Times and Paige Winfield Cunningham of The Washington Post.

Also, Rovner interviews Ceci Connolly, president and CEO of the Alliance of Community Health Plans.

Among the takeaways from this week’s podcast:

  • “Medicare-for-all” was in the spotlight again this week with the release of Sanders’ bill, which is co-sponsored by four of the five other Senate Democrats running for president. Still, neither Sanders nor any other candidates — or their proposals — focus on how to pay for it. Experts differ on how much expanding Medicare would cost. But, whether it’s moving around money already being spent or raising new taxes, expanding Medicare to more people would result in winners and losers, a key political factor going forward.
  • Both parties face internal divisions over health care, revolving around whether to create something new or stick with the status quo. Within the GOP, the split is between Republicans who point to years of unsuccessful efforts to repeal and maybe replace the ACA and want to move on to other things, and others — including some in the White House — who are continuing the push. Democrats’ division is between those who back House Speaker Nancy Pelosi’s call to strengthen and improve the ACA and those who back various efforts to create a Medicare-for-all system.
  • The GOP is playing both offense and defense on the ACA. Leaders say they want to be the party of health care and protect people with preexisting medical conditions, even as the Justice Department is officially backing a court ruling in Texas that would invalidate the entire law, including those protections.
  • There was lots of talk but little action on drug prices at hearings before Congress. Lawmakers heard from drug companies and pharmacy benefit managers, but are no closer to answering the question about what to do about high drug prices. While there may be incremental changes that can be adopted, few expect legislation that would fundamentally change business practices, intellectual property rights or the ability for Medicare to negotiate drug prices.
  • Action in the Utah and Idaho legislatures around Medicaid expansion show that even successful ballot initiatives to expand the program can be changed by lawmakers in ways voters may not have expected. In both state capitols, elected officials reduced the number of people eligible for expansion below what voters approved.

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’ “Would ‘Medicare for All’ Save Billions or Cost Billions?” By Josh Katz, Kevin Quealy and Margot Sanger-Katz

Sarah Kliff: Politico’s “Public Option Hits a Wall in Blue States,” by Rachana Pradhan and Dan Goldberg

Margot Sanger-Katz: Politico’s “Obamacare Fight Obscures America’s Real Health Care Crisis: Money,” by Joanne Kenen

Paige Winfield Cunningham: STAT News’ “Amazon Alexa Is Now HIPAA-Compliant. Tech Giant Says Health Data Can Now Be Accessed Securely,” by Casey Ross

To hear all our podcasts, click here.

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

As Sanders Officially Revives Medicare-For-All, Plan B For Democrats Gains Traction

As Democratic presidential primary candidates try to walk a political tightrope between the party’s progressive and center-left wings, they face increasing pressure to outline the details of their health reform proposals.

On Wednesday, Sen. Bernie Sanders (I-Vt.) reaffirmed his stance by reintroducing a “Medicare-for-all” bill, the idea that fueled his 2016 presidential run.

As with its previous iterations, Sanders’ latest bill would establish a national single-payer “Medicare” system with vastly expanded benefits, prohibit private plans from competing with Medicare and eliminate cost sharing. New in this version is a universal provision for long-term care in home and community settings (but Medicaid would continue to cover institutional care).

Already, it has an impressive list of Senate cosponsors — including Sanders’ rivals for the Democratic presidential nomination, Cory Booker (D-N.J.), Kirsten Gillibrand (D-N.Y.), Kamala Harris (D-Calif.) and Elizabeth Warren (D-Mass.).

But many of the candidates — even official Medicare-for-all co-sponsors — are at the same time edging toward a more incremental approach, called “Medicare for America.” Proponents argue it could deliver better health care to Americans while avoiding political, budgetary and legal objections.

It comes as politicians tread carefully over the political land mines a Medicare-for-all endorsement could unleash, while seeking to capitalize on a growing appetite for health reform.

During the 2018 midterm election campaigns, some congressional candidates talked about allowing people older than 55 to join Medicare, or allowing people younger than 65 to buy into it if they choose (the “public option”). Many aren’t eager to face the industry opposition that a full-on Medicare expansion would surely trigger.

From the consumer perspective, sweeping reform poses a risk. Despite Medicare’s popularity with its beneficiaries, the majority of Americans express satisfaction with their health care, and many are nervous about giving up private options. Also, many analysts are worried that a generous Medicare-for-all plan that promises everything would break the bank without any patient payments.

That tension is pushing a number of candidates toward an emerging option called “Medicare for America.” The bill was introduced last December to little fanfare by two Democrats, Rep. Rosa DeLauro (Conn.) and Rep. Jan Schakowsky (Ill.). It hasn’t been reintroduced in the new Congress.

This proposed system would guarantee universal coverage, but leaves job-based insurance available for those who want it. Unlike Medicare-for-all, though, it preserves premiums and deductibles, so beneficiaries would still have to pay some costs out-of-pocket. It allows private insurers to operate Medicare plans as well, a system called Medicare Advantage that covers about a third of the program’s beneficiaries currently, and which would be outlawed under Medicare-for-all.

“Before policies get defined, what you see is people endorsing a plan that is a little, perhaps, less subject to early attack,” said Celinda Lake, a Democratic pollster. “A lot of candidates feel if they endorse a plan that leaves some private insurance, they get more time to say what their ideas are about.”

Medicare for America got its first high-profile endorsement from former Texas Rep. Beto O’Rourke, who launched his own 2020 bid in mid-March. Other candidates — including Warren, Gillibrand and Pete Buttigieg, the mayor of South Bend, Ind. — have tiptoed toward it without making any endorsements, suggesting they back Medicare-for-all in theory but also support a system that retains private insurance, at least temporarily.

Such an approach is perhaps unsurprising. Polling indicates voters want strong health reform. Candidates, election experts say, need something powerful to deliver.

Improving the Affordable Care Act, an idea backed by Sen. Amy Klobuchar, a Minnesota Democrat running in the primary’s moderate lane, may not suffice.

“The ACA is popular at the 50 percent level, but it’s not energetic. It doesn’t get people who really like it,” Blendon said. “What they’re looking for is something that is exciting but isn’t threatening.”

Both Medicare-for-all and Medicare for America, experts noted, offer something that presidential candidates can campaign on and a health alternative that at first blush sounds appealing to many. But the latter could skirt some potential obstacles.

Approval for Medicare-for-all drops when people learn that, under such a program, they would likely lose their current health plan (even if the government-offered plan could theoretically provide more generous coverage).

The cost-sharing element of Medicare for America, meanwhile, would ostensibly quiet some of the concerns about paying for Medicare’s expansion, though critics on the left worry it would mean some people would still be unable to afford care.

This also tracks with recent polling which suggests that, while Medicare-for-all support can be swayed, voters of all political stripes favor some sort of way to extend optional Medicare coverage, without necessarily eliminating the private industry altogether.

Employers would have to offer plans that were at least as generous as the government program, or direct employees to Medicare. Employers who stop offering health benefits would have to pay a Medicare payroll tax.

For now, most candidates are still avoiding a concrete stance on Medicare for America. Despite signs of interest, the Buttigieg, Gillibrand and Warren campaigns all declined to directly answer questions about whether they endorse Medicare for America. The campaigns of other candidates in the race — Harris, Klobuchar, Booker, former Housing and Urban Development Secretary Julian Castro and Washington Gov. Jay Inslee — similarly declined to comment.

Reading between the lines, though, their promises to achieve universal health care by expanding Medicare — while retaining private insurance — leaves them few options besides something like Medicare for America, argued one of its main architects.

“There are variations besides this particular plan, but once you start to actually dig into this, if you want universal coverage you’re going to have to do the kinds of things” spelled out in Medicare for America, argued Jacob Hacker, a political scientist at Yale University, who played a lead role in devising this proposal.

Still, though, it has prompted objections from both the left and the right.

On the far left, the cost sharing is a dominant concern. (Under Medicare for America, an individual would have a $3,500 out-of-pocket limit; a family would have a $5,000 limit. Premiums would be capped at almost 10% of a household’s income.) Those critics also say the plan’s accommodations to private insurance limit the government’s ability to negotiate lower prices.

Conservatives repeat many of the arguments levied against Medicare-for-all — too expensive, too disruptive.

Hospitals, insurance, drugmakers and doctors, who have already mobilized against Medicare-for-all, also can be expected to make just as strong a showing against Medicare for America, political analysts said. More Medicare means less revenue for the medical industry.

Said David Blumenthal of the Commonwealth Fund: “The fact of expanded Medicare will be the focus of attacks.”

N.C. Lawmakers Working Toward Covering More Low-Income People, But Shy Away From Politically Charged ‘Medicaid Expansion’ Term

The NC Health Care for Working Families Act would help low-income people get coverage through the state’s Medicaid program, but it wouldn’t technically be “expanding” Medicaid. It’s estimated that about 543,000 people would end up gaining coverage through the proposal. Medicaid news comes out of North Dakota, Illinois and Ohio, as well.

Consumers Rejected Drug Plan That Mirrors Trump Administration Proposal

Unraveling how much of a prescription drug price gets swallowed by “middlemen” is at the forefront of Tuesday’s drug price hearing in the Senate. One thing bound to come up: rebates.

Both major political parties have shown interest in remedying high drug prices, and drugmakers have bemoaned how rebates to middlemen keep them from reaping every dollar associated with those price tags.

Pharmacy giant CVS Health criticized the Trump administration’s proposal to end these post-transaction discounts as they apply to Medicare. Yet, in January the company rolled out a Medicare drug plan that experts say is similar “in spirit” to the administration’s proposal.

The CVS Caremark plan wasn’t popular with customers, and CVS Health, which owns CVS Caremark, was quick to point this out as evidence that consumers prefer the current rebate system.

“We had a very, I would say, small number of seniors enroll in that program,” Larry Merlo, CVS Health’s CEO said on a February earnings call with investors. “And we think one of the barriers to that was the increase that we saw in the monthly premium.”

The CVS plan’s premium was $80 a month, which is about double the average Medicare Part D monthly charge. But since it is designed to pass on a portion of rebates directly to patients at the pharmacy counter, certain patients would wind up with smaller out-of-pocket costs than they previously paid.

“Even very well-informed consumers would not necessarily understand that a higher premium plan in this case means that they’re incurring smaller amounts at the point of sale,” said Rachel Sachs, an associate law professor at Washington University in St. Louis who specializes in health care.

So why did only 25,000 people sign up for the plan, called SilverScript Allure? Either consumers didn’t want the plan or perhaps they just didn’t understand it?

We’ll break it down for you.

Untangling Jargon: The Way Things Are And How They Could Change

A pharmacy benefit manager, or PBM, handles drug claims for health insurance companies. The big ones are Express Scripts, CVS Caremark and OptumRx. Every time you fill a prescription and use your drug plan, your PBM is involved in paying the claim and determining how much money you owe the cashier.

A rebate is a discount the PBM negotiates with a drug manufacturer off the price the drugmaker sets, which is called a list price. Rebates are not made public, and they typically don’t get passed on to the patient at the pharmacy counter in the form of a lower copayment, experts say.

When the drugmaker eventually pays the rebate back to the PBM, the PBM often uses this money to lower premiums, which are the monthly fees that Medicare Part D plans charge beneficiaries. They differ for each drug plan.

In a way, patients taking drugs with high list prices and big rebates wind up subsidizing other patients’ premiums, said Erin Trish, the associate director of the University of Southern California Schaeffer Center for Health Policy and Economics. Premiums on average haven’t substantially increased in more than a decade, but it may be “unfair” to the patients paying higher prices for drugs at the pharmacy counter.

“Some may argue, ‘They’re sicker… Maybe they should [pay more],’” Trish said. “Look. We decided everyone should pay the same premium in this market. [Rebates] shouldn’t be a roundabout way to make a subset of beneficiaries pay more.”

That could all change under a new Trump administration proposal that would ban rebates as they exist today. The negotiated discounts would be applied at the pharmacy counter, meaning discounts would be passed on to patients as out-of-pocket costs that are calculated based on the discounted price, not the higher list price.

For patients taking drugs with high list prices and large rebates, like insulin, it could mean noticeable savings, Sachs said. For patients taking drugs without big rebates, like generics or brand-name drugs without other branded competition, they’re not likely to see much change at the pharmacy counter.

Everyone, however, will see premiums go up. It’s unclear yet how much, but Trish said the SilverScript Allure plan CVS Caremark is offering isn’t necessarily the best indicator. Consultants hired by the Department of Health and Human Services estimated premiums will go up $3.20 to $5.64 per month if the rule takes effect in 2020. The average Medicare Part D premium for 2019 was $41.21, according to the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

So Why Didn’t Patients Want The CVS Caremark Plan?

It’s not clear how well seniors shopping for drug plans understood the SilverScript Allure plan, among their many options. They could see it had a high premium, but no deductible. They might not have realized it required smaller payments on drugs at the pharmacy counter.

Research shows that the premium is the most important factor seniors consider when choosing a plan, Sachs said.

On top of that, people are unlikely to leave their current plans even if there’s a better one available.

What’s more, we don’t know how well CVS Caremark marketed the plan to seniors who would benefit. They wouldn’t tell us, despite multiple calls and emails.

OptumRx, a competing PBM, started offering customers similar discounts at the pharmacy counter — but for people with commercial insurance, not Medicare or Medicaid. Unlike CVS Caremark, it has a web page with basic language, like “point of sale discounts mean lower costs,” and a link to request more information about switching. OptumRx did not respond to a request for comment.

PBMs: Helping Or Hurting?

Rebates for individual plans and drugs are confidential, but in Medicare Part D, they’ve increased on average from 9.6% of total spending in 2007 to 19.9% in 2016, according to annual reports to the Medicare boards of trustees.

So it’s perhaps unsurprising the brand-name drug trade group, the Pharmaceutical Research and Manufacturers of America, said it “applaud[s]” the proposal to overhaul the rebate system. PhRMA says it pushes them to raise prices in order to offer larger rebates, because drugs with larger rebates often get preferential treatment by PBMs.

Still, PBMs offer the benefit of batting down net prices (the price after rebate), and keeping down drug spending overall.

There are multiple estimates on how much the rebate proposal would cost the Centers for Medicare & Medicaid if it took effect, and they indicate that unless there are other changes to Medicare Part D, it would likely cost more money than the current system, Sachs said.

“It is startling to see the administration moving forward so rapidly with this proposal without a better understanding of how different actors might respond,” she said. As a result, there’s a “huge amount of uncertainty” over how this could all play out.

The Ripple Effects From Medicaid Expansion: Study Finds It’s Linked To Fewer Heart-Related Deaths

“The overall results of this study are that after expansion of Medicaid in 2014, the areas in the country that did expand had a significantly lower mortality rate compared to if they had followed the same trajectory as the areas in the country that didn’t expand,” said Dr. Sameed Khatana, a fellow in cardiovascular disease at the Hospital of the University of Pennsylvania. Other Medicaid news comes out of Illinois, Kansas and Tennessee.

The Ripple Effects From Medicaid Expansion: Study Finds It’s Linked To Fewer Heart-Related Deaths

“The overall results of this study are that after expansion of Medicaid in 2014, the areas in the country that did expand had a significantly lower mortality rate compared to if they had followed the same trajectory as the areas in the country that didn’t expand,” said Dr. Sameed Khatana, a fellow in cardiovascular disease at the Hospital of the University of Pennsylvania. Other Medicaid news comes out of Illinois, Kansas and Tennessee.

Must-Reads Of The Week From Brianna Labuskes

Happy Friday! The question for the day is: If there were a drug that would turbocharge your brain, would you take it? I’ve seen enough sci-fi movies to make me, uh, less than enthused about the idea, but as my second cup of coffee of the day has yet to kick in, I find it interesting to ponder.

Anyway, on to this roller coaster of a news week!

Republicans on the Hill have been quietly pretending they might wake up and this renewed focus on the health law will all have been a fever dream. But Democrats are doing their best to make sure everyone knows exactly where everyone stands on President Donald Trump’s recent legal attacks. On Wednesday, the House Dems officially voted to condemn the president’s decision to tell the courts to nullify the entire health law instead of just parts of it. In practice, this means nothing, but it puts Republicans on record of once again voting against popular health law provisions.

Trump, meanwhile, softly backpedaled on his promises that Republicans were coming up with a “spectacular” replacement plan before 2020. This came after a talk with Senate Majority Leader Mitch McConnell — who essentially channeled his inner Ariana Grande and said thank u, next to the issue that has left the party with political bruises the past two years.

But Trump is remaining steadfast in his message that Republicans need to reclaim health care as a winning topic for 2020. “We can’t run away” from health care, he said. “We’ll lose.”

The bumpy week, for some, was a reminder of the surprises that could be in store for the upcoming election season.

The Wall Street Journal: Democrats, Trump Try to Keep Spotlight on Health Care

The Associated Press: Pivoting on Pledges, Trump Explores Art of the Climb-Down

Bloomberg: Trump Says GOP `Blew It’ on Health Care and Must Run on New Plan

Politico: Killing Obamacare Kills Trump’s Health Agenda, Too


Going on name only, the Violence Against Women Act sounds like one of the least controversial bills out there, but a closer look at its history reveals fault lines. The House this week passed its version of the legislation (which is geared toward protecting women from violence and domestic abuse and has to be renewed every few years), but don’t expect smooth sailing the rest of the way. This time the underlying drama stems from a new provision that expanded law enforcement’s ability to strip domestic abusers of their guns.

The New York Times: A Brief History of the 25-Year Debate Over the Violence Against Women Act


Fill-in-the-blank copycat bills powered by special interests and businesses have infiltrated the legislative process to a shocking extent. USA Today, The Arizona Republic  and the Center for Public Integrity has an amazing two-year investigation that examined nearly 1 million bills in all 50 states and Congress to root out legislation that was nearly identical to others. These measures touched on almost every subject imaginable, from sugary drinks to “right-to-try” legislation to abortion to gun control. The investigation found that these bills are often drafted with deceptive titles, include misleading information on the extent of expert or public support, and push agendas that override the will of voters. Be sure to check out this story — it has examples of the bills, data and charts, and all kinds of fun goodies to delve into.

USA Today: Abortion, Gun Control: How Special Interest Groups Push Legislation


A veritable flurry of movement on drug pricing bills is coming up in the next week or so, with legislation and hearings that will focus on PBMs, the price of insulin, transparency, public accountability for pharma and more. With that as context …

Express Scripts this week announced that it is capping the price of insulin at $25 per month. Under the new plan, employers who cover their workers through Cigna and Express Scripts can opt into the program, and the extra costs will be picked up by the three drugmakers that sell insulin — Eli Lilly, Novo Nordisk and Sanofi. Advocates deemed the decision nothing but a PR move, saying it does little to address the actual problems of high list prices for people who aren’t lucky enough to be on one of the plans.

The New York Times: Express Scripts Offers Diabetes Patients a $25 Cap for Monthly Insulin

Stat: House Committee to Weigh Bills Aimed at Shedding Light on High Drug Prices


“One medical emergency, that’s all it would take to wipe me out financially,” is something I’ve heard friends worry about time and again, so a grim new report about the reality of paying for health care in America came as no surprise. Over the past year, Americans have borrowed $88 billion (billion! with a b!) to pay for health care. A survey went on to report that nearly half of Americans are haunted by fears of medical-related bankruptcy, and 1 in 4 people have skipped needed care because of the cost. Not only that, about 70% of respondents across the political spectrum said they had no confidence in their elected officials to bring prices down.

The New York Times: Americans Borrowed $88 Billion to Pay for Health Care Last Year, Survey Finds


This technically happened last Friday, but not in time for the Breeze: The Trump administration approved a work-requirements waiver for Utah — just days after similar restrictions were struck down for both Kentucky and Arkansas. The Utah story is even more nuanced, though, because voters in that state approved full expansion of the program. Lawmakers have been scrambling to put rules into place ever since the ballot measure passed.

The New York Times: Trump Administration Approves Medicaid Work Requirements in Utah

Meanwhile, both HHS Secretary Alex Azar and CMS Administrator Seema Verma have been quietly trying to sell states on applying for block grant waivers, with Verma, in particular, pushing Alaska to become the first in the nation to apply. A legal challenge would almost certainly follow any such decision.

The Hill: Trump Administration Urging Alaska to Be First to Apply for Medicaid Block Grant


In the same vein as this happened late last week but you should know about it: The Trump administration announced the recipients of $250 million in Title X federal family planning grants, including a chain of anti-abortion clinics designed to siphon off patients from Planned Parenthood. The group had been turned down last year because it doesn’t provide birth control other than natural family planning and abstinence. Meanwhile, Planned Parenthood and its affiliates saw a steep drop in what it had been previously receiving — going from about $50 million-$60 million to $16 million.

Politico: Millions in Family Planning Grants Given to Groups and States Fighting Trump’s Policy Changes


In the miscellaneous file this week:

• A look at how a former congressman has become a one-man gate-keeping operation when it comes to lobbying the VA.

Politico: Millions in Family Planning Grants Given to Groups and States Fighting Trump’s Policy Changes

• A wild investigation into how high-speed chases, while frowned upon in other agencies, are a strategy often used by the Border Patrol, despite the fact that they can often end in gruesome injuries and death.

Los Angeles Times/ProPublica: Border Patrol Agents Are Granted Wide Latitude When Trying to Catch Drivers Seeking to Enter U.S. Illegally

• Torture, rape, murder and other violence in the Alabama prison system is “severe and systematic,” a new Department of Justice report finds. Fair warning, the details are pretty disturbing, but it’s worth a read.

The New York Times: Alabama’s Gruesome Prisons: Report Finds Rape and Murder at All Hours

• Can getting drugs to treat libido issues or thinning hair be as easy as ordering off a restaurant menu? That’s what these new types of websites offer: a way for patients to self-diagnose their problems and then get a sign-off from a doctor whom they don’t even meet with. The sites often don’t include warnings about side effects of the medications, and it’s entirely unclear whether their doctor-screening process follows any kind of standards.

The New York Times: Drug Sites Upend Doctor-Patient Relations: ‘It’s Restaurant-Menu Medicine’

• The “lede” on this story was a cold reality check about the intersection of public health fears and prejudice when it comes to vulnerable populations. Rockland County, N.Y., where one of the country’s largest measles outbreaks is rippling through the Jewish Orthodox community, is serving as a model of how those tensions can boil over in times of crisis.

The New York Times: An Outbreak Spreads Fear: Of Measles, of Ultra-Orthodox Jews, of Anti-Semitism

• “Healthy Holly” may sound like an innocuous children’s book, but the controversy surrounding it — and its author, Baltimore Mayor Catherine Pugh — will likely bring down several careers.

The Baltimore Sun: As a Maryland Senator, Pugh Pushed Bills to Benefit Hospitals While Getting Book Payments From Medical System


And make sure to check out this fun history on how the concept of personal space is hard-wired into our brains. Have a great weekend!

Podcast: KHN’s ‘What The Health’ The GOP’s Health Reform Whiplash

President Donald Trump last week insisted that Republicans would move this year to “repeal and replace” the Affordable Care Act. Or possibly not. Senate Majority Leader Mitch McConnell made it clear the GOP Senate did not plan to spend time on the effort as long as the House is controlled by Democrats. So, the president changed his tune. At least for the moment.

Meanwhile, states with legislatures and governors that oppose abortion are racing to pass abortion bans and get them to the Supreme Court, where, they hope, the new majority there will overturn or scale back the current right to abortion.

This week’s panelists are Julie Rovner of Kaiser Health News, Rebecca Adams of CQ Roll Call, Anna Edney of Bloomberg News and Alice Miranda Ollstein of Politico.

Also, Rovner interviews KHN’s Paula Andalo, who wrote the latest “Bill of the Month” feature about a very expensive knee brace.

If you have an exorbitant or inexplicable medical bill you’d like to submit for our series, you can do that here.

Among the takeaways from this week’s podcast:

  • Although Trump’s political base may support his actions to undermine the entire federal health law, Republican lawmakers are flummoxed. They are hesitant to take up the cause because Democrats used the issue so effectively against Republicans in last fall’s election. They also know that many Republicans like key provisions of the health law, such as its closing of the doughnut hole in the Medicare drug benefit, letting adult children stay on parents’ plans up to the age of 26 and protecting people with preexisting conditions.
  • The unveiling this week of a new Democratic health initiative — Medicare X — signals an increasing push by party moderates to move away from progressives’ call to dramatically reshape American health care with a “Medicare-for-all” system. Medicare X is a much smaller initiative that would allow some people to buy in to the Medicare system, but it would be rolled out gradually over a number of years.
  • In other ACA news, a federal judge struck down the administration’s regulations allowing small businesses to join association health plans, saying it was an end run to avoid the health law. Thousands of people could be affected by the decision, and Labor Secretary Alex Acosta said he will decide by the end of the May whether to appeal.
  • Anti-abortion activists in many states are pushing new laws to test whether the retirement last summer of Justice Anthony Kennedy has left the Supreme Court more willing to turn back the Roe v. Wade decision. Among the types of cases going forward are state laws that would ban abortions once a fetal heartbeat could be determined, which often happens about six weeks into a pregnancy or before many women even know they are pregnant.
  • Despite a stiff rejection last week by a federal judge who overturned the Trump administration’s permission for work requirements in the Medicaid expansion approved in Arkansas and Kentucky, federal officials said that Utah could go forward with a plan to start work requirements as part of a partial expansion. Supporters of the ACA insist that expansion should be for anyone earning up to 138% of the federal poverty level. But the issue is tough for Democrats, some of whom say a partial expansion is better than none.

Ask Us Anything!

Do you have a health policy question you’d like the panelists to answer? You can send it to whatthehealth@kff.org. Please include where you’re from and how to pronounce your name.

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

Julie Rovner: Vox.com’s “The Doctor’s Strike That Nearly Killed Canada’s Medicare-for-All Plan, Explained,” by Sarah Kliff

Rebecca Adams: CQ Roll Call’s “Legal Challenges Are Threatening Trump Administration Changes to the ACA,” by Sandhya Raman

Anna Edney: The Baltimore Sun’s “Baltimore Mayor Pugh to Take Leave of Absence in Midst of ‘Healthy Holly’ Book Controversy” by Ian Duncan and Yvonne Wenger

Alice Miranda Ollstein: The New York Times’ “Rituals of Honor in Hospital Hallways,” by Dr. Tim Lahey

To hear all our podcasts, click here.

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