Tagged Medicaid

Must-Reads Of The Week From Brianna Labuskes

We’re barreling toward November, folks. (How is it mid-October already?) As you might expect, election stories made up the bulk of the health care news this week. Other great gems and intriguing developments surfaced, though, so let’s get right to it.

Republicans on the campaign trail have been hammered by attack ads over their stance on the health law, with “preexisting conditions protections” — insurance safeguards for patients diagnosed with chronic illness — becoming a catch-all phrase for the most popular parts of the Affordable Care Act. Even the law’s most vocal opponents have been reading tea leaves and softening their stances. That’s why statements from GOP leadership this week that Congress could revisit their “repeal” fight post-midterms may have landed with a thunk.

The New York Times: Republican Candidates Soften Tone on Health Care As Their Leaders Dig In

The Washington Post: Trump Says ‘All Republicans’ Back Protections for Preexisting Conditions, Despite Repeated Attempts to Repeal Obamacare

Democrats are pulling out a tried-and-true talking point that seemed perfectly timed for them as news of the federal deficit reignited Republican talk about cutting entitlement programs. Dems (who have been playing defense over Medicare) seized the opportunity to accuse Republicans of putting the beloved program on the chopping block.

The Associated Press: Dems Shift Line of Attack, Warning of GOP Threat to Medicare

As the parties duke it out on the trail, voters seem to agree on one thing: Our health care system is broken and someone needs to fix it. “It’s crippling people. It’s crippling me,” one voter says in Politico’s deep read that takes us to a Pennsylvania county where the “margins of electoral victories traditionally are as slim as the spectrum of political opinion is vast.”

Politico Magazine: The Great American Health Care Panic

On the state level, a Missouri Democrat opposed to abortion struggles to find her place in the party. And Georgia becomes a preview of the growing political clout of home health aides.

The New York Times: Is It Possible to Be an Anti-Abortion Democrat? One Woman Tried to Find Out

Politico: Home Health Aides Test Political Clout in Georgia Governor’s Race


The Trump administration this week proposed a requirement that pharma add drug prices to TV ads — triggering skepticism. One problem is that ad prices wouldn’t reflect what most people end up paying for a drug at the pharmacy counter.

Politico: Trump Set to Force Drugmakers to Post Prices in Ads

What I found surprising, considering how common those ads are, is that just a few dozen drugmakers run any at all — nearly half are put out by five companies. Those manufacturers would bear the brunt of the new rules.

Stat: Five Drug Makers Will Be Hit Hardest By Trump’s New Proposal on Drug Ads

Trying to think outside the box to rein in high drug prices, several states are considering treating pharma as they would a public utility — with rate-setting bodies to review, approve or adjust medication prices.

Stat: A Growing Number of States Consider Legislation to Treat Pharma As a Utility

And keep an eye on this battle: Minnesota became the first state to sue drugmakers over the price of insulin, but I don’t think it will be the last. The “life-or-death” drug has gotten a lot of attention recently, synthesizing the human toll of high costs into a digestible talking point.

Stat: Minnesota Becomes First State to Sue Major Insulin Makers Over Price-Gouging


Another 4,100 Arkansas beneficiaries were dropped from the state’s Medicaid rolls, and 4,800 more are at risk next month (on top of the original 4,353 people dropped last month) — all because of the state’s new work requirements. For critics of the restrictions, their worst fears are realized, while state and national officials focus on what they call positive outcomes. It’s unclear why so many workers are failing to report their hours, but experts suggest limited internet access and lack of knowledge about the requirements as possibilities.

Modern Healthcare: 4,100 More Arkansans Lose Medicaid Over Work Requirements


Anthem was slammed this week with a $16 million settlement over its massive data breach. (Remember the biggest known health care hack in U.S. history?) That penalty is nearly three times the previous record paid over such a case.

The Associated Press: Insurer Anthem Will Pay Record $16M for Massive Data Breach


I’m not sure whether it’s because I saturate myself in health care stories, but I detect a serious reckoning in the field of medical research. The latest call for retractions involves a prominent cardiologist.

The New York Times: Harvard Calls for Retraction of Dozens of Studies by Noted Cardiologist


In the miscellaneous must-read file:

• A mysterious polio-like illness that causes sudden paralysis is hitting children in states across the country. The wave of cases is similar to one officials saw in 2014 and 2016, but experts are baffled.

Los Angeles Times: What Is AFM? Everything You Need to Know About the Polio-Like Virus Suddenly Affecting Children Across the U.S.

• I have to admit, this is the headline that most piqued my interest this week. Gene editing is such a hot field, but in the racially charged landscape of the country, scientists are worried their research into genes and genetic diversity will be twisted by hate groups to support their views.

The New York Times: Why White Supremacists Are Chugging Milk (And Why Geneticists Are Alarmed)

• Why hasn’t #WhyIStayed caught on fire like #MeToo? Stigma, for one. But also the #MeToo movement has shown how powerful multiple accusations can be, amplified to the point they can’t be ignored. In a domestic violence situation, it’s often only one survivor speaking out.

The New York Times: Domestic Violence Awareness Hasn’t Caught Up With #MeToo. Here’s Why.

• Viruses don’t always have to be a scary thing. This therapy uses bacteriophages — literally, eaters of bacteria — that inject themselves into germs and cause them to explode. (As this delightful image from the Stat article describes: The viruses can “pop bacteria the way middle schoolers pop zits.”)

Stat: How The Navy Brought a Once-Derided Scientist Out of Retirement — and Into the Virus-Selling Business

• “Pregnant? Don’t want to be? Call Jane.” That’s how a clandestine underground abortion network advertised during the years leading up to Roe v. Wade, according to this retro report from the NYT.

The New York Times: Code Name Jane: The Women Behind a Covert Abortion Network


It turns out, it is now scientifically supported that daylight helps kill germs indoors. So make sure to let the sun in this weekend! And have a good one.

Must-Reads Of The Week From Brianna Labuskes

We’re barreling toward November, folks. (How is it mid-October already?) As you might expect, election stories made up the bulk of the health care news this week. Other great gems and intriguing developments surfaced, though, so let’s get right to it.

Republicans on the campaign trail have been hammered by attack ads over their stance on the health law, with “preexisting conditions protections” — insurance safeguards for patients diagnosed with chronic illness — becoming a catch-all phrase for the most popular parts of the Affordable Care Act. Even the law’s most vocal opponents have been reading tea leaves and softening their stances. That’s why statements from GOP leadership this week that Congress could revisit their “repeal” fight post-midterms may have landed with a thunk.

The New York Times: Republican Candidates Soften Tone on Health Care As Their Leaders Dig In

The Washington Post: Trump Says ‘All Republicans’ Back Protections for Preexisting Conditions, Despite Repeated Attempts to Repeal Obamacare

Democrats are pulling out a tried-and-true talking point that seemed perfectly timed for them as news of the federal deficit reignited Republican talk about cutting entitlement programs. Dems (who have been playing defense over Medicare) seized the opportunity to accuse Republicans of putting the beloved program on the chopping block.

The Associated Press: Dems Shift Line of Attack, Warning of GOP Threat to Medicare

As the parties duke it out on the trail, voters seem to agree on one thing: Our health care system is broken and someone needs to fix it. “It’s crippling people. It’s crippling me,” one voter says in Politico’s deep read that takes us to a Pennsylvania county where the “margins of electoral victories traditionally are as slim as the spectrum of political opinion is vast.”

Politico Magazine: The Great American Health Care Panic

On the state level, a Missouri Democrat opposed to abortion struggles to find her place in the party. And Georgia becomes a preview of the growing political clout of home health aides.

The New York Times: Is It Possible to Be an Anti-Abortion Democrat? One Woman Tried to Find Out

Politico: Home Health Aides Test Political Clout in Georgia Governor’s Race


The Trump administration this week proposed a requirement that pharma add drug prices to TV ads — triggering skepticism. One problem is that ad prices wouldn’t reflect what most people end up paying for a drug at the pharmacy counter.

Politico: Trump Set to Force Drugmakers to Post Prices in Ads

What I found surprising, considering how common those ads are, is that just a few dozen drugmakers run any at all — nearly half are put out by five companies. Those manufacturers would bear the brunt of the new rules.

Stat: Five Drug Makers Will Be Hit Hardest By Trump’s New Proposal on Drug Ads

Trying to think outside the box to rein in high drug prices, several states are considering treating pharma as they would a public utility — with rate-setting bodies to review, approve or adjust medication prices.

Stat: A Growing Number of States Consider Legislation to Treat Pharma As a Utility

And keep an eye on this battle: Minnesota became the first state to sue drugmakers over the price of insulin, but I don’t think it will be the last. The “life-or-death” drug has gotten a lot of attention recently, synthesizing the human toll of high costs into a digestible talking point.

Stat: Minnesota Becomes First State to Sue Major Insulin Makers Over Price-Gouging


Another 4,100 Arkansas beneficiaries were dropped from the state’s Medicaid rolls, and 4,800 more are at risk next month (on top of the original 4,353 people dropped last month) — all because of the state’s new work requirements. For critics of the restrictions, their worst fears are realized, while state and national officials focus on what they call positive outcomes. It’s unclear why so many workers are failing to report their hours, but experts suggest limited internet access and lack of knowledge about the requirements as possibilities.

Modern Healthcare: 4,100 More Arkansans Lose Medicaid Over Work Requirements


Anthem was slammed this week with a $16 million settlement over its massive data breach. (Remember the biggest known health care hack in U.S. history?) That penalty is nearly three times the previous record paid over such a case.

The Associated Press: Insurer Anthem Will Pay Record $16M for Massive Data Breach


I’m not sure whether it’s because I saturate myself in health care stories, but I detect a serious reckoning in the field of medical research. The latest call for retractions involves a prominent cardiologist.

The New York Times: Harvard Calls for Retraction of Dozens of Studies by Noted Cardiologist


In the miscellaneous must-read file:

• A mysterious polio-like illness that causes sudden paralysis is hitting children in states across the country. The wave of cases is similar to one officials saw in 2014 and 2016, but experts are baffled.

Los Angeles Times: What Is AFM? Everything You Need to Know About the Polio-Like Virus Suddenly Affecting Children Across the U.S.

• I have to admit, this is the headline that most piqued my interest this week. Gene editing is such a hot field, but in the racially charged landscape of the country, scientists are worried their research into genes and genetic diversity will be twisted by hate groups to support their views.

The New York Times: Why White Supremacists Are Chugging Milk (And Why Geneticists Are Alarmed)

• Why hasn’t #WhyIStayed caught on fire like #MeToo? Stigma, for one. But also the #MeToo movement has shown how powerful multiple accusations can be, amplified to the point they can’t be ignored. In a domestic violence situation, it’s often only one survivor speaking out.

The New York Times: Domestic Violence Awareness Hasn’t Caught Up With #MeToo. Here’s Why.

• Viruses don’t always have to be a scary thing. This therapy uses bacteriophages — literally, eaters of bacteria — that inject themselves into germs and cause them to explode. (As this delightful image from the Stat article describes: The viruses can “pop bacteria the way middle schoolers pop zits.”)

Stat: How The Navy Brought a Once-Derided Scientist Out of Retirement — and Into the Virus-Selling Business

• “Pregnant? Don’t want to be? Call Jane.” That’s how a clandestine underground abortion network advertised during the years leading up to Roe v. Wade, according to this retro report from the NYT.

The New York Times: Code Name Jane: The Women Behind a Covert Abortion Network


It turns out, it is now scientifically supported that daylight helps kill germs indoors. So make sure to let the sun in this weekend! And have a good one.

As Billions In Tax Dollars Flow To Private Medicaid Plans, Who’s Minding The Store?

With no insurance through his job, Jose Nuñez relied on Medicaid, the nation’s public insurance program that assists 75 million low-income Americans.

Like most people on Medicaid, the Los Angeles trucker was assigned to a private insurance company that coordinated his medical visits and treatment in exchange for receiving a set fee per month — an arrangement known as managed care.

But in 2016, when Nuñez’s retina became damaged from diabetes, the country’s largest Medicaid insurer, Centene, let him down, he said. After months of denials, delays and erroneous referrals, he claimed in a lawsuit, the 62-year-old was left nearly blind in one eye. As a result, he lost his driver’s license and his livelihood.

“They betrayed my trust,” Nuñez said, sitting at his kitchen table with his thick forearms folded across his chest.

The current political debate over Medicaid centers on putting patients to work so they can earn their government benefits. Yet some experts say the country would be better served by asking this question instead: Are insurance companies — now receiving hundreds of billions in public money — earning their Medicaid checks?

More than two-thirds of Medicaid recipients are enrolled in such programs, a type of public-private arrangement that has grown rapidly since 2014, boosted by the influx of new beneficiaries under the Affordable Care Act.

States have eagerly tapped into the services of insurers as one way to cope with the expansion of Medicaid under the ACA, which has added 12 million people to the rolls. This fall, voters in three more states may pass ballot measures backing expansion. Outsourcing this public program to insurers has become the preferred method for running Medicaid in 38 states.

Yet the evidence is thin that these contractors improve patient care or save government money. When auditors, lawmakers and regulators bother to look, many conclude that Medicaid insurers fail to account for the dollars spent, deliver necessary care or provide access to a sufficient number of doctors. Oversight is sorely lacking and lawmakers in a number of states have raised alarms even as they continue to shell out money.

“We haven’t been holding plans to the level of scrutiny they need,” said Dr. Andrew Bindman, former director of the federal Agency for Healthcare Research and Quality and now a professor at the University of California-San Francisco. “This system is ripe for profit taking, and there is virtually no penalty for performing badly.”

In return for their fixed fees, the private insurers dole out treatment within a limited network, in theory allowing for more judicious, cheaper care. States contract with health plans as a way to lock in some predictability in their annual budgets.

More than 54 million Medicaid recipients are now covered by managed-care plans, up from fewer than 20 million people in 2000. (In traditional Medicaid, states pay doctors and hospitals directly for each visit or procedure — an approach that can encourage unnecessary or excessive treatment.)

Already, states funnel nearly $300 billion annually to Medicaid insurers. That’s up from $60 billion a decade ago. Today’s spending is approaching what Pentagon awards annually to contractors.

Jose Nuñez says he and daughter Diana Nuñez took turns calling his Medicaid plan and waiting on hold for answers after his eye surgery was canceled twice. He waited three months for his insurer to approve the operation, he says. By that time, his retina had deteriorated and Nuñez was nearly blind in one eye.(Heidi de Marco/KHN)

Medicaid is good for business: The stock price of Nuñez’s insurer, Centene, has soared 400 percent since the ACA expanded Medicaid eligibility. The company’s chief executive took in $25 million last year, the highest pay for any CEO in the health insurance industry. In California, the largest Medicaid managed-care market with nearly 11 million enrollees, Centene and other insurers made $5.4 billion in profits from 2014 to 2016, according to a Kaiser Health News analysis.

Plans get to keep what they don’t spend. That means profits can flow from greater efficiency — or from skimping on care and taking in excess government payments.

“States are just giving insurers the keys to the car and a gas card,” said Dave Mosley, a managing director at Navigant Consulting and former finance director at the North Carolina Medicaid program. “Most states haven’t pressed insurers for the information needed to determine if there’s any return on their investment.”

Two of California’s most profitable insurers, Centene and Anthem, ran some of California’s worst-performing Medicaid plans, state quality scores and complaints in government records show. California officials have been clawing back billions of dollars from health plans after the fact.

For nearly two decades, federal officials have tried building a national Medicaid database that would track medical care and spending across states and insurers. It’s still unfinished, hampered by differing state reporting methods and refusals by some health plans to turn over data they deem trade secrets.

In July, a federal inspector general’s report accused Medicaid insurers of purposefully ignoring fraud and overpayments to doctors because inflated costs can lead to higher rates in the future.

In a report last month, the U.S. Government Accountability Office disclosed that California’s Medicaid program is unable to electronically send records justifying billions of dollars in spending, forcing federal officials to sift through thousands of documents by hand. California said it can’t share key files electronically because it uses 92 separate computer systems to run the program.

“You simply cannot run a program this large when you can’t tell where the money is going and where it has been,” said Carolyn Yocom, a health care director at the GAO.

Today, Medicaid consumes the single-largest share of state budgets nationwide at nearly 30 percent — up from less than 21 percent a decade ago — crowding out funding for education, roads and other key priorities.

“If anything, our results suggest that the shift to Medicaid managed care increased Medicaid spending,” researchers at the Congressional Budget Office and the University of Pennsylvania concluded in 2013, based on a nationwide analysis.

Industry officials insist that managed care saves money and improves care. Medicaid Health Plans of America, an industry trade group, points to a study showing that health plans nationally saved the Medicaid program $7.1 billion in 2016.

Health plans also say they can help modernize the program, created more than a half century ago, by upgrading technology and adopting fresh approaches to managing complex patients.

Getting it right has big implications for patients and taxpayers alike, but the results in many states aren’t reassuring.

State lawmakers in Mississippi, both Republicans and Democrats, criticized their Medicaid program last year for ignoring the poor performance of two insurers, UnitedHealthcare and Centene, even as the state awarded the companies new billion-dollar contracts.

In Illinois, auditors said the state didn’t properly monitor $7 billion paid to Medicaid plans in 2016, leaving the program unable to determine what percentage of money went to medical care as opposed to administrative costs or profit.

In April, Iowa’s state ombudsman said Medicaid insurers there had denied or reduced services to disabled patients in a “stubborn and absurd” way. In one case, an insurer had cut a quadriplegic’s in-home care by 71 percent. Without the help of an aide to assist him with bathing, dressing and changing out his catheter he had to move to a nursing home, according to the ombudsman, Kristie Hirschman.

“We are not talking about widgets here,” Hirschman said. “In some cases, we are talking about life-or-death situations.”

Meanwhile, the Trump administration has sent mixed signals on Medicaid oversight. Seema Verma, administrator for the Centers for Medicare & Medicaid Services, has promoted a new, nationwide scorecard and vowed to ramp up audits targeting states and health plans.

“We need to do better,” Verma said in a Sept. 27 speech to the Medicaid managed-care industry. “Medicaid has never developed a cohesive system of accountability that allows the public to easily measure and check our results.”

But consumer advocates also are concerned that Verma’s efforts to roll back “burdensome regulations” will weaken accountability overall. Many also disagree with her support of Medicaid work requirements.

Nuñez, the truck driver who lost much of his sight, is suing a unit of Centene for negligence and breach of contract. The company has denied the allegations in court filings and declined to comment further, citing the pending litigation.

Talk of requiring Medicaid recipients to work is hard for him to take. “I need my health to work,” he said. “They took that away from me.”


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

GOP’s Talk About Medicare Cuts Provides Democrats With Tried-And-True Talking Point Weeks Before Midterms

The widening budget deficit announced in recent days has sparked conversation among Republicans of cutting budgets and look for trims to entitlement programs. The Democrats are seizing on the tone shift, and using the potential changes to Medicare, Medicaid and other safety net programs as talking points on the campaign trail.

Children’s Hospitals Again Cry For Help From Voters. But Are They Really Hurting?

Back in 2004, California’s children’s hospitals asked voters to approve a $750 million bond measure to help fund construction and new medical equipment. In 2008, they asked for $980 million more. Now they’re hoping voters will agree on Nov. 6 to cough up an additional $1.5 billion.

The state’s 13 children’s hospitals treat California’s sickest kids — including those with leukemia, sickle cell disease, rare cancers and cystic fibrosis — so approving their fund-raising requests is an easy “yes” for many voters.

Despite the feel-good nature of the requests, some health care experts and election analysts question the hospitals’ multiple appeals for taxpayer money — and are warning voters to review this year’s proposal with a critical eye.

“I think it’s a misuse of the initiative process for private groups to sponsor ballot measures that are intended to benefit them exclusively,” said Elizabeth Ralston, a former president of the League of Women Voters of Los Angeles who analyzes state finance measures for the group. The league recommends a “no” vote on the measure.

Repeatedly asking taxpayers to pay for the construction of state-of-the-art facilities is not standard practice, according to critics who believe it raises questions about financial accountability — and whether the hospitals truly need some of the projects on their wish lists.

This pattern “could leave children’s hospitals with little incentive to control their costs,” said Ge Bai, a professor at the Johns Hopkins University Carey Business School, who added that each hospital should take care of itself.

The initiative, Proposition 4, needs a majority vote to pass. The 2004 and 2008 children’s hospital bond measures passed with 58.3 percent and 55.3 percent of the vote, respectively.

The California Children’s Hospital Association said its members can’t afford to pay for their building and technology needs without help from the state’s taxpayers, who would be on the hook to pay off $1.5 billion plus interest. The state Legislative Analyst’s Office estimates that would come to $2.9 billion — or about $80 million a year over the next 35 years.

Private donations often aren’t the answer because donors frequently specify how their money should be used, said Ann-Louise Kuhns, the association’s CEO. The posh playrooms and gardens at some of these hospitals, for example, are completely funded by private donations, she said.

“We do fund-raise, we ask donors to make contributions and we issue our own debt,” Kuhns said. “But it’s hard to completely close that gap for what’s needed … without a little bit of assistance.”

The association, which sponsored the initiative, said the bond measure would help pay for construction, remodeling, equipment and seismic retrofitting at the state’s eight private, nonprofit children’s hospitals and the five that are part of the University of California medical system.

The California Health Facilities Financing Authority would have to approve the hospitals’ use of the bond money. The agency weighs whether projects would expand access and improve patient care but does not determine whether a project is necessary or prudent.

That’s up to the hospitals.

(Story continues below.)

California Children’s Hospitals

The state’s 13 children’s hospitals — eight private nonprofits and five that are part of the University of California medical system — are asking voters to approve a $1.5 billion bond measure on the Nov. 6 ballot to help them pay for construction and equipment. If the measure passes, the private hospitals will receive about three-quarters of the proceeds, or about $135 million each, regardless of their profits or losses.

Source: Hospital data come from the last financial report audited by the Office of Statewide Health Planning and Development — either 2016 or 2017. Income information for UC hospitals was not available.

The campaign in support of the bond measure — funded by the nonprofit hospitals themselves — has raised nearly $11 million this year, according to the California secretary of state’s office.

In their last financial reports audited by the state, six of the eight private, nonprofit hospitals reported annual profits ranging from $18 million to nearly $176 million. The bond issuance would provide each with $135 million, regardless of its profits or losses.

Almost three-quarters of the bond proceeds would go to the nonprofits because they have the most beds, but nonprofit hospitals already receive certain perks, Bai explained. For instance, they’re exempt from paying property taxes, as well as state and federal income taxes.

Eighteen percent would be allotted to the UC system hospitals. And the proposal would offer 10 percent in competitive grants for approximately 150 hospitals that aren’t classified as pediatric hospitals, but treat children nonetheless.

The hospitals argue they need to expand because they are facing greater demand for services, as general and community hospitals increasingly transfer their patients to them for specialized pediatric care.

Children’s hospitals also rely heavily on Medi-Cal, the state’s insurance program for low-income people, Kuhns said. Medi-Cal pays hospitals less than private insurance.

Nancy Kane, a professor in the department of health policy and management at the Harvard T.H. Chan School of Public Health, pointed out that nationwide “many children’s hospitals have the same payer mix, but manage to do this anyway without the government paying for their capital.”

Kuhns said that California hospitals also face deadlines to meet seismic safety mandates. By 2020, they must be ready to withstand a major earthquake, and by 2030, they must be deemed safe enough to continue operating after a quake.

About 28 percent of the beds in the eight nonprofit children’s hospitals do not meet the 2030 seismic standards, so significant investments must be made, she said.

Tim Curley of Valley Children’s Healthcare in Madera said the previous bond measures helped pay for a 60,000-square-foot expansion of operating rooms. If this year’s bond measure is approved, the hospital would consider renovating its laboratories and pharmacy, he said.

At the end of last year, it had just under $28 million in funds remaining from the 2008 bond, a report by the financing authority said.

Loma Linda University Children’s Hospital is still using its share of the 2008 bond to help with the construction of a nine-story tower that will house most departments and labs.

The new tower, expected to be completed by 2021, will help the children’s hospital operate independently of the rest of the medical center — which serves adults —  and meet the growing demand for space, said Scott Perryman, a senior administrator.

But Ralston, with the League of Women Voters, said Californians should consider whether the money could be better used elsewhere.

“You’re committing state money,” she said, “and that means that’s money not spent on something else” like affordable housing or aging roads.

Should voters nonetheless approve this third bond measure, Bai wonders if and when the requests for taxpayer money will stop. “There are always new things to buy,” she said.


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

Architect Of Maine’s Conservative Reforms To Social Safety Net Tapped For Position Overseeing Medicaid

Mary Mayhew, who was announced as the deputy administrator and director of Medicaid and the Children’s Health Insurance Program, worked previously as Maine’s health commissioner under Gov. Paul LePage, a Republican known as a fierce opponent to Medicaid expansion.

Listen: Health Care Issues Reverberate In The States

Julie Rovner, chief Washington correspondent for Kaiser Health News, joined “1A” host Joshua Johnson, Scott Greenberger, the executive editor of Stateline, and Reid Wilson, national correspondent for The Hill, to discuss health policy initiatives in the states.

Among the topics they examined are Medicaid expansion efforts, work requirements that some states are implementing for Medicaid, efforts to bring down the price of prescription drugs and programs to battle the opioid epidemic. You can listen to the discussion on the “1A” broadcast page.

Listen: Health Care Issues Reverberate In The States

Julie Rovner, chief Washington correspondent for Kaiser Health News, joined “1A” host Joshua Johnson, Scott Greenberger, the executive editor of Stateline, and Reid Wilson, national correspondent for The Hill, to discuss health policy initiatives in the states.

Among the topics they examined are Medicaid expansion efforts, work requirements that some states are implementing for Medicaid, efforts to bring down the price of prescription drugs and programs to battle the opioid epidemic. You can listen to the discussion on the “1A” broadcast page.

American Hospital Association, Other Health Care Groups Speak Out About Trump’s Proposed Green Card Policy

Experts say that hundreds of thousands of children and other members of low-income legal immigrant families could drop out of public programs providing health care, nutrition and housing assistance due to the rule, which directs immigration officials to take into account things such as Medicaid assistance when determining green card eligibility. Meanwhile, House Democrats have introduced a bill to block the Trump administration’s policy.

American Hospital Association, Other Health Care Groups Speak Out About Trump’s Proposed Green Card Policy

Experts say that hundreds of thousands of children and other members of low-income legal immigrant families could drop out of public programs providing health care, nutrition and housing assistance due to the rule, which directs immigration officials to take into account things such as Medicaid assistance when determining green card eligibility. Meanwhile, House Democrats have introduced a bill to block the Trump administration’s policy.

No More Secrets: Congress Bans Pharmacist ‘Gag Orders’ On Drug Prices

For years, most pharmacists couldn’t give customers even a clue about an easy way to save money on prescription drugs. But the restraints are coming off.

When the cash price for a prescription is less than what you would pay using your insurance plan, pharmacists will no longer have to keep that a secret.

President Donald Trump was expected to sign two bills Wednesday that ban “gag order” clauses in contracts between pharmacies and insurance companies or pharmacy benefit managers — those firms that negotiate prices for employers and insurers with drugstores and drugmakers. Such provisions prohibit pharmacists from telling customers when they can save money by paying the pharmacy’s lower cash price instead of the price negotiated by their insurance plan.

The bills — one for Medicare and Medicare Advantage beneficiaries and another for commercial employer-based and individual policies— were passed by Congress in nearly unanimous votes last month. A spokesman for Sen. Susan Collins (R-Maine) said her office had been told the president would sign the bills Wednesday. The White House declined to comment.

“Americans deserve to know the lowest drug price at their pharmacy, but ‘gag clauses’ prevent your pharmacist from telling you!” Trump wrote on Twitter three weeks ago, shortly before the Senate voted on the bills. “I support legislation that will remove gag clauses.” The change was one of the proposals included in Trump’s blueprint to cut prescription drug prices issued in May.

Ronna Hauser, vice president of payment policy and regulatory affairs at the National Community Pharmacists Association, said many members of her group “say a pharmacy benefit manager will call them with a warning if they are telling patients it’s less expensive” without insurance. She said pharmacists could be fined for violating their contracts and even dropped from insurance networks.

According to research published in JAMA in March, people with Medicare Part D drug insurance overpaid for prescriptions by $135 million in 2013. Copayments in those plans were higher than the cash price for nearly 1 in 4 drugs purchased in 2013. For 12 of the 20 most commonly prescribed drugs, patients overpaid by more than 33 percent.

Yet some critics say eliminating gag orders doesn’t address the causes of high drug prices. “As a country, we’re spending about $450 billion on prescription drugs annually,” said Steven Knievel, who works on drug price issues for Public Citizen, a consumer advocacy group. The modest savings gained by paying the cash price “is far short of what needs to happen to actually deliver the relief people need.”

After the president signs the legislation affecting commercial insurance contracts, gag order provisions will immediately be prohibited, said a spokesman for Collins, who co-authored the bill. The bill affecting Medicare beneficiaries wouldn’t take effect until Jan. 1, 2020.

But there’s a catch: Under the new legislation, pharmacists will not be required to tell patients about the lower cost option. If they don’t, it’s up to the customer to ask.

The Pharmaceutical Care Management Association, a trade group representing pharmacy benefit managers, said gag orders are increasingly rare. The association supported the legislation. Some insurers have also said their contracts don’t include these provisions. Yet two members of Congress have encountered them at the pharmacy counter.

At a hearing on the gag order ban, Collins said she watched a couple leave a Bangor, Maine, pharmacy without their prescription because they couldn’t afford the $111 copayment and the pharmacist did not advise them about saving money by paying directly for the medicine. When she asked him how often that happens, he said every day.

“Banning gag clauses will make it easier for more Americans to afford their prescription drugs because pharmacists will be able to proactively notify consumers if a less expensive option may be available,” she said last week.

When Rep. Debbie Dingell (D-Mich.) went to a Michigan pharmacy to pick up a prescription recently, she was told it would cost $1,300. “After you peeled me off the ceiling, I called the doctor and screamed and talked to the pharmacist,” she recalled during a hearing last month. “I’m much more aggressive than many in asking questions,” she admitted, and ended up saving $1,260 after she learned she could get an equivalent drug for $40.

While the legislation removes gag orders, it doesn’t address how patients who pay the cash price outside their insurance plan can apply that expense toward meeting their policy’s deductible.

But for Medicare beneficiaries there is a little-known rule — not found in the “Medicare & You” handbook or on its website —that helps people with Medicare Part D or Medicare Advantage coverage. If they pay the lower cash price for a covered drug at a pharmacy that participates in their insurance plan and then submit the proper documentation to their plan, insurers must count it toward patients’ out-of-pocket expenses.

The total of those expenses are important because that amount affects the drug coverage gap commonly called the “doughnut hole.” (This year, the gap begins after the plan and beneficiary spend $3,750 and ends once the beneficiary has spent a total of $5,000.)

And beneficiaries don’t have to wait until the gag order ban takes effect in two years.

The Medicare rule also says that if a senior asks about a lower price for a prescription, the pharmacist can answer.

Rep. Buddy Carter (R-Ga.), a pharmacist who sponsored the Medicare gag order bill, said he wasn’t surprised by the bipartisan support for the legislation. “High prescription drug costs affect everyone,” he said.


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